Exercise-induced alterations in phospholipid hydrolysis, airway surfactant, and eicosanoids and their role in airway hyperresponsiveness in asthma.

The mechanisms responsible for driving endogenous airway hyperresponsiveness (AHR) in the form of exercise-induced bronchoconstriction (EIB) are not fully understood. We examined alterations in airway phospholipid hydrolysis, surfactant degradation, and lipid mediator release in relation to AHR severity and changes induced by exercise challenge. Paired induced sputum (n = 18) and bronchoalveolar lavage (BAL) fluid (n = 11) were obtained before and after exercise challenge in asthmatic subjects. Samples were analyzed for phospholipid structure, surfactant function, and levels of eicosanoids and secreted phospholipase A2 group 10 (sPLA2-X). A primary epithelial cell culture model was used to model effects of osmotic stress on sPLA2-X. Exercise challenge resulted in increased surfactant degradation, phospholipase activity, and eicosanoid production in sputum samples of all patients. Subjects with EIB had higher levels of surfactant degradation and phospholipase activity in BAL fluid. Higher basal sputum levels of cysteinyl leukotrienes (CysLTs) and prostaglandin D2 (PGD2) were associated with direct AHR, and both the postexercise and absolute change in CysLTs and PGD2 levels were associated with EIB severity. Surfactant function either was abnormal at baseline or became abnormal after exercise challenge. Baseline levels of sPLA2-X in sputum and the absolute change in amount of sPLA2-X with exercise were positively correlated with EIB severity. Osmotic stress ex vivo resulted in movement of water and release of sPLA2-X to the apical surface. In summary, exercise challenge promotes changes in phospholipid structure and eicosanoid release in asthma, providing two mechanisms that promote bronchoconstriction, particularly in individuals with EIB who have higher basal levels of phospholipid turnover.

Canal wall reconstruction in cholesteatoma surgeries: rate of residual.

To evaluate the rates of residual and recurrent cholesteatoma following canal wall reconstruction (CWR) tympano-mastoidectomy with mastoid obliteration, for the treatment of chronic otitis with cholesteatoma. Consecutive cohort study. We included patients following surgical cholesteatoma removal by CWR tympano-mastoidectomy with hydroxyapatite mastoid obliteration from 2008 to 2012. We analyzed audiometric and postoperative radiologic data. We determined the rates of residual disease and recurrence, and evaluated postoperative complications. Thirty-six ears were included in this study. The mean follow-up after surgery was 24 months (range 12.3-51.4 months). The recurrence rate was 3.1% (one case) and the rate of residual disease was 6.2% (two cases including one of iatrogenic cholesteatoma). No canal-wall-down tympanoplasty was required. Local infection was detected in 33% of cases and was successfully treated with appropriate antibiotics. Postoperative audiometry showed no impairment of the cochlear reserve. No postoperative facial palsy or deafness was observed. CWR permits well exposure of the lesion, making complete excision of the cholesteatoma possible. This study showed a decreasing of the rate of residual cholesteatoma and must be confirmed with further studies. CWR makes it possible to use hearing aids for auditory rehabilitation.

[Use of inomeric cement: preliminary results in revision stapes surgery]. / Utilisation d'un ciment ionomère: résultats préliminaires dans la chirurgie de révision d'otospongiose.

OBJECTIVES: Lonomeric cement can be used in revision of stapes surgery to extend the long process of the incus. Indeed, necrosis of the long process of the incus is the most common peroperative finding in this surgery. The objective in this study is to describe the technique and precautions of using SerenoCem, in the reconstruction of the long process of the incus in this indication. TYPE OF STUDY: Prospective study. PATIENTS AND METHODS: Consecutive patients with necrosis of the long process of the incus were included from September 2009 to October 2010. We analyzed peroperative findings and evaluated functional results by hearing tests before and three months after surgery. RESULTS: Nine patients, were included. The preoperative air-bone gap was 29 dB (+/- 14) whereas postoperative air-bone gap was 16 dB (+/- 10). The rate of postoperative air-bone gap closure to within 10 dB was 55% (n = 5). No sensorineural hearing loss occured in this study. Results of revision surgery were more successful when the piston is directly attached to the incus remnant and stabilized with cement, compared to incus reconstruction followed by piston attachment. CONCLUSION: Ionomeric cement permits reconstruction of the necrosis of the long process of the incus during revision surgery. Preliminary results reveal a significant hearing improvement, without complementary morbidity.

