In the treatment of head and neck carcinoma involving the carotid artery, resection of the carotid artery and direct reconstruction using a vein graft has been commonly been employed. But the procedure of grafting itself carries the risc of preventing complete tumor removal especially when the higher portion of the internal carotid artery is involved by the tumor. Furthermore, contamination due to salivary fistula in cases of meso or hypopharyngeal carcinoma may result in graft rupture or thrombosis. We developed a new surgical procedure, namely, a contralateral external carotid-middle cerebral artery bypass operation to overcome these problems. This bypass system is designed at directly supplying bloodflow to the cerebral hemisphere on the carotid ligation side through a vein graft running entirely outside the cervical operation field. Between June 1990 and October 1993, six patients underwent this surgery prior to the radical oreration including the carotid resection. No one developeped a serious neurological post operative complications. We observed changes of intra and extracranial hemodynamics of these patients using the ultrasonic color doppler method. It was confirmed that the bypass system could steadily supply enough bloodflow to the cerebral hemisphere on the carotid resection side in the long term. Therefore this bypass system proved to be a very safe and reliable procedure for the vascular reconstruction in cases of head and neck cancer requiring the carotid resection.

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The surgical procedure of lifting of a PMMC flap and points of particular attention are described. The axial vessels can be better preserved, and hemorrhage reduced, by sufficiently undermining the incised skin and lifting the entire greater pectoral muscle. The operative maneuvers around the axial vessels must be carried out carefully without using an electric cautery. Also, soft tissues must be removed thoroughly from the clavicle, which is the pivot point, and care must be exercised during and after the end of the procedure not to compress the clavicular region, where the vascular pedicle is reversed. PMMC flap shows small variation in the location of the axial vessels behind the muscle, and can be lifted safety by the procedure described here.

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En-bloc resection of the anterior skull base was performed successfully in 61-year-old female with squamous cell carcinoma of the frontal sinus. The frontal sinus was destryoed completely by the tumor and the tumor infiltrated both to the dura and the forehead-skin. Thorough transcranial and transf acial approach, the cancer was separated from sorrounding tissue with safety margin and removed en-bloc. The skull base was reconstructed using the rectus abdominis muscle flap, which filled the orbit after exenteration of orbit. She is alive NED after 21 months after surgery.

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In the use of radiotherapy for pituitary tumors, high-dose irradiation applied to the pituitary from outside the body has been known for a number of years. Ithas been reported that instead of using high-dose irradiaton, but a very small amount of radioisotope has been used, inserted directly into the sella turcica.
We encountered a 28-year-old male patient who had had transf rontal oraniotomy twice for pituitary tumor in the department of neurosurgery. The patient was subsequently referred to the department of otorhinolaryngology because the tumor recurred again. The sella was penetrated transsphenoidally and³²P was inserted. This treatment was very effective, and the patient was cured.
1. A ten-year follow-up revealed a very good outcome and no recurrence of tumor.
2. This new treatment is easy to apply, safe effective and is considered to be particularly suitable for elderly or physically weak patients, patients with recurrence after craniotomy and those who are afraid of suragery.

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Immediate jejunal autograft was proposed for reconstruction of the defect of the hypopharynx and cervical esophagus in 1959. Since then various free grafts of viscera, including the colon, gastric antrum, and sigmoid colon, have been employed to restore digestive continuity after pharyngolaryngoesophagectomy. The recent advancement of microvascular surgery has provided alternatives for reconstructing of defects. Jejunal free graft with microvascular reanastmosis is now accepted as one of the most reliable methods of restoring digestive continuity. Although the blood flow through vascular anastmosis during early stage after operation has a great influence on graft survival, there has been few report concerned with the occlusion in the late stage. The patient, a 64-year-old female, underwent pharyngolaryngoesophagectomy and bilateral neck dissection with one-stage reconstruction of the pharyngoesophageal defect a using free jejunal graft. Although a small fistula occurred at the esophageal anastmosis, it closed spontaneously in 2 weeks. The patient started to swallow and developed to have gruel at 5 weeks after the operation. However she complained of dysphagia at 2 months postperatively. A barium swallow study of digestive tract revealed a stenosis of jejunal graft. The complete occlusion of jejunal artery was detected by angiography. Clinical course of dysphagia, fluoroscopic examination, and angiography indicated that late thrombosis of jejunal artery led to partial necrosis of submucous layer followd by the stricture of transplanted jejunum caused by the scar formation.

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The stenosis of the mesopharynx is a type of blockage in the upper airway in patients with obstructive sleep apnea syndrome (OSAS). The purpose of Uvulopalatopharyngoplasty (UPPP) is not only to excise the soft palate but also to expand the airway by reconstructing the mesopharynx. In this study, we measured the size of the mesopharynx in patients with OSAS and in those with snoring pre-and postoperatively in order to evaluate their anatomic condition and the effect of the operation. The width of the uvula in patients with OSAS was wider compared with that of the snoring group and the length of the uvula in snoring group was longer than that of OSAS group. The size of the mesopharynx of the Japanese OSAS patients was found to be midway between those of American OSAS patients and snoring group. The width of the uvula was significantly wider in the "UPPP-responder group" compared with the " UPPP non-responder group". The mesopharynx expansion which was the purpose of UPPP were achieved, both in responder group and in non-responder group. The result would indicate that there is another area of blockage other than the mesopharynx. We concluded that the judgment of the effectiveness of UPPP was insufficient only by the respiratory disturbance index.

