In the United States, Australia and in Europe, the number of children who receive cochlear implants is increasing dramatically, but it is still rather small in Japan. However, before any rapid increase of pediatric cochlear implantation in our country, the following two factors should be considered; 1. growth of the temporal bone in Japanese children (for better surgical results); 2. intellectual development (to plan appropriate rehabilitation). From the anatomical point of view, the child should be more than 5 years old at the time of the surgery. CT scans of Japanese children reveal slower development of the temporal bone than in Euro-American children. Also, to facilitate rehabilitation after surgery, more than 4 years of age is recommended so as to obtain consistent responses to verbal stimulation. In the United States, no objective evidence has been obtained to support an earlier age for implantation in respect to better hearing acquisition. In conclusion, 4 years of age appears to be the lower limit for cochlear implantation in Japanese children.

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We evaluated tinnitus with a five-score scale for each of three subjective complaints: 1) loudness, 2) annoyance, and 3) difficulties in activities of daily life (ADL). We divided 147 outpatients with tinnitus into five groups according to the relationship between scores of annoyance and of difficulties in ADL in relation to scores of loudness, and analyzed the following characteristics of each group: hearing loss, duration from onset of tinnitus and psychological factors. The numbers in each group among out-patients differed considerably from those among in-patients reported previously. In most of the patients with scores of annoyance higher than the other two scores, hearing loss was not very severe. On the contrary, in more than half of the patients whose scores of difficulties in ADL were higher than the other two scores, hearing loss was moderate or severe, and the duration of tinnitus was less than one year. In addition to these two characteristics (moderate to severe hearing loss and relatively short duration of tinnitus), patients with scores of both annoyance and difficulties in ADL which were higher than those of loudness might be considered to have psychological problems. These results suggest that the degree of hearing loss, duration from the onset of tinnitus and psychological factors influence the subjective complaints of patients with tinnitus, and that the most important factor is the degree of hearing loss. This method of tinnitus evaluation appears to be very useful clinically, since it examines various aspects of tinnitus.

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A 75-year-old male was admitted to our hospital because of dizziness and gait disturbance. Angiography revealed complete obstruction of the left vertebral artery and severe stenosis of the right vertebral artery. The posterior circulation was not sufficiently filled by either of the carotid arteries. Caloric tests indicated left canal paresis. Smooth pursuit was disturbed and ocular dysmetria was found in saccade. OKN showed that pursuit eye movement was severely disturbed and nystagmus waves were irregular. We speculated that these disturbances were mainly of the left vestibular nuclei and the cerebellar vermis and were caused by insufficiency of the posterior circulation. Because conservative therapy was not effective, superficial temporal artery-superior cerebellar artery (STA-SCA) anastomosis was carried out on the right side. Dizziness disappeared and gait disturbance was improved. Pursuit eye movement towards the left was markedly improved, and ocular dysmetria disappeared.

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Hearing tests of 57 ears performed after type IV tympanoplasty are reviewed. The results were assesed by the following criteria: 1) air-bone gap within 20dB, 2) air conduction hearing level within 40dB, 3) air conduction hearing gain more than 15dB. Postoperative hearing levels of one or more of the three criteria were considered to indicate success. The success rate was 63.2%. Postoperative results were analyzed according to kinds of columella, method of operation, patient's age, preoperative bone conduction hearing level and preoperative air conduction hearing level. The type of columella (autograft ossicle, autograft cartilage, hydroxyapatite), operative method (canal up or canal down, one stage or two stage), patient's age and preoperative bone conduction hearing level (<20dB or >20dB) were not significant by related to success. Only the preoperative air conduction hearing level (<60dB or >60dB) was significant (p<0.01).

