Volume-rendered computed tomography images of the surgical field for endolymphatic sac surgery.

PURPOSE: Identification of the endolymphatic sac has failed occasionally. Postoperative complications have also rarely been reported. Given a safer and more reliable surgery, preoperative anatomical assessments are valuable, however, the vestibular aqueduct has seldom been seen with multi-planar reconstruction (MPR) computed tomography (CT) images yet. Our study aimed to determine the significance and utility of volume-rendered (VR) CT images of the surgical field for identifying the vestibular aqueduct, compared with MPR CT images. SUBJECTS AND METHODS: 14 patients with Meniere's disease who underwent endolymphatic sac surgery between 2008 and 2011. Location and size of the vestibular aqueduct were assessed using VR and MPR CT images, independently. RESULTS: Accuracy of identifying the location differed significantly between VR and MPR CT images (rate of total correct evaluations: 100% by VR CT images vs 75% by MPR CT images, p = 0.02). Size was correctly identified in cases with a small endolymphatic sac using VR CT images (rate of total correct evaluations for size of the vestibular aqueduct: 100% by VR CT vs 57% by MPR CT, p = 0.046). VR CT images also demonstrated clearly the relationship between the endolymphatic sac and high jugular bulb. In two cases, the endolymphatic sac was identified by VR images, not by MPR images. CONCLUSION: Accurate information about the location and size of vestibular aqueduct can allow sac surgeons to identify a tiny endolymphatic sac more easily and certainly, and also aids surgical trainees to learn sac surgery safely.

Five-year postoperative outcomes of modified staged canal wall up tympanoplasty for primary acquired cholesteatoma.

OBJECTIVE: For successful canal wall up tympanoplasty (CWUT) for the treatment of cholesteatoma, the restoration of stable middle ear aeration is also important; however, little is known about the dynamics of such aeration or the optimal surgical procedure. In this study, alternative additional surgical procedure was selected based on the grade of middle ear aeration during the second-stage operation. SUBJECTS AND METHODS: Patients included in this study underwent staged CWUT surgeries with mastoid cortex plasty (MCP) for well-aerated ears (grade 3) and bony mastoid obliteration (BMO) for poorly aerated ears (grade 2-0). Of the 115 ears included in this study, 62 were followed for more than 5 years. Recurrence rates with deep retraction pocket formation were assessed using the Kaplan-Meier survival analysis. The aeration was graded as: 0, no aeration; 1, aeration of only the mesotympanum; 2, aeration of the entire tympanic cavity; and 3, aeration of both the tympanic and mastoid cavities. RESULTS: No recurrence was observed in ears associated with grade 3 aeration that underwent MCP or in ears with grade 2 aeration that underwent BMO during second-stage surgery. For grades 0 and 1 aeration ears, the recurrence rates were 8.1% after 5 years and 12.5% after 10 years (p < 0.05), and the aeration of recurrent ears deteriorated to grade 0. CONCLUSION: Aeration during second-stage surgery predicts the final outcome.

Osseous eustachian tube and peritubal cells in patients with unilateral cholesteatoma comparison between healthy and diseased sides using high-resolution cone-beam computed tomography.

OBJECTIVES: We investigated the factors that may possibly cause primary acquired cholesteatoma. SETTING: University-affiliated hospital. SUBJECTS AND METHODS: In 20 adult patients with unilateral cholesteatoma, the sizes of the osseous eustachian tubes (ETs) and the extent of peritubal and mastoid cell development in healthy and diseased ears were examined using high-resolution cone-beam computed tomography. The height and width of the ET were measured at the tympanic orifice, the isthmus, and the midpoint, as was the length of its axis. We also assessed the extent of development of peritubal and mastoid cells. RESULTS: There were no significant differences in the size of the osseous ET between the healthy and cholesteatoma sides, but significant correlations were found in height and width between the sides at the tympanic orifice and at the isthmus. In 80% of ears with cholesteatoma, the development of both peritubal and mastoid cells was poor and, in 5% more, one or the other was poor. Mastoid and peritubal cell development was good in 60% of healthy ears and poor in 20%. In the remaining 20%, only peritubal cell development was poor. CONCLUSION: There were no significant differences in the size of the osseous ET between the healthy and diseased sides of patients with unilateral cholesteatoma. Our results indicate that inhibition of air cell development in not only the mastoid region but also the peritubal region may contribute to cholesteatoma development.

