Good understanding of the antomy of the paranasal sinues is the basis for endoscopic sinus surgery (ESS) . Antomical terminlogy of the paranasal sinuses has not always been clearly defined so far and, in some cases, confusing. The word inf undibulum has been used to indicate different places in the paranasal sinuses. The author tried to clear the difficulties and explain the anatomy of the paranasal sinus in explicit way for practical use in ESS.

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In order to understand appropriate surgical procedures in the endoscopic endonasal sinus surgery, the history of development of sinus surgery in the last hundred year is reviewd. During the former half of this century, various kinds of radical procedures for sinus surgery had developed under severe controversy whether to take radical or conservative procedures . The surgical results, however, remained unsatisfactory . The endonasal sinus surgery which belongs conservative surgical procedures were reevaluated as a safer and better surgical procedure by the introduction of endoscopes making junction with TV system. Reported surgical results have shown a remarkable improvement compared with radical procedures. Important requisites to perform appropriate emdoscopic sinus surgery are to keep attention for individual anatomical variations of the sinus and nasal cavity under careful observation with endoscopes and imaging, to follow postoperative patients up for a long period to prevent cyst formation, and to establish systematic training programs for the surgeons.

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Previously, most sinus surgery was performed via an extranasal or trans-maxillary approach providing a narrow, deep, and dark surgical field. The development of endoscopes and video equipment has revoluntionized the trans-anterior nares method (endonasal method) and has greatly expanded the indications for the endonasal approach in sinus surgery, contributing significantly to the progress of such surgery . With the spread of endoscopic endonasal surgery, improvement of the available surgical instruments and th e development of new ones has occurred . Five conditions for performing safe and precise ESS in relation to the impro vement and development of surgical instruments are as follows : 1) To obtain a well -illuminated view . 2) To obtain a wide and expanded view . 3) To obtain multi-directional viewing and manipulation. 4) To obtain a wide space for surgical manipulation . 5) To be well acquainted with the instruments . The improved instruments (forceps, punches, suction tubes, knives, chisels, elevators, curettes, etc.) for endoscopic endonasal surgery are small, thin, curved and flexible, thus allowing precise manipulation in the sinuses and insertion via an endoscop e under 4mm in diemeter introduced through the anterior flares . The present paper introduces the surgical instruments for ESS in the treatment of chronic sinusitis, sinus cysts, sinus tumors, septal deviation, optic nerve decompression, and blow-out fractures. The efficacy of these instruments and points for improvement in th e future are also discussed.

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Complications of endoscopic sinus surgery can be prevented by understanding of clinical anatomy and preoperative evaluation of anatomical variations between patients, and giving attention to some high-risk areas, namely lamina papyracea, the roof of the ethmoid sinus, latecal lamella of the cribrif orm plate, the optic canal, the anterior and posterior ethmoid arteries, the sphenopalatine artery and the internal carotid artery . It is also important to find the surgical complication as soon as possible if it occured . In most cases you can prevent a complication from developing into a serious one by finding it immediately and treating it in the proper way . However serious comlications can occur in endoscopic sinus surgery, if you do not give attention to important points mentioned above.

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Endoscopic Sinus Surgery (ESS) is generally accepted as a safe surgery, however, surgeons who have poor understanding of surgical anatomy and variation of paranasal sinus cause troubles such as injury lamina papyracea, blood vessel and ethmoid roof (CSF leak) during surgery. Orbital tissue injury is the most frequent among the problems of sinus surgery. When only orbital fat tissue is pulled out, the patient will have just edema and subcutaneous hemorrhage around the eye. However, if the orbital muscle, especially medial rectal muscle, is injured, disturbance of eye movement occurs. Severe bleeding during surgery generally causes these problems, because surgical field is not identified under endoscope. Therefore, the important things which prevent injury and perform safe surgery are as f of lows : 1. Full knowledge of surgical anatomy 2. Manipulation of forceps under clear observation 3. Control bleeding, pain and blood pressure by sufficient anesthesia 4. Selection of appropriate forceps and correct manipulation of forceps 5. Adequate and quick treatment for injuries.

