[Spheno-ethmoidal rhinoscleroma. Report of a case and review of the literature]

We report an unusual case of spheno-ethmoidal rhinoscleroma. This chronic granulomatous disease occurs sporadically in Western Europe. Culture is necessary for diagnosis showing the causative organism of rhinoscleroma, Klebsiella rhinoscleromatis. Immunocytochemistry is used in any suspicious case with a negative culture. Antibiotics are the mainstay of therapy for several weeks, using ciprofloxacine or rifampicin, until the nasal biopsies demonstrated no Klebsiella organism.

Transvenous versus perinervous stimulation of the phrenic nerve to assess the diaphragmatic strength in rabbits

Diaphragmatic strength can be measured by transdiaphragmatic pressure during phrenic nerve stimulation. In order to avoid phrenic nerve dissection, a transjugular approach of the phrenic nerve can be performed. The objective of this study was to verify the identity of perinervous and transvenous techniques of phrenic nerve stimulation to assess diaphragmatic force. In intact (n = 9) or right phrenicotomized (n = 12) rabbits, we compared esophageal pressure (Peso) induced by supramaximal perinervous stimulation of the phrenic nerve with that obtained by transvenous stimulation of the phrenic nerve. Electromyography (EMG) of the thoracic muscles was studied in four animals. We found no difference between Peso induced by perinervous (PNS) and transvenous (TVS) unilateral or bilateral phrenic nerve stimulation. During unilateral stimulation, no EMG activity was recorded in the non stimulated diaphragm, or in the middle part of the esophagus, or in ipsi- and contralateral accessory inspiratory muscles. We conclude that in rabbits, unilateral or bilateral TVS of the phrenic nerve is functionally equivalent to PNS, whatever the side of stimulation; Peso is not altered by esophageal contraction in TVS. Transvenous stimulation can replace perinervous stimulation in experimental studies, when cervical access is difficult.

Selective resection of the phrenic nerve roots in rabbits. Part II: Respiratory effects

This study evaluates the delayed respiratory consequences of selective resection of one or several roots of the right phrenic nerve in rabbits. A total of 50 animals were operated on according to five modalities of root resection. A total of 11 animals served as control. The breathing pattern was analysed 8 weeks after surgery. Transdiaphragmatic pressure was measured during transjugular supramaximal stimulation of the phrenic nerve, unilaterally or bilaterally and during prolonged tracheal occlusion (PImax). No difference was observed between the esophageal pressure observed during bilateral phrenic nerve stimulation (BilPeso) in control animals when compared to animals with resection of the highest root of the right phrenic nerve (16.2 +/- 1.0 versus 14.5 +/- 1.0 cmH2O (mean +/- SE). Resection of the two highest or of the two lowest roots of the right phrenic nerve resulted in a similar BilPeso (11.3 +/- 0.8 versus 11.1 +/- 1.2 cmH2O). Preservation of only the accessory phrenic nerve (PN) resulted in a low value of BilPeso (9.8 +/- 1.0 cmH2O) similar to that obtained with complete denervation of the right hemidiaphragm. Ventilation and PImax were not different between the denervated or intact rabbits during quiet breathing. We conclude that in rabbits: (1) Diaphragmatic function is preserved after resection of the highest root of the phrenic nerve. (2) Diaphragmatic function is altered if only the APN is preserved.

Selective resection of the phrenic nerve roots in rabbits. Part I: Cartography of the residual innervation

Partial unilateral diaphragmatic paralysis remains poorly understood. This study evaluates the residual innervation of the diaphragm after selective resection of one or several roots of the right phrenic nerve in rabbits. Forty-seven animals were operated on according to five root resection modalities. Seven animals served as control. Eight weeks after surgery, the different regions of each hemidiaphragm were analyzed. Electromyographic activity was measured during quiet inspiration and the following histomorphometric parameters were studied: mean fiber area, fiber area dispersion, and ratio large diameter over small diameter. The results obtained from the two measurements were similar. When the accessory phrenic nerve was spared, the crural diaphragmatic region was preserved; denervation was encountered in anterior and lateral parts of the hemidiaphragm. When the highest root of the right phrenic nerve was resected, denervation denervation was limited to the sternal region. When resection of the two highest roots was performed, partial denervation was observed in each region, with residual innervation in the posterior hemidiaphragm. When resection of both the lowest roots was performed, denervation was maximal in the costal region; sternal region remained intact. No contralateral innervation was observed. We conclude that in rabbits: 1) resection of a single root of the phrenic nerve preserves consistent residual innervation. 2) somatotopy of the diaphragm innvervation follows an anteroposterior distribution.

