[Community-acquired acute maxillary sinusitis or rhinosinusitis in adults in France: current management]. / Etat actuel de la prise en charge de la sinusite ou rhinosinusite maxillaire aiguë communautaire de l'adulte en France.

Sinus infections, often viral, are a common reason for physician visits. The multiplicity of clinical presentations makes its diagnosis difficult. The problem is to recognize bacterial infection without additional testing, except in cases of treatment failures, complications or relapse. Patients with signs suggestive of rhinosinusitis fall into one of four basic clinical situations: common colds, 'doubtful' rhinosinusitis, apparent acute maxillary bacterial rhinosinusitis, and complications. Anterior rhinoscopy may help confirm diagnosis. Current bacterial epidemiology is based on the results of clinical studies, microbial ecology, and samples taken in cases of treatment failure. The two bacteria isolated most frequently are Streptococcus pneumoniae and Haemophilus influenzae, both of which pose resistance problems. Moraxella catarrhalis, Streptococcus pyogenes and Staphylococcus aureus are isolated less often. The dominant issue in management of acute rhinosinusitis is whether to use antibiotic or symptomatic treatment. For viral infections, antibiotic therapy is useless and highly inadvisable. For 'doubtful' infections, symptomatic treatment is likely to lead to recovery. The use of non-recommended antibiotics also increases the risk of selection of resistant bacteria. When bacterial rhinosinusitis is strongly suspected, recourse to antibiotic treatment is recommended in view of the benefits in this situation (AFSSAPS 2005). This treatment is probabilistic, should be decided at the end of the consultation, and follows the AFSSAPS guidelines.

[Levofloxacin in the treatment of acute and bacteriologically documented sinusitis with high risk of complications]. / Efficacité et tolérance de la lévofloxacine dans le traitement des sinusites aiguës bactériologiquement documentées et à risque de complications.

OBJECTIVES: The authors had for aim to evaluate the efficacy and tolerance of oral levofloxacin (500 mg once a day during ten days), as a treatment for acute bacterial sinusitis at risk for complications in adult patients. PATIENTS AND METHODS: This was a prospective, multicenter, open, non-comparative, efficacy and tolerance study of levofloxacin in acute sinusitis at risk for complications, radiologically confirmed, and with documentation of the bacterial origin by fiberoptic rhinoscopy. RESULTS: Two hundred and thirty-one patients were included and 174 patients had an X ray confirmed sinusitis. The localization was frontal in 81% patients, sphenoidal in 9.2%, ethmoidosphenoidal in 2.3%, and 7.5% patients had a pansinusitis. One hundred and thirty-three patients had a probable or proven bacterial infection, involving: Streptococcus pneumoniae (26.0%), enterobacteriaceae (19.7%), Haemophilus influenzae (17.3%), Staphylococcus aureus (15.0%), streptococci other than S. pneumoniae (7.9%), and Branhamella catarrhalis (5.5%). One hundred and one patients constituted the per protocol population. Clinical success was observed in 94.1 % patients (95/101), and 85.1% (86/101), respectively 7 to 14 days and three to four weeks after the end of treatment, with consistent success rates according to the localization of the infection, and the various pathogens involved. The tolerance data was as expected for levofloxacin. CONCLUSIONS: The results of this study show that levofloxacin, (one 500 mg tablet QD during ten days) is efficient in over 94% patients with bacteriologically documented sinusitis at risk for complications.

Clinical efficacy and tolerability of cefixime in the treatment of acute sinusitis.

In a noncomparative trial, 73 adults with acute sinusitis confirmed by x-ray received cefixime 400mg once daily for approximately 10 days. At the end of treatment, 60 patients (82%) were cured, 2 (2.7%) had improved and 7 (9.6%) had failed therapy; 4 patients were not evaluable. No relapses were observed at follow-up. Haemophilus influenzae, Streptococcus pneumoniae and Branhamella (Moraxella) catarrhalis were the main pretreatment pathogens, accounting for 65% of all bacterial isolates. Overall, 84% of pathogens were eradicated after treatment. Cefixime was well tolerated, moderate gastrointestinal disturbances being the most frequent adverse effects noted (3 of 4 patients with adverse effects). These results are comparable to those obtained with cefixime 400mg administered orally in 2 divided doses.

