Bilateral vocal cord paralysis after endoscopic placement of fully covered self-expandable metal stent for palliative treatment of malignant proximal esophageal obstruction: two case reports.

BACKGROUND: Oesophageal stents have several well-known respiratory complications, including aspiration pneumonia, fistula and airway compression. However, bilateral vocal cord paralysis has rarely been described. METHODS: We describe two patients who presented with refractory dysphagia due to malignant proximal oesophageal strictures. Both received palliative treatment consisting of fully covered self-expandable metal stents that were placed across the strictures. RESULTS: Both patients developed inspiratory stridor and acute hypoxemic respiratory failure shortly after the stent was placed. Flexible bronchoscopy revealed vocal cord paralysis in paramedian position, potentially due to extrinsic compression of the posterior branch of the recurrent laryngeal nerve following the progressive opening of the esophageal prosthesis. One patient recovered after the stent was removed. CONCLUSIONS: Bilateral vocal cord paralysis is a rare but potentially fatal complication of proximal esophagus stenting.

Evaluating noninvasive ventilation using a monitoring system coupled to a ventilator: a bench-to-bedside study.

Empirically determined noninvasive ventilation (NIV) settings may not achieve optimal ventilatory support. Some ventilators include monitoring modules to assess ventilatory quality. We conducted a bench-to-bedside study to assess the ventilatory quality of the VPAPIII-ResLink (ResMed, North Ryde, Australia). We tested the accuracy of minute ventilation (MV) and leak calculations given by VPAPIII-ResLink compared to those measured by a bench model at varied leak levels and ventilator settings. We systematically assessed NIV efficacy using this system from 2003 to 2006. Ventilation was considered inadequate if leak (>24 L x min(-1)), continuous desaturation (>30% of the trace) or desaturation dips (>3%) were present. On the bench test, both methods were highly correlated (r = 0.947, p>0.0001 and r = 0.959, p<0.0001 for leak and MV, respectively). We performed 222 assessments in 169 patients (aged 66.42+/-16 yrs, 100 males). Abnormalities were detected on 147 (66%) out of 222 occasions. Leak was the most common abnormality (34.2%) followed by desaturation dips (23.8%). The most effective therapeutic solutions were a chin strap if leak was detected (61.2%) and expiratory positive airway pressure increase for desaturation dips (59.5%). In 15.7% of cases, when abnormalities persisted, a polygraphy was performed. The systematic use of this device enables NIV to be optimised, limiting the indication of sleep studies to complex cases.

[Difficult weaning due to tracheal compression by an esophageal bezoar]. / Difficulté de sevrage par compression trachéale due à un bézoard.

INTRODUCTION: Bezoars result from the aggregation of ingested materials (food, drugs, hair) that accumulate at a certain anatomic level in the gastrointestinal tract. It is a rare condition, which is favoured by a reduction in intestinal motility, or by a primary abnormality reducing the patency of gastrointestinal tract. CASE REPORT: We present a case when acute respiratory symptoms revealed an oesophageal bezoar. The patient presented with compression of the posterior tracheal wall by an oesophageal bezoar. The diagnosis was confirmed by oesophageal endoscopy. Treatment consisted in endoscopy-guided fragmentation and removal of the bezoar followed by topical lavage. CONCLUSION: Oesophageal bezoars may account for compression of the posterior tracheal wall causing acute respiratory failure or difficult weaning from the ventilator. The close anatomic proximity between the gastrointestinal and respiratory tract may explain the impact of oesophageal bezoars on the respiratory tract.

[CT angiography of the neck: technical considerations]. / Technique d'exploration des vaisseaux cervicaux et encéphaliques: angioscanner.

Examination of acute stroke by CT angiography is an alternative to MRI. Technological improvement of multidetector CT scanners allows neuroimaging of stroke in a multimodal protocol including plain CT, cerebral CT perfusion and CT angiography of the cervical and intracranial arteries. CT angiography is a reliable non invasive technique for the evaluation both extracranial and intracranial vessels that may be used as an alternative to MR angiography.

Relative survival analysis of 252 patients with COPD receiving long-term oxygen therapy.

