Open-type cholesteatoma is the predictive factor for residual disease in congenital cholesteatoma treated with TEES.

OBJECTIVE: To determine the predictive factors for residual disease occurring after surgical removal of congenital cholesteatomas and whether these predictive factors differ between microscopic ear surgery (MES) using data from the literature and transcanal endoscopic ear surgery (TEES) using data from our own institution. METHODS: Twenty-three patients with a congenital cholesteatoma who underwent surgical treatment at Yamagata University Hospital between December 2011 and December 2017 were retrospectively investigated. We divide TEES into three different approaches: non-powered TEES, powered TEES and dual MES/TEES. Main outcome measures were Potsic stage, closed or open congenital cholesteatoma type, TEES surgical approach, appearance of residual disease, tympanoplasty type and hearing outcome. RESULTS: A logistic regression analysis was conducted on the Potsic stage, closed or open type, TEES surgical approach and age to obtain the odds ratio for residual disease. The chance of residual disease significantly increased in the presence of an open-type congenital cholesteatoma (odds ratio: 30.82; 95 % confidence interval: 1.456-652.3; p = 0.0277), but not for any of the other factors including Potsic stage. The timing of the confirmation of residual disease after ossicular chain reconstruction was analyzed using a Kaplan-Meier analysis. The residual disease rate was significantly higher with an open-type congenital cholesteatoma (log-rank test, p < 0.05). In addition, all residual disease occurred within three years after surgery. CONCLUSIONS: Our results showed that an open-type congenital cholesteatoma is the strongest predictive factor for residual disease when removing a congenital cholesteatoma by TEES.

Ergonomics of Various Modalities for Ear Surgery.

Objective: Evaluate ergonomic differences of various modalities for performing middle ear surgery. Study Design: Observational study. Setting: Two academic tertiary care centers. Methods: Attending physicians and residents performing middle ear surgery were photographed intraoperatively. Intraoperative photographs were analyzed using the validated Rapid Upper Limb Assessment (RULA) tool to measure musculoskeletal disease (MSD) risk. Descriptive statistics and significance testing were used to characterize and compare ergonomic differences between surgical modalities. Multivariable ordinal regression was performed to assess factors associated with increased MSD risk, as determined by the final RULA score. Results: Most of our 110 intraoperative photos featured attendings (82.7%) performing combined middle ear surgery and mastoidectomy (60.0%). Body angles and the final RULA score varied significantly among modalities. On subset analysis, microscopic surgery exhibited significantly worse wrist, trunk, and neck angles compared to endoscopic and exoscopic surgery. Exoscopic surgery had significantly lower final RULA scores than both endoscopic and microscopic surgery, indicating significantly lower MSD risk. Microscopic and endoscopic surgery final scores did not vary significantly. In a multivariable ordinal regression of factors associated with increased RULA score, exoscopic surgery had statistically significantly less ergonomic risk relative to microscopic surgery (odds ratio = 0.12, 95% confidence interval = [0.03-0.43]). Conclusion: Exoscopic, endoscopic, and microscopic surgery all featured low ergonomic risk, although exoscopic middle ear surgery demonstrated the lowest risk profile among studied surgical modalities. This demonstrates the importance of using each modality in combination with other ergonomic interventions to provide meaningful musculoskeletal benefits.

Clinical course of five patients definitively diagnosed with idiopathic perilymphatic fistula treated with transcanal endoscopic ear surgery.

