Efficacy and complications of microvascular decompression in patients over 70 years with trigeminal neuralgia.

OBJECTIVE: Treatment of choice for trigeminal neuralgia (TN) by neurovascular conflict in case of failure of medical treatment is microvascular decompression (MVD). It is a safe and effective technique in the short and long term. But what about older patients who are considered more fragile anesthetically and surgically? Our Objective is to demonstrate the efficacy and complication rate of microvascular decompression (MVD) for older and younger patients with trigeminal neuralgia (TN) due to neurovascular conflict. METHODS: 102 patients with TN due to neurovascular conflict were included (June 2005-December 2016) in a single Regional hospital. 25 were included in the group composed of ≥ 70-year-old patients (G1), while 77 were included in the < 70-year-old group (G2). The patients were operated on by the same surgical team using a retro-sigmoid approach to access the neurovascular conflict. The epidemiologic, clinical, anesthetic, and surgical data were extracted. RESULTS: The immediate efficacy of surgical treatment (BNI pain intensity = I) was 96% in G1 and 96.10% in the G2 group (p = 0.71). At 3-year follow-up, the efficacy rate was 89% and 86%, respectively (p = 0.93). At 5 years, it was 92% and 92% (p = 0.98). Complication rates were comparable between the two groups (20% versus 27%; p = 0.47) and no deaths occurred despite the fact that G1 group had worst preoperative anesthetic score (ASA-NYHA). CONCLUSION: MVD is a durable procedure in patients over 70 years of age diagnosed with essential TN. The complication rate and immediate-, medium-, and long-term efficacy were similar to those of younger patients.

Long-term efficacy of vestibular neurotomy in disabling Ménière's disease and Tumarkin drop attacks.

OBJECTIVE: When Ménière's disease (MD) becomes disabling due to the frequency of attacks or the appearance of drop attacks (i.e., Tumarkin otolithic crisis) despite "conservative" medical and surgical treatments, a radical treatment like vestibular neurotomy (VN) is possible. An ideal MD treatment would relieve symptoms immediately and persist after the therapy. The aim of this study was to identify if VN was effective after 10 years of follow-up regarding vertigo and drop attacks, and to collect the immediate complications. METHODS: The authors report a retrospective, single-center (i.e., in a single tertiary referral center with otoneurological surgery activity) cohort study conducted from January 2003 to April 2020. All patients with unilateral disabling MD who had received a VN with at least 10 years of follow-up were included. The therapeutic efficacy was defined by complete disappearance of vertigo and drop attacks. The postoperative complications (CSF leak, total deafness, meningitis, death) were determined immediately after the surgery, and the hearing thresholds were determined during the patient follow-up with the pure tone average (PTA). RESULTS: A total of 74 patients (of 85 who were eligible), average age 51.9 ± 11.1 years, including 38 men (51.4%), with disabling MD and/or Tumarkin drop attacks (24.3%) received VN, with at least 10 years of follow-up after surgery. After an average follow-up of 12.4 ± 1.7 years (range 10.0-16.3 years), 67 patients (90.5%) no longer presented any vertiginous attacks, and no patient experienced drop attack. The mean variation in early pre- and postoperative PTA was not statistically significant (n = 64, 2.2 ± 10.3 decibels hearing level [range -18 to 29], 95% CI [-0.4 to 4.37]; p = 0.096), and 84.4% of the patients evaluated had unchanged or improved postoperative PTA. Three significant complications were noted, including two surgical revisions for CSF leak. There was no permanent facial paralysis, meningitis, or death. CONCLUSIONS: In case of disabling MD (disabling vertigo refractory to conservative vestibular treatments-Tumarkin drop attacks), VN via the retrosigmoid approach must be the prioritized proposal in comparison to intratympanic gentamicin injections, because of the extremely low complication rate and the immediate and long-lasting effect of this treatment on vertigo and falls.

Efficacy and Complications of Microsurgical Neurovascular Decompression in 55 Patients With Hemifacial Spasm.

