Balloon dilation for persistent unilateral chronic obstructive Eustachian tube dysfunction is effective: a prospective multicentre study

PURPOSE

Balloon dilatation of the Eustachian tube (BDET) is an option for treating chronic obstructive Eustachian tube dysfunction (COETD). In this prospective multicentric study, the main objective was to evaluate the results of BDET in unilateral COETD refractory to medical treatment.

METHODS

Adults with unilateral COETD whose Eustachian Tube Score (ETS) was less than 5 despite medical pressure therapy were included. The primary endpoint was the change in ETS measured at 2, 6, and 12 months after BDET. Secondary objectives were the evolution of clinical symptoms assessed by the Eustachian Tube Questionnaire (ETDQ-7), audiometry, tympanometry, and otoscopy changes after BDET.

RESULTS

Twenty-eight patients were included between May 2014 and December 2017 and were treated with BDET without adverse effects in three different referral centers. Population's median age was 52 (Q25; Q75: 24, 82) years. The median follow-up time was 381 (Q25; Q75: 364; 418) days. The median ETS was 2 (Q25; Q75: 1; 4) before BDET. There was a significant improvement in ETS at 2 and 6 months and 1 year after BDET (score at 1 year: 6 (Q25; Q75: 2; 8) (p < 0.0001)). There was a significant, sustained improvement in the ETDQ-7 with a score of 4.21 (Q25; Q75-3.50; 4.79) before BDET and 3.43 (Q25; Q75-2.43; 4.14) (p = 0.0012) at 1 year. There was a suggestive improvement in tympanometry results at 1 year (p = 0.025).

CONCLUSION

BDET provides an improvement in symptoms and objective measures assessed at 1 year in patients with COETD who have failed medical treatment.

TRIAL REGISTRATION

NCT02123277 (April 25, 2014).

Intratemporal facial nerve schwannomas: multicenter experience of 80 cases

PURPOSE

To provide more data on the clinical presentation and natural evolution of facial nerve schwannomas and to provide guidance for therapeutic decision making.

METHODS

A retrospective case review of eighty patients diagnosed with a facial nerve schwannoma between 1990 and 2018 in ten tertiary referral centers in Europe was performed. Patients' demographics, symptomatology, audiometry, anatomical site (segments involved), size and whenever possible volume measurement were registered.

RESULTS

At presentation, transient or persistent facial palsy was the most common symptom, followed by hearing loss. The schwannoma involved more than one segment in the majority of the patients with the geniculate ganglion being most commonly involved. Initial treatment consisted of a wait and scan approach in 67.5%, surgery in 30% and radiation therapy in 2.5% of the patients. Tympanic segment schwannomas caused mainly conductive hearing loss and were more prone to develop facial palsy at follow-up. Internal auditory canal or cerebellopontine angle schwannomas presented with significantly more sensorineural hearing loss.

CONCLUSIONS

Although modern imaging has improved diagnosis of this tumor, choosing the best treatment modality remains a real challenge. Based on the literature review and current findings, more insights into the clinical course and the management of facial nerve schwannomas are provided.

Conservative treatment of vestibular schwannoma: growth and Penn Acoustic Neuroma Quality of Life scale in French language

The aim of this study was to determine the natural history of growth and quality of life (QoL) outcomes for vestibular schwannoma (VS) managed conservatively, and to validate the disease-specific Penn Acoustic Neuroma Quality-of-Life (PANQOL) scale in French language. We retrospectively studied 26 patients with VS managed conservatively. Patient characteristics and radiological findings were collected. Two scales were used to measure QoL: the Short Form-36 Health Survey (SF-36) and the PANQOL scale translated into French. Internal consistency and scores were compared with previous studies. The mean follow-up was 25 months (range 6-72). We observed tumour growth in 14 patients (53.8%), no growth in 12 patients (46.2%) and no case of tumour shrinkage. The mean tumour growth was 2.22 mm/year. No predictive factor of growth was found. Patients with vertigo or dizziness experienced a poorer QoL according to the SF-36 (Social Functioning and Emotional Role Limitation dimensions) and to the PANQOL scale (Balance and Energy dimensions). Our results were comparable with the literature using the SF-36. With the PANQOL scale, our scores were not statistically different with those from Dutch and North American studies except in the field of hearing (p = 0.019). Quality of life becomes essential in the management of VS. According to these results, we support a non-conservative strategy associated with vestibular rehabilitation for patients with dizziness or vertigo. The PANQOL is a validated specific scale for VS, which can be useful in French.

Cerebellopontine angle gangliogliomas: Report of two cases

BACKGROUND

Gangliogliomas are rare tumors of the central nervous system. We report two unusual cases of gangliogliomas located in the cerebellopontine angle (CPA).

POPULATION AND METHODS

The first patient was a 57-year-old woman, who presented with dizziness and harbored a non-enhanced heterogeneous mass located in the cisternal space of the CPA. A partial microsurgical removal was performed, and the pathological examination concluded a grade I ganglioglioma according to the WHO Classification. The postoperative course was uneventful without any adjuvant treatment and the 5-year imaging follow-up indicated a stable remnant tumor. The second patient was a 35-year-old male who presented with acute vertigo and imbalance associated with recent prominent headaches; MR imaging showed a large heterogeneous and post-contrast enhanced tumor mass located in the CPA cistern with a mass effect on the brain. An optimal subtotal surgical resection was performed. The pathologists concluded a WHO grade III ganglioglioma. In spite of adjuvant radiotherapy and chemotherapy, the evolution proved unfavorable and patient died from cancer complications within a 2-year period. In both cases, the precise origin of the tumor could not be clearly identified even if the major component was present in the cisternal space.

CONCLUSION

Gangliogliomas growing into the cisternal spaces are exceedingly rare particularly in the CPA. Due to its infiltrating behavior and major difficulties to identify the tumor margins, total resection is not routinely feasible. The histological grading is the most important predictor for oncological prognosis.

Quality of life in bimodal hearing users (unilateral cochlear implants and contralateral hearing aids)

The main objective was to evaluate the bimodal self-rated benefits on auditory performance under real conditions and the quality of life in two groups of cochlear-implanted adults, with or without a contralateral hearing aid. The secondary objective was to investigate correlations between the use of a hearing aid and residual hearing on the non-implanted ear. This retrospective study was realized between 2000 and 2010 in two referral centers. A population of 183 postlingually deaf adults, implanted with a cochlear experience superior to 6 months, was selected. The Speech, Spatial, and other Qualities of Hearing Scale were administered to evaluate the auditory performances, and the Nijmegen Cochlear Implant Questionnaire to evaluate the quality of life. The population was divided into two groups: a group with unilateral cochlear implants (Cochlear Implant-alone, n = 54), and a bimodal group with a cochlear implant and a contralateral hearing aid (n = 62). Both groups were similar in terms of auditory deprivation duration, duration of cochlear implant use, and pure-tone average on the implanted ear. There was a significant difference in terms of pure-tone average on low and low-to-mid frequencies on the non-implanted ear. The scores on both questionnaires showed an improvement in the basic sound perception and quality of social activities for the bimodal group. The results suggest that the bimodal stimulation (cochlear implant and contralateral hearing aid) improved auditory perception in quiet and the quality of life domain of social activities.

