There are many essential functions, such as respiration, ingestion, phonation, etc as well as cosmetically important features in the head and neck region. Good results, not only in the functional sense but also in the cosmetic sense are demanded of reconstructive surgery of this region after cancer ablation. Transplantation of the right amount of proper tissue to the right place is mandatory for good reconstructive results.
With the developement of microvascular surgery, it has become possible to transplant the necessary amount of tissue to the right site in the human body. The introduction of microvascular techniques to head and neck reconstruction has brought about great progress in this field.
The authors recommend 5 free flaps for reconstructive surgery of the head and neck. Each of these flaps has special characteristics and all of them have a large vascular pedicle which guarantees safe anastomosis.
The flaps are listed below.
1) Radial forearm flap is a thin and flexible skin flap which has a long vascular pedicle and is used mainly for the repair of the inside of the mouth.
2) Rectus abdominis musculocutaneous flap consists of a large amount of muscle, fat and skin. It is suitable for the repair of large defects such as those resulting from total glossectomy or maxillectomy.
3) Scapular osteocutaneous flap has both a skin portion and a skeletal portion with a single pair of vascular pedicles. It is good for the simultaneous repair of skeletal and soft tissue defects such as those resulting from mandibulectomy or maxillectomy. The position of the patient must be changed from supine to lateral or prone during the flap harvesting, which is rather time consuming.
4) Iliac crest bone flap can be harvested at the same time as the head and neck surgery. A skin flap can be included, but the blood supply to the skin is not so reliable.
5) Jejunum flap is a free flap of tubed organ and is suitable for repair of the hypopharynx and/or esophagus. The vascular pedicle containing mesenteric vessels is large enough in caliber but rather short.
Five illustrative cases of head and neck reconstruction are presented for a better understanding of how the flaps are applied in clinical cases.

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This study was designed to evaluate the effectiveness of the suppression of severe tinnitus by the alternating polarity electrical promontory stimulation (EPS) method. The three types of stimulation used in this study were electrical burst (duration 0.5 sec., 1 Hz) of 1) biphasic pulsed AC, 2) pulsed anodal DC and 3) pulsed cathodal DC. In 27 subjects (42 ears), tinnitus was suppressed after EPS in 25 ears (60%), and the effect lasted for more than two days in 12 ears (29%). When anodal DC was applied, some patients complained of severe earache during EPS, but tinnitus suppression after EPS was more frequent and longlasting. We conclude that in spite of rather severe earache occasionally, pulsed anodal DC EPS is more effective than biphasic pulsed AC or pulsed cathodal DC EPS in cases of severe tinnitus.

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In 38 patients with Meniere's disease (29 unilateral and 9 bilateral) treated with surgical drainage of the endolymphatic sac (ELS) between 1986-1991, the surgical findings and temporal bone CT findings were correlated. At surgery the position and size of the ELS were recorded. The position of the ELS was classified into 3 types according to Arenberg's parameters (type I, type II and type III) and the size of the ELS was large, intermediate or small. CT scans encompassing the lateral semicircular canal were used to measure the minimum distance between the posterior semicircular canal and the posterior petrous surface (P-P distance). The P-P distance in 23 type III position ELSs was significantly shorter (2.25 mm) than that in 15 type I or type II position ELSs (3.29 mm). The P-P distance of the 9 large ELS was significantly longer (3.99 mm) than that of the 20 intermediate size ELSs (2.40 mm) and of the 9 small ELSs (1.92 mm). Significant correlations were found in Meniere's patients between the short P-P distance and the type III position, and between the short P-P distance and intermediate or small size ELSs.

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A clinical survey on 143 patients with Meniere's disease who visited our clinic after October 1983 has been retrospectively carried out. The patients surveyed comprised 94 confirmed and 49 suspected cases according to the evaluation criteria of the Japan Committee of Meniere's Disease Study Group.
Of these 143 patients, 61 were males and 81 were females (M: F ratio=1:1.3) and the age distribution of this survery showed a shift toward an older population than that of other previously reported series in Japan. It was our impression that the percentage of patients over 60 years old might have been increasing.
Involvement of the disease was unilateral in 88.1% and bilateral in 11.9%. Pure tone audiograms of the patients varied relatively widely, but the audiometric patterns mainly observed were flat (30.8%), upslope (30.1%) and descending (22.4%). Pure vertiginous episodes were more common that merely dizzy or unsteady conditions. Tinnitus, hearing loss and sensation of fullness in the ear, which the patients subjectively complained of were noted in 87.4%, 83.2% and 72.7%, respectively.
A further follow-up study is necessary since the symptomatology and prognosis are highly variable in every individual during the course of the disease and the appropriate management procedures also differ.

