[Good practices in telemedicine]. / Bonnes pratiques en matière de télémédecine.

Telemedicine, or remote medicine, has become an important tool for health care providers as a result of the SARS-Cov2 pandemic. It must be considered as a tool capable of improving the practice of modern medicine. This text reminds the rules of its practice and encourages the organization of teaching.

[Facial nerve outcome after vestibular schwannoma surgery: About 89 patients]. / Fonction du nerf facial après chirurgie du schwannome vestibulaire: àpropos de 89 patients.

OBJECTIVES: We evaluated the postoperative facial nerve function after vestibular schwannoma (VS) surgery and analyzed factors causing it. MATERIAL AND METHODS: We included 89 consecutive patients undergoing surgical excision of unilateral VS. Patient and tumor characteristics, surgical approaches, facial nerve function, extent of tumor resection and complications were analyzed. RESULTS: Complete tumor resection was achieved in 85% of cases. Anatomic preservation of the facial nerve was achieved in 96% of patients. In all tumor stages, 88.2% of patients, have a normal or subnormal facial function within one year of the intervention, the rate was 100% in patients carrying a VS stage I or II. No severe complication or death was reported. CONCLUSION: Short- and long-term facial nerve outcome was comparable with results of other recent series reported in literature. The facial nerve function after surgery was better with small VS compared to large VS. The intraoperative decision of near-total excision of the tumor followed by adjuvant radiotherapy, in some cases, can prove to be a good option in the interest of better preservation of the facial nerve function. The adhesion of the facial nerve and its complex relationship with the tumor remain mysterious; RMI can bring significant refinements, helping to get the best preservation offacial function rate, in the coming years.

In vivo characterization of the vestibulo-cochlear nerve motion by MRI.

The motion of the vestibulo-cochlear nerve (VCN) was quantified at the level of the cerebello-pontine angle in 28 healthy volunteers enrolled in a prospective study performed on a 3T MRI scanner. A phase contrast MRI (PCMRI) sequence was used. The VCN was divided into a cisternal part and a meatic part, both of which were measured for motion in the cranio-caudal (CC) and antero-posterior (AP) directions. Motion was cardiac-cycle-dependent in these two directions. The meatic VCN motion was delayed compared to the cisternal VCN motion. In the CC direction, the mean amplitude of the cisternal VCN motion was twice larger than the mean amplitude of the meatic VCN motion (0.37+/-0.14 mm versus 0.17+/-0.08 mm). In the AP direction, the mean amplitude of the cisternal VCN was 0.19+/-0.08 mm versus 0.16+/-0.14 mm for the meatic VCN. We used an "oscillating string" to explain the VCN motion. Reproducibility tests have shown small variations in measurements of the CC motion. PCMRI can be used to assess the VCN motion at the level of the cerebello-pontine angle.

Trigeminal neuralgia related to arteriovenous malformation of the posterior fossa: three case reports and a review of the literature.

OBJECTIVE: To describe the rare association of trigeminal neuralgia (TGN) with a brain arteriovenous malformation (bAVM) of the posterior fossa. PATIENTS AND METHODS: This is a report of three patients presenting with TGN due to vascular compression by a bAVM of the posterior fossa, with emphasis on clinical presentation, diagnostic imaging, management and follow-up. Magnetic resonance imaging (MRI) was performed with sequences in thin slices in the same section plane using a 3D time of flight (TOF) and axial T2-weighted driven equilibrium (DRIVE) of the posterior fossa. RESULTS: No bleeding episodes were documented in the three patients. MRI and digital subtraction angiography (DSA) showed a posterior fossa bAVM with a nidus surrounding the trigeminal nerve, fed by arteries from the carotid and vertebrobasilar systems. Within a few days, medical treatment effectively alleviated the symptoms, with no more pain during follow-ups at 6, 10 and 18months. No invasive treatment was performed because the bAVMs were considered to have a low risk of bleeding. CONCLUSION: TGN related to a bAVM can mimic classical TGN. MRI and DSA are the imaging methods of choice. Medical treatment remains the first line of therapy, but if that fails, multimodal invasive treatment may be an alternative for pain relief.

