Imaging of the human cochlea using micro-computed tomography before and after cochlear implantation: comparison with cone-beam computed tomography.

PURPOSE: Analysis of cochlear structures and postoperative temporal bone (TB) imaging are gaining importance in the evaluation of cochlear implantation (CI°). Our aims were to explore the microarchitecture of human cochlea using micro-computed tomography (µCT), analyze electrode's placement inside cochlea after CI°, and compare pre-/post-implantation µCT scans with cone-beam CT (CBCT) scans of same TBs. METHODS: Cadaveric TBs were scanned using µCT and CBCT then underwent CI° using straight electrodes. Thereafter, they underwent again µCT and CBCT-imaging. RESULTS: Ten TBs were studied. µCT allowed visualization of scala tympani, scala vestibuli, basilar membrane, osseous spiral lamina, crista fenestrae, and spiral ligament. CBCT showed same structures except spiral ligament and crista fenestrae. After CI°, µCT and CBCT displayed the scalar location and course of electrode array within the cochlea. There were 7 cases of atraumatic electrode insertion and 3 cases of insertion trauma: basilar membrane elevation, electrode foldover with limited migration into scala vestibuli, and electrode kinking with limited migration into scala vestibuli. Insertion trauma was not correlated with cochlea's size or crista's maximal height but with round window membrane diameter. Resolution of µCT was higher than CBCT but electrode artifacts were similar. CONCLUSIONS: µCT was accurate in visualizing cochlear structures, and course and scalar position of electrode array inside cochlea with any possible trauma to cochlea or array. CBCT offers a good alternative to µCT in clinical practice for cochlear imaging and evaluation of CI°, with lower radiation and higher resolution than multi-slice CT. Difficulties related to non-traumatic CI° are multifactorial.

Balloon dilation for persistent unilateral chronic obstructive Eustachian tube dysfunction is effective: a prospective multicentre study.

PURPOSE: Balloon dilatation of the Eustachian tube (BDET) is an option for treating chronic obstructive Eustachian tube dysfunction (COETD). In this prospective multicentric study, the main objective was to evaluate the results of BDET in unilateral COETD refractory to medical treatment. METHODS: Adults with unilateral COETD whose Eustachian Tube Score (ETS) was less than 5 despite medical pressure therapy were included. The primary endpoint was the change in ETS measured at 2, 6, and 12 months after BDET. Secondary objectives were the evolution of clinical symptoms assessed by the Eustachian Tube Questionnaire (ETDQ-7), audiometry, tympanometry, and otoscopy changes after BDET. RESULTS: Twenty-eight patients were included between May 2014 and December 2017 and were treated with BDET without adverse effects in three different referral centers. Population's median age was 52 (Q25; Q75: 24, 82) years. The median follow-up time was 381 (Q25; Q75: 364; 418) days. The median ETS was 2 (Q25; Q75: 1; 4) before BDET. There was a significant improvement in ETS at 2 and 6 months and 1 year after BDET (score at 1 year: 6 (Q25; Q75: 2; 8) (p < 0.0001)). There was a significant, sustained improvement in the ETDQ-7 with a score of 4.21 (Q25; Q75-3.50; 4.79) before BDET and 3.43 (Q25; Q75-2.43; 4.14) (p = 0.0012) at 1 year. There was a suggestive improvement in tympanometry results at 1 year (p = 0.025). CONCLUSION: BDET provides an improvement in symptoms and objective measures assessed at 1 year in patients with COETD who have failed medical treatment. TRIAL REGISTRATION: NCT02123277 (April 25, 2014).

Benign Paroxysmal Vertigo of Childhood. Video Recordings of Episodes.

