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Objective: To analyze the clinical diagnosis, treatment ，and surgical timing of otogenic intracranial complications. Methods: The clinical data of 11 patients with intracranial complications with ear symptoms as the first manifestation in Department of Otorhinolaryngology Head and Neck Surgery, Qilu Hospital of Shandong University（Qingdao） from December 2014 to June 2022 were collected, including 8 males and 3 females, aged from 4 to 69 years. All patients had complete otoendoscopy, audiology, imaging and etiology examination, and the diagnosis and treatment plan was jointly developed through multidisciplinary consultation according to the critical degree of clinical symptoms and imaging changes. Among the 11 patients, 5 cases were treated with intracranial lesions first in neurosurgery department and middle ear lesions later in otolaryngology, 3 cases of meningitis, were treated with middle ear surgery after intracranial infection control, 1 case was treated with middle ear lesions and intracranial infection simultaneously, and 2 cases were treated with sigmoid sinus and transverse sinus thrombosis conservatively. They were followed up for 1-6 years. Descriptive statistical methods were used for analysis. Results: All the 11 patients had ear varying symptoms, including ear pain, pus discharge and hearing loss, etc, and then fever appeared, headache, disturbance of consciousness, facial paralysis and other intracranial complication. Otoendoscopy showed perforation of the relaxation of the tympanic membrane in 5 cases, major perforation of the tension in 3 cases, neoplasia in the ear canal in 1 case, bulging of the tympanic membrane in 1 case, and turbidity of the tympanic membrane in 1 case. There were 4 cases of conductive hearing loss, 4 cases of mixed hearing loss and 3 cases of total deafness. Imaging examination showed cholesteatoma of the middle ear complicated with temporal lobe brain abscess in 4 cases, cerebellar abscess in 2 cases, cholesteatoma of the middle ear complicated with intracranial infection in 3 cases, and sigmoid sinus thrombophlebitis in 2 cases. In the etiological examination, 2 cases of Streptococcus pneumoniae were cultured in the pus of brain abscess and cerebrospinal fluid, and 1 case was cultured in streptococcus vestibularis, Bacteroides uniformis and Proteus mirabilis respectively. During the follow-up, 1 patient died of cardiovascular disease 3 years after discharge, and the remaining 10 patients survived. There was no recurrence of intracranial and middle ear lesions. Sigmoid sinus and transverse sinus thrombosis were significantly improved. Conclusion: Brain abscess, intracranial infection and thrombophlebitis are the most common otogenic intracranial complications, and cholesteatoma of middle ear is the most common primary disease. Timely diagnosis, multidisciplinary collaboration, accurate grasp of the timing in the treatment of primary focal and complications have improved the cure rate of the disease., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.)

Purpose of Review: To review the principles of oncolytic virotherapy and summarize the recent preliminary evidence on the efficacy of oncolytic virotherapy for cholesteatoma (CHST) treatment in vitro in human CHST cells and in a gerbil CHST model., Recent Findings: The use of oncolytic virotherapy for nonmalignant lesions is innovative. In-vitro results showed that oncolytic herpes simplex virus 1 (oHSV) selectively targets and kills CHST cells. In a gerbil model of CHST, local oHSV injections were associated with a decrease in CHST volume and modulation of bony changes., Summary: Surgical treatment options for CHST are limited by high morbidity and recidivism, emphasizing the need for developing treatment alternatives. Preliminary results support the potential therapeutic effect of oncolytic virotherapy on CHST, yet further research is needed to evaluate this novel approach.

