Simple underlay myringoplasty, which was first developed by Yuasa in 1989, is widely used to repair tympanic membrane (TM) perforation. However, the closure rate of TM perforation using Yuasa’s procedure is reported to be 75-85%, which is less than that using standard myringoplasty. We hypothesize that TM perforation may not be completely repaired by simple underlay myringoplasty because of delayed wound healing of the TM epithelium in a dry environment and displacement of the graft from the TM perforation edge. Accordingly, we enhanced the simple underlay myringoplasty technique in our department, by focusing on firm fixing of the connective tissue, which becomes a graft, and maintaining a moist environment conducive to wound healing. First, Terudermis^® (collagen-based artificial dermis) is placed over the TM perforation and connective tissue, followed by fixing with fibrin glue to prevent detachment of the connective tissue in the middle ear. Further, the external auditory canal is filled with Spongel^® (gelatin sponges) with antibiotic eardrops to maintain a moist environment. We applied this improved simple underlay myringoplasty to 52 ears from April 2010 to November 2014, and 45 of these ears were observed for more than 12 months. In this study, there was no significant difference in the operation time between surgeons with more than 5 years of otologic surgical experience and those with <5 years of experience. The closure rate of TM perforation and the success rate of hearing improvement based on the decision criteria of the Japan Otological Society were 91.1% and 94.6%, respectively. Favorable outcomes were obtained using this improved simple underlay myringoplasty.

Since bleeding during middle ear surgery for auditory ossicular malformation is expectedly low, auditory ossicular malformation may be a good indication for transcanal endoscopic ear surgery (TEES). We retrospectively analyzed 9 cases (10 ears) with auditory ossicular malformation between March 2013 and December 2015 at our clinic. There were 4 men (5 ears) and 5 women (5 ears), with an average age of 29 years. Classification of the pathologic condition based on surgical findings showed separation of the incus-stapes joint in 7 ears and fixation of the stapes footplate in 3 ears. Ossicular reconstruction was performed by modified type III in 4 ears, modified type IV in 3 ears, and stapedotomy in 3 ears. The postoperative hearing success rate was 80% according to the criteria proposed by the Japan Otology Society in 2010. It is suggested that TEES would be effective for auditory ossicular malformation surgery, because it enables bright, fine, and wide view of the surgical fields around the auditory ossicles.

Sports activities enhance children’s mental and physical health development. All children, including those with hearing impairments, should be encouraged to participate in sports, particularly during their early childhood and school-age development stages. However, in children with cochlear implants (CIs), various parts of the hearing device, such as the speech processor, cable, and coil, may hinder participation in sports. Such children may also experience communication difficulties.

The aim of this study was to identify ways to decrease device-related issues and to help improve the quality of life of children with hearing impairments. A survey was conducted on the sports participation of pediatric CI receivers, including the problems and limitations they face during participation. The current measures taken to overcome these issues were also investigated.

A questionnaire was sent out to 150 patients with bilateral severe sensorineural hearing impairments, who had received CIs at Okayama University Hospital at the age of 18 years or below. The participants were in first grade elementary school or higher grade as of March 2015. Of the 150 questionnaires sent out, 76 (50.7%) were completed and returned. There were 42 male and 34 female participants. Their mean age was 12 years (range, 7 to 27 years), and the mean duration of CI usage was 7 years (range, 1 to 16 years). Of these participants, 53 (69.7%) were or had been involved in some extracurricular sports activity, such as school club activities or lessons, and 23 (30.3%) had not been involved in any sport activity. Among the participants with sports experience, 39 (73.6%) constantly wore the CIs while participating in sports. Most of the participants who did not use, or only occasionally used, CIs during sports activities participated in swimming practice. Among the device-related issues experienced by the participants, cable disconnection was the most frequent, followed by processor malfunction, rusting, and coil defects. Implant failure due to sports activity was not reported. Additionally, many participants reported inconvenience caused by the detachment of the external components, communication difficulties, and getting the device wet with sweat or rain. These issues were handled in various ways.

