A case of 13 year-old female with traumatic bilateral bone fractures was reported. The patient got injured since she had jumped down to the ground from a porch located on the 3rd floor. She was unconscious immediately after trauma and then gradually regained con sciousness. She visited our Otolaryngological clinic on day 9 after the oncet, complaining her hearing loss, tinnitus and facial palsy. A transverse fracture in the left temporal bone and perilymphatic fistula in the left ear were diagnosed. A longitudinal fracture in the pyramid of the right temporal bone accompanied with right facial palsy was also detected. The first hearing test revealed almost total deafness in her left ear. On day 16 after the onset, surgical obliteration of the left perilymphatic fistula was performed. Her hearing ability recovered up to 45dB after surgery. Her right facial palsy was improved completely by conservative therapy with steroids.

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The Larynx and trachea are the organs which suffer trauma comparatively less owing to the anatomical structure. However, once the organs suffer trauma and develop stricture, great hardships are experienced at the treatment of the lesion. One of the causes for the hardships is that the states of severity, site and stricture of the trauma differ by case, because of which the therapeutic method also differ. A report is made this time on our recent experience of 2 cases on whom we were able to try the same therapeutic method.

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The problems of facial injury in children were discussed. From 1982 to 1991, 287 cases of children were presented to the Fukuoka University Hospital Otolaryngological Clinic with facial injury. The ages of the children ranged from 0 to 15 years with two peaks incidence 1 and from 13 to 15. The largest number of these injuries were nasal bone fracture. In infants or younger children, most injuries were due to stumble and fall. Sports injuries occured in more elder children. A case of 6 old years boy who was died to penetrate his soft palate with bamboostick accidentally was reported. The body structures of children are unlike to adalts organically and mechanically, so facial injuries in children developing physical and mental demanded careful treatment.

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15 patients with epithelial and 19 patients with nonepithelial malignant tumors in the head and neck, aged less than 18 years, had been treated by combination therapy consisting of chemotherapy, surgery and radiation in our Department for 18 years from 1972 to 1990. Pathological diagnosis of nonepithelial tumors were malignant lymphoma in 6 cases and rhabdomyosarcoma in 5 cases. The most common sites of origin were nasopharynx, nose, paranasal sinuses and oral cavity. Epithelial tumors were found in parotid gland in 5 cases and in nasopharynx in 4 cases. Nine out of 10 patients with epithelial tumors and 7 out of 11 patients with nonepithelial tumors in whom more than 5 years had elapsed after termination of the therapy survived more than 5 years. Survival rates were much higher in childhood patients compared to those of adult patients. The most common late complications of the combined therapy were growth inhibition of the facial bone observed in 2 cases, loss of teeth in one case and orbital atrophy with blindness in one case induced by radiation. Development of secondary cancer was observed in one patient 17 years after surgery and chemotherapy (cyclophosphamide) followed by radiation for extensive neuroblastoma of the neck compressing the upper airway in a new-born infancy. Judging from the results of recently developed superhigh-dose chemotherapy with combination of auto-bone marrow transplantation and also the present data on long-term follow-up of our patients, particularly on late complications induced by radiation, it was assumed that foranaplastic and poorly differentiated malignant tumors of the head and neck in childhood, primary modality of the therapy should be chemotherapy. Importance of planned multidiscipllinary approach on head and neck malignant tumors in childhood was emphasized.

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We made a retrospective study to evaluate the role of surgical procedure in thetreatment of childhood head and neck malignancies. In National Cancer Center Hospital, Tokyo, 69 children were treated for head and neck malignancies during 29 years. Of 17 cases with epithelial carcinoma, 13 belonged to the age-groupe between 11 and 15 years. No case was under six yeras of age. Of 11 case who recieved surgery alone, ten survived for more than five years. Surgical therapy yielded a very good result in the treatment of epithelial carcinoma. Fifty-tow children had non-epithelial malignancies. In this group, 27 cases belonged to the age -groupe under six years and 17 cases to that between six and t en years. Most often, the non epithelial malignancy was a rhabdomyosarcoma (23 cases), which was followed by nonHodgkin's malignant lymphoma (18 cases). Of 52 non-epitherial malignancies, thirteen under went surgery, where five cases with additional chemotherapy is still alive. We must conclude that chemothery plays a important part in the treatment of childhood non-epithelial malig nancies.

