Surgical epidemiology of Antarctic stations from 1904 to 2022: A scoping review

In Antarctica, it is extremely difficult to organise medical evacuations in winter. Antarctic physicians are often alone and must be prepared to perform surgery and dentistry, even if they are not specialists. This scoping review summarises epidemiological data on the types of surgical procedures performed in Antarctica and identifies gaps in the literature in this area. We searched PubMed and Google Scholar, without language restriction, for papers published between 1 January 1904, and 1 February 2022. Of the 35 papers on 12 Antarctic programs, very few were retrospective observational epidemiological studies; the majority were medical reports. The search identified 41 surgical procedures or reasons for surgical consultation, 19 different reasons for medical evacuations, and 12 causes of death that may have required surgical management. The diagnostic classifications used and the prevalence of each reported surgical speciality were heterogeneous. The most cited specialities were orthopaedics, dentistry, and digestive surgery. Telemedicine was integrated into on-site care or medical evacuation decisions. The current literature is poor, and most studies do not apply to surgical issues. The heterogeneous data collection methodologies limit their interpretation. A standardised diagnostic classification and detailed and systematic epidemiological registers will help define the contours of surgical management in Antarctica.

Surgical training strategies for physicians practicing in an isolated environment: an example from Antarctica. International survey of 13 countries with active winter stations

For 60 years, human presence in Antarctica has required particularly demanding medical skills. Nevertheless, the preparation of physicians working in this extreme environment remains unknown and deserves clarification. This study aimed to summarise data on the surgical training given to physicians by different countries. In April 2020, we conducted a questionnaire-based study of 14 countries wintering in Antarctica. Responses were descriptively analysed. Regarding the profiles of physicians recruited by the wintering countries, 30% to 55% were non-surgeon doctors compared with 45% to 70% for surgeons depending on the year. Of the 13 countries answering the questionnaire, nine organised practical surgical training and six used theoretical material. All countries reported practical training for dental surgery, while only five countries provided training in four other surgical specialities (orthopaedic, digestive, thoracic, and ear, throat, and nose). All 13 countries reported using a telemedicine system. These results revealed heterogeneous training strategies among the recruited physicians, reflecting the difficulties of practice on this extreme continent. Future work may assess the effectiveness of each strategy. A better understanding of surgical epidemiology and a detailed referencing of the equipment available at the bases would help better define the contours of surgical care in Antarctica.

Review of olfactory cleft roof anatomy

Progress in skull-base endoscopic surgery has improved our knowledge of olfactory cleft (OC) anatomy. This article presents a review of current knowledge concerning the OC roof: descriptive anatomy, radiological exploration, and endoscopic observation. The OC is a narrow area in the most superior part of the nasal cavity. Its roof is the thinnest structure separating the nasal cavities from the brain; it comprises three superimposed tissues: nasal mucosa, ethmoid cribriform plate (ECP), and dura mater. The ECP comprises the anterior ECP containing the ethmoidal slit (ES) medially and the cribroethmoidal foramen (CEF) laterally; and the posterior ECP, comprising the olfactory foramina. The OC roof is bordered anteriorly by the nasal bone roof, laterally by the lateral ethmoid masses, and posteriorly by the jugum and anterior wall of the sphenoid sinuses. Imaging is crucial for analyzing this wall, providing precise detailed information on conformation and anatomic relations with adjacent structures such as the anterior ethmoidal artery. Understanding OC roof anatomy and correct interpretation of imaging are essential for safety in present-day functional endoscopic sinus surgery and anterior skull-base oncologic surgery.

Radiological relationship of the ethmoid slit with the frontal sinus and the anterior ethmoidal artery and applications to the frontal sinus drillout

PURPOSE

To compare two types of CT acquisition parameters: CT scan of the facial bone and CT scan of the sinuses, for studying the ethmoidal slit and its relationship with the frontal sinus and anterior ethmoidal artery.

MATERIALS AND METHODS

Retrospective study of 145 scans of the sinuses and 79 of the facial bones performed between 2012 and 2016. On each scan, the visibility of the ethmoidal slits, their length, their distance from the ethmoidal artery, and their relationship with the anterior and posterior wall of the frontal sinus were studied.