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We observed the results of neck dissection on oropharyngeal and laryngeal cancer for the last 15 years, and report on the modified technique for neck dissection procedure, boundaries of the lymph node groups removed, and elective dissection. First, based on cases of neck dissection on oropharyngeal cancer, we showed how we decide whether a redical or a modified neck dissection procedure would be taken. Next, we calculated the frequency of positive pathological metastasis cases by lymph node group, and a certain pattern could be observed. We found that if the oropharygeal cancer was located on the lateral wall, the internal jugular group and posterior triangular group of the affected side, and the contralateral upper jugular group should be dissected. In the same way, if the oropharyngeal cancer was located on the anterior wall, the bilateral internal jugular group should be dissected. In the case of a supraglottic laryngeal cancer, the bilateral internal jugular group, and the case of glottic laryngeal cancer, the internal jugular group of the affected side as well as the paratracheal area should be dissected respectively. For the indication of elective dissection, we observed the pathological metastasis frequency of laryngeal cancer . Here, we reached the conclusion that the indication was necessary in cases of advanced supraglottic laryngeal cancer, and for residual and recurrent cases over T2 or above which underwent radiotherapy.

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A retrospective analysis of previously untreated 1045 patients with squamous cell carcinoma of the larynx, curatively treated at our clinic from 1979 to 1993, was performed. The goals of this study were to clarify the optimal neck dissection (ND) procesure and its indication for laryngeal carcinoma . The rates of occult neck metastasis according to site, laterality and T-stage were examined to determine the indication of elective ND for the clinical N0 neck . We considered that if the probability of occult neck metastasis was greater than 20%, elective ND was warranted. The results suggested that the indication for elective ND was as follows : supraglottis /lateral (L) -type T3, 4, median (M) -type T2, 3, 4, transglottis (Tr) / L-type T2, 3, 4, M-type T3, 4 and glottis/ L-type T4, M-type T3, 4 ; bilateral ND were necessary in all except Tr/ L-type. Our procedures for ND were classified into the following five types based on Suen & Goepf ert's classification ; standard radical ND ( RND), modified RND ( MRND), modified ND ( MND), lymphadenectomy (LAD) and paratracheal ND ( PND) . We have employed MND most frequently. The recurrence rates in the NO neck treated by MND were 4/107 (4%) for the ipsilateral side of L-type, 1/23 (4%) for the contralateral side and 3/43 (7%) for M-type ; those in the N + neck were 3/55 (5%) for N1, 0/5 (0%) for N2a and 2/14 (14%) for N2b (the N2c neck was reclassified on each side, e. g., N1 on the right and N2a on the left). By the comparison of the recurrence rates and morbidity between ND procedures, the following procedures were considered as optimal : MND for NO, N1, N2a, MND, MRND or RND for N2b and RND for N3. A relationship was examined between subglottic extension of carcinoma and metastasis in the paratracheal region ; the former was divided into five grades . The rates of metastasis were greater than 20% in grade 3, 4, in which PND was indicated. Our technique of PND was suggested to be appropriate .

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One hundred forty-three primary cases of squamous carcinoma of the mobile tongue were treated from 1973 to 1992 by operation in association with radiotherapy. The observed three years actual survival was 79.7% in total (94.1% for stage I, 88.9% for II, 85.1% for III, 40.0% for IV). Retrospective analysis of these patients was performed to assess the value of neck dissection. (1) In N 0 cases, the effectiveness of the elective neck dissections in controlling local diseases and affecting survival was proved, however the selective criteria for elective treatment is still insufficient. The analysis of histopathologic appearance in tongue cancer could not predict the subsequent development of cervical node metastasis . Modified radical or functional neck dissection seemed to be adequate in the patients needed the reconstructi on with flaps to improve postoperative functions even after hemiglossectomy . (2) In N + cases, the local treatment failures were sometimes observed . The radical neck dissection would be adequate to perform en bloc dissection with primary tumor .

