Intraoperative recordings of electromyogenic responses from the human stapedius muscle.

Following surgical implantation of a cochlear implant, the external processor must be programmed individually, which is typically achieved by behavioral measurements, with the user indicating the perceived loudness between the threshold and the maximum comfort levels (MCLs). However, the stapedius reflex measurement could be used instead, as the basis for programming the fitting maps. The electrically evoked stapedius reflex threshold is known to have a high correlation with the MCLs and thus is used as an objective tool to determine the MCL, especially in children and non-cooperative patients. Previous studies demonstrated that the electromyogenic (EMG) activity of the stapedius muscle could be measured to determine stapedius reflex responses. The objective of this study was to demonstrate that intraoperative EMG recordings from the stapedius muscle could be performed with an EMG recording electrode designed for chronical implantation. Ten adult subjects with single sided deafness (SSD) participated in this study. The study was split up into a pre-, intra- and postoperative phase. In the preoperative phase the subjects were screened for the presence of the acoustic stapedius reflex by using a standard tympanometer in the ear to be implanted, while the contralateral ear was stimulated acoustically. During the intraoperative phase an EMG recording electrode was placed in the stapedius muscle and EMG responses were recorded during acoustical and electrical stimulation. The surgical procedure consisted of two interconnected procedures: A classical surgical approach for cochlear implantation with two additional surgical steps, and the temporary placement of an EMG recording electrode in the stapedius muscle made through an opening in the pyramidal eminence, allowing EMG recordings. The postoperative phase was used to evaluate the preservation of the stapedius reflex postoperatively at 1- and 6-months with contralateral acoustic and ipsilateral electrical stimulation. The EMG recording electrode could successfully be placed in the stapedius muscle in all subjects and was able to reliably record EMG signals from the stapedius muscle elicited by acoustic and electrical stimulation. Overall, EMG recordings were obtained intraoperatively in all subjects tested (8 out of 8 subjects). Contralateral acoustic stapedius reflexes were obtained in 6 out of 8 subjects and ipsilateral electrical stapedius reflex in 7 out of 8 subjects. In the postoperative phase, the preservation of the postoperative reflex was observed in 6 out of 10 subjects 1-month after surgery and in 8 out of 10 subjects 6-months after surgery. The study showed that intraoperative EMG recordings from the stapedius muscle can be performed with an EMG recording electrode designed for chronical implantation. The minimally invasive procedure is promising; in particular with regard to the future perspective of measurements in the long-term with an integrated closed-loop self-fitting system.

Influence of the pre- or postlingual status of cochlear implant recipients on behavioural T/C-levels.

INTRODUCTION: Previous auditory experience modifies the sensitivity of the auditory cortex to the afferent activity of the auditory pathways and may influence the threshold (T) and comfort (C) levels in patients receiving a cochlear implant (CI). Literature data on this particular topic is very scarce. OBJECTIVE: This study aimed to evaluate the differences in T/C-levels between pre- and postlingually implanted cochlear implant patients. METHODS: Retrospective case review in a quaternary otologic referral centre was performed. Data on the T/C-levels have been collected in 90 consecutive CI patients divided into 2 groups. Group 1 comprised 16 prelingually deaf children implanted between 8 months and 10 years of age. Group 2 comprised 74 postlingually deaf adults (average age of 62 years). All patients were users of the Nucleus 24RECA (Freedom, Contour Advance-of-Stylet electrode) cochlear implant. All measurements were performed at the fifth implant programming session at 4-6 months after surgery, when stable T/C thresholds have already been obtained. RESULTS: The behavioural C-levels present important and statistically significant differences between the pre- and postlingually implanted patients for all electrode contacts that could reach 30 CL. For the T-levels the observed differences were smaller and statistically insignificant for most electrode contacts. CONCLUSIONS: The previous auditory experience (pre- or postlingual deafness) seems to be an independent parameter influencing the T/C-levels in patients receiving a CI. Together with the electrode contact impedance and the contact position in the electrode array it can explain up to 37% of the variability in the definition of the C-levels. The fact that the stabilised C-levels measured 4-6 months postoperatively can be up to 30 CL higher in the prelingually deaf patients than in the postlingual ones results also in a much higher dynamic range observed in prelingual subjects. Therefore implant programming of the prelingual patients should be very cautious in order to avoid the risk of overstimulation.

Prediction of Behavioral T/C Levels in Cochlear Implant Patients Based Upon Analysis of Electrode Impedances.