OBJECTIVES: The main objective was to describe the nystagmus observed during benign paroxysmal vertigo (BPV) of childhood, which is one of the criteria included in the three versions of the International Classification of Headache Disorders that has never been specified. The secondary objectives were to emphasize the usefulness of a mobile phone to record nystagmus and discuss the physiopathology of this nystagmus. PATIENT: A 6-year-old boy complained of approximately 30 to 50 vertigo attacks, most of them lasting around 1 minute, during a 6-month period. INTERVENTION: Otoneurologic history and examination, audiovestibular exploration, and brain imaging were performed between the attacks. Video recording by the parents' mobile phone and video electroencephalography recording during a 1-day hospitalization were performed during the episodes. MAIN OUTCOME MEASURE: Analysis of seven video recordings performed by the parents and four during a 1-day hospitalization, as well as follow-up. RESULTS: The assessment between the attacks confirmed the diagnosis of BPV according to International Classification of Headache Disorders criteria. Video recordings constantly demonstrated a strong left horizontal nystagmus present at fixation in all direction of gaze, enhanced in left gaze. This nystagmus was associated with a rightward body deviation. CONCLUSION: The clinical presentation was more consistent with a peripheral vestibular deficit than with a central disorder. We encourage video recording of their child by the parents because it will help both to define the ictal nystagmus and to understand the underlying pathophysiology. The latter is discussed and is probably more complex than initially thought in BPV.

Clinical Features and Management of Drop Attacks in Menière's Disease. Special Emphasis on the Possible Occurrence of Vertigo After the Drop Attacks.

INTRODUCTION: Tumarkin first described drop attacks (DA) in patients with a peripheral vestibular syndrome and speculated the role of a mechanical deformation of the otolith organs. We emphasized on the possible occurrence of vertigo/dizziness after a DA. In the light of the oculomotor examination of one patient right after the DA, we discussed on the mechanisms. We also described the management of DA. MATERIAL AND METHOD: This study included patients with definite Meni�re's disease (MD) and at least one DA without associated neurological symptoms. Patients with vertigo/dizziness after the fall were not excluded. RESULTS: Fifteen patients with MD complained of DA that was complicated either by severe head trauma (n = 1) or various fractures (n = 4). Seven patients complained of vertigo/dizziness after the DA. In one patient, DA occurred in the waiting room with a vertical illusion of movement immediately after the fall and a predominant down beating nystagmus that later changed direction. Follow up was favorable in all patients after oral medication alone (n = 7), chemical labyrinthectomy (n = 7) or vestibular neurotomy (n = 1). CONCLUSIONS: We suggest that a subset of patients with MD can complain of vertigo after a DA. We conclude on the possible occurrence of a vertical mainly down beating nystagmus in MD. Since this latter nystagmus is likely related to a semicircular canal rather than an otolith dysfunction, we discuss on the mechanisms of DA followed by vertigo/dizziness. Due to the risk of trauma in DA, chemical labyrinthectomy is a reasonable and effective option although spontaneous remission is possible.

Proteomic Imaging of Vestibular Schwannomas and Normal Nerves. Histopathologic Correlations.

