The parapharyngeal space is frequently invaded by advanced oropharyngeal carcinoma through direct extension and lymph node metastasis, and previous reports have suggested that the lymphatic drainage of the oropharynx consists of parapharyngeal space. The surgical approach to the tumor of the oropharynx originating from the lateral wall in our deparment allows adequate margins on lateral and posterior sides and in the depth around the lesion with the mandibular swing procedure and we perform parapharyngeal dissection. As for five-year survival rate and locoregional control rate, preliminary data in our department has suggested that this approach is useful for the treatment of locally advanced carcinoma of the oropharynx. However, challenging problems regarding postoperative function of speech and swallowing remain in reconstructive surgery after wide resection of the lateral and superior wall of the oropharynx. We performed a specific velopharyngoplasty named the Gehanno method using the pharyngeal myomucosal flap. This reconstructive technique is simple and reliable, and achieves satisfactory velopharyngeal function from short to long term after repairing extensive defects of the oropharynx.

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Although various methods and flaps have been reported for the reconstruction of wide defects of the lateral oropharyngeal wall, there is no global standard. We devised a new reconstructive technique after wide excision of an oropharyngeal lateral wall. A long jejunum with a mesentery was gathered. The chorion side of the jejunum was filled up with sufficient mesentery after having formed a jejunum in the shape of a dome. We reconstructed the lateral wall so that the jejunum projected in the oropharyngeal cavity. The resulting swallowing function in patients whose oropharynx were reconstructed with this technique was exellent. We suggest that this method be the treatment of choice for reconstruction of extensive defects of the oropharyngeal lateral wall.

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Squamous cell carcinoma of the posterior oropharyngeal wall is relatively rare and has a poorer prognosis than other types of oropharyngeal cancer. We report here a retrospective study of 25 patients (23 men and 2 women; mean age: 67 years) with carcinoma of the posterior wall oropharynx who received radical treatment at the Department of Otolaryngology Head and Neck Surgery, Kurume University Hospital between 1974 and 2005. There were 3 stage I, 6 stage II, 6 stage III, and 10 stage IV patients. The primary disease was surgically treated in 18, and reconstruction was added in 5, such as by free jejunum (4) and forearm flap (1). Radical treatment by radiation alone was done in 7. Five-year cause-specific survival rate, determined by the Kaplan-Meier method, was 43%. Five-year local control was 48%. Seven died of primary oropharyngeal cancer. To improve the survival rate, local control seemed to be the most important. Regarding postoperative swallowing function, patients who received subtotal resection or resection of two-thirds of the posterior wall suffered from severe aspiration. For quality of life, if an en bloc resection of the tumor with subtotal resection and two-thirds resection of the posterior wall is possible, a laryngectomy for squamous cell carcinoma of the posterior oropharyngeal wall can be performed. In such patients, a total laryngectomy should therefore be applied to improve quality of life.

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Because the anterior wall of the oropharynx plays a very important role in speech intelligibility and swallowing function, the treatment of patients with tongue base cancer remains controversial. The purpose of this study was to investigate surgical approaches for tongue base cancer and postoperative swallowing function. In the period from 1993 until 2006, 23 patients who had undergone resection of the base of the tongue and subsequent reconstruction in our hospital were reviewed. The patients consisted of 18 males and 5 females, and the mean age was 56.7 years old. Four patients were in T1, 3 were in T2, 6 were in T3 and 10 were in T4. In all of the T1 and T2 patients and 3 of the T3 patients it was possible to preserve the larynx, but for the other T3 and all of the T4 patients laryngectomy was performed. In 3 of the T1 cases the larynx was removed by a suprahyoidal approach, and primary closures were performed. These patients had satisfactory postoperative swallowing function. It was a very useful approach for early tongue base cancer. More advanced cases were resected by a mandible swing approach or pull-through method and free flap reconstruction was necessary for these cases. Functional results of those cases were similar to those of patients who underwent microsurgical reconstruction after radical surgery for advanced tongue cancer. It is thought that laryngeal preservation was decided by the surgical defect of epiglottis. When total epiglottectomy was performed, laryngeal preservation was very difficult.

