Cochlear implants have become the standard of care for patients suffering from profound sensorineural hearing loss. Unfortunately, access to cochlear implantation as well as cochlear implant rehabilitation may be limited. In order to facilitate access to cochlear implantation and cochlear implant rehabilitation, implantation was performed at a satellite medical facility over 250 miles from the Carolina Ear and Hearing Clinic's cochlear implant center, and the implants were programmed over the Internet via a virtual private network (VPN). A separate video conferencing system was used to insure synchronization of the video and audio signals.
Initially, an IRB approved pilot study was conducted comparing the postoperative HINT and CNC word scores for seven patients who had undergone remote mapping and programing of their cochlear implants. Their scores were compared with the mean scores of seven patients who had been programmed at the Carolina Ear and Hearing Clinic by the same audiologist over a twelve-month period. All patients in each group were successfully programmed and there were no statistically significant differences in postoperative HINT and CNC word scores.
Based on the success of this pilot study, the remote programming system was expanded to include young children. Their ages ranged from 22 months to 5 years of age. All five children were successfully programmed remotely. To date, over 48 adult and pediatric patients have been implanted and successfully programmed using this remote programming system. The ability to remotely program cochlear implant patients offers the potential to extend cochlear implantation to areas without a tertiary cochlear implant center. This model, which is safe, effective, and maintains patient confidentiality, may have application for other implant centers attempting to provide patients access to cochlear implant technology.

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Target numbers for surgical procedures an ENT should experience within the first 10 years were established based on a survey. The following target numbers for surgeries that one should have experienced as a practitioner could be established based on the survey results: myringoplasty 19 cases, tympanoplasty 38 cases, and mastoidectomy 29 cases. However, it was considered difficult to achieve these levels within 10 years.
Accordingly, in order to correct for bias in mastered fields, at our department we prepared and submitted monthly records on numbers of various types of surgeons to young doctors with less than 10 years experience as ENT physicians, shared data between young physicians and lead doctors, and sent feedback onsite. Shared data included individual technical level of achievement and group means, and target values, etc., and we were able to gain an understanding of individual numbers of surgeries and make comparisons with others. This type of technical visualization is useful for correcting bias of mastered fields, and is necessary for post-graduate education.

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The author thinks that the fundamental operative procedures in otological surgeries should become integrated into the optimum styles for trainees and should be shared in various institutions. On the other hand, there seem so many variations even in the fundamental techniques at present.
Therefore, several procedures with good theoretical superiority have been collected from other institutions and modified at our department. These are classified and presented according to three traineeship levels including the resident, the fellow and the subspecialist aiming for the specialist of ear surgery.
The author hopes that these procedures are discussed as tentative plans for educational training for ear surgeries in Japan.

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The resident training program for otology is arranged by each sponsoring institution in Japan. In the United States, ACGME (Accreditation Council for Graduate Medical Education) has a special education program for Otolaryngology Head and Neck Specialist. During their five year residency, they efficiently obtain skills in special areas (anatomy, embryology, physiology and so on), patient care, and surgical procedures. The educational system for otology between the United States and Japan was discussed.

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My paroxysmal unilateral patulous eustachian tube (ET) was studied by transnasal endoscopy and computed tomography (CT).
The symptom of my patulous ET is hearing my own voice and breathing in my right ear, which occurs suddenly and only when I am talking with my chin lifted, and only in summers in which I am experiencing weight-loss. This symptom disappears immediately when I utilize a self-administered therapeutic maneuver. The maneuver consists of repetitive swallowing while pushing upward on the area between the submandibular gland and the angle of the mandible.
Endoscopic study revealed several findings. During the resting state of the ET, the belly of the levator veli palatine muscle (LVPM) was flat, and the ET lumen was opened widely. These observations suggest that the LVPM deviates inward. My ETs are always opened when I yawn. While yawning, the LVPM contracted and moved inward. Similar findings were also discovered when I opened my mouth with my chin lifted. The LVPM plays a significant role in opening my ETs.
There are two maneuvers to alleviate the symptom. The pharyngeal orifice of my right ET was blocked immediately at the front by the protrusion provided by applying my maneuver. It was also blocked slowly at the lateral lamina by the swelling caused by pushing on the jugular vein. The former is more efficient.
My mandibule deviates rightward due to my temporomandibule joint disorder. While moving my mandible rightward, the super pharyngeal constrictor muscle contracted, and the lateral lamina moved also rightward leading to the dilation of my right ET lumen. Coronal CT examinations revealed that my right ET orifice was located higher than my left orifice. These observations suggest the excessive rotation of my right ET. This rotation might be due to my mandible. In addition, the fat-loss in my ET, the possible absence of the salpingopharyngeal muscle, and the possible laxity of my sliding joints in my ET cartilage might also be related to the excessive rotation.
Repetitive swallowing is essential for the maneuver, which means that the rotation of my ET is necessary to fix my patulous ET. I hypothesize that my patulous ET is due to the excessive rotation, resulting in the dislocation of the medial lamina to the lateral side of the LVPM. Only by re-rotating the cartilage would the medial lamina return to its normal place.
This hypothesis is only based on my patulous ET.

