Imaging of tumors and tumor-like lesions of the knee.

Tumors and tumor-like lesions of the knee are common conditions. Because the synovial membrane covers a large part of the knee, tumors and tumor-like lesions of the knee are mostly synovial. Magnetic resonance imaging (MRI) plays a major role in the assessment and characterization of these lesions. However, the diagnostic approach of these lesions must be performed systematically. First, the lesion must be precisely located, and then the anatomical structure involved must be determined. Finally, clinical background that includes the age of the patient, frequency of the disease and, if any, associated signs as well as MRI characteristics must be analyzed. In this review, we describe the anatomy of the knee and its compartments and provide a description of the main tumors and tumor-like lesions of the knee. We present a diagnostic approach based on the location within the knee of the lesions and the anatomical structures involved.

Imaging of the postoperative knee.

On sagittal images after anterior cruciate ligament (ACL) reconstructions, the femoral tunnel aperture should be at the junction of the line drawn along the posterior femoral cortex and the line drawn along the roof of the intercondylar notch (Bluemensaat line). The tibial tunnel aperture should be in the anterior portion of the second third, i.e. anterior aspect of the middle of the tibial epiphysis. An inaccurate placement of the femoral tunnel affects the graft isometry. A tibial tunnel too anteriorly placed results in intercondylar notch roof impingement. After meniscus surgery, first-line MRI is often sufficient to diagnose new tears; however, sometimes it is necessary to perform CT arthrography or MR arthrography. Surgical cartilage repair is evaluated based on articular congruity and on the appearance of the subchondral bone.

Hoffa's disease: a report on 5 cases.

We report the case of five patients referred to our department with Hoffa's disease: three patients were at the initial stage of the disease and the two others had reached the chronic stage. This condition is one of the less well-documented causes of pain in the anterior compartment of the knee. The pathophysiological mechanism is still unclear. It is probably caused by repetitive micro trauma resulting in inflammatory, haemorrhagic and fibrous changes to Hoffa's fat pad. The final outcome of the disease is an osteochondroma. The diagnosis is established by MRI, which demonstrates inflammation of the fat pat. At the chronic stage, a standard X-ray is sufficient to demonstrate ossification of the fat pad.

Fetal airway management on placental support: limitations and ethical considerations in seven cases.

The aim of this study was to evaluate the paediatric and maternal outcome after ex utero intrapartum treatment (EXIT). A retrospective review was carried out of the medical charts (gestational age, circumstances of diagnosis, multidisciplinary prenatal decision, date of surgery, paediatric and maternal outcome) of all the fetuses eligible for/delivered via the EXIT procedure in our paediatrics and obstetrics tertiary care and teaching centre, between October 2004 and May 2011. Seven fetuses with cervical teratoma, epignathus tumour or congenital high airway obstruction syndrome (CHAOS) were included in our study. Two pregnancies were terminated and five fetuses were delivered alive. The airway was secured in all five cases (two endotracheal intubations and three tracheostomies). No maternal complications were observed. On average, babies were delivered at 32 gestational weeks, and spent 31 days in the intensive care unit. All but one baby were ventilated for 18 days. Long-term paediatric outcome was favourable. It is concluded that airway management by the EXIT procedure has become an efficient technique. A multidisciplinary prenatal assessment is essential in order to select appropriate cases.

Tumors of the rib.

The authors propose a pictorial review illustrating the imaging features of chest wall tumors and their specific features that discusses the main differential diagnoses. This review is based on published information and on our own experience.

[Audiophonological evaluation of 16 children fitted with cochlear implants for sensorineural hearing loss induced by bacterial meningitis]. / Implants cochléaires dans les surdités après méningite bactérienne: suivi audiologique de 16 enfants.