Efficacy of microsurgical vascular decompression in trigeminal neuralgia.

OBJECTIVES: Analysis of the long-term efficacy of microvascular decompression surgery in trigeminal neuralgia. MATERIAL AND METHODS: A single-center retrospective study included patients undergoing microvascular decompression surgery for trigeminal neuralgia after failure of well-conducted medical or complementary therapy, with visualization of nerve compression syndrome on MRI. RESULTS: Eighty-seven patients were included. Nerve compression was alleviated without interposition of polytetrafluoroethylene in 79.3% of cases. Postoperative efficacy on pain was immediate in 97.7% of cases. There were no postoperative deaths, and the rate of severe complications was low (2.3%). The efficacy of microvascular decompression surgery was total at 2 years in 90.8% of cases and at 10 years in 92.3%, without resumption of medical treatment. The failure rate was 10.3%; 26.3% of these patients had been previously treated by a lesional technique (P: 0.043) and 33.3% by interposition of polytetrafluoroethylene (P: 0.003). CONCLUSIONS: With confirmed clinical and radiological diagnosis, microvascular decompression surgery for trigeminal nerve compression was safe, with total effectiveness in the immediate, short and long terms. It should be considered in first line in case of failure or intolerance of well-conducted medical treatment.

[Tinnitus treatment: neurosurgical management]. / Traitement des acouphènes: aspects neurochirurgicaux.

Tinnitus is a very frequent symptom affecting 10% of the general population. It corresponds to the perception of an internal noise that can severely impair the quality of life. Tinnitus management requires a multidisciplinary approach in which neuromodulation and neurosurgery tend to play major roles. Classification of tinnitus separates objective tinnitus (i.e., tinnitus that can be heard or recorded) from the more frequent subjective tinnitus (i.e., tinnitus only perceived by the patient). Objective tinnitus is either pulsatile synchronous with heartbeat or asynchronous. In the former, appropriate radiological testing should search for a vascular abnormality as well as other neurological diseases (intracranial hypertension, Arnold-Chiari malformation, vascular loops, etc.). Asynchronous objective tinnitus generally corresponds to muscular contractions that require specific management. The pathophysiology of subjective tinnitus is more complex, showing strong analogies with postamputation pain syndromes. After peripheral middle ear or inner ear damage, auditory deafferentation could result in hyperactivity and/or functional reorganization within central auditory and nonauditory structures. This could explain the persistence of tinnitus after total hearing amputation (e.g., translabyrinthine approach for vestibular schwannoma) and associated symptoms such as hyperacusis or anxiety and depression. This central model finds strong support in animal experiments and in functional neuroimagery (PET, fMRI, MEG). Since no etiologically based therapies are currently available, severe subjective tinnitus management only targets tinnitus tolerance with sound enrichment or cognitive behavior therapy. However, in the near future better knowledge of tinnitus pathophysiology and innovative therapeutic tools could emerge from neuromodulation techniques such as repeated transcranial magnetic or epidural electric stimulation.

Drilling and control of the internal auditory canal by fixed endoscope.

Preservation of vestibular structures, particularly the posterior semicircular canal, is essential to ensure hearing preservation in addition to complete tumour resection during retrosigmoid surgical resection of a vestibular schwannoma. Drilling of the internal auditory canal (IAC) is a delicate step, during which these structures can be accidentally perforated. The orientation of the IAC results in the formation of poorly visible zones that can predispose to perforation of these structures when drilling is performed with a microscope. Hand-held endoscopy exposes all of the operative field, but immobilizes one of the surgeon's hands, making this surgery even more delicate. Fixed endoscopy is a solution that gives the surgeon greater freedom of movement, while ensuring precise control of the surgical procedure. It allows identification and avoidance of vestibular structures, while allowing resection as close as possible to the tumour. The schwannoma can be entirely cleaved when the fundus of the IAC is correctly controlled, while sparing the facial and cochlear nerves.

Vestibular rehabilitation therapy.