RESULTS

The ethmoidal slit was better visualized on CT scans of the facial bone (58.2%) than on those of the sinuses (43.1%) (p = 0.02). The distance between the anterior ethmoidal artery and the anterior part of the cribriform plate was 9.3 mm for CT scans of the facial bone and 8.4 mm for CT scans of the sinuses. The theoretical risk of damaging the glabellar soft tissue and that of damaging the meninges during a frontal sinusotomy was evaluated, respectively, at 9.6% and 26.1% for CT scans of the facial bone, and at 6.2% and 21.5% for sinus scans.

CONCLUSIONS

CT scans of the facial bone are better than CT scans of the sinuses for identifying ethmoidal slits and their distance from the canal of the anterior ethmoidal artery. The identification of these elements is relevant for the surgeon during frontal sinus surgery and makes it possible to assess the risk of damaging the glabellar soft tissue or meninges. Performing a CT scan of the facial bone seems preferable to that of a CT scan of the sinuses in certain pathological situations, such as cerebrospinal rhinorrhea or revision surgeries of the frontal sinus.

Motion Sickness Lessons from the Southern Ocean

BACKGROUND: The objectives were to assess the prevalence, severity, and medication taken, and to look for predictive factors in order to better identify characteristics of passengers at risk of motion sickness during transport from Hobart in Tasmania to the French polar stations in Antarctica. METHODS: There were 239 passengers who were surveyed over 4 yr with 4 round trips per year using the Motion Sickness Susceptibility Questionnaire (MSSQ), Simulator Sickness Questionnaire (SSQ), state-trait anxiety test (STAI-Trait and STAI-State), and general parameters (age, gender, number of trips, jet-lag, direction of the trip), medication, calculation of the distance of each passengers cabin to the center of gravity (CoG). RESULTS: While the passengers had a low intrinsic sensitivity to motion sickness (MSSQ), 94 reported at least one SSQ symptom of motion sickness, and 38 vomited. Five associated factors were discovered: greater initial sensitivity (MSSQ), anticipation of being ill, younger age, higher level of anxiety at midtrip, and greater distance from the CoG. Of the passengers, there were 54 who took anti-motion sickness medication at different times of the trip, however, these passengers experienced more nausea. This could be due to self-selection since they were more sensitive to motion sickness. CONCLUSION: We identified three predictive factors of motion sickness (greater intrinsic susceptibility, younger age, and greater cabin distance from the CoG). For preventive purposes, two associated factors of MS (anticipation of being ill, MSSQ score) were determined to classify three groups of risk of MS to improve passenger care during the trip. Besnard S, Bois J, Hitier M, Vogt J, Laforet P, Golding JF. Motion sickness lessons from the Southern Ocean. Aerosp Med Hum Perform. 2021; 92(9):720727.

Impaired Attentional Processing During Parabolic Flight

Previous studies suggest that altered gravity levels during parabolic flight maneuvers affect spatial updating. Little is known about the impact of the experimental setting and psychological stressors associated with parabolic flight experiments on attentional processes. To address this gap, we investigated the level of alertness, selective and sustained attention in 1 and 0 g using a Go/No-Go Continuous Performance Task. We also identified several parameters associated with the experimental set-up of a parabolic flight that could be expected to affect attentional processing. These included the use of scopolamine, sleep quality prior to the flight day, participant’s stress level as well as mood and anxiety state before and after the parabolic flight. We observed a deterioration in attentional processing prior to the first parabola that was further aggravated in weightlessness and returned to baseline after the last parabola. Reaction Time, Hit and False Alarm Rate were moderately correlated with self-reported anxiety state, but not cortisol levels or emotional states. The use of scopolamine had minor effects on Reaction Time. Our results confirm previous studies reporting impairments of cognitive performance in 0 g, and highlight important aspects that should be considered for the design of behavioral research experiments in future parabolic flight campaigns.

Stratification of hippocampal electrophysiological activation evoked by selective electrical stimulation of different angular and linear acceleration sensors in the rat peripheral vestibular system