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The pathogenicity of coagulase-negative Staphylococci (CNS) in aural infectious diseases is controversial. To determine the contribution of CNS to the development of aural infectious diseases, bacteriological studies of otorrhea obtained from patients with otitis externa, acute otitis media, chronic otitis media and tympanostomy tube complications were performed. Six species and 49 CNS including 22 S. simulans, 14 S. epidermidis, 9 S. capitis, 2 S. auricularis, one S. hominis and one S. sciuri were isolated from the 48 otorrheas, and 21 of them were isolated without any other bacteria. Some CNS were resistant to a variety of antimicrobial drugs and had β-lactamase. This study indicates that some CNS may induce inflammatory processes directly by a parasite-host relationship, and/or indirectly by inactivating antimicrobial drugs.

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A 54-year-old man presented with a two-week history of hearing disturbance on the left. He reported that a molten iron fragment flew into his left ear while welding iron as a job. At that time he felt pain and vertigo. Furthermore, he noticed loss of taste on the affected side. A large tympanic membrane perforation was found. A computed tomogram of the temporal bone demonstrated a metal density foreign body in the middle ear. The foreign body was removed and tympanic membrane perforation was closed with the myringoplasty procedure. However, profound sensorineural hearing disturbance remained.

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Myringotomy is commonly performed in the treatment of otitis media with effusion (OME). However, it has been reported that the effect of myringotomy is limited and that OME recurs frequently after this procedure.
In this investigation, the recurrence rate of OME 6 months after myringotomy and factors which affect the recurrence were examined in 94 patients with OME, aged 6 to 83 years. Forty-six patients had paranasal sinusitis, and 9 had allergic rhinitis. Nasal mucociliary function was examined with the saccharin test, described in a previous report.
The recurrence rate of OME was 68.1%, similar to that in previous reports. Patients with mucoid effusions had more frequent recurrences than did those with serous effusions (p<0.01). The recurrence rate was significantly higher in children than in adults (p<0.05). Patients with OME for more than 3 months (p<0.001) or bilateral OME (p<0.001) had higher recurrence rates than did those with OME for less than 3 months or those with unilateral OME. OME recurred more frequently in patients with paranasal sinusitis (p<0.001) or allergic rhinitis (p<0.05) than in those without these nasal diseases. The incidence of markedly prolonged saccharin time (over 30 minutes) was significantly higher (p<0.001) in the recurrent group than in the cured group.

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Four years after a facial injury, a 63-year-old woman complained of frontal sinus pain and recurrent cutaneous fistula. Repeated headaches and swelling of the right frontal region had started 2.5 years after the injury. The cutaneous fistula was resected but recurred. CT examination revealed a fracture of the anterior wall of the right frontal sinus. Surgical exploration showed that inflammatory granulation and rotten bone fragments obstructed the nasofrontal duct. The duct was opened widely and the fistula closed postoperatively.

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A true malignant mixed tumor (TMMT), a neoplasm in which both epithelial and non-epithelial components of pleomorphic adenoma show malignancy, is very rare. We treated an extraordinarily rare case of TMMT of maxillary sinus origin.
A 65-year-old woman visited our clinic having a one-month history of left cheek pain. The CT scan suggested a benign or low-grade-malignant tumor of the left maxillary sinus. Probe maxillotomy was performed, and its macroscopic findings were a soft, whitish tumor. The histological diagnosis was “malignant mixed tumor”, the epithelial component of which was adenocarcinoma, and the non-epithelial component of which was fibrosarcoma. There was no cervical or distant metastasis.
Combination therapy for maxillary squamous cell carcinoma, consisting of irradiation, chemotherapy and necrotomy, was performed. After 60 Gy of irradiation, since no malignant cells were found in the abraded tissue from the sinus, the patient was discharged.
The patient has shown no evidence of recurrence as of 3 months after the irradiation therapy.