Evaluation of nasopharyngeal cultures for bacteriologic assessment of acute otitis media in children.

BACKGROUND: The recent emergence of penicillin-resistant Streptococcus pneumoniae, particularly in acute otitis media (AOM), has increased interest in the development of noninvasive procedures that might help to predict the bacterial etiology of this condition. We conducted an open multicenter study to evaluate the predictive value of the nasopharyngeal (NP) sampling in children with AOM by comparing the bacteriologic results of NP cultures with those of pus collected by myringotomy in the same patients. METHODS: The NP secretions and the pus obtained by myringotomy were collected concomitantly in 354 children younger than 6 years of age with clinical signs of AOM. The clinical usefulness of NP culture was determined by calculating its sensitivity and specificity, and especially its positive and negative predictive values for the three main pathogens responsible for AOM, Haemophilus influenzae, S. pneumoniae and Moraxella catarrhalis. RESULTS: A positive NP culture was found to have little predictive value for H. influenzae (52%), S. pneumoniae (43%) and M. catarrhalis (19%). In contrast the negative predictive value of NP cultures was much greater and was accompanied by negative middle ear fluid cultures in more than 95% of children, especially for S. pneumoniae. Furthermore the incidence of beta-lactamase-producing strains of H. influenzae at both sampling sites was similar (30 and 35%, respectively), as was the incidence of penicillin-resistant S. pneumoniae (50 and 54%). CONCLUSION: It appears that the correlation between results of NP and middle ear fluid cultures in children with AOM is too weak to allow NP culture to be recommended for the bacteriologic documentation of this disease. However, these results should not overshadow the considerable epidemiologic value of NP cultures, particularly with reference to the monitoring of pneumonococcal susceptibility in children. The collection of NP cultures should therefore be promoted for their collective epidemiologic value.

Five vs. ten days of antibiotic therapy for acute otitis media in young children.

BACKGROUND: Many publications in recent years have argued in favor of shortened therapy for acute otitis media. However, doubt persists regarding children younger than 2 years, and some authors therefore restrict short course therapy to children older than 2 years. METHODS: In a prospective, comparative, double blind, randomized, multicenter trial we compared cefpodoxime-proxetil, 8 mg/kg/day in two divided doses for 10 days, with an identical 5-day regimen followed by a 5-day placebo period. RESULTS: Between October, 1996, and April, 1997, 450 children (mean age, 14.3 months) were enrolled, 227 in the 5-day group and 223 in the 10-day group. In the per protocol analysis clinical success was obtained on Days 12 to 14 after the beginning of treatment (main analysis) in 175 (84.1%) of the 208 children receiving the 5-day regimen and 194 (92.4%) of the 210 children receiving the 10-day regimen (P = 0.009). The superiority of the standard regimen was more marked among children cared for outside their homes (92.5% vs. 81.5%). Clinical success persisted on Days 28 to 42 among 134 (85.4%) of the 157 assessable patients in the 5-day group and 144 (83.7%) of the 172 assessable patients in the 10-day group (P = 0.68). CONCLUSIONS: The 10-day regimen resulted in a higher success rate at the conclusion of therapy, but there were no differences between the two study groups 4 to 6 weeks after enrollment in the study protocol.

Pathogens isolated during treatment failures in otitis.

