Five-Year Hearing Outcomes in Bilateral Simultaneously Cochlear-Implanted Adult Patients.

OBJECTIVE: To report the speech performance and sound localization in adult patients 5 years after bilateral simultaneous cochlear implantation and to evaluate the change in speech scores between 1 and 5 years. DESIGN: In this prospective multicenter study, 26 patients were evaluated 5 years after implantation using long straight electrode arrays (MED-EL Combi 40+, standard electrode array, 31 mm). Speech perception was measured using disyllabic words in quiet and noise, with the speech coming from the front and a cocktail party background noise coming from 5 loudspeakers. Speech localization measurements were performed in noise under the same test conditions. These results were compared to those obtained at 1 year reported in a previous study. RESULTS: Five years after implantation, an improvement in speech performance scores compared to 1 year after implantation was found for the poorer ear both in quiet and in noise (+12.1 ± 2.6%, p < 0.001). The lower the speech score of the poorer ear at 1 year, the greater the improvement at 5 years, both in quiet (r = -0.62) and at a signal-to-noise ratio of +15 dB (r = -0.58). The sound localization on the horizontal plane in noise provided by bilateral implantation was better than the unilateral one and remained stable after the results observed at 1 year. CONCLUSION: In adult patients simultaneously and bilaterally implanted, the poorest speech scores improved between 1 and 5 years after implantation. These findings are an additional element to recommend bilateral implantation in adult patients. The use of both cochlear implants and speech training sessions for patients with poor performance should continue in the period after 1 year following implantation, since the speech scores will improve over time.

Effect of corticosteroids on facial function after cerebellopontine angle tumor removal: a double-blind study versus placebo.

The aim of this study was to assess the effect of corticosteroids administered intra- and postoperatively on the occurrence of facial palsy after a cerebellopontine angle (CPA) tumor resection, and to investigate pre- and intraoperative prognostic factors. A multicenter, prospective, randomized, double-blind and versus-placebo study was conducted between 2006 and 2010. Three hundred and ten patients operated on for a CPA tumor (96% vestibular schwannomas, 4% miscellaneous) were included by five participating centers. The population was stratified into patients with small (≤15 mm CPA on axial MRI views) and large tumors. In each group, patients were randomized to receive corticosteroid (1 mg/kg/day i.v. methylprednisolone intraoperatively and at postoperative days 1-5) or placebo. Steroids did not affect the facial function at postoperative days 1, 8 and 30 in patients with small or large tumors as evaluated by House and Brackmann grading.

Improvement of cognitive function after cochlear implantation in elderly patients.

IMPORTANCE: The association between hearing impairment and cognitive decline has been established; however, the effect of cochlear implantation on cognition in profoundly deaf elderly patients is not known. OBJECTIVE: To analyze the relationship between cognitive function and hearing restoration with a cochlear implant in elderly patients. DESIGN, SETTING, AND PARTICIPANTS: Prospective longitudinal study performed in 10 tertiary referral centers between September 1, 2006, and June 30, 2009. The participants included 94 patients aged 65 to 85 years with profound, postlingual hearing loss who were evaluated before, 6 months after, and 12 months after cochlear implantation. INTERVENTIONS: Cochlear implantation and aural rehabilitation program. MAIN OUTCOMES AND MEASURES: Speech perception was measured using disyllabic word recognition tests in quiet and in noise settings. Cognitive function was assessed using a battery of 6 tests evaluating attention, memory, orientation, executive function, mental flexibility, and fluency (Mini-Mental State Examination, 5-word test, clock-drawing test, verbal fluency test, d2 test of attention, and Trail Making test parts A and B). Quality of life and depression were evaluated using the Nijmegen Cochlear Implant Questionnaire and the Geriatric Depression Scale-4. RESULTS: Cochlear implantation led to improvements in speech perception in quiet and in noise (at 6 months: in quiet, 42% score increase [95% CI, 35%-49%; P < .001]; in noise, at signal to noise ratio [SNR] +15 dB, 44% [95% CI, 36%-52%, P < .001], at SNR +10 dB, 37% [95% CI 30%-44%; P < .001], and at SNR +5 dB, 27% [95% CI, 20%-33%; P < .001]), quality of life, and Geriatric Depression Scale-4 scores (76% of patients gave responses indicating no depression at 12 months after implantation vs 59% before implantation; P = .02). Before cochlear implantation, 44% of the patients (40 of 91) had abnormal scores on 2 or 3 of 6 cognition tests. One year after implant, 81% of the subgroup (30 of 37) showed improved global cognitive function (no or 1 abnormal test score). Improved mean scores in all cognitive domains were observed as early as 6 months after cochlear implantation. Cognitive performance remained stable in the remaining 19% of the participants (7 of 37). Among patients with the best cognitive performance before implantation (ie, no or 1 abnormal cognitive test score), 24% (12 of 50) displayed a slight decline in cognitive performance. Multivariate analysis to examine the association between cognitive abilities before implantation and the variability in cochlear implant outcomes demonstrated a significant effect only between long-term memory and speech perception in noise at 12 months (SNR +15 dB, P = .01; SNR +10 dB, P < .001; and SNR +5 dB, P = .02). CONCLUSIONS AND RELEVANCE: Rehabilitation of hearing communication through cochlear implantation in elderly patients results in improvements in speech perception and cognitive abilities and positively influences their social activity and quality of life. Further research is needed to assess the long-term effect of cochlear implantation on cognitive decline.

