Blast injury of the ear by massive explosion: a review of 41 cases.

BACKGROUND: Blast injuries in modern warfare are common, and the ear is often affected as it is an effective pressure transducer. This study aimed to evaluate military blast injuries of the ear. METHODS: From May 2002 to October 2014, all patients referred to two military hospitals near Paris, France following exposure to massive explosions were analysed. RESULTS: Among the 41 patients (82 ears), 36 of them reported tinnitus, 25 hearing loss, 14 earache and 8 vertigo. It was noted that 44% of the patients had tympanic membrane perforations and that this was bilateral in two-thirds of the cases. The hearing loss in 29% of the cases was pure sensorineural, in 55% it was mixed and in 15% it was a pure conductive hearing loss. There was no correlation between the impact of middle ear lesions and the severity of the inner ear injury. Three patients had a pharyngolaryngeal blast injury detected on the battlefield associated with blast lung injury, but only two of them had tympanic perforations. Nine tympanoplasty procedures were performed, of which 44% succeeded in sealing the perforation. CONCLUSIONS: Blast injuries of the ear are characterised by significant functional signs and are not correlated to otoscopic examinations. Sensorineural hearing loss is almost immediately final. When deciding on initial management, the status of the tympanic membrane does not provide any information about the risk of a primary blast injury of the lung; laryngeal nasofibroscopy seems a more relevant screening test.

[Nasal polyposis and olfactory function: results of the surgical treatment]. / La polypose nasosinusienne et l'odorat: intérêt de la chirurgie.

INTRODUCTION: Hyposmia is a common cause of functional complaint in patients with nasal polyposis. The aim of the current study was to report the olfactory functional results after sinus surgery. MATERIALS AND METHODS: A systematic review of the scientific literature was achieved in the Pubmed database. RESULTS: Overall, 10 series published between 1989 and 2013, involving 959 patients, were selected. The surgery for nasal polyposis, adjuvant medical treatment, may allow olfactory improvement. The results are even better than surgery is as wide as possible and the evolutionary stage is low.

[Diagnosis and therapeutic pathways in head and neck cancers]. / Parcours de soins du patient présentant un carcinome epidermoïdes des voies aéro-digestives supérieures.

BACKGROUND: Cancers of uppers aero-digestives tracts represent, infrequency, the 5th cancer in the French population. Most of them (about 70%) are diagnosed at an advanced stage (stage III or IV) while they are associated with a poor prognosis (only 40% five year survival). The objective of our study was to analyze the care pathway of patients with cancers of uppers aero-digestives tracts in order to target efforts to improve the survival of these patients. METHODS: It was a descriptive and retrospective study, on medical files, on the health care pathway of patients with cancers of uppers aero-digestives tracts cared in the Head and Neck surgery department of Val de Grâce in Paris and Percy in Clamart between January 2004 and December 2006. The patients were adults with squamous cell carcinoma of uppers aero-digestives tracts. RESULTS: One hundred thirty-eight files of patients were analyzed. Fifty-five percent of patients were diagnosed at an advanced stage. On average patients have waited two months and twenty-one days before consulting a doctor for the first time. The time interval between the specialist consultation and the start of treatment was on average 7 weeks. The overall 5-year survival rate was 61%. CONCLUSION: Squamous cell carcinoma of uppers aero-digestives tracts remains serious and has a poor diagnosis, even in a population with a high social-cultural level. The long time interval before the first consultation may be reduced by improving health education among the general practitioner (primary and secondary prevention), and by establishing health care public campaigns. This would allow earlier diagnosis, more conservative therapeutic opportunities and therefore a better prognosis.

[Deafness in adults. Study of practices in general medicine]. / Les surdités de l'adulte. Etude de pratiques en médecine générale.