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To clarify the ideal method of free jejunal autograft reconstruction after circumferential pharyngolaryngectomy (CPL) in cases with a high pharyngeal defect, we retrospectively evaluated the swallowing function of these patients who underwent CPL for cancer of the hypopharynx and cervical esophagus. Thirty-nine patients were included in this study and 29 of them underwent total pharyngo-laryngectomy (TPL) at the level of hyoid bone and 10 had pharyngoesophageal defects with a high pharyngeal deficit extending up to the upper level of one side of the palatine tonsillar fossa. The types of jejunal autograft used were both oral and esophageal end-to-end anastomosis and 2 segments' (a patch segment for the lateral defect of oropharynx and a circumferential end-to-end segment) anastomosis with a single vascular pedicle. Functional outcome was evaluated based on the content of diet and time taken for eating by reviewing medical records. Twenty-seven out of 29 patients who underwent TPL could take a normal diet within 20-40 minutes. In cases with a high pharyngeal defect, although 3 out of 5 patients with both oral and esophageal end-to-end anastomosis could take a normal diet within 40-60 minutes, all cases with 2 segments' reconstruction could take a normal or soft diet within 20-40 minutes. These results suggest that one pedicle and two segments' reconstruction with oropharyngeal patch and an end-to-end anastomosis could be a more useful method of reconstruction in cases of a high pharyngeal defect after CPL.

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We report two cases of perforation of reconstructed gastric tube ulcer after laryngopharyngoesophagectomy for advanced hypopharyngeal cancer. One case was a 59-year-old woman who had undergone laryngopharyngoesophagectomy with reconstruction by a gastric tube in 1994. A cuta-neo-gastric tube fistula in her neck, with no recurrence of cancer, was recognized in 2000. We per-formed surgery to close the fistula by a pectoralis-major-myocutaneal flap and a delto-pectoral flap. In 2004, a fistula formed again in the same part of her neck. We performed surgery again with free jejunum flap and skin graft. The other case was a 48-year-old man who had undergone laryngopharyngoesophagectomy with reconstruction by a gastric tube and a free jejunum flap in 1999. He had no recurrence of cancer and showed good progress for 1 year and 8 months. He consulted us complaining of hematemesis in 2001. Endoscopic examination revealed an ulcerative lesion of the reconstructed gastric tube that had perforated the right common carotid artery. Angiographical embolization was performed, but he was not successfully rescued.

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To understand the significance of functional management of the thyroid gland in surgery for advanced malignancy of the larynx and the hypopharynx, we analyzed 59 patients who underwent surgery, retrospectively. These patients underwent total laryngectomy or total pharyngo-laryngectomy and bilateral neck dissection with preservation of the ipsilateral lobe of the thyroid and parathyroid glands. The outcome of preserving the thyroid function was evaluated 3 months after surgery based on the need for thyroid hormone replacement. Successful preservation of the function of the thyroid gland postoperatively was possible in only 40.7% of cases (24 of 59 patients). Retrospective analysis of the intraoperative findings suggested that preservation of the superior thyroid vein was most important. In those cases with insufficient preservation of the superior thyroid vein, the rate of successful preservation was significantly lower. We also reported the outcome of functional management of the thyroid gland on the parathyroid glands. In those cases with successful management of the thyroid gland, the rate of successful preservation of the parathyroid glands was significantly higher. These results indicate that appropriate preservation of thyroid function is not easy in advanced malignancy of the larynx and the hypopharynx, but that preservation of the thyroid gland during surgery is crucial for better functional outcomes for both the thyroid and parathyroid glands.

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We report the case of an 81-year-old man who had undergone segmental mandibulectomy for inferior gingival carcinoma. The defect was reconstructed with tongue flap and titanium plate. He had undergone resection of one third of his tongue for tongue carcinoma 5 years and 5 months previously.
During postoperative follow-up, we detected the inferior gingival carcinoma. He has suffered from non-insulin-dependent diabetes and angina pectoris for many years. Considering his age and those underlying diseases, we judged that reconstruction with tongue flap and titanium plate for the defect was indicated rather than free flap. He is currently without recurrence or metastasis after follow-up, for 1 year, and he has no swallowing disturbance or speech disorder.

