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.

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.

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.

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.

Evaluation of a temporal bone prototype by experts in otology.

BACKGROUND: Inexperienced otologists require training on the temporal bone drilling process, prior to any surgical activity. The shortage of cadaveric temporal bones exerts pressure to create realistic physical prototypes. This paper describes the evaluation by otology experts of a specially developed temporal bone resin model. METHODS: Computed tomography images were transformed into digital files, and anatomically identical right temporal bone models were created using stereolithography. These hand-painted resin prototypes were sent to 25 otologists, accompanied by a 20-item questionnaire. RESULTS: Satisfaction rate was 92 per cent. The overall prototype score was 48.87 out of 60. Average scores were: 12.63 out of 15 for anatomy-morphology, 6.98 out of 9 for quality of drilling, 16.74 out of 21 for identification of anatomical elements and 7.41 out of 9 for stages of drilling. Limitations of the model included an excessively vivid facial nerve colour and difficulty in identifying the posterior semicircular canal. Disadvantages related to the thickness of the resin and its residues were identified. CONCLUSION: The prototype appears to provide an attractive solution to the shortage of cadaveric temporal bones. However, interest in the model for drilling technique training for inexperienced otologists has not yet been assessed.

Oropharyngeal teratomas in newborns: management and outcome.

OBJECTIVES: Congenital teratomas of the oropharyngeal cavity are extremely rare and are associated with a high neonatal mortality rate due to severe airway obstruction. Management has been improved with progress in antenatal diagnosis. The authors describe this progress in the light of a series of 4 cases and a review of the literature. METHODS: The medical charts of four neonates treated in the department since 1995 were reviewed. The following criteria were studied: age at diagnosis, clinical and radiological features of the tumour, management at birth and outcome. RESULTS: All four cases occurred in female neonates with an antenatal diagnosis in two cases, allowing preparation for endoscopy in the delivery room in one case and an EXIT procedure in the other case. Three neonates had to be intubated in the delivery room. Imaging showed invasion of the infratemporal fossa in 3 of the 4 cases. Surgical resection via various approaches to the infratemporal fossa was complete in every case. Adjuvant chemotherapy was administered in one case. CONCLUSION: Surgery for these mostly benign tumours is very challenging and requires a multidisciplinary team. Perinatal planning allows appropriate management at birth, decreasing the risk of airway obstruction. Surgery is the mainstay of treatment of teratomas.

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.

Lipoleiomyosarcoma of the larynx.

BACKGROUND: Lipoleiomyosarcoma is a rare tumor consisting of well-differentiated liposarcoma and leiomyosarcoma. The ear-nose-throat location of lipoleiomyosarcoma has not been previously described. METHODS AND RESULTS: A 37-year-old man with a dysphagia had a dyspnea after an endoscopy. A large tumor was exteriorized from the man's mouth. The lesion was pedicled to the epiglottis. A histologic examination determined that the tumor was a lipoleiomyosarcoma. MDM2 and CDK4 gene amplification were positive. Due to the risk of recurrence, a second intervention was performed to complete the excision. CONCLUSION: These tumors develop in cavities slowly and gradually. The treatment of this lesion is surgical with a sufficient resection margin.

Minimization of cochlear implant artifact in cortical auditory evoked potentials in children.

OBJECTIVES: In congenitally deaf children fit with a cochlear implant, little is known about the maturation of the auditory cortex. Cortical auditory evoked potentials are a useful methodology to study the auditory cortical system of children with cochlear implants. Nevertheless, these recordings are contaminated by a cochlear implant artifact. The objective of this study was to use independent component analysis to minimize the artifact of the cochlear implant to study cortical auditory evoked potentials. STUDY DESIGN: Prospective study. METHOD: A total of 5 children ranging in age from 21 to 49 months who were fitted with a cochlear implant for at least 6 months were included in this study. The stimuli were pure tones (750 Hz, 200 ms duration, 70 dB SPL) presented with an irregular interstimulus interval (1000-2000 ms) via loud speakers. The cortical auditory evoked potentials were recorded from 17 Ag-AgCl electrodes referenced to the nose. The peak latency and amplitude of each deflection culminating at the fronto-central and temporal sites were analyzed. MAIN OUTCOME MEASURES: The P100-N250 peak latencies and amplitudes of the cortical auditory evoked potentials recorded from children fitted with cochlear implants. Scalp map potentials distributions were done for each child for the N250 wave. RESULTS: The use of independent component analysis permitted to minimize the cochlear implant artifact for the five children. Cortical auditory evoked potentials were recorded at fronto-central and temporal sites. Scalp map potentials distributions for the N2 wave showed activation of temporal generators contralateral at the CI for the five children. CONCLUSION: This preliminary electrophysiological study confirms the value and the limits of independent component analysis. It could allow longitudinal studies in cochlear implant users to examine the maturation of auditory cortex. It could also be used to identify objective cortical electrophysiological measures to help the fitting of CIs in children.

Canal wall up tympanoplasty for middle ear cholesteatoma in adults: modeling cartilage.