INTRODUCTION: Deafness is a sensory disability responsible for communication disorder, sometimes impairing social life. In children, the hearing is an important concern for all stakeholders in early childhood (systematic neonatal screening, etc.). On the other hand, in the adult, it is rarely tested, and patients do consult when their audiometric status is already badly impaired. But their care is all the better if the deafness diagnosis is made early, as for the audio-prosthetic rehabilitation for example. Today, the general practitioner is the first link of the diagnostic and therapeutic management chain. The objective of this study was to evaluate the diagnostic practices of practitioners in front of deafness in adults. SUBJECTS AND METHODS: This prospective study included 74 practitioners based in "Ile de France" interviewed using a multiple choice questionnaire (MCQ) on otoscopic and audiometric diagnostics and a Script Concordance test (SC) on clinical adult deafness situations validated by a 5 experts panel. RESULTS: The obtained average score was 66.35% of correct answers to the MCQ and 47.76% to the SC. CONCLUSIONS: In our study, the surveyed practitioners showed a good level of otoscopic and audiometric diagnosis in the MCQ. However, their answers were not concordant with those of the expert panel in the SC. They have been particularly poorly performing on issues related to functional signs and their use in a given clinical situation, often driving to establish an otoscopic misdiagnosis while their diagnostic recognition of a pathological eardrum in the MCQ was rather good. These results reflect a lack of confidence in their otoscopic diagnosis related to the lack of knowledge of the causes of deafness in adults and their symptoms.

Pulsatile tinnitus and venous cerebral thrombosis: report of a case and literature review.

BACKGROUND: Pulsatile tinnitus can be caused by fatal vascular disease. The authors reported a very rare case of pulsatile tinnitus that revealed a sigmoid sinus thrombosis. CASE REPORT: A 43-years-old man was referred to our department for a left pulsatile tinnitus that had lasted for 2 years. The CT angiography and the MRI retrieved a sigmoid sinus thrombosis that was responsible for emissary vein ectasis. The biological check up was normal. The tinnitus disappeared after two months of anticoagulation. CONCLUSIONS: Ten cases of pulsatile tinnitus associated with cerebral venous thrombosis have been published in the literature. In most of cases, pulsatile tinnitus was the only symptom. Few cases of headache, hearing loss and vertigo were described in association with the tinnitus. In 5 cases a cause was retrieved (hemostasis troubles, head injury and dural arteriovenous fistulas). Full recovery can be obtained for nearly all cases as a result of anticoagulation.

[Signs of upper airways digestive tract cancers and the general practitionner. Study of the practices by a Script Test Concordance]. / Les signes d'appels des cancers des voies aéro-digestives et le Médecin généraliste. Etude de pratique par un Test de Concordance de Script.

INTRODUCTION: Upper Airways digestive tract cancers are the 4th more frequent cancer. They are responsible for non specific symptoms. The examination of this antomical region is very difficult for a general practitioner. The precoce diagnosis of these cancers is based on the good recognition of the clinical situations by the general practitioner. The aim of this study was to test the practice of the general practitioner in front of clinical situations typical of head and neck cancers by a Script test concordance. METHOD: The study was performed on 107 parisian general practitioners who answered a questionnaire based on a Script Concordance Test (SCT). The SCT is a questionnaire that test the clinical way of thinking comparing the use of an information of experts versus non experts. RESULTS: The answers of the practitioners tested were quite in accordance with the panel of experts' anwers. They were particularly good concerning the risk factors and the buccal and oropharyngeal cancers. The scores were lower concerning the nasopharyngeal, laryngeal and paranasal sinuses cancers. The scores were significantly better for the most experimented practitioners. DISCUSSION: The fact that the rhinopharygeal, the laryngeal and the paranasal sinuses cancers are less frequent and the fact that these cancers can not be seen directly during a standard physical examination of general practitioner can explain the lower scores for these types of head and neck cancers. That is why practitioners have to be particularly aware of the symptoms and have to ask a specialized advice in case of doubt.

Prevalence of and risk factors for obstructive syndrome apnea.

