Diffusion-weighted MR imaging for evaluation of pediatric recurrent cholesteatomas.

OBJECTIVE: To compare the efficiency of diffusion-weighted MR imaging (MRI) vs. high resolution CT in predicting recurrent or residual cholesteatoma in children who underwent prior middle ear surgery. DESIGN: Prospective study. SETTING: Tertiary care university hospital. PATIENTS: Seventeen patients (4 with 2 recurrences) aged 5-17 years (mean 11.4) previously surgically treated for a cholesteatoma of the middle ear, were included for follow-up with systematic CT scan and MRI, between 2005 and 2007. METHODOLOGY: CT scan was performed on a Siemens Somaton 64 (0.5/0.2 mm slices reformatted in 0.5/0.3 mm images), parallel and perpendicular to the lateral semi-circular canal for each ear (100 mmx100 mm FOV). MRI was undertaken on a Siemens Avanto 1.5 T unit, with an adapted protocol for young children. Diagnosis of recurrent cholesteatoma was based on the evidence of a hyperintense image at B1000 on diffusion-weighted images. Results of CT scan and MRI were compared with operative diagnosis. RESULTS: Nine patients had a positive MRI, among which 8 had cholesteatoma confirmed during revision surgery. In the 12 negative MRI cases, 5 were positive on revision surgery. None of these lesions was over 3mm. Two of them were diagnosed on the CT scan. CT scan alone had a positive predictive value of 75%, and a negative predictive value of 58%. CONCLUSION: Diffusion-weighted MRI is associated with a high positive predictive value for the detection of recurrent cholesteatoma. CT scan remains the first choice imaging technique. In case of doubtful CT scan, diffusion-weighted MRI could confirm a recurrence or, when negative, avoid second-look surgery.

Nasal lavage with sodium hypochlorite solution in Staphylococcus aureus persistent rhinosinusitis.

OBJECTIVE: To determine a selected concentration of sodium hypochlorite (NaOCl) in saline solution for nasal lavage and evaluate its clinical efficiency in the treatment of symptomatic patients with persistent, Staphylococcus aureus (SA) associated rhinosinusitis (RS). MATERIAL AND METHODS: In vitro tests for cilia and epithelial cell viability were done on reconstituted primary epithelial cells in vitro. Cells were exposed for 5 and 15 minutes twice daily for 5 consecutive days to one of the following conditions, (1) saline, (2) 0.5% NaOCl in saline, and (3) 0.05% NaOCl in saline. In order to evaluate tolerance, immunostaining was done for ezrin and F-actin network and observed with confocal microscopy. The patients (n=20) were all persistent SA symptomatic carriers, with unique patient-specific SA clonotypes, and multiple infection recurrence despite effective systemic antibiotic therapy. Each patient applied first saline alone for 3 months followed by saline + 0.05% NaOCl solution, as nasal lavage twice daily on both nostrils for 3 months. Symptom intensity and endoscopic findings were recorded with visual analogue scale (VAS). Nasal airway resistance (NAR) and nasal Nitric Oxide (NO) levels were measured before and after the saline lavage regimen, and after the saline + NaOCl treatment. RESULTS: F-actin network loss and decreased expression of ezrin were significant in cells exposed to 0.5%, but not in those exposed to 0.05% NaOCl. These changes were more obvious when exposed for 15 min. than 5 min. daily. The nasal lavage with 0.05% NaOCl in saline was well tolerated and a significant improvement in nasal obstruction (p = 0.001), posterior nasal discharge (p = 0.018), olfaction (p = 0.007) and headache (p = 0.009) was demonstrated. Significant improvement was also recorded in nasal endoscopic grading of oedema (p = 0.001), erythema (p = 0.001), purulent discharge (p = 0.002), nasal crusts (p = 0.001), and NAR (p = 0.05) as measured by rhinomanometry. There was no significant improvement in nasal NO production or subjective anterior nasal discharge. Bacteriological cultures of middle meatus secretions collected one month after the end of the treatment revealed the persistence of SA. CONCLUSION: Nasal lavage with 0.05% NaOCl solution in saline is suitable for long-term use and seems to be a good alternative to lavage with saline alone in the management of symptomatic RS associated with recurrent SA infections due to patient-specific SA clonotypes.