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We investigated the cervial metastatic pattern of a series of 89 hypopharyngeal and cervical esophageal cancer patients. The five-year accumulative survival rate among this group was 55%. The correlation between N classification and the five-year survival rate was as follows ; N 0 (30 cases) :70%, N 1 (16 cases) :58%, N 2 a (14 cases) :39%, N 2 b (16 cases) :49%, N 2 c (8 cases) : 58%, and N 3 (5 cases) : 25%. The most frequently involved site was the mid-jugular chain followed by the superior jugular chain, the inferior jugular chain, and the occipital triangle lymph nodes. In seven patients, the metastatic lymph node was located at the contralateral side of the primary lesion. Bilateral modified neck dissection with the preservation of internal jugular vein was employed as a routine surgical option for the metastasized lymph nodes . Post-surgical pathology examination (pN) revealed 54% of the lymph node specimen was positively involved by cancer. Thirty-seven N positive patients were treated with radiation therapy without surgical intervention. Among them, 18 patients with successfully controlled . In 10 patients, cervical lymph node metastasis was identified at the time of patients' demise. We concluded that our good treatment result was due to the high percentage of the successfully controlled N positive cases.

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Eighty previously untreated patients with hypopharyngeal carcinoma treated in our hospital from 1976 to 1990 were reviewed. The cumulative 5 year survival rate was 33%. Neck dissectin was performed on 31 patients who had nodal metastasis, and their cumulative 5 year survival rate was 25%. Our present principle of neck dissection for hypopharyngeal carcinoma with FAR therapy and neo-adjuvant chemotherapy based on our experience is as follows: 1. Neck dissection is performed only on the case with nodal metastasis. 2. Preoperative therapy of FAR therapy and neo-adjuvant chemotherapy is performed. 3. Accessary nerve and parotid gland without tumor invasion are preserved. 4. Neck dissection is performed even if nodal metastasis were disappeared after preopera tive therapy. 5. Internal jugular vein and sternocleidomastoid muscle are resected on neck dissection.

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Two hundred and sixty-eight patients with parotid tumor were treated in our department from 1985-1994. Eight patientd (3 %) were with mucoepidermoid tumor. In all 8 cases, tumors were partially fixed to surrounding tissues. However, facial paralysis and pain were noted in one patient respectively. Seven patients were examined ultrasonographically. Malignant pattern was found in 6 cases and intermediate pattern in one, and boundary echo was unclear in all cases. Aspiration biopsy was performed in 6 cases ; malignancy was suggested in 5 cases, and 2 were diagnosed as mucoepidermoid tumor. Total parotidectomy with removal of involved surrounging tissue was done in all 8 patients. A regional lymph node dissection was done in 5 cases, and 2 had lymph node metastasis. Postorative radiotheraphy was done in 4 cases. Generally, a progonsis of mucoepidermoid tumors is good except for high grade malignant tumor, which have predominent epidermoid cells. In our cases, one have died of disease, and 7 patients are alive with no evidence of tumors. We propose a new histological grading criteria for mucoepidermoid tumors. Recommendations for treatment should be based no a histological grading of the tumor.

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Juvenile nasopharyngeal angiof ibroma (JNA) is characterized by aggressive growtn and hemorrhage. It is difficult to treat of the advanced stage of JNA due to its a clinical character. Recently, it has been reported that extended operations such as that for as craniof acial surgery, can be performed at an advanced stage. However, such operations have some complications and a large part of the patients with JNA are treated in adolescence. Furthermore, as it is known that JNA shows spontaneous regression, we need to consider the possibility of performing a noninvasive operation after the JNA shows spontaneous regression to some extent. In considering this issue, a case observed for a long period is very important. We had an advanced case of JNA (stage II) removed totally by endonasal approach after its spontaneous regression 8 year after first examination. We here present its clinical course and histopathological changes of sex hormones such as estradiol, progesterone, testosterone and dihydrotesterone in tumor tissue. The histopathological change of the fibroblast growth factor receptors in tumor tissue is also presented . The natural history of JNA and the treatment for JNA in advanced stage are discussed.

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Pleomorphic adenoma of the parotid gland is basiclly benign tumor . However, the reccurence of the tumor is sometimes found because of cell contamination . So the enucleation of the tumor is contra-indication, and we should perform lobectomy of the parotid gland. It is the most important technique to protect facial nerve in this operation . We often suffer from the bleeding of parotid gland because gland tissue is rich in blood vessels. So we usually use the radio knife to cut the gland tissue after protecting facial nerve with this technique and investigated the frequency of postoperative facial nerve paralysis. Though temporary facial paralysis was observed in 13 out 51 patients postoperatively, there was no permanent facial paralysis. All temporary paralyses were recoverd within 5 months.