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Intra-operative monitoring for facial nerve function has been widely used in vestibular schwannoma surgery. We have devised new surgical instruments named “stimulus dissectors and scissors”, which can be useful not only as a probe for facial nerve monitoring but also as a dissector and a scissor. In this report, we present how to use these new surgical instruments in actual surgical manipulation. Although only a few patients have so far undergone vestibular schwannoma surgery using these instruments, we have got several benefits as follows: 1) The operation time has become shorter because it doesn't need to switch the instrument, 2) the intracranial facial nerve anastomosis has become easier because the facial nerve can be easily identified with these instruments.
The usefulness of the facial nerve monitoring in vestibular schwannoma surgery are also discussed with a review of literatures.

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A 68-year-old woman showing necrotic tumor on right soft palate was admitted to the Kitakyushu municipal medical center. Tissue biopsy revealed well differentiated squamous cell carcinoma. A lcm and a 1.2cm lymph nodes could be palpated in the right upper-jugular chain and submandibular area. Before operation 30Gy of external radiation combined with weekiy administration of CBDCA (50mg) was done. A total excision of soft palate including right tonsillar pillar and right radical neck dissection were performed. We reconstructed entiere soft palatal defect with both superiorly and inferiorly based pharyngeal flap, and mucoperiosteal flap from the hard palate. The patient can speech and swallow with no difficulty after reconstruction. Compared with reconstructive surgery using forehead flap or deltopectoral flap or free flap, our method has some advantages mentioned below.1. This method is non-invasive, short-time operation, and does not require specific technique.2. Management following operation is simple.3. This patient reveals satisfactory function in speeking and swallowing.

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Neurinoma of the skull base is relatively uncommon tumor. Its definitive management is surgery. Recently, the issue of modern skull base surgery is not only complete resection but also the achievement of excellent functional results, which are related to the site and size of the tumor. We review seven neurinomas of the skull base, derived from trigeminal nerve, vagal nerve, hypoglossal nerve, sympathetic nerve and jugular foramen nerve bundle. The surgical approaches and postoperative management of them are described.

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We reported at the 3rd Congress that the Le Fort I osteotomy is useful for resection of chondrosarcoma in the posterior extremity of the nasal septum. This approach allows us to operate not only on the nasopharynx but also on the medial region of the base of the skull, safely and with a wide field of view. We have successfully used this method to treat cancer of the nasopharynx. We will report those results and discuss the indications for the Le Fort I osteotomy.

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There are many controversial points involved in surgical treatment for patients with cancers in the head and neck with infiltration into the middle skull base. In this study, the preoperative MRIs were compared with intraoperative findings primarily from patients who have an invasion into the cavernous sinus. The rerationship between a tumor and the bone of the skull base, or dura mater of the cavernous sinus, when the tumor extended in contact with the cavernous sinus, and that between a tumor and cerebral parenchyma, or internal carotid artery, when the tumor invaded into the sinus, were examined on MRI images to determine stages according to the difficulty of tumor removal.

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It is well known that tracheotomy disturbs swallowing function by preventing the laryngeal elevation during swallowing. In order to evaluate the necessity of tracheotomy in extensive resection of oral and oropharyngeal cancer requiring reconstruction, twelve non-trachetomized cases were compared with 10 tracheotomized ones about speech communication and oral feeding in the postoperative period. It was revealed that non-tracheotomized cases tended to have shorter postoperative periods until they could utter and eat without feeding tubes. Nontracheotomized patients required special care in timing of airway tube removal and postoperative management. However, we had no case with serious complications like aspiration pneumonia or dyspnea. From these results, we can conclude that, in most cases, we can safely manage the patients with oral or oropharyngeal cancer, without tracheotomy, during the postoperative periods. Thus we must be very careful to decide the indication of tracheotomy in such cases.

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Thirty six cases with parotid gland tumors were treated in our clinic from June, 1989, to December, 1993. Histological examination showed 29 benign and 7 malignant tumors. Of the 7 malignant tumors, 5 were primary parotid cancers and 2 were metastatic tumors. To evaluate the accuracy of ultrasonically guided fine needle aspiration cytology (FNAC) and Ga scintigraphy as preoperative diagnostic method, the results of these diagnosis were analysed. The accuracy of FNAC for parotid grand tumor was 96%, and Ga scintigraphy 62%. Therefore, FNAC was very useful in preoperative pathological diagnosis and was also useful to decide the treatment of the tumors. There were no effect of chemothrapy for the 4 cases of primary malignant tumors. This suggests that surgical treatment is nesessary for malignant parotid tumors, and total par-otidectomy or extensive total parotidectomy would be necessary for high-grade malignant tumors. When total parotidectomy or extensive total parotidectomy was performed, the reconstruc-tion method such as the facial nerve grafting, the face lifting and cheek suspension would be effective to obtain better facial nerve function.

