In considering Japanese medical practices in the future, the following issues are important: 1) our aging society, 2) changes in distribution of diseases, 3) advances in medical techonology, 4) rise of medical costs, 5) changing from quantity to quality, 6) oversupply of medical doctors, 7) changes in our thinking about medical care.
In view of these changes in the medical situation in Japan, I have thought about ENT practice will change and how we as otorhinolaryngologists should respond to these changes.
I describe the actual conditions of otorhinolaryngologists, the relationship between primary care and ENT, etc. In addition, I consider the direction in which ENT research, education and professionalism will proceed in the future.

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Two patients with bilateral Meniere's disease and two with inner ear syphilis who had been treated mainly with steroids for several years were studied clinically. In all four patients the level of hearing depended on the dose of steroid: an increase in the dose improved hearing and a decrease worsened it. The two patients with syphilis had relatively high level of circulating immune complexes (CH50 and/or Clq), while in the two with bilateral Meniere's disease, the level of circulating immune complexes was not abnormal.
The use of steroids in the treatment of Meniere's disease and syphilis is discussed.

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In this study of the pathogenesis of refractory otitis media with effusion (OME), we evaluated eustachian tube function, the condition of the upper respiratory tract and sex differences.
One hundred and thirty ears of 98 patients with refractory OME were examined. A study of the passive function of the eustachian tube showed higher than normal tubal opening pressure in 34% of the ears, and lower than normal pressure in 14%, indicating that in approximately one half of the patients with refractory OME, there was an organic abnormality of the tube. In 46% of the patients, paranasal sinusitis was identified. Thus, eustachian tube dysfunction and upper respiratory tract inflammation (URI) appear to be the most important factors in the pathogenesis of refractory OME.
The incidence of URI showed an unequal sex distribution, being present in 60% of the males but only 30% of the females. However, tubal organic disorders showed no significant sex difference.
When we treat refractory OME in adolescents, persistent URI represented by nasal sinusitis should be taken into account more in males than in females. On the other hand, in females eustachian tube dysfunction is considered to be a more important factor than upper respiratory tract inflammation.

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Using a tubal catheter, we examined the test-retest reliability of sonotubometry and of the tubal air insufflation test in normal subjects. The tubal insuffiation test was evaluated by the measurement of tubal opening pressure and sound pressure during air insufflation with a tubal catheter. At the initial examination a tubal catheter was inserted into the pharyngeal tubal orifice under fiberscopic inspection. On another day, the second examination was done in the same way but without fiberscopic inspection.
The mean values of the test results were the same on both days, except that the baseline sounds measured by sonotubometry, were slightly higher on the second day. A comparison of the results of sonotubometry tests showed that a correlative rate between each value on the first day and on the second day in sound amplitude was significantly higher both before (p<0.10) and after air insuffiation (p<0.01), and the correlative rate in sound duration was higher only after air insuffiation (p<0.01). However, no significant correlations were found in the results of air insuffiation test.
We conclude that sonotubometry with a tubal catheter is a more reliable and stable method of evaluating tubal function than the tubal air insufflation test.

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A 40-year-old female presented with tinnitus in the right ear induced by facial movements. Examination revealed that contraction of the stapedial muscle was induced when the patient closed her mouth tightly. She had no history of facial nerve disorder, no abnormality was found on otoscopic examination, pure tone audiometry, tympanography or acoustic stapedial reflex. This phenomenon is usually accompanied by facial spasm or appears during recovery from facial palsy. It is quite rare in persons without any facial nerve disorder. The pathogenesis of the tinnitus in this patient is discussed in light of the available literature.

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Five patients with Ramsay Hunt's syndrome and 14 with Bell's palsy were evaluated with facial scores (full score: 40) and the nerve excitability test (NET) to determine the method of therapy, including decompression surgery. ATP, vitamin B_{1, 6, 12} and hydrocortisone were administrated and vidarabine was added in the treatment of patients with Ramsay Hunt's syndrome. The NET results were assessed by the difference between the affected and healthy sides in the minimum current level needed to stimulate the nerve (ΔNET in mA). Low ΔNET values were demonstrated in 16 patients. Fifteen of them received conservative therapy and recovered completely. Denervation developed in three of the patients with increased ΔNET values, and two of them were operated on and recovered successfully. The final facial scores reached 38-40 in all patients except one drop-out and one very old patient. We conclude that frequent evaluation of the facial nerve is necessary to detect nerve denervation, and that the NET is clinically useful.

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A 69-year-old male, complaining of pain in the left ear, had a history of left temporal bone fracture 34 years ago. The cartilaginous portion of the left external auditory canal was completely blocked by scar tissue. A CT scan revealed a huge soft tissue mass occupying the whole temporal bone space except for the pyramidal portion. At surgery, the cholesteatoma was opened only to the reconstructed external ear canal, care being taken to preserve the facial nerve, because the cholesteatoma matrix was extensively adherent to the dura of the middle and posterior cranial fossa as well as to the facial nerve. In patients with post-traumatic atresia of the external auditory canal, we should pay attention to the presence of secondary cholesteatoma and diagnose it by CT and MRI image before it becomes large.

