[Perilymphatic effusion as a complication of otosclerosis]. / Geyser lors de la chirurgie de l'otospongiose.

INTRODUCTION: Stapes gusher means the leakage of perilymphatic liquid when opening the perilymphatic cistern. The perilymphatic liquid with a high pressure gushes with a great flow out of the cistern when the stapedotomy is executed. Otosclerosis surgery sometime brings to light abnormal contact between the inner ear and the sub-arachnoidian spaces in patients who didn't presented ear malformations. It's a very rare event (1/1000) which is different from a much more common and more moderate form of perilymphatic liquids high pressure (1/200). About 4 clinical observations, we compared our experience with other authors in specialist reviews. PURPOSE OF THE STUDY: About four observations, we confronted our experience with that of the literature. MATERIAL AND METHODS: Retrospective study between 1971 and 1998. It was about 3 males and 1 female, without antecedent except one of them who had been operated 5 years before for the opposite ear without gusher but without good audiometric result. They presented a conductive deafness with no answer of the stapedial reflex. We had 4 geysers during the platinotomia which were sealed with some connective tissue. RESULTS: Two patients had a post operative complete sensory hearing loss, one, a sensitive decline of the conduction thresholds (average 50 dB), the last one kept his bone conduction level with a mild sensory hearing loss. The most recent case had a scanner preoperatively which had not shown abnormality except for the focus of otosclerosis. DISCUSSION: Perilymphatic gusher is an unpredictable event that can not be diagnosed before the surgery, nether with clinical facts nor radiological elements. This involves serious consequences concerning not only the continuation of the surgical operation and the prognostic of the hearing but also concerning the danger of secondary meningeal infections. The best way to proceed in case of favourable cases consists in fitting the ossicular prothesis into the stapedotomy, when it's not to wide. Pieces of muscle can be used in some cases, taped on with biologic glu. Various techniques are used to lower the pression of the cerebrospinal liquid: hypertonic solutes, diuretic drugs, lumbar diversion. In all cases, it is necessary to start a wide spectrum antibiotic treatment and a vaccination against pneumococcis. CONCLUSION: The surgeon has to know all the option of the treatment when confronted with this situation in order to try to avoid tricky defect of the inner ear.

Current and historical perspectives on endolymphatic sac surgery.

The 70-year history of the Ear, Nose and Throat School, Bordeaux, is inextricably linked to the achievements of Georges Portmann who pioneered surgery of the endolymphatic sac (ELS) and who contributed to the reputation of the institution. This review comprises three parts: the experiment work of Portmann on the ELS, the research into clinical techniques that has been conducted at the School; and current viewpoints on Meniere's disease. We will also present a summary of the results of a comparison of ELS surgery and neurectomy of the vestibular nerve.

[Tympanoplasty in clinical practice: use and results]. / Tympanoplast en clinique: utilisation et résultats.

The halt in the use of allografts has resulted in the use in clinical practice in humans of a product that has been known for at least thirty years: collagen. Interesting experimental animal studies have been performed with the type I and type III collagen currently used: the Tympanoplast. This collagen, already used in numerous medical fields (digestive, renal and neuro-surgery) is of bovine origin. It is purified, and comes in the form of a reticulated plate. It is known for its qualities of reepithelialisation. We have been using it for more than a year for the reconstruction of the tympanic membrane. We use Tympanoplast 100 microns thick. All the cases of myringoplasties have been performed on dry ears, and essentially on partial perforations in reinforcement surgery. The results are most encouraging and depend on the surgical technique employed. On the other hand, the grafts performed on total perforations failed to produce the expected results. The paper presents work of the School, with the anatomical results and comments on the precautions to be taken when using Tympanoplast.

Does peri-operative guanethidine prevent reflex sympathetic dystrophy?

The use of intravenous guanethidine blocks is an accepted treatment for established reflex sympathetic dystrophy (RSD). Some units administer intravenous guanethidine peri-operatively with the intention of protecting their patients from post-operative dystrophy. There have been no studies confirming this protective effect of peri-operative guanethidine. Between 1992 and 1994 we performed a prospective randomized double blind study in 71 patients undergoing fasciectomy for Duputyren's disease. Peri-operative guanethidine did not prevent post-operative RSD in our series.

[Use of the Ilisarow device for correction of extensive Madelung's deformity]. / Anwendung des Ilisarow-Apparates zur Korrektur der ausgeprägten Madelung'schen Derformität.

After a historical review of the Madelung's deformity, an operative technique is presented, using the Ilisarow distractor to correct severe deformities in adolescence. The goal of surgery at this age is the prevention of complications in a later period. These complications include arthrosis, pain, progressive limitation of motion in the wrist, and ruptures of extensor tendons. Our method is useful to do an operative correction - also of big angles - without using an autologous bone graft. Furthermore, the use of Ilisarow techniques allows gradual non-invasive corrections in the first postoperative period, and we can avoid surgery of the distal ulna to maintain the distal radio-ulnar joint. In 1991, three patients were treated in this manner and the results are encouraging.