OBJECTIVES: Proteomic analysis of vestibular schwannoma (VS), non-vestibular schwannoma (NVS), and normal nerve (NN) using mass spectrometry and imaging of matrix assisted laser desorption ionization-time of flight (MALDI-TOF). METHODS: Retrospective, qualitative, and descriptive study on VS, NVS, and NN. Samples were provided by our Tumor Bank. They were analyzed histologically then sprayed by acid matrix. The laser beam of MALDI performed desorption-ionization of the sample. A mass spectrogram (MS) was drawn depending on time of flight of ionized peptides, and MALDI-imaging was obtained which is a summation color spectrum depending on sample's peptide content. The slice was reexamined histologically and results compared with MALDI-imaging. RESULTS: Fifty schwannomas were sampled, of which 27 exploitable: 22 VS (17 Antoni type A and five type B) and five NVS (all Antoni type B). Eleven NN were analyzed. Among the 22 VS, near-total correlation between MALDI-imaging and pathology was found in two cases (9.1%), partial correlation in four (18.2%), and no correlation in 16 (72.7%); correlations were more frequent in VS of the Antoni type B. MS showed a peptide spike at 2,000 m/z in 7 (31.8%) and 5,000 m/z in 21 (95.5%). Among the five NVS, near-total correlation was found in three cases (60%), partial correlation in one (20%), and no correlation in one (20%). MS showed a peptide spike at 2,000 m/z in two (40%) and 5,000 m/z in all (100%). Among the 11 NN, near-total correlation was found in nine cases (81.8%), partial correlation in one (9.1%), and no correlation in one (9.1%). MS showed no peptide spike at 2,000 or 5,000 m/z. Behind homogeneous areas on histology, there was great heterogeneity on MALDI-imaging and MS, regarding VS and NVS, but not NN. CONCLUSIONS: There was a lack of correlation between MALDI-imaging and pathology in VS (except Antoni type B) as compared with NVS and NN. The lack of correlation in VS of the type A as compared with type B VS and NVS could be attributed to the overexpression of degeneration-associated proteins/peptides in VS of the type B as well as NVS that are better correlated with histologic findings. The two peptide spikes detected in schwannoma and not in NN opens up the prospect of tumor biomarkers identifiable by sequencing. The proteomic polymorphism found in VS and NVS was absent on histology which is a new morphologic characteristic of schwannoma. Further studies should be performed in the future to confirm the benefit and usefulness of the MALDI in the analysis of VS and NVS.

Trans-mastoid approach for cerebrospinal fluid leak repair.

PURPOSE OF REVIEW: To describe the technique and discuss the advantages and outcomes of the trans-mastoid approach (TMA) for temporal bone cerebrospinal fluid (CSF) leak. RECENT FINDINGS: TMA for CSF leak repair is an alternative to middle cranial fossa approach (MCFA) with less morbidity and good outcomes. SUMMARY: Persistent CSF leak in the temporal bone whether idiopathic, congenital or acquired, is an indication for surgery. TMA is a valid option for surgery, competing with MCFA in selected cases. Surgical technique consists of a standard mastoidectomy, exposure of the osteodural defect, and repairing it using multiple layers in an inlay and overlay fashion. Outcomes show low recurrence and complication rates with good hearing results. However, long-term follow-up should be made, as recurrences can be delayed.

Relationship Between Audio-Vestibular Functional Tests and Inner Ear MRI in Meniere's Disease.

OBJECTIVES: Meniere's disease is an inner ear disorder generally attributed to an endolymphatic hydrops. Different electrophysiological tests and imaging techniques have been developed to improve endolymphatic hydrops diagnosis. The goal of our study was to compare the sensitivity and the specificity of delayed inner ear magnetic resonance imaging (MRI) after intravenous injection of gadolinium with extratympanic clicks electrocochleography (EcochG), phase shift of distortion product otoacoustic emissions (shift-DPOAEs), and cervical vestibular-evoked myogenic potentials (cVEMP) for the diagnosis of Meniere's disease. DESIGN: Forty-one patients, with a total of 50 affected ears, were included prospectively from April 2015 to April 2016 in our institution. Patients included had definite or possible Meniere's disease based on the latest American Academy of Otolaryngology-Head and Neck Surgery guidelines revised in 2015. All patients went through delayed inner ear MRI after intravenous injection of gadolinium (three dimension-fluid attenuated inversion recovery sequences), pure-tone audiometry, extratympanic clicks EcochG, shift-DPOAEs, and cVEMP on the same day. Endolymphatic hydrops was graded on MRI using the saccule to utricle ratio inversion defined as when the saccule appeared equal or larger than the utricle. RESULTS: Abnormal EcochG and shift-DPOAEs in patients with definite Meniere's disease (DMD) were found in 68 and 64.5%, respectively. The two methods were significantly associated in DMD group. In DMD group, 25.7% had a positive MRI. The correlation between MRI versus EcochG and MRI versus shift-DPOAEs was not significant. MRI hydrops detection was correlated with hearing loss. Finally, 22.9% of DMD group had positive cVEMP. CONCLUSIONS: EcochG and shift-DPOAEs were both well correlated with clinical criteria of Meniere's disease. Inner ear MRI showed hydrops when hearing loss was higher than 35 dB. The shift-DPOAEs presented the advantage of a rapid and easy measurement if DPOAEs could be recorded (i.e., hearing threshold <60dB). In contrast, EcochG can be performed regardless of hearing loss. In combination with shift-DPOAEs, it enhances the chances to confirm the diagnosis with a better confidence.