It has become well established that vestibular information is important for hippocampal function and spatial memory. However, as yet, relatively little is known about how different kinds of vestibular information are 'represented' in different parts of the hippocampus. This study used selective electrical stimulation of each of the 5 vestibular sensors (the horizontal (HC), anterior (AC) and posterior (PC) semi-circular canals, and the utricle and saccule) in the rat and recorded local field potentials (LFPs) across the hippocampus, using a 16 electrode microarray. We found that stimulation of any vestibular sensor in the left labyrinth evoked triphasic LFPs in both hippocampi, although it was clear that, in general, the amplitudes were greater for the right, contralateral side. This was particularly true for Phase 1 for the HC, AC, utricle and saccule, Phase 2 for the HC, PC, utricle and saccule, and Phase 3 for the AC, PC and saccule. Overall, our results suggest that vestibular input to the hippocampus is bilateral, preferentially contralateral, but highly stratified in that stimulation of the same vestibular sensor results in activation of different specific areas of the hippocampus, with different LFP amplitudes and latencies. This suggests the possibility that different regions of the hippocampus use different kinds of vestibular information for different purposes and that there may be a high degree of redundancy in the representation of vestibular input, perhaps ensuring that the hippocampus is more robust to the partial loss of vestibular information.

How to identify the anterior cribriform plate in the medial approach to the frontal sinus

Draf III frontal sinusotomy is one of the most complex surgical procedures on the frontal sinus, designed to limit the risks of restenosis by ensuring unification of the two ostia and resection of the floor of the sinus. This procedure requires a good knowledge of anatomy and sufficient surgical expertise to avoid the risk of CSF leak and to limit the risk of restenosis. The surgeon can use various landmarks, consisting of foramina, bone grooves and arteries located on the anterior part of the cribriform plate to guide the procedure. The purpose of this technical note is to explain the use of these landmarks to ensure safe Draf III frontal sinusotomy via a medial approach.

New landmarks in endonasal surgery: from nasal bone to anterior cribriform plate including branches of anterior ethmoidal artery and nerve and terminal nerve

BACKGROUND

Despite the development of anterior skull base surgery, the anatomy of the nasal bone and anterior cribriform plate remains unclear. A recent study confirmed 2 distinct foramina in the anterior part of cribriform plate: the ethmoidal slit (ES) and the cribroethmoidal foramen (CF). The aim of this study was to specify their content, their anatomic relationship to the frontal sinus and skull base, and their potential value in skull base surgery.

METHODS

Dissections were performed on 36 cadaver heads. Macro- and microscopic examinations were carried out. Microcomputed tomography scans contrasted with osmium were performed to identify vessels and nerves. Histology with neural, meningeal, or luteinizing hormone-releasing hormone immunomarkers was performed on the content of the foramina. Finally, endonasal surgical dissections were carried out.

RESULTS

The ES and the CF were observed in all cases. They measured a mean of 4.2 and 1.6 mm, respectively. The ES contained dura mater, arachnoid tissues, lymphatics, and the terminal nerve. The CF contained the anterior ethmoidal nerve and artery. This foramen continued forward with the cribroethmoidal groove, which measured a mean of 2.5 mm. This groove was under the frontal sinus and in front of the skull base. We also described a "cribroethmoidal canal" and a "nasal bone foramen."

CONCLUSION

The clinical applications of this new anatomic description concern both cribriform plate and frontal sinus surgeries. Identifying the terminal nerve passing through the ES is a step forward in understanding pheromone recognition in humans.

New detailed description of the anterior part of the cribriform plate using anatomic specimens and computed tomography

PURPOSE

Ethmoidal slit (ES) and cribroethmoidal foramen (CF) have been poorly studied, without any radiological description. They may ease cribriform plate's diseases. The objective was to describe the frequency, size, and computed tomography (CT) appearance of these foramina.

METHODS

A two-part anatomoradiological study was performed: first on dry skulls using a surgical microscope and CT, second on patients CT scans. For each, foramina were searched for, described, and measured when possible.

RESULTS

Thirteen dry macerated skulls were studied. The orbitomeatal plane was relevant for studying ES. With microscope, ES and CF were identified in, respectively, 92% and 100% of cases. Using CT, all ES and CF were visible, with a mean length and width of, respectively, 3.9 ± 1.7 mm and 0.9 ± 0.3 mm for ES and 1.6 ± 1 mm and 0.9 ± 0.3 mm for CF. CT scans from 153 patients were reviewed. ES and CF were identified in, respectively, 80% and 91% of cases, with a mean length and width of, respectively, 3.9 ± 0.8 mm and 0.8 ± 0.2 mm for ES.

CONCLUSION

Large-sized ES was found frequently, and were clearly visible in patients CT scans. CF was markedly smaller, but seen in most patient scans. ES and CF could be areas of least resistance in the anterior part of the cribriform plate. CT might be helpful in understanding their pathological implications.

