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Aim To report the effect of oval and round window reinforcement surgery performed in two patients with the Tullio phenomenon. Case 1: A male with bilateral superior canal dehiscence syndrome. Downbeat nystagmus with leftward horizontal eye movement was recorded in an electronystagmogram using a pure-tone sound of 110 dB at 2000 or 4000 Hz in the right ear. Case 2: A female who had undergone stapes surgery. Computed tomography revealed an ossicular prosthesis in the vestibule. An audiogram indicated mild to moderate hearing impairment in the right ear. Leftward horizontal nystagmus was recorded in an electronystagmogram using a pure-tone sound of 110 dB at 500 or 1000 Hz in the right ear. Surgical findings indicated that the prosthesis was inserted deep into the oval window, which was closed with thin connective tissue. Outcomes After oval and round window reinforcement surgery was performed in the right ear, and loud, pure-tone sounds elicited neither nystagmus nor dizziness in either patient.

Intraoperative ultrasound during transsphenoidal surgery (TSS) for pituitary tumors has been reported. In reports of endonasal ultrasound (US), Doppler US vessel images were informative and effective in endoscopic TSS. We performed endoscopic US imaging with high flow mode, which is a novel technology, to visualize small vessels during endonasal endoscopic TSS. Six patients (five with pituitary adenomas and one with Rathoke’s cleft cyst) underwent endoscopic US-assisted TSS. A small endoscopic US probe (Olympus, BF-UC260FW; diameter, 6.9 mm) was inserted transsphenoidally to the sellar floor and into the sella turcica, and endoscopic US monitoring was performed. By rotating the endoscopic US probe, the internal carotid artery, anterior cerebral artery, middle cerebral artery, various small vessels, optic nerve, and residual tumor were clearly visualized on the endoscopic US images. Real-time animated vessel images around the tumor could be generated when needed during TSS. The tumors were removed without leakage of cerebrospinal fluid in the six patients, and their visual acuity was restored. Endoscopic US with high flow mode can visualize not only main cerebral arteries but also intracranial small vessels on B-mode US images. Pituitary tumors were clearly recognized and removed safely and precisely by monitoring the cerebral artery and its small branches as landmarks.

A 57-year-old woman presented to our department with a 2-month history of pain and paresthesia on the left side of the face 12 years after having undergone surgery for breast cancer. We performed an endoscopic biopsy and diagnosed metastatic breast cancer to the pterygopalatine fossa. There has been no recurrence for two years since the metastatic tumor was treated by radiation therapy. A literature search shows only one case of metastatic breast cancer with severe trigeminal neuralgia located in the V2 division of the trigeminal nerve area. Metastatic disease should be considered part of the differential diagnosis in patients presenting with trigeminal neuropathy.

We report endonasal ultrasonography (US)-assisted neuroendoscopic transsphenoidal surgery (TSS) in seven patients. With sagittal and coronal US images, internal carotid arteries, anterior cerebral arteries, residual tumor, and lateral ventricles were recognized, and the tumors were removed without leakage of cerebrospinal fluid in patients with pituitary adenoma. US images clearly depicted the carotid arteries, anterior cerebral arteries, middle cerebral arteries, chiasmatic cistern, and residual tumor. Endonasal US images can provide real-time animated information and may help neuroendoscopic TSS, whenever needed during TSS.

A 59-year-old Japanese woman presented with right visual impairment and tunnel vision. Pituitary gland tumor was diagnosed and nasal endoscopic transsphenoidal surgery was performed. Following partial removal of the posterior wall of the sphenoid sinus and extension of the ultrasonography probe to contact the dura mater, the bilateral carotid arteries and the pituitary gland tumor were clearly visualized. The ultrasonography image became clearer when the sphenoid sinus was filled with physiological saline. Histopathological analysis of the resected specimen revealed a pituitary adenoma. Ultrasonography was particularly useful in depicting the arteries, showing the tumor at the nasal endoscopic transsphenoidal surgery.

Gas gangrene generally occurs in the extremities, and rarely in the neck.A 63-year-old male visited our clinic complaining of sore throat and dyspnea. He had fever and swelling in his neck. A CTscan showed gas formation in the soft tissues. We performed emergency tracheotomy and surgical drainage from his neck. We administered antibiotics and performed debridement of necrotic tissues. These treatments were very effective.Culture of the pus revealed Clostridium perfringens and Bacteroides interrmedium. We diagnosed gas gangrene.

Operative records of 75 patients with acquired attic cholesteatoma were evaluated and compared with preoperative HRCT findings. The cholesteatoma extensions were classified into five groups as follows; Group 1 (cholesteatoma limited to the attic, 9 cases), Group 2 (cholesteatoma occupying both the attic and the aditus, 5 cases), Group 3 (cholesteatoma extending down to the posterior tympanum, also occupying an area as in Group 2, 6 cases), Group 4 (cholesteatoma occupying the attic, the aditus and the mastoid antrum, 14 cases), and Group 5 (cholesteatoma extending down to the posterior tympanum, also occupying an area as in Group 4, 41 cases). Ventilatory conditions, or the existence of soft tissue density, were evaluated by HRCT at such locations as the supratubal recess, mesotympanum, anterior and posterior parts of the tympanic isthmus, epitympanum, and mastoid antrum. Results are as follows. In Group 1, all these locations were aerated with the exception of a few cases. In Group 2, complete opacification was observed in almost all of the antrums. Soft tissue masses involved the anterior and/or posterior parts of the tympanic isthmus in both Groups 3 and 5. In Group 3, the posterior part of tympanic isthmus was less aerated than the anterior part of tympanic isthmus. In Group 5, all locations were filled with soft tissue density except the supratubal recess and the mesotympanum, where some degree of aeration was observed. These results indicate that blockage of the ventilatory passages is not essential for formation of an attic cholesteatoma. Soft tissue density in HRCT is not the cause, but rather, the result of extension of a cholesteatoma.

A 32-year-old woman with Von Recklinghausen's disease had a malignant peripheral nerve sheath tumor that had progressed to malignancy from a neurofibroma arising in the left phrenic nerve. The tumor was removed combining a neck incision and thoracotomy. It should be more widely recognized that neurofibroma associated with Von Recklinghausen's disease may progress to malignancy. Primary treatment requires a broad surgical excision to obtain an adequate margin.