Takahashi reported that in surgical treatment of cholesteatoma by the canal up method, postoperative aeration of the mastoid cavity depends only on preservation of the mastoid mucosa and not on the ventilation routes made by anterior and/or posterior tympanotomy. Takahashi suggested that aeration of the mastoid is maintained by the gas exchange function of the preserved mucosa. In this paper, my refutation of Takahashi's theory will be described as follows:
1. His citation of the literature is limited to papers which support his theory.
2. His cases are too few in number to make any negative recommendation regarding the clinical suitability of anterior tympanotomy in cholesteatoma surgery.
3. His conclusion is one-sided and ignores data incompatible with his theory.
My opinion is that a new ventilation route between the eustachian tube and the epitympanomastoid cavity made by anterior tympanotomy is much more effective than the gas exchange via the mucous membrane for aeration of the postoperative tympano-mastoid cavity after cholesteatoma surgery.

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Prognosis in cases of sudden deafness depends on the time period prior to starting medical treatment, and delay in treatment usually produces poor hearing recovery. This report describes a case who showed substantial improvement in hearing following the administration of prostaglandin E₁ (PGE₁) at 59 days after the onset of deafness. The patient was a 64-year-old man who suffered from sudden hearing loss of the left ear, accompanied by vertigo. Following intensive treatment with methylprednisolone, ATP and mecobalamin, the vertigo subsided but hearing and tinnitus did not improve. He visited our hospital at 43 days after the onset. Administration of PGE₁ together with prednisolone, ATP, mecobalamin and low-molecular-dextran was effective in improving hearing. Air-conduction hearing level improved from 52.5dB to 22.5dB, 13 days after treatment.

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Glomus tympanicum tumor in the right ear of a 44-year-old female is described. Her primary symptom was pulsatile tinnitus in the right ear. otoscopic examination revealed a reddish mass behind the inferior portion of the tympanic membrane. CT, MRI and angiography located a tumor in the middle ear cavity. The tumor was completely resected through a posterior hypotympanotomy with a small amount of bleeding. Pulsatile tinnitus and a retrotympanic reddish mass seen through the tympanic membrane are typical signs of glomus tympanicum tumor. Imaging with CT, MRI and angiography is very helpful in the determination of the origin and extent of the tumor in adjacent structures.

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In the present study we describe the clinical course and features of otitis media with effusion (OME) in children with Down's syndrome. Of the 190 children with Down's syndrome between aged 3 months to 13 years whom we examined, 94 had unilateral or bilateral OME. We were not able to diagnose the presence or absence of middle ear effusion in 33 children because of narrow external auditory canals or poor patient compliance. We treated and followed 67 children with OME for 1 to 13 years (mean: 3.4 years). Moderate hearing loss was noted in 51% of the children at the first visit. During the follow-up period, resolution of the effusion was observed with age in some cases, and 45 ears were free of effusion. However, only 16 children (24%) showed free of effusion bilaterally. Ten children (13 ears) had sequelae of OME, such as middle ear cholesteatoma, chronic otitis media with perforation and atelectatic ears. Therefore, OME in Down's syndrome appears to be relatively intractable and resistant to therapy. Eighty-eight percent of the 67 children had frequent upper respiratory tract infections, which may contribute to the high incidence and persistence of OME. We conclude that the children with Down's syndrome should be checked otologically and followed from a younger age, and that active treatment is needed for children with moderate hearing loss caused by OME to potentiate their speech and language development.

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In chronic otitis media, bone conduction hearing impairments at high frequencies are common. However, it is unclear whether the raised bone conduction thresholds are a reflection of inner ear damage or an artificial elevation of bone conduction thresholds associated with a conductive disorder. Bone conduction measurements were performed on 7 ears from patients with acute mastoiditis, on one ear from an OME patient, and on two ears from cholesterol granuloma patients. In these ears, the raised bone conduction thresholds were characteristically demonstrated at 2000Hz before treatment. After the insertion of a tympanostomy tube, the bone conduction hearing improved in a few days. Therefore, the raised bone conduction thresholds are not likely to reflect the damage to the inner ear. The characteristic findings in these cases were of purulent and mucoid effusion in the middle ear and the mastoid cavity, and granulation tissue around the incus and stapes.
The cause of the bone conduction hearing loss was considered to be related to an abnormal sound conduction mechanism, such as the suppression of the resonant point of ossicle, rather than to disease damage to the inner ear.

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Pleomorphic adenoma originating from the external auditory canal (EAC) is reportedly very rare. Only six cases were found in the Japanese literature.
A 31-year-old female visited us with a four-year history of hearing loss and otorrhea of the left ear. The left EAC was occupied by a firm elastic tumor. On January 7, 1994, the tumor was excised under general anesthesia through an incision of the posterior auricular sulcus.
The excised tumor was grayish-whited, 1.2×1.4×1.5cm in size. The histopathological diagnosis was pleomorphic adenoma. The tumor has not recurred during the year since the operation.

