Oto-Rhino-Laryngologie Chirurgie de la Face et du Cou ------------------------------------------ Centre Hospitalier Universitaire 37044 Tours cedex FRANCE
Abstract: OBJECTIVE: Mastoidectomy is the standard management for exteriorized mastoiditis. The objective of this study was to assess the results of conservative management of acute mastoiditis and to study the types of bacteria isolated and their sensitivity to antibiotics. METHODS: A retrospective study including children admitted with acute mastoiditis was conducted between 1994 and 2007. Intravenous antibiotics were systematic. Since 2002, mastoidectomy has been replaced by retroauricular puncture and grommet tube insertion. RESULTS: Forty-four children had acute mastoiditis. All but one (temporozygomatic swelling) had postauricular swelling. The culture was positive in 78% of cases. Streptococcus pneumoniae was the most common bacteria identified. Twenty-six subperiosteal abscesses were found on the CT scan. Mastoidectomy was performed in 17 cases, 16 of which took place before 2002. The hospital stay has been decreased by six days with retroauricular puncture and grommet tube insertion management. CONCLUSION: In the absence of intracranial complications and suspicion of Fusobacterium necrophorum, a retroauricular puncture and grommet tube insertion associated with antibiotic therapy is an effective alternative to mastoidectomy in the treatment of acute mastoiditis with subperiosteal abscess.
Abstract: INTRODUCTION:: The anatomy of the temporal bone (TB) can only be mastered by repeated surgical and anatomic dissections, and surgical teaching initiative had a major effect on outcomes. The aim of this study was to investigate the validity of an artificial TB model devoted to surgical training and education. MATERIALS AND METHODS:: A helical computed tomographic (CT) scan was used to acquire high-resolution data of cadaveric TB. Digital imaging and communications in medicine (DICOM) data were converted into.stl files after data processing. Cadaveric TBs were prototyped using stereolithography. The validation of the prototype needed several steps. First of all, we have studied on CT scan the positional relationship between the facial nerve and other structures of the cadaveric TBs and prototyped bones. Otoendoscopy of the middle ear and the internal acoustic canal and visualization of anatomic landmarks during TB drilling of the cadaveric TBs and prototyped bones were also performed. RESULTS:: Seven normal CT scans of cadaveric TB were selected to make prototyped bone using stereolithography. Measurements of volume and distance showed no significant difference between prototypes and cadaver TBs. Classic mastoid surgical procedures were performed in the Anatomy Department: exposing sigmoid sinus, facial nerve, labyrinth, dura mater, jugular bulb, and internal carotid artery. Two simulations of implantable middle ear prosthesis were made successfully. CONCLUSION:: These prototypes made using stereolithography seem to be a good anatomic model for surgical training. This model could also be interesting for surgical planning in congenital ear anomalies before middle ear prosthesis implantation.
Abstract: OBJECTIVE: Describe the management of subglottic stenosis in a patient with Wegener's granulomatosis. MATERIAL AND METHOD: Case report. RESULTS: We report the case of a 26-year-old woman who presented Wegener granulomatosis and subglottic stenosis, with renal, skin, oropharyngeal, nasal, and paranasal locations. Medical treatment had cured all the locations except the subglottic stenosis. An endoscopic dilatation was performed. Two months later, the endoscopic treatment was repeated twice with intralesional corticosteroid injection. One year later, the patient was in complete functional remission. CONCLUSION: Respiratory obstruction in Wegener granulomatosis can result from subglottic stenosis. In this case, intralesional corticosteroid injection seemed to be a good adjunct to local treatment with an effective long-term result.
Abstract: OBJECTIVES: To study the circumstances of diagnosis, imaging techniques and therapeutic management of cavernous hemangioma of the nasal cavity. MATERIAL AND METHOD: We report the case of a 60-year-old woman, who presented epistaxis CT scan and nasal obstruction. RESULTS: Rhinoscopy showed a purplish, regular mass that filled the left nasal cavity. Computed tomographic and MRI images showed the tumor in contact close to the middle turbinate. An arteriography with selective embolization was performed. The lesion was completely removed by endonasal endoscopic surgery. The histological examination showed a cavernous hemangioma of the nasal cavity. CONCLUSION: Even if cavernous hemangiomas are rare, the practitioner must suggest the diagnosis if the patient has a purplish bleeding mass of the nasal cavity. CT scan, MRI, and arteriography can help make the diagnosis. Before surgical management, embolization is recommended.
