Clinical and Radiological Characteristics of Malignant Tumors Located to the Cerebellopontine Angle and/or Internal Acoustic Meatus.

OBJECTIVE: Metastatic lesions to the internal auditory meatus (IAM) and/or the cerebellopontine angle (CPA) are rare and may appear like a vestibular schwannoma (VS). We herein raise the issue of the diagnosis and treatment of nine malignant cases of the CPA and IAM among three referral centers in France and Japan. The aim of this study was 1) to report malignant lesions of the CPA, their diagnosis and treatment, 2) to review the literature, 3) to propose criteria of suspicion for malignant tumors of the CPA. METHODS: Nine patients who had malignant lesions of the CPA and/or IAM for whom the final diagnosis was made by surgery, lumbar puncture, or PET scan were included. The main outcomes measured were: rapid onset of symptoms, association of cochlea-vestibular symptoms with facial palsy, and MRI analysis. RESULTS: Among the nine patients with malignant tumor of the CPA, 8 of them (89%) had a facial palsy associated with cochlea-vestibular symptoms. Rapid growth of the tumor was observed in 77% (7/9) of the cases in a mean time interval of 4.6 months. The initial diagnosis evoked was VS in 44% of the cases (4/9). Atypical MRI aspect was seen in 67% of the cases (6/9) with bilateral tumors in 55% of cases (5/9). CONCLUSION: Although rare, malignant tumors of the CPA and/or IAM should be evoked in case of association of cochleovestibular symptoms and facial palsy, rapid onset and atypical MRI aspect.

Value of systematic analysis of the olfactory cleft in case of cerebrospinal rhinorrhea: incidence of olfactory arachnoid dilatation.

To report on the presence of olfactory arachnoid dilatations (OAD), a previously undescribed radiologic feature of spontaneous cerebrospinal fluid (CSF) rhinorrhea originating from the cribriform plate of the ethmoid bone. The medical records of all patients treated between 2001 and 2011 at a tertiary care center for a spontaneous CSF rhinorrhea originating from the cribriform plate were retrospectively reviewed. The radiological work-up included high-resolution computed tomography and magnetic resonance imaging with at least the following sequences: T1, T2, and T2 with fast imaging employing steady state acquisition (FIESTA). Thirty cases were identified. The mean age at diagnosis was 49. Fourteen patients (47 %) had a body mass index (BMI) of 30 or more and 3 patients (10 %) had a BMI between 25 and 29.9. Five patients had a history of meningitis. The imaging work-up revealed a bone defect of the cribriform plate in 6 cases (20 %), associated to a typical meningocele in 14 cases (47 %). In ten patients (33 %), there was no defect of the cribriform plate, but ultrathin coronal T2-FIESTA sequences revealed an OAD, i.e. a dilatation of the arachnoid sheath of the olfactory fibers, in nine cases (30 %), or a "pseudo-polyp" outlined by a thin layer of arachnoid (1 patient, 3 %). Preoperative imaging should be carefully analyzed for the presence of OAD or "pseudo-polyp" in patients presenting with a CSF rhinorrhea without bony defect of the cribriform plate.

Chronic Invasive Aspergillus Sinusitis and Otitis with Meningeal Extension Successfully Treated with Voriconazole.

Invasive aspergillosis (IA) is a severe disseminated fungal disease that occurs mostly in immunocompromised patients. However, central nervous system IA, combining meningitis and skull base involvement, does not occur only in groups with classic risk factors for IA; patients with chronic renal failure and diabetes mellitus are also at risk for more chronic forms. In both of our proven IA cases, voriconazole monotherapy was effective without surgery, and cerebrospinal fluid and serum 1,3-ß-d-glucan test results were initially positive, in contrast to galactomannan antigen results.

Petrous and sphenoid arachnoid cysts: diagnosis and management.

BACKGROUND: Intraosseous arachnoid cysts are rare and difficult to diagnose. The purpose of this study was to describe the clinical and radiological semiology of petrous and sphenoid arachnoid cysts and to propose a specific management strategy. METHODS: This was a retrospective, descriptive study of patients with arachnoid cysts, which utilized CT, MRI, and the patients' medical histories. RESULTS: Ten patients were included in this study. On CT, the lesions were lytic with bony delineation. On MRI, the lesions exhibited the same signals as cerebrospinal fluid and were not enhanced after contrast. On fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted sequences, the arachnoid cysts' signal disappeared, which is a key feature for eliminating the diagnosis of cholesteatoma. Two patients underwent surgery because of misdiagnosis, either with a meningocele or a cholesteatoma. CONCLUSION: MRI FLAIR and diffusion-weighted sequences, together with osseous CT scans, help to distinguish arachnoid cysts from meningoceles and avoid unnecessary surgeries with potential complications.