Yanagihara facial nerve grading system as a prognostic tool in Bell's palsy.

OBJECTIVE: The aim of this study was to evaluate the accuracy of the Yanagihara facial nerve grading system in assessing the course of recovery and in determining the probability of a complete recovery of Bell's palsy within 1 week after onset. STUDY DESIGN: Retrospective study of patients at a single trial center. SETTING: Tertiary referral center. PATIENTS: Six hundred sixty-four patients with Bell's palsy were assigned to three groups by degree of facial palsy using the Yanagihara 40-point system. MAIN OUTCOME MEASURE: The rate of recovered patients was assessed until 6 months after onset. RESULTS: Ultimately, 151 (23.1%) patients were assessed with mild palsy, 286 (43.7%) with moderate palsy, and 217 (33.2%) with severe palsy. The average Yanagihara score in the recovered patients was 15.7, whereas the score in the nonrecovered patients was 8.4. The rate of recovered patients in the mild group was 99.3%, that in the moderate group was 95.1%, and that in the severe group was 80.2%. These differences among the groups were significant (p < 0.05). CONCLUSION: The Yanagihara system was able to distinguish the probability of a complete recovery of the facial palsy within 1 week after the onset of palsy. We believe that the key point in improving the prognosis of Bell's palsy is to diagnose the severity, using the Yanagihara system, and to treat it promptly to prevent progressive nerve degeneration.

Prognostic factors of Bell's palsy: prospective patient collected observational study.

The purpose of this study was to evaluate various parameters potentially influencing poor prognosis in Bell's palsy and to assess the predictive value for Bell's palsy. A single-center prospective patient collected observation and validation study was conducted. To evaluate the correlation between patient characteristics and poor prognosis, we performed univariate and multivariate analyzes of age, gender, side of palsy, diabetes mellitus, hypertension, and facial grading score 1 week after onset. To evaluate the accuracy of the facial grading score, we prepared a receiver operating characteristic (ROC) curve and calculated the area under the ROC curve (AUROC). We also calculated sensitivity, specificity, positive/negative likelihood ratio, and positive/negative predictive value. We included Bell's palsy patients who attended Ehime University Hospital within 1 week after onset between 1977 and 2011. We excluded patients who were less than 15 years old and lost-to-follow-up within 6 months. The main outcome was defined as non-recovery at 6 months after onset. In total, 679 adults with Bell's palsy were included. The facial grading score at 1 week showed a correlation with non-recovery in the multivariate analysis, although age, gender, side of palsy, diabetes mellitus, and hypertension did not. The AUROC of the facial grading score was 0.793. The Y-system score at 1 week moderate accurately predicted non-recovery at 6 months in Bell's palsy.

Width of the normal facial canal measured by high-resolution cone-beam computed tomography.

CONCLUSIONS: In the facial canal, discrepancies between left and right side measurements at each point may be useful in the assessment and diagnosis of facial canal-related pathologies. OBJECTIVES: This study was performed to obtain accurate and high-resolution images of the normal facial canal and measure its widths on cross-sections of the canal at anatomically and clinically important sites using high-resolution cone-beam computed tomography (CBCT). METHODS: CBCT volume data of bilateral temporal bones were obtained from 28 healthy adult volunteers. The widths of the bony facial canals were measured at the meatal foramen, the cochleariform process, the stapes, the pyramidal eminence, and the point of emergence of the chorda tympani in the vertical segment. RESULTS: The widths of the facial canal at each point were similar bilaterally (r = 0.54-0.85, p < 0.01), but showed regional differences and site-specific variations. The narrowest of the five sites was the level of the meatal foramen (p < 0.05), as reported previously. The second narrowest site was the level of the stapes (p < 0.01) followed in order by the level of the cochleariform process, the pyramidal eminence, and the point of emergence of the chorda tympanis (p < 0.01).