Objectives: An idiopathic perilymphatic fistula (PLF) can be difficult to diagnose because patients present with sudden sensorineural hearing loss (SSHL) and/or vestibular symptoms without any preceding events. In such cases, we currently test for cochlin-tomoprotein (CTP) to confirm the diagnosis of idiopathic PLF because CTP is only detected in the perilymph. In this study, we report the clinical course of five patients definitively diagnosed with idiopathic PLF who underwent PLF repair surgery using transcanal endoscopic ear surgery (TEES). Patients and methods: Five patients were initially treated with intratympanic dexamethasone for SSHL, at which time a CTP test was also performed (preoperative CTP test). Due to refractory hearing loss and/or fluctuating disequilibrium, PLF repair surgery using TEES was performed to seal the oval and round windows using connective tissue and fibrin glue. These patients were diagnosed with definite idiopathic PLF based on pre- or intra-operative CTP test results (negative, < 0.4 ng/mL; intermediate, 0.4-< 0.8 ng/mL; and positive, > 0.8 ng/mL). We evaluated pre- and intra-operative CTP values, intraoperative surgical findings via a magnified endoscopic view, and pre- and post-operative changes in averaged hearing level and vestibular symptoms. Results: Pre- and intra-operative CTP values were positive and intermediate in three patients, positive and negative in one patient, and negative and positive in one patient. None of the patients had intraoperative findings consistent with a fistula between the inner and middle ears or leakage of perilymph. Only two patients showed a slight postoperative recovery in hearing. Four patients complained of disequilibrium preoperatively, of whom two had resolution of disequilibrium postoperatively. Conclusion: A positive CTP test confirms PLF in patients without obvious intraoperative findings. The CTP test is considered more sensitive than endoscopic fistula confirmation. We consider that CTP test results are important indicators to decide the surgical indication for idiopathic PLF repair surgery. In our experience with the five cases, two of them showed improvements in both hearing and vestibular symptoms.

The use of basic fibroblast growth factor to treat intractable Bell's palsy administered via transcanal endoscopic ear surgery.

PURPOSE: Facial nerve decompression surgery is an invasive procedure which has hitherto been the main option for patients with severe intractable Bell's palsy which is resistant to drug treatment. We have developed a new salvage treatment for such patients by using minimally invasive transcanal endoscopic ear surgery (TEES) to deliver the biological regenerative agent, basic fibroblast growth factor (bFGF), to the damaged facial nerve. MATERIALS AND METHODS: An endoscopic salvage treatment group was studied prospectively and was made up of severe intractable Bell's palsy patients who did not respond to high dose steroid treatment and had an ENoG value of 5 % or less. This surgery group was retrospectively compared to a similar control group who had received high dose steroid only. RESULTS: Complete recovery to House-Brackmann (HB) Grade I was achieved by 44.8 % of the endoscopic salvage treatment group which was significantly higher than the 21.2 % of the control group at one-year follow up. Patients with an ENoG value of 1 % to 5 % exhibited a significantly higher complete recovery rate of 71.4 % in the endoscopic salvage treatment group than the 28.6 % of the control group. In addition, no complications were observed including hearing loss. CONCLUSIONS: bFGF delivered via TEES shows considerable promise as a new salvage treatment of severe intractable Bell's palsy that is resistant to high dose steroid treatment without the risks presented by facial nerve decompression surgery.

A Minority Population of Non-dye-decolorizing Bacillus subtilis enhances the Azo Dye-decolorizing Activity of Enterococcus faecalis.

Microbes live in communities in biological wastewater treatment plants and in the intestines. However, limited information is currently available on the mechanisms by which minority bacterial populations assist other bacteria besides syntrophic relationships as well as on the microbial food web. Therefore, the present study investigated the effects of non-dye-decolorizing Bacillus subtilis strain S4ga at population levels ranging between 0.04 and 4% on the activity of dye-decolorizing Enterococcus faecalis strain T6a1 using a dye decolorization assay. The results obtained revealed that the minority population of B. subtilis S4ga enhanced the dye-decolorizing activity of E. faecalis T6a1, resulting in a shorter lag time and longer active time of dye decolorization. These effects were related to redox potential values rather than O2 concentrations. Comparisons of the extracellular metabolites in individual incubations of E. faecalis T6a1 and B. subtilis S4ga and a co-incubation suggested a mutual relationship through the cross-feeding of specific amino acids (tyrosine, methionine, tryptophan, phenylalanine, valine, and leucine from B. subtilis S4ga to E. faecalis T6a1; glutamine, histidine, aspartic acid, and proline from E. faecalis T6a1 to B. subtilis S4ga). An ana-lysis of intracellular primary metabolites indicated that the arginine deiminase (ADI) pathway, an ATP-producing energy-generating process, was more strongly activated in co-incubated E. faecalis T6a1 than in E. faecalis T6a1 incubated alone. These results suggest that a co-incubation with B. subtilis S4ga promoted ATP production by E. faecalis T6a1 cells and enhanced its dye-decolorizing activity.

The Feasibility and Treatment Results of Transcanal Endoscopic Myringoplasty.

