Combination of bioactive factors and IEIK13 self-assembling peptide hydrogel promotes cartilage matrix production by human nasal chondrocytes

Nasal reconstruction remains a challenge for every reconstructive surgeon. Alloplastic implants are proposed to repair nasal cartilaginous defects but they are often associated with high rates of extrusion and infection and poor biocompatibility. In this context, a porous polymeric scaffold filled with an autologous cartilage gel would be advantageous. In this study, we evaluated the capacity of IEIK13 self-assembling peptide (SAP) to serve as support to form such cartilage gel. Human nasal chondrocytes (HNC) were first amplified with FGF-2 and insulin, and then redifferentiated in IEIK13 with BMP-2, insulin, and T3 (BIT). Our results demonstrate that IEIK13 fosters HNC growth and survival. HNC phenotype was assessed by RT-PCR analysis and neo-synthesized extracellular matrix was characterized by western blotting and immunohistochemistry analysis. BIT-treated cells embedded in IEIK13 displayed round morphology and expressed cartilage-specific markers such as type II and type IX collagens and aggrecan. In addition, we did not detect significant production of type I and type X collagens and gene products of dedifferentiated and hypertrophic chondrocytes that are unwanted in hyaline cartilage. The whole of these results indicates that the SAP IEIK13 represents a suitable support for hydrogel-based tissue engineering of nasal cartilage. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 107A: 893-903, 2019.

International consensus (ICON) on functional and aesthetic rhinoplasty

During the 2017 IFOS international congress in Paris, a roundtable discussion on the topic of functional and aesthetic rhinoplasty was organised. Five experts, from the five continents and renown in the field of rhinoplasty, were brought together to discuss the issue from an international perspective and to put forward a consensus or on the contrary practical differences. Five questions were put to the experts beforehand to guarantee independent answers, which were then discussed during the roundtable. The questions were the following: - What are the age limits for achieving a rhinoplasty? - Do you use objective measurements before, during and after surgery? (facial landmarks, airflow, peroperative measurements) - How do you manage the preoperative general information and computer imaging of the patient? - What are the indications in your practice to perform a CT-scan or endoscopic examination before doing a rhinoplasty? - What kind of graft or prosthesis do you use for an augmentation rhinoplasty? This paper offers a synthesis of the roundtable based on the experts' answers to the different questions.

Factors associated with Clostridium difficile infection: A nested case-control study in a three year prospective cohort

BACKGROUND

Clostridium difficile infection (CDI) is a serious medical condition that is associated with substantial morbidity and mortality. Identification of risk factors associated with CDI and prompt recognition of patients at risk is key to successfully preventing CDI.

METHODS

A 3-year prospective, observational, cohort study was conducted in a French university hospital and a nested case-control study was performed to identify risk factors for CDI. Inpatients aged 18 years or older, suffering from diarrhea suspected to be related to CDI, were asked to participate.

RESULTS

A total of 945 patients were included, of which 233 cases had a confirmed CDI. CDI infection was more common in men (58.4%) (P = 0.04) compared with patients with diarrhea not related to C. difficile. Previous hospitalization (P < 0.001), prior treatment with antibiotics (P = 0.001) or antiperistaltics (P = 0.002), liver disease (P = 0.003), malnutrition (P < 0.001), and previous CDI (P < 0.001) were significantly more common in patients with CDI. Multivariate logistic regression analysis showed that exposure to antibiotics in the last 60 days (especially third generation cephalosporins and penicillins with β-lactamase inhibitor), chronic renal or liver disease, malnutrition or previous CDI, were associated with an independent high risk of CDI. Age was not related with CDI.

CONCLUSIONS

This study showed that antibiotics and some comorbid conditions were predictors of CDI. Patients at high risk of acquiring CDI at the time of admission may benefit from careful monitoring of antibiotic prescriptions and early attention to infection control issues. In future, these "high-risk" patients may benefit from novel agents being developed to prevent CDI.

Impact of anti-inflammatory drug consumption in peritonsillar abscesses: a retrospective cohort study

BACKGROUND

The experience of clinicians in charge of the in-hospital management of peritonsillar abscesses supports the association between severe forms and anti-inflammatory drug (AID) consumption. However, this observation is based on a limited number of clinical studies. Our objective was to assess the prevalence and impact of AID consumption in patients with peritonsillar abscesses.

