Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular tumor that originates in the nasopharynx of young males. The primary treatment is surgical excision. Conventional surgical approaches are associated with significant morbidity and facial deformity.We report a 25-year-old male with JNA, which extended toward the sphenoid sinus and the root of the pterygoid process. He had undergone surgery endoscopically with preoperative embolization and image-guided navigation system. Preoperative embolization reduced the volume of blood loss, and the image-guided navigation system helped the surgeons to identify the target structures in an accurate and reliable manner. There has been no recurrence so far. Endoscopic management of JNA appears to be effective for small to medium tumors combined with preoperative embolization and image-guided navigation system. The method used in this case should be considered as a first choice for these cases.

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We report a case of a 45-year-old male who suffered an external orbital injury from a wooden foreign body. Computed tomography showed that the foreign body had penetrated the orbit, lamina papyracea, posterior ethmoid sinuses and reached the bilateral sphenoid sinuses. Endoscopic sinus surgery (ESS) was performed to extract the foreign body. ESS techniques provided a safe and effective approach for extraction of a 70-mm-long and 10-mm-diameter twig with minimal morbidity.

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A 69-year-old female was referred to our clinic with recurrent nasal bleeding and resultant anemia (Hb 7.3 g/dl) . The patient had septal perforation as a result of frequent laser vaporization and the margins of the perforation were the sources of nasal bleeding. She had teleangiectatic lesions on her tongue, positive Rumpel-Leede test, and a brother with similar episodes of nasal bleeding, so she was diagnosed as having hereditary hemorrhagic telangiectasia (HHT or Rendu-Osler-Weber disease). To treat the septal perforation as well as recurrent nasal bleeding, the anterior aspects of the nasal septal mucosa were denuded and replaced with a facial artery musculomucosal (FAMM) flap on the left side, and with a split thick skin on the right side. She is now almost free from nasal bleeding. The FAMM flap is useful for treating patients with HHT especially with septal perforation.

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Ten patients (9 females and 1 male) with recurrent pleomorphic adenomas of the parotid gland were investigated clinically. Two of them were treated primarily in our hospital, 6 were treated by other otolaryngologists and 2 were treated by general surgeons. The cause of recurrence depends on the tumor type, their capsule and initial treatment. Partial parotidectomy is the first procedure that should be performed in these cases.Surgery was performed in all 10 patients: total parotidectomy in 1, partial parotidectomy in 7, and tumor enucleation in 2. The myxoid type and multiple tumor were the most common recurrent tumors. Tumors recurred again in 3 of our cases that had not undergone resection of their incision scars. Complete resection of the tumor and the surrounding scar is essential in the treatment of a recurrent tumor. Although preservation of the facial nerve is important, it is sometimes necessary to cut the nerve. These tumors can become malignant, so the management of each recurrent tumor should be monitored carefully.

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A parotid duct is frequently cut and simply ligated in radical surgery for buccal mucosa carcinoma. We performed reconstruction of the salivary duct by microsurgical repair using a submandibular duct graft in a case of buccal mucosa carcinoma (T3N1MO). We made a bypass between the new orifice and the cut end of the parotid duct using a submandibular duct graft which was obtained by selective neck dissection (level I to II ). The defect after resection of the buccal mucosa was covered with the free radial forearm flap. The reconstructed submandibular duct graft collapsed after the postoperative radiotherapy. The function of the parotid gland could not be preserved ; however, this method was useful because the postoperative complications such as salivary fistula or swelling of the parotid gland could be avoided. This method is simple and minimally invasive. This method should be indicated in the case of N positive oral carcinoma in which parotid function is normal preoperatively. A case of parotid duct repair using a submandibular duct graft is reported.