Dizziness and balance disorders are frequent complaints in the general population. Vestibular rehabilitation exercises have been shown to be efficient in controlled studies, provided that a precise, individual diagnosis has previously been made. Depending on the pathology, a subject with a peripheral vestibular pathology can benefit from manoeuvres aiming at dislodging or repositioning otoliths, from non-specific muscles strengthening techniques, from techniques for vestibular-ocular or vestibular-cervical stabilisation of gaze, or from physical exercises aimed at strengthening proprioceptive afferents, inhibiting a sensory predominance, or improving spatial orientation and navigation. These analytical exercises should then be implemented in an ecological context in order to favour transfer to daily-living activities. These physical exercises can enable the development of compensation strategies following vestibular damage (habituation, adaptation and substitution).

[Universal hearing screening in the Champagne-Ardenne regions: results and consideration after 55 000 births from January 2004 to June 2007]. / Dépistage auditif systématique en région Champagne-Ardenne: résultats et réflexion à propos des 55 000 enfants nés entre janvier 2004 et juin 2007.

AIM: This study presents the results of the Universal Newborn Hearing Screening (UNHS) experience in Champagne-Ardenne from January 2004 to June 2007. MATERIALS AND METHODS: A UNHS program was introduced in the entire French region of Champagne-Ardenne in January 2004. Developed upon a strong demand from public and private medical institutions, the program's aim is the early detection and treatment of bilateral profound or severe hearing loss. The program is composed of 2 steps: the first test is realised in maternity and consists of automated OtoAcoustic Emissions (aOAE). When absent in both ears at first test (positive screening test), the child is referred to a second test 15 days after maternity discharge (aOAE or automated Auditory Brainstem Response (aABR)). If the second test is still failed (positive screening test), the child is referred to a diagnostic procedure (Auditory Brainstem Response) realised by a paediatrician ENT in a reference centre. The UNHS program differs for newborns in Neonatal Intensive Care Units where aABR is realised at first test because of the high frequency of auditory neuropathy in this population. All results are collected in the Regional Neonatal Screening Centre, in charge of the UNHS follow-up. RESULTS: 53 930 newborns benefited from the UNHS program, which represent 98.7% of the 54 790 births in the region during this period. 591 newborns had a positive first test (no aOAE responses) and were referred to the second test. 532 had a negative second test and 46 had a positive second test. 22 children could not have the second test: 4 children deceased, 9 were lost to follow-up (the families moved outside the region) and 9 families refused the second test. The 46 neonates were referred to the diagnostic ABR test and 42 of those 46 babies were diagnosed with neonatal bilateral hearing losses before the age of 6 months. CONCLUSION: This UNHS experience demonstrates that such UNHS programs are feasible and reliable, at least in a region as wide as Champagne-Ardenne. It achieved to diagnose 42 hearing impaired children, who could benefit from an early intervention for their handicap.

[Systematic hearing screening for newborns in the Champagne-Ardennes region: 32,500 births in 2 years of experience]. / Dépistage auditif néonatal systématique en région Champagne-Ardenne: à propos de 30500 naissances en deux années d'expérience.

OBJECTIVES: To report a Universal Newborn Hearing Screening (UNHS) program developed in the Champagne-Ardennes region in 2004-2005. METHODS: A team of ENT specialists and pediatricians set up a UNHS program designed to reduce the age of diagnosis and care of bilateral congenital deafness. The program was mainly based on automated acoustic otoacoustic emissions and a strict follow-up by the Regional Neonatal Screening Center. RESULTS: In 2004 and 2005, 29,944 neonates from 30,518 births were screened (98.11%). Of the neonates screened, 409 (1.38%) failed the test and were referred. The average retest delay was 2 weeks. Eleven were lost to follow-up, 371 (94%) had a successful second test on one or both ears, 27 (7%) failed the test a second time and had a diagnosis of ABR. Twenty-four cases of bilateral deafness were identified early, 14 of which had no risk factors. One of the children lost to follow-up was actually deaf, which was diagnosed at 18 months of age. Since the beginning of the UNHS program, the average age of diagnosis was lowered to less than 3 months. CONCLUSION: Our experience tends to demonstrate that UNHS is possible and the program allows an early diagnosis of bilateral congenital hearing loss.

