D. Bakhos

Conservative Management of Acute Mastoiditis in Children

OBJECTIVEnTo determine whether treatment of acute mastoiditis in children using antibiotics combined with retroauricular puncture and grommet insertion is effective compared with standard management with mastoidectomy.nnnDESIGNnRetrospective study.nnnSETTINGnTertiary pediatric center.nnnPATIENTSnWe identified 50 patients younger than 14 years with acute mastoiditis (mean age, 32 months). Individuals with subacute mastoiditis and cholesteatoma were excluded from this study. All the children had received antibiotic drug treatment. Before 2002, a subperiosteal abscess (SA) was managed by mastoidectomy. Beginning in 2002, however, conservative management was initially attempted to avoid mastoidectomy.nnnMAIN OUTCOME MEASUREnThe proportion of cured children after conservative management of SA in acute mastoiditis.nnnRESULTSnAcute mastoiditis occurred in 30 patients already treated with antibiotics before hospital admission. On examination, 1 child had facial palsy. All the patients except 1 (who had temporozygomatic swelling) had postauricular swelling. Myringotomy or retroauricular puncture isolated bacteria in 38 patients. Streptococcus pneumoniae was identified in 28 patients. Computed tomography (43 patients) diagnosed 31 SAs, including 3 cases of sigmoid sinus thrombosis and 1 subdural abscess. All the children were cured without complications regardless of the type of treatment. Comparing the periods before and after 2002, the number of SAs was similar (15 and 16, respectively), but the number of mastoidectomies was reduced (16 and 1, respectively). The hospital length of stay of patients who underwent aspiration was shorter than that of patients who underwent cortical mastoidectomy.nnnCONCLUSIONnAntibiotic drug use combined with retroauricular puncture and grommet insertion is an effective alternative to mastoidectomy in the treatment of acute mastoiditis with SA in children.

Three-dimensional modeling of the temporal bone for surgical training.

Introduction: The anatomy of the temporal bone (TB) can only be mastered by repeated surgical and anatomic dissections, and surgical teaching initiative had a major effect on outcomes. The aim of this study was to investigate the validity of an artificial TB model devoted to surgical training and education. Materials and Methods: A helical computed tomographic (CT) scan was used to acquire high-resolution data of cadaveric TB. Digital imaging and communications in medicine (DICOM) data were converted into.stl files after data processing. Cadaveric TBs were prototyped using stereolithography. The validation of the prototype needed several steps. First of all, we have studied on CT scan the positional relationship between the facial nerve and other structures of the cadaveric TBs and prototyped bones. Otoendoscopy of the middle ear and the internal acoustic canal and visualization of anatomic landmarks during TB drilling of the cadaveric TBs and prototyped bones were also performed. Results: Seven normal CT scans of cadaveric TB were selected to make prototyped bone using stereolithography. Measurements of volume and distance showed no significant difference between prototypes and cadaver TBs. Classic mastoid surgical procedures were performed in the Anatomy Department: exposing sigmoid sinus, facial nerve, labyrinth, dura mater, jugular bulb, and internal carotid artery. Two simulations of implantable middle ear prosthesis were made successfully. Conclusion: These prototypes made using stereolithography seem to be a good anatomic model for surgical training. This model could also be interesting for surgical planning in congenital ear anomalies before middle ear prosthesis implantation.