Late pneumolabyrinth after undiagnosed post-traumatic perilymphatic fistula. Case report illustrating the importance of systematic emergency management

INTRODUCTION

Temporal bone fracture is a common complication of high-energy cranial trauma. Labyrinth involvement is rare, but there is a risk of perilymphatic rupture that is often underestimated on initial clinical examination due to the predominance of neurological and/or somatic symptoms.

CASE REPORT

A patient presented with overlooked perilymphatic fistula, decompensated by hyperpressure effort due to poorly adapted management.

DISCUSSION

Following a review of the literature on post-traumatic pneumolabyrinth, overall management (from diagnosis to treatment, via prevention advice) was analyzed. A constructive critique of the patient's treatment was thus made.

CONCLUSION

We argue for a systematic management protocol in cranial trauma with temporal bone fracture, comprising ENT examination, millimetric-scale cross-sectional imaging of the fracture site, and standardized counseling to prevent late complications.

[Middle ear barotraumas due to rhinopharyngeal scar tissue: tubomanometry diagnostic and therapeutic contribution]

OBJECTIVE

Evaluation of tubomanometry contribution to diagnosis middle ear barotraumas in relation with rhinopharyngeal scar tissue, and contribution to check postoperative effectiveness of scar tissue surgical resection.

METHODS

Clinical cases study of two stewardesses who have lost their flight fitness consecutively to barotraumatic otitis during landing, engendered by rhinopharyngeal scar tissue.

RESULTS

Pre-operative tubomanometric parameters were abnormal in both cases: decrease of intratympanic pressure in one case, variability of tube opening latency index and lengthening of intratympanic pressure rising time in the other case. Surgical section during endonasal endoscopy results in initially abnormal tubomanometric parameters normalization, allowing resumption of flight fitness without any barotrauma.

CONCLUSION

Some abnormal tubomanometric parameters help to establish causality link between middle ear barotrauma and rhinopharyngeal scar tissue for which surgical section is thus indicated. Post-operative tubomanometric parameters normalization prove surgical effectiveness. Then, flight fitness could then be restored.

Transoral surgical treatment of Eagle's syndrome: case report and review of literature

Eagle's syndrome is a symptomatic abnormal length of the styloid process and/or a calcification of the stylohyoid ligament. Diagnosis is based on common pharyngeal symptoms and is confirmed by radiologic examination, more particularly CT-scan. Medical and surgical treatments are described. Medical treatment consists in repeated local anaesthetics, steroid infiltration or analgesics administration. It is purely symptomatic and has no long-term effectiveness. Surgical treatment remains the treatment of choice and consists of removal of the abnormal process. Both transoral and external approaches have been described. The advantages of the transoral approach is a shorter operative time, the absence of aesthetic prejudice and a lesser risk of neurovascular injury. Few post operative complications have been described (surgical cervical emphysema, cervical swelling, trismus and moderate breathing difficulty) but none of the studies reported neurovascular injury, deep cervical infection nor long-term complication. We present the technique, a case report and a review of the literature of the transoral approach.

Comparison of [¹¹¹In]pentetreotide-SPECT and [¹⁸F]FDOPA-PET in the localization of extra-adrenal paragangliomas: the case for a patient-tailored use of nuclear imaging modalities

AIMS AND METHODS

The aim of this prospective study was to compare the diagnostic value of [¹⁸F]FDOPA-PET and [¹¹¹In]pentetreotide-SPECT somatostatin receptor scintigraphy (SRS) in patients with nonmetastatic extra-adrenal paragangliomas (PGLs). Twenty-five consecutive unrelated patients who were known or suspected of having nonmetastatic extra-adrenal PGLs were prospectively evaluated with SRS and [¹⁸F]FDOPA-PET. ¹³¹I-MIBG and [¹⁸F]FDG-PET were added to the work-up in patients with a personal or familial history of PGL, predisposing mutations, abdominal PGLs, metanephrine hypersecretion and abdominal foci on SRS and/or [¹⁸F]FDOPA-PET.

RESULTS

SRS correctly detected 23/45 lesions of which 20 were head or neck lesions (H&N) and 3 were abdominal lesions. [¹⁸F]FDOPA-PET detected significantly more lesions than SRS (39/45, P < 0·001). Both SRS and ¹⁸F-DOPA-PET detected significantly more H&N than abdominal lesions (66·7% vs 20%, P = 0·003 and 96·7% vs 67%, P = 0·012, respectively). In two patients with the succinate dehydrogenase D (SDHD) mutation, [¹⁸F]FDOPA-PET missed five abdominal PGLs which were detected by the combination of SRS, [¹³¹I]MIBG and [¹⁸F]FDG-PET. A lesion-based analysis using a forward stepwise logistic regression model demonstrates that size ≤ 10 mm (P = 0·002) and abdominal lesions (P = 0·031) were independently associated with "[¹⁸F]FDOPA-PET diagnosis only". In turn, a previous history of surgery and/or the presence of germline mutation was associated with lower lesion size (P = 0·001).

CONCLUSIONS

The sensitivity of SRS for localizing parasympathetic PGLs is lower than originally reported, and [¹⁸F]FDOPA-PET is better than SRS for localizing small lesions. SRS should be replaced by [¹⁸F]FDOPA-PET as the first-line imaging procedure in H&N PGL, especially in patients at risk of multifocal disease (predisposing mutations and or previous history of surgery).

[Paraganglioma of the cerebellopontine angle: report of two cases]

Paragangliomas of the cerebellopontine angle are exceptional tumours. We report two cases of paragangliomas of the cerebellopontine angle. To our knowledge, including these two cases, only five cases have been reported in the international literature. The emerging field of genetic study of these tumours will prove critical for their diagnosis and prognosis. The presence of paraganglioma in this area is explained by an abnormal embryologic migration of paraganglionic cells into the cerebellopontine angle, associated with tumorogenesis. These tumors can be associated with others cervico-facial tumours and to genomic abnormalities. The preoperative diagnosis of these tumours is very difficult, with clinical signs like hearing loss, vertigo and tinnitus are very ambiguous. Radiologic assessment of the cerebellopontine angle is also vague. The final diagnosis is only made possible peroperatively and by the post-operative histopathologic study. ENT and neurosurgeons should be awarded of the possible existence of paragangliomas of the cerebellopontine angle, and the necessity of a systemic and genetic assessment.

New perspectives for middle ear implants: first results in otosclerosis with mixed hearing loss

Middle ear implantation is an efficient procedure to restore moderate to severe sensorineural hearing loss (HL) in selected patients. Implantation of such devices requires ossicular chain integrity. Patients suffering from otosclerosis with mixed HL should be eligible for this treatment after stapes surgery with air-bone gap closure. To address this issue, we report four cases of middle ear implantation after or during stapes surgery. Results and complications obtained with Vibrant SoundBridge, MedEl and Middle Ear Transducer, Otologics are reported. Audiologic results were similar to those obtained in cases of sensorineural HL. One case of postoperative labyrinthitis was observed.

[Middle ear cholesteatoma]

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.