Tolerance and osteointegration of TricOs(TM)/MBCP(®) in association with fibrin sealant in mastoid obliteration after canal wall-down technique for cholesteatoma.

CONCLUSION: The TricOs™/MBCP(®) and fibrin sealant composite was a convenient, effective, and well-tolerated material for mastoid cavity filling and immediate reconstruction of the external auditory meatus after cholesteatoma surgery with canal wall down (CWD). OBJECTIVE: To assess the tolerance and osteointegration of a bone graft substitute, TricOs™/MBCP(®), in association with fibrin sealant for filling the mastoid cavity after cholesteatoma surgery using the CWD technique. METHODS: In this prospective observational study 57 patients with cholesteatoma suitable for CWD were recruited from April 2006 to April 2008 and followed up for 1 year. The mastoid cavity was filled with TricOs™/MBCP(®) followed by immediate reconstruction of the external auditory meatus covered with fascia temporalis and/or cartilage. The main outcome was skin tolerance assessed by a novel weighted score emphasizing long-term results. The typical weighted reference score was 1.67; skin tolerance was considered acceptable if 75% of patients had a score ≤ 1.67. Secondary outcomes were otorrhea and/or otalgia, hearing, and osteointegration assessed through computed tomography scanning at 12 months. RESULTS: Forty-one patients had a complete follow-up; 34 (82.3%) patients achieved the main end point with scores ≤ 1.67. Otorrhea decreased postoperatively. No otalgia interfering with daily tasks was reported. Ossicular reconstruction was carried out in 29 patients. Absence of cochlear toxicity was confirmed by unimpaired bone conduction. Preoperative and postoperative speech audiometry results were similar. No serious adverse events were observed. Osteointegration was satisfactory with hyperdensity or intermediate density in 95% of patients at 12 months.

Predictive factors of cochlear implant outcomes in the elderly.

OBJECTIVE: To analyze predictive factors of cochlear implant outcomes and postoperative complications in the elderly. STUDY DESIGN: Prospective, longitudinal study performed in 10 tertiary referral centers. METHODS: Ninety-four patients aged 65-85 years with a profound, postlingual hearing loss were evaluated before implantation, at time of activation, and 6 and 12 months after cochlear implantation. Speech perception and lipreading were measured using disyllabic word recognition in quiet and noise, and lipreading using disyllabic words and sentences. The influence of preoperative factors on speech perception in quiet and noise at 12 months was tested in a multivariate analysis. Complications, presence of tinnitus and of vestibular symptoms were collected at each evaluation. RESULTS: The effect of age was observed only in difficult noisy conditions at SNR 0 dB. Lipreading ability for words and sentences was negatively correlated with speech perception in quiet and noise. Better speech perception scores were observed in patients with shorter duration of hearing deprivation, persistence of residual hearing for the low frequencies, the use of a hearing aid before implantation, the absence of cardiovascular risk factors, and in those with implantation in the right ear. General and surgical complications were very rare, and the percentage of vestibular symptoms remained stable over time. CONCLUSION: This study demonstrates that cochlear implantation in the elderly is a well-tolerated procedure and an effective method to improve communication ability. Advanced age has a low effect on cochlear implant outcome. Analyses of predictive factors in this population provide a convincing argument to recommend treatment with cochlear implantation as early as possible in elderly patients with confirmed diagnosis of a severe-to-profound hearing loss and with only limited benefit from hearing aid use in one ear.