OBJECTIVES: A survival analysis was conducted on patients with COPD receiving long-term oxygen therapy (LTOT) to compare two different statistical methods. METHODS: We used a multivariate crude (observed) survival model (Cox) and a multivariate relative survival model (Hakulinen). Only the latter is able to correct the survival by adjusting it to the normal life expectancy of the studied patients. PATIENTS: Two hundred fifty-two hypoxemic COPD patients (207 male) requiring LTOT were included. Mean PaO2 was <50 mm Hg before oxygen therapy. Mean age was >69 years (SE: 9.9). They had severe bronchial obstruction: mean FEV1 was <33% (10.6) of predicted values, with some CO2 retention: mean PaCO2 was 45.6 (7.1) mm Hg. By December 31, 1995, 189 patients had died (75%) and 13 (5%) were unavailable for follow-up. RESULTS: The overall crude survival was poor: 80.9% after 1 year, 67.1% after 2 years, 34.7% after 5 years, and 7.1% after 10 years. In the crude multivariate analysis (Cox), the negative prognostic factors were age and hypercapnia. The overall relative survival (Hakulinen), corrected for life expectancy, was 82.8% after 1 year, 70.8% after 2 years, 41.5% after 5 years, and 10.25% after 10 years. In the final multivariate relative model, age was no longer significant and the only bad prognostic factor was hypercapnia with a relative risk of 1.97 (1.16 to 3.34). CONCLUSION: This work shows the inadequacy of the Cox observed survival model when it comes to appreciating the real prognostic impact of age, because of the confusing factor associated with a normal life expectancy.

Reduced brain N-acetyl-aspartate in frontal lobes suggests neuronal loss in patients with amyotrophic lateral sclerosis.

We performed proton magnetic resonance spectroscopy (1H-MRS) in three patients with amyotrophic lateral sclerosis (ALS) to evaluate the distribution and extent of cortical neuronal damage as demonstrated by decreased N-acetyl-aspartate (NAA) levels. We examined primary motor (precentral gyrus) and parietal neocortical (superior parietal gyrus) regions. ALS was defined with lower and upper motor neuron signs. Compared with matched healthy controls, ALS patients had a significant decrease in NAA levels in the primary motor cortex (p < 0.001) compared with parietal regions and homologous regions in healthy controls. Two clinical applications can be extracted: first, the upper motor neuron signs present in the ALS, come from a neuronal loss within the primary motor cortex and may explain the frontal syndrome associated with ALS. Second clinical applications of 1H-MRS could include identification of extent of upper motor neuron involvement, aiding diagnosis of syndromes presenting with an ALS-like syndrome.

Cerebral metabolism after transient ischemic attack. A 1H MR spectroscopy study.

Metabolic changes induced by cerebral infarction or by stenosis and occlusion of the internal carotid artery have been previously described in 1H Magnetic Resonance Spectroscopy (1H MRS). These changes are essentially characterized by decreased N-acetyl-aspartate (NAA) and increased lactate concentration. Little is known about the metabolic changes observed in the three days following a transient ischemic attack (TIA), in the absence of stenosis or occlusion of the internal carotid artery, and without visible infarction on Magnetic Resonance Imaging (MRI). We studied five patients with a TIA lasting between 30 min and 3 h, affecting the sensory and motor functions of the brachio-facial territory with or without aphasia. A Computerized Tomography Scan (CT-scan), an electro-encephalogram, cervical Doppler ultrasound and MRI with proton magnetic resonance spectroscopy were performed on the affected cerebral area and on the normal contralateral homologous cerebral area within three days of the onset of TIA. None of the five patients had stenosis or occlusion of the internal carotid artery on Doppler ultrasound, or cerebral infarction on MRI. From 1H MRS ratio measurements, we did not observe any significant changes in the NAA/Creatine ratio. However, a rise in Lactate/Creatine ratio was observed in the symptomatic non-infarcted area compared with the normal cerebral tissue. During the first three days following a transient ischemic attack, there is an increase in lactate production. This change may reflect transient local hypoperfusion which could be long enough to stimulate lactate production, but short enough not to induce infarction. This region could be at risk from infarction in the long term.

[Agenesis of the corpus callosum: modes of manifestation in adults]. / Agénésie du corps calleux: les modes de révélation chez l'adulte.