A case of pneumolabyrinth induced by Eustachian tube air inflation.

OBJECTIVES: Here, we report a case of pneumolabyrinth induced by Eustachian tube air inflation (ETAI) with a catheter and present evidence that multiple air bubbles entered the perilymphatic space through a preexisting oval window fistula. SETTING: Tertiary referral center. PATIENT: Sixty-six-year-old woman. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Air bubbles in the perilymphatic space revealed by cone beam computed tomography (CT) volume rendering imaging. RESULTS: The patient was referred to us because of vertigo, unsteadiness, and right hearing loss after ETAI using a Eustachian tube catheter. On Day 2, an audiogram showed right total deafness, and the perilymphatic space could not be identified on T2-weighted magnetic resonance imaging. A high-resolution cone beam CT scan obtained on Day 3 showed multiple air bubbles in the labyrinth. The volume rendering images clearly revealed a larger air bubble in the vestibule inside the footplate of the stapes and small air bubbles in the horizontal semicircular canal, superior semicircular canal, and basal and second turns of the cochlea. This finding indicates that the air bubbles entered the perilymphatic space through an oval widow fistula caused by a sudden elevation in intratympanic air pressure. Two months later, the air bubbles had disappeared, and the patient's high tone hearing had improved slightly. CONCLUSION: ETAI can cause a pneumolabyrinth if the intratympanic pressure rises beyond a certain critical level. In this situation, volume rendering imaging of high-resolution cone beam CT can be used to quantify and identify the air bubbles present. The images taken in this study suggest that air bubbles entered the perilymphatic space through a perilymphatic fistula.

Position of TORP on the stapes footplate assessed with cone beam computed tomography.

OBJECTIVE: To improve hearing outcomes of ossiculoplasty with a total ossicular replacement prosthesis (TORP) in ears lacking a footplate superstructure, 3-dimensional computed tomography (3D CT) images were reconstructed to verify the position of the TORP on the footplate and contact between the TORP and the stapes footplate. STUDY DESIGN: Retrospective study. SETTING: University-affiliated tertiary referral center. PATIENTS: Six ears of 6 patients who underwent ossiculoplasty with TORP and were followed for greater than 3 years postoperatively. INTERVENTION: Cone beam CT (CBCT) images. MAIN OUTCOME MEASURES: An en face view of the stapes footplate and a volume-rendered 3D image were reconstructed. RESULTS: The en face view of the stapes footplate showed whether the TORP was centered on the stapes footplate. Volume-rendered 3D CBCT images revealed TORP malpositioning or migration, which were not detected on 2-dimensional CBCT images. In such cases, the TORP shaft was in contact with the wall of the oval window niche or the TORP had moved from the stapes footplate. CONCLUSION: Accurate visualization of TORP location on the footplate is important. Images that accurately show the position of the TORP on the stapes footplate will help improve hearing outcomes.

Re-implantation of the Rion E-type semi-implantable hearing aid: status of long-term use and hearing outcomes in eight patients.

OBJECTIVES: The Rion Ehime (E)-type implantable hearing aid (IHA) is the first middle ear implant. We implanted 39 IHAs into 39 patients, and found that the IHA functioned well for >15 years. So far, 28 IHAs have been removed because they stopped functioning. An IHA was re-implanted in 8 of the 28 cases. This study assessed the status of long-term use and hearing outcomes in the eight patients to confirm the safety and advantages of repeated implant operation. METHODS: Current status and operational findings of the eight re-implantees and hearing outcomes were investigated by reviewing the patients' records. RESULTS: Four of the eight cases still use their devices; all four originally suffered from cholesteatoma. In the remaining four cases, the devices stopped functioning 2.4-9.4 years after re-implantation; they suffered from chronic otitis media. Preoperative air and bone conduction hearing and IHA hearing 3 months after the first implantation were 61.1±13.1dB, 40.6±11.3dB, and 26.9±10.5dB, respectively (n=8). At the time of removal, they were 59.4±12.4dB, 40.2±14.2dB, and 42.9±14.9dB, respectively. Three months after re-implantation, they were 60.4±14.6dB, 37.3±14.7dB, and 29.4±13.4dB, respectively. CONCLUSIONS: Re-implantation of an IHA is beneficial and safe for patients. As the absence of active inflammation has a crucial effect on the period of use, re-implantation should be judged carefully after deterioration of the initial implant.

