[Oral appliances or maxillomandibular advancement osteotomy for severe obstructive sleep apnoea in patients refusing CPAP]. / Orthèse d'avancée mandibulaire ou ostéotomie maxillo-mandibulaire pour le traitement des syndromes d'apnées obstructives du sommeil sévères refusant la PPC.

OBJECTIVES: The management of patients with severe obstructive sleep apnea syndrome (OSAS) refusing or not tolerating continuous positive pressure ventilation (CPAP) remains problematic. We evaluated the effectiveness of oral appliances and of maxillomandibular advancement osteotomy. METHODS: One hundred and two patients with severe OSAS were included between 2001 and 2006. Maxillo-mandibular advancement osteotomy was proposed to patients less than 60 years of age, non obese and without comorbidities. The other patients were treated with oral appliances. All patients underwent polysomnography at 3 months. RESULTS: Group A: 25 patients with mean apnea-hypopnea index (AHI) at 45/h were treated by maxillo-mandibular advancement. Three months after the surgery, AHI had decreased from 45 to 7. The success rate was 89% when AHI was less than 15/h and 74% when AHI was less than 10/h. Sixteen patients performed a polysomnography one year after surgery with similar results. There were no major postoperative complications. Group B: 77 patients with a mean AHI at 41/h were treated with oral appliances. Only 23 patients underwent polysomnography at 3 months. The mean AHI had decreased from 41/h to 22/h. The success rate was 56% when AHI was less than 15/h and 30% when AHI was less than 10/h. DISCUSSION: We are confronted with an increasing number of severe OSAS patients with CPAP failure or intolerance. Surgery for maxillo-mandibular advancement is an effective alternative. However, it is not always indicated or accepted by the patient. So an oral appliance remains a useful therapeutic option despite its moderate success rate.

Non-CPAP therapies in obstructive sleep apnoea.

In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.

Decreased motivational properties of morphine in mouse models of cancerous- or inflammatory-chronic pain: implication of supraspinal neuropeptide FF(2) receptors.

Our main purpose was to evaluate the influence of cancer pain on the rewarding properties of morphine. Opioids are very addictive when used by healthy persons, conversely the occurrence of an opioid addiction seems very low when patients suffering from cancer are treated with morphine. We investigated the reinforcing properties of morphine in the place preference paradigm on a new model of mice suffering from a cancer pain induced by syngenic melanoma cells injected in the hind paw. These data were compared with mice suffering either from a short-term- or a chronic-inflammatory pain induced respectively by injection of carrageenan or complete Freund's adjuvant. Remarkably, mice suffering from cancer pain or chronic inflammatory pain did not develop any preference for the environment associated with the injection of morphine. In mice injected with melanoma cells, the specific binding of [(125)I]EYWSLAAPQRF-NH(2), an agonist of neuropeptide FF(2) receptors, was increased in several brain areas involved in the rewarding properties of opiates, including the shell of the nucleus accumbens, the major islands of Calleja, the ventral endopiriform nucleus and the amygdaloid area. Our study is the first to reveal a modification of morphine rewarding properties under cancer pain in rodents. We postulate that anti-opioid neuropeptides might contribute to the suppression of morphine rewarding effects in this murine model of cancer pain.

[Mandibular advancement surgery in patients with severe obstructive sleep apnea uncontrolled by continuous positive airway pressure. A retrospective review of 25 patients between 1998 and 2004]. / Prise en charge par chirurgie d'avancée des maxillaires des patients porteurs d'un syndrome d'apnées du sommeil sévère en échec d'un traitement par pression positive continue: étude rétrospective de 25 patients entre 1998 et 2004.

INTRODUCTION: Continuous positive airway pressure (CPAP) is ineffective in some patients with obstructive sleep apnoea syndrome (OSAS) and some patients do not tolerate it. This study evaluated the outcomes of maxillo-mandibular advancement in OSAS patients without morbid obesity or severe maxillo-mandibular deformity who had first been treated with CPAP for at least 6 months. METHODS: A retrospective study reporting on the experience of the CHU Toulouse Rangueil sleep disorder centre between 1998 and 2004. We performed polysomnography and cephalometry before and 3 months after surgery. RESULTS: 25 male patients with mean apnoea hypopnoea index at 45/hour (+/-15) were treated by maxillo-mandibular advancement. The mean age of participants was 48 years (+/-7), and the mean body mass index was 28 kg/m2 (+/-3.4). Cephalometry demonstrated a retroposition of the mandible (SNB < 80 degrees +/-5) and narrow linguopharyngeal space (ELP = 8 mm+/-3). 3 months after surgery the apnoea hypopnoea index (AHI) had decreased from 45+/-15 to 7+/-7 (p < 0.0001), the Epworth sleepiness scale decreased from 11+/-5 to 6+/-4 (p < 0.01). The linguopharyngeal space was larger (ELP = 14 mm). Success rate defined as an AHI < 15/hour was 89%, and 74% for an AHI < 10/hour. 16 patients underwent polysomnography one year after surgery. The results were the same. There were no post surgical complications, except for one patient who developed permanent labial hypoesthesia. CONCLUSIONS: Maxillo-mandibular advancement seems to be an effective 2nd line therapy for the treatment of severe OSAS.