Diagnostic and therapeutic strategy in Menière's disease. Guidelines of the French Otorhinolaryngology-Head and Neck Surgery Society (SFORL).

OBJECTIVES: The authors present the guidelines of the French Otorhinolaryngology-Head and Neck Surgery Society (Société française d'oto-rhino-laryngologie et de chirurgie de la face et du cou: SFORL) for diagnostic and therapeutic strategy in Menière's disease. METHODS: A work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, then read over by an editorial group independent of the work group. The guidelines were graded according to the literature analysis and recommendations grading guide published by the French National Agency for Accreditation and Evaluation in Health (January 2000). RESULTS: Menière's disease is diagnosed in the presence of the association of four classical clinical items and after eliminating differential diagnoses on MRI. In case of partial presentation, objective audiovestibular tests are recommended. Therapy comprises medical treatment and surgery, either conservative or sacrificing vestibular function. Medical treatment is based on lifestyle improvement, betahistine, diuretics or transtympanic injection of corticosteroids or gentamicin. The main surgical treatments, in order of increasing aggressiveness, are endolymphatic sac surgery, vestibular neurotomy and labyrinthectomy.

[The tumors of the ear]. / Les tumeurs de l'oreille.

Any cutaneous lesion of the outer ear must be managed jointly by a dermatologist and an ENT, regardless of the age of the patient. The presence of a malignant cutaneous carcinoma (Squamous cell carcinoma or melanoma) of the pavilion requires a minimum extension assessment by a cervical ultrasound, CT-scan and MRI will be prescribed according to the degree of infiltration and the presence of clinics signs (lymphadenopathy, facial paralysis, cognitive impairment). A polyp of the external auditory meatus must be systematically biopsied in consultation and, if necessary, in the operating room with fresh anatomopathological analysis. Any "otitis externa", which does not progress favorably under local treatment, must lead to eliminate a tumoral pathology of the external acoustic meatus or of the middle ear. Any suspicion of cholesteatoma should lead to an ENT consultation to confirm the diagnosis and consider its treatment to limit the auditory dysfunction. Any unilateral neurosensorial hearing loss or unilateral vestibular involvement with normal otoscopy should lead to eliminate a inner ear tumor by an MRI of the inner ear and the ponto-cerebellar angle in millimeter sections.

[Postoperative radiotherapy in N0 laryngeal cancer]. / Radiothérapie postopératoire des cancers laryngés classés N0.

PURPOSE: A retrospective study to re-assess the indications for postoperative radiation therapy in squamous cell carcinoma of the larynx staged N0 after gross resection. PATIENTS AND METHODS: Between January 1975 and December 2000, 166 patients with squamous cell carcinoma of the larynx were treated by total laryngectomy with or without neck dissection. Surgery was completed by external radiotherapy delivering 45 to 65 Gy to the tumour bed and 45 to 50 Gy to cervical lymphatic chains. Minimal follow-up was 36 months and median follow-up was 98 months. RESULTS: The rate of nodal recurrence was 6% (median time for relapse was 9 months). The survival rates at 1, 2, 3 and 5 years were 93.5, 84, 80 and 69% respectively, with a 8 year 3 month median survival. The univariate analysis showed 4 parameters, which significantly increased the risk of local recurrence: the medical necessity for immediate tracheotomy, the subglottic involvement, the involvement of the whole larynx and the presence of lymphatic embols in the neck dissection. There was no statistically significant difference between the patients with or without a neck dissection. Fifty-nine secondary cancers were observed, 15 of them occurring in the head and neck area. The late complications consisted of cervical subcutaneous fibrosis (7%), oesophageal stricture (4%), oeso-tracheal fistula (l%), hypothyroidism (3%), bone necrosis (1%). CONCLUSION: Prophylactic cervical radiotherapy in laryngeal cancers resulted in 6% cervical node recurrence rate. This value may represent the maximal rate to accept if one would favour new therapeutic strategies based on restricted indications for radiotherapy.

[Curthoys and Halmagyi Head Impulse test: an analytical device]. / "Head Impulse test de Curthoys & Halmagyi". Un dispositif d'analyse.