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Most thyroid tumors have been found incidentally by the doctor. Palpation of the neck is important for detection of the thyroid mass lesion. The hard tumor with irregular surface and poor mobility suggests malignancy. Ultrasonagraphic study helps to detect non-palpable small lesions and also to differentiate malignancy. Fine-needle aspiration (FNA) has been the most valuable test in helping to differentiate cancerous from benign conditions. We compared the preoperative cytologic results with the postoperative histologic results in 502 thyroid nodules from patients who underwent surgery at Tenri Hospital. Sensitivity and specificity for the malignant tumor was 77.7% and 97.4 respectively. 94% of the class four or five nodules proved to be malignant and 90% of the class two nodules proved to be benign postoperatively. False-negative diagnosis occured mainly in cases of the calcified tumor or the cystic tumor where sufficient material was not obtained. False-positive diagnosis were obtained from cases with the atypical adenoma or the adenomatous goiter with papillary change. In the presense of large masses, especially with compressive signs and symptoms, the imaging study we currently find of most benefit is the magnetic resonance imaging (MRI).

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Site and frequency of lymph node .metastasis was analyzed in cases of papillary carcinoma of the thyroid., 504 primary and 64 secondary. All patients underwent surgery at our hospital. Regional lymphadenectomy excised around the trachea in 454 primary cases showed lympy node metastasis in 287 (63%). Metastasis to the deep cervical lymph nodes was recognized in 164 primary cases (38%). The following kinds of cases had high metastatic rates : (1) those in which tumor diameter exceeded 3cm, (2) those with marked extragrandular infiltration, (3) those with multiple intraglandular metastases, (4) those with poorly differentiated carcinoma, and (5) those with multiple lymph node metastases around the trachea. Of the 34 primary cases with bilateral metastasis to the deep cervical lymph nodes, 27 (27%) had carcinomas bilaterally in lobes of the thyroid glands.

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On the basis of direction of the tumor extension, we divided the 68 advanced thyroid cancers with extracapsular spread into five types. Medial type was the most frequently seen in 35% of all differentiated thyroid cancers. The sites of extracapsular spread in medial type as follows : recurrent nerve was the most frequently invaded in 30%, trachea 16%, cervical esophagus 14%, larynx 5% and hypopharynx 1%. The majority of tumors invaded recurrent nerve, trachea or cervical esophagus arised from the primary tumors. With regard to the depth of tracheal invasion, in 68% of the patients with tracheal invasion, the tumor invaded within the tracheal wall, not beyond the tracheal mucosa. On the other hand, in all patients with eso phageal invasion, the tumor invaded within the muscle layers, not beyond the esophageal mucosa. Lateral type, inferior and anterior was seen in 10%, 2.5% and 19%, respectively. Therefore, in anterior type strap muscles should be resected with tumors as necessary. Radical neck dissection is indicated in patients whose metastatic inferior internal jugular node is more than 4cm in size, considering extracapsular invasion. The incidence of paratra cheal nodal metastasis was the most frequent (42.1%). It should be taken into account that a great tendency to extracapsular spread into recurrent nerve or trachea in a case of metastatic paratracheal node more than 2cm in size. Extracapsular spread was found more common in older men and in 91% of poorly differentiated thyroid cancers.

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From 1978 through 1990, 27 patients with well-differetiated carcinoma of the thyroid gland invading the trachea, larynx or cervical esophagus were treated surgically. Three patients were Ml cases. The mean age of these were 62.3 years old. Twenty-three patients underwent partial resection of the cervical trachea with or without partial laryngectomy. Other 4 patients underwent cervical esophagectomy, subtotal-laryngectomy, total laryngectomy, pharyngo-laryngo-esophagectomy, respectively. Secondary recostruction of the trachea were performed with skin flaps in 16 patients. Five patients were died of distant metastasis and 4 patients were alive with disease. A case of advanced thyroid cancer with invasion of the hypohparynx were reported and conservative surgical procedures were discussed.