Abstract: OBJECTIVES OF THE STUDY: To evaluate our results on the postoperative facial function, its pre and preoperative predictive factors, and the application of the surgical technique to lesions of decreasing size. PATIENTS AND METHODS: A series of 248 patients operated of an unilateral vestibular schwannoma has been reviewed. We have compared the results gathered over two periods corresponding to the evolution of our surgical technique since 1998. RESULTS: Immediate and 1 year postoperative facial function is significantly better among patients operated after 1998 (satisfactory in 75 and 88% respectively). This trend marked by the improvement of the results since 1998 has to be discussed according to other predictive factors. One of predictive factor is the decrease of the size of the lesion during the same period. The other factors are the hearing level, deafness duration, trigeminal nerve involved, vestibular status and ABR desynchronization. CONCLUSION: The positive predictive factors are usually correlated with the size of the tumour This implies the necessity of an early diagnosis of the schwannomas. The second predictive factor of the facial function is the use of a soft surgical technique.
Abstract: The microanatomy of the cerebellopontine cistern (CPC) is of interest to many surgeons and has been the subject of controversial works especially concerning the study of the subarachnoid space in the internal acoustic meatus (IAM). The CPC lies in the cerebellopontine angle between the brainstem, cerebellum and petrous bone. It contains in its upper part the trigeminal nerve with the superior petrosal vein. The cochleovestibulofacial bundle occupies the middle portion and lies between the pontomedullary sulcus and the IAM. The glossopharyngeal, vagus and accessory nerves are located in the inferior part of the cerebellopontine angle close to the vertebral artery and the posteroinferior cerebellar artery. The acousticofacial cistern is a lateral extension of the CPC in the IAM. The anatomy of the meningeal layers within the IAM is discussed especially concerning 'the arachnoidal cleavage plane' in acoustic neuroma surgery.
Abstract: INTRODUCTION: In vestibular schwannoma (VS) surgery, the arachnoidal duplication, based on an epiarachnoidal origin of the tumor, is reputedly induced by medial growth of tumor and helpful in atraumatic dissection. This study was intended to verify the epiarachnoidal origin of VS. MATERIALS AND METHODS: We studied 49 human temporal bones (TBs) specimens. Twenty-two TBs from 18 patients with VS were selected. An additional series of 27 TBs without any tumor within the internal auditory meatus were also included. We identified the location of the meninges and the position of the transition zone inside the meatus and described the lateral extension of the subarachnoid spaces. RESULTS: In VS specimens, psammoma bodies were seen at the fundus along the arachnoidal layer. No connective tissue or protrusion of a psammoma body was observed between the nerves and the VS. High magnification failed to demonstrate any meningeal cleavage plane between the facial or cochlear nerve and the tumor. The subarachnoid space was visible within the internal auditory meatus and extended from the porus to the fundus. In every case, the transition zone, the vestibular ganglion, or the VS was located in the subarachnoid fluid space. CONCLUSION: We were not able to identify any layer between tumor and the intrameatal contents and did not observe any conjunctive-tissue capsule surrounding the intrameatal VS, as an epiarachnoidal tumor origin would suggest. These observations are in contradiction with the descriptions concerning the epiarachnoidal origin of VS.
Abstract: BACKGROUND: The aim of the retrospective study was to compare the indications, the postoperative outcomes, and the survival of the supracricoid laryngectomy with cricohyoidoepiglottopexy and the anterior frontal laryngectomy. METHOD: Nineteen patients who underwent cricohyoidoepiglottopexy (group I) and 23 patients who underwent reconstructive anterior frontal laryngectomy (group II) from January 1992 and December 2004 have been reviewed. We have compared their respective indications and postoperative outcomes. RESULTS: There were no differences for median time before decanulation. Median time for removal feeding tube, for first oral alimentation, and hospital stay period were significantly shorter in group II. Five-year survival was 85% (group I) and 95% (group II). Local tumor control was obtained in 83% in group I and in 87% in group II. CONCLUSION: Cricohyoidoepiglottopexia (CHEP) was used more often than anterior frontal laryngectomy when there was contralateral vocal fold spread but resulted in longer postoperative outcomes.
Abstract: Polymorphonuclear neutrophils (PMN) play a key role in innate immunity. Their activation and survival are tightly regulated by microbial products via pattern recognition receptors such as TLRs, which mediate recruitment of the IL-1R-associated kinase (IRAK) complex. We describe a new inherited IRAK-4 deficiency in a child with recurrent pyogenic bacterial infections. Analysis of the IRAK4 gene showed compound heterozygosity with two mutations: a missense mutation in the death domain of the protein (pArg(12)Cys) associated in cis-with a predicted benign variant (pArg(391)His); and a splice site mutation in intron 7 that led to the skipping of exon 7. A nontruncated IRAK-4 protein was detected by Western blotting. The patient's functional deficiency of IRAK-4 protein was confirmed by the absence of IRAK-1 phosphorylation after stimulation with all TLR agonists tested. The patient's PMNs showed strongly impaired responses (L-selectin and CD11b expression, oxidative burst, cytokine production, cell survival) to TLR agonists which engage TLR1/2, TLR2/6, TLR4, and TLR7/8; in contrast, the patient's PMN responses to CpG-DNA (TLR9) were normal, except for cytokine production. The surprisingly normal effect of CpG-DNA on PMN functions and apoptosis disappeared after pretreatment with PI3K inhibitors. Together, these results suggest the existence of an IRAK-4-independent TLR9-induced transduction pathway leading to PI3K activation. This alternative pathway may play a key role in PMN control of infections by microorganisms other than pyogenic bacteria in inherited IRAK-4 deficiency.
