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Discussions of surgical results in chronic otitis media involving cholesteatoma usually include hearing improvement, side effects, and cholesteatoma recurrence, although such talks could easily involve the influence on surgical results of the intraoperative extension of the cholesteatoma-affected area around the tympanomastoid cavity. Based on intraoperative chronic otitis media staging involving cholesteatoma proposed by the Japan Otological Society in 2010, we studied our tympanoplasty results between April 1997 and March 2010. Hearing improvement in all subjects with pars flaccida cholesteatoma was 79.0% (n= 100) and that with pars tensa 73.3% (n = 30)--results not significantly influenced by intraoperative staging grade but significantly dependent on stapes presence (tympanoplasty type I and III) or absence (type IV). Nine cases of recurrence were seen in pars flaccida and four in pars tensa. Intraoperative side effects and postoperative recurrence often occurred in advanced cases. These findings suggest that intraoperative chronic otitis media staging involving cholesteatoma may make it important to be aware of the need for more careful procedures during surgery and in follow-up.

Delayed facial nerve palsy (DFP) is rarely experienced after otologic surgeries that do not directly touch the facial nerves, such as tympano-mastoidectomy, cochlear implants, and stapes surgery, and is troublesome to both surgeons and patients if it happens. Here, we report 7 cases of DFP, including one case that developed DFP after endolymphatic sac surgery. The ratios of occurrence were as follows: 0.7% (2/305) for tympano-mastoidectomy, 0.8% (3/354) for cochlear implant, 0.4% (1/260) for stapes surgery and 1.0% (1/98) for endolymphatic sac surgery. All otologic surgeries, except for endolymphatic sac surgery, exposed the chorda tympani, and all surgeries, except for stapes surgery, underwent drilling for a mastoidectomy. Furthermore, DFP was always observed ipsilaterally to the operated ear after otologic surgeries and was never seen after benign parotid tumor surgery or total laryngectomy. Therefore, there may be a strong relationship between DFP and the procedures, used during otologic surgeries.

We analyzed the first audiological assessment and latest pure tone audiometry (PTA) in 29 hearing-impaired children (58 ears) visiting Osaka University for their first audiological assessment at the ages of 0, 1, and 2. We evaluated their hearing thresholds with PTA during follow-up and compared them to their first assessments. We combined auditory brain-stem response (ABR), behavioral audiometry, and conditioned orientation reflex (COR) for audiological evaluation of infants. Hearing thresholds assessed by 2 or 3 of these methods were sufficiently precise for hearing aid fitting. Thresholds of recorded ABR waves in 14 ears at loud sound pressure correlated well with later pure tone thresholds at high frequencies. Pure tone thresholds of those in whom no ABR waves were observed at 100 dB, were often out of scale at high frequencies--14% at 4000 Hz and 73% at 8000 Hz. Because of residual hearing at low frequencies, 4-frequency-averaged hearing at 500 Hz, 2 x 1000 Hz, 2000 Hz was better than 100 dB in 7 of 44 ears (16%), and 4 of 22 children (18%) did not fit the severest rank, 2, of the Disabled Persons, Welfare Law in Japan.

The jugular bulb may be present in different positions and dimensions within the temporal bone. In general, high jugular bulbs were classified into 2 types: lateral in which the jugular bulb protrudes into the middle ear and up into the tympanic cavity and medial in which the jugular bulb is abnormally placed more superiorly and medial to the cochlea. We report, a unique case of a high jugular bulb which came round from behind of the internal auditory canal and the cochlea protruding into the posterosuperior part of the mesotympanum. It was a very rare pattern of a high jugular bulb which varies in position. The occurrence of adhesive otitis media caused the high jugular bulb to bleed easily in the only hearing ear. There would be risks of making the patient suffer severe bilateral healing impairment due to only one hearing ear and excessive hemorrhage in surgical treatment. With only one hearing ear, we should therefore select transcatheter interventional angiography when the quantity and frequency of bleeding from the jugular bulb increase so.

We treated 33 cases of intractable Meniere's disease with endolymphatic sac drainage and steroid-instillation surgery (EDSS), attaining good long-term results in vertigo and hearing. To elucidate how EDSS affects the diseased inner ear, we examined changes in plasma inner ear hormones after EDSS. Among inner ear hormones, plasma vasopressin was significantly decreased after EDSS compared to after mastoidectomy. In cases with good long-term results in vertigo and hearing, postoperative plasma vasopressin remained lower over the long term than in cases with poor results. In cases with negative glycerol test results one year after surgery, postoperative plasma vasopressin also remained significantly lower over the long term than in cases with positive results. Previous studies reported that vestibular neurons projected into hypothalamic supraoptic and paraventricular nuclei and that changes in the inner ear pressure were related to plasma vasopressin. Taken together with present findings, this suggests that EDSS may reduce plasma vasopressin through modification of the diseased inner ear environment, resulting in improved inner ear function.