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Twenty patients with advanced carcinoma of the floor of the mouth and the tongue were treated with hemiglossectomy (12 patients), subtotal (7 patients), or total glossectomy (1 patient) and immediate reconstruction with various kinds of flaps : rectus abdominis mus culocutaneous free flap, radial forearm free flap, or pectoralis major musculocutaneous flap. The reconstructed tongues were divided into three groups in shape (protuberant, flat, and depressed one) by intraoral inspection and intelligibility of speech was evaluated by a speechtherapist over 6 months after surgery. The results indicated intelligibility was more impaired in the patients underwent more extensive glossectomy. In the protuberant group the patients with hemiglossectomy (7 patients) had the best speech intelligibility, in the flat group (4 patients) the second, and in the depressed group (1 patient) the worst. On the other hand, we could not compare these groups in subtotal and total glossectomied patients because of almost of the reconstructed tongue to be protuberant. In the protuberant group of the patients with hemiglossectomy mobility of the remaining tongue was not interfered by the transferred laps. We suppose that may be one of the reasons for good intelligibility of postoperative speech.

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A 44 years-old Japanese female was seen with the chief complaints of right cheek swelling. At the initial visit, a subcutaneous diffuse swelling, measuring 40mm in diameter, was seen in the right masseter muscle region. The swelling revealed itself as an elastic soft mass immediately following the contraction of masseter muscle by chewing or biting hard, without spontaneous pain or tenderness. The mass disappeared soon after the muscle relaxation. No bruit or palpable pulsation was present over the mass. Such imaging modalities were done preoperatively as ultrasonography and dynamic enhanced CT. The physical examination was otherwise normal. Preoperative diagnosis of hemangioma of the right cheek was obtained by clinical findings and imaging modalities. Surgery was performed under general anesthesia, the mass lesion removed by extraoral approach and the tumor, measuring 30×17×15mm, was located on the right masseter muscle. Phlebolith, measuring 5mm in diameter, was found within the tumor. Histopathological diagnosis was intramuscular hemangioma. As of 15 months after surgery, the patient follows an uneventful course with neither complica tions nor signs of swelling at contraction of the masseter region and of recurrence.

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The evalution of masticatory ability was made in 64 cases of maxillary prosthesis wearers after resection of maxilla and of unilateral palate against maxillary cancer. 70.3 % of cases had good masticatory ability, though 17.2 % showed poor. In the cases with residual teeth in the healthy side, the ability was generally good and the kinds of the flaps had been used for the reconstruction did not significantly affect the ability. However, in the edentulous cases, 51 showed good ability and it partially depended on the kind of flaps. The reconstructions with free-musculocutaneous flaps resulted in poor function.

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A case of simultaneous occurence of two adenoid cystic carcinoma in bilateral parotid glands was reported. The patient was a sixty-five-year-old male complaining of foreign body sensa tion of his neck. In the left parotid gland, there were two tumors : one in the superficial lobe, the other in the deep lobe. Two tumors were also found in the right parotid gland : both in the superficial lobe. Initial histopathological diagnosis of these tumors was pleomorphic adenoma, which was finally corrected as adenoid cystic carcinoma. Several factors for the induction of multiple adenoid cystic carcinomas in parotid gland were discussed. This is the first report of multiple occurence of adenoid cystic carcinoma in bilateral parotid glands.

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A case of 51-year-old male with the aneurysm of the superior thyroid artery was reported. Vascular diseases in the head and neck region are relatively rare and this case report was the second one since Biglioli reported first in 1977 as far as we referred . The patient visited our institution complaining of the mass on his left anterior neck and series of examination, including the dynamic CT and carotid angiography, revealed the aneurysm of the left superior thyroid artery. The aneurysm was surgically ligated and removed . One case of the superior thyroid aneurysm and eleven cases of the inferior thyroid aneurysm had been reported in the previous papers. Eight of thirteen cases containing this report presented sudden ruptures or dissections, two of which caused death. These previous reports pointed out that it was necessary to surgically remove this kind of aneurysm in the head and neck region as soon as possible after they were radiologically confirmed in order to avoid the possible disorder, for example sudden lethal airway obstruction due to thier ruptures or dissections.