Benefit of Preoperative Temporal Bone CT for Atraumatic Cochlear Implantation.

HYPOTHESIS: Evaluate the benefit of preoperative surgical planning using computed tomography (CT) for atraumatic cochlear implantation. BACKGROUND: The surgical technique has a direct impact on hearing and structure preservation. Much interest has been given to depth of electrode insertion. We focused on electrode diameter depending on exposure of round window membrane (RWM) as calculated on preoperative CT. METHODS: Measurements were calculated radiologically and anatomically on 10 temporal bones. Results were compared with CT scans of a control population. Thereafter, preoperative CT scan measurements were applied to seven additional temporal bones that underwent cochlear implantation with the insertion of two electrodes of different diameters (14 implantations) to validate radiological analysis. RESULTS: RWM size was 1.5 ±â€Š0.2 mm on CT and 1.2 ±â€Š0.2 mm during dissection; posterosuperior bony overhang of round window niche was 1.1 ±â€Š0.1 mm on CT and 1.3 ±â€Š0.2 mm during dissection. There was no statistically significant difference between radiological and anatomical measurements and between radiological measurements of cadaveric temporal bones and control population (p > 0.05 for both). Also, preoperative surgical planning was reliable in the seven temporal bones implanted with two electrode types (accuracy 93%, sensitivity 85.7%, specificity 100%) yielding no damage to intracochlear structures. CONCLUSION: Difficulties to access RWM could be predicted on preoperative CT of temporal bones and control population, which correlated well with anatomical dissections and surgical findings during cochlear implantation. According to CT planning, electrode insertion through RWM was feasible in most patients, with or without drilling posterosuperior bony overhang of round window niche. Promontory cochleostomy could be recommended when electrode apical diameter exceeded maximal RWM exposure. There was no case of intracochlear trauma on microdissections.

Hearing eyeball and/or eyelid movements on the side of a unilateral superior semicircular canal dehiscence.

Hearing of eyeball movements has been reported in superior semicircular canal dehiscence (SSCD), but not hearing of eyelid movements. Our main objective was to report the hearing of eyeball and/or eyelid movements in unilateral SSCD. Our secondary objective was to access its specificity to SSCD and discuss the underlying mechanism. Six patients with SSCD who could hear their eyeball and/or eyelid movements were retrospectively reviewed. With the aim of comparisons, eight patients with an enlarged vestibular aqueduct (EVA), who share the same mechanism of an abnormal third window, were questioned on their ability to hear their eyeball and/or eyelid movements. Three patients with SSCD could hear both their eyeball and eyelid movements as a soft low-pitch friction sound. Two patients with SSCD could hear only their eyelid movements, one of whom after the surgery of a traumatic chronic subdural hematoma. The latter remarked that every gently tapping on the skin covering the burr-hole was heard in his dehiscent ear as the sound produced when banging on a drum, in keeping with a direct transmission of the sound to the inner ear via the cerebrospinal fluid. One patient with SSCD, who could hear only his eyeball movements, had other disabling symptoms deserving operation through a middle fossa approach with an immediate relief of his symptoms. None of the eight patients with EVA could hear his/her eyeball or eyelid movements. Hearing of eyeball and/or eyelid movements is highly suggestive of a SSCD and do not seem to occur in EVA. In case of radiological SSCD, clinicians should search for hearing of eyeball and/or eyelid movements providing arguments for a symptomatic dehiscence. The underlying mechanism is discussed particularly the role of a cerebrospinal fluid transmission.

