This review considers the framework of voice therapy by the SLHT (speech-language-hearing therapist) to otolarngologists using the 5-R concept. The 5-R concept is “Right” client, voice therapy, time, dose, and route. “Right” is used in the sense of “most appropriate”.
First, Right client means that the right voice client with “functional” (no visible structural or neurological laryngeal pathology) voice problems must be selected because voice therapy by the SLHT is most effective for functional voice disorders. If the client does not have a functional problem with phonation, voice therapy might not be effective.
Second, Right voice therapy means that the SLHT should carefully choose the right therapeutic technique to treat the client's voice symptom. In this review, I will introduce a tube-phonation exercise and vocal hygienic advice, which are evidence-based.
Third, Right time refers to when the SLHT should start and stop voice therapy. Voice therapy should be begun as soon as possible after the client is diagnosed with a functional voice disorder. The SLHT must also know when to terminate a series of voice therapy sessions.
Fourth, Right dose refers to how many sessions of voice therapy and number of phonatory repetitions are effective. Unfortunately, there is a lack of research data in this area. My recent study shows that more than 1500 phonatory repetitions (50-repetitions per day) may be needed to retain the effect 1-month post-therapy.
Fifth, Right route indicates that the SLHT should have extensive knowledge of the motor-learning system because voice therapy is a behavioral modification, which is based on motor-learning theory. Some previous research in speech therapy, which is based on motor-learning therapy has shown that summary-feedback and randomized task exercises are effective to promote retention of new motor behaviors.

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Angioleiomyoma is a benign tumor composed of smooth muscle cells and vascular endothelial cells, which is most commonly found in the uterus, skin, and alimentary canal as a painful mass. In the head and neck region, the incidence of this tumor is rare and pain is usually absent. We report a rare case of angioleiomyoma occurring in the left subcutaneous extrernal nose. A 41-year-old man visited our hospital complaining of a swelling on the left side of the nose. Physical examination revealed a soft mass in the left subcutaneous extrernal nose. CT scan and MRI with gadolinium enhancement showed well-enhanced mass in the left subcutaneous extrernal nose without bone destruction or apparent invasion into the left nasal cavity. Aspiration biopsy cytology revealed blood only. The tumor was fully excised without major intraoperative bleeding, and the postoperative course was successful. Immunohistochemical study revealed postive staining for vimentin and α-smooth muscle actin in tumor cells, and the tumor was diagnosed as angioleiomyoma. For over a year following surgery, there has been no evidence of recurrence.

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Objective: Eosinophilic otitis media is an intractable inflammation of the middle ear combined with bronchial asthma. According to a national epidemiological investigation on eosinophilic otitis media, it is assumed that eosinophilic otitis media are combined with sinusitis in about 74% of their cases. On the other hand, organizational images of eosinophilic otitis media and eosinophilic sinusitis are similar, and steroid therapy is effective together, and it is thought that they are involved in the idea of one airway one disease, but the details of sinusitis combined with the eosinophilic otitis media are unidentified. Therefore, we examined the kinds of the sinusitis combined with eosinophilic otitis media.
Material and Method: We diagnosed 18 cases (male: 2 cases, female: 16 cases) (average age: 54.6 years old) as eosinophilic otitis media according to the diagnostic criteria.. And, by the CT views of a paranasal sinus, blood tests, existence of the nasal polyp, etc, we investigated the kinds of sinusitis combined with eosinophilic otitis media.
Result: It turned out that bronchial asthma was combined with eosinopilic otitis media in 17 of 18 cases (airway hypersensitivity did sthenia of one case, but the asthma did not yet developed), and 6 cases were combined with aspirin induced asthma (AIA), and 3 cases were combined with Churg-Strauss syndromes (CSS). 10 case (55.6%) of 17 eosinopilic otitis media were combined with eosinophilic sinusitis. And 4 cases (22.2%) of 17 eosinopilic otitis media were combined with chronic sinusitis, 4 cases (22.2%) of 17 eosinopilic otitis media were not combined with sinusitis.
Conclusion: We concluded that eosinophilic otitis media was not always combined with eosinophilic sinusitis. The idea of one airway one disease was not applied to this examination.

