Fetal airway management on placental support: limitations and ethical considerations in seven cases.

The aim of this study was to evaluate the paediatric and maternal outcome after ex utero intrapartum treatment (EXIT). A retrospective review was carried out of the medical charts (gestational age, circumstances of diagnosis, multidisciplinary prenatal decision, date of surgery, paediatric and maternal outcome) of all the fetuses eligible for/delivered via the EXIT procedure in our paediatrics and obstetrics tertiary care and teaching centre, between October 2004 and May 2011. Seven fetuses with cervical teratoma, epignathus tumour or congenital high airway obstruction syndrome (CHAOS) were included in our study. Two pregnancies were terminated and five fetuses were delivered alive. The airway was secured in all five cases (two endotracheal intubations and three tracheostomies). No maternal complications were observed. On average, babies were delivered at 32 gestational weeks, and spent 31 days in the intensive care unit. All but one baby were ventilated for 18 days. Long-term paediatric outcome was favourable. It is concluded that airway management by the EXIT procedure has become an efficient technique. A multidisciplinary prenatal assessment is essential in order to select appropriate cases.

Imaging of tumors and tumor-like lesions of the knee.

Tumors and tumor-like lesions of the knee are common conditions. Because the synovial membrane covers a large part of the knee, tumors and tumor-like lesions of the knee are mostly synovial. Magnetic resonance imaging (MRI) plays a major role in the assessment and characterization of these lesions. However, the diagnostic approach of these lesions must be performed systematically. First, the lesion must be precisely located, and then the anatomical structure involved must be determined. Finally, clinical background that includes the age of the patient, frequency of the disease and, if any, associated signs as well as MRI characteristics must be analyzed. In this review, we describe the anatomy of the knee and its compartments and provide a description of the main tumors and tumor-like lesions of the knee. We present a diagnostic approach based on the location within the knee of the lesions and the anatomical structures involved.

Imaging of the postoperative knee.

On sagittal images after anterior cruciate ligament (ACL) reconstructions, the femoral tunnel aperture should be at the junction of the line drawn along the posterior femoral cortex and the line drawn along the roof of the intercondylar notch (Bluemensaat line). The tibial tunnel aperture should be in the anterior portion of the second third, i.e. anterior aspect of the middle of the tibial epiphysis. An inaccurate placement of the femoral tunnel affects the graft isometry. A tibial tunnel too anteriorly placed results in intercondylar notch roof impingement. After meniscus surgery, first-line MRI is often sufficient to diagnose new tears; however, sometimes it is necessary to perform CT arthrography or MR arthrography. Surgical cartilage repair is evaluated based on articular congruity and on the appearance of the subchondral bone.

Cartilage tympanoplasty for posterosuperior retraction pockets of the pars tensa in children.

OBJECTIVE: To assess the functional and anatomic results of cartilage grafting in children with a severe retraction pocket of the posterosuperior part of the pars tensa and operated on by pocket excision and cartilage grafting. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Fifty six children (60 ears) with severe posterosuperior retraction pockets. INTERVENTION: Excision of the pocket and tympanic reinforcement with a tragal or conchal cartilaginous graft. MAIN OUTCOME MEASURES: Postoperative anatomic (otoscopy, computed tomography) and functional (pure tone audiometry thresholds) outcome. The follow-up time was 27 +/- 18 months (mean +/- SD). RESULTS: Retraction recurrences requiring additional surgery occurred in 5 cases (8%). The risk of recurrence was lower in children older than 10 years and when the whole surface of the pars tensa was reinforced (chi(2) test, p< 0.05 for both factors). Functionally, hearing was improved even when the ossicular chain was intact. In case of disrupted ossicular chain, direct contact between the graft and eroded incudostapedial joint gave good hearing results. CONCLUSIONS: Cartilage reinforcement of the whole surface of the pars tensa is probably the best treatment of a severe posterosuperior retraction pocket. The flexibility and thinness of cartilage from the cymba conchae makes it particularly suitable in this indication.

Surgical treatment for laryngeal paralysis in infants and children.

Clinical and endoscopic data of 219 cases of laryngeal paralysis in newborns, infants, and children are briefly reported. The management of severe cases of persistent dyspnea then is discussed, according to the literature. Of 219 cases, 22 young patients underwent a surgical procedure because of lack of spontaneous recovery and poor tolerance of their disease after 6 to 9 months of follow-up. Arytenoidectomy technique has been used three times and arytenoidopexy 19 times, with fair to excellent results. Other possible treatments for infants are discussed. On the basis of this important series of surgical pediatric cases, the arytenoidopexy technique is advocated, besides arytenoidectomy, to avoid the risks of a long-term tracheostomy in young patients with vocal cord paralysis and severe dyspnea.

