In this article, we summarized the diagnoses of tonsillar focal infection and the enormous clinical results obtained by our department, focusing especially on the clinical effects of tonsillectomy.
We proposed a general idea of complications related to tonsil-pustulosis palmaris et plantaris, certain skin diseases, bone joint diseases and IgA nephropathy.
Considering the diagnosis of tonsillar focal infection and tonsillectomy result, we recognized that immunity was related with tonsillar focal infection.
We also recognized the importance of careful clinical observation of the general disease, mainly focusing on the tonsil and its expanded clinical accumulations.

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We examined age-related changes in the mean hearing level in 460 ears (81 males and 149 females) at intervals of ten years.
1) The average hearing level showed gradual deterioration at 125Hz and 250Hz.
2) The turning point for the worsening of hearing changes with aging.
3) The turning point exists at 1kHz for men and women in their seventies.
4) The turning point exists at 2kHz for men and women in their seventies.
5) The turning point exists at 4kHz and 8kHz for women in their fifties and sixties.
6) The turning point exists at 4kHz and 8kHz for men in their fifties and seventies.

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Apogeotropic direction-changing positional nystagmus is considered to appear in patients with disorders of the central nervous system. However, this peculiar nystagmus is more likely to be caused by peripheral vestibular disorder. The mechanism of apogeotropic direction-changing positional nystagmus can be explained by benign paroxysmal positional vertigo (BPPV) caused by cupulolithiasis in the horizontal semicircular canal.
We used the canalith repositioning procedure (CRP) in a patiant with apogeotropic direction-changing positional nystagmus diagnosed as BPPV, and observed the change from upper-beating nystagmus to down-beating nystagmus during the procedure. The change in the direction of nystagmus seemed to indicate the dispersion of otolithic debris from the cupula, that is to say, the conversion of cupulolithiasis to canalolithiasis. We observed the disappearance of nystagmus and vertigo after three days.

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Renal cell carcinomas rarely metastasize to the bones of the skull. We report here the case of a renal cell carcinoma that metastasized to the temporal bone.
The patient was an 85-year-old female who had been diagnosed with renal cell carcinoma and had undergone a left nephrectomy in October 1987. In December 2000, she noticed a swelling in her left temporal region. The tumor was 35×50mm, elastic and soft, and accompanied with a heartbeat upon palpation. A blood-filled tumor which had destroyed the left temporal bone without penetrating into the dura mater, with metastasis to the right ribs, was detected by CT, MRI, US and cerebral angiography (radiological features). It was diagnosed as a metastatic renal cell carcinoma of the alveolar, common clear cell subtype by open biopsy. We judged that it was impossible to perform a curative resection, so the patient was treated internally with cimetidine which has an immunity activation action. It was also important to maintain her quality of life and to boost her immunity.
Renal cell carcinomas tend to be highly metastatic, and metastasis after more than ten years is not uncommon. Therefore, it is prudent to always take renal cell carcinoma into consideration in the differential diagnosis of blood-filled tumors. In addition, caution should be exercised since these tumors are friable and tend to bleed during diagnosis and treatment.

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We report a case of temporal bone necrosis that emerged after radiotherapy for epipharyngeal carcinoma performed 13 years ago. The patient was a 51-year-old male. His major complaint was left facial swelling. Present illness: The patient underwent chemotherapy and radiotherapy (Co 60, 6120 rad), as the treatment of that period, for epipharyngeal carcinoma from September 30, 1986 to January 31, 1987. He also underwent lobectomy of the left temporal lobe in brain surgery for left temporal lobe necrosis in August, 1989. After that operation, we saw constriction in his left external acoustic meatus and continued the follow-up. On October 22, 1999 he felt a left facial swelling. We found skin defects and ulcer formation in the front part of his left ear. Although we administerd an antiseptic and antibiotic to the diseased area, his condition did not improve. He was hospitalized for the purpose of undergoing medical treatment on January 6, 2000. Status: We found extensive skin necrosis and defects in his left auricular area. The corrupted temporal bone reached the zygomatic, the bone department external acoustic meatus and the mastoid process was exposing. Treatment: We performed debridement of the diseased area on January 19, 2000. On February 23, we performed reconstruction by left trapezius muscle flap after debridement once again. One year after the operation, the flap was completely incorporated.

