Abstract: This study was performed to establish the swallowing trigger by using the reaction time from an auditory stimulus. With this stable temporal starting point, we described the chronology of the different acoustic, electrophysiologic, and respiratory events that occurred during swallowing in a population of normal adults. We studied the swallowing reaction time (SRT) in 18 subjects aged 23 to 73 years by using acoustic, electroglottographic (EGG), and aerodynamic recordings. The chronology (the beginning of EGG activity, apnea, and respiratory sound and release) was identified in 91% of the recordings. The average SRT was 264 ms and the average swallowing duration was 977 ms, without any significant difference with respect to gender. The swallowing sound produced during apnea was composed of either two or three components. The reaction time procedure also demonstrated that the first sound component was unstable. By using this procedure for studying swallowing, we were able to stabilize the chronology of the different events, improve the subjects' attention, and establish a fixed benchmark for performing temporal measurements.

Abstract: OBJECTIVE: To assess the role of the CT-scan in the preoperative evaluation of juvenile otosclerosis and to study additional outcome data. DESIGN AND SETTING: We performed a retrospective case series study from an academic referral hospital using data from 1992 to 2005. PATIENTS AND METHODS: We selected patients younger than 18-year-old who had undergone primary stapedectomy for otosclerosis among the 10 stapedectomies performed over the study period and analyzed the patients' systematic pre- and post-operative audiograms and CT-scan findings. RESULTS: For this survey, complete data was available for 7 children, totaling 10 primary stapedectomies for otosclerosis. Their ages at diagnosis ranged from 10 to 17 years. In 4 children, CT-scan demonstrated bilateral findings typical of otosclerosis: poorly calcified foci near the fissula ante fenestram, associated with a hypodense edging surrounding the labyrinthine capsule in 2 children. The youngest patient had no CT-scan abnormalities. Stapedectomy was performed in one case and laser stapedotomy in 9 cases. Seven children were immediately improved following surgery and no postoperative facial palsy or prolonged vertigo was reported. The mean (S.D.) postoperative ABG was 6.5dB (+/-3.7). The mean closure was 19dB (+/-11.2). The mean change in high-tone bone conduction level was 1.8dB (+/-7.5). Six children had a postoperative ABG less than 10dB while in one, the ABG was inferior to 20dB. CONCLUSION: Preoperative CT-scan is useful for the preoperative diagnosis of otosclerosis in children. The images seen must be distinguished from other footplate pathologies or deformities of the ossicular chain which are often associated with poorer surgical results. This survey provides additional evidence that stapes surgery is an effective procedure for treating juvenile otosclerosis.

Abstract: Our aim was to report our experience in the management of malignant primary and non-primary parotid neoplasms and to compare the clinical presentations, the treatment modalities and the outcomes in these two groups. We performed a retrospective review of the clinical and surgical data contained in patient files. Between January 1995 and December 2004, 60 patients with malignant parotid tumors were admitted to our department. Two groups were isolated: a group of 42 patients with primary parotid malignancies (group 1) and a group of 18 patients with non-primary parotid malignancies (intra-parotid metastasis and parotid lymphoma), (group 2). We compared the preoperative data, the surgical procedures performed total parotidectomy (TP) versus superficial parotidectomy (SP), the need for sacrificing the facial nerve and postoperative facial nerve function in the two groups. Actuarial survival rates were calculated using the Kaplan-Meier method in combination with the Log Rank test for comparison of the results in the two groups. Preoperative clinical facial nerve impairment was significantly more frequent in group 1 (33%) as compared to group 2 (6%) (P = 0.023). A SP was performed in 15 patients in group 2 while a TP was performed in 37 patients in group 1. The facial nerve was completely or partially sacrificed in 17 cases in group 1 and in only one case in group 2 (P = 0.03). One month after surgery, 18 patients in group 1 had persistent facial nerve dysfunction compared to only one patient in group 2 (P = 0.004). In group 1, the overall 1, 3 and 5-year survival rates were, respectively, 94, 76 and 69%. In group 2, the respective survival rates were 84, 62 and 40% (P = 0.4). This study outlines the differences in clinical presentation, surgical management and outcomes in the two main groups of malignant parotid tumors. The prognosis of facial nerve function was better in non-primary parotid malignancies. SP was the standard surgical option in group 2 patients while a TP was performed in the majority of the patients in group 1. Except when melanoma or lymphoma were present (which require specific treatment), adjuvant radiotherapy had the same indications in both groups when the tumors were high-grade, AJCC stages III and IV or when they had positive margins or lymph node and facial nerve involvement.

