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.

Spondylodiscitis after transoral robotic surgery: Retrospective 7-case series from the GETTEC group.

BACKGROUND: Cervical spondylodiscitis is a rare but severe complication of pharyngeal surgery. MATERIAL AND METHODS: This multicenter retrospective study reported all patients in the database of the French head and neck tumor study group (GETTEC) affected by cervical spondylodiscitis after transoral robotic surgery (TORS) for malignant pharyngeal tumor from January 2010 to January 2017. OBJECTIVES: To describe cases of post-TORS cervical spondylodiscitis, identify alarm signs, and determine optimal management of these potentially lethal complications. RESULTS: Seven patients from 6 centers were included. Carcinomas were located in the posterior pharyngeal wall. Tumor stage was T1 or T2. All patients had risk factors for spondylodiscitis. Mean time to diagnosis was 12.6days. The interval between surgery and spondylodiscitis diagnosis ranged from 20days to 4.5months, for a mean 2.1months. The most common symptom was neck pain (87%). Infections were polymicrobial; micro-organisms were isolated in 5 cases and managed by intravenous antibiotics, associated to medullary decompression surgery in 3 cases. Follow-up found favorable progression in 4 cases, and 3 deaths (mortality, 43%). CONCLUSION: This French multicenter study found elevated mortality in post-TORS spondylodiscitis, even in case of limited resection. Surgeons must be aware of this complication and alerted by persistent neck pain, fever, asthenia, impaired or delayed posterior pharyngeal wall wound healing or elevation of inflammatory markers. MRI is the most effective diagnostic radiological examination.

Hearing aids in patients with vestibular schwannoma: Interest of the auditory brainstem responses.

OBJECTIVE: Hearing loss subsequent to a unilateral vestibular schwannoma (VS) has an impact on the social life of non-operated patients. We investigated the utility of auditory brainstem responses (ABRs) for predicting the results of auditory rehabilitation in such patients. DESIGN: Prospective study. SETTING: University tertiary medical centre. PARTICIPANTS: We collected the demographic, audiometric, ABR and imaging data of non-operated patients with unilateral VS. A hearing aid trial was performed over 1 month. We assessed auditory performance following the auditory rehabilitation according to the ABR results. Patients with distinct waves (I, III and V) were included in the "distinct ABR" group and patients with no ABR were included in the "desynchronised ABR" group. MAIN OUTCOME MEASURES: Following the trial, audiometric performance and quality of life were evaluated with the Glasgow Benefit Inventory (GBI). SUBJECTS AND METHOD: We collected the demographic, audiometric, ABR and imaging data of non-operated patients with unilateral VS. A hearing aid trial was performed over 1 month. Following the trial, audiometric performance and quality of life were evaluated with the Glasgow Benefit Inventory (GBI). We assessed auditory performance following the auditory rehabilitation according to the ABR results. Patients with distinct waves (I, III and V) were included in the "distinct ABR" group and patients with no ABR were included in the "desynchronised ABR" group. RESULTS: In total, 25 patients were included in this prospective study; 15 in the "distinct ABR" group and 10 in the "desynchronised ABR" group. The speech recognition threshold (SRT, P < .0001; W = -120) and speech discrimination score (P = .0005; W = 78) were significantly improved in the aided vs unaided conditions. These improvements were not observed in the "desynchronised ABR" group for the SRT (P = .48; W = -10) and word recognition score (P = .06; W = 15). Ninety-three per cent of the patients in the "distinct ABR" group kept significantly (P = .04) the hearing aids following the trial compared to 20% in the "desynchronised ABR" group. CONCLUSIONS: Auditory brainstem responses can help to predict the auditory performance following auditory rehabilitation in unilateral non-operated VS patients.

Combined local anesthesia and monitored anesthesia care for cochlear implantation.

INTRODUCTION: Cochlear implantation has become a routine procedure for patients with hearing loss. In some patients, general anesthesia might be contraindicated due to multiple co-morbidities. We describe a successful protocol for cochlear implantation under local anesthesia with light sedation. CASE REPORT: An 81-year-old patient presented with profound sensorineural hearing loss. Her past medical history revealed ischemic coronaropathy, managed by stenting. After multidisciplinary evaluation and clear adapted information to the patient, surgery was performed under local anesthesia with light sedation and monitored anesthesia care. The procedure lasted 70 min, and was without incident and under good conditions for the surgeon. During the intervention, the patient was comfortable. No nausea or vomiting was noted. The postoperative period was smooth and uneventful. CONCLUSION: We find local anesthesia with light sedation a good alternative to general anesthesia for patients where general anesthesia is contraindicated. An experienced surgical and anesthesiology team is essential to shorten the duration of the procedure.

Cancer of the external auditory canal.

INTRODUCTION: Cancer of the external auditory canal is a rare tumour with an annual incidence of one per one million inhabitants. The objective of this study was to evaluate the 5-year overall survival and disease-free survival rates in a series of patients with carcinoma of the external auditory canal and to compare our results concerning the clinical presentation, management and survival with those of the literature. PATIENTS AND METHOD: Ten patients were included in this retrospective, single-centre study over a 20-year period. Data concerning age, symptoms, imaging, TNM stage according to the Pittsburgh classification, histology, management, sequelae, recurrences and survival were recorded. RESULTS: The mean age of the patients of this series was 60.7 years. Seven patients had a squamous cell carcinoma. The other histological types were undifferentiated carcinoma, adenoid cystic carcinoma and neuroendocrine carcinoma. Staging was based on the Pittsburgh classification with one stage I, one stage III and eight stage IV tumours. Five-year overall survival rates were 100%, 50% and 0%, respectively. The mean 5-year overall survival rate was 35% and the mean 5-year disease-free survival rate was 24%. CONCLUSION: Carcinoma of the external auditory canal is a difficult diagnosis when the tumour does not present as a fungating mass protruding from the external auditory canal. The Pittsburgh classification was used for TNM staging of these tumours, allowing comparison of our results with those of the literature. The clinical findings and survival rates observed in this study are comparable to those reported in the literature. These tumours are associated with a poor prognosis on the basis of our results and published data.