"Tumulus" stabilization of a total ossicular replacement prosthesis.

Functional failure of total ossicular replacement prostheses (TORP) is often due to secondary displacement, ranging from simple subluxation to prosthesis extrusion following recurrence of severe tympanic membrane retraction. Several surgical techniques have been proposed to stabilize a TORP, mostly using superimposed non-organic or resorbable heterologous materials. We describe a simple so-called "tumulus" surgical technique that limits prosthesis displacement and extrusion, regardless of the type of TORP, by using a few fragments of autologous cartilage that are always available and perfectly tolerated at no cost. Review of 31 cases treated by this technique did not reveal any cases of prosthesis displacement and only one case (3.2%) of prosthesis extrusion with audiometric results comparable to the best results reported in the literature.

[Myringoplasties for anterior tympanic perforations: Our surgical technique]. / Myringoplastie pour les perforations tympaniques antérieures: notre technique opératoire.

Anterior tympanic perforations are actually the most difficult to close and a number of different techniques exist. This article represents the author's surgical procedure for type I tympanoplasties (myringoplasties) for this kind of perforation using the tragal cartilage and the perichondrium after preparation (revival, cleaning) of the perforation edge with a laser. This technique does not use a skin incision of external auditory meatus, when this one is large.

[Reconstruction of bone defects in the earcanal with hydroxyapatite]. / Reconstruction des defects osseux du conduit auditif externe par ciment d'hydroxyapatite.

Traditional reconstruction methods of osseous defects within the tympanic frame, most often being the atticotomy, within the framework of chronic otitis media surgery, still do not produce stable or definitive results, usually due to displacement or partial lyse of the transplanted material (cartilage, bone ...). The reconstruction procedure with the aid of hydroxyapatite cement as presented by the authors, allows for a complete, stable and definitive reconstruction.

Esteem 2 middle ear implant: our experience.

INTRODUCTION: The Esteem is a totally implantable hearing system that uses piezoelectric technology. It is indicated in case of moderate to severe stable sensorineural hearing loss with a minimum discrimination score of 60% and a middle ear which is anatomically and functionally intact. Its two components (sensor and driver) are positioned and fixed in the mastoid cavity and coupled respectively to the incus body and capitulum with cement. STUDY DESIGN: Retrospective study. SETTINGS: Tertiary referral center. MATERIALS AND METHODS: Pure-tone average (PTA) gain in the implanted ear was calculated at 1, 2, and 4 KHz, word recognition score (WRS) gain at 50 dB SPL, and average WRS (AWRS) gain at 40, 55, and 70 dB SPL. WRS was also evaluated in silence and noise. All patients were asked to fill in the abbreviated profile of hearing aid benefit (APHAB) questionnaire pre- and postoperatively as well as an Esteem questionnaire. RESULTS: Thirteen patients received implants between May 2008 and April 2010. Five minor complications occurred (1 temporary partial facial palsy, 1 secondary healing difficulty, and 3 revision surgeries for poor and deteriorating functional results and progressive gain loss after use of a heart defibrillator). Two patients (15%) suffered major complications and their implants had to be removed 4 months postoperatively because of a Staphylococcus aureus wound infection. One patient underwent reimplantation 6 months later. Mean PTA gain was 25 ± 11 dB, mean WRS gain at 50 dB SPL was 64 ± 33%, and mean AWRS gain was 40 ± 20%. WRS in silence and with a signal-noise ratio of 10, 0, and -5 dB was 91 ± 11, 85 ± 14, 71 ± 19, and 64 ± 30%, respectively. The APHAB questionnaire revealed 84% of satisfaction improvement compared to the previous classic hearing aid. CONCLUSION: The totally implantable hearing device Esteem 2 can offer good functional and satisfaction results. Careful selection of patients is required, however, based on hearing tests, exclusion of middle ear ventilation problems, and CAT-scan middle ear anatomy. Specific surgical training and experience are also needed. The implant is safe and only associated with classic auditory implant complications.

[Ossiculoplasty with hydroxyapatite bone cement]. / Apport du ciment d'hydroxyapatite en ossiculoplastie.