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We report a 34-year-old man who received a penetrating injury with a rod about 3 cm in diameter that pierced the lower left jaw and entered the oral cavity. Since bleeding continued from the lower left jaw and oral cavity, emergency CT was performed, revealing extensive hematoma around the jaw. Emergency surgery was performed to remove the hematoma and arrest the bleeding. During the operation, a hematoma was found beneath the platysma muscle, the submandibular gland was completely ruptured, and continuous bleeding from the submandibular gland parenchyma was seen through a communication between the gland and the oral cavity. The submandibular gland was completely resected and the opening into the oral cavity was closed with absorbable sutures. The neck wound was left open, and tracheotomy was subsequently performed. The open wound was cleaned daily with 0.02% povidone iodine solution and continuous aspiration was done through the cervical drain. He also received short-term steroid therapy and antibiotics. The postoperative course was good and he was discharged on Day 24 after surgery.

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Bony reconstruction is sometimes necessary for a defect in maxilla or mandible in head and neck surgery. Vascularized osseous tissue such as fibular bone, iliac bone and scapular bone is often used for the reconstruction. Scapular bone flap harvesting needs intra-operative positional change of the patient, which prolongs the operation time. Recently we started to harvest scapular bone flap in a spine position utilizing scapular bone mobility. This procedure makes scapular bone harvesting simple and eliminates the necessity of intra-operative positional change of the patient. Average harvesting time was 127 minutes (115 to 145) in four cases. Although it is impossible to harvest a long bone such as the fibula in this site, this procedure facilitates simultaneous harvesting of a short segment of good quality bone and relatively small skin flap.

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Mediastinal tracheostomas have poor tissue separating the tracheal skin suturing area and the mediastinum and therefore, infection occurring in the suture area readily extends to the mediastinum. In addition, there is the risk of rupture of the brachiocephalic artery due to mediastinitis or tracheal necrosis. To avoid this postoperative complication, we have performed an operative technique in which the mediastinal tracheostoma and the surrounding area are covered using a pectoralis major muscle flap for separation of the tracheostoma from mediastinal major blood vessels. In this study, we evaluated 6 patients who underwent mediastinal tracheostomy at our department between 1998 and 2003. No fatal complications such as tracheal necrosis, f istulation between the trachea and brachiocephalic artery, or mediastinitis were observed in any patient.

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We examined 32 patients who underwent subtotal thyroidectomy for Graves' disease by the same operater (chief author) in Tenri Hospital during 2 years (from 2002 to 2003) in a retrospective study. The first 13 patients were treated with subtotal resection on both sides and the second 19 patients underwent subtotal resection with contralateral hemithyroidectomy (Hartley-Dunhill method). We perform surgical treatment aiming at the euthyroid and the weight of remnant thyroid tissue of about 6 g for QOL. There was no statistically significant difference between the two groups concerning loss of blood and operation time. Postoperative hypocalcemia tended to occur in large goiter whose weight was more than 100 g. However, there was no statistically significant difference between the two groups concerning the incidence of post-operative hypocalcemia. In this study we did not perform transplantation of parathyroid glands in all cases, even if we could not preserve parathyroid vascular supply and they became ischemic. Although permanent tetany was seen in one case, that was a giant goiter with the total weight of 280g.

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We report a rare case of malignant fibrous histiocytoma of the larynx. A 70-year-old Japanese woman presented with an increasing hoarseness. A 10-mm tumor of the vocal cord was discovered on nasopharyngoscopy; however cord function was normal. CT and MRI findings confirmed a tumor of the larynx. Laryngomicrosurgery was performed under general anesthesia resulting in complete removal of the tumor. Histopathological examination revealed the mass to be composed of f ibroblast-like and histiocyte-like cells, exhibiting a connective tissue structure, consistent with the pathological appearance of MFH. No recurrence or metastasis has been reported during 18 months of postoperative follow-up and the patient continues to be monitored in our clinic. The literature contains only a small number of treated cases of laryngeal MFH, hence no standard protocol of treatment currently exists, and the disease appears to be treated on a case-by-case basis. In Japan, the tumor tends to be removed at an earlier stage than in other countries and laryngomicrosurgical resection is consequently the most common therapeutic choice; however reports of recurrence and metastasis are few. Tumor size thus appears to be related to prognosis.

