The relationship between the treatment outcome and three important prognostic factors; the time from onset, initial hearing level, and vertigo, in idiopathic sudden sensorineural hearing loss were investigated for grading of the severity of diseases based on prognosis. The borderlines that induced different outcome were indicated between ten and eleven days from onset, 59 and 60dB, 89 and 90dB, and 99 and 100dB of initial hearing level. Vertigo also affected the outcome independent both of the time from onset and the initial hearing level. Although the grading system previously established by the Ministry of Health and Welfare in Japan was almost seemed valid, we recommended some small revisions in the criterion of day from onset and initial hearing level.

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In our department, 140 ears with middle ear cholesteatoma were treated surgically between 1985 and 1997. The canal wall down method was employed for 107 ears and the canal wall up method for 33 ears. As we changed our surgical policy in 1993, the proportion of canal wall up tympanoplasty increased since then. The mean follow-up periods were 78 and 51 months for canal down and canal up methods, respectively. With respect to hearing acuity, the success rates were 50.0%(canal down) and 78.6%(canal up) when assessed using a guideline for reporting hearing results in middle ear and mastoid surgery (Otology Japan 11, 62-63, 2001). Recurrence of' cholesteatoma was found in 5.6% of canal down cases and in 27.3% of canal up cases, and it could be controlled by second surgery. The major problem after the canal down surgery was the mastoid cavity problem, which occurred in 14.6% of total cases and in 21.7% of cases under 16 of age. The majority of ears with the mastoid problem required additional surgery. We concluded that the canal up method should be employed in the first surgery in view of the better hearing acuity and the preservation of the physiological external canal. It was thought that the higher rate of cholesteatoma recurrence cannot be a reason to reject the canal up method as recurrent cases were well controlled by second surgery. Exceptional cases to which the canal down method is recommended are those with extensive destruction of the external canal wall and dysfunction of Eustachian tube. When the general condition of patients is not likely to allow second surgery, the canal down method should be employed also.

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Between January 1990 and September 2000, 151 ears with middle ear cholesteatoma were operated in Mie University Hospital. One hundred and twelve ears (74.1%) were operated on by tympanoplasty with canal reconstruction, 22 ears by canal wall down tympanoplasty, 14 ears by canal wall up tympanoplasty, and 3 ears by radical mastoidectomy. Staged operation was performed in 59 of 151 ears (39.1%); 24 of 37 ears (64.9%) in children under 15 years old, and 35 of 111 ears (30.7%) in adults over 15 years old. Of the 59 ears, 29 (49.2%) had residual cholesteatoma at second stage operation; 13 of 24 children (54.2%), and 16 of 37 adults (43.2%). Residual cholesteatoma was observed at follow-up in 10 of 92 ears (10.9%) with onestage group, and 3 of 59 ears (5.1%) with staged operation group. All 3 ears with residual cholesteatoma in the staged group were children. Revision tympanoplasty was performed in 6 of 13 ears with residual cholesteatoma. These results indicate the high incidence of residual cholesteatoma in children, and the usefulness of staged tympanoplasty for preventing the residual cholesteatoma.

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It is difficult to make a diagnosis of hearing loss, either conductive or sensorineural, in the patients with intact or unperforated eardrum. We analyzed the preoperative diagnosis and postoperative results in 28 ears of 26 patients with or without middle ear abnormalities including 5 ears with final diagnosis of sensorineural hearing loss. Four ears with otosclerosis, 10 ears with congenital anomalies, 5 ears with traumatic dehiscience of the ossicular chain and 3 ears with perilymph fistula were included.
In the group of otosclerosis, stapedectomy was performed in all cases and postoperative hearing improvement was achieved in all cases. In the group of congentital anomalies, modified type M tympanoplasty was performed in 7 cases and the success rate of postoperative hearing improvement was 100%. In the group of traumatic dehiscience of ossicular chains, postoperative hearing improvement was observed in 3 of 5 patients. In the group of perilymph fistula, vertigo was disappeared in all 3 cases and postoperative hearing improvement was 100%.
Five patients was finally diagnosed as sensorineural hearing loss. Though we have to avoid the unneccesary exploratory tympanotomy for these patients with sensorineural hearing loss. The exploratin of the tympanic cavity is mondatory to make a final diagnosis in some cases.

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Two cases of congenital external auditory canal stenosis that caused infection of the temporal bone were reported. A 7-year-old boy complained of a discharge from the fistula in the right retroauricular region. CT scan showed the right external ear canal and middle ear occupied with soft tissue mass. The fistula was connected to the cholesteatoma in the bony portion of the external ear canal. After remval of the cholesteatoma, the cartilaginous part was enlarged. The second case was a 37-year-male complaining of a painful swelling in his right retroauricular region. CT and MRI examinations showed that the inferior part of the external ear canal was widely destructed and the soft tissue mass extended into the deep cervical region. Surgical exploration revealed that the right external ear canal and the parapharyngeal space were occupied with cholesteatoma. After remval of cholesteatoma, the bony external ear canal wall was covered with a free skin graft. Postoperatively, both cases showed hearing improvement.

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Cholesteatoma in the external ear canal is characterized by bony destruction of the canal wall and accumulation of debris. There have been a few reports on rediation - induced cholesteatoma of the external auditory meatus. We experienced 2 young patients with bilateral cholesteatoma in the bilateral external ear canal. The irradiation was reported to induce some bony changes such as resorption, replacement by fibrous tissue, ulceration, and cutaneous hyperkeratinization. It is generally believed that the cause of cholesteatoma in the external ear canal is migration disorder. In both cases, bilateral ears developed cholesteatoma 5 and 10 years after irradiation. If the external ears have been exposed in the irradiation field, we should observe them regularly with the possibilitiy of development of cholesteatoma, and cholesteatoma should be treated at its early stage.

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