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: The aim of this study was to identify the origin of swallowing sound components by using modern techniques that can provide numeric, synchronized acoustic-radiologic data. We enrolled 15 volunteer subjects (10 men and 5 women, average age = 29.5 +/- 8 years) and used an X-ray camera connected to a video acquisition card to obtain synchronized acoustic-radiologic data (25 images/s). The subjects were asked to swallow 10 ml of a barium suspension. Each sound component was associated with a specific position of the bolus and the anatomic structure that was moving. The average duration of the pharyngeal sound was 690 +/- 162 ms. The durations of the laryngeal ascension sound and the laryngeal release sound were significantly different (72 +/- 38 ms and 106 +/- 47 ms, p < 0.001). The upper-sphincter opening sound was present in 100% of the recordings. Its duration was 185 +/- 103 ms and was significantly different from the two other sounds. The duration of the first interval was 108 +/- 44 ms and the duration of the second was 236 +/- 139 ms. This study allowed us to determine the origin of the three main sound components of the pharyngeal swallowing sound with respect to movements in anatomic structures and the different bolus positions.

Abstract: Cervical auscultation is a noninvasive technique for studying swallowing that was first used in the 1960s. The aim of our study was to use the numeric acoustic recording technique for analyzing swallowing sound signals in healthy subjects while they ingested a defined volume and consistency of a specific substance. Twenty males and ten females were included in the study and given 10 ml of a barium suspension to swallow. A microphone was placed on the skin overlying the lateral border of the trachea, directly under the inferior border of the cricoid, and connected to a computer. For each sound recording, the total duration of the sound (td), the number (n) of sound components (SC), the duration of each SC (c1, c2, c3,...), and the intervals (i1, i2,...) between the SCs were measured. For all the recordings, the mean durations of acoustic parameters (TDm, C1m, C2m, C3m, I1m, I2m) were calculated and compared by using Student's t test. In the 20 male subjects, the mean acoustic parameters were calculated (MTDm, MC1m, MC2m, MC3m, MI1m, MI2m) and compared with the mean acoustic parameters (FTDm, FC1m, FC2m, FC3m, FI1m, FI2m) in the ten females by using a Wilcoxon nonparametric statistical test. We were able to interpret 80% of the recordings. The TDm was 710 +/- 28 ms. Three main SCs were detected: C1m = 100 +/- 56, C2m = 150 +/- 90, C3m = 80 +/- 54 ms; I1m = 100 +/- 66, I2m = 190 +/- 120 ms. No significant difference in these parameters was observed with respect to gender. This study enabled us to decompose the swallowing sounds into three main SCs and to quantify their normal durations. These results should prove useful for the assessment of sound variations in pathologic conditions.

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: 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: In 2000, 19,600 new cases of head and neck carcinomas, oral cavity, pharynx and larynx cancer occurred in the French population. In men, these tumours are predominant and represent the 4th cancer incidence rank with 16,855 new cases, and the 5th cancer mortality rank with 6309 deaths. For women, in 2000, the incidence was 2830 new cases with 900 deaths (14th rank among women cancer). The decrease of alcohol and tobacco consumption and the improvement of treatment efficacy explain the decreasing head and neck cancer incidence and mortality in the past decades in France.