Endolymphatic sac surgery is one of the most widely accepted techniques used to treat intractable Meniere's disease. To improve this surgery, we developed the following techniques: A simple mastoidectomy was used to expose the endolymphatic sac between the sigmoid sinus and inferior margin of the posterior semicircular canal. The sac was opened and filled with a mass of prednisolone. A bundle of absorbable gelatin films was then inserted into the sac lumen to expand it, followed by gelatin sponges dipped in a high concentration of dexamethasone. Long-term results (17-32 months) in 20 patients with intractable Meniere's disease treated with endolymphatic sac drainage and steroid-insertion surgery (EDSS) showed that definitive spells were completely controlled in 15 of 20 cases (75%); all reports of vertigo decreased; hearing improved in 12 of 20 cases (60%); and annoyance due to tinnitus decreased in 15 of 20 cases (75%). Steroids directly instilled into the endolymphatic cavity may thus be more effective with the diseased inner ear organs than those applied via any other route. Draining of endolymphatic fluid at the sac into the mastoid cavity also contributed to these satisfactory EDSS results.

Understanding the appearance of vestibular symptoms during periods of convalescence after surgery for the treatment of Meniere's disease is important for determining when a patient can return to work as well as the long-term results of the operation. We have treated 20 cases of intractable Meniere's disease with endolymphatic sac drainage & steroid-instillation surgery (EDSS) [Kitahara T, et al., Ann Otol Rhlnol Laryngol in press, 2000] and observed the subjective symptoms and objective vestibular findings using electronystagmogram (ENG) during the subsequent period of convalescence. The average postoperative durations of subjective static and evoked vestibular symptoms were 1.7 and 6.7 days, respectively. Those of spontaneous, positional and positioning nystagmus observed using ENG were 1.2, 2.0 and 7.9 days, respectively. In cases with a long history of Meniere's disease, postoperative static vestibular sensation and positional nystagmus lasted significantly longer than in cases with short histories. In cases with poorly developed temporal bony pneumatization in the area behind the posterior semicircular canal, postoperative evoked vestibular sensations and positioning nystagmus lasted significantly longer than in cases with well developed temporal bony pneumatization. Vestibular symptoms resulting from direct invasion during EDSS were considered to be slighter than those resulting from vestibular neurectomy or gentamicin treatment and almost the same as those resulting from endolymphatic sac surgery.

Because profound bilateral hearing impairment is a catastrophic event, the management and care of an individual with an 8th nerve lesion in an only/better hearing ear remains a significant challenge for both patient and physician. Current options regarding the treatment of the acoustic tumor in an only/better hearing ear include: observation, attempted hearing preservation surgery and stereotactically guided radiation therapy. In this article, we present 3 cases of acoustic tumor within the internal auditory canal in an only/better hearing ear diagnosed by gadolinium-enhanced MRI and discuss the recommendations, especially observation, available in the care of these cases. In one patient, hearing disturbance caused by the tumor in a better hearing ear made the patient quite depressive and desperate. One of the most important consideration is for the physician to provide the patient with adequate informed consent regarding the possibility of profound bilateral hearing loss caused by either the natural growth or surgical removal of the tumor in the future, and alternative methods of communication with others such as: hearing aid and lip reading, cochlear implant and brainstem implant.

