Transcanal endoscopic ear surgery (TEES) is a minimally invasive surgical treatment technique for middle ear diseases and is recently becoming popular around the world. TEES enables accurate surgical manipulation under a wide magnified, and clear surgical view. We describe the results of surgical treatment for congenital middle ear anomalies by comparing the hearing outcomes between patients treated by TEES and those treated by microscopic ear surgery (MES). Congenital middle ear anomalies were safely treated by TEES, with comparable hearing outcome to those after MES. The surgical field is limited in the tympanic cavity, inflammation is usually absent, and there is little bleeding during the operation; therefore, TEES is a feasible surgical approach for the treatment of congenital middle ear anomalies. However, as middle ear anomalies are diverse, preoperative diagnosis is sometimes difficult, and the surgeon must be adequately prepared in advance for various types of procedures.

EAS (electric and acoustic stimulation) is a hybrid system which has two parts, a cochlear implant and a hearing aid. This system is useful for patients with residual acoustic hearing in the lower frequencies. Herein, we report one case in which EAS implantation was useful.

The patient was a 23-year-old woman with bilateral hearing loss from childhood. She had residual hearing at low tones. She had the greatest difficulty while having a conversation with someone. She complained of dizziness and vertigo sometimes. Equilibrium function testing showed bilateral vestibular hypofunction of the inner ear. CT and MRI revealed no inner ear anomalies. We treated this patient by EAS implantation. Complete hearing preservation at low frequencies was achieved at 1 year and 6 months after the operation. Speech discrimination testing at 6 months after the operation revealed marked improvement of monosyllable recognition from 50% to 95%. The c-VEMP at 1 year after the operation was normal. These results indicate that EAS may be useful for patients with residual hearing.

A dip-type audiogram is relatively rare in cases of idiopathic sudden sensorineural hearing loss.

I performed a retrospective analysis of the data of 10 patients with idiopathic sudden sensorineural hearing loss with a dip-type audiogram who visited my clinic between October 2008 and September 2021.

The patients consisted of three men and seven women, ranging in age from 17 to 38 years, with a mean age of 27.3 years. In regard to the chief complaint, four patients presented with hearing loss, two presented with tinnitus, and four presented with ear fullness. None of the patients had any vestibular symptoms. The dip in the audiogram was located at 1000 Hz in two cases, at 2000 Hz in six cases, and at 3000 Hz in two cases. The hearing level at the dip was between 25 and 50 dB. All patients were treated with mecobalamin, ATP and betamethasone until the hearing became normal and the symptoms disappeared. Most of the patients were cured within a short period of time.

If cochlear symptoms are present and octave frequency pure tone audiometry does not reveal hearing impairment, a half octave audiometry should be performed.

We reviewed the results of surgical treatment of 14 ears with middle ear cholesterol granulomas. The goals of surgery for cholesterol granulomas are to remove the focus and improve the ventilation disorder. There are two ways to treat the mastoid cavity in surgery for cholesterol granulomas: one is to form a pneumatic cavity by keeping the ventilation route (canal wall up (CWU), canal wall down (CWD) and canal reconstruction), and the other is to lighten the burden of the Eustachian tube by narrowing the ventilation space (CWU with mastoid obliteration, CWD).

The results of 3 ears treated by CWU, 5 ears treated by CWD with canal reconstruction, 2 ears treated by CWU with mastoid obliteration, and 4 ears treated by CWD are presented. The success rate for good control of otorrhea was 87.5% in cases in which the surgery involved formation of the pneumatic cavity, and 100% in cases in which the surgery involved reducing the burden of the Eustachian tube by narrowing the ventilation space. The success rate for hearing improvement was 37.5% in cases in which the surgery involved formation of the pneumatic cavity, and 50.0% in cases in which the surgery involved reducing the burden of the Eustachian tube. The hearing improvement following treatment for cholesterol granuloma seemed to be related not only to ventilation, but also to the presence/absence of other disorders, such as fixation of the ossicles or lack of fit of the columella. The degree of inflammation of the mastoid and tympanic cavities is also a very important factor for selecting the type of surgery.

In conclusion, if inflammation of the mastoid cavity is not very severe, surgery to form the pneumatic mastoid cavity would be recommended, whereas surgery to reduce the ventilation space, such as obliteration of the mastoid cavity or CWD, would be performed in cases with severe inflammation, with granulation tissue filling the mastoid cavity.

We present, herein, the hearing results of 112 cases of stapes surgery for otosclerosis (75 ears), congenital ossicular malformation (18 ears), and tympanosclerosis (19 ears).

According to the statement of the Otological Society of Japan and the guideline of the American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO), the success rate for hearing improvement after stapes surgery is the highest for otosclerosis, followed by congenital ossicular malformation, and then tympanosclerosis, in that order.