The survey results showed that even CI users could participate in sports activities without excessive restriction. Doctors or speech pathologists should provide information and appropriate guidance to patients about CIs, including precautions and countermeasures against device malfunction and head trauma.

Heerfordt’s syndrome was first reported in 1909 and was shown to be a subtype of sarcoidosis in 1938. This syndrome was described to be a combination of uveitis, parotid gland swelling, facial palsy, and slight fever. In this report, we describe a 28-year-old woman who presented with right facial, upper- and lower-limb sensory nerve deficits, and double vision. Her primary care physician referred her to a neurologist at our hospital. Head and thoracic magnetic resonance imaging (MRI) displayed no abnormal findings. However, the patient developed bilateral parotid swelling and left facial palsy and was, therefore, referred to us in the Department of Otolaryngology. We measured angiotensin-converting enzyme (ACE) levels and determined them to be slightly higher than normal; therefore, we consulted a pulmonologist. Transbronchial lung biopsy and bronchoalveolar lavage were performed. The tissue was negative for noncaseating epithelioid granuloma, but the CD4/CD8 ratio was high. At this stage, the patient once again presented with bilateral parotid gland swelling, so we biopsied the parotid gland and finally diagnosed sarcoidosis by pathological diagnosis of the biopsy. On the thoracic MRI, we were also able to diagnose radiculopathy and sensory disturbance of the trunk. Heerfordt’s syndrome accompanied with radiculopathy is very rare, and, to the best of our knowledge, this is only the fourth reported case. We report this very rare case in light of a previous report.

Electric Acoustic Stimulation (EAS) improves hearing ability for patients with high-frequency hearing loss in whom standard hearing aids are ineffective. Since 2014, EAS has been approved for social health insurance coverage in Japan. The development of new electrode designs and minimally invasive surgery have enabled the preservation of residual hearing. However, there still remains consideration of longitudinal results in preserved hearing in the lower frequencies after EAS surgery. We compared the results of pure-tone audiometry at pre-operation, thorough one year after as a short-term result, and until 5 years after as a long-term result. With regard to a short-term, hearing thresholds deteriorated slightly at one month after surgery, and no changes were observed afterwards. In a long-term result, hearing thresholds deteriorated as a natural history of hearing loss in some patients that showed progressive hearing loss in the non-implanted side as well. The lower frequency hearing preservation with cochlear implant can be possible by round window approach as atraumatically surgical technique and EAS electrode. The results with EAS demonstrate that this newly devise is effective in the patients with high frequency hearing loss.

Hearing loss is one of the most common sensory impairments, and hearing loss with hearing level of 41 dB or greater is prevalent in approximately one in 5-6 men, and one in ten women in their seventies, according to our estimate from the population-based study named the National Institute for Longevity Sciences - Longitudinal Study of Aging (NILS-LSA).

Domestic and international epidemiologic studies have demonstrated that hearing loss is involved with varying adverse effects in individuals and society. Hearing loss in the elderly has been linked with depression, apathy, lower cognitive functioning, brain volume declines, frailty, falls, and poor activities of daily living, through communication difficulties and decreased social participation. Resent researches have indicated that hearing loss has also played a role in low health literacy, poor adherence to medical intervention, long-term care risk, and increased mortality, in addition, that it can bring disadvantages in driving performance, employment and income. Hearing aid use can hopefully attenuate the cognitive decline accelerated by hearing loss.

Tympanoplasty for elderly patients is very common and its opportunity is increasing. Perioperative clinical characteristic of elderly patients with chronic otitis media was high incidence of fungus and secondary acquired cholesteatoma. The aim of ear surgery for elderly patients is to improve and support their QOL and social activity. To obtain good surgical outcomes in elderly patients, there are various matters to keep in mind including antithrombitic agents. In this symposium, we presented our experiences in management of tympanoplary for elderly ( > or = 75) following some important guidelines.

