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We encountered a 38-years-old female patient who was complaining of an unpleasant sensation of the left cervical area due to a recurrent tumor originating from the middle pharynx. She had a history of surgically resected neurofibroma and lipoma from the anterior oropharyngeal wall respectively 5 years and 11 years previously. The preoperative diagnosis of a benign, non-epithelial neoplasm was made based on the imaging studies and surgical treatment was scheduled. An extended surgical resection of the middle pharynx including normal mucosa and a part of the tongue base was successfully accomplished. To cover the pharyngeal defect, a right antero-lateral thigh musculo-cutaneous flap was used for reconstruction. Microscopically, the surgically resected tissue showed a mixed condition of mature cartilaginous, bony and fibroadipose tissue without atypia. The final diagnosis was a benign mesenchymoma which was thought to have developed from pluripotential mesenchymal cells. We considered that the past tumorous lesions had possibly originated in those cells. Because pluripotential mesenchymal cells cannot easily be identified with ordinary histopathological examination, the determination of optimal surgical margins is difficult. In the case of mesenchymoma, substantial marginal tissue should be resected in order to prevent recurrence even in the case of a pathologically-proven benign tumor.

The use of ultrasonography in the diagnosis of maxillary sinusitis in pediatric patients has been reported recently because of the improvement of the accuracy of ultrasound technology. We thus compared B-mode ultrasonography and computed tomography in the diagnosis of maxillary sinusitis in pediatric patients. Thirty-six maxillary sinuses in 18 patients (10 females, 8 males, ages ranging from 7-15 years with an average age of 10.4 years) were examined. Ultrasonography of the maxillary sinus was performed in the horizontal and the vertical direction. Paranasal computed tomography and B-mode ultrasonography were performed within a few days. In some of these patients the maxillary sinuses were examined with a fiberscope. Sensitivity, specificity, false-positive, false-negative, positive predictive value and negative predictive value of B-mode ultrasonography compared with computed tomography were 92.6%, 100%, 0%, 7.4%, 100% and 81.8%, respectively. It appeared that ultrasonography was more sensitive than X-ray imaging, because the sensitivity and specificity of X-ray imaging of the maxillary sinus in pediatric patients compared with CT was reportedly 70-80%. A meaningful correlation of ultrasonography and CT was accepted as an assessment of desease severity. There are some problems with diagnosis by ultrasonography. There is no differentiation of mucosal thicking, cyst and discharge and imaging are less useful in pediatric patients. Because of these reasons, clinical sign and views in the nose are important for a correct diagnosis in pediatric patients. Furthermore, the most suitable age range to diagnose maxillary sinusitis correctly in pediatric patients must be examined.

Community-based hearing screening projects have the objectives of screening hearing to identify early and intervene in cases of hearing-impaired infants and to consider how to implement mass screening, education, and support suitable. This project started in Tochigi prefecture in 2002. Of 6198 infants undergoing automatic auditory brainstem response (ABR), those rescreened accounted for 1.1% and those referred for diagnostic testing for 0.7%. After initial thorough audiometric testing, 20 infants were suggested to have bilateral hearing loss, although this was finally reduced to 17. Inconsistency between automatic and conventional ABR was found in 10 cases. Automatic ABR showed 7 false-positive and 3 false-negative cases, all of which finally proved to be within normal range hearing. Newborn-hearing screening enabled infants with hearing loss to be identified early. Japan has yet, however, to implement needed medical treatment and appropriate educational and support systems for hearing-impaired infants.

Sarcoidosis is a multiorgan granulomatous disease of unknown cause, named after the characteristic histopathological findings of the disease. In this article, we shall report a case in which biopsy needed to be repeated three times until a final diagnosis of laryngeal sarcoidosis could be made. Since sarcoidosis associated with only a laryngeal pathology may not be associated with any laboratory abnormalities in many cases, first priority should be attached in suspected cases to detect the presence of noncaseating epithelioid cell granulomas. In this case, the results of the first and second laryngeal biopsies did not show non-caseating epithelioid cell granulomas, while the third biopsy showed noncaseating epithelioid cell granulomas with giant cells. Finally, the diagnosis of laryngeal sarcoidosis was made after the results of whole-body imaging became available. Laryngeal sarcoidosis must be borne in mind as a suspected diagnosis in cases where the larynx shows yellowish-white diffuse swelling.