OBJECTIVES: A prospective study in the Paris region to evaluate the clinical and bacteriologic epidemiology of acute otitis media in infants in whom oral antibiotic therapy resulted in clinical failure. METHODS: The study included 186 children with a mean age of 17.5 +/- 13.1 months. Two-thirds of them attended a day-care center and 40.8% had a history of recurrent otitis media. The most frequently prescribed prior antibiotics were amoxicillin-clavulanic acid (43% of cases), an oral third generation cephalosporin (22.6%), erythromycin-sulfisoxazole (11.8%) and a first generation cephalosporin (10.2%). The average duration of antibiotic therapy was 6.9 +/- 2.65 days. Specimens for bacterial cultures included 188 samples of middle ear fluid obtained by tympanocentesis and 37 collected from otorrhea fluid. RESULTS: One hundred forty-one samples (62.7%) from 126 children yielded 170 bacterial isolates. In 60 children (32.3%) the culture of the ear pus was sterile. Among the 170 bacterial isolates: 67 (39.4%) were Streptococcus pneumoniae (59 patients), of which 77.6% had reduced susceptibility to penicillin (PRSP with penicillin MIC > or = 0.125 mg/l); 61 (35.9%) were Haemophilus influenzae (56 patients) of which 49.2% were beta-lactamase producers; and 8 were Moraxella catarrhalis (8 patients), of which 87.5% were beta-lactamase producers. Thirty-six patients were infected by S. pneumoniae with penicillin MIC > or =1 mg/l. In our study attending day-care center (P = 0.04), temperature >38 degrees C with signs of otalgia (P = 0.02), age <2 years (P = 0.048) and prior antibiotic treatment with erythromycin-sulfisoxazole (P = 0.006) were independently predictive risk factors for patients infected with penicillin-resistant S. pneumoniae. Pneumococcal serogroups 23, 14 and 19 were predominant (25.4, 25.4 and 23.8%, respectively). Penicillin resistance was mainly associated with serogroups 23 and 14. CONCLUSIONS: Penicillin-resistant S. pneumoniae isolates are frequently responsible for therapeutic failure in cases of acute otitis media in the Paris region.

Microbiology of otitis media in the Paris, France, area from 1987 to 1997.

PURPOSE OF THE STUDY: To investigate epidemiologic trends in the bacteriology of acute otitis media, data were recorded during a 10-year period by the same group of investigators during clinical studies in pediatric outpatients. METHODS: Bacterial samples were obtained before antibiotic treatment from 2149 children (age 3 to 36 months) with acute otitis media. All samples were transported, handled and cultured in the same way throughout the 10-year period. RESULTS: From the study patients 1862 samples of middle ear secretion were collected by tympanocentesis and 287 samples were collected from spontaneous otorrhea occurring within 24 h. Pathogens were isolated from 70% of patients. Pathogens included Haemophilus influenzae (40%), Streptococcus pneumoniae (31%) and Moraxella catarrhalis (8%). The incidence of beta-lactamase-producing H. influenzae was approximately 20% from 1987 to 1989, was approximately 35% from 1990 to 1995 and increased to 60 and 70% during the last 2 years. The rate of S. pneumoniae with decreased susceptibility to penicillin gradually increased from 7% in 1987 to 70% in 1996 and 1997. CONCLUSION: The very high incidence of antimicrobial resistant strains reached during a short period in pediatric acute otitis media in our area, emphasizes the need for frequent epidemiologic studies.

Short course therapy with cefuroxime axetil for acute otitis media: results of a randomized multicenter comparison with amoxicillin/clavulanate.

BACKGROUND: Otitis media is a common infection of childhood. Increasing antibiotic resistance rates among the principal causative pathogens, Streptococcus pneumoniae and Haemophilus influenzae, are associated with failure of first line agents. OBJECTIVE: This open, randomized, multicenter study compared the clinical efficacy of a short 5-day course of cefuroxime axetil (CAE) suspension with that of amoxicillin/clavulanate (A/CA) suspension for 8 or 10 days. METHODS: Children age 6 to 36 months with acute otitis media with effusion, diagnosed by tympanocentesis and microbiologic culture, were randomized to receive CAE (30 mg/kg/day in two divided doses for 5 days) or A/CA 40 mg/kg/day in three divided doses for 10 days (A/CA-10). In French centers A/CA was given at 80 mg/kg/day in three divided doses for 8 days (A/CA-8). Patients were assessed 1 to 4 days after completing the course (posttreatment) and followed up at 21 to 28 days after completing the course. RESULTS: Of the 716 patients randomized, 252 were treated with CAE, 255 with A/CA-10 and 209 with A/CA-8. In the clinically evaluable population, the proportions of patients with clinical cure at posttreatment were 175 of 203 (86%), 181 of 205 (88%) and 145 of 164 (88%) in the CAE, A/CA-10 and A/CA-8 groups, respectively, demonstrating equivalence among the three treatments. For patients <18 months old, clinical cures were 111 of 134 (83%), 116 of 131 (89%) and 83 of 99 (84%) in the CAE, A/CA-10 and A/CA-8 groups, respectively; equivalence was also demonstrated. At follow-up, 130 of 175 (74%) CAE, 121 of 172 (70%) A/CA-10, and 112 of 142 (79%) A/CA-8 had maintained cure. A total of 837 pretreatment pathogens were isolated from middle ear fluid in 73% (522 of 716) patients, the majority of isolates were S. pneumoniae (30%) and H. influenzae (27%). The most common adverse events were gastrointestinal, the incidence of drug-related diarrhea being higher in the A/CA-10 group (18%) than in either the CAE or A/CA-8 groups (10%). CONCLUSIONS: A 5-day course of CAE, given twice daily, was shown to be equivalent to the two regimens of A/CA for treatment of acute otitis media with effusion in children.