Influence of surgical technique on residual cholesteatoma location and prevalence.

OBJECTIVE: Compared to canal wall up (CWU) tympanoplasty, canal wall reconstruction (CWR) allows better visualization of cholesteatoma extension. The canal wall up approach provides good functional outcomes, but with higher rates of residual cholesteatoma. The aim of this study was to compare residual cholesteatoma prevalence and location between the two approaches. METHOD: Subjects were adult patients with residual cholesteatoma following CWU or CWR surgery between January 1, 2010 and December 31, 2015. During this period, 94 patients underwent CWU and 71 CWR; 22 presented with residual cholesteatoma: 16 after CWU (R-CWU group) and 6 after CWR (R-CWR group). RESULTS: There was no significant inter-group difference in residual cholesteatoma prevalence: 17% after CWU, 8.4% after CWR. Locations comprised: 13 (81%) in the attic, 9 (56%) in the tympanic cavity and 4 (25%) in the mastoid in the R-CWU group, and 6 (100%) in the attic in the R-CWR group. There were significantly fewer tympanic cavity locations after CWR compared to CWU (P=0.046). CONCLUSION: Residual cholesteatoma prevalence did not significantly differ between the CWU and CWR approaches. The most frequent location was the attic; significantly more locations were in the tympanic cavity with the CWU approach. These findings are important for surgeons and neuro-radiologists during follow-up.

Otosclerosis in children and adolescents: a clinical and CT-scan survey with review of the literature.

OBJECTIVE: To assess the role of the CT-scan in the preoperative evaluation of juvenile otosclerosis and to study additional outcome data. DESIGN AND SETTING: We performed a retrospective case series study from an academic referral hospital using data from 1992 to 2005. PATIENTS AND METHODS: We selected patients younger than 18-year-old who had undergone primary stapedectomy for otosclerosis among the 10 stapedectomies performed over the study period and analyzed the patients' systematic pre- and post-operative audiograms and CT-scan findings. RESULTS: For this survey, complete data was available for 7 children, totaling 10 primary stapedectomies for otosclerosis. Their ages at diagnosis ranged from 10 to 17 years. In 4 children, CT-scan demonstrated bilateral findings typical of otosclerosis: poorly calcified foci near the fissula ante fenestram, associated with a hypodense edging surrounding the labyrinthine capsule in 2 children. The youngest patient had no CT-scan abnormalities. Stapedectomy was performed in one case and laser stapedotomy in 9 cases. Seven children were immediately improved following surgery and no postoperative facial palsy or prolonged vertigo was reported. The mean (S.D.) postoperative ABG was 6.5dB (+/-3.7). The mean closure was 19dB (+/-11.2). The mean change in high-tone bone conduction level was 1.8dB (+/-7.5). Six children had a postoperative ABG less than 10dB while in one, the ABG was inferior to 20dB. CONCLUSION: Preoperative CT-scan is useful for the preoperative diagnosis of otosclerosis in children. The images seen must be distinguished from other footplate pathologies or deformities of the ossicular chain which are often associated with poorer surgical results. This survey provides additional evidence that stapes surgery is an effective procedure for treating juvenile otosclerosis.

[Epidermoid cysts of the fourth ventricle mimicking benign paroxysmal positional vertigo]. / Vertige positionnel paroxystique découvrant un kyste épidermoïde du quatrième ventricule.

OBJECTIVE: To report a case of atypical positional vertigo revealing a fourth ventricle epidermoid cyst. MATERIAL AND METHODS: We report a case of a thirty-year-old woman suffering from positional vertigo with downbeat nystagmus. Except for these symptoms, the physical examination was normal, apart from intermittent headaches. On videonystagmography, a decrease in the average speed of beats and lowered benefits obtained by slow motion were noted. MRI revealed a fourth ventricle epidermoid cyst. RESULTS: Physical examination may provide several signs that are likely to enable the examiner to distinguish between central nervous system or peripheral vertigos. Atypical symptoms such as a downbeat nystagmus, a lack of reversal in nystagmus beats when returning to the sitting position and a lack of a latency period in vertigo and nystagmus occurrence during the Dix-Hallpike maneuver suggest a central nervous system etiology. CONCLUSION: With atypical symptoms noted when questioning the patient or during physical examination, a central nervous system etiology should be mentioned and explored with cerebral MRI.