Abstract: Neuroendocrine adenomas are rare tumors, which can appear in the middle ear. Approximately a hundred cases have been reported in the literature. We report the case of a 58-year-old man who consulted for an abnormal sensation of fullness in the right ear. The otoscopic examination showed a retrotympanic tumefaction. The CT scan and MRI of the middle ear demonstrated a well-defined tissue mass without any osteolysis. We performed surgical exeresis by transcanal procedure with a cartilage graft tympanoplasty. Microscopic examination and immunohistochemistry revealed an endocrine adenoma of the middle ear. Neuroendocrine adenomas can develop in a number of different sites. When they appear in the middle ear they usually produce hypoacousia. The otoscopic examination shows non-specific findings with only retrotympanic swelling. Surgical exeresis enables histologic and immunohistochemically analysis of the surgical specimen. The adenoma is composed of two cellular types: neuroendocrine (which closely resemble carcinoid tumors) and glandular. Regular clinical and radiologic follow-up is necessary since recurrence is possible. The formal diagnosis of neuroendocrine adenomas of the middle ear requires histologic and immunohistochemically confirmations since the clinical symptoms are non-specific. Surgical excision with removal of the ossicular chain is the treatment of choice in order to prevent recurrence.
Abstract: INTRODUCTION: Intrathyroid metastases are uncommon. Clinically, the distinction may be difficult with thyroid malignant tumor. CASE REPORT: A 76-year-old woman was referred to our department for an evaluation of a dysphonia. She had a past history of renal cancer 6 months ago. A multinodular goiter was noticed at the palpation. Left recurrent laryngeal nerve palsy was observed; there was no cervical lymph node. Fine-needle aspiration was not contributive. Computed tomography confirmed the multinodular goiter. Total thyroidectomy was performed and final histologic examination revealed a metastasis of a renal cancer. CONCLUSION: Even if intrathyroid metastasis are rare, the practitioner must suggest the diagnosis if the patient had a thyroid tumor and a past history of cancer. A fine-needle aspiration can help the diagnosis. The surgical management is recommended for isolated metastasis to the thyroid gland especially in renal cancer.
Abstract: OBJECTIVES: Analyze the diagnosis and treatment of differentiated thyroid carcinomas with laryngo-tracheal invasion. MATERIALS AND METHODS: Among the 117 patients operated for a differentiated thyroid carcinoma in the ENT department of Tours Hospital (France) between January 1990 and December 2003, seven presented laryngo-tracheal invasion and were included in this retrospective study. RESULTS: Laryngo-tracheal resection resulted in a thyroid cartilage-shaving in two patients. We performed a resection of one side of the thyroid cartilage in one patient, a thyro-tracheal resection-anastomosis with a partial cricoidectomy in one patient, a partial vertical laryngectomy extended to the first tracheal ring in one patient and a total laryngectomy in one patient. No laryngo-tracheal resection was done in one patient. Early complications were swallowing disorders (n = 2), transitory hypoparathyroidism (n = 1), definitive recurrent nerve paralysis (n = 2), subcutaneous emphysema and hematoma (n = 1) and Claude Bernard-Horner's syndrome (n = 1). Locoregional recurrences (n = 2) and distant metastasis (n = 2) were discovered six months to four years after the laryngo-tracheal resection. With a mean follow-up of 40 month, four patients were alive (two disease free) two patients had died and one was lost of follow-up at three months. CONCLUSION: The frequency of locoregional recurrences and distant metastasis is higher for the differentiated thyroid carcinomas with laryngo-tracheal invasion than the others. In these cases, we performed macroscopic carcinological surgery preserving laryngeal functions as much as possible.