[Diagnosis, etiopathogenesis and therapy of carpal tunnel syndrome]. / Zur Diagnose, Atiopathogenie und Therapie des Karpaltunnelsyndroms.

This is a retrospective study analyzing the operation records of 637 patients cured for carpal tunnel syndrome. No statistical difference could be demonstrated between the mean age of female compared to male. However a highly significant statistical difference between age distribution in between sex could be demonstrated (p = 0.0015). 61.3% of the female (male: 47.6%) are affected by the disease between 40 and 65 years and only 16.4% (male 27.6%) later on. Under 40 years of age both sex are affected in the same proportion. This confirms that hormonal factors related to sex play a major role in the etiology of this disease affecting mainly women (71%). On the contrary, combined pathology as tendovaginitis, ulnaris neuropathy at the elbow, synovitis bound to rheumatoid arthritis and epicondylitis were equally distributed between sex.

[Apropos of the infratemporal pre-auricular approach (its value in the approach to the midline skull base]. / A propos de la voie pré-auriculaire infra-temporale et sous-temporale (son intérêt dans l'abord de la base du crâne médiane).

The role of the infratemporal pre-auricular pathway to the median base of the skull resides in the fact that it enables very wide access to this region while sparing the facial and auditory nerves. Among the operations performed on the approaches of the base of the skull by their teams, the authors chose a particularly typical observation dealing with the indication of this pathway: a 34-year old male with a giant cholesteatoma of the tip of the petrous bone totally surrounding the internal carotid artery along its entire (intrapetrous) length, from the cervical region to the cavernous sinus, having invaded the clivus and pushed back the brainstem. This lesion is located on the side of the only healthy ear. The patient is completely deaf in the ear on the other side. The operation enabled its complete exeresis while respecting the facial, auditive and vestibular functions.

[20 years of tympano-ossicular allografts]. / 20 ans d'allogreffes tympano-ossiculaires.

As ossicular homografts have been readily used since 1965 and tympanic and tympano-ossicular grafts since 1970, we felt it would be interesting to analyse over 3000 cases taken from two centers (Paris and Bordeaux) and to consider the evolution and development of these grafts. The study concentrates on five main points: the indications for tympanic and tympano-ossicular homografts; the immediate and long-term anatomical results; the immediate and long-term functional results; the disadvantages and risks associated with their use; the evolution and development of homografts Looking at the whole study we consider the results to be very satisfactory especially when one considers the pathological context in which they are achieved. We comment on the problems encountered with these homografts. However these should not constitute a contra-indication to their use.

[Exostosis of the external auditory canal: clinical and therapeutic aspects]. / Les exostoses du conduit auditif externe: aspects clinique et thérapeutique.

Based on the study of 25 cases, the authors recall the frequency and pathogeny of these lesions, specifying the surgical technique and presenting their results. The risks of this surgery lie in the ever possible impairment of the facial nerve and labyrinthization on treble frequencies (2 cases). The incidents are tympanic perforation (1 case) and the opening of the temporomandibular joint. It is not always possible to preserve the skin of the external auditory canal. It can be reconstructed by a free (3 cases) or pedicle (3 cases) graft of more simply in case of small loss of substance by a temporal fascia graft.

[Techniques of reconstruction of the middle ear]. / Techniques de reconstruction de l'oreille moyenne.

Reconstruction of the middle ear, after eradication of evolutive lesions, consists of the functional restoration of the transmission components, i.e. the ossicles and the tympanic membrane. Several materials and forms of assembly are available both for the ossicles and for the tympanic membrane. The essential features of ossiculoplasty by columella effect are its simplicity, efficacy and safety. There are also indications, for partial or total anatomic assemblies by tympano-ossicular allografts. The choice of the type ot tympano-ossicular reconstruction will depend on the pathological context, to obviate the creation of an iatrogenic pathology. The results for each type of reconstruction are presented together with the short and long term evolution, through the evaluation of failures.

[Labyrinthine fistulae]. / Les fistules labyrinthiques.

The study is based on 44 cases of labyrinthic fistulas which were almost always discovered per-operatively. The authors describe the different stages of evolution, grouped under the term of "fistula". Having summed up the main therapeutic guidelines published since 1950 and following the study of the different cases presented, a therapeutic approach is proposed which takes into account the condition of the opposite ear and the open or closed technique selected. As far as audiometry is concerned, the cochlear reserve must be safeguarded. Technically speaking, the best attitude is to carry out the ablation of the matrix in one or two phases depending on the size, to prefer a closed technique and to drain the fistula at the end of the operation.

Anatomical and surgical particularities of cholesteatomas in children.

In children, cholesteatoma is closely related to dysfunction of the eustachian tube and evolves inside a malleable temporal bone. The importance of auditory and speech functions in such patients has caused us to use a very particular clinical philosophy. At the present time we have studied 154 cases of cholesteatomas in children under 15 years old. The following three points have been shown: the pathogenesis of a cholesteatoma can be of the primary type, secondary (due to an unfavorable extension of retraction pocket or to squamous cell migration) or even be iatrogenic; anatomical and clinical findings (with X-ray studies) predicate the treatment used; surgical treatment frequently requires a "second-look" operation.