Facial nerve decompression surgery using bFGF-impregnated biodegradable gelatin hydrogel in patients with Bell palsy.

OBJECTIVE: Basic fibroblast growth factor (bFGF) promotes the regeneration of denervated nerves. The aim of this study was to evaluate the regeneration-facilitating effects of novel facial nerve decompression surgery using bFGF in a gelatin hydrogel in patients with severe Bell palsy. STUDY DESIGN: Prospective clinical study. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Twenty patients with Bell palsy after more than 2 weeks following the onset of severe paralysis were treated with the new procedure. The facial nerve was decompressed between tympanic and mastoid segments via the mastoid. A bFGF-impregnated biodegradable gelatin hydrogel was placed around the exposed nerve. Regeneration of the facial nerve was evaluated by the House-Brackmann (H-B) grading system. The outcomes were compared with the authors' previous study, which reported outcomes of the patients who underwent conventional decompression surgery (n = 58) or conservative treatment (n = 43). RESULTS: The complete recovery (H-B grade 1) rate of the novel surgery (75.0%) was significantly better than the rate of conventional surgery (44.8%) and conservative treatment (23.3%). Every patient in the novel decompression surgery group improved to H-B grade 2 or better even when undergone between 31 and 99 days after onset. CONCLUSION: Advantages of this decompression surgery are low risk of complications and long effective period after onset of the paralysis. To the authors' knowledge, this is the first clinical report of the efficacy of bFGF using a new drug delivery system in patients with severe Bell palsy.

Facial nerve decompression surgery in patients with temporal bone trauma: analysis of 66 cases.

BACKGROUND: In the treatment of facial nerve paralysis after temporal bone trauma, it is important to appropriately determine whether nerve decompression surgery is indicated. The aim of this study was to examine the efficacy of facial nerve decompression surgery according to fracture location and the ideal time for surgery after trauma by analyzing the therapeutic outcome of traumatic facial nerve paralysis. METHODS: In total, 66 patients with facial nerve paralysis after temporal bone trauma who were treated at our institution between 1979 and 2009 were studied retrospectively. The patients were divided into five subgroups, according to the fracture location and the period of time between trauma and surgery. RESULTS: The number of patients who achieved complete recovery of House-Brackmann (H-B) grade 1 was 31 of 66 (47.0%). There was no difference in therapeutic outcomes among the subgroups classified by fracture location. The rate of good recovery to H-B grade 1 or 2 in patients undergoing decompression surgery within 2 weeks after trauma reached 92.9%, resulting in a significantly better outcome than that of patients undergoing later decompression surgery (p < 0.01). CONCLUSIONS: The results of this study demonstrated that the ideal time for decompression surgery for facial nerve paralysis after temporal bone fracture was the first 2 weeks after trauma in patients with severe, immediate-onset paralysis. Our study also showed that surgery should be performed within 2 months at the latest. These findings provide useful information for patients and help to determine the priority of treatment when concomitant disease exists.

Lateral orifice of Prussak's space assessed with a high-resolution cone beam 3-dimensional computed tomography.

OBJECTIVES: To describe how to obtain high-resolution computed tomography (CT) images of the en face view of the lateral orifice of Prussak's space (Ps orifice) and tympanic ring and to investigate the shape and size of these structures in normal ears and in those with chronic otitis media and attic cholesteatoma. SETTING: University-affiliated referral center. METHODS: Using the Accuitomo image reconstruction algorithm, the slope of the eardrum was turned to vertical on both coronal and axial images. A sagittal slice view at the eardrum gave the en face view of the eardrum. The width and height of the Ps orifice and vertical axis of the tympanic ring were measured with an automatic measuring device. RESULTS: In the normal Ps orifice, the height is less than 1.30 mm, and the width is less than 2.63 mm. The height and width in the Ps orifice with attic cholesteatoma were significantly larger than those in normal ears and in ears with COM (p < 0.01). In the ears with COM, the width and height on average seemed larger than normal, but no significant difference was verified. The vertical axis of the tympanic ring was unaffected by the diseases. CONCLUSION: CT imaging of the en face view of the Ps orifice obtained by the present method is useful as an objective measure to assess bone destruction at the Ps orifice, a scutum defect, in ears with COM and attic cholesteatoma.

