Temporal bone lesions, including cholesteatoma, tumors, and meningoencephaloceles, sometimes involve the skull base of the middle cranial fossa. Bone defects in the skull base of the middle cranial fossa may be associated with impairment of the dura mater and cerebrospinal fluid (CSF) otorrhea. A variety of techniques have been used for repair of the dura mater and/or skull base bone, and reconstruction may be performed with autologous or artificial materials through the transmastoid, middle fossa, or combined approach. Management of skull base defects in the middle cranial fossa is an area of continued innovation. Herein, we review materials and strategies for the reconstruction of the skull base of the middle cranial fossa.

Acute low-tone sensorineural hearing loss (ALHL) is an ailment presenting with a sudden sensorineural hearing loss in which the hearing impairment is confined to the lower frequencies. In the present study, the records of patients diagnosed with ALHL from among the patients of hearing loss who visited my clinic in the last 6 years were extracted, and a retrospective analysis of the subjective symptoms, recovery rate, recurrence, and a tendency of progression to Meniere’s disease were recorded. A total of 146 cases were diagnosed as having ALHL, of which 34 were male and 112 were female. The most common subjective symptom was aural fullness, reported by 131 patients (89.7%). The 116 cases who were given isosorbide, Wu-Ling-San (Goreisan), and ATP as initial treatment recovered. Out of the 30 patients who did not respond to the initial treatment and were given steroids and vitamin preparations, 20 cases showed recovery. The overall recovery rate was 93.2%. There was no improvement in 10 cases (6.8%). Based on the severity, Grades 1, 2, and 3 showed a recovery rate of 90% or more. Grade 4 showed a low recovery rate of 68.8%. The cases who showed no improvement were either elderly patients or patients diagnosed as having a high severity at the first visit. Out of the 146 cases, the post-one year follow-up was performed for 82 cases (56.2%). Out of the cases who underwent the post-one year follow-up, there was recurrence in 31 cases (21.2%). Out of the patients with recurrence, 22 cases progressed to cochlear Meniere’s disease. 6 cases progressed to Meniere’s disease, all of which were females. The severity grade of all the 6 cases who progressed to Meniere’s disease was Grade 3 or Grade 4. Patients progressing to Meniere’s disease had a higher severity of the disease.

A cerebrospinal fluid (CSF) gusher is a rare complication encountered during cochlear implantation surgery in children with inner ear malformation. Tight sealing of the cochleostomy site is needed to control a CSF gusher, but it is sometimes challenging. The FORM electrode^© is a special electrode that was developed to control the CSF gusher. The electrode has a conical stopper at its base and this stopper effectively seals the cochleostomy site. We experienced two cases of CSF gusher controlled with the FORM electrode. The first case was a 5-year-old girl with incomplete partition type I malformation. The second case was a 7-year-old girl with incomplete partition type I malformation. The latter was a revision case due to internal auditory canal insertion. In both patients, the CSF gusher was easily stopped during the surgery by pushing the conical stopper perpendicular to the bony surface around the cochleostomy site. In one case, post-operative CSF leakage occurred due to elevation of the intracranial pressure. Fixation of the electrode array at the facial recess may be preferable in using the FORM electrode.

Recently, congenital cholesteatoma (CC) has become easier to diagnose because of the widespread use of microscopy and endoscopy; the number of diagnosed cases is increasing. However, bilateral CC remains rare. We report a case of bilateral CC that was treated by transcanal endoscopic ear surgery (TEES).

A 3-year-old boy was referred to us with suspected CC, based on the finding of bilateral white masses in the anterior-superior quadrants of his tympanic membrane on both sides. Pure tone audiometry (collected using a headphone) showed an average of 8.3 dB in the right ear and 13.3 dB in the left ear. The auditory brainstem responses were normal in both ears. Computed tomography revealed a soft tissue masses measuring 3.4 mm and 3.7 mm in diameter in the right middle ear and left middle ear, respectively. We found no bony erosions or ossicular malformation. Type I tympanoplasty was performed via TEES, initially on the left side. Six months later, right-ear type I tympanoplasty was performed. Four years after the left ear operation, no recurrence was evident in either ear and the average hearing threshold was 11.7 dB in the right and 13.3 dB in the left ear.

Although spontaneous CC regression is known to occur rarely, in general, CC should be diagnosed early and treated promptly. In particular, if both ears are affected, it is important to maintain or improve hearing and to definitively remove the CC. TEES is a minimally invasive surgical technique and is the optimal treatment modality for CC in the early stage. When both ears are affected, simultaneous operations should be considered according to the pathological stage, hearing level and skill level of the surgeon.

We report herein on a case of cholesterol granuloma at the petrous apex with mixed conductive-sensorineural hearing loss. A 34-year-old man was referred to our hospital with symptoms of slowly progressing left-side hearing loss and tinnitus. Mixed hearing loss was confirmed via pure tone audiometry. Computerized tomography (CT) revealed bone destruction and cystic lesions in the petrous apex, the anterior wall of the internal auditory meatus, and a part of the cochlea. Magnetic resonance imaging (MRI) revealed that the cochlear nerve was compressed by the cystic lesion. Drainage surgery was conducted to avoid radical extirpation of the lesion with risk of total deafness. Postsurgical CT revealed that the cystic lesion had disappeared and was replaced by an air-filled space. MRI confirmed that the compression in the cochlea nerve had been relieved. The patient’s mixed hearing loss improved, with mild residual sensorineural hearing loss at high frequencies. Thanks to the indication of drainage surgery, the patient recovered from mixed conductive-sensorineural hearing loss.