Background: Aural cholesteatomas, also called tympanokeratomas, are destructive and expansile growths of keratinizing epithelium that develop in the middle ear. They have been reported sporadically in dogs, and surgery is usually the recommended treatment., Objectives: To describe the common clinical, radiological and histological findings of cholesteatoma; to report on the outcome of conservative management., Animals: Eleven dogs (13 ears) with cholesteatomas., Methods and Materials: Medical records were reviewed for dogs diagnosed with cholesteatoma between 2012 and 2018. All dogs had computed tomography (CT) and/or magnetic resonance imaging (MRI) followed by trans-canal endoscopic procedure (TEP) for removal and biopsy of middle ear lesions. Dogs were then treated with in-clinic flushing initially weekly tapered to monthly, as well as at-home ear cleaning and application of topical otic steroid medication, initially daily then tapered to once or twice weekly., Results: Nine dogs had a history of chronic otitis externa; head tilt or facial paralysis was present in seven and four cases, respectively. Otic examination identified a protruding nodule in seven ears. CT demonstrated soft tissue-like material in 12 bullae and expansion in seven bullae. MRI revealed minimally contrast-enhancing bulla contents in 12 ears. Post-TEP and with maintenance medical treatment, nine ears had no further signs of middle ear disease during a mean follow-up of 27.9 months., Conclusions and Clinical Importance: The results suggest that otitis externa may not necessarily precede cholesteatoma in all dogs. MRI appears to be more sensitive than CT for identifying cholesteatomas. Conservative treatment of cholesteatomas could be useful before or as an alternative to surgery., (© 2018 ESVD and ACVD.)

Objective: In the assessment of chronic otitis media (COM) and its treatment, patient-reported outcomes are becoming increasingly important. The aim of the present study was to translate and validate the Zurich chronic middle ear inventory (ZCMEI-21) in Japanese in order to provide the first Japanese-language instrument for measuring health-related quality of life (HRQoL) in COM., Methods: The ZCMEI-21 was translated into Japanese according to published guidelines. In order to assess validity, the ZCMEI-21-Jap total score was compared to a question directly addressing HRQoL as well as the five-level version of the EQ-5D questionnaire, a generic measure of HRQoL., Results: Demographic data and validity were assessed in a total of 91 COM patients. The ZCMEI-21-Jap total and subscale scores were well comparable to those of the original validation study. Cronbach's α of the ZCMEI-21-Jap was 0.85, indicating an excellent internal consistency. The ZCMEI-21-Jap total score showed a strong correlation (r=0.68, p<0.0001) to the question directly addressing HRQoL and, as expected, only a moderate correlation to the EQ-5D scores (r=0.49, p<0.0001 for descriptive system score and r=0.44, p<0.0001 for VAS score)., Conclusion: We successfully translated the ZCMEI-21 into Japanese and were able to obtain sufficient information during the validation process for the use of the ZCMEI-21-Jap to quantify HRQoL in patients with COM. With the current study, we aim to take a step forward towards an international standardization of reporting HRQoL in COM., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Formation of labyrinth fistulas and destruction of the facial nerve canal in children with middle ear cholesteatoma is rare. Data of children with cholesteatoma of the middle ear, operated in the ENT department of MONIKI, is analyzed. Several clinical observations of multiple-aged patients with the presence of cholesteatoma intra-temporal complications are presented. The preoperative computer tomography made it possible to diagnose the presence of the labyrinth fistula and the destruction of the facial nerve channel, which was confirmed intraoperatively.

This manuscript intends to review types, pathogenesis, associated risk factors, and potential methods of prevention and treatment of the retraction pockets in adults and children. The importance of retraction pockets (RP) lies in loss of original histological and anatomical structure which is associated with development of ossicular chain erosion, cho¬lesteatoma formation and potentially life threatening complications of cholesteatoma. The trans-mucosal exchange each gas in the middle ear (ME) is towards equalizing its partial pressures with the partial pressure in the environ¬ment. MEs that have abnormalities in the volume and ventilation pathways in the epitympanic may be more suscep¬tible to retraction pockets. Sustained pressure differences and/or inflammation leads to destruction of collagen fibers in the lamina propria. Inflammatory mediators and cytokines lead to release of collagenases result in viscoelastic properties of the lamina propria. The process of changes in the tympanic membrane structure may evolve to the cho¬lesteatoma formation. There are many different staging systems that clinicians prioritize in their decision making in the management of RP. The authors discuss the management possibilities in different clinical situations: RP without and with ongoing or intermittent evidence of Eustachian Tube Dysfunction (ETD), presence of adenoid hypertrophy or re-growth of adenoids, presence or absence of effusion, invisible depth of RP without effusion. invisible depth of RP with effusion, ongoing RP after VT insertion, and finally suspicion of cholesteatoma in a deep RP with ME effusion. A decision algorithm regarding the management of TM retraction and retraction pockets is provided.