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The contact Nd-YAG laser surgery was clinically applied to 790 patients with head and neck disease during the past 8 years : 341 cases with malignant head and neck tumors, 122 ones with benign tumors and 327 ones with inflammatory diseases and other diseases. This method permits accurate and precise incision because of its remarkably high controllability. In addition, it causes less bleeding with minimal damage to adjacent tissue. So, contact Nd-YAG laser surgery is a clinically beneficial modality for the operation of head and neck cancer, especially in the case of oropharyngeal cancer required the reconstructive surgery . In tonsil lectomy using contact Nd-YAG laser we found less bleeding and could resect easily scar tissues. The turbinotomy using contact Nd-YAG laser is effective especially to improve nasal obstruction and it can be done without tampon after the operation.

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A case of glossopharyngeal neuralgia of 61 years old man is reported and cervical anatomy of glossopharyngeal nerve is also discussed. The patient complained of severe pain at the left side of his throat and diagnosed as glossopharyngeal neuralgia. First, section of the nerve was performed through oropharyngeal approach on December, 1980. He was completely free from the pain. After three and a half years'remission, the pain recurred. The glossopharyngeal nerve was cut through cervical approach on July, 1987, Postoperativly, the attacks of the pain disappeared. Complete relief has ensued for about five years. The author recommend the oropharyngeal approach for the operative procedure of the glossopharyngeal neuralgia. If the recurrence shouud occur, the cervical approach will be done. To clarify the site where the glossopharyngeal nerve passes across the internal and external carotids, the nerve was exmined during the operation of 5 cases of oropharyngeal cancer . The site where the nerve crosses external carotid is variable from one individual to another and ranges 25mm-45mm from the carotid bifurcation.

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We reviewed pre-operative findings of imaging tests such as plain X-P, enhanced CT, high resolution CT and Gd-enhanced MRI in 48 cases with surgically proven unilateral acoustic neuroma who were operated on by the Extended Middle Cranial Fossa Approach in Keio University Hospital over the last 2 years. We analyzed the usefulness and limitation of these techniques ; as a result, the plain X-P was found to be still valid for the diagnosis of acoustic neuroma as a screening test, and MRI is confirmed to be the final diagnostic technique for acoustic neuroma at the present. In addition, the charges for the imaging techniques in Japan and the Untited States for diagnosing AN were compared and discussion about the significance of these imaging techniques was made from the view point of health economics.

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Either surgical or conservative therapy is chosen for the treatment of cystic lymphangioma in the head and neck region. At the authors' institution, surgery has been the choice as long as tumor is resectable without any major sequelae. They surgically treated four patients successfully since 1986. Case 1, two-month-old boy, and case 2, four-month-old girl, complained of progressive inspiratory dyspnea due to the tumor in the neck and were surgically treated. Case 3 was a girl of three years and six months. She was noticed to have right buccal swelling at her birth. She had been followed until the tumor rapidly enlarged with severe pain. The tumor, which replaced the lateral lobe of the parotid gland and adhered to the facial nerve branches, was resected without facial nerve palsy. Case 4, a 26-month-old boy, had a left submandibular swelling and was treated surgically.

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Computed tomography combined with sialography (CT-sialography) was performed before the operation on 30 patients with parotid gland tumors. The valuable information obtained by CT-sialography is the determination of the location of the tumor in relation to the facial nerve. But CT-sialography has two disadvantages. One is the possibility of the appearance of false tumor because of the space of external carotid artery and retromandibular vein or because of insufficient injection of contrast medium. Another is the difficulty of diagnosis of invaded lesion of high grade malignant tumor and cystic tumor. Indication of CT-sialography must be selected carefully.

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In this report, four patients who had undergone extended laryngotracheal resection were reviewed. Each case requiered low cervical or mediastinal tracheostomy becouse of wide resection of the trachea. The most critical complication of these cases is bleeding from the great vessels, and one of our cases died of rupture of the brachiocephalic artery. To avoid this complication, tension between the remining tracheal stump and the skin must be minimized. Accordingly, following points seemed to be important at surgical procedures. 1) In each case, skin flap for reconstruction of tracheostomy should be selected carefully. To decrease the tension on the flap, anterior thoracic skin defect left behind should be covered with a split-thickness skin graft. 2) Removal of the manubrium, the clavicular head and the first and second costal cartilages allowes the thoracic skin flap to dip down into the mediastinum. 3) The great vessels must be protected from direct contact with the trachea by bulky tissues.

