Yutaka Yamamoto

Objective: To examine the association of habitual sniffing with mastoid cell development and contralateral ear abnormalities in acquired pars flaccida cholesteatoma. Study design: Retrospective comparative study. Setting: Two tertiary referral hospitals. Patients: A total of 124 adults (133 ears) underwent primary surgery for acquired pars flaccida cholesteatoma between 2012 and 2026. Intervention(s): Primary cholesteatoma surgery. Main outcome measure(s): Mastoid cell development score classified according to the Japan Otological Society criteria and abnormal contralateral ear findings. Results: Habitual sniffing was identified in 67 of 133 ears (50.4%). The sniffing group had higher MC scores than the non-sniffing group, indicating better mastoid cell development (1.48±0.68 vs. 1.17±0.67; effect size r =0.222; P =0.010). Ordinal logistic regression showed that habitual sniffing was independently associated with better mastoid cell development [odds ratio (OR)=2.35; 95% confidence interval (CI), 1.15-4.87; P =0.020]. Among 110 ears with evaluable contralateral endoscopic findings, contralateral abnormalities were more frequent in the sniffing group than in the nonsniffing group (71.4% vs. 35.2%; OR=4.536; P =0.0002). Binary logistic regression showed that habitual sniffing was independently associated with abnormal contralateral ear findings (OR=4.57; 95% CI, 1.94-11.34; P =0.0007). Conclusions: Habitual sniffing was associated with better mastoid cell development and frequent contralateral ear abnormalities in acquired pars flaccida cholesteatoma, suggesting a distinct pathophysiologic subgroup related to dynamic negative pressure loading.

BACKGROUND: To evaluate postoperative hearing outcomes in patients undergoing tympanoplasty for acquired cholesteatoma and to identify candidates suitable for revision surgery or implantable hearing devices. METHODS: This retrospective study analyzed 177 patients who underwent primary tympanoplasty for acquired cholesteatoma between 2009 and 2015. Postoperative hearing outcomes were classified based on the air-bone gap (ABG), with ≤15 dB defined as successful. Candidates for revision tympanoplasty were identified according to the presence of an intact stapes, aerated mesotympanum on CT, and absence of tympanic membrane adhesion. Eligibility for cochlear implants (CIs), bone-anchored hearing aids (Baha®), and Vibrant Soundbridge (VSB) was assessed following Japan Otological Society (JOS) guidelines. RESULTS: Of 177 patients, 98 (55.3%) had unsuccessful hearing outcomes. Among these, 46 (46.9%) were candidates for revision tympanoplasty and 37 (37.7%) for implantable hearing devices (3 for CI, 13 for Baha®, and 27 for VSB), with partial overlap. Overall, 71 of the 98 patients (72.4%) were eligible for either revision surgery or hearing device implantation. CONCLUSION: More than half of the patients undergoing tympanoplasty for acquired cholesteatoma had suboptimal postoperative hearing; however, many patients remained candidates for additional interventions, highlighting the importance of structured postoperative reassessment, individualized auditory rehabilitation, and collaborative care between physicians and institutions.

Inner ear malformations can cause abnormal communication between the inner ear and subarachnoid space, leading to otogenic cerebrospinal fluid (CSF) leakage and subsequent bacterial meningitis. Persistent leakage may result in recurrent meningitis, which is associated with neurological sequelae and poor prognosis; thus, early diagnosis and surgical intervention are essential. Various surgical strategies have been reported, commonly termed middle ear obliteration and inner ear obliteration. However, their definitions remain ambiguous, and techniques vary widely in approach and effectiveness. This study describes 2 pediatric cases of incomplete partition type I (IP-I) malformation complicated by recurrent meningitis that were treated with translabyrinthine fistula closure via the lateral semicircular canal, a form of inner ear obliteration. Both patients exhibited high vestibular CSF pressure due to hypoplasia of the internal auditory canal fundus. Patient 1 had undergone 4 previous window closure surgeries elsewhere without success, whereas Patient 2 had no residual hearing and required prompt management. In both cases, the fistula was directly identified and sealed with a three-layer construct under direct visualization, allowing secure closure. Postoperative follow-up revealed no recurrence of meningitis for >8 years in Case 1 and more than 1 year in Case 2, without complications. This technique may represent a reasonable treatment option for controlling CSF leakage in severe inner ear malformations, including cases refractory to conventional treatments, even at the cost of sacrificing inner ear function. Using 2 representative pediatric cases, this study presents a case-based review that clarifies the classification, indications, and limitations of current surgical strategies for otogenic CSF leakage associated with inner ear malformations.

Surgical treatment is the only option for cholesteatoma; however, the recurrence rate is high, and the incidence of residual cholesteatoma recurrence largely depends on the surgeon’s skill. Training deep neural network (DNN) models typically requires large datasets, but the prevalence of cholesteatoma is low (1 in 25,000 people). It also remains difficult to treat. Developing analytical methods to improve accuracy with limited datasets remains a significant challenge in medical artificial intelligence (AI) research. This study introduces an AI-based system for detecting residual cholesteatoma in surgical field videos. A retrospective analysis was conducted on 144 cases from 88 patients who underwent surgery. The training dataset comprised videos of cholesteatoma lesions recorded during surgery and intact middle ear mucosa after lesion removal. These videos were captured using both an endoscope and a surgical microscope for AI model development. The diagnostic accuracy was approximately 80% for both endoscopic and microscopic images. Although the diagnostic accuracy for microscopic images was slightly lower, focusing on the lesion center improved the accuracy to a level comparable to that of endoscopic images. This study demonstrates the diagnostic feasibility of AI-based cholesteatoma detection despite a limited sample size, highlighting the value of proof-of-concept studies in clarifying technical requirements for future clinical systems. To our knowledge, this is the first AI study to use videos from both modalities.