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Preservation rate of the facial nerve in acoustic neuroma (AN) surgery has recently improved with the development of microsurgical techniques and state-of-the-art instruments . However, there are still cases in which facial nerve preservation is difficult due to the tumor adhering to the nerve and if the nerve fans out . These factors may lead to the damage of the nerve during surgical manipulations in a large tumor . In this paper the result of various methods of intracranial anastomosis in 20 cases were compared with those of hypoglossal-facial nerve anastomosis in 29 cases using the House-Brackmann method in all cases. Intracranial anastomosis should be done as a first choice . This procedure brings favorable results in most cases and makes it possible to exclude any later hypoglossal-facial nerve anastomosis. Lately, we highly recommend end-to-end anastomosis because we have attained better results than when using grafting techniques.

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Three patients with intramuscular tumors of the masseter were surgically treated. Because intramuscular tumors of the masseter involve intramuscular variants of malignant tumors and lack of accurate preoperative diagnosis, external tumor excision with a margin surrounding of normal muscle appears to be the best surgical procedure for the tumor. The external subcutaneous approach is recommended for masseter tumors because of the advantages of shorter duration of surgery, excellent exposure of the tumor for excision, and visualization of facial nerve branches at the anterior edge of the gland without handing the parotid gland.

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Between 1979 and 1991, 209 of 316 patients with previously untreated supraglottic squamous cell carcinomas were diagnosed as clinical N0. Of those, 148 cases treated by surgery were investigated retrospectively as to occult neck metastases in order to decide the indication of an elective neck dissection on the basis of clinical features of primary lesions by means of T classification and Sato's classification. According to this classification, supraglottic carcinomas are classified into the following three groups : epilarynx, supraglottis and transglottis. Furthermore, each is divided into median type and lateral type respectively. More than 20% incidence of occult neck metastases may be regarded as high risk and justify elective neck dissection. Occult neck metastases were shown in 46 of 148 cases (31 %), especially 20 bilaterally and 4 as stomal recurrences. The incidence of occult neck metastases according to T classification was as follows : T1, 0 % (0/1) ; T2, 17% (9/54) ; T3, 36% (24/66) ; T4, 48% (13/27). The incidence of ones in T2 according to Sato's classification was as follows : transglottis, anterior type, 8% (1/13) ; transglottis, lateral type, 29% (2/7) ; supraglottis, median type, 25% (3/12) ; supraglottis, lateral type, 14% (3/22). Addition of Sato's classification suggested the possibility of selection of high risk cases in T2. No contralateral neck metastases was found in transglottic lateral type. Our study clearly demonstrates that the indication of an elective neck dissection in supraglottic carcinoma should be T3, T4 and part of T2 cases (transglottis, lateral type and supraglottis, median type) and bilateral jugular node dissection (lateral neck dissection) should be required of all but ones in transglottis, lateral type.

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We have experienced acoustic neuroma surgery by middle cranial f ossa approach for 31 cases, among which 29 cases were fresh cases. They were 15 males and 14 females. The age distribution was from 13 to 69 years old with an average of 51.6. Intracanalicular tumor was 2, small 11, middle 7 and large 9. Anatomical preservation of the facial nerve was accomplished in 26 cases. As for the post - operative facial nerve palsy, Grade I was 14, Grade II 7 and Grade III 8 according to House - Brackmann Grading system. Hearing acutiy was preserved in 9 cases. One patient's hearing recovered remarkably after the surgery.

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We performed electively the jugular neck dissections for N0 44 patients with papillary carcinoma of the thyroid. On jugular neck dissection, upper, middle and lower jugular nodes and supraclavicular nodes are removed . The pathological metastatic rate was 84% all nodes and 75% in the jugular nodes. A injury of the recurrent and the accessory and a chylorrhea are recognized in three patients as operative complications . On the hand, we performed therapeutically the modified radical neck dissection for Ni 35 patients The pathological metastatic rate was low in the accessory nodes ; 6% in the upper and in the lower region. Therefore, the jugular neck dissection is a reasonable and safety method and also has complication for the patients with NO nodal status of the thyroid cancer.