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Combined cranial and facial procedures for resection of malignancies of the paranasal sinuses and nasal cavity have been increasing in recent years.
For patients undergoing combined craniofacial procedures for these tumors are reported. In three of these cases, the defect caused by a resection of the skull base was reconstructed with a free rectus abdominis flap.
The patients in this series showed no major complications and all have remained free of disease during the short follow-up period.

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A 51-year-old female with pleomorphic ademoma occupying the parapharyngeal space and deep lobe of the parotid gland is reported. A skin incision was made from the infraaural to the submandibular region. Thorough removal of the tumor was accomplished through this skin incision after cutting of the stylomandibular ligament. Intraaural incision was not necessary. This approach is recommended for the removal of dumb-bell type tumors of the parotid gland.

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A case of metastatic sebaceous carcinoma of the parotid gland, in a 47-year-old man, is reported. The primary lesion on the left lower eyelid was removed surgically about 5 months before his first visit to our university hospital. The first medical examination revealed a small nodule (24 x 14 mm, hard touch, smooth surface, well defined, and mobile tumor) on the preauricular lesion, and a definite diagnosis of the tumor could not be made clinically. He was carefully followed up for a while, and then did not visit us for 13 months. During that period the parotid mass gradually grew to 57×43 mm in size accompanying facial paralysis. He was admitted and underwent left radical neck dissection with parotidectomy. The parotid gland was almost completely occupied by the tumorous mass, and the facial nerve trunk was also invaded. Histopathologically, metastatic sebaceous carcinoma was found in the parotid tumor, submandibular lymphnode, and profound cervical lymphnodes. After the surgery he received prophylactic radiation therapy of 50 Gy. Pathologic features of the parotid metastatic tumor consisted of lobulated masses of sebaceous carcinoma cells which had foamy cytoplasm and atypical nuclei. No recurrent tumor has been seen during the 19 months after the surgery.

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A rare case of mucus-producing adenopapillary carcinoma of the parotid gland in a 12-year-old man has been reported. The clinical and pathological characteristics of mucus producing adenopapillary carcinoma of the parotid gland and its management have been discussed.

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From 1984 to 1991, four patients (1 male and 3 females, average age: 42.5 years) with pleomorphic adenoma of the submandibular gland were treated surgically in this department. In a previous report I described the distinctive features of the capsule in pleomorphic adenoma of the parotid gland. In this report I describe those of the submandibular gland capsule and compare the capsular features of pleomorphic adenoma in the two glands. In some areas of the submandibular glands in all four patients there were tumor projections. The capsule over these areas was a little thin and contained small infiltrations of tumor cells but showed no defect, daughter tumor or unevenness. On the other hand, in other parts of the capsules which were adjacent to submandibular gland tumores, there were uneven areas, daughter tumors, defects and infiltration of the capsule by tumor cells. These findings were similar to those of pleomorphic adenoma of the parotid gland. They suggest that the capsule of pleomorphic adenoma of the submandibular gland is formed by the same process as that of parotid gland pleomorphic adenoma. During surgery one must extirpate the tumor along with the entire submandibular gland and the adjacent connective tissue.

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A 44-year-old man visited our clinic with discomfort of the pharynx. Flexible endoscopy revealed a large, smooth, red-brown tumor on the posterior wall of the pharynx. This tumor obstructed the view of the glottis and extended to the level of the epiglottis. A CT scan revealed a well-defined low density mass with an enhanced rim.
We performed surgical resection through a lateral pharyngotomy. The tumor was diagnosed pathologically as cavernous lymphangioma.

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Pharyngeal fricatives and affricatives in cleft palate speech due to velopharyngeal incompetence have been considered to be produced in the pharynx. Fluorovideoscopic and fiberscopic examinations in five patients revealed that so-called pharyngeal fricatives and affricatives, as judged on the basis of auditory impression, were both produced at a constriction formed by backward tilting of the epiglottis and elevation of the arytenoid. The velopharyngeal port remained open during production of these sounds but was almost closed during stop and vowel productions. These faulty articulations are adequately termed laryngeal fricatives and affricatives rather than pharyngeal fricatives and affricatives.

