Pedicled flap can be classified as f aciocutaneous flap, such as deltopectoral flap or as myocutaneous flaps, such as pectoralis major and latissimus dorsi flap. Head and neck surgery was revolutionnized in the late 1970s by the use of regional myocutaneous flaps. This provides a large amount of well-vascularized tissue and has allowed single-stage reconstruction of almost any defect in the head and neck cancer. However, this flap have a limited length, skin paddle size, and arc of rotation. The pectoralis major myocutaneous (PMMC) flap and latissimus dorsi myocutaneous (LDMC) flap are the most popular flaps in the head and neck region. Deltopectoral flap is also useful flap though it became the primary method of resurfacing cutaneous and mucosal defects because PMMC flap became popularized in the late 1970s. We discussed the choice and the design of the flap, surgical technique, postoperative management and the management for necrosis of the flap in each flap.

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In order to determine the causative factor of microvascular free flap failure and discuss its prevention, we rewiewed 126 patients undergone head and neck reconstruction by the flaps including 67 radial forearm flaps, 26 rectus abdominis myocutaneous flaps, 22 free jejunal flaps, and 11 free colon flaps at Oita Medical University. Out of the total number, 13 flaps (10%) developed a vascular complication and total free flap necrosis occurred in 8 flaps (6.3%). The incidence of diabetes mellitus, hypertension, and previous operation of head and neck was high and they were considered to be risk factors of the free flap f alure. The comlication was due to arterial failure in five flaps and venous congestion in 8 flaps. Cause of the arteial obstruction was thought to be arteriosclerosis which is intrinsic factor of artery itself. Reexploration for the rescue of flaps was attempted, but no flap could be salvaged. The trouble on veins was caused by extrinsic factors that included hematoma and the planning of microvascular anastomosis. Abnormality of the flap was found ralatively early and 5 of 8 flaps could be salvaged. In order to prevent the free flap necrosis, therefore, it was conclued as following. (1) Changing over from a free flap to a vascular pedicled flap should be considered when severe arteriosclerosis is observed during the operation. (2) Avoiding compression of the vein by hematoma and abscess et al, and appropriate planning of microvascular anastomosis are important. (3) The reexploration is initiated as soon as posible in venous congestion.

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In the cases of arteriosclelosis, post-radical radiotherapy and without good arteries to anastomose because of re-operation, it is possible to occur flap necrosis in free microvascular tissue transfers. It is very important to select artery with good flow and to anastomose intima precisely. On the one hand, most of the venous thrombus is mainly due to a twist, to be oppresssed by surrounding tissue and setting of indwelling drain. Furthermore, to be improved success rate for free tissue transfers, main technique we introduced is internal jugular vein end-to-side anastomosis, anticoagulative therapy and carotid artery end-to-side anastomosis. As a result, we succeeded in expanding indication for difficult cases of microvascular anastomosis.

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We reviwed 74 cases of head and neck reconstruction surgery using bone compound musculocutaneous flap, between 1980 and 1997, at our hospital. The tissue used for these reconstructions are as follows ; rib-compound latissimus dorsi MC flap for 39 cases, rib compound PMMC flap for 18 cases, latissimus dorsi and rib-compound serratus anteriol MC flap for 14 cases and 3 other flaps. Total flap necrosis was seen in 2 cases (2.7%). Due to severe local infection, rib had to be removed in 10 cases. For successful management of bone componnd tissue transfer, we have to take care for these points, (1) not to disturb microvascular circulation around the rib, (2) to avoid local infection, (3) to remove the flap immedia tely after total necrosis, (4) sometimes to remove only grafting rib in order to reduce local infection.

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A total of 98 patients with early glottic squamous carcinomas (61 patients in Tla, 6 in T1b and 31 in T2) received vertical partial laryngectomy (VPL) from 1979 to 1998. All over 5-year survival rate, cause-specific survival rate and laryngeal preservation rate were 90%, 95% and 89%, respectively. There were no differences in those rates between the following three groups VPL for salvage after failure of irradiation on 47 patients, VPL as initial treatment on 35, and VPL as salvage surgery on 16 with previous irradiation in other hospitals. Consequently radiotherapy is better than VPL as initial treatment for early glottic carcinomas with taking account of quality of voice, and VPL is suitable for salvage after failure of irradiation. By means of questionnaires as to aspiration, no patients suffered from aspiration pneumonia, even if, with insufficient glottal closure for a long postoperative period.