Differential regulation of NMDA receptor-expressing neurons in the rat hippocampus and striatum following bilateral vestibular loss demonstrated using flow cytometry

There is substantial evidence that loss of vestibular function impairs spatial learning and memory related to hippocampal (HPC) function, as well as increasing evidence that striatal (Str) plasticity is also implicated. Since the N-methyl-d-aspartate (NMDA) subtype of glutamate receptor is considered essential to spatial memory, previous studies have investigated whether the expression of HPC NMDA receptors changes following vestibular loss; however, the results have been contradictory. Here we used a novel flow cytometric method to quantify the number of neurons expressing NMDA receptors in the HPC and Str following bilateral vestibular loss (BVL) in rats. At 7 and 30 days post-op., there was a significant increase in the number of HPC neurons expressing NMDA receptors in the BVL animals, compared to sham controls (P ≤ 0.004 and P ≤ 0.0001, respectively). By contrast, in the Str, at 7 days there was a significant reduction in the number of neurons expressing NMDA receptors in the BVL group (P ≤ 0.05); however, this difference had disappeared by 30 days post-op. These results suggest that BVL causes differential changes in the number of neurons expressing NMDA receptors in the HPC and Str, which may be related to its long-term impairment of spatial memory.

How to perform microscopic/endoscopic resection of large petrous apex lesions

The endoscope and microscope can be used conjointly in certain sites, such as middle ear cholesteatoma or for resection of cerebellopontine angle tumours. Petrous apex tumours are classically accessed via a lateral otological approach, or, for the most anterior tumours, via an endonasal endoscopic approach. Surgical access via a lateral incision is limited inferiorly by the superior bulb of the internal jugular vein, medially by the labyrinth, facial nerve and internal auditory canal, superiorly by the dura mater, and laterally by the internal carotid artery. Via an anterior endonasal approach, the corridor formed by the internal carotid artery and the paraclival dura limits access to the posterior part of the petrous apex, restricting this approach to certain cholesterol granulomas or small cholesteatomas. None of these approaches, on its own, is sufficient in the case of an extensive petrous apex lesion. The objective of this technical note is to describe the combined microscopic/endoscopic approach comprising sequential use of the microscope and the endoscope via a lateral approach for the management of large petrous apex lesions.

Extended endonasal approach versus maxillary swing approach to the parapharyngeal space

BACKGROUND

The nasopharyngeal and parapharyngeal spaces are difficult for surgeons to access. Of the various external routes described, the maxillary swing has emerged as the gold standard because of its simplicity. However, its morbidity has led to the development of less invasive techniques. The purpose of our study was to compare the surgical anatomy of the maxillary swing with that of the endoscopic endonasal approach.

METHODS

Each procedure was performed on 10 anatomic specimens. The exposure and the limits obtained were evaluated. A CT scan analysis was performed.

RESULTS

The endoscopic endonasal approach extended the limits, offering wider exposure. The endoscopic endonasal approach made possible better visualization of deep structures and precise dissection of the parapharyngeal spaces. However, the maxillary swing provided better access to the oropharynx and could be completed 3 times faster.

CONCLUSION

The endoscopic endonasal approach provides excellent exposure, a wide dissection range, and precise definition of anatomic structures, making it an alternative of choice rather than the maxillary swing approach.

What vestibular tests to choose in symptomatic patients after a cochlear implant? A systematic review and meta-analysis

Vestibular function after cochlear implantation is difficult to understand, as subjective vestibular symptoms seem uncorrelated with the results of objective tests. Consequently, clinicians may struggle to decide what assessments to perform for a symptomatic patient. We used a systematic review and meta-analysis approach to enlighten this point. After a study inclusion process, results were classified into four different groups for each test in each study: (1) 'true positive' if the test showed impairment from pre-operative to post-operative in symptomatic patients; (2) 'false positive' if the test showed impairment from pre-operative to post-operative in asymptomatic patients; (3) 'true negative' if the test showed no impairment in asymptomatic patients; and (4) 'false negative' if the test showed no impairment in symptomatic patients. From these groups, sensitivities and specificities of each test were calculated in a meta-analysis. After reviewing more than 3000 references, 16 studies were included, representing 957 patients. The meta-analysis revealed a sensitivity of 0.21 (CI 95 % 0.08-0.40) for the caloric tests, of 0.32 (CI 95 % 0.15-0.54) for the cervical vestibular evoked myogenic potentials (c-VEMP), and of 0.5 (CI 95 % 0.07-0.93) for the head impulse tests. The analysis of prevalence revealed that c-VEMPs were the most often impaired, and the HIT the most often conserved. Our review and meta-analysis revealed that no vestibular test is sensitive enough to be recommended as a single test. Ideally, all the five vestibular sensors should be tested. In clinical practice, we suggest a case-to-case strategy according to patient's symptoms and their suspected origin.

