[Cervico-facial necrotizing fasciitis]. / Cellulites cervico-faciales.

Cervical fasciitis is a life-threatening condition often due to a benign pharyngeal or dental infection, leading to extensive necrosis, spreading along the fascia of the neck and possibly to the mediastinum. It represents one of the most severe ENT emergencies which requires immediate treatment by a multidisciplinary team. Facing any banal infection of the head and neck, great attention should be paid to any functional or general symptoms and signs of severe sepsis. Patient should be urgently referred to a tertiary center where a CT scan should immediately be done, followed by surgical drainage of the any cervical or thoracic abscesses. Intensive medical care is then needed to treat the frequently encountered cardio-hemodynamic failures or secondary pulmonary or mediastinal infections. The extreme severity of the condition is attested by a mortality rate averaging 5-10%, pneumopathy developing in 1/3 of the patients, hemodynamic failure or mediastinitis in half of the patients, mean duration of mechanical ventilation of 10 days, intubation of 13 days, tracheostomy of 31 days, intensive care unit of 17 days and hospitalization of 26 days. Functional and esthetic sequellae were observed in half of the patients. No predisposing factors could be identified except possibly inadequate initial medical treatment and self-medication by non steroidal antiinflammatory drugs.

Auditory outcomes after implantation and electrical stimulation of the lateral ampullar nerve in guinea pig.

OBJECTIVE: To determine in a guinea pig model the factors of invasiveness of a bipolar electrode implanted in the horizontal semicircular canal (HSC) and to evaluate the consequences on hearing of electrical stimulation of the ampullary nerve. DESIGN: Sixteen guinea pigs divided into four groups underwent surgical opening of the HSC of one ear as follows: control (group 1), cyanoacrylate glue application on the HSC opening (group 2), electrode implantation with cyanoacrylate glue on the HSC opening (group 3), and electrode implantation with electrical stimulation (1 hr/day) for 9 days (group 4). Auditory brainstem responses were recorded before and after surgery and after electrical stimulation. The effectiveness of electrical stimulation in producing a horizontal vestibulo-ocular reflex was evaluated by recording eye movement with video-oculography. RESULTS: Group 1 animals showed hearing loss, and in group 2, sealing the HSC opening with cyanoacrylate glue preserved the hearing thresholds. After electrode implantation, seven of the eight animals showed hearing loss compared with preoperative values. Electrical stimulation did not induce additional hearing loss. CONCLUSION: Electrode implantation at the canal level entailed a risk of hearing loss in an animal model, but electrical stimulation of the horizontal ampullary nerve did not further alter hearing function.

[Practitioners facing balance disorders in older subjects]. / Qu'est-ce qu'un trouble de l'equilibre? Le praticien face a un trouble de l'equilibre du sujet agé.

As life expectancy keeps increasing, balance disorders in older patients represent a major medical and public health issue, mostly because they are the most important risk factor for repeated falls. The inevitable deterioration of the physiological mechanisms which control balance explains their important prevalence and their often multifactor nature. A multidisciplinary approach should thus be adopted. However, during physical examination, practitioners can and must identify the general causes (polymedication, metabolic or cardiovascular diseases, etc.), take certain simple environmental actions and, most importantly, look for risk factors for falls. Falls are indeed the first complication of balance disorders and represent a frequent cause of mortality, loss of independence and high institutionalization and, as such, have serious socioeconomic consequences. Any balance disorder in older subjects thus requires in-depth examination and quick medical management.

Reversible cerebral vasoconstriction syndrome in two patients with a carotid glomus tumour.

We report two patients with reversible cerebral vasoconstriction syndrome (RCVS) and carotid glomus tumour. The first patient presented with multiple thunderclap headaches. Cervical and cerebral magnetic resonance imaging showed diffuse cerebral vasoconstriction on magnetic resonance angiogram (MRA) and a carotid glomus tumour. The second patient presented with a cervical mass and was diagnosed with a non-secreting paraganglioma of the carotid body. Surgery with pre-operative angiography was followed by thunderclap headaches and MRA showed segmental cerebral vasoconstriction. Both patients were treated with nimodipine and headaches stopped. Both had normal cerebral arteries on the control MRA at 3 months. These two cases suggest that a paraganglioma may increase the susceptibility to develop RCVS. As a consequence, patients with RCVS should be investigated for a carotid glomus tumour, and patients with paraganglioma reporting severe headaches should have a cerebral MRA in order to rule out cerebral vasoconstriction.