Aryepiglottic fold excision for the treatment of severe laryngomalacia.

Laryngomalacia is the most common laryngeal anomaly. Clinical presentation is most often associated with stridor, which usually resolves spontaneously by the second year of life. Infrequently, laryngomalacia can be severe and cause dyspnea and feeding difficulties. These children require surgical treatment, including tracheostomy. A new procedure has been recently described for the endoscopic excision of the aryepiglottic folds. The authors report results in 39 patients who have been treated with this procedure. One failure required tracheostomy. No recurrence of dyspnea was noticed in the other children. Gastroesophageal reflux, associated with 50% of our cases, was also noted in our only failure. We advocate endoscopic treatment in children with severe laryngomalacia.

Involvement of cochlear nerve in acoustic tumours.

With conventional light and transmission electronmicroscopy we studied 10 cases of acoustic nerve tumour, 3 of which proved to be instances of von Recklinghausen neurofibroma and 7 of schwannoma. Schwannomas were not found to infiltrate the cochlear nerve. Hearing loss, if present in cases of schwannoma, could be related to non-specific lesions of the uninfiltrated cochlear nerve in the vicinity of the vestibular nerve tumour. Only neurofibromas were found to infiltrate the cochlear nerve. Distinction between tumour infiltration and non-specific lesion could be made by electron microscopy.

The origin of acoustic neuromas.

Small acoustic neuromas, operated on through transpetrosal approaches were studied by light and transmission electron microscopy. All schwannomas were found to interpenetrate the vestibular ganglion without a space or a capsule. In the abnormal ganglion areas, free tumour Schwann cells were observed. These results suggest that acoustic neuromas originate from the vestibular ganglion. The fact that the sheath of vestibular ganglion bipolar cells in man are devoid of myelin may account for the elective origin of acoustic neuromas in the Scarpa ganglion in the human.

[Acute external mastoiditis in children: report of a series of 48 cases]. / Mastoïdites aiguës extériorisées de l'enfant: à propos d'une série de 48 cas.

DESIGN: To determine the impact of the emergence of penicillin-resistant strains of pneumococci on the frequency of acute mastoiditis in children, and to assess the importance of laboratory and imaging studies in the treatment of acute mastoiditis. METHOD: Retrospective review of the medical records of children with postauricular swelling and otoscopic signs of acute otitis media from January 1993 through December 2000. RESULTS: Forty-eight children aged three months to 14 years (median 17 months) were identified. The number of cases was almost the same from one year to another. All children had bacteriological examinations. The mastoid pus and the otorrhea was sterile in 22 cases. The most frequent pathogen was Streptococcus pneumoniae (17 cases), which was resistant to penicillin in 71% of cases. The initial body temperature, the number of polymorphonuclears and the CRP were not different between the group of 18 children with periostitis, which required medical treatment alone, and the group of 30 children who had a mastoid abscess which required surgery. The difference between periostitis and mastoid abscess was seen on clinical examination and CTscan.

[Variations of nasopharyngeal pH in nasopharyngitis in children]. / Variations du pH rhinopharyngé dans les rhinopharyngites de l'enfant.

In view of the well-known relationship between gastro-oesophageal reflux (GOR) and inflammatory diseases of the bronchi, trachea and larynx, the possibility of a pathogenic acid reflux reaching the pharynx has sometimes been suspected but never demonstrated. Paediatric E.N.T. specialists are often confronted with chronic inflammatory rhinopharyngitis of no obvious origin. In order to test the hypothesis of rhinopharyngeal contamination by gastric acid, the nycthemeral local pH was recorded in children presenting with chronic rhinopharyngitis and gastro-oesophageal reflux, and in two groups of controls without rhinopharyngitis and with or without GOR. Falls in rhinopharyngeal pH were found to be more frequent and to last longer in the 18 patients than in controls. The most significant criterion was the time during which the pH was lower than 6 compared with the total time of recording in these cases where pharyngeal pH measurements were recorded over 15 to 26 hours. It seemed most probable that this acidity resulted from the gastro-oesophageal reflux. Such variations in acid-base balance at the surface of a respiratory mucosa might be instrumental in the genesis or maintenance of the nasopharyngeal inflammatory reaction. However, these two hypotheses must be confirmed or infirmed by further studies.

[Measurement of pH of the rhinopharynx in children with gastroesophageal reflux]. / Mesure du pH du rhinopharynx chez l'enfant atteint de reflux gastro-oesophagien.