[Total unilateral deafness in children. Etiologies and long-term consequences]

A retrospective study of 72 children with a profound (average hearing loss > 90 dB) unilateral sensorineural hearing loss (PUSNHL) was carried out in the ENT department at the Rouen hospital in 1988 and 1994. This study intended to investigate the etiologies, how it was recognized, the age of the onset and the results of the medical evaluation of these PUSNHL. We found, in 2 cases, that vestibular lesions of the healthy ear were present before the onset of a hearing loss on this side, turning the PUSNHL into a bilateral deafness. We tried to correlate the etiologies, age of onset of the PUSNHL, status of the opposite ear and possible scholar problems in the group of the 42 children followed-up for more than 2 years (mean follow-up time = 7 years). Among children suffering from PUSNHL, we specified a group with higher risk of school failures, allowing ENT physicians to propose more accurate management to these children.

[Management of caustic burns of the esophagus in children]

The authors describe their therapeutic approach to caustic burns of the esophagus in pediatric patients. Initially, early endoscopic evaluation is carried out under general anesthesia using a stiff tube then a fiberoptic endoscope. During this procedure, severity of esophageal damage is determined: stage I: mild burn requiring no treatment; stages II and III: severe burn with a risk of subsequent esophageal stricture requiring insertion of a nasogastric stent. A repeat endoscopy is performed after approximately 25 days to evaluate healing. If healing has occurred, the nasogastric tube is removed and dynamic esophagography is performed 2 to 7 days later. Patients with strictures should be treated with repeated endoscopic dilatation at gradually increasing intervals. Surgery is indicated only in patients with complications or multiple strictures after failure of dilatation; trans-mediastinal colon esophagoplasty with removal of the burned esophagus is the method of choice.

[Caustic stenoses of the esophagus]

Oesophageal stenosis is a frequent complication of caustic burns, especially when deep injuries are present, due to the presence of scar tissue. After the treatment of initial complications and after an initial endoscopic evaluation, a few preventive measures can be decided to protect the upper part of the gastrointestinal tract. These measures include complete parenteral nutrition for some, and calibrating nasogastric tube for others; corticosteroid treatment is discussed. When stenosis is present, endoscopic dilatations can be performed. If they failed or instead of them, surgical replacement can be proposed with gastro or coloplasty. Resection of burned oesophagus prevents the risk of mucocele or cancer.

[Ingestion of caustics by children. Report of 23 deep lesions. Therapeutic attitude and long-term results]

In children, 23 caustic injuries of oesophagus with deep lesions (second or third degree of burn) were treated in pediatric ENT department (Pr ANDRIEU--Rouen) during a 19 years long period. Endoscopy in emergency, nasogastric tube for stent and repeated dilatations were the bases of the treatment. 14 second degree burns and 7 third degree burns were complicated of 9 stenosis and one death. The mean duration of total treatment was 43 months. The mean number of dilatations was 38 months. 4 stenosis were definitely cured. 8 children had normal feeding. Mean following was 8 years with good long term results.

Selective reinnervation of the abductor and adductor muscles of the canine larynx after recurrent nerve paralysis

Functional rehabilitation of the larynx after unilateral vocal cord paralysis was attempted in the dog by selective reinnervation of the laryngeal muscles. The intralaryngeal branches of the right recurrent nerve were dissected. The adductor branch was anastomosed with the ansa cervicalis; the abductor branch was anastomosed with the trunk of the phrenic nerve either within the larynx or through the recurrent nerve, the adductor branch of which was sectioned. Results could be analyzed in seven dogs: mobility of the vocal cord was checked, and electromyography, stimulation of the nerves, and histologic studies were performed. Functional reinnervation of both the adductor and abductor muscles was obtained in only one case, with good abduction. Adduction was recorded in five cases. False-positive results emphasize the necessity of collecting several types of data before concluding that functional reinnervation has been accomplished. The reliability of the procedure can and must be improved.

[Postoperative cervicofacial subcutaneous emphysema]

Two cases of post-operative subcutaneous emphysema are reported. After excessive airway pressure, air or anaesthetic gases may spread to the neck, mediastinum, abdomen or pleural cavity. Pathogenesis and mechanisms are discussed. Possible aetiologic factors are outlined. The consequences of this condition are limited after adequate emergency treatment.

Unilateral congenital choanal atresia and maxillary sinus development

Most authors feel that the maxillary sinus and dento-alveolar arch do not develop normally in case of choanal atresia. This as explained by respiratory deficiency on the atretic side. A series of 11 cases of unilateral choanal atresia, either untreated or treated after the period of maximum growth, have been studied by clinical examination, serial X-rays and cephalometric tracings in order to compare atretic and normal sides. No significant difference has been found, neither for size nor shape of the maxillary sinus. These observations are therefore in contradiction to earlier reported findings and require further study.

[Lower trapezius musculocutaneous flap for the repair of neoplastic loss of substance of the ear]

Large defects created by oncological resections of the auricular area require to fill and cover the gap to achieve their reconstruction. The lower trapezius myocutaneous island flap meets these two principles more easily and more reliably than previous loco-regional skin flaps. About two patients, who undergone resection of spread carcinoma of the external ear, the authors discuss the advantages and disadvantages of this flap, that appears seldom utilised; they point out some practical problems encountered when raising the flap.