Abstract: PURPOSE: Evaluation of the prevalence of a pericochlear hypodensity on CT in children. Materials and methods. This study correlates the findings on temporal bone CT to the indications for CT (headache, trauma). Helical CT acquisitions using 0,5 mm, 0,6 mm or 0,75 mm slice thickness according to the material available, with multiplanar reconstructions. Only patients with significant pericochlear hypodensity, larger or equal to 0,4 mm, were taken into account, and the curvilinear or nodular nature of the lesion on axial and coronal sections was recorded. RESULTS: A pericochlear hypodensity was identified in nearly 40% of cases. There was no population predominence according to the indication for the CT. The curvilinear type was more frequent on coronal images, with unilateral and bilateral involvement being equally frequent. There was no significant difference according to the sex. Patients of all ages showed lesions, from newborns to adolescents, with increased frequency in childhood. CONCLUSION: This study confirms a high prevalence of pericochlear hypodensity in a paediatric population, without clinical correlation, which requires prudence when interpreting the significance of this CT sign commonly described in association with pericochlear otosclerosis and the pericochlear form of osteogenesis imperfecta.
Abstract: OBJECTIVES: To present a series of temporal en plaque meningiomas involving the middle ear or mastoid, whose main symptoms suggested a serous otitis media. STUDY DESIGN AND SETTINGS: Multicentric retrospective study reviewing clinical records originating from eight tertiary referral centers. MATERIALS AND METHODS: The clinical records of 10 patients presenting with signs and symptoms suggesting serous otitis media and whose neuroimaging studies revealed a temporal en plaque meningioma involving the middle ear or mastoid are reported. RESULTS: All the patients were women, ranging from 49 to 71 years old. The delay between the onset of symptoms and the diagnosis of meningioma varied from 1 to 10 years. All the patients underwent various procedures usually applied for the treatment of serous otitis media, which failed in all the cases, particularly ventilating tube placement, which was followed by severe episodes of discharge. In all cases, the computed tomographic scans showed three imaging signs: soft tissue mass filling the middle ear or mastoid, hyperostosis of the petrous bone, and hairy aspect of the intracranial margins of the affected bone. This imaging triad must alert the otologist of the possibility of intracranial meningioma. Magnetic resonance imaging was the method of choice to assess the diagnosis of intracranial meningioma involving the middle ear or mastoid. When analyzing management options, it appeared that conventional middle ear procedures were inefficient. CONCLUSION: Temporal en plaque meningioma involving the middle ear or mastoid can mimic a serous otitis media. A computed tomographic scan is recommended for cases of atypical or prolonged unilateral serous otitis media to investigate indirect signs of a meningioma, which has to be confirmed with magnetic resonance imaging.
Abstract: INTRODUCTION: Congenital isolated tracheo-oesophageal fistulae without oesophageal atresia account for about 4% of tracheo-oesophageal malformations. An Otolaryngologist, even with a paediatric practice, is unlikely to treat a lot of cases during his career. We report 3 cases and discuss the investigations and management of the fistulae. PATIENTS AND METHODS: Three neonates with an isolated congenital tracheo-oesophageal fistula were treated between 1997 and 2002. We describe their presentation, investigation and treatment. We present radiology, endoscopic and surgical images for one case. RESULTS: The mean age at diagnosis of congenital isolated fistula was 6.7 days. In retrospect, the symptoms were usually present from birth. A barium swallow had demonstrated the tracheo-oesophageal fistula in 2 infants. In all three cases the fistula was clearly visualized by tracheoscopy. The most distal fistula was 25 millimetres below the true vocal cords. The closure of the fistula was made by cervicotomy in all cases. Our results are discussed with regards to the literature. CONCLUSION: Congenital tracheo-oesophageal fistulae are rare malformations. Diagnostic delay is common. Tracheo-oesophageal endoscopy is the investigation of choice. Good results are obtained with surgery treatment via a cervical approach. The management of such fistulae requires medical teams familiar with neonatal endoscopy and cervical surgery.
Abstract: INTRODUCTION: Intrapetrous cholesteatoma can be recalled with regard of facial paralysis, mixed deafness, cholesteatoma visible under an otoscopy and some characteristic signs in imaging. Its treatment is a real dilemma between its complete exeresis and the preservation of the facial nerve. METHODOLOGY: We studied the diagnostic and therapeutic aspects of the 7 operated cases from 1994 to 2004. RESULTS: We noted 5 men and 2 women with an average age of 37.29 years. One case was primitive. We observed 6 translabyrinthic lesions, 5 supralabyrinthic lesions and 2 infralabyrinthic lesions. The surgical approach was: translabyrinthic (1 case), translabyrinthic and suprapetrous (2 cases), suprapetrous (1 case), suprapetrous and petrectomy (1 case), petrectomy (2 cases). The diversion of the facial nerve was often associated. After the surgical operation the activity of the facial nerve was conserved in 4 patients and improved in 2 patients. The facial nerve paralysis that appeared on a patient after being operated on, totally recovered after 7 months. In spite of the appropriate surgical approach, the residual lesions were not rare (2 cases). This situation imposes a clinical and radiological follow-up for life. CONCLUSION: Intrapetrous cholesteatoma is rare. The X-ray confirmed the diagnosis. The new MRI techniques allow to detect recurrences and residues. A second surgical operation can be necessary.