Associating portal embolization and artery ligation to induce rapid liver regeneration in staged hepatectomy

BACKGROUND

Insufficient volume of the future liver remnant (FLR) is a major cause of unresectability in patients with bilobar colorectal liver metastases (CLM). The objective of this study was to evaluate the safety and efficacy of the novel associating portal embolization and artery ligation (APEAL) technique before extended right hepatectomy during a two-stage procedure for CLM.

METHODS

All patients who had undergone extended right hepatectomy during two-stage surgery for CLM between 2012 and 2014 were identified retrospectively from a prospectively maintained database. In the first stage, right portal vein embolization, partial right hepatic artery ligation and devascularization of segment IVb along the round ligament without parenchymal transection were associated with clearance of the FLR and/or primary tumour resection. Liver volumetry was performed using OsiriX software on postoperative day (POD) 7 and 30.

RESULTS

Ten patients underwent the APEAL procedure. During the first stage, APEAL was combined with colorectal resection in seven patients. The median (range) interval between the two stages was 45 (31-71) days. The FLR volume increased from 327 (214-537) cm(3) before surgery to 590 (508-1072) cm(3) on POD 7 and 701 (512-1018) cm(3) on POD 30. This corresponded to a FLR regeneration rate of 104 (42-185) and 134 (53-171) per cent respectively. There were no deaths. The overall morbidity rate was 60 per cent (6 of 10) after each procedure, with severe morbidity occurring in two and three of ten patients after the first and second procedures respectively.

CONCLUSION

APEAL induces fast, safe, reproducible and effective FLR growth when an extended right hepatectomy is scheduled in patients with multiple bilobar CLM.

State of the art of endoscopic frontal sinus cerebrospinal fluid leak repair

Frontal sinus cerebrospinal fluid leaks are rare and their surgical management is difficult. Up until recently, they could only be treated by open surgery with an osteoplastic flap. With the development of endoscopic surgery, less invasive techniques such as an exclusive endoscopic approach can now be used, ensuring a simpler postoperative course. However, these techniques require a thorough knowledge of frontal sinus anatomy and endoscopic CSF leak repair. This knowledge is essential both to ensure closure of the CSF leak and to preserve frontal sinus patency.

Human rather than ape-like orbital morphology allows much greater lateral visual field expansion with eye abduction

While convergent, the human orbit differs from that of non-human apes in that its lateral orbital margin is significantly more rearward. This rearward position does not obstruct the additional visual field gained through eye motion. This additional visual field is therefore considered to be wider in humans than in non-human apes. A mathematical model was designed to quantify this difference. The mathematical model is based on published computed tomography data in the human neuro-ocular plane (NOP) and on additional anatomical data from 100 human skulls and 120 non-human ape skulls (30 gibbons; 30 chimpanzees / bonobos; 30 orangutans; 30 gorillas). It is used to calculate temporal visual field eccentricity values in the NOP first in the primary position of gaze then for any eyeball rotation value in abduction up to 45° and any lateral orbital margin position between 85° and 115° relative to the sagittal plane. By varying the lateral orbital margin position, the human orbit can be made "non-human ape-like". In the Pan-like orbit, the orbital margin position (98.7°) was closest to the human orbit (107.1°). This modest 8.4° difference resulted in a large 21.1° difference in maximum lateral visual field eccentricity with eyeball abduction (Pan-like: 115°; human: 136.1°).

Lateral Semicircular Canal Asymmetry in Idiopathic Scoliosis: An Early Link between Biomechanical, Hormonal and Neurosensory Theories?

INTRODUCTION

Despite its high incidence and severe morbidity, the physiopathogenesis of adolescent idiopathic scoliosis (AIS) is still unknown. Here, we looked for early anomalies in AIS which are likely to be the cause of spinal deformity and could also be targeted by early treatments. We focused on the vestibular system, which is suspected of acting in AIS pathogenesis and which exhibits an end organ with size and shape fixed before birth. We hypothesize that, in adolescents with idiopathic scoliosis, vestibular morphological anomalies were already present at birth and could possibly have caused other abnormalities.