Spontaneous Cerebrospinal Fluid Rhinorrhea: Association with Body Weight and Imaging Data.

Objective Spontaneous cerebrospinal fluid rhinorrhea (SCSFR) might be the only clinical manifestation of idiopathic intracranial hypertension (IIH), which has been historically related to overweight. Our goal was to search for an association between SCSFR and increased body weight on the one hand and SCSFR and imaging findings suggestive of IIH on the other hand. Materials and Methods We retrospectively collected clinical and radiological data of patients operated on endoscopically for SCSFR in our institution from 1993 to 2013. Analyzed factors were body mass index (BMI), extended sphenoid sinus pneumatization on computed tomography, and empty sella and distention of the optic nerve sheath on magnetic resonance imaging. Results There were 15 patients: 8 females/7 males; mean age 50 years. Primary surgical success rate was 86.7%. Regarding body weight, 80% were overweight (BMI ≥ 25) versus 32% in the French general population ( p < 0.001). Among patients with SCSFR, 20% were obese (BMI ≥ 30) versus 15% in French individuals without SCSFR ( p = 0.483). Increased pneumatization of sphenoid sinuses was observed in 92.9 versus 27.5% in the general population ( p < 0.0001). Empty sella was found in 46.2 versus 3% in the general population ( p < 0.00001). Dilation of the optic nerve sheath was observed in 46.2 versus 15% in the general population ( p < 0.01). Conclusion We found statistically significant associations between SCSFR and overweight, increased pneumatization of sphenoid sinuses, empty sella, and dilation of optic nerve sheath, but not with obesity, which did not have any additional impact of CSF leak than did overweight.

Intraoperative monitoring of the recurrent laryngeal nerve by vagal nerve stimulation in thyroid surgery.

The aim of the present study was to evaluate the thyroarytenoid muscle response during bilateral thyroid surgery using vagal nerve stimulation. 195 patients (390 nerves at risk) underwent a total thyroidectomy. The recurrent laryngeal nerve's function was checked by analyzing the amplitude and the latency of the thyroarytenoid muscle's responses after a vagal nerve's stimulation (0.5 and 1 mA) using the NIM3 Medtronic system. All patients were submitted to preoperative and postoperative laryngoscopy. 20 patients get no thyroarytenoid muscle response to the vagal nerve stimulation, and 14 postoperative recurrent laryngeal nerve palsies were confirmed (3.8 %). Two palsies were present after 6 months (0.51 %). All the patients with muscle's response have normal mobility vocal fold. The test sensitivity was 100 % and the test specificity was 98 %. Physiologically, the mean latencies of the muscular potentials for the right RLN were, respectively, 3.89 and 3.83 ms (p > 0.05) for the stimulation at 0.5 and 1 mA. The mean latencies for the left RLN were, respectively, 6.25 and 6.22 ms for the stimulation at 0.5 and 1 mA (p > 0.05). The difference of the latencies between the right and the left nerve was 2.30 ms (1.75-3.25 ms) with a stimulation of 0.5 or 1 mA (p < 0.05). Thyroarytenoid muscle's response via a vagal nerve stimulation showed a functional asymmetry of the laryngeal adduction with a faster right response. Surgically, this method can predict accurately an immediate postoperative vocal folds function in patients undergoing a bilateral thyroid surgery.

Vestibular results after intratympanic gentamicin therapy in disabling Menière's disease.

