Although reconstruction of the anterior skull base has been usually done with a pericranial flap, the necessity of bone grafting has been discussed. The bone grafting are divided into two types, free bone grafting and peduculated bone grafting. The free bone grafting often induces bone resorption, resulting in higher rate of the infection. In contrast, the peduculated bone grafting has an advantage to maintain viability of bone graft, resulting in lesser risk of flapnecrosis and infection. In this paper, we propose a new method of skull base reconstruction with vascularized frontal outer table flap, which can achieve reliable closure of the skull base defect.

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Three patients with stomal recurrence after laryngectomy were treated in Yamada Red Cross Hospital. Every case had been diagnosed as glottic laryngeal cancer, and underwent total laryngectomy following radiotherapy. Of these patients, one was given a reduction operation, which was followed with postoperative radiotherapy for residual mediastinal tumor. This patient is still alive for 2 year and 6 months without recurrence. One patient was conducted salvage operation for stomal recurrence, and reconstructed of the trachea with DP-flap. This patient is still alive for more than 5 months without recurrence. Stomal recurrence after laryngectomy is still miserable, and salvage operation has a tendency to be avoided. But occasionally, aggressive operation can relief from miserable prognosis. For the prevention of stomal recurrence, neck dissection of bilateral anterior compartment is necessary for patients with laryngeal cancer who undergo laryngectomy.

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Since the possession of firearms is severely restricted in Japan, gunshot wounds are rarely encountered. This paper reports an experience of the management of a patient with a perforating gunshot wound. On the evening of August 20th, 1999, a 31-year old Japanese male was brought into the emergency ward of Kobe University Medical Center approximately twenty-five minutes after receiving a gunshot to the face. An entry wound was found in the left parotid lesion and there was diffuse swelling of the surrounding area. As he felt dyspnea even in a seated position, he was given a nasal intubation and brought to our department. The patient was alert and his vitalsigns were relatively stable. An X-ray examination and a computed tomography revealed a left mandibular fracture and a bullet lodged in the right submandibular triangle. An emergency operation was performed to remove the bullet and debride contaminated tissue such as the bilateral submandibular glands and hematoma. The bullet penetrated the mandible at the jaw angle. It is assumed that the bullet's path was altered, as it turned to the right and passed through the suprahyoid muscles. It is also assumed that the bullet lost most of its energy along its penetration, which would explain the relatively little damage inflicted on the surrounding tissues, such as large vessels and some cranial nerves. The patient was discharged eight days later without any deformity following uneventful post-operative course.

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The purpose of this study was to investigate how closing the tympanic membrane perforation for chronic perf orative otitis media (COM) changes the air volume of the middle ear space. High resolution computerized tomography scan of the temporal bone (HRCT) with axial section was obtained in 12 cases of COM before and 18 or more months after myringoplasty. The slice width and thickness were 2 mm. With digital image processing described by Isono in 1994, the air volume of the middle ear space on HRCT was divided in to several planes, the volume of each of which was calculated separately. The sum of the partial volumes yielded the total volume of the middle ear space. The results were as follows 1) The postoperative air volume of the total middle ear space was larger than the preoperative volume (1.44±1.15 ml [Mean±S.D .] and 1.18±0.96 ml, respectively ; n=12). 2) The postoperative air volume of the tympanic cavity was larger than the preoperative volume (0.38±0.07 ml and 0.36±0.10 ml, respectively ; n=12). 3) The postoperative air volume of the mastoid cavity was larger than the preoperative volume (1.06±1.12 ml and 0.82±0.93 ml, respectively ; n=12). 1)-3), statistical analysis of the correlation between the preoperative and postoperative volumes indicated a significant difference (p<0.05). 4) All five cases without preoperative aditus aeration could not attain any aeration of the mastoid cavity postoperatively, either. We interpret the results to mean that, once the tympanic membrane perforation was closed, the middle ear space became normalized and its mucosa swelling improved. In addition, it was aerated again by ventilation through the Eustachian tube and its mucosa. On the other hand, we consider that the aditus mass in the five cases without any aditus aeration was organized and thus obstructed the aeration route to the mastoid cavity.

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We examined the postoperative masticatory and articulatory function of 21 cases who underwent surgical treatment for malignant tumors of maxillary sinuses at Kobe University Hospital. Ten of these cases underwent maxillectomy or extended maxillectomy without reconstruction except for the orbital floor (non-reconstruction group), three were treated with maxillary reconstruction using rectus abdominis myocutaneous flaps after maxillectomy or extended maxillectomy (reconstruction group), and eight were given irradiation, intraarterial infusion chemotherapy and curettage of the necrotic tumor (combined therapy group). The masticatory and articulatory function were examined by means of questionnaires. The masticatory function was further assessed with the low-adhesive, color-developing, chewing-gum method (chewing gum test), and the articulatory function was also evaluated with the intelligibility for 100 monosyllables (intelligibility test). The responses to the questionnaires demonstrated that all of them could take a normal diet, and that none of them needed writing as an aid to conversation. The chewing gum test showed that mastication was less satisfactory for the non-reconstruction and combined therapy groups than for the reconstruction group. The intelligibility score of 100 monosyllables was 75% for the reconctruction group, 69.9% for the combined therapy group, and 49 .5% for the nonreconstruction group. Although the superior masticatory and articulatory functions of the reconstruction group were demonstrated in this study, recurrences are hard to assess because the musculocutaneous flap is filled up in this modality. As the postoperative masticatory and articulatory functions were better than we expected, we conclude that patients with malignant tumors in maxillary sinuses should undergo en-bloc resection without reconstruction.

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