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Postoperative bone conduction threshold, as well as postoperative air conduction threshold, is frequently examined, because one of the aims of hearing improvement operation is to close the air-bone gap. We evaluated the effects of hearing improvement operation on postoperative bone conduction thresholds. A total of 207 ears of 201 patients underwent first time operations for hearing improvement from January 2007 to December 2009. Audiometric evaluation was based on pure tone audiograms, taken before and more than 6 months after surgery.
The mean postoperative bone conduction threshold at three speech frequencies and the mean postoperative air conduction threshold improved significantly by 2.8 dB and 16.6 dB compared with preoperative hearing levels. Eighty-five out of 207 (41%) cases showed more than 5 dB improvement of the mean bone conduction threshold after operation. The mean postoperative bone conduction thresholds showed significant improvements at 1000Hz and 2000Hz, but not 500Hz and 4000Hz. In bone conduction thresholds of each middle ear disease, greater than 10 dB improvement rates after operation were as follows: chronic otitis media 5/52 (9.6%), pars flaccid cholesteatoma 4/43 (9.3%), otosclerosis 10/28 (35.7%), chronic otitis media with tympanosclerosis 3/22 (13.6%), tympanosclerosis 4/14 (28.6%), ossicular malformation 3/14 (21.4%), adhesive otitis media 0/13 (0%), pars tensa cholesteatoma 2/9 (22.2%), congenital cholesteatoma 0/6 (0%), and secondary cholesteatoma 2/6 (33.3%). At 6-12 months after operation, the mean postoperative bone conduction threshold improved significantly by 1.7 dB compared with preoperative hearing levels. At more than 12 months after operation, the mean postoperative bone conduction threshold improved significantly by 3 dB.
These results showed that the postoperative air and bone conduction thresholds improved significantly compared with preoperative hearing levels in each middle ear disease, and postoperative air and bone conduction thresholds at more than 12 months after operations improved compared with at 6-12 months after operation. Thus, the evaluation of hearing improvement operation is recommended to examine air and bone conduction threshold at the same time at more than 12 months after operation.

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We reviewed the 10-year outcomes of 115 ears operated on by a single surgeo. Ten-year hearing outcomes were estimated using postoperative air-bone gap with preoperative and postoperative bone conduction thresholds. Hearing outcomes were considered successful if postoperative air-bone gap was within 20 dB after tympanoplasty and 10 dB after stapes surgery. The ten-year successful hearing rate was 46.1% for preoperative bone conduction thresholds, but 60.9% for postoperative ones. Patients older than 60 years old at surgery had significant deterioration of bone conduction thresholds at 1, 2, and 4 kHz and those younger than 60 years old had significant deterioration only at 2 kHz.
We concluded that postoperative bone conduction thresholds should be used to estimate long-term hearing outcomes in order to exclude aging effects.

