The drug resistant bacteria was examined in 417 pediatric patients diagnosed as having severe acute otitis media between January 2011 and December 2012 according to the guideline of diagnosis and management of acute otitis media in children 2009. Drug resistant Streptococcus pneumoniae (DRSP) and ampicillin (ABPC) resistant Haemophilus influenzae were detected in 48% and 77% of the patients, respectively. Examination of the relationship between the age and prevalence of drug resistant bacteria showed a significantly higher prevalence of DRSP in patients younger than 3 years of age as compared with that in those aged 3 years or over, although no such difference was observed for ABPC resistant H. influenzae. The relationship between attendance at a group nursery and the prevalence drug resistant bacteria was examined for patients younger than 3 years of age, and a significantly higher prevalence was detected in the group-nursery group as compared with that in the non-group nursery group, both for DRSP and ABPC resistant H. influenzae. Pediatric patients younger than 3 years of age attending a group nursery and diagnosed as having severe acute otitis media may require a careful selection of antimicrobial agents because of a higher risk of infection with drug resistant bacteria, and they should have careful follow-up.

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We reported three cases of ANCA positive refractory otitis media started with otitis media with effusion. All patients initially complained of hearing loss induced by otitis media with effusion, which were not improved by treatments with tympanostomy tube and antibiotics. Serum MPO-ANCAs were detected in all three patients. Two cases were definite in the diagnosis criteria of otitis media with ANCA-associated vasculitis: OMAAV by Harabuchi et al., and one case was ANCA positive otitis media with Polyarteritis nodosa (PAN). In recent years, there has been an increase in reports of patients with OMAAV. The early treatment is needed for good prognosis in terms of hearing preservation. This disease sometimes causes mortal condition, such as subarachnoid hemorrhage. The early diagnosis and early treatment is very important for this disease.

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We report a case involving a cholesterol granuloma of the petrous apex that was drained using the infra-labyrinthine approach.
A 16-year-old boy presented with complaints of severe headache that was not relieved by painkillers. Computed tomography (CT) scan revealed an isodense mass in the right petrous apex. On magnetic resonance imaging (MRI), T1-weighted images of the mass showed heterogeneous iso- to hyperintensity whereas T2-weighted images showed homogeneous hyperintensity, and the mass was not enhanced after gadolinium administration. A non-echo planar diffusion-weighted MR image (non-EP DWI) did not reveal hyperintensity in the mass. The mass was diagnosed as a cholesterol granuloma of the right petrous apex. The patient did not suffer from hearing loss, dizziness, facial palsy, or any other neurologic defects. The severe headache was the sole symptom noted.
Surgery was performed using the infralabyrinthine approach without any complications such as facial palsy, hearing loss, dizziness, or cerebrospinal fluid leakage. A drainage tube was indwelled between the petrous apex and mastoid cavity.
After surgery, his headache improved; however, mild recurrence was observed three months later. CT revealed a scar tissue in the mastoid cavity, which obstructed the drainage tube. The mastoid cavity was cleaned under local anesthesia, and his headache improved further.
The aims of petrous apex cholesterol granuloma surgery are drainage and aeration. Multiple approaches have been described for treating these lesions, such as middle cranial fossa, retrosigmoid, transotic/ translabyrinthine, infralabyrinthine, infracochlear, and transsphenoidal approaches. The approach selected depends on the patient's inner ear and facial nerve function, position of the blood vessels, and the site and extent of the lesion. Since the drainage route created during this approach is relatively narrow, recurrence is often observed. Therefore, further studies are required to develop an effective method to create a continual drainage route.

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An 86-year-old man with type 2 diabetes who underwent middle ear surgery for otitis media in his childhood was referred to our hospital with a complaint of left otalgia. Local findings and imaging diagnoses revealed non-neoplastic granulomatous tissues continued from the external auditory canal to the tympanic cavity, inflammation with abscess extending from the middle ear cavity to the infratemporal fossa and dural thickening. No pathogenic bacteria including acid fast bacteria were detected by a bacteriological examination, and systemic inflammatory diseases including granulomatous polyangitis were not suggested by blood biochemical analysis. The histopathological diagnosis also showed non-specific inflammatory granuloma. Based on these findings, this patient was diagnosed as having inflammatory middle ear disease due to long-term interruption of medical treatment by an otologist after the middle ear surgery. The disease responded poorly to antibiotics but improved by the systemic administration of glucocorticoids. An otological examination showed improvement of disease but he died of inflammatory bowel disease.

