Recently, dysphagia has been a critical issue in a medical and social field with an arrival of aging community. Aging deteriorates swallowing function resulting in an increase of a risk of aspiration pneumonia. We herein describe the mechanism and fashion of age-related swallowing impairment. With the morphological studies of the inferior pharyngeal constrictor muscle, the thyropharyngeal muscle, driver of the bolus, decreases its function. Conversely, the cricopharyngeal muscle, upper esophageal sphincter muscle, maintains its function. We clinically studied swallowing functions in healthy aged (>60 y.o.) volunteers by videoendoscopy, videofluorography and manometry. Delay and decrease of swallowing reflex, elongation of pharyngeal transit time of the bolus, insufficient opening of the upper esophageal sphincter were revealed. These disorders were improved by an administration of capsaicin troche, suggesting that capsaicin could be a choice of preventive and therapeutic management for age-related swallowing disorders.

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We report a patient who had been preoperatively diagnosed as having an antrochoanal polyp, in whom the subsequent surgical findings revealed the diagnosis of inverted paranasal sinus papilloma. The patient was a 40-year-old Japanese female who had been referred to the authors' department with the chief complaint of nasal congestion. At the previous clinic, histopathological examination had suggested an inflammatory polyp, and a preoperative CT scan of the paranasal sinuses showed a soft-tissue shadow occupying the area from the left maxillary sinus to the choana. Based on these findings, the patient was diagnosed as having a left antrochoanal polyp, and left endoscopic intranasal surgery was performed under general anesthesia. Intraoperatively, a lobulated, solid, bleeding tumor was observed in the left maxillary sinus. Consideration was given to the possibility that the lesion was a paranasal papilloma, and the base of the tumor, together with the surrounding mucosa, was resected. Histopathological examination of permanent sections indicated the diagnosis of an inverted paranasal sinus papilloma. At present, two months after the operation, there is no evidence of recurrence. Nonetheless, because of the high recurrence rate reported for paranasal sinus papillomas, close follow-up of this patient is considered essential. In the treatment of unilateral paranasal sinus lesions, correct diagnosis should not be constrained by the preoperative findings, and operative findings should also be taken into consideration. It is also important to keep in mind the possibility of a paranasal sinus papilloma.

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We report a case of meningoencephalocele of the temporal bone. A 40-year-old male was diagnosed as having a pars-flaccid type of cholesteatoma, and treated by staged operation. One year later, the external canal was found to be markedly swollen, and debris was noted. CT and MRI examinations demonstrated a bone defect at the skull base and cerebral herniation. Suspecting a recurrent cholesteatoma and meningoencephalocele, surgery was undertaken via a combined middle cranial fossa and transmastoid approach. Through the middle cranial fossa approach, the herniated brain tissue was amputated. The dural defect was closed with a fascial graft, and the bone defect was repaired with a piece of the temporal bone. Through the transmastoid approach, the amputated brain tissue with the cholesteatoma was removed. The posterior canal wall was reconstructed with cartilage and the mastoid cavity was obliterated with bone chips and bone patty. No complications were noted postoperatively. At present, 12 months post surgery, there is no evidence of recurrence of either the meningoencephalocele or the cholesteatoma.
Meningoencephalocele can occur secondary to infection, previous surgery, head trauma, or congenital defects. It is a rare and potentially life-threatening condition that requires prompt surgical intervention. Each surgical approach has its own unique advantage, and in general, the preferred surgical approach is determined by the position and size.

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Acute longus colli calcific tendinitis causes acute neck pain and stiffness associated with dysphagia. It is an inflammation caused by the deposition of hydroxyapatite crystals in the superior oblique tendon fibers of the longus colli muscle. Detection of calcification in the front axis (C2) and swelling of the soft tissue in front of the cervical vertebrae is very important for a CT diagnosis of this condition. This disease must be differentiated from retropharyngeal abscess, purulent spondylitis, meningitis, and cervical vertebral injury. However, acute longus colli calcific tendinitis has a better prognosis as compared to the aforementioned conditions from which it must be differentiated. As a rule, spontaneous recovery occurs in about 1 to 2 weeks. Treatment consists of pain control.
We report 2 cases of acute longus colli calcific tendinitis. The first patient was initially suspected as a case retropharyngeal abscess and incision was performed; however, no drainage of pus was found. Based on this finding and the findings on CT and MRI that were performed in addition, the patient was diagnosed as having acute longus colli calcific tendinitis. On the basis of this experience, we were able to diagnose the second case as acute longus colli calcific tendinitis at the first examination at our hospital. Acute longus colli calcific tendinitis is not a rare disease. We hope that an increased awareness of this hydroxyapatite crystal deposition disease in the longus colli tendon will result in improved early diagnosis.