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Pirif orm sinus fistula is a well-known congenital deformity derived from a third, fourth or fifth branchial cleft (pharyngeal pouch). This disease often causes repeated cervical infection or acute suppurative thyroiditis. In the last five years, we experienced three cases of pirif orm sinus fistula with a symptom of neck swelling, and fortunately complete removals of the fistulae were successfully carried out. Three cases are briefly introduced herein.Case 1 was a 15-year-old female, and case 2 was an 8-year-old boy. They suffered from left neck swellings. Barium esophagographies revealed fistulas originating from the apex of the left pirif orm sinuses. These fistulae were confirmed to be pirif orm sinus fistulae before surgical intervention, and were completely resected out.Case 3 was a 4-year-old girl, showing right neck swelling and fever. In neck magnetic resonance imaging (MRI), the abscess formation in the right lobe of the thyroid gland was highly suspected. During the operation, we found that this fistula originated from the hypopharynx and entered into the thyroid gland. Therefore, we performed complete resection of this fistula together with the right lobe of the thyroid gland.All the patients have good prognoses and no recurrence has been found to date.

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Patients with hypopharyngeal cancer usually visit the hospital in their advanced stages and their therapeutic prognosis is not satisfactory. For better therapeutic effect and organ preservation, the authors have been using the FAR regimen, a kind of chemoradiotherapy. which consists of 5-FU, vitamin A and radiotherapy. If the therapeutic effect is CR or is close to CR at the dose of 30 Gy, the FAR regimen may be continued until the total dose of 60-70 Gy. If the therapeutic effect was poor at the dose of 30 Gy, succeeding radical operation may be selected. The total cause-specific five-year suvival rate was 49%. The result for the early stage groups (Stage I and Stage II) was satisfactory (92%), while that for Stage III and Stege IV remained at 55% and 35%, respectively. In the surgical operation after chemoradiotherapy, preservation of the external cervical vein contained in the lateral skin flap and Grillo type tracheostomy are important to prevent post-operative fistula formation. There results indicate that the FAR therapy may be recommended for hypopharyngeal cancer for better survival rate and organ preservation.

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A 23-year-old male who had undergone auriculoplasty and enlargement operation for external meatal stenosis for the left microtia and external meatal stenosis during his childhood complained of difficulty in wearing in-the-ear hearing devices because of restenosis of external meatus. First, plasty of the vestibule of the left external meatus and caven conchae was performed and the diameter of the external meatus was enlarged, but in-the-ear hearing device slipped off during biting or eating. Second, the skin flap pedicled at the inferior part of the open vestibule of the external meatus was elevated. The top of the flap was partially resected, the rest was double folded, and a small bank was built at the open vestibule resulting in closed vestibule and caven conchae. Additionally, part of the auricular cartilage at the posterior side of the caven conchae was resected to make the closed caven conchae like a pocket and to prevent the hearing device from slipping off. Finally, the hearing device could be worn stably.

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[in Japanese]

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Sebaceous carcinomas of the eyelid are rare neoplasms, accounting for less than 1% of all eyelid tumors, but they frequently metastasize to regional lymph nodes. The five-year survival rate is about 50% among patients who develop metastasis to lymph nodes of the neck. Often, the macroscopic border of a tumor does not match the microscopic findings. Therefore, the tumor should be removed with a safety margin of at least 5 mm, considering the possibility of local recurrence. We experienced two cases of lower eyelid sebaceous carcinoma. After tumor resection, eyelid reconstructions were performed using the malar flap with the hard palate composite graft (periosteum and mucosa). Good results were obtained for these cases. Nowadays, it is rare for otolaryngologists to treat patients with sebaceous carcinoma. However, the chance of head and neck surgeons having to treat these patients is expected to increase in future.

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