Agenesis of corpus callosum is an uncommon brain malformation that is usually detected in childhood. In adult, focal epileptic seizure is the most frequent manifestation. Otherwise, asymptomatic patients can be detected by cerebral imagery with specific criteria. Neither developmental disability nor interhemispheric transfer dysfunction are observed in those patients. Minor facial abnormalities can be found. Agenesis of corpus callosum in adult is usually paucisymptomatic. The prognosis depends on cerebral associated malformations which are involved in epilepsy and cognitive disturbances.

[Contribution of magnetic resonance imaging in sclerotic combined degeneration of the spinal cord due to vitamin B12 deficiency]. / Intérêt de l'imagerie par résonance magnétique dans la sclérose combinée de la moelle par carence en vitamine B12.

Subacute combined degeneration (SCD) of the spinal cord is known to present histopathologically degenerative lesions in the spinal cord, but few studies on the neuroradiological findings have so far been reported. We present the interest of initial and follow-up MR findings in three cases of SCD. In the three cases, a causal event precipitated the onset of neurological symptoms: general anesthesia for the first and the third one and folic acid treatment for the second one. Clinical evolution was favorable after specific treatment with nearly total recovery. The initial MR study disclosed lesions predominantly involving the posterior columns of the spinal cord: high intensity on T2 weighted image was seen in the initial MR study and disappeared three months after treatment in correlation with good recovery, but with a delay. The recognition of this MR pattern suggests that MRI may be used in conjunction with clinical assessment to confirm the diagnosis and to monitor the efficacity of treatment in SCD.

[N-acetyl-aspartate abnormalities in internal-temporal epileptic foci using proton magnetic resonance spectroscopy]. / Anomalies du N-acétyl-aspartate observées dans les foyers epileptiques temporaux internes par spectroscopie de résonance magnétique nucléaire du proton.

The aim of this study was to characterize the neurochemical abnormalities related to N-acetyl-aspartate which is a neuronal marker, within an epilepticus focus located in the internal-temporal area, using proton magnetic resonance spectroscopy. Eleven patients with a mono-hippocampal epileptics focus on clinical and per-critical electroencephalographical criteria, were matched with 11 controls by age, sex and laterality. Proton spectroscopy of a volume of 8 cm3 was performed within the ipsilateral and the contralateral internal-temporal area and within the 2 hippocampus of controls. Volumetry of the ipsilateral and the contralateral hippocampus and of the 2 hippocampus of controls was performed using resonance magnetic imaging. All these measurements were performed during the interictal stage. The results were concordant to show a decrease of the ratio N-acetyl-aspartate/choline and N-acetyl-aspartate/creatine within the epilepticus focus, in relation with a hippocampal atrophy. This study finds similar results to those of other previous works. The decrease of N-acetyl-aspartate levels within the epilepticus focus could be related to a decrease of the neuronal cell density. This procedure is able to show a decrease of the levels of this metabolite within an internal temporal epilepticus focus and associated with a hippocampal atrophy.

[Comparison of MRA and angiography in the follow-up of intracranial aneurysms treated with GDC]. / Comparaison de l'ARM et de l'artériographie dans le suivi des anévrismes intracrâniens traités par gdc.

OBJECTIVE: Evaluation of TOF 3D MRA compared to angiography in the follow-up of intracranial aneurysms treated by Guglielmi detachable coils (GDC). MATERIAL: and method: Prospective analysis of follow-up MRA and angiographies for 20 patients with 22 aneurysms. There were 2 MRAs for 3 aneurysms giving a total of 25 cases. RESULTS: A poor correlation between MRA and angiography was observed in 21 cases of 25. For 9 cases, stable exclusion (95-100%) visible on MRA was confirmed by angiography. For 12 other cases, a residual flow within the aneurysmal neck or a residual flow between coils was detected by MRA and confirmed by angiography. A poor correlation was found in 4 cases out of 25: 3 residual flows within the aneurysmal neck and 1 residual flow within the coil mass not visible on MRA. MRA has a sensibility of 75% for the detection of an anomaly, a specificity of 100%, a positive predictive value of 100% and a negative predictive value of 69.2%. MRA is able to detect a large residual flow within aneurysmal neck and a re-growth, which would need a second embolization. Anomalies not visible on MRA as observed in our study, residual flow within the coil mass and the aneurysmal neck, do not require complementary treatment. CONCLUSION: A normal TOF 3D MRA can avoid an angiography in the follow-up of an intracranial aneurysm treated by GDC.