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En block resection is a basic philosophy of the surgical treatment for the complete removal of the tumor whether it is benign or malignant. It is necessary to operate under the wide surgical field which you can observe an entire figure of the tumor for performing surgery more safely and preventing postoperative recurrence from the field dissemination of tumor cells. Clival and parasellar areas and the dome of the parapharyngeal space are situated deep in the center of the skull and surrounded by such structures as maxilla, zygoma, mandible, sphenoid, and the base of the skull.
Approaches for removing a tumor of these areas are many, of which such medial facial approaches as end nasal transseptal, transantral, maxillary swing, Le Forte I osteotomy, or mandibular swing are often adopted as a single approach, and such lateral facial approaches as transparotid, or transmastoid are selected as a combined approach with a middle cranial fossa approach. In this article, lateral facial approaches with a middle cranial fossa infratemporal approach are mainly discussed on clinical cases.

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We would report our experience and arrangement on using neurosurgical navigation system to the endoscopic sinus surgery (ESS). The case is 34-year-old woman who has bilateral and multiple postoperative maxillary cysts. The ESS was performed under the guidance of navigation system, StealthStation TRIA, but it has been installed software only for neurosurgery. One of problems like the point that the monitor CT image becomes right and left was improved by using the mirror. Another problem like the head setting with three point pin was improved by the head band fixation.
It might be impossible and also generates cost according to the equipment for installing software for otolaryngology. It was thought that it was possible to correspond for the otolaryngological surgery by some technical arrangements.

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We described a case report that Vector Vision (Brain LAB) was a very useful navigation system for the operation of post operative maxillary cyst. Vector Vision has many features. Laser registration, which is quick and reliable, can be calculated automatically offering unparalleled accuracy in seconds. Vector Vision puts the power of choice back in the hands of the surgeon by offering the easy integration of existing ENT instrumentation. Unique touchscreen interface and wizard-driven workflows put an unprecedented range of specialized IGS applications, diagnostic imaging techniques, intra-operative visualization and instrument integration options at our fingertips.

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Post-operative maxillary cyst (POMC) treated by endoscopic sinus surgery (ESS) is sometimes recurred when cyst is multiple, small, being far from inferior meatus. We have used navigation system to record for opening cysts. In addition, we have been used mucosal flap technique in ESS that keeps windows open and resulted in good outcome for POMC. We have designed a single mucosal flap adjust to the windows of multiple cyst with navigation system accurately. Here, we reported that efficacy of navigation assisted surgery for multiple maxillary cyst.

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Image-guided surgery has made marked progress in ENT, especially in sinonasal surgery. However, in temporal and skull base surgery, its accuracy level is insufficient. We investigated the usefulness of image-guided system in temporal and skull base surgery involving eight patients (three acoustic neurinoma, one facial neurinoma, two jugular foramen neurinoma, and two petroclival meningioma). The level of accuracy was acceptable in image-guided surgery for patients with acoustic and facial neurinoma. However, errors were noted in patients with jugular foramen neurinoma and petroclival meningioma. We had to discontinue the use of the image-guided system in two patients because of gross errors. Errors tended to occur in extended operations and with deeper operative fields.
We considered the following as causes of and solutions for errors. The first cause is a skin shift of the retroauricular and occipital area occurring on preoperative scannning. Generally, when patients underwent a preoperative CT scan, they would lie in a supine position using a pillow, which pushed the occipital skin. Therefore the scan data was distorted near the occipital area. In order to prevent this skin shift, a small and somewhat stable pillow is necessity. The second cause is skin shift occurring in the surgical position. A ventilation tube required to maintain general anesthesia and some electrodes to monitor nerve functions were placed on the patient's face. They strain the patient's facial skin, thereby causing skin shift. We must be careful to prevent this. The third cause is instability of the reference frame. We usually use a reference frame fixed to a neurosurgical head holder. The system consists of long arms and multiple joints between the head holder and reference frame. The development of a noninvasive and stable reference frame is awaited. The last cause is carelessness in registration. As mentioned above, the image guided-system receives inaccurate data due to skin shift. If we performed registration of the deformed portion near the occipital area, some errors may be observed. We must pay more attention to any difference between of the intra- and preoperative data regarding the head.