INTRODUCTION: Obstructive Sleep Apnea Syndrome (OSAS) is becoming an important public health problem because of its frequency and adverse health consequences. The objective of this prospective study was to evaluate the prevalence of and risk factors for OSA in a cohort of subjects working for the french Army. SUBJECTS AND METHODS: This prospective study was carried out on a sample of volunteers working for the French army. The subjects were recruited at their annual work visit between November 2008 and September 2009. Subjects were asked to complete 2 screening questionnaires (Epworth and Berlin) and were given a medical examination. Subjects suspected of having OSAS (based on high questionnaire scores) were monitored by nocturnal ventilatory polygraphy. OSAS was diagnosed if the subject was found to have an apnea/hypopnea index (AHI) greater than or equal to 5. RESULTS: In this healthy, young and active population (n = 1054), 4.20% of subjects were diagnosed with OSA. Comparing our two groups of subjects (OSA and non-OSA), several statistically significant (p < .05) differences emerged that may be associated with OSA: the individuals with OSA were older by an average of 7 years, they presented with an average BMI greater than 4.5 kg/m2, an average abdominal girth greater than 12.2 cm and an average cervical circumference greater than 2.6 cm. In addition, they consumed more tobacco when they were smokers and were more likely to present with permanent nasal obstruction. They were also more likely to suffer from gastroesophageal reflux and present with skeletal class II. Finally, they presented with a longer average soft palate as determined by the Mallampati scoring system. CONCLUSION: We found that the major risk factors for OSAS were age, BMI, abdominal girth and cervical circumference (linear correlations determined by bi-variate analysis).

[Facial nerve monitoring in the parotidectomy]. / Le monitorage du nerf facial dans la parotidectomie.

INTRODUCTION: Facial palsy (FP) is a feared complication of parotidectomy. Facial nerve monitoring (FNM) has been poorly evaluated since it was created at the beginning of the 90's. The authors described a retrospective series and discussed it reviewing the literature data. SUBJECTS AND METHOD: From January 2002 to January 2009, 75 parotidectomies were performed in 72 patients (34 males, 38 females), without FNM in 28 cases (group 1) and with FNM in 47 cases (group 2). RESULTS: In group 1, 9 FP were noted, 5 were transient and 4 were definitive. In group 2, 12 FP were noted, 9 were transient and 3 were definitive. Both one month and six months after parotidectomy, the FP rate was significatively higher in group 1 than in group 2 for the reoperations. CONCLUSIONS: Facial nerve monitoring is an adjunctive method available to a surgeon during parotid surgery to assist with the functional preservation of the facial nerve. It did not allow to improve the facial prognosis in benign tumours removal but it improved the facial prognosis in reoperations. Its interest should be tested for malignant tumour removal.

[Post-traumatic carotid cavernous fistula: report of two cases]. / Fistule carotido-caverneuse post-traumatique: à propos de deux cas.

Carotid cavernous fistula (CCF) is an abnormal communication between the cavernous sinus and the carotid arterial system. The authors reported the clinical presentation and therapeutic procedure of two cases. The physician has to be aware of this diagnosis when a patient is referred for a posttraumatic exophthalmia. The medical behaviour is multidisciplinary (ENT, ophthalmologist, radiologist and neurosurgeon). The imaging of choice is the angiography but angio-MRI and angio-CT can help to confirm the diagnosis. The endovascular embolization is the treatment of choice. It presents an acceptable risk of complication and a low risk of failure. In this paper the authors report 2 posttraumatic CCF cases treated with success by endovascular embolization.

[Endoscopic-assisted retrocaruncular approach for management of medial orbital wall lesions: a review of 6 cases]. / La voie rétro-caronculaire assistée par endoscopie dans la prise en charge des lésions de la paroi interne de l'orbite: à propos de 6 cas.

BACKGROUND: Medial wall orbital fractures can result from external trauma (midfacial trauma, blow out) or from endonasal trauma (functional endoscopic sinus surgery). Entrapment of the medial rectus muscle can lead to optical complications if not treated (restriction of ocular mobility, diplopia). Enophtalmos can also be the result of extrusion of orbital fat into the ethmoïdal cavities. Surgical repair entails treatment and prevention of these complications. OBJECTIVE: Define the contribution of endoscopy and retrocaruncular incision, particularly in terms of accessibility and visibility of the posterior third of the medial wall of the orbit. MATERIAL AND METHODS: Six patients with medial orbital wall fractures were treated between May 2006 and May 2007 using a retrocaruncular approach assisted peroperatively by endoscopy. No complications occurred during the postoperative follow up. The authors describe the surgical techniques used. CONCLUSIONS: Retrocaruncular approach is a safe and effective technique that presents the particular advantage of not leaving a dysesthetic scar. Peroperative endoscopy allows then a better accessibility and visibility of the posterior third of the medial orbital wall.

