According to the combination of otomicroscopic surgery and otoendoscopic surgery, it may be possible to have wide selection of otosurgical procedure with the advantages of otoendosurgery. So I investigated the utility of otoendosurgery. In this study, I had three cases of ossicle chain impairment, six cases of chronic otitis media and eight cases of cholesteatioma. In conclusion, this combine approach is atraumatic for the lining mucosa of the middle ear cavity with preserving the physiological morphology of middle ear, and endoscopy has made it possible to explore the smallest recesses without any blind zone. So it is suggested that this approach have high utility for otosurgery.

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We report here our method of the image-guided surgery for middle cranial fossa approach. We applied a volume sampling to the patients who had been scheduled to suffer middle cranial fossa approach for removal of the acoustic neuroma or vestibular nerve section using a helical CT and re-construct three-dimensional images. After obtaining three-dimensional images, we modified those images and obtain surgical-view image that indicated the position of the internal auditory canal and superior semicircular canal. Referring to the images, we drilled to open the internal auditory canal and these images were thought to be useful. Clinical applications of three-dimensional images heve been variously reported. Our image-guided surgery for the middle cranial fossa approach is thought to be one of the beneficial method.

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The indications of facial nerve decompression were discussed based on our 15 years of cinical ex-perience. In Bell's palsy and Hunt syndrome, the indications of facil nerve decompression remain controversial. Although facial palsy with severe denervation is generally indicated for decompression surgery, the optimal timing of the operation and the method of approach remain in question since the efficacy of such decompression is often less than satisfactory. Recently, few patients with Bell's palsy and Hunt syndrome are thus indicated for decompression, owing to the recent success of high - dose steroid therapy developed by Stennert. It should also be noted, however, that patients with recurrent facial palsy, who are considered to have Bell's palsy, are often dignosed to have facial neurinoma. In facial neurinoma and traumatic facial palsy, better results can be expected by decompression without a damaged nerve and tumor resection than by nerve transplantation after a damaged nerve and tumor resection, when the continuity of the remnant facial nerve fiber can be maintained. Facial palay due to cholesteatoma is considered to be clearly indicated for decompression and tym-panoplasty.

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A new staging system is proposed for malignant tumors of the temporal bone, based on findings obtained from CT scans and MR imaging. All of important anatomical sites are included in this T classification system and divided into 6 groups depending on the direction of the tumor extension. A tumor in T1 category is defined that tumor locates in the external auditory meatus (EAM) and does not infiltrate into the bony structure. A T2 tumor infiltrates into the bony part of EAM but does not extend into the middle ear. A T3 tumor locates within the temporal bone including the middle ear. A T4 tumor extends beyond the temporal bone. Using this staging system, appropriate selection of the surgical treatment for the malignant tumors of the temporal bone was investigated.

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A rare case of postoperative hypopharyngeal and cervical esophageal severe re-stricture is presented. On 1961, he had undergone pharyngectomy followed by reconstruction with local skin flap (Wookey operation) for hypopharyngeal stricture after extirpation of hypopharyngeal foreing body. On October 16, 1995, a 42-year-old male came to our hospital with a chief complaint of difficulty in swallowing. He had right recurrent laryngeal nerve paralysis. Fluorographic examination revealed the severe re-stricture. On 28 November 1995, he underwent resection of the skin flap tube followed by recon-struction with free jejunal graft preserving the larynx and Biller's laryngoplasty to prevent aspiration. He could accept a normal diet without aspiration after surgery. The voice was also preserved.

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Treating patients with carotid body tumor occasionally requires permanent occlusion of the internal carotid artery. In this paper, we report two cases with some problems in dealing with the internal carotid artery in the operation. To determine the indication of ligation of internal carotid artery (ICA), we usually try balloon occlusion test and measure stump pressure and cerebral blood flow (CBF) with studying EEG, neurological findings, and collateral circuration. One case was a 53-year-old woman. We could extirpate the carotid body tumor in the subadventitial plane. After the extirpation we found subadventitial-hematoma-like change. It did not increase in size and we left it. She had no problem after the operation. The other case was a 41-year-old man. When we were resecting the carotid body tumor, the wall of ICA was lacerated. We sutured the wall by 7-0 nylon. 48hours after the operation, he complained upper left quadrantic hemianopsia. We studied brain CT and found brain infarction in right posterior lobe. We could not determine it was because of thrombosis of posterior cerebral artery from the suture of ICA or decrease of blood flow. We think 1) wash-out of thrombus before finishing the suture of ICA and 2) heparinization during and after the operation 3) ligation of ICA and 4) more detailed examination of preoperative angiography and etc. are necessary.

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Four patients with oral cavity squamous cell carcinoma were treated with Nd-YAG or KTP laser at Osaka University Medical School Hospital from September 1996 to August 1997. The primary sites consisted of three tongues (T1 N2 bMO, T2 NOMO, T3 N2 bMO) and one floor of mouth (T1 NOMO). The resection beds were left open without any reconstruction and patients did not complain of any severe symptoms. The laser surgery for oral cavity malignancies is a useful and advantageous method because of 1) no need of reconstruction, 2) wider safety margin and little postoperative pain, 3) early detection of recurrence, 4) good swallowing and speech function, and 5) less invasive. This method is indicated for locarized oral cavity malignancies without skin nor bone invasions, elder patients, patients with severe complications, and patients who want only to keep minimum comunication with their friends and family.

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We report a case of metastasis of renal cell carcinoma to the posterior paranasal sinuses. A 75-year-old man who had had a left nephrectomy six months previously due to a renal cancer, visited our hospital with a complaint of severe nasal bleeding. On examination, he had a mass in the left olfactory cleft. CT and MRI showed an abnormal shadow occupying the bilateral sphenoid sinuses with extension to the left posterior ethmoid cells. A biopsy revealed a metastatic clear cell carcinoma from the renal cancer. The patient underwent selective intraarterial embolization of bilateral maxillary arteries and left ascending pharyngeal artery, followed by the removal of the tumor using a complete rhinotomy approach. He has remained well for 15 months postoperatively without evidence of recurrence.

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We report the importance of anterior mediastinal tracheostomy with pectoralis major myocutaneous and fascio-cutaneous flaps in 2 advanced cancer cases. The first case is a 59-year-old male with cervico-thoracic esophageal cancer (squamous cell carcinoma). The patient recieved pharyngo-laryngectomy, total esophagectomy with neck and anterior mediastinal dissection after thoracotomy. The second case is a 53-year-old male with bronchogenic cancer (adenocarcinoma). The patient recieved pharyngo-laryngo-cervical esophagectomy with neck and anterior mediastinal dissection after thoracotomy. One of the problems of anterior mediastinal surgery is fatal hemorrhage due to a rupture of the innomiate artery. To avoid undue tention at the tracheal cutaneous suture line and to keep sufficient blood supply to the tracheal stump are important. We used pectoralis major myocutaneous and fascio-cutaneous flaps in anterior mediastinal tracheostomy as rotation flaps. We consider this fascio-cutaneous flap to be easy to make and safe to use in these kinds of patients.

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