The relationship between gastro-oesophageal reflux and inflammatory airway pathology is well known as regards the trachea and bronchi. It is disputed by some authors but clearly established by others as regards the pharynx and larynx (recurrent laryngitis, subglottic stenosis, laryngospasm). A number of authors have empirically observed that gastro-oesophageal reflux is associated in some cases with chronic inflammation of the rhinopharynx and middle ear. We studied the 24-hour pH of the rhinopharyngeal mucosa in 3 groups of children: 3 healthy children acting as controls, 1 child with known gastro-oesophageal reflux but without rhinopharyngeal pathology, and 2 children with both gastro-oesophageal reflux and mucosal obstruction of the nose and pharynx unascribable to the usual causes. Minimal to considerable variations of rhinopharyngeal pH were observed in children of the third group, while controls had a remarkably stable 24-hour pH (6.7 to 7.4 depending on the subject). Owing to the small number of cases studied, these results should be regarded as preliminary and devoid of significant value concerning the real impact of the acid reflux on rhinopharyngeal pathology.

[Perilymphatic fistula]. / Fistule périlymphatique.

Perilymphatic fistulae are the first cause of perceptive deafness that may be amenable to surgical treatment. After a complete study of the literature, we have made a retrospective analysis of 48 ear explorations in 37 children. These children presented with a variable degree of progressive or fluctuating perceptive deafness without any obvious etiology. Computed tomography, especially aimed at detecting an abnormality in the patency of the aqueduct of the cochlea, seems to be the most efficient criterion of selection to establish an indication for surgical exploration. The extent of the perilymphatic fistulae and their location, mainly at the level of the fissura ante fenestram, call to our mind the possibility of an arrest in the differentiation of the otic capsule, with a persistent anomalous patency of the aqueduct of the cochlea. The results of this study mainly demonstrate stabilizations of hearing, while spectacular improvements still are anecdotal. On the other hand, morbidity is very low and mainly results from insufficient surgery to fill in the fistula. Further studies are needed, especially to better understand the pathophysiology of the perilymphatic fistulae, and their results must certainly be appreciated in the longer term.

[Pathology and surgery of tumors located under the internal auditory canal. 1. Neurinoma of mixed nerves]. / Pathologie et chirurgie des tumeurs situées sous le conduit auditif interne. I. Les neurinomes des nerfs mixtes.

The schwannomas of foramen jugulare are infrequent although progress in diagnosis of these tumors have been obtained by CT scan. We report five cases of the caudal nerves that where developed into the foramen jugulare. One may suspect these tumors in presence of any minimal, unilateral defect of otological, facial and pharyngo-laryngeal functions. The surgical approach to the tumors depends of both its location and its symptomatology. The mastoid-retro-sigmoid approach allow in most cases to preserve the eight and seven nerve functions.

[Long-term esophageal and oropharyngeal pH-metry in ORL manifestations of gastroesophageal reflux in children]. / La pH-métrie couplée, oesophagienne et oro/hypopharyngée, de longue durée dans les formes ORL de reflux gastro-oesophagien de l'enfant.

Several studies published over the last few years have pointed out the importance of gastroesophageal reflux (GER) in the pathogenesis of certain cases of chronic or recurrent pharyngo-laryngitis. While the presence of an acid reflux at the level of the pharyngo-larynx has recently been demonstrated in certain cases, the real incidence and pathogenic impact of this reflux is not precisely known. A new technique of continuous 24 hour bi-level monitoring of endoluminal pH in the esophagus and the oro/hypopharynx has made it possible to observe the variations in acid-base balance in contact with the pathological mucosa. 21 patients, 2 months to 7.5 years old, presenting recurrent episodes of pharyngitis or laryngitis, underwent continuous pH monitoring during a 24 hour hospitalization. 6 control subjects, 1 month to 13 years old, presenting no chronic or recurrent ear, head or neck pathology and no sign or symptom of GER were subjected to the same monitoring regimen. A statistically significant difference between the 2 groups is evident for most of the parameters analysed. The most discriminative parameter is the fraction of the total recording time where the pharyngeal readings remain under ph6 (p < 0.0005). These results demonstrate that, in this clinical condition, acid of gastroesophageal origin is in contact with the pharyngeal mucosa. This suggests that the acid has a causal role in the pathological changes observed in the pharyngolaryngeal mucosa.

[Surgery of acoustic neuroma and other tumors of the internal auditory canal and cerebellopontile angle. Apropos of 602 cases]. / Chirurgie du neurinome de l'acoustique et autres tumeurs du conduit auditif interne et de l'angle ponto-cérébelleux. A propos de 602 cas.