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Navigation system as a supporting tool for surgery exhibits its usefulness particularly in cases where operation is repeated due to a loss in a landmark or where anatomical positions of vein and nerve are complex. Around the temporal bone, there exist many anatomically complex sense organs surrounded by osseous tissues. Operations are aimed at retaining the functions or reconstruction and must avoid inflicting the sense organs, so the navigation system becomes more useful as the operation area spreads deeper such as in cases of petrous apex and inner ear.
On the other hand, the biggest problem relating to navigation technologies for use in otologic and lateral skull base surgery is where to attach the markers that are necessary for spatial measurements on the patient. It is often necessary to move the surgical microscope and to reposit the patient's head in order to adapt to the surgical field, and each time it becomes necessary to measure the intraoperative positional changes of the surgical field. It is necessary to place the markers on the basis of careful anticipation of the movements of the surgical microscope, the position of the surgeon, etc., during the operation. However, unfortunately, the reference flames with the markers attached to the patient in the past was all invasive.
Accordingly, we created a new reference flame less invasive to human body and can be attached to the mouth. The teeth of the upper jaw are the only hard tissue of the human body that is exposed to the outside environment, and the use of the reference frame with markers attached to the mouth makes it possible to carry out highly precise measurements of positional changes of the surgical field.
We can state that this flame is a steady reference flame contributing to further raise the safety of otologic and lateral skull base surgery and at the same time even from the aspect of the spread of navigation surgery in these fields, its contribution can be said to be very high.

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For accurate removal of the bony lesion in fibrous dysplasia, we made superimposed images of normal and affected maxilla then determined the area of excessive bone. We remove the lesion referring this superimposed image on the navigation system. As a result, accurate drilling of the protruding bony lesion was safely accomplished and a satisfactory result was obtained.

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We investigated whether the general belief is true that image-guided surgery improves surgical safety but increases the surgical time. We compared intraoperative complications and surgical time in our cochlear implant and acoustic tumor removal surgeries with or without the assistance of image guidance. No comparison was possible in complications which were very rare in both groups. Surgical time was similar in cochlear implant surgeries, which is an established surgery with little variances, with no increase in surgical time was noted in image-guided group. On the other hand, in acoustic tumor removal cases which is more difficult and require more experience, the surgical time was much longer in the image-guided group. It was suggested that surgical time elongation in image-guided surgery depends on the proficiency of the surgeon to the specific surgery, rather than on the use of image-guided surgery itself.

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Navigation system can provide otolaryngologist with an image-guided surgery to avoid damage for important organ of the ear and nose, i.e. the facial nerve or orbital organ. Endoscopic surgery is also important and safe key for difficult ear and nasal surgery. Therefore, navigation and endoscope have been used together in our ear and nose clinic.
We have introduced magnetic and optical system of navigation in difficult cases of the ear surgery as well as the nasal surgery to perform a safe operation since 2004. The operation have included a lesion of the petrous apex and inner ear, sphenoid sinus, an unexpected anomaly, severely damaged trauma and multi-operated case. A probe is moved in the operative field and three axial CTs are simultaneously monitored on a workstation to show the tip location. There are several type of probe in size and shape, and so it is very easy to handle the device in narrow space of the ear and nose. Accuracy of the system is within 1.5 mm to identify the point anatomical of probe. With the navigation system, disease like cholesteatoma or paranasal tumor could be thoroughly and safely removed.
We can conclude that navigation and endoscope should be used together for safe ear and nasal surgery. When normal anatomy might be missing in difficult cases, identification of operative anatomy in real time is very important surgical cue for a safe operation. Combined use of navigation and endoscope system is now practical and available for surgery of the ear and nose. Problem or disadvantage may be only cost for installing both expensive systems. However, iatrogenic damage needs more expensive compensation.

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Using the navigation system in the sinus surgery was admitted by the health insurance in 2008. It was thought that the adjustment setting of use of the navigation system was necessary. After a basic policy concerning the navigation adjustment had been set, the navigation was used for 17 cases of 40 cases of operating on the sinus surgery for the period from April to August, 2008. It was thought that our standard was appropriate under the present situation.