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We report two cases of mucoid type Streptococcus pneumoniae otitis media and mastoiditis that had spread into intracranial space. The first case is an otherwise healthy 55-years-old male who had presented ear fullness and otalgia.
He had been prescribed oral antibiotics at several clinics for three months without improvement. He eventually developed severe headache and disordered consciousness, and was admitted to our hospital as an emergency patient. A CT scan showed soft density area spreading not only to the tympanic area but also to the mastoid cells. Bacteria test of the spinal fluid indicated mucoid type S. pneumoniae involvement. He was diagnosed with otogenic meningitis and was treated initially with intravenous administration of penicillin. Subsequently, he underwent mastoidectomy and tympanoplasty and had complete relief of symptoms.
The second case is a 59-years-old male with untreated severe diabetes mellitus who had presented with otorrhea. Symptoms persisted for two months despite treatment with oral antibiotics. Then, he started having other symptoms such as dizziness and severe unilateral hearing loss and was referred to our hospital. MRI showed inner ear fistula, subcutaneous and subperiosteal abscess, cerebellar abscess and inflammation. Bacteria testing of the subcutaneous abscess indicated mucoid type S. pneumoniae involvement. Alongside initiating diabetes care, he was hospitalized and treated with intravenous administration of TAZ/PIPC and immuno-globlin. During the treatment he developed sigmoid sinus thrombosis, which was an unfavorable condition for surgery. Nevertheless, the intravenous treatment dramatically improved the disease. Isolation and identification of pathogenic bacteria is crucial for treatment decision making because mucoid type S. pneumoniae is mostly resistant against cephem. Occasionally, surgical treatment may also be considered.

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We reported 2 cases of inner ear malformation presenting with bacterial meningitis developing at younger adult age, which are thought to be relatively rare. They were found to have bilateral profound hearing loss in their childhood and thereby have been wearing hearing aids. The first case was a 21-year-old female who had neither history of otitis media nor of meningitis and developed bacterial meningitis a month before. She had deafness of the left ear and 100 dB sensorineural hearing loss in the right ear. CT scan showed bilateral cochlear hypoplasia with left vestibular anomaly (classical Mondini) and fluid collection in the left middle ear. The second case was a 25-year-old male who had no history of otitis media and developed the first episode of bacterial meningitis a month before. He had right ear deafness and 105 dB sensorineural hearing loss in the left ear. CT scan demonstrated bilateral cochlear hypoplasia with bilateral wide vestibule and fluid collection in the right middle ear. In both cases, perilymph gusher and cerebrospinal fluid (CSF) leakage from vestibular window were confirmed by exploratory tympanotomy, and the stapes was found to have minor deformity in the footplate. Stapedectomy was done, and then multiple layers obliteration into the inner ear with periosteum, temporal muscles, and auricular cartilage were performed to control the perilymph gusher. A sheet of temporal fascia was placed on the vestibular window to seal it. Neither middle ear obliteration nor spinal drainage to reduce the CSF pressure was added. No episodes of recurrence were encountered in either case during longer than 1 year follow up, and these results might indicate this surgical technique with multiple layers obliteration alone into the inner ear was working effectively enough to control the perilymph gusher.

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Congenital absence of the oval window is a rare middle ear anomaly. In general, patients with middle ear anomalies are considered candidates for surgery to rehabilitate hearing loss. However, surgery in cases of congenital absence of the oval window is challenging because of the possibility of surgical complications. We report a case of congenital absence of the oval window wherein hearing thresholds improved after a cochlear drill-out procedure was performed.
An 8-year-old boy was referred to our hospital with a complaint of bilateral hearing loss. Audiometry revealed bilateral conductive hearing loss. High-resolution computed tomography showed absence of the stapes and displacement of the long process of the incus, in both ears. We suspected congenital ossicular anomaly: therefore, an exploratory tympanotomy was performed in his right ear.
The absence of the oval window and the stapes was confirmed by surgery. Even though the tip of the long process of the incus was attached to the vertical portion of the facial canal, ossicular mobility was found to be satisfactory. Because no facial nerve anomaly was observed, cochlear drilled-out was performed, and a Tefron-wire piston was attached to the manubrium of the malleus. The average hearing thresholds of the right ear improved from 65.0 to 23.3 dB after surgery.
Air-conduction hearing aids, bone-anchored hearing aids, and cochlear drill-out procedures are considered for the treatment of congenital absence of the oval window. The hearing outcomes of the cochlear drill-out procedure are excellent, and patients receiving this treatment do not require hearing devices. Therefore, this method was considered to be effective for the treatment of congenital absence of the oval window.

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