The success rate for hearing improvement is 93.3% for otosclerosis, 83.3% for ossicular malformation, and 52.6% for tympanosclerosis, according to the statement of the Japan Otological Society.

The success rate for cases with a postoperative air-bone gap of less than 10 dB is 72% for otosclerosis, 38.9% for ossicular malformation, and 21.1% for tympanosclerosis, according to the guideline (AAO).

Analysis of variance revealed a significant difference in the postoperative air-bone gap between case of otosclerosis and ossicular malformation, as between those of otosclerosis and tympanosclerosis; however, the postoperative air-bone gap was not significantly different between cases of ossicular malformation and tympanosclerosis. The inferior hearing results in cases of congenital ossicular malformation and tympanosclerosis were considered as being probably attributable to the higher degree of difficulty of the surgery. These two groups had morphological deformities, such as the absence of the long process of the incus, severe rigidity of the footplate of stapes, and absence of the oval window, which led to difficult surgery, and postoperative re-fixation of the ossicles was often seen in cases tympanosclerosis.

The incidence of severe dizziness as a complication of stapes surgery was also examined. When severe dizziness occurred immediately after stapedectomy, computed tomography often revealed pneumolabyrinth. This pneumolabyrinth with evidence of perilymphorrhea continued to persist in case with persistent dizziness. However, while the size and duration of the pneumolabyrinth did not lead to worsening of the hearing results, pneumolabyrinth accompanied by protrusion of the prosthesis into the labyrinth made the hearing worse.

It has been reported that delayed facial nerve palsy could sometimes occur after otologic surgery. We encountered a case of delayed onset of Ramsay Hunt syndrome after cochlear implantation.

The patient was a 71-year-old woman who began wearing hearing aids at the age of 69 for bilateral hearing loss. She then visited our department for cochlear implantation. Cochlear implantation was performed in a routine manner, and was completed without exposure of the facial nerve or chorda tympani. The insertion of the electrodes was smooth. After left cochlear implantation, the patient had good hearing. However, 12 days after the surgery, she presented with dizziness, auricular herpes zoster, and facial nerve palsy. The serum titer of varicella zoster virus (VZV) IgG was significantly high and the patient was diagnosed as showing VZV reactivation. She did not improve with the usual medications or to ENoG, and facial nerve decompression was performed; we used the TEES approach for the facial decompression in consideration of the effect on the inserted electrodes. Facial nerve decompression via the TEES approach is considered to be useful for decompressing at the horizontal portion of the facial nerve. The facial nerve palsy is slowly improving, and we are continuing to monitor the patient’s progress.

We think that careful follow-up after otologic surgery is necessary, keeping in mind the possibility of development of delayed facial nerve palsy and Ramsay Hunt syndrome.

Varicella zoster virus (VZV) establishes latency in ganglionic neurons, and reactivation of VZV can produce a broad spectrum of neurological disorders involving these neurons, including lower cranial nerve palsies. It is rare for reactivation of VZV to manifest as lower cranial nerve palsies alone. We report three cases of VZV reactivation that presented with lower cranial nerve palsies. Case 1: A 52-year-old woman presented to our department with the complaints of right earache and dysphagia. Examination revealed no abnormal findings, except for right vocal cord palsy and oropharyngeal palsy. Cervicothoracic CT and head MRI did not show any abnormalities. Based on these findings and the results of blood tests, we suspected cranial nerve palsy due to reactivation of VZV and initiated the patient on antiviral drug and steroid treatment. Case 2: A 69-year-old woman visited our hospital with a 6-day history of pharyngeal pain and dysphagia. Laryngoscopy at another hospital revealed left vocal fold paralysis and saliva residue in the hypopharynx. As in Case 1, after closer examination, cranial nerve damage due to reactivation of VZV was suspected, and treatment was initiated. Case 3: An 82-year-old man presented with a 5-day history of throat pain and dysphagia. Based on the presence of a unilateral mucous membrane rash and severe pharyngeal pain, the patient was diagnosed as having pharyngolaryngitis caused by reactivation of VZV, and was started on antiviral medication. From the time of the initial examination, he had persistent hiccups and difficulty in sleeping. After treatment, the hiccups disappeared along with disappearance of the mucous membrane rash.

Reactivation of VZV should be included in the differential diagnoses of lower cranial neuropathy, and it is desirable to start treatment as soon as possible after the diagnosis.