OBJECTIVE: To analyze the efficacy and complications of microvascular decompression for hemifacial spasm. STUDY DESIGN: Retrospective study. SETTING: Regional hospital. METHODS: Fifty-five patients with hemifacial spasm were treated by microvascular decompression. All patients with hemifacial spasm who underwent retrosigmoid microvascular decompression from May 2004 to January 2017 were included. Patients with no conflict on preoperative magnetic resonance imaging or with an alternate diagnosis were excluded. RESULTS: The overall cure rate was 83.64%, with an average follow-up of 7.4 years. A left-sided hemifacial spasm was a healing-promoting factor (P = .01). The median healing was 0.03 months, and the mean was 6 months. The efficacy remained high in the medium term (88% at 3 years), long term (90.24% at 5 years), and very long term (90.48% at 8 years). The recurrence rate was 9.8%. Favorable criteria included a right-sided spasm (P = .01) and an average age of 62 years (P = .03). The specific complications were permanent facial palsy (3.63%), unilateral deafness (5.45%), and hearing loss (3.63%). No death was reported. Regarding the quality of life of the patients, 94.7% had a modified HFS-8 postoperative score of 0 (Hemifacial Spasm 8 Quality of Life Scale). CONCLUSION: Microvascular decompression for hemifacial spasm is an effective and lasting technique. Its low rate of complications and the considerable quality-of-life improvement should lead surgeons to propose it to patients as soon as botulinum toxin injections become ineffective or poorly tolerated.

[Deafness in children: to be detected as soon as possible]. / Surdité de l'enfant : la repérer le plus tôt possible.

Épidémiologie et dépistage de la surdité de l'enfant. L'intérêt d'un dépistage systématique de la surdité à la naissance n'est plus discuté ; 1 enfant sur 1 000 naît malentendant. La France, en retard dans ce domaine, a rendu ce dépistage obligatoire en avril 2012, confiant aux agences régionales de santé le soin de l'organiser dans un délai de deux ans. Théoriquement donc, dans toutes les maternités françaises, des signes de l'audition sont recherchés chez tous les nouveaunés à l'aide de la détection des otoémissions acoustiques ou de l'enregistrement des potentiels évoqués auditifs. Les enfants suspects sont alors adressés rapidement au centre référent de la maternité, centre chargé de confirmer l'éventuelle surdité, puis de la qualifier et de la quantifier. L'article fait le point quant à l'organisation de ce dépistage et ses résultats sur le territoire national en 2018, et rappelle le rôle primordial du médecin traitant prenant en charge les nourrissons et en mesure de vérifier si ce dépistage a bien été effectué.

[Epidemiology and newborns universal hearing screening]. / Épidémiologie et dépistage de la surdité de l'enfant.

Epidemiology and newborns universal hearing screening, The value and benefits of newborns' systematic hearing screening is no longer debated; one in a thousand children is born deaf. France, being behind in this field, made this screening mandatory in April 2012, giving to the Regional Health Agencies the duty and care to organise this screening within a period of two years. Therefore, theoretically, in all French maternities, hearing signs are sought in all newborns using the detection of otoacoustic emissions or the recording of auditory evoked potentials. Suspected children are then sent promptly to the referring center of the maternity, which will be responsible for confirming the possible deafness and, subsequently, qualifying and quantifying it. The article takes stock of the organisation of this screening process and its results in France in 2018. It is, especially, a reminder of the key role of the general practitioner who is taking care of infants and who is also able to verify if this screening has been performed.

Épidémiologie et dépistage de la surdité de l'enfant. L'intérêt d'un dépistage systématique de la surdité à la naissance n'est plus discuté ; 1 enfant sur 1 000 naît malentendant. La France, en retard dans ce domaine, a rendu ce dépistage obligatoire en avril 2012, confiant aux agences régionales de santé le soin de l'organiser dans un délai de deux ans. Théoriquement donc, dans toutes les maternités françaises, des signes de l'audition sont recherchés chez tous les nouveaunés à l'aide de la détection des otoémissions acoustiques ou de l'enregistrement des potentiels évoqués auditifs. Les enfants suspects sont alors adressés rapidement au centre référent de la maternité, centre chargé de confirmer l'éventuelle surdité, puis de la qualifier et de la quantifier. L'article fait le point quant à l'organisation de ce dépistage et ses résultats sur le territoire national en 2018, et rappelle le rôle primordial du médecin traitant prenant en charge les nourrissons et en mesure de vérifier si ce dépistage a bien été effectué.