[Evolution of facial nerve prognosis in vestibular schwannoma surgery by translabyrinthine approach]. / Evolution du pronostic du nerf facial dans la chirurgie du neurinome de l'acoustique par voie translabyrinthique.

OBJECTIVES OF THE STUDY: To evaluate our results on the postoperative facial function, its pre and preoperative predictive factors, and the application of the surgical technique to lesions of decreasing size. PATIENTS AND METHODS: A series of 248 patients operated of an unilateral vestibular schwannoma has been reviewed. We have compared the results gathered over two periods corresponding to the evolution of our surgical technique since 1998. RESULTS: Immediate and 1 year postoperative facial function is significantly better among patients operated after 1998 (satisfactory in 75 and 88% respectively). This trend marked by the improvement of the results since 1998 has to be discussed according to other predictive factors. One of predictive factor is the decrease of the size of the lesion during the same period. The other factors are the hearing level, deafness duration, trigeminal nerve involved, vestibular status and ABR desynchronization. CONCLUSION: The positive predictive factors are usually correlated with the size of the tumour This implies the necessity of an early diagnosis of the schwannomas. The second predictive factor of the facial function is the use of a soft surgical technique.

Electrophysiological exploration of hearing.

Electrophysiologic hearing tests have been developed since the 1960s to determine hearing thresholds objectively. They are now implemented in newborn hearing screening. While they determine thresholds, interpretation requires subjective pure-tone and speech audiometry to determine the type of hearing loss. Each examination tests a different anatomic region, enabling the auditory system to be explored from the organ of Corti to the auditory cortex. Thus, the various objective audiometric examinations are complementary.

[Intrapetrous cholesteatoma. A retrospective study of seven operated cases]. / Cholestéatome intrapétreux. Etude rétrospective de sept cas opérés.

INTRODUCTION: Intrapetrous cholesteatoma can be recalled with regard of facial paralysis, mixed deafness, cholesteatoma visible under an otoscopy and some characteristic signs in imaging. Its treatment is a real dilemma between its complete exeresis and the preservation of the facial nerve. METHODOLOGY: We studied the diagnostic and therapeutic aspects of the 7 operated cases from 1994 to 2004. RESULTS: We noted 5 men and 2 women with an average age of 37.29 years. One case was primitive. We observed 6 translabyrinthic lesions, 5 supralabyrinthic lesions and 2 infralabyrinthic lesions. The surgical approach was: translabyrinthic (1 case), translabyrinthic and suprapetrous (2 cases), suprapetrous (1 case), suprapetrous and petrectomy (1 case), petrectomy (2 cases). The diversion of the facial nerve was often associated. After the surgical operation the activity of the facial nerve was conserved in 4 patients and improved in 2 patients. The facial nerve paralysis that appeared on a patient after being operated on, totally recovered after 7 months. In spite of the appropriate surgical approach, the residual lesions were not rare (2 cases). This situation imposes a clinical and radiological follow-up for life. CONCLUSION: Intrapetrous cholesteatoma is rare. The X-ray confirmed the diagnosis. The new MRI techniques allow to detect recurrences and residues. A second surgical operation can be necessary.

Surgical treatment of Graves' disease.

Seven men and 81 women were operated on for Graves' disease. Their median age was 33 years. Eleven patients underwent a bilateral subtotal lobectomy; 77 patients underwent a complete lobectomy with contralateral partial lobectomy. Forty-seven patients were treated before 1981. In these patients, the weight of the thyroid remnant was estimated empirically between 5 and 12 g. In the 41 patients treated since 1981, the remnant weight was estimated at 5 g by comparative weighing. There were no postoperative deaths. Functional results were established in 83 patients with an average follow-up of 50 months (range 12 to 156 months), with control of vocal cord mobility demonstrated by indirect laryngoscopy in 66 patients. Hormonal determinations were carried out in 74 patients. There were no cases of permanent hypoparathyroidism. Three patients (4.5 percent) had unilateral vocal cord dysfunction. Twelve patients (14.5 percent) had clinical and biologic hypothyroidism, which occurred within 1 year postoperatively in 11 cases. Seven patients (8.3 percent) had latent hypothyroidism only discovered by hormonal determinations. Fifteen patients (17.8 percent) had recurrent hyperthyroidism, 6 of whom were diagnosed by hormonal determinations. The actuarial recurrence rate increased progressively up to the sixth postoperative year. The only predictive factor for recurrence was the type of operation. Patients who underwent a bilateral subtotal lobectomy had more recurrences than patients who underwent a complete lobectomy with partial contralateral lobectomy (p less than 0.01). These results suggest that patients should be followed closely for many years and should undergo hormonal determinations regularly, as some recurrences can occur 5 years or more after operation with very few symptoms.