Minimally invasive video-assisted thyroidectomy: tips and pearls for the surgical technique.

BACKGROUND: The objectives of this study were first to show principles of the minimally invasive video-assisted thyroidectomy (MIVAT), based on a video highlighting critical steps, and second to discuss tips and pearls to assist surgical teams that would like to start using this technique. METHODS: Based on a video, we described tips and pearls of a MIVAT. RESULTS: MIVAT includes 5 main steps: (1) skin incision and identification of the common carotid artery, (2) dissection and ligation of the upper pedicle, (3) identification of the inferior laryngeal nerve and parathyroid glands, (4) isthmectomy and lobe extraction, and (5) closure. DISCUSSION: Coordination between the surgeon and the 2 assistants is of paramount importance for the performance of MIVAT. Appropriate material is also required. The magnification and tissue contrast emphasizes the identification of the vessels, the superior and inferior laryngeal nerves, and parathyroid glands, on a large-view screen.

Comparison of 3 procedures for hypoglossal-facial anastomosis.

OBJECTIVE: We aimed to evaluate rehabilitation of complete facial palsy with 3 procedures for hypoglossal-facial anastomosis: end-to-end ("original"), partial end-to-end with interpositional jump grafting ("jump") and the new partial end to end without grafting ("modified"). METHODS: A medical jury reviewed videos of 36 patients with complete facial palsy who underwent surgery from 1998 to 2008 by original (n = 13), jump (n = 13), and modified (n = 10) procedures. The jury of 5 ear, nose, and throat surgeons who were blinded to the procedure evaluated rehabilitation by 3 facial nerve grading systems-House and Brackman (HB), Sunnybrook, and Freyss scales-and 3 subjective scores for the face at rest and during voluntary and emotional motions. RESULTS: Recovery time was shorter with the modified and original procedures than jump procedure (5, 6, and 8 mo, respectively). All patients achieved at least good results. Scores on the HB scale (I-VI) were mainly III. HB and Sunnybrook scores did not differ by procedure. Freyss score was better for the modified procedure than original and jump procedures. Scores for the face at rest did not differ by procedure, but those during voluntary and emotional movements were worse for the jump procedure than for other procedures. Synkinesis was more severe with the original procedure than other procedures. CONCLUSION: The 3 procedures give satisfactory results for rehabilitation after surgery for facial palsy. The original procedure should be performed in patients with strong mimic or long-standing facial palsy. The jump procedure is delicate and entails risk of weak reinnervation. The modified procedure is a good compromise in terms of muscle tone and side effects.

[Rhino-orbito-cerebral mucormycosis, surgical treatment, state of the art]. / Mucormycoses rhino-orbito-cérébrales - Traitement chirurgical, état de l'art.

Rhino-orbito-cerebral mucormycoses constitute a severe fungal infection. These infections mostly arise in immunosuppressed patients. The surgery aiming at resecting necrosed hurts showed its interest in term of survival for lung and cutaneous mucormycosis. However, treatment of rhino-orbito-cerebral location of mucormycosis is not well defined. Transnasal endoscopic surgery allows local control of the disease, better post-operative outcomes than transfacial approaches and less sequelae. However, transfacial approaches are sometimes necessary to allow cutaneous resection or exenteration, the indications of which still remain controversial. The retrospective study of 22 patients with mucormycosis allowed to show that radical surgical treatment allowed local control of the disease with an improved survival. Further prospective studies (PHRC MICCA, current) are required to standardize the management of this rare but potentially lethal pathology.

Surgical management of inverted papilloma: approaching a new standard for surgery.

BACKGROUND: Inverted papilloma surgery is currently performed primarily with an endoscopic approach, a technique that has a recurrence rate of 12%. However, a recent study reported a recurrence rate of 5% with a strategy based on subperiosteal dissection of the tumor, with limited indications for using an external approach. The aim of this work was to evaluate whether different teams using the same surgical concepts could reproduce the excellent results that were recently reported. METHODS: This study is a retrospective chart review of 71 consecutive patients with inverted papilloma who were treated during the last 10 years. RESULTS: In all, 80% of the patients were treated using a purely endoscopic approach. The mean follow-up period was 31.6 months. The recurrence rate was 3.3% for cases with at least a 12-month follow-up. CONCLUSIONS: This work confirms the results described in recent literature and further supports transnasal endoscopic surgery to manage inverted papilloma.

