Elisabeth Sauvaget

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) × 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.

Sudden sensorineural hearing loss as a revealing symptom of vestibular schwannoma

Conclusions Sudden sensorineural hearing loss (SSHL) is a frequent symptom of vestibular schwannoma (VS), often reveals small VSs and does not exhibit specific features. Therefore, every case of SSHL should be evaluated using systematic MRI to rule out VS in order to improve hearing and preservation facial nerve function. Objective SSHL leads to the discovery of a VS in a small proportion of cases (2%). However, SSHL appears to be a more frequent occurrence in the history of patients with VS (3–23% in the literature), suggesting a large disparity in the evaluation of SSHL. Material and methods A total of 139 consecutive unilateral VSs operated on between 2000 and 2002 were reviewed and analyzed regarding the prevalence, clinical and audiological features of SSHL and their relation to the size of the tumor. Results SSHL was observed in 20% of cases at some point in their VS history. The characteristics of SSHL were: (i) lack of a specific audiometric pattern, except that low-tone loss was rare; and (ii) a high rate of hearing recovery (50%). Tumor size was significantly smaller in SSHL-associated VSs compared to other VSs. In the former cases, 96% involved the internal auditory canal.

Our experience in the management of petrous bone cholesteatoma.

We present the management of a series of petrous bone cholesteatomas. We performed a retrospective analysis on 28 patients with petrous bone cholesteatoma who underwent surgery between 1991 and 2008 at Lariboisiere Hospital, Paris, France. Main outcome measures included age of patients, surgical approaches, complications, and recurrence. The mean age was 47 years. Five were congenital cholesteatomas and 23 were acquired ones. Seventeen patients had undergone previous mastoid surgery elsewhere. Ninety-six percent of patients presented with hearing loss and 37.5% with facial nerve palsy. The surgical approaches varied according to the classification. Postoperatively, four patients developed facial nerve palsy; two patients, XII nerve paresis; one patient, X nerve paresis; and eight patients, deafness. The mean follow-up was 5 years. Twenty patients had no long-term recurrence. Two cases of petrous apex cholesteatoma presenting with double vision were removed by an endoscopic transsphenoidal approach. Control of the lesion was satisfactory in both cases. However, a minor pontic stroke resulted in transient hemiparesis in the case with dehiscent dura around the petrous bone cholesteatoma. Petrous bone cholesteatoma surgery is difficult. Lateral transtemporal and middle fossa approaches are classically used to remove petrous bone cholesteatoma. Recent progresses in endoscopic surgery, using image guidance system, allow removal of the petrous apex cholesteatoma by an endoscopic transsphenoidal approach with minimal morbidity.

Potassium channel ether à go-go mRNA expression in the spiral ligament of the rat

Identification of the K+ transporters located in the lateral wall of the cochlea is essential for a better understanding of the mechanisms by which a positive endocochlear potential and a high K+ concentration are achieved in endolymph. In this study, we have determined the distribution of the K+ channel rat ether à go-go (eag) mRNA in the cochlea. After reverse transcription of adult rat cochlear tissues, cDNA was amplified with primers specific to eag channel. The eag mRNA was localized in cochlear tissues by in situ hybridization using specific oligonucleotide probes tailed with digoxigenin conjugated UTP. Eag mRNA was detected in the organ of Corti but mainly in the fibrocytes of the spiral ligament but not in spiral prominence or in stria vascularis. The expression pattern of rat eag transcript in spiral ligament is complementary to the Na+,K+-ATPase distribution in the cochlear lateral wall. The localization of eag mRNA suggests that eag potassium channel may be produced in the corresponding cells. Considering the importance of the K+ gradient in the cochlea, the result reported here suggests that eag channel may play a role in the control of K+ fluxes in the spiral ligament.

Minimally invasive video-assisted thyroidectomy: Learning curve in terms of mean operative time and conversion and complication rates

The purpose of this study was to evaluate the learning curve for minimally invasive video‐assisted thyroidectomy (MIVAT).

Juvenile Nasopharyngeal Angiofibroma Does the External Approach Still Make Sense

Objective The aim of this study was to review recent management of juvenile nasopharyngeal angiofibroma (JNA) in our institution during the past 10 years and to analyze the shift in surgical paradigm based on the rate of endoscopic approach and Radkowski staging. Study Design Case series with chart review. Setting The study was conducted from April 2000 to August 2010 in a tertiary care university hospital (Lariboisière, Paris, France). Subjects and Methods All patients referred for a JNA were included in the study. Medical files and imaging data were retrospectively analyzed. Surgical management was then evaluated for 2 different periods (group 1, n = 31, consecutive patients operated on from April 2000 to June 2005, and group 2, n = 41, from July 2005 to August 2010). Results Seventy-two patients were operated on, with a mean age of 16.25 years (range, 9-33 years). The rate of the endoscopic approach was significantly higher in group 2 than in group 1 (82.9% vs 45%). Rates of recurrence and complications were similar. Recurrences (ie, residual disease growing and treated by redo) were noted in 6 cases or 8.3% (group 1, n = 3; group 2, n = 3; P > .05). Conclusion Progress in skull base anatomy, instrumentation, cameras, and surgical strategy allows for expansion of the indications for endoscopic removal of JNA. This approach may have a better outcome in terms of blood loss, hospital stay, and local sequelae. Still, an external approach should be considered only for selected cases due to massive intracranial extension or optic nerve or internal carotid artery entrapment by the tumor.

