Medical risk management for prevention of medical adverse events is not a question of morality, but science. Medical risk management activities should improve the quality of medical management, in addition to taking countermeasures against mistakes. Surgical risk management activities consist of informed consent with good doctor-patient communication, surgical skills to avoid postoperative complications and detailed surgical records. Risk management in surgery for the treatment of vertigo is discussed.

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The risk management of endoscopic sinus surgery is reported. Complications of endoscopic sinus surgery have increased in recent years. In the preoperative management, both the evaluation of sinonasal cavity by CT scan and getting informed consent are crucial. Possible complications include hemorrhage, CSF leak and orbital injury as major complications. Orbital injury may lead to medical suits, because it is the most severe and irreversible among these complications. Early identification of the lamina papyracea reduces the potential for orbital injury. Dissection in the lateral wall of the most posterior ethmoid cells and sphenoid sinus should be minimized to avoid damage to the optic nerve. Excessive bleeding during surgery happens upon approaching the roof of anterior ethmoid cells, the posterior ostium of the maxillary sinus and the lower portion of the frontal wall of the sphenoid sinus. Blind treatment must never be performed. Supporting devices such as image-guided surgery or powered instruments may reduce intraoperative complications. To prevent surgical accidents, a detailed preoperative evaluation, a thorough knowledge of the regional anatomy, and meticulous surgical technique are important while performing endoscopic sinus surgery. Training courses, seminars and training instruments using textbooks or CDs are useful sources of knowledge of endoscopic sinus surgery.

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Twenty-seven cases of submandibular gland tumors treated in our department between 1982 and 2000 were reviewed. There were 20 benign and 7 malignant tumors. All of the benign tumors were pleomorphic adenomas (n=20). Two of the 7 malignant tumors were adenoid cystic carcinomas, 2 were adenocarcinomas, 2 were carcinoma et pleomorphic adenomas and one was high grade malignant mucoepidermoid carcinoma. Ultrasonography, CT, and/or MRI, was performed preoperatively. MRI is supposed to be more useful than other diagnostic imaging modalities. Fine needle aspiration biopsy (FNA) was performed in 20 cases, and its diagnostic accuracy for malignancy was 89.5%. Intraoperative frozen section examination was performed in 23 cases, and 17 of 18 benign cases and 1 of 5 malignant cases were in accord with the final pathological diagnosis. Extirpation of the submandibular gland and tumor, with resection of the adjacent connective tissue was performed in all cases. In the two adenocarcinoma cases, modified radical neck dissection and postoperative radiotherapy were added to the two adenocarcinoma cases. Postoperative radiotherapy was also performed in the mucoepidermoid carcinoma case. There was no recurence observed in any of the benign cases, and the 5-year-survival rate was 71% in the 7 malignant cases.

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A case with ethmoidal cemento-ossifying fibroma extending into the anterior skull base and orbit was reported. A 9-year-old boy presented with proptosis of the right eye and double vision. A CT scan demonstrated a large expansive tumor involving right ethmoid sinus which was well defined by an eggshell osseous capsule. Microscopical examination of a biopsy specimen revealed cemento-ossifying fibroma. The tumor was removed by anterior craniof acial approach. No evidence of recurrence of tumor was found for 9 months after operation.

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This study investigated which clinico-histopathologic factor, especially the depth of primary tumor invasion, is the most important parameter for predicting cervical lymph node recurrence in early carcinoma of the tongue. Twenty-nine patients with pT1N0 carcinoma of the tongue, who previously underwent partial glossectomy, were analyzed histologically for the relation between postoperative cervical metastasis and the surface size, depth of invasion, depth of muscle invasion, and bottom surgical margin. The overall cervical metastatic rate was 34.5% (n=10/29). The depth of invasion and depth of muscle invasion were statistically significant predictors of the cervical metastasis. When the depth of muscle invasion was more than 1 mm, the cervical metastatic rate was significantly higher: 47.4% (n=9/19), p=0.020. We concluded that the depth of muscle invasion (i.e., the presence of muscle invasion) was more important than the depth of invasion for predicting the postoperative cervical metastasis.

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Carcinoma arising in the thyroglossal duct remnants is rare: only 56 cases have been reported in the Japanese literature. An additional case was discoverd incidentally on histological examination of specimens following Sistrunk's operation for removal of thyroglossal duct remnant. The possibility of preoperative clinical diagnosis and the modalities of treatment are discussed.

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Cricohyoidoepiglottopexy (CHEP) is indicated for early stage and selected advanced stage laryngeal cancers. In this subtotal laryngeal surgery, thyroid cartilage is removed along with its intrinsic tissues leaving single or both arytenoids. The laryngeal defect is closed by approximat-ing and fixing the cricoid cartilage to the hyoid bone. Surgical procedure and technical tips are presented. Care must be taken to avoid recurrent laryngeal nerve injury during resection adjacent to the inferior horn of the thyroid cartilage. The surgical margin must be perfectly clear during the resection around arytenoids. The laryngeal defect must be sufficiently closed by approximating and fixing the cricoid cartilage to the hyoid bone to avoid cervical infection. These are three major points which might affect the surgical outcome.

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