The relationship among the extent of cholesteatoma and re-pneumatization, hearing improvement, recurrence rate after canal wall up tympanoplasty (CWU) were evaluated in 109 cases of pars flaccida cholesteatoma. Subjects were divided into 3 groups according to the extent of cholesteatoma based on the staging criteria for cholesteatoma 2008 Japan. The extent of postoperative aeration was widely variable in cases showing the same stage preoperatively. The staging of cholesteatoma did not show any consistent relationship to postoperative pneumatization. However, in cases showing aeration in the mastoid, re-pneumatization to the attic or mastoid was achieved even in cases showing the same cholesteatoma stage. The postoperative hearing level was not influenced to the extent of cholesteatoma. The postoperative recurrence rate increased with more extensive cholesteatoma. We could not necessarily predict the extent of re-pneumatization based on the staging of cholesteatoma, however the postoperative recurrence rate was affected by cholesteatoma staging.

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To clarify whether adult patients with attic cholesteatoma show clinical features that differ with age, 99 ears of the patients with attic cholesteatoma who underwent canal wall reconstruction tympanoplasty in our hospital were included in this study. Patients who had already undergone tympanoplasty in other hospital were excluded. They were divided into the following two groups according to their age; younger age group consisted of the patients in their twenties and thirties, and elderly age group consisted of the patients in their fifties and sixties. The following three items were analyzed in the patients of both age groups.
1) The size of mastoid cells measured by preoperative temporal bone CT.
2) The extent of middle ear aeration evaluated by postoperative temporal bone CT.
3) Postoperative hearing.
Statistical analyses were carried out using the unpaired t-test and the χ² test. P values of less than 0.05 were considered statistically significant.
As the results, compared with elderly age group, younger age group showed the following statistically significant differences.
1) Larger size of the mastoid cells. (P＜0.001, t test).
2) Better postoperative mastoid aeration (P<0.001, χ² test).
3) Better hearing outcomes (P<0.001, χ² test).
It was concluded that adult patients with attic cholesteatoma showed different clinical features depending on their age. This suggested that there may be some etiological differences between the two age groups.

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We studied the correlation between polymorphisms of oxidative stress related genes and hearing impairment in middle-aged and elderly Japanese.
The subjects entered into this study were participants in the National Institute for Longevity Sciences, Longitudinal Study of Aging (NILS-LSA). The NILS-LSA is a large population based study of aging and age-related diseases. 2128 subjects aged 40-79 yr and living in Aichi prefecture, Japan were followed up biennially, and the cumulative number of subjects for 3 sequential examinations in 6 years was 6704. Detailed questionnaires, pure-tone audiometry measurements, polymorphisms of glutathione peroxidase 1 Pro198Leu, glutathione S-transferase P1 (GSTP1) Ile105Val, NADH/NADPH oxidase p22phox C242T, nitric oxide synthase 3 (NOS3) 4a/4b and G894T, paraoxonase (PON)1 Gln192Arg and Met55Leu, PON2 Ser311Cys, and superoxide dismutase 2 Val16Ala were examined. Associations between thresholds of better hearing ear at each frequency and gene polymorphisms controlled for age, sex, history of occupational noise-exposure, history of diabetes mellitus, history of cardiovascular disease, history of ear disease and smoking status were analyzed using mixed models under dominant models. Using generalized estimating equations, associations between hearing impairment and these gene polymorphisms were also analyzed.
Polymorphisms of some genes did exhibit significant associations with thresholds of some frequencies. These were NOS3 4a/4b polymorphism with 500, 1000, 2000, and 8000 Hz, GSTP1 Ile105Val polymorphism with 1000 and 2000 Hz, p22phox C242T polymorphism with 500, 1000 Hz. And then, NOS3 4a/4b polymorphism showed significant association with hearing impairment (odds ratio 1.326, 95%CI:1.020-1.724, p=0.035).
Oxidative stress is considered as important mechanism of aging, and this study showed that some polymorphisms of oxidative stress related genes, especially NOS3 4a/4b polymorphism, had significant effect on hearing impairment in middle-aged and elderly population.

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The shape of an audiogram provides highly useful informations for diagnosing patients with hearing loss. However, any specific audiometric patterns of acoustic neuromas have rarely been described. We investigated the audiometric patterns of 105 patients with acoustic neuroma.
The most frequent audiometric pattern in acoustic neuromas was high-tone hearing loss, followed by mid-tone hearing loss. When we reclassified the patterns by the hearing difference compared to the contralateral ear, mid-tone hearing loss became the most frequent pattern. In sudden-onset hearing loss patients, mid-tone hearing loss was the most common pattern. However, all totally deaf patients complained of gradually progressive hearing loss. Increase in the mid-tone hearing level, especially in sudden-onset hearing loss patients, may be specific in acoustic neuromas. There was no correlation between the audiometric patterns and tumor size, but the condition of the fundus of the internal auditory canal related to total deafness in acoustic neuroma.
Understanding the characteristic audiometric pattern of the acoustic neuromas is important to diagnose this disease correctly.

