Introduction: Recent technological progress has made it possible to precisely identify appropriate locations and directions in the surgical field using a navigation system. In July 1999, we started navigation surgery with an optical-tracking system. In this report we evaluate the advantages and indications for navigation surgery based on our experiences with 77 patients.
Subjects and Methods: Seventy-seven patients underwent surgery under the use of an optical-tracking navigation system (Stealth Station) from July 1999 to August 2002. This system was mainly composed of a work station, reference probe, image marker and positioning sensor unit. Patients consisted of 36 with nasal and paranasal lesions, 40 with temporal bone lesions and 1 with head & neck lesion.
Results: It was very useful to identify and observe the target points and structures accurately during surgery. Measured accuracy was 1.02mm in nasal and paranasal lesions and 0.42mm in temporal bone lesions. Time required for registration was 17min. in nasal and paranasal lesions and 43min. in temporal bone lesions.
Conclusion: In conclusion, this navigation system is safe, accurate and reliable, and was useful for reconfirming skull base lesions. The disadvantages of this system are its high cost and time for registration.
Congenital anomalies, re-operative cases losing their anatomical landmarks, petrous apex lesions, cochlear implants in ossified cochlea, cystic or small lesions in frontal, ethmoid or sphenoid sinuses and pituitary lesions are regarded as good indications for using this system.

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2 cases of suspected Wegener's granulomatosis showing inflammation in the middle ear and progressive sensorineural hearing loss (SNHL) are reported. The first patient was a 73-year-old female who visited our hospital with a complaint of sudden onset of hearing loss. She had SNHL and administration of steroid hormone improved her hearing acuity temporarily, but then her hearing deteriorated. Subsequently she showed subglottic stenosis, pneumonia and saddle nose. The second patient was a 55-year-old male with otalgia and hearing loss. He had progressive SNHL and ear polyp, and then showed saddle nose. His hearing loss was almost fully recovered after treatment with cyclophosphamide and predonisolone. It was considered in these cases that sensorineural hearing loss had an autoimmune origin. Otitis media is well known as an otological manifestation of Wegener's granulomatosis, but SNHL is comparatively rare.
Diagnosis of Wegener's granulomatosis was made by clinical symptoms because c-ANCA titers of our cases were negative, and histopathological studies were not typical. In these cases, they took predonisolone before diagnosis. We suggest that steroid hormones may suppress disease activity and make diagnosis difficult.
It is important to look for this disease among SNHL patients and perform general examination in the early stage, because early therapy can lead to an improvement in the morbidity and survival of this disease.

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The long-term prognosis of vertigo and hearing loss in patients with Ramsay Hunt syndrome was examined in the present study. We treated 23 patients with facial palsy, herpes zoster oticus and vertigo and/or hearing loss with steroids and acyclovir at our university hospital between 1998 and 2000. Facial palsy and herpes zoster oticus were accompanied by vertigo in 11 patients and by sensorineural hearing loss in 7 patients. One year after onset, 4 of 11 patients with vertigo showed persistent severe CP (canal paresis). They had persistent head-shaking after nystagmus and were handicapped in their daily life due to dizziness. The prognosis of vertigo is similar to that of vestibular neuronitis, but unlike that of vertigo with sudden deafness, in which a lesion is likely present in the inner ear. This finding suggests that vertigo with Ramsay Hunt syndrome is due to a lesion of the vestibular nerve. One year after onset, all 7 patients with mild to moderate sensorineural hearing loss demonstrated by falling audiogram showed normal hearing irrespective of accompaniment of vertigo. The prognosis of sensorineural hearing loss is different from that of sudden deafness. This finding suggests that sensorineural hearing loss with Ramsay Hunt syndrome is due to a lesion of the cochlear nerve.