METHODS

All patients referred to the ear, nose and throat surgery department for a peritonsillar abscess were included in a retrospective cohort study (2012-2014).

RESULTS

Among the 216 included patients (male, 55 %; median age, 32 years [IQR, 26-40]), 127 had received AID (59 %), including corticosteroids (n = 67, 31 %) and/or non-steroidal AIDs (NSAIDs, n = 76, 35 %). 199 patients (92 %) benefit from a puncture and 5 (2 %) from a surgery under general anesthesia, associated with ceftriaxone/metronidazole (51 %) or amoxicillin/clavulanic acid (46 %). An iterative surgical procedure was required in 93 cases (43 %), including 19 % under general anesthesia. Bacteriological analysis (79 %) mainly disclosed streptococci (66 %) of A (18 %) and/or milleri (33 %) groups. The prevalence of anaerobes was higher in patients using AIDs (46 % versus 29 %, p = 0.034), regardless of prior antibiotic therapy. 65 patients benefited from a CT-scan; AID consumption was associated with larger abscesses (6.8 [IQR, 3.7-12.7] versus 2.9 [IQR, 0.9-7.8] cm(3); p = 0.005). AID consumption was not a risk factor of iterative surgical procedure.

CONCLUSIONS

In comparison to the prescribing habits in uncomplicated upper respiratory tract infection, the high prevalence of AID consumption in patients with peritonsillar suppuration suggests a role of AIDs in promoting these complications.

Study of Cyfra 21–1, a Tumor Marker, in Head and Neck Squamous Cell Carcinoma

Objectives:

We performed a prospective study to determine the cutoff value and the prognostic value of Cyfra 21–1, a serum tumor marker, in head and neck squamous cell carcinoma (HNSCC).

Methods:

The serum concentration of Cyfra 21–1 was measured in a group of 300 patients (group 1) with HNSCC, in a control group of 71 healthy subjects (group 2), and in a group of 73 patients with a nonmalignant tumor or inflammatory disease (group 3). The concentrations were compared between the various groups and subgroups; the cutoff value was calculated with a receiver operating characteristic curve. Furthermore, the serum concentrations of Cyfra 21–1 before treatment in the group of 300 patients were compared with the stage of the disease and with the evolution of the overall survival rate and the disease-free survival rate. Finally, to determine whether Cyfra 21–1 is an independent prognostic factor, we compared the concentrations, by a Cox model, with the classic prognostic factors of HNSCC.

Results:

At the cutoff value of 1 ng/mL, the specificity was 94% and the sensitivity was 72%. The serum concentrations of Cyfra 21–1 were statistically correlated with the stage of the disease. The overall survival rate and the disease-free survival rate were lower in patients with high serum concentrations, and these differences were statistically significant (p <.001). The Cox model allows us to conclude that Cyfra 21–1 is a prognostic marker that is independent of other classic prognostic factors.

Conclusions:

Cyfra 21–1 is an interesting tumor marker that could be proposed for the early detection of HNSCC with a cutoff value of 1 ng/mL. Furthermore, Cyfra 21–1 can be considered an independent prognostic marker.

[Reconstruction of nasal cartilage defects using a tissue engineering technique based on combination of high-density polyethylene and hydrogel]

AIM OF THE STUDY

Nasal reconstruction remains a challenge for any surgeon. The surgical indications for nasal reconstruction after oncologic resection, trauma or as part of cosmetic rhinoplasty, are steadily increasing. The current attitude for reconstruction is the use of autologous cartilage grafts of various origins (septal, ear or rib) trying to restore a physiological anatomy but their quantity is limited. Thus, in order to produce an implantable cartilaginous model, we developed a study protocol involving human nasal chondrocytes, growth factors and a composite biomaterial and studied at the molecular, cellular and tissue level the phenotype of the chondrocytes cultured in this model.

MATERIALS AND METHODS

After extraction of chondrocytes and their amplification on plastic, the cells were cultured for 15 days either in monolayer or within an agarose hydrogel or a composite biomaterial (agarose/high density polyethylene: Medpor(®)) in the presence or not of a cocktail of soluble factors (BIT): bone morphogenetic protein-2 (BMP-2), insulin and triiodothyronine (T3). The quality of the chondrocyte phenotype was analyzed by PCR, western blotting and immunohistochemistry.