[The outcome of treatments for carcinoma of the external auditory canal]

OBJECTIVE

A retrospective analysis of management and survival of patients treated for temporal bone carcinoma.

PATIENTS AND METHODS

Thirty patients underwent treatment for carcinoma of the temporal bone. Twenty-five squamous cell carcinomas, 1 melanoma, 2 basocellular carcinomas and 2 adenoid cystic carcinomas were treated. Thirteen patients were treated before for the same disease.

RESULTS

Staging revealed 12 T1 and T2, 6 T3 and 12 T4 tumours. The mean follow up was 5 years (2-276 months). The Kaplan Meier survival curves showed survival rates at 2 years of 82%, 67% and 32%, and at 5 years of 82%, 67% and 17%, respectively for the stages T1 or T2, T3 and T4. At the end of follow up at 9 years the survival rates were 66%, 66% and 17% for the stages T1 or T2, T3 and T4 respectively. Overall stages a complete remission was found in 65% and 23%, and deceased was 35% and 77%, respectively for the primary treatment group and the salvage surgery group.

CONCLUSION

Long-term prognosis of the carcinoma of the external auditory canal mainly depends on the stage and primary treatment. Surgery (lateral temporal bone or subtotal temporal bone resection, both in combination with a neck dissection and a parotidectomy) and adjuvant radiotherapy is the treatment of choice for part of stage T1 and all T2 and T3 tumours. The improved survival (65%) of patients treated de novo compared with those treated with salvage surgery (23%) suggests that early referral and aggressive primary surgical treatment with postoperative radiotherapy offer the greatest chance of cure.

[The jugulotympanic paragangliomas: 41 cases report]

OBJECTIVE

The jugulotympanic paragangliomas (JTP) represents the most frequent tumour of the middle ear but also of the temporal bone, after the acoustic neurinoma. The management of these vascular tumours remains uncleared. The purpose of this study was to report our experience about JTP in the CHU of Grenoble.

MATERIALS AND METHODS

Retrospective study of 41 patients, between 1973 and 1996. Six stages A, 8 stages B and 27 stages C are reported in whom 20 cases (49%) presented an intracranial extension (classification of Fisch). There were 2 familial cases with multiple localisations, in particular carotid. All the patients were divided in 3 groups: surgery or radiation therapy in first intention, surgery followed by radiation therapy.

RESULTS

A total tumor removal without recurrence was achieved by surgery in more than 95% of the cases with 6 years follow-up but was associated with significant morbidity (major cranial nerve injury). We noticed one death by laryngospasme (C2Di2 tumour operated by infratemporal A approach). A stabilization of the tumour was obtained with radiotherapy in first intention in 75% of the cases (5 years follow-up) but with a risk of radionecrosis. A revision surgery was necessary in 3 cases.

CONCLUSION

The comparaison of our different therapeutic management, surgery (23), radiation therapy (16) or combined (2), encourage us to perform a radical surgery whenever possible. Because of the slow rate of growth, the radiotherapy is indicated for older patients, at risk for surgery or extensive tumors. The objectives of the radiation therapy are to obtain a tumoral stabilization with improvement of the symptoms and low morbidity. The management of this rare pathology must be multidisciplinary. The recent discoveries on genes encoding three succinate dehydrogenase subunits (SDHD, SDHB et SDHC) will allow a genetic detection of asymptomatic case and will define the procedures for their management, coordinated by a national network PGL.NET. A retrospective study could also study the real incidence of familial paragangliomas.

[Implication of mitochondrial apoptosis in neural degeneration of cochlea in a murine model for presbycusis]

HYPOTHESIS

Pathologies of senescence, in particular those of neurosensory organs represent an important health problem. The improvement of the life expectation entails the fast increase of the frequency of the presbyacusis in the population. The biological and molecular causes of this degenerative pathology of the inner ear are linked to the disappearance of the sensory cells (inner and outer hair cells) and are associated to nervous damages of the spiral ganglion in the cochlea. We were interested in mechanisms causing the cochlear degeneration in a model of mouse CD 1 presenting prematurely auditive losses.

MATERIALS AND METHODS

We tried to correlate the evolution of the hearing and the appearance of apoptotic phenomena by marking with specific antibody, activated anti-caspase-3, in the cochlea during time. We studied the role and the involvement of proteins controlling the apoptosis as the P53 protein and from an energy point of view at the level of the mitochondria such as proteins of the Bcl-2 family and the cytochrome c in the various structures of the cochlea.

RESULTS

After implantation of electrodes for auditory nerve acoustic thresholds measurements, the audition of mice CD 1 presented a characteristic profile of hearing losses which begins in the high frequencies from the age of 1 month and which quickly evolves towards the low frequencies. The observation (between the 1st and 3rd month of age) of spiral ganglion cells revealed an unchanged number of cellular bodies of type 1 neurons, on the other hand a characteristic morphology of apoptosis of glial cells with the formation of apoptotic body was noted. Indeed, glial cells expressed activated caspase-3. Furthermore, this phenomenon seems to be under the control of the pro-apoptotic protein Bax by its overexpression and a increased release of the cytochrome c. This phenomenon was followed at 3 and 6 months by the disappearance of the outer hair cells by 9 and 48% respectively.

CONCLUSION

The apparition of the deafness in the murin model CD 1 allowed us to demonstrate that the degeneration of cochlear structure begins at the level of glial cells of the spiral ganglion from 3 months, followed thereafter by the deterioration of the nervous conduction between the spiral ganglion and the sensory cells. As a consequence, because of the impoverishment in nervous signals, the outer hair cells would begin to disappear during the 6th month. In conclusion, the understanding of the sequence and the cause of these mechanisms responsible for the neural degeneration and the loss of hearing could eventually, allow us to optimize the various treatments of the presbyacusis.

Caractérisation du test vibratoire. Comparaison avec les résultats du « Head shaking test »

OBJECTIVES

The purpose of this work was to study the complementary contribution of the vibratory test (VT), the head shaking test (HST) and the caloric test (CT) in patients with total or partial vestibular lesions. We investigated the usefulness of these three tests, particularly the high frequency VT, for multiple-frequency vestibular study.

MATERIALS AND METHODS

The study cohort included 40 patients with total vestibular lesions (TVL) and 47 patients with partial vestibular lesions (PVL), the latter group including 21 patients with recent Menière disease, 15 with sudden-onset loss of vestibular function (SLVF), 5 with tumors of the cerebropontine angle, and six with diverse conditions. The HST protocol was 2 Hz stimulation (head speed greater than 180 degrees /s). The VT used an ABC 100 Hz vibrator operating at 0.8 mm and an S stimulator delivering frequencies between 30 and 115 Hz during 10 s stimulations. An LIVN-2 videoscope (biodigital France) and a 2D and 3D videonystagmograph (synapsis France) were used for the recordings. Mastoid stimulation was used for the VT.

