Recent investigations on the pathophysiology of otitis media with effusion (OME) were summarized from several points of view.
(1) Experimental study of OME: The long-standing mucoid type of OME was induced for the first time by the impairment of eustachian tube active function and the administration of immunosuppressant drugs.
(2) Bacterial adherence to nasopharynx: In vitro experiments on adherence of nontypable Haemophilus influenzae and Streptcoccus pneumoniae to nasopharyngeal epithelial cells clarified the significance of bacterial adherence to the nasopharynx in the pathogenesis of OME in children: a secretory immunoglobulin (IgA) in nasopharyngeal secretions is related to a decrease of bacterial adherence.
(3) Lipid A in the middle ear: The instillation of lipid A component of endotoxin into the middle ear cavity can induce inflammatory changes with middle ear effusion. The lipid A interacts with glycoconjugates on the epithelial surface and with secretion from goblet cells. Excess secretion from the goblet cells to exclude endotoxin from the middle ear cavity seems to play an important role in the pathogenesis of OME.
(4) Pressure regulation in the middle ear: Middle ear pressure is thought to be regulated not only by active opening of the Eustachian tube but also by transmucosal gas exchange in the middle ear cavity. In addition to poor dynamic tubal function, impaired transmucosal pressure regulation due to mucosal inflammation is thought to be related to the pathoetiology of OME.
(5) Size of the mastoid pneumatization: The suppression of mastoid pneumatization is closely related to a persistent state of middle ear inflammation. Patients with OME can be treated by conservative therapy or by tube insertion based on the degree of mastoid pneumatization seen on x-ray films. Patients with a well-pneumatized mastoid air system can be managed with conservative treatment alone.

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A 35-year-old woman complained of left facial palsy and a sensation of fullness of the left ear of 3 days duration. Physical examination revealed left abducens nerve palsy and gaze nystagmus. CT scans and MRI showed a well-enhanced tumor in the 4th ventricle. She was treated neurosurgically and both facial palsy and hearing loss were improved. Althouth it is rare for peripheral facial palsy to be caused by a lesion of the brain stem, it is necessary to perform both audiological vestibular examinations to determine the location of the lesion.

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A 45-year-old woman with hypertension developed tinnitus and a feeling of obstruction in her right ear after taking a new antihypertension drug. The next morning she complained of vertigo and hearing loss in her right ear. After ten days, the vertigo disappeared but Jumbling phenomenon was occurred. The patient could not walk without holding on to a handrail. Otoneurologic testing revealed unilateral hearing loss and bilateral vestibular disorder. We explained the importance of rehabilitation to the patient and gave instructions for exercising. After a few weeks she could walk alone.
Although her equilibrium disorder was reduced, in otoneurologic test showed little improvement. Plasticity of the central nervous system seemed to have compensated for her disorder.
A few cases of bilateral sudden hearing loss and bilateral vestibular neuronitis have been reported. They were thought to have been caused by virus infection, vascular disorder of the inner ear, syphilis, diabetes, cancer metastasis to the temporal bone, etc.
We felt that the etiology in our patient was a vascular disorder of the inner ear due to an excessive reduction in blood pressure. This case emphasizes the importance of rehabilitation in nonacute vestibular disorders.

