Aminoglycoside antibiotics (AGs) are used in the treatment of serious infections with gram-negative bacilli or with staphylococci. Their major limitations are their nephro-and ototoxic side effects.
The daily dose has generally been administered to patients in two or three divided doses or continuous infusions. Such regimens were originally devised to avoid excessively high peak serum concentrations that were feared to be toxic.
The relationship between pharmacodynamic characteristics of serum concentrations and the ototoxicity of AGs is complex and multifactorial, but in recent years, the risk of ototoxicity has been considered to be related not to peak but to trough serum concentrations. Therefore, the risk of ototoxicity would be minimized with lower trough serum concentrations. Less frequent administrations produce lower trough serum concentrations.
On the other hand, it has been clarified that the rate of bactericidal activity of AGs is concentration-dependent, i.e. higher concentrations result in a faster and greater reduction in the number of bacteria. Moreover, AGs induce prolonged postantibiotic effects against gram-positive and gram-negative bacilli.
On the basis of this information, it seems that less frequent doses of AGs may be feasible and even advantageous, and a once-daily dosage regimen has been evaluated experimentally and clinically.
We believe that once-daily dosing with high peak serum concentrations is less toxic than divided intermittent doses or continuous infusions. The toxicity and efficacy of a once-daily dosage regimen should be evaluated by further experimental studies and clinical trials.

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A 52-year-old housewife with a chief complaint of vertigo and right tinnitus, suddenly fell into a coma 12 days after admission and died in 24 hours. Autopsy revealed massive hemorrhagic necrosis of both adrenal cortices, disseminated intravascular coagulation in various organs, and otic meningitis.
These findings suggested the possibility that otic meningitis caused WaterhouseFriderichsen syndrome.
The purpose of this case report is to describe Waterhouse-Friderichsen syndrome due to otic meningitis and to call attention to the early signs of impending neurotologic complications.

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Drug therapy to suppress tinnitus is the easiest method for busy clinicians. However, there are many kinds of drugs and how to use of them is not clear. We tried to establish guidelines for choosing drugs based on the loudness of the tinnitus.
We prescribed alprazolam or bromazepam for tinnitus patients. Their efficacy is about 50-60% when used without regard to the loudness of tinnitus. However, when alprazolam was used for tinnitus of 0-5 dB SL and bromazepam for tinnitus of more than 6 dB SL, their efficacy was about 70-80%.
The anticonvulsant action of bromazepam is about twice that of alprazolam. We considered that very loud tinnitus is associated with higher seizure activity than less loud tinnitus, so it responds better to stronger anticonvulsant drugs.
Patients requesting treatment for not very loud tinnitus are generally nervous and have high MAS scores. Alprazolam is a stronger tranquilizer than bromazepam, and such patients respond well to alprazolam.
This medicinal treatment of tinnitus based on loudness showed good results.

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Cochlear implantation with the multipeak method was performed in 6 patients with total or high level sensorineural hearing loss. It had been hoped that this multipeak method would improve especially consonant recognition ability, because consonant recognition by cochlear implant patients is poor. Vowel and consonant confusion tests were performed, however the results were not better than with the previous method. The patients were partially satisfied with the new system, bacause the newly deviced speech processor is lighter than the pervious one.

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Cholesterol granuloma of the middle ear is frequently observed in patients with otitis media with effusion but has never been reported in a patients with middle ear malformation. Our patient, a 21-year-old woman, had severe middle ear cholesterol granuloma extending from the mastoid cells to the eardrum and through the epitympanum, mesotympanum, and hypotympanum. Early operation was required to rule out neoplasms, such as glomus tumor; venous anomaly; and cholesteatoma, since the initial symptoms were rapidly deteriorating hearing ability with continuous bloody ear discharge. The malleus head and incus body were located near the aditus ad antrum, and the chorda tympanic nerve, which is usually located between the malleus handle and the long process of the incus, was anomalously located across the middle tympanic cavity. The severe cholesterol granuloma was considered to have arisen from bleeding from a small vein near the chorda tympanic nerve, narrowed aditus ad antrum combined with the anomalous locations of the malleus head and incus body, and disturbed function of the auditory tube with otitis media with effusion. This severe cholesterol granuloma was treated with intact canal wall staged tympanoplasty of type III with mastoid obliteration.