Non-invasive intraoperative monitoring of cochlear function by cochlear microphonics during cerebellopontine-angle surgery.

In vestibular-schwannoma (VS) surgery, hearing-preservation rate remains low. Besides damage to the cochlear nerve, intraoperative cochlear ischemia is a potential cause of hearing loss. Here, we used non-invasive cochlear microphonic (CM) recordings to detect the cochlear vascular events of VS surgery. Continuous intraoperative CM monitoring, in response to 80-95 dB SPL, 1-kHz tone-bursts, was performed in two samples of patients undergoing retrosigmoid cerebellopontine-angle surgery: one for VS (n = 31) and one for vestibular neurectomy or vasculo-neural conflict causing intractable trigeminal neuralgia, harmless to hearing (n = 19, control group). Preoperative and postoperative hearings were compared as a function of intraoperative CM changes and their chronology. Monitoring was possible throughout except for a few tens of seconds when drilling or suction noises occurred. Four patterns of CM time course were identified, eventless, fluctuating, abrupt or progressive decrease. Only the VS group displayed the last two patterns, mainly during internal-auditory-canal drilling and the ensuing tumor dissection, always with postoperative loss of hearing as an end result. Conversely, eventless and fluctuating CM patterns could be associated with postoperative hearing loss when the cochlear nerve had been reportedly damaged, an event that CM is not meant to detect. Cochlear ischemia is a frequent event in VS surgery that leads to deafness. The findings that CM decrease raised no false alarm, and that CM fluctuations, insignificant in control cases, were easily spotted, suggest that CM intraoperative monitoring is a sensitive tool that could profitably guide VS surgery.

Impact of multi-task on symptomatic patient affected by chronical vestibular disorders.

PURPOSE: After a vestibular deficit some patients may be affected by chronical postural instability. The aim of this study was to identify the emotional and cognitive factors of these symptomatic patients. In particular, the double cognitive task and the anxiety disorder were identified by our patients. Through a retrospective study, 14 patients (65.4 ± 18 years) participated in the experiment. METHOD: The experimentation consists in the study of the standing position of our patients through the aggregate of the trajectories of the center of pressure (COP) using a force plate device. With the aim of isolating the emotional and cognitive influence, this experimentation was defined in two conditions. In the first one, the patients were asked to maintain their balance without additional tasks. In the second one, the patients were submitted to an additional cognitive arithmetic task. The stabilogram surface, length (the forward and backward displacement distance during deviations in COP), lateral and the antero-posterior deviations were assessed. RESULTS: Our results showed an increase of postural instability of patients affected by chronical vestibular disorders when submitted to the double task. The patients submitted to the cognitive task present a larger surface of activity in comparison with the free-task one (Wilcoxon test p-value equals p = 0.0453). In addition, their displacements inside this area are more important (p = 0.0338). The COP of all our patients deviated forward in the presence of the double task. CONCLUSION: The increase in instability during the double cognitive task could be explained by an additional stress caused by the desire to make a success of the cognitive task.

Prophylactic neck dissection for low-risk differentiated thyroid cancers: Risk-benefit analysis.