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The function of the autonomic nervous system in patients with vertigo was examined, and several parameters of the RR interval were analyzed quantitatively in the supine and upright positions. Fifty-five patients with vertigo associated with autonomic nerve dysfunction were examined, and were analyzed by computer. Patients with normal autonomic function (Group 1: n=26) and those with autonomic dysfunction (Group 2: n=25) were compared statistically. Group 2 contained four subgroups: Group 2a: 15 patients with sympathetic hyperfunction; Group 2b: 9 patients with sympathetic hypofunction; Group 2c: 2 patients with parasympathetic hyperfunction; and Group 2d: 6 patients with parasympathetic hypofunction). Six patients had double dysfunctions.
The parameters examined were:
1. Heart Rate (HR).
2. Coefficient of variation of RR interval (RRcv).
3. Relation between RRcv and age.
4. Power spectrum of RR interval.
HR and RRcv were recorded in the supine and upright positions. RR intervals of 20 seconds were computed with FFT, and 2 major components (low frequency; 0.1Hz (P₁): high frequency; 0.3Hz (P₂)) of the power spectrum were analyzed. HR of Group 2a was significantly higher than that of Group 1 in both the supine and upright positions. RRcv of Group 2b was lower than that of Group 1. RRcv of Group 2c was reduced in the upright position. RRcv of Group 2d was lower than that of Group 1 and tended to rise in the upright position. RRcv of Group 1 in the upright position was related to age (r=-0.62), but that of Group 2 showed no significant relation. The power spectrum of Group 1 showed a dominant P₂ in the supine position and a dominant P₁ in the upright position, but the power spectrum of Group 2a revealed a dominant P₁ in both the supine and upright positions and that of Group 2b showed no marked P₁ and P₂ components.

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The fistula to the first branchial cleft was situated over the facial nerve in one patient, under the facial nerve in the second patient, and between the buccal branch and other branches of the facial nerve in the third. The clinical variations reported previously were also observed in these patients, and incomplete resection was considered to give rise to recurrence of infection. Although the incidence of first branchial cleft anomaly is lower than that anomaly of the second or third branchial clefts, knowledge of the anatomical relationship between the fistula and the facial nerve is important in the planning of surgical treatment.

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A 73-year-old man was treated surgically for a 20×18mm granulomatous hemorrhagic squamous cell carcinoma on the posterior aspect of the middle third of the helix. Tumor excision with a 7-8mm margin including subjacent cartilage left a rectangular skin defect on the anterior surface and a wedge shaped skin defect on the posterior. The width of the helical defect was 3.5mm.
A chondrocutaneous advancement flap, as described by Antia, was modified conform to the arterial supply to the ear. The auricular segmental defect was repaired successfully with a wider chondrocutaneous helical flap than that described by Antia. The reconstructed ear was reduced by 9mm longitudinally and 2mm transversely, with the lobulus 6mm shorter than its original size.
No signs of recurrence were visible seven month after surgery.

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In this objective evaluation of the efficacy of prophylactic treatment for Japanese cedar pollinosis during natural allergen exposure, topical ketotifen (0.3-0.4mg/day) was administered during the spring of 1992. Ten patients received prophylactic treatment, and others were treated after the onset of symptoms. Subjective symptom scores, blood eosinophil counts and serum MBP values were examined and compared.
The total subjective symptom scores, blood eosinophil counts and serum MBP values in the prophylactic treatment group were significantly lower than in the group treated after the onset of symptoms. Thus, the effect of prophylactic treatment can be evaluated objectively.

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The saccharine test was used to measure nasal mucociliary clearance in 71 patients with nasal allergy (56 without and 15 with chronic sinusitis), 12 patients with asthma (7 without and 5 with chronic sinusitis) and 7 patients with aspirin-induced asthma. The results were compared with those of a control group of 15 healthy subjects. The saccharine time (ST) in patients with nasal allergy without chronic sinusitis (16.9±9.9min) and in those with asthma without chronic sinusitis (20.1±9.4min) did not differ not significantly from that in the healthy subjects (16.3±5.3mm). But the ST in patients with nasal allergy and chronic sinusitis (37.6±22.9min) and in those with asthma and chronic sinusitis (57.0±6.7min) was significantry longr than in the controls (p<0.01). The ST in aspirin induced asthma (13.0±5.4min) was not higher than the ST in the control group. These results suggest that allergic reactions in patients with allergic diseases do not affect nasal mucociliary clearance and that the nature of the mucus and the relationship between ciliary movement and the mucus layer are important in nasal mucociliary clearance.