Facial nerve palsy causes disfigurement with cosmetic, functional and psychological repercussions. The facial nerve can be affected anywhere along its course. A comprehensive assessment considering all differential diagnoses is critical to optimal management, as prompt, appropriate therapy leads to better outcomes.

The existence of acquired cholesteatoma has been recognized for more than three centuries; however, the nature of the disorder has yet to be determined. Without timely detection and intervention, cholesteatomas can become dangerously large and invade intratemporal structures, resulting in numerous intra- and extracranial complications. Due to its aggressive growth, invasive nature, and the potentially fatal consequences of intracranial complications, acquired cholesteatoma remains a cause of morbidity and death for those who lack access to advanced medical care. Currently, no viable nonsurgical therapies are available. Developing an effective management strategy for this disorder will require a comprehensive understanding of past progress and recent advances. This paper presents a brief review of background issues related to acquired middle ear cholesteatoma and deals with practical considerations regarding the history and etymology of the disorder. We also consider issues related to the classification, epidemiology, histopathology, clinical presentation, and complications of acquired cholesteatoma and examine current diagnosis and management strategies in detail.

Bony destruction of the labyrinth is usually associated with long-standing cholesteatomatous otitis media. The promontory is not a common site for bone resorption because (1) it is not an area that is involved in accumulation of cholesteatoma perimatrix substances, (2) it is the densest bone of the human body, and (3) pressure necrosis from overlying tissue is uncommon. We report a case of cochlear erosion associated with noncholesteatomatous middle ear disease. As far as we know, this is only the second such case reported in the literature. We also review decision-making factors and techniques for the safe management of this condition.

Infratentorial subdural empyema is a neurosurgical emergency that is associated with an alarmingly high morbidity and mortality if appropriate management is delayed. It is an important differential to consider when confronted with a patient with a reduced Glasgow Coma Scale, focal neurology and symptoms of raised intracranial pressure in the presence of a head and neck infection. It is also important that the primary team managing these patients is aware of the many pathogens that may be involved, including Escherichia coli. Early recognition, prompt diagnosis, timely involvement of the appropriate multidisciplinary teams, including neurosurgery, otorhinolaryngology, radiology and microbiology should be sought, and urgent intervention are imperative in avoiding a fatal outcome. This article presents a case of E coli-positive infratentorial subdural empyema secondary to mastoiditis due to underlying cholesteatoma, and a review of the pertinent literature.

Objectives: Myospherulosis is a foreign body reaction induced by the application of oil-based ointments. Myospherulosis in the ear is extremely rare. Only 4 cases have been described, all of which occurred after (repeated) mastoid surgery., Methods: We present a case of persistent otorrhea and conductive hearing loss caused by myospherulosis in the middle ear following tympanoplasty., Results: The patient underwent revision middle ear surgery with removal of abnormally thick, pale tissue in the middle ear. Histology showed a foreign body reaction with signs of myospherulosis., Conclusions: Myospherulosis is a very rare complication of the use of oil-based ointments. Surgeons should be aware that these products might cause a foreign body reaction leading to myospherulosis. In patients who have chronic otorrhea after previous mastoid or middle ear surgery, myospherulosis should be considered in the differential diagnosis.