BACKGROUND: The benefit of neck dissection is the subject of debate in differentiated thyroid cancer (DTC). We analyze the risk-benefit of neck dissection for low-risk DTC without detectable lymph nodes. METHODS: We conducted a retrospective study from 1983 to 2003; which included 295 patients without detectable lymph nodes who were treated by thyroidectomy with (C+) or without (C-) neck dissection. All patients had iodine131 therapy. We compared the frequency of remission, disease progression, and permanent complications between groups. RESULTS: Two hundred twelve patients comprised the C+ group, and 83 patients the C- group. Respectively for C+ versus C-, remission rates were 92% versus 89.2% (p = .40), and progressive disease observed was 3.3% versus 7.2% (p = .10). Permanent hypoparathyroidism occurred in 15.1% in C+ versus 3.6% in C- (p = .006). CONCLUSION: The risk-benefit analysis of neck dissection in patients with low-risk DTC shows no benefit in terms of complete remission or occurrence of progression. However, risk of complications seems to be higher in patients with neck dissection. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1091-1096, 2016.

[Results and lessons after 10 years of universal neonatal hearing screening in the Champagne-Ardenne region of France]. / Dépistage systématique de la surdité à la naissance : résultats et enseignements au terme de 10 ans de pratique en Champagne-Ardenne.

In France, universal newborn hearing screening has been mandatory since April23rd, 2012, but it began in the Champagne-Ardenne region on January 15th 2004. More than 99 % of 160 196 newborns have since been systematically screened in this region. Bilateral hearing impairment was thus identified in 116 infants when they were around 3.5 months old. Earlier diagnosis improves the outcome of deafness, which is only diagnosed around age 20 months without screening. The authors report their experience and the lessons learnt.

Temporal-envelope reconstruction for hearing-impaired listeners.

Recent studies suggest that normal-hearing listeners maintain robust speech intelligibility despite severe degradations of amplitude-modulation (AM) cues, by using temporal-envelope information recovered from broadband frequency-modulation (FM) speech cues at the output of cochlear filters. This study aimed to assess whether cochlear damage affects this capacity to reconstruct temporal-envelope information from FM. This was achieved by measuring the ability of 40 normal-hearing listeners and 41 listeners with mild-to-moderate hearing loss to identify syllables processed to degrade AM cues while leaving FM cues intact within three broad frequency bands spanning the range 65-3,645 Hz. Stimuli were presented at 65 dB SPL for both normal-hearing listeners and hearing-impaired listeners. They were presented as such or amplified using a modified half-gain rule for hearing-impaired listeners. Hearing-impaired listeners showed significantly poorer identification scores than normal-hearing listeners at both presentation levels. However, the deficit shown by hearing-impaired listeners for amplified stimuli was relatively modest. Overall, hearing-impaired data and the results of a simulation study were consistent with a poorer-than-normal ability to reconstruct temporal-envelope information resulting from a broadening of cochlear filters by a factor ranging from 2 to 4. These results suggest that mild-to-moderate cochlear hearing loss has only a modest detrimental effect on peripheral, temporal-envelope reconstruction mechanisms.

[Rehabilitation of balance disorders for elderly]. / Rééducation des troubles de l'equilibre de la personne agée.

The problems encountered by elderly in balancing themselves, possibly causing instability, perception troubles, and even falls, are the consequence of physiopathological causes. Their comprehension by the way of a thorough clinical survey gives a lead to the rehabilitation based on precise objectives. The subsequent programme of exercises presents the significant features of modularity, clarity of objectives and a progress led by the evolution of the symptoms. This personalized undertaking may include a correction of the musculosqueletics troubles, a sensorial resetting, a development of postural stabilization capabilities independent of the internal or external circumstances, a self-balancing capability independent of the current cognitive condition, a restoration of self-confidence, a physical resetting and an adaptation of the living place. The transposition of the exercises in ecological situation, the virtual reality of which is getting closer and closer, remains a priority in order to achieve the best results.

Transcranial resection of a large sinonasal juvenile psammomatoid ossifying fibroma.