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The surgical management of labyrinthine fistula caused by cholesteatoma is still controversial. We analyzed the clinical features, surgical management and postoperative hearing of 41 patient with labyrinthine fistula. Before the operation, about 40% had bone conduction within 20dB of normal, and only three patients were totally deaf. Three surgical approaches were employed for the labyrinthine fistula in the first stage operation: 1) complete removal of the cholesteatoma matrix followed by closing of the fistula, 2) leaving the matrix on the fistula in situ, and 3) leaving the subepithelial granulation tissue in situ with removal of the cholesteatoma matrix. Of the 23 patients treated with total removal of matrix at the first operation, three became totally deaf and bone conduction deteriorated in three others. On the other hand, no postoperative deterioration of bone conduction was observed in those with matrix or granulation tissue left in situ. In the former group, pathogenic bacteria were frequently isolated from patients with deterioration of bone conduction, indicating that the inner ear damage was caused by bacterial infection of a labyrinth through the fistula. We conclude that the labyrinthine fistula should be treated in a second stage operation after inflammation has subsided, if the ear has definite infection and/or inflammation at the first stage.

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A 22-year-old male visited our outpatient clinic with a complaint of bleeding from the left auricle. The left auricle measured 80 by 50mm and the right 55 by 35mm. Engorgement vessels with pulsation was noted inside the helix and in the upper half of the auricle. CTscan, MRI, thermographic examination and angiography were performed, and arteriovenous malformation of the auricle was diagnosed. The main feeding arteries were the superficial temporal artery and the posterior auricular artery, as demonstrated by angiography via the left external carotid artery. Lingation of the superficial temporal artery and the posterior auricular artery was performed under local anesthesia. After a relapse, lingation of the external carotid artery was performed under general anesthesia. The post-operative course was good, and pulsation in the helix disappeared. Two months after surgery, plastic surgery of the left auricle was performed at the patient's request.

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Capillary hemangiomas of the nasal mucosa, which account for 20% of all benign tumors of the nose, are generally called “bleeding nasal polyps”, and there is fear of severe epistaxis during surgery. Therefore, some preoperation procedure such as cryotherapy, electrocoagulation, artery ligation or embolization, is necessary to prevent severe hemorrhage.
Recently we treated a 28-year-old-pregnant woman with a capillary hemangioma developing from her right inferior nasal turbinate. We performed embolization followed by surgery as an elective method of treatment.
The intraoperative blood loss was 640 ml. This technique is thought to be useful. Reports published from 1981 to 1994 indicated that hormonal receptors are an important factor in the etiology of capillary hemangiomas.

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A 46-year-old male complained of oral and pharyngeal pain and hoarseness. Multiple irregular erosions with white coating were noted in the oral cavity, oropharynx, and larynx. The coating was removed easily, but the removal caused bleeding. There were no skin lesions. Biopsy of the oral mucosa was performed for diagnosis, but the result was inconclusive. About a month later several bullae developed on the upper and lower limbs. A biopsy of the skin of the left forearm showed intraepidermal bullae caused by acantholysis. A fluorescent antibody test (direct method) revealed intercellular IgG depositions. These findings led to a diagnosis of pemphigus vulgaris.
It is difficult to diagnose pemphigus vulgaris by biopsy of only the oral mucosa when lesions are limited to the oral cavity, because the oral mucosa peels easily, and specimens are often damaged. Therefore, cytological examination of the oral lesion and serological examination with a fluorescent antibody technique (indirect method) should be added when pemphigus vulgaris is suspected.

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Carcinoid tumors are rare in the otorhinolaryngeal area. There have been no reports of oropharyngeal carcinoid, as far as we know. Recently we treated a patient with this tumor.
A 68-year-old woman visited our hospital because of a mass on her hard palate. A biopsy was performed. The histological diagnosis was atypical carcinoid. Partial maxillectomy, including the soft and hard palate, was done. No further treatment, such as radiation therapy or chemotherapy, was given. There has been no sign of recurrence for over one year after surgery.