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This paper describes a malignant schwannoma which was detected in the left cervical region of a 60-year-old man. It must have been well advanced from a histopa thological viewpoint as well, since it was refractory through and through. Since its primary growth in 1984, it has recurred time and again for 10 years, slightly shifting its position from one site to another. The tumor has ultimately failed to resolve despite 4 surgeries, radio therapy, and chemotherapy.

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The case was a 52 y/o, female patient that visited our OPD with the c. c. of swelling around submandibular area. Radiological examination revealed that there was a mass on the bifurcation of the carotid artery. We approached the tumor locating on this area and started tumor resection with bipolar coagulator divice at first, however it was difficult to continue surgical maneuver because of much bleeding. Internal shunt divice was applied to control bleeding. After installation of this device, it was possible to resect the tumor easily with less bleeding. Pathological diagnosis was paraganglioma. In the cases of carotid body tumor (paraganglioma) ; Shamblin Group 2 ; we consider this internal shunt device is useful to resect tumor with less bleeding. In the cases of carotid body tumor, Shamblin Group 3, there are any chances of resection of tumor with the preservation of carotid artery using this shunt device which was thought to be impossible so far.

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The 35 cases of neurogenic tumors in the head and neck were treated in recent 15 years. 35 patients, 13 males and 22 females, ranging in age from 8 to 71 years, had extracranial solitary neurogenic neoplasms. The nerve involved were vagus nerve in 4, cervical plexus in 3, cervical sympathetic plexus in 2, chemodectoma of carotid bifurcation in 2, olfactory epithelium in 2, 6 other nerves, and unknown in 20. Treatment was surgical excision in 29, enucleation in 2, biopsy in 1. Patients with malignant lesions had radical resection or combination of wide resection and postoperative irradiation or chemotherapy. Biopsy only is given in one of the chemodectoma of carotid bifurcation. There was no evidence of tumor growing. Local recurrence has been found in two patients. One has a tumor originated from the cervical sympathetic trunk (120×42mm). Because the vertebrae and muscles were invaded, the tumor was resected patialy. Since the second operation, there was no evidence of tumor growing. Other has a tumor in the parapharyngeal space and the recurrent tumor was removed by a cervical-transpharyngeal midline mandibulotomy. There was no evidence of recurrence since the second eperation. On condition that strict follow-up is possible and there is no evidence of tumor growing, tumors are not always required for surgical resection.

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The modality of surgical treatment for benign pleomorphic adenoma of the superficial lobe of the parotid gland was investigated in 60 patients in our University Hospital. Enucleation of tumor was performed in 24 patients, partial lobectomy of the superficial lobe in 36 patients. Out of 60 cases, 54 patients, including 34 partial lobectomy and 20 enucleation cases, were followed up for more than one year. Recurrence of the tumor was found in 4 out of all 54 cases (7.4%), and it was found in 4 out of 20 (20%) of the patients received enucleation and none in those who received partial lobectomy. Postoperatively, temporary or permanent facial paralysis was observed in 8 out of 60 patients. However, permanent paralysis was found in one patient treated with partial par-otidectomy and one treated with enucleation. Frey's syndrome was complicated in 2 out of 20 (10%) of the patients received enucleation, and 5 out of 34 (14.7%) in those received partial lobectomy. Postoperative salivary fistula was found in 3 patients treated with partial lobectomy. As a conclusion, we assumed that partial lobectomy is the best treatment of choice for pleomorphic adenoma of the superficial parotid gland.

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Subtotal temporal bone resection was done for two patients with squamous cell carcinoma of the middle ear. In the first patient, a 68-year-old man, intracranial resection was performed with the resection of the dura mater of middle and posterior cranial fossa, the sigmoid sinus, and total length of auditory tube. In the second patient, a 48-year-old woman, extradural resection was pertormed. Both patients are free of disease over thirty nine months and thirty two months, respectively. From these experiences, key points of this operation are discussed in this paper. Firstly, for wider resection of the tip of petrous bone, release of the carotid artery from the carotid canal is mandatory. It is achieved by drilling the ventral aspect of the carotid canal. Secondly, total resection of the auditory tube including the pharyngeal orifice is mandatory when the tumor extension into the tube is strongly suggested. Thirdly, the significance of the preservation of the lower cranial nerves at the pars nervosa of the jugular foramen, and that of the vein of Labbe are stressed.

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Use of slides and OHP has been a prevailing method in most conferences. However, it is not always easy to present dynamic information like various type of surgery. Number of video session has been increasing to show many sophisticated surgical techniques and to establish a computer aided educational system. Video presentation can be prepared fairly easily unless high quality image is required. We are using SONY 8mm video devices which support RC time code : a handycamcorder CCD-V800 for shooting and a computer video deck CVD-1000 to edit video tapes. By using a personal computer (Macintosh) and VISCA protocol (which provides computer-controlled synchronization of up to seven AV devices on a daisy chain network), we can prepare more easily and effectively from video tapes of various surgical procedures. Digital video editing environment based on QuickTime system is also reported.

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