[Labyrinthitis, or inflammatory pseudotumor after stapedectomy]. / Labyrinthite ou pseudotumeur inflammatoire après stapédectomie.

OBJECTIVES: To describe an extensive pseudotumor as a complication of stapes surgery. METHODS: Radiological workup and surgical exploration in a 38-year-old man suffering from postoperative hearing loss. The patient presented with tinnitus, inferior facial palsy, vertigo, and rapidly progressive hearing loss after his operation. RESULTS: The initial postoperative CT scan was normal. However, seven months after surgery, the CT scan showed an enlargement of the inner ear canal and complete vestibular destruction. The CISS sequence of the magnetic resonance imaging (MRI) enhanced after gadolinium injection revealed the presence of a mass filling the entire inner ear canal, the cochlear, the posterior labyrinth, and the middle ear. The aspect suggested an inflammatory pseudotumor. Surgical exploration confirmed the invasive aspect of the mass and pathological analysis revealed inflammatory tissue associated with microcalcifications. DISCUSSION: Hearing loss, vertigo, and tinnitus after stapes surgery require a radiologic workup. The CT scan is done first. It could be normal or eliminate other diagnoses. MRI may lead to a more precise diagnosis. It can reveal an inflammatory process of the inner ear after gadolinium injection. Surgical exploration is indicated in case of aggressive and extensive lesions. CONCLUSION: In the context of hearing loss complicating otosclerosis surgery, an imaging workup should include a CT scan. In case of a suspected expansive and inflammatory mass, it should be completed by an MRI (CISS sequence and gadolinium injection). An inflammatory lesion of the inner ear could indicate extensive pseudotumor.

Intracellular residency is frequently associated with recurrent Staphylococcus aureus rhinosinusitis.

AIM: The prevalence of intracellular Staphylococcus aureus organisms in the nasal mucosa of patients with recurrent infectious rhinosinusitis episodes was studied. METHOD: Twenty-seven consecutive adult patients who failed medical management of chronic rhinosinusitis (CRS) of multiple origins, associated or not with nasal polyposis, were consecutively enrolled for endonasal sinus surgery (including partial middle turbinectomy, middle antrostomy, ethmoidectomy, sphenoidotomy) and followed for a 12-month post-operative period. RESULTS: Seventeen of these patients showed the presence of intracellular S. aureus as detected by confocal laser scan immunofluorescence microscopy in epithelial cells of surgical intranasal biopsy specimens. Nine of the patients with and two without intracellular bacteria yielded S. aureus in endoscopically guided cultures of middle meatus secretions, despite the recent administration of prophylactic antibiotics. Eleven of the 17 patients with intracellular S. aureus relapsed for rhinosinusitis within the 12-month follow-up period. Molecular typing of sequential S. aureus isolates demonstrated the persistence of unique patient-specific S. aureus clonotypes in nine of the patients with intracellular bacteria during the 12-month follow-up. CONCLUSION: The presence of intracellular S. aureus in epithelial cells of the nasal mucosa is a significant risk factor for recurrent episodes of rhinosinusitis due to persistent bacterial clonotypes, which appear refractory to antimicrobial and surgical therapy.

Conservation laryngeal surgery for selected pyriform sinus cancer.

AIMS: This study reports the treatment of a cohort of patients with pyriform sinus squamous cell carcinoma, using conservative surgery and radiotherapy. METHODS: Thirty-four patients with pyriform sinus SCC were treated between 1986 and 2001, using partial laryngopharyngectomy with or without complementary radiotherapy. Seventy-six percent had stage III-IV lesions. Quality of life questionnaire and clinical examination were used for evaluation of laryngeal function. RESULTS: Conservation surgery was undertaken. All patients underwent neck dissection. Two thirds of the patients received post-operative radiotherapy. Reconstruction was achieved by local muscular flap in 13 cases, radial forearm free flap in 18 and pectoralis major flap in three. Five-year overall and disease-specific survival rates were 50 and 65%, respectively. Successful laryngeal function preservation with local control was achieved in 80% of the patients. CONCLUSION: Partial laryngopharyngectomy is a suitable treatment for early and selected advanced stage pyriform sinus carcinoma with a good functional and oncologic outcome.