Workplace air-conditioning and health services attendance among French middle-aged women: a prospective cohort study.

OBJECTIVES: To assess the relationship between type of ventilation in the workplace, health services attendance, and sickness absence among middle-aged women. METHODS: In a national sample of 920 professionally active women aged 49-65 yr from the SU.VI.MAX cohort, recruited from the general population in France, health services attendance and sickness absence were assessed prospectively during 1999. RESULTS: Being exposed to heating, ventilation, and air-conditioning (HVAC) systems in the workplace proved to be a risk factor for attendance at global and several specialist medical services. The adjusted odds ratio for otorhinolaryngologist attendance was 2.33 (95% CI = 1.35-4.04) in the HVAC group compared with the natural ventilation group, and 1.70 (1.13-2.58) for sickness absence. Dermatologist and global medical services attendance rates may also be higher in this group (P = 0.06 in both cases). CONCLUSIONS: Exposure to HVAC systems was a strong and significant risk factor for otorhinolaryngologist attendance and sickness absence. HVAC systems are prevalent in recent office buildings and have been shown to be associated with several adverse health effects in terms of morbidity and mortality. From a public-health perspective, our results outline the need for a quantitative assessment of the health impact of ventilation systems, taking into account the possible loss of production that exists in addition to the direct costs of medical services use.

Telithromycin (HMR 3647) achieves high and sustained concentrations in tonsils of patients undergoing tonsillectomy.

Telithromycin, the first ketolide antimicrobial to be developed for clinical use, has potent activity against group A beta-haemolytic streptococci (GABHS), including macrolide-resistant strains. The penetration of telithromycin into tonsils was assessed in 22 adults undergoing tonsillectomy at 3, 12 or 24 h after the fourth dose of oral telithromycin 800 mg once daily. Telithromycin rapidly penetrated tonsillar tissues, achieving a mean concentration of 3.95 mg/kg at 3 h post dose, 3.4 times greater than the corresponding plasma concentration (1.22 mg/l. The mean tonsil:plasma concentration ratio increased to 13.1 at 24 h post dose, indicating slower elimination from tonsils than plasma. Tonsillar and plasma concentrations exceeded the MIC(50) for GABHS throughout the 24-h dosing period. These findings suggest that telithromycin may be an effective new alternative treatment for GABHS tonsillopharyngitis.

Clinical experience with 1000 patients treated with cefetamet pivoxil.

Clinical studies have been carried out world-wide on cefetamet pivoxil, a new orally active cephalosporin. This paper reports on the first 1000 patients treated with the antibiotic; another 505 patients received standard antibiotics, mainly cefadroxil and cefaclor, for comparison. The results show that single doses of 1500 and 1200 mg cefetamet pivoxil were fully effective in gonorrhoea. Comparative trials in uncomplicated urinary tract infection indicate a significant superiority of a single dose of 2 g cefetamet pivoxil (n = 158; 90.0% cure) versus 2 g cefadrox (n = 162; 77.0% cure). In complicated urinary tract infections, a comparable outcome was achieved with a single daily dose of 2 g cefetamet pivoxil for 10 days (n = 99; 90% cure) and 1 g cefadroxil twice daily for 10 days (n = 98; 76.5% cure). The clinical response rate in acute exacerbation of chronic bronchitis was 89.4% in the group receiving cefetamet pivoxil (136 patients) and 83% in the cefaclor-treated group (n = 122). Treatment with 1000 or 2000 mg cefetamet pivoxil achieved a (bacteriological) success rate of 96% compared to 95% with cefaclor in acute ear, nose and throat-infections (n = 91). Overall, based on 894 isolated pathogens prior to therapy, the bacteriological response rate was 90% and it would appear that in vivo the spectrum of this cephalosporin covers a wide range of Gram-negative and Gram-positive pathogens, including urinary pathogens, but excluding Enterococci and Pseudomonas. Cefetamet pivoxil proved to be well tolerated. Mild to moderate adverse events were reported in 7.1% of patients but only 2 of the 1000 patients treated with cefetamet pivoxil were withdrawn because of diarrhoea, which subsided rapidly. There were no clinically relevant deviations in laboratory parameters.