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The 2008 revisions to the medical fee payment system included long-awaited provisions for remuneration for image-guided navigation-assisted endoscopic sinus surgery. The related revision actually entails a 2,000 point allowance for navigation used in surgery of the paranasal sinuses, cranial base, spine, or vertebrae. In the case of paranasal sinus surgery, there are no clear restrictions regarding location or other factors. This is a historic first step for not only the Oto-Rhino Laryngological Society of Japan, but for the entire field of computer-aided surgery. In the current study, we investigated the extensiveness of use of such equipment since the new regulations came into effect, as well as whether the allocated 2,000 points is an appropriate number from the standpoint of the current cost of navigation equipment and the prices that have been set for advanced medical treatment. We also looked at whether the allocated number of points is adequate when key hospitals within our prefecture apply to purchase the necessary equipment.

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The aim of our research is to develop systems that can be applied to present clinical medicine and to develop new medical imaging techniques for the future. High-dimensional imaging have enabled noninvasive, realistic, uninhibited, and accurate observations of human spatial structures and their dynamics. In addition, the availability of real-time imaging, robotics and medical VR techniques expand the possibilities for diagnosis, treatment, and education.
Surgical simulation system that allows operation in a virtual environment has been developed to make pre-operational surgical planning. Our system allows surgeon to perform interactive surgical procedures with an organ model for visualization of tissue deformations.
Some kind of surgical navigation systems that allow 3D visualization of inner structures such as blood vessels or tumors located under other organs within surgical field, have been developed. Also we have designed and constructed a new operating room that equipped new imaging devices for evaluating our system in clinical use.

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Endoscopic sinus surgery (ESS) has become the typical care for with chronic rhinosinusitis (CRS). Balloon catheter technology (Balloon sinuplasty) has been recently introduced in sinus surgery as a minimally invasive tool for dilation of the maxillary, sphenoid, and frontal sinus drainage pathways. We reported two cases to be treated with Balloon sinuplasty. This technology has many advantages for dilating sinus drainage pathways, though there are some problems for the adaptation of CRS with a focus on the ethmoid sinus , and for the cost of instruments.

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FESS is considered as the mainstream in current sinus surgery that is expanded around the ostium of sinus without remove the mucosal membrane for the purpose of the physiological ventilation and function of the sinus mucosa. With out the deep surgical damage to the mucosa, the early recovery of the physiologic function can be anticipated. The concept of the balloon sinuplasty (BSP) is pursue the concept of isthmus surgery with balloon dilation at narrowed ostium of sinus.
The balloon catheter is unurthrized of Pharmaceutical Affairs Act in Japan, modified of the cardiovasucular catheter. BSP has been operated over 43,000 cases at 43 countries in the world until now, especially in Europe and USA. The good outcome of long period had been reported, BSP is of current interest of the world. This clinical trial had been started at several university hospitals in Japan, and we will present the clinical cases of our experience. The guide wire is carried into sinus with endoscope as the technique of the cardiac catheter using image-guide and/or illumination system called ‘LUMA’. The surgical damage to the mucosa is very few with the balloon dilation, and no serious insult had been reported. The difference of the back grand in the sinusitis between Japan and Europe or USA may occer, the indication would be limmited in Japan. We think the best indication is the isolated neutrophilic inflammation in maxillary, frontal or sphenoid sinus. BSP has the possible potential for the high-frontal cell case like Kuhn type 4, without invasive surgical proedure, the modified endoscopic Lothrop for example. BSP is not the replacement of ESS, but it might be a power full new equipments for the sinus surgery with new idea and the selection of indication.

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We have evaluated the usefulness of navigation surgical system in otology by asking the surgeons and the assistants of its contribution. The diseases that are rare and/or normal anatomy was not preserved, for example, congenital atresia, skull base tumor and petrosal apex lesion, were recommended to use the system. On the other hand, it's not necessary for cholesteatoma and cochlea implant cases. For the further evaluation, more cases and periods are required.

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As experience with endoscopic sinus surgery (ESS) has grown, the techniques and equipment have been found to be adaptable to treatment of lesions of the skull base. Image-guided surgery is also helpful to safety expand minimally invasive transnasal endoscopic techniques for the skull base diseases. This system has been proven to facilitate complicated ESS and decrease the need for revision procedure. However, this system did not apply to the intraoperative anatomic changes that occur throughout the procedures. Nowadays, intraoperative CT scanning can be performed undergoing ESS in our hospital. We think that intraoperative update has the potential to improve the extent of surgery in patients with complicated anatomy and extensive diseases, such as skull-base diseases or orbital diseases.

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Surgical treatment of 16 patients was performed with the help of the navigation system in our hospital. The navigation system proved to be a useful supplement when we cut cranial base bone, identify important structures such as internal carotid artery, and adjust the place for the reconstruction using three-dimensional model. Craniofacial approaches with intraoperative neuronavigational guidance allow logical simulation before surgery and safe resection at some difficult parts of the skull base.