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The idication of partial laryngectomy for laryngeal cancer was investigated. Eighty four patients (glottic 69, suprag0lottic 15) underwent extended f rontolateral larygectomy and sixty eight patients (glottic 2, supraglottic 66) underwent horizontal laryngectomy between 1971 and 1996 in Kurume University Hospital. The cause-specific five year survival rate for the patients with extended f rontolateral laryngectomy case was 91%, and that for the patients with horizontal laryngectomy case was 73%. The five year local control rate was 84% and 81% respectively. The five year local control rate was 100% for the patients with extended f rontolateral laryngectomy against the recurrence of radiotherapy or laser surgery, suggesting that they were good indication for extended f rontolateral leryngectomy. Postoperative recurrence occurred at the anterior commissure or subglottis in patients with extended frontolateral laryngectomy and at the anterior commissure, ventricle or base of the tongue in patients with horizontal laryngectomy. It should be noticed that, in patients who received frontolateral laryngectomy, cases with cancer cell invasion to the ventricle or aryepiglottic fold were more susceptible to local recurrence as compared to cases without invasion. Also, in patients who received horizontal laryngectomy, cases with cancer cell invasion to the vocal fold or ventricle were more susceptible to local recurrence as compared to cases without invasion.

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We studied 86 cases of orbital blowout fracture treated in our in-patient department between October 1981 and June 1999. Orbital floor fractures occurred in 51 cases, medial orbital wall fractures occurred in 12 cases, and both types occurred in 23 cases. Surgery was performed in 79 of these cases under general anesthesia. The eyelid approach, transantral approach, or the two approaches combined were used in cases of orbital floor fracture. The extranasal or intranasal approach via endoscope was used for cases of medial orbital wall fracture. Surgical treatment improved diplopia in 66 out of 74 cases. Postoperative improvement of double vision was better in cases treated surgically within 2 weeks after injury than in cases treated surgically more than 2 weeks later. It was thought that injury of the inferior rectus muscles occurred in cases with a relatively poor outcome.

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35 patients with blowout fracture were surgically treated between 1997 and 1999. We applied the endonasal approach to 29 of the 35 cases (medial fracture 11 and inferior fracture 18) using endoscope. Septoplasty on four and submucous conchotomy was complemented on 24 cases during surgery because of allergic rhinitis and acute/or chronic sinusitis. Bone fragments adhesive to the orbital contents protruded into the sinus were carefully removed. The periorbita was preserved as much as possible. Intraoperative traction test both after the repair as above mentioned and the temporary fixation using tampon gauze or balloon catheter was performed on all the patients to confirm the improvement of mobility of the eyeball. The result of the traction test related to the prognosis. Only three cases still showed slight diplopia postoperatively. This result indicates that endoscopic sinus surgery can be applied even to the orbital floor fracture.

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We reviewed cases of orbital blow-out fracture, which were endoscopically operated upon in our institution in the 1990s (229 cases). When diplopia and/or disturbed eye movement could not be improved after one week's conservative treatment, we performed endoscopic surgery as follows. Fracture of the lamina papyracea was repaired endonasally and fixed with a silicone plate and gauze packing. Fracture of the orbital floor was repaired either endonasally or trans-maxillarily and fixed with a balloon catheter. In the case of surgery performed under local anesthesia, improvement of the patient's complaints was able to be confirmed even during the surgery. However, when we have to perform surgery under general anesthesia, such as in a child, sufficient removal of the fractured bone as well as the traction test during surgery is needed. Post-operative improvement was evaluated on the bases of an ophthalmologic examination and the change in the patient's subjective symptoms. In about 90% of all cases, a good clinical course was achieved. When the fracture occurred in a narrow area, so that the intra-orbital content was got between fractured bones, the post-operative improvement tended to be insufficient. We, therefore, concluded that the prognosis after the operation depends, to some extent, on the severity of the injury to the orbital content at the time of the injury.

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Recently in Japan, the importance of informed consent for cancer patients has often been discussed. That for the patients with head and neck cancer is more important, because it is closely related to the quality of life. Truth disclosure is necessary for it, however, disclosure of a terminal illness is quite difficult, especially in Japan. Informed consent in the course of treatment in 61 patients with head and neck cancer who died after our examination and/or treatment were analyzed to clarify the present problems of telling the truth. In Nippon Medical School hospital, disclosure of cancer diagnosis was possible in 98% and that of recurrence of the disease was possible in 74% of the patients, however, that of a terminal illness was possible only in 9 % of the patients. These insufficient rates of disclosure were mainly because of psychological demerit for the patients. Truth disclosure including informing the patients about their terminal illness might be more important than before, considering the cost-effectiveness of cancer treatment and choice of maintaining the quality of life. One other problem about informing the patients truthfully is that terminal care performed at home and hospital is not sufficient for the patients and their families.