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The detection of cochlin-tomoprotein (CTP) in the middle ear has been included in the revised Japanese diagnostic criteria for a definitive perilymph fistula (PLF). We have performed a retrospective study of six patients who were suspected to have PLF and underwent a CTP detection test by ELISA from December 2011 to January 2013 in our department. The CTP detection test had been performed from 11 days to one year after the onset of symptoms. Among these six patients, four patients were positive for CTP. One of the two patients whose chief complaint was dizziness was positive for CTP. Although this patient had a habit of nose blowing, she did not have any specific preceding events that might have triggered the PLF. The CTP detection test was extremely effective in this case for both making the diagnosis and deciding on the course of treatment. Three of four patients suffering from hearing loss and/or tinnitus were positive for CTP. In these three patients, the preceding events of the onset included sneezing, diving or head trauma. All four patients who showed positive test results had undergone an exploratory tympanotomy. The fistula was visually identified in only one of the four patients. It is expected that the CTP detection test will establish a new way to identify spontaneous PLF in the future.

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Functional hearing loss is often misdiagnosed as sensorineural hearing loss, and patients may be forced to receive unnecessary treatment including corticosteroid administration. In this study, we examined the clinical characteristics of patients with functional hearing loss.
One hundred forty-three patients with functional hearing loss (243 ears) were enrolled. They were 33 men and 110 women aged 4-80 years with an average of 17.6 years. Patients' medical records were reviewed for their clinical course. Hearing was evaluated by the one-fourth method of the mean hearing threshold levels. One hundred patients (69.9%) were affected bilaterally, and 111 ears (45.7%) showed horizontal-type audiograms. Sixty-four patients (44.8%) had psychogenic factors, and 43 patients (30.1%) were unconscious of hearing loss.
There were no significant differences in sex, age, ear side, hearing level, consciousness of hearing loss, or type of audiogram between patients with psychogenic factors and those without, but consciousness of hearing loss was more frequently seen in patients with psychogenic factors than those without (73.4% vs. 53.1%; P=0.013). On the other hand, patients who were conscious of hearing loss were higher in age (20.9±1.4 years vs. 10.0±0.8 years; P<0.001), less frequently affected bilaterally (60.0% vs. 93.0%; P<0.001), and showed severer audiogram (25.6% vs. 14.5% of ears with hearing levels≥90 dB; P=0.046), compared with those who were unconscious of hearing loss. Moreover, consciousness of hearing loss and severe audiogram (≥90 dB, deaf type) were more frequently seen in adult patients than in children (P<0.001, P=0.004, P=0.024).
These results indicated that the clinical characteristics of functional hearing loss depends on the patient's age and consciousness of hearing loss rather than the presence of psychogenic factors.

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Ear surgery had been generally performed using microscopic approach. However, the straight-line view provided by the microscope results in blind corners, and residual cholesteatoma can be left behind. In recent years, transcanal endoscopic ear surgery (TEES) has been increasingly performed, particularly in cholesteatoma surgery. The endoscope coupled with a full high-definition camera system offers many advantages over the microscope, including a wider angle of view usually encompassing the entire tympanic cavity and a better magnified visualization of hidden structures such as sinus tympani, sinus subtympanicus in retrotympanum and tympanic isthmus. This greatly enhanced visualization gives surgeons greater confidence and allows them to make better informed decisions during surgery. This article shows a full detail of “in vivo” endoscopic middle ear anatomy using rigid endoscopes with an outer diameter of 2.7 mm and a full high-definition camera. The ear surgeon should be familiar with “endoscopic” anatomy of middle ear so that TEES can be a minimally invasive, secure and functional surgical technique for middle ear pathology.

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The feature and the procedure of canal wall down tympanoplasty were presented.
The controversy over canal wall down tympanoplasty (CWD) or canal wall up tympanoplasty (CWU) is still far from resolved. The advantage of CWD is the complete elimination of recurrent or residual cholesteatoma. However the post operative epithelization is slow and complete in one to two month.
The surgical principle of CWD technique is adequate exteriorization of the cavity. It implies shaping the cavity as an inverted truncated cone. The bottom of the cavity includes the grafted part of the mesotympanum.
The lowering of facial ridge over mastoid segment of fallopian canal and the extended canalplasty with removal of anteroinferior overhang of tympanic bone is recommended.
As the final stage of the operation, the adequate meatoplasty is performed.

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In the intact canal wall technique (ICWT) for cholesteatoma, two techniques are available to create a new communication route between the tympanic cavity and mastoid antrum: an anterior route created anterosuperiorly to the malleus and incus and a posterior route created posteroinferiorly to the malleus. The creation of a new communication route widens the tympanic attic, thereby improving ventilation of the mastoid antrum. The posterior route is also required for the removal of a cholesteatoma formed around the auditory ossicles with disarticulation of the incus-stapes joint. The creation of these communication routes provides a wider surgical field and reduces the risk of complications and cholesteatoma recurrence. This report describes in detail tips for creating the anterior and posterior routes for the surgical removal of cholesteatoma.

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