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Frontal sinus cyst is a relative common disease; however, this disease is often difficult to manage clinically since recurrence sometimes occurs even if patients are treated with surgery. We retrospectively analyzed 30 cases of the frontal sinus cyst, treated with surgery in our hospital between 1994 and 2006. The most common symptom was forehead swelling, followed by forehead pain, exophthalmos, and double vision; however, 3 (10%) cases did not have any clinical symptoms. Of 30 cases, 16 (53.3%) were postoperative cysts, and 14 (46.7%) were idiopathic cysts. Thirteen (43.3%) cases were treated by an external approach, and 12 (40.0%) cases were treated by an external approach combined with endonasal sinus surgery (ESS). Five (16.7%) cases were treated by ESS without external incision. The overall postoperative patency rate was 72.4%. The patency rate treated by the external approach, external approach combined with ESS, and ESS alone was 66.7%, 75.0%, and 80.0%, respectively. Although the number of patients treated by ESS alone was small, the clinical outcome of ESS was favorable. In several endonasal approaches, the endoscopic modified Lothrop procedure has been performed, and the postoperative clinical course is good. Thus, a modified Lothrop procedure might be a useful approach for frontal sinus cysts. The findings of the present study suggest that ESS would be the first choice of surgical approach for frontal sinus cysts.

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Rhabdomyosarcoma is a common pediatric tumors, but soft palate rhabdomyosarcoma is very rare.
In the case reported here, the patient was an-82-year-old female with bullous pemphigus who was referred to our clinic with a chief complaint of soft palate mass. On MRI, the tumor displayed a high intensity signal on T2-weighted images. We removed the lesion surgically using a CO2 laser. Histological examination showed that the tumor consisted of growing spindle cells with a positive reaction for vimentin myoglobin and actin (HHF-35) immunohistochemically. Based on those findings, the tumor was diagnosed as embryonal type rhabdomyosarcoma.
The patient is alive after resection alone without chemotherapy or radiation.

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One hundred three patients with peritonsillar abscess treated between January 2001 and June 2005 were clinically analysed. Seventy-four patients were male and 29 were female. The male to female ratio was 2.5:1. Patient ages ranged from 10 to 76 years old. The average age was 32.4 years old. Fourty nine patients were affected in the right side, and 54 in the left side. Sixty-four of 103 patients were referred to us by other doctors. The local findings deteriorated during the course of treatment in 4 of 103 patients are these four patients developed recurrent peritonsillar abscess. Only 2 patients were diabetic.
All patients were treated with a peritonsillar incision and retropharyngeal incision if retropharyngeal abscess was seen, and at the same time antibiotics were administered intravenously. The most common etiological bacteria was Genus Streptococcus viridans seen in 32 patients, i. e. 33% of 97 patients examined. The second most common was Streptococcus pyogenes seen in 18 patient.
Deep neck infection due to peritonsillar abscess was seen in 8 patients, that is, 8% of this series. Of these 8 patients, all but one were over 40 years old. Four patients had cellulitis and the other 3 had an abscess in the retrophalyngeal space. The former were incised independently from the peritonsillar incision, and the latter were incised from the peritonsillar to retropharyngeal region. Another patient had cellulitis in the parapharyngeal space and was cured with a peritonsillar incision and intravenous antibiotics alone without an external skin incision. This finding was considered an indication that peritonsillar abscess should be correctly treated before deterioration of deep neck infection, especially in patients over 40 years old.

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In the present study, the efficacy of monopolar electrocautery, harmonic scalpel, coblater, and cold knife was evaluated in tonsillectomy. Fifty two adult patients with chronic tonsillitis were divided into four groups, and the operation time and postoperative pain were examined. The mean operation time of tonsillectomy was 35.0±13.2min with monopolar electrocautery, 40.0±10.0min with harmonic scalpel, 54.0±19.1min with coblater, and 101.0±24.1min with cold knife. Thus, the operation time of tonsillectomy with cold knife was significantly prolonged, in comparison with those employing the other three devices (p<0.05). On the contrary, postoperative pain evaluated by self-reporting scales was decreased in the order of cold knife, coblater, harmonic scalpel, and monopolar electrocautery. The pain level after tonsillectomy with monopolar electrocautery was significantly greater than that with cold knife on postoperative days 2-7 (p<0.01). In conclusion, the efficacies of harmonic scalpel and coblater in tonsillectomy lay midway between those with monopolar electrocautery and cold knife.