Abstract: OBJECTIVE: To study the incidence, location, pre- and postoperative symptoms (hearing loss, tinnitus, vertigo, facial palsy), preoperative diagnostic imaging, and surgical treatment of labyrinthine fistulae (LF). DESIGN: Retrospective case review. PATIENTS: Twenty-two cases of LF over 382 mastoid operations performed in a 168-month period. MAIN OUTCOME MEASURES: Clinical, imaging, and surgical correlation of extensive fistulae and bone fistulae. RESULTS: LF prevalence was 5.8%. The main primary symptoms were otorrhea and hypoacusis. Only four patients presented vertigo as their main complaint. All patients underwent preoperative computed tomographic (CT) scans and preoperative audiometry. LF diagnosis was made before surgery for 100% of patients on the basis of CT scan. A second fistula was, however, misdiagnosed by imaging in two patients. With respect to surgical technique, a canal wall down procedure was performed in 77% and a conservative procedure was performed in 23%. Fistula was located in the horizontal semicircular canal in 100% of cases, and in 9%, a second fistula was operatively diagnosed. In 91% of cases, the matrix was removed, whereas it was left in the course of a canal down procedure in 9%. With a follow-up of 5.7 years, hearing remained unchanged in 80% of patients. CONCLUSIONS: Surgery with removal of the cholesteatoma matrix and sealing of the fistula with temporalis fascia is a safe procedure that can help preserve cochlear function. The choice of a canal down procedure would be influenced by cholesteatoma characteristics rather than by the finding of an LF.
Abstract: The need for repeated auditory screening throughout early childhood faces the obstacle of the lack of objective validated material. OBJECTIVES: The goal of this two-year prospective study was to create and validate frequency-based word/picture lists appropriate for four-year-olds. Words were chosen not on the basis of the acoustic frequency of phoneme production, but on frequencies corresponding to their optimal recognition. Responses thus were to predict pure-tone threshold curves. MATERIAL AND METHODS: First of all, the linguistics laboratory created lists. Next, we proceeded to validate the form of the test: this involved verifying that the words selected on the basis of their frequency characteristics were common and well-known to children of this age. During the first year of the study, the picture boards were tested in a hospital otolaryngology service (66 children) and in a public health service (500 children) and corrected. RESULTS: All of the words and pictures were known during the next year by 5088 children. The second step was the audiometric validation of the test in a paediatric otolaryngology service. We compared classification of normal and impaired ears according to tonal audiograms and according to "Audio 4": 360 children were tested. Results were the following ones: Se: 0.81, Sp: 0.96, PPV: 0.91, NPV: 0.93. "Audio 4" therefore allows for prediction of pure-tone curves. CONCLUSION: This gives us hope that, directly interpretable by physicians, Audio 4, a rapid test which is attractive to children, will be used in diagnostic paediatric examinations whenever necessary.
Abstract: Cerebrospinal fluid (CSF) fistulae can produce leakage through a defect in the bony skull and meninges into the contiguous air-filled cavities at the base of the skull. The major risk is central nervous system infection. When abundant clear rhinorrhea or otorrhea is present, the diagnosis is obvious and imaging is used to localize the fistula. Computed tomography (CT) with millimetric slices and magnetic resonance imaging (MRI) are the most effective diagnostic tools. CT cisternography, an invasive procedure, should only be used when the diagnosis remains uncertain following CT scan and MRI. When CSF leakage is sparse or intermittent, the diagnosis can be made by measuring beta-2 transferrine in the escaping fluid. CT scan followed by MRI are also useful for making the diagnosis and locating the fistula when exterior leakage is absent. CT scan alone is effective for assessing isolated otorrhea. If the diagnosis remains uncertain after all these studies have been used, the patient should be closely followed clinically and isotopic study or surgery should be considered.
Abstract: OBJECTIVE: Three laryngectomized patients developed metachronous sinonasal squamous-cell carcinoma. We reviewed their files to search for clinical features useful for early diagnosis of this localization. CASE REPORTS: Two of the patients, a textile worker and a food processing worker, had occupation exposure risk factors for sinonasal squamous-cell carcinoma. The anatomic modifications created by laryngectomy contributed to late diagnosis of the metachronous tumor at an advanced stage. Surgery was performed in all three patients. Local recurrence was observed at one year in two patients. DISCUSSION: Sinonasal fibroscopy should be part of the surveillance scheme in laryngectomized patients to enable early diagnosis and treatment of metachronous tumors.