Intrasphenoidal transsellar encephalocele repaired by endoscopic approach.

Spontaneous sphenoidal encephaloceles are rare entities. In the case of intrasphenoidal encephaloceles, most defects are temporosphenoidal and occur in the lateral wall of the sphenoidal sinus. There have been to our knowledge only 7 reports of medial, transsellar encephaloceles in the literature. We report a case of intrasphenoidal transsellar encephalocele that was successfully managed through an endoscopic approach with complementary lumboperitoneal shunting. This disorder presents a challenge in surgical management because of the involvement of opticochiasmatic structures, the hypothalamopituitary axis, and the delicate vasculature of the circle of Willis in and around the encephalocele, besides proximity to the cavernous sinus. Rhinologists should be aware of these malformations, since the optic nerve or chiasma may be totally exposed in the sphenoidal sinus in the course of this disease. This case illustrates the need for magnetic resonance imaging in case of sphenoidal abnormalities, as well as the possibility of endonasal repair without a transcranial approach for large intrasphenoidal encephaloceles.

Ethmoid sinus osteoma: diagnosis and management.

Ethmoid sinus osteomas are uncommon, benign, osteogenic tumors. The purpose of this retrospective study was to describe their usual clinical presentation and to discuss their surgical management.

Comparison of 3 procedures for hypoglossal-facial anastomosis.

Objective We aimed to evaluate rehabilitation of complete facial palsy with 3 procedures for hypoglossal–facial anastomosis: end-to-end (“original”), partial end-to-end with interpositional jump grafting (“jump”) and the new partial end to end without grafting (“modified”). Methods A medical jury reviewed videos of 36 patients with complete facial palsy who underwent surgery from 1998 to 2008 by original (n = 13), jump (n = 13), and modified (n = 10) procedures. The jury of 5 ear, nose, and throat surgeons who were blinded to the procedure evaluated rehabilitation by 3 facial nerve grading systems—House and Brackman (HB), Sunnybrook, and Freyss scales—and 3 subjective scores for the face at rest and during voluntary and emotional motions. Results Recovery time was shorter with the modified and original procedures than jump procedure (5, 6, and 8 mo, respectively). All patients achieved at least good results. Scores on the HB scale (I–VI) were mainly III. HB and Sunnybrook scores did not differ by procedure. Freyss score was better for the modified procedure than original and jump procedures. Scores for the face at rest did not differ by procedure, but those during voluntary and emotional movements were worse for the jump procedure than for other procedures. Synkinesis was more severe with the original procedure than other procedures. Conclusion The 3 procedures give satisfactory results for rehabilitation after surgery for facial palsy. The original procedure should be performed in patients with strong mimic or long-standing facial palsy. The jump procedure is delicate and entails risk of weak reinnervation. The modified procedure is a good compromise in terms of muscle tone and side effects.

Surgical treatment of facial nerve schwannomas.

Facial nerve schwannomas are rare. They occur all along the nerves course from the cerebellopontine angle to the parotid region. Clinically, intracranial facial nerve schwannomas often present with facial nerve paralysis or hearing loss and may initially be misdiagnosed as vestibular schwannomas. Modern imaging techniques allow diagnosis and evaluate tumor location, size and extension. Functional tests evaluate facial nerve and hearing function. All this information results in an individual management plan. Microsurgery, stereotactic radiosurgery and observation are the therapeutic options. Surgery is planned depending on tumor features and the preoperative functional status. Subtemporal, transmastoid, translabyrinthine and retrosigmoid approaches are the principal routes. Preservation of facial nerve function is the main surgical difficulty. Anatomical nerve conservation, nerve resection with immediate grafting or delayed hypoglosso-facial nerve anastomosis are possible. The main predicting factors of postoperative facial function are the degree and duration of facial paralysis before surgery. Observation is an option for small tumors and asymptomatic patients. In these cases, a close follow-up is mandatory. The optimal timing for surgery is critical: waiting maximizes the time with good facial function, but increases the risk of hearing loss by cochlea erosion and lowers the chances of postoperative facial nerve recovery once paralysis has occurred. The role of radiosurgery is still to be determined: it seems suitable for inoperable patients and recurrent tumors.