BACKGROUND: Bacterial meningitis (BM) is the primary etiology of acquired sensorineural hearing loss (SNHL) in children and may compromise language development. Since the 1990 s, cochlear implants (CIs) have become part of the management of children with profound SNHL with encouraging results. The aim of this study was to analyze the audiophonological performance of children before and after cochlear implantation for SNHL following bacterial meningitis. METHODS: Retrospective study of all children fitted with CIs for bilateral severe to profound SNHL after bacterial meningitis in the Robert-Debré pediatric ENT department between August 1990 and March 2009. Audiophonological performance was assessed using the APCEI profile. RESULTS: Of the 283 children receiving implants during that period, 16 children (6%; 6 boys, 10 girls) underwent CI implantation after bacterial meningitis (Streptococcus pneumoniae in 8 cases, Neisseria meningitidis in 2 cases, and Haemophilus influenzae in 4 cases). The mean time from meningitis to SNHL was 8.3 months (median, 1.5 months; range, 1 day to 13 years). The mean time from meningitis to cochlear implantation was 2 years and 3 months (median, 7 months; range, 1 month to 13 years 3 months). Twelve children (75%) presented partial cochlear and/or vestibular ossification on presurgical CT scan. Three children received bilateral implants. DISCUSSION: Thirteen children (81%) developed early SNHL in the first 3 months, whereas 3 children developed SNHL more than 10 months after meningitis. As for the benefits of cochlear implantation, 11 children presented near to normal intelligibility and optimal use of their cochlear implant; 5 children presented partial benefits due to neurological sequelae (1), a long delay before implantation (1), technical problems (2), or a social problem in relation to low socioeconomic status (1). CONCLUSION: After bacterial meningitis, audiological evaluation must be made carefully during the first 3 months to detect early SNHL, but SNHL may also develop several years later. In case of profound SNHL and a modified signal of the labyrinth on the MRI, cochlear implantation must be performed without delay before cochlear and/or vestibular ossification. Cochlear implantation is an effective technique with good long-term audiologic results. The coexistence of neurological lesions may compromise the results, but it should not contraindicate a cochlear implantation.

Cartilaginous tumours and calcified lesions of the hand: a pictorial review.

Cartilaginous tumours of the extremities are commonly seen in radiographs. Enchondroma is the most frequently encountered tumour. Since the vast majority of enchondromas are asymptomatic, they are typically discovered as incidental findings or along with a pathologic fracture. The authors propose a pictorial review to illustrate the imaging features of cartilaginous bone lesions of the hand and their specificities, and discuss the main differential diagnoses.

Long term results of ossiculoplasties with partial and total titanium Vario Kurz prostheses in children.

OBJECTIVE: To assess and compare the efficacy of the Kurz titanium prostheses for total or partial ossicular reconstruction in children. PATIENTS AND METHODS: Retrospective chart review was performed for 71 consecutive children who underwent 74 ossicular reconstructions with Kurz prostheses between December 1999 and October 2007 (27 PORP and 47 TORP). Audiological parameters using four-frequency averages (0.5, 1, 2 and 4 kHz) were assessed pre- and postoperatively. Clinical and audiometric follow-up times were respectively 33±18.6 and 30±17.7 months (mean±SD). RESULTS: Fifty-two percent of all patients achieved an air bone gap (ABG) ≤20 dB, 53.8% in the PORP group and 51.1% in the TORP group. The improvement of the mean ABG was 13.3 dB, 9.4 dB for PORP and 14.6 dB for TORP. Overall mean pure tone averages improved 13.2±1.8 dB (mean±SEM) with 10±2.7 dB for PORP and 15±2.4 dB for TORP. The sensory neural hearing loss rate was 1.4% (one TORP) and the extrusion rate was 2.7% (n=2/74). CONCLUSION: The success rate (ABG≤20 dB) and the pure tone averages were not different between PORP and TORP. Kurz titanium ossicular prostheses offer high biocompatibility and high stability with low complication rates in pediatric ossicular reconstruction.

Cartilage tympanoplasty for posterosuperior retraction pockets of the pars tensa in children.

OBJECTIVE: To assess the functional and anatomic results of cartilage grafting in children with a severe retraction pocket of the posterosuperior part of the pars tensa and operated on by pocket excision and cartilage grafting. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Fifty six children (60 ears) with severe posterosuperior retraction pockets. INTERVENTION: Excision of the pocket and tympanic reinforcement with a tragal or conchal cartilaginous graft. MAIN OUTCOME MEASURES: Postoperative anatomic (otoscopy, computed tomography) and functional (pure tone audiometry thresholds) outcome. The follow-up time was 27 +/- 18 months (mean +/- SD). RESULTS: Retraction recurrences requiring additional surgery occurred in 5 cases (8%). The risk of recurrence was lower in children older than 10 years and when the whole surface of the pars tensa was reinforced (chi(2) test, p< 0.05 for both factors). Functionally, hearing was improved even when the ossicular chain was intact. In case of disrupted ossicular chain, direct contact between the graft and eroded incudostapedial joint gave good hearing results. CONCLUSIONS: Cartilage reinforcement of the whole surface of the pars tensa is probably the best treatment of a severe posterosuperior retraction pocket. The flexibility and thinness of cartilage from the cymba conchae makes it particularly suitable in this indication.

[Acute external mastoiditis in children: report of a series of 48 cases]. / Mastoïdites aiguës extériorisées de l'enfant: à propos d'une série de 48 cas.