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For children with nasal cartilage fractures, conservative treatment is preferred to surgical procedures.
Nasal bone fracture is common, and its manipulations have been described in many reports. On the other hand, cartilage fractures of the nose are less common and more difficult to treat. Even without any defect of nasal tissue, deformity of the nostril border or saddle nose deformity may result from cartilage fracture.
We applied nostril retainers (Koken Co.) to fix the nostril borders and dorsum nasi of three patients, two six-year-old girls and one seven-year-old boy. In one patient, deformity was absent after three months, but it then reappeared. Three more months of application proved to be a sufficient fixation period and no deformity or stiff scarring remained. Satisfactory results were obtained after six months of application in all three patients.
We assume that the fractured fragments were fixed appropriately, or that contraction of the surrounding tissue was prevented by the use of nostril retainers. In children, connective tissue is less firmly attached to the adjacent skin as in adults. Although we have had no experience with adult patients, this simple procedure is effective, and its use should be considered in the treatment of children with fracture of the nasal cartilage.

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Anhidrotic ectodermal dysplasia is a rare genetic disorder characterized by absent or diminished numbers of structures derived from the ectoderm. The main clinical characteristics are hypohidrosis, hypodontia and hypotrichosis. Our patient was a 14-year-old boy with atrophic rhinitis, saddle nose, anhidrosis, hypodontia, hypotrichosis, bronchial asthma and allergic rhinitis. The clinical and pathological features are discussed, and the clinical examinations needed for the diagnosis of anhidrotic ectodermal dysplasia are described.

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A 33-year-old female complaining of sudden nasal bleeding, left buccal pain and maxillary swelling was sent to our hospital for further examination. CT scans showed a cystic lesion with bone formation in the left maxillary sinus. The patient underwent en bloc removal of this cystic lesion by Denker's operation.
Histological examination revealed that the ossification originated in scar tissue in the cystic wall. The origin of this cystic lesion was presumed to be a polypoid growth from the maxillary sinus mucosa which elongated and folded to form a cyst. Fibrous ossification probably developed in the process following scar formation due to chronic inflammation in the cystic wall.

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There have not been many reports of ethmoid osteomas in the Japanese literature. The most commonly described symptons are facial pain and headache. We recently treated a patient with ethmoid osteoma causing epiphora by compression of the lacrimal sac.
She was 60 years old and complained of left epiphora. We diagnosed ethmoid osteoma on the basis of X-ray and CT scan findings. The epiphora was completely relieved by removal of the osteoma compressing the lacrimal sac.

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Most of the patients with hypopharyngeal cancer had advanced stage lesions (III or IV). This may account for the poor prognosis. We investigated the process of diagnosis in 45 patients treated in our clinic during the past nine years. In 32 of them (71%) advanced disease was diagnosed before treatment. The interval between the onset of initial symptoms and the definite diagnosis before treatment ranged from less than one month to more than 12 months (average of 5.1 months). After the first medical examination, nine of the 45 patients required more than three months before diagnosis of hypopharyngeal cancer was comfirmed. At the first visit for consultation about the initial symptoms, 32 patients visited an otolaryngologist, and 13 patients visited an internist or a general surgeon. Three patients who were older than 74 years and complained of pharyngo-laryngeal discomfort were included in the above group of nine patients receiving a late diagnosis. The present study indicates that it is empirically feasible to diagnose or rule out hypopharyngeal cancer in elderly patients complaing of abnormal sensation in the pharyngo-laryngeal portion. Since hypopharyngeal cancer in the early stage is not easily detectable in the usual manner, such as indirect laryngoscopy or hypopharynx fluoroscopy, endoscopy with a well-equiped fiberscope and biopsy or cytology should be conducted periodically, if signs suggest the presence of hypopharyngeal cancer.

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An unusual case of pleomorphic adenoma of the subglottis is described. A 33-year-old female complained of dysphagia similar to asthma. Examination showed that the subglottic area was occupied by a tumor protruding from the left subglottic wall. Emergency tracheotomy was performed and then the tumor was completely removed by an external approach after laryngofissurectomy under general anesthesia. The extirpated tumor measured 1.5cm in diameter and had a capsule. The cut surface of the tumor was solid, and the histological diagnosis was pleomorphic adenoma. The patient has shown no evidence of recurrence for more than one year. This is the second case of pleomorphic adenoma of the subglottis to be reported in Japan.