RESULTS

For the 40 patients with TVL, the three tests (VT, CT, HST) were in agreement for all frequencies. The nystagmus produced by the VT demonstrated a horizontal component in 96% of the patients, a vertical component in 47%, and a rotational component in 30%. For the 47 patients with PVL, 9 of the 21 with Menière disease had a normal CT. Conversely, nystagmus was triggered by the HST in 10 and by the VT in 6. Nystagmus triggered by the VT and the HST was non-coherent with opposing direction in two-thirds of the patients. In certain cases, the VT demonstrated a variation in the direction of the nystagmus depending on the stimulation frequency, 30 or 100 Hz. Among the 15 patients with SLVF, the HST triggered nystagmus in only 5 and the VT in 14 (5 patients had nystagmus non-coherent with the side of the lesion). For the 5 patients with tumors of the cerebropontine angle (small neuroma or meningioma), the CT was negative in all 5, the HST was negative in 3, and the VT demonstrated lesional nystagmus in 4. Looking at the overall results, in the 47 patients with PVL (including 21 cases of Menière disease outside an acute phase) the CT demonstrated significant hypovalence in 70%, while the nystagmus demonstrated asymmetrical response in 44% when triggered by the HST and in 85% when triggered by the VT.

CONCLUSION

The VT is less invasive than the HST, particularly for elderly patients with osteoarthritis. It would be interesting in patients with bilateral tympanic perforation since the CT cannot be performed. It can reveal vestibular asymmetry. For unilateral partial vestibular lesions, the VT triggers nystagmus more often than the HST. It is particularly sensitive between acute episodes in patients with Menière disease. A discordance between the direction of the nystagmus triggered by the HST and the VT is particularly frequent in patients with labyrinthine hydropsis who exibit a normal CT. In certain cases of apparent bilateral areflexia to the CT for low frequencies, the VT can disclose vestibular asymmetry for high frequencies. The nystagmus triggered by the VT begins and ends with stimulation with little or no tiring. The nystagmus triggered by the HST occurs after the stimulation and depends on the frequency of the head shaking. Thus, the HST (2 Hz and its harmonics), the VT (100 Hz) and the CT (<0.01 Hz) all make significant contributions to multiple-frequency analysis of vestibular function, particularly useful in patients with partial vestibular lesions. These tests probably solicit cells with different topographies or different frequency sensitivities.

[Failure rate and revision surgery in ossiculoplasty with Kurz titanium prosthesis]

Despite its excellent biocompatibility, failures and in particular extrusion of the prosthesis have been described in ossiculoplasty with titanium prosthesis.

OBJECTIVE

Report our experience with revision ossicular recontruction in ossiculoplasty with Kurz prosthesis. Identify causes of failure in ossiculoplasty using the titanium prosthesis.

MATERIAL AND METHODS

Retrospective chart reviews were performed for 110 patients who had undergone titanium ossicular implants between November 1998 and 2002. All patients had undergone ossiculoplasty using titanium middle ear implants. Patients were divided into 2 groups: in group 1 patients underwent revision ossiculoplasty; in group 2 patients had a successful surgery at first stage. Anatomic and functional results have been studied in these two groups. Causes of failures were analysed.

RESULTS

The overall failure rate was 20% (22/110). Twenty patients underwent revision ossiculoplasty. Nine primary failures were attributable to a short implant. Two extrusions were observed. At long term billow-up, the functional gain between the primary and revision ossiculoplasty was comparable.

CONCLUSION

Revision ossiculoplasty is worthwhile for those patients who have failure of the titanium prosthesis in ossiculoplasty. A large cartilage graft interposition is necessary to prevent extrusion. The overall luxation rate observed in our series was mainly due to a too short prosthesis and we recommend now a reconstruction with longer prosthesis.

[Nystagmus and vibratory test: evidence for mechanism. Material conditions and methods in the fast detection of unilateral vestibular lesions]

OBJECTIVE

The aim of the present study was to examine the characteristics of vibratory nystagmus (VN), optimise the topography and the frequency of the stimulus, determine the origin of the VN and analyze its clinical implications.

MATERIAL AND METHOD

Fifty-two severe unilateral vestibular lesions (SUVL) (post-surgical vestibular areflexy) were studied. The vibratory nystagmus was measured by 2D and 3D videonystagmography (Synapsis, France). The stimulus was applied with a 3S vibrator at the vertex, both mastoïds, and posterior cervical muscles, at frequencies ranging from 20 to 150 Hz. For topographic optimization, stimulation was given with S vibrator (Synapsis, France) at 100 Hz. The interferences between the vibratory test (VT) and the caloric test (CT) were studied on the normal ear (in 11 subjects). The same study was carried out with the optokinetic test.

RESULTS

The VT revealed a defective nystagmus at all frequencies of stimulation. Optimal response was obtained in a band frequency of 80-120 Hz. Stimulations at 100 Hz showed optimal responses for mastoid topography (responses in 96% of the cases). Stimulation at the posterior cervical muscles and at the vertex indicated respectively a response in 90% and 60% of the cases. The efficiency of the mastoid stimulation was not correlated with the side of stimulation (p=0.9). The interference between the VT and caloric test (CT) with cold water (30 degrees C and 20 degrees C) exhibited the inversion of the caloric nystagmus during the vibrator stimulation. The resulting nystagmus was respectively an algebraic subtraction or addition between the pre-existing caloric nystagmus and the value of the vibratory nystagmus obtained before the caloric test. Adaptation of the VN was moderate. The interference between the VT and the optokinetic test resulted in a subtraction or addition effect, according to the side of the lesion and the direction of the optokinetic stimulus.

CONCLUSION

The VT is an efficient stimulation in mastoid topography. The vestibular contribution is bilateral by bony conduction of the vibration, it explores frequencies ranging from 30 to 120 Hz, with a maximum of response at 100 Hz. The VT interacts with the caloric test and the optokinetic test. The stimulation is very strong, and is able to inverse the caloric nystagmus at cold water stimulation (20 degrees C) In labyrinthine-defective subjects, the VN is always defective at all frequencies, whatever the topographic location of the stimulus, and the position of the head.

[Nystagmus and vibration test research of mechanisms, theoretical methods: on 52 cases of unilateral vestibular lesions]

OBJECTIVE

The aim of the present study was to examine the characteristics of the Vibratory Nystagmus (VN) optimise the topography and the frequency of the stimulus, determine the origin of the VN and analyse its clinical implications.

MATERIAL AND METHOD

52 severe unilateral vestibular lesions (SUVL) (post-surgical vestibular areflexy) were studied. The vibratory nystagmus was measured by 2D and 3D videonystagmography (Synapsis, France). The stimulus was applied with a 3S vibrator at the vertex, both mastoïds, and posterior cervical muscles at frequencies ranging from 20 to 150 Hz. For topographic optimisation, stimulation was given with S vibrator (Synapsis, France) at 100 Hz. The interferences between the vibratory test (VT) and the caloric test (CT) were studied on the normal ear (in 11 subjects). The same study was carried with the optokinetic test.

