Therapeutic strategy for otitis media with effusion (OME) in children according to age was described. OME in young children under the age of 3 is important in the sense that OME during this period is highly related to the etiology of its sequelae such as cholesteatoma, and should be extensively controlled by various treatments including explaining the harm of day care and tympanostomy tube insertion. Low-dose long-term mefenamic acid is also sometimes effective. OME in children between 4 and 9 years of age generally has a good prognosis, and the treatment, particularly surgical treatment, should be strictly indicated. OME in children over 10 years of age can be regarded as already intractable similar to that in adults, and should be aggressively treated, because this period is the last chance to prevent OMEs from tranforming into sequelae, although the management is not easy. The first thing that we otolaryngologists should do for such patients is to detect particular pathogenetic factors that OME children in this age group often have, such as organic abnormalities in the eustachian tube including obstruction or closing failure, or intractable inflammation in the nasopharynx such as adult-type chronic sinusitis. Low-dose long-term macrolides is sometimes effective for these pathologic factors.

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Audiography, X-ray (Stenvers view) and Magnetic Resonance Imaging (MRI) were performed on 88 patients exhibiting unilateral tinnitus. We diagnosed 4 cases (4.5%) of vestibular schwannoma and 41 cases (46.6%) of other abnormalities, including 2 cases of meningioma, 24 cases of old cerebral infarction, and 5 cases of mastoiditis.
MRI was considered to be a first-line clinical examination for patients with unilateral tinnitus.

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We report two cases of high jugular bulb presenting with conductive hearing loss. Although patients with high jugular bulb are frequently asymptomatic, it should be recognized that high jugular bulb can occasionally cause tinnitus, hearing loss and dizziness.

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We report a case in which mastoiditis caused meningitis with consciousness disturbance due to acute otitis media in patient with cerebral arteriovenous malformation (following AVM surgery), occurring 14 years after surgery.
The patient was a 32-year-old, female. X-ray and CT scan of the mastoid showed clouding and a fusion image involving part of the mastoid cells on the affected side. A burr hole showed the presence of mastoid cells, and thus it was thought to be the route of infection.
The patient underwent mastoidectomy. A bone defect was recognized in the middle cranial fossa, but there was no dura mater defect or leakage of cerebrospinal fluid observed. However, leakage of cerebrospinal fluid did later develop 12 days after the initial surgery. Craniotomy was performed over a wider area than that during the previous AVM surgery.
An increase in the size of the cerebrospinal fluid fistula and in the degree of granulation was recognized in the osteotomy region and in the dura mater that had been incised during the previous AVM surgery. This case supports the findings of previous reports which indicated that factors such as inner ear deformity or duraplasty in an area behind acute otitis media may be related to intracranial otogenic complications. Craniotomy for AVM may be a potential route of infection for intracranial otogenic complications. The surgical method should thus be selected and managed carefully in order to avoid postoperative onset of such infections.

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We presented 10 cases of eosinophilic otitis media (EOM) at Asahikawa Medical College Hospital and related institutions. All cases had non-atopic asthma, 8 had chronic sinusitis, 6 had nasal polyps, 5 had allergic rhinitis, and 8 had hyposmia. One case had sensorineural hearing loss. A high IgE value or a positive serum RAST score existed in 6 cases, but there was no antigen specificity. Myringotomy, corticosteroid eardrops, and anti-allergic drugs were used for primary treatments. For the cases in which primary treatments were ineffective or which had sensorineural hearing loss, we systematically administrated prednisolone. All 6 cases that were systematically given prednisolone improved in otologic findings. With hyposmia, 1 case that had primary treatment and 6 cases that were systematically given prednisolone improved hyposmia with improvement of otologic findings. In these cases that required prednisolone, there were tendencies for multifocal eosinophilic inflammation, uncontrollable asthma, or long-term morbidity of ear symptoms. In EOM, the cases that may be systematically given prednisolone are not rare. Considering the side effects of medication with prednisolone, the establishment of a safer and more effective treatment than systematic prednisolone medication is necessary.

