Hyrtl's fissure: a case of spontaneous cerebrospinal fluid otorrhea.

Spontaneous CSF otorrhea is a relatively rare entity. Adequate diagnosis and treatment are needed to avoid life-threatening complications such as meningitis. Because diagnosis is based on CT findings, identification of the different pathways of congenital fistulas requires detailed knowledge of embryology and anatomy. The facial canal, petromastoid canal, and tympanomeningeal (Hyrtl's) fissure can be responsible for CSF fluid otorrhea in the absence of any abnormality of the adjacent membranous labyrinth. We report the first documented and imaging case of Hyrtl's fissure and its treatment.

[Autografts versus biomaterials for ossiculoplasty with normal stapes; a comparative analysis of functional outcome in 100 cases]. / Résultats fonctionnels comparés des autogreffes et des biomatériaux dans les ossiculoplasties à étrier intact. A propos de 100 cas.

Ossicular graft is usually considered as the reference for surgical substitution in ossiculoplasties. Nevertheless, according to the infectious risks, nothing but autografts or synthetic prosthetic substitutes should be used nowadays. Authors compare hearing results for 100 patients after ossiculoplasty with either ossicular autograft or calcium-phospathe chain reconstruction. Audiometric results were retreived using both Glasgow Benefit Plot study and post-operative air-bone gap thresholds closure. Significant hearing improvement was statistically demonstrated in both conditions, and 60% of the patients had a post-operative hearing gain. Autograft ossicular reconstructions did not show to provide higher results. Biocompatibility and functionnal properties of calcium-phosphate materials retreived in this study, indicate that those ceramic substitutes should be considered as the best alternative to autografts.

[Maurice Sourdille and the operating microscope]. / Le microscope opératoire et Maurice Sourdille.

The authorship of the operating microscope appears to be shared by Nylén, who had the idea of using a microscope for ear surgery and Gullstrand, who invented the slit-lamp and who was probably the counsellor of Hölmgren in his work on operative field magnification. Hölmgren was the first to use an operating binocular magnifying glass and Sourdille created the first binocular magnifying glass designed for microsurgery.

[Tympanoplasty and Sourdille]. / La tympanoplastie et Maurice Sourdille.

In his article published earlier in 1929, Maurice Sourdille proposed two innovations in middle ear surgery: the tympanomeatal flap and surgery of chronic otitis. Those events were not only the starting point of a new era of modern tympanoplasty but also led to the way to the development of middle ear exploration with purposeful resection of the tympanic framework for accessing to the windows and for sealing a perforated tympanic membrane.

[A century in the history of chronic ear surgery]. / Un siècle d'histoire de la chirurgie d'otite chronique.

Although some advocated surgery of the tympanic membrane and stapes as early as early as the end of the nineteenth century, it took a long time for widespread development. Mastoid surgery had just been born and was to be greatly improved over the next century. Preservation of the tympano-ossicular its later reconstruction gradually came into use with the creation of the tympanomeatal flap and the recent development of middle ear surgery, followed by posterior tympanotomy and myringoplasty, thus allowing closed tympanoplasty. Likewise, the ventilation tube, forgotten for more than half a century, has found an important place in the treatment of chronic otitis with a closed ear drum.

[The role of areolar tissue on otologic surgery]. / Intérêt du tissu aréolaire temporal en chirurgie otologique.

Areolar tissue is a loose conjunctive tissue, located between the fascia temporalis superficialis and the temporal aponeurosis. It can be used in several circumstances during otologic surgery. First, in stapes surgery, it can be used as an interposition between the piston and the platinotomy. Its thickness has no equivalent in comparison with other temporal tissues, explaining in part its usefulness in this indication. In perilymphatic fistula surgery, the areolar tissue is especially recommended for round window and oval window grafting because of its spontaneous adhesive capacity. It can be useful in myringoplasty, to reenforce an atrophic tympanic membrane or to close a small perforation. Also areolar tissue can be used as a flap or as a free graft to reconstruction of the external acoustic meatus. It's a good conjunctive support, which can be covered by skin graft. Finally areolar tissue is an interesting and useful material for otologic surgery. Its qualities are complementary to those of the temporal aponeurosis.

[The value of beta-2 transferrin analysis and MR cisternography for the diagnosis of cerebrospinal fluid fistulas]. / Intérêt de la recherche de beta2 transferrine et de la MR cisternographie pour le diagnostic des fistules de liquide céphalorachidien.

The diagnosis of cerebrospinal fluid (CSF) fistula may require invasive techniques. Detection of CSF and perilymph-specific beta 2 transferrin and MR cisternography which greatly enhances the CSF signal are sensitive and noninvasive techniques which allowed a precise diagnosis in seven patients with suspected CSF fistula. We review the different diagnostic techniques used for CSF fistula, beta 2 transferrin analysis and MR cisternography appear to provide accurate and noninvasive methods for investigating CSF fistulae. They should replace invasive techniques such as CT cisternography.

[Definition and nosology of otitis]. / Définition et nosologie des otites.