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: OBJECTIVE: Chondrosarcoma of the larynx is a rare neoplasm generally observed on the cricoid. The purpose of this study was to define the most appropriate surgical management depending on tumor extension and histological grade. PATIENTS AND METHODS: Three males and one female were treated for chondrosarcoma of the cricoid between 1990 and 2003 in the Ear, Nose and Throat department in Tours, France. There were three grade I tumors and one grade II tumor. Tumor resection by thyrotomy was performed in two patients, total laryngectomy in one and laser desobstruction in one. RESULTS: The patient who underwent total laryngectomy remained in complete remission at five years. Among the two patients who had thyrotomy, one remained in remission at three years and the other experienced recurrence at four years and underwent a second operation. He died five years later due to another disease. Total follow-up was nine years. The patient treated by laser therapy achieved stabilization at twelve months. CONCLUSION: Computed tomography and histological grading enable choosing the best surgical procedure. Partial laryngeal surgery is indicated for small or low-grade chondrosarcomas. For large or high-grade tumors, total laryngectomy must be performed. In the event of patient refusal, laser desobstruction can provide clinical stabilization.

Abstract: Hereditary Hemorrhagic Telangiectasia is a systemic autosomal dominant disorder involving blood vessels. The most common symptom is recurrent epistaxis. The treatments of these epistaxis are numerous but such treatments are often symptomatic and their effects are often not sustained. Some of these treatments may be complicated by visceral vascular malformations. The aim of this study is to propose a treatment plan for these patients with hierarchical organisation of therapeutic options taking into account of their previous therapy. METHOD: H. Plauchu organized in Paris, december 2002 a meeting with any medical specialists of this disease. They have analysed variety of therapies that have been proposed for epistaxis control in Hereditary Haemorrhagic Télangiectasia. RESULTS: Most common use packing of nasal fossa and then hyperselective embolization of the internal maxillary and facial arteries for severe epistaxis. For chronic epistaxis, best treatment use sclerotics products (Ethibloc) and laser. After discussion, primary embolization could be useful to reduce vascularization of nasal fossa. CONCLUSION: Treatment of epistaxis in Hereditary Haemorrhagic Telangiectasia could increase in few years. Use of an index card of for epistaxis in the disease of Rendu-Osler could help to find treatment of choice.

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: 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: 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: Rhabdomyoma in adults is a rare benign neoplasm of the skeletal muscles generally arising in the pharyngolaryngeal region. These slow-growing tumors remain asymptomatic for a long period. We report a case of basilingual rhabdomyoma. Computed tomography and magnetic resonance imaging demonstrated a well-encapsulated tumor with a line of cleavage between the base of the tongue muscles. Deep transmucosal biopsies were obtained. Well-differentiated skeletal muscle cells with large eosinophilic granulular cytoplasm and cross striations gave the histologic diagnosis. Complete endoscopic resection was successful. The differential diagnoses of rhabdomyoma in adults are myoblastoma or Abrikossof tumor, rhabdomyosarcoma and hibernoma. The risk of late recurrence implies long-term clinical and radiologic follow-up.

Abstract: We report two cases of fourth branchial pouch in adult. This rare and little-known pathology is indeed responsible for suppurative thyroiditis and left lower cervical abscess recurring in spite of antibiotic treatment and incision-drainage. CT scan using, iv contrast, air as a agent contrast with Valsalva test, shows air in the thyroid and perithyroid soft tissue infection, proving communication between the pyriform fossa and the thyroid. Bubble of air behind the left thyroid alar in the sinus track is the best argument for diagnosis. Hypopharyngoscopy shows the mucous opening of the bottom at the pyriform sinus.

Abstract: A case of bilateral progressive stenosis of both external auditory canals with resultant conductive hearing loss is presented. The stenosis revealed multifocal erosive and synechiant lichen planus. To our knowledge, this is the first reported case of lichen planus involvement of the external ear.

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.