Use of gastro-omental free flaps in major neck defects.

BACKGROUND: The reconstruction of extensive neck defects with minimum deformity and rapid return to normal food intake is successfully achieved by the use of gastro-omental flaps. We report a series of 18 patients who underwent such reconstructive surgery for major full-thickness defects involving the skin in addition to the larynx and pharynx. Fifteen patients had earlier undergone radiotherapy and 3 chemoradiotherapy; 14 of them had undergone previous surgery. The cause of the defect was tumor recurrence in 10 patients, a pharyngostoma in 6, and postoperative cellulitis in 2. PATIENTS AND METHODS: Harvesting of the flap included elevation of a segment of the greater curvature of the stomach together with the omentum pediculated on the right gastroepiploic vessels. In 8 patients with a circumferential pharyngeal defect, the graft was used in the form of a tube; in the other 10, the graft was converted into a patch to reconstruct the missing anterior pharyngeal wall. In all cases, the omentum was used to fill in the defect. In 5 patients, neck vessels were chosen as recipient vessels, and axillary vessel systems were selected in 13 because the surgical approach to neck vessels was contraindicated. RESULTS: There was no instance of total flap necrosis. Fifteen patients had an uneventful postoperative course, and oral food intake was begun on the 15th day. The remaining 3 patients developed fistulas, which healed spontaneously. The omentum was left to granulate in all patients, and skin grafts were required in 5 patients only. No abdominal complications occurred in any patients. CONCLUSIONS: These results suggest that gastro-omental free flaps are a method of choice that should be seriously considered for the reconstruction of full-thickness defects of the neck.

A comparison of the safety and efficacy of moxifloxacin (BAY 12-8039) and cefuroxime axetil in the treatment of acute bacterial sinusitis in adults. The Sinusitis Study Group.

The aim of this multicentre, randomized study was to compare the efficacy and safety of moxifloxacin (BAY 12-8039), a new 8-methoxy fluoroquinolone, with that of cefuroxime axetil for the treatment of acute bacterial sinusitis in adults. Diagnosis was made on a range of clinical signs and symptoms combined with radiology and microbiology. A 400 mg dose of moxifloxacin was administered once daily for 7 days to 242 patients and 250 mg twice daily of cefuroxime axetil was administered to 251 patients for 10 days. The clinical success rate at the end of treatment in the evaluable population was significantly higher (96.7%) in the moxifloxacin group (204/211) than in the cefuroxime axetil group (204/225, 90.7%; 95% confidence intervals 1.5%; 10.6%). At follow-up the success rate in the moxifloxacin group was 90.7% and that for the cefuroxime axetil group was 89.2% (95% confidence intervals -4.3%; 5.4%). The predominant pathogens isolated were Streptococcus pneumoniae and Haemophilus influenzae, followed by Moraxella catarrhalis and Staphylococcus aureus. The bacteriological eradication rates were higher for moxifloxacin (94.5%, 103/109) than for cefuroxime axetil (83.5%, 96/115; 95% CI 3.6%; 19.7%). Only one S. pneumoniae infection persisted following moxifloxacin therapy in contrast with three in individuals on cefuroxime axetil. There were slightly more adverse events in the moxifloxacin group than in the cefuroxime axetil group, but there were fewer serious adverse events following moxifloxacin treatment (three vs. eight). The drug was discontinued because of adverse events in 14 moxifloxacin patients and in 11 cefuroxime axetil patients. Overall, in all assessments, moxifloxacin was at least as effective clinically and bacteriologically, and as well tolerated, as cefuroxime axetil in the treatment of acute sinusitis.

Cost saving of 5-day therapy with cefpodoxime proxetil versus standard 10-day beta-lactam therapy for recurrent pharyngotonsillitis in adults. A prospective general practice study.