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Somatosensory and muscle functions decline with age. Such changes have been related with diminished balance performance. Recent work indicates mechanical stimulation of ther soles might attenuate muscle atrophy. The purpose of this study was to examine what daily mechanical foot stimulation to the plantar surfaces could ameliorate age-related impairments in standing balance control. The participants stimulated the plantar surfaces of their feet by rolling golf ball under their barefeet everyday. The subjects were 31 elderly female participants. Seventeen participants stimulated their feet and 14 participants did not. The parameters used for standing balance control in this study were the duration times of the Mann test and one-leg standing test. The parameters were measured monthly after the participants started the stimulation. The average of those parameters were compared between the participants with, and without stimulation. The parameters of the participants using stimulation were significantly longer than before using stimulation. On the other hand, we could not find any significant differences in the participants without stimulation. Daily stimulation to the plantar surfaces of the feet by rolling a golf ball might be efficacious against age-related impairments in standing balance control.

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Granulocytic sarcoma, also termed as chloroma, is a rare tumor derived from myeloblast. This tumor can be found in any location of the body, but rarely causes facial palsy. We experienced 2 cases of granulocytic sarcoma with facial nerve palsy. Case 1 is a 20-year-old man who presented with right facial weakness. He had a past medical history of acute lymphocytic leukemia. Magnetic resonance (MR) imaging showed a cerebellopontine angle tumor, which was diagnosed recurrent leukemia, namely granulocytic sarcoma. Case 2 is a 40-year-old woman who was under treatment of adult acute myelocytic leukemia, and presented with facial weakness. MR imaging showed a large tumor in the temporal bone. She was diagnosed of granulocytic sarcoma. We strongly suggested that MR imaging or computed tomography should be performed if a patient with the past history of leukemia with facial palsy.

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A 53-year-old female with bilateral hearing loss and otorrhea presented with bilateral external auditory canal stenosis that was due to chronic external otitis. Surgery was performed to enlarge the external auditory canal. We performed bilateral operation simultaneously because we assumed that the risk of hearing loss caused by the operation would be low and because the patient desired a successful outcome by one procedure. There was recurrence of stenosis, and the patient was satisfied with the outcome. Because external auditory canal stenosis can cause significant complications, patients with this condition require a close long-term follow-up with careful management, and when it was indicated, surgery should be performed at an early stage.

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In recent years, association between P-ANCA positive hypertrophic pachymeningitis and Wegener's granulomatosis has been suggested, including several reports showing that intractable otitis media is an initial sign of P-ANCA positive hypertrophic pachymeningitis.
A 69-year-old male was referred from a local clinic to our facility because of bilateral progressive hearing loss and dizziness. The tentative diagnosis of exudative otitis media was made, and the patient was treated with antibiotics, steroid and insertion of a ventilation tube into the tympanic cavity. His ear symptoms became alleviated by the treatment. However, as the steroid tapering, the symptoms exacerbated, accompanied by intense headache. After admission to hospital, he remained resistant to antibiotics. Contrast-enhanced MRI was carried out and revealed hypertrophic pachymeningitis. It seemed probable that inflammation had spread from the middle ear to the dura mater. Mastoidectomy with radical middle ear operation was performed, but headache did not alleviate. The involvement of ANCA-associated disease was suspected, steroid was then re-administered resulting in remarkable alleviation of ear symptoms and headache. Although headache relapsed following steroid tapering, the symptoms subsided in response to combined use of an immunosuppressor.

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We reported a case of meningeal carcinomatosis associated with preceding symptoms of dizziness, headache and acute sensorineural hearing loss. A 66- year- old man complaining dizziness and headache was admitted to a local hospital and referred to our hospital as his condition was not improved. He was diagnosed as acute bilateral sensorineural hearing loss. Since the patient did not respond to steroid therapy, tumor marker testing was performed and showed a high CEA value, 531 ng/ml. Further examinations revealed gastric cancer (signet ring cell carcinoma) with intracranial metastases of the tumor cells. It was concluded that enhanced head MRI, tumor marker testing and repeated spinal fluid examinations should be necessary when intracranial metastases of a malignant tumor was suspected even in case of acute sensorineural hearing loss.