Objective: The Rion implantable hearing aid (IHA) Ehime (E)-type was developed for ears with middle ear diseases. This study focused on the current status of the patients, device problems, postoperative difficulties, and preventive measures against them., Study Design: Case series with chart review., Setting: Tertiary referral hospital., Subjects and Methods: Subjects were 30 patients who were implanted with the IHA E-type between 1984 and 1997 and followed up for more than 10 years. Current status of IHA implantees, incidents of device problems, and postoperative troubles and hearing outcomes were reviewed., Results: Eleven patients (36.7%) still use the original device. The average period of use was 16.6 +/- 3.3 years (21 years at most). The incidence of problems was lower with the second version of the device compared to the first version. Frequencies of the troubles were related to the types of original ear diseases: seven of 17 cases with chronic otitis media (41.2%), two of seven cases with cholesteatoma (28.6%), and two of six cases with tympanosclerosis (33.3%). No cholesteatoma occurred after surgical procedures (i.e., external ear canal closure and tympanic membrane lateralized) (P = 0.06). The device was exposed through a retroauricular skin fistula where the internal coil had been implanted. Significantly fewer infections were observed when the two-stage operation was used (P < 0.01)., Conclusion: For long-term success in implantation of the IHA, careful control of middle ear inflammation and measures against eustachian tube dysfunction are required in addition to technological advancements., (Copyright 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. Published by Mosby, Inc. All rights reserved.)

Conclusion: In all, 4 of 19 children with a cochlear implant (CI) with otitis media developed cholesteatoma. The insertion of a CI may interfere with normal mastoid pneumatization, stimulate mucosa as foreign body, or act as a nidus of infection. Regular follow-up is necessary for children with a CI at the prevalent ages of otitis media. Antibiotic treatment is suggested whenever acute otitis media is suspected, to prevent chronic progress of infection, cholesteatoma, or even meningitis., Objective: To evaluate treatment modality and outcomes of otitis media-related diseases in children with a CI., Patients and Methods: This was a retrospective case review in a tertiary referral center of Taipei Medical University, Chi Mei Medical Center. All patients had a history of otitis media or related disease in the implanted ear. Treatments included antibiotics, tympanotomy, and tympanomastoidectomy., Results: In all, 19 of 186 children with a CI were identified as having otitis media, and 4 of them as having cholesteatoma. Among the others, 10 were identified as having acute otitis media, 4 as having middle ear effusion, and 1 as having mastoiditis in the implanted ear. Surgery was performed in children with cholesteatoma and mastoiditis. The CIs of three children were eventually explanted to eradicate cholesteatoma.

Objective: To report on the value and limitations of new MRI techniques in pre- and post-operative MRI of cholesteatoma. The current value of magnetic resonance imaging (MRI) in diagnosing congenital, acquired, and post-operative recurrent or residual cholesteatoma is described., Methodology and Results: High resolution computed tomography (HRCT) is still considered the imaging modality of choice for detecting acquired or congenital middle ear cholesteatoma. However, MRI may provide additional information on the delineation and extension of cholesteatoma and on potential complications. Detecting post-operative residual or recurrent cholesteatoma with HRCT was shown to be inaccurate due to the technique's low sensitivity and specificity., Conclusions: Recently, improvements in MRI techniques have led to a more accurate diagnoses of cholesteatoma using delayed contrast enhanced T1-weighted imaging and diffusion-weighted imaging.

Background: Cholesteatoma represents the most common destructive disease of the ear, affecting the adult and paediatric population alike., Objective: This article describes the pathogenesis of cholesteatoma and provides a guide to the examination and management of this common disease., Discussion: Despite advances in surgery and imaging, the diagnosis of cholesteatoma is often delayed. A favourable outcome following treatment of a cholesteatoma rests in part on an early diagnosis, and in reducing significant complications and associated morbidity. Primary care physicians should maintain a high index of suspicion for the presence of cholesteatoma, awareness of otoscopic findings and promptly refer for investigations and management.