Revision surgeries and medical interventions in young cochlear implant recipients

OBJECTIVEnTo report devices failures and postoperative or medical complications after cochlear implantation in children and to discuss revision surgeries and medical interventions occurring during follow-up.nnnMETHODSnIn this retrospective study in a tertiary referral pediatric hospital, we included a consecutive sample of children younger than 15 years old who received implants between January 1994 and June 2010. All complications and treatments were systematically reviewed.nnnRESULTSnOne hundred and forty children were included in this study. Four children received bilateral cochlear implantation. Mean age at implantation was 43.6 months (age ranged from 11 months to 15 years). Overall, 74 children were boys (52.1%) and 35 children (25%) received implants before the age of two. Inner ear malformations were found in 19 children (13.5%), while 18 children (12.9%) experienced complications: cochlear reimplantations (n=8), other revision surgeries (n=3) and medical treatment (n=7). Excluding device failures, 13 children (9.2%) experienced complications. Postoperative infection was the principal cause of these complications (10 cases). Four children younger than 2 years at implantation suffered complication postoperatively. In these children, there was no statistically significant increase in complications compared to older children (P>0.05). Complete electrode insertion was achieved in 7 of the 8 reimplanted children.nnnCONCLUSIONnCochlear implantation could be considered a safe and reliable rehabilitation for deafened young children. Reimplantation was feasible and complete electrode insertion was achievable. Long-term follow up was mandatory to minimize and control surgical complication.

Midmodiolar reconstruction as a valuable tool to determine the exact position of the cochlear implant electrode array.

Hypothesis: A midmodiolar reconstruction with multislice computed tomography could potentially be used clinically to determine the cochlear implant electrode array position if the technique was validated with a cadaveric temporal bone study. Background: Several radiologic studies using sophisticated techniques have been described. This study was designed to validate a standard multislice computed tomography scan technique to determine the electrode array position. Methods: This ex vivo study was conducted on 18 cadaveric temporal bones without malformation. Cochlear electrode dummies were implanted by a single experimented surgeon with the Advance Off-Stylet technique. After randomization, the placement was processed through an anteroinferior or superior cochleostomy for respective scala tympani or vestibuli positioning with direct location of the basilar membrane. Cadaveric temporal bones were then scanned (Philips Brilliance 40 computed tomographic scan) and reconstructed into the midmodiolar computed tomography scan plane (±45 degrees, z-axis in the cochlear coordinate system). Two independent neuroradiologists, who were unaware of the implanted scala, evaluated the electrode array position on a computed tomographic scan through the midmodiolar reconstruction. In the end, the microanatomic study was the criterion standard to determine the exact scala localization of the electrode array. Results: Nine electrodes were inserted into the scala tympani, and 9 were inserted into the scala vestibuli. According to our anatomic criterion standard, the midmodiolar reconstruction sensitivity and the specificity for the scala tympani position were 0.875 (range, 0.722-1.0) and 1.0, respectively; the sensitivity and specificity for dislocation and the scala vestibuli position were both 1.0. The radioanatomic concordance was 0.94 (range, 0.89-0.98) for determining the electrode array position into scalae with midmodiolar reconstruction. Conclusion: Our cadaveric study validates midmodiolar reconstruction as a valuable tool to routinely determine the precise position of the cochlear implant electrode array. This study opens the field for further clinical studies.

Cancer of the external auditory canal.

INTRODUCTIONnCancer of the external auditory canal is a rare tumour with an annual incidence of one per one million inhabitants. The objective of this study was to evaluate the 5-year overall survival and disease-free survival rates in a series of patients with carcinoma of the external auditory canal and to compare our results concerning the clinical presentation, management and survival with those of the literature.nnnPATIENTS AND METHODnTen patients were included in this retrospective, single-centre study over a 20-year period. Data concerning age, symptoms, imaging, TNM stage according to the Pittsburgh classification, histology, management, sequelae, recurrences and survival were recorded.nnnRESULTSnThe mean age of the patients of this series was 60.7 years. Seven patients had a squamous cell carcinoma. The other histological types were undifferentiated carcinoma, adenoid cystic carcinoma and neuroendocrine carcinoma. Staging was based on the Pittsburgh classification with one stage I, one stage III and eight stage IV tumours. Five-year overall survival rates were 100%, 50% and 0%, respectively. The mean 5-year overall survival rate was 35% and the mean 5-year disease-free survival rate was 24%.nnnCONCLUSIONnCarcinoma of the external auditory canal is a difficult diagnosis when the tumour does not present as a fungating mass protruding from the external auditory canal. The Pittsburgh classification was used for TNM staging of these tumours, allowing comparison of our results with those of the literature. The clinical findings and survival rates observed in this study are comparable to those reported in the literature. These tumours are associated with a poor prognosis on the basis of our results and published data.