DESIGN: To determine the impact of the emergence of penicillin-resistant strains of pneumococci on the frequency of acute mastoiditis in children, and to assess the importance of laboratory and imaging studies in the treatment of acute mastoiditis. METHOD: Retrospective review of the medical records of children with postauricular swelling and otoscopic signs of acute otitis media from January 1993 through December 2000. RESULTS: Forty-eight children aged three months to 14 years (median 17 months) were identified. The number of cases was almost the same from one year to another. All children had bacteriological examinations. The mastoid pus and the otorrhea was sterile in 22 cases. The most frequent pathogen was Streptococcus pneumoniae (17 cases), which was resistant to penicillin in 71% of cases. The initial body temperature, the number of polymorphonuclears and the CRP were not different between the group of 18 children with periostitis, which required medical treatment alone, and the group of 30 children who had a mastoid abscess which required surgery. The difference between periostitis and mastoid abscess was seen on clinical examination and CTscan.

Nucleus 21-channel auditory brainstem implant in patients with previous tumour removal.

Three patients with neurofibromatosis type 2 who had undergone previous cochlear nerve tumour removal were implanted with the Nucleus 21-channel auditory brainstem implant (ABI). The time intervals between tumour removal and implantation were 4, 5, and 7 years, respectively. Total bilateral deafness was confirmed before implantation. One patient was also blind after acute intracranial hypertension. The translabyrinthine approach was used in all cases. The choice of side for implantation depended on pre-operative magnetic resonance imaging study, the facial nerve function, the presence of recurrent and/or other lesions, and the patient's preference. Although the scarring of prior surgical procedure largely changed the anatomical structures in the cerebello-pontine angle, various landmarks could be found to locate the foramen of Luschka, where the ABI electrode was inserted into the lateral recess of the fourth ventricle. During surgery, the electrically evoked auditory brainstem responses were recorded to confirm that the ABI stimulation activated the auditory system; the electromyogram of the 7th and 9th nerves was helpful in finding the landmarks and minimising the triggering of the cranial nerves with ABI stimulation. The number of active electrodes was 21, 7, and 4 in the three patients. All obtained meaningful pitch scaling and useful auditory sensations. One patient, with 21 activated electrodes, has achieved functional open-set speech understanding. The second patient, with 7 activated electrodes, has benefited from environmental sound awareness and improved lipreading. The last, blind, patient, with 4 electrodes activated, achieved only perception of environmental sounds.

[Surgical management of laryngeal stenosis in children]. / Traitement chirurgical des sténoses laryngées de l'enfant.

Surgical management of children with laryngotracheal stenosis changed recently because of the procedure of single-stage approach. Between January 1992 and April 1997, 101 children underwent surgery for laryngotracheal stenosis in our department: 47 of them had a single stage procedure, and 54 a classic laryngotracheoplasty with stenting with an Aboulker's tube or silastic sheets. The majority of the cases were acquired stenosis (64%) and the others congenital. The degree of stenosis was graded into four categories according to Cotton's classification. Thirty six cases were grade 2, 44 cases were grade 3, 21 cases were grade 4. Subglottic localization of the stenosis was found in 64% of the cases and the mobility of the vocal folds was normal in 60% of the cases. The surgery was considered successful after one procedure when there was a permanent and permeable laryngotracheal lumen (no more than grade 1) not requiring a tracheotomy. Of the 47 single-stage procedures, 38 were successful (81%); of the 54 cases managed with classic methods, 30 were successful (55%). These results and the indications of the different surgical procedures are discussed.

Facial neuromas in children: delayed or immediate surgery?

OBJECTIVE: The objective of this study was to investigate the clinical characteristics and outcome of facial nerve neuromas in children. To date, no specific study has focused on children, and the management of these tumors is not codified. DESIGN AND SETTINGS: A review of case series treated in a tertiary care center of pediatric otolaryngology. SUBJECTS: The treatment and outcomes for 7 children (4 infants and 3 adolescents) were analyzed. RESULTS: Six patients underwent complete removal of tumor and immediate restoration of the nerve continuity. The grade of facial palsy improved in 4 of the 6 children, but did not get better than grade 3 (House classification). The remaining patient was managed conservatively and remained stable clinically and radiologically after 9 years follow-up. CONCLUSIONS: These findings support the reasonable strategy of combining conservative assessment of these slow-growing tumors with regular clinical and radiologic evaluations and radical surgery using various procedures. The choice depends on the age of the child, the extent and growth rate of the tumor, the grade of facial palsy, and the hearing function.

