Sylvain Moreau

Anatomic variations of the arteries of the nasal fossa.

OBJECTIVE: This study was performed for knowledge about the vascular supply of the nasal fossa and a description of the site of division and number of branches of the sphenopalatine artery. STUDY DESIGN: This study was performed on 10 fresh nonembalmed cadavers. Anatomic variations of nasal fossa arteries were studied. METHODS: First, 10 cephalic anatomic preparations were injected with red color latex into the right and left carotid arteries. Then, these specimens were sagittally cut to dissect the sphenopalatine artery. Twenty vascularization cases were studied for the external branch of the sphenopalatine artery, and 10 cases were studied for the internal branch. RESULTS: The principal observations were: 1, the sphenopalatine artery division is 18 times in the infratemporal fossa and twice in the nasal fossa; 2, the nasopalatine artery supplies blood to the lower part of the septum and its anterosuperior area; and 3, the vascularization of the external wall is via the sphenopalatine artery through the arteries of the meatus and conchae. CONCLUSION: This study defines the vascular territories of the nasal fossa arteries and includes photographs of dissections.

The recurrent laryngeal nerve: Related vascular anatomy

This study was based on 34 recurrent laryngeal nerve dissections after arterial casting with red‐colored latex. The aim was to provide specific information about the perineural microvasculature. This study established the following points: 1. a great anatomic variability does exist; 2. the laryngeal nerve is usually in relation to the posterior branch of the inferior thyroid artery; and 3. this vascular branch is sometimes replaced with a vascular network. In all cases, this microvascularization must be preserved during thyroid surgery. Key Words: Recurrent laryngeal nerve, anatomy, inferior thyroid artery.

Alagille syndrome with cavernous carotid artery aneurysm

We present a case of right sided blindness caused by a cavernous carotid artery aneurysm in a 17-year-old patient presenting with an Alagille syndrome. The diagnosis was made by magnetic resonance imaging and confirmed by angiography. This aneurysm was treated successfully with endovascular placement of detachable balloons. Cerebral vascular malformations are rarely reported in association with this syndrome. We discuss the clinical presentation, diagnosis, treatment and detection of this type of abnormality.

Persistent stapedial arteries in human: from phylogeny to surgical consequences

The stapedial artery is an embryonic artery which disappears during the tenth week in utero, in human species. During its short life, this artery shapes the stapes and transforms the middle meningeal artery from the internal carotid artery to a branch of the external carotid system. Nevertheless, a persistent stapedial artery is seen in 0.2–4.8 per thousand of human adults. This persistence is usually asymptomatic but can sometimes cause pulsatile tinnitus or conductive hearing loss. Despite the risk of facial palsy, hearing loss and even hemiplegia argued by several authors, some surgeons have succeeded in coagulation without side effects. Reviewing the literature, we seek to enlighten the actual knowledge about the persistent stapedial artery to evaluate the risk to coagulate it. Embryologic studies explain the four types of persistent stapedial arteries: the hyoido-stapedial artery, the pharyngo-stapedial artery, the pharyngo-hyo-stapedial artery and aberrant internal carotid with persistent stapedial artery. Phylogenetic studies show that the stapedial artery persists in adulthood in many vertebrates. Its disappearance is therefore either a random effect or an adaptative convergence. This adaptation could be partially linked to the negative allometry of the stapes. Practically, the risk to coagulate a stapedial artery seems limited thanks to anastomoses, for example with the stylomastoid artery. The risk of hemiplegia reported is in fact an extrapolation of variation in rats’ embryos. A persistent stapedial artery can therefore reasonably be coagulated, with special attention to the facial nerve, because the facial canal is always dehiscent where the artery penetrates.

Failure of antibiotic therapy in acute otitis media

The aim of this retrospective study was to determine the possible causes of failure of antibiotic therapy in children with acute otitis media (AOM). Thirty-nine samples of middle-ear fluid were obtained by myringotomy from 31 children suffering from AOM, unrelieved by antibiotic therapy administered for over 48 hours. The samples were analysed by the usual microbiological techniques, including cultures, tests for beta-lactamase producing strains and the determination of the minimal inhibitory concentration of penicillin for Streptococcus pneumoniae. In 14 samples, no bacterial strains were detected in the cultures of middle-ear fluid; and in two samples the cultures revealed two strains of bacteria. The bacteria most frequently identified were Haemophilus influenzae, found in 11 samples, and Streptococcus pneumoniae, found in seven samples, of which four produced strains with reduced susceptibility to penicillin. The failure of antibiotic therapy in AOM appears to be related to the increased resistance of Haemophilus influenzae and to the reduced susceptibility of Streptococcus pneumoniae to penicillin. Other factors contributing to the failure of antibiotic therapy in AOM may be the viruses or the bacteria that produce multiple pathogens in the middle ear.