Abstract: INTRODUCTION: Extracranial aneurysm of the internal carotid artery is an exceptional finding. CASE REPORT: An 89-year-old woman consulted for a peritonsillar mass. Physical examination revealed a parapharyngeal pulsatile mass in the oropharynx. Computed tomography (CT) provided the diagnosis of extracranial internal carotid artery aneurysm. Endovascular or surgical treatment were declined. Anticoagulation medication was given. DISCUSSION: We reviewed the CT and magnetic resonance imaging findings and the clinical manifestations of extracranial internal artery aneurysm. Endovascular treatment is an alternative to open surgery.
Abstract: OBJECTIVE: Acute mastoiditis (AM) represents the most frequent complication of acute otitis media (AOM) in children. In the literature, its incidence is stable but with an impressive increase in pneumococci with reduced sensitivity to penicillin (PRSP). The aim of this study was to assess the incidence of AM in the area of Tours and the prevalence of PRSP. METHOD: This was a retrospective study of children admitted to the regional paediatric centre in the Tours area, between January 1994 and May 2001. The coded AM files were analysed, excluding all the sub-acute forms or those complicating a cholesteatoma. The criteria studied concerned the clinical signs on admission, the imaging data and the bacteriological samples and the results of treatment. RESULTS: Seventeen children (8 boys, 9 girls) were admitted for an AM during the study period. Their mean age was of 3.2 years (range: 6 months to 13 years). In 24% of cases, the mastoiditis existed on admission and in 59% of cases it complicated an AMO already treated with antibiotics. In 3 cases (18%), the AM was complicated on admission with peripheral facial paralysis in one case and thrombosis of the lateral sinus in 2 cases. The germ responsible was identified in 14 cases (82%) with a predominance of pneumococci (11 cases). Eight were PRSP-type. Scan of the pars petrosa identified a subperiosteal abscess in 13 cases. Fourteen mastoidectomies were performed and the mean duration of antibiotic therapy was of 23 days. The outcome was always good. CONCLUSION: Over the past 7 years, the incidence of AM has been estimated at 1.2/100 000 children aged under 15 per year. The prevalence of PRSP is high but does not change the principles or the results of the treatment of AM.
Abstract: Most clinical studies on carbon dioxide (CO2) (lambda = 10.6 mm) laser stapedotomy have been carried out with the laser guided by a conventional lens-based micromanipulator, with the attendant risks of correct aiming (HeNe) and surgical (CO2) beam misalignment. Hence, engineering advances have attempted to improve laser targeting as well as the spot size focus. The development of the mirror-based micromanipulator was a response to this need but no data concerning its use in stapes surgery is available. We performed a retrospective case-series review of patients treated for otosclerosis between 1992 and 2000. Primary laser stapedotomy was performed in 218 consecutive patients. In the first 78 procedures, the aiming beam (HeNe, lambda = 632 nm) and surgical beam (CO2) were guided with a conventional lens-based micromanipulator whereas in the subsequent 140 procedures, they were guided by using a mirror-based micromanipulator. Hearing was tested at six and 12 months. The mean (SD) airbone gap was 5 dB (4.5) and 4.5 dB (3.9). The mean closure was 15 dB (9.9) and 14.4 dB (9.4). The mean change in the high-tone bone-conduction level was 5.5 dB (7.3) and 7.8 dB (7.5). Overheating of the facial canal produced transient facial paralysis in one case and was due to misalignment of the beams with the lens-based micromanipulator. Use of the mirror-based micromanipulator obviated the need to verify alignment. The light-weight and superior optical yield of this system made it possible to reduce the number of impacts on the footplate by the integral restitution of the energy source. This study demonstrated that the CO2 laser is an effective method for performing stapedotomy. In addition, microtrauma to the labyrinth is reduced by its ability to perform calibrated footplate fenestration without mechanical or vibrational injury to the inner ear. The optical reflection micromanipulator simplified beam alignment and enhanced surgical comfort.
Abstract: We report a new case of myoepithelial carcinoma of the parotid gland in an 8-year-old girl. This is the first case published in a child. The parotid tumour was slightly tender and measured almost 2 cm in diameter. There was no associated facial nerve paralysis despite surgical and histologic evidence of massive facial nerve infiltration. We performed total parotidectomy with resection of the intra-mastoid portion of the facial nerve completed with prophylactic lymph node dissection. Eight months after surgery, MRI revealed a deep-lying recurrence, which required reintervention. There has been no subsequent recurrence 18 months after surgery. Microscopic examination of operative specimens confirmed the diagnosis of parotid myoepithelial carcinoma with fusiform cells. Immunohistochemical markers were positive for cytokeratin, epithelial membrane antigen, smooth muscle actin, S-100 protein, anti-desmine and anti-vimentine. This difficult to diagnose tumour, which was individualised by the World Health Organisation in 1991, is considered a moderate to high-grade malignancy when it develops in a pleomorphic adenoma or appears de novo.