The objective of the present study was to evaluate the hemodynamic relationship between the left atrium (LA) and left ventricle (LV) during atrial systole in the presence of an elevated left ventricular end-diastolic pressure (LVEDP) and LV failure using pulsed tissue Doppler imaging (TDI). Fifty-three patients with LV systolic dysfunction and no regional LV asynergy were divided into 3 groups: relaxation failure group (RF, n=20) with a ratio of peak early diastolic to atrial systolic velocity of the transmitral flow (E/A) < or = 1; pseudonormalization group (PN, n=19) with 1 or =2. In addition, 20 normal patients (E/A > or = 1) were studied as a control group. The transmitral and pulmonary venous flow velocities were recorded by transesophageal pulsed Doppler echocardiography. The wall motion velocity patterns were recorded at the middle portion of the LV posterior wall (LVPW) and at the mitral annulus (MA) of the LVPW site in the apical LV long-axis view by transthoracic pulsed TDI. The LVEDP was significantly greater in the PN and RS groups than in the RF and control groups. The moan pulmonary capillary wedge pressure was greatest in the RS group. The percent fractional change of the LA area during atrial systole determined by 2-dimensional echocardiography was significantly lower in the RS group than in the PN group. The peak atrial systolic pulmonary venous flow velocity was significantly greater in the PN group than in the RS group. The peak atrial systolic motion velocity (Aw) at the LVPW was significantly lower in the PN and RS groups than in the RF and control groups. The Aw at the MA was significantly lower in the RS group than in the other groups. There was no significant difference in Aw between the LVPW and MA in the RS group, whereas Aw at the MA was significantly greater than that at the LVPW in the PN group. In conclusion, the measurements of Aw at the LVPW and MA can be used to noninvasively evaluate the hemodynamic relationship between the LA and LV during atrial systole in patients with LV failure.

Global left ventricular (LV) pump function is generally preserved in patients with hypertrophic cardiomyopathy (HCM). However, it is unknown whether regional myocardial contractility is impaired, especially in nonhypertrophied regions. The purpose of this study was to evaluate regional LV myocardial contraction in patients with HCM using magnetic resonance (MR) spatial modulation of magnetization (SPAMM) myocardial tagging. The study group comprised 20 patients with asymmetric septal hypertrophy (HCM group) and 16 age-matched normal patients (control group), and data were collected using transthoracic M-mode and 2-dimensional echocardiography, and MR SPAMM myocardial tagging. The systolic strain ratio, maximum systolic strain velocity, and time from end-diastole to maximum systolic strain (deltaT) in the anterior, ventricular septal, inferior and lateral regions for 2 LV short-axis sections at the levels of the chordae tendineae and papillary muscles were measured at 50-ms intervals by MR myocardial tagging. The end-diastolic anterior and ventricular septal wall thicknesses and LV mass index were significantly different between the HCM and control groups. The systolic strain ratio for all 4 walls, particularly the anterior and ventricular septal regions, was significantly lower in the HCM group. In the HCM group, the maximum systolic strain velocity was significantly lower and deltaT was significantly shorter for all 4 walls, particularly the anterior and ventricular septal regions. The standard deviation for the deltaT, calculated from the deltaT for the 8 regions of the 2 LV short-axis sections, was significantly greater in the HCM group. In conclusion, regional LV myocardial contraction is impaired in both hypertrophied and nonhypertrophied regions, and systolic LV wall asynchrony occurs in patients with HCM.

Adult bilateral perilymph fistula (PLF) is rare. We report a case of a 55-year-old man who suffered from sudden bilateral hearing loss after blowing his nose. On the first day, he also had bilateral tinnitus but no vertigo. However, he gradually developed vertigo, and nystagmus to the left side began to appear in the following days. Exploratory bilateral tympanotomies were performed and perilymph fistulas were observed at the round window niche in both ears. The round windows were obliterated with fascia of the temporal muscles. After the operation no changes were found in both sides on a pure tone audiogram even at a one-year follow-up. The literature was reviewed and several features were statistically analyzed. In the adult bilateral PLF group, the proportion of the cases in which the cause of PLF was clear was significantly higher than that in the adult unilateral PLF group, but the other clinical features were almost the same. The results suggest that in adults the occurrence of bilateral and unilateral PLF could depend on the level of pressure applied to the middle or inner ear. On the other hand, in the child PLF group, the ratio of bilateral involvement was considerably higher than that in the adult PLF group, and in most cases the PLF was associated with middle and/or inner ear malformations. Healing in the child bilateral PLF group was poor than that in the adult PLF group. Those results suggest that the etiology of bilateral PLF in children may be considerably different from that of adult PLF.

