Based on our surgical experiences for facial nerve palsy, we introduced our principles of restoring facial function in this paper. When the facial nerve is sacrificed in its intracranial portion, hypoglossal-facial nerve anastomosis is indicated. When the nerve is sacrificed in its intratemporal portion, nerve grafting is indicated. When the nerve is sacrificed in its extratemporal portion, nerve grafting, partial or total, is indicated. When the nerve is removed in its intra-and expra-temporal portions, muscle transfer techniques (the temporalis, masseter and digastricus) with multiple facial suspension are employed. To reinforce the effect of reconstruction by nerve repair, we have recently added muscle transfer techniques and facial suspension. For facial suspension, we use a Gore-Tex Soft Tissue Patch.

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Analysis of speech and swallowing functions after reconstruction in patients who had radical resection of the tongue and the oral floor.Akiyoshi Konno, Tsuyoshi Hino, Nobuhisa Terada, Yoshitaka Okamoto. Degree of articulatory and swallowing disfunctions associated with radical surgery and primary reconsruction were evaluated in 20 patients with tongue cancer and 12 patients with anterior oral floor cancer by measuring swallowing pressure in the pharynx and intelligibility of speech. The following conclusions were obtained . (1) In total glossectomized patients in whom laryngeal suspensatory muscles were resected, primary laryngeal suspension and cricopharyngeal myotomy were absolutely necessary for prevention of aspiration. (2) In total glossectomized patients who also had total laryngectomy, reconstruction of simple wide passway of food was best suited for easiest transit of liquid food from the mouth into the esophagus, although swallowing pressure was almost negligible in the pharynx . (3) In subjects who had more than 2/3 of the tongue resected, ample augmentation of the oral floor by transplantation of voluminous tissue was indicated to improve postglossectomy intelligibility of speech. (4) Postoperative oral function was apparently poor in subjects who had pull-through operation for anterior oral floor cancer compared with those who had tongue cancer of same local extension. This is due to complete loss of bilateral genioglossus muscle function and partial or extensive loss of bilateral hypoglossus muscle function even in T2 cases. For improvement of oral function in these cases, anchorage of resected free edge of genioglossus muscles to the mandible by fascia lata transplantation may be worth trying.

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As with almost all swallowing disorders that might require surgical correction, the medical management of such diseases is frustrating because the accompanying neurological disorders are often unstable from the functional aspects. Some diseases are progressive and others are fluctuated in pathophysiology. In this series of surgical investigations, the following findings resulted in the further promotion of the surgical treatment for the swallowing disorders: 1. The pharyngeal flap operation is effective for the type of cases which involve the first phase of swallowing disorders (mastication). 2. Cases which involve the second phase of swallowing desorders (hypopharynx through the entrance of the esophagus), especially deglutitive problems regarding the phase of elevation of the larynx respond to the cricopharyngeal myotomy, etc. 3. Neurological disorders which involve misswallowing are precautious to the choice of surgical treatment.

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Since October 1983, we have experienced 30 surgical treatments for unilateral and bilateral recurrent laryngeal nerve paralysis. As dynamic reconstruction, 7 cases underwent free nerve grafting, 5 pedicled nerve muscle grafting, and 1 end-to-end anastomosis. Recovery of the vocal cord mobility was not seen in all cases. But they were free from atrophy of the vocal cords, which proves the efficiency of the treatments in prevention of vocal cord atrophy. In 69% of the cases, the maximum phonation times (MPT) were kept more than 10 seconds in the long time followings. As static reconstruction, 11 cases underwent thyroplasty type I (Isshiki), and 2 cases underwent intracordal silicone injection. Fifty percent of them obtained MPT more than 10 seconds after operations. In cases of bilateral paralysis, we used a one-way valve cannula (KOKEN) to keep both good phonation and safety respiration.

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During the past 14 years the tracheoesophageal (TE) shunt operation has been performed on 207 patients, and 172 patients (83%) retained fluent and intelligible speech with TE shunt. Out of 112 patients with the use of bilateral esophageal muscle flaps to avoid aspiration, 99 (88%) obtained the postoperative speech, while 73 of 95 patients (77%) with original technique obtained the postoperative speech.Out of 172 patients who had TE speech, 8 obtained voice capability with esophageal speech and the vibratory source during phonation with esophageal voice was located at hypopharynx as well as with TE speech. As far as the swallowing function is concerned, the patients with the use of bilateral esophageal muscle flaps had significantly less aspiration than those with the original technique.