Sinobronchial syndrome (SBS) is characterized by chronic sinusitis with chronic infection of the bronchus. Chronic bronchitis, bronchiectasis and diffuse panbronchiolitis are also examples of complicating lower airway disease. In Japan, the surgical treatment of sinusitis is not considered to improve the lower airway diseases. Most published reports describe the Caldwell-Luc method. However ESS (Endoscopic Sinus Surgery) can heal sinusitis while maintaining the morphology and function of the paranasal sinus. In addition, its surgical results are satisfactory. This report describes the improvement of patients with SBS who underwent ESS. Twelve patients with sinobronchial syndrome who underwent ESS at our department between 1989 and 1993 were enrolled in the study. Subjective improvement in sinusitis and the lower airway diseases were evaluated using a questionnaire. Objective improvements in sinusitis were evaluated using endoscopic findings of the ethmoid sinuses, while objective improvements in the lower airway diseases were evaluated by measuring the vital capacity and FEV 1.0%. These examinations were performed one year after the operation; the results of long-term follow-up examinations performed more than 6 years after the operation were also studied. In all of the patients, subjective nasal symptoms and objective endoscopic findings were satisfactory, with improvement rates of 91.7% and 83.3%, respectively. Regarding the lower airway symptoms, all the patients subjectively rated the symptoms as having improved, and an improvement in the FEV 1.0% was improved in all of the cases. In the present study, the lower airway symptoms improved after ESS. ESS enables the paranasal sinuses to be treated while maintaining the morphology of the paranasal sinus. Consequently, surgical results are better. The improvement of chronic sinusitis reduces the direct inflow of postnasal drippings into the bronchus. Restoring the normal functions of the nasal sinus defends the lower airway by warning, and humidifying the inspiratory air and removing dusts; these functions are though to have a favorable effect on the lower airway.

We report a case of allergic fungal sinusitis (AFS) caused by Penicillium sp. and Cladosporium sp. in a 57-year-old man satisfying the following diagnostic criteria: (1) chronic rhinosinusitis revealed by computed tomographic scan, (2) Japanese cedar pollinosis for 3 years, (3) positivity for Penicillium sp. and Cladosporium sp. by a skin test, (4) increased immunoglobulin E (IgE) specific to these fungi, (5) increased total IgE, (6) nasal polyps with severe eosinophilic invasion, (7) allergic mucin revealed by histopathological examination, (8) fungal hyphae revealed by histopathological examination and (9) detection of Penicillium sp. and Cladosporium sp. revealed by fungi culture. The patient was treated by endoscopic sinus surgery. Four weeks after surgery, nasal polyps recurred, but his condition was improved by oral administration of steroids and nebulizer treatment with steroids and fluconazole. Total IgE, specific IgE and eosinophil count in the peripheral blood decreased, apparently reflecting this improvement. After obtaining the patient's consent, we conducted an allergen provocation test, which is as highly diagnostic as a skin test, to test for an antigen causing type I hypersensitivity. The immediate phase response was positive, indicating that type I hypersensitivity intermediated by IgE was involved in AFS.

Endoscopic transethmoidal.transsphenoidal surgery was performed on 30 patients with pituitary tumors, and the usefulness of this procedure was evaluated. As with conventional endoscopic intranasal surgery, the ethmoidal sinuses were opened and a broad window was created in the ethmoidal sinus from the directions of the middle meatus and the olfactory cleft. Then an endoscopic washing device was attached to a 0 degree or 30 degrees rigid endoscope and it was immobilized in the left nasal cavity with an endoscope immobilization apparatus. Removal of the tumor was then started from the right side by a bimanual technique. Based on the results, this surgical procedure was judged to be useful for the following reasons (1) it makes it easy to carry out the operative manipulations even in a narrowed nasal cavity, thereby reducing the overall time required for surgery, and (2) it is possible to prevent postoperative deformities of the nasal cavity morphology caused by pressure on its lateral wall. In additional, (3) the surgical wound can be observed, and CSF leakage can be repaired immediately after completion of the operation. Corrective surgery can be performed on an outpatient basis early after the initial operation to correct postoperative deformities of the nasal paranasal cavities, which might later cause nasal obstruction or an olfactory disturbance. Finally, (4) employing the route of endoscopic transethmoidal.transsphenoidal surgery facilitates the performance of a second operation soon, or even several months, after the first operation. A second operation may be necessary in the event of recurrence of the pituitary tumor or complication by chronic sinusitis. On the basis of our experience in the this study, we conclude that our method of endoscopic transethmoidal.transsphenoidal surgery will be useful for reducing invasiveness in the nasal cavities and achieving maximum prevention of postoperative complications. In order to fulfill its potential, neurosurgeons will need to master forceps techniques in the visual field provided by the endoscope and to cooperate with otorhinologists who are skilled in endoscopic techniques.