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Hypoglossal-facial nerve anastomosis is a procedure for restoring facial nerve function after facial palsy caused by surgery for removal of cerebellopontine angle tumors. Classical hypoglossal-facial nerve anastomosis, however, sacrifices the hypoglossal nerve, inevitably causing hemitongue atrophy. To preserve hypoglossal nerve function, we tried hypoglossal-facial nerve side-to-end anastomosis for a 67-year-old woman who suffered from complete facial nerve palsy due to the removal of an acoustic neuroma. In this technique, the facial nerve in the mastoid cavity is exposed to the level of the external genu and then transected. The hypoglossal nerve is also exposed at the level of the axis and dissected as proximally as possible. One-third of the hypoglossal nerve is transected and the distal stump of the facial nerve is anastomosed without tension. In the postoperative stage, this technique provided facial reanimation without hypoglossal nerve dysfunction within one year. In conclusion, hypoglossal-facial nerve side-to-end anastomosis is a useful treatment for patients with long-standing facial palsy who do not want to have tongue dysfunction.

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Chondroblastoma is a rare tumor of the bone that represents approximately 1% of all primary bone tumors. This tumor frequently grows within the epiphysis of long bones, and, very rarely, in the temporal bone.
We report a case of chondroblastoma of the temporal bone and discuss the clinical features, histopathological findings, differential diagnosis and treatment.

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We report a case of giant pleomorphic adenoma of the left parotid gland. The patient was a 72-year-old female who had noticed the mass 20 years ago. At that time she visited a hospital and was recommended for surgical treatment. The tumor was not treated becouse of fear of the surgery. The tumor gradually enlarged. She suddenly noticed pain and visited our hospital. Initial examination revealed a giant tumor in the left parotid gland without facial palsy. The giant tumor was extirpated under general anesthesia. The tumor originated from the deep lobe of the parotid gland. Histopathologically, the tumor was diagnosed as pleomorphic adenoma without evidence of malignancy. The extirpated tumor was 14cm in diameter and weighed 720g. Postoperatively, palsy of the mandibular marginal branch of the facial nerve occurred. The palsy improved within 3 months. There has been no recurrence for 8 months.

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We report a case of laryngeal carcinoma metastasizing to the small intestine. A 51-year-old man who had been treated for laryngeal carcinoma presented with abdominal pain. CT of the abdomen revealed hypertrophy of the ileum wall. There was an incomplete obstruction of ileum. After resection of the obstruction, the patient was free from abdominal pain and became able to eat. The specimen demonstrated an infiltration of the small intestine by squamous cell carcinoma, speculated to be from the larynx.

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Rituximab is a mouse/human chimeric monoclonal antibody that targets the CD20 antigen found on the surface of malignant and normal B lymphocytes. The cytotoxic effects of rituximab appear to involve antibody-dependent cell-mediated cytotoxicity, complement-dependent cytotoxicity and induction of apoptosis. We treated two elderly patients having MALT lymphoma with rituximab combined with cyclophosphamide, pirarubicin, vindesine and prednisolone chemotherapy. It seems that rituximab in combination with conventional chemotherapy is a safe treatment in elderly patients.

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We report a case of inflammatory pseudotumor (IPT) of the parapharyngeal space, clinically mimicking a neoplastic process. A 68-year-old man was admitted to our hospital because of swelling of his left face and difficulty in opening the mouth. We found an ulcer with fur on his buccal mucosa, surrounded by granulation, and a palpable lymph node on his left submandibular region.
CT and MRI findings revealed the left parapharyngeal mass had invaded the left maxillary sinus with destruction of the posterior bony wall. A PET revealed that administered FDG was accumulated on the left parapharyngeal space, which subsequently appeared to the left buccal mucosa, and also on the right upper lobe of the lung.
The first biopsy of the abnormal buccal mucosa showed no malignancy. We performed an open biopsy of the parapharyngeal mass via the left maxillary sinus under general anesthesia. The pathologic findings were fibrotic tissue and inflamed granulation tissue.
Prednisolone at 20mg/day was instituted and decreased gradually, and totaled 555mg after 30 weeks; the tumorous findings in the left parapharyngeal space and lungs were extinguished.
IPT is a benign disease with no specific inflammatory findings pathologically, but with demonstrated bone destruction, which simulates malignant disease clinically. Our case was successfully treated with steroid therapy, without wide surgical excision.
IPT of the parapharyngeal space is an extremely rare lesion, compared with that of the paranasal sinus.