Long-term results with the Rion E-type semi-implantable hearing aid.

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.

Total mastoid obliteration in staged canal-up tympanoplasty for cholesteatoma facilitates tympanic aeration.

OBJECTIVE: To assess middle ear aeration after total mastoid obliteration using bone pate and hydroxyapatite performed at the second stage of intact-canal-wall (ICW) tympanoplasty. STUDY DESIGN: Retrospective study. SETTING: Tertiary referral hospital. PATIENTS: Forty-two ears with cholesteatoma underwent the obliteration. Computed tomography (CT) scan 1 week before the second-stage operation showed disturbance of middle ear aeration.In the 27 ears of these cases, temporal bone CT scans taken 3 years or more after the operation were available. INTERVENTION: We performed second-stage ICW tympanoplasty 1 year after the first-stage canal-up operation. After mastoidectomy and ossiculoplasty, communication between the tympanic cavity and antrum was blocked with cartilage flaps, and the antrum and mastoid cavity were obliterated totally with bone pate alone or combined with hydroxyapatite granules. MAIN OUTCOME MEASURES: Otomicroscopic and otoendoscopic assessment for ear drum retraction was graded. Tympanic aeration assessed with CT when available. RESULTS: After the total mastoid obliteration in the second-stage ICW tympanoplasty, no postoperative complications nor residual cholesteatoma were encountered. The incidence of ear drum retraction was significantly correlated with the grade of tympanic aeration. CONCLUSION: The total mastoid obliteration done at the second-stage ICW tympanoplasty is a safe procedure that facilitates aeration of the tympanic cavity. In ears with restored tympanic aeration, the probability of a retraction pocket development is low. On the contrary, possibility of retraction pocket development is high in the ears with poor tympanic aeration after the second-stage operation.

Mouth movement disturbance as a sequela of bilateral Bell's palsy.

OBJECTIVE: Bell's palsy rarely recurs or arises bilaterally. We describe unique oral motor sequelae that manifest with bilateral facial palsy. PATIENTS: Two rare patients with alternating bilateral Bell's palsy experienced compromised mouth movement, affecting eating, speaking, and air exchange, and reduced quality of life. INTERVENTIONS: Rehabilitation programs. MAIN OUTCOME MEASURES: Electromyography and electroneuronography. RESULTS: On electromyography study, little activity of the orbicularis oris muscle was seen in any mouth or eye movement in Case 1. In Case 2, the electromyography activity of the depressor anguli oris and depressor labii inferioris muscles was stronger than that of the orbicularis oris muscle. The 2 cases demonstrated different patterns of recovery after the same subsequent treatment. CONCLUSION: Different patterns of reinnervation occur in bilateral Bell's palsy. Mouth movement disturbances after bilateral Bell's palsy are most disabling when incomplete reinnervation (as suggested by electroneuronography) of the orbicularis oris muscle occurs. Misdirection of regenerating nerve fibers produces lesser levels of oral motor impairment.

Improvements to staged canal wall up tympanoplasty for middle ear cholesteatoma.

OBJECTIVE: To describe our improvements to staged canal wall up tympanoplasty with mastoidectomy (SCUT) for middle ear cholesteatoma, and to show more successful outcomes of the surgery compared with our data previously reported. STUDY DESIGN: Retrospective study in a tertiary referral hospital. SETTING: 78 ears of 76 patients with extensive cholesteatoma were operated on using the improved SCUT between July 1998 and December 2006. Improved SCUT included new techniques such as scutum plasty and mastoid cortex plasty performed in a staged manner. RESULTS: Only 2 ears showed retraction pocket formation (7.7%) without recurrence in 26 ears followed for more than 5 years. In 48 followed for more than 3 years, frequency of postoperative retraction pocket formation (5/48; 10.4%) was significantly lower compared to our previous results (41/134; 30.6%, P < 0.01). CONCLUSION: Our improvements to SCUT contributed to the decreasing of frequency of postoperative retraction pocket that may lead to cholesteatoma recurrence, although a longer follow-up study is required.