Biofilms on tracheoesophageal voice prostheses: a confocal laser scanning microscopy demonstration of mixed bacterial and yeast biofilms.

The aim of this study was to demonstrate the presence of yeast and bacterial biofilms on the surface of tracheoesophageal voice prostheses (TVPs) by a double-staining technique with confocal laser scanning microscopy (CLSM). Biofilms of 12 removed TVPs were visualized by scanning electron microscopy, then stained with ConA-FITC and propidium iodide for CLSM. Microbial identification was by partial 16S rRNA gene analysis and ITS-2 sequence analysis. Microbial biofilms on the TVPs consisted of bacteria and filamentous cells. Bacterial cells were attached to the filamentous and unicellular yeast cells, thus forming a network. Sequence analyses of six voice prostheses identified the presence of a variety of bacterial and yeast species. In vivo studies showed that Klebsiella oxytoca and Micrococcus luteus efficiently attached to Candida albicans. CLSM with double fluorescence staining can be used to demonstrate biofilm formations composed of a mixture of yeast and bacterial cells on the surface of TVPs.

Conservative management of 386 cases of unilateral vestibular schwannoma: tumor growth and consequences for treatment.

OBJECT: The object of this study was to evaluate the natural history, pattern, and occurrence of tumor growth and its consequences for treatment of small-sized vestibular schwannomas (VSs). METHODS: From 1990 to 2005, 386 patients underwent conservative management for VS because of the following: age > 60 years, poor health/medical risks, risk of deterioration of good hearing, small tumor size, minimal or no incapacitating symptoms, and/or patient preference. Tumor size was measured by MR imaging according to the guidelines of the Committee on Hearing and Equilibrium. The first MR imaging study was performed 1 year after diagnosis, and subsequent imaging was performed yearly or every 2 years depending on the appearance of new symptoms, tumor growth, or both. RESULTS: Sixty-one patients were lost to follow-up the first year after presentation. Of the 325 patients for whom 1-year follow-up data were available, 39 showed tumor growth > or = 3 mm. Conservative management was discontinued for these 39 patients. The patients who returned for follow-up were evaluated at 1- or 2-year intervals depending on tumor growth. The authors extrapolated to obtain data for 2-year intervals, yielding data for 160, 56, 21, and 8 patients at 3, 5, 7, and 9 years after initial presentation, respectively. The overall mean tumor growth rate (+/-standard deviation) was 1.15 +/- 2.4 mm/year. This rate was estimated by pooling all values of tumor growth that had been determined for all patients and dividing by the total number of "events," with each assessment constituting an event. In 58.6% of patients, the annual tumor growth rate was < 1 mm/year; in 29.2%, 1-3 mm/year; and in 12.2%, > or = 3 mm/ year. The growth rates of intrameatal (1.02 +/- 1.8 mm/year) and extrameatal (1.40 +/- 3.1 mm/year) tumors did not differ significantly. No significant association was found between tumor growth rate and sex, age, initial hearing status, or initial tumor grade. Delay in diagnosis was the only significant factor associated with tumor growth rate. During follow-up, conservative management was discontinued for 77 (23.7%) of the 325 patients for whom at least 12-month follow-up data were available; surgery was performed in 60 (77.9%) and radiation therapy in 17 (22.1%). CONCLUSIONS: The results of this study support the role of a conservative "wait-and-scan" policy of management for small-sized VSs because most have a slow growth rate. Long-term neuroimaging follow-up is needed even with non-growing tumors.

Evolving concepts in the management of jugular paraganglioma: a comparison of radiotherapy and surgery in 88 cases.