MATERIALS AND METHODS

The vestibular organ of 18 adolescents with AIS and 9 controls were evaluated with MRI in a prospective case controlled study. We studied lateral semicircular canal orientation and the three semicircular canal positions relative to the midline. Lateral semicircular canal function was also evaluated by vestibulonystagmography after bithermal caloric stimulation.

RESULTS

The left lateral semicircular canal was more vertical and further from the midline in AIS (p = 0.01) and these two parameters were highly correlated (r = -0.6; p = 0.02). These morphological anomalies were associated with functional anomalies in AIS (lower excitability, higher canal paresis), but were not significantly different from controls (p>0.05).

CONCLUSION

Adolescents with idiopathic scoliosis exhibit morphological vestibular asymmetry, probably determined well before birth. Since the vestibular system influences the vestibulospinal pathway, the hypothalamus, and the cerebellum, this indicates that the vestibular system is a possible cause of later morphological, hormonal and neurosensory anomalies observed in AIS. Moreover, the simple lateral SCC MRI measurement demonstrated here could be used for early detection of AIS, selection of children for close follow-up, and initiation of preventive treatment before spinal deformity occurs.

Unique human orbital morphology compared with that of apes

Humans' and apes' convergent (front-facing) orbits allow a large overlap of monocular visual fields but are considered to limit the lateral visual field extent. However, humans can greatly expand their lateral visual fields using eye motion. This study aimed to assess whether the human orbital morphology was unique compared with that of apes in avoiding lateral visual field obstruction. The orbits of 100 human skulls and 120 ape skulls (30 gibbons; 30 orangutans; 30 gorillas; 30 chimpanzees and bonobos) were analyzed. The orbital width/height ratio was calculated. Two orbital angles representing orbital convergence and rearward position of the orbital margin respectively were recorded using a protractor and laser levels. Humans have the largest orbital width/height ratio (1.19; p < 0.001). Humans and gibbons have orbits which are significantly less convergent than those of chimpanzees/bonobos, gorillas and orangutans (p < 0.001). These elements suggest a morphology favoring lateral vision in humans. More specifically, the human orbit has a uniquely rearward temporal orbital margin (107.1°; p < 0.001), suitable for avoiding visual obstruction and promoting lateral visual field expansion through eye motion. Such an orbital morphology may have evolved mainly as an adaptation to open-country habitat and bipedal locomotion.

Endovascular treatment of symptomatic vestibular aqueduct dehiscence as a result of jugular bulb abnormalities

A new endovascular treatment consisting of stent-assisted coil implantation is described for jugular bulb abnormalities causing symptomatic vestibular aqueduct dehiscence. Three patients presenting with vertigo associated with pulsatile tinnitus or hearing loss were treated. This technique cured the vertigo and pulsatile tinnitus in all patients and preserved normal cerebral venous drainage with no side effects.

Vestibular pathways involved in cognition

Recent discoveries have emphasized the role of the vestibular system in cognitive processes such as memory, spatial navigation and bodily self-consciousness. A precise understanding of the vestibular pathways involved is essential to understand the consequences of vestibular diseases for cognition, as well as develop therapeutic strategies to facilitate recovery. The knowledge of the “vestibular cortical projection areas”, defined as the cortical areas activated by vestibular stimulation, has dramatically increased over the last several years from both anatomical and functional points of view. Four major pathways have been hypothesized to transmit vestibular information to the vestibular cortex: (1) the vestibulo-thalamo-cortical pathway, which probably transmits spatial information about the environment via the parietal, entorhinal and perirhinal cortices to the hippocampus and is associated with spatial representation and self-versus object motion distinctions; (2) the pathway from the dorsal tegmental nucleus via the lateral mammillary nucleus, the anterodorsal nucleus of the thalamus to the entorhinal cortex, which transmits information for estimations of head direction; (3) the pathway via the nucleus reticularis pontis oralis, the supramammillary nucleus and the medial septum to the hippocampus, which transmits information supporting hippocampal theta rhythm and memory; and (4) a possible pathway via the cerebellum, and the ventral lateral nucleus of the thalamus (perhaps to the parietal cortex), which transmits information for spatial learning. Finally a new pathway is hypothesized via the basal ganglia, potentially involved in spatial learning and spatial memory. From these pathways, progressively emerges the anatomical network of vestibular cognition.