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Fine needle aspiration biopsy (FNA) performed for thyroid tumors at Tenri hospital during the past 6 years was evaluated in 502 nodules all resected by surgery. The cytological diagnosis was classified as positive (class N or V) or suspicious (class III) for malignacy, or negative (class II).
1. Sensitivity and specificity for malignant tumor was 77.7% and 97.4%. Accuracy was 90.9%.
2. 94% of the positive group proved to be malignant and 90% of the negative group proved to be benign by histopathological examination after surgery.
3. FNA should be repeated when the cytological diagnosis is class III.
4. The false negative group consisted mainly of calcified tumor and cystic tumor.
5. The false positive group consisted of atypical adenoma and the adenomatous goiter with papillary change.

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Combined rupture of Reissner's membrane and round window membrane (doublemembrane rupture) as a cause of acute profound hearing loss was investigated in guinea pigs. Action potentials (APs) of the cochlea nerve in response to tone pip stimuli (1, 2, 4, 8 kHz) were recorded before and after rupture of Reissner's membrane at the second or third turn of the cochlea. Then the round window was perforated to create leakage of the perilymph. Ninety minutes later, AP was again recorded. After these procedures, the animal was sacrificed for histological examination to confirm the rupture of Reissner's membrane. The ear with rupture at the second turn showed a severe decrement in AP amplitude at all test frequencies. However, in the ear with rupture at the third turn, the increment of AP thresholds ranged between 0 and 15 dB.

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Dysfunction of the eustachian tube has been regarded as one of the causes of cholesteatoma. However, we found that the eustachian tube in a number of patients with cholesteatoma functioned normally.
In this study, we examined patients with cholesteatoma to find out whether or not they had any dysfunction of the eustachian tube, and whether there was any relationship between the affected and the contralateral ear. Pathological conditions around the tympanic orifice of the tube were also examined to clarify the effect of the inflammation on the function of the eustachian tube.
Eustachian tube function was tested in 131 ears of patients with cholesteatoma prior to ear surgery.
1. Retraction-type cholesteatoma often showed normal opening pressure, and half of these ears showed normal tubal function.
2. The majority of ears with the perforation type of cholesteatoma showed impaired tubal function and marked inflammation around the tympanic orifice of the tube.
3. Almost all cholesteatoma ears showed poor pneumatization, suggesting impaired tubal function in childhood.
4. Abnormal findings were frequent in the contralateral eardrum in patients with cholesteatoma. Retraction pockets which might be related to cholesteatoma were noted in about 30%. Thus, common pathogenic factors in the two ears were suspected to be important in the development of cholesteatoma.

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Factors influencing the degree of annoyance caused by tinnitus and the clinical effectiveness of ibudilast (Ketase) in the treatment of tinnitus were analyzed in 43 patients complaining of persistent tinnitus.
1) Multiple regression analysis demonstrated that the degree of annoyance caused by tinnitus tended to be worsened by the awareness of hearing loss (p<0.05), persistence of tinnitus (p=0.08) or presence of a middle ear lesion (p=0.12). Discriminant analysis showed that the critical limit of hearing at 2 kHz was 32.6 dBHL for an awareness of hearing loss.
2) At 2 weeks 64.5% and at 4 weeks 61.9% of the 43 patients treated with ibudilast reported some improvement in the degree of annoyance caused by tinnitus. In 19.4% (2 weeks) and in 33.3% (4 weeks), respectively, the improvement was marked.
3) Multiple regression analysis of the subjective improvement of tinnitus 1, 2, 4, 6 and 8 weeks after the beginning of ibudilast medication indicated that advanced age (critical age 65.2 years, p<0.05), high tone loss (p<0.05) and variety of tinnitus (p<0.01) were correlated with subjective improvement. On the other hand, the presence of a middle ear lesion (p<0.05), vestibular symptoms (p<0.05) and bilaterality of tinnitus (p<0.05) were factors which prevented subjective improvement with ibudilast therapy. These results indicate that ibudilast is effective, especially for elderly patients complaining of tinnitus and for those with tinnitus and high tone hearing loss.
4) No severe side effects were noted in this study.

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Tosufloxacin a new pyridone-carboxylic acid derivative, was used to treat 110 patients with otorhinolaryngological infections. They were 43 with otitis media, 38 with sinusitis and 29 with tonsillitis.
The clinical efficacy rate was assessed as excellent in 27 patients, good in 68 patients, fair in 13 patients and poor in 2 patients, the clinical efficacy rate being 85.5%. The bacterial examinations revealed an excellent eradication rate. No adverse events or abnormal laboratory finding were observed.

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