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We have performed maxillary reconstructions using a free rectus abdominalis flap before . But, gradually, the facial deformity advances and the flap hangs down due to the atrophy of rectus abdominal muscle. A bone reconstruction is necessary for the prevention of these deformity. The separated osteocutaneous scapular flap preserving the angular branch includes the ability to design multiple cutaneous flaps and two separated bone flaps allowing improvement in three-dimentional spatial relationships for maxillary reconstruction . We have performed the maxillary reconstruction using the separated osteocutaneous scapular flap preserving the angular branch and experienced excellent results . The authors report the operation method of maxillary reconstruction .

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A retrospective study was performed on 40 patients with malignant major salivary gland tumors treated with surgery between 1979 and 1991. Nineteen cases were located in the parotid gland ; 18 in the submandibular gland, and three in the sublingual gland. The most common histological type was adenoid cystic carcinoma (38%) . The cervical lymph node involvement (N+) was recognized in 30. 5%. Five-year and ten-year survival rates were 46%, 46% for the parotid gland and 53%, 11% for the submandibular gland, respectively. The locoregional recurrence rates were superior with the submandibular gland vs. the parotid gland (19% vs . 50%, respectively) the difference was not statistically significant . Five-year survival rates were 18% for the patients with clinical N+ and 63% for the patients with clinical N0. Locoregional recurrence rates were 64% for the patients with clinical N + and 17% for the patients with clinical N0. These were statistically significant difference (<0.05) . Prognosis of the cases of cervical lymph node involvement was remarkably poor . Distant metastases developed in 30% of our patients following treatment and developed despite locally controlled desease. Not only locoregional control with surgery but also adjuvant therapy to prevent distant metastases are essential to obtain better prognosis.

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During the year of 1986 to 1994, four cases of malignant melanoma of the nose and paranasal sinuses were experienced. The four cases comprise three cases of male and one case of female. The age ranged from 18 to 78 with the mean of 47. Chief complaints were mostly nosebleed and stuffy nose with the predominance of the former . The duration from the onset of symptoms to the visit to medical institutions ranged from one month to two years with the mean of 14 months. The nasal septal mucosa was the most frequent location of the tumor. Such imaging modalities as MRI and 123I-IMP showed characteristic findings and contributed much to the diagnosis of the lesion . Definite diagnosis was done by histopathological studies including histochemical and electronmicroscopic evaluations . As for the treatment, surgeries as radical as possible were complimented with chemotherapy (DAV) and immunotherapy (Interferon). Only two cases are alive, one with tumor and one free of tumor after 12 to 14 months, one other case expired and the remaining one was lost to follow-up study.

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A functional dissection is described as a new techique that preserves the spinal accesory nerve, cervical plexus and sternocleidomastoid muscle . This technique, introduced by author's experience based on a large series of radical neck dissection, allows dissection of lymphnodes in the neck as effectively as standard radical neck dissection dose in the area of upper jugular chain where metastatic nodal disease is presumed to occur most frequently . Further more, this surgical approach minimizes the morbility associated with standard radical neck dissection. At surgery, the spinal accessory nerve is identified and preserved as it ransverses the sternocleidomuscle. The cervical nerves are carefully preserved as the dissection is carried out over the deep cervical fascia, taking care not to disturd the fascia. The underneath of the sternocleidomastoid muscle is separated from the deeper tissue, while dissection of the muscle from the overlying dermal and platysmal layer is kept as minimum as possible

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Sixteen cases of zygomatico-maxillary fractures were reduced and fixed surgically. The reduction of dislocated and rotated fractures of the zygomatic part was elevated and corrected simultaneously, which facilitates fixation, using a levator through the lateral aspect of eyebrow incision and by manipulation through the classic Caldwell-Luc approach. The fractured bones of the maxilla were reduced and corrected by manipulation and/or curved instrument. Comminuted fractures of the inferior orbital ridge and maxilla are extremely difficult to fix by malleable miniplate and wire. Fibrin glue, by comparison, simplifies reduction and stabilization. The framework of maxillary sinus was fixed by the antral inflated water balloon technic and supported by fibrin glue. The results in all sixteen cases was good. We demonstrated and discussed this useful method of reducing and fixing zygomatico-maxillary fractures.

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