Vibrant Soundbridge middle ear implant in mixed hearing loss. Indications, techniques, results.

OBJECTIVES: The aim of this article is to illustrate the aetiologies of mixed hearing loss that can benefit from a Vibrant Soundbridge (VSB) middle ear implant, the techniques performed and the first results. MATERIALS AND METHOD: The authors report their experience of 13 implantations in mixed hearing loss due to otosclerosis, sequelae of chronic otitis media and congenital aural atresia. The VSB implant was implanted alone or in association with another middle ear surgical procedure, on the ossicular chain or on the round window membrane. RESULTS: The average auditory gain for all patients is 32 dB for pure tone thresholds, and 25 dB for speech recognition. It results from the addition of a gain on the conductive hearing loss by direct stimulation of the inner ear, to a gain on the sensorineural hearing loss by amplification. CONCLUSION: Middle ear implants are the only hearing aids affording a gain in both the conductive and sensorineural components of mixed hearing losses.

[Middle ear cholesteatoma]. / Cholestéatome de l'oreille moyenne.

Cholesteatoma is a serious form of chronic otitis media. The aim of this paper is to present the state of the art of disease management, including recent data from the literature and the authors' derived from their Mentors' teaching, Professor Pierre Roulleau (Paris, France) and Professor Robert Charachon (Grenoble, France). The main recent advances concern the use of cartilage grafts to reconstruct the canal wall and/or tympanic membrane (allowing a significant reduction in residual cholesteatoma) and progress in medical imaging allowing more acute preoperative determination of extension of the cholesteatoma (in order to propose an optimally designed surgical technique) and a less invasive postoperative follow-up.

Use of the subgaleal fascia to construct the auditory canal in microtia associated with aural atresia. A preliminary report.

In this paper we introduce the use of a subgaleal flap to construct the auditory canal in cases of microtia associated with aural atresia. The anatomy, the vascularisation, and the nomenclature of the different planes that constitute the temporal region are wellknown. The subgaleal fascia, also referred to as the loose areolar fascia has been until now the less surgically exploited of these planes. Nevertheless, it has a structure and a vascularisation that enables it to be dissected and used surgically. The subgaleal flap used to line the neoauditory canal drilled into the bone provides a vascular bed that greatly improves the quality of the skin graft and supports the tympanoplasty. The procedure is done while the ear is being raised, which constitutes the second stage of the two-stage ear reconstruction. This new approach has been used on 22 ears. A preliminary analysis of the results shows that construction of the auditory canal has been improved.

Argon laser and Gherini-Causse Endo-Otoprobe in otologic surgery.

The authors describe the various surgical indications and techniques of the argon laser and Gherini-Causse Endo-Otoprobe in otologic surgery, from otosclerosis to chronic otitis. The advantages are numerous, permitting the surgeon to vaporize or coagulate tissue with optimal effect, avoiding excessive mobilization of the ossicular chain and diminishing the risk of damage to the facial nerve and inner ear structures.

Ossiculoplasty with J.B. Causse composite prostheses: our experience with 500 cases.

In ossicular pathology, many options are available when the restoration of the columellar effect is required. Autoplasty, heteroplasty and homoplasty have advantages and disadvantages, but considerable recent progress in development of the prosthesis has changed the state of the situation. 500 partial and total prostheses (Porp and Torp) of composite material (Flex HA and Teflon HA) designed by Jean-Bernard Causse and developed by Microtek, were used from January 1992 until December 1993. The authors present results at short and middle term involving all aspects of otologic surgery, as well as surgical techniques that were used.

Ossiculoplasty with composite prostheses. Overview and analysis.

Aeration of a mucosa-lined tympanic cavity is essential for a functioning middle ear. Extrusions of even the best-designed prostheses occur from abnormal middle ear conditions such as atelectasis, middle ear fibrosis, recurrent cholesteatoma, tympanic membrane perforation, and otitis media. Various polymers have been developed in an attempt to maximize prosthetic biocompatibility and ease of use while minimizing the chance of extrusion. One such polymer is a composite of hydroxyapatite and Silastic, known as Flex H/A. This material has been incorporated into two ossicular prostheses, the Universal Plus and the Causse Flex H/A prostheses. Certainly, refinements will continue to be made in the chemical makeup of the bioceramics in order to achieve optimal biocompatibility. In addition to biocompatibility, cost containment issues have influenced the development of ossicular prostheses. A universal prosthesis eliminates the need to stock multiple designs, thereby reducing the cost to institutions. One of the greatest challenges in the future will be to define the appropriate prosthetic design for optimal sound transmission. Consideration of prosthesis weight, head size, and footplate attachment are future research questions that need to be addressed in a scientific biologic model.

Herpes simplex virus ICP0 and ICP4 immediate early proteins strongly enhance expression of a retrovirus harboured by a leptomeningeal cell line from a patient with multiple sclerosis.