European multi-centre study of the Nucleus Hybrid L24 cochlear implant.

OBJECTIVES: To investigate the preservation of residual hearing in subjects who received the Nucleus Hybrid L24 cochlear implant. To investigate the performance benefits up to one year post-implantation in terms of speech recognition, sound quality, and quality of life. DESIGN: Prospective, with sequential enrolment and within-subject comparisons. Post-operative performance using a Freedom Hybrid sound processor was compared with that of pre-operative hearing aids. STUDY SAMPLE: Sixty-six adult hearing-impaired subjects with bilateral severe-to-profound high frequency hearing loss. RESULTS: Group median increase in air-conduction thresholds in the implanted ear for test frequencies 125-1000 Hz was < 15 dB across the population; both immediately and one year post-operatively. Eighty-eight percent of subjects used the Hybrid processor at one year post-op. Sixty-five percent of subjects had significant gain in speech recognition in quiet, and 73% in noise (≥ 20 percentage points/2 dB SNR). Mean SSQ subscale scores were significantly improved (+ 1.2, + 1.3, + 1.8 points, p < 0.001), as was mean HUI3 score (+ 0.117, p < 0.01). Combining residual hearing with CI gave 22-26 %age points mean benefit in speech recognition scores over CI alone (p < 0.01). CONCLUSIONS: Useful residual hearing was conserved in 88% of subjects. Speech perception was significantly improved over preoperative hearing aids, as was sound quality and quality of life.

Midmodiolar reconstruction as a valuable tool to determine the exact position of the cochlear implant electrode array.

HYPOTHESIS: A midmodiolar reconstruction with multislice computed tomography could potentially be used clinically to determine the cochlear implant electrode array position if the technique was validated with a cadaveric temporal bone study. BACKGROUND: Several radiologic studies using sophisticated techniques have been described. This study was designed to validate a standard multislice computed tomography scan technique to determine the electrode array position. METHODS: This ex vivo study was conducted on 18 cadaveric temporal bones without malformation. Cochlear electrode dummies were implanted by a single experimented surgeon with the Advance Off-Stylet technique. After randomization, the placement was processed through an anteroinferior or superior cochleostomy for respective scala tympani or vestibuli positioning with direct location of the basilar membrane. Cadaveric temporal bones were then scanned (Philips Brilliance 40 computed tomographic scan) and reconstructed into the midmodiolar computed tomography scan plane (± 45 degrees, z-axis in the cochlear coordinate system). Two independent neuroradiologists, who were unaware of the implanted scala, evaluated the electrode array position on a computed tomographic scan through the midmodiolar reconstruction. In the end, the microanatomic study was the criterion standard to determine the exact scala localization of the electrode array. RESULTS: Nine electrodes were inserted into the scala tympani, and 9 were inserted into the scala vestibuli. According to our anatomic criterion standard, the midmodiolar reconstruction sensitivity and the specificity for the scala tympani position were 0.875 (range, 0.722-1.0) and 1.0, respectively; the sensitivity and specificity for dislocation and the scala vestibuli position were both 1.0. The radioanatomic concordance was 0.94 (range, 0.89-0.98) for determining the electrode array position into scalae with midmodiolar reconstruction. CONCLUSION: Our cadaveric study validates midmodiolar reconstruction as a valuable tool to routinely determine the precise position of the cochlear implant electrode array. This study opens the field for further clinical studies.

Revision surgeries and medical interventions in young cochlear implant recipients.

