Results of 28 cases with atticoplasty in open tympanomastoidectomy were reported.
The attic was reconstructed with a cortical bone chip after eradication of pathological changes. The purpose of this procedure is to keep the tympanic membrane in normal position. Therefore, the posterior buttress was kept high. This enabled preservation of air space in the postero-superior part of the mesotympanum.
Success of hearing gain was obtained in 93% of 14 cases with modified type III tympanoplasty and in 63% of 8 cases with type IV tympanoplasty. It was found that this procedure resulted in a care-free shallow mastoid cavity.

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During the period of 1986 and 1989 staged tympanoplasty was carried out on 22 cases of chronic otitis media. Fourteen were cholesteatoma, 7 chronic otitis media with granulation and an adhesive otitis media respectively. The first stage surgery was carried out using intact canal wall tympanoplasty with posterior tympanotomy and 6-9 months later the second stage was performed to reconstruct the ossicular chain.
Aerations of both mastoid antrum and tympanic cavity before the first stage and before the second stage were evaluated by high-resolution CT with coronal view. The aeration pattern was classified as follows, 1) good aeration in both mastoid and tympanic cavity, 2) good aeration in the tympanic cavity alone, 3) good aeration in the mastoid cavity alone, and 4) no aeration in both cavities. After the first stage surgery, good aeration was observed in 7 cases out of 22 (31.8%) in the mastoid cavity, while good aeration in the tympanic cavity was seen in 17 cases out of 22 (77.3%).
It is crucial to reconstruct the aerated middle ear cavity for the restoration of sound transmission. Therefore it is important to analyze the aeration mechanism before and after the tympanoplasty for evaluation of the surgical results. High-resolution CT was the most useful tool for this purpose.

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The microorganisms cultured from otorrhea of chronic draining ears and their sensitivities to the antibiotics were analyzed, and the modification of the topical treatment was discussed on the stand point of the bacteriological survey.
Of 95 cultures in 67 patients with chronic otitis media in our hospital during the period of 1989-1988, 29 strains of staphylococcus aureus, 21 pseudomonas aeruginosa, 18 staphylococcus epidermidis were isolated, whereas of 110 specimens 39 pseudomonas aeruginosa, 31 staphylococcus aureus, 13 staphylococcus epidermidis in patients in the other hospital specialized for the mentally and physically handicapped.
Stastistically there was no significant difference of the distribution of the culture results between these two faculties.
From the fact that pseudomonas aeruginosa was most sensitive to SP (S/C) and LMOX in vitro, ear drop therapy with 2% SP solutions and dexamethason was carried out.
This method showed a remarkable reduction of discharge not only in young patients but also in the elderly.
It would be concluded that this method of topical treatment with antibiotics should be applied to the elderly patients with chronic draining ears on whom surgery was not indicated, and a much close attention must be paid to the drug allergy and gain of torelance and/or fungal contamination.

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Two cases of congenital cholesteatoma of the middle ear with bilateral profound deafness probably due to congenital sensorineural hearing loss are presented. Recently, many cases of congenital cholesteatoma associated with ossicle anomalies are reported. These cases are interesting in relation to pathogenesis of congenital cholesteatoma.
On the other hand, there are few reported cases of congenital cholesteatoma associated with congenital anomalies of inner ear. But, the possibility of the association of inner ear anomalies to congenital cholesteatoma must not be overlooked. In such cases, it may be difficult to find the cholesteatomas which might be present in cases of profound deafness, so a careful attention must be paid to the tympanic membrane, in the clinical examination of deafness.

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A 63-year-old woman underwent a right radical mastoidectomy 33 years ago. For the last several years, she had two complaints: a feeling of dullness on right temporal area and right intermittent otorrhea. She developed a severe headache in November, 1988.
When she visited our clinic, a fistula with pus existed in the right postoperative mastoid tegmen. CT demonstrated a low density mass containing air in right temporal region. MRI was performed, and T1-and T2-weighted images delineated low and high intensity area in the region respectively. A cholesteatoma in the right temporal lobe was suspected. Removal of the cholesteatoma was performed by neurosurgical procedure and during operation, squamous epithelium was found to invade the intradural space through a dural defect of the mastoid tegmen and forming a cholesteatoma.
To our knowledge, an intradural cholesteatoma within the middle cranial fossa has not been reported previously in association with invasion of squamous epithelium from the postoperative mastoid cavity.

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The incidence and degree of sensorineural hearing loss associated with otitis media with effusion (OME) were studied in 334 ears of 176 children, who had been previously diagnosed in our clinic as having OME, with average 6 years, history. The cases in which the bone-conduction level was deteriorated more than 30 dB, for at least one frequency from 500Hz to 8kHz, were analyzed according to their prognosis.
Bone conduction impairment more than 30 dB was recognized in 40 ears (12%) of the patients. The incidence had a close relationship with their prognosis of OME, and the well healed ears showed the lower incidence, and the ears with intractable OME showed the higher. Most of the impairment were found at 4kHz and 8kHz, from 30dB to 40dB.
It is concluded that the duration and degree of OME in pediatric patients have significant effect on the bone-conduction level. However, only a few cases showed severe clinical problems.