A leptomeningeal cell line (LM7) harbouring an unknown retrovirus was recently isolated from the cerebrospinal fluid of a patient with multiple sclerosis. However, spontaneous expression of the LM7 retrovirus in this primary culture is quite low. We present results showing that in vitro infection of LM7 cells with herpes simplex virus type 1 (HSV-1), but not that of control cells, results in (i) potent stimulation of the specific reverse transcriptase (RT) activity detected in the culture supernatant and (ii) co-expression of both typical HSV-1 virions and abundant retrovirus-like particles. Transfection of LM7 cells with plasmids expressing HSV-1 immediate early (IE) ICP0 and ICP4 proteins produced a similar enhancement of RT activity in culture supernatants with retrovirus-like particles being identifiable by electron microscopy. These effects were not observed with a plasmid expressing ICP27 or with the parental plasmid in LM7 cells, nor with any of these four plasmids in control cells. These results show that HSV IE trans-activating proteins strongly enhance the expression of the latent retrovirus present in LM7 cells. The possible role in vivo of herpesviruses as 'triggering' cofactors in the retrovirus hypothesis for multiple sclerosis aetiology is also discussed.

In vitro transmission and antigenicity of a retrovirus isolated from a multiple sclerosis patient.

We have recently isolated an apparently novel retrovirus (LM7) from a patient with multiple sclerosis (MS). We present here results showing that (1) LM7 retrovirus can be transmitted in vitro to a normal human leptomeningeal cell culture and that (2) specific antibody against this retroviral strain can be detected in MS cases. Our results suggest that, if this virus is an endogenous retrovirus, it is different from human endogenous elements already described.

Chondrosarcomas of the petrous apex.

From 1974 to 1988, four patients with chondrosarcomas of the petrous apex were followed. Average age was 46 years (range, 30 to 61), one man and three women. The mean delay between the first patient's symptoms and the visit was 18 months (range, 15 to 24). The surgical treatment consisted of two infratemporal approaches (type A), one transcochlear approach, and one partial excision by retrofacial route. For the four patients, the surgery was followed by cobalt therapy. Three of four patients are alive and one patient died 5 years later of a cerebrovascular lesion and bilateral acute parotiditis. None presented with a recurrent disease.

[Congenital cholesteatoma of the middle ear in children]. / Les cholestéatomes congénitaux de l'oreille moyenne chez l'enfant.

In a series of 16 middle ear cholesteatomas of a congenital type are reported in children; the youngest (18 months) presented with a bilateral case. Whereas a simple tympanoplasty could cure a localized pearl, typically anterosuperior in the mesotympanum, the stapes is fast eroded (7 cases) if progression goes on. Intact canal wall technique in 2 stages was the typical procedure. Good hearing results were generally achieved (except in one case of fixed footplate): 9 cases/14 with an ABG within 20 dB and an AC level within 30 dB.

[Tumors of the petrous apex]. / Les tumeurs de l'apex pétreux.

Diagnosis and treatment of petrous apex tumors are difficult. The paucity of their presenting symptoms stands out in sharp contrast with an often massive tumoral spread. Their diagnosis is sometimes of an uncertain nature in spite of M.R.I., requiring a biopsy by the middle fossa approach. Electron microscopy should always be requested. Surgical excresis is always delicate by one of the following approaches: middle fossa, translabyrinthine, infra-temporal, transcochlear. The clinical series presented here consists of 7 cases of cholesteatomas, 4 cases of chondrosarcomas and 1 case of giant-cell fibrous histiocytosis.

[Meningo-encephalomyelitis in Lyme disease]. / Méningo-encéphalomyélite de la maladie de Lyme.

A case of isolated central nervous system involvement in Lyme disease is described. A 13 year-old boy developed progressive spastic quadraparesis, chronic lymphocytic meningitis with a low CSF glucose concentration and demyelinating lesions of the white matter on MRI. The diagnosis was proved serologically by high antibody titers against Borrelia burgdorferi (BB) in the serum (1:5, 120) and CSF (1:1,280). There was evidence of specific intrathecal immune response against the BB antigen. The patient was treated with penicillin G and then ceftriaxone. The CSF abnormalities quickly improved but improvement of the neurologic symptoms was gradual and to date still incomplete.

Anatomical and functional reconstruction of old radical mastoidectomy cavities by obliteration tympanoplasty.

One hundred and seventeen patients who had previous radical mastoidectomies, atticotomies or Bondy operations were operated on between 1973 and 1984. An open technique with obliteration and traction meatoplasty was used in one stage in 19 ears (normal mucosa in mesotympanum) and in 2 stages in 98 ears (poor mesotympanum which needed to be dissected and covered with silastic sheeting). The second stage was performed 12 to 18 months later. Closure of the tympanic membrane was achieved in 93% of ears at the first stage. In 6 ears out of 81 second stages, residual cholesteatoma was found in the mesotympanum. No residual cholesteatoma was subsequently observed behind the flap but only 4 ears were checked behind the flap at the second stage. An air-bone gap within 20 dB was achieved in 85% of ears if the stapes was intact and surgery was performed in one stage, and in 55% of ears of the stapes was intact and surgery performed in 2 stages. If the crura were missing, an air-bone gap within 20 dB was achieved in 57% of ears in 2 stages.

