The effect of the transtympanic middle ear overpressure treatment using a Meniett® device on the symptoms of Meniere's disease was investigated. After a tympanostomy tube was inserted under local anesthesia, the treatment using the Meniett® was started. The subjects were six patients with Meniere's disease suffering from intractable vertiginous attacks. In five of the six patients, the attacks were reduced. However, there were no patients whose hearing was improved. Treatment using a Meniett® device was extremely safe and is indicated for high risk patients with Meniere's disease (for example, the aged, bilaterally affected, affected in only hearing ear, high risk for general anesthesia).

View full abstract

There are controversial reports about endolymphatic sac surgery (ESS) stating that simple mastoidectomy can obtain results as good as those by ESS. ESS does not last forever and demonstrates a high rate of recurrence due to closure of the endolymphatic sac (ES) after granulation or scar formation, which reduce the reliability of ESS.
It is considered that ESS would be used in more patients with MD if the problems of ESS could be reduced and its reliability improved. We perform a retroauricular incision 1 cm posterior to that performed in regular tympanoplasty because anatomical landmarks which help locate the ES, such as the sigmoid sinus and the posterior cranial fossa dura mater, are easily exposed, and a wide working field of view can be obtained, leading to safe identification of the ES.
Moreover, we report a new technique to fix the flipped external wall of the ES using harvested temporal fascia to prevent restenosis and closure.

View full abstract

To enhance the treatment effects for intractable Meniere's disease, we tried to expose the opened endolymphatic sac to high concentrations of steroids. This technique - endolymphatic sac drainage and steroid-instillation surgery (EDSS) - involves the application of a mass of prednisolone followed by absorbable gelatin sponges soaked in a high concentration of dexamethasone into the sac lumen opened and expanded with a bundle of absorbable gelatin films. These sponges are also placed around the sac and coated with biochemical adhesive so that the medicine is slowly delivered into the sac over a prolonged period of time as a natural sustained-release vehicle. EDSS was performed for 50 patients with intractable Meniere's disease by the first author (Tadashi Kitahara) at Osaka Rosai Hospital from 1998 to 2001. The long-term results (AAO-HNS criteria in 1995) in 50 patients treated by this technique showed that definitive spells were completely controlled in 80% out of the 50 cases. Hearing was improved by more than 10 dB in 50% out of the 50 cases. Mechanisms of EDSS effects on the labyrinthine functions are thought to be multiple steroid effects: anti-inflammatory, anti-edematic and vasoactive effects. Steroids directly instilled into the endolymphatic cavity may be more effective on the diseased inner ear organs than those applied via any other route.

View full abstract

Total maxillectomy is a basic operative procedure for a malignant tumor of the maxillary sinus. Although multidisciplinary treatment is often conducted for epidermoid cancer, total maxillectomy is conducted if it is a malignant tumor other than an epidermoid cancer. Total maxillectomy can be conducted with a clear visual field of the lesion provided by an endoscope. This method is effective in separating the periosteum of the periorbit and cutting the mucosa membrane on the floor of the nasal cavity and the epipharynx, in particular. To minimize bleeding, it is important to sever the skeletal muscle process of the lower jaw and ligate the maxillary artery before surgery. To maintain the original face shape after surgery, it is important to leave two incisor teeth and form the shape of the cheekbones to protect the eyeballs from sagging. It is best to reconstruct the face by maintaining the positions of the eyes and cheeks by applying the outer panel of skull bone to the orbital floors and covering them with a free rectus abdominal muscle flap.

View full abstract

[in Japanese]

View full abstract

In reconstruction of the ossicular chain, an autograft material would be an ideal ossicle substitute because of its excellent biocompatibility. When the stapes superstructure remains intact, a remnant of the ossicle (usually the incus) is appropriately trimmed and placed between the stapes capitulum and the tympanic membrane. When such ossicle is not available, a piece of cortical bone or auricular cartilage is applied instead. In contrast, when the stapes superstructure is missing, we use Apaceram ossicle with a sliced auricular cartilage on the surface of its head. According to the criteria proposed by the Otological Society of Japan, successful restoration of hearing was obtained in 70%-92% in tympanoplasty type III and 71% in tympanoplasty type IV in the study of 94 cases operated on during the last 5 years.

View full abstract

[in Japanese]

View full abstract

Indications, techniques, outcomes, advantages, and disadvantages of endoscopic endonasal or transmaxillary repair of orbital fracture are reported. The goal of this surgery is 1)to completely free intra-orbital tissues from entrapment and/or adhesion by fractured bone fragments and to restore smooth ocular movement, and 2)to reconstruct the orbital wall by returning orbital tissue from the sinus into the orbit and fixing it there. Fracture of the medial orbital wall is repaired endonasally and fixed with gauze packing for a week. Orbital floor fracture is repaired endonasally or transmaxillary and fixed with a urinary bladder catheter for a week. These techniques of repair have a wider operative field and allow easier forceps manipulation than does conventional microscopic transorbital repair, especially in the posterior part of the orbital floor. By virtue of the clear and magnified field of view in various directions and angles provided by the 0- and 70-degree rigid endoscopes, various tissues, such as the sinus mucosa, bone fragments, periostium, and periorbital adipose tissue, can easily be distinguished, decreasing the risk of injury of intra-orbital tissue. On the other hand, possible disadvantages of the endonasal approach include the difficulty of reinserting bone fragments after removal of fractured bone fragments to reconstruct the orbital floor. We believe that during the one-week period of fixation, regenerating sinus mucosa and connective tissue completely cover the wound and form new supporting tissue that covers the bone defect. Long-term follow-up is, however, necessary to determine whether enophthalmos will develop or not in the future. Endoscopic repair is considered an appropriate and less-invasive method for orbital fractures. Diplopia resolved postoperatively in 80.7% of our patients. However, in several patients with trapdoor fractures, the orbital tissues became fibrotic and diplopia persisted after surgery. When trapdoor fractures are suspected, repair should be performed as soon as possible.