Intratympanic injection of gentamicin is increasingly used in the treatment of unilateral disabling Menière's disease (MD). Several objective functional and subjective tests have been developed to assess the control of vertigo after gentamicin treatment. The aim of this study was to show that subjective results require a vestibular deafferentation as profound as possible, evidenced with multifrequency vestibular assessment. Sixty four patients with intractable MD in situation of medical treatment failure longer than 6 months were included between 1998 and 2013 in this case control study. A 2-year follow-up was performed after the last intratympanic gentamicin performed with the titration technique. A vestibular assessment was applied before and after 2 years of treatment with a functional level score using the AAOHNS vertigo scale and multifrequency vestibular assessment: skull vibration-induced nystagmus test (SVINT), head-shaking test (HST) and caloric test (CaTe). The correlation between the results of the questionnaire and the level of the deafferentation as evaluated by the tests was analyzed with the Spearman test. Among the 64 included patients, 56 (87.5 %) described vertigo control. There was a correlation (=-0.33 [-0.53; -0.09], p = 0.008) between subjective improvement (AAO -HNS 1 or 2) and the degree of vestibular deafferentation as evidenced by a destructive nystagmus (beating toward the safe side) with the HST and the SVINT, as well as a caloric hypofunction >90 % with the CaTe. The present study demonstrates that a profound vestibular deafferentation confirmed with multifrequency test evaluation is needed to have a subjective improvement in the treatment of unilateral disabling MD with intratympanic gentamicin.

Parotid gland tumours: MR tractography to assess contact with the facial nerve.

OBJECTIVES: To assess the feasibility of intraparotid facial nerve (VIIn) tractographic reconstructions in estimating the presence of a contact between the VIIn and the tumour, in patients requiring surgical resection of parotid tumours. METHODS: Patients underwent MR scans with VIIn tractography calculated with the constrained spherical deconvolution model. The parameters of the diffusion sequence were: b-value of 1000 s/mm(2); 32 directions; voxel size: 2 mm isotropic; scan time: 9'31'. The potential contacts between VIIn branches and tumours were estimated with different initial fractional anisotropy (iFA) cut-offs compared to surgical data. Surgeons were blinded to the tractography reconstructions and identified both nerves and contact with tumours using nerve stimulation and reference photographs. RESULTS: Twenty-six patients were included in this study and the mean patient age was 55.2 years. Surgical direct assessment of VIIn allowed identifying 0.1 as the iFA threshold with the best sensitivity to detect tumour contact. In all patients with successful VIIn identification by tractography, surgeons confirmed nerve courses as well as lesion location in parotid glands. Mean VIIn branch FA values were significantly lower in cases with tumour contact (t-test; p ≤ 0.01). CONCLUSIONS: This study showed the feasibility of intraparotid VIIn tractography to identify nerve contact with parotid tumours. KEY POINTS: • Diffusion imaging is an efficient method for highlighting the intraparotid VIIn. • Visualization of the VIIn may help to better manage patients before surgery. • We bring new insights to future trials for patients with VIIn dysfunction. • We aimed to provide radio-anatomical references for further studies.

Scalar localization by cone-beam computed tomography of cochlear implant carriers: a comparative study between straight and periomodiolar precurved electrode arrays.

OBJECTIVE: To compare the incidence of dislocation of precurved versus straight flexible cochlear implant electrode arrays using cone-beam computed tomography (CBCT) image analyses. STUDY DESIGN: Consecutive nonrandomized case-comparison study. SETTINGS: Tertiary referral center. PATIENTS: Analyses of patients' CBCT images after cochlear implant surgery. INTERVENTION(S): Precurved and straight flexible electrode arrays from two different manufacturers were implanted. A round window insertion was performed in most cases. Two cases necessitated a cochleostomy. The patients' CBCT images were reconstructed in the coronal oblique, sagittal oblique, and axial oblique section. MAIN OUTCOME MEASURES: The insertion depth angle and the incidence of dislocation from the scala tympani to the scala vestibuli were determined. RESULTS: The CBCT images and the incidence of dislocation were analyzed in 54 patients (61 electrode arrays). Thirty-one patients were implanted with a precurved perimodiolar electrode array and 30 patients with a straight flexible electrode array. A total of nine (15%) scalar dislocations were observed in both groups. Eight (26%) scalar dislocations were observed in the precurved array group and one (3%) in the straight array group. Dislocation occurred at an insertion depth angle between 170 and 190 degrees in the precurved array group and at approximately 370 degrees in the straight array group. CONCLUSION: With precurved arrays, dislocation usually occurs in the ascending part of the basal turn of the cochlea. With straight flexible electrode arrays, the incidence of dislocation was lower, and it seems that straight flexible arrays have a higher chance of a confined position within the scala tympani than perimodiolar precurved arrays.