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Salivary duct carcinoma is an uncommon tumor, and mainly originates in the parotid gland. We treated two patients with salivary duct carcinoma in the submandibular gland. One patient was a 60-year-old male who complained of right submandibular swelling. Submandibular sialoadenectomy, right neck dissection and postoperative radiation were performed. Four months later, multiple bone metastase were found. The other patient was a 40-year-old male who complained of right submandibular and bilateral cervical swelling. Submandibular sialoadenectomy, bilateral neck dissection, and postoperative radiation and chemotherapy were performed. Six months later, skin metastasis was found. Histologically, both were diagnosed as salivary duct carcinoma based on the presence of cribriform pattern and comedo necrosis. Preoperative diagnosis of salivary duct carcinoma is difficult. This carcinoma resists combined therapy and has a poor prognosis.

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We report a case of a 67 year-old woman with salivary gland amyloidosis which occurred secondary to multiple myeloma. The clinical complaints were obvious tumor of bilateral parotid and submandibular glands, and xerostomia.

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We report a case of hypopharyngeal fistula which was suspected of being a late complication due to radiotherapy. The patient was 54-year-old female who had undergone total thyroidectomy for thyroid carcinoma in 1967, receiving a total of 75Gy postoperative irradiation. In 2001 she came to our hospital complaining of neck pain and difficulty in swallowing. On pharyngoesophagogram we found a hypopharyngeal fistula. The fistula was located under the posterior wall of the hypopharynx between C4 and C7. It was undetectable with flexible fiberscope but was detected with rigid endoscope under the general anesthesia. We suspected it was a late complication of the irradiation. We performed endoscopic laser surgery (KTP), resected the tissue between the upper and lower openings of the fistula, and vertically exposed the fistula in the hypopharyngeal space. Her dysphagia improved. We discuss the mechanism of fistula formation in this case.

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Eleven patients diagnosed with spontaneous tonsillar hemorrhage (STH) of noniatrogenic/nontraumatic causes are reported and discussed.
Patients ranged from 4 to 63 years old (29.6 on average), consisting of six males and five females. Eight of the eleven STHs were secondary to acute tonsillitis without any hematologic disorders. Two cases of STH were observed in patients with idiopathic thrombocytopenic purpura; one case involved acute tonsillitis. In an elderly female patient, there was diffuse parenchymatous tonsillar bleeding of unknown origin. All cases involved peripheral tonsil vessel hemorrhage. In ten patients, the bleeding stopped spontaneously; in one patient, oxidized cellulose application by local pressure was used for hemostasis.
STH is not a disease, but symptomatic bleeding from the tonsil, mainly associated with acute tonsillitis, and it may be frequently overlooked without recognition of this rare entity.

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We report a case of arytenoid dislocation, which may have been caused by endotracheal intubation.
A 44-year-old man underwent surgery for middle ear cholesteatoma under general anesthesia with endotracheal intubation. The intubation was performed with no difficulty, but at the end of the operation the patient moved strongly before extubation. Postoperatively, he presented hoarseness. Fiberscopic study revealed immobility of the right vocal cord but normal mobility of right arytenoid cartilage, suggesting that the right crico-arytenoid joint may have been dislocated. After two weeks, there was no improvement, and we performed closed reduction. Immediately after fixation with laryngomicrosurgery, there was neither improvement of voice nor mobility of right vocal cord. After he started voice therapy, his voice began to improve, three weeks after the last surgery. Four weeks later, fiberscopic examination showed almost normal mobility of the right vocal cord.
From the literature review, we concluded that closed reductions should be performed as soon as possible after such an incident.