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A statistical analysis was conducted of 279 patients with neck masses treated in the Department of Otolaryngology, Niigata University School of Medicine from 1981 to 1990. 7.6% of all 3, 654 hospitalized patients. The mean age was 50.3 years; 155 were males and 124 were females.
There were 124 malignant tumors (44.4%), 95 benign tumors (34.1%), 29 inflammatory diseases (10.4%), 29 congenital diseases (10.4%) and two others. Malignant tumors predominated in males, and benign tumors in females; both were more common in patients over 50 years of age. Of the malignant tumors, 67 were metastatic lymphnodes, 21 were malignant lymphomas, 17 were thyroid cancers, and 14 were parotid cancers; there were five other miscellaneous lesions. All primary sites of the 67 metastatic lymphnodes were in the head and neck areas. The majority of benign tumors were 61 parotid tumors, 33 of which were pleomorphic adenomas. Of the inflammatory diseases, 11 were submandibular sialoadenitis and six were nonspecific cervical lymphadenitis. Most of the congenital diseases were lateral cervical cysts or cervical median cysts.
Masses with spontaneous pain were suspected of being due to inflammatory diseases. Hard masses with tenderness, poor mobility and obscure margins were apt to be malignant tumors or inflammatory diseases. Soft masses with good mobility, distinct margins, and no tenderness were usually benign tumors or congenital diseases.
It follows from the present findings that careful examination of the head and neck, keeping in mind the possibility of malignant tumors and particularly metastatic lymphnodes, is the first step in the identification of diseases causing neck masses. Careful consideration should precede decisions for open biopsy with special attention to the patient's history and local findings. Detailed inspection and palpation are essential in deciding the proper course of treatment.

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Focal myositis is an inflammatory pseudotumor of the skeletal muscle that often mimics a growing neoplasm.
We report the tenth case of focal myositis in the head and neck region; the first in the temporal muscle.
A 42-year-old man was referred to our hospital with a subcutaneous mass in the right temporal region. An excisional biopsy was performed under general anesthesia. The mass was localized within the right temporal muscle. The histopathological diagnosis was focal myositis.
Since focal myositis is a self-limited disease which regresses spontaneously, no further treatment is required. However, careful observation is necessary to exclude localized initial symptoms of polymyositis.

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Low power LASER has been reported to accelerate healing of injured peripheral nerves and soft tissue and to reduce inflammation and pain. With a 30mW Ga-Al-As diode LASER with a wave length of 790nm, we irradiated the cochlea directly through the round window membrane to determine whether LASER irradiation has any effect on the guinea pig cochlea.
An electrode was put on the basal turn of the cochlea, and compound action potential (CAP) and cochlear microphonics (CM) were recorded continuously. Sound stimuli of 4kHz and 8kHz tone bursts at the level of 10 and 20dB SPL above the threshold were given by open field.
In all guinea pigs, the amplitude of CAP fell to 60-80% immediately after the beginning of the irradiation and returned to the original level soon after the end of the irradiation. This phenomenon was more apparent with 8kHz sound stimuli and 10dB SPL above the threshold. The amplitude of CM changed somewhat during LASER irradiation, but no definite tendency was detected.
Some different mechanisms, including activation of the efferent system, are thought to be working in the cochlea simultaneously during LASER irradiation.

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We studied the distribution of aspoxicillin (ASPC) in the maxillary sinus mucosa after the rapid intravenous injection of this drug (2g) and the distribution of the same drug in the nasal fluid and discharge following drip infusion (2g).
1. The percentage of ASPC in the maxillary sinus mucosa reached a peak (72.0% of the dose) 30 minutes after the rapid intravenous injection of the drug, and its concentration was still high (about 30%) 120 minutes after the injection. Thus, ASPC showed rapid transfer into the maxillary sinus mucosa and maintained a satisfactorily high level there after rapid injection.
2. In healthy adults, the ASPC level in nasal fluid reached a peak immediately after the start of drip infusion, while in patients with sinusitis the peak was reached 60 minutes later. Thus, the transfer and attenuation of ASPC into and from the nasal fluid tended to be slower in patients with sinusitis than in healthy adults.
3. The drug transfer into nasal discharge reached a peak about 60 minutes after the start of drip infusion. The transfer was rapid and the peak level was high.
4. These results suggest the following method of ASPC administration for patients treated surgically. If surgery takes 60 minutes or less, only a single 2g intravenous dose is needed. If surgery takes 2 hours or more, a 1g intravenous dose should be given before surgery followed by a second 1g intravenous dose about 30 minutes (for 2-hour surgery) or 60 minutes (for 3-hour surgery) after the start of surgery. Considering the transfer of the drug into nasal fluid and discharge as well as the stress to the patient caused by drip infusion, we conclude that a 30-minute drip infusion is optimum postoperative ASPC treatment.
5. ASPC was transferred into the maxillary sinus mucosa and nasal fluid and discharge in satisfactorily high levels, so it appears to be useful in the treatment of nasal and sinus infections and in the treatment and prevention of postoperative infections.

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The effectivness, safety and utility of AZ-X liquids for external application were evaluated in 138 patients with pharyngolaryngeal and oral diseases in an eight-institution open comparative trial.
In the final overall evaluation 79.0% were marked improved or moderately improved. The examination in safeness showed 100% success. No side effects were noted. The general rate of marked or moderate efficacy was 79.0%.
It was concluded that AZ-X is a usefull drug for treating oral and pharyngo-laryngeal disease.

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