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Sinonasal inverted papillomas (IP) are the one of the most common benign neoplasm of the nasal and paranasal sinus lesions. Transnasal endoscopic medial maxillectomy (EMM) for this tumor was developed and IP could be managed by endonasal approach. However the IP attached to the anterior wall of the maxially sinus could not be managed with EMM. We present new technique make a small hall in the nasal septum and use instruments from opposite side of nasal cavity. We resected 4 case of IP patients and completely control of the tumor without complication. This approach provided better visualization and wide working space of the instruments.

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We have performed sixteen cases of coblation-assisted adenoidectomy in children suffering from sleep disturbed breathing. Compared with cold instruments like curettage, coblation offered better visualization of the surgical field due to minimal intraoperative bleeding throughout the procedure. Coblation and coaglation must be performed by turns to avoid the removed adenoid tissue clog up with the blade of wands. To avoid the incomplete tissue removal, especially close to the nasal septum, wands was needed to be flexed. How to use a coblation in tonsillectomy is also reported.

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The use of navigation system assisted surgery provided numerous benefits when treating temporal bone lesion. Because the lateral skull lesions tend to consist of firm bony structures, and the accuracy of registration was usually maintained until the end of the operation.
We have applied this navigation system to the cases of foreign body, deep abscess and bone fractures of facial area as well as temporal bone lesion. As a result, navigation assisted surgery has to be favorable for firm bony structures than soft tissue due to the intraoperative volume shift.

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Various surgery supported equipments have recently advanced remarkably. The possibility of the navigation system as the tool for surgical skill improvement was evaluated in 30 cases between January, 2006 and September, 2008. The 28 cases was assessed as “Useful” of the navigation system, and the 8 cases was assessed as “Necessary” of the navigation system. It was concluded that the usefulness of navigation system had being changed by the surgeon's experience from the first stage to the present and it will play an important role in the surgical skill improvement and safe operation.

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The authors had already reported that a 3-dimensional temporal bone model prototyped using selective laser sintering method is useful for surgical training and simulation. In this study, we used the model for surgery of recurred cholesteatoma that extended into the parapharyngeal space. The powder layers were laser-fused based on the detailed CT data and accumulated to create a 3-D structure. The CT threshold was adjusted to simultaneously replicate the soft tissue and the bony structure. The major vessels and cholesteatoma were well replicated together with the bone structure. The cholesteatoma that extended from the hypotympanum, styloid process sheath and internal carotid artery sheath could be removed safely with the minimum skin incision. The model was useful for surgical planning for a case involving the complex structure of the bone and soft tissue.

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Using the craniofacial CT data of advanced sinus cancer, a simulated 3D model of a skull was prototyped by selective laser sintering method. Eight patients were evaluated for this study, and validity for the operation was considered. The model was dissected using conventional instruments prior to surgery. The model was disinfected and handled by the surgeon during the operation. Simulation of osteotomies reduced intraoperative errors. Rapid-prototyped bone model provides presurgical simulation, intraoperative accuracy in localizing tumors, and a good educational material.

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Objective: To clarify the effect of visual transformation by an endoscope on the performance of a simple line-drawing task.
Subjects: 9 adults, all right handed.
Equipment: A nasal rigid endoscope (0 deg., 4 mm in diameter, Shinko Optical Ltd., Japan) was hanged over a table with 45 deg. angle of depression. Endoscopic image was shown on a 15 inch LCD.
Task: The subject sat at the table and was asked to draw a line with a red fiber-tipped pen in a circle, along the edge of a hexagram, clockwise. The shape was printed on a A4-sized paper placed on the table. The subject was asked to draw as close to the edge and as quickly as possible.
Procedure: It was a two-day experiment and in each day the subject underwent the following trials:
(1) Baseline condition (×3 times): Subjects saw the stimulus shape directly with their eyes during the task.
(2) Endoscope condition (×3 sets): Subjects watched endoscopic image on the LCD and performed the task. Endoscopic viewing direction was set to each of {0, 60, 120, 180, 240, 300} (deg.) in a random order, where 0 deg. was the same direction as the subject's face watching the LCD.
Results: Task completion time and length of the drawn line was measured. (1) Both indices showed significant difference over the visual conditions between 120-300 deg. and the trial (two-way ANOVA, 1-5% level). (2) The baseline and 0-60 deg. conditions were not different.
Discussion: The result #2 suggests that not only the head direction, which was the same as 0 deg. cond., but the direction of the right hand, which was very close to 60 deg. condition, is important in our body coordinate system.
Conclusions: To obtain best performance in endoscopic surgery, it is important to keep the direction of the endoscopic field of view between 0, or the same direction as the surgeon's head, and 60 deg.