OBJECTIVE: To report devices failures and postoperative or medical complications after cochlear implantation in children and to discuss revision surgeries and medical interventions occurring during follow-up. METHODS: In this retrospective study in a tertiary referral pediatric hospital, we included a consecutive sample of children younger than 15 years old who received implants between January 1994 and June 2010. All complications and treatments were systematically reviewed. RESULTS: One hundred and forty children were included in this study. Four children received bilateral cochlear implantation. Mean age at implantation was 43.6 months (age ranged from 11 months to 15 years). Overall, 74 children were boys (52.1%) and 35 children (25%) received implants before the age of two. Inner ear malformations were found in 19 children (13.5%), while 18 children (12.9%) experienced complications: cochlear reimplantations (n=8), other revision surgeries (n=3) and medical treatment (n=7). Excluding device failures, 13 children (9.2%) experienced complications. Postoperative infection was the principal cause of these complications (10 cases). Four children younger than 2 years at implantation suffered complication postoperatively. In these children, there was no statistically significant increase in complications compared to older children (P>0.05). Complete electrode insertion was achieved in 7 of the 8 reimplanted children. CONCLUSION: Cochlear implantation could be considered a safe and reliable rehabilitation for deafened young children. Reimplantation was feasible and complete electrode insertion was achievable. Long-term follow up was mandatory to minimize and control surgical complication.

Cardiovascular and thromboembolic risk factors in idiopathic sudden sensorineural hearing loss: a case-control study.

OBJECTIVE: The pathogenesis of idiopathic sudden sensorineural hearing loss (ISSHL) remains unknown, but vascular involvement is one of the main hypotheses. The main objective of this study was to investigate the association between ISSHL and cardiovascular and thromboembolic risk factors. STUDY DESIGN: Multicentric case-control study. METHODS: Ninety-six Caucasian patients with ISSHL and 179 sex- and age-matched controls were included. Patients were evaluated on the day of the inclusion and 1 week, 3 weeks and 3 months later. Clinical information concerning personal and familial cardiovascular and thromboembolic risk factors and concerning the ISSHL was collected. Blood samples were collected for genetic analysis of factor V Leiden and G20210A polymorphism in the factor II gene. The severity of the hearing loss was classified as mild (21-40 dB), moderate (41-70 dB), severe (71-90 dB) and profound or total (>90 dB). Hearing improvement was calculated as a relative improvement of hearing thresholds using the contralateral ear as baseline. RESULTS: Systolic blood pressure was higher in patients (130 ± 1.7 mm Hg) than in controls (124 ± 1.1 mm Hg, p = 0.003). The personal/familial history of cardiovascular events was also more prevalent in patients (p = 0.023 and p = 0.014, respectively), whereas no difference was found in the prevalence of personal cardiovascular risk factors (hypertension, diabetes mellitus, hyperlipidemia, smoking habits). There was no correlation between the audiogram type, the hearing outcome and the presence of cardiovascular risk factors. No significant difference was observed in the personal/familial history or in the presence of thromboembolic risk factors. The prothrombin and factor V mutations were uncommon in both patients and controls. The final hearing threshold was only correlated with the severity of the initial hearing loss (p < 0.001), but not influenced by the presence of vertigo, audiogram type, time elapsed from onset of ISSHL to hospitalization or failure of a previous oral therapy. Hearing stabilization was obtained at 21 days in 92% of patients. CONCLUSION: These results support the theory of vascular involvement as the etiology of some cases of ISSHL. The sole predictive factor of poor final hearing is the severity of the initial hearing loss.

A rare case of radiation-induced osteosarcoma of the ethmoid sinus.

Radiation therapy has been recognized as a useful modality of treatment in head and neck malignant tumors. However, radiation over 10 Gy may predispose to secondary tumors. Radiation-induced osteosarcoma of the ethmoid sinus is unusual. These tumors may present long after radiation with epistaxis. Computed tomography, magnetic resonance imaging, and biopsy are the modalities of diagnosis. We report a case of radiation-induced osteosarcoma of the ethmoid sinus 9 years after initial exposure. We describe the clinical presentation, the radiological findings, and the management.

Three-dimensional modeling of the temporal bone for surgical training.