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A 32-year-old male complained of left nasal bleeding and nasal obstruction. A tumor was removed by Denker's procedure. Histological examination revealed fibromatosis. Local recurrence and metastasis have not occurred so far, 7 months postoperatively. Fibromatosis is extremely rare in the nasal cavity. Recent concepts of the clinicopathlogy of fibromatosis are discussed.

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The authors analyzed statistically 287 patients with cleft lip and/or cleft palate, who had visited the ENT clinic of Ehime University Hospital, from 1976 to 1990.
Sixty-five patients (22.6%) had other congenital malformations. Malformations of the limbs were observed most frequently, then malformations of the ear, and third of the heart. Sixteen patients (5.6%) had congenital malformation syndromes, four of them with anomalies of chromosomes. The incidence of normal language development after palate plasty was 92.7% in patients without associated malformations and 58.3% in those with associated malformations.
The authors recommend a team approach, including pediatrician, anesthesiologist and speech therapist in the treatment of cleft palate speech when other congenital malformations are present.

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Acute suppurative sialoadenitis is now rare because of the progress of antibiotics. Four patients with acute suppurative Sialoadenitis visited our clinic. Three had parotitis, and one had submaxillary gland infection.
All four patients were 70-80 years old. One of them had leukemia. Staphylococcus aureus was isolated from three patients.
It is difficult to differentiate between acute suppurative sialoadenitis and salivary gland malignant'. We recognize various images in CT scans of acute suppurative sialoadenitis, from tumor formation to total salivery gland swelling, so differentiation is difficult by CT scan.
We examined one patient with MRI, and we noted a great increase in the signal level of the salivary gland, which indicated inflamation and a low signal level which indicated abscess. MRI is considered to be useful for the differentiation between acute suppurative sialoadenitis and salivary gland malignancy

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In the therapy of nasopharyngeal carcinoma, intracavitary radiation from the nasopharynx by a remote afterloading system (RALS) has been used in combination with ex-ternal beam therapy in several hospitals, but this method is not available for intracranial remnant tumors, because the dose is insufficient.
For such cases, we tried RALS therapy from the sphenoid sinus and obtained good results. Two T4 patients were treated with this method; both had intracranial remnant tumors after 66Gy of external beam radiation. After opening the sphenoid sinus surgically, an application tube was inserted into the sinus from the naris. RALS therapy was done twice or 4 times. In one patient, the remnant tumor vanished, and in the other, the tumor was significantly reduced in size.
This method is effective for intracranial remnant tumors, which do not respond to RALS therapy from the nasopharynx.

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A peroneal flap, developed by Yoshimura et al, has been used mainly for the repair of lower leg injuries. We applied this flap to the reconstruction of the posterior pharyngeal wall of a 49-year-old female with pharyngeal cancer, resected through a transmandibular approach.
A free vascularized peroneal flap has pedicles consisting of peroneal artery and vein and their cutaneous branches. Under a microscope, the facial artery and external cervical vein were anastomosed to the peroneal artery and vein respectively. The peroneal flap has the following advantages : 1) It is thin enough to fit the posterior pharyngeal wall. 2) Primary closure of donor site is possible. 3) The donor site is less conspicuous than that of forearm flap.

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A 63-year-old man complained of dysphagia. He had had tongue cancer treated by resection of the left half of the tongue and surgical repair with a greater pectoral muscle flap . This time, hypopharyngeal carcinoma was diagnosed and chemotherapy was attempted, but it was not successful. After resection of the hypopharynx, larynx and cervical esophagus, reconstitution was carried out with a left anterolateral thigh flap (AL-T flap). On day 14 after surgery, he was able to eat. The benefits of anterolateral thigh flap are reported, and the literature is reviewed.