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Bilateral tumors of the same histotype can occur in the parotid glands. Warthin's tumor is the most common bilateral tumor. Pleomorphic adenoma is very rere.
We recently treated a patient with pleomorphic adenoma in both parotid glands. This 58-year-old woman was referred to our hospital because of a slowly growing mass in the left parotid region. Preoperative MRI revealed masses in both parotid regions. Bilateral superficial parotidectomy with preservation of the facial nerve was performed simultaneously under general anesthesia. The histopathologic diagnosis was pleomorphic adenoma in both glands.

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It is generally known that in 20-30% of patients with Behcet's disease (BD) the first attack occurs after acute tonsillitis.
We performed provocation tests on the tonsils and tonsillectomy in 13 patients with BD and chronic tonsillitis and followed 10 of them for 17 to 81 months.
The tonsil provocation test was positive in 11 patients. Aphthous stomatitis, genital ulcers or skin eruptions like erythema nodusum decreased or disappeared after tonsillectomy in 8 of 10 patients with BD.
These results suggest that some types of BD accompanied with chronic tonsillitis may be regarded as tonsillar focal infection disease. In such patients, tonsillectomy may be effective clinical treatment.

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Neurogenic tumors of the hypopharynx are rare. We report a case of neurilemmoma of the hypopharynx.
A 64-year-old female visited our hospital because of dysphagia for two years. Fiberscopic examination revealed a submucosal smooth round mass occupying the left pyriform sinus and left arytenoid. CT showed the mass on the left side of the hypopharynx with an isodensity portion with moderate enhancement and a low density portion in its center. Biopsy under direct laryngoscopy suggested benign neurogenic tumor. The patient underwent lateral pharyngotomy under general anesthesia after tracheostomy, and a submucosal tumor in the left pyriform sinus was extirpated. The histopathological diagnosis was neurilemmoma because almost all the tumor cells were S-100 protein-positive and had a typical Antoni-B type appearance.

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Because of the incomplete closure of the glottis which they cause, vocal cord polyps are ordinarily associated with a complaint of hoarseness. However, when the polyps are small, patients often complain of abnormal sensations of the throat or coughing, rather than hoarseness as a result of poor closure. This report describes two patients, who complained of functional dysphonia althouth their polyps were too small to cause hoarseness. In both, good results were achieved with laryngomicrosurgery and postoperative voice therapy.

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A 37-year-old man suffered from dysphasia and hoarseness two weeks after an upper respiratory infection. Damage to the Vth, VIIIth, IXth, Xth and XIth cranial nerves was found by neurological examination.. The titers of CF antibody and ELISA antibody (IgG) were markedly increased, but the titers of ELISA antibody (IgM) was normal. Therefore, the authors speculated that the cause of his clinical symptoms was reactivation of latent VZV in the sensory neuroganglia.

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Subcutaneous emphysema occurring in the head and neck is comparatively rare. A 61-year-old female complained of neck swelling and left tinnitus when opening and closing her mouth. Crepitation was heard around the left parotid gland, masseteric region and neck. There were no abnormalities of the left eardrum, nose, pharynx, larynx or skin of the neck. Hearing was normal. She had no systemic disease. A high serum amylase value was the only abnormality in blood chemistry tests. Bacterial culture revealed a-Streptococcus and Neisseria. A sialogram showed chronic parotitis. A CT scan revealed subcutaneous emphysema. Swelling of the neck and tinnitus disappeared after the adminstration of antibiotics (CLDM and TFLX). It is thought that the causes of subcutaneous emphysema in the head and neck are wounds, surgical invasion, gas forming infection and increase of pressure in the pulmonary alveoli. Although we could not discover the cause of this emphysema, we suspected it was a slight gas forming infection associated with chronic parotitis.

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A 56-year-old man complained for one year of a right neck node swelling. We examined his head and neck region, but we could not detect any origin of a neck node metastasis. We performed an open biopsy. The biopsy specimens of the neck node suggested branchial cleft cyst because of the almost normal thin stratified squamous epithelium of the cyst wall. So we performed “branchial cleft cyst resection”. Histological examination of this mass showed transition from squamous dysplasia of the cyst wall to invasive well differentiated squamous cell carcinoma. The histological appearance, location of the mass and the absence of a site of origin led us to a diagnosis of branchiogenic carcinoma.
Radiation therapy (45 Gy/18f) and radical neck dissection were performed. He has been followed for 3 years and shows no evidence of recurrence of disease.