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We report a rare case of first and second branchial arch syndrome with fistula originated from the first pharyngeal pouch. A 10-day-old female was referred to our clinic with a complaint of left microtia with fistula at the mandibular angle. On preoperative examinations, X-ray with angiography flexible wire inserted into the fistula and computed tomography with contrast enhancement of the fistula revealed that the fistula was connected to the middle ear cavity. Fistulectomy was performed at the age of 7. Pathological examinations demonstrated that the fistula consisted of a single layer of cylindrical epithelium, suggesting that it originated from the endoderm. Based on surgical, imaging, and pathological findings, the fistula originated from first pharyngeal pouch. Preoperative X-ray with angiography flexible wire inserted into the fistula and the computed tomography with contrast enhancement of the fistula were useful for planning operation.

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A 47-year-old male was injured by a neck puncture while hammering large blocks of iron. He developed cough, bloody sputum and neck pain. Laryngoscopy discovered reddening in the front anterior wall of the trachea just under the vocal cords, and we thought that a piece of iron had penetrated the trachea. A piece of iron was identified between the esophagus and the thyroid on preoperative CT scan. Eighteen days after the injury, during operation, the piece of iron was removed surgically from inside fascia longus colli.

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Glucocorticoids are effective medications and have been used for a multitude of indications. However, adverse effects and intolerance reactions have been reported since 1974.
We report a steroid-induced hypersensitivity reaction in a case with Bell's palsy. A 40-year-old male consulted our out-patient clinic due to right peripheral facial palsy.
As soon as he was injected with the hydrocortisone sodium succinate, he developed erythema all over his body, moderate itchiness and respiratory distress. His condition was improved immediately after the cessation of infusion.
The medication for facial palsy was altered from infusion to oral prednisolone. Thereafter, he showed no hypersensitivity reaction. Intradermal reaction was positive for three steroids with succinate-ester and negative for two steroids with phosphate-ester. We speculated that the succinate-ester component of hydrocortisone played a pivotal role in the anaphylactoid reaction in this case.

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We report a case of Tsutsugamushi disease (scrub typhus) diagnosed not by serum antibody test but by the clinical symptoms and course. A 15-year-old boy was admitted to our hospital, complaining of general fatigue and severe submandibular swelling. Physical investigation showed a fever, and CT scanning revealed severe swelling of subcutaneous tissue and lymph nodes in the neck. Laboratory data revealed slight leukocytosis and elevated CRP. On the first day of hospitalization, submandibular cellulitis was suspected and treatment with intravenous cephem antibiotics was started. On the second day after hospitalization, we found eschar on his back and a rash on his face, neck and back. As he had stayed in the mountains 10 days before hospitalization, Tsutsugamushi disease was strongly suspected and treatment with tetracycline antibiotics was added. On the day ten, he had recovered completely from all symptoms and left the hospital.
To confirm the diagnosis of Tsutsugamushi disease, a serum antibody test using three classical serotypes of Kato, Karp and Gilliam strains was performed and was negative. Around Shizuoka prefecture, novel Kawasaki and Kuroki types have developed as major strains recently. A serological test or PCR method targeting these new serotypes was necessary for definitive diagnosis, but we could not perform those tests because we lacked blood samples from the acute phase.

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We report a 85-year-old male with impalement injury caused by a metal pipe that passed through the left neck to the oral floor.
In this case, enhanced CT was effective for evaluating the large vessels, organs, and degree of injury.
The therapeutic guidelines of impalement injury comprise clarification of the entry route and organ injury before the administration of tetanus toxoid and/or antibiotics and surgical treatment, such as removal of the penetrating object, debridement, and wound drainage.
We could save the patient's life by following the therapeutic strategy of impalement injury.

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To assess the effects of early intervention with suplatast tosilate (IPD^® capsules, 100mg), a Th2 cytokine inhibitor, in patients with allergies to Japanese cedar and cypress pollen, we studied 93 patients with this type of allergy. Symptom, medication, and symptom medication scores were lower in patients who received early intervention with suplatast tosilate than in those who received suplatast during the pollen season. The results of a survey performed with the Japanese Allergic Rhinitis Standard Quality of Life Questionnaire also indicated that the early intervention group had good outcomes. Early intervention with suplatast was thus an effective treatment for patients with allergies to cedar and Japanese cypress pollen.
We also surveyed the expectations of patients regarding drug treatment. We found that patients want to have drugs that exhibit a prolonged duration of action and are very effective without causing drowsiness.

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