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In recent years, aged patients with cacer of the head and neck have been increasing. However, it is not rare that treatment of these cases has an influence by the patient's general condition, complications, environments and progressing age. During from 1973 to 1989, 1, 020 patients with head and neck cancer were treated in Gunma cancer Center. The ratio of the patients over seventy years of age was 285/1, 020 27.9% and that of the patients from seven decade years of age was 227/1, 020 22 .3%, and that of the patients over eighty years of age was 58/1, 020 5.7%. The incidence ratio of primary site of the head and neck region shows laryngeal cancer 33. 5%, hypopharyngeal cancer 31.1% and followed maxillary cancer 29.7%. Surgical intervention in the patients with head and neck cancer of aged 153 patients can be performed with safety even under general anesthesia. The cummulative five year survival was shown as 39.0% in 41 cases of aged laryngectomized patients. In consideration of the quality of life of the patients, it will be ideal to obtain cooperation of the family as well as medical staff in postoerative rehabilitation.

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The complications after head and neck surgery in aged populations was discussed. Thirteen cancer patients over 80 years old were received surgical treatment under general Anesthesia. No operative motarity was noted and also medical complications in aged were minimum and acceptable. Decreased functions of vital organs by aging and history of complicated organ failure is able to induce postoperative complications. The risked patients was picked up by careful preoperative examination. Funcional changes of head and neck regions were significantly in aged patients over 70. Modification of surgical procedure can make minimum morbidity and keep acceptable postoperative function.

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In order to see if surgery in the elder patients is risky, particularly in the wound healing and recovery of the function, a survey of the postoperative states was done on 102 more than 70 years-old patients (the elder group) and 252 younger than 69 year-old patients (the control group) with head and neck cancer who underwent radical operation following or followed by radiation and /or chemotherapy . There was no difference between two groups in postoperative wound healing and recovery of the function. The age of patients was not regarded as a risk factor for radical operation, but, the association with systemic disorders, such as DM, liver cirrhoris, hypertension, etc., was much more risky in the wound problems . There was no tendency of wound infection with psudomonas or MRSA in the elder group . Results of this survey suggest that radical operation should not be denied in the elder patients on the basis of age alone.

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Merits and demerits of free tissue transfer with microvascular anastomosis for large head and neck defects in the elderly are discussed as compared with the standard pedicled flaps. Results of consecutive 190 flap transfers revealed that, in the elderly, 1) large flap transfers can safely be applied as in younger generations, 2) no definitive limitation is present in indicating various kinds of free tissue transfers, 3) the free rectus abdominis flap and the jejunal segment are the recommended free grafts, 4) as to pedicled flaps delto-pectoral flap is recommended while pectoralis major flap having danger of local complications, 5) the real risk factor is the general complication namely diabetes mellitus and liver cirrhosis.

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Diagnostic usefulness of such preoperative diagnostic techniques as xeroradiography, aspiration biopsy cytology, ultrasonography, and RI scintigraphy was evaluated in 454 patients with histopathologically established malignant thyroid tumore and 328 patients with similarly confirmed benign thyroid diseases who were seen at our department from 1980 through 1989. Results indicated that the probability of tumor malignancy ran higher in patients for whom xeroradiography, aspiration biopsy cytology, or ultrasonography results were positive. Adequate combination of these diagnostic tools seemed to result in a higher rate of correct diagnosis, although all fell sort of establishing diagnoses of tiny or follicular carcinomas.

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The outcome of surgery for Grave's disease was studied in 160 patients undergoing subtotal thyroidectomy between 1983 to 1989. The weight of preserved thyroid tissue was about 6 grams. There was a low operative morbidity and a zero motality. Hyperthyroidism had recurred in 28 patients (20%) and 23 (16%) were hypothyroid. The risk of developing recurrent toxicity was greater in female in her twenties. After surgery for Grave's disease lifelong follow-up is necessary.

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This paper discusses nineteen patients with advanced thyroid cancers treated in the Department of Otorhinolaryngology, the Center for Adult Diseases, Osaka, from 1979 to 1990. For the sake of convenience, we divided advanced thyroid cancers into four groups: those who had stridor or dyspnea due to laryngotracheal invasion (group 1), those who with the invasion of major blood vessels (group 2), those who had dyspnea due to bilateral recurrent nerve palsy (group 3), and those who with pulmonary metastases at the time of initial diagnosis (group 4). In the case of a potential of major vessel invasion, vasculosurgery or midline sternotomy should be prepared to perform. Radioactive isotope of iodine (131I) should be considered after total thyroidectomy in cases of pulmonary metastases at the initial visit.