OBJECTIVE: To analyze the results obtained with hydroxyapatite bone cement (HABC). PATIENTS: A total of 73 ossiculoplasties with HABC were evaluated. Ears were divided into 4 groups: Group 1: Reinforcement of the incudo-stapedial joint with HABC; Group 2: Reconstruction of an incus long process defect with HABC; Group 3: Partial ossicular reconstruction between stapes and malleus handle with HABC; Group 4: Reconstruction of stapes with mobile or fixed footplate with moderate or extensive incus long process erosion using a titanium piston glued to the incus remnant using HABC. RESULTS: The mean follow-up was 21 months. The percentage of postoperative average air-bone gap (ABG) < or = 20 dB for groups 1, 2, 3 and 4 were 100%, 95%, 83% and 91% respectively; for ABG < or = 10 dB: 90%, 71%, 50% and 50%. No complications related to HABC and extrusion occurred. CONCLUSION: Today, the use of HABC seems to help us improve our functional results and also to avoid extrusion. In our experience, ossiculoplastie with HABC seems to provide better and more stable functional results. HABC is safe and easy to use. The use of cement with or without biocompatible ossicular prostheses allows us to repair different types of ossicular defects whilst trying to conserve an anatomical and physiological ossicular chain. Reconstruction of the incus long process or incudo-stapedial joint defect with cement is preferable rather than using partial ossicular reconstruction with HABC.

[Evaluation of the efficiency of ERTL4/6 screening tests for language disorders for children with a 22q11 deletion]. / Etude de l'efficacité des epreuves de repérage de troubles de langage ERTL4/A6 sur des enfants porteurs d'une microdélétion 22q11.

OBJECTIVE: ERTL (Epreuves de Repérage de Troubles de Langage) tests have been designed as a screening test to detect rapidly language disorders. To evaluate the effectiveness of these tests, we have compared them to the form P (NEEL-P) tests for the examination of language in 6 children with a 22q11 microdeletion. MATERIALS AND METHOD: 6 children aged from 4 years and 4 months to 5 years and 4 months, 4 boys and 2 girls have been tested. These tests have been performed in two sessions lasting between 1 and 1 1/2 hour. RESULTS: They are consistent in both tests. ERTL has identified all the children with a disorder. CONCLUSION: These fast tests should be used more often to detect children requiring additional and more complex language and neuropsychological evaluations.

Tinnitus and otosclerosis.

OBJECTIVE: To establish the origin of tinnitus in patients with otosclerosis. METHODOLOGY: We performed a literature review to identify the characteristics of tinnitus in the general population and among patients with otosclerosis. RESULTS: Characteristics of tinnitus among patients with otosclerosis differ from those among the general population, suggesting mechanisms other than those implicated in presbycusis. Considerable improvements in the prevalence of tinnitus following corrective surgery demonstrate the limited contribution of diffuse labyrinth lesions. Middle ear and possibly secondary inner ear dysfunction produced by stapes blockage appear to be major etiopathogenic factors in the development of tinnitus in patients with otosclerosis. CONCLUSION: The conductive hearing deprivation produced by otosclerosis is associated with limited and reversible modifications in the central auditory pathway that are linked to tinnitus.

Today's indications for cochlear implantation.

Today's indications for cochlear implantation. During the last twenty years, the indications for cochlear implants (CIs) extended significantly due to positive experience with CIs, improved CI technology, and safer surgery. This paper reviews the classical and emerging indications for CIs anno 2007. Providing a postlingually deaf adult with a unilateral CI has been the earliest indication and remains the standard indication. However, CIs are also indicated for prelingually deaf adults, and for children younger than one year old. Recently, CIs are also indicated for adults with residual hearing: when best aided sentence recognition scores in quiet are lower than 70%. CIs for patients with residual hearing sometimes imply the use of a bimodal CI; a device that stimulates the cochlea both electrically and acoustically. Another promising evolution is bilateral implantation. Nowadays, it has also become possible to place a CI in the malformed cochlea. When an auditory nerve is absent or when implantation failed despite a functional device, auditory brainstem implants can restore some form of hearing to the deaf.

[TRT: results after one year treatment]. / TRT: efficacité après un an de traitement.