Transoral robotic surgery versus conventional surgery in treatment for squamous cell carcinoma of the upper aerodigestive tract

The purpose of our work was to compare a group of patients undergoing transoral robotic surgery (TORS group) for squamous cell carcinoma of the upper aerodigestive tract and a matched group of patients undergoing conventional surgery (conventional surgery group) for the same indication.

A review of 89 revision stapes surgeries for otosclerosis.

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

Radiofrequency tonsillotomy versus bipolar scissors tonsillectomy for the treatment of OSAS in children: A prospective study

INTRODUCTIONnTonsillotomy is an effective treatment for the management of obstructive sleep apnoea syndrome (OSAS) in children with tonsillar hypertrophy and appears to be associated with less pain and postoperative morbidity.nnnOBJECTIVEnTo compare postoperative morbidity and short-term and intermediate-term efficacy of radiofrequency tonsillotomy (TT) and bipolar scissors tonsillectomy (TE) in children.nnnPATIENTS AND METHODSnChildren with OSAS due to tonsillar hypertrophy were included in a prospective, non-randomized study between February 4, 2008 and March 20, 2010. Exclusion criteria were recurrent tonsillitis (≥ 3 episodes per year), clotting disorders and age less than 2 years. Postoperative complications, efficacy on OSAS, and operating times were evaluated. Pain was evaluated by the Postoperative Pain Measure for Parents score on D0, D1, D7 and D30.nnnRESULTSnOne hundred and ninety-three children were included: 105 in the TE group (age: 4.75 ± 2.37 years) and 88 in the TT group (age: 4.88 ± 2.6 years). The pain score was significantly lower in the TT group than in the TE group during the first postoperative week (P<0.05). A significant difference was observed for the secondary postoperative bleeding rate (1 after TT versus 8 after TE). No significant difference was observed between the two techniques in terms of the efficacy on OSAS. At 1 year, the tonsil regrowth rate in the TT group was 4.5%.nnnCONCLUSIONnRadiofrequency tonsillotomy is a safe technique for the treatment of obstructive tonsillar hypertrophy in children with good results on OSAS and a reduction of postoperative pain.

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

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

Ultrasound analysis of the upper esophageal sphincter during swallowing in the healthy subject.

OBJECTIVESnThe purpose of this study was to develop a methodology and standard settings for ultrasound study of the upper esophageal sphincter (UES) during swallowing.nnnMATERIAL AND METHODSnThis was a prospective study of 25 healthy volunteers (15 women and 10 men) aged 20 to 56 years. Neck ultrasonography was performed as each volunteer swallowed 10 mL of water three times. The parameters studied were: diameter of the closed UES; diameter of the open UES; anterior and lateral displacement (measured in cm) of the UES as the water bolus flowed through it; duration of UES opening; and average duration of UES displacement (measured in ms). Students t tests for paired and unpaired samples were applied for the statistical analysis.nnnRESULTSnThe mean diameter of the closed UES was 0.78 ± 0.13 cm, while the mean duration of opening was 415 ± 57.66 ms and the mean duration of displacement was 937 ± 120.98 ms. Maximum anterior and lateral displacement of the UES was 0.42 ± 0.12 cm and 0.35 ± 0.18 cm, respectively. There was a significant difference between men and women for lateral displacement of the UES (P=0.04).nnnCONCLUSIONnThis study established standards for ultrasound study of the UES during swallowing, using a non-invasive readily accessible method that may be useful for assessing swallowing disorders involving the UES (Zenkers diverticulum, fibrosis, stricture).