In order to discuss the management strategy of facial nerve schwannoma arising in the temporal bone, a retrospective review was carried out on 20 patients referred to our department in the past 15 years. Twelve patients underwent tumor removal (excision group) and 8 were managed more conservatively (conservative group). In the excision group, the facial score improved no better than House-Brackmann grade III palsy after complete nerve resection and nerve graft. On the other hand, there was no deterioration of the facial nerve score in the conservative group for 2-10 (average 5.3) years. We conclude as follows: 1) In the case of facial nerve schwannoma without facial palsy or with slight palsy (patients with House-Brackmann grade I or II), tumor removal with facial nerve resection should not be performed. 2) For patients with sudden onset facial palsy, the administration of steroid hormone or facial nerve decompression is preferable in the acute phase. If the facial score reveals no improvement better than H-B grade III palsy despite those treatments, total tumor removal with facial nerve resection and nerve graft should be planned. 3) Partial tumor removal is not suitable for treatment of facial nerve schwannoma within the temporal bone. 4) In the case of a tumor arising from the greater superficial petrosal nerve, total tumor resection can be performed without facial score deterioration. The differential diagnosis should be carefully done to select these spe-cial cases among facial nerve schwannomas.

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Schwannoma is the most frequent neoplasma of the parapharyngeal space. Schwannomas are generally benign and slow-growing tumors. They usually do not affect their nerve of origin, however, some cases have paralysis of cranial nerves. The parapharyngeal space is an area with complex anatomic relationships, so it is difficult to remove tumors with nerve preservation from this area. Currently, MRI provides the most useful preoperative information about the appearance and the extent of the tumor in addition to its relationship to surrounding structures. Using MRI, we must carefully determine the best surgical approach to the parapharyngeal space. We should also adequately explain to the patient the high complication rate including damage to the cranial nerve.

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This paper discusses the pre-operative diagnosis of neck neurinoma and evaluates the result of the operation that attempts to preserve the nerve function, based on our experience and a review of the literature. Clinical data of 13 patients with neck neurinomas operated on at the Kanagawa Cancer Center over the past 11 years were reviewed. Preoperative imaging characteristics such as change of rounded shape mass to spindle shape at the end of it imaged by ultrasonography and MRI facilitated the diagnosis of neurinomas. Location and depth of the mass relative to the common carotid artery, the internal jugular vein and the vagus nerve also provided useful information for an accurate diagnosis. The location or direction of cord-like structures imaged by ultrasonography suggested the original nerves. The procedures of intracapsular extirpation or enucleation under monitoring with a nerve stimulator helped to preserve motor nerve function.

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We conducted a literature review of the malignant transformation of schwannoma, introducing various cases. Twenty-nine cases were reported to be malignant in the literature, except the intracranial schwannoma, of which 10 cases head and neck region. In conclusion, it is recommended that schwannoma should be surgically removed in a manner of enucleation (so-called intercapsular resection technique) with preservation of the nerve continuity and function, because the malignant transformation of a schwannoma is extremely rare.

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We report complete resection of a pediatric rabdomyosarcoma of the cheek followed by immediate reconstruction using a free flap in a 2-year-old girl. After chemotherapy and radiotherapy, extirpation was performed for the residual tumor. The extensively damaged skin and subcutaneous tissue of her right cheek were reconstructed using a free scapula flap. The vascular pedicle was anastomosed to the right facial artery and vein. Potential problems with anastomosis due to the usually small calibers of these vessels in children did not eventuate in this patient. First priority was given to the success of the graft, and thus a 7-day sedation was planned for the patient. The patient was sedated starting immediately after surgery. Laryngeal edema due to tracheal intubation occurred on the third day after surgery, but gradually decreased and thus extubation was performed on the 14th day after surgery. The free tissue transfer was successful, but after reviewing this case we consider an appropriate rest period and shorter intubation and sedation preferable after microvasucular tissue transfer to decrease the likelihood of laryngeal edema. Regarding the selection of free flaps in children, donor site morbidity should be taken into consideration more seriously than in adults.