RESULTS

The VT revealed a defective nystagmus at all frequencies of stimulation. Optimal response was obtained in a band frequency of 80-120 Hz. Stimulations at 100 Hz showed optimal responses for mastoïd topography (responses in 96% of the cases). Stimulation at the posterior cervical muscles and at the vertex indicated respectively a response in 90% and 60% of the cases. The efficiency of the mastoïd stimulation is not correlated with the side of stimulation (p = 0.9). The interference between the VT and caloric test (CT) at cold water (30 degrees et 20 degrees C) exhibited the inversion of the caloric nystagmus during the vibrator stimulation. The resulting nystagmus is respectively an algebric subtraction or addition between the pre-existing caloric nystagmus and the value of the vibratory nystagmus obtained before caloric test. Adaptation of the VN is moderate. The interference between the VT and the optokinetic test resulted in a subtraction or addition effect, according to the side of the lesion and the direction of the optokinetic stimulus.

CONCLUSION

The VT is an efficient stimulation in mastoïd topography. The vestibular contribution is bilateral by bony conduction of the vibration, it explores frequencies ranging from 30 to 120 Hz, with a maximum of response at 100 Hz. The VT interacts with the caloric test and the optokinetic test. The stimulation is very strong, and is able to inverse the caloric nystagmus at cold water stimulation (20 degrees C). In labyrinthine-defective subjects, the VN is always defective at all frequencies, whatever is the topographic location of the stimulus, and the position of the head.

[Cavernous angiomas of the brain stem: auditory and vestibular manifestations]

AIMS

To establish the correlation between the clinical manifestations of hearing and balance disturbance and the anatomical site within the pons of cavernous angiomas, and to describe their clinical features, and the findings on ABR and MRI.

MATERIALS AND METHODS

Two clinical cases of cavernous angioma with cochlear and vestibular manifestations underwent audiometric evaluation, with VNG and ABR as well as CT and MRI scans.

CONCLUSION

Cavernous angiomas are rare (less than 2% of intra-cranial space-occupying lesions). Their most common topographical site is midline in the pons, and may give rise to symptoms in attacks (due to episodes of bleeding within the tumour) which may mimic symptoms of peripheral origin (sudden deafness, fluctuating hearing loss, Menière-like vertigo). There may be ectopic remnants of the embryonic blood vascular system. They may be associated with other malformations (intra-cerebral venous angiomas, cavernous angiomas at other sites). Their development is often by sudden progression which may be dramatic, and have accompanying neurological features. For investigating the hearing and balance, ABR is an excellent test, giving a typical picture of a retro-cochlear lesion that necessitates progression to MRI, the investigation of choice. This will demonstrate the typical rosette-like appearance with a heterogeneous T2 image (a less dense peripheral ring, with a denser central signal). There is no specific medical treatment for this condition, and surgery is indicated only exceptionally. There is a contraindication to anticoagulant therapy, to platelet-dispersing medication and to violent sports activities. Two cases of cavernous angioma are reported; one was more anteriorly situated, and had mainly vestibular features, and the other was more posterior near the floor of the IVth ventricule, with mainly auditory features. The correlation of the anatomical and clinical findings with those of the MRI are discussed, especially in relation to our understanding of the auditory and vestibular pathways within the brainstem (the auditory striae, the crossed auditory pathways and the nuclei of the corpus trapezoideum for the auditory effects, and the paramedian reticular nucleus and crossed inter-commissure pathways to the cerebellum and vestibular nuclei, together with the proximity of the direct midline vestibulo-spinal tract, for the vestibular effects).

Diagnostic value of vibration-induced nystagmus obtained by combined vibratory stimulation applied to the neck muscles and skull of 300 vertiginous patients

On subjects with unilateral vestibular dysfunction, the application of a vibratory stimulation (100 Hz) to the two mastoids and the vertex, and to the right and left dorsal neck muscles produces a nystagmus directed towards the good ear in 85% of patients. Fixation must be suppressed by Frenzel's glasses or video nystagmoscopy. To be significant this nystagmus must appear in at least 3 of the 5 vibratory stimulated sites. On healthy subjects nystagmus is present in 6% of cases but never in those below 30 years. In subjects affected by central vertigo, nystagmus was elicited in 10% of cases and in subjects suffering from vertigo of unknown origin in 6% of cases. Vibration nystagmus which stops immediately after stimulation differs from head shaking nystagmus which is present in only 34% of unilateral vestibular dysfunctions. Vibration occasionally produces a pseudo-caloric nystagmus which persists after stimulation. We believe that vibratory stimulation is a useful test, quick and easy to perform. In conjunction with questionnaires, clinical examination, positional testing and the results of audiometry, it gives an immediate indication of a peripheral lesion when the vertigo is seen for the first time. With unilateral deafness, a positive test leads one to suspect an acoustic neuroma. Conversely if the test becomes negative after a vestibular neuritis when it was initially positive, it is a sign of recovery.

A multicenter study of the Vibrant Soundbridge middle ear implant: early clinical results and experience

OBJECTIVE

The Vibrant Soundbridge (VBS; Symphonix Devices, Inc., San Jose, CA, U.S.A.) is an active, semi-implantable, middle ear hearing device that directly drives the ossicular chain and is used in the treatment of patients with mild to severe sensorineural hearing loss. The benefits of the VBS and the effects of surgery were examined and compared with the preoperative aided condition in 25 patients with implants.

STUDY DESIGN

Single-subject repeated-measures evaluations were performed with each patient acting as his or her own control. Objective audiologic measures and subjective questionnaires also were used.

SETTING

Five tertiary referral and teaching hospitals.

SUBJECTS

Adult patients had bilateral sensorineural hearing loss (average hearing loss, 56 dB; range, 33-80 dB). Twenty-one patients had worn a conventional hearing aid before surgery (11 binaurally, 10 monaurally). Four patients had not used a conventional hearing aid before surgery.

INTERVENTION

Rehabilitative.

RESULTS

No significant change in residual hearing after surgery was observed. Functional gain was significantly superior with the VBS. No significant differences were observed for aided speech recognition in quiet. A significant improvement in communication in various listening conditions was reported with the VBS as compared with conventional hearing aids.

CONCLUSION

The VBS surgical implantation procedure does not affect the residual hearing level in the implanted ear, nor does it present any unacceptable risk. Measurable benefit from the VBS in comparison with conventional amplification was demonstrated with regard to the provision of superior usable amplification and greater ease in communication in daily listening environments for the majority of patients.

[Computer-assisted video-endoscopic endonasal surgery]

To make the surgical procedure safer and more precise in FESS, a non-invasive markerless computer-assisted system (CAS) is described for intra-operative navigation whenever the critical regions may be affected by surgical manipulation.

PATIENTS AND METHODS

Twenty patients with benign diseases of the paranasal sinuses were treated by Computer Assisted Video-endoscopic surgery, between December 1997 and March 1998. For the determination of accuracy and reproducibility of the system, ten anatomical landmarks on each side of the paranasal sinuses were chosen and measured. All of these points were identified on the direct live video-endoscopy image and compared to those obtained with the Optical Digitizing System (Flashpoint 5000(R)), on axial, coronal and sagittal view. The Optical Localizer we used detects the position of the relative coordinates of two rigid bodies made of IR-LED's each, one rigid body is secured to the head' of the patient with a headset, so that patient motion can be tracked, and the second rigid body attached to the operating instrument, leading to direct localization of the tip of the instrument. We use a markerless, skin surface-based registration method, which has the advantage to avoid doing a second CT scan examination usually performed to process the position of the fiducial markers. We register the data from the patient's usual paranasal CT scan.