Craniofacial differences according to the body mass index of patients with obstructive sleep apnoea syndrome: cephalometric study in 85 patients.

We examined the craniofacial characteristics of patients with obstructive sleep apnoea syndrome (OSAS) and correlated them with the body mass index (BMI (weight (kg) x height (m2)). Eighty-five men with OSAS diagnosed by conventional polysomonography were divided into two groups according to their BMI (< 30 and > or = 30). Cephalometry was analysed by using 31 measurements of the size of the bone structures, their relationships and the size of the airways. The groups were comparable for age and the apnoea-hypopnoea index (mean 49, standard deviation (SD) 23). Patient with a BMI < 30 had a shorter anterior floor of cranial base, a smaller mandible and retroposition of the mandible compared with severly obese patients. These skeletal differences were associated with narrower velopharyngeal and linguopharyngeal spaces. This study sh ows that there is a craniofacial difference between two populations, divided according to their BMI.

[Actinomycosis presenting as a chronic excavated pneumonia in a young woman]. / Pneumopathie abcédée chronique chez une jeune femme, révélant une actinomycose thoracique.

INTRODUCTION: Pulmonary actinomycosis is an anaerobic bacterial infection occurring primarily in debilated patients with poor oral hygiene. Before the penicillin era, thoracic actinomycosis looked like tuberculosis or neoplasia with chest wall invasion and fistula formation. OBSERVATION: We report the case of a 39 years old woman presenting with a chronic lung abscess of the left upper lobe hospitalised after several unsuccessful courses of antibiotics. The diagnosis was made after thoracic surgery. Three years after lobectomy, which had been followed by three months of amoxycillin and multiple dental extractions, there was no sign of relapse of the infection. CONCLUSIONS: We review the role of thoracic surgery, antibiotic treatment and diagnosis in pulmonary actinomycosis.

[Influenza and asthma]. / Grippe et asthme.

The relationship between infections of the respiratory tract and exacerbations of pulmonary symptoms in individuals with asthma is well established on clinical grounds. Patients having an acute attack of asthma often give a history of a "cold" before the onset of the exacerbation. The identification rate of viruses during exacerbations of asthma (10-30%) is much higher than the viral identification rate generally found during asymptomatic periods in asthmatics (3%). The mechanisms whereby upper respiratory viruses might induce or contribute to attacks of asthma are currently unknown: epithelial damage, increased cytokines releasability, mouth breathing.... Influenza vaccination is recommended in patients with chronic pulmonary diseases. However, bronchial hyperreactivity has been reported after influenza vaccination in asthmatics. Reactions to these vaccines may be due to non-immunogenic impurities, which are not present in the more recently developed subunit vaccines. In spite of the lack of double-blind studies between subunit and killed influenza virus vaccines, and because of the potential bad prognosis of influenza infection on airway obstruction, influenza vaccination should be recommended in asthmatics with stable respiratory function but influenza vaccination rate remains low.

[Chronic necrotizing pulmonary aspergillosis and ankylosing spondylarthritis]. / Aspergillose pulmonaire nécrosante chronique et spondylarthrite ankylosante.

Fibro-bullous disease is a late complication of ankylosing spondylarthritis. Its radiologic features frequently mimics tuberculosis or excavated neoplasm. About 50 to 65% of patients with ankylosing spondylarthritis have chronic aspergillus colonization of their airways. Pulmonary aspergillosis infection occurs in 10 to 30% during evolution. We report two cases of patients with spondylarthritis who developed chronic necrotizing pulmonary aspergillosis. Diagnosis was based on serology, mycologic examination of expectoration and in one case on histology obtain by transbronchial biopsies. Pulmonary complications due to aspergillus species frequently reveal an associated fibro-bullous disease in patients with ankylosing spondylarthritis. This can be reported to diminished chest wall movements in such patients. Treatment is based on administration of anti-fungal drugs. In case of medical treatment failure, thoracic surgery may be indicated.

[An unusual opacity of the right base]. / Une curieuse opacité de la base droite.