OBJECTIVE: We reported on transcanal endoscopic myringoplasty in 25 cases preliminarily in 2014. Now our number of transcanal endoscopic myringoplasty reached to 209 ears and allowed us to adequately investigate the visibility, necessity of canalplasty, treatment results, and multivariate analysis. STUDY DESIGN: A prospective case series. SETTING: Tertiary referral center. PATIENTS: Transcanal endoscopic myringoplasty was performed on 209 ears in 201 patients between 2011 and 2019 and followed up over 1 year. METHODS: Preoperative endoscopic and microscopic views for the same patient were compared. We examined success rates at 1 year after surgery according to operation type, perforation size, operation side, gender, cause of perforation, and age, and also examined hearing results. Logistic regression analysis was performed to investigate the basic demographic and clinical characteristics of the patients associated with perforation closure. RESULTS: The anterior edge of the preoperative perforation was not visible under microscopy in 14.4% of patients. In contrast, endoscopic views revealed the entire tympanic membrane in one field. However, canalplasty was required in 2.4% of tympanic procedures due to difficulty of manipulation. The overall closure rate for perforations was 90.4%. Logistic regression analysis revealed that age > 11 was the only significant factor associated with perforation closure. The average reduction in air-bone gap was 12.1 dB. CONCLUSION: The endoscopic myringoplasty produced better visualization, the same or better closure rates, and the same or lower complication rates as compared with traditional microscopic techniques.

Multicenter Study of Congenital Middle Ear Anomalies. Report on 246 Ears.

OBJECTIVES/HYPOTHESIS: Congenital middle ear anomalies represent a relatively rare condition. This study aimed to describe the characteristics and the surgical outcomes for patients with middle ear anomalies. METHODS: A multicenter study was conducted of consecutive patients with congenital middle ear anomalies who underwent primary surgical treatment between January 2008 and December 2017. Demographics, surgical procedures, and audiometric data were registered into the institutional database. Hearing changes and postoperative air-bone gap (ABG) were evaluated 1 year after surgery. RESULTS: A total of 246 patients (246 ears) (median age: 14 years, range: 4-75 years old) were included in this study. Anomalies were subdivided using the Teunissen and Cremers classification: 53 ears (22%) were categorized as class I, comprising only stapes ankylosis; 35 ears (14%) as class II, having ossicular chain anomalies with stapes ankylosis; 139 ears (57%) as class III, having ossicular chain anomalies with a mobile stapes-footplate; and 19 ears (8%) as class IV, with aplasia of the oval window. Evaluation of hearing outcomes for 198 ears with more than 1 year of follow-up revealed that good postoperative ABG (≤20 dB) was achieved in 82% of class I, 68% of class II, 74% of class III, and 23% of class IV anomalies. The postoperative ABG in class IV was significantly worse than in class I (P < .001) or class III (P < .01). CONCLUSIONS: This study demonstrated that class III anomalies comprised the majority of middle ear anomalies and surgical outcomes for class IV anomalies are unfavorable. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2323-E2328, 2021.

Measurement of the Pediatric and Adult Osseous External Auditory Canal: Implications for Transcanal Endoscopic Ear Surgery.

OBJECTIVE: To develop a method for measuring the diameter of the osseous external auditory canal (OEAC) in pediatric and adult patients. STUDY DESIGN: Retrospective analysis of imaging data from patients with a cholesteatoma who underwent transcanal endoscopic ear surgery (TEES) to remove the cholesteatoma by analyzing preoperative sagittal cone beam computed tomography (CBCT) images using ImageJ. METHODS: Pediatric and adult patients were included who underwent TEES for a cholesteatoma between December 2011 and March 2015 and had available preoperative CBCT scans. Sagittal CT imaging data were analyzed by ImageJ to measure the maximum and minimum Feret diameters along the OEAC. The output data were then analyzed to determine the smallest maximum and smallest minimum Feret diameters for each patient. RESULTS: Fifty-one patients ranging in age from 3 to 83 years old were included in this study. The smallest maximum Feret diameter ranged from 6.5 to 10.1 mm (mean: 8.0 mm) for pediatric patients (<16 years of age) and 6.9 to 15.0 mm (mean: 8.9 mm) for adult patients, while the smallest minimum Feret diameter ranged from 3.6 to 5.9 mm (mean: 5.1 mm) for pediatric patients and 3.4 to 6.4 mm (mean: 5.4 mm) for adult patients. Moreover, the smallest maximum Feret diameters of children were significantly smaller than those of adults. CONCLUSION: We have developed a novel method for measuring the diameter along the OEAC and determining its narrowest site. This method can be incorporated into the preoperative evaluation of patients who are candidates for TEES.