INTRODUCTION: Juvenile psammomatoid ossifying fibroma (JPOF) is a benign but potentially locally aggressive fibroosseous lesion predominantly arising in the paranasal sinuses in children and young adults. Intracranial extension is rare but occurs sometimes. In such cases, tumor resection may often require the combination of neurosurgical and facial approaches. Histological diagnosis remains a challenge because the lesion can be easily mistaken for another fibroosseous lesion or for a meningioma. CASE REPORT: We report the case of a 12-year-old boy with a JPOF arising from the right paranasal sinuses and extension towards the anterior skull base and the orbit. Despite the tumor had eroded through nasal septum, medial orbit wall, and right maxilla, it could be entirely removed performing an extended frontobasal approach via a bifrontoorbital craniotomy, obviating the need for a transfacial approach. CONCLUSION: Radiologically and histologically, the lesion could be mistaken either for a meningioma or another type of ossifying fibroma. Histological aspects and alternative surgical approaches to these rare entities are discussed.

Universal newborn hearing screening: a 27-month experience in the French region of Champagne-Ardenne.

OBJECTIVES: This article reports the creation of a Universal Newborn Hearing Screening (UNHS) program in a French region, Champagne-Ardenne, and the results of its first 27 months. MATERIALS AND METHODS: We introduced a UNHS program in all the Champagne-Ardenne maternities in order to screen all newborns in the region. We used a two-step strategy. The first test consists of automated transiently evoked otoacoustic emissions (TEOAE) and is performed before discharge by a nurse or a midwife. If TEOAE are absent in both ears (positive screening test), the baby is referred to the second test, which could be either TEOAE or automated auditory brainstem response (aABR) 15 days after discharge, by a physician in an outpatient clinic. If the retest is positive in both ears, the baby is referred to diagnostic tests in a reference centre. This procedure also applies to newborns in neonatal intensive care units but, in those cases, the first test procedure is aABR because of the higher incidence of auditory neuropathies in those units. UNHS data are recorded with the other neonatal screening tests in the Regional Neonatal Screening Center, which facilitates the follow-up of newborns. RESULTS: A total of 33 873 newborns were screened, which represents a coverage rate of 92.42%. In those babies, 33 431 had a negative first test and 429 were retested. There were 34 positive retests. Among those 34 children, 27 were actually deaf (0.08%). The median age at diagnosis was shortened from 17 months to 10 weeks. CONCLUSION: Those 27-month results demonstrate the validity of our UNHS program, which relies on the cooperation with maternities, an easy protocol and a strong follow-up procedure.

Surgical therapy in intractable benign paroxysmal positional vertigo.

OBJECTIVES: Benign paroxysmal positional vertigo (BPPV) is the most frequent vestibular disorder. Although it is easily cured with canal repositioning maneuvers for the majority of patients, it can be disabling in rare cases. For these patients, surgical solutions may be proposed. The aim of this article is to review the techniques used, the reported cases in the literature, and to discuss their indication in intractable BPPV. STUDY DESIGN: Literature review. MATERIALS AND METHODS: All the articles from 1972 to 2005 that discussed a specific surgical therapy in BPPV were reviewed. Many of them reported cases of operated patients and described original techniques. Some others are anatomic studies that discussed the two techniques used: singular neurectomy and posterior semicircular canal occlusion. RESULTS: Singular neurectomy (posterior ampullary nerve transsection) and posterior semicircular canal occlusion are the 2 specific techniques used in intractable BPPV surgery. The numbers of operated cases are 342 and 97, respectively. These small numbers indicate that the procedures are difficult and risk compromising hearing and that a very small population of patients require surgical treatment of BPPV. The operated cases have been decreasing since the early 1990s because of improved management in BPPV. This article summarizes the techniques and their results and proposes a currently recommended practice of surgical therapy in BPPV as well as new insights into intractable BPPVs' physiopathology.

Walking performance of vestibular-defective patients before and after unilateral vestibular neurotomy.

