[Aesthetic parotidectomy: face lift incision and SMAS flap]. / Parotidectomie esthétique: incision dissimulée de lifting pré-capillaire et lambeau de SMAS.

INTRODUCTION: Traditional parotidectomy skin incision (bayonet-shaped incision) is adapted from an extirpative standpoint but not ideal cosmetically. There are three main drawbacks: Scar, retro-mandibular depression and Frey syndrome. The goal of this prospective study was to evaluate the feasibility of this facial incision for extirpative purposes and to define the clinical benefit in terms of scar and retromandibular depression. METHOD: Ten patients with parotid tumors were included during the period 2005-2006. All patients had benign tumours: 5 males and 5 females. Mean age was 49 yrs. (42-67). Investigated parameters were: "retromandibular depression", "skin scar" and "Frey syndrome". Analogic visual satisfaction scale (1-10) was used by patients to assess these data postoperatively at 15 days, 1 month and 6 months. RESULTS: This face lift approach allowed very good surgical exposure not only of the parotid area but the posterior submandibular region and over the sternocleidomastoid muscle. Postoperative lateral facial contour was symmetric and good in all cases. Six patients assessed this parameter 8/10 and 4 assessed 10/10. After removal of stitches the facial skin scar was considered good in 100% of cases. Six patients assed this parameter 9/10 and 4 assessed 10/10. No Frey syndrome was reported by any patients within 16 months postoperatively. CONCLUSION: Association of a face skin lift approach and a SMAS flap yields a very good cosmetic outcome after surgical parotidectomy. As aesthetic considerations are obvious in breast surgery, aesthetic considerations have a great place in parotid and head and neck surgery.

[Trigeminal neuralgia: results of microsurgical and endoscopic-assisted vascular decompression]. / Névralgie du trijumeau: résultats de la décompression vasculaire micro-chirurgicale et endoscopique.

INTRODUCTION: Vascular compression of the Vth cranial nerve is the leading cause of trigeminal neuralgia. Microvascular decompression has been promoted by Jannetta since 1970. We used the minimally invasive retrosigmoid approach, with the complementary help of endoscopic procedure. OBJECTIVES: MRI results, surgical findings and pain relief were studied after endoscopic assisted microvascular decompression. MATERIAL AND METHODS: Between 1991 and 2000, 98 surgeries were performed on 79 patients unresponsive to medical treatment, after an average of 6 years from the onset of the disorder. The mean follow-up period after operation was 28 months. RESULTS: MRI predicted neurovascular conflict with sensitivity of 93.6% and specificity of 100%. Pain relief after surgery was complete in 69% of the cases, partial in 21%. Surgery was a failure in 6% of the cases and 4% of patients were lost. Complications were limited to 10% of CSF disorders but only 1% (1 patient) needed a surgical revision. CONCLUSION: Microvascular decompression, performed through a key-hole approach, without cerebellum retraction and with endoscopic assisted surgery, yields a low risk of morbidity, even in elderly patients, and could be considered acceptable causal treatment of trigeminal neuralgia.

[Adenocarcinoma of the endolymphatic sac in children. A case report]. / Adénocarcinome du sac endolymphatique chez l'enfant. A propos d'un cas.

We report a case of an adenocarcinoma of the endolymphatic sac in a 13 years old child, which was fortuitously discovered at the time of radiological investigation of growth delay. Arising from the end of the endolymphatic sac, this rare tumour shares a similar clinic expression with other cerebellopontine angle pathologies. Radiological investigation reveals a moth eaten appearance to the posterior temporal bone and specific bony inclusions. With MRI there is an intense and/or intermediate signal on T1, a hyper signal on T2 and T1 enhancement with injection of gadolinium. Treatment is surgical and local recurrences are not uncommon. After histological confirmation, a search for Von Hippel-Lindau disease is mandatory because this tumour is not exceptional among this subset of patients. Diagnosis and therapeutic criteria will be highlighted by our case and a review of the literature.

Cochlear schwannomas.

