Valérie Franco-Vidal

Necrotizing external otitis: a report of 46 cases.

Objectives: To define germs involved, clinical presentation, treatment regimen, and prognostic factors in necrotizing external otitis. Patients and Methods: Retrospective study reviewing a series of 46 patients treated during 10 years in a tertiary care center. Diagnosis was confirmed by using otomicroscopy, computed tomographic and/or magnetic resonance imaging scan and bone scintigraphy (Te 99 and Ga 26 bone scan). Patients were provided ceftazidime and ciprofloxacin intravenously and monitored using a Ga-67 bone scan. The following were assessed: presenting symptoms, general context, bacteriological analysis, imaging protocol sensitivity, complications, delay to healing, and cure rate. Results: Sex ratio was 2.29 (mean age, 73.6 yr). The most common presenting symptoms were otalgia and otorrhea in 97.8 and 91.3%, respectively. Facial paralysis was present in 19.6% of cases. Thirty patients had diabetes mellitus (65.2%), and 8 were immunocompromised (17.4%). Pseudomonas aeruginosa was isolated in 69.2% of cases and was resistant to ciprofloxacin in 18.5%, but was susceptible to ceftazidime in all cases. Four patients died during the treatment (4.4%), but only 2 of disease. The mean delay to healing was 14 weeks (SD, 9.7). Healing rate was 95.6%. No relapse was observed after a mean follow-up of 78.4 weeks (SD, 36.5 wks). Two factors significantly influenced the prognosis: facial paralysis and existence of systemic factors for immune deficiency (p = 0.023 and 0.038, respectively). Conclusion: The association of ciprofloxacin and ceftazidime was efficient in countering the increasing resistance of P. aeruginosa to quinolones. We propose a prognostic classification of necrotizing external otitis based on the presence of facial paralysis and/or systemic factors.

Corticosteroids in the Treatment of Vestibular Neuritis: A Systematic Review and Meta-Analysis

Objective: To systematically review and meta-analyze the results of all randomized controlled trials comparing corticosteroids with placebo for the treatment of patients with vestibular neuritis. Data Sources: An electronic search was performed in MEDLINE, EMBASE, Cochrane Library, and CENTRAL databases, and then extensive hand-searching was performed for the identification of relevant studies. No time and language limitations were applied. Study Selection: Prospective randomized controlled trials comparing corticosteroids with placebo for the treatment of patients with vestibular neuritis. Data Extraction: Odds ratios (ORs), weighted mean differences (WMD), 95% confidence intervals (CIs), and tests for heterogeneity were reported. Data Synthesis: Four studies were eventually identified and systematically reviewed. Meta-analysis was feasible for 3 studies. Regarding the recovery of clinical symptoms, the proportion of patients with clinical recovery at 1 month after the initiation of therapy did not differ significantly between the corticosteroids and placebo groups (OR, 1.45; 95% CI, 0.26-8.01; p = 0.67). The proportion of patients with caloric complete recovery was significantly different between the corticosteroids and placebo groups both at 1 (OR, 12.64; 95% CI, 2.6-61.52; p = 0.002; heterogeneity, p = 0.53; fixed effects model) and 12 months (OR, 3.35; 95% CI, 1.45-7.76; p = 0.005; heterogeneity, p = 0.03; random effects model) after the initiation of therapy. The caloric extent of canal paresis at 12 months after the initiation of therapy seemed to differ significantly between patients who received corticosteroids and those who received placebo (WMD, −12.15; 95% CI, −19.85 to −4.46; p < 0.05; heterogeneity, p < 0.05; random effects model). Conclusion: The present systematic review and meta-analysis, based on the currently available evidence, suggests that corticosteroids improve only the caloric extent and recovery of canal paresis of patients with vestibular neuritis. At present, clinical recovery does not seem be better in patients receiving corticosteroids.

Surgery of Cerebellopontine Angle Epidermoid Cysts: Role of the Widened Retrolabyrinthine Approach Combined with Endoscopy:

OBJECTIVES: To evaluate the use of the retrolabyrinthine approach (RLA) combined with endoscopy with particular reference to preservation of cranial nerve function and completeness of excision in surgery of epidermoid cysts. METHODS: A retrospective study was performed on a series of 8 consecutive patients of whom 7 have undergone surgery. MAIN OUTCOME MEASURES: Measures include audiological and neurological status preoperatively and postoperatively, size of the lesion, the surgical approach, completeness of excision, and operative morbidity. RESULTS: The tumors were all large, ranging from 2 × 3 cm to 6 × 6 cm. Presenting symptoms were headache (75%), dysequilibrium (62%), trigeminal nerve palsy (38%), abducens nerve palsy (25%), and, rarely, auditory symptoms. Seven patients underwent surgery, 5 by the RLA, 1 by a translabyrinthine approach (TLA), and 1 by a transcochlear approach. Complete excision was achieved in 5 of the 7 patients. A transtentorial approach was combined in 2 cases (1 RLA, 1 TLA). Endoscopy was used in 3 cases. It allowed a complete tumor excision. One case of keratinous meningitis was observed. Trigeminal nerve function returned to normal in all patients. Postoperative facial nerve function was grade I in 5 cases and grade III in 2 cases. Hearing was preserved in 3 cases as class A, 1 case as class B. In the 2 cases presenting with abducens nerve palsy preoperative symptoms were initially aggravated before returning to normal function by 1 year postoperatively. The RLA with endoscopy allowed less invasive surgery and preservation of hearing in 4 of the 5 cases where it was attempted. Tumor control appeared better than with the suboccipital approach. Mortality and postoperative morbidity also appear reduced. CONCLUSION: RLA combined with endoscopy should be considered as the standard approach for excision of epidermoid cysts. Extension of this approach into a TLA or transcochlear approach will depend on preoperative difficulties and preoperative hearing.

Unique case of malignant transformation of a vestibular schwannoma after fractionated radiotherapy.

OBJECTIVE Malignant transformation of vestibular schwannoma is considered a rare clinical entity. Radiotherapy, as a treatment option for vestibular schwannoma, is regarded as a potential risk factor for secondary malignancy. Recently, radiotherapy with dose fractionation has been proposed, intended to diminish the risk of radiation-induced neuropathy. CASE PRESENTATION The aim of the present study is to report the first case, to the best of our knowledge, of malignant transformation of a residual vestibular schwannoma 19 years after fractionated radiotherapy, describing its characteristics with regard to those previously reported in the literature. CONCLUSIONS The main purpose of the present work is to state that the knowledge of the iatrogenic potential pitfalls of any technique of radiotherapy in clinical oncology is becoming a necessity. Finally, our report demonstrates that the irradiated patients must be monitored for life because a secondary malignancy may appear after a very long delay.

Intraorbital apocrine hidrocystoma.

A 33-year-old man reported an 18 months history of a progressive right eyelid swelling, a sensation of eye pain and headaches. He noted a visual discomfort. Physical examination showed right eyelid edema, without skin lesion. The patients acuity was unchanged from the baseline; neither exophthalmia nor deficit in the visual field was noted. Magnetic resonance image showed an intraorbital, extraconal cystic lesion. Histopathologic examination revealed apocrine hidrocystoma.

Multifrequency Immittancemetry in Experimentally Induced Stapes, Round Window and Cochlear Lesions

Objectives: To establish that admittance (Y) and susceptance (B) conductance (G) tympanograms at 2 kHz can reflect the status of the annular ligament and the cochlear pressure. Methods: Seven experiments were set up in 22 guinea pigs: ventilation of the bulla, blockage of the stapes and round window membrane (RWM), fistula, fluid removal from the cochlea, injection of saline in the scala tympani and acoustic trauma. Resonance frequency, Y, B and G at 2 kHz and curve shapes were analyzed before and after lesions. Results: A supplementary peak was observed in Y/G tympanograms in all RWM fistulas and in some cases of acoustic trauma; injection of saline into the scala tympani induced constant, immediate and reproducible changes; RWM and stapes blockages induced foreseeable peaking at 2 kHz; fluid removal from the cochlea induced multiple peak curves. Conclusion: Experimentally induced modifications at the AL result in noticeable, constant and reproducible changes in tympanogram curves at 2 kHz and seem to reflect inner ear pressure.

Gradenigo Syndrome Without Acute Otitis Media

Acute otitis media complications are less and less common, thanks to the more widespread availability and use of adequate antibiotics. Nevertheless, when they occur, they may be inconspicuous or silent but with dangerous evolution. Described here is the case of a 5-year-old child suffering from incomplete Gradenigo syndrome without acute otitis media, which was managed medically with favorable outcome.

