Interest of diffusion-weighted and gadolinium-enhanced dynamic MR sequences for the diagnosis of parotid gland tumors.

PURPOSE: This study aimed to evaluate the value of diffusion-weighted imaging (DWI) and gadolinium-enhanced dynamic magnetic resonance imaging (MRI) for differentiating benign and malignant parotid gland tumors, and for characterizing the various histological types (pleomorphic adenoma, and Warthin's and malignant tumors). PATIENTS AND METHODS: This retrospective study involved 60 patients with suspected parotid gland tumors (mean age: 59.4 years), and was carried out from April 2005 to February 2008. All had undergone pathological examination. All MRI examinations were performed using the Siemens Magnetom Avanto 1.5T MRI system. Non-enhanced T1-weighted (T1W), gadolinium-enhanced fat-suppressed T1W and T2-weighted (T2W) images were obtained for all 60 patients, with diffusion-weighted echoplanar imaging (DW-EPI) and apparent diffusion coefficient (ADC) evaluation in 59 patients, and gadolinium-enhanced dynamic MRI sequences in 51 patients. Interpretation was carried out by two experienced radiologists (the first evaluation used T1W, gadolinium-enhanced fat-suppressed T1W and T2W images; the second evaluation used T1W, T2W, DWI and dynamic MRI) and, for each case, the benign/malignant nature of the tumor and its histological type were determined. RESULTS: After the second reading, increases were noted in sensitivity, specificity, malignant positive predictive value (PPV) and negative predictive value (NPV), as well as in accuracy (90-100% for the first observer, and 90-97% for the second observer). Interobserver reliability also showed a significant increase from the first to the second reading (kappa=0.63 to 0.87, respectively). CONCLUSION: Gadolinium-enhanced dynamic MRI and DW-EPI with ADC evaluation improved the performance of MRI in distinguishing between benign and malignant parotid gland tumors, and characterizing the different histological types of benign tumors (pleomorphic adenoma and Warthin's), thus leading to greater consensus in interpretation of the images.

Lateral semicircular canal plugging: a simple and effective surgical treatment against incapacitating Menière's disease.

OBJECTIVES: To present lateral semicircular canal plugging (LCP) technique and late results dedicated to patients with incapacitating Menière's disease. METHOD: In a prospective case-controlled baseline study, patients with unilateral incapacitating Menière's disease were treated either by LCP (n = 11) or by vestibular neurotomy (VN) (n = 11). LCP was performed by retro auricular approach, vestibular neurotomy by retro sigmoid approach. According to Menière's disease therapeutic evaluation guidelines, disability and hearing loss were assessed before and after both surgical treatments, with a 2 years followup at least. After LCP, a CT and MRI scan analyse was performed on the inner ear RESULTS: LCP was effective (A or B class) in 82% of cases (n = 9/11), 91% after VN (n = 10/11). When treatment was effective, 100% of patients regained a normal life after LCP (postoperative functional level I or 2, n = 9/9), versus 50% after VN (n = 5/10). After LCP, postoperative hearing level was unchanged in 82% of cases, n = 9/11 (73% after VN, n = 8/11), and decreased of about 30 dB in 18% (n = 2/11). There was no surgical complication. The endolymph interruption area was well visualized on MRI, allowing determining the optimal plugging area to be as far as possible from the ampulla. CONCLUSION: LCP is a simple and safe new treatment that could be very useful to control vertigo in Menière's disease. Early and late tolerance are excellent. This prospective study will go on to evaluate the potential of this innovating treatment: LCP could be recommended as an alternative to VN or chemical labyrinthectomy, except in case of drop attacks.

[Reconstruction of the anterior mandibule using a porous titanium implant: a case report]. / Reconstruction de la symphyse mandibulaire par implant de titane poreux: à propos d'un cas.

OBJECTIVE: Anterior mandibular arch reconstruction. PATIENT AND METHOD: A 55-year-old immuno-depressed female underwent resection of the lower third of the face subsequent to extensive mucormycosis-related necrosis. Reconstruction of the anterior part of the mandible and adjacent soft tissue was carried out with a mandibular prosthesis and a latissimus dorsi flap. The mandibular prosthesis was made of titanium T40 micro-beads, consolidated by two parallel plates of titanium. The porous structure is intended to enhance cellular and bone integration. RESULTS: The tolerance of the prosthesis was still excellent after 36 months. Labial continence was restored in a second procedure. Unrestricted diet was allowed from the third month. Radiological investigations confirm the good stability of the prosthesis. CONCLUSION: This original prosthesis design offers an alternative to the reconstruction of an anterior mandibular arch by plate or by vascularised free osseous tissue transfer that is sometimes associated with significant morbidity.