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Recently, laryngotracheal stenosis caused by endotracheal intubation and laryngeal injuries has increased. We encountered three cases of laryngotracheal stenosis which success fully treated with a silicone T-tube. A 26-year-old male had been treated with intubation of a cuffed tube for 9 days, because of respiratory failure after sugery. Laryngoscopic examination showed circumscribed stenosis in the subglottis. 3 tracheal rings resection followed by end-to-end anastomosis were performed. The posterior wall of the cricoid cartilage was necrosed. 5 months later, however, fiberscopic findings showed a posteriorly based web in the suture ends, which was treated with a silicone T-tube for a period of 8 weeks. A 63-year-old male struck his neck with an iron pipe. At an operative findings, the cricoid cartilage showed depressed fracture, which was reduced and a mucous membrane graft was placed. After 1 month of operarion, fiberscopic findings showed the subglottic granuloma, which was treated with a silicone T-tube for a period of 6 weeks. A 6-year-old girl had been treated with intubation of a cuffed tube for 6 days, because of abdominal trauma. Fiberscopic examination showed circumscribed stenosis in the subglottis, which was treated with a silicone T-tube for a period of 3 weeks. After the extubation, however, slight stridor on exertion was noticed. A silicone T-tube was further inserted for 8 weeks. All cases are able to breathe and phonate almost normally without dyspnea after the extubation. Based on our experience, we considerated that the period of T-tube intubation for 4-8 weeks was a standard of this therapy.

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To evaluate the reliability of diagnostic aids of computed tomography (CT) and magnetic resonance imaging (MRI) for detection of metastatic cervical lymph nodes, fifty one patients with head and neck cancers, who were recived 81 neck dissections, had preoperative CT and MRI examinations. Lymph nodes were interpreted as malignant on palpation, CT examination and MRI exami nation if their maximal diameter were 10mm or more. In addition, if the lymph nodes showed central necrosis regardless of their size on CT examination, they were also interpreted as malignant. The overall accuracy of palpation, CT examination and MRI examination were 72%, 67% and 75%, respectively. In comparison with the results of CT examination, those of MRI examination showed smaller false positive ratio and greater falsenegative ratio. This suggests that MRI is superior to CT as a supplemental imaging modality in the diagnsis of neck metastases. Especially, in cases with clinically negative node, MRI examination plays some times an important role for detection of the occult metastatic lymph node.

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Conventional high resolution CT scannings are not optimal for demonstrating three-dimensional anatomic relationships. In otorhinolaryngology-head and neck surgery these critical relationships are often highly complex, and their complete understanding is essential to a successful surgical outcome. A new computer generated image display format, 3-Dimentional High Resolution CT Scanning (3-D HRCT), facilitates the understanding of these critical anatomic relationships the underforming conventional imaging data into clinically relevant 3-D images. Conventional two-dimensional CT scans are obtained for routine clinical indications of operation. Unlike many other 3-D reconstruction algorithms, 3-D HRCT suffers minimal data loss in the conversion process, which in turn provides for superior image solution. This better allows the application of 3-D technology for small or complicated anatomic structures such as middle ear components, maxillary sinus, orbital structures those are frequently encountered in otolaryngology-head and neck surgery. Advances in computer-controlled manipulation that further enhances the evaluations of desired pathologic features have been achieved. This study contains representative clinical cases chosen to illustrate the potential utility of 3-D HRCT in otolaryngology-head and neck surgery. The authors believe 3-D HRCT images will enhance the surgeon's understanding of the 3-D anatomic relationships that exist between critical pathologic features and surrounding vital structures and be useful for the explanation to the patients and young doctors.

