Surgical treatment of large vestibular schwannomas (stages III and IV).

OBJECTIVE: Study the results of surgical treatment of large vestibular schwannomas. MATERIAL AND METHODS: Between January 1995 and December 2005, 87 stage III and IV unilateral vestibular schwannomas (Koos classification) were operated. RESULTS: The approach used was for the most part translabyrinthine. Nine patients were operated in two phases. Tumor exeresis was total in 79% of the cases, nearly total in 17%, and subtotal in 3.6%. Good facial function was preserved in 63% of the patients. Mortality was zero. Tumor control after a mean follow-up of 45 months was 86%. CONCLUSIONS: Surgery for large vestibular schwannomas should have a 0% mortality rate and low morbidity. Otoneurosurgical collaboration, with a preference for the translabyrinthine approach, with surgery undertaken in several phases if need be, provides maximum safety and good functional results as well as an acceptable residual tumor rate.

[Recurrent giant cystic vestibular schwannomas: role of cystoperitoneal shunt]. / Schwannomes vestibulaires kystiques géants: intérêt du drainage kystopéritonéal.

INTRODUCTION: Surgical removal of giant cystic vestibular schwannomas is difficult because of adherences between the cyst membrane, brainstem, and the VII-VIII nerve complex. The recurrence of the cyst is frequent and requires reoperation. The aim of this study was to analyze the role of the palliative cystoperitoneal shunt in giant cystic vestibular schwannomas. MATERIALS AND METHODS: Eighty-eight patients with a diagnosis of stage III or IV vestibular schwannoma were managed surgically from January 2000 to December 2005 in our department. Six schwannomas were deemed to be cystic according to the following criteria: a voluminous cystic component with mass effect causing symptoms as well as radiological and intraoperative identification of cystic elements. RESULTS: Complete tumor removal was achieved in two patients. After a follow-up of 5 and 7 years, these patients were asymptomatic. In four cases, we performed cyst drainage. For three patients, we implanted a permanent cystoperitoneal shunt. These patients were asymptomatic with a mean follow-up of 19.7 months. CONCLUSIONS: The cystoperitoneal shunt with no valve is a valid palliative surgical solution to remove brain stem compression. Neuronavigation allows proper positioning of the drain and secures the procedure.

[Atypical laryngo-tracheal post-intubation complications: three case reports]. / Complications laryngo-trachéales post-intubation atypiques: à propos de 3 cas.

Endotracheal intubation can induce iatrogenic laryngeal and tracheal complications, particularly when the intubation lasts for a long time. The ENT pratician's job is not only to cure the laryngeal sequelaes but also to prevent and diagnose them. Authors report three atypical cases of laryngeal and tracheal post-intubation complications (laryngeal bilateral immobility, interarythenoidal synechia, oesotracheal fistulae) and discuss them regarding medical literature data.

[Long-term results of facial palsy's rehabilitation by end-to-end hypoglossal-facial anastomosis]. / Résultats à long terme de la réhabilitation des paralysies faciales périphériques par anastomose hypoglosso-faciale termino-terminale.

OBJECTIVE OF THE STUDY: To evaluate the long term functional and esthetical results of the patients who underwent a facial palsy rehabilitation surgery by a hypoglossal-facial anastomosis. PATIENTS AND METHODS: In this retrospective study, 11 patients (8 males and 3 females) with a complete facial palsy (grade VI House-Brackmann) due to an otoneurosurgery performed between 1985 and 2006 (6 vestibular schwannomas, 1 facial schwannoma of the geniculate ganglion and 4 meningiomas) were evaluated (with the help of an auto-questionnary, a physical exam and electromyography) between July and september in 2008. RESULTS: The voluntary palpebral closure was obtained in 8 cases out 11 (grade III of House-Brackmann). The lingual hemiatrophy was constant. It was major for the patients who didn't take part in a specific re-education. In these cases patients had troubles during feeding and elocution. CONCLUSION: The hypoglossal-facial is a dynamic surgical rehabilitation of choice for the facial palsy. It nearly achived 80% of good palpebral results. The end-to-end anastomosis gives a lingual hemiatrophy which is not the case with a side to end anastomosis. This atrophy can be reduced with an intensive and specific reeducation. Moreover this re-education improves the functionnal and the esthetical results for the patients who underwent an hypoglossal-facial anastomosis. This lingual hemiatrophy was then responsible for troubles for feeding and elocution.

[Cat scratch disease: a diagnosis to be aware of!]. / Maladie des griffes du chat: un diagnostic a ne pas méconnaître!