[Use of a free antero-lateral thigh flap for two-stage reconstruction of a large thoracic defect]

In case of extremely large thoracic full-thickness defects where no pedicled flap is available, very large free flaps are sometimes the only options. Dealing with such full-thickness defects where failure of the flap could be lethal, Servant and al described the concept of "two stage free flap" using Latissimus Dorsi muscular or myocutaneous flap. We present a reconstruction of a wide right posterior trunk radionecrosis with exposure of an underlying infected prosthesis using this two-stage free flap strategy with a fasciocutaneous antero-lateral thigh flap.

[Morbidity of neck dissection submuscular recess (sublevel IIb) in head and neck cancer]

OBJECTIVES

The impact of neck dissection on quality of life has often been considered less important than the oncological control. Dissection of level IIb doesn't improve oncologic control everytime, knowing that an injury of the spinal nerve can occur. The aim of our study was to assess the impact of neck dissection including level IIb on shoulder function and quality of life in N0 patients.

MATERIALS AND METHODS

Fifteen patients with squamous cell carcinoma of the upper aerodigestive tract, clinical and radiological NO, were included. They were assessed by validated scales (QLQ-C30, H&N35 and DASH) and they underwent an examination of the shoulder.

RESULTS

Almost half of the patients had pain in the shoulder. The functional scale score QLQ-C30 was statistically more altered (49.7%) than that of patients with cancer in general (74.9%, p = 0.00016) and of the general population 60 to 69 years (85.4%, p = 0).

CONCLUSION

The results of our study underscore the morbidity on shoulder function after neck dissection. These findings, combined with the low prevalence of occult lymph node metastases in level IIb among T1-T2 patients, must question the systematic inclusion of this level in neck dissection.

New Treatment of Vertigo Caused by Jugular Bulb Abnormalities

Objective. Jugular bulb abnormalities can induce tinnitus, hearing loss, or vertigo. Vertigo can be very disabling and may need surgical treatments with risk of hearing loss, major bleeding or facial palsy. Hence, we have developed a new treatment for vertigo caused by jugular bulb anomalies, using an endovascular technique. Patients. Three patients presented with severe vertigos mostly induced by high venous pressure. One patient showed downbeat vertical nystagmus during the Valsalva maneuver. The temporal-bone computed tomography scan showed a high rising jugular bulb or a jugular bulb diverticulum with dehiscence and compression of the vestibular aqueduct in all cases. Intervention. We plugged the upper part of the bulb with coils, and we used a stent to maintain the coils and preserving the venous permeability. Results. After 12- to 24-month follow-up, those patients experienced no more vertigo, allowing return to work. The 3-month arteriographs showed good permeability of the sigmoid sinus and jugular bulb through the stent, with complete obstruction of the upper part of the bulb in all cases. Conclusion. Disabling vertigo induced by jugular bulb abnormalities can be effectively treated by an endovascular technique. This technique is minimally invasive with a probable greater benefit/risk ratio compare with surgery.

Aspergillus vertebral osteomyelitis in immunocompetent subjects: case report and review of the literature

Aspergillus spondylodiscitis (AS) is rare in immunocompetent (IC) patients. A 65-year-old diabetic IC male subject presented with cervical AS 18 months after otomycosis. Two serological tests, mastoidectomy and biopsy of the sphenoid bone, were negative. A prevertebral biopsy identified A. flavus. The patient was successfully treated with voriconazole. Forty-three cases of AS in IC patients have been published. A predisposition was found in 84 % of cases. Fever was reported in 20 % of cases, whereas neurological defects were present in 41 %. Serology was inconsistently positive (5/7) and diagnosis was confirmed by biopsy or surgery. A. fumigatus was the most frequently isolated species (74 %). All episodes were medically treated, associated with surgery in 57 % of cases, and 73 % of patients fully recovered. AS must be discussed in IC patients presenting with risk factors, including diabetes mellitus. Biopsy is necessary to confirm diagnosis, since serology offers low sensitivity. Nevertheless, the prognosis is good.