In the lateral temporal bone resection, the external auditory canal (EAC) is removed as en bloc specimen with the tympanic membrane and the malleus. In this surgery, a cortical mastoidectomy with facial recess exposure and drilling by expanding the extended facial recess inferiorly and anteriorly are necessary as standard techniques. On the other hand, ways of resection for the glenoid fossa would be various by each surgeon. Some surgeons use their thumbs to crack bony attachment after they isolate the EAC from above, behind, and below. Others use a chisel to fracture the anterior bony wall through the facial recess or the glenoid fossa.

I suggest that exposing chorda tympani anteriorly would be important to excise the front wall of mastoid. The chorda tympani come out anteriorly through a canal in the petrotympanic fissure. It runs anteriorly between the roof of middle cranial fossa and EAC. Additionally, it exists above bony part of the Eustachian tube. In all surgical process, it is significant to drill bones around the EAC with cutting burs or diamond burs under the microscope without fracture using his thumb or a chisel. I would like to show the knack and the pitfall in lateral bone resection.

This paper describes complications occurring after cochlear implantation which lead to revision surgery and discusses about surgical technique to avoid complications in cochlear implantation. Between April 1987 and March 2015, 549 ears had cochlear implantation placed at Toranomon hospital, and 32 ears (5.8%) had received revision surgery. Causes of postoperative complications which lead to revision surgery were reviewed retrospectively. 32 cases had complications which lead to revision surgery. As for complications, 9 cases had device failure, 5 cases had wound infection and necrosis with or without the receiver-stimulator extrusions, 3 cases had electrode exposure at external auditory canal, 3 cases had facial nerve stimulation, 3 cases had device failure caused by head injury, 2 cases had electrode problems caused by treatment of ear canal, 2 cases had poor performance after activation, 2 cases had recurrent middle ear infection, 2 cases had cholesteatoma and 1 case required surgery to take out magnet before MRI. As for revision surgery, 16 cases had received re-implantation on the same side, 8 cases had received re-implantation on the other side, 4 cases had received revision surgery with using initial device, and 3 cases had taken out initial device without re-implantation and 1 case had taken out magnet before MRI. Most frequent cause of revision surgery was device failure which is not able to avoid. But it will be possible to reduce numbers of complications related to skin, flap and external ear canal. Design of skin incision, fixation of electrode, fixation and tie down of receiver stimulator, and canal wall reconstruction are important to avoid complications. Safety and reliability of surgery will increase the numbers of cochlear implantation patients. Incision and fixation of device will be important to avoid complications. Long term follow up is also important in order to find complication early.

Cochlear implamt (CI) has a history of over 30 years in Japan, and the number of recipients is estimated more than 10,000. It is not rare for clinicians to encounter difficult cases that need reimplantation. In the Osaka University Medical Hospital, implantations had been performed in 607 ears from January 1992 to March 2015. Among them, reimplantation had been needed in 47 ears (7.7%). The most frequent cause of reimplantation was device failure in pediatric patients. On the other hand, slipping-out of the electrode was the most major reason in elderly patients. We discuss how to decide the side of reimplantation in this paper.

Intraoperative monitoring of the facial nerve is essential to achieve high rate of facial nerve functional preservation after translabyrinthine approach to vestibular schwannomas (VSs). Recently an advanced monitoring method has been reported to improve preservation rate of function: facial nerve root exit zone-elicited compound muscle action potential (FREMAP) monitoring (Nakatomi et al. 2015). Here we report two representative cases: one case of VS by translabyrinthine approach with a highly-prevailed nerve monitoring system using an electromyographic monitor; and the other case of VS by the same approach but with the continuous FREMAP monitoring. We also discuss on a future direction of preservation of cochlear nerve function in VS surgery. Cochlear nerve preservation surgery by translabyrinthine approach and simultaneous insertion of cochlear implant can be one direction, and a using retrolabyrinthine approach with continuous cochlear nerve monitoring can be another direction as a minimally invasive surgery to VSs with hearing preservation.