Otorrhea is an ambiguous symptom that underlies diverse clinical pictures. Fundamentally, the treatment of uncomplicated acute otitis externa and media can be carried out by the family physician. An ENT specialist should be definitely consulted in cases of complications or development of a chronic condition.

Objectives: To regenerate of the mastoid air cells and their functions for the treatment of incurable otitis media., Materials and Method: In situ tissue-engineered mastoid air cells using three-dimensional hydroxy apatite (3D-HA) of honeycomb-like structure were used as artificial pneumatic bones. This 3D-HA is made of calcium phosphate and has a high ratio of micropores, 90%. Its surface is coated with collagen. Ten patients (4 males, 6 females) for this clinical study were randomly selected among the patients with severe cholesteatoma, adhesive otitis media, and purulent chronic otitis media, and they were to be received a staged operation. At the first stage of tympanoplasty, collagen-coated 3D-HA was put into the newly opened mastoid cavity, and it was fixed by fibrin glue. Recovery of mastoid aeration and regeneration of the pneumatic air cells of the mastoid cavity were estimated by images of high-resolution computed tomography (HRCT) after the first operation. At the second stage of operation, histopathologic examinations of specimens of HA taken from the reopened mastoid cavity were performed., Results: Aerations in the mastoid cavity were observed in 9 of the 10 patients within 12 months after the second operation. Moreover, the pneumatic structure in the mastoid cavity was partially regenerated in five patients. In these successful cases, mucosa with newly formed capillaries was observed on the surface of the implanted HA at the second stage of operation. In the failure cases, however, connective tissues and granulations invaded the space of the 3D-HA. They were observed as soft-tissue density areas in the HRCT scan images., Conclusions: This study indicates that mucosa can grow on the surface of implanted artificial 3D-HA and can have a gas exchange function in the newly opened mastoid cavity. These tissue-engineered mastoid air cells may be a possible treatment for intractable otitis media.

Objectives: To describe middle ear carcinoma originating from the matrix of primary acquired cholesteatoma in a 43-year-old man and to discuss the relationship between middle ear carcinoma and cholesteatoma., Study Design: Case report., Setting: Department of Otolaryngology, Head and Neck Surgery of Niigata University Medical and Dental Hospital, which is a tertiary care center, Niigata, Japan., Patient: A 43-year-old man demonstrated symptoms resembling those of cholesteatoma: facial palsy, gradually progressive hearing loss, and chronic draining of the right ear. Other objective findings also supported a finding of cholesteatoma, but a computed tomographic scan and magnetic resonance imaging scan showed a well-enhanced mass and extensive bony erosion in the middle ear. At surgery, a granulous tumor in the mastoid cavity was diagnosed as squamous cell carcinoma, and closely coexisting cholesteatoma was found. Surgical specimen demonstrated carcinoma and cholesteatoma in the same field., Intervention: Radiation and chemotherapy were performed followed-up by mastoidectomy., Conclusion: Because middle ear carcinoma has a poor prognosis, it is important to detect lesions early. It is necessary to consider that middle ear carcinoma arises from not only chronic otitis media or surgical invasion but also from primary acquired cholesteatoma.

There are a variety of causes of otorrhea in children. The most important factor in reaching the proper diagnosis and providing relief of the problem is aural toilet. Once adequate debridement has been performed, the diagnosis is usually clearer, and treatment with ototopicals is significantly more effective. Most cases of otorrhea are due to infection or granulation tissue and can be managed initially with appropriately selected ototopical medication, thereby avoiding the risks and side effects of systemic therapy and the need for referral to a specialist. However, otorrhea in children that is refractory to medical therapy may be due to retained tympanostomy tubes or insidious pathology such as cholesteatoma or malignancy. In such cases, prompt referral to the otolaryngologist can facilitate accurate diagnosis and successful management.