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The treatment of chronic serous otitis media with ventilation tube has been widely accepted. However, many tubes are extubated before healing occurs in cases ofatelectatic ear or glue ear.
A first or main tube was inserted into anterior inferior quadrant of the ear and a second or supporting tube was inserted into the anterior superior quadrant in pediatric patients with otitis media with effusion.
The main tube is beneficial for drainage and the supporting tube for ventilation, later, both tubes are useful for ventilation. The duration from intubation to extubation was longer than 6 months. Hearing loss was markedly improved most of ears after intubation. There was no complications with double ventilation tube therapy.
Double ventilation tube therapy seems to be very useful for middle ear effusion in children.

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Six cases of middle ear disease, in which abnormal sniffing was considered to be of significance, are reported. In all six cases, this habit of sniffing had developed as a way to alleviate unpleasant hyperacusis caused by insufficient eustachian tube closure. Upon sniffing, negative pressure is created in the middle ear cavity, which subsequently locks the eustachian tube and reduces the unpleasant hyperacusis. Due to the longstanding negative pressure load in the middle ear, tympanic membranes were either atrophic, atelectatic or adhesive. As the diseased eardrums were normalized in two patients only when they refrained from sniffing, it can be seen that it is important to ascertain whether patient with middle ear disease has a sniffing habit, and if so, to encourage him to break this habit.

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To determine whether a given overgrowth of bone is a true neoplasm or whether it merely represents the site of reactive overgrowth of bone is said to be extremely difficult in some cases. Grabam reported not only the clinical but histopathological evidence which clearly demonstrates the difference between the osteoma and exostosis of the external auditory canal. He stressed “fibro-vascular channel” as a charateristic histopathological feature of the osteoma of the external auditory canal. However, the characterized histopathological feature of the osteoma of the mastoid has not been mentioned.
In order to clarify the problem, we reviewed 8 clinical reports, which has been published to date by Japanese authors, and 3 cases of our own. Although 3 papers did not mentioned the histopathology of the osteoma, 5 articles clearly demonstrated the loose vascular connective tissue among the bony lamellar space. Moreover, histopathology of 3 cases of our own clealy demonstrated the fibrovascular channel, eventhough they were composed of dense, compact bone tissue.
Accordingly, we regarded the fibro-vascular channel as a characteristic features of the osteoma of the mastoid.

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A rare case of neurinoma in the middle ear, originated at the horizontal segment of the facial nerve was reported. A 57-year-old female was suffered from multiple subcutaneous nodules at her neck and breast, and systemic von Recklinghausen disease was diagnosed before onset of facial palsy. The examination revealed a hearing impairment of mixed type and canal paresis of the right ear. A polyp-like mass was protruded throught a hole of the ear drum 3 weeks after incision of the drum. High density shadow was detected by enhanced CT, and a high intensity area was demonstrated in the right mastoid by MRI. However, both the internal auditory canal and cerebellopontine angle were intact. A biopsied specimen from the tympanum revealed neurinoma. Surgical removal of the tumor and repair of the facial nerve by nerve grafting were done successfully.

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Twelve cases of malignant middle ear tumor, seen in the past 16 years and 10 months; were presented. The major chief complaints were bloody otorrhea, facial palsy and Otalgia. All cases had squamous cell carcinoma, 8 moderately differentiated, 4 highly differentiated.
Combination chemotherapy, using CDDP mainly, were effective in some cases. We could not estimate the intracranial invasion so definitely in all these cases preoperatively, though we tried to analyze it using CT scan and another radiological methods. We would like to make further evaluation upon it using MRI in the future.

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Two cases of squamous cell carcinoma of the middle ear were reported. In one case, labyrinthectomy and postoperative irradiation were performed. The tumor disappeared temporarily but the patient died of an intracranial invasion of the recurrent cancer 16 months later.
In the other case, subtotal petrosectomy with resection of the affected area of dura mater of the middle cranial fossa was performed. There was no severe per-operative or postoperative complications. The patient is still alive without recurrence for 1 year after the treatment.
Therefore, it is assumed that a wide resection of the middle ear cancer as described in this paper should be recommended more strongly, and this active attitude for a wide operation could improve the prognosis of cancer of the middle ear.

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A 53-year-old female was suffering from a hearing loss of her right ear for four months and mild tinnitus for half a year. She received routine neuro-otological examinations, CT scan and MRI imaging of the skull. As the result, a half round shaped meningioma of 2 cm in diameter was found in the right cerebello-pontine angle. This tumor was removed subtotally by suboccipital approach without damaging any cranial nerves and arteries. After the operation, the patient obtained a better hearing acuity and a better response against caloric stimulation of her right ear than before.