Choanal atresia and deafness.

Nine cases of bilateral choanal atresia are reported. The association with other malformations and deafness is evaluated. The choanal atresia is associated with multiple malformation in two cases and bilateral deafness in 5 cases. Before discussing surgery, a complete evaluation has to be performed, deafness has to be evaluated with modern electrophysiological methods. The risks of the surgery should be considered in case of cardiac malformation and cerebral anoxia.

[Is the afferent auditory message modulated by the cortex?]. / Le message afférent auditif est-il modulé par le cortex?

An eventual modulation of the afferent auditory message by the cortex is the subject of this study. To test this hypothesis, clicks (10 Hz, 100 microseconds) of white noise of 40 and 70 dB Hl were sent alternatively into the ears of normally hearing volunteers, while the brainstem evoked potentials were recorded. The subjects were asked to focus or relax their attention on one or other ear. Thirty subjects aged less than 25 years (15 men and 15 women) with normal hearing level, were split into two groups. The first group was asked to focus first on the more strongly stimulated ear (70 dB), the second group on the more weakly stimulated one (40 dB). Each subject received (1) without any instruction about attention: 40 dB on the left ear (L), 70 dB on the right ear (R); 40 dB then 70 dB bilateral; (2) 2 runs with 40 dB on the L and 70 dB on the R focussing on the most or less strongly stimulated ear; (3) a run without instruction with 70 dB on the L and 40 dB on the R, and (4) two runs with 70 dB on the L and 40 dB on the R focussing enough on the more or less strongly stimulated ear. On the evoked potentials simultaneously recorded, amplitudes and latencies of the pikes were measured and compared. From these experiments, the following elements were obtained. (1) The measured potentials were always caused by ipsilateral stimuli. (2) Focussing on left or right ear was not equivalent. (3) A gender difference appeared in the brainstem auditory responses. (4) Preferential attention paid to the left ear was more efficient than to the right one. (5) Attention can alter the whole nervous pathway with considerable lengthening of O-I, O-III, O-V, III-V, I-V but not I-III latencies. The III wave amplitude generally decreased on the side where attention was focussed while V waves seemed not to vary. These first results indicate that a cortico-efferent pathway stimulated by the attention plays a role in the auditory responses modifying the afferent message. These effects were not the same among the side focussing attention and among sex.

Bilateral conductive deafness related to erosive lichen planus.

A case of bilateral progressive stenosis of both external auditory canals with resultant conductive hearing loss is presented. The stenosis revealed multifocal erosive and synechiant lichen planus. To our knowledge, this is the first reported case of lichen planus involvement of the external ear.

[Acute mastoiditis in children: clinical and bacteriological study of 17 cases]. / Mastoïdite aiguë de l'enfant: étude clinique et bactériologique de 17 cas.

OBJECTIVE: Acute mastoiditis (AM) represents the most frequent complication of acute otitis media (AOM) in children. In the literature, its incidence is stable but with an impressive increase in pneumococci with reduced sensitivity to penicillin (PRSP). The aim of this study was to assess the incidence of AM in the area of Tours and the prevalence of PRSP. METHOD: This was a retrospective study of children admitted to the regional paediatric centre in the Tours area, between January 1994 and May 2001. The coded AM files were analysed, excluding all the sub-acute forms or those complicating a cholesteatoma. The criteria studied concerned the clinical signs on admission, the imaging data and the bacteriological samples and the results of treatment. RESULTS: Seventeen children (8 boys, 9 girls) were admitted for an AM during the study period. Their mean age was of 3.2 years (range: 6 months to 13 years). In 24% of cases, the mastoiditis existed on admission and in 59% of cases it complicated an AMO already treated with antibiotics. In 3 cases (18%), the AM was complicated on admission with peripheral facial paralysis in one case and thrombosis of the lateral sinus in 2 cases. The germ responsible was identified in 14 cases (82%) with a predominance of pneumococci (11 cases). Eight were PRSP-type. Scan of the pars petrosa identified a subperiosteal abscess in 13 cases. Fourteen mastoidectomies were performed and the mean duration of antibiotic therapy was of 23 days. The outcome was always good. CONCLUSION: Over the past 7 years, the incidence of AM has been estimated at 1.2/100 000 children aged under 15 per year. The prevalence of PRSP is high but does not change the principles or the results of the treatment of AM.