Subacute cervical lymphadenopathy among young adults may be of an infectious or malignant aetiology. We report two cases of young males with chronic cervical lymphadenopathy. A diagnosis of Cat scratch disease (CSD) was made by serological and molecular studies. CSD is one of the most frequent infectious lymphadenopathies among young people. Diagnosis of CSD is dependent on clinical, epidemiological, molecular and histological criteria. The detection of antibodies to Bartonella Henselae and the amplification of its DNA by Polymerase Chain Reaction (PCR) are the two main methods of laboratory diagnosis. The evolution of CSD is usually benign; however therapeutic management remains problematic, particularly in atypical forms.

[Positron emission tomography in head and neck squamous cell carcinomas]. / La tomographie par émission de positons dans les carcinomes épidermoïdes de la tête et du cou.

18F-Fluorodeoxyglucose positron emission tomography (PET) is an imaging modality which is becoming increasingly esential in oncology, especially in the management of head and neck squamous cell carcinomas (SCC). The most common uses of the PET are listed in this thematic study: initial staging, cervical lymph node metastases from an unknown primary tumor and post-therapeutic follow-up. The advantages and drawbacks of this imaging tool are exposed here according to both our experience and data from the literature. Decision schemes are suggested for each use so as to optimize the use of this imaging modality in the management of these SCC. Other fields of application for the PET are mentioned, such as the in-progress evaluation of response to chemotherapy, the interest of this imaging tool in radiotherapy as well as current biochemical developments concerning new tracers.

[Postoperative quality of life for patients with a vestibular schwannoma]. / Qualité de vie chez les patients opérés d'un schwannome vestibulaire.

OBJECTIVES: To determine the prognoses criteria of quality of life's impairment after vestibular schwannoma surgery. STUDY DESIGN: Our study includes retrospectively 104 consecutive patients operated between 1991 & 2000 of a vestibular schwannoma. Patients with bilateral tumors were not included, neither patients lost of follow-up. The french version of the Short Form-36 self assessment questionnaire was sent to all patients. RESULTS: The response rate was 68% (71 patients). The patients' postoperative quality of life was lower of the norm, especially for psychical dimensions. This impairing of health whatever age, tumor size, operative approach or follow-up time. Sex and 2nd surgery were the only factors associated with a lower score. Women had worse rating of physical functioning. CONCLUSION: To operate small tumors should not assume that the impact on patients'life would be necessary less than following the removal of larger tumors. Women should have particularly clear explications before surgery and while follow-up.

Acute laryngeal paralysis induced by the migration of a totally implantable venous access device's catheter tip.

The authors report a case of acute vagus nerve paralysis that appeared during a course of chemotherapy. The drugs had been administered through a totally implantable venous access device (TIVAD), whose catheter tip had migrated into the right internal jugular vein (IJV) and was surrounded by a complete venous thrombosis. The supposed aetiology of this paralysis was a leakage of the cytotoxic drug (5-fluorouracil) from the vessel wall into the surrounding carotid space, because of the stagnation of the chemotherapeutic agent above the thrombosis. Four months after cessation of chemotherapy, the laryngeal paralysis was still evident.

[Susac syndrome or microangiopathy of the cochlea, brain and retina]. / Syndrome de Susac ou microangiopathie cochléo-encéphalo-rétinienne.

OBJECTIVES: Susac syndrome, also called SICRET syndrome (small infarction of cochlear, retinal, and encephalic tissue) is a rare condition difficult to diagnose. Sudden deafness may be the inaugural sign. MATERIAL AND METHODS: A female patient developed subacute encephalopathy, bilateral sensorineural hearing loss, and ischemic retinopathy. The patient was given cyclophosphamid and methylprednisolone for six months, followed by prednisone for eight months. RESULTS: Signs of encephalopathy had totally regressed by month 14 and retinal arteries were free of obstruction. Deafness remained unchanged. CONCLUSION: Diagnosis of this microangiopathy involving the inner ear, the brain, and the retina is suggested by the clinical triad and established on the basis of tonal audiometry, fundus examination, fluorescein angiography, examination of the cerebrospinal fluid, magnetic resonance imaging. Multiple sclerosis is the main differential diagnosis. The pathogenesis remains unknown. We observed transient-evoked otoacoustic emissions. There is no consensus concerning treatment. Many advocate combining corticosteroids and immunosuppressors. Otolaryngologists should be aware that an ophthalmological examination is required for patients with central or visual disorders associated with hearing loss.

[Current aspects of laryngeal tuberculosis: a report of four cases]. / Aspects actuels de la tuberculose laryngée. A propos de 4 cas.