[Mandibular osteitis and tertiary syphilis]

The authors report the case of a 65 years old man, who suffered from an osteitis, involving the mandible. Within a few months, and despite of a well established treatment, sequestration occurred following a pathologic fracture. No specific germ was encountered after several laboratory examinations. The discovery of a primary syphilis forty years ago, confrontation of clinic and paraclinic data, suggested the actual osteitis could be a complication of tertiary syphilis. A specific treatment was started, and the situation improved progressively. After five months of treatment, mandibular reconstruction was decided. Diagnostic arguments are discussed, and the case is compared with those, not numerous, reported in the literature.

[Association of posterior laryngeal cleft and atresia of the oesophagus. Two cases treated successfully (author's transl)]

Two rare cases of oesophageal atresia associated with a posterior laryngeal cleft were treated successfully: a so-called "O" interarytenoid cleft recognised secondarily to the type II atresia, not treated surgically; a so-called II cricoid cleft recognised before the treatment of type I atresia was closed in a first stage by an anterior transl-laryngeal approach. A bibliographical review is followed by a discussion of the diagnosis aspects and therapeutic possibilities of laryngeal cleft, the approach, the timing of surgery on the basis of its type and the type of oesophageal atresia.

Normal vestibular responses to air caloric tests in children

One hundred and forty normal children, divided into four age-groups (2-3, 4-5, 6-7, 8-10 years old) have been submitted to a vestibular examination by caloric tests with air, and the responses were recorded. This technique is sure and easily reproducible. Frequency of nystagmus, and maximum eye speed in slow phase of nystagmus (M.E.S.) were examined during 30 sec after caloric stimulation. Frequency of nystagmus increases, and M.E.S. decreases as the children become older. A significant difference between the 2-3 and 4-5 year old groups is also noticed. Normal variations are fixed for each age group. A quantitative relation between frequency, M.E.S. and height is established.

[Febrile acute torticollis (author's transl)]

Febrile acute torticollis in the child represents a special clinical picture. Of variable cause, it may be indicative of an inflammatory, infectious or dystrophic pathology affecting any of the anatomical structures of the neck. Treatment is quite clearly defined, and it may be a therapeutic emergency. All ENT specialists must be familiar with this since they are most likely to be the first physician to whom such a child is brought.

[The treatment of chronic cholesteatomatous otitis media in the child (author's transl)]

On the basis of 38 cases seen in the child, with a postoperative follow-up of more than 2 years, the authors note the special and early aggressive nature of cholesteatoma of the middle year at this age. Its development depends upon tubal factors which in general remain in an underlying position but involve the risk of inducing direct complications during the postoperative course. These reasons lead to the suggestion of a technique involving sacrifice of the osseous meatus and tympanoplasty which often saves hearing. Preservation of the osseous meatus is still to be recommended in limited forms and in the absence of any notable tubal factor, not encountered in this series.

[Digestive duplications affecting the pharynx or fistulae of the fourth endo-branchial pouch. Four cases (author's transl)]

Four cases of children with recurrent latero-cervical epithelial cystic tumours which where identified as exceptional derivatives of the 4th endobranchial pouch on the basis of their connections with the pharynx and in particular the piriform fossa. The opportunity is taken to review the characteristics of equally rare digestive, duplications and congenital diverticula at a cervical and buccopharyngeal level. This diagnosis was made initially in the first of these cases.

[Respiratory and swallowing difficulties after oesophageal atresia (author's transl)]

The main reason for these problems is a tracheo-oesophageal fistula, either recurrence of the T.O. fistula, either persistance of a fistula which has been neglected during surgery. It has been observed in 7 infants from 19 operated atresias with such problems. These functionnal troubles may be produced by different other anomalies: oesophageal stenosis and or dyskinesia often observed, gastro-oesophageal reflux, associated anomalies of the larynx or trachea; laryngeal paralysis, tracheomalacia, tracheal epithelium metaplasia, tracheal compression by abnormal vessel, neurological dysmaturity, loss of swallowing reflex after a long postoperative course. Radiography and endoscopy are fundamental and complementary investigations. Endoscopy, under general anesthesia, must be minute (with optics), explore oesophageal and laryngo-tracheo-bronchic tract, and use several tests to demonstrate permeability of the fistula when it has been located. A special technique is presented. Several points must be outlined: 1--classical symptoms of persistant fistula are not reliable in authors' experience; any recurrent respiratory and swallowing problem requires investigations; 2--endoscopy and radiographic study have to be repeated sometimes to prove fistula; 3--responsability of some anomalies must be always discussed, because of their possible association with a fistula; several fistulas may also exist.