UNLABELLED: Described in 1988 by Curthoys and Halmagyi, the Head Impulse test enables checking the individual response of each of the six semicircular canals to fast head movements within less than one minute. Interpretation of test results requires careful clinical observation of the eye/head synchronism. But, due to the very short duration of the phenomenon, such synchronism is often difficult to confirm. This is so difficult that, sixteen years after its first description, the test is still rarely performed in daily practice. OBJECTIVES: We describe hereafter a device which allows confirmation of the positive or negative test results for each of the six canals without increasing test duration. METHOD: A high resolution and high light sensitivity video camera located in front of the patient's face at a distance of 80 cm is connected to a computer for automatic image analysis. RESULTS: With this device, the practitioner can confirm a positive test by simple observation on the videooculocephaloscope (HIT scope) and record an image for later reference. With videooculocephalography (HIT graph), movements can be recorded for analysis to quantify the deficit of each semicircular canal.

[Treatment of voice prosthesis leakage. Preliminary results]. / Traitement des fuites sur prothèse phonatoire. Résultats préliminaires.

UNLABELLED: Numerous voice prostheses have been developed since the early eighties. The device, located in the tracheo-esophageal wall, can generate local complications. The most frequent and the hardest to treat is peri-prosthetic salivary leakage. OBJECTIVE: To present a new management scheme for peri-prosthetic salivary leakage by BIOPLASTIQUE injection. PATIENTS AND METHOD: Five patients, with residual peri-prosthetic salivary leakage after different treatments were managed by peri-prosthetic injection of BIOPLASTIQUE, a medical silicone elastomere. The injection was performed under general anesthesia in four points around the prosthesis: above, below, left and right. RESULTS: Leakage disappeared after one or two injections in all patients. No technical problem was encountered. CONCLUSION: Although this method still has to pass the test of time, our preliminary results are encouraging. Such a procedure could be performed under local anesthesia in order to minimize its cost.

[Sinuso-nasal sarcoidosis]. / Les localisations naso-sinusiennes de la sarcoïdose.

OBJECTIVES: Sinonasal sarcoidosis is unusual and may be misdiagnosed. We describe the characteristic clinical presentation observed in three patients treated in our institution and define the complementary explorations leading to diagnosis. Basis for treatment is also developed. PATIENTS AND METHODS: Among one hundred and one patients treated for sarcoidosis between 1983 and 2003 in three department of RD Hospital, three had histologically proved sinonasal sarcoidosis. These three cases were retrospectively analyzed and compared with the literature. RESULTS: All patients complained of chronic rhinosinusitis without improvement under usual treatment. Computed tomography showed usual aspects of chronic rhinosinusitis. The diagnosis was finally based on the biopsy of the nasal mucosa. Even if sarcoidosis had been already diagnosed, the main point was the delay between ENT symptoms and diagnosis because all clinical presentations and radiological aspects were aspecific. CONCLUSION: This case report underlines the difficulty to diagnose sinonasal sarcoidosis. When a patient is treated for sarcoidosis, sinonasal localization of the disease must be suggested in the event of chronic rhinosinusitis. On the other hand, sarcoidosis must be suggested and specific complementary examination must be performed in the event of chronic rhinosinusitis without improvement under usual treatment. ENT biopsy remains the main argument for diagnosis.

[Benign positional vertigo, an armchair for diagnosis and for treatment: description and significance]. / Vertige positionnel paroxystique bénin, un fauteuil au service du diagnostic et du traitement: description et intérêt.