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A retrospective clinical study was conducted on 121 patients with laryngeal cancer treated in our department during the 10 years between January 1986 and December 1995.
Their mean age was 63.9 years, and the male to female ratio was 23:1.
These patients consisted of 73 (60.3%) with glottic cancer, 42 (34.7%) with supraglottic cancer, and 6 (5.0%) with subglottic cancer.
Metastases to cervical lymph nodes were observed in 3 (4.1%) patients with glottic cancer and 13 (31.0%) with supraglottic cancer, and incidence of cervical lymph node metastases was significantly higher in supraglottic cancer.
According to the 1987 UICC TNM classification, 46 (38.0%) were in stage I, 44 (36.4%) were in stage II, 16 (13.2%) were in stage III, and 15 (12.4%) were in stage IV.
The five-year survival rates were 92.9% in glottic cancer, 68.3% in supraglottic cancer, and 53.3% in subglottic cancer.
The overall five-year survival rates was 82.7%, including 95.3% in stage I, 85.2% in stage II, 62.5% in stage III, and 60.0% in stage IV.
The five-year larynx preservation rate was 80.3% in T1, 68.6% in T2, 22.2% in T3, and 0% in T4.

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Superselective arterial infusion for patients with advanced head and neck cancer has been increasingly applied in Japan. We analyzed our experiences and evaluated the efficacy and safety of this treatment.
Patients and methods: Through October 1999 to March 2002, 29 patients, ranging in age between 33 and 71 years (median 52 years), received superselective intra-arterial infusion therapy of cisplatin (100-120mg/m²/week) with simultaneous intravenous infusion of thiosulfate for neutralizing cisplatin toxicity, and conventional concomitant extrabeam radiotherapy (65Gy/26f/6.5 weeks). Four patients were diagnosed with stage III and 25 with stage IV. Thirteen patients were considered contraindicated for surgery, and the other 16 patients rejected radical surgery. Primary tumor sites included paranasal sinus (11 patients), hypopharynx (7), oropharynx (6), oral cavity (4), and parotid gland (1).
Results: During the median follow-up period of 20 months, there was no apparent recurrence in 14 (48.3%) of 29 patients. Eleven (37.9%) patients died of disease, and three (10.3%) were alive with disease. In twenty-one patients (72.4%) the primary lesions were well-controlled. Acute toxic effects were moderate, and severe toxic events occurred in four cases, namely, MRSA pneumonia, sepsis, tetraplasia, and osteoradionecrosis.
Conclusions: We confirmed the effectiveness and safety of superselective arterial infusion and concomitant radiotherapy. Furthermore, we must establish the optimal procedures and schedule, as well as the indications for this treatment. This treatment protocol may improve the prognosis of patients with unresectable disease and patients rejecting surgical treatment. Further study in this particular area is needed.

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We report a case of spindle cell lipoma of the cheek. A 44-year-old female presented with left cheek swelling. Physical examination showed a large and soft mass in the left cheek. Computed tomography and magnetic resonance imaging revealed a large lipomatous tumor, which included an enhanced solitary lesion. The tumor was completely removed under general anesthesia, and was histopathologically diagnosed as spindle cell lipoma. Spindle cell lipoma is a variant of the typical benign lipoma, and is characterized by mixture of mature fat cells and fibloblast-like spindle cells in a matrix of collagen. It usually occurs in the subcutaneous tissue of the back, shoulders, and neck, and is rare in the cheek.

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Since the discovery of the spontaneous regeneration of inner ear hair cells in birds and mammals from the late 1980's to the early 1990's, its mechanisms have been studied. Three mechanisms of regeneration of the inner ear hair cells have been reported so far: regeneration by mitosis of supporting cells, transdifferentiation of supporting cells into hair cells, and self-repair of the sublethal hair cells. However, which mechanism contributes most to the regeneration of the inner ear hair cells has remained to be elucidated.
Extrinsic and diffusible factors like various growth factors have been reported to proliferate hair cell numbers in the inner ear. Regeneration of organs could be achieved not only by induction of proliferation with extrinsic factors but also by repeating their developmental pathways in adult organs. Molecular biology and gene targeting reveal that various intrinsic factors and signaling pathways such as cell cycle regulators, WNT signaling, and Notch signaling have important roles in the development of inner ears, and that progenitors of sensory epithelium would exist at the greater epithelial ridge in the inner ear. Further analysis and application of these factors will contribute to regeneration of the inner ear hair cells.

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