OBJECTIVE: Laryngeal tuberculosis is a rare condition. This new clinical pattern of tuberculosis should be recognized by clinicians. METHODS: We report our experience with four cases of laryngeal tuberculosis. RESULTS: The principal differences in the disease pattern are an increase in the number of cases of primary laryngeal tuberculosis without any evident pulmonary involvement and the declining number of pseudotumor forms with an larger number of nonspecific laryngeal localizations. CONCLUSION: Tuberculosis should be entertained as a possible diagnosis in patients with nonspecific laryngeal disease. The diagnosis is confirmed by identification of granulomatous inflammation and acid-fast bacilli. New culture techniques and molecular biology methods such as polymerase chain reaction allow early identification of Mycobacterium tuberculosis.

[Cephalic vein access for implantable venous access devices. Technique and long-term follow-up]. / Veine céphalique et chambre à cathéter implantable. Technique et suivi à long terme.

OBJECTIVE: To evaluate 1) the advantages and drawbacks of the cephalic vein access for totally implantable venous access devices (TIVAD); 2) the complications of such devices at long-term follow-up. PATIENTS AND METHODS: A retrospective study of a series of 107 cephalic vein accesses attempted on 105 patients from January 1997 to December 2001, in our department. They were 87 men and 18 women, aged from 25 to 85 years (mean: 59). The authors evaluated in each case the surgical technique, the preoperative incidents, the side of surgery, and the short-term and long-term complications. The total follow-up reached 41 284 days. RESULTS: The cephalic vein access attempt failed in 12 cases (11%). These failures were due to intravenous blockade of the flexible catheter or to misroutine of the catheter in 5 cases and to a too thin vein in 7 cases. There was no statistically significant difference between the right and left sides. There was no technique-related complication. There were 18 postoperative complications (19%) out of the 95 devices that were implanted: 6 venous thrombosis, 7 infections, 4 catheter disconnections including 3 intra-cardiac migrations, 1 catheter occlusion. In 12 of these cases, the whole device had to be withdrawn. In the whole series, the devices were withdrawn at mean of 435 days after implantation. CONCLUSION: The use of a TIVAD is necessary when a chemotherapy must be delivered for treatment of a cancer. Cephalic vein access appears to be easy, quick and relatively safe. Postoperatively, serious complications can be encountered like with any type of TIVAD. These complications must be well-known if one wants to manage them well.

[Positron emission tomography in head and neck oncology: five cases]. / La tomographie à émission de positons en oncologie ORL. Une revue à propos de 5 cas.

FDG-PET (18-fluoro-desoxyglucose positron emission tomography) is a fonctionnal imaging method based on the high rate of glycolysis in different types of cancer-cells. We report the first five cases where FDG-PET was used in France for head and neck cancers. The results were analyzed on the basis of data reported to date in the literature, leading to a proposal for rational use of this diagnostic available in only a few centers in France. For primary assessment of cervicofacial carcinomas, different imaging techniques such as CT and MRI have improved tumor staging. Although 18-FDG-PET cannot replace these techniques used to monitor size and structural changes in tumors and lymph nodes, it will be helpful in following their metabolic activity. This diagnostic tool consequently is greatly helpful for detection and post-therapeutic evaluation of head and neck carcinomas and their recurrence. 18-FDG-PET is currently under evaluation as a tool for detecting cervical lymph nodes and early assessment of response to chemotherapy.

Fine alterations of distortion-product otoacoustic emissions after moderate acoustic overexposure in guinea pigs.

Guinea pigs were exposed to a pure tone at 6 kHz and 80 dB SPL for 30 minutes in order to induce mild reversible auditory fatigue over the 4 hours following exposure. Cochlear monitoring aimed to compare the shifts in round-window compound action potentials (CAP) thresholds to those of 2f1-f2 distortion-product otoacoustic emissions (DPOAE, frequency of stimuli f1 and f2). Both responses were evaluated every 1/10th octave between 6 and 12 kHz for CAP thresholds, and from 4 to about 14 kHz for DPOAEs in response to 50- and 70-dB SPL stimuli. The auditory fatigue turned out to be sufficiently mild that DPOAEs remained present, so that their microstructure could be followed up while the stimulus frequency ratio f2/f1 was swept from 1.06 to 1.30 (fixed f2) so as to derive DPOAE level profiles against f2/f1 and group latencies. CAP thresholds decreased by about 10 dB above 7.2 kHz, whereas DPOAE amplitudes decreased at most f2 frequencies from 6.6 kHz to 15.2 kHz, with the range of decrease being slightly narrower at higher stimulus intensities. While the mean DPOAE shift after 1 hour was around 5 dB irrespective of stimulus intensity, it tended to increase slightly after 2 hours despite stable CAP thresholds. DPOAE profiles against f2/f1 were slightly modified by the auditory fatigue, so that the maximum tended to be reached at lower ratio. No significant variation of DPOAE latencies was found after acoustic overstimulation. These experiments show that complex DPOAE changes were induced by auditory fatigue and their relationship to CAP threshold changes does not seem to be straight-forward. Nonetheless, fine DPOAE recordings might be useful to detect early changes in cochlear mechanics.