INTRODUCTION: The anatomy of the temporal bone (TB) can only be mastered by repeated surgical and anatomic dissections, and surgical teaching initiative had a major effect on outcomes. The aim of this study was to investigate the validity of an artificial TB model devoted to surgical training and education. MATERIALS AND METHODS: A helical computed tomographic (CT) scan was used to acquire high-resolution data of cadaveric TB. Digital imaging and communications in medicine (DICOM) data were converted into.stl files after data processing. Cadaveric TBs were prototyped using stereolithography. The validation of the prototype needed several steps. First of all, we have studied on CT scan the positional relationship between the facial nerve and other structures of the cadaveric TBs and prototyped bones. Otoendoscopy of the middle ear and the internal acoustic canal and visualization of anatomic landmarks during TB drilling of the cadaveric TBs and prototyped bones were also performed. RESULTS: Seven normal CT scans of cadaveric TB were selected to make prototyped bone using stereolithography. Measurements of volume and distance showed no significant difference between prototypes and cadaver TBs. Classic mastoid surgical procedures were performed in the Anatomy Department: exposing sigmoid sinus, facial nerve, labyrinth, dura mater, jugular bulb, and internal carotid artery. Two simulations of implantable middle ear prosthesis were made successfully. CONCLUSION: These prototypes made using stereolithography seem to be a good anatomic model for surgical training. This model could also be interesting for surgical planning in congenital ear anomalies before middle ear prosthesis implantation.

Speech performance and sound localization in a complex noisy environment in bilaterally implanted adult patients.

OBJECTIVE: To evaluate speech performance, in quiet and noise, and localization ability in adult patients who had undergone bilateral and simultaneous implantation. STUDY DESIGN: Prospective multi-center study. METHODS: Twenty-seven adult patients with profound or total hearing loss were bilaterally implanted in a single-stage procedure, and simultaneously activated (Med-El, Combi 40/40+). Subjects were assessed before implantation and at 3, 6 and 12 months after switch-on. Speech perception tests in monaural and binaural conditions were performed in quiet and in noise using disyllabic words, with speech coming from the front and a cocktail party background noise coming from 5 loudspeakers. Sound localization measurements were also performed in background noise coming from 5 loudspeakers positioned from -90 degrees to +90 degrees azimuth in the horizontal plane, and using a speech stimulus. RESULTS: There was a bilateral advantage at 12 months in quiet (77 +/- 5.0% in bilateral condition, 67 +/- 5.3% for the better ear, p < 0.005) and in noise (signal-to-noise ratio +15 dB: 63 +/- 5.9% in bilateral condition, 55 +/- 6.9% for the better ear, p < 0.05). Considering unilateral speech scores recorded in quiet at 12 months, subjects were categorized as 'good performers' (speech comprehension score > or =60% for the better ear, n = 19) and 'poor performers' (n = 8). Subjects were also categorized as 'asymmetrical' (difference between their 2 unilateral speech scores > or =20%, n = 11) or 'symmetrical' (n = 16). The largest advantage (bilateral compared to the better ear) was obtained in poor performers: +19% compared to +7% in good performers (p < 0.05). In the group of good performers, there was a bilateral advantage only in cases of symmetrical results between the 2 ears (n = 10). In the group of poor performers, the bilateral advantage was shown in both patients with symmetrical (n = 6) and asymmetrical results (n = 2). In bilateral conditions, the sound localization ability in noise was improved compared to monaural conditions in patients with symmetrical and asymmetrical performance between the 2 ears. No preoperative factor (age, duration of deafness, use of hearing aids, etiology, etc.) could predict the asymmetrical performance, nor which ear would be the best. CONCLUSION: This study demonstrates a bilateral advantage (at 12 months after the implantation) in speech intelligibility and sound localization in a complex noisy environment. In quiet, this bilateral advantage is shown in cases of poor performance of both ears, and in cases of good performance with symmetrical results between the 2 ears. No preoperative factor can predict the best candidates for a simultaneous bilateral implantation.

Vestibular schwannoma: dissection of the tumor and arachnoidal duplication.