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We performed carotid artery resection and vascular reconstruction for an advanced case of thyroid carcinoma invading the left carotid artery. Preoperatively, we performed small cranial fenestration (burr hole) surgery in the left temporal region above the zygomatic arch to make an acoustic window for transcranial Doppler (TCD) and a carotid occlusion test (TCD guided Matas'test) was performed. Though this test showed collateral circulation was sufficient, vascular reconstruction was performed considering the effect of cerebral hemodynamics. Total thyroidectomy, total laryngectomy, partial pharyngectomy, neck dissection at both sides and resection of the left common carotid artery and internal carotid artery were performed. Furthermore, contralateral external carotid-ipsilateral internal carotid artery bypass grafting was performed using a saphenous vein graft. INVOS 4100 is very useful for monitoring cerebral circulation in real time. No serious central nervous system complications, including hemiplegia, were observed and no local recurrence and metastasis were found in this patient.

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Metastases in the nasal cavity and paranasal sinuses are uncommon, and radical resection has been indicated in very few such cases. We report a 67-year-old male who, 8 years after left total nephrectomy, presented with a metastatic renal cell carcinoma in the right anterior ethmoidal sinus and underwent radical resection of the lesion. MRI showed a tumor in the right ethmoidal sinus invading to the tegmen of the ethmoidal sinus and destroying the lamina papyracea. We selected a combined approach from the intracranium and face to complete the resection because of a third operation for a recurrent ethmoidal sinus lesion. The patient has been disease-free for one year and six months after resection of the metastatic lesion. We discuss the therapeutic strategy for a metastatic renal cell carcinoma in the nasal cavity and paranasal sinuses.

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Chondrosarcoma of the larynx is a very rare disease, and it is considered to account for less than 1 % of laryngeal malignant tumors. We report two cases that had different clinical courses. Case 1 was a 62-year-old woman who complained of a sensation of having a foreign body in the throat. Direct laryngoscopy revealed a smoothly rimmed tumor in the subglottic area. Incisional biopsy was performed, and the histologic diagnosis was chondrosarcoma (grade II). Case 2 was a 67-year-old man who complained of severe dyspnea requiring tracheotomy. He had been operated on for a posterior-subglottic benign chondroma 12 years ago previously and had not been followed up. Direct laryngoscopy was performed. The recurrent tumor was resected and the histologic diagnosis was chondrosarcoma (grade II). Partial laryngectomy or tumor resection preserving the function of the larynx is considered a curative surgery for low-grade chondrosarcoma. However, we performed total laryngectomy, because they had recurrent nerve palsy and the tumor involved most of the cricoid cartilage.

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Secondary hyperparathyroidism with parathyroid hyperplasia is a common complication of chronic renal failure. We herein report a dialysis case of hyperparathyroidism with adenoma change of all four parathyroid glands. The patient was a female with a 14-years history of dialysis and demonstrated hypercalcemia, hyperphospheremia, and an increased level of intact parathyroid hormone (PTH). Diagnostic images including ultrasonography and magnetic resonance indicated swelling of all four parathyroid glands, which were pathologically diagnosed as adenoma indicating tertiary hy-perparathyroidism. We did not autograft the parathyroid tissue because of the possibility that the grafted adenoma tissue might show tumor growth. Further investigations into the management of parathyroid graft are needed in the cases of tertiary hyperparathyroidism.

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One cause of external auditory canal bone defects is failure of temporal bone adhesion in childhood. We report a case of idiopathic bone defect of the external auditory canal and describe the reconstruction procedure. The patient was a 61-year-old man who suffered from left otalgia and fullness of the ear during biting. He had no history of ear disease or trauma. We confirmed the projection of the anterior wall of the external auditory canal when he bit, and its projection was retracted when he opened his mouth. Computed tomography (CT) examination revealed that the anterior wall of the bony external ear canal was partially defective. We thought that this defect was caused by the failure of the foramen of Huschke to close during development. He underwent an operation to close the bone defect. A vertical extended endaural incision was made, and temporalis fascia and tragal perichondrial graft were placed between the mandibular joint and the external auditory canal. More than two years after the operation, the patient has no symptoms and he is satisfied with the results. In our report, we discuss this case and the surgical incisions and approaches to the external auditory canal.