[MRI screening of vestibular schwannomas without gadolinium: usefulness of the turbo gradient spin echo T2-weighted pulse sequence]. / Dépistage du schwannome vestibulaire en IRM sans gadolinium: intérêt de la séquence turbo gradient spin écho pondérée T2.

The purpose of this retrospective MRI work was to evaluate the use of turbo gradient spin echo (TGSE) high resolution imaging for the detection of eighth nerve schwannomas, without injection of gadolinium. The TGSE sequence (slice thickness: 3 mm with 1.5 mm interleaving; matrix: 512) was compared with a reference sequence: T1-weighted spin echo (SE) after gadolinium injection (slice thickness: 3 mm, matrix: 256). Among 380 internal auditory meatus (IAM) explored, 34 abnormalities were detected on T2-weighted TGSE images compared with 19 on contrast-enhanced T1-weighted SE images. This new sequence has a 100% sensitivity, a 96% specificity and a 100% negative predictive value. Using a rigorous protocol for IAM analysis with the TGSE sequence, gadolinium injection may no longer be needed systematically for vestibular schwannoma screening, but might only be necessary when an abnormality or a doubt persists after TGSE. This approach allows about 20% cost reduction for each patient, a savings of 11,433 euros considering only the true negatives observed in this study.

[Pulmonary edema and tocolysis with beta-agonists]. / OEdème pulmonaire et tocolyse par bêta-mimétiques.

It is not unusual for respiratory specialists to be called to deal with respiratory problems in pregnancy. However, some conditions, such as tocolysis-induced pulmonary edema, although common, are largely unknown to our specialty. We report on the cases of three pregnant women, who developed pulmonary edema in the context of tocolysis with the intra-venous infusion of B-agonists. In all three patients, tocolysis was required because contraction developed well before term. Triple pregnancy was present in one patient. In another patient, mechanical ventilation was required. The outcome was good with full recovery in all three cases.

[Lung disease due to Mycobacterium xenopi excluding AIDS. Apropos of 8 cases]. / Atteintes pulmonaires à Mycobacterium xenopi en dehors du SIDA. A propos de 8 cas.

Between 1994 and early 1999, Mycobacterium xenopi was isolated in 11 HIV-negative patients seen at the Respiratory Disease Department of the Dijon University Hospital. Eight of these patients met the criteria of lung infection. Clinical and radiological features simulated pulmonary tuberculosis which delayed diagnosis until the germ was identified. Treatment is considered to be mandatory though it is difficult to manage and often disappointing. In spite of long-term medical care, sometimes associated with surgery, outcome is currently determined by the underlying disease rather than by Mycobacterium xenopi infection.

[Management of obesity and respiratory insufficiency. The value of dual-level pressure nasal ventilation]. / Prise en charge de l'obèse en décompensation respiratoire. Intérêt de la ventilation nasale à double niveau de pression.

Obstructive Sleep Apnea (OSA), Obesity-Linked Hypoventilation (OLH)--a hypoventilation which is independent of apneas and increased by sleep--, and COPD are mechanisms for respiratory failure in obese patients. We thought nasal bi-level positive airway pressure to be a suitable treatment: EPAP is useful to maintain upper airway patency and IPAP-EPAP difference to correct OLH and COPD hypoventilation. Our purpose is to report the results of such a therapeutic approach. We included 41 patients that we first treated by nasal bi-level positive airway pressure for a respiratory failure with an uncompensated respiratory acidosis. The initial setting was about 4 cm H2O for EPAP and 16 for IPAP. Under supervision of a real-time printed oximetry tracing, we furthermore increased EPAP until disappearance of repetitive dips in oxygen saturation (that we assimilated to obstructive events) and IPAP until obtaining an acceptable level of steady saturation (we assimilated a low level to a steady hypoventilation). Age (mean +/- SD) was 63 +/- 11 years, BMI 42 +/- 9 kg/m2, pH 7.32 +/- 0.04, PaCO2 71 +/- 13 mmHg, PaO2 45 +/- 7 mmHg. Thirty-nine out of 41 patients returned home without need for tracheal intubation. At 7 days of treatment, PaCO2 was 50 +/- 6 mmHg. Thus, nasal bi-level position airway pressure appears to be an efficient treatment in these patients.