RESULTS

During their amplification in monolayer, chondrocytes dedifferentiate. However, our results show that the BIT cocktail induces redifferentiation of chondrocytes cultured in agarose/Medpor with synthesis of mature chondrogenic markers. Thereby, chondrocytes associated with the agarose hydrogel will colonize Medpor and synthesize an extracellular matrix characteristic of nasal cartilage.

CONCLUSION

This nasal cartilage tissue engineering protocol provides the first interesting results for nasal reconstruction.

ELLIPSE Study: a Phase 1 study evaluating the tolerance of bevacizumab nasal spray in the treatment of epistaxis in hereditary hemorrhagic telangiectasia

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is a dominantly inherited genetic vascular disorder in which epistaxis is the most frequent manifestation, responsible for high morbidity. Management of this symptom has no standard, and local treatments are often aggressive. Their efficacy is variable and has not been proven. Anti-angiogenic drugs, such as bevacizumab, are a new treatment strategy. Its systemic administration in patients with HHT improves liver damage-related symptoms and epistaxis. To limit the systemic adverse effects of bevacizumab and to ease administration, a local administration seems suitable.

PRIMARY OBJECTIVE

To evaluate the tolerance of increasing doses of bevacizumab administered as a nasal spray in patients with HHT-related epistaxis. Secondary objectives were to study the bioavailability and efficacy of bevacizumab against epistaxis when given as a nasal spray.

METHODOLOGY

Phase 1, randomized, double-blind, placebo-controlled, monocentric study performed sequentially (dose escalation) on 5 groups of 8 patients. Each group was made up of 6 verum and 2 placebos. Five increasing doses of bevacizumab nasal spray (25 mg/mL) were evaluated: 12.5, 25, 50, 75 and 100 mg.

RESULTS

A total of 40 patients were included between October 2011 and October 2012. Bevacizumab nasal spray was well tolerated in all patients and the drug was not detected in their serum. No dose limiting toxicity was observed. No efficacy was observed at any dose in this study.

CONCLUSION

Based on these results, bevacizumab nasal spray is a safe treatment of epistaxis in HHT. However, a randomized Phase 2 study is needed to determine its efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier #NCT01507480.

Saddle nose: classification and therapeutic management

INTRODUCTION

The understanding and treatment of saddle nose have always been a surgical challenge. The authors propose a three-stage classification of this deformity as well as a treatment strategy adapted to each case.

MATERIALS AND METHODS

A retrospective study was carried out on 25 patients with saddle nose. After defining the three stages of saddle nose: minimal, moderate and major, the authors describe the treatment protocol adopted for each stage.

RESULTS

This series comprised 3 cases of minimal saddle nose, 17 cases of moderate saddle nose and 5 cases of major saddle nose. Minimal saddle nose was treated by extracorporeal rhinoplasty, an inverted U-shaped conchal graft was used to treat moderate saddle nose, and costal cartilage was used to reconstruct major saddle nose. Surgical approaches varied according to the technique adopted. Surgical revision was never required.

CONCLUSION

Saddle nose is a classical condition in facial reconstructive surgery. The proposed treatment strategy is based on detailed analysis of the clinical signs, resulting in a graduated solution adapted to each clinical case according to the severity of the deformity.

[Smile "forced" smile versus "spontaneous": comparison of 3 techniques of reconstructive surgery of the face. Myoplasty temporal muscle, hypoglossal facial anastomosis and gracilis muscle free flap]

The facial palsy cause serious consequences for patients. Studies have also shown that in these patients, the inability to produce an appropriate and spontaneous smile would be a key factor of depression. When facial palsy is considered complete and the nerve cannot be repaired, the patient can benefit from palliative surgery to regain a better quality of life in the aesthetic, functional, and psychological aspects. The hypoglossal-facial anastomosis (AHF), temporal myoplasty (MAT) and gracilis transposition (TG) are the major surgeries currently used for this purpose. The aim of our study is to assess quantitatively and qualitatively the effects of each of these surgeries on the lip mobility and production of smile. From this perspective, we proposed a protocol of an evaluation of facial motricity, of quality of life, and more particularly on the quality and the analysis of the smile. The results underline that there is no significant difference in the recovery of the facial motricity according to the surgery. Only the slower, deferred deadline of recovery at the patients AHF and TG who have to wait several months, it is for the same levels as that of the patients' MAT. A premature and intensive rehabilitation such as the patients of our protocol benefited from it what is nevertheless essential to a good recovery whatever is the surgery.