OBJECTIVES: The authors report their experience with a variant cartilage tympanoplasty technique in a canal wall up (CWU) procedure for middle ear cholesteatoma, comparing reliability with other techniques. Functional results are analyzed according to ossicular chain status. MATERIALS AND METHODS: A retrospective study was performed in adults operated on with CWU tympanoplasty for middle ear cholesteatoma. The surgical technique of "modeling" cartilage is described. RESULTS: One hundred and nine patients were included (113 procedures). There were four recurrences (3.5%). Mean follow-up was 48 months (range, 24-96 months). In case of normal ossicular chain, postoperative pure-tone average air-bone gap was always less than 20dB, and less than 20dB following myringostapedopexy in 60% of cases with incus destruction. CONCLUSION: Modeling cartilage is a reliable reconstruction technique to prevent recurrent cholesteatoma, and contributes to the quality of functional results in ossiculoplasty.

Residual cholesteatoma: prevalence and location. Follow-up strategy in adults.

OBJECTIVES: To assess prevalence and location of residual cholesteatoma following closed "canal wall up" tympanoplasty (CWUT). The evolution of follow-up strategy is discussed. PATIENTS AND METHODS: A retrospective study was run in adults operated on by CWUT for middle-ear cholesteatoma and who had undergone second look surgery and/or postoperative radiology (CT-scan, diffusion-weighted MRI). RESULTS: One hundred and nine patients (113 ears) underwent the procedure. Mean follow-up was 48 months (range, 24-96 months). Twenty-nine residual cholesteatomas were found (25%), including 11 located in the anterior attic (38%). Follow-up included 77 second look operations (70%), and 71 radiological examinations (62 CT-scans and nine diffusion-weighted MRIs). Second look surgery was without benefit for the patient (no residual, no ossiculoplasty) in one third of cases. CONCLUSION: Residual cholesteatoma in the anterior attic is a problem in CWUT. When postoperative auditory results are good, second look surgery should not be systematic but guided by high quality imaging.

Two cases of temporal bone metastases as presenting sign of lung cancer.

OBJECTIVE: To report the clinical and radiological features of temporal bone metastases and their association with primary lung cancer. CASE REPORTS: Both patients complained of headache, cochlear signs or cranial nerve palsy. Computed tomography of the petrous temporal bones and magnetic resonance imaging showed an osteolytic lesion of the temporal bone. The preoperative work-up was completed by chest, abdomen and pelvis computed tomography and positron emission tomography. Bronchoscopic biopsies confirmed the diagnosis of lung cancer. DISCUSSION/CONCLUSION: The discovery of an osteolytic lesion of the temporal bone requires an aetiological work-up, including the search for a lung tumour based on the hypothesis of temporal bone metastasis. Positron emission tomography should now be performed in the context of such lesions. Management consists of palliative chemotherapy and analgesic radiotherapy.

[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.

A review of 89 revision stapes surgeries for otosclerosis.

OBJECTIVES: The aim of this study was to identify the causes and the audiometric results of revision surgery following stapedotomies and stapedectomies. PATIENTS AND METHODS: We retrospectively reviewed a series of 89 revisions after surgery for otosclerosis between 1993 and 2008. Intraoperative findings, causes of failure, and pre- and postoperative audiometric results were noted retrospectively. RESULTS: The leading causes of failure found intraoperatively included dislocated prosthesis and necrosis of the long process of the incus. The average postoperative air-bone gap was 13 dB. Closure of the air-bone gap to within 10 dB was achieved in 52% of patients. CONCLUSION: Stapes revisions had less satisfactory results compared with primary procedures in this series. However, certain precautions during initial surgery should decrease the number of stapes surgery revisions.

[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.

[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.

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.

Neuro-endocrine adenoma of the middle ear: a case study.

Neuroendocrine adenomas are rare tumors, which can appear in the middle ear. Approximately a hundred cases have been reported in the literature. We report the case of a 58-year-old man who consulted for an abnormal sensation of fullness in the right ear. The otoscopic examination showed a retrotympanic tumefaction. The CT scan and MRI of the middle ear demonstrated a well-defined tissue mass without any osteolysis. We performed surgical exeresis by transcanal procedure with a cartilage graft tympanoplasty. Microscopic examination and immunohistochemistry revealed an endocrine adenoma of the middle ear. Neuroendocrine adenomas can develop in a number of different sites. When they appear in the middle ear they usually produce hypoacousia. The otoscopic examination shows non-specific findings with only retrotympanic swelling. Surgical exeresis enables histologic and immunohistochemically analysis of the surgical specimen. The adenoma is composed of two cellular types: neuroendocrine (which closely resemble carcinoid tumors) and glandular. Regular clinical and radiologic follow-up is necessary since recurrence is possible. The formal diagnosis of neuroendocrine adenomas of the middle ear requires histologic and immunohistochemically confirmations since the clinical symptoms are non-specific. Surgical excision with removal of the ossicular chain is the treatment of choice in order to prevent recurrence.