[Long-term esophageal and oropharyngeal pH-metry in ORL manifestations of gastroesophageal reflux in children]. / La pH-métrie couplée, oesophagienne et oro/hypopharyngée, de longue durée dans les formes ORL de reflux gastro-oesophagien de l'enfant.

Several studies published over the last few years have pointed out the importance of gastroesophageal reflux (GER) in the pathogenesis of certain cases of chronic or recurrent pharyngo-laryngitis. While the presence of an acid reflux at the level of the pharyngo-larynx has recently been demonstrated in certain cases, the real incidence and pathogenic impact of this reflux is not precisely known. A new technique of continuous 24 hour bi-level monitoring of endoluminal pH in the esophagus and the oro/hypopharynx has made it possible to observe the variations in acid-base balance in contact with the pathological mucosa. 21 patients, 2 months to 7.5 years old, presenting recurrent episodes of pharyngitis or laryngitis, underwent continuous pH monitoring during a 24 hour hospitalization. 6 control subjects, 1 month to 13 years old, presenting no chronic or recurrent ear, head or neck pathology and no sign or symptom of GER were subjected to the same monitoring regimen. A statistically significant difference between the 2 groups is evident for most of the parameters analysed. The most discriminative parameter is the fraction of the total recording time where the pharyngeal readings remain under ph6 (p < 0.0005). These results demonstrate that, in this clinical condition, acid of gastroesophageal origin is in contact with the pharyngeal mucosa. This suggests that the acid has a causal role in the pathological changes observed in the pharyngolaryngeal mucosa.

[Variations of nasopharyngeal pH in nasopharyngitis in children]. / Variations du pH rhinopharyngé dans les rhinopharyngites de l'enfant.

In view of the well-known relationship between gastro-oesophageal reflux (GOR) and inflammatory diseases of the bronchi, trachea and larynx, the possibility of a pathogenic acid reflux reaching the pharynx has sometimes been suspected but never demonstrated. Paediatric E.N.T. specialists are often confronted with chronic inflammatory rhinopharyngitis of no obvious origin. In order to test the hypothesis of rhinopharyngeal contamination by gastric acid, the nycthemeral local pH was recorded in children presenting with chronic rhinopharyngitis and gastro-oesophageal reflux, and in two groups of controls without rhinopharyngitis and with or without GOR. Falls in rhinopharyngeal pH were found to be more frequent and to last longer in the 18 patients than in controls. The most significant criterion was the time during which the pH was lower than 6 compared with the total time of recording in these cases where pharyngeal pH measurements were recorded over 15 to 26 hours. It seemed most probable that this acidity resulted from the gastro-oesophageal reflux. Such variations in acid-base balance at the surface of a respiratory mucosa might be instrumental in the genesis or maintenance of the nasopharyngeal inflammatory reaction. However, these two hypotheses must be confirmed or infirmed by further studies.

[Perilymphatic fistula]. / Fistule périlymphatique.

Perilymphatic fistulae are the first cause of perceptive deafness that may be amenable to surgical treatment. After a complete study of the literature, we have made a retrospective analysis of 48 ear explorations in 37 children. These children presented with a variable degree of progressive or fluctuating perceptive deafness without any obvious etiology. Computed tomography, especially aimed at detecting an abnormality in the patency of the aqueduct of the cochlea, seems to be the most efficient criterion of selection to establish an indication for surgical exploration. The extent of the perilymphatic fistulae and their location, mainly at the level of the fissura ante fenestram, call to our mind the possibility of an arrest in the differentiation of the otic capsule, with a persistent anomalous patency of the aqueduct of the cochlea. The results of this study mainly demonstrate stabilizations of hearing, while spectacular improvements still are anecdotal. On the other hand, morbidity is very low and mainly results from insufficient surgery to fill in the fistula. Further studies are needed, especially to better understand the pathophysiology of the perilymphatic fistulae, and their results must certainly be appreciated in the longer term.

Involvement of cochlear nerve in acoustic tumours.

With conventional light and transmission electronmicroscopy we studied 10 cases of acoustic nerve tumour, 3 of which proved to be instances of von Recklinghausen neurofibroma and 7 of schwannoma. Schwannomas were not found to infiltrate the cochlear nerve. Hearing loss, if present in cases of schwannoma, could be related to non-specific lesions of the uninfiltrated cochlear nerve in the vicinity of the vestibular nerve tumour. Only neurofibromas were found to infiltrate the cochlear nerve. Distinction between tumour infiltration and non-specific lesion could be made by electron microscopy.