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In a conventional surgical navigation system, surgeons recognize anatomical structures, lesions and hazardous areas based on the objective 2D representation of the pointer tip within reconstructed models obtained from axial, coronal and sagittal plane CT scans. We developed a superimposed image-guided surgery navigation system for endoscopic sinus surgery, in which operative field structures are depicted three-dimensionally and in real-time.
The newly developed system allowed improved representation and visualization of the sinus-adjacent inner structures in 3D field of view, and more accurate localization of potentially hazardous areas. Furthermore, in the stereoscopically visualized surgical field, it became easy to recognize the target location and manipulation areas.

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BrainLAB develops, manufactures and markets software-driven medical technology that enables procedures that are more precise, less invasive, and therefore less expensive than traditional treatments.
Over the last 20 years, BrainLAB (Germany) has gained a reputation as the technology leader in the field of image-guided surgery for various clinical subspecialties.
Among the core products are image-guided systems that provide highly accurate real-time information used for navigation during surgical procedures. This utility has been further expanded to serve as a computer terminal for physicians to more effectively access and interpret diagnostic scans and other digital medical information for better informed decisions. BrainLAB solutions allow expansion from a single system to operating suites to digitally integrated hospitals covering all subspecialties from neurosurgery, orthopedics, ENT, CMF to spine & trauma and oncology.
The single modality, Kolibri, and the multiple modality system, VectorVision^® are two of our navigation systems. Patient registration and handling of navigation instruments are the same for both systems. All of the instruments are very durable and lightweight. Multiple instruments can be tracked at the same time and due to the wireless design the surgeon has unparalleled flexibility.
Besides integrating with all major PACS vendors, BrainLAB not only supports DICOM but has the capability to complete an Automatic Image Fusion within seconds due to advanced image processing algorithms.
Our advanced registration technologies such as the laser-based z-touch as well as the quick-surface registration pointer, Softouch^®, are the key elements to a fast and efficient surgical setup.
z-touch^® is the proven gold standard in image-guided procedures for ENT. It provides fast patient registration in seconds. z-touch is a special laser pointer that allows the IGS system to utilize the surface anatomy of each patient's face and head to calculate an advanced surface-matching algorithm.
Softouch^® is a quick surface matching registration that can be applied as an alternative or supplement to laser registration. Softouch provides additional flexibility in point collection and patient setup.
The unique technology of the Softouch pointer senses the skin on contact, collecting registration points even in difficult-to-access areas such as above the hairline, under OR drapes and outside of the direct line of sight of the navigation camera.
To be able to influence the future of medical technology, BrainLAB is currently developing a multi-touch display that allows surgeons and physicians to instantly access and manipulate digital medical data through the power of touch. The large interactive display ensures faster, easier medical data access and utilization. Synchronizing seamlessly with PACS, surgical planning server, and other hospital data sources, the display enables you to better collaborate with colleagues in different departments, and across different stages of the treatment cycle.
BrainLAB is committed to providing truly innovative software that will leverage physicians' skills, providing patients with consistently better, standardized and more cost-effective healthcare.

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As a member of Medtronic Group, we have marketed surgery navigation systems, StealthStation TREON and TRIA system to support ENT surgery. Recently, the utility of the navigation has been recognized in surgery that may obscure the operative field under direct vision, including ESS for chronic sinusitis, or in re-operative cases in which anatomical landmarks are lost. A drill for nasal surgery StraightShot M4 and a drill for ear surgery Visao, which have been marketed by ENT Division of Medtronic Japan Co., Ltd., one of the Group's divisions, have a dedicated port that facilitates the connection with the navigation, and a nerve monitoring system NIM-Response enables monitoring of both anatomical and physiological information on one platform by feeding monitor information into the navigation
As future prospect, we are proceeding with the preparation for the introduction of a magnetic navigation system into Japan to overcome spatial limitations imposed by the size of instruments or a camera's field of view, which are problems associated with optical systems.
Not only the navigation, we will continue to suggest system improvement and fusion with new dedicated instruments and peripheral equipment to totally support ENT surgery as a member of Medtronic Group.

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