Rare case study of a primary carcinoma of the petrous bone and a brief literature review.

BACKGROUND: Temporal bone carcinoma is an aggressive tumor with multiple unconfirmed risk factors. METHODS AND RESULTS: Herein, we present a rare case of a primary petrous bone carcinoma in a female patient (65 years old) with an irrelevant medical history. She presented a postauricular swelling that revealed a multilocular osteolytic cystic lesion of the mastoid portion of the temporal bone on the CT scan. The patient underwent resection of the lesion and pathological analysis revealed moderately to well-differentiated squamous cell carcinoma. Postoperative radiotherapy was carried out. Until the present time, the patient shows complete remission on regular clinical and radiological follow-up. CONCLUSION: Although no widely accepted strategy for managing temporal bone tumors exists, a review of the literature showed that surgery with or without radiotherapy is the treatment of choice. Preoperative assessment and accurate staging are vital in ensuring that the treatment is adequate for each disease stage.

Segments of the internal carotid artery during endoscopic transnasal and open cranial approaches: can a uniform nomenclature apply to both?

BACKGROUND: The classic anatomic view of the course of the internal carotid artery (ICA) and its segments familiar to neurosurgeons by a 3-dimensional microscopic cranial view may be challenging to understand when seen in the unique 2-dimensional view of transnasal endoscopic surgery. OBJECTIVE: We re-examined our 1996 classification of 7 (C1-C7) segments of the ICA, comparing the arterial course in cadaveric dissections for both a transnasal endoscopic transpenoidal approach and frontotemporal craniotomy. METHODS: Five formalin-fixed cadaveric heads injected with colored silicone underwent thin-cut computed tomographic scanning for bony and vascular analysis. The ICA's intracranial course viewed by transnasal endoscopic dissection was compared with the view of a bilateral frontotemporal crantiotomy, from the petrous (C2) to communicating (C7) segments. RESULTS: Refinement of our 1996 ICA classification provides an anatomical understanding for endoscopic exposures transnasally along an inferior skull base trajectory. The changing course of the ICA, initially termed loop is now termed bend (i.e., implying a change in direction). Four bends are described as the ICA enters into the skull base as C2, C3-C4, C4, and C4-C5. We discuss delineation of certain problematic ICA segments and identify landmarks for endoscopic endonasal approaches. CONCLUSIONS: Our classification of the segments of the ICA achieves consistency without sacrificing either clinical or anatomic accuracy for either transcranial or endoscopic approaches. Universal application of this established nomenclature can avoid new and misleading terms, respects anatomical landmarks delineating segments, and provides a universal language for clear communication between disciplines.

Trigeminal nerve deficit in large and compressive acoustic neuromas and its correlation with MRI findings.