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This study was designed to demonstrate how each layer of the guinea pig tympanic membrane responds during the healing of a perforation. Epidermal growth factor (EGF) and platelet-derived growth factor (PDGF) were employed to stimulate the healing process of the outer and middle layers, respectively.
The tympanic membrane was perforated by an electrical burn, and each growth factor was injected daily into the otic bulla through the external auditory meatus. The tympanic membrane perforations were examined with hematoxylin-eosin and immunohistochemically with bromodeoxyuridine. The maximal thickness of each layer at the margin of the perforation was measured light microscopically and the labeling index of bromodeoxyuridine was calculated.
Tympanic membrane perforations closed more rapidly in the PDGF-treated than in the EGF-treated ears. Significant proliferation of the epithelial layer was obtained with both treatments. However, proliferation of the middle layer was greater in the PDGF-treated than the EGF-treated ears. These results suggest that proliferation of the middle layer stimulates the epithelial layer and that proliferation of the epithelial layer directly quickens the closure of perforation of the tympanic membrane.

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The change of fundamental frequency (F₀) per unit change of transglottal pressure (dF/dP) is determined by the amount of displacement of the vocal folds. Since the amount of displacement varies with the stiffness of the vocal folds, this study was designed to determine whether the stiffness of the vocal folds can be evaluated with dF/dP. In a preliminary study the correlation between F₀ and dF/dP was examined in normal subjects; 14 humans and 5 dogs.
Method. 1) Transglottal pressure (Pt) changes were produced during sustained phonation in 6 male, and 6 female adults and 2 children. The pressure changes were applied by closing a shutter valve mounted on a mouthpiece. F₀ and intraoral pressure were measured. 2) Pt changes were produced in 5 living adult dogs. The pressure changes were applied by closing a shutter valve mounted on a tube for insufflating the larynx. F₀ and subglottal pressure were measured.
Result. 1) The values of dF/dP, in modal register, decreased linearly and increased linearly as F₀ increased in all subjects. The smallest values of dF/dP were observed around 200-250Hz in males and 250-300Hz in females and children. The value of dF/dP was larger in falsetto voice in terms of the same F₀ between high pitch modal register and low pitch falsetto. 2) The same pattern of correlation between F₀ and dF/dP was also observed in adult dogs. The correlation between F₀ and dF/dP in this study indicated a potential usefulness for the evaluation of the stiffness of the vocal folds.

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Tissue concentrations of ofloxacin (OFLX) and pronase were determined in 58 tonsils and 43 maxillary sinus mucosal biopsies collected surgically after a single oral dose of 200mg of OFLX with or without a daily dose of 54, 000 units of pronase given for the previous 4 days. In tonsils the tissue concentration of OFLX 90 minutes after administration was 2.37μg/g in the OFLX group and 3.72μg/g in the combined group. In maxillary sinus mucosa the tissue OFLX concentration 90 minutes after administration was 1.29μg/g in the OFLX group and 1.79μg/g in the combined group. In both specimens penetration in the combined group was higher than in the OFLX group.
The clinical effectiveness, safety and utility were evaluated in 39 patients with paranasal sinusitis who were given OFLX in a daily dose of 600mg for 14 to 28 days with or without pronase in a daily dose of 54, 000 units. In the combined group the clinical efficacy, defined as percentage of patients with exellent or good responses, was 42.9% in those with chronic sinusitis and 83.3% in those with acute exacerbation of chronic sinusitis. On the other hand, in the OFLX group the efficacy was 40% and 50%, respectively. No clinical side effects were observed in the combined group.
The results indicate that OFLX with pronase is useful in the treatment of chronic sinusitis and tonsillitis.

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