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Prognostic Factors in Papillary and Follicular Carcinomas of the Thyroid . We analyzed several prognostic factors in papillary and follicular carcinomas of the thyroid gland on the basis of 15 and 20 year cumulative survival rates in our series followed up from 14 to 28 years. We Serected sex, age at surgery, TNM classification, and histopathological type as predominant factors and performed multivariate analyses based on Cox's proportional hazard model. Age at surgery was the single most important prognostic factor with the risk ration of 34. 38. T and N classifications were of some prognostic signficance with the risk ratios of 1 .90 and 3.05, respectively. We could not confirm the existing hypothesis that male patients with thyroid cancer had worse prognosis.

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From 1985 to 1990, 347 patients, 269 were men and 78 were women, presented to the Fukuoka University hospital Otolaryngologycal Clinic with facial bone fracture. Their age ranged from 2 to 68 years with a peak age of 1519 years. Of these, 210 cases were treated in an outpatient clinic and another 137 cases were received sergical treatment in a hospital. Sports injury and traffic accident were the most frequent cause of facial bone fracture. The most many cases of fracture region were nasal bone, but compound fractures of facial bone were not so rare in traffic accident. Three dimension CT was very useful for diagnosis and treatment of facial bone fracture. For surgical treatment of facial bone fracture, minimaturized screwed osteosynthesis plates were used.

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A study was made of orbital wall fractures, the so-called "Blow-out" fractures, in twenty seven patients. The fractures frequently occured in males (23 of 27 cases) . The common causes are interpersonal conflict injuries, incidents in sports and automobile accidents. For reduction of the orbital floor fractures, surgical approach via the maxillary sinus is the method of choice, since an otolaryngologist is familiar with sinus surgery and it is, therefore, easier to inspect for the inner aspects of the sinus and repair prolapse of orbital soft tissue into the sinus removing bone chips. The fractures of the medial wall of orbita are repaired via the ethmoid sinuses, using endoscope and silastic plate. It is not favorable to place an inplant of synthetic materials in the orbit. A support to maintain the repaired wall is usualy removed later through the sinuses.

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This paper reports 138 patients with trauma of the temporal bone seen at our Department from May, 1975 to September, 1990. Thirty-seven of them suffered from facial palsy. Twenty-two patients, 21 with longitudinal fracture and 1 with transverse fractures, were treated surgically. At surgery, temporal bone fracture was found to reach the geniculate ganglionic f ossa in 11 patients. The facial nerves were decompressed to the geniculate ganglion. Surgery was indicated for facial palsy which occurred simultaneously with trauma, which failed to improve for 2-3 weeks after trauma and which was accompanied by increasing dysfunction of the electroneuromuscular response, conductive deafness and epidermal retraction into the fracture line. Significant improvement following decompression surgery was demonstrated in some patients. The sequelae following traumatic facial nerve palsy were quantitatively analyzed.

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The surgical treatment of congenital aural atresia was analized statistically to find the pathogenesis in stenosis of created canal and loss of improved hearing. Thirty eight ears with congenital aural atresia were operated on to improve hearing during the recent 8 years. Tympanoplasty was performed in 19 ears and canaloplasty in the other 19 ears. Hearing was improved satisfactorily in 31.6% of canaloplasty cases and 84.2% of tympanoplasty cases. The most unpleasant and clinically important postoperative complications were the stenosis of created canal and the loss of improved hearing. The postoperative loss of improved hearing is caused by the scarring in the created canal and the middle ear cavity. The lateralization of new tympanic membrane and narrowing of created canal resulted in the same pathological changes. The results gained from our operated cases led to the following conclusions.1. Stenosis of the created external auditory canal is prevented by creating of canal with the diameter, 1.5 times longer than normal.2. The presence of a mobile stapedial f ootplate is the first condition to result in satisfactory postoperative hearing in the case operated with tympanoplasty.3. Lateralization of the created tympanic membrance is the primary cause of thegloss of improved hearing.

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The larynx has functions such as speaking, swallowing and respiration. The most important point in the treatment of the laryngeal trauma is that whether respiration was done or not without problem. The most negligence in the laryngeal trauma is a speaking. We represent some cases with laryngeal trauma and report therapeutic methods being carried out in our clinics. Three points such as removal of the necrotic cartilage, formation of the frame and enlargement of the glottis are important. The combined use of these 3 surgeries is performed according to cases. There is still limit in the treatment. The function as an air passage is just obtained at the present time.

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Development of osteosynthesis materials has contributed to the advancement of thetreatment of mandibular fractures and reconstruction of the mandible. Titanium, that is composed of pure titanium, has excellent biocompatibility which can be kept in a tissue for a long time. Now, this plate is replacing the instead of stainless steel plate, such as Chamy plate. The use of titanium plate fixation at mandibule reconstruction was reviewed in a series of 19 patients with fracture. It is possible that titanium plate may almost comeletely replace conventional treatment.