[Surgery of acoustic neurinoma. Apropos of a personal series. Development of techniques and results]. / La chirurgie du neurinome de l'acoustique. A propos d'une série personnelle. Evolution des techniques et résultats.

Between 1973 and 1987, 125 acoustic neurinomas were operated on in oto-neuro-surgery. The sub-occipital approach route was used for Stages III and IV up to 1982 (30 cases). Subsequently, surgery for all the neurinomas used the translabyrinthine approach route (82 cases), except for those cases where an attempt was made to preserve hearing by a supra-petrosal route (6 cases) or a retrosigmoid route (6 cases). The translabyrinthine approach route provided the simplest sequellae and the best preservation of the function of the facial nerve: grades I and II in 68% of cases (in 80% of cases by excluding Stage IV). Preservation of hearing was perfect in 2 cases, and partial in 2 cases, out of 12 attempts. The use of a facial nerve monitor proved highly satisfactory.

[Natural history of Menière's disease concerning 92 cases from 1971 to 1980]. / Histoire naturelle de la maladie de Ménière. A propos de 92 cas inclus de 1971 à 1980.

The author analyzes 92 cases of Ménière's disease seen for the first time between 1971 and 1980 (average duration: 3 years and 11 months). The isolated forms of cochlear and vestibular onset are respectively in the order of 21% with periods of 10 to 13 years before the appearance of the second symptom. In this series, the frequency of bilateral forms appears to be low (7.5%). It is probably much greater in the long term, justifying conservative therapeutic methods for hearing. A total of 22 patients underwent surgery: decompression of the saccus endolymphaticus (10 cases); vestibular neurectomy (11 cases); decompressive plate (3 cases); and sacculotomy operation of Fick (2 cases). Four patients were operated on twice.

Melanin in the inner ear. An experimental study with control and kanamycin-intoxicated colored guinea-pigs.

Following several studies on the effects of kanamycin toxicity on the inner ears of guinea pigs, we have studied the importance of melanin in this phenomenon. Transmission electron microscopy showed that, under the influence of kanamycin, the intermediate strial cells developed a secretory aspect similar to that seen in skin melanocytes. This aspect as yet has never been described for the inner ear cells. A planimetric, morphometric method was also used to determine the strial cell melanin status in control animals. Additional findings in the study confirmed an increase in the number of melanosomes during kanamycin poisoning. Statistical data are discussed.

[Maternal-child transmission of Chlamydia trachomatis. A prospective inquiry in 168 pregnant women]. / Transmission materno-infantile de Chlamydia trachomatis. Enquête prospective chez 168 parturientes.

A prospective study was performed in 168 pregnant women in order to evaluate the frequency of perinatal transmission of Chlamydia trachomatis and to measure its effects on the child's health during his first 3 months of life. The micro-organism was detected by an immunoenzymatic method specific to Chlamydia antigens, and microimmunofluorescence was used for serological testing. Cervical smears taken at the end of pregnancy were positive in 3 women (1.7 per cent), while the sera of 37 women were positive for Chlamydia trachomatis. Altogether, 26.8 per cent of the women explored had had a contact with the micro-organism. Conjunctival smears taken from 1 month old infants were all negative, but 4 infants (out of 126) had positive nasal smears. The mothers of 2 of these had been exposed to the bacterium, but all 4 mothers had negative cervical smears. Antibody titres in 3-month old infants were 1.2 dilution on average below those found in the mothers. Women exposed to Chlamydia trachomatis are frequently unmarried; their pregnancies tend to shorter than normally, and their infants have more frequent episodes of rhinitis. These peculiarities are insufficiently pronounced to single out a population at risk that might benefit from detection of the bacterium.

Closed versus obliteration technique in cholesteatoma surgery.

In 533 surgical procedures for cholesteatoma, a closed technique was used in 60%, an obliteration technique with Palva flap was used in 35%, and an open technique was used in 5%. The closed technique has been done in stages in the authors' institution since 1973. The obliteration technique was only staged if the mesotympanum was dissected. In some cases, the Palva flap was partially lifted from the bone to check posterior cavities. A closed technique in one stage provided intact tympanic membrane in 97% of cases, but retraction pocket occurred in 25%; ABG was within 20 dB in 68% of ears if the stapes was intact and in 40% if crura were missing. Obliteration technique in one stage (if the mesotympanum was normal) provided intact tympanic membrane in 100% of cases, but one late residual cholesteatoma under the flap eroded the semicircular canal after 5 years. ABG within 20 dB was achieved in 68% of the ears if the stapes was intact and in 40% if crura were missing. Closed technique in two stages with Silastic sheeting achieved intact tympanic membrane in 97% of the ears. Residual cholesteatoma was removed at the second stage in 24% of the ears. ABG within 20 dB was achieved in 57% of the ears if stapes was intact and in 52% if crura were missing. Ten percent of the ears underwent an obliteration transformation at the second stage because of large mesotympanum cholesteatoma or retraction pocket. Late retraction pockets were observed in 10% of cases. Obliteration technique in two stages provided an intact tympanic membrane in 96.8% of the ears.(ABSTRACT TRUNCATED AT 250 WORDS)