Skull-base osteomyelitis occurs as a result of spread of inflammatory disease around the temporal bone into the adjacent skull base, and carries a poor prognosis. Occasionally, patients present with paralysis of the lower cranial nerves, which further worsens the survival. Prolonged intravenous antibiotic therapy for six to eight weeks is needed for treatment. Herein, we present a case of skull-base osteomyelitis caused by Pseudomonas aeruginosa that developed in a 78-year-old male patient with diabetic nephropathy who was under maintenance hemodialysis. He presented to our hospital with the complaints of earache and otorrhea on the left side. Exploratory tympanotomy revealed pus and granulation tissue filling the tympanic cavity and mastoid, and destruction of the tympanic portion of the temporal bone; based on the findings and results of pus culture, we made the diagnosis of skull-base osteomyelitis caused by Pseudomonas aeruginosa. While the osteomyelitis was gradually improving with intravenous meropenem, the patient desired early discharge from the hospital. Therefore, the intravenous antibiotic therapy was switched earlier than intended to oral antimicrobial therapy, which led to progression of the disease, and the patient presented with lower cranial nerve palsies three months after his discharge. He was initiated again on intravenous meropenem. While the osteomyelitis improved gradually with the intravenous antimicrobial therapy for two months, the levels of inflammatory markers, such as the serum c-reactive protein, increased again soon after discontinuation of the intravenous antibiotic therapy. Therefore, we decided to continue the patient on intravenous meropenem every other day administered at the outpatient clinic after dialysis. The treatment was continued for four months after discharge, and the improvement was maintained. We reaffirmed the importance of long-term intravenous antibiotic therapy to treat skull-base osteomyelitis. Intravenous antibiotic administration every other day at the outpatient clinic after dialysis could be a useful treatment strategy to treat skull-base osteomyelitis in patients under maintenance hemodialysis.

Malignant otitis externa (MOE) is a fatal disease, in which inflammation spreads from the external auditory canal to the skull base, resulting in skull base osteomyelitis. We report an atypical case of MOE without otalgia.

The patient, a 76-year-old man with a history of diabetes mellitus developed left otorrhea, and 3 months later, he presented with facial paralysis and dysphagia. He was referred to our department due to intractable otitis externa. The left external auditory canal was filled with white otorrhea fluid and was circumferentially swollen with granulation tissue. Pseudomonas aeruginosa was cultured from the otorrhea fluid. Examination revealed left facial and glossopharyngeal nerve paralyses. Computed tomography (CT) showed soft tissue involvement with bony destruction in the left external auditory canal and surrounding tympanic cavity. Despite these severe inflammatory lesions, the patient had no otalgia. Left tympanomastoidectomy was performed to rule out malignancy. Histopathology revealed no malignancy, but inflammatory cell infiltration. Postoperative magnetic resonance imaging (MRI) showed inflammation extending to the left skull base. Therefore, the patient was diagnosed as having MOE and was started on treatment with ofloxacin ear drops, intravenous levofloxacin 500 mg/day, and ceftazidime 6 g/day. Since the inflammatory findings were trending towards improvement, the intravenous antibiotics were discontinued after 6 weeks. Thereafter, the patient received oral levofloxacin for about 2 years. The patient has been under follow-up until date, without any evidence of relapse. However, the left facial and glossopharyngeal paralyses have still not fully recovered.

MOE is occasionally difficult to differentiate from simple otitis externa. It is important to recognize the possibility of atypical MOE without otalgia and to diagnose and treat this condition before any cranial nerve palsies become manifest.

We present the case of a 77-year-old male patient with relapsing polychondritis localized to the nasal septum, who presented with a history of recurrent epistaxis and nasal pain. After definitive confirmation of the diagnosis of relapsing polychondritis by biopsy, the patient was kept under observation and the lesion healed spontaneously, without steroid administration; the patient was followed up for 5 years, with no signs of recurrence. Careful follow-up might be an option for patients with localized relapsing polychondritis without systemic symptoms.

Fungal sinusitis is categorized into invasive and non-invasive. Non-invasive fungal sinusitis generally carries a favorable prognosis, while invasive fungal sinusitis carries a poor prognosis and could prove fatal if it spreads intracranially.

We report two patients with invasive fungal sinusitis that invaded the skull base, who were treated by endoscopic sinus surgery (ESS) and voriconazole.

Case 1: The patient was a 78-year-old diabetic man who presented with the chief complaints of severe headache and vomiting, but no ocular symptoms. Magnetic resonance imaging (MRI) revealed mycosis of the right maxillary sinus and pachymeningitis. ESS was performed twice for residual lesions and voriconazole was administered for 12 months. No recurrence has been observed for 44 months since the diagnosis.

Case 2: The patient was a 74-year-old man who presented with the chief complaint of postnasal discharge, and computed tomography (CT) revealed findings of sphenoiditis and a bone defect in the skull base. ESS was performed, but it was thought that the lesion could not be opened sufficiently, due to hyperostosis and lack of a proper navigation system. A second ESS was scheduled, but while waiting for the surgery, he presented with oculomotor nerve palsy of gradual onset, resulting from intracranial invasion of the mycosis. After the second ESS and voriconazole administration for 7 months, no recurrence has appeared for 29 months.