[Post-operative evaluation of 63 cases of rhinoseptoplastie by nasal frameworks]

INTRODUCTION

The rhinoplasty is a difficult operation in plastic surgery of the face. The principles of the extracorporeal septoplasty were launched in the 50's, consisting of the treatment of the septal framework outside the nose. The most recent evolution, which is the creation of nasal frameworks required a precise evaluation of the results.

PATIENTS AND METHODS

The patients having benefited from a rhinoseptoplasty by nasal frameworks are included. Eleven criteria are studied. Every patient is rated before and after rhinoplasty procedure, one point if improvement of the criterion, zero if no modification and -1 if degradation of the criterion.

RESULTS

Sixty three patients were operated, 54 women and 9 men. The postoperative average follow-up is of 5 months.

CONCLUSIONS

The cartilaginous nasal frameworks, allows on complex noses (diverted, traumatic), an improvement of the righteousness of the dorsum (88%), of the projection of the tip (82.5%), of the naso-labial angle (84%), lines of Sheen (63%). An extension of the middle nose is observed in 28% of the patients, counterparty of a functional and inhaling nose.

[Management of labial incompetence and gummy smile using profiloplasty]

INTRODUCTION

Gummy smile and labial incompetence are frequent for consultation in plastic surgery. We wanted to show that rhinoplasty and genioplasty should correct these anomalies.

PATIENTS AND METHODS

Profiloplasty was performed on 20 patients. Aesthetic and functional items were evaluated.

RESULTS

There is a correlation between aesthetic and functional results. Results seem to be better for patients having an important labial incompetence without gummy smile.

CONCLUSION

Those results are based on anatomical and surgical considerations. Some non surgical procedures do exist to treat this problem. It should be a challenge to find the place for each procedure.

Hearing rehabilitation in congenital aural atresia using the bone-anchored hearing aid: audiological and satisfaction results

CONCLUSION

The BAHA (bone-anchored hearing aid) remains the most reliable method of auditory rehabilitation for patients with congenital aural atresia and improves hearing outcome and quality of life in these patients who are otherwise unable to benefit from traditional hearing aids. New techniques are being developed, such as fully implantable hearing devices, and will have to prove their efficacy and safety in this indication.

OBJECTIVE

To evaluate the audiological results and patient satisfaction after rehabilitation of congenital aural atresia using the BAHA.

METHODS

Sixteen patients suffering from bilateral congenital aural atresia were implanted with unilateral BAHA. Preoperative air- and bone-conduction thresholds and air-bone gap (ABG), preoperative sound reception threshold (SRT), postoperative aided thresholds, implantation complications, patient satisfaction, and the APHAB questionnaire were collected.

RESULTS

After a mean follow-up period of 6.5 years, 15 patients were still using their device. Each patient had an average improvement of 33 ± 7 dB. Closure of the ABG within 15 dB of the preoperative bone-conduction thresholds occurred in 10 patients. Adverse skin reactions appeared in 50% of patients over 6.5 years of follow-up. Eleven of the 12 patients used their BAHA for more than 8 h per day.

[The nasal framework in rhinoplasty and its dimensions: the importance of a third element]

INTRODUCTION

Reconstructing a crooked nose has been a challenge. Reshaping a nose reducing or improving its profile may be followed by irregularities and functional troubles. The principles of the extracorporeal septoplasty were launched in the 50's, consisting of the treatment of the septal framework outside the nose. Thus, it is replaced and fixed inside the nose. Dorsal irregularity or low projection may be overcome with a dorsal onlay graft.

OBJECTIVE

To describe an evolution of extracorporeal rhinoseptoplasty based on a three-dimensional reshaping of the nasal framework, and its average dimensions.

PATIENTS AND METHODS

Data of patients presenting nasal obstruction related to septal deviation and operated by the proposed technique were collected prospectively. The dimensions of the framework were measured during the surgery.