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Glucocorticoids are often used for the treatment of acute sensorineural hearing loss. We presented a case of woman who developed steroid-induced psychosis after receiving glucocorticoid therapy for sudden-onset sensorineural hearing loss. Treatment with psychiatric medications was effective in this patient.
Severe psychiatric reaction occurred in approximately 5% of steroid-treated patients. High doses of steroids may be a risk factor for complications such as psychosis. However, neither the dose nor duration of steroid treatment seems to affect the severity of mental disturbances. The onset of such psychiatric reactions is unpredictable, because most patients have no history of serious psychiatric illness.
Steroid-induced mental disturbances usually disappear on dose reduction or discontinuation of the drug. In some cases, special treatments such as administration of psychotropic drugs or antidepressants, electroconvulsive therapy, or psychotherapy may be indicated. In such cases, it is important to detect the minor initial symptoms and initiate early treatment.

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A 34-year-old woman had bilateral slight hearing loss at her junior or junior high school days. She complained of gradual progressive hearing loss within a couple of days and got to feel handicaps especially in her left ear during her working activity.
In our hospital, her bilateral tympanic membranes appeared intact, and tympanometry and stapedial reflex test were within normal level. CT scanning revealed no remarkable findings. Pure tone audiometry and speech discrimination test demonstrated bilateral moderate mixed hearing loss. We made a decision to try expiratory tympanotomy in her left worse hearing ear under local anesthesia.
After fore-auricular incision, the tympano-meatal flap was lifted. Without any damage to chorda tympani, we observed a loose incudo-stapedial joint in the tympanic cavity. The mobility of stapes was not so bad. We made a decision to try ossicular chain reconstruction using a small piece of cortical bone and connective tissues, and inserted into small lacks in the incudo-stapedial joint as Tympanoplasty IIIi-I. We could get good hearing result 6 month after surgery. In the next year, we also performed the same surgery in her right ear and then could get the similar good hearing result. We would like to discuss about differential diagnosis and surgical strategy in the present case.

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At the planning cholesteatoma surgery, a choice of procedure is difficult in patients with adhesions to the dura mater or sigmoid sinus. Our patient was a 16-year-old girl with cholesteatoma widely adherent to the dura of the posterior cranial fossa and the sigmoid sinus, and difficulty in resecting of the lesion was anticipated. Considering the patient's age and the good pneumatization of her mastoid cavity, we first attempted total resection of the cholesteatoma epithelium by canal wall up tympanoplasty. As a result, the cholesteatoma epithelium was successfully separated and removed from the posterior cranial fossa dura and the sigmoid sinus. In view of the patient's age and a possibility of residual cholesteatoma, we performed staged surgery. At the second-look operation, no residual cholesteatoma was identified, but the mastoid cavity was filled with granulation tissue. Accordingly, mastoid obliteration with bone putty was performed. We collected answers from the audience to our questions regarding this case and compared them with the actual operative procedure.

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Here I present a case of a 7-year-old girl who presented congenital middle ear cholesteatoma with extensive damage to the ossicles, but without any associate hearing loss. A white mass was identified through the tympanic membrane during a routine school physical examination. Surgical intervention was undertaken, and the decision was made to perform ossicular chain reconstruction using the remaining incus by one-stage tympanoplasty. Here I discuss the surgical strategy, especially the timing of the operation, the type of incision and the ossicular chain reconstruction.

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Tympanosclerosis is characterized by the deposition of calcareous plaques in the eardrum and middle ear, usually results from prior middle ear infections. Surgery for tympanosclerosis involves excision of the sclerotic tissue and many variationsof reconstruction of the ossicular chain. My aim is to present clinical findings and results of treatment of a patient with tympanosclerosis, in order to discuss the better surgical treatment of tympanosclerosis. I report a case of a 53-year-old male who have suffered from otorrhea and combined hearing loss. Otoscopic examination revealed a calcification and perforation in the tympanic membrane. Tympanosclerosis resulting from chronic otitis media was suspected. The calcareous plagues in the middle ear were resected surgically with canal wall up method and posterior tympanotomy. The ossicular chain was reconstructed with incus replacement technique. The myringoplasty was performed using thin sliced island cartilagegraft. Postoperatively, the problem disappeared and his hearing recovered well.

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The identification of patients with acoustic neuromas is changing due to constraints forced by escalating medical costs. Evolving diagnostic technologies are providing alternatives for well established diagnostic tools. With respect to treatment, careful retrospection has lead to a shift from the prior nearly ubiquitous surgical option to a more thoughtful approach of treatment choices. Weighing factors such as tumor size, patient age, involvement of the lateral reaches of the internal auditory canal, hearing status and the presence of other symptoms, otologists are now able to provide an individualized treatment plan best suited for each patient harboring an acoustic neuroma.

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