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A 58-year-old male with a sensation of nasal obstruction and a mass on the right side of his neck was examined. The initial biopsy report was undifferentiated carcinoma of olfactory neuroblastoma. Right lateral rhinotomy and radical neck dissection were performed. Immunohistochemical studies showed positive staining for vimentin, cytokeratin, neurofilament, chromogranin, neuronspecific enolase (NSE), and S-100 protein. In addition, epithelial membrane antigen (EMA) was present in most of the tumor cells. The diagnosis was therefore neuroendocrine carcinoma of the nasal cavity. It is possible that the cases of olfactory neuroblastoma reported previously included some neuroendocrine carcinomas of the nasal cavity. The usefulness of immunohistochemical studies is discussed.

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A 20 year-old male was admitted because of disturbed consciousness. X-ray and CT examinations showed cloudiness in the maxillary sinus, anterior ethmoid sinus, frontal sinus and subdural space. We diagnosed rhinogenic subdural abscess. Caldwell-Luc and Killan's operations and 3 times drainage of the subdural space were carried out, in addition to antibiotic therapy. He recovered completely and was discharged 89 days after admission.
We surveyed 51 cases reported during the past 11 years and rhinogenic intracranial complications seems not to be declining.
MRI, in addition to CT, is considered to be very useful in the diagnosis of subdural abscess.

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We treated a patient with ethmoid sinus malignant melanoma by both intracranial and facial surgery.
Case: A 49-year-old woman complained of right nasal obstruction and nasal bleeding for three months. A light pink tumor was seen in the right nasal meatus. Hematoxylineosin stained intranasal biopsy specimens of the mass suggested malignant melanoma, and Fontana-Masson and S-100 protein stains confirmed the diagnosis. Surgery was performed first both cranial and facial, to resect the tumor along with the contents of the right orbit, the anterior skull base and the right hard palate. The defect was reconstructed with a free abdominal flap only. Postoperatively she was treated with chemotherapy (DTIC, ACNU and Vincristin) and immunotherapy (IFN).
This patient has been followed for 2 years and shows no evidence of recurrence of the disease.

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Benign lymphoepithelioma is a comparatively rare disease which shows sialaden tissue findings which are pathohistologically similar to those seen in Sjögren's syndrome. We recently treated 27-year-old female with a benign lymphoepithelioma in the parotid gland. She had no signs or symptoms other than a tumor in the right parotid gland. There was no xerostomia. A definite diagnosis was reached from the pathohistological appearance of resected tissue. Since benign lymphoepithelial lesions may become malignant lymphomas, this patient must be followed carefully.

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Three cases of ectopic thyroid at the base of tongue are reported. The patients (17, 29 and 32-year-old females) had complained of abnormal sensation of the throat and sore throat. Tumors were found at the base of the tongue. They were hemispheric, smooth surfaced and approximately 2×2cm in size. Ectopic thyroid was diagnosed by Tc scintigram and CTscan. Tc scintigram showed accumulation not in the anterior neck but at the base of the tongue. CTscans revealed the absence of thyroid gland tissue in the anterior neck. Thyroid function tests were within the normal range in two patients. One patient had low levels of T₃ and T₄ but no clinical symptoms or signs. All three patients are being followed without surgical treatment.

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Two patients with obstructive sleep apnea syndrome (OSAS) were treated with nasal bilevel positive airway pressure (nasal BiPAP), and their upper airway cavities were observed with nasendoscopy during the treatment.
BiPAP, widening of the upper airway cavity quickly achieved, which, in turn, decreased apnea and intraesophageal negative pressure and improved the sleep pattern.
In a comparison with nasal continuous positive airway pressure (nasal CPAP), BiPAP proved to be superior, because the patients felt more comfortable as positive airway pressure was decreased during expiration.