Brain Abscess as a Rare Complication of Primary Extranodal Nasal-type Natural Killer/T-cell Lymphoma.

We present the case of a 58-year-old Japanese woman with a natural killer T (NK/T)-cell lymphoma complicated by brain abscess. NK/T-cell lymphomas represent a rare type of lymphoma derived from either activated NK cells or, rarely, cytotoxic T cells. They are aggressive Epstein-Barr virus (EBV)-associated lymphomas that involve mainly the nasal cavity. Brain abscess associated with primary extranodal nasal-type NK/T-cell lymphoma is extremely uncommon: to our knowledge, this is the first reported case of this lymphoma with brain abscess as the initial clinical manifestation. Endoscopic surgery was performed for definitive diagnosis under intraoperative navigation system. Chemotherapy followed by radiotherapy was performed and was effective: 72 months later the tumor has not recurred. Recommendations of endoscopic management for diagnosis and treatment of this rare neoplasm are discussed.

Facial nerve and chorda tympani schwannomas: Case series, and advantages of using non-rigid registration of post-enhanced 3D-T1 Turbo Field Echo and CT images (TURFECT) in their diagnosis and surgical treatment.

OBJECTIVE: Facial nerve schwannomas (FNSs) and chorda tympani schwannomas are very rare. Diagnosis of these tumors is sometimes difficult, and treatment consensus has not yet been reached. We report here a series of cases of FNS and chorda tympani schwannoma and highlight the usefulness of our newly developed technique of non-rigid registration of post-enhanced 3D-T1 Turbo Field Echo and CT images (TURFECT) in their diagnosis and treatment. METHODS: MRI images were adjusted with the corresponding CT images in terms of angle and position in order to index the anatomical structures. The well-enhanced T1-Gd+ lesions of tumors having good blood flow show up as bright red after color mapping. RESULTS: Between 2014 and 2018, five patients were diagnosed with schwannomas in the temporal bone: three with FNS and two with chorda tympani schwannoma. Gd-enhanced MRI showed only a high-intensity mass, and we could not detect the relationship between tumor-like mass and bone (including the ossicles) by MRI only. In contrast, TURFECT was very useful for diagnosing the precise location, allowing us to decide on an endoscopic surgical plan in some of our cases. An endoscope enabled visualization of the medial wall of the tympanic cavity and the status of the tumors, thus we could successfully perform transcanal endoscopic biopsy and resections. CONCLUSION: TURFECT can be very useful for diagnosis of FNSs and chorda tympani schwannomas and for deciding surgical treatments such as a transcanal endoscopic approach.

Transcanal Endoscopic Ear Surgery for Congenital Middle Ear Anomalies.

OBJECTIVE: To demonstrate the efficacy of transcanal endoscopic ear surgery (TEES) for congenital middle ear anomalies. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Twenty-one patients ranging in age from 4 to 62 years old (median: 15 yr) who underwent TEES between 2011 and 2017 were compared with 19 patients ranging in age from 3 to 49 years old (median: 11 yr) who underwent microscopic ear surgery (MES) between 2000 and 2011. INTERVENTION: Ossiculoplasty or stapes surgeries were performed with TEES or MES. TEES was performed using a rigid endoscope with an outer diameter of 2.7-mm coupled with a full high-definition video system. MES was performed via a transcanal approach with a retroauricular incision. MAIN OUTCOME MEASURE: Middle ear anomaly classification, operating time, and hearing outcomes based on the American Academy of Otolaryngology and Head and Neck Surgery criteria were evaluated and compared between the TEES and MES groups. RESULTS: For Teunissen and Cremers class III anomalies, defined as ossicular chain malformations with a mobile stapes footplate, postoperative air-bone gap closure to 10 dB or less was achieved in 50% of the TEES group and 47% of the MES group. Postoperative air-bone gap closure to 20 dB or less was achieved in 86% of the TEES group and 100% of the MES group. No significant difference was found in the operating time between the two groups. All MES procedures required a retroauricular incision. CONCLUSION: Our results indicate that TEES has similar auditory outcomes compared with MES while avoiding a retroauricular incision.

Comprehensive analysis of syndromic hearing loss patients in Japan.