Transpetrosal approaches for meningiomas of the posterior aspect of the petrous bone: Results in 43 consecutive patients

OBJECTIVE To assess outcome following excision of meningiomas of the posterior aspect of the petrous bone through transpetrosal approaches. MATERIAL AND METHOD We carried out a retrospective case-series study in a multidisciplinary tertiary care center on all patients who underwent meningiomas removal from January 1989 to September 2005. Surgical approaches were transpetrosal: widened retrolabyrinthine, translabyrinthine, transotic and transcochlear, occasionally combined with a subtemporal transtentorial approach. Epidemiology, symptoms, preoperative evaluation, surgery, postoperative complications and facial and auditory results were analyzed using standardized grading systems. The Desgeorges and Sterkers classification was used to assess tumor size and location. RESULTS Forty women and three men underwent surgery (mean age: 56.7). Medium-sized tumors stages 2 and 3 (84%) and AM and P localization (34% and 20.4%) predominated. In 65% of cases, the tumor extended beyond the CPA. Main presenting symptoms were balance disorders (72%) and sensorineural hearing loss (53.5%). Mortality was nil. A preoperative facial nerve paresis was present in 14% of patients. Tumor removal was complete in 79.1% of cases. At 1-year post-op, 73% of patients had a normal or subnormal facial function and 55% had serviceable hearing. A cerebrospinal fluid leakage occurred in 6.9%. DISCUSSION Posteriorly attached meningiomas are less symptomatic and of better prognosis than medially inserted ones. Transpetrosal approaches are reliable for the removal for all types and sizes of such tumors, and can be easily combined in the same procedure with a subtemporal transtentorial approach to remove extensions to the clivus and tentorium. They offer low morbidity and a high proportion of facial nerve and hearing preservation.

Clinical presentation of intralabyrinthine schwannomas: a multicenter study of 110 cases.

Objective To describe the presentation of intralabyrinthine schwannomas (ILSs). Study Design and Setting Retrospective multicenter study involving 12 European skull base surgery tertiary referral centers. Patients One hundred ten patients with the diagnosis of ILS, either labyrinth confined or extending into the internal auditory meatus for less than 50% of their volume. Main Outcome Measures Data collected were age, sex, nature and timing of presenting symptoms, hearing (according to the AAO-HNS grading system), results of vestibular tests (caloric tests and cervical vestibular-evoked myogenic potentials [c-VEMPs]), and tumor localization. Presenting symptoms and laboratory test results were studied according to the extension of the lesion into the cochlea (C) and vestibule (V), on one hand, and according to unifocal (L1) or plurifocal (L2) extension into the labyrinth, on the other. Results Intracochlear type was more common (50%) than vestibular (19.1%) and more diffuse forms (30.9%). The mean delay for diagnosis was long (72.5 mo; SD, 76.6). Mean age was 53.9 years (SD, 13.2). Deafness was the most common symptom (77.8 dB HL [SD, 33.6], with only 24.6% of patients keeping viable hearing. Caloric tests (65.5% of patients) were abnormal in 77.8% of cases. c-VEMPs were abnormal in 65.7% of the 36 cases analyzed. In V forms, hearing was significantly better (class A + B in 21.1% in C and 45.8% in V forms) (p = 0.03), and vestibular function was more altered (C: 57%, V: 100%, p = 0.0009*). L2 forms were diagnosed later (L1: 59.1 mo, L2: 104.5 mo; p = 0.004*) and were associated more frequently with a dead ear (L1: 13.1%, L2: 41.2%, p = 0.002*) than L1 forms. Conclusions This series, which is the largest in the literature, demonstrates that even very small and localized ILSs heavily compromise labyrinthine functions.

Zinc Protection against Pneumolysin Toxicity on Rat Cochlear Hair Cells

Streptococcus pneumoniae can induce local and systemic diseases such as meningitis, otitis media, and pneumonia. One third of these meningitis cases can be associated with irreversible sensorineural hearing loss whose mechanisms likely involves the exotoxin pneumolysin (PLY) that irreversibly damages cochlear hair cells (HCs). In the respiratory system and in neuron it has been demonstrated that zinc deficiency increases severity and mortality of such infections in animal models and in children. Moreover, zinc supplementation can decrease the severity of pneumococcal respiratory infections. The aim of our study was to assess the potential protective effect of zinc against PLY toxicity on HCs in culture. Our results showed that in the presence of zinc at concentration as low as 1 µM, the toxicity of PLY was largely reduced by about 50% for both inner and outer HCs. At 300 µM of zinc, protection significantly increased with 62 and 55.2% for IHCs and OHCs, respectively. Our results suggest that the protective effect of zinc is likely due to an inhibition of the toxin incorporation and aggregation into the plasma membrane, thus preventing calcium influx through the toxin pores. Our findings raise the possibility that treatments with zinc may help to prevent debilitating otological sequelae from pneumococcal infection.