Procedures for tympanoplasty in Japan had been varied from the open method (canal wall down technique) to the closed method (canal wall up technique), and further to the staged operation and the obliterative method (mastoid obliteration). The reasons for the former change had been attributable to the cavity problem after the open method, and the latter to the high recurrence rate of cholesteatoma after closed method. Additionally, these procedures required mastoidectomy, which means destruction of mastoid cells. Recently, severity of inflammatory process of chronic otitis media has been decreasing, and normal mastoid cell mucosa has been recognized to perf orme gas-exchange of the middle ear, as a result, the number of operation for chronic otitis media in which mastoid cells are preserved is increasing gradually.

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In the treatment of cholesteatoma employing intact canal wall tympanoplasty staging the operation has been employed to re-establish aeration of the middle ear and to eradicate possible causes of recurrence, cholesteatoma residue and retraction pocket. The paper describes the surgical procedures evolved by the authors to prevent postoperative retraction pocket. At the first stage operation following three procedures are important to re-establish aeration of the tympanic cavity ; 1) widening of the tympanic isthmus with posterior hypotympanotomy in conjunction with removal of the incus and the head of the malleus, 2) scutum plasty with use of bone pate and 3) placement of a silastic sheet in the tympanic cavity. At the second stage operation, one of the following three types of operations is performed according to the grade of aeration of the tympanic cavity : type S-1, only ossiculoplasty ; type S-2, ossiculoplasty and scutum plasty ; and type S-3, ossiculoplasty, scutum plasty and mastoid obliteration. Details of the surgical technics were described together with some of the results of long term follow-up study. Emphasis was placed on the importance of long term follow-up examinations with aid of operation microscope and CT.

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So far, acquired middle ear cholesteatoma (cholesteatoma of pars flaccida and pars tensa) is operated based on two basic concepts. One is preservation of postoperative physiological morphology and auditory function (preservation of external ear canal and middle ear mucosa), and the other is selection of operating method according to the pathological state of choleste atoma. Transcanal attico-antrotomy (TCA) + canal reconstruction is generally employed as the method of operation for cholesteatoma. Cholesteatoma affecting only attic and/or aditus ad antrum is approached by TCA alone, while mastoidectomy is also employed for cholesteatoma showing further invasion. In this paper, the author described operating methods for chronic otitis media, particularly middle ear cholesteatoma, their characteristics, basic concepts of operation, criteria for selection of operating method and treatment of mastoid cavity opened by cortical mastoidectomy.

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Strategy regarding the appropriate choice of mode of ear surgery that we have established for these several years through several clinical observations of transmucosal gas exchange function and aeration of the middle ear, particularly mastoid in ears with otitis media was introduced in this review article. 1. Both mastoid gas exchange and aeration are lost after total mastoidectomy. 2. Loss of the gas exchange function and aeration in the mastoid may cause postoperative attic retration and possibly recurrent cholesteatoma. 3. If mastoidectomy is indicated, therefore, canal-wall-down procedure is safe, while canal-wallup procedure is justified only when mastoid mucosa can be preserved particularly around epitympanum. 4. Impaired mastoid gas exchange function due to accumulation of inflamed soft tissues in the mastoid may be improved by conservative treatment such as low-dose long-term macrolides, and such a preoperative treatment may contribute to minimizing the surgical intervention and the better postoperative course. 5. Such a minimally invasive surgery combined with conservative treatment should be considered further as a future prospect of ear surgery.

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In this report Canal Down and Obliterative Reconstruction with Intact Canal Skin Technique developed in our department was reported. This technique utilized temporary removal of the bony canal wall and obliterative reconstruction with bone pate without making tympanomeatal flap. This method has the advantage in following points. The first ; complete removal of cholesteatoma is not so difficult and reconstruction of ossicular chain is easier because of its wide surgical view. The second ; post operative self cleaning ability in external auditory canal is preserved by intact canal skin. The third ; the obliteration of the attic and mastoid cavity can prevent post operative retraction pocket. In last 5 years, there is no recurrent cholesteatoma in 159 tympanoplasties of the cholesteatoma with this method.

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We examined the efficiency of some new techniques : that is, navigation system, bone-cutting laser, and microdebrider, which has been recently introduced in endoscopic sinus surgery to assist to perform an accurate and minimally invasive surgery. The image-guided navigation system proved its usefulness avoid misunderstanding manipulation to the risk area which may occur in a well experienced surgeon. The bone-cutting laser technique using KTP/532 laser and Ho : YAG laser proved its effectiveness against a thick bony wall of maxillary cyst within a narrow endonasal cavity. The microdebrider was useful to remove polypoid masses efficiently in the narrow nasal cavity with less bleeding. These new techniques were proven to introduce a reassuring assistance to perform endonasal sinus surgery safely and minimally invasively, even though there were several assignments to each technique to maintain their own accuracy, easiness to apply, and effectiveness.