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During the last nine and a half years (1991-2000) endoscopic electrocautery was performed on 18 patients (16 males and 2 females) with epistaxis at Ehime Prefectural Central Hospital. Using the endoscope all patients were investigated in the nasal cavity under general anesthesia. Six patients had bleeding sites at the posterior portion of the middle nasal meatus, seven patients in the olfactory cleft, three patients at the sphenoethmoidal recess, two patients in the inferior nasal meatus and one patient at the nasal septum. One patient had multiple bleeding sites. For these bleeding sites, electrocautery using the endoscope was successful. There were no complications after endoscopic electrocautery. Because of reduced invasion and greater safety, endoscopic electrocautery should be the first choice for patients who require complete surgical treatment of the posterior epistaxis.

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Asymptomatic sphenoid abnormality in a 55-year-old female was detected on brain magnetic resonance imaging during a medical check-up. Local and radiological findings suggested a meningoencephalocele, but these modalities could not identify an apparent bony defect in the skull base or communication with the brain. Endonasal endoscopic sphenoidal antrostomy was performed to establish a definitive diagnosis. Membranous pulsation, which suggested dura mater, was found on penetration of the anterior bony wall. Serous fluid containing glucose was collected with a fine needle puncture, establishing a diagnosis of meningoencephalocele. The puncture hole was sealed with mucosa from the ipsilateral inferior turbinate. When asymptomatic paranasal meningoencephalocele is suspected by computed tomography scanning and magnetic resonance imaging, a minimally invasive endoscopic approach is recommended to establish a definitive diagnosis.

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Recently, most frontal sinus mucoceles have been successfully managed by endonasal procedures. However, endonasal frontal sinus surgery will not be successful if the disease cannot be reached or longterm stable drainage is not established, despite opening the frontal sinus wide (with a type II or III drainage according to Draf), or prolonged stenting at the neo-ostium. In these cases an external approach is necessary. We report a patient suffering from a giant mucocele of the right frontal sinus extending into the right orbit and lateral to the right anterior cranial fossa. The wall of the mucocele was totally dissected under microscopic control with great care. The cavity in the frontal base left after the removal of the wall of the mucocele was packed with the reflected pericranium and rotated temporal muscle flap. The patient has been event free for 10 months postoperatively and will be followed up periodically.

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We performed uvulopalatopharyngoplasty (UPPP) and nasal surgery simultaneously for 13 patients with sleep-disordered breathing.
Comparing these patients with 21 cases who underwent UPPP and nasal surgery, respectively, for age, body mass index (BMI), nasal cavity resistance, quantity of bleeding, operation duration, post-operative course and hospitalization period, there were no statistically significant differences except hospitalization period. (p<0.05).
No major complications such as airway loss, near-fatal hemorrhage, or arrythmia occurred.
We performed simultaneous operations under patient selection standards as follows: 1) aged under 45, 2) BMI less than 30kg/m², 3) no cardiopulmonary diseases, 4) the subject has simple snoring or obstructive sleep apnea with an apnea index of less than 20times/hour, 5) no indications for the type of tongue base.
We consider that maintaining these standards and careful respiratory management will lead to good results.

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Congenital piriform sinus fistula, which is usually unilateral, is recognized as a cause of acute suppurative thyroiditis. We have encountered a rare case of bilateral piriform sinus fistulae. The patient, a 53-year-old female, was referred to our hospital because of right neck swelling, which improved after conservative treat. Three months later, an abscess of the left thyroid lobe was presented and was improved after incision and drainage. The diagnosis of bilateral piriform sinus fistulae was made by hypopharyngeal enhancement radiography. Total fistulectomies were performed. There was no recurrence observed six months after surgery.

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Objective: In this study, we evaluated the efficacy of uvulopalatopharyngoplasty (UPPP) in patients with obstructive sleep apnea syndrome (OSAS) both subjectively and objectively, on the basis of responses to a mailed questionnaire from subjects, as well as pre- and post-operative physiological examinations and upper respiratory magnetic resonance imaging (MRI).
Subjects and Methods: This study comprised 23 patients who had undergone UPPP during the 9-year period from 1990 to 1998, together with physiological examinations and upper respiratory MRI before and 3-6 months after the UPPP, and who responded to the mailed questionnaire. The questionnaire survey was conducted before and 43 months (mean) (±23.8; range: 13-89) after UPPP: the response rate was 64.7%.
Results: The frequency of snoring was significantly correlated with the postoperative length of the soft palate (p<0.05), that is, the shorter the postoperative length of the soft palate, the lower the frequency of snoring became. In addition, postoperative sleep quality was found to be significantly correlated with AHI improvement rates (p<0.05) as well as to the postoperative transverse diameter of the pharyngeal cavity (p<0.01). In other words, sleep quality increased in parallel with the increase in AHI improvement rates as well as with the increase in the transverse diameter of the pharyngeal cavity. With regard to the degree of interference in the sleep of a bed-partner, the higher the preoperative AHI (p<0.05), the lower the degree of interference. The degree of general satisfaction with the surgical outcome was higher among patients with higher preoperative AHI (p<0.01).
Conclusion: These findings indicate that the length of the soft palate is associated with the frequency of snoring and that the transverse diameter of the pharyngeal cavity is related to the frequency of sleep apnea. Therefore, shortening of the soft palate and the uvula as well as lengthening the diameter of the pharyngeal cavity may be indicated as surgical treatment for snoring and sleep apnea, respectively.