We experienced two cases of brain abscess secondary to middle ear cholesteatoma. One, a 61-year-old woman, presented with left otalgia, appetite loss and nausea. The computed tomography obtained on admission revealed a middle ear cholesteatoma. The magnetic resonance image showed the presence of a brain abscess in the cerebellum. The brain abscess was drained and the cholesteatoma was removed using the canal down procedure under general anesthesia. Part of the cholesteatoma invaded the posterior cranial fossa was could not be removed from the otological surgical field. The patient has been under observation as an outpatient for 6 months already and no abnormal signs have been detected. The other patient, a 55-year-old man, was admitted to our hospital for a detailed examination because he had right otalgia and progressive headache. The examination of spinal fluid obtained by lumbar puncture showed marked elevation of the white blood cells count. Computed tomography revealed a middle ear cholesteatoma. The magnetic resonance image obtained on admission showed an area of low-intensity encapsulated by an area of high-intensity in the right temporal lobe. The abscess was drained and the cholesteatoma was removed using the canal down procedure under general anesthesia. The patient has been under observation for 1 year already and has presented no signs of recurrence.

Purpose of Review: Bacterial biofilms have recently been shown to be important in diseases of the head and neck. Because the concept of biofilms is novel to most practitioners, it is important to gain a basic understanding of biofilms and to recognize that strategies developed to treat planktonic bacteria are ineffective against bacteria in a biofilm., Recent Findings: Bacteria preferentially exist in complex, surface-attached organizations known as biofilms. Bacteria in biofilms express a different set of genes than their planktonic counterparts and have markedly different phenotypes. Biofilm bacteria communicate with each other, and have mechanisms to diffuse nutrients and dispose of waste. Biofilms provide bacteria with distinct advantages, including antimicrobial resistance and protection from host defenses. Thus, bacteria exist in a far more complex fashion than previously thought and can best be thought of as "self-assembling multicellular communities." Although a focus on the planktonic form of bacteria has been useful in understanding acute infections, chronic infections are much better understood as biofilm illnesses. Biofilms have been shown to be involved in chronic otitis media, chronic tonsillitis, cholesteatoma, and device-associated infections., Summary: Now that basic research has demonstrated that the vast majority of bacteria exist in biofilms, the biofilm concept of disease is beginning to spread throughout the clinical world. Understanding that many of the infections that affect structures of the head and neck are actually biofilm related is fundamental to developing rational strategies for treatment and prevention.

Cholesteatomas are benign tumors that develop in the middle ear, and their rapid growth patterns can impinge on local structures, resulting in adverse sequelae such as hearing loss, pain, or neuropathies. These late signs and symptoms can be avoided by early identification and prompt intervention. Primary care providers should be aware of the incidence, prevalence, identification, and associated symptoms of cholesteatomas to reduce the later untoward affects and promote prompt referral.

Objective: Clinico-audiological and CT scan assessments of the contralateral ear in patients with unilateral cholesteatoma can be a good predictive method for the fate of these ears., Material and Methods: Fifty patients with unilateral cholesteatoma and 25 control subjects with bilateral normal ears were subjected to otomicroscopical and audiological assessment. Axial and coronal computed tomography (CT) for the mastoid bone at 1 mm slice thickness was done for all ears. A simplified method was used to find out the surface area (SA) of the air cells at each individual section and semi-automatically calculate the total volume of the matstoid air cells., Results: Otomicroscopically, 72% of the contralateral ears showed signs of retraction pockets, granulation tissues and other signs of chronicity. Audiologically 20% of the control ears showed moderate to severe conductive hearing loss while 10% showed mixed hearing loss. As regards mastoid pneumatization, the mean air cell volumes were 6.1, 12.68 and 29.92 CC in cholesteatomatous, contralateral and control ears respectively. This indicates a highly significant difference in the mean air cell volume between the control ears and the other two groups., Conclusion: It can be concluded that continuous follow up of the contralateral ear in cholesteatomatous ears is mandatory to detect subtle pathological changes and manage them early. Volumetry of contralateral ear using the applied simple method can lead to a reduction in major surgery and can affect the choice of the surgical approach.