Among otitis, various classifications have been made of those that affect the middle ear during the last century. The various types of otitis media that have been described have long been considered as clearly separate entities. Only in relatively recent years has a new overall vision emerged of this disorder, which would rather be a continuum. The different types of middle ear otitis would mostly be variable expressions of a true otitis disease.

[Radio-anatomical study of the external auditory canal. Comparison between anatomical pieces and x-ray computed tomography]. / Etude radio-anatomique du conduit auditif externe (CAE). Comparaison entre pièces anatomiques et tomodensitométrie.

Ear canal CT scan is widely used in addition to clinical examination, for diagnosis and evaluation of disease extension. Ear mouldings were performed on 11 cadavers (22 mouldings), 5 measurements were taken on each specimen and compared with CT scan measurement. Moulding measurements varied from side to side in one specimen, and moreover from one specimen on another one. Comparison between mouldings and CT scan showed that medial meatus measurements are identical. On the other hand, there are wide gaps for the lateral measurements. Biometrical disparity of the external auditory canal (EAC) was confirmed by this study. CT scan measurements in the lateral portion of the EAC are not reliable. Quantitative usefulness of CT scan is therefore limited to the study of the bony meatus.

[Restoration of the mandible after trans-mandibular approach of invasive tumors of the oropharynx (43 cases)]. / La réparation de la mandibule après abord transmandibulaire des tumeurs étendues de l'oropharynx (43 cas).

Preservation of the mandible is often possible in surgery of invasive malignant tumors of the oropharynx. From 1983 to 1993, we operated 158 T3 of the oropharynx: 73% with mandibulectomy and 27% with osteotomy (43 cases). Now, the osteotomy of the mandible is performed in more than 90% of the patients. The osteosynthesis needs two titanium plates; the pharyngoplasty is made with a pectoralis major myocutaneous flap. Followup: 36 cases of 43 gave satisfactory results. The osteotomy complication rate was 5 (12%): 5 osteitis (2 after radiotherapy).

[Vertigo and middle ear pathology]. / Vertiges et pathologie de l'oreille moyenne.

The association of vertigo and diseases of the middle ear is not uncommon. It occurs especially during the course of chronic or acute otitis but can also occur as a sequela. Vestibular involvement is due to several pathophysiological mechanisms that influence the choice of treatment. The same is true for expansive processes of the tympanic cavity. When associated to otospongiosis, vertigo occurring during Ménière's disease can transiently contraindicate an operation on the tapes. On the contrary, vertigo resulting from traumatic lesion of the middle ear can suggest surgical intervention. Surgery of the middle ear can itself cause severe vertigo which sometimes requires a new operation. Lastly, the fortuitous association of disease of the middle ear with labyrinth disease, especially retrolabyrinthic such as eighth cranial nerve neurinome, is not uncommon, but can be long overlooked if it is not routinely suggested in the presence of labyrinth type symptoms.

Controlled prospective study of oral ciprofloxacin versus amoxycillin/clavulanic acid in chronic suppurative otitis media in adults.

The efficacy and tolerability of ciprofloxacin (500 mg twice daily) was compared with that of amoxycillin/clavulanic acid (500 mg three times daily) in 76 patients with acute exacerbations of chronic non-cholesteatomatous suppurative otitis media enrolled in this open randomized multicentre trial. A total of 40 ciprofloxacin-treated patients and 35 amoxycillin/clavulanic acid-treated patients were evaluable for clinical efficacy following the 9-day treatment period. Pseudomonas aeruginosa was the main pathogen isolated prior to treatment. At the end of treatment, otorrhoea had disappeared in 57.5% of the ciprofloxacin group and 37.1% of the amoxycillin/clavulanic acid group (p = 0.04). Bacterial eradication rate was also significantly greater with ciprofloxacin (69.7%) than with amoxycillin/clavulanic acid (27.3%). Both treatments were well tolerated. Ciprofloxacin appears to be an effective treatment of chronic otitis media, and superior to amoxycillin/clavulanic acid.

A double-blind comparison of ciprofloxacin and amoxycillin/clavulanic acid in the treatment of chronic sinusitis.

A total of 251 adults with chronic sinusitis were enrolled into this prospective multicentre, double-blind, double-placebo comparison of ciprofloxacin (500 mg twice daily) with amoxycillin/clavulanic acid (500 mg three times daily). The diagnosis of chronic sinusitis (persistence of clinical symptoms for at least 3 months) was confirmed by computerized tomography scan and/or sinusoscopy prior to therapy. Patients at inclusion had purulent or muco-purulent rhinorrhoea. Staphylococcus aureus (n = 45), Haemophilus influenzae (n = 35), Streptococcus pneumoniae (n = 32) and enterobacteriaceae (n = 31) were isolated from pre-treatment aspirates of the middle meatus. Treatment lasted 9 days, at the end of which nasal discharge disappeared in 71/118 (60.2%) patients of the ciprofloxacin group and 69/123 (56.1%) of those in the amoxycillin/clavulanic acid group. The clinical cure and bacteriological eradication rates were 58.6% versus 51.2% and 88.9% versus 90.5% for ciprofloxacin and amoxycillin/clavulanic acid, respectively. These differences were not significant, however, amongst patients who had a positive initial culture and who were evaluated 40 days after treatment. Ciprofloxacin recipients had a significantly higher cure rate than those treated with amoxycillin/clavulanic acid (83.3% vs. 67.6%, p = 0.043). Clinical tolerance was significantly better with ciprofloxacin (p = 0.012), essentially due to a large number of gastro-intestinal related side-effects in the amoxycillin/clavulanic acid group (n = 35). Ciprofloxacin proved to be at least as effective as amoxycillin/clavulanic acid. The superior safety profile, a twice daily dosage regimen, suggests that ciprofloxacin may be a useful therapeutic alternative for the treatment of chronic sinusitis.