[Clinical manifestations of various mycoses of the upper respiratory and digestive tracts in African pathology]. / Manifestations cliniques de quelques mycoses des V.A.D.S. en pathologie Africaine.

Mycotic infections are prevalent in tropical Africa, and are sometimes observed North and South of this zone, but they are usually localized to the lower limbs (mycetoma), without manifestations in the ORL sphere. However, various ubiquitous superficial mycoses are also encountered in Africa, particularly Aspergilloses and Candidoses. Their clinical expression (apart from several cases of pseudo-tumoral sinusal aspergillosis...) differs only slightly from that observed and treated everywhere, and they are not discussed. Also excluded are several cases of North-American Blastomycosis reported North and South of the Sahara (Blastomyces Dermatidis). Their ORL manifestations do not appear to have been studied. Three very well known major forms remain: Histoplasmoses, Rhinosporidiosis, Phycomycoses (or Rhino--Entomophtoroses). Sporotrichoses with nasofacial manifestations may also, perhaps, be included.

[Surgical correction of saddle nose. Apropos of 23 cases]. / Correction chirurgicale des ensellures nasales. A propos de 23 cas.

Choice of graft for repair of a saddle nose in 23 patients, usually late sequelae of nasal fracture, varied with degree of concavity : moderate anomalies usually by cartilaginous graft, major lesions by iliac bone graft. Postoperative course was always simple. The Rethi approach was used when a bone graft was necessary, with a minimum esthetic ransom, and a skin flap of V-Y advancement at the expense of the white labrum when there was insufficiency of columellar height. Although results were assessed as satisfactory by the patients, the difficulties in obtaining excellent results in this type of rhinoplasty are emphasized, imperfections being frequent : filling of nasofrontal angle, asymmetry of naries orifices and fixed nose appearance.

[Use of coral implants in maxillofacial and otorhinolaryngologic surgery]. / Utilisation des implants coralliens en chirurgie oto-rhino-laryngologique et maxillo-faciale.

The coral, as bio-compatible implant, has been used in several indications: in Otology: for ossicular chain and external auditory canal reconstruction. In Maxillo-facial surgery: for orbital floor, maxillary sinus and jawbone reconstruction. The first results of this study are favorable but coral resorption might be prevent by a careful sealing of the implant deep under the surface layer.

[Cholesteatoma of the external auditory canal]. / Cholestéatome du conduit auditif externe.

Epidermal plugs of the external auditory canal were described initially by Toynbe in 1850, and since that time epidermal plugs and canal cholesteatomas have often been classified under the same heading. However, auditory canal cholesteatoma represents a separate clinical entity, although its pathogenicity remains unrecognized. Therapy may be medical or surgical, but a more eclectic therapeutic approach is to be preferred. Two recent cases of auditory canal cholesteatoma are reported.

[Otogenic thrombosis of the lateral sinus]. / Les thromboses otogènes du sinus latéral.

Otogenic thrombosis of the lateral sinus, which has become rare since the use of antibiotics, nevertheless still poses diagnostic and therapeutic problems. Based on 4 cases treated at the University Teaching Hospital in Tours since 1982, the authors study the various clinical and paraclinical elements in the diagnosis, stressing the value of CT examination using contrast. Management is then proposed in diagramatic form: the indication for surgery depending on the efficacy of antibiotic therapy and internal jugular vein ligation being required in the event of septic emboli manifest cervical signs.

[A rare paraneoplastic syndrome: Bazex' syndrome (author's transl)]. / Un syndrome para-néoplasique rare: le syndrome de Bazex.

The authors report a case of Basex' syndrome in its typical and complete form of the cutaneous syndrome, appearance of the skin lesions preceding the pharyngeal symptoms. The squamous cell carcinoma confirmed by histopathological examination was treated by radiotherapy only.