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We devised a new method of dynamic reconstruction which sutures the cricothyroid muscle with the paralyzed lateral cricoarytenoid muscle.
Since this method achieved remobilization of paralyzed vocal cords in dogs, we applied it to seven patients with unilateral recurrent laryngeal nerve paralysis (four, postsurgical paralysis; three, idiopathic paralysis).
The results were as follows: 1) in all cases, tension of the vocal cord was good and voice quality was improved, 2) in four patients, remobilization of the paralyzed vocal cord was obtained.
We conclude that the clinical application of this method can serve as a new dynamic reconstruction for the treatment of unilateral recurrent laryngeal nerve paralysis.

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We recently treated a 16-year-old male patient with Castleman's lymphoma (hyalinevascular type) of the neck. The tumor was in the upper lateral cervical area, was surgically removed under general anesthesia. The pathohistological diagnosis was hyaline-vascular type of Castleman's lymphoma. In general, the hyaline-vascular type of Castleman's lymphoma has a good prognosis.
The pathogenesis of Castleman's lymphoma is not known, but immunohistological studies suggests that it is a lymph node hamartoma.
Although Castleman's lymphoma occurs most frequently in the mediastinum, it may occur in the head and neck region. In Japan there have been only 61 reports including this case. We must consider entity in the differential diagnosis of head neck masses.

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Acute suppurative thyroiditis is a comparatively rare disease. Case reports have recently increased since we now know that a piriform sinus fistula is one of the causes of this disease. We have treated 7 patients with acute suppurative thyroiditis showing various clinical features. An echogram was useful in the diagnosis in a 2-year-old boy with a neck mass which we thought was a tumor. We could not find a piriform sinus fistula, although we searched carefully for one with fluoroscopy of the hypopharynx. About 1 year later we found the fistula with an esophagogram and removed it. Another patient who had been operated on 3 years earlier had a recurrence. We found the rest of the piriform sinus fistula with an esophagogram, and performed a reoperation. We present here 7 cases including these 2, and show the usefulness of ultrasonagraphy and of the determination of thyroglobulin in the diagnosis of acute suppurative thyroiditis. We stress that examination for a piriform sinus fistula and complete removal of the fistula are very important in patients with acute suppurative thyroiditis.

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Echo-guided aspiration biopsy cytology (EGABC) performed for nodular goiter in the past 3 years was evaluated in 605 cases. A correlation of cytologic findings with histologic findings was possible in 127 patients who underwent surgery. Fifty-two of 62 cancers diagnosed histologically were cytologically positive (83.9%), 4 were suspicious (6.5%) and 6 were negative (9.7%). EGABC of the thyroid is an excellent method for eliminating unnecessary operations in patients with thyroid nodules.

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The etiology, prognosis and clinical management of minute thyroid carcinoma has been receiving considerable attention. Between 1981 and 1989, 258 thyroid tumors were ex-amined in our clinic. The clinical features of minute thyroid carcinoma were investigated. This article describes 13 minute thyroid carcinomas.
1) A minute carcinoma was detected in 13 of the 258 (5.0%) thyroid tumors.
2) Three of the 13 patients had clinical signs of carcinoma, 4 had occult carcinoma and 6 had latent carcinoma.
3) All carcinomas were of the papillary type.
4) Soft tissue roentgenography was useful in the diagnosis of symptomatic carcinoma.
5) In occult carcinoma, ipsilateral and/or bilateral neck dissection should be done.

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It has become evident that an active process in the cochlea is necessary for fine tuning and high sensitivity in mammals. Recently, motile responses of the outer hair cells have been demonstrated which are believed to be responsible for the active process. The role of the efferent olivocochlear system is controversial, but it might influence hearing by modulating the active process. In this paper, the anatomical and physiological features of hearing are reviewed. The mechanism of the active process is also discussed.

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A charge barrier has been found in the glomerular basement membrane of the kidney which plays an important role in the filtration of solutes.
In the present study, we observed electronmicroscopically the anionic sites of the charge barrier in the inner ear of healthy guinea pigs.
Tissues were removed after decapitation and immersed in a solution of cationized polyethyleneimine (PEI, MW 1800).
The results showed an arrangement of PEI particles with two strata in the basement membrane of the epithelium and the capillary.
These sites function as a charge barrier, and their locations in the stria vascularis and the endolymphatic sac may play important roles in the filtration system of water, ions and macromolecules.