INTRODUCTION: Tinnitus Retraining Therapy (TRT) (which aims to induce changes in the mechanisms responsible for transferring signals from the auditory system to the limbic and autonomic systems) is a method for treating Tinnitus and decreased sound tolerance. An individualised explanation of Jastreboff's neurophysiological model allows greater insight and motivation on the part of the patient. Previous studies have demonstrated that daytime TRT is effective. As sleep forms a significant component of the distress associated with Tinnitus however, we hypothesised that night-time TRT could represent a useful tool in the treatment of this disabling condition. MATERIAL AND METHODS: 46 patients were studied (30 male, 16 female). Patients were selected from an ENT outpatient clinic. Patients with significant psychological disability were excluded. Patients were reviewed twice by their doctor and 5 times by a therapist over 12 months. Treatment consisted of 8 hours nighttime white noise stimulation, at progressively increasing intensity. Although several objective assessments of response were undertaken, patients' subjective testimonies were considered a more accurate signal of success. RESULTS: In total, 80% of patients had a satisfactory response after 1 year of treatment. 20% had no response. Patients were subcategorised according to Jastreboff's categories as follows: 1. Tinnitus (n = 6), 100% improved; 2. Tinnitus with hearing loss (n = 16); 62% improved; 3. Hyperacusis (with or without Tinnitus) (n = 16), 88.5% improved; 4. Hyperacusis (with or without Tinnitus, exacerbated by noise) (n = 8), 75% improved. CONCLUSION: Tinnitus is a symptom rather than an illness, and TRT gives patients greater control, allowing re-integration of normal perception. Night-time TRT is an effective treatment for Tinnitus and decreased sound tolerance. It has the potential advantage over day-time TRT of rapidly improving sleep and decreasing use of sedative hypnotics, a secondary effect noted in the personal testimonies of our cohort of patients. Further studies are needed to confirm this advantage, in view of the significant risks associated with long-term use of benzodiazepines. When investigating therapies for Tinnitus, it is necessary to measure success in terms of quality of life, as it is to this that the patient attaches the most importance.

[Pathophysiology of cholesteatoma]. / La physiopathogénie des cholestéatomes.

OBJECTIVE: To describe the development of cholesteatoma using current knowledge. METHOD: Review of the literature. RESULTS: Cholesteatoma describes a mass of keratin (skin) in the middle ear which consists of a perimatrix and matrix. There are at least three kinds of cholesteatoma in the middle ear one resulting from invagination (retraction's pocket), another from migration and the last one from congenital inclusion. Cholesteatoma needs three successive inflammatory phases, the first leading to a retraction pocket, the second leading to pathology of the epidermis and of the floor of the external auditory canal and the third is the actual phase of cholesteatoma with invasion and middle ear auto-destruction with bone resorption. In this last phase, many factors play a role, collagenasis, osteoclats, cytokines, NO, bacteria and their biofilm and rupture of the retraction pocket. CONCLUSION: Cholesteatoma is an inflammatory disease of the ear caracterised by bone resorption. Current research is starting to appreciate the important role the immune system plays in the pathophysiology of cholesteatoma.

The Tutopatch graft for transcanal myringoplasty.

OBJECTIVE: This article describes the technique and the preliminary results of transcanal myringoplasty for small or midsized tympanic membrane perforations with the Tutopatch (Tutogen Medical, Inc., Alachua, FL, USA), a xenograft derived from bovine pericardium. METHODS: All procedures started with a Rosen incision. The meatal skin was loosened from the bone up to the fibrous annulus, which was dislocated out of the sulcus, and the tympanic membrane was elevated from the malleus handle. The Tutopatch was placed over the malleus handle, the annulus, and the denuded bone. RESULTS: Eleven patients were included, and follow-up ranged from 3 to 14 months. Ten of the eleven eardrums were successfully closed. One patient developed myringitis 2 months after the procedure. The average air-bone gap at 0.5, 1, 2, and 4 kHz, of all but one patient was less than 10 dB. CONCLUSION: When anatomically feasible, a transcanal myringoplasty with a Tutopatch graft yields similar audiological results compared to fascia temporalis, perichondrium or tragal perichondrium-cartilage, but reduces the surgical trauma, the complications of the autograft harvesting, and the negative cosmetic and psychological impact of this procedure.

Rehabilitation of high-frequency hearing loss with the RetroX auditory implant.