The scimitar syndrome or pulmonary venolobar syndrome is a rare, complex and variable malformation of the right lung characterized by an abnormal right sided pulmonary venous drainage in the inferior vena cava, malformation of the right lung, abnormal arterial supply and sometimes cardiac malformations. We present a case in which this diagnosis was suspected on an abnormal routine chest radiograph in a 38-year-old asymptomatic woman. Most patients are asymptomatic; symptomatic patients have a marked left-to-right shunt or a severe congenital heart disease. They usually suffer from shortness of breath, asthenia or repeated chest infections. Usually, the posteroanterior chest radiograph can confirm the diagnostic. It shows the abnormal vein draining into the inferior vena cava as a curved vascular shadow with a scimitar like appearance. However, in some cases, when the scimitar vein is masked by the overlying cardiac shadow, computed tomography, angiography and magnetic resonance imaging can be helpful by showing the abnormal vein and its insertion into the inferior vena cava. Scimitar syndrome seldom necessitates surgical intervention. However, repeated lung infections can sometimes require lobectomy or pneumonectomy, left-to-right shunt vascular surgery to redirect the scimitar vein into the left atrium.

[Nocardia respiratory infection in patients with chronic obstructive lung disease]. / L'infection respiratoire à Nocardia chez les patients présentant une bronchopneumopathie chronique obstructive (BPCO).

Pulmonary nocardiosis is a respiratory infection which is usually described in the immunocompromised. We report three cases in patients suffering from chronic airflow obstruction. In two cases there was a parenchymal disorder and in one case bronchial suppuration without involvement of the alveolar region. The diagnosis was made in all cases by bacteriological examination from specimens obtained at fiberoptic bronchoscopy. The outcome was favourable in all three cases after appropriate treatment. These observations underline the diversity of the clinical forms of respiratory nocardiosis. Furthermore, it demonstrates their possible occurrence in non-immunocompromised patients and the need to look for this germ specifically in long drawn infections. A bacteriological diagnosis is vital to start early and appropriate antibiotic therapy which should be prolonged because of the risk of recurrence and disseminated infection.

[Role of nocturnal oximetry in screening for sleep apnea syndrome in pulmonary medicine. Study of 329 patients]. / Place de l'oxymétrie nocturne dans le dépistage du syndrome d'apnée du sommeil en milieu pneumologique. Etude de 329 patients.

Nocturnal oximetry can show nocturnal oxygen desaturation. This examination was proposed as an investigation for the early detection of the sleep apnoea syndrome (SAS). We have compared the results of nocturnal oximetry and polysomnography in 329 consecutive patients seen in the department of thoracic medicine for the early detection of the SAS between June 1990 and June 1995. The diagnosis of SAS was confirmed at the time of polysomnography using an hypopnoea/apnoea index (IAH) greater or equal to 15 per hour. Two parameters of oximetry were well correlated with IAH less than 15 per hour: if the mean oxygen saturation is greater than 92% and for less than five per cent of the time of the examination there was a saturation of less than 90%. The sensitivity was 89.7% and the specificity was 57.8%. Among the 48 false positive cases on oximetry 17 patients were found to be suffering from COPD and 31 patients were probably suffering from a syndrome of upper airways resistance or possibly from the hypoventilation obesity syndrome. Amongst the 22 false, negatives to oximetry 10 non COPD patients with an IAH of greater than 30 per hour and diurnal somnolence had important anomalies of the oro-pharyngeal pathway as the origin of their nocturnal apnoea. The 12 other false negatives were patients with moderate SAS with an IAH of between 15 and 20 per hour. Logistical analysis has shown the association of the two oximetric criteria (mean oxygen saturation or percentage of time with a saturation of less than 5%) with clinical criteria (body mass index and formation on diurnal somnolence from a questionnaire) would enable a probable diagnosis of SAS in 75% of cases. Our study shows that nocturnal oximetry used an early diagnosis test, associated with clinical and respiratory function data enables the number of requests for polysomnography to be reduced.

[Results of 248 patients with sleep apnea syndrome treated by continuous positive pressure ventilation between 1990 and 1995. A study of compliance and outcome of the apnea-hypopnea index]. / Suivi de 248 patients présentant un syndrome d'apnée du sommeil traités par pression positive continue entre 1990 et 1995. Etude de l'observance et du devenir de l'index d'apnée-hypopnée.