Surgical treatment is the only option for cholesteatoma; however, the recurrence rate is high, and the incidence of residual cholesteatoma recurrence largely depends on the surgeon's skill. Training deep neural network (DNN) models typically requires large datasets, but the prevalence of cholesteatoma is low (1 in 25,000 people). However, cholesteatoma remains difficult to treat. Developing analytical methods to improve ac-curacy with limited datasets remains a significant challenge in medical artificial intelli-gence (AI) research. This study introduces an AI-based system for detecting residual cholesteatoma in surgical field videos. A retrospective analysis was conducted on 144 cases from 88 patients who underwent surgery. The training dataset comprised videos of cholesteatoma lesions recorded during surgery and intact middle ear mucosa after lesion removal. These videos were captured using both endoscope and microscope for AI model development. The diagnostic accuracy was approximately 80% for both endoscopic and microscopic images. Although the diagnostic accuracy for microscopic images was slightly lower, focusing on the lesion center improved the accuracy to a level comparable to that of endoscopic images. This study demonstrates the diagnostic feasibility of AI-based cholesteatoma detection despite a limited sample size highlighting the value of proof-of-concept studies in clar-ifying technical requirements for future clinical systems and is the first AI study to use videos from both modalities.

BACKGROUND: A labyrinthine fistula is a severe complication of middle ear cholesteatoma that can cause profound sensorineural hearing loss and vertigo. However, there is no consensus regarding the transition to postoperative hearing. Although hearing deteriorates gradually with a delay in some cases of labyrinthine fistula, insufficient consideration has been given to this point. We examined perioperative changes in cases of middle ear cholesteatoma with labyrinthine fistulas. METHODS: We retrospectively reviewed the medical records of 578 patients with middle ear cholesteatoma who underwent tympanoplasty at our hospital between 2016 and 2021. Patients with labyrinthine fistulas were selected; their perioperative bone-conduction hearing was assessed. Fistula depth was determined following the classification reported by Dornhoffer et al. The hearing was compared preoperatively, early postoperatively (3-6 months), and 1 year postoperatively. RESULTS: Forty-eight patients (8.3%) had labyrinthine fistulas. Regarding depth, 21 cases were type I, 14 were type IIa, 3 were type IIb, and 10 were type III. Preoperative bone-conduction hearing was significantly poor in invasion type IIb or deeper cases. Cases with type IIb or deeper fistulas, multiple fistulas, or vertigo deteriorated postoperatively. Type III cases or those with multiple fistulas deteriorated further from the early postoperative period to 1 year postoperatively. Concerning frequency, 500 and 2000 Hz showed a delayed deterioration. CONCLUSION: This is a valuable report of delayed hearing loss after surgery in patients with a labyrinthine fistula. This change is associated with the labyrinthine fistula’s depth and multiple fistulas—this is important during preoperative counseling of patients undergoing surgery. Cite this article as: Takahashi M, Nakazawa T, Kurihara S, Yamamoto K, Yamamoto Y, Kojima H. Postoperative late hearing deterioration in cholesteatoma with labyrinthine fistulas. J Int Adv Otol. 2024;20(2):154-157.

Background: The indications for transcanal endoscopic ear surgery (TEES) for middle ear cholesteatoma have expanded for cases involving mastoid extension. However, TEES is not indicated for all cases with mastoid extension. In addition, predicting the extent of external auditory canal (EAC) removal needed for cholesteatoma resection is not always easy. The purpose of this study was to use augmented reality (AR) to project the lesion onto an intraoperative endoscopic image to predict EAC removal requirements and select an appropriate surgical approach. Methods: In this study, patients showing mastoid extension were operated on using a navigation system with an AR function (Stryker). Results: The results showed that some cases with lesions slightly extending into the antrum required extensive resection of the EAC, while cases with lesions extending throughout the antrum required smaller resection of the EAC, indicating TEES. Conclusions: By predicting the extent of the needed EAC removal, it is possible to determine whether TEES (a retrograde approach) or canal wall-up mastoidectomy, which preserves as much of the EAC as possible, should be performed. We believe that our findings will contribute to the success of middle ear surgeries and the implementation of robotic surgery in the future.

Objective: To analyze the time trends of recidivism of acquired cholesteatoma using the Kaplan-Meier method. Study Design: We conducted a retrospective, observational study of 256 patients having their first cholesteatoma surgery. The cumulative recidivism-free rate was calculated using Kaplan-Meier survival analysis related to the follow-up period, pathophysiology, the extent of the disease, and recidivism pathologies. Results: Pars flacida cholesteatoma with tympanic cavity progression had a high likelihood of recurrence disease. Pars tensa cholesteatoma led to more recurrence of the disease than the residual disease. In both pars flacida and pars tensa cholesteatoma, the incidence of disease recurrence increased even 3 years after surgery. On the contrary, the incidence of residual disease peaked within 3 years after surgery, and thereafter, the incidence of residual disease tended to be small. In particular, pars flacida cholesteatoma extending into the mastoid cavity or tympanic cavity tended to recur up to 5 years postoperatively. Conclusions: We calculated the cumulative recidivism-free rates of 256 patients with cholesteatoma using Kaplan-Meier survival analysis. These results can lead to better estimates of the length of the follow-up period. Level of Evidence: Level IV evidence from case-control studies.