OBJECTIVES: The benign positional vertigo is a very frequent pathology. It requires to establish the diagnosis, to fixe the head in some positions to get various nystagmus which are observed directly or by video-nystagmoscopy or analyzed by video-nystagmography. PURPOSE: To describe the diagnostic and therapeutical interests of a special armchair, now available, whose characteristics are to be able to swivel around two axes of vertical and horizontal rotations, the patient being completely interdependent of the armchair. It thus makes it possible to place the patient's head in position wished with a high degree of accuracy and facility. METHODS: After a short description of the characteristics of armchairs classically used, the authors describe in detail this new armchair Its geometrical characteristics are reported and its capacities, like its mode of use: fixing of the patient with armchair then mobilization of the unit "armchair-patient" and setting in position of the head at the point of the space desired by the ENT. RESULTS: The authors report the main advantages of this armchair. It allows a great accuracy of movement given to the semicircular canals, a possible mobilization with an amplitude until there ever reached, a significant reduction of the proprioceptive entries of patient, a perfect safety of the examination, a possible mobilization of obese or arthritic patients and, finally, a very increased comfort for the patient himself. Finally future technological developments possible are brought back. CONCLUSION: Thanks to the use of the armchair of mechanical assistance, the diagnosis and treatment of benign positional vertigo appear more certain, more precise and more practical at the same time for the medical doctor and the patients. A multicentric study is in process to show its interest in this pathology.

Auditory efferents involved in speech-in-noise intelligibility.

Following studies proposing that medial olivocochlear efferents might be involved in the processing of complex signals in noise, we tested the involvement of efferent feedback in speech-in-noise intelligibility. Two approaches were used: measures of speech-in-noise intelligibility in vestibular neurotomized patients with cut efferents and comparison with normal hearing subjects; and correlations between effectiveness of olivocochlear feedback, assessed by contralateral suppression of otoacoustic emissions and speech-in-noise intelligibility in normal subjects. Contralateral noise improved speech-in-noise intelligibility in normal ears. This improvement, which was almost absent in de-efferented ears of vestibular neurotomized patients, was correlated with the strength of the olivocochlear feedback. Together, these results suggest that olivocochlear efferents play an antimasking role in speech perception in noisy environments.

Evidence of a medial olivocochlear involvement in contralateral suppression of otoacoustic emissions in humans.

Otoacoustic emissions (OAEs) evoked by click stimuli were recorded in both ears of 20 normal human subjects, in the presence and absence of a contralateral masking broad band noise. No difference in the amplitude of OAE suppression was noted between the first tested ear and the second one. In addition, 20 pathological subjects were tested according to the same protocol. Ten of them belonged to a group of patients whose vestibular nerve was sectioned on one side to relieve incapacitating vertigo and thus represented a group in whom olivocochlear efferents were severed. A great reduction of suppression observed in the operated ear suggested that olivocochlear efferent fibers are necessary to obtain a full suppressive effect. Three of the pathological subjects were patients who had undergone a decompression of the facial nerve which necessitated the same surgical approach as vestibular neurotomy, but without any section of vestibular fibers. This surgical control group demonstrated that the surgical act by itself cannot explain the difference observed in the neurotomized group. Finally, seven of the pathological subjects were patients with Bell's palsy, which paralyses the facial nerve and abolishes the stapedial reflex. No suppression difference was observed between healthy ears and ears without stapedial reflex. Therefore, it appeared that the stapedial reflex was not involved in the contralateral suppression of EOAEs. However, as the tensor tympani muscle remained functional in these patients, its involvement in the suppressive effect cannot be excluded.

On the role of the olivocochlear bundle in hearing: 16 case studies.

Earlier we presented data (Scharf et al. (1994) Hear. Res. 75, 11-26) from a young patient (S.B.) who had undergone a vestibular neurotomy, during which the olivocochlear bundle (OCB) was severed. Those data are complemented by measurements on 15 other patients-some like S.B. with normal audiometric thresholds, none with a loss greater than 35 dB at experimental frequencies. Comparisons of performance for the same ear before and after surgery or between the operated and healthy ears do not provide evidence that the lack of OCB input impairs the following psychoacoustical functions: (1) detection of tonal signals, (2) intensity discrimination, (3) frequency selectivity, (4) loudness adaptation, (5) frequency discrimination within a tonal series, (6) in-head lateralization. Data on single-tone frequency discrimination are equivocal. These mostly negative results apply to listening both in the quiet and, where relevant, in noise. The only clear change in hearing after a vestibular neurotomy is that most patients detect signals at unexpected frequencies better than before. This change suggests an impaired ability to focus attention in the frequency domain. Although limited in scope, our finding that human hearing without OCB input is essentially normal agrees with much of the relevant literature on animal behavior and with the patients' self-reports.