Tympanosclerosis involving the ossicular chain: mobility of the stapes in association with hearing results.

CONCLUSION: The preoperative bone conduction level provides not only prognostic information but also information on the mobility of the stapes in tympanosclerosis. The surgical results depend upon the stapes mobility. OBJECTIVES: We aimed to evaluate operative findings and hearing results of tympanosclerosis involving the ossicular chain, in order to understand the pathophysiology and to establish better surgical treatment of tympanosclerosis. PATIENTS AND METHODS: Between January 1998 and March 2004, 29 patients (29 ears) with tympanosclerosis involving the ossicular chain underwent tympanoplasty at our hospital. Patients with myringosclerosis only, or with an associated cholesteatoma, were excluded from this study. The clinical and operational records and pre- and postoperative pure tone audiograms were reviewed retrospectively. RESULTS: Intact canal wall tympanoplasty was applied to all 29 patients. A non-staged operation was performed on 21 patients, and a staged operation was performed on the remaining 8 patients. In 25 patients (86.2%), the sclerotic lesion of the ossicles was located in the epitympanum. In the remaining four, the sclerotic lamella coated only the ossicular chain. On average, the preoperative air conduction hearing level of 57.9 dB was significantly improved to 46.3 dB after tympanoplasty. The success rate of middle ear surgery was 65.5% (19 of 29 patients), according to the criteria of the Otological Society of Japan. In 16 patients (55.2%), the mobility of the stapes was preserved (group A), while in the remaining 13 patients (44.8%), the stapes was fixed (group B). The mean preoperative bone conduction of 25.5 dB in group A was significantly better than that of 37.2 dB in group B. The hearing result significantly improved in group A but not in group B. The success rates were 75% (12 of 16 patients) in group A and 53.8% (7 of 13 patients) in group B.

Digital volume tomography: radiologic examinations of the temporal bone.

OBJECTIVE: We evaluated the clinical applicability and the value of digital volume tomography for visualization of the lateral skull base using temporal bone specimens. MATERIALS AND METHODS: Twelve temporal bone specimens were used to evaluate digital volume tomography on the lateral skull base. Aside from the initial examination of the temporal bones, radiologic control examinations were performed after insertion of titanium, gold, and platinum middle-ear implants and a cochlear implant. RESULTS: With high-resolution and almost artifact-free visualization of alloplastic middle-ear implants of titanium, gold, or platinum, it was possible to define the smallest bone structures or position of the prosthesis with high precision. Furthermore, the examination proved that digital volume tomography is useful in assessing the normal position of a cochlear implant. CONCLUSION: Digital volume tomography expands the application of diagnostic possibilities in the lateral skull base. Therefore, we believe improved preoperative diagnosis can be achieved along with more accurate planning of the surgical procedure. Digital volume tomography delivers a small radiation dose and a high resolution coupled with a low purchase price for the equipment.

Surgical treatment of retraction pocket with bone pate: scutum plasty for cholesteatoma.

OBJECTIVES: Postoperative attic retraction pocket is a critical issue and may be indicative of disease recurrence after canal-up tympanoplasty for middle ear cholesteatoma. Although scutum plasty is an acceptable procedure that can be used to prevent the pocket formation, how the scutum is reconstructed has remained controversial. The aim of this study was to clarify the value of scutum plasty using bone pate. STUDY DESIGN: Retrospective study. SETTING: Bone pate scutum plasty was performed in 69 ears during first-stage operations. We attempted to reconstruct a smooth attic bony wall. At the time of the second-stage operations, the results of the scutum plasty were examined. RESULTS: The incidence of retraction pocket was statistically reduced from 20.2% to 5.8%. CONCLUSION: Although the reconstructed scutum showed atrophy to some extent, bone pate scutum plasty is effective in preventing postoperative retraction pocket if a smoothly shaped attic wall can be reconstructed.