In a series of 179 cerebellopontine angle (CPA) tumors, the authors present nine cases (5%) that were cochlear nerve neuromas. There were six men and three women (mean age, 51 years). Preoperative magnetic resonance imaging confirmed the diagnosis in one case with a labyrinthine extension and raised suspicions in the other four cases, which were confirmed during surgery. The remaining neuromas were discovered intraoperatively. The mean time between first observation and surgery was 9 months. Preoperatively, all patients underwent a complete otoneurological assessment. The middle fossa approach was used for the patient with the labyrinthine extension, and the retrosigmoid approach was used for the other eight cases. In all patients facial nerve function was preserved. Sudden or major hearing loss without associated vestibular symptoms or preoperative facial paralysis may be predictive of a cochlear component of a CPA tumor. The near-field relationships of cochlear neuromas located at the level of the acoustic and facial nerves can be appreciated because of their small size and strong contrast enhancement.

[Our current results with acoustic neurinoma surgery]. / Nos résultats actuels de la chirurgie du neurinome de l'acoustique.

Out of 130 CPA tumors operated on between 1993 and 1997, 91 were vestibular schwannomas less than 25 mm with preoperative hearing and normal facial function. The pre and postoperative facial and hearing functions were analyzed prospectively. The surgical technique applied was the complete tumor removal via retrosigmoid approach under facial nerve monitoring and CPA endoscopy. Clinical features were analyzed to determine postoperative facial grading (House-Brackmannn) and tonal and vocal audiometrical datas (PTA-SDS) at 8 days, 90 days and 1 year. We achieved 96 % of good facial results (Grade I and II/HB) and 46,5 % of postoperative conserved hearing. For tumors less than 25 mm in the CPA, good preoperative hearing level, preoperative AOE and BER seem to be predictive factors for hearing preservation. Early diagnosis associated with the advances in minimal invasive otoneurological techniques leads to perform complete removal of this type of tumors with respect of facial and hearing functions.

Craniofacial fibrous dysplasia associated with primary hyperparathyroidism.

Isolated presentation of fibrous dysplasia or primary hyperparathyroidism is a common finding. Only few cases of craniofacial dysplasia associated with hyperparathyroidism have been reported in the literature. A case of a patient with fibrous dysplasia of craniofacial bones associated with primary hyperparathyroidism without additional endocrinophaties or associated disorders, will be presented. Beside the facial dysmorphism caused by dysplasia, the only clinical symptoms were due to the primary hyperparathyroidism.

[Intact ossicular chain cholesteatoma: aspects and results of conservative surgery]. / Le cholestéatome à chaîne intacte. Aspects et résultats de la chirurgie conservatrice.

We present a 24 case-study of intact ossicular chain cholesteatomas among 158 first-look procedures performed between august 93 and april 96 (15%). The eradication of the disease was achieved via canal wall up technique without disrupting the ossicular chain in 20 cases (84%). Technical procedures are described. This new surgical attitude has enabled us to achieve better functional results. Second look procedures have not been necessary in all cases and occurrence of residuals has not been increased on a 14 months follow up period (2 cases out of 24 patients: 8%). Therefore, a longer follow up period is necessary to validate the results obtained using this recent concept.

[Fixed mallear head syndrome]. / Le syndrome de la tête du marteau fixée.

Fixed head malleus syndrome is a rare anatomoclinical entity first described by Goodhill in 1966. We present a series of 9 patients who underwent surgery between 1991 and 1997 and discuss the technical procedures used and functional outcome. Ossicular mobility can be re-established with two surgical methods. The more simple method consists in a classical incus transposition with malleus neck section. The more physiological method consists in drilling the synostosis fixing the malleus without disrupting the ossicular chain; stapedotomy is associated in certain cases (Type III).

[Neuro-vascular decompression in hemifacial spasm: anatomical, electrophysiological and therapeutic results apropos of 100 cases]. / Décompression neuro-vasculaire dans le spasme de l'hémiface: résultats anatomiques, électrophysiologiques et thérapeutiques à propos de 100 cas.