The pedicle superficial temporalis fascial flap in oncologic reconstructive surgery of the oral cavity: how we do it and its functional results.

OBJECTIVE: The authors described how they perform a pedicle superficial temporalis fascial flap in oncologic reconstructive surgery of the oral cavity and evaluated its functional results. STUDY DESIGN: A prospective study was performed in an university hospital from September 2001 to July 2007. SUBJECTS AND METHODS: Nine male patients underwent a pedicle superficial temporalis fascial flap to repair a soft tissue loss in the oral cavity following a tumour extraction (seven cases) or to repair osteoradionecrosis (two cases). RESULTS: Twelve months after the intervention, a correct functional state was restored in seven out of nine cases and the anatomical congruence was correct in eight out of nine cases. CONCLUSION: The pedicle superficial temporalis fascial flap can be useful in the reconstruction of the oral cavity, especially for patients who underwent radiotherapy. This flap was shown to be reliable, with acceptable post-operative complications, though it requires surgical experience. It is of interest for posterior and/or superior oral cavity reconstruction because the flap length, which is considerably reduced by its arc of rotation and by its path near the zygomatic process, does not allow for reconstruction of the anterior floor of the mouth. Because this flap is thin, only moderate soft tissue loss can be repaired.

[Atypical laryngo-tracheal post-intubation complications: three case reports]. / Complications laryngo-trachéales post-intubation atypiques: à propos de 3 cas.

Endotracheal intubation can induce iatrogenic laryngeal and tracheal complications, particularly when the intubation lasts for a long time. The ENT pratician's job is not only to cure the laryngeal sequelaes but also to prevent and diagnose them. Authors report three atypical cases of laryngeal and tracheal post-intubation complications (laryngeal bilateral immobility, interarythenoidal synechia, oesotracheal fistulae) and discuss them regarding medical literature data.

[Long-term results of facial palsy's rehabilitation by end-to-end hypoglossal-facial anastomosis]. / Résultats à long terme de la réhabilitation des paralysies faciales périphériques par anastomose hypoglosso-faciale termino-terminale.

OBJECTIVE OF THE STUDY: To evaluate the long term functional and esthetical results of the patients who underwent a facial palsy rehabilitation surgery by a hypoglossal-facial anastomosis. PATIENTS AND METHODS: In this retrospective study, 11 patients (8 males and 3 females) with a complete facial palsy (grade VI House-Brackmann) due to an otoneurosurgery performed between 1985 and 2006 (6 vestibular schwannomas, 1 facial schwannoma of the geniculate ganglion and 4 meningiomas) were evaluated (with the help of an auto-questionnary, a physical exam and electromyography) between July and september in 2008. RESULTS: The voluntary palpebral closure was obtained in 8 cases out 11 (grade III of House-Brackmann). The lingual hemiatrophy was constant. It was major for the patients who didn't take part in a specific re-education. In these cases patients had troubles during feeding and elocution. CONCLUSION: The hypoglossal-facial is a dynamic surgical rehabilitation of choice for the facial palsy. It nearly achived 80% of good palpebral results. The end-to-end anastomosis gives a lingual hemiatrophy which is not the case with a side to end anastomosis. This atrophy can be reduced with an intensive and specific reeducation. Moreover this re-education improves the functionnal and the esthetical results for the patients who underwent an hypoglossal-facial anastomosis. This lingual hemiatrophy was then responsible for troubles for feeding and elocution.

Endoscopic septoplasty: Learning curve.

AIMS: The aim of the current study was to report the learning curve for endoscopic septoplasty for a senior surgeon already trained in endonasal sinus surgery. MATERIAL AND METHODS: From November 2011 to September 2012, 100 patients were prospectively included and grouped in 5 consecutive groups of 20 by date of surgery. The primary endpoint was operative time. Intra- and postoperative complications and functional assessment were also analyzed. RESULTS: Operative time decreased with the surgeon's experience and became stable after 60 procedures. Operative time saving was about 10min per 20 procedures. Mean operative time was stable between groups 4 (21.1±9.6min) and 5 (19.2±8.2min). There was a 2% rate of conversion to conventional surgery for technical problems. The number of procedures free of accidental mucosal lesion increased and became stable after 40 procedures. There was a 4% rate of residual postoperative perforation. Nasal Obstruction and Septoplasty Effectiveness (NOSE) score improved postoperatively in each group (P<0.05). CONCLUSION: After 60 endoscopic septoplasty procedures, a senior surgeon masters the surgical technique with satisfactory operative times, and a decreasing rate of intra- and postoperative complications.