The RetroX is a new semi-implantable hearing aid which does not occlude the external ear canal. It consists of an electronic unit that plugs into a titanium tube which is implanted under the pinna so as to connect the retroauricular sulcus with the inside lumen of the external ear canal. Implantation requires minor surgery which can be performed under local anesthesia. Moreover, a pre-implant simulator exists and allows patients to try the device before deciding on definite implantation. The RetroX auditory implant is indicated in case of high-frequency sensorineural hearing loss with a steep slope (ski-slope audiogram). We implanted 25 adults suffering from such a hearing loss, and we report their hearing measured after 2.5 to 15 months of use. Four patients developed a persistent granulomatous reaction which disappeared after explantation. Two patients complained of acoustic feedback and needed supplementary fitting. Twenty three of our 25 subjects are satisfied or even extremely satisfied with the hearing improvement provided by the RetroX; they wear the implant daily, from morning until evening. Audiometrically, we observed a statistically significant improvement of the pure-tone thresholds at 1, 2, 4 and 8 kHz. In quiet, the speech reception thresholds decreased by 10 dB SPL and in noise, speech intelligibility increased by 15% for signal-to-noise ratios between -5 dB and +5 dB. Up till now, our patients were implanted monaurally because of financial considerations and our initial inexperience with this new implant. The overall results, however, are promising and nowadays, we advise bilateral implantation for patients who tolerate the first implant. By doing so, we hope to improve hearing in noise and spatial sound perception.

Metastatic renal cell carcinoma to the temporal bone: case report.

We report an extremely rare case of metastasic renal cell carcinoma to the temporal bone which presented initially as a jugulotympanic paraganglioma. The clinical and radiological appearances were misleading.Investigations of concomitant high blood pressure revealed a tumour of the right kidney. Biopsy of the mastoid mass was histologically compatible with a metastasis from a clear cell renal carcinoma. The patient underwent a radical nephrectomy and local external radiotherapy to the head. He also received adjuvant treatment with interferon-_ and interleukin 2. The clinical presentation, the radiological and histological features, the patterns of spread, the treatment options and the prognosis of these tumours are discussed. A review of the literature confirms the extremely unusual occurrence of this localisation.

[Normative study and reliability of French version of the dizziness handicap inventory]. / Etude normative et de la reproductibilité d'une échelle du handicap lié aux troubles de l'équilibre et aux vertiges. "Dizziness Handicap Inventory" version française.

GOAL: To determine the normality per age group of the "Echelle du Handicap lié aux Troubles de l'Equilibre et aux Vertiges" (EHTEV) French version of the "Dizziness Handicap Inventory" (DHI) and to assess the effect of sex on the scores and the reproductibility. SUBJECTS AND METHODS: The normative scores and the effect of the sex were determined in a group of 120 subjects without any instability disorder. Sixty-three women and 57 men, aged 20-79 years were graded by age section of 10 years. After 8-10 weeks the same questionnaire was submitted again to 47 individuals of this same group to assess the reproductibility. RESULTS: The scores of the instability showed that handicap increased with the age. The mean score for the 50-79 year-old group is almost four times greater that of the 20-49 years old. Correlation between scores and age is 0.70 for physical handicap, 0.76 for emotional handicap, 0.69 functional handicap and 0.83 for global score. There is no significant influence of sex. The reproductibility coefficient is 0.98. CONCLUSION: The scores of the EHTEV increase with age. There is no significant influence of sex on scores and the coefficient of the reproductibility is good. But the translation of this handicap scale, need a study of validity and reliability.

[Adolescence and cochlear implant]. / Adolescence et implant cochléaire.

During adolescence, the identity is constructed and the communication changes. The cochlear implant may disturb the identity's construction. The restrictions and advantages may be misunderstood due to the communication difficulties. It is important to take time to discuss and explain the limits of this hearing aid. It must not be perceived as a miracle resolving all auditory and oral communication problems. The hearing aid is effective for motivated and informed adolescents. The outcome depends on the level of auditory experience and oral language development before implantation. It can be very positive. (full article translated in English available on www.ent-review.com).

[Benefit of rotational exercises for patients with Meniere's syndrome, method used by the ENT department of St-Luc university clinic]. / Intérêt du traitement par exercices rotatoires chez les patients atteints de syndrome de Ménière, méthode utilisée au service d'ORL des cliniques universitaires Saint-Luc.