OBJECTIVES: Evaluate the prevalence of preoperative trigeminal nerve deficit in large/compressive acoustic neuromas and try to find a correlation between pre/postoperative magnetic resonance imaging (MRI) findings and pre/postoperative trigeminal nerve deficit. STUDY DESIGN: Case series with chart review. SETTING: University medical center. SUBJECTS AND METHODS: Retrospective study (1994-2009) including patients with stage 4 or 5 acoustic neuromas (Zini-Magnan classification). All patients underwent surgical resection. Pre- and postoperative trigeminal symptoms were sought. Imaging criteria were sought on pre- and 3-month postoperative MRI scans. Pearson χ(2) statistical test was used. RESULTS: Fifty-three patients (27 females, mean 51 years) were operated on. Preoperatively, 3 patients (5.7%) had trigeminal neuralgia, 1 (1.9%) trigeminal anesthesia, and 28 (52.8%) trigeminal hypoesthesia. Sixteen patients (30.2%) had no corneal reflex (ophthalmic branch); keratitis occurred in 1 patient (1.9%). Postoperatively, 2 patients (3.8%) had trigeminal neuralgia, 1 (1.9%) trigeminal anesthesia, and 24 (45.3%) trigeminal hypoesthesia. Twenty-six patients (49%) had no corneal reflex; keratitis occurred in 11 patients (20.7%). Preoperative trigeminal hypoesthesia was statistically correlated with impaction of the tumor on cerebellar peduncles on preoperative MRI. Postoperative trigeminal hypoesthesia was statistically correlated with nonvisibility of the trigeminal nerve on postoperative MRI. CONCLUSION: In large/compressive acoustic neuromas, trigeminal nerve deficit has to be sought to avoid corneal complications in particular. Trigeminal hypoesthesia occurs preoperatively in about half of the cases. It remains relatively stable after tumor removal, but there appears to be an increased rate of absent corneal reflex and keratitis postoperatively. We were able to correlate pre/postoperative trigeminal hypoesthesia with pre/postoperative MRI findings.

Skull vibration-induced nystagmus test in unilateral superior canal dehiscence and otosclerosis: a vestibular Weber test.

CONCLUSIONS: The skull vibration-induced nystagmus test (SVINT) acts as a vestibular Weber test and reveals a vibration-induced nystagmus (VIN), elicited mainly on the vertex location, with a horizontal or torsional component beating more often toward the side of the lesion in superior canal dehiscence (SCD) than in otosclerosis (OS). In SCD, the VIN vertical component is most often up-beating. These results suggest more a global vestibular contribution than the sole stimulation of the superior semicircular canal. OBJECTIVES: This study aimed to evaluate the possible occurrence of nystagmus during SVINT in unilateral conductive hearing loss related to SCD or OS. METHODS: The slow-phase velocities (SPVs) of the VIN horizontal, torsional, and vertical components were recorded in patients with a unilateral otologic lesion (17 SCD, 38 OS) and 12 control subjects. Vibratory stimulations (60 Hz, 100 Hz) were applied on the vertex and on each mastoid. RESULTS: In SCD, VIN was observed in 82% of patients with a primarily torsional, horizontal, and vertical (up-beating) component in 40%, 30%, and 30%, respectively. Horizontal and torsional components beat toward the side of the lesion more often than in OS. Higher SPVs were observed after vertex stimulation. In OS, VIN was sparse with low amplitude and was not systematically lateralized to a specific side.

Lemierre syndrome: study of 11 cases and literature review.

BACKGROUND: Lemierre syndrome is a rare but serious illness that associates throat infection and thrombosis of the internal jugular vein (IJV) or one of its tributaries with subsequent distant septic emboli. The purpose of our study was to review the pathogenesis, clinical presentation, and treatment of this disease. METHODS: Patients with confirmed Lemierre syndrome were included in our retrospective monocentric study. All patients had bacteriologic analyses as well as radiologic imaging. RESULTS: There were 11 patients in our study (from 1998-2012). Fusobacterium necrophorum was responsible for the infection in 45% of cases. Surgical drainage of pharyngeal, cervical, or mediastinal abscesses was carried out in 8 cases. All patients received broad-spectrum antibiotics. Six patients were admitted to the intensive care unit (ICU). One patient (9%) died. CONCLUSION: Treatment with broad-spectrum antibiotics is the primary choice of treatment of Lemierre syndrome. Surgery is indicated in case of abscess formation.