More than 400 syndromes associated with hearing loss and other symptoms have been described, corresponding to 30% of cases of hereditary hearing loss. In this study we aimed to clarify the mutation spectrum of syndromic hearing loss patients in Japan by using next-generation sequencing analysis with a multiple syndromic targeted resequencing panel (36 target genes). We analyzed single nucleotide variants, small insertions, deletions and copy number variations in the target genes. We enrolled 140 patients with any of 14 syndromes (BOR syndrome, Waardenburg syndrome, osteogenesis imperfecta, spondyloepiphyseal dysplasia congenita, Stickler syndrome, CHARGE syndrome, Jervell and Lange-Nielsen syndrome, Pendred syndrome, Klippel-Feil syndrome, Alport syndrome, Norrie disease, Treacher-Collins syndrome, Perrault syndrome and auditory neuropathy with optic atrophy) and identified the causative variants in 56% of the patients. This analysis could identify the causative variants in syndromic hearing loss patients in a short time with a high diagnostic rate. In addition, it was useful for the analysis of the cases who only partially fulfilled the diagnostic criteria.

Comparison of Postoperative Pain in Patients Following Transcanal Endoscopic Versus Microscopic Ear Surgery.

OBJECTIVE: To compare levels and causes of postoperative pain after cholesteatoma removal by transcanal endoscopic ear surgery (TEES) versus microscopic ear surgery (MES). STUDY DESIGN: Prospective case series. SETTING: Tertiary referral center. PATIENTS: One-hundred-and-sixty-one patients who had undergone middle ear surgery between February 2013 and April 2016. INTERVENTIONS: Comparison of postoperative pain between TEES and MES groups and among TEES and MES subgroups divided by range of bone removal. MAIN OUTCOME MEASURES: Two parameters were used to assess postoperative pain: a pain numeric rating scale (NRS) and number of times a non-steroidal anti-inflammatory drug (NSAID) was taken from postoperative days (PODs) 1 to 7. We also examined the primary factor behind postoperative pain looking at: 1) the surgical incision; 2) bone removal; and 3) number of involved middle ear regions. RESULTS: One-hundred-and-six patients underwent TEES and 55 underwent MES. The mean pain NRS for the 7-day postoperative period was significantly lower for the TEES group (1.1) than the MES group (2.8) (p < 0.001, Mann-Whitney U test). The number of times a NSAID was taken was lower for the TEES group (1.3 pills/wk) than the MES group (5.5 pills/wk) (p < 0.001, Mann-Whitney U test). The mean pain NRS of the TEES and MES subgroups also suggests that extent of bone removal or number of involved middle regions was less important in causing postoperative pain than presence or absence of the retroauricular incision. CONCLUSIONS: TEES is associated with lower postoperative pain and lower use of NSAIDs compared with MES patients.

Long-term natural remediation process in textile dye-polluted river sediment driven by bacterial community changes.

The textile and dyeing industries are major sources of environmental water pollution all over the world. The textile wastewater effluents discharged into rivers often appear dark red-purple in color due to azo dyes, which can be transformed into carcinogenic aromatic amines. The chemicals used in dyeing are not readily degraded in nature and thus precipitate in river sediment. However, little is known about how dyeing chemicals affect river sediment and river water or how long they persist because they are difficult to monitor. To assess undetectable dyes and byproducts in river sediments, we evaluated the potential of river sediment bacteria to degrade dyes and aromatic amines. We describe the natural remediation of river sediment long-contaminated by textile dyeing effluent. After cessation of wastewater discharge, the dye-degradation potential decreased, and the aromatic amine-degradation potential increased initially and then declined over time. The changes in degradation potential were consistent with changes in the sediment bacterial community. The transition occurred on the order of years. Our data strongly suggest that dyes remained in the river sediment and that aromatic amines were produced even in transparent- and no longer colored-river water, but these chemicals were degraded by the changing sediment bacteria. Time-course monitoring of the degradation activities of key bacteria thus enables assessment of the fate of dye pollutants in river sediments.

Suppression of cadmium uptake in rice using fermented bark as a soil amendment.