Auditory outcomes after implantation and electrical stimulation of the lateral ampullar nerve in guinea pig.

OBJECTIVE: To determine in a guinea pig model the factors of invasiveness of a bipolar electrode implanted in the horizontal semicircular canal (HSC) and to evaluate the consequences on hearing of electrical stimulation of the ampullary nerve. DESIGN: Sixteen guinea pigs divided into four groups underwent surgical opening of the HSC of one ear as follows: control (group 1), cyanoacrylate glue application on the HSC opening (group 2), electrode implantation with cyanoacrylate glue on the HSC opening (group 3), and electrode implantation with electrical stimulation (1 hr/day) for 9 days (group 4). Auditory brainstem responses were recorded before and after surgery and after electrical stimulation. The effectiveness of electrical stimulation in producing a horizontal vestibulo-ocular reflex was evaluated by recording eye movement with video-oculography. RESULTS: Group 1 animals showed hearing loss, and in group 2, sealing the HSC opening with cyanoacrylate glue preserved the hearing thresholds. After electrode implantation, seven of the eight animals showed hearing loss compared with preoperative values. Electrical stimulation did not induce additional hearing loss. CONCLUSION: Electrode implantation at the canal level entailed a risk of hearing loss in an animal model, but electrical stimulation of the horizontal ampullary nerve did not further alter hearing function.

Online script concordance test for clinical reasoning assessment in otorhinolaryngology: the association between performance and clinical experience.

OBJECTIVE: To report on the creation and administration of an online Script Concordance Test (SCT) for ear, nose, and throat (ENT), the ENT-SCT. DESIGN: Prospective study. SETTING: Two tertiary care university centers. PARTICIPANTS: In total, 132 individuals were asked to test an ENT-SCT of 20 cases and 94 questions based on the major educational objectives of the ENT residency program. MAIN OUTCOME MEASURES: Three levels of experience were tested: medical students, ENT residents, and board-certified otorhinolaryngologists as the expert panel. The test's construct validity-whether scores were related to clinical experience-was statistically analyzed. Reliability was estimated by the Cronbach α internal consistency coefficient. Participants' perception of the test was assessed with the use of a questionnaire. RESULTS: The 65 respondents with usable data were medical students (n = 21), ENT residents (n = 22), and experts (n = 22). Total mean (SD) test scores differed significantly: 76.81 (3.31) for the expert panel, 69.05 (4.35) for residents, and 58.29 (5.86) for students. The Cronbach α coefficient was 0.95. More than two-thirds of the participants found the test to be realistic and relevant for assessing clinical reasoning. The test was also considered fun, interesting, and intuitive. CONCLUSIONS: The Web-based ENT-SCT is feasible, reliable, and useful for assessing clinical reasoning. This online assessment tool may have applications for residency programs and continuing medical education.

Surgical treatment by electrical stimulation of the auditory cortex for intractable tinnitus.

Tinnitus is a public health issue in France. Around 1% of the population is affected and 30,000 people are handicapped in their daily life. The treatments available for disabling tinnitus have until now been disappointing. We are reporting on the surgical treatment by electrical stimulation of the auditory cortex of a female patient affected by disabling tinnitus that resisted classical treatments. The tinnitus appeared suddenly 10 years ago after a left ear tympanoplasty. The acouphenometry measures revealed a bilateral tinnitus, predominant on the right side, constant, with high frequency (6000 Hz). Transcranial magnetic stimulation (TMS) was performed at first with several supraliminal and infraliminal protocols. This showed promising results. Anatomic and functional magnetic resonance imaging (fMRI) of the auditory cortex before and after repetitive TMS (rTMS) demonstrated a modification of the cortical activity and where the ideal location for a cortical electrode might be, to straddle primary and secondary auditory cortex. After these investigations, two quadra polar electrodes (Resume, Medtronic Ltd, Hertfordshire, UK), connected to a stimulating device implanted under the skin (Synergy, Medtronic Ltd), were extradurally implanted. The surgical procedure was similar to the one performed for analgesic cortical stimulation. No surgical complications were reported. The activation of the stimulator provided a reduction of 65% of the tinnitus impact, with a persistent effect on the right side. The feasibility of the cortical stimulation in symptomatic treatment of tinnitus was proven by this preparatory work. The middle- and long-term therapeutic effects remain to be evaluated.