Surgery for jugular paraganglioma (PGL) tumors often results in the acquisition of neurological deficits where none had been present previously. This has a significant impact on the quality of life. Radiotherapy is a recognized alternative therapy. The aim of this study was to compare the results of radiotherapy and surgery for the management of jugular PGL in terms of function and tumor control to define a treatment algorithm. We conducted a retrospective and comparative analysis of the treatment of 41 patients by conventional radiotherapy and 47 patients by surgery via tertiary referral at an academic medical center. Forty-seven patients with type C and/or D jugular PGLs (mean age, 46 years) underwent surgery after endovascular embolization between 1984 and 1998 using an infratemporal fossa type A approach. The facial nerve was transposed in 18 patients. An adjunctive neurosurgical procedure was required in 14 patients. Mean follow-up was 66 months (range, 17 months to 14 years). Forty-one patients with type C jugular PGLs (mean age, 59.5 years) were treated by external beam or conformational radiotherapy between 1988 and 2003 with a total mean dose of 45 Gy (range, 44 to 50 Gy). Mean follow-up was 50 months (range, 18 months to 13 years). The primary outcome measures were tumor control and cranial nerve status. Surgical resection, total or subtotal, yielded an overall 86% rate of either cure or tumor stabilization. Radiotherapy achieved local control in 96% of patients. For surgery, the main postoperative complications were dysphagia, aspiration, and facial paralysis. Patients treated by radiotherapy developed minor disabilities. We concluded that radiotherapy and surgery achieve similar oncologic outcomes, but the former achieves tumor control with less morbidity. Our data favor radiotherapy as treatment for jugular PGLs, but we acknowledge that the aims of these two treatment modalities are different, namely, eradication of tumor by surgery versus stabilization of tumor with radiotherapy. The search for the better quality of life has to be weighed against the uncertainty of the long-term behavior of the tumor.

Middle ear gas loss in inflammatory conditions: the role of mucosa thickness and blood flow.

Several middle ear (ME) pathologies are associated with ME gas deficit. These include in particular the chronic otitis media diseases that are associated with inflammation (hence, increased ME mucosal blood flow) and/or reduced Eustachian tube (ET) function. The present study models the trans-mucosal gas exchange in normal and inflamed middle ears of rats. The model evaluates the role of the gas diffusion path in the ME mucosa using mucosa thickness as its index and the role of the mucosal blood flow rate on ME gas economy in order to compare between normal and inflamed MEs. An experimental method employing ME gas volume changes at constant pressure due to trans-mucosal gas exchange, and blood gas values from the literature, was used in anaesthetized rats to corroborate the model. Mucosa thickness was measured as an index of the gas diffusion path between the ME space and the ME circulation. ME inner surface area was estimated from its measured gas volume. Inflammation was inflicted by applying lipopolysaccharide (LPS) into one ear. The contralateral ear served as control. ME gas volume decreased significantly faster with time (p=0.02) in inflamed ears (-0.107 microL min(-1) +/- 0.034 S.D., n=10) versus control ears (-0.067 microL min(-1) +/- 0.036 S.D., n=10). Mucosa thickness was significantly thicker in inflamed ears (48.4 microm +/- 11.0 S.D.) versus controls (20.5 microm +/- 10.1 S.D.). The mathematical model, the experimental results, and the blood gas values were used to estimate the relative effective mucosal blood flow rate. The model predicts that in spite of almost doubling mucosa thickness in LPS treated ears, the increased gas loss in inflamed ears may be explained by increased mucosal blood flow rate. We suggest that the ability to estimate ME blood flow as obtained by applying the model to the measurements, is relevant to medical management of inflamed ME.

Demonstration of bacterial cells and glycocalyx in biofilms on human tonsils.

OBJECTIVES: To demonstrate mucosal biofilms in human tissue by direct visualization of bacteria and glycocalyx using confocal laser scanning microscopy with double fluorescent staining on tonsils and to compare the findings with the results of scanning electron microscopy analysis. DESIGN: Prospective study. SETTING: Tertiary university-based referral center. PATIENTS: Twenty-four tonsils were obtained from children with chronic or recurrent tonsillitis. INTERVENTIONS: Tonsils were prepared for analysis by scanning electronic microscopy and by confocal laser scanning microscopy. MAIN OUTCOME MEASURES: Double fluorescent staining for confocal laser scanning microscopy consisted of propidium iodide staining to detect bacterial cells and fluorescein isothiocyanate concanavalin A staining to detect the glycocalyx matrix. Images were analyzed for characteristic biofilm morphologic features by 3 investigators who evaluated the images independently in a blinded retrospective manner. Consensus of all observers was required to demonstrate the presence of a biofilm in a specimen. RESULTS: Findings from analyses using scanning electronic microscopy suggested the presence of biofilm formations on tonsils by showing bacterial cells in microcolonies. Double-staining technique using confocal laser scanning microscopy showed bacterial cells and the glycocalyx matrix, providing visual evidence for the presence of biofilms on tonsils. CONCLUSION: Using a novel visualization approach in single sections of human mucosal tissue, the presence of biofilms was demonstrated on tonsils in most (17/24 [70.8%]) patients with tonsillitis.

Early postoperative CT scanning for juvenile nasopharyngeal angiofibroma: detection of residual disease.