Background: It has become evident that mitral regurgitation (MR) is not uncommon in healthy subjects, and Doppler color flow mapping is a technique that imparts important information relevant to its detection., Hypothesis: Using transthoracic echocardiography, this study evaluated the mechanism of physiologic MR in young normal subjects using transthoracic echocardiography., Methods: The study population consisted of 48 young normal subjects (mean 21 +/- 5 years) with MR (physiologic MR group), 40 age-matched young normal subjects (mean 20 +/- 5 years) without MR (control group), 45 patients (mean 41 +/- 15 years) with mitral valve prolapse with MR (MVP group), and 27 patients (mean 59 +/- 13 years) with ruptured chordae tendineae (rupture group)., Results: Men were predominant in the rupture group, whereas there were no significant gender differences in the other three groups. Left ventricular end-diastolic dimension and left atrial systolic dimension were slightly smaller in the physiologic MR group than in the control group, but were significantly smaller than those in the MVP and rupture groups. The ratio of the maximum anteroposterior diameter to the maximum transverse diameter on chest radiography and the ratio of the short- to long-axis diameter of the left ventricular cavity at end diastole, determined from two-dimensional short-axis echocardiogram, were significantly lower in the physiologic MR group than in the other three groups. Mitral regurgitation occurred more frequently at the posteromedial commissural site in the physiologic MR and MVP groups, whereas there was no preference for location in the rupture group. Early systolic MR was often observed in the physiologic MR group, whereas pansystolic MR was common in the MVP and rupture groups., Conclusion: As a causal mechanism for physiologic MR detected in young normal subjects, "flattening" of the thorax during growth may cause morphologic abnormalities of the left atrial and ventricular cavities, resulting in spatial imbalance of the mitral complex and resulting in malcoaptation of the valve.

It is well known that sensorineural hearing loss rarely occurs after middle ear surgery. Five cases of postoperative sensorineural hearing loss were reviewed. These operations amounted to 0.9% of all middle ear operations in which the first author was involved. The causes of hearing loss were believed to be labyrinthitis through the fistula in cholesteatoma case 1, and acoustic trauma from the bone-cutting burr in cases 2 and 3. In cases 4 and 5 postoperative sensorineural hearing loss occurred several months after stapes surgery and the causes of hearing loss were unknown. On the basis of the available literature discussion focused on management of labyrinthine fistula, the acoustic effect of the bone-cutting burr and the possibility of sensorineural hearing loss caused by stapes surgery.

This study examined 131 patients with idiopathic sudden deafness in whom the averaged of five frequency hearing levels was greater than 60dB. Since combined pharmacotherapy has been used in the treatment of idiopathic sudden deafness, it is hard to make a quantitative analysis of single-drug efficacy. We used a single-drug treatment in turn to assess the drug efficacy within 30 days after the onset. There was no significant difference among patients treated within 6 days and not less than 7 days after the onset with steroid therapy, PGE1 therapy, and defibrinogenation therapy. Similarly, there was no significant difference among patients treated within 6 days and not less than 7 days after the onset with steroid and defibrinogenation combined therapy, steroid and PGE1 combined therapy, and steroid, defibrinogenation and Lasix-Vitamin combined therapy. In case of no steroid effect, treatment with defibrinogenation, PGE1 and Lasix-Vitamin therapy could achieve hearing improvement.

Tympanoplasty on only hearing ears was performed on 11 patients in Osaka University Hospital and Osaka Rosai Hospital during 1986 1994; this was 0.68% of all cases of middle ear surgery. The patients consisted of 5 with cholesteatoma, 5 with chronic otitis media and 1 with cholesterin granuloma. The mean age was 47.6 years (13-68 years) and the mean follow-up period was 2 years and 7 months (6 months-4 years). Postoperative hearing results was obtained in 9 patients (81.8%) according to the criteria of Otology Japan (1987), and all ears were dry at the final examination. Compared with the preoperative hearing level, postoperative hearing level showed improvement in 3 cases, not in 7 cases (within difference of 5 dB) and deterioration by 10-15 dB in 1 case. Although indications for surgery on only hearing ears are still controversial, we suggest the following: 1) patients with cholesteatoma should be operated on in the ordinary way; 2) patients with chronic otitis media should be operated on only by myringoplasty; 3) all patients must be operated on very carefully by skillful surgeons.

Thirteen cholesteatomas, with hearing within 20dB, were operated on from 1985 to 1992. Their mean age was 22.1 years, and the mean follow-up period 1.8 years. Eleven cases were pars flaccid type, and 2 cases pars tensa type. Tympanoplasties were performed by the canal down method (4 cases), the canal up method (3 cases), both transmeatal atticotomy and scutumplasty (4 cases) and both the canal down method and mastoid obliteration (2 cases). Postoperative hearing results of three averaged speech frequencies were within 20dB in 11 cases and between 20 and 30dB in 2 cases. No recurrent cholesteatoma or extrusion of columella occurred during the follow-up period. One of the cases operated on by the canal down method showed postoperative mastoid cavity problems, and one of the cases operated on by the canal up method showed retraction of the pars flaccida. These findings prompted us to operate on cholesteatoma cases with normal hearing and to recommend tympanoplasty with transmeatal atticotomy and scutumplasty.