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After surgery of advanced maxillary cancer, we generally faced severe facial deformity even through using prosthesis. We performed new procedure to reconstruct wide defect after extended total maxillectomy. The orbital floor, nasal cavity, plate and/or cheek skin which were removed in operation were simultaneously reconstructed by using free rectus -abdomimal flap . This free flap was partially denuded in order to reconstruct the orbital floor and to obtain good possisition of the eye ball. This operative procedure protect diplopia due to the dislocation of the eye ball. In addition, this procedure was cosmetically so effective to avoid postoperatively severe retraction of the cheek Generally patients were able to start oral intake within 2 weeks after this surgery. In addition, we have not any cases of trismus at all since the free flap overlay the pterygoid muscle.

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In 32 patients with carcinoma of the tongue, oral floor and oropharynx, functions of articulation and swallowing were studied. More than half of the tounge was removed in 23 cases of oral carcinoma, and two or more sites were excised in 9 cases of oropharyngeal carcinoma. Articulation function was evaluated with Japanese monosyllables. For the oral carcinoma, understandable monosyllables ranged from 7 to 82%, depending on the size of the resection. Reconstruction with a myocutaneous flap had little effect on articulation. From 11 to 76% of monosyllables were understandable for the oropharyngeal carcinoma . After wide resection of the base of tongue, articulation was poor. Articulation was moderately disturbed by combined resection of hard palate, and restored well by reconstruction with a rectus abdominalis myocutaneous flap. Four cases out of 32 intook the liquid food only, and four patients somtimes aspirated a small amount of liquid. No patients needed the feeding tube. The function of articulation was significantly correlated with that of swallowing.

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Resection of paranasal sinus tumor often presents difficult technical problems when it invades cranial base. In this paper, we discuss the possibility of complete en bloc resection of paranasal sinus carcinomas extending to the cranial base by comparing operative findings with such imagings as CT, MRI, 3-DCT and microangiography. Clinicoradiographic findings about resectablity of the craniomaxillofacial units involved by paranasal sinus carcinomas reveal that complete en bloc resection is possible with the combined extracranial and extra-or intradural approach except in cases of 1) extensive infiltrations to the anterior and middle cranial base, 2) invasions to the sphenoid body and/or ICA and into the cavernous sinus, and 3) invasions into the brain. Three dimensional CT contributes significantly to make pre and post operative evaluations about resectability of the cranial base. A free rectus abdominis musculocutaneous flap is very useful for the reconstruction of the cranial base and a large maxillofacial defect.

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It is well known that the incidence of carcinoma of the middle ear and that the prognosis is poor. A case of squamous cell carcinoma of the middle ear extended to the skull base is presented in this paper. The case was a 49 year-old female complained of otorrhea in the left ear. Biopsy revealed the tumor which pressed the external ear canal from behind to be squamous cell carcinoma. CT and MRI studies suggested a destructive lesion of tegmen of the temporal bone and tumor infiltration to dura mater in this area. After preoperative irradiation and chemotherapy she was treated by the modified radical neck dissection and subtotal resction of the temporal bone with dura mater suggestive to be tumor infiltration. The defect after resection was reconstructed by the artificial dura, abdominal fat and DP flanp Any severe complication was not experienced. From our result and the literature briefly reviewed we concluded en block surgical resection of the temporal bone offers the patient with the middle ear carcinoma the best chance for cure.

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Surgical methods of the parotid gland have, in general, been standardized among otolaryngologists and head & neck surgeons. However, analysis of the surgical procedures in detail among our 123 cases disclosed atypically treated cases in 10-15 %. A group discussion has found there are slight discrepancies in understanding among the surgeons about the definition of the names of surgery. This study aims to reach the same common idea to the names of surgical methods, and to set a classification of the surgical procedures which is applicable to any individual case. By the extent of removal of the gland, the procedures were classified into partial resection (location), lobectomy (superficial, deep), parotidectomy and extended parotidectomy. The term “enucleation” was omitted because of inadequateness for the parotid tumor surgery. The treatment to the facial nerve is recorded independently from the extent of removal of the gland. Defect of surrounding organs and the way, of local reconstruction, the mode of neck dissection, preventive procedure to gustatory sweating and flushing also are recorded separately.

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Evaluation of cases operated with hyperparathyroidism. 24 cases of hyperparathyroidism were reported. Priamry 16 cases and secondary 8 cases were discussed with reference to the procedures of preoperative diagnosis and operation. During the surgery, all of the four parathyroid glands must be searched since more than two glands may occasionally be accompanied with hyper function. Results were succeeded in all cases except a case.

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