We evaluated the advantages and disadvantages of image-guided endoscopic endonasal surgery for various diseases. Thirty-three patients, including 8 with chronic sinusitis, 14 with paranasal cysts, 1 with paranasal tumor (biopsy), 1 with sellaturcial cyst (Rathke's cleft cyst) and 9 with pituitary tumors were endonasally operated on from September 1998 to May 1999, with an electromagnetic navigation system, The Insta Trak (Visualization Technology Inc. USA). The Insta Trak system is composed of a computer, a metal probe with a nonmetallic suction tube attachment, and a soft-type headset with an electromagnetic sensor. This freehand, armless system compensates well for patient's head movement during surgery, and precludes the need for head fixation. Either straight or curved suction tube (probe) can be used to access almost of all pathological sites in the sinus cavity. Location of the metal probe is displayed on the computer moniter as an intersection point on the axial, coronal and sagital CT images. In all cases, Insta Trak showed the surgeon the appropriate location and direction of each lesion. The Insta Trak also indicated the location of the orbit, optic canal, nasolacrimal duct and/or skull base, thus, preventing intraoperative complications. When the anatomy was distorted by previous surgery and/or when there was uncontrollable bleeding from a severe lesion so that the surgeon had difficulty finding the proper orientation, the usefulness of image-guided surgery was sufficiently recognized. However, the following disadvantages were also pointed out. An additional 15 to 20 minutes is needed for equipment set up and operation, unless the surgeon and the operation room staff are familiar with the machine. The patient's CT image used for navigation relies on data obtained preoperatively, that is to say, it can not reflect morphological changes produced during surgery. Moreover, the surgeon must consider possible errors of the navigational point that may result in the headset during surgery, as well as, errors the machine may originally possess. The image-guided system successfully integrated the most up-to-date computer technology with a surgeon's anatomical knowledge for improved treatment of endoscopic endonasal surgery. However, we also concluded that the system should be used as a surgical supporting device for safer and more adequate procedures.

The relationship between eosinophil and chronic sinusitis was investigated by measuring the concentration of eosinophil cationic protein (ECP). In addition to the blood, a cytological brush was inserted into middle meatus to scrape the nasal membrane, and the concentration of ECP in the collected specimen was measured. There was a moderate degree of correlation between the blood eosinophil count and the ECP concentration in the blood (r = 0.543, p < 0.01). On the other hand, there was high degree of correlation between the number of EG2-positive cells and ECP of the nasal membrane in the middle meatus (r = 0.805, p < 0.001), reflecting the amount of ECP in the nasal mucous membrane. The ECP in 10 control group subjects and 14 patients with severe chronic sinusitis and nasal polyps was significantly lower than that in 14 patients with severe chronic sinusitis and asthma (p < 0.01). The ECP concentration of the nasal membrane in the middle meatus was significantly lower in patients showing a good postoperative course compared with patients showing a poor postoperative course following Endoscopic Sinus Surgery (p < 0.01). These findings suggest that eosinophils are closely related to the pathology and clinical course of chronic sinusitis, and that the ECP concentration of the nasal membrane in the middle meatus reflects the pathology of chronic sinusitis. The ECP concentration thus has potential as a prognostic indicator for chronic sinusitis.

The platelet-associated IgG (PAIgG) has been reported to elevate in the patients with idiopathic thrombocytopenic purpura (ITP) and other autoimmune diseases. However, low PAIgG levels have been often recognized in thrombocytopenia. We speculated about the increasing of other platelet-associated proteins in those patients, and tried to determine platelet-associated IgM (PAIgM) and platelet-associated C3 (PAC3) using a high sensitive competitive micro-ELISA as well as PAIgG. Our results showed the specific elevation of PAIgM and PAC3 in thrombocytopenia as well as the PAIgG level (p less than 0.01). Further, the weak correlations among these levels were found (PAIgG/PAIgM: n = 7, correlation coefficient (r) = 0.55, PAIgG/PAC3: n = 73, r = 0.61, PAIgM/PAC3: n = 56, r = 0.39). We discussed on the possibility that the PAIgM and PAC3 also could be an indicator for the platelet injury and may cause the short platelet life span resulting thrombocytopenia as well as PAIgG.