BACKGROUND AND PURPOSE: High recurrence rates and early recurrence have been reported for juvenile nasopharyngeal angiofibroma (JNA) involving the skull base. The purpose of this study was to evaluate the diagnostic accuracy of contrast-enhanced CT scanning for the detection of residual disease (RD) in the early postoperative course after surgical excision of JNA. METHODS: We retrospectively reviewed data in 20 male patients (mean age +/- SD, 15.4 +/- 5 years; range, 10-32 years) who underwent enhanced helical CT in the days after apparent complete surgical excision of JNA with initial expansion in the skull base. Four independent, blinded readers evaluated the occurrence of RD. Final diagnoses were rendered on the basis of histologic examination of excised specimens of RD or clinical and radiologic follow-up. The Cohen kappa test was performed to examine interreader agreement. RESULTS: Postoperative contrast-enhanced CT had a sensitivity of 75%, a specificity of 83%, a positive predictive value of 75% and a negative predictive value of 83% for the detection of RD. The prevalence of RD was 40%. The base of pterygoids was the most frequent location of RD. Interreader agreement was high for the detection of putative RD (kappa=0.83). Variabilities in readers' interpretations were encountered for false-positive results and for disease in the foramen lacerum. False-negative results involved the base of pterygoids. Early postoperative CT scanning was well tolerated by all patients. CONCLUSION: Contrast-enhanced helical CT is an accurate tool to evaluate excision of JNA in the days after surgery.

Idiopathic sudden sensorineural hearing loss is not an otologic emergency.

OBJECTIVE: To investigate whether delay in treatment has any influence on the audiometric outcome at Day 30 in idiopathic sudden sensorineural hearing loss. STUDY DESIGN: Prospective study. SETTING: Otorhinolaryngologic emergency center in Paris, France. PATIENTS: Three hundred forty-seven consecutive cases of sudden sensorineural hearing loss were examined. A neurologic or retrocochlear cause was revealed in 17 cases. Four additional cases were lost for follow-up. Three hundred twenty-six cases of "idiopathic" sensorineural hearing loss seen within 7 days of onset were enrolled and classified by type according to five audiogram shapes: low tone (Type A), flat (Type B), high tone (Type C), cup-shaped (Type D) or total or subtotal (Type E). Because of loss for follow-up, the hearing outcome at 1 month could be evaluated in only 249 cases. INTERVENTION: All 326 patients were given 1 mg/kg per day corticosteroids intravenously for 6 days and 500 ml mannitol 10% in the subgroup presenting ascending audiometric shape. MAIN OUTCOME MEASURES: The following parameters were used. The first parameter was hearing recovery (initial PTA-PTA at Day 6 or Day 30). It was considered as complete if final PTA was below 25 dB. The second parameter was incidence of hearing recovery based on the following formula: (initial PTA-PTA on a given test day)/(initial PTA) x 100%. Using regression analysis and ANOVA, the audiometric outcome was analyzed at Day 6 and Day 30 as a function of the day of onset of treatment and of the audiometric type. RESULTS: Whatever the audiometric type, there was no significant difference in final outcome whether the treatment was started within the first 24 hours or within the first week. CONCLUSIONS: Delay in initiating treatment does not appear to influence the final degree of hearing loss. Idiopathic sudden sensorineural hearing loss cannot be considered as an otologic emergency.

An international otology database.

There are many reports in the literature on the outcome of ear surgery. However, it is difficult to make comparisons from these reports because of a lack of uniformity in the way in which outcomes are reported. At the same time, the general public expects doctors to provide them with information regarding the benefits and risks of surgery. Many ear surgeons will not be able to provide this information because few have an up-to-date database. A group of otologists in Europe has attempted to establish a common otology database. The aim is to create a framework whereby surgeons in Europe can contribute to a common ear database using a web-based system. The proposed methodology involves two levels of data entry. Level 1 is a minimal database where the main outcomes are included. Level 2 is a comprehensive database where detailed information on pathologies, risk factors, and surgical procedures is also recorded. As both databases share the same core data, clinicians using database 1 can still compare their outcomes with those using database 2. Clinicians will be able to input and retrieve ear data onto or from the web-based database. There has already been an international consensus on the content of the common ear database. The website address is www.ear-audit.net. The international project has now been in operation for more than 6 months, and Ear UK has already given its endorsement. The founder members include 27 otologists from 12 European countries. The cumulative outcome from this group of surgeons will be used as the benchmark for the purpose of comparative audit. These benchmark sites will be subjected to regular external validation. The web-based system is interactive and gives instant feedback to individual surgeons who wish to compare their results to the benchmark. Therefore, it can be a good learning tool for trainees or less experienced surgeons. The common data entry system also provides an opportunity for clinicians to collaborate in clinical research.