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A case of sudden deafness in a child with vertigo was reported. Sudden deafness in children is very rare disease. As for children it might be difficult to perceive or complain of sudden onset of their hearing loss, diagnosis of this disease is very difficult and in many cases treatment in the early stage is impossible. Viral infection can not be distinguished. Sudden deafness in children may be treated as that in adults.

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5 cases of bilateral simultaneous sudden deafness were reported.
The hearing levels in 5 cases were various, and audiograms were flat in 8 ears, down-sloping in 2. But audiogram was almost symmetric in each case. Prognosis was relatively good.
We thought that the pathogenesis of bilateral simultaneous sudden deafness was still obscure.

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Idiopathic bilateral sensorineural hearing loss (IBSH) was characterized by bilateral progressive hearing impairment. There were two types, slow or rapid progression of hearing loss.
We reported 3 cases of rapid progression of hearing impairment in IBSH. The 3 cases had unilateral severe hearing loss before rapid progression, resulted in bilateral profound hearing loss.
Various treatments were not effective for hearing loss in cases with rapid progression.

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A 78-year-old female with malignant external otitis accompanied by lower cranial nerve palsy is reported.
She initially complained of left headache, earache, and ear discharge, and had granulation tissue occupying the external auditory meatus, although pseudomonous aeruginosa was not detected. After control of diabetes mellitus by systemic insulin treatment, debridement of granulation tissue, meatoplasty, and tympanoplasty were performed, since no morbid findings except the granulation tissue and central perforation of ear drum existed in the osseous external ear and tympanic cavity.
Two months after recovery and discharge from hospital, sudden horseness and dysphagia, which indicated multiple lower cranial nerve paralysis (9th, 10th, 11th, and 12th), appeared with recurrent granulation tissue in the external auditory meatus. This time, the bacteriological studies demonstrated pseudomonous aeruginosa. She was treated with a large dose of antibiotics in conjuction with systemic insulin therapy including intra-aural injection of insulin. The inflammation of the external auditory meatus was completely controled and the cranial nerve function recovered.
Control of diabetes after discharge from hospital is particularly important and strict control of the diabetes, especially, local administration of insulin in addition to systemic insulin treatment and local and systemic antibiotic therapy are very useful in the treatment of malignant otitis externa.

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The statistical analysis of herpes zoster infection in the head and neck region in our clinic was conducted. For the recent 11 years, 81 patients visited our clinic because of oto-rhino-laryngo logical symptoms caused by herpes zoster infection. There were 47 males and 34 females. Their median age was 44 years with a range of 13 to 89 years. 68 patients presented with Hunt's syndrome and 13 patients presented with other neurological signs.
In patients with Hunt's syndrome, 13 patients (19%) presented with the other neurological symptoms, such as trigeminal nerve, glossopharyngeal nerve and cervical nerve symptoms. It seems likely that herpes zoster virus easily spread to the other nerves through their anastomosis which are tightly connected in the head and neck region. Meningitis and regional encephalitis following Hunt's syndrome were detected.
In the other 13 cases without Hunt's syndrome showed the trigeminal, cervical and other cranial nerves involvements. The mean age of these patients was 54 years and it was higher than that of Hunt's syndrome (42 years, P<0.05).

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A questionaire survey was performed to study the behavioral changes in usual conversation following cochlear implantation. The subjects were fifteen implantees using the Nucleus 22-channel cochlear implant system. The results of the survey are as follows: 1) All but one patients evaluate the device to be useful, and become regular users. 2) Most of the patients need hand signals, sigh language, and/or speech-reading associated with the device for better communication. 3) After the cochlear implantation, patients become socially active and mentally stable compared with preimplantation although difficulties in listening exist in some conditions. It seems to be important to be aware of the benefit and the limit of cochlear implant by patients themselves for reasonable use.

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The effect of anaesthetic agents on the auditory brainstem response (ABR) was studied in 34 patients with 68 ears.
Twenty-four cases received NLA anaesthesia and 10 cases received GOE anaesthesia. After the induction with thiopental and succinylcholinchrolide, anaesthesia was maintained with 66% nitrous oxide in oxygen.
The cases with NLA anesthesia were divided into three groups as follows according to anesthetic agents.
A: Droperidol and fentanyl (7 patients, 14 ears)
B: Diazepam and pentazocine (7 patients, 14 ears)
C: Droperidol and pentazocine (10 patients, 20 ears)
Ten cases, 20 ears anaesthetized with 1.5% concentration enflurane were classified as group D.
ABRs were recorded 30 minutes after intubation, and latencies of waves I, III, V and interpeak latencies of waves I-III, III-V, and I-V were analysed.
The results showed that under NLA method there was no significant prolongation of latencies of ABR waves except absolute latency of wave I. However, in the cases anaesthetized with 1.5% enflurane, latency of wave V and interpeak latencies of waves I-V and III-V showed significant increases.
The results suggested that enflurane delays neural transmission of auditory pathway in the upper brainstem.

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