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There are a number of patients of perennial allergic rhinitis and vasomotor rhinitis whose symptoms are severe and resistant to conservative treatment. So far, there are only a few treatments that can control the symptoms effectively in these patients. Vidian neurcctomy has been one of the choices of surgical treatment. However, vidian neurectomy has been applied to a very limited number of cases because of its side effect (dry eye) and technical complexity. In this article, a new endonasal vidian neurectomy for intractable perennial nasal hyperreactivity is described. The advantages of this technique include : 1) The technique is simple and causes patients less stress than previous techniques ; 2) The vidian nerve is approached through the middle meatus and can be easely accessed even in children ; 3) There is no risk of bleeding from the sphenopalatine artery during the surgery because the vidian nerve is exposed subperiosteally through a control hole, not through the sphenopalatine foramen. Additionally, in this article, our new surgical treatment—transnasal endoscopic resection of the posterior nasal nerve-is reported. This surgery entails less manipulation and less risk, and is expected to be an effective treatment for controlling all symptoms of severe perennial allergic rhinitis and vasomotor rhinitis without side effects.

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Endoscopic laryngeal surgery is usually performed under general anesthesia using microlaryngoscope. Hence, the patient must be hospitalized for several days. Generally speaking, in order to let the patient be out of the hospital immediately after the operation, topical anesthesia should be carried out instead of general anesthesia. However, in this case, painful and uncomfortable sennsation can not be avoided to the patient because of using a direct laryngoscope. Avoiding painful and uncomfortable sennsation, a lot of ideas have been developed and reported by many authors. In our clinic, a therapeutic and flexible f iberscope has been developed and applied to remove laryngeal lesions like the vocal fold polyp. From our experience, we indicate that f iberscopic surgery must be performed for small polyps and nodules which are easilly def erenciated from the vocal fold itself. If the surgery is not indicated to restore the normal voice, f iberoptic surgery can be performed, for example, to biopsy for further histopathological study. Even today, fiberoptic surgery should not be applied for polypoid vocal folds, large polyps and so on. And the indication of the f iberopyic surgery is influenced by the patient's occupational reasons. If the patient is a famous opera singer, micro scar formation after the operation must be avoided, which will disturb the musical activity of the vocal foils. In this case, more presice operation must be done under the microlaryngoscope. However, the indication of the f iberoptic surgery will be expanded in future, thanks to newly designed surgical tools like f orseps and laser technique.

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Tear fluid drains into the lacrimal passage after making preoccular tear film. Obstruction of the lacrimal passage induces epiphora. Most lacrimal passage obstructions are healed by porbing, direct silicone intubation and dacryocystorhinostomy and their combinations. The lacrimal passage consists of the upper and lower puncta, upper and lower canaliculi, common canaliculus, lacrimal sac and the nasolacrimal duct, which drains into the inferior nasal meatus. Therefore, it is necessary to see the opening of the nasolacrimal duct using an endoscope, inserting it into the inferior nasal meatus when performing the probing and/or direct silicone intubation. Oberbation of the rhinostomy using an endoscope is important for dacryocystorhinostomy. Also a necessity is irrigation, using endoscope not only for the examination during operation but also for the postoperative examination and treatment.

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Pituitary tumor of 11 patients were excised via the endonasal-transsphenoidal approach. Their age ranged from 21 to 64 years, and the disease was non-functional in 4 cases, GHoma in 4, PRLoma in 2 and cystic mass in one. As complications, arterial hemorrhage occurred in one case, cerebrospinal fluid in one and dysosmia in one, but good sinus morphology was able to be retained in all cases. Although surgical manipulation and control of hemorrhage are troublesome, its invasiveness is low, and postoperative observation of wound and reoperation are easy. If this approach is employed under cooperation between an otorhinologist with skilled endoscopic manipulation and neurosurgeon, this approach is thought to be an effective surgical method for pituitary tumor.

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Neurof ibroma under Jugular foramen could be resected without mastoidectomy or transposition of facial nerve by means of infratemporal approach. The patient was 44 year old male with a complaint of right hypoglossal nerve paralysis. The tumor was revealed by means of MRI at the right region of retropharyngeal compartment under jugular foramen. It may be suggested that this is surgical approach useful for a small tumor at the region of retropharyngeal compartment and that MRI is useful examination for diagnosis of neurogenic tumors.

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Many complications accompanied with intra-arterial infusion and radiotherapy for head and neck cancer have been reported. Among them facial paralysis is ralatively rare. Researchers say, the incidence of it has been about 5-9 % and its prognosis is usually benign. Two cases of it with preceding damage of auricle are reported. Case 1: 84-year-old woman with maxillar carcinoma. Treatment was intra-arterial infusion of 5-Fluorouracil (5-FU) through the superficial temporal artery and radiotherapy. Total dose of them were 6, 000 mg and 50 Gy. Erosion of the auricle occured at first and then perichondritis, and soon facial paralysis followed. The paralysis was recovered completely after eight weeks, but auricle was necrotizing and f alled into decay. Case 2 : 71-year-old man with maxillar carcinoma. Method of therapy in this case was same as case 1, but the total dose of 5-FU and radiation differed from that, 6, 250 mg and 47.5 Gy was given. Inflammation of auricle appeared and facial paralysis occurred soon after the end of series of infusion and radiation. His auricle came to be well cured, but facial paralysis has not improved yet. It is concluded that facial paralysis and inflammation of auricle in such cases is considered to be caused by ischemic change of the external carotid artery area.

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