Abstract: OBJECT: The authors studied the cadaveric heads of 22 adults to describe the internal acoustic meatus (IAM) and its contents. Special attention was paid to the length of the arachnoidal and dural sheaths surrounding the neural structures, including the vestibular ganglion. An additional goal of this study was to verify anatomically the concept of arachnoidal duplication, which is reputedly induced by medial growth of vestibular neuromas and helpful in atraumatic dissection. METHODS: Twelve cadaveric heads (24 IAMs) were injected with colored latex and fixed in formalin. Cautious removal of the skull vault and the brain or the skull base allowed superior and anteroinferior views of the IAM, respectively. Photographs were obtained after removal of the bone canal and dissection of the meninges with the aid of optic magnification. Ten IAMs were prepared for histological study and the osteological anatomy of the fundus was endoscopically described for the remaining 10. The dura mater covered the bone structures of the IAM, and the arachnoidal membrane of the cerebellopontine cistern invaginated into this dural cul-de-sac as a "muff." The entire neurovascular content of the IAM, including the vestibular ganglion, was surrounded by this arachnoidal sheath in which cerebrospinal fluid circulated. The length of this arachnoidal sheath was the same ventrally and dorsally and, in all specimens, the entrance of the cochleovestibulofacial complex into the subarachnoid space was located at the fundus level. CONCLUSIONS: In this study the authors demonstrated the existence of an acousticofacial cistern containing every nerve of the vestibulocochleofacial complex, including the vestibular ganglion from which acoustic neuromas develop. These findings clearly contradict the theory of the duplication of arachnoidal layers during medial growth of vestibular neuromas and may explain some of the intraoperative difficulties encountered in the atraumatic dissection of these tumors.
Abstract: OBJECTIVE: Evaluate the comfort in children after ambulatory tonsillectomy, disregarding the surgical technique and with a systematic prescription of paracetamol and codeine. The study lasted 4 days including the day of surgery. STUDY DESING: Prospective study during 5 months. PATIENTS AND METHODS: We performed a prospective study over a five-month period to evaluate the comfort in children after ambulatory tonsillectomy. Opioids were used for analgesia during surgery, morphine and propacetamol in the recovery room, and a systematic prescription of paracetamol-codeine between Day 0 to Day 3 at home. The assessment of pain was made by nurses and the family, considering 6 endpoints: spontaneous pain and when swallowing by verbal scale (0 to 4), occurrence of PONV (0 or 1), quality of sleep (0 or 1), quality of feeding (0 or 1) and play (0 or 1), combined in a global score of 0 to 12, with a score < or = 4 very satisfactory. RESULTS: 78 children were included, 49 tonsillectomy by dissection, 29 by Sluder. The score were < or = 4 at Day 0 and Day 1 in 53 children, but statistical analysis (univariate analysis) showed difference between the two surgical procedures with a global comfort score better and PONV lower with dissection procedure. CONCLUSION: The use of paracetamol-codeine after tonsillectomy offers a reliable analgesia with very satisfactory scores of comfort. Such prescription is effective in ambulatory tonsillectomy if a rigorous selection of patients is made.
Abstract: Vertebral cervical hyperostosis is frequent in the general population but is rarely symptomatic. Dysphagia is the most frequently encountered symptom. We report three cases of cervical hyperostosis leading to ENT symptoms. Two patients had bilateral laryngeal paralysis, rarely described in the literature. These three cases were treated surgically.
Abstract: Teratomas are tumors which develop in childhood or early adulthood, generally in the gonads. More rarely these tumors may be found in an axial localization, notably in cervicofacial forms. We report three cases of teratomas observed in rhinopharynx of three neonates operated at the Clocheville General Hospital. We present the main anatomoclinical features of these tumors, focusing on the cervicofacial forms in neonates. All three cases occurred in female neonates presenting acute dyspnea within the first hours of life, requiring intubation in two cases. The first two tumors invaded the infratemoral region and the third was a pediculated tumor of the velum exteriorized via the mouth. In one case antenatal ultrasound had suggested the diagnosis of a right temporomaxillary tumor. Rapid excision of the rhinopharngyeal component allow extubation for the two intubated infants and pathology diagnosis. In the first infant operated at 2 months, the lateral route was adapted to age, with mandibulotomy with section of the coronoid process but preserving the mandibular condyle. The second infant was operated at the age of 3 weeks using a wide frontotemporoperitonial approach then at the age of 3.5 months for recurrence extending to the floor of the temporal fossa and the middle ear. A type C infratemporal approach was used with lost-bone temporal craniectomy. Per-buccal excision was possible in the third infant with resection at the base of implantation. No recurrence has been observed in the first two cases at 3.5 and 2.5 months follow-up in the first two cases. The third infant was lost to follow-up.