View full abstract

[in Japanese]

View full abstract

[in Japanese]

View full abstract

Head and neck reconstruction by free tissue transfer is an important technique also for patients with a history of prior head and neck surgery. In these cases, careful attention must be paid to preparing the recipient vessels and to preventing infection. In this retrospective study, we analyzed our experiences of using free tissue transfer for patients with a history of head and neck surgery and indications of these surgeries were assessed. From 1997 to 2004, we performed 16 surgeries with free tissue transfer for head and neck reconstruction in patients with a history of prior head and neck surgery. Fifteen of these patients were male patients and one was female. Mean and standard deviation of age was 66.4 and 14.2 years. Nine of these surgeries were done for recurrence of cancer, 4 were done for post-operative fistulae, and 3 were done for the development of a second primary head and neck cancer. Although the success of these surgeries depends on several factors, one of the most critical steps is careful selection and isolation of the recipient vessels in the head and neck. In our experience, we often use the transverse cervical artery. This artery is usually preserved in the initial neck dissection, and can be relatively easily isolated even in the dissected field at a second surgery. We often choose the internal jugular vein as the recipient vein and perform end-to-side anastomosis. Preventing inflammation of the operative area is also crucial. In the cases described above, free jejunum was totally necrosed by post-operative infection in the region of the microvascular pedicle, however, all free tissue transfers were successful after controlling the infection.

View full abstract

Papillary cystadenocarcinoma is an uncommon neoplasm of salivary gland origin that rarely occurs in the minor salivary gland. A case of papillary cystadenocarcinoma of buccal mucosa is reported. A 66-years-old man is referred to us because of a painless swelling of the buccal mucosa. The tumor was excised with the surrounding minor salivary gland under local anes thesia. The postoperative course was uneventful.

View full abstract

Chondroid syringoma or so-called mixed tumor of the skin is a rare benign tumor. Two cases of chondroid syringoma from the right cheek and the external auditory canal are presented. Hematoxylin and eosin staining of this section showed histology corresponding to a chondroid syringoma. The clinical presentation, histology and treatment, and a review of the relevant literature, are discussed.

View full abstract

Four cases with olfactory neuroblastoma (ONB) during the 13-year period from 1991 to 2004 are reported. The patients were 27, 68, 67 and 52 year-old men. The chief complaints of all cases were unilateral nasal obstruction and epistaxis. To make a final diagnosis, immunohistochemical examination was very useful in addition to light microscopic findings. MRI is a valuable examination to assess intracranial involvement. As ONB is known to be radiosensitive, all patients were treated with preoperative radiotherapy (45 to 50.4 Gy), followed by craniofacial resection with reconstruction using Galleal flap. The efficacy of chemotherapy has not been established for this tumor, therefore, our cases were not treated with chemotherapeutic drugs. Two cases had local recurrence over 5 years after the initial treatment. In conclusion, we suggest that long-term follow-up is essential because of the high rate of local recurrence or metastasis, and that to control this disease, though chemotherapy might be considered, the combination of craniofacial surgery and radiotherapy is effective.

View full abstract

Cyclosporine is an immunosuppressant that suppresses cell-mediated immunity; it is used not only in organ transplantation to prevent rejection, but also outside of transplantation such as for nephrotic syndrome and severe inflammatory diseases. Infection induced by immunosuppressants is well known, and the incidence of infection related to immunosuppressants is rising with their increasing use for various diseases. We describe a patient with an epiglottic abscess who had been taking cyclosporine 4mg/kg/day for prurigo. Because antibiotics and steroid therapy were not usable, we performed surgical drainage of the epiglottic abscess under infrapsychic nasotrachial intubation.

View full abstract

We report three cases of first bite syndrome (PBS) after parotid surgery. The interval between surgery and the PBS episode differed in each case. The symptoms of PBS did not disappear or change. The tumors were located in or adjacent to the deep layer of the inferior pole of the parotid gland, and surgery was not performed in the parapharyngeal space, except in one case. The external carotid artery, superficial temporal artery and retromandibular vein were exposed at parotid surgery in all three cases. Although these vessels were generally not ligated, PBS appeared. Therefore, it is necessary to explain first bite syndrome even to patients whose external carotid artery, superficial temporal artery and retromandibular vein will be exposed during surgery for a parotid tumor in the deep layer of the inferior pole of the parotid gland.

View full abstract

[in Japanese]

View full abstract

It is not easy to make a definitive diagnosis of cystic lesions on CT, because various conditions in-cluding true cysts, neoplasms and metastatic or inflammatory lymph nodes exhibit similar cystic appearances on CT. Differential diagnosis of cystic lesions in the neck is discussed in this paper. In our series, cystic lesions on CT were pathologically diagnosed as fluid-containing cyst, hemorrhage, cystic degeneration and central necrosis of neoplasms. The preoperative diagnosis could be correctly estab-lished based on disease-specific findings, location, number of compartments, thickness of the wall and growth speed. The diagnosis could be more easily made in cases with more specific findings. On the contrary, the diagnosis was difficult in cases with previous history of inflammation or treatment at other hospitals. Collaboration between surgeons and radiologists is essential for correctly diagnosing cystic lesions on CT.

View full abstract