During the last two decades, 602 tumors of the internal auditory canal and of the cerebello-pontine angle were operated on, using the trans-temporal approaches. Among these tumors, 548 were unilateral acoustic neuromas, that were removed by the trans-labyrinthine approach (57%), the retro-labyrinthine-retro-sigmoid approach (33%) and the middle fossa approach (M.F.) (6%). Five fatalities occurred (1%). The facial nerve was preserved in 94% with an immediate normal function in 58%. The auditory function was preserved in 23% (51 cases).

[Origin of acoustic neuroma]. / L'origine des neurinomes de l'acoustique.

Acoustic neurinomas are vestibular schwannomas. Ultramicroscopic examination of the root of these tumors, removed using a petrosal approach (translabyrinthic, suprapetrosal) in 20 cases, investigated the site of origin of the schwannoma. Tumoral capsule was absent between Scarpa's ganglion cells and tumoral cells, these two types of cells being intermingled. The fact that the very small tumors, 3 to 5 mm in diameter, were all derived from Scarpa's ganglion and were separated by a capsule from the other structures of internal auditory canal prove that acoustic neurinoma arises from Scarpa's vestibular ganglion. Other studies have shown the absence of myelin surrounding bodies of Scarpa's ganglion cells in humans, inversely to findings in other vertebrates. Since on the one hand the appearance in humans is similar to that observed during development of Scarpa's ganglion in the rat, and on the other hand acoustic neurinoma has never been demonstrated in the animal, it can be suggested that acoustic neurinoma development in humans corresponds to cellular immaturity of Scarpa's ganglion.

[Neurinoma of the intratemporal facial nerve. Anatomo-clinical classification of 12 cases]. / Neurinomes du nerf facial intra-temporal. Classification anatomo-clinique de 12 cas.

Neuromas of the intratemporal facial nerve are uncommon benign tumors, mostly schwannomas. An anatomo-clinical classification is proposed in view of the 12 cases reported here: neuromas of the internal auditory canal and of the cerebello-pontine angle, presented as a sensorineural hearing loss; neuromas of the geniculate ganglion area, presented as a progressive facial palsy, or mimicking a facial palsy a frigore; tympano-mastoid neuromas, presented as a retro-tympanic mass or a tumor extended into the external auditory canal, associated with a conductive hearing loss. Complete excision of the tumor requires the resection of a segment of the nerve that is immediately restored with end-to-end anastomosis or placement of a cable-graft. In some cases, however, the facial nerve can be preserved.

[Surgical management of laryngeal stenosis in children]. / Traitement chirurgical des sténoses laryngées de l'enfant.

Surgical management of children with laryngotracheal stenosis changed recently because of the procedure of single-stage approach. Between January 1992 and April 1997, 101 children underwent surgery for laryngotracheal stenosis in our department: 47 of them had a single stage procedure, and 54 a classic laryngotracheoplasty with stenting with an Aboulker's tube or silastic sheets. The majority of the cases were acquired stenosis (64%) and the others congenital. The degree of stenosis was graded into four categories according to Cotton's classification. Thirty six cases were grade 2, 44 cases were grade 3, 21 cases were grade 4. Subglottic localization of the stenosis was found in 64% of the cases and the mobility of the vocal folds was normal in 60% of the cases. The surgery was considered successful after one procedure when there was a permanent and permeable laryngotracheal lumen (no more than grade 1) not requiring a tracheotomy. Of the 47 single-stage procedures, 38 were successful (81%); of the 54 cases managed with classic methods, 30 were successful (55%). These results and the indications of the different surgical procedures are discussed.

[Current status of petrositis]. / Les pétrosites actuelles.

Actual symptomatology of petrositis is often poor; Gradenigo's syndromes are rare. Petrositis can occur as large cystic cholesterol granuloma of the petrous apex. Their C.T. scan, surgical and pathological aspects are different from cholesteatoma of the apex.

[The cochlear aqueduct and congenital perilymphatic fistula. An initial report]. / Aqueduc cochléaire et fistules péri-lymphatiques congénitales. Rapport préliminaire.

The authors present 3 preliminary case reports of congenital perilymphatic fistula and describe their approach, which in the presence of clinical symptoms composed of progressive or fluctuating deafness, should suggest the diagnosis of congenital perilymphatic fistula leading to examination of the cochlear aqueduct by high resolution computed tomography. An anomaly detected on the CT scan, particularly on the intermediate and internal segments, is a decisive argument in the decision to operate on these congenital perilymphatic fistulae.