RESULTS

Computer-assisted surgery does not increase significantly the duration of the operation. Our markerless skin surface points registration method is reliable enabling of the movements patient's head during the procedure. Computer assistance can be used in almost any type of endoscopic sinonasal procedure. We obtained a registration and calibration accuracy of less than 1.5 mm in 89.2% of cases.

CONCLUSION

CAS enables the surgeon to have a more thorough understanding of the complicated anatomy of paranasal sinuses, and may be especially helpful in revision surgery when normal anatomic landmarks are lacking. Due to the passive optical technology (Passive Polaris(R)), we are continuing clinical studies in ENT surgery in order do improve the system and to simplify its current management.

[Semiologic value and optimum stimuli trial during the vibratory test: results of a 3D analysis of nystagmus]

Nystagmus signaling vestibular dysfunction was observed after vibratory stimulation with a 100 Hz ABC stimulator in a population of 36 patients with unilateral labyrinthine pathology (ULP) (pre and postoperative neuromas, vestibular neurectomies) and 10 patients with vestibular neuritis. The stimulus was applied on 3 bony points of the skull (vertex and 2 mastoids) and 2 muscular points of the neck (right and left posterior cervical region). These results were compared with those in 95 normal subjects and 19 cases of central disease and were correlated on the same day with results of the caloric test and head shaking test (HST). A consistent nystagmus was found in only 6 % of the normal subjects (specificity 94 %) and in 10 % of the central lesions, but in 94 % of the 36 peripheral ULP. The sensitivity of the test was equivalent to the HST. The signal was optimized in 30 patients: stimulus frequency, amplitude, stimulator mass, form of the contact, patient tolerance. The best results were obtained for a frequency of 100 Hz and an amplitude of 0.5 mm (there was no response under 0.1 mm vibration amplitude). Under videoscopy and 3D videonystagmography, the direction or side of the nystagmus was constant, but its axis (horizontal, oblique or rotational) changed according to the location of the stimulator: on the mastoid (elective location of stimulation with responses in 94 % of cases) the axis was most often horizontal or horizontal rotational. On the vertex location (where nystagmus was observed in 60 % of cases) the axis of nystagmus was most often rotational or oblique and sometimes horizontal-rotational. The nystagmus showed short latency (less than 200 ms). It started and stopped as stimulation was initiated and interrupted. Nystagmus persisted for the duration of patient tolerance. This nystagmus generally signifies unilateral vestibular weakness rather than vestibular predominance. It is a good indicator of unilateral vestibular dysfunction and could serve as a useful test in clinical practice. We discuss the origin of the nystagmus which may originate in muscle proprioception (by propagation of the vibration to neck muscles) or in the labyrinth (simultaneous excitation of 3 canals on each side).

Phase II trial of cisplatin, 5-fluorouracil and folinic acid using a weekly 24-h infusion schedule for locally advanced head and neck cancer: a pharmacokinetic and clinical survey

The objective of this phase II prospective study was to determine the efficacy and the toxicity of a new schedule of neoadjuvant chemotherapy in locally advanced squamous cell carcinomas of the head and neck (SCCHN). Thirty-three patients were included in this study (13 stage III and 20 stage IV). Cisplatin (CDDP: 35 mg/m2), 5-fluorouracil (FU: 2 g/m2) and folinic acid (FA: 500 mg/m2) were administered by continuous i.v. infusion for 24 h, once every 7 days. Six cycles of neoadjuvant chemotherapy were planned before definitive locoregional treatment. A total of 195 cycles were analysed for toxicity: mucositis was observed in 11/195 cycles; 12/195 showed diarrhea and vomiting occurred in 10/195. The myelosuppression was low (neutropenia: 4/195, thrombopenia: 3/195). One treatment-related death was observed after grade IV neutropenia at the fourth cycle. Thirty-two patients were evaluated for response. The objective response rate was 87%, with 50% complete response (CR) and 37% partial response. Failure rate was 13% (stable disease). There was no progressive disease. Survival and DFS duration were significantly higher in cases of CR or in laryngeal localization. The average peak plasma levels for the 6 courses of CDDP, 5-FU, dl-FA and mTHF were 4.9+/-0.76 microM, 4.1+/-0.54 microM, 29.1+/-2.4 microM and 4.8+/-0.31 microM respectively. Therefore, the administration of the 3 drugs by a 24 h continuous i.v. infusion reached an efficient level for drug modulation. This new weekly schedule is as active as other standard therapy in the disease but significantly less toxic as neoadjuvant chemotherapy in advanced untreated SCCHN. With the low toxicities observed with this schedule, additional treatment (surgery and/or radiotherapy) is warranted to evaluate the impact on overall survival of SCCHN.

[Middle ear cholesteatoma surgery]

To verify the efficiency of surgical techniques used by the senior author in cholesteatoma surgery, 1,048 cases operated on between 1966 and 1997 are reviewed: 739 in adults and 309 in children. In adults, the majority of cases were between 16 and 40 (64.5%) without difference between both sexes. On the contrary in children, boys were 200 and girls 109; 30 cases were less than 4. In adults only 312 cases were operated on first hand, instead in children almost all cases were operated on first hand (273 cases). The beginning of the cholesteatoma was usually the Shrapnell membrane in adults (58%) while in children the postero-superior region was as common as the Shrapnell membrane (34% 35%); the cholesteatoma was congenital in 13% of cases. Surgical techniques: Mostly two techniques were used: closed technique in two stages and obliteration technique in one or two stages. The closed technique requires remodeling of the postero-superior region of the bony canal, performing a correct posterior tympanotomy, placing a silastic sheeting in all the middle ear to prevent fibrosis and finally rebuilding all the bony defects and a large part of the tympanic membrane with thin cartilage with its perichondrium. The second stage is performed 18 months later in children, 24 months in adults. The ossiculoplasty is often performed at the first stage if the stapes arch is intact and safe. The obliteration technique requires also a precise removal of the lesions, a lowering of the facial ridge, the rebuilding of the tympanic membrane with fascia and the posterior cavities obliteration with Palva flap and free connective grafts. If the tympanic and posterior cavities are reasonably safe, and if the stapes arch is intact, one stage is performed. Otherwise a second stage is performed usually 18 months later, ossiculoplasty only or combined with a second look of posterior cavities under the flap.

RESULTS

Residual cholesteatoma was noticed in adults in 16% of first hand closed technique and 19% of second hand closed technique. It is only of 7% in first hand obliteration technique and 13% in second hand obliteration technique. It was 16% in radical cavity reconstruction. Retraction pocket was almost only observed in closed technique. In adults, an early retraction pocket was observed in 3.5% of cases and in children 12.5% of cases at the moment of the second stage. A larger cartilage more precisely fixed with fibrin glue seems to have almost suppressed the early retraction pocket. Some late retraction pockets nevertheless appeared: 6 cases in adults over 394 and 5 cases in children over 236. Hearing results in adult were the best with first hand closed technique 84% of good results if the stapes was intact and 51% if the crura were missing. If the closed technique was performed second hand, these results were only 57% if the stapes was intact and 29% if the crura were missing. For the obliteration technique these results are for the first hand 70% of good result if the stapes was intact and 60% if the crura were missing, for the second hand, only 36% if the stapes was intact and 39% if the crura were missing. In radical cavity reconstruction 63% of good results were achieved when the stapes was intact and 48% if the crura were missing. The good result is an air-bone gap between 0 and 20 dB for the three frequencies 0.5, 1 and 2 kHz.