[Fat embolism with lung hemorrhage]. / Embolie graisseuse à forme hémorragique pulmonaire.

Post-traumatic fat embolism was disclosed by a picture of alveolar hemorrhage. Acute hypoxemia associated with dense bilateral pulmonary infiltrates was observed in a 21 year-old woman, 4 days after an accident with closed tibial fracture. Cruoric pulmonary thromboembolism was ruled out, as was an acute pulmonary edema. Neither infectious nor immunologic etiology was found. The diagnosis of alveolar hemorrhage was based on bronchoalveolar lavage. Lipid droplets in macrophages stained by "Oil Red O" established the relationship with fat embolism. The outcome was favorable. The association of fat embolism and alveolar hemorrhage has already been reported, but remains rare.

[Acute respiratory failure in obesity]. / Les décompensations respiratoires aiguës de l'obèse.

Obstructive sleep apnea, obesity-related hypoventilation - a hypoventilation which is independent of apneas and increased by sleep -, and hypoxemia related to local ventilation-perfusion disorders are the main mechanisms of respiratory failure occurring during acute respiratory decompensation following an often minimal triggering event. Non-invasive ventilation has been found to be an effective treatment, particularly with a ventilator capable of maintaining positive expiratory and pressure. The level of the expiratory positive airway pressure must be adapted to cure episodes of obstructive apnea or hypopnea. The level of the inspiratory positive airway pressure (pressure support ventilator), or the tidal volume (volume-controlled ventilator) must be adapted to correct the residual hypoventilation. These adaptations can be made by proper assessment of nocturnal SaO(2) recordings. In particularly severe cases, use of endotracheal ventilation may be necessary to control a state of shock or consciousness disorders incompatible with the patient cooperation necessary for non-invasive ventilation.

Hypoxaemia associated with an enlarged aortic root: a new syndrome?

OBJECTIVE: To assess the mechanisms through which an enlarged aortic root may facilitate right to left shunting through a patent foramen ovale. PATIENTS: 19 patients with the platypnoea-orthodeoxia syndrome (POS) were compared with 30 control patients without platypnoea. INTERVENTIONS: Multiplane transoesophageal echocardiography. MAIN OUTCOME MEASURES: The aortic root diameter, atrial septal dimension behind the aortic root, and amplitude of the phasic oscillation of the septum were measured. Four groups of patients were compared: 12 platypnoeic patients with a dilated aortic root (POS-D), 7 platypnoeic patients with a normal aortic root (POS-N), 15 control patients with a dilated aortic root (CONT-D), and 15 control patients with a normal aortic root (CONT-N). RESULTS: In POS-D and CONT-D patients, the apparent atrial septal dimension was 16.3 (2.7) mm and 17.4 (5.9) mm respectively, compared with 24.4 (5.2) mm in POS-N patients and 25 (4) mm in CONT-N (p < 0.005). Furthermore, the amplitude of septal oscillation was 14.7 (2.5) mm in the POS-D group versus 5.8 (2.4) mm in CONT-N (p < 0.001) compared with 23.3 (3) mm in seven patients with an atrial septal aneurysm (p < 0.001). CONCLUSION: Patients with an enlarged aorta have an apparently smaller dimension and increased mobility of the atrial septum. These findings appear to result from compression by the aortic root and decreased septal tautness. Consequently, a "spinnaker effect" with the inferior vena caval flow may take place, opening the foramen ovale and leading to sustained right to left shunting.

Fatal ball-valve airway obstruction by an extensive blood clot during mechanical ventilation.

A ball-valve airway obstruction by a blood clot cast of almost the whole bronchial tree occurred in a small-cell lung cancer patient, who had been on mechanical ventilation for 9 days. Chest radiographs revealed overinflated lungs. Attempts to remove the cast via fibreoptic bronchoscopy were unsuccessful and the patient died. A postmortem extraction of the clot was performed with a rigid tube. This case is rare because of absence of severe haemoptysis and lung volume reduction.