Major advances in reconstruction continue to be made in the treatment of chronic middle ear disease, while little prophylaxis is available and indications for intervention remain in many cases controversial. This reflects our lack of knowledge of the true causes of these diseases.

Objective: The aim of this study was to examine the clinical presentation and natural history of chronic myringitis (CM)., Study Design: Retrospective case review., Setting: Tertiary referral center., Patients: Chronic myringitis is defined as a loss of tympanic membrane epithelium for >1 month without disease within the tympanic cavity. Seven hundred fifty patient records were reviewed to determine the prevalence of CM in an academic otology practice. The records of 40 patients (45 ears) with CM seen between 1995 and 1999 inclusive were reviewed., Main Outcome Measures: The series was reviewed with attention to previous medical and otologic history, the nature and duration of symptoms, the physical findings, and management., Results: The prevalence of CM was found to be -1% (approximately one fourth as common as cholesteatoma). Symptoms were often present for many years before the diagnosis of CM, with CM often mistaken for chronic otitis media. Sixty percent of patients had undergone previous otologic procedures. There did not appear to be an association between CM and systemic disease. Physical findings were varied, with granulation tissue and tympanic membrane perforations often occurring transiently. The clinical course of CM is typified by recurrent episodes of symptoms, often interspersed with long asymptomatic periods. A subset of CM can result in an acquired atresia. The most effective treatment appeared to be prolonged topical medications, surgery being reserved for only the most refractory cases., Conclusions: Chronic myringitis is often mistaken for chronic otitis media. Such confusion prolongs the initiation of appropriate management and sometimes leads to needless tympanomastoid surgery. The otologist should be aware of this clinical entity and its varied presentation.

Forty-one patients in whom otogenic brain abscess was diagnosed and has been treated since 1968 are presented. Sixty-five percent of the patients were between 5 and 15 years of age. All patients had chronic otitis media, and 95% had cholesteatoma. Abscess was located in the temporal lobe in 54%, in the cerebellum in 44%, and in both locations in 2% of the cases. Most patients had radical mastoidectomy and evacuation of the abscess through the mastoidectomy (61%). In addition to mastoidectomy, burr hole drainage was used in 20% and craniotomy in 15%. The most common micro-organism involved was Proteus. Overall mortality in this series is 29%, but after 1976, when CT became available for the diagnosis and follow-up, the mortality rate was reduced to 10%.

Childhood cholesteatoma is an aggressive disease that demonstrates higher rates of recidivism than its adult counterpart. The priorities in ideal management include total removal, followed by hearing restoration, followed by preserving the ear anatomy. Especially in children, one must endeavor to preserve ear anatomy if it does not jeopardize total removal of cholesteatoma. Absolute indications for CWD surgery include an only-hearing ear, a severely destroyed posterior canal wall, an extremely contracted mastoid, and matrix overlying a semicircular canal fistula. Reasons for staging childhood cholesteatoma include suspected residual disease, uncertainty about total removal of cholesteatoma, severe mucosal disease, and CWU procedures in which the cholesteatoma has diffusely invaded the bone. Adequate long-term follow-up is imperative. Patients and their families should be reminded frequently of the importance of close follow-up because recidivism is frequent. Successful management of cholesteatoma in children does not involve a rigid, "one-way" approach. The surgeon must be flexible and capable of employing the most appropriate procedure for the patient.

There are several types of eustachian tube dysfunction, including obstruction and abnormal patency. This article presents an update on several selected areas of eustachian tube function and dysfunction, including surfactants, cleft palate, tympanic membrane atelectasis, abnormal eustachian tube patency, and long-term middle ear ventilation.