The contamination of rice paddies with heavy metals has become a serious concern due to their high toxicity to human health. In this study, we developed a chemical-free, fermented bark amendment (FBA) and used it for organic rice cultivation. The application of FBA resulted in the fixation of heavy metals, especially cadmium (Cd), in the soil and suppressed their uptake in brown rice. The suppression of Cd uptake was most effective, since its uptake in rice from FBA-supplemented soil was 10 times lower than that from untreated soil under ordinary water-filling conditions. These results could be explained by the rapid conversion of sulfate ions to sulfide ions, which subsequently react with Cd producing insoluble sulfide species, as well as Cd adsorption to the decomposed bark in soil. The FBA did not affect the uptake of metals, such as calcium and iron, which are necessary for the growth of rice. Thus, the FBA may suppress Cd uptake in rice, and its effectiveness is related to application time and water regime.

Safety of heat generated by endoscope light sources in simulated transcanal endoscopic ear surgery.

OBJECTIVE: To determine whether heat generated by endoscope light sources during ear surgery is safe. METHODS: Transcanal endoscopic ear surgery (TEES) was simulated using 2.7-mm or 4-mm endoscopes coupled to xenon or LED light sources and a 3D model of human temporal bone. The endoscope tip was fixed at the center of tympanic annulus. Light sources were tested at clinical (30% for xenon and 40% for LED) and 100% settings. Temperatures were measured using thermocouples attached to the endoscope tip and three points within the middle ear cavity: promontory, horizontal portion of the facial nerve and lateral semicircular canal. RESULTS: Maximum temperatures measured within the middle ear cavity were below 31°C at clinical settings, while the temperatures rose to 44.1°C using a 4-mm endoscope with a xenon light source set at 100%. Temperatures measured at the tip were all safe at clinical settings, but rose dramatically to 110.1°C for the 4-mm endoscope with xenon at 100%. CONCLUSION: Endoscopes can be safely used within the middle ear at clinical settings. However, operators should not exceed clinical settings, particularly with 4-mm endoscopes with a xenon light source, to ensure temperatures generated within the middle ear cavity are safe.

Orotate phosphoribosyltransferase localizes to the Golgi complex and its expression levels affect the sensitivity to anti-cancer drug 5-fluorouracil.

Orotate phosphoribosyltransferase (OPRT) is engaged in de novo pyrimidine synthesis. It catalyzes oronitine to uridine monophosphate (UMP), which is used for RNA synthesis. De novo pyrimidine synthesis has long been known to play an important role in providing DNA/RNA precursors for rapid proliferative activity of cancer cells. Furthermore, chemotherapeutic drug 5-fluorouracil (5-FU) is taken up into cancer cells and is converted to 5-fluoro-UMP (FUMP) by OPRT or to 5-fluoro-dUMP (FdUMP) through intermediary molecules by thymidine phosphorylase. These 5-FU metabolites are misincorporated into DNA/RNA, thereby producing dysfunction of these information processing. However, it remains unclear how the subcellular localization of OPRT and how its variable expression levels affect the response to 5-FU at the cellular level. In this study, immunocytochemical analysis reveals that OPRT localizes to the Golgi complex. Results also show that not only overexpression but also downregulation of OPRT render cells susceptible to 5-FU exposure, but it has no effect on DNA damaging agent doxorubicin. This study provides clues to elucidate the cellular response to 5-FU chemotherapy in relation to the OPRT expression level.

Transcanal endoscopic ear surgery for pediatric population with a narrow external auditory canal.

OBJECTIVES: To retrospectively determine the size of the external auditory canal (EAC) in a pediatric population and to describe our experience with transcanal endoscopic ear surgery (TEES) in this pediatric population which had been successfully treated for middle ear disease using TEES. METHODS: We analyzed 31 patients ranging in age from 2 to 13 years old (median: 7.6 years) with middle ear disease who underwent TEES between November 2011 and August 2014. Sixteen of these patients had surgery for cholesteatomas; 11 for chronic otitis media; and 4 for malformation of the middle ear. A preoperative CT scan was performed to evaluate the middle ear disease. Transcanal endoscopic tympanoplasty was performed using a rigid endoscope with a 2.7mm outer diameter. Transcanal endoscopic atticoantrotomy was also performed, as necessary, on some patients to access pathologies in the antrum. The values of anterior-posterior diameters and superior-inferior diameters of the bony parts of EAC were measured retrospectively based on the preoperative CT scan data. RESULTS: TEES was successfully performed in all 31 pediatric patients without resorting to a retroauricular incision. Twenty-seven patients were evaluated for postoperative hearing levels which were found to fall within an acceptable range and for postoperative air-bone gap (ABG) by pure tone audiometry with a resulting mean of 8.6dB. The smallest anterior-posterior diameters of the external ear canal ranged from 3.2 to 7.1mm (5.0±1.0mm) and the smallest superior-inferior diameters ranged from 3.4 to 10.3mm (5.9±1.3mm). CONCLUSION: TEES can be used to safely and effectively treat middle ear disease even in the pediatric population in its narrow EAC.