We experienced two cases of hemophilia A revealed by repeated post-tonsillectomy hemorrhages. Patient 1 was a female in her thirties and tonsillectomy was performed because of IgA nephropathy. Post-tonsillectomy hemorrhages were observed at POD 5, 10 and 14. At each point of hemorrhage, hemostasis was carried out. Hemophilia A was revealed based on a blood test performed after the third hemostasis. Patient 2 was a male in his twenties and tonsillectomy was performed because of habitual angina. Post-tonsillectomy hemorrhages were observed at POD 8 and 16. Hemostasis was carried out at POD 8, but at POD 16, we suspected endogenous bleeding and treated conservatively. A blood test revealed decreased coagulation factor VIII activity and he was diagnosed as having hemophilia A. In both patients, hemophilia A was revealed from their decreased coagulation factor VIII activity revealed in blood tests performed after repeated post-tonsillectomy hemorrhage. It is very important to check pre-operative tests and Coagulation factors when post-operative hemorrhages occur repeatedly, because endogenous bleeding would be suspected.

Infantile fibromatosis is a rare type of soft tissue tumor, which could arise from bones, muscles, or tendons. It occurs most commonly in the head, neck, and limbs, but rarely in the cheek. Although it is a benign, it shows aggressive local invasion and is associated with high recurrence rates after surgical excision. The general treatment is radical resection, but it is often difficult to achieve radical resection with satisfactory functional and cosmetic results.

A 6-month-old girl presented with a left cheek tumor, which had rapidly increased in size. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a 50-mm sized tumor that had invaded the fasciae and hypodermis of the skin. Taking into account the potential effects on the respiratory tract, we performed radical resection of this tumor. Histopathologic examination revealed that the tumor was an infantile fibromatosis (desmoid) and that the resection was microscopically incomplete.

Although there is no evidence yet of a correlation between residual tumor and recurrence, a previous report indicated that the recurrence rate was higher in cases with residual tumor. Therefore, this case requires intensive follow-up.

Epiglottic abscess is one of the complications of acute epiglottitis. It can cause airway obstruction and require emergency attention. Epiglottic abscess is very rarely caused by gas-forming bacteria, but herein, we report two cases of epiglottic abscess caused by gas-forming bacteria. In the first case, a 66-year-old woman presented with a one-week history of slight sore throat. Fiberoptic laryngoscopy revealed epiglottic swelling in the shape of a heart and CT showed gas in the epiglottis. Antibiotics were administered, however, the laryngeal swelling progressed and tracheostomy was performed. The abscess then resolved, and the patient was discharged from the hospital on the twelfth hospital day. In the second case, a 43-year-old man presented with a history of severe dyspnea and sore throat, and he also suffered from orthopnea. CT showed the presence of much gas in the epiglottis and arytenoid region, fiberoptic laryngoscopy revealed severe laryngeal swelling and tracheostomy was performed immediately; however, the patient went into cardiac arrest before tracheal fenestration. Cardiac resuscitation restored the heartbeat and tracheostomy was performed, however, the patient died on the twenty-first hospital day. Both cases needed tracheostomy; this case report serves to underscore the need to bear in mind the possibility of invasive airway access while managing cases of gas-forming epiglottic abscess.

Malignant fibrous histiocytomas (MFHs) are reported to be the most common soft tissue tumor in late adult life. However, they rarely occur in the neck. A 68-year-old female with MFH in the left side of her neck is reported. A dissection under general anesthesia was performed to establish a definitive diagnosis. The histopathological findings were suggestive of MFH. The postoperative course has been uneventful without recurrence or metastasis for three years. We recommend that close follow-up is necessary due to the high risk of recurrence and distant metastasis.

Introduction: Recently, the number of patients receiving anti-thrombotic therapies has been increasing. Anti-thrombotic therapy increases the risk of bleeding during surgical procedures, while interruption of the therapy would increase the risk of intraoperative thromboembolism. This is the reason why decision-making on surgical procedures in patients receiving anti-thrombotic therapy is sometimes quite troublesome. Here, we retrospectively investigated the impact of anti-thrombotic therapy in patients undergoing surgery at our institution during the several years.

Method: The retrospective study was performed in 3893 patients who underwent surgeries, except ear surgeries at our department, between 2013 to 2018. The distributions of the age, gender, type of surgery, amount of intraoperative bleeding, and incidence of postoperative bleeding were compared between the patients in whom the anti-thrombotic therapy was interrupted and those in whom it was continued.

Results: About 13% of patients were receiving anti-thrombotic therapy prior to the scheduled operation. There were higher numbers of patients on anti-thrombotic therapy among male and elderly subjects and among patients with malignancy. Of these patients, the anti-thrombotic therapy was continued in 40% and interrupted in 60% of patients. The duration of surgery and volume of bleeding were lower in the patients in whom the anti-thrombotic therapy was continued, presumably because these patients mainly underwent minor surgeries or surgeries under local anesthesia. Among the cases that underwent major surgeries under general anesthesia, there was no statistically significant difference in the incidence of postoperative bleeding between the patients in whom the anti-thrombotic therapy was continued and those in whom it was interrupted.

Conclusion: We concluded that surgical procedures can be performed safely even in patients in whom anti-thrombotic therapy is continued, if we limit the scale of the operation and modify the intensity of the anti-thrombotic therapy. However, it is noteworthy that we encountered several cases with delayed onset of postoperative bleeding among the cases in whom the anti-thrombotic therapy was continued.