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A satisfactory prognostic test for peripheral facial paralysis has not yet been established. Using an impedance meter (NEG Sanei, Type 4134), we attempted to quantify the movement of the upper lip to judge the prognosis more accurately (impedance method: IM).
The deviation of the upper lip correlates well with the amount of change in impedance (ΔZ) when supramaximal stimulation is applied to the facial nerve. We expressed the ratio of ΔZ on the affected side to that on the healthy side as ΔZ% and used this ratio as an indicator to judge the prognosis.
The subjects were 61 patients with Bell's palsy or Hunt's syndrome. All patients received conservative treatment.
Patients with an ENoG value less than 18.7% were defined as the poor prognosis group. Seventeen patients were judged to belong to this poor prognosis group, and 8 of them had a complete recovery after treatment. The accuracy of selecting poor prognosis patients by means of ENoG was 56%.
Then the prognostic diagnosis was carried out with a combination of ENoG and TM. The patients with an ENoG value less than 18.7% and those with a ΔZ% less than 43.2% were defined as the poor prognosis group. This time, 11 patients were judged to belong to the poor prognosis group, and only 2 patients had a complete recovery. The accuracy of selecting the poor prognosis patients with a combination of ENoG and IM was 82%.
In conclusion, with a combination of ENoG and IM the prognosis of facial palsy can be predicted more accurately than with ENoG alone.

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The nuclear DNA content of head and neck tumors (57 malignant, 20 benign) was determined by flow cytometory (FC M).
We used fresh specimens and analyzed the ploidy pattern, S phase fraction and G2M phase fraction. Twenty-six of the 57 (45.6%) malignant tumors were aneuploid and all the benign tumors were diploid. Recurrent tumors tended to be aneuploid.
DNA indices of the recurrent tumors were higher than those of the fresh tumors (p<0.01).
The S phase fraction of diploid malignant tumors were larger than that of benign tumors (p<0.001).
There was no difference in the G2M phase fraction between malignant and benign tumors.

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To study the prophylactive effect of Triludan® (Terfenadine) on Japanese cedar pollinosis, we administered Triludan® to patients before or after the start of the dispersion of pollen in the air in the Gifu and Takayama regions. The nasal symptoms of the two groups were compared.
Triludan® treatment started before dispersion significantly inhibited nasal discharge during the peak time and significantly prolonged the time taken to reach the peak for nasal discharge and sneezing.
The prophylactive effectiveness was fair or good in 53.2% of those treated. In a questionaire survey, 42.8% of the patients replied that they noted some prophylactive effect.
Nasal symptoms were milder in those treated before than in those treated after the start of pollen dispersion both in the Gifu region where the pollen count is high and in the Takayama region where it is low.

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Seventy-nine children with sinusitis, seen at our hospital between December 1990 and July 1991, were treated with cefixime (CFIX) in a daily dose of 10 mg/kg (given in two divided doses). The clinical effect inveness of this therapy was assessed.
1. The following 95 bacterial strains were detected; 36 strains (37.9%) of S. pneumoniae, 23 strains (24.2%) of Haemophilus (including H. influenzae), 17 strains (17.9%) of Neisseria, and 8 strains (8.4%) of M. (B.) catarrhalis.
2. The overall clinical effectiveness recorded charge was 82.3%, while that determined by objective evidence of improvement
3. The corresponding figures were 91.2% and 97.1% for patients with those with acute sinusitis 65.2% and 78.3% for those with chronic sinusitis, and 86.4% and 86.4% for acute exacerbations of chronic sinusitis.
4. Effectiveness according to the causative bacteria was 77.8% for S. pneumoniae. 87.5% for Haemophilus, and 100% for M. (B.) catarrhalis. CFIX was also very effective against several other bacterial infections (95.8%).
5. The only adverse reaction was soft stool in one of the 79 patients.
It was concluded that a daily dose of 10 mg/kg of CFIX is safe and very effective.

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