INTRODUCTION: In vestibular schwannoma (VS) surgery, the arachnoidal duplication, based on an epiarachnoidal origin of the tumor, is reputedly induced by medial growth of tumor and helpful in atraumatic dissection. This study was intended to verify the epiarachnoidal origin of VS. MATERIALS AND METHODS: We studied 49 human temporal bones (TBs) specimens. Twenty-two TBs from 18 patients with VS were selected. An additional series of 27 TBs without any tumor within the internal auditory meatus were also included. We identified the location of the meninges and the position of the transition zone inside the meatus and described the lateral extension of the subarachnoid spaces. RESULTS: In VS specimens, psammoma bodies were seen at the fundus along the arachnoidal layer. No connective tissue or protrusion of a psammoma body was observed between the nerves and the VS. High magnification failed to demonstrate any meningeal cleavage plane between the facial or cochlear nerve and the tumor. The subarachnoid space was visible within the internal auditory meatus and extended from the porus to the fundus. In every case, the transition zone, the vestibular ganglion, or the VS was located in the subarachnoid fluid space. CONCLUSION: We were not able to identify any layer between tumor and the intrameatal contents and did not observe any conjunctive-tissue capsule surrounding the intrameatal VS, as an epiarachnoidal tumor origin would suggest. These observations are in contradiction with the descriptions concerning the epiarachnoidal origin of VS.

Benefit of the Vibrant Soundbridge device in patients implanted for 5 to 8 years.

OBJECTIVES: To assess audiological performance, satisfaction rate, and side effects of 100 patients who have been using the middle ear implant Vibrant Soundbridge (VSB) for 5 to 8 yr when compared with data collected from 3 to 18 mo postsurgery. DESIGN: Audiological testing and subjective evaluation using self-assessment scales were performed in 77 out of the 100 patients using the VSB for 5 to 8 years. The results were compared to data collected 3 months (audiological testing) and 18 months (self-assessment scales) after surgery. Twenty-three patients have not been evaluated for different reported reasons. RESULTS: Pure-tone hearing thresholds decreased similarly in both implanted and contralateral ears. The satisfaction ratings and the functional gain provided by the VSB remained stable. Speech comprehension in quiet conditions without the VSB decreased from 56 to 37% in 5 to 8 yr, but an 81% score was achieved with the VSB. CONCLUSIONS: This study demonstrates that the performance of the VSB does not deteriorate for more than 5 yr, without adverse effect. These results confirm the safety and the effectiveness of the VSB with a long-term follow-up.

Antibodies to myelin protein zero (P0) protein as markers of auto-immune inner ear diseases.

BACKGROUND/AIMS: The inner ear can be the target of autoimmune disorders. Recognition of autoimmune inner ear disease is important, as it is one of the very few forms of sensorineural hearing loss (HL) that can be successfully treated by medical therapy. The aim of this study was to evaluate whether the detection of antibodies to myelin protein P0 (MPZ) could be a diagnostic test for inner ear disease of autoimmune cause. METHODS: This multicentric prospective study included 129 patients: patients with progressive sensorineural HL or with Menière's disease, together with their control group corresponding to patients with similar symptoms, but of presumably known origin. Detection of antibodies to myelin P0 protein was performed by using western blots. NORMAL: The prevalence of antibodies to myelin P0 protein in patients with rapidly progressive HL was not statistically different from that of the control group corresponding to genetic HL patients (30 versus 28%). In patients with Menière's disease, the prevalence was lower than that of the control group corresponding to patients with benign paroxysmal positional vertigo (5.4 versus 18.7%). No patient with auto-immune disease had antibodies to myelin P0 protein. CONCLUSIONS: The sole presence of antibodies to myelin P0 may not be used as a marker of inner ear disease of autoimmune origin.

Retrospective case study of carbon dioxide laser stapedotomy with lens-based and mirror-based micromanipulators.