Laryngeal paraganglioma mimicking a laryngeal haemangioma

Paraganglioma are uncommon neuroendocrine tumours arising from extra-adrenal chromaffin cells of the autonomic nervous system. In the head and neck region, these neoplasms most commonly arise from the carotid body, the vagus nerve, and the jugulotympanic area. We present the case of a 69-year-old woman who suffered from dyspnoea and dysphonia for six months. A biopsy diagnosed a laryngeal haemangioma and a resection of the tumour was performed using supraglottic pharyngolaryngectomy. Definitive histopathological examination revealed a laryngeal paraganglioma. Laryngeal paraganglioma and haemangioma must be evoked when confronted with a submucosal vascular laryngeal tumour. In such cases biopsies should be avoided. Exhaustive imaging is a key factor in the diagnosis and should include an MRI and an arteriography in order to rule out other differential diagnoses. To our knowledge this is the first case focusing on this issue.

Predictive factors for lateral occult lymph node metastasis in papillary thyroid carcinoma

Management of lateral no necks in papillary thyroid carcinoma (PTC) is very controversial. The aim of this study was to find predictive factors of lateral neck involvement in N0 PTC to help the clinician in his decision to treat the lateral compartment. We retrospectively analysed 173 patients who underwent thyroidectomy and lateral prophylactic neck dissection for PTC >10 mm. Predictive factors for occult lateral lymph node metastasis including sex, age, tumour size, multifocality and bilaterality, tumour extracapsular spread, vascular invasion and presence of a tumour capsule were examined by multivariate analysis. There were three independent predictive factors for occult lateral lymph node metastases in multivariate analysis: tumour extracapsular spread (p < 0.0001), vascular invasion (p < 0.001) and age <45 years (p < 0.027). When none of these factors was present, the risk of occult metastases was <5 %. The risk increased up to 56 % when at least two of these factors were present. These findings suggest that, in patients older than 45 years with neither tumour extracapsular spread nor vascular invasion on histopathological examination, occult lymph node metastases are very uncommon. In that case further discussion regarding the risks and benefits of lateral nodal dissection may be warranted.

Occult Lymph Node Metastases Increase Locoregional Recurrence in Differentiated Thyroid Carcinoma

Objectives:

The impact of occult lymph node metastasis (OLNM) on locoregional recurrence (LRR) and survival in patients with N0 differentiated thyroid carcinoma is unclear, because no large study has been carried out. A retrospective study was conducted in our department to assess the influence of OLNM.

Methods:

We included 201 patients treated by prophylactic neck dissection for N0 differentiated thyroid carcinoma between 1974 and 2006. The incidence of OLNM and predictive factors for recurrence and survival were assessed.

Results:

The incidence of OLNM was 20%. Necks were involved at levels VI, III, II, IV, V, and I, in decreasing order of frequency. After a mean follow-up of 9 years, the rate of LRR was 8.9% and the rate of distant metastasis was 3.4%. An age of greater than 55 years and the presence of OLNM were predictive factors for LRR. An age of greater than 55 years and the presence of LRR were predictive factors for distant metastasis. The presence of distant metastasis was the only factor that significantly and independently influenced the disease-specific survival.

Conclusions:

We found that OLNM occurred in only 20% of N0 patients. The presence and especially the number of OLNMs on neck dissection were major risk factors for LRR in this study, but did not affect the disease-specific survival.

Psychosocial quality of life in hereditary haemorrhagic telangiectasia patients

OBJECTIVES: The aim of this study was to evaluate psychosocial quality of life (PQoL) in patients with Hereditary Haemorrhagic Telangiectasia (HHT). STUDY DESIGN AND SETTING: A retrospective study was performed on PQoL in HHT patients presenting with epistaxis. One hundred fifteen patients were interviewed using a questionnaire designed by two sociologists and a head and neck surgeon. Changes over time were assessed according to information on psychosocial well-being, social life, family support, occupation, and medical and demographic data regarding age, gender and patient appearance. RESULTS: Analysis of Psychosocial Quality of Life (PQoL) revealed no statistical difference in relation to gender, marital status, household income or place of residence (rural or urban); however, a significant difference was observed with age. Elderly patients had a poorer PQoL than younger patients. Workers had a better PQoL than unemployed patients. Epistaxis and professional duties were correlated: workers with less than one episode of epistaxis per month were more active. Frequent episodes of epistaxis and abundant bleeding decreased PQoL. These patients felt different and often experienced a desire to withdraw compared to others. CONCLUSION: Epistaxis in hereditary haemorrhagic telangiectasia patients was associated with the impairment of many PQoL criteria, together with relationship modifications.