The present study investigated goal-directed linear locomotion in nine Menière's patients before and after (1 week, 1 and 3 months) a curative unilateral vestibular neurotomy (UVN). Experiments were done using a 3D motion analysis system in subjects walking eyes open (EO) and eyes closed (EC) towards a real or memorized target, respectively. Locomotor pattern (velocity, step length, step frequency and walk ratio) and walking trajectory deviations were evaluated for normal and fast speeds of locomotion and compared to those recorded in 10 healthy subjects. Before UVN, patients showed no walking deviation but gait pattern changes characterized by slower walks compared to the controls, mainly due to step length and step frequency reductions for both visual conditions and locomotion speeds. In the acute stage after UVN, locomotor pattern impairments were significantly accentuated. On the other hand, patients showed strong walking deviations towards the lesioned side with EC. Opposite lateral deviation towards the intact side were observed with EO for normal speed only. Recovery from impaired locomotor pattern was achieved within 1 month for normal speed but remained uncompensated 3 months post-lesion for fast speed particularly in EC condition. Finally, the walking trajectory deviation towards the lesioned side in the dark was maintained up to 3 months after UVN. The results show that central processing of visual and vestibular cues contributes to an accurate locomotor pointing. They argue for an increased weight of visual reference frame on locomotor functions when vestibular function is unilaterally impaired.

Does repeated hyperbaric exposure to 4 atmosphere absolute cause hearing impairment? Study in Guinea pigs and clinical incidences.

HYPOTHESIS: Direct pressure applied on the inner ear cannot induce hearing loss. BACKGROUND: Three possible causes have been described in the literature for inner ear permanent lesions during scuba diving: pressure imbalance between the middle ear and the external ear, appearance of microbubbles in the internal ear, and direct effect of pressure on the inner ear. We seek to determine whether this last factor can be involved. METHODS: We submitted two groups of guinea pigs previously implanted with an electrode in the round window to a protocol of air diving in a hyperbaric chamber. Eardrums of animals in one of the two groups had been perforated beforehand. Twenty dives were practiced over 4 weeks. We chose dive parameters consistent with common sport diving: maximal pressure of 4 atmosphere absolute and duration of 30 minutes. Auditory threshold and cochlear spontaneous activity were recorded at regular intervals. Furthermore, we recorded spontaneous cochlear activity in Heliox 400-m and 600-m dives to determine whether our conclusions hold for "extreme" diving. RESULTS: In the group with perforated eardrums, no variation of those parameters were recorded, even in extreme diving. Important variations were noticed in the other group. CONCLUSIONS: Pressure applied directly on the inner ear during diving does not disturb cochlear activity.

Cerebellopontine angle paraganglioma.

BACKGROUND: Acoustic neuroma account for 80% of cerebellopontine angle tumors. Paraganglioma is a rare tumor in this region. OBJECTIVE: The authors report a case of cerebellopontine angle paraganglioma arising from the anterior inferior cerebellar artery. RESULTS: The clinical and radiologic features were indistinguishable from those of a neuroma, and only the intraoperative view showed a vascular tumor. Definitive diagnosis was made by histopathologic methods. CONCLUSIONS: This unique paraganglioma location may be explained by existing embryologic data. The minimal retrosigmoid approach, assisted by endoscopy, allows safe and complete removal of the tumor.

Retrosigmoid approach for small and medium-sized acoustic neuromas.

OBJECTIVE: Clinical study of the keyhole acoustic neuroma retrosigmoid approach for facial nerve and hearing preservation. STUDY DESIGN: This was a prospective case review from October 1993 to December 1998 in a referral hospital care unit. PATIENTS: A total of 119 consecutive patients with a tumor size of <25 mm in the cerebellopontine angle corrected by a retrosigmoid approach were included in the study. INTERVENTIONS: Standard audiometric and imaging assessments, complete tumor removal by using endoscopy-assisted control, and nerve monitoring. MAIN OUTCOME MEASURES: House-Brackmann facial nerve grade and hearing level by the American Academy of Otolaryngology-Head and Neck Surgery classification. RESULTS: Grades I and II facial nerve function was obtained in 96% of cases, measurable hearing was preserved in 49% of cases, and 30% of cases achieved serviceable hearing. CONCLUSION: The retrosigmoid approach is a safe and reliable approach in random patients with small and medium-sized acoustic neuromas.