Most clinical studies on carbon dioxide (CO2) (lambda = 10.6 mm) laser stapedotomy have been carried out with the laser guided by a conventional lens-based micromanipulator, with the attendant risks of correct aiming (HeNe) and surgical (CO2) beam misalignment. Hence, engineering advances have attempted to improve laser targeting as well as the spot size focus. The development of the mirror-based micromanipulator was a response to this need but no data concerning its use in stapes surgery is available. We performed a retrospective case-series review of patients treated for otosclerosis between 1992 and 2000. Primary laser stapedotomy was performed in 218 consecutive patients. In the first 78 procedures, the aiming beam (HeNe, lambda = 632 nm) and surgical beam (CO2) were guided with a conventional lens-based micromanipulator whereas in the subsequent 140 procedures, they were guided by using a mirror-based micromanipulator. Hearing was tested at six and 12 months. The mean (SD) airbone gap was 5 dB (4.5) and 4.5 dB (3.9). The mean closure was 15 dB (9.9) and 14.4 dB (9.4). The mean change in the high-tone bone-conduction level was 5.5 dB (7.3) and 7.8 dB (7.5). Overheating of the facial canal produced transient facial paralysis in one case and was due to misalignment of the beams with the lens-based micromanipulator. Use of the mirror-based micromanipulator obviated the need to verify alignment. The light-weight and superior optical yield of this system made it possible to reduce the number of impacts on the footplate by the integral restitution of the energy source. This study demonstrated that the CO2 laser is an effective method for performing stapedotomy. In addition, microtrauma to the labyrinth is reduced by its ability to perform calibrated footplate fenestration without mechanical or vibrational injury to the inner ear. The optical reflection micromanipulator simplified beam alignment and enhanced surgical comfort.

Massive infra-clinic invasion of the facial nerve by a myoepithelial carcinoma of the parotid.

We report a new case of myoepithelial carcinoma of the parotid gland in an 8-year-old girl. This is the first case published in a child. The parotid tumour was slightly tender and measured almost 2 cm in diameter. There was no associated facial nerve paralysis despite surgical and histologic evidence of massive facial nerve infiltration. We performed total parotidectomy with resection of the intra-mastoid portion of the facial nerve completed with prophylactic lymph node dissection. Eight months after surgery, MRI revealed a deep-lying recurrence, which required reintervention. There has been no subsequent recurrence 18 months after surgery. Microscopic examination of operative specimens confirmed the diagnosis of parotid myoepithelial carcinoma with fusiform cells. Immunohistochemical markers were positive for cytokeratin, epithelial membrane antigen, smooth muscle actin, S-100 protein, anti-desmine and anti-vimentine. This difficult to diagnose tumour, which was individualised by the World Health Organisation in 1991, is considered a moderate to high-grade malignancy when it develops in a pleomorphic adenoma or appears de novo.

Management of cholesterol granulomas of the petrous apex based on clinical and radiologic evaluation.

OBJECTIVE: The purpose of this study was to analyze the imaging characteristics of 12 cholesterol granulomas as a function of their clinical symptoms. The results of the different surgical approaches and the management of these lesions are discussed. STUDY DESIGN: Retrospective case review. SETTING: Five tertiary referral centers. PATIENTS: Twelve patients managed for a cholesterol granuloma of the petrous apex. INTERVENTIONS: All patients were evaluated via computed tomography and magnetic resonance imaging. Eight patients required surgical drainage: through a conservative approach in seven patients (infralabyrinthine, n = 5; infracochlear, n = 2) and a transotic approach in one patient. Clinical and radiologic follow-up without surgery was the mode of treatment for four patients. The mean follow-up period was 18 months for patients who underwent operations and ranged from 6 months to 10 years for patients without operations. RESULTS: Four patterns of clinical symptoms were noted: retrocochlear signs by an involvement of the internal auditory meatus (n = 8), headaches by a traction of the dura (n = 4), serous otitis media by a compression of the eustachian tube (n = 2), and asymptomatic lesions with no involvement of the adjacent structures (n = 2). Hearing and facial functions were preserved in all the cases treated by a noninvasive procedure. No recurrence or complication was reported in the patients who underwent operations. None of the noninvasively treated patients with cholesterol granulomas showed significant enlargement on follow-up imaging. CONCLUSION: Clinical manifestations of cholesterol granulomas depend on their anatomic location and the involvement of the adjacent structures. Aggressive lesions in patients with residual hearing can be drained via an infralabyrinthine or an infracochlear approach with minimal morbidity. Follow-up must be preferred for patients with nonaggressive lesions. Although magnetic resonance imaging provides a specific diagnosis tool for cholesterol granulomas, computed tomography is essential for an accurate evaluation of the location of the cyst and choice of the surgical procedure.