[The respiratory mucociliary system and its exploration in primary ciliary dyskinesia]. / Le système mucociliaire respiratoire et son exploration dans le cadre de la dyskinésie ciliaire primitive.

BACKGROUND: We analyzed the main characteristic features of the respiratory epithelium mucociliary system and the different tests of ciliary beat and mucociliary transport (mucociliary clearance). This knowledge is necessary for an often interdisciplinary diagnosis and treatment of primary ciliary dyskinesia. METHODS: Review of the literature and personal experience of the different tests of ciliary structure and function. RESULTS: This disease is characterized by abnormalities in ciliary structure/function. The genetic mechanisms and the ultrastructural abnormalities that are involved are heterogenous compared to the relative homogeneity of the clinical presentation. CONCLUSION: The diagnostic criteria are compatible clinical features (chronic upper airway and bronchopulmonary infections, situs inversus...) coupled with tests of ciliary structure and function.

[Primary ciliary dyskinesia. Clinical presentation and diagnosis]. / La dyskinésie ciliaire primitive. Etude clinique et diagnostic.

UNLABELLED: Primary ciliary dyskinesia (PCD) is a genetic disease characterized by abnormalities in ciliary structure/function. OBJECTIVE: We analyzed the main clinical features and test results of PCD in order to evaluate their usefulness for diagnosis. PATIENTS AND METHODS: Retrospective study of 35 cases of PCD evaluated by the same team, with nasal brushings in all cases (special light microscopy) and electron microscopy and/or by isotopic mucociliary clearance study in some. RESULTS: In a cohort of 145 patients with suspected PCD, the diagnosis of PCD was established in 35 cases using a combination of compatible clinical features coupled with the study of nasal brushings: 13 females and 22 males, average age at time of diagnosis 25 years, situs inversus in 12 patients (34%). CONCLUSION: In the absence of consensus in the literature for diagnosis of PCD, we propose the association of the following diagnostic criteria: upper airway and bronchopulmonary infections beginning often early in the life, more inconstantly situs inversus, familial cases of PCD, consanguinity, infertility and permanent and ubiquitous abnormalities of ciliary structure/function. Nasal brushing with ciliary study (special light microscopy) seems to be an easy and reliable diagnostic criterion. Electron microscopy is necessary for proving ultrastructural abnormalities.

[Surgical treatment of malignant sinonasal tumors with orbital extension: 20 patients]. / Traitement des tumeurs malignes des cavités nasosinusiennes à extension orbitaire. A propos de 20 patients.

OBJECTIVE: The purpose of this work was to assess changes in surgical treatment of malignant sinonasal tumors with orbital extension, with or without orbital exenteration, on the basis of clinical, radiological and preoperative data. MATERIAL AND METHODS: We conducted a retrospective analysis of twenty patients with malignant sinonasal tumors with orbital extension operated on from 1995 to 2002 in the ENT and head and neck department of the Strasbourg University Hospital. CT-scan and MRI were performed before surgery. When periorbital invasion was observed without orbital extension and confirmed by histological examination in the operative theatre, the orbit was preserved during the surgical procedure. Orbital exenteration was necessary for the other patients. Adjunct postoperative radiotherapy was performed in all patients (n=20). Clinical, radiological and surgical data were compared with patient follow-up to search for correlations between radiological signs and the difficult surgical decision for orbital exenteration. RESULTS: For orbital extension, the histological examination performed in the operative theatre did not confirm the results of the preoperative CT-scan in 15% of patients and the preoperative MRI in 11%. In a first group of nine patients with bony wall extension (78%, 7/9) or periorbital extension (22%, 2/9), there were no cases of recurrence at six years follow-up. In a second group of eleven patients with intraorbital extension, orbital exenteration was not performed in two (18%) because of surgically unresectable massive extension. Four of the nine other patients who underwent orbital exenteration were free of local recurrence at ten months follow-up and five were considered to have achieved oncological cure at four years follow-up. CONCLUSION: Preoperative CT and MRI are essential but the decision for orbital exenteration must be made on the basis of the histological examination performed during the operative procedure because imaging often underestimates tumor extension.