Facial Nerve: Vascular-Related Anatomy at the Stylomastoid Foramen

We dissected 30 facial nerves in fresh cadavers after arterial casting with red latex to provide specific information about the arterial-related anatomy of the trunk of the facial nerve from the stylomastoid foramen to its bifurcation. We found that a wide anatomic variability does exist. The trunk of the facial nerve was in proximity to the stylomastoid artery, which originated from the posterior auricular artery in 70% of the specimens (21/30), from the occipital artery in 20% (6/30), and directly from the external carotid artery in 10% (3/30). The stylomastoid artery passed medially to the trunk of the facial nerve in 63 of the specimens (19/30) and laterally in 37% (11/30). Among these 11 specimens, 8 were large-caliber stylomastoid arteries. During parotid surgery, the main trunk of the facial nerve may be difficult to identify, because a large-caliber stylomastoid artery can mask it. Therefore, it is important to dissect this artery with caution.

Lateral Semicircular Canal Asymmetry in Idiopathic Scoliosis: An Early Link between Biomechanical, Hormonal and Neurosensory Theories?

Introduction Despite its high incidence and severe morbidity, the physiopathogenesis of adolescent idiopathic scoliosis (AIS) is still unknown. Here, we looked for early anomalies in AIS which are likely to be the cause of spinal deformity and could also be targeted by early treatments. We focused on the vestibular system, which is suspected of acting in AIS pathogenesis and which exhibits an end organ with size and shape fixed before birth. We hypothesize that, in adolescents with idiopathic scoliosis, vestibular morphological anomalies were already present at birth and could possibly have caused other abnormalities. Materials and Methods The vestibular organ of 18 adolescents with AIS and 9 controls were evaluated with MRI in a prospective case controlled study. We studied lateral semicircular canal orientation and the three semicircular canal positions relative to the midline. Lateral semicircular canal function was also evaluated by vestibulonystagmography after bithermal caloric stimulation. Results The left lateral semicircular canal was more vertical and further from the midline in AIS (p = 0.01) and these two parameters were highly correlated (r = -0.6; p = 0.02). These morphological anomalies were associated with functional anomalies in AIS (lower excitability, higher canal paresis), but were not significantly different from controls (p>0.05). Conclusion Adolescents with idiopathic scoliosis exhibit morphological vestibular asymmetry, probably determined well before birth. Since the vestibular system influences the vestibulospinal pathway, the hypothalamus, and the cerebellum, this indicates that the vestibular system is a possible cause of later morphological, hormonal and neurosensory anomalies observed in AIS. Moreover, the simple lateral SCC MRI measurement demonstrated here could be used for early detection of AIS, selection of children for close follow-up, and initiation of preventive treatment before spinal deformity occurs.

New treatment of vertigo caused by jugular bulb abnormalities.

Objective. Jugular bulb abnormalities can induce tinnitus, hearing loss, or vertigo. Vertigo can be very disabling and may need surgical treatments with risk of hearing loss, major bleeding or facial palsy. Hence, we have developed a new treatment for vertigo caused by jugular bulb anomalies, using an endovascular technique. Patients. Three patients presented with severe vertigos mostly induced by high venous pressure. One patient showed downbeat vertical nystagmus during the Valsalva maneuver. The temporal-bone computed tomography scan showed a high rising jugular bulb or a jugular bulb diverticulum with dehiscence and compression of the vestibular aqueduct in all cases. Intervention. We plugged the upper part of the bulb with coils, and we used a stent to maintain the coils and preserving the venous permeability. Results. After 12- to 24-month follow-up, those patients experienced no more vertigo, allowing return to work. The 3-month arteriographs showed good permeability of the sigmoid sinus and jugular bulb through the stent, with complete obstruction of the upper part of the bulb in all cases. Conclusion. Disabling vertigo induced by jugular bulb abnormalities can be effectively treated by an endovascular technique. This technique is minimally invasive with a probable greater benefit/risk ratio compare with surgery.

State of the art of endoscopic frontal sinus cerebrospinal fluid leak repair.

Frontal sinus cerebrospinal fluid leaks are rare and their surgical management is difficult. Up until recently, they could only be treated by open surgery with an osteoplastic flap. With the development of endoscopic surgery, less invasive techniques such as an exclusive endoscopic approach can now be used, ensuring a simpler postoperative course. However, these techniques require a thorough knowledge of frontal sinus anatomy and endoscopic CSF leak repair. This knowledge is essential both to ensure closure of the CSF leak and to preserve frontal sinus patency.

Extended endonasal approach versus maxillary swing approach to the parapharyngeal space

The nasopharyngeal and parapharyngeal spaces are difficult for surgeons to access. Of the various external routes described, the maxillary swing has emerged as the gold standard because of its simplicity. However, its morbidity has led to the development of less invasive techniques. The purpose of our study was to compare the surgical anatomy of the maxillary swing with that of the endoscopic endonasal approach.