A prospective economic evaluation was undertaken as part of a randomised clinical trial conducted in French general practice. Its aim was to compare the costs and therapeutic outcomes of a 5-day course of cefpodoxime proxetil 100 mg twice daily with 10-day courses of phenoxymethylpenicillin (penicillin V) 1 MIU 3 times daily and amoxicillin-clavulanic acid 500/125 mg 3 times daily for the treatment of recurrent pharyngotonsillitis in 575 adults. Over the 6-month study period, the total cost to society per patient treated with cefpodoxime proxetil was 123 French francs (FF; 1993 values) lower than that for patients treated with phenoxymethylpenicillin and FF227 lower than that for patients treated with amoxicillin-clavulanic acid. This cost saving was primarily attributable to a lower initial drug acquisition cost, and a reduction in the cost associated with lost productivity and general practitioner consultations. Furthermore, as a consequence of a lower relapse rate, the cost-saving ratio for cefpodoxime proxetil, expressed as FF per month free of recurrence, was FF50 less than for phenoxymethylpenicillin and FF60 less than for amoxicillin-clavulanic acid. Thus, a 5-day course of cefpodoxime proxetil is likely to be less costly for treatment of pharyngotonsillitis in the general practice setting than standard 10-day courses of phenoxymethylpenicillin and amoxicillin-clavulanic acid.

Advanced carcinoma of the tongue: total glossectomy without total laryngectomy. Review of 80 cases.

Opinions are divided over the validity of total glossectomy without associated total laryngectomy for advanced carcinoma of the tongue. This retrospective study evaluates the oncologic and functional results obtained in 80 patients who underwent total glossectomy as a primary procedure or as salvage surgery. Satisfactory swallowing ability was obtained in 41 patients, and speech was understandable in 49 patients. The survival rate at 1 year was 65%, with early recurrence of the disease, which was especially frequent in patients with prior radiotherapy, being the major cause of death. The study confirms the poor prognosis of cases with mandibular involvement, and the fact that partial laryngectomy, when required, impairs functional results. In the light of the authors' experience, total glossectomy without total laryngectomy should only be undertaken in motivated and well-supported patients able to accomplish the difficult rehabilitation process.

Otogenic intracranial infections in adults.

OBJECTIVE: To assess the type and bacteriology of otologic diseases associated with bacterial meningitis in adults. METHOD: Retrospective review of 79 patients over an 18-year period. RESULTS: Acute otitis media was diagnosed in 32 patients, chronic otitis in 29 (16 with cholesteatoma), and cerebrospinal fluid leak in 18. Streptococcus pneumoniae was a common cause of meningitis-complicating acute otitis media (69%) or cerebrospinal fluid leak (50%), whereas other bacteria or negative cultures were found in the cerebrospinal fluid of patients with chronic otitis. Surgery was performed promptly in 26 patients; four patients died. CONCLUSIONS: Early diagnosis of otogenic bacterial meningitis is essential to allow appropriate antimicrobial treatment. Antimicrobials active on gram negative bacilli and anaerobes should be used in patients with chronic otitis. An emergency surgical procedure is required in patients whose neurologic or infectious status fails to improve under antimicrobial treatment.

Prognostic value of lymph node involvement in oral cancers: a study of 137 cases.

OBJECTIVE: The aim of this study was to assess the prognostic value of lymph node involvement in patients with squamous cell carcinoma of the oral cavity. STUDY DESIGN: Retrospective study of 137 patients with T4 squamous cell carcinoma of the oral cavity treated by surgery and radiotherapy (84 N0, 23 N1, 16 N2,14 N3). Twenty-three patients in the N0 group had a history of surgery or radiotherapy. One hundred fourteen patients underwent limited or radical neck dissection unilaterally or bilaterally. METHODS: The histological charts were reviewed and correlated with preoperative lymph node clinical stage. The local failure rate and the overall survival curves were calculated with respect to clinical and histological stages. The causes of death were analyzed. RESULTS: No evidence of lymph node metastasis was found in 47.4% of cases (54 of 114 patients). Among the node-positive (N+) patients, 39 had rupture of the lymph node capsule (R+). In the N0 group, 27.8% of patients were N+. Regional control rates after surgery and radiotherapy were 95% at 1 year and 85.4% at 5 years. The local failure rates were 6% in N0, 8.7% in N1, 31.2% in N2, 51.7% in N3, 9% in node-negative (N-), and 29% in N+R+ patients. The overall survival rates at 3 and 5 years were, respectively, 44.7% and 34.8% in the N0 group, 37.7% and 37.7% (same rate at 3 and 5 years) in the N1 group, and 31.2% and 15.8% in the N2 group. None of the patients in the N3 group survived beyond 2 years. The overall survival rates at 5 years were 42.8% and 17.5% in the N- and N+ groups, respectively. CONCLUSIONS: In patients with locally advanced tumors (T4), clinical nodal status and histological nodal invasion were key prognostic factors. The presence of occult metastases in the N0 group justifies routine neck dissection.