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We report here a case of anaplastic thyroid carcinoma with a high serum GM-CSF level. A 75-year-old man was admitted because of a rapidly enlarging neck mass. Investigation demonstrated that the neck mass consisted of anaplastic carcinoma of the throid gland. Although radiation therapy was performed, he died 3 months after admission due to respiratory insufficiency caused by metastatic lung carcinoma. Marked elevation of the number of leukocytes to 95, 700/mm³ was observed during the clinical course, and an increase in the GM-CSF level (46.90pg/dl) was demonstrated in the serum. We discuss the clinical course and prognosis of this tumor based on our case with reference to the literature.

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A 21-year-old male with an extracranial trigeminal neurinoma is presented. Swelling of the pre-auricular region was noted in 1998 and the patient consulted in one of our clinics. CT scan and MRI demonstrated a lesion consisting of five linked nodules that seemed to extend along the extracranial course of the mandibular nerve, passing between the medial and lateral pterygoid muscles and extending laterally toward the medial aspect of the compressed parotid gland. The anterior condyle of the mandible was displaced. Pathological diagnosis by fine needle aspiration biopsy showed neurinoma. The tumor seemed to originate from the mandibular nerve. After the diagnosis was established, the patient was observed for 2 years without surgery. In 2000, repeat CT examination demonstrated that the tumors had enlarged and erosion of the oval foramen had progressed. Therefore, surgical treatment was indicated. Surgery was performed in September 2000. A bicoronal skin incision was made with extension to the periauricular and cervical area. An infratemporal extradural approach combined with a zygomatic and mandibular osteotomy. The moniliform tumor was totally extirpated. Postoperatively, the patient displayed sensory defects of the mandibular nerve and trismus. The latter was improved by rehabilitation one year postoperatively.

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A 65-year-old female complained of swelling in the temple area, general fatigue and discharge from the right ear.
CT and MRI found multiple abscesses in the brain, temporal muscle and intraorbital tissue, and acute otitis media, mastoiditis and acute sinusitis were also found.
All samples taken from blood, abscess in the temporal muscle, intraorbital abscess, discharge from the ear and discharge from the nose revealed that all of these infection were caused by S. constellatus which belongs to Streptococcus milleri group, forming part of the resident flora of mouth.
The patient was cured with ABPC and drainage was effective.
The gram-staining method was useful for selecting effective antibiotics in the early phase of treatment.

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We present two cases of serious deep neck abscess. Case 1 was a 60-year-old female with mediastinal abscess secondary to deep neck abscess complicating chronic hepatitis C during interferon treatment. Case 2 was an 81-year-old female with extensive deep neck abscess, and during treatment she was discovered to have diabetes mellitus. Computed tomography was most useful in both diagnosis and conducting post-operative observation. Surgical drainage in combination with intravenous infusion of appropriate antibiotics improved the abscess in both cases.

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“3DX Multi-Image Micro CT” is a new compact three dimensional X-ray CT that is incorporated with the limited cone beam X-ray CT (Ortho-CT). Using a very sensitive image intensifier, 512 projection images in a cylinder with a height of 30mm and a diameter of 40mm are stored as mass volume data in a personal computer. On the monitor, the axial, coronal and sagittal CT images are simultaneously displayed in a window by processing the stored data. Two cursors crossing at a right angle on each CT window indicate planes of the slices of the other two CT windows. By dragging the cursors the plane of the slices changes and the CT images move according to the structural change. Considering the size of the cylinder, we thought that the ear would be a suitable structure to investigate using this new type of imaging technology. The paper describes the principle of the system and direction of slices to obtain CTs showing fine structures of the normal middle and inner ear. Using the middle ear slice the ossicular chain and the structures of the middle ear wall such as the facial canal and oval and round window niches are clearly visible on the monitor window. The inner ear slice, the detailed bony structure of the cochlea, vestibule and semicircular canals and the internal auditory canal are discernible. As far as the bony structure is concerned quality of the image is superior to that of conventional CT. Not only for clinical diagnosis, this new imaging technology is useful to investigate and to teach both anatomy and pathology of the ear.

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