Spontaneous intracranial hypotension: a rare cause of labyrinthine hydrops.

Spontaneous intracranial hypotension should be considered as a possible cause of cochlear hydrops. We report a case of unilateral hearing loss attributed to spontaneous intracranial hypotension on the basis of characteristic abnormalities seen on magnetic resonance imaging. The diagnostic gold standards for intracranial hypotension are lumbar measurement of cerebrospinal fluid pressure and magnetic resonance imaging. The usual treatment is an autologous blood injection into the peridural spaces. The mechanism of hearing loss is thought to involve secondary perilymph depression due to a patent cochlear aqueduct. This perilymph depression would induce a compensatory expansion of the endolymphatic compartment, with a subsequent decrease in basilar or Reissner's membrane compliance. Endolymphatic hydrops can occur in the course of intracranial hypotension, and not only because of abnormal endolymph production or resorption. Hydrops can thus be classified into 1) syndromes of endolymphatic origin and 2) syndromes of perilymphatic origin, in which loss of perilymph induces compensatory expansion of the endolymphatic space.

Ipsilateral beating nystagmus after acoustic schwannoma resection.

OBJECTIVE: To highlight the alert value of an ipsilateral beating nystagmus to detect any potential vascular complication in the early postoperative course of acoustic schwannoma (AS) surgery. METHODS: In a series of 432 cases of AS operated by the same surgeons between January 1991 and December 2000, two cases of vascular complications were detected by an ipsilateral beating nystagmus toward the operated side. RESULTS: One case of arterial infarction giving rise to a partial AICA syndrome and one case of hematoma of the cerebello-pontine angle (CPA) were revealed by an ipsilateral beating nystagmus. It was the first or the only objective neurologic sign encountered in the early postoperative course of AS surgery. CONCLUSIONS: An ipsilateral beating nystagmus after AS resection, even appearing as the only abnormal objective neurologic finding, should always raise suspicion of a brain stem event. Early extubation is recommended for systematic neurologic assessment in order to detect as quickly as possible any potential vascular complication in the early postoperative course of AS.

Online script concordance test for clinical reasoning assessment in otorhinolaryngology: the association between performance and clinical experience.

OBJECTIVE: To report on the creation and administration of an online Script Concordance Test (SCT) for ear, nose, and throat (ENT), the ENT-SCT. DESIGN: Prospective study. SETTING: Two tertiary care university centers. PARTICIPANTS: In total, 132 individuals were asked to test an ENT-SCT of 20 cases and 94 questions based on the major educational objectives of the ENT residency program. MAIN OUTCOME MEASURES: Three levels of experience were tested: medical students, ENT residents, and board-certified otorhinolaryngologists as the expert panel. The test's construct validity-whether scores were related to clinical experience-was statistically analyzed. Reliability was estimated by the Cronbach α internal consistency coefficient. Participants' perception of the test was assessed with the use of a questionnaire. RESULTS: The 65 respondents with usable data were medical students (n = 21), ENT residents (n = 22), and experts (n = 22). Total mean (SD) test scores differed significantly: 76.81 (3.31) for the expert panel, 69.05 (4.35) for residents, and 58.29 (5.86) for students. The Cronbach α coefficient was 0.95. More than two-thirds of the participants found the test to be realistic and relevant for assessing clinical reasoning. The test was also considered fun, interesting, and intuitive. CONCLUSIONS: The Web-based ENT-SCT is feasible, reliable, and useful for assessing clinical reasoning. This online assessment tool may have applications for residency programs and continuing medical education.

The use of dabigatran in elderly patients.

Recent approval by the US Food and Drug Administration (FDA) of dabigatran etexilate, an oral direct thrombin inhibitor, for the prevention of stroke in patients with atrial fibrillation will likely extend its administration in elderly patients. The risk of major overdosage of dabigatran etexilate in this population is, however, much increased owing to frequent renal function impairment, low body weight, drug interactions that cannot be detected with a routine coagulation test, and no antagonist available. We report herein 2 clinical cases, including 1 fatal case, illustrating our concern regarding the risk of bleeding events in elderly patients.