Detection of hypoxia by measurement of DNA damage and repair in human lymphocytes (comet assay): a predictive variable for tumor response during chemotherapy in patients with head and neck squamous cell carcinoma

BACKGROUND

Only few studies have tried to identify parameters at the time of diagnosis or during treatment that can assist the clinician in predicting the response to Cisplatin, 5-Fluorouracil +/- Folinic acid therapy in patients with head and neck squamous cell carcinoma (HNSCC).

MATERIALS AND METHODS

The alkaline comet assay was used to measure both cellular hypoxia and DNA single-strand break (ssb) kinetics in individual lymphocytes of HNSCC patients undergoing combined therapy. The intracellular level of FdUMP, dUMP and mTHF were also measured during treatment.

RESULTS

Two distinct types of cell populations were detected, from the less damaged population representing the hypoxic cells to the most damaged cells population representing the aerobic cells. We also described a direct relationship between DNA damage and repair and drug metabolism in lymphocytes and treatment efficacy.

CONCLUSION

The response of tumors to chemotherapy is thought to be a function of the drug's pharmacological properties (the intracellular level of FdUMP and mTHF). In addition, a relationship between platinum DNA adduct levels in lymphocytes DNA (comet assay) and tumor response has been observed, suggesting that clinical resistance to platinum drugs is attributable to DNA repair functions of the host, and thus the degree of cytotoxicity is similar across all cell types.

Benign positioning vertigo (BPV) and three-dimensional (3-D) eye movement analysis

Fifty two patients with positioning nystagmus were studied with the V.N.G. three-dimentional device of ULMER. In benign paroxysmal positional vertigo (BPPV) the torsionnal component is not pure: a vertical and a less important horizontal components also exist. They are not of the same amplitude on both eyes. The torsionnal and horizontal components are more important on the eye ipsilateral to the BPPV. The vertical component is more important on the contralateral eye. The horizontal canal B.P.V. (2% of the cases of B.P.V.) is so defined by the absence of vertical and torsionnal components. Three-D Eye Movement Analysis is helpful for differential diagnosis with the positional protocol described. The characteristics of central and peripheral paroxysmal positional nystagmus are given. The head Tilt and the ocular counter rolling reflex (O.C.R.) can be quantified with this device. It will be useful in the future to better explore the inferior root of the eighth nerve and the otolith organ. For clarity we propose to describe the torsionnal nystagmus so that the results are expressed with respect to the patient: clockwise nystagmus (in reference to the patient) would thus be also right rotatory nystagmus while left rotatory nystagmus would be also anticlockwise.

p53 mutations and p53, Waf-1, Bax and Bcl-2 expression in field cancerization of the head and neck

Squamous cell carcinomas of the Head and Neck (SCCHN) are related to carcinogens and proceed through multiple genetic and morphological steps. The aim of this study was to establish the status of p53 gene and p53-regulated proteins (Bax, Bcl-2 and Waf-1) expression in head and neck simultaneous preneoplastic and invasive lesions from patients with chronic alcohol and tobacco exposure. PCR-SSCP analysis of p53 gene and immunohistochemical analysis of Waf-1, Bax and Bcl-2 proteins were performed in 30 representative microdissected samples of mucosa exposed to carcinogens and preneoplastic or invasive lesions from 8 patients. P53 mutations were detected in all steps of carcinogenesis, but not in normal mucosa without carcinogen exposure. P53 mutations were different and multiple in concomittant areas of mucosa exposed to carcinogens, preneoplastic and invasive lesions at distant locations. Waf-1 and Bax protein expression was found in 100% of biopsies. Bcl-2 presented as basal cell positive staining in 95% of normal and preinvasive lesions and was overexpressed in only 30% of tumors, independently of p53 gene status. Bax/Bcl-2 ratio was > 1 in all premalignant lesions and < 1 in tumor samples only. There is evidence for the early, polyclonal origin of synchronous multiple preneoplastic and neoplastic lesions in the cancerization field. A P53 independent pathway seems to be implicated in Waf-1, Bax and Bcl-2 expression with an inversion of the Bax/Bcl-2 ratio restricted to invasive carcinomas.

Implications of p53 alterations and anti-p53 antibody response in head and neck squamous cell carcinomas

Point mutations at the tumour suppressor gene p53 are one of the most frequent genetic alterations in squamous cell carcinoma of the head and neck (SCCHN), which lead to the nuclear accumulation and overexpression of inactive p53 protein. The overexpression of mutant p53 protein can induce a specific humoral response in cancer patients. p53 protein was studied in 112 SCCHN. Biopsies and sera samples were collected before initiation of treatment. 74 patients received neoadjuvant chemotherapy (5-fluorouracil-cisplatin-folinic acid). p53 protein expression was evaluated by immunohistochemistry (IHC) on paraffin-embedded sections. The analysis of mutations was assessed by PCR-SSCP of exons 5-10 on DNA from 28 representative cases. Antibodies specific for p53 protein were analysed in sera of 74 patients by an ELISA procedure. Overexpression (> 20% positive cells) of p53 protein was frequent (56%: 63/112) and was correlated with localisation of the primary tumour and tumour stage. p53 mutations were detected in 57% (16/28) of studied cases. The prevalence of p53 antibodies in sera was high (44% 32/74) and among this population, 68% (20/29) had a positive immunophenotype and 67% (6/9) a p53 mutation in the tumour. In addition, the presence of anti-p53 antibodies was slightly associated with complete response to neoadjuvant chemotherapy. If the humoral response seems to be an indicator of the p53 protein status, the detection of anti-p53 antibodies could be a good approach in the early detection of the presence of p53 alterations in SCCHN and recurrent tumours or the appearance of second primary cancer.

Analysis of p53 antibody response in patients with squamous cell carcinoma of the head and neck

p53 alterations are the most common alteration found in human cancer. Protein p53 was studied in 102 patients with early lesions or advanced squamous cell carcinoma of the head and neck (SCCHN). Biopsies and sera samples were collected before the initiation of treatment. Protein p53 expression was evaluated by immunohistochemistry using Pab 1801, Pab 240, DO7 and CM1 antibodies on paraffin-embedded sections. Antibodies specific for p53 protein were analysed in the sera of these patients by an ELISA procedure. We demonstrated that p53 protein overexpression (> or = 20% positive cells) was an early event in the carcinogenesis of SSCHN and correlated to the progression of carcinogenesis. Overexpression of protein p53 was frequent (56.5%) in advanced tumors. No correlation was found with clinical stage or the differentiation status of the tumor, but we demonstrated differences in protein p53 expression according to the initial localisation of the tumor, with high expression in hypopharynx (67%) and oropharynx (65%) versus larynx (12%). The prevalence of p53 antibodies was high (44%) and was correlated with the rate of p53 overexpression (> or = 30% positive cells) in tumors (p < 0.0001 chi square test). These results suggest that the humoral response is an indicator of the presence of squamous cell carcinoma with immunogenic mutant p53 protein. Therefore the detection of anti-p53 antibodies could be used as a precocuous marker of p53 alteration and a prognostic marker, in order to screen for patients with a better prognosis.