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Adenoid and tonsillar hypertrophy is the most important cause of obstructive sleep apnea syndrome (OSAS) in children. A majority of these patients are successfully treated with adenotonsillectomy. However, it is difficult to treat those who have no adenotonsillar hypertrophy.
We studied 5 children with severe OSAS who showed no signs of adenotonsillar hypertrophy. All of them had other congenital malformations and associated systemic disorders. They were tested with inductive plethysmography and pulse oximetry. Apnea had been present since birth and had become worse recently. In relation to upper airway obstruction, micrognathia was noted in 4 patients, anterior dislocation of the atlas in 2 and cerebral palsy in 2. In children with cerebral palsy general muscular hypotonia plays a significant role in their obstruction.
Cephalometric analysis showed no signs of adenotonsillar hypertrophy. Poor prognathism of the maxilla and mandible and low positioned hyoid bones were thought to contribute to upper airway obstruction.
We performed tracheostomy in 2 patients. Uvulopalatopharyngoplasty (UPPP) was effective in the 1 patient. A nasopharyngeal tube was useful for treatment and for locating the site of the obstruction. If no adenotonsillar hypertrophy was apparent, UPPP with or without adenotonsillectomy improved OSAS in selected children. Because UPPP can enlarge the diameter of the nasopharyngeal airspace.

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Innervation patterns of primary vestibular neurons in the guinea pigs utricle were examined with the HRP method. Nerve fibers which do not bifurcate connect with type I hair cells in the striola. Nerve fibers which bifurcate connect with type I and type II hair cells throughout the utricular maculae.
Single neuron physiology was investigated in the superior vestibular ganglions. Irregularly firing neurons with higher coefficience of variation (CV) had higher gain to tilt. Among the lateral tilt reactive neurons, ipsilateral tilt neurons were greater in number than contralateral neurons, but this tendency was seen only in regularly firing neurons and not in irregularly firing ones.
Single cellular HRP studies of neurons identified electrophysiologically as of otolith origin showed that primary utricular neurons which do not bifurcate and connect with type I hair cell are irregularly firing neurons with a higher gain for tilt.

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The etiologies of sudden deafness are often unclear. Ischemia of the inner ear is considered to be a cause of sudden deafness. In the present study the efficacy of defibrinogenation therapy using Batroxobin was examined in 4 patients with sudden deafness who had not responded to steroid therapy. Some level of hearing improvement after Batroxobin administration was seen in 2 of the 4 patients, and slight improvement of tinnitus and dizziness was seen in 1 patient. Adverse reactions, for example bleeding tendency, were not seen. The results of the present study indicate that defibrinogenation therapy has the potential of becoming an effective tool in the treatment of sudden deafness.

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We used Sairei-to in an attempt to alleviate vertigo in 14 patients with Meniere's disease. Sairei-to was administered orally in a dose of 9 grams per day, divided into 3 portions. Subjective symptoms (duration and severity of vertigo) and objective findings (standing test, nystagmus, caloric test, audiometry and the frequency of vertigo) were examined before and 6 months after the start of treatment. The glycerol test, electrocochleography and furosemid-VOR test were used to determine the degree of endlymphatic hydrops.
Of the 13 patients treated for 6 months, five were rated as markedly improved, four as moderately improved, three as unchanged and one as worse. One patient complained of diarrhea as a side effect. Sairei-to was effective in seven of the ten patients, who had positive tests for endolymphatic hydrops.
Sairei-to has diuretic, anti-allergic, sedatve and anti-coagulative effects. It appears to be effective in the treatment of vertigo in some patients with Meniere's disease.

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In a series of 191 patients with chronic paranasal sinusitis 54.4% had foreign-body sensation in the throat (FBST). Roxithromycin (RXM) was administered for about 2 months. The post-arytenoid area was examined for pus and the patients were divided into the following three groups: 1) pus present but disappeared with treatment (35 patients); 2) pus present both before and after treatment (9 patients); 3) no pus either before or after treatment (60 patients). Group 1 had much higher rates of recovery from nasal symptoms and efficacy rates than did group 2. The FBST scores of group 1 patients improved with treatment (4.02→3.04), but there was virtually no change in group 2 (3.53→3.64).
These results indicate that FBST can be induced by postnasal discharge in patients with chronic paranasal sinusitis and can usually be reduced by treatment with appropriate antibiotics.

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