[Recovery of saccular function after vestibular rehabilitation]. / Récupération de la fonction sacculaire après rééducation vestibulaire.

OBJECTIVE: The authors present a case of recovery of saccular function after vestibular rehabilitation. MATERIAL AND METHOD: Vestibular rehabilitation is proposed to a patient presenting a left lateral body deviation as well as postural disorders at the time of the vertical movements and in car, associated with an unilateral abolition of vestibular evoked myogenic potentials (VEMP). RESULTS: We observe a recovery of VEMP and a disappearance of symptomatology after vestibular rehabilitation. CONCLUSION: A loss of saccular function can involve a postural disorder in some circumstances. The best treatment is vestibular rehabilitation. We insist on the need for knowing otolithic semiology in order to propose suitable explorations and therapy.

Modelling the action of caloric stimulation of the vestibule. IV. The global mechanical model.

Caloric stimulation acts on the bio-accelerometer (the semi-circular canal), as on engineered ones, through second order type multiple pathways. Three temperature induced peripheral actions have been described in our previous reports. The hydrostatic mechanism induces in the endolymph a gravity dependent transcupular stationary pressure difference. The differential expansion of the membranous duct and its content creates a local volume variation, while the modification of the transmembranous exchanges causes a local pressure variation. These two last mechanisms are gravity independent. They depend on parameters of the membrane, and induce a transcupular transient pressure difference and a stationary variation of the inflating pressure. It seems reasonable to assume the independency of these three mechanisms. If this assumption is true, than the global effect of caloric stimulation should be the sum of the effects of the three partial mechanisms. It is shown here that, for the physical model, this assumption holds. For humans, in the more general frame of the caloric vestibulo-ocular reflex experiments reported in the first paper, qualitatively and quantitatively this assumption holds, too. The model predicts a percentage of gravidity dependent effects of about 75%. It is shown that the reported human experiments lead to compatible estimates of this percentage. For humans in the earth gravity field, enduring the caloric stimulation it is not necessary to include neither otolithic interactions, nor significant modifications of the mecano-neural transduction, in the limits of precision of today's experimentation.

Modelling the action of caloric stimulation of the vestibule. I. The hydrostatic model.

In this first article of four the problem is displayed using experiments on humans for two kinds of gravity related positions. In each case the nystagmus depends sinusoidally on a particular orientation of the canal to the vertical. In each case, too, a dissymmetry of the response occurs. This kind of behavior confirms that the caloric stimulation induces both a gravity dependent and a gravity independent effect. A simple mechanical model gives account of the gravity dependent effect. It does not imply the otolithic system. Since the cupula adheres to the ampullar wall and to the crista, this is a hydrostatic model in contrast to Bárány's model, which is of hydrodynamic type.

Modelling the action of caloric stimulation of vestibule. III. Caloric nystagmus induced by osmotic pressure variation.

The properties of the membranous wall of the semi-circular canal and of the labyrinthine fluids give as a result the inflating pressure of this inflatable structure. The difference of osmotic pressure between perilymph and endolymph, which is involved in this problem, depends on temperature. Therefore, a caloric stimulation leads to a change in the inflating pressure. A numerical model, similar to the model used to study the effects of relative volume variations, gives a quantitative estimation of the transcupular pressure arising in a horizontal semi-circular canal (i.e. without gravity dependent effects) during a caloric stimulation, according to the inflating pressure change. As a consequence, it appears that rotational and caloric stimulations are not quite similar. The caloric stimulation leads not only to a transcupular pressure difference but also to a change in inflating pressure. As a result of the change in inflating pressure, the stiffness of the cupula varies. This modifies the gain and the dynamics of the vestibulo-ocular reflex, and may explain the asymmetry between hot and cold stimulations.

Modelling the action of caloric stimulation of the vestibule. II. The mechanical model of the semi-circular canal considered as an inflatable structure.