The Efficacy of Color-Mapped Diffusion-Weighted Images Combined With CT in the Diagnosis and Treatment of Cholesteatoma Using Transcanal Endoscopic Ear Surgery.

OBJECTIVE: To assess the efficacy of a color-mapped diffusion-weighted image combined with a computed tomography scan (CMDWI-CT) in preoperatively evaluating the anatomical location of cholesteatomas and determining whether a patient is indicated for transcanal endoscopic ear surgery (TEES) to reduce intraoperative switching to microscopic ear surgery (MES). STUDY DESIGN: Prospective case study. SETTING: A single university hospital. PATIENTS: Fifty-five patients scheduled for middle ear cholesteatoma surgery. INTERVENTION: The CMDWI-CT is produced in a multistep process. A color-mapped fusion image (CMFI) is created by performing MR cisternography on a 1-mm thin-slice nonecho planar diffusion-weighted imaging (non-EPI DWI) and then by performing color mapping on the resulting image to enhance cholesteatoma visualization. False positives are reduced by taking a T1-weighted image (T1WI), whereas false negatives are further reduced by preoperative endoscopic examination. As cholesteatomas are difficult to locate on a CMFI in the temporal bone region, we stripped out the MR cisternography data from the CMFI and then fused the CMFI to the initial computer tomography (CT) scan to create a CMDWI-CT. This CMDWI-CT better clarifies the cholesteatoma position within temporal bone. MAIN OUTCOME MEASURE(S): CMDWI-CT preoperative findings were compared with intraoperative findings. The positive predictive value and negative predictive value were also evaluated depending on the cholesteatoma location. RESULTS: CMDWI-CT facilitated accurate detection of the cholesteatoma anatomical location in the temporal bone region which was reflected in positive predictive and negative predictive values of over 90% for all areas of the middle ear. CONCLUSION: CMDWI-CT is a reliable diagnostic modality for evaluating the anatomical location of cholesteatomas that seem as high-signal regions on a CMFI and for determining whether TEES is indicated for treatment in such patients.

Detectability and anatomical correlation of middle ear cholesteatoma using fused thin slice non-echo planar imaging diffusion-weighted image and magnetic resonance cisternography (FTS-nEPID).

Cholesteatomas show high intensity in diffusion-weighted imaging (DWI). We performed fused thin slice non-echo planar imaging (EPI) DWI and magnetic resonance cisternography (FTS-nEPID) for cholesteatoma patients to increase the detectability of FTS-nEPID for cholesteatoma. The subjects are 77 consecutive patients who underwent FTS-nEPID as a preoperative study (mean age: 53.3±21.8, 47 men and 30 women). Otorhinolaryngologists performed the operations. We anatomically classified the middle ear into four portions. A radiologist evaluated the images for cholesteatoma and assessed the anatomical invasive range in four portions using only FTS-nEPID. We classified large cholesteatomas that invaded more than three portions and small ones that invaded less than two portions based on the results obtained from surgery, and calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). For all cholesteatomas with an existing diagnosis, the sensitivity, specificity, PPV, and NPV were 71%, 70%, 94%, and 27%, respectively. In anatomical evaluation, the sensitivity, specificity, PPV, and NPV were 49%, 85%, 77%, and 64%, respectively. For large cholesteatomas with an existing diagnosis, the sensitivity was 86%. In anatomical evaluation, the sensitivity, specificity, PPV, and NPV were 51%, 57%, 88%, and 18%, respectively. For small cholesteatomas with an existing diagnosis, the sensitivity, specificity, PPV, and NPV were 59%, 78%, 92%, and 30%, respectively. In anatomical evaluation, the sensitivity, specificity, PPV, and NPV were 40%, 85%, 60%, and 71%, respectively. FTS-nEPID may be useful for diagnosing cholesteatomas. Further research is needed for anatomical evaluation because there were many false-negative results.