Endoscopic vs. conventional septoplasty: A review of the literature.

The aim of this review of literature was to compare conventional and endoscopic septoplasty in terms of operating time, functional efficacy and perioperative morbidity. A systematic review of the scientific literature was performed on the PubMed database, Google and Google Scholar, searching for randomized prospective trials comparing endoscopic and conventional septoplasty. The primary endpoint was operating time, and the secondary endpoints were intra- and postoperative complications, postoperative pain, hospital stay and functional result. Twenty-nine articles published between 1991 and 2012 compared conventional and endoscopic septoplasty, five of which were prospective randomized trials. Operating time was shorter with endoscopic surgery (P<0.001), with less mucosal damage (P<0.01); there was less synechia (P<0.01) and residual deformity (P<0.05); and postoperative pain was milder. Endoscopic septoplasty thus shortened surgery time and reduced perioperative complications, but the functional result was the same as with conventional septoplasty.

Endoscopic septoplasty: Tips and pearls.

This article is designed to provide a step-by-step description of our endoscopic septoplasty technique and discuss its difficulties and technical tips. Endoscopic septoplasty comprises 10 steps: diagnostic endoscopy, subperichondral infiltration, left mucosal incision, dissection of the left subperichondral flap, cartilage incision (0.5 centimetre posterior to the mucosal incision), dissection of the right subperichondral flap, anterior cartilage resection, perpendicular plate dissection, dissection and resection of the maxillary crest, endoscopic revision, mucosal suture and Silastic stents. A satisfactory postoperative result was observed at 3 months in 97% of cases in this series. The main contraindication to endoscopic septoplasty is anterior columellar deviation of the nasal septum requiring a conventional procedure.

Catheterization of post-traumatic parotid duct sialocele.

INTRODUCTION: Parotid duct sialocele is a salivary cavity arising at the expense of the parotid duct. Many cases of parotid sialocele have been published, but very few cases of parotid duct sialocele have been reported. CASE REPORT: We report a case of post-traumatic parotid duct sialocele that was assessed by MR sialography. The parotid duct was catheterized via the oral cavity and the catheter was left in place for ten days. No recurrence was observed. DISCUSSION: Published cases of parotid duct sialocele are rare, as only seven cases were identified in the literature. Several treatment options are available for sialocele involving the parotid gland or parotid duct. Subcutaneous injection of botulinum toxin is commonly used, with good results. Parotid duct catheterization has also been reported, mainly for parotid gland sialoceles. To the best of our knowledge, apart from the present case, the use of this technique for parotid duct sialocele has only been reported once before. This technique is minimally invasive, with very low morbidity and good results.

Oval window niche height: quantitative evaluation with CT before stapes surgery for otosclerosis.

BACKGROUND AND PURPOSE: Stapes surgery for otosclerosis can be challenging when the oval window niche is narrow. We analyzed the reliability of CT to evaluate the height of the OWN and propose a quantitative criterion to distinguish normal and narrow OWNs. MATERIALS AND METHODS: Fifty-six patients were scheduled for primary stapes surgery and, with available preoperative CT scans, were prospectively enrolled in the study at a tertiary care hospital. OWN height was measured on coronal CT and qualitatively evaluated during surgery. CT findings and surgical observations were matched to determine the preoperative imaging criterion of a narrow OWN. RESULTS: OWN was found to be narrow during surgery in 8 of 56 patients (14%). On CT, mean OWN height measurement was 1.1 mm for the narrow group and 1.8 mm for the normal OWN surgical cases. The cutoff between normal and narrow OWN was computed at 1.3 mm by using discriminant analysis and at 1.4 mm with boxplot analysis. These CT cutoff values allowed a correct classification of "normal" and "narrow" OWN, compared with visual evaluation during surgery. CONCLUSIONS: Measurements of the OWN height provide an accurate and relevant evaluation of this region before otosclerosis surgery. A width below 1.4 mm should be considered at risk for technical difficulties during the stapes footplate approach.