Both cases were treated with ESS and voriconazole. The symptoms resolved, and there has been no recurrence. The first patient presented without ocular symptoms, which is atypical for invasive fungal sinusitis. In the second patient, it became difficult to determine when to perform the second ESS, because we could not definitively diagnose the presence of residual inflammation/invasion.

In immunocompromised patients diagnosed as having fungal sinusitis, prompt surgery and medical treatment are important, even if invasion by the fungus cannot be confirmed, given that it can be difficult to distinguish between invasive or non-invasive fungal sinusitis.

Granular cell tumor (GCT) is a benign tumor that can arise in any organ. Laryngeal GCT is rare. In most cases of laryngeal GCT, the tumor is reported to arise from a vocal cord. Epiglottic GCT is extremely rare, with only 1 case reported in the literature until date.

An asymptomatic 52-year-old male patient was referred to our hospital after he was detected as having an epiglottic lesion during a routine upper gastrointestinal endoscopy. A white mass measuring about 1 cm in diameter was found on the epiglottis. We performed trans oral surgery using a flexible-tip rigid endoscope under general anesthesia. Histological examination of biopsy specimens revealed the diagnosis of well-differentiated SCC. Therefore, we immediately performed total resection of the tumor, including the epiglottic cartilage. Histopathological examination of the resected specimen revealed large cells with granular eosinophilic cytoplasm, which showed positive immunohistochemical staining for s-100 protein. Thus, the diagnosis of GCT with pseudoepithelial hyperplasia was confirmed by histopathology.

Presence of pseudoepithelial hyperplasia is common in cases of GCT, which could cause it to be mistaken for well-differentiated SCC, especially in small biopsy specimens. Treatment of GCT is surgical resection with a clear margin. End-flexible-rigidscopic transoral surgery (E-TOS) for epiglottic GCT may be useful as a minimally invasive surgery. GCT is usually a benign neoplasm, although malignant transformation has been reported in 1%–2% of patients. Our patient showed no sign of recurrence until the last follow-up at 3 years after surgery. However, further regular follow-up is necessary.

Laryngeal chondroma is a rare disease, accounting for less than 1% of all laryngeal primary tumors. Tissue biopsy, CT, and MRI are useful for the diagnosis, but differentiation from chondrosarcoma is often difficult. The primary treatment is surgery. Although chondromas are benign tumors, among cases in which the tumor is left unresected, the recurrence rate is high, and in many cases, depending on the size and location, they may affect the respiratory tract. Therefore, it is necessary to select a treatment approach that would include tumor resection, laryngeal preservation, and airway maintenance. We report a case of laryngeal chondroma with airway obstruction in which we performed a total laryngectomy.

The patient was a 45-year-old man, in whom hypertrophy of the cricoid cartilage was incidentally detected on CT. The patient was referred to an otolaryngologist, who made the diagnosis of laryngeal chondroma. The only symptom at the first visit was mild dyspnea in the supine position, but more than half of the cricoid cartilage had been replaced by a tumor, and it was difficult to remove it while preserving the larynx. Five months following the first visit, a tracheostomy was performed because of exacerbation of respiratory distress caused by enlargement of the tumor. The patient was kept under follow-up, but after 1 year 4 months, he developed airway obstruction and dysphonia due to further growth of the tumor, and we performed a total laryngectomy. Based on a review of past reports and the course of this case, we consider that early surgery with larynx preservation is desirable if the tumor is resectable at the time of diagnosis. On the other hand, if the tumor is found to be unresectable with preservation of the larynx at the time of diagnosis, follow-up observation with imaging after securing the airway is one of the useful treatment options. In such cases, total laryngectomy may be performed in the event of development of airway obstruction caused by tumor growth.

Minor salivary gland tumors are rarely encountered head and neck tumors. These tumors are more often malignant than neoplasms of the major salivary glands. In this article, we report a patient with mucoepidermoid carcinoma of the lower lip. The patient was a 50-year-old woman who presented with the chief complaint of pain in the lower lip. On examination, a small nodule was palpable on the right side of the lower lip, with tenderness. MRI did not reveal any lesion. Therefore, we performed surgery under local anesthesia for diagnosis and treatment. The nodule was confirmed by palpation and removed with the surrounding tissue. Histopathology revealed the diagnosis of low-grade mucoepidermoid carcinoma, and the resection margins were negative. Although the incidence of minor salivary gland tumors is low, they must be included in the differential diagnosis of nodular lesions of the lower lip, as the incidence of malignant transformation of these tumors is relatively high.