The diagnosis and treatment of patulous eustachian tube were discussed with review of the literature. In addition, some new findings from the author's group related to this difficult disorder were presented.
We have used 3-dimensional reconstruction of the computed tomography (3D-CT) of the eustachian tube lumen to detect very severe cases of the patulous eustachian tube. The new treatment of the intractable patulous eustachian tube developed by us, transtympanic plugging of the eustachian tube with a specially designed silicone plug, was found very useful to the cases in which various conservative treatment had been ineffective.

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Fifty-one ears with labyrinthine fistulas underwent surgery in our hospital between May 1987 and December 1997. Forty-eight of the 51 ears had middle ear cholesteatoma, 2 had chronic otitis media, and 1 had eosinophilic granuloma. The fistulas were located in the lateral semicircular canal in 47 ears, in the cochlea in 2 ears, in the anterior semicircular canal in 1, and in both the lateral and anterior semicircular canals in 1. Labyrinthine fistulas were detected by temporal bone computed tomography (CT) in 35 of 40 ears tested (87.5%), indicating that temporal bone CT is necessary before surgery for middle ear disease. In patients with dizziness before surgery, bone conduction tended to be worse before and after surgery than in patients without dizziness. Inflammatory granulation tissue and a cholesteatoma matrix over the fistula should be removed at surgery, and the fistula should be covered immediately; this will prevent postoperative impairment of inner ear function. In 41 ears (about 80%), destruction of bone in other sites, such as facial canal dehiscence or exposure of the middle f ossa dura or the sigmoid sinus, was detected at surgery.

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Keratoacanthoma is a benign epithelial tumor. It most frequently arises in an area of sun-exposed skin, particularly the facial surface. It is sometimes difficult to distinguish keratoacanthomas from squamous cell carcinomas because of their similar clinical and microscopic characteristics.
We have experienced a case arising in the nostril.
The patient was a 43-year-old woman. She found a tumor in the left nostril in December 1998, but was not examined. Then she was examined at another hospital because of increasing pain in April 1999. However, a definitive diagnosis was not obtained, so she visited our hospital in May. At the first examination, we found a dark red tumor covered by crust measuring 14×16mm in the left nostril. We resected the tumor along with the crust. Histopathological tissue showed neutrophil invasion on the corium with defective epidermis and hyperkeratosis with a pseudohorn cyst. The final diagnosis was a keratoacanthoma. The resected region was well epithelized one month after surgery. Periodical follow-up continues.

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To study the role of Haller's cell in the pathogenesis of chronic sinusitis, CT findings examined prior to endoscopic sinus surgery of patients with chronic sinusitis were investigated. Of 51 cases, Hailer's cell was present in 19 unilaterally or bilaterally. No significant correlation was found between the presence of Hailer's cell and the severity of a pathological shadow in the maxillary, anterior ethmoid, or frontal sinuses. However, in 13 cases of unilateral Hailer's cell, the pathological findings were significantly more severe in maxillary sinuses with Hailer's cell than in the oposite side without Hailer's cell (p<0.01). These findings suggest that Hailer's cell might be one of the important factors associated with the pathology of ostiomeatal complex as well as the pathogenesis of chronic inflammation in maxillary sinuses.

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A newborn male baby was referred to our clinic with upper airway obstruction caused by a huge mass in the mesopharynx. A CT scan revealed a huge tumor existing from the left parapharyngeal space to just under the skullbase. No communication with the inside of the skullbase was detected. The tumor was determined to be heterotopic brain tissue of the parapharyngeal space and was partially excised. Since the infant was asymptomatic with normal breathing and feeding, follow up is planned in the future.

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Parapharyngeal lesions comprise the greatest number of neoplasms. The majority are histologically benign. However, lipomas of the parapharyngeal space are very rare, and only case reports have been documented. A 56-year-old woman complained of a foreign body sensation of the pharynx. A CT scan of the head and neck showed a low density mass in the right parapharyngeal space extending to the retropharyngeal space. T1 and T2-weighted MR images showed a parapharyngeal tumor, which demonstrated a high signal in both images. These imagings supported the parapharyngeal Lipoma without findings from a fine needle aspiration biopsy. We performed tumor extirpation uneventfully with a transverse cervical incision and a small horizontal incision on the posterior pharyngeal wall. We report the radiological features and the surgical approaches of parapharyngeal tumors.

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We report 2 adult cases of inspiratory dyspnea caused by an epiglottal prolapse.
The first case was a 61-year-old man who was suffering from inspiratory dyspnea, especially while sleeping. A laryngofiberscopic examination revealed that the epiglottis was contacting the posterior pharyngeal wall during inspiration, causing airway obstruction. A partial epiglottectomy with a Holmium: YAG laser improved respiratory dystress during sleep.
The second case was a 60-year-old man who also suffered from dyspnea while sleeping. The laryngofiberscopic findings were the same as in the first case, and a partial epiglottectomy was also effectve for the dyspnea during sleep. A pathological examination revealed degeneration of the epiglottic cartilage
The Holmiun: YAG laser was useful in resecting the epiglottic cartilage in both cases.