Otogenic meningoencephalitis induced by Streptococcus pneumoniae in gerbils.

OBJECTIVE: Study and development of a gerbil model of pneumococcal meningoencephalitis secondary to acute middle ear (ME) otitis. Preliminary data raised the hypothesis of a direct bacterial dissemination from the ME focus to the central nervous system. This infection pattern was examined. DESIGN: Animals were inoculated bilaterally by transbulla challenge with a serotype 3 strain of Streptococcus pneumoniae at various inoculum sizes. The incidence and course of meningeal complications were studied in relation to the course of ME otitis. RESULTS: After inoculation of 40 bacteria per ear, lethal meningeal complications occurred in 14 (29%) of 48 cases. A 76% rate (25 of 33 animals) of early meningeal involvement was observed after inoculation of 10(4) bacteria per ear. Actual involvement of brain was confirmed histologically for both infection schemes. Bacterial counts 20 to 22 hours after infection with the higher inoculum showed various phases of the extension of the ME infection to brain tissue, cerebrospinal fluid, and bloodstream. Bacterial counts in ME and brain tissue were strongly correlated (P < .001). Nine of the 25 animals with infection of the central nervous system had positive brain tissue cultures without bacteremia. CONCLUSION: Gradations in inflammatory aspects of the meninges and cerebral parenchyma, together with bacteriologic findings, indicate a primary invasion of meningeal spaces that can result in lethal encephalitis and septicemia. This model might be useful for preclinical therapeutic assays on pneumococcal meningeal complications, including infections due to strains with abnormal susceptibility to antibiotics.

Laryngectomized patients' education and follow-up.

Functional and aesthetic problems due to mutilating surgical excisions and adjuvant radiotherapy prolonging the therapeutic period and increasing consequences, are common to all cervicofacial tumors. Laryngectomy is the most representative example, because it affects the aero-digestive tract, the site of major functions; breathing, phonation and swallowing. It necessitates excellent information to the patient post-operatively, and then adapted rehabilitation requiring the learning of oesophageal speech. A close follow-up is required to track loco-regional relapses, secondary neoplastic sites and metastases, cessation of alcohol and tobacco use, and to provide family, social and professional rehabilitation. There are often problems to manage with socio-culturally disadvantaged classes, and physically and psychologically fragile patients, whose hope of surviving is, in general, mediocre.

Multicenter study of the efficacy and safety of oral ciprofloxacin in the treatment of chronic suppurative otitis media in adults. The French Study Group.

Chronic suppurative otitis media is a common and potentially dangerous clinical condition that is difficult to treat because the most common infecting organisms are often resistant to many antibiotics. Recently, fluoroquinolones such as ciprofloxacin have provided a new therapeutic possibility, offering a wide range of antibacterial activity and proven concentration in the middle ear. Therefore in the current study, we assessed the efficacy and safety of oral ciprofloxacin (500 mg twice daily for 10 days) in the treatment of suppurative chronic otitis media in adults. One hundred sixty-four patients were enrolled during a 3-month period by 49 ear, nose, and throat physicians in general practice. The mean duration of symptoms was 158 months, with the acute exacerbation lasting 72.5 days. Staphylococcus aureus, Pseudomonas aeruginosa, and Proteus mirabilis were most commonly isolated. At the end of treatment, the otorrhea had disappeared in 104 of the 155 (67.1%) evaluated patients. The bacteriologic eradication rate was 64.5%. After 4 weeks of follow-up care, 93.2% of patients had no recurrence of infection. In 4 patients, treatment was discontinued prematurely after an adverse event. We conclude that ciprofloxacin is an effective and well-tolerated general practice treatment for suppurative chronic otitis media in adults.