In order to explain the mechanical effects that arise when a semi-circular canal is thermally stimulated in the horizontal position (i.e. in the absence of gravity effects) a physical model was used. The duct (corresponding to the canal) is deformable, the pressure transducer (corresponding to the ampulla) is not deformable. There is no thermal similarity but a dynamical similarity has been respected, so the mechanical phenomena occurring in the semi-circular canal and in the model are identical. The time scale is close to one. The physical model showed that the relative volume variations (fluid/duct) due to caloric stimulation lead to a pressure variation measured by the pressure transducer at the place of the ampulla and the cupula. The time history and the value of this pressure depend on the mechanical and thermal properties of the duct and the fluid. The qualitative responses of the physical model and of the vestibulo-ocular reflex after caloric stimulation were coherent. A numerical model simulating the same mechanisms yielded a quantitative estimation of the transcupular pressure arising in a horizontal semi-circular canal (i.e. without gravity dependent effects) during caloric stimulation. The physical model and the numerical simulation take no account of the inflating pressure variation.

Intra-laryngeal endoprosthesis: an alternative therapeutic approach to surgical procedures of laryngeal exclusion.

The uncertain results of aryepiglottopexy in our personal experience led us to develop, for patients with aspirations associated with the risk of severe pneumonitis, three types of intralaryngeal endoprostheses (ILEP) under the systematic cover of a tracheostomy. From September 1997 to May 1999, seven protheses were implanted in six patients. It was not possible to restore the full range of laryngeal functions, i.e. deglutition, phonation and respiration. However, our results, that were obtained with an intracricoidal prothesis closed at its upper end or equipped with a phonatory valve, are quite encouraging, even more so when in association with early alimentary re-education and support continuation of our trial. These ILEPs are simple to place, well tolerated, efficacious in preventing deglutition pneumonitis and easy to remove. Furthermore, the reversibility of this bloodless procedure facilitates the monitoring of a possible recovery of the laryngeal functions.

[A new approach to the mechanism of vestibular response to caloric stimulation]. / Nouvelle approche du mécanisme de la réponse vestibulaire à la stimulation calorique.

Barany's classical hydrodynamic theory has been called into question by the zero-gravity Spacelab experiments, and several new hypotheses are put forth to explain the vestibular response to caloric stimulation. We have developed a mathematic model based on the analysis of an experimental model of the semicircular canal, incorporating observations done with zero-gravity and with gravity. Two purely mechanical phenomena are involved: one one hand, the modification of the hydrostatic pressure on both sides of the cupula due to a temperature variation if the semicircular canal is not in the horizontal plane in normal gravity conditions; on the other hand, local changes in endolymph pressure and volume due to the mechanical and osmotic properties of the canal, which are independent from gravity and from the position of the canal. These mechanical processes, though not exclusive, are predominant and therefore sufficient to explain the caloric response of the vestibulum in all cases.

[Uncommon caseous maxillary sinusitis of dental origin caused by Microsporum canis]. / Une sinusite maxillaire caséeuse d'origine dentaire exceptionnelle à Microsporum canis.

The authors report an uncommon case of maxillary sinusitis due to Microsporum canis. To their knowledge this is the first observation in which a zoophilic dermatophytic fungus which grows usually on keratin has been isolated in a dental maxillary sinusitis in human. This observation makes it possible to discuss nosologic and diagnostic features of dental caseous sinusitis and fungal sinusitis which are often or too often called aspergillosis sinusitis.

[Surgical treatment for squamous-cell carcinoma of the posterior pharyngeal wall: reconstruction with a free forearm flap]. / Traitement chirurgical des carcinomes épidermoïdes de la paroi pharyngée postérieure: reconstruction par un transplant antébrachial à pédicule radial.

Squamous-cell carcinoma of the posterior pharyngeal wall is a rare finding. Surgical treatment with preservation of laryngeal function is usually associated with relatively poor functional outcome. We report the cases of 5 patients treated by pharyngectomy with preservation of the laryngeal function. The posterior pharyngeal wall was reconstructed with a free forearm flap. This reconstruction method provided satisfactory functional results. Swallowing disorders resolved within 2 to 6 weeks following the reintroduction of oral food intake. Mean follow-up of nearly 3 years did not evidence any local tumor recurrence.

[Mucormycosis-actinomycosis and caseous dental sinusitis associated with sinusal foreign body]. / Mucormycose-actinomycose et sinusite caséeuse dentaire avec corps étranger intra-sinusien.