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Solitary or isolated involvement of the sphenoid sinus (Isolated sphenoid sinus disease; ISSD ) is a relatively uncommon disease. The present study reviews retrospectively 125 patients with ISSD treated at the Departments of Otolaryngology, Eye Ear Nose and Throat Hospital, Shanghai Medical University (109), and Hyogo College of Medicine (16) over a period of 25 years. Diagnosis was made on the basis of history, signs, nasal endoscopy, imaging techniques with CT/MRI. The final diagnosis of ISSD was established after histopathological and microbiological examinations of the excisional specimen. The pathology was sphenoid sinusitis (40), sphenoid cysts (35), fungal diseases (19), malignant tumors (9), and others (20). The most common initial symptom was headache, followed by visual changes and cranial nerve palsies due to the nearby involvements. Increasing use of routine imaging techniques with CT/MRI and diagnostic nasal endoscopy resulted in the increased numbers of early ISSD. Recent nasal endoscopic ostial sphenoidotomy warrants for the precise pathological diagnosis, and at the same time for the safe and immediate treatment, prior to the sequential extension to adjacent vital structures even to the serious or fatal stage.

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Fifty five cases with middle ear cholesteatoma which were performed second look and revision surgery were studied. In those cases, at the first operation, the posterior wall of the external auditory canal was reconstructed after canal down mastoidectomy. At the second operation, in 27 cases, the reconstructed posterior wall was totally removed, again, for investigation of residual cholesteatoma. In 26 cases, partial removal near to the epitympanum and the tympanic cavity was enough for inspection of the residual cholesteatoma. As the part was reconstructed with small cartilage, it was not complicated to remove it. At the second surgery, reconstruction of the mastoid cavity and the posterior wall was performed in 37 cases, and in 16 cases, the mastoid cavity was obliterated because of its severe pathological changes. After the second surgery, small bony absorption of the reconstructed posterior wall was observed in two cases, and abnormal findings of the eardrum were recognized in 10 cases. However, no cases were needed for frequent management or additional surgery. Improvement of hearing was succeeded in 100% of the cases with type I, 60% with type III and 30% with type IV tympanoplasty.

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In the present study, we retrospectively investigated states of occult metastases and recurrent nodes of laryngeal cancer to find appropriate mode of neck dissection for laryngeal cancer. One hundred and eleven patients with laryngeal cancer received treatment at this department from 1989 to 1998 and 30 patients who had undergone neck dissection were available for the present study. As a result, we found 1 case with recurrent node at level N in NO glottic cancer, while two cases of occult metastasis were observed at level II in NO supraglottic cancer. Neither occult metastases nor recurrent node were observed at level V in NO and N1 laryngeal cancer. On the other hand, we experienced some case with occult metastases at level V in N2 glottic and supraglottic cancer. Consequently, we conclude that neck dissection is not exactly essential for NO glottic cancer, but we should perform level II and III neck dissection for NO supraglottic cancer. Level II to N neck dissection is thought to be appropriate for N1 laryngeal cancer. We thought it necessary to perform radical neck dissection or modified neck dissection just for N2 laryngeal cancer.

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The melanotic neuroectodermal tumor of infancy is a rare, pigmented neoplasm that most frequently arises from the anterior maxillary alveolar ridge. This tumor presents in the first few months of life, and usually follows a benign course. The importance of early conservative surgical excision is emphasized with a good prognosis but it should be followed up for long periods because of the possibility of unusual malignant change in the tumor. A case of melanotic neuroectodermal tumor of infancy involving the anterior maxillary alveolar ridge of a 5 month old boy was reported. A partial maxillectomy with removal of the tumor was performed through a gingivobuccal sulcus incision at a 9 month old. The bilateral side of the maxillary alveolus and palate bone were removed and the mucosal flap of hard palate was applied in order to close the resulting defect. He could take milk perorally after one postoperative day and there is no sign of recurrence at 25 months after the removal. This tumor should be included in the differential diagnosis of head and neck neoplasms in infants and young children.

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