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We reported two cases of Schwannoma in the brachial plexus. A 51-year-old female and a 66-year-old male presented with a mass in the right lateral neck with pain in the right upper limb at palpation. MRI scans showed that the masses were neurogenic tumors originating from the right brachial plexus in both cases. We resected these tumors, which were encapsulated with enucleation. These tumors proved to be Schwannoma of Antoni A and Antoni B type on histological examination. Postoperative complications appeared in both cases. One had pain in the right upper limb at the C6 level, which improved in 16 months, and the other had disturbance in right limb elevation, which gradually improved in 5 months.

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We report a 44-year-old man with elongated styloid process and greater cornu of hyoid bone. The chief complaint was right neck pain on turning his head and the symptom had continued for one year. CT scan was useful for the diagnosis of both lesions. Surgical shortening of elongated styloid process and greater cornu of the hyoid bone was performed using the transcervical approach, and his symptom disappeared. The transcervical approach had the advantage of wide visualization and we could perform the surgical therapy safely.
The case involved hypertrophy of the tibial tuberosity and block vertebra (Th7-8). These findings suggest that the elongated styloid process and hyoid bone were part of systematic ossifying changes of the osteo-chondro tissue.

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Background.
This is a retrospective review of medical and financial records, conducted to test the hypothesis that the use of clinical pathways specifically designed for the management of the operation for thyroid and parotid tumors will result in the improved outcomes of patients.
Methods.
Twenty-six patients before implementation of a clinical pathway for thyroid tumor were compared with forty-six patients after implementation of the pathway. Also, twenty-five patients before implementation of a clinical pathway for parotid tumor were compared with twenty-nine patients after implementation of the pathway. Analyses of clinical outcome, length of hospitalization, and cost were performed. An unpaired t-test was used for statistical analysis.
Results.
‹Thyroid tumor clinical pathway›
For pathway patients, the average number of days using a drain tube was decreased to 2.8±1.1 days, versus 3.5±1.2 days for prepathway patients (p=0.03). The average length of hospitalization was decreased to 10.8±3.5 days, versus 15.2±4.7 days (p<0.0001). The average length of postoperative hospitalization was decreased to 6.5±2.3 days, versus 8.5±3.0 days (p=0.004). The average cost was decreased to 56, 994±15, 296 points (1 point=10 yen), versus 65, 619±18, 083 points (p=0.03).
‹Parotid tumor clinical pathway›
For pathway patients, the average length of hospitalization was decreased to 12.0±1.0 days, versus 22.0±3.2 days for prepathway patients (p=0.002). The average length of post-operative hospitalization was decreased to 6.9±0.8 days, versus 13.1±2.5 days (p=0.01). The average cost was decreased to 60, 424±3, 217 points (1 point=10 yen), versus 86, 286±12, 801 points (p=0.04).
Conclusions.
In using clinical pathways for thyroid and parotid tumors, we have maintained the quality of the operation and patient care, and have decreased the length and cost of hospitalization. With this study, we have concluded that implementing clinical pathways for thyroid and parotid tumors is beneficial for all parties.

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Tezon^® is a supplement containing trace elements (iron, zinc, copper, selenium, and other minerals). We presented this supplement for 10 taste disorder patients (32 to 72 years old, mean 56.3 years old, four males and six females). Serum copper/zinc ratios were improved and selenium levels were raised in all cases. The overall rate of improvement in all patients was 80% (eight cases). These results indicate that Tezon^® may be useful for taste disorder patients.

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