Between 1990 and 1995, 369 patients were investigated for obstructive sleep apnea syndrome (OSAS) by polysomnography. Among them, 248 patients with a mean Apnea-Hyponea index (AHI) of 37.7 per hour were treated by nasal continuous positive airway pressure (n-CPAP). Mean follow up was 39.5 +/- 20.4 months. In this group, 23 patients (9.2%) refused nCPAP immediately or after the first night and 39 (15.7%) gave up later. 15 patients (6%) died during the period of the study. The cumulative compliance reached 70% at 72 months. Non compliant patients usually gave up n-CPAP before the end of the first year. We compared the group of 150 patients always treated at the date of 31/12/95 with the group of 62 patients who refused nCPAP initially or gave up later. There was no difference in clinical parameters or polysomnographic data between the two groups. In 94 patients treated by nCPAP for more than a year we evaluated the outcome of AHI by a polysomnography performed after 72 hours of nCPAP cessation. Mean AHI of the group at this time was 38.2 +/- 20.3/h and was well correlated with the initial index (r = 0.41, p < 0.0001). However for 28 patients (29.7%) we observed, at the time of this second AHI determination, a variation (plus or minus) of at least 50% of the index. 6 patients, without any significative weigth loss, had an AHI below 5/h at this second determination. In this small group nCPAP was interrupted for 6 to 12 months, then another polysomnography was performed. At this time mean AHI was 42.4/h and clinical symptoms had reappeared in all patients. This study demonstrated that compliance to nCPAP in OSAS patients is good. No clinical or polysomnographic factors allow to predict non compliance. AHI is not modified by long term treatment with nCPAP.

[Coccidioidomycosis presenting as a pulmonary nodule after pneumonia]. / Opacité tumorale apparue au decours d'une pneumonie fébrile révélant une coccidioïdomycose thoracique.

Coccidioidomycosis is a fungal infection endemic in the south west of the United States. Sixty percent of infected individuals remain asymptomatic. Symptomatic disease manifests itself with variable signs such as pneumonia, pleural effusion, empyema or acute respiratory distress syndrome. Residual disease includes pulmonary nodules and fibrosis. We report a case of a woman, returning from a trip to Arizona, presenting with an acute respiratory infection associated with erythema nodosum and arthralgia. She was successfully treated with routine antibiotics. The acute pneumonia resolved and the radiological infiltrate contract into a solitary pulmonary nodule. We suspected a malignant nodule in a previous smoker. The diagnosis of pulmonary Coccidioidomycosis was made after surgical resection. One year later, the patient is asymptomatic and well. This review focuses on the most common clinical manifestations, the diagnostic strategy and the treatment and management of pulmonary Coccidioidomycosis.

[Upper airway changes after mandibular setback osteotomy. Concerns for obstructive sleep apnea]. / Modification des voies aériennes supérieures après ostéotomie de recul mandibulaire. Intérêt en pathologie obstructive du sommeil.

INTRODUCTION: Cases of obstructive sleep apnea syndrome have been described after setback osteotomy. Although such cases are rare, they emphasize the importance of taking into account the structure of the upper airways when performing this type of procedure. We studied the modifications provoked in the upper airways by mandibular setback osteotomy performed for dysmorphism. MATERIAL AND METHOD: We conducted a retrospective cephalometric study in a series of 25 patients. Preoperative and late postoperative films were digitalized to obtain a precise measurement of the bone displacements and changes in the caliber of the retrovelar and retrolingual spaces. The statistical analysis examined the parameters modified by surgery, particularly airway parameters, and those factors which influenced these modifications. RESULTS: We observed a reduction in the retrolingual space [mean 1.7 mm (p < 0.05)] and displacement of the hyoid bone [mean 2 mm lowering compared with the bi-spinal plane (p < 0.05) and 4.1 mm setback in the Francfort projection (p < 0.01)]. These modifications were not correlated with the mandibular setback (measured as the gonial mental angle) but were strongly dependent on variations in the gonial angle. In 20% of the cases, mandibular setback produced a paradoxical effect: enlargement of the airways. DISCUSSION: Little work has been done on the modifications in the upper airways provoked by osteotomies. Mandibular setback osteotomy can, though only a few cases have been reported, create an anatomic situation favoring obstructive sleep apnea. This series demonstrated the very wide variability of the effects on the upper airways. CONCLUSION: The risk of apnea should be included as an important parameter in assessing indications for setback osteotomy.

Metastatic pulmonary calcification after renal transplantation.

Metastatic pulmonary calcifications, unlike dystrophic calcifications, occur in the normal healthy lung. The radiological pattern is quite specific. The disease is commonly described in chronic renal failure with calcium disorders. The prognosis is totally unpredictable. In 1992, a 50 yr old man underwent a successful renal transplantation during the final stage of chronic renal failure. He subsequently developed asymptomatic diffuse nodular opacities, that were discovered in 1995. An open lung biopsy confirmed the diagnosis of metastatic pulmonary calcification. There was no calcium disorder in this patient. In contrast to the benign course of pulmonary calcification in most patients, some fulminant pulmonary calcifications complicating renal transplantation or hypercalcaemia have been described. Radiographic identification of such entities is important to permit correction of calcium disorders. Otherwise, the condition is a potentially progressive and fatal cause of respiratory failure.