Hemifacial spasm is a neurological disorder due to abnormal hyperactivity of the facial nerve. The most common cause of hemifacial spasm is a neuro-vascular conflict in the cerebellopontine angle between a vascular loop and the root of the facial nerve (96% of cases). Tumors are the cause of hemifacial spasm in only 1% of cases). The authors present their results in 100 patients who underwent microvascular decompression for essential hemifacial spasm between 1990 and 1995. They used microsurgical and endoscopic procedures by a minimal retrosigmoid approach in all cases. The most common offending vessels were the posterior inferior cerebellar artery (70%), the vertebral artery (41%) and the anterior inferior cerebellar artery (28%). An aberrant vein was found in 2 cases. There were 38% of multiple artery-nerve conflicts. Physiopathology of hemifacial spasm is explained by two principal theories: in the ephaptic theory, hyperactivity and an abnormal nervous impulse pathway are due to a short demyelinated area on the nerve trunk caused by the offending vessel, inducing short circuiting between adjacent nerve fibers. In the nuclear theory, hyperactivity of the facial nerve is due to an abnormal and automatic activity of the facial nerve nucleus itself, induced by the vessel. The authors used pre and postoperative electromyographic tests and intraoperative electromyographic tests. Their results tend to prove the nuclear theory. Ninety per cent of the patients had a good result, with a mean follow-up time of 30 months in 60 cases. In 82% of the cases, there was a total recovery after a single procedure. There was no mortality and no facial palsy. Hearing loss occurred in less than 5%.

Canal wall prosthesis--new devices.

In our experience, management of the troublesome mastoid cavity a "rehabilitation" of the middle ear, usually involves post canal wall reconstruction. The purpose of the long canal wall reconstruction is to restore the anatomy as perfectly as possible in order to induce satisfactory wound healing of both epidermal a mucosal layers. The numerous materials and different surgical procedures to date, demonstrate the difficulty of reconstruction of the ear canal. Over twenty years we have performed 386 cases using various materials: cortical bone, ear canal allograft, ceravital, porous and dense hydroxylapatite. More recently to improve the anatomical results we have used a new titanium prosthesis. The pros and cons of each device are discussed.

[Role of endoscopy and vascular decompression in the treatment of hemifacial spasm]. / Place de l'endoscopie et de la décompression vasculaire dans le traitement du spasme de l'hémiface.

Although it has long been hypothesized that hemifacial spasm could arise from a conflict between the nerve and the artery, it is very difficult to distinguish between a normal arterial loop and a pathological conflict leading to facial symptoms. Several new elements would help in the definition of the cause and allow less traumatic treatment of idiopathic hemifacial spasm. They include magnetic resonance imagery with CISS sequences, limited retrosigmoid approach, endoscopy of the cerebellopontine angle and monitoring the facial nerve. In our experience with 20 cases, retrosigmoid approach with a combined surgical and endoscopic procedure has led to total involution of the spasms in 80% of the cases.

[Contribution of endoscopy of the cerebellopontine angle by retrosigmoid approach. Neuroma and vasculo-nervous compression]. / Apport de l'endoscopie de l'angle ponto-cérébelleux par voie rétro-sigmoïde. Neurinomes et conflits vasculo-nerveux.

An endoscopic approach to the cerebellopontine angle has been suggested by several authors over the last 20 years but it is only recently that the technical and operative conditions for successful endoscopy could be met. The retrosigmoid approach provides simple and direct access to the cerebellopontine zone. The endoscope, with its distal light source, provides excellent illumination of a wide visual field within an anatomical site particularly rich in neurovascular structures. Endoscopic and microsurgical techniques may be combined for the surgical management of acoustic neuroma with the advantage of assuring better exposure of structures adjacent to the tumor and better control of the quality of dissection of the fundus of the internal auditory canal. The addition of endoscopic techniques, during surgery for trigeminal neuralgia or unilateral facial spasm, makes it possible to accurately locate the site of neurovascular compression without either retraction of the cerebellum or unnecessary dissection.

[Hemichorea-hemiballismus and toxoplasmosis in AIDS]. / Hémichorée-hémiballisme et toxoplasmose au cours du SIDA.

The authors report two cases of hemichorea-hemiballism revealing a toxoplasmic abscess in the subthalamic nucleus during AIDS. Despite the great frequency of this opportunistic infection such cases are exceptional. This rarity seems to be explained by the frequent association of other lesions of the basal ganglia which may prevent the movement disorders. Nevertheless an hemichorea-hemiballism in young people must suggest a cerebral toxoplasmosis. Finally a symptomatic treatment is often necessary; in these cases the use of sodium valproate must be considered, this drug being able to induce a clinical improvement.