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Tumors of the sublingual gland are rare, and Pleomorphic adenomas in this location are exceedingly rare. A 58-year-old woman was referred to our hospital because of a submucosal mass in the left oral floor. MRI showed a well demarcated sublingual mass. Fine needle aspiration biopsy revealed that the mass was comprised of spindle cells without atypia, suggesting pleomorphic adenoma. Under general anethesia, the tumor and the left sublingual gland were removed en bloc after removal of the left submandibular gland through an extra-oral approach. A well encapsulated tumor was present in the anteroinferior part of the left sublingual gland. The histopathological diagnosis was pleomorphic adenoma.

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We treated two patients with oral florid papillomatosis (OFP) of the buccal mucosa, which developed into squamous cell carcinoma during a long term follow-up period.
The first is a 62-year-old female who developed to squamous cell carcinoma 13 years after OFP, and the second is a 65-year-old female who developed it after 9 years. Both were resistant to laser surgery, irradiation, and chemotherapy, and had agressive local infiltration. In the second case, autopsy revealed generalized metastases.
The clinical and pathological characteristics of OFP were tendency of frequent local recurrence, resistance to treatment, and broad papillary proliferation in the basal layer of the epithelium.
A review of the literature and a discussion of the histopathological features and treatment of OFP are also presented in this paper.

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The 42 cases of tongue cancer treated at the Department of Otolaryngology, Shiga University of Medical Science, from 1978 to 1994 were evaluated clinically.
There were 23 males and 19 females with an average age of 58.9 years. Most of the patients were complained of tongue pain, the majority of lesions located on the edge of the tongue.
Stage classification was: stage I, 24%, stage II, 31%, stage III, 21% and stage IV, 24%. The five-year survival rate was: stage I, 80%, stage II, 77%, stage III, 89% and stage IV, 0%.
This retrospective study suggests that the treatment for stage IV should be a more extensive operation, and elective neck dissection should be for T2NO.

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Parotid gland tumors are usually unilateral, and bilateral parotid gland tumors are rare, Warthin's tumor (adenolymphoma) being the most common. We present a case of bilateral multiple parotid gland tumors in a patient with Sjögren's syndrome. A 62-year-old female came to our department because of a slowly growing mass in the right parotid region. CT-scan and MRI showed multiple cystic lesions in both parotid glands. The masses on the right side were removed surgically, with preservation of the facial nerve. The histological diagnosis was benign lymphoepithelial cyst (branchial cyst). Benign lymphoepithelial cysts are usually unilateral and single. The findings in this patient are very unusual.

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Laryngeal lipoma which is unusual, was diagnosed in two patients: a 71-year-old female who had been suffering from progressive feelings of constriction in the hypopharynx and a 60-year-old female with a foreign body sensation in the hypopharynx. In both a large, bullky mass with intact mucosa was seen in the Vallecula extending from the epiglottis. The mass was surgically removed by means of a laryngomicro technique through the mouth under modified NLA. Light microscopic examination of both surgical specimens revealed mature lipocytes; the diagnosis was simple lipoma. There has been no recurrence during the 2 years since surgery. We found only 14 cases of laryngeal lipoma reported in the Japanese literatures.

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A 72-year-old female visited our clinic with mild dyspnea and hoarseness. Laryngoscopic examination revealed a mass in the subglottic space and partial paralysis of both vocal cords. A CT scan showed a mass arising from the cricoid cartilage: half of the mass could be visualized. Biopsy under direct laryngoscopy was done, and the pathohistological examination revealed chondrosarcoma of low grade malignancy according to the classification of Lichtenstein and Jaffe. Because the tumor was large, total laryngectomy was performed. Chondrosarcoma of the larynx is an uncommon cartilaginous tumor. Only 13 cases have been reported in Japan since Shibui's description in 1973. The clinical features, pathohistological findings and management of this tumor are discussed, and the literature is reviewed.

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Seventy eight patients with laryngeal carcinoma, treated in our department from 1979 to 1989, were retrospectively reviewed and the results were analysed.
The male to female ratio was approximately 12: 1. The incidence was highest in the seventh decade.
The five-year survival rate was 75% (83% in the glottic type and 57% in the supraglottic type). Supraglottic T₁ and T₂ lesions can be controlled by radiation with voice conservation, while the prognosis for supraglottic T₃ and T₄ lesions was very poor because of untreatable cervical nodes and distant metastasis.
Some “glottic T₂ lesion” could not be controlled by radiation, so the five-year survival rate was the same as that of patients with “glottic T₃ lesion” treated with total laryngectomy.
Factors to improve survival rates of carcinoma of the larynx are discussed.