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We studied the incidence of complications and treatment results in 85 cases of malignant tumors of the nose and paranasal sinus tumors, for which resection and reconstruction of the skull base was performed from 1984 to 2004. The breakdown of cases was: meningitis 10 cases (12%), cerebral infarction or brain contusion 6 cases (7%), intracranial hematoma 3 cases (4%), sequestrum 1 case (1%), general complications 1 case (1%) and non-complications 64 cases (75%). The death rate with surgical complications was 7% (6/85). The 5-year disease-specific survival rate was 34% in 45 cases of squamous cell carcinoma and 43% in all cases. When the cases were divided into two groups, namely resection of the frontal skull base alone and resection of the middle skull base, the incidence of encephalopathy was higher in the latter 17% (8/48) than in the former 3% (1/37). The 5-year disease specific survival rate in the cases of squamous cell carcinoma was 46% in the frontal skull base alone resection group and 27% in the middle skull base resection group.These findings suggest that resection of the frontal skull base alone is a stable type of operation with better surgical results and lower incidence of complications than resection of the middle skull base.

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Five cases with olfactory neuroblastoma (ONB) during the 3-year period from 2002 to 2005 are reported. All patients were treated by craniofacial resection with using Galleal flap. One case which had not been treated with radiation for negative surgical margin had local recurrence five months later. Another case, invading near the sinus cavernosus, could be treated by craniofacial resection after superselective intra-arterial chemotherapy using CDDP with radiation. We consider that ONB must be treated with radiotherapy in cases with negative surgical margin, and selective intra-arterial chemotherapy with radiation is effective for difficult cases for surgery.

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The patient was a 45-year-old female. She visited our hospital complaining of mass of the right neck. From physical examination, ultrasonography, CT scan, MRI and FNA, we suspected it as neurinoma derived from cervical vagus nerve. We prepared a microscope for the operation. The mass was connected with the vagus nerve, so we extracted the mass while carefully preserving the nerve under general anesthesia. The size of this mass was 2.7×1.6×1.3cm. Pathologically it was diagnosed as neurinoma. After the operation, she suffered from palsy of the right recurrent nerve, but gradually recovered and she has attended our hospital. If possible, it is important to try to preserve the vagus nerve, and a microscope is useful for the operation.

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Sinovial sarcoma, springing from mesenchyme rather than mature synovial tissues, is one of the soft malignant tumors which frequently breaks out to the limbs of a young man. Between 3% and 10% of all synovial sarcomas originate in the head and neck. It is thought that head and neck synovial sarcoma has a better prognosis than tumors of the extremities. We report a case of sinovial sarcoma of 16-year-old girl. The mass was completely excised. Postoperatively, the patient received chemotherapy. This case showed a biphasic cellular pattern verified by immunohistochemical staining. At 40 months of follow-up, the patient remains disease-free.

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We report here a rare case of perilymphatic fistula which developed ten years after surgical facial nerve decompression. A 39-year-old man visited our hospital complaining of sudden loss of hearing in his right ear immediately after scuba diving. He had undergone conservative treatment for this at another hospital, but his hearing worsened. He had suffered right temporal bone fracture with facial paralysis in a traffic accident ten years previously, and had undergone surgical facial nerve decompression. Exploratory tympanotomy was performed for diagnosis and treatment. The horizontal portion of the facial canal was exposed and hung to a pronounced extent over the superstructure of the stapes, and the footplate and major part of the superstructure of the stapes were hidden. No leakage of perilymph was noted around the stapes and round window niche. The oval window was sealed blindly with temporal fascia and fibrin glue. The round window niche was also sealed in the same fashion. Hearing in the right ear improved postoperatively, and perilymphatic fistula was diagnosed based on the clinical course. The pathogenesis of perilymphatic fistula in this case and the problems associated with surgical treatment following facial nerve decompression are discussed.

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A review board for producing medical instrument guideline has been set up for smoothly carrying out equipment development and examination with navigation system under the Ministry of Health, Labour and Welfare, and the Ministry of Economy, Trade and Industry since 2005. Medical treatment with navigation system was defined as "treatment which uses equipment for the precise operation in a broad sense which the Japan computer surgical association defines as an important treatment means". The three aspects of 1) surgical navigation, 2) surgical manipulation, and 3) surgical robot are now being evaluated. In the otolaryngology field, clinical application is advancing in the field of the surgical navigation. The ESS under the navigation guidance was approved as an advanced medical treatment in August 2006. In the future, solving urgent problems in the domestic medical instrument industry and research are desired.

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