Some aspects of iron metabolism during erythropoietic depression in the mouse.

Spleen and bone marrow patterns of response differ in mice subjected to erythropoietic depressors. Radioiron injected a few hours after a high dose of cyclophosphamide or x-irradiation is retained in the bone marrow. The magnitude of medullary retention is closely related to the number of cells able to synthesize hemoglobin at the moment of iron administration, and to the rate of cell death provoked by the cytotoxic agent. Depressors such as Actinomycin and transfusion, that block the differentiation of stem cells while allowing normal maturation of the erythroid cohort, do not induce marrow entrapment of iron. By contrast, retention is never observed in the spleen, where the 59-Fe turnover is not influenced by the mechanism and magnitude of aplasia. A functional lack of homogeneity of splenic and bone marrow erythropoiesis, hemoglobin metabolism and/or handling of iron stores is proposed. These results would be in agreement with other data from the literature reporting physiological differences among the various sectors of the reticuloendothelial system.

The role of autotransplanted spleen in the erythropoietic recovery of the mouse.

Erythropoietic recovery was studied in mice subjected to subcutaneous splenic autotransplantation and compared with that observed in normal and splenectomized animals. Radioiron uptake into spleen and erythrocytes and splenic weight were measured at different times after lethal irradiation and injection of 5 x 10(5) bone marrow cells. Dose-response curves were also performed with increasing amounts of cells injected. Hematocrit recovery as a function of time after a single large dose of phenylhydrazine was also studied. Results indicate that autotransplants act qualitatively as normal spleens, but their erythropoietic capacity is diminished and the animals show an intermediate response between normal and splenectomized mice. Histological observation showed no obvious differences in morphology and spatial distribution between colonies developing in normal and transplanted spleens. It is concluded that transplants lead to normal lodgment, proliferation and erythroid differentiation of circulating stem cells. However, changes in transplant size, anatomical position and other factors such as fibrosis and blood flow may decrease their trapping area and their capacity of expansion even under conditions of high erythropoietic stimulation.

The role of autotransplanted spleen in the erythropoietic recovery of the mouse.

Erythropoietic recovery was studied in mice subjected to subcutaneous splenic autotransplantation and compared with that observed in normal and splenectomized animals. Radioiron uptake into spleen and erythrocytes and splenic weight were measured at different times after lethal irradiation and injection of 5 x 10(5) bone marrow cells. Dose-response curves were also performed with increasing amounts of cells injected. Hematocrit recovery as a function of time after a single large dose of phenylhydrazine was also studied. Results indicate that autotransplants act qualitatively as normal spleens, but their erythropoietic capacity is diminished and the animals show an intermediate response between normal and splenectomized mice. Histological observation showed no obvious differences in morphology and spatial distribution between colonies developing in normal and transplanted spleens. It is concluded that transplants lead to normal lodgment, proliferation and erythroid differentiation of circulating stem cells. However, changes in transplant size, anatomical position and other factors such as fibrosis and blood flow may decrease their trapping area and their capacity of expansion even under conditions of high erythropoietic stimulation.

The role of autotransplanted spleen in the erythropoietic recovery of the mouse

Erythropoietic recovery was studied in mice subjected to subcutaneous splenic autotransplantation and compared with that observed in normal and splenectomized animals. Radioiron uptake into spleen and erythrocytes and splenic weight were measured at different times after lethal irradiation and injection of 5 x 10(5) bone marrow cells. Dose-response curves were also performed with increasing amounts of cells injected. Hematocrit recovery as a function of time after a single large dose of phenylhydrazine was also studied. Results indicate that autotransplants act qualitatively as normal spleens, but their erythropoietic capacity is diminished and the animals show an intermediate response between normal and splenectomized mice. Histological observation showed no obvious differences in morphology and spatial distribution between colonies developing in normal and transplanted spleens. It is concluded that transplants lead to normal lodgment, proliferation and erythroid differentiation of circulating stem cells. However, changes in transplant size, anatomical position and other factors such as fibrosis and blood flow may decrease their trapping area and their capacity of expansion even under conditions of high erythropoietic stimulation.