Abstract: OBJECTIVE: To examine the indications and the results of surgical excision of severe subglottic hemangiomas. DESIGN: Retrospective study and case series. SETTING: Four academic tertiary care centers of pediatric otolaryngology. PATIENTS: Twenty children were included from 1991 to 1997. All presented with severe subglottic hemangiomas resistant to classical treatments such as corticosteroids and/or CO2 laser. INTERVENTION: Six children were operated on using laryngotracheal reconstruction and prolonged stenting by a reinforced Silastic roll and 14 children were operated on by a single-stage laryngotracheoplasty and postoperative intubation in a pediatric intensive care unit. RESULTS: All patients were successfully decannulated or extubated and have been free from recurrent hemangiomas. CONCLUSION: The surgery of severe subglottic hemangiomas is a reliable technique in selected patients and should be considered in corticoresistant or corticodependent, circular, or bilateral hemangiomas.
Abstract: OBJECTIVES: To evaluate the effects of the size of the footplate opening on the hearing results in surgical treatment of otosclerosis and the use of CO2 laser in this indication. PATIENTS AND METHODS: 190 patients with otosclerosis underwent 227 procedures between 1986 and 1995. Hearing results and symptoms were analyzed to compare the different procedures: 140 stapedectomies, 87 Fisch's stapedotomies, 35 of them with manual perforator, 52 of them with CO2 laser. RESULTS: Air/bone gap closure within 10 dB was obtained in 87, 92 and 97 percent of stapedectomies and in 80, 84 et 90 percent of stapedotomies after 3 months, 1 and 3 years (NS). Bone conduction was improved in 81, 80 et 63 percent of stapedectomies and 87, 97, 60 percent of stapedotomies after the same time (NS). Air/bone gap closure within 10 dB was obtained in 75 and 80 percent of manual perforator stapedotomies and in 84 and 88 percent of CO2 laser stapedotomies after 3 months, and 1 year (NS). Bone conduction was improved in 78 and 96 percent of manual perforator stapedotomies and 95 and 100 percent of CO2 laser stapedotomies after the same time (NS). No facial palsy or prolonged vertigo occurred. There was one case of anucusis following a stapedectomy. CONCLUSION: Although both stapedectomy and stapedotomy produced equivalent air/bone gap closure, reduction of inner ear trauma was noted with Fisch's stapedotomy. CO2 laser technique is a safe procedure, which optimizes the Fisch's stapedotomy.
Abstract: Vestibular neurotomy, in addition to the fact that it preserves the hearing, is considered to be the most effective form of treatment for incapacitating unilateral Menières disease which is resistant to medical treatment. The authors have carried out a retrospective study of 20 cases of vestibular neurotomy operated on between 1986 and 1996. They have evaluated the results of the suppression of vertigo and the improvement of quality of life. Each patient was given a questionnaire. The parameters studied were the quality of daily life, professional life and driving ability. The mean follow-up period was 3 years. This study confirms the good results obtained with vestibular neurotomy for vertigo: complete control of attacks of vertigo was obtained in 90% of cases according to the criteria laid down by the American Committee on Hearing and Balance, as modified in 1985 (AAO, 1985). This study has also confirmed that the quality of patients lives is greatly enhanced both for everyday activities, professional activities and driving.
Abstract: Acute otitis media (AOM) and otitis media with effusion (OME) are very common in the young children. The relation ship between these two pathologies has not been completely established. The AOM incidence ranges between 22 to 74%. The OME which persists after onset of AOM is more frequent (20% at 2 months) than the chronic OME which concern 4.4 to 10% of the child population before the age of five. The highest age specific incidence for all episodes of AOM is one year of age. AOM and OME are most likely to occur in the winter. The OME risk factors are: the first episode of OMA before 6 month of age, the males sex, no breastfeeding, day-care centers, low socio-economic conditions and familial genetic predisposition. Passive-smoke exposure and allergy are discussed. The epidemiology assesses the actual state of these pathologies to settle, with the family, the optimum choices for the prevention.
Abstract: Solitary fibrous tumour is a particular kind of mesenchymal tumour, classically arising in the pleura. We report the first case arising in the larynx, associated with a metastasizing adenocarcinoma. The diagnosis is mainly histopathological, especially when strong immunoreactivity for the CD34 antibody is present.
Abstract: Tularemia is a rare infectious disease, due to Francisella tularensis, a virulent bacterium transmitted by a carrier insect (essentially ticks) or by the meat of an infected animal (generally hares). We report 3 cases that occurred in the same family, showing the various symptoms of this disease. Revealing head and neck manifestations may mislead diagnosis.