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A 68-year-old woman consulted our clinic exhibiting a bilateral nasal obstruction which had lasted for 2 months. Anterior rhinoscopic examination revealed the presence of necrotic tumor which was raised from the posterior portion of the right nasal cavity or epipharynx. Since only slight tumor reduction was obtained through 40Gy of radiotherapy, surgical excision was done endonasaly using an endoscope. Intra-operative findings indicated that the tumor was raised from the posterior portion of the right inferior turbinate. En bloc resection was carried out, but viable tumor cells were exposed at the surgical margin. An additional 30Gy of post-operative radiotherapy and lateral nasal wall resection using a lateral rhinotomy approach were carried out. Moreover, right neck dissection was done for right cervical lymph node metastasis.
Surgical excision with a wide margin is the most desirable method of treatment for this kind of tumor. Though this method is difficult to carry out in the head and neck region, we suggested that excision with marginal margin combined with radiotherapy could produce good results.

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We reviewed the surgical treatment of 7 patients with advanced parotid carcinomas treated with radical parotidectomy. Histological types of the group consisted of 2 adenoid cystic carcinomas, 1 adenocarcinoma, carcinosarcoma, salivary duct carcinoma, undifferenciated carcinoma and mucoepidermoid carcinoma. Four were new patients and three had recurrent cases. Preoperative facial nerve paralylsis was observed in all patients, and severe trismus was noted in two.
All patients underwent some type of radical parotidectomy, four of whom had an en block excision, two had a total removal of the tumor in two pieces, and one had microscopic cancer involyment on the resection margins (because of perineural invasion to the facial nerve in the fallopian canal). The facial nerve was sacrificed in all patients, one of which was reconstructed immediately with the cervical plexus and three were reconstructed postoperatively with cross facial anastomoses. Over a variable period of time (2-28 months), three patients had died, two were associated with distant metastases and one had local recurrence.
As a result, we emphasize the importance of an en block excision of a tumor and control of possible distant metastases in the treatment of advanced parotid carcinomas. For the purpose of an en block excision, skull base surgery must be performed when the tumor involves the styloid process or the deep structure of the infratemporal fossa, or when perineural invasions to the facial nerve in the fallopian canal are strongly suspected.

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Synovial sarcomas occur primarily in the periarticular region and are predominantly located in the extremities. However, they can arise in the head and neck region. In the available Japanese literature, only 14 cases have been reported. We encountered a rare case of synovial sarcoma of the parapharyngeal space. Thus, we report this case with some consideration according to literature. The patient was a 15-year-old male with no clinical symptoms. Swelling of the right mesopharynx and soft palate was noted by his general practitioner at school. From the initial examinations of CT, MRI, Gallium-67 citrate scan and FNA, a malignant tumor of the parapharyngeal space with no metastasis was revealed. Then, an excisional biopsy was performed and the pathological diagnosis was SYNOVIAL SARCOMA (biphasic type). After the biopsy, the tumor rapidly spread to the oral cavity. Therefore, embolization of the right maxillary artery was performed to reduce the blood supply to the tumor. After the tracheostomy, radical surgery was performed using the mandibular swing maneuver, which enabled us to approach the tumor. Complete en-bloc resection of the tumor was carried out.
During the operation, there was no significant association between the tumor and the mandibular joint. After the operation, adjuvant chemotherapy and radiotherapy were to be applied, but we were unable to obtain informed consent. Therefore, we decided to apply only radiotherapy (total 60Gy) on an out-patient basis. Although he has been alive and disease free for 8 months, it is necessary to check for local recurrence and lung metastasis regularly. Although the prognosis of the disease is not good, we can overcome this disease by means of cytogenetic therapy in the future.

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We report two rare cases of spindle cell carcinomas of the larynx. A 65 year-old man with a left glottic spindle cell carcinoma (T1aN0) was treated with 60 Gy of radiation because of a cardiac infarction. The tumor has completely disappeared without recurrence for 6 years. Another case was a 59 year-old man with a left glottic spindle cell carcinoma (T1bN0). He was successfully treated with 60Gy of radiation. However, there was a recurrent carcinoma (rT2N0) 6 months after the treatment. Therefore, a total laryngectomy was performed.
Most laryngeal spindle cell carcinomas in Japan are found at an early stage. For these diseases, operative therapy rather than radiation therapy is recommended. It is believed that operative therapy without loss of laryngeal functions for an early staged laryngeal spindle cell carcinoma is the first choice of treatment, but radiation therapy could be a better choice.

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An elongated styloid process stimulates the pharyngeal wall or cervical nerves and causes pharyngeal pain, foreign body sensation of the pharynx, or pain in the ear. The only satisfactory and effective method to alleviate the complaints associated with an elongated styloid process is surgical shortening. In this report, one case of a giant elongated styloid process is discussed. In this patient, the styloid process was highly elongated and the tip of the process had connected with the hyoid bone. Major symptoms were swelling of the submandibular region and dysphagea because the styloid process had formed nodules behind the submandibular gland pressing it and obstructing movement of the hyoid bone. Surgical shortening was performed using the transcervical approach, and as a result, the symptoms disappeared immediately. The transcervical approach has an advantage of wide visualization over the intraoral approach and is recommended when the styloid process is extremely long and thick.

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We studied the healing process of tympanic membrane perforations in the external auditory canal in guinea pigs. The perforations were made apart from or adjacent to the malleus. The time for the closure of the tympanic membrane perforations was longest in perforations adjacent to the malleus, and in those cases the perforated part of the tympanic membrane regenerated and thickened around the malleus in the healing process. Moreover, immunohistological staining, using anti-BrdU antibody, revealed few stained cells in the intermediate layer except at the tip of the malleus. We consider that these findings were related to the delayed closure of the perforation.
Histological study of the regenerated tympanic membrane revealed that after closure of the perforation, a thinning of the epithelial layer was first observed, but cells in the layer later increased.

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