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Medullary carcinoma of the thyroid gland, constituting about 2% of all thyroid carcinomas, occurs in both sporadic and familial forms. It may be part of multiple endocrine neoplasm (MEN) type 2a or 2b.
We report a case of sporadic medullary carcinoma of the thyroid gland. A 34 year-old female noted anterior neck swelling six years ago. She underwent a left partial thyroidectomy and dissection of the paratrachea lymph nodes. Histopathological dignosis was medullary carcinoma. Serum calcitonin and CEA levels examined after surgery were high, but they gradually decreased to the normal range.
Although medullary carcinoma is a rare thyroid tumor, we must always take it into consideration.

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Recent advances in the diagnosis and treatment of head and neck malignancies seem to have increased the chances of finding multiple primary cancers.
Of the 220 patients with head and neck malignancies, treated in Shizuoka Red Cross Hospital from November, 1989 to October, 1994, 23 (10.5%) had multiple primary malignancies. The mean age of the 23 patients was 64.2 years and the male to female ratio was 4.8:1. Sixteen cancers developed metachronously and 4 synchronously. The most frequent site of second malignancies was the digestive tract, particularly the esophagus.
We shoud pay attention to the possibility of multiple malignant tumors. Endoscopic examination of the upper digestive tract with Lugol's solution staining is recommended for all patients with head and neck malignancies.

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An analysis of 3360 clinical cytological smears prepared in the department of Oto-Rhino-Laryngology from 1981 to 1992 showed:
1. Of the total 3360 smears (2029 were obtained by brushing, 1090 by aspiration, 80 by needle puncture, 147 from sputum, and 12 by other means).
2. The origin of 697 specimens was an oral lesion, 599 came from the pharynx, 428 from the larynx, 366 from lymphnodes, and 338 from nasal and paranasal areas.
3. The 12 years were divided into four periods (I-IV); 610 smears were examined in period I, increasing to 1066 in proportion to the number of ABC (aspiration biopsy cytology) specimens.
4. In period I, before the introduction of ABC, smears obtained by brushing accounted for 88.2% and, ABC for only 1.0%. However, in periods II-IV, after the introduction of ABC, the percentages were 50.2% and 43.6%, respectively.
5. Of the 786 smears diagnosed as malignant (class IIIb-V) only 4 were false positives (0.5%). The false negative rate could not be determined.
6. Of the 693 smears with a cytological diagnosis of suspected carcinoma, 62 were nonepithelial malignant tumors, and 34 were reported only as malignant change. Histological examination showed an incorrect cytological diagnosis in 6 specimens of ABC.
7. Although clinical diagnostic cytology is not a substitute for histo-pathological diagnosis, it can meet the demands of clinicians who want microscopic evidence before medical treatment. It is an ideal method of examination which imposes little burden on patients, and it can be used for daily medical examinations.

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Morphological and elemental analyses of otoconia under normal and pathological condition following streptomycin intoxication were carried out using scanning electron microscopy and energy dispersive X-ray microanalysis.
Young pigmented guinea pigs were used in this study. In the control group, typical cylindrical otoconia in the superficial layer of otolithic membrane had abundant calcium, and were used as a standard (=100%). On the surface of supporting cells, two types of globular substances were observed. One had 14% calcium content compared to the standard, and the other had 2.5%, although these could not be distinguished morphologically. The former may be a precursor of otoconia, while the latter may be a precursor of the otolithic membrane and subcupular meshwork. In the deep portion of the otoconial layer, immature otoconia had 15-30% calcium. On the dark cells of the ampullary area, oval shaped otoconia with a lower calcium content (30%) were observed at the utricular side. At the canal side, round shaped otoconia with a lower (12%) calcium content were observed.
In the streptomycin treated group, the globular substances on the supporting cells contained markedly less calcium. On the surface of the otolithic membrane, giant otoconia were observed. Their calcium content was reduced to about 35%. On the dark cells of the ampullary area, only round shaped otoconia were observed in both sides. Calcium content was lower (20%) at the utricular side, but the same as the control (12%) at the canal side. Non-calcium elements were detected in both sides.
These observations suggest that streptomycin may affect not only the sensory hair cells but also the supporting cells and the dark cells, and thus may interfere with the ion regulating system of the inner ear.

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A prospective, randomized study was undertaken to investigate the efficacy of Beriplast® P, a fibrin sealant, on postoperative pain in tonsillectomy.
Sixty-five patients consecutively undergoing tonsillectomy were subdivided by the envelope method into Groups A, B and C. The postoperative wound in Group A following tonsillectomy was covered with Beriplast® P and Betamethasone, and with Beriplast® P only in Group B. Nothing was used to cover the wound in Group C.
Pain was measured by the time period to return to a normal diet and the extent to which pain-relieving medications were used. The results showed that in Groups A and B tonsillectomy was less painful than in Group C. We concluded that the use of Beriplast® P to cover the wound reduced postoperative pain in tonsillectomy.

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