[Positron emission tomography in head and neck oncology]. / Tomographie par émission de positons en oncologie de la tête et du cou.

Defining a therapeutic strategy in oncology requires a substantial amount of imaging data provided by modern techniques. While the description of the lesions and their environment has become very precise, there remains a certain degree of uncertainty concerning tissue typing. Positron emission tomography is a scintigraphy technique which can produce quantitative images of metabolic characteristics. 18F-fluorodeoxyglucose is a tracer allowing an analysis of glucose metabolism known to be highly increased in malignant tissues. Increased uptake is an indication of malignancy with an established correlation with proliferative capacity. The only limitation of the method is the generally weak uptake observed in benign hypermetabolic inflammatory or infectious areas. All stages of the disease are concerned for head and neck cancer patients. Clinical experience to date indicates that PET can be applied most usefully to search or residual disease with a possible differentiation between post-therapeutic fibrosis and viable tumor tissue as well as the identification of early relapse. Study of early response to chemotherapy is also an interesting application. Search for extension can also be improved with this technique allowing both regional and whole body explorations. Positron emission tomography is not widely available in France at the present time so all patients cannot be examined with this technique. Positron emission tomography is an evolving technique with improvements being proposed both in the technique and in tracer elements. Further information will be available with new developments in this non-invasive exploration tool.

[Value of positron-emission tomography in the post-treatment follow-up of epidermoid carcinoma of the head and neck]. / Intérêt de la tomographie par émission de positons dans le suivi post-thérapeutique des carcinomes épidermoïdes de la tête et du cou.

UNLABELLED: This study aimed at pointing out the supply of the positron emission tomography (PET) in the posttherapeutic follow-up of the head and neck squamous cell carcinomas and to determine the best period to perform this test. PATIENTS AND METHODS: Twenty patients have been included in this series, 16 men and 4 women. The PET was performed between 3 and 6 months after the end of all therapy. It systematically included radiation therapy. The results of the PET have been compared with those obtained by histology. The average distance of the follow-up of the patients after the achievement of the test was 11 months. RESULTS: They divided up according to the presence or not of an abnormal fixation on the PET imaging. Negative PETs: eight cases. Among those, a patient showed a metastatic cervical adenopathy at five months. Positive PETs: twelve cases which can be divided into three groups according to the area of the fixation. Primary site: 8 cases, 4 of which false-positive. Cervical lymph nodes: one case. Other sites: three cases. In our series PET had a sensitivity of 87% and a specificity of 67%. CONCLUSION: The PET is an original imaging as it allows a corporal metabolic study at one go. It seems to be very useful in the follow-up of patients who show a head and neck squamous cell carcinoma. The best period to perform it is the third or fourth posttherapeutic month. The high sensitivity is interesting within the context of an early detection of a residual tumour, for it allows to think of a suitable therapy quicker.

[Traumatic and occupational deafness]. / Surdités traumatiques et professionnelles.

The frequency of accidental, traumatic hearing loss is increasing due to a sometimes violently noisy environment and to the development of sports as leisure activities. The diagnosis is based on knowledge of the circumstances of the trauma and on otoscopic examination. Total audiometry localises the damage. Occupational hearing loss forms a special subset of traumatic deafness. This trauma is usually due to intense noise occurring at the work-place. It is of insidious onset, irreversibly progressive and without treatment once under way; Prevention is based on knowledge of the deleterious effects of noise and on the individual factors of the subject at risk.

[Rehabilitation of the paralyzed face by hypoglossal-facial nerve anastomosis. An analysis of 7 cases]. / Réhabilitation de la face paralysée par anastomose hypoglosso-faciale. Analyse de sept cas.

After facial nerve injury, in cerebello-pontine tumors surgery, hypoglossal-facial anastomosis is the most common procedure, to rehabilite a paralysed face, if direct facio-facial graft is not possible. This procedure must be done, in a second time, during the next year and followed with a specific reeducation. In seven patients operated between 1985 and 1996, we performed clinical evaluation and electrophysiological examination. The best evaluation is the clinical evaluation using the G. Freyss's facial testing. Best results are seen in early, specific and continued reeducation. All our patients have a good recovery of facial nerve function, but clinical examination and electrophysiological results are not correled with an objective video performance. The management of such patients needs efficient oto-neurosurgical team and specific trained physiotherapists.