The authors report an uncommon case of caseous dental sinusitis with infection or superinfection by mocorales and actinomycetes. The patient was healthy, without diabetes mellitus, but was treated for lymphoma 18 years before. This observation leads to a discussion of nosologic, diagnostic and therapeutic features of caseous sinusitis, dental or not, fungal or not, which are often or too often called aspergillosis sinusitis. The recovery of the patient was complete after surgery, amphotericin B and hyperbaric oxygen.

[Cholesteatoma in children. Apropos of 110 cases]. / Le cholestéatome de l'enfant: a propos de 110 cas.

This retrospective study of 110 middle ear cholesteatomas, concerning children up to 15 years old which have been treated between 1982 and 1992 in the ENT department of the university hospital of Strasbourg, analyzes the particularities of this disease and the therapeutic strategy adopted. The evolution of middle ear cholesteatoma is more rapid in childhood than in adulthood, due to greater growth potential of tissue in childhood, persistence of Eustachian tube dysfunction and aggressive extension in middle ear. The surgical removal is said to be difficult with numerous postoperative recurrences. Closed technique tympanoplasty was used for 47 cholesteatomas (43%), with a postoperative recurrence rate of 54%. An open technique was used for 63% cholesteatomas (57%), with a recurrence rate of 29%. The postoperative follow up has to be continued as long as possible, whatever the technique used may be.

[Allergic fungal sinusitis: ten cases]. / La Sinusite Fongique Allergique (SFA). A propos de 10 cas.

OBJECTIVES: Diagnosis, nosological individualization, and treatment of allergic fungal sinusitis remain difficult and controversial despite the increasing number of publications. We present ten cases of allergic fungal sinusitis and review the literature to highlight the main clinical, radiological, biological, immunoallergological, mycological, and therapeutics features. MATERIAL AND METHODS: This retrospective study included ten patients (six men and four women, mean age 45 years) with allergic fungal sinusitis diagnosed on the basis of all diagnostic criteria reported in the literature. RESULTS: Six patients had isolated allergic fungal sinusitis which was associated with allergic bronchopulmonary aspergillosis in the four others. Treatment combined endoscopic sinus surgery and corticosteroids, which provided good results in six patients and average results in three. Treatment failure was observed in one patient. CONCLUSION: As in the case of allergic bronchopulmonary aspergillosis, a set of clinical, radiological, histopathological, immunoallergological and mycological criteria is necessary for precise diagnosis and to avoid fungal drift. The most appropriate endoscopic sinus surgery and the best corticosteroid regimen remain to be determined.

[Neuroendocrine giant-cell epithelioma. Description of a clinical case and review of the literature]. / Les épithéliomas neuroendocrines à grandes cellules. Description d'un cas clinique et revue de la littérature.

Neuroendocrine tumors are rare neoplasms of the larynx and hypopharynx. This tumors are divided in paragangliomas (usually benign, although malignant case have been reported), large cell neuroendocrine carcinoma, described in this case as a primary pharyngo-laryngeal locate, and small cell neuroendocrine carcinoma (characterized by early and diffuse metastatic disease, and best treated by radiotherapy and chemotherapy). Through the international literature, the authors reviewed the characteristics of the large cell neuroendocrine tumors and their management.

[Correlations between anatomy and x-ray computed tomography in cancers of the pharyngo-larynx. Apropos of a prospective study of 35 patients]. / Corrélations anatomo-scanographiques des cancers du pharyngo-larynx. A propos d'une étude prospective portant sur 35 patients.

A prospective study has been conducted in 35 cases of pharyngolaryngeal's carcinoma, between december 1990 and june 1992 in the department of Head and Neck Surgery of Strasbourg. The authors compared, in a statistic analysis, Computed Tomography and histopathologic's correlations. The operative specimen were sectioned in the horizontal plane to correspond with the CT sections. 11 structures were studied more particularly. Results revealed an excellent sensibility for the study of the pre-epiglottic spaces (100%). Inversely, the study of the para glottic space is less good (69% of sensibility). We found that the CT Scan was of no value for the study of the thyroid cartilage, particularly for detection of subclinical lesions. Overall, this study allowed to confirm the value of the CT Scan in the investigation of pharyngolaryngeal tumors but its limits also.