[Perilymph fistula: diagnosis by detection of perilymph in the middle ear by beta-2 transferrin immunofixation]. / Fistules périlymphatiques: diagnostic par la détection de la périlymphe dans l'oreille moyenne par immunofixation de la beta 2 transferrine.

beta 2-transferrin is a specific protein found in the cerebrospinal fluid and in the perilymph. Detecting beta 2-transferrin in the middle ear is of great interest when a fistula of the perilymph is suspected. This protein can be detected on microsamples with an immunofixation technique. We searched for beta 2-transferrin in pure perilymph, cerebrospinal fluid and serum in 8 patients operated by translabyrinthine approach for acoustic tumor removal. Search for beta 2-transferrin was performed in liquid from the inner ear in 3 labyrinthectomies. Samples were taken on collagen sponges or with micro syringes. beta 2-transferrin was detected in the perilymph of patients operated for neurinoma and in 2 of the 3 labyrinthectomies. This protein was found in only one of the patients for which the diagnosis of perilymphatic fistula had been retained. Detection of beta 2-transferrin in the middle ear can be proposed as a specific diagnostic test for perilymphatic fistula when the clinical situation does not suggest a fistula involving cerebrospinal fluid.

[Post-traumatic perilymphatic fistulas]. / Les fistules périlymphatiques post-traumatiques.

Perilymphatic fistulas (often secondary to trauma) are abnormal communications between the middle ear and the perilymphatic space involving a flow of perilymphatic fluid into the middle ear. The diagnosis is suggested by the association of cochleovestibular symptomatology in a traumatic context. The clinical context is of considerable importance in establishing the diagnosis. Thus, different etiological forms of post-traumatic fistula have been described, i.e., after stapedectomy (those initially reported), due to head trauma, resulting from direct ear injury, or by excessive pressure changes. Lesions are found at the level of round or oval windows, or between the two, at a fracture site of the typed noted after head trauma. Paraclinical explorations are of little value. Only caloric hypo-excitability or unexcitability associated with even partial conservation of cochlear function is a very good indicator. The diagnosis is determined during careful surgical exploration of the middle ear. Treatment requires closing the fistula with connective tissues such as temporal aponeurosis or stapedectomy with interposition in the event of marked dehiscence of the oval window. There are notable differences in the various therapeutic results reported. Vertigo was improved or cured in more than half the cases, whereas hearing was much less improved.

[Antibiotic prophylaxis in ORL surgery and oral medicine]. / Antibioprophylaxie en chirurgie ORL et stomatologique.

Postsurgical infection has always been a cause for major concern in ENT surgery. Papers on the topic allowed to identify indications for antibiotic prophylaxis. In ear surgery, in the absence of prior infection (stapes surgery, medium dry ear surgery), studies' results are not in favour of antibiotic prophylaxis. On the other hand, however, when the ear is inflamed or infected, the use of antibiotics is indicated, if possible after having first taken a sample. For nose and sinus surgery, antibiotic prophylaxis seems to be worthless in the absence of a prolonged packing. If a packing has to be maintained or if a transplant is used, an antibiotic administration has to be considered; the most appropriate antibiotic and its mode of use still have to be specified. In case of facial trauma, antibiotic prophylaxis using cefazolin reduces the risk of infection of paraymphysis fractures and angle fractures. The postoperative course after tonsillectomy is simplified by a prolonged antibiotic administration based on ampicillin. In clean cervico-facial surgery, without buccopharyngeal opening, the antibiotic prophylaxis seems to be worthless. In the opposite, antibiotherapy is required in case of buccopharyngeal opening. Indeed the presence of potential pathogenic bacteria in the buccopharyngeal cavity, the difficulties of mucosa closing, the importance of the tumoral extension, the length of the procedure, radiotherapy and use of myocutaneous flaps may all be the cause of a high infection rate (80%) in the absence of antibiotic prophylaxis. Two types of antibiotics seem to be suitable, cefazolin and clindamycin. Antibiotics active against Gram negative bacteria seem to be useless. There is a disagreement concerning the duration of antibiotic administration. The populations studied are too small to obtain significant results. Both points of view (prolonged antibiotic administration or true antibiotic prophylaxis) can be considered. Only large scale prospective studies with an adequate methodology will provide credible data for this debate.