OBJECTIVE: To date, the effectiveness of balanced rehabilitation for patients with Meniere's syndrome has not been unanimously acknowledged by all physicians and physiotherapists. The purpose of this study is to assess the therapeutic efficacy of rotational exercises in the treatment of disequilibrium for patients with unilateral Meniere's syndrome. METHODOLOGY: Rotational stimuli were used to symmetrize and reduce postrotatory nystagmic response. Three reference sources were used to assess the efficacy of this management: vestibulospinal function tests: pre- and post-treatment results at the Romberg test, the Unterberger-Fukuda stepping test, the Babinski-Weil test, and gait testing with eyes closed; rotational tests: pre- and post-treatment results; and the self-perceived impact of vertigo: assessed by the Dizziness Handicap Inventory (DHI) and a scale based on the guidelines of the Japanese Society of Equilibrium Research (JSER, 1993). The JSER scale provides quantitative vertigo evaluation; the DHI reflects the patient's perceptual evaluation of handicap. RESULTS: Patients required 11 sessions (mean value) to attain subjective improvement. Of the 23 patients, only seven required optokinetic stimulation (mean requirement: three sessions). Rotational tests and dynamic tests of the vestibulospinal function improved. The DHI and JSER results show that patients' post-rehabilitation perceptual evaluation significantly improved. CONCLUSION: The objective and subjective measures of disequilibrium in patients with unilateral Meniere's syndrome were significantly improved.

Tympanoplasty without skin incision of the external auditory canal: preliminary results.

INTRODUCTION: Most tympanoplasty techniques require skin incision of the external auditory canal. This step is not without morbidity and postoperative complications such as delayed healing, granulation tissue, lateralization, blunting and iatrogenic cholesteatoma. For small or midsize non-marginalized tympanic membrane perforations of the posterior or inferior quadrants, a transmeatal approach without incision of the cutaneous epidermis of the external auditory canal can theoretically offer advantages such as rapid healing and reduced postoperative complications. In this paper we present the preliminary results of a tympanoplasty technique with a retroauricular approach without skin incision of the canal and an overlay graft. MATERIALS AND METHODS: We performed 10 tympanoplasties without skin incisions for small or midsize non-marginalized perforations, which do not exceed one third of the tympanic membrane surface, located in the inferior or posterior quadrants. RESULTS: With a minimum follow up of 3 months all patients showed excellent anatomical results without complications. Nine of them closed their average air bone gap at less than 10 dB. CONCLUSION: When anatomically feasible, our technique combines a post auricular approach and the absence of skin incision. It ensures rapid healing, preserves the anatomy of the eardrum and external auditory canal and reduces the risk of blunting and lateralization phenomena. The main difficulty concerns the cleavage of the epidermal and fibrous layer.

[The art of tympanoplasty and its clinical illustration]. / L'art de la tympanoplastie et son illustration clinique.

INTRODUCTION: The development of tympanic membrane surgery is based on 150 years of surgical experiences, medical and technological innovations. There are two major techniques of tympanic membrane reconstruction depending on the graft related to the different anatomic layers of the eardrum. AIM OF THE STUDY: We evaluate different risk factors of the tympanoplasty such as the age of the patient, the tubal function, the middle ear inflammation, the status of the contra-lateral ear, the localization and the size of the perforation, the surgical techniques and the type of the graft. METHODS: We illustrate and comment on those risk factors considering 122 simple tympanoplasties and a large overview of the literature. RESULTS: We show that the graft position doesn't interfere with the surgical results and we specify our attitude to control the risk factors. CONCLUSION: To obtain excellent results, surgical indications have to be extremely rigorous as with surgical techniques.

Overlay versus underlay tympanoplasty. Comparative study of 122 cases.

INTRODUCTION: In tympanoplasty, the most common two techniques for positioning the graft relative to the remnant of both the tympanic membrane and of the annulus, are the "overlay" and the "underlay" techniques. Each technique has advantages and disadvantages. METHODS: One hundred and twenty-two cases over the age of 8 years who had undergone a tympanoplasty for tympanic membrane perforation secondary to chronic otitis media were included. All patients had a minimum 3-month postoperative otoscopic and audiometric follow-up. RESULTS: of 122 cases, 115 tympanoplasties (94%) were anatomically successful. At frequencies of 0.5, 1, 2, and 4 kHz, the mean air-bone gap improved significantly from 21.7 dB preoperatively to 8.4 dB postoperatively giving a mean gain of 13.3 dB. CONCLUSION: In our series the underlay or overlay positioning of the graft does not significantly influence the rate of postoperative perforations or complications with the exception of epithelial pearls, which occur significantly more frequently following the overlay technique for perforations that require fibro-epidermal cleaving across a large area.