[Surgical treatment under endoscopic control of cerebrospinal fluid rhinorrhea of sphenoid origin. A propos of 5 cases]

From 5 to 15% of cerebrospinal fluid (CSF) leaks come from the sphenoid, subdivided in two groups: traumatic and spontaneous. Many surgical approaches are used for their treatment, with consistent morbidity. Five sphenoidal CSF leaks (3 traumatic and 2 spontaneous) were operated only by endoscopic endonasal route from 1993 to 1995, after endoscopic and computerized tomography (CT) scan evaluation. A sphenoidotomy by a simple endonasal route through the spheno-ethmoidal recess was performed in 3 cases. In the other 2 cases, the sphenoidotomy required a trans-ethmoidal approach through the posterior part of the ethmoid. After identification of the leak and the removal of mucosa, the sphenoid sinus was filled up by abdominal fat kept in place by biological glue and supported by a silastic sheat. No post-operative complication appeared. The median duration of hospitalization was 6.5 days (5-13). During the follow-up (19.5 months, 8-30), 4/5 complete remission was observed. The last case needed a second obturation at 11 months, due to a retraction of the fat, without recurrence. This endonasal endoscopic approach is safe and efficient for leaks closure, with no morbidity compared with others invasive approaches.

Differential c-myc, c-jun, c-raf and p53 expression in squamous cell carcinoma of the head and neck: implication in drug and radioresistance

The expression of oncogenes c-myc, c-jun and c-raf and tumour suppressor gene p53 was assessed by northern blot analysis of 42 tumours and p53 protein expression by immunohistochemistry on paraffin-embedded sections from 36 specimens of squamous cell carcinoma of the head and neck (SCCHN) obtained before therapy. Of the 42 tumours, 89, 100 and 100% expressed c-myc, c-jun and c-raf oncogenes, respectively. These oncogene expressions did not correlate with sex, age or clinical stage of the disease. However, an association was found between low c-myc expression (P = 0.0001) and high c-jun expression (P = 0.0001) and absence of tumoral response to neoadjuvant chemotherapy. On the other hand, c-raf overexpression was observed in patients resistant to radiation therapy (P = 0.0494). Forty-two per cent of the tumours showed p53 protein overexpression, which did not correlate with any clinical parameter. This p53 protein overexpression was associated with high p53 mRNA levels (REL) (P = 0.0223). A correlation was found between increased c-myc RNA expression and lack of p53 protein expression (P = 0.0407). In addition, a lack of p53 protein expression was indicative of tumour relapse (P = 0.05). None of these biological parameters were associated with disease-free survival (Cox-Mantel test). In conclusion, the overexpression of c-myc, c-jun and c-raf may be independently associated to tumoral response to chemotherapy or radiotherapy, or to tumour relapse, but fail to predict long-term survival.

Coexistence of plasma cell granulomas of lung and central nervous system

A rare case of concurrent plasma cell granulomas (PCG) of the lung and the central nervous system (CNS) is reported. A 30-year-old man was presented with recurrent left headaches lasting for two years. Computerized tomographic (CT) scan and magnetic resonance imaging (MRI) of the head disclosed a process extending from the lateral aspect of the left cavernous sinus to the tentorium cerebelli and the infratemporal fossa through the foramen ovale. At the same time, chest-X ray and CT scan showed three symptomless masses of the pulmonary right lower lobe. Histological examination of cerebral samples and of one of the pulmonary nodules revealed the presence of a fibrous tissue containing numerous lymphocytes and plasma cells as well as remnants of vascular and respiratory structures. Immunohistochemical study proved these cells to be polyclonal. Ultrastructural analysis confirmed the presence of lymphoid cells and failed to disclose any argument for meningioma or histiocytosis X. The differential diagnostic problems of PCG are discussed as well as considerations about clinicopathological features, histogenesis and pathogenesis of inflammatory pseudotumours (IPT).

Immunohistochemical detection of p53 protein in preneoplastic lesions and squamous cell carcinoma of the head and neck

Alterations in the p53 tumor suppressor gene are the most frequent genetic abnormalities in human cancers. The p53 protein is present in normal cells, and is assumed to induce G1 arrest or apoptosis in the presence of DNA lesion. The mutant protein lacks this property. Squamous cell carcinomas of the head and neck (SCCHN) are related to carcinogens in tobacco and alcohol, and provide a good model of multiple-step carcinogenesis in association with DNA damage and p53-related tumorigenesis. Stabilization of the mutant p53 protein allows immunohistochemical analyses (IHC) to be routinely used to demonstrate the mutant p53 protein in tissue samples, whereas normal p53 protein is undetectable. Ninety-nine squamous cell carcinomas, 8 in situ carcinomas, 31 preneoplastic lesions and 79 normal carcinogen-exposed mucosas of the head and neck from a total of 107 patients were examined for the expression of p53 tumor suppressor gene protein. Samples were collected before treatment, and stained with p53 specific mono- and polyclonal antibodies (DO-7, Pab 1801 and 240, CM1) using an indirect immunoperoxidase technique. Proliferating cell nuclear antigen (PCNA) provided semiquantitative estimates of proliferation. The main localizations were the pharynx (64/107) and the larynx (21/107). Positive IHC detection of p53 was observed in 9% of normal-appearing carcinogen-exposed mucosas, 37% of hyperplasias, 68% of dysplasias, 75% of in situ carcinomas, and 56/99 (56.5%) of primary tumor samples. Mucosas from 15 control patients under 10 years of age were negative. There was no correlation between p53 IHC and localization, differentiation or TNM staging.(ABSTRACT TRUNCATED AT 250 WORDS)

[Computed tomographic aspects of secondary cholesteatomas of the middle ear and petrous bone]

The authors present their experience of secondary cholesteatomas of the middle ear explored by computerized tomography (CT). Following a brief anatomicopathological description of secondary petrous bone cholesteatomas, and of the CT technique used for their exploration, they describe and illustrate the classical "bag-shaped" internal or external attical forms usually extended to the antrum and the mastoid process, and the less common locations often due to relapse or postoperative recurrences (anterior hypotympanic or posterior mastoidal). The holotympanic forms, usually due to "lamellar" cholesteatomas, create diagnostic problems with other opacities in the cavity, as also do certain forms that are evacuated spontaneously or by aspiration. One of the qualities of CT lies in the preoperative extension assessment. The lesion may extend towards the internal wall of the cavity (lateral semicircular canal, second portion of the facial nerve), towards the labyrinth to the petrosal apex and/or the geniculate ganglion, and above all towards the inferior labyrinth which might bring the cholesteatoma into contact with large vessels (e.g. jugular vein bulb for postero-inferior extensions, carotid canal for antero-inferior extensions). Extension into anfractuosities of the cavity walls (sinus tympani, subratubal fossette) must be systematically looked for in order to avoid postoperative recurrences.

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.