Parapharyngeal metastases from thyroid cancer.

AIM: To emphasise the pattern of lymphatic dissemination in the parapharyngeal space from thyroid cancer. PATIENTS AND METHOD: Among 696 patients treated for thyroid cancer between 1986 and 2001, parapharyngeal metastasis was diagnosed in three patients, previously treated for papillary thyroid carcinoma. RESULTS: All three patients have been treated by surgical resection through lateral cervical approach. Two of them were controlled regionally whereas the remaining one had a submucosal pharyngeal metastasis locally resected 27 months after parapharyngeal resection. CONCLUSIONS: Parapharyngeal metastasis is rare, but should be a recognized pattern of lymphatic dissemination from thyroid carcinoma to avoid unnecessary radioiodine and because surgical resection is efficacious with acceptable morbidity.

Gastric choristoma of the midline neck in a newborn: a case report and review of the literature.

The current report describes a 3-week-old boy presenting with a gastric choristoma of the anterior compartment of the neck. Initial examination at birth found 3 masses in the anterior region of the neck. The only remarkable symptom consisted of episodes of cyanosis induced by neck flexion. The neck mass was removed after computed tomography scan assessment. Pathology finding showed the diagnosis of gastric choristoma. Cervical location of a gastric choristoma in children is rare. Its presentation as a clinically palpable anterior compartment cervical mass at birth even more rare.

Lymphatic malformations of the head and neck: a retrospective review and a support for staging.

BACKGROUND: Lymphatic malformations (LM) are rare benign congenital tumors appearing mainly in the head and neck with a considerably variable outcome. A need exists to validate a staging system, taking into account the prognosis of the malformation, including preoperative and postoperative complications, long-term sequelae, and persistence of the disease to improve parental counseling and evaluate the outcome of a surgical treatment of such tumors. METHODS: Twenty-two patients treated for LM were selected from a series of 129 patients operated on for congenital malformations of the head and neck between 1986 and 1997 at St-Luc University Hospital, Brussels, Belgium. Their charts were reviewed retrospectively, with a special focus on the anatomic location of the lesions and all the complications reported. According to de Serres et al, LM up to now have been divided into six possible categories according to their unilateral or bilateral infrahyoid and/or suprahyoid locations. RESULTS: Stage I (unilateral infrahyoid): nine patients, 11% of complications (without mediastinal extension: 0%, with mediastinal extension: 50%); stage II (unilateral suprahyoid): three patients, 33% of complications; stage III (unilateral suprahyoid and infrahyoid): eight patients, 75% of complications; stage V (bilateral suprahyoid and infrahyoid): two patients, 100% of complications. None of the children was initially seen with stage IV (bilateral suprahyoid) or stage VI (bilateral infrahyoid) LM. Overall complications, preoperative complications, postoperative com- plications, and long-term morbidity showed a significant in- crease from stage I to V (p <.01, p =.002, p =.02, and p =.03, respectively). CONCLUSIONS: A staging system of cervicofacial LM based on the anatomic location can be reliably used for prognostic purposes, allowing a more accurate assessment of the global risk of complications and determination of surgical outcome. Mediastinal extension in stage I patients seems to be associated with a higher rate of complications. Such information can be used to inform parents more appropriately regarding the management and long-term prognosis of their children's malformation.

Obstructive sleep apnea syndrome after reconstructive laryngectomy for glottic carcinoma.

Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive episodes of partial or complete obstruction of the upper airway during sleep. The obstruction predominantly occurs along the pharyngeal airway but other sites of obstruction have occasionally been described. We report our experience with three patients suffering from OSAS suspected to be of laryngeal origin. OSAS developed after reconstructive laryngectomy for glottic carcinoma and upper airway obstruction seemed to be located in the reconstructed laryngeal area. The three patients were given nCPAP (nasal-continuous positive airway pressure) treatment associated with peroral endoscopic CO2 laser vaporization of the laryngeal edema. After CO2 laser treatment, one patient was able to stop nCPAP treatment. The other two have remained on nCPAP therapy. OSAS may arise in the post-operative period of reconstructive laryngectomy for glottic carcinoma and can be managed by CO2 laser vaporization (laryngeal edema in the reconstructed area) in association with nCPAP treatment.

[Surveillance of laboratory based infections by biological and medical analyses: review of the literature]. / La surveillance des maladies infectieuses basée sur les laboratoires d'analyses biologiques et médicales: revue de la littérature.

Infectious disease surveillance is one of the priorities of public health programmes. This review aims to describe laboratory-based infection surveillance systems. The following surveillance networks are described: the Belgian microbiology network, AIDS surveillance in Philadelphia, EPIBAC, and the Salm-Net network. Laboratory-based surveillance provides the advantage of constituting an easily accessible computerised data bank that allows for studying age-old tendencies and evaluating the effectiveness of certain prevention programmes. The main inconveniences remain with the difficulty of eliminating duplications as well as the lack of clinical information. These difficulties can be surmounted by improving communication systems among the diverse participants in the network with electronic mail. Such surveillance systems will facilitate information exchanges at both the national and international level.

[Assessment of perilymphatic pressure using the MMS-10 tympanic membrane displacement analyzer (Marchbanks' test) in patients with Meniere's disease: preliminary report]. / Intérêt de l'évaluation de la pression périlymphatique par le test de Marchbanks (MMS-10) dans la maladie de Ménière: étude préliminaire.

OBJECTIVES: The aim of this study was to investigate non-invasive measurement of perilymphatic pressure using the MMS-10 tympanic displacement analyzer (Marchbanks' test) in patients with Meniere's disease. METHODS: We performed measurements in 20 patients with Meniere's disease and in 9 normal subjects with normal hearing. Data were collected in three groups: healthy ears of normal-hearing patients, healthy and affected ears in patients with Meniere's disease. RESULTS: We found no significant differences between the 3 groups for the types of the graph. Measurements of the tympanic membrane displacement test variables (Vi and Vm) showed large inter-subject variations. No significant difference was found between the 3 groups for cochlear aqueduct patency. CONCLUSION: Preliminary results of this short series show that assessment of perilymphatic pressure using the MMS-10 procedure does not seem to be useful in Meniere's disease.

Microangiopathy of the inner ear, retina, and brain (Susac syndrome): report of a case.

Microangiopathy of the inner ear, retina, and brain was first described in 1979 by John O. Susac. Since then, approximately 60 cases have been reported. Otolaryngologists must be aware of this syndrome, in which cochleovestibular symptoms are an important part of the diagnosis. In this article, we report a new case of Susac syndrome and discuss the diagnosis, physiopathologic characteristics, and treatment of this disease.

Obliterative otosclerosis.

From January 1990 to December 1996, 293 primary stapedectomies for otosclerosis were performed, among which 14 had obliterative otosclerosis (4.7 per cent). Probability of bilateral obliterative disease was 50 per cent. With this particular condition, a drill-out procedure was used to perform either a stapedectomy or a stapedotomy. In two patients with bilateral 'far-advanced otosclerosis', surgery was effective in enabling the patient to benefit from hearing-aids. In patients with a measurable hearing-loss, an air-bone gap closure to within 10 dB was achieved in 62.5 per cent of the cases and to within 10-20 dB in 37.5 per cent of the cases, with no deterioration of air-conduction thresholds at 8 kHz. A mild sensorineural hearing loss at 4 kHz was observed in 25 per cent of the cases. There was no statistical difference between stapedectomy and stapedotomy. According to these results, the drill-out technique is a safe and effective procedure in cases of obliterative otosclerosis.