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Hypopharyngeal cancer is frequently associated with neck lymphnodal metastasis, which largely affects the prognosis. We investigated the prognosis and the recurrence in the neck region in comparison between bilateral neck dissection and lateral neck dissection in hypopharyngeal cancer, and also studied what types of neck dissection should be indicated according to location of primary lesion and stage of lesion. In the Department of Head andNeck Surgery, Cancer Institute Hospital, 165 cases of primary hypopharyngeal cancer were treated in the period from 1978 to 1989. Of these 165 cases, 72 cases were treated by bilateralneck dissection and 42 cases by lateral neck dissection. In conclusion, 1) it was possible to control, by lateral neck dissection, lateral piriform sinus type of lesion of nodal stages N0, N1 and N2a which was not invading the opposite side, 2) for the other types, bilateral neck dissection was necessary, and 3) in cases with recurrence after radiotherapy, bilateral neck dissection was essntially recommended. 4) Paratracheal node dissection may be indispensable for every type of hypopharyngeal cancer.

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CT-scan could differentiate malignant from benign nodules with sensitivity 87.5% (42 cases). CT-scan could differentiate either group with sensitivity 1. papillary carcinoma (12 of 14 cases ; 85.7%), 2. malignant tumor except for papillary carcinoma (4 of 8 cases ; 50%), 3. follicular adenoma and adenomatous goiter (22 of 24 cases ; 91%), 4. another benign lesion (0 of 2 cases ; 0%). This classification in CT study is useful for diagnosis and treatment of thyroid disease.

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MRI was speculated to be a necessary preoperative examination because it visualized tumor infiltration more clearly than CT. The following two standards were instituted for diagnosing dura matal infiltration : (1) dura matal thickening and (2) dura matal pressure exerted by enlarged tumor. Based on the fact that cases with these symptoms showed dura matal infiltration, we considered MRI results to be useful diagnostic standards.

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5 year crude survival rates of the patients with cancer of the hard palate, upper gingiva and upper gingivobuccal sulcus which were treated by combination therapy consisting of Linac X ray irradiation (2Gy×18), intraarterial chemotherapy (5FU, 250mg×18) and radical surgery with primary reconstruction if necessary were 11/14, 8/10, and 4/6 respectively. Although no patients with cancer of the hard palate died of original cancer, 3 out of 4 treatment failures in cancer of the upper gingiva and upper gingivobuccal sulcus were due to local recurrences. In 22 patients who had reconstruction of the hard palate using various methods after extensive resection of the hard palate together with upper gingiva, the effect of difference of reconstruc tive methods on postoperative oral functions were evaluated. By complete closure of the palatine defects by any methods, both articulatory and swallowing dysfunctions could be fully prevented in all cases. However the palates reconstructed with soft tissue such as DP flap and free myocutaneous flap tended to droop with undesirable cheek contour. Wearing of the effective dentures were impossible in all edentulous patients in whom more than 2/3 of the hard palate had been resected. The rigid palates without drooping could be reconstructed by using the osteocutaneous scapular flap in 2 cases which could also restore desirable cheek contour. However, as for postoperative masticatory function, advantage of reconstruction of the rigid palate were not obvious due to difficulty of wearing of the dentures in these cases.

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Recently, free tissue transfer has become very popular procedure in head and neck reconstruction. But, free tissue transfer is not available in the patient whose general condition is very poor or there is no vessels suitable for microanastomosis in the head and neck region. In this case pectoralis major M-Cf lap shoued be selected in head and neck reconstruction. Recently modified PMMC flap has been described by many workers, that is vascular pedicle island flap and preserving as much of the sternocostal part of pectoralis major muscle as possible. In this paper, we described the method that refines this modified PMMC flap by passing it through subclavicula for the purpose of more increasing pedicle length and getting more wider arc of rotation. As result this procedure has proved to increase pedicle length of approximately 3cm, and make it useful for the reconstruction of oropharynx. We have used this method in 12patients for head and neck reconstruction and get good result. Although we are afraid that postoperatively clavicula may choke vascular pedicle of the flap, there were no case that had blood circulation of flap disturbed, or rather we consider that clavicula was protector of the pedicle of flap and PMMC flap was more safely transferd to head and neck region by this procedure. Thus, in the case that free tissue transfer is unsuitable, modified PMMC flap passed through subclavicula is very useful and a safe alternative method in head and neck reconstruction.

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