BACKGROUND: Fitting cochlear implants in babies and noncooperative patients is cumbersome and time consuming. Therefore, objective parameters have been sought in order to predict the subjective threshold (T) and maximum comfort (C) levels. Measurements of the electrically evoked compound action potentials (ECAPs) have been widely used for this purpose, yet the correlation between these objective measures and the subjective T/C levels is weak to moderate. PURPOSE: This article aims (1) to evaluate correlations between the subjective parameters of the fitting maps such as thresholds (T level) and maximum comfort levels (C level), the impedance of the electrode contacts, and the ECAP thresholds, and (2) to compare the value of the electrode impedances and the ECAP measures for prediction of the T/C levels. RESEARCH DESIGN: Case review study in a quaternary otologic referral center. STUDY SAMPLE: Ninety-eight consecutive CI patients were enrolled. The average age of the patients was 49 years. All patients were users of the Nucleus 24RECA (Freedom, Contour Advance-of-Stylet electrode) cochlear implant. DATA COLLECTION AND ANALYSIS: Data on impedance of the electrode contacts and the behavioral T/C levels at the first fitting session (2-5 weeks after surgery) and at the 5th fitting session (4-6 months after surgery) have been retrospectively collected in 98 consecutive CI patients. Additionally, the intraoperative impedance values and the ECAP thresholds (tNRT) have been recorded. RESULTS: Impedances of electrode contacts show significant strong negative correlations with the stabilized T/C levels at 4 to 6 months after implantation and are an important predictor for the behavioral T/C levels. They can explain R 2 = 28 to 41% of the variability of the behavioral T/C levels. In multiple regression analysis electrode contact impedances can explain twice as much of the variability of the stabilized T/C levels than the tNRT values. The electrode impedances together with the tNRT values are able to explain R 2 = 37 to 40% of the global variability of the T/C levels while the tNRT thresholds solely are able to explain only R 2 = 5 to 14% of the T/C levels variability. CONCLUSION: Impedances of electrode contacts correlate strongly with the stabilized behavioral T/C levels and may be used as an objective measure for fitting of cochlear implants.

Massive pneumomediastinum with subcutaneous emphysema after elective adenotonsillectomy in children: Involvement of the Boyle-Davis mouth gag.

Adenotonsillectomy, a very common surgical procedure in otorhinolaryngology, is considered easy and safe surgery. However, clinicians should be aware of some less common but potentially life-threatening complications. This report discusses subcutaneous emphysema with pneumomediastinum following elective adenotonsillar surgery in children. The Boyle-Davis mouth gag seemed to play a part in the pathogenic mechanism of this rare complication in this case. Better insights in the mechanism of this severe complication of adenotonsillectomy may contribute to the prevention of this complication.

[From plastic surgery to space conquest. First microsurgical procedure and first surgical procedure in man during weightlessness]. / De la chirurgie plastique à la conquête spatiale. Première microchirurgie et première opération chez l'homme faites en apesanteur.

The authors present their experience of surgery in weightlessness conditions. Russians and Americans already focused on that subject but two questions were still unsolved: what was the limit of human skill in these extreme conditions and was it possible to operate a human under total safety? Between 2003 and 2007, using a 0G plane for our experiment, we focused on two goals: firstly, the conception of a microsurgical module to test complex microsurgical procedures in rats and secondly, the construction of a surgical workstation with specific air filtration device and define surgical and anaesthetic protocols to carry on a surgery in man. In September 2003, we succeeded to perform the microscopic report of a 0,5mm artery (which is the smallest we can suture in terrestrial conditions) by using seven stitches of 10 x 0 monofilament suture. The 27th of September 2007, we removed a lipoma from the forearm of a 47-year-old man. These experiments take place in a wide program of development of telesurgery controlled through satellite transmission with all forthcoming civil, military and humanitarian applications.

[Lumbar puncture: indications and limitations]. / A propos de la ponction lombaire: indications et limites.

Fast deterioration of the neurological status of patients with raised intracranial pressure after lumbar puncture is not rare. Cerebral coning or rebleeding occur in consequence of cerebrospinal fluid leak. An experimental model correlates leakage with needle gauge. Computed tomography is indicated for diagnosis at the time of the initial examination. Puncture with needles of small diameter (less than 0.5 mm) is recommended.

[Hypoglycemia-inducing islet cell tumors. Measurement of blood glucose and insulin levels during operation. Results in seven cases (author's transl)]. / Les tumeurs langerhansiennes hypoglycémiantes. Intérêt des dosages per-opératoires de la glycémie et de l'insulinémie. A propos de sept observations.

The identification of hypoglycemic langerhans tumours by the surgeon, being sometimes difficult, per-operative quantity determinations of the glycemia and insulinemia levels help to ensure that all the insulino-secretory tissue has been removed. The technical protocol described includes an excess of glucids. In the 5 cases of adenomas, between 30 and 60 minutes after exeresis, a distinct increase in glycemia was noted (on average 1,25 g/l) in comparison to the initial level; this increase was not however significant in the 2 observations of adenomatous hyperplasia. Following the removal of the lesion, the fall in insulinemia is also more noticeable in adenomas (reaching 75,8 per cent of the initial level) than in adenomatous hyperplasia. Nonetheless, the fall in the latter is still considerable (42,4 per cent). This examination would be the best test, excvept that the results are known only after the operation. The 7 patients operated on recovered after 2 enucleo-excisions, and 5 isthmo-corporal-caudal splenopancreatectomies, the average post-operative period reaching 4 years.

[New ventilation technic in anesthesia for direct suspension laryngoscopy]. / Nouvelle technique de ventilation lors des anesthesies pour la laryngoscopie directe en suspension

The authors bring not only the results of their experience but a solution of the respiratory problems during anaesthesia in suspension laryngoscopy, thanks to the devising of a new intubation probe and a pre-set automatic insufflator with varying volum flow.