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Tuberculosis of the parotid gland is not a common disease. We report here a case of tuberculosis of the parotid gland without active pulmonary lesion. The patient was a 65-year-old woman having swelling of the left parotid gland. MRI findings suggested a parotid gland tumor, so the fine needle aspiration (FNA) was performed. After the FNA, the skin of the part that was pricked with the needle became reddish. A malignant tumor of the parotid gland was strongly suggested, so superficial parotidectomy with skin excision was performed. A histological examination revealed tuberculosis of the parotid gland. Tuberculosis is one of the most important of the re-emerging infectious diseases in the world. When examining head and neck lesions, tuberculosis should be taken into consideration in the diagnosis.

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A case of extramedullary plasmacytoma originating in the left submandibular region in a 77-year-old man is reported. Plasmacytoma is a disease in which the blood plasma cells cause tumor proliferation. Extramedullary plasmacytoma is a rare disease that occurs outside marrow. Frequent sites are the head and neck region, the nasal cavity, the upper respiratory tract, etc, but occurrence under the submandibular region is rare. Because of the conversion to multiple myeloma or delayed recurrence, patients with plasmacytoma require long-term follow-up.

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Between 2002 and 2006, 31 cases of deep neck abscess were treated with surgical drainage in our hospital. In the 7 patients with diabetes mellitus, the duration of admission was longer than that of the patients without diabetes mellitus. It was considered that special care is needed in the treatment of patients with diabetes mellitus. In 5 cases, the deep neck abscess extended to the mediastinum. The duration of admission in these 5 cases was longer than that of other cases. Therefore, it was considered that the most important point is to prevent the spread of infection, especially downward into the mediastinum. In the cervical approach, it is essential to drain the abscess from the pre-tracheal space, pen-vascular space, and pre-visceral space. For mediastinal abscesses, thoracoscopic drainage with collaboration by thoracic surgeons is safe and effective. It is safe to perform tracheotomy with surgical drainage. Computed tomography was very useful in both diagnosis and conducting postoperative observation. We consider that early surgical drainage and intravenous administration of appropriate antibiotics is essential for the treatment of deep neck abscess.

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The dismasking flap is a very useful approach for skull base tumors. We report a rare case of using this flap in which the recurrent skull base tumor could be resected completely. A 51-year-old man presented with a recurrent mucoepidermoid carcinoma in the skull base in July 2006, 3 years after the first resection of the tumor with skull base reconstruction. We resected the recurrent tumor by using the dismasking flap and midfacial degloving methods in September 2006. He had no complications and enjoyed a high quality of life after the operation.

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At present, there are not many medical institutions with otorhinolaryngology departments in which cervical esophageal cancer can be treated. In addition, there have been many cases in which such disease had already progressed when confirmed at a medical institution. Therefore, it is often very difficult to select appropriate treatments for such cases. Herein, we report five cases in which we provided treatment for cervical esophageal cancer. We also discuss the treatment, progression of the disease, selection of treatment methods, and approaches taken by our department. The diseases of the five cases were cervical esophageal cancer, and surgical treatment was performed in all cases.

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Residents should be trained efficiently in order to solve the shortage of head and neck surgeons. We think it is important for trainees to learn how to use the basic surgical instruments and to teach them how to handle a scalpel, electric knife, scissors, and forceps accurately and safely. In this paper the educational points in neck dissection as well as the fundamental training are described. By giving trainees many opportunities to be operators early on, they can improve their ability of preoperative image diagnosis, know the detailed causal relationship between surgical procedures and postoperative complications, and can serve as good assistants during operations. It will also motivate them to become good surgeons. However, the key point is the trainer's skill.

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