RESULTS

25 patients were operated from February to September 2010. Fifteen (60%) cases were related to previous trauma or surgery. The other 40% (N=10) were primary, claiming mainly a reduction rhinoplasty. A closed approach was used for all but one (4%). In 12% (N=3) of the patients no lateral osteotomies were performed after opening the bony roof. Tip surgery was performed in 32% (N=8).

CONCLUSIONS

The principles of the "three-dimensional framework technique" are globally reproducible independently of the amount of residual septal cartilage. We believe that our technique assures more stability to the framework and offers a better regularity of the nasal dorsum, eliminating the need of an open approach if other manoeuvres requiring it are not associated.

[Partial allotransplantation of the face including the mandible: a feasibility study]

OBJECTIVE

Facial grafts are useful in that they allow the repair of severe facial defects in one step in contrast to the actual available techniques which require staged procedures with limited cosmetic and functional results. The aim of our study was to determine whether it would be possible to include part of the mandible in a partial allotransplant of the face.

MATERIAL AND METHODS

An anatomical study on the arterial and venous vascularisation of the face and the mandible was performed on 7 heads. Then nine heads were used to describe an anatomical model of harvesting two-thirds of the lower face.

RESULTS

The study determined that a graft could be viable with a facial artery, inferior dental artery and two veins facial. Thus, a reliable method for harvesting hemi-mandible and total mandible is developed. The average sampling time was 4 hours and thirty minutes. Harvesting a total mandibular graft was more tedious because of the loss of joint laxity caused by the absence of mandibular osteotomy.

CONCLUSION

Partial allotransplant of the face including the mandible is feasible. In such transplantations, functional difficulties related to the temporo-mandibular joint and orthognathic problems need to be overcome.

[Importance of a molding nasolabial flap in the reconstruction of mobile nose defects, a review of 25 cases]

INTRODUCTION

Mobile nose reconstruction, because of its location, its anatomy and its functional role is a surgical challenge. We describe throughout this article the surgical technique and the importance of the nasolabial flap in a single-step procedure for repairing mobile nose defects.

MATERIALS AND METHODS

We present 25 cases of mobile nose defects secondary to an oncologic etiology, affecting the supratip, the alar margin and the columella. Patients benefited from a superiorly pedicled molding nasolabial flap harvested in a one-step procedure under local anesthesia.

RESULT

Aesthetic result of each repair was evaluated according to 5 criteria and was considered as very satisfactory by the surgeons. No complication such as necrosis or infection was recorded.

DISCUSSION

A molding nasolabial flap allows optimum repair of the mobile nose. It represents reliability, elasticity at the price of minimal scarring. We find it an important tool in the therapeutic armamentarium in patients with tissue loss in mobile nose.

[Evaluation of 3D imaging software to study computed tomography images of middle ear defects]

OBJECTIVE

Evaluate the contribution of original 3D reconstruction software based on the principle of region growing segmentation of CT images to diagnosis of ossicular malformations of the middle ear.

METHOD

Prospective study on a population of ten patients presenting uni- or bilateral transmission deafness. Twenty ears were studied using multislice CT. All the data were treated using original software segmentation based on the principle of region growing segmentation. The 3D images were compared with the original CT slices to judge the software's potential contribution to the management of these patients.

RESULTS

All the images obtained were deemed of sufficient diagnostic quality. The two normal ears on the CT slices were also found to be normal on the 3D images. Typical CT images of otospongiosis found in two patients were not visible on the 3D images. The 18 ossicular malformations were well analyzed on the images obtained, which also provided better visualization of the abnormalities and associated lesions (particularly the anomalies in facial nerve position), thus providing quality surgical planning as judged by the surgeon.

CONCLUSION

The image reconstruction method studied, using region growing segmentation seems to be, in this limited sample, a useful complement to classical CT images in the study of constitutional abnormalities of the middle ear.

The pattern of auditory brainstem response wave V maturation in cochlear-implanted children

OBJECTIVE

Maturation of acoustically evoked brainstem responses (ABR) in hearing children is not complete at birth but rather continues over the first two years of life. In particular, it has been established that the decrease in ABR wave V latency can be modeled as the sum of two decaying exponential functions with respective time-constants of 4 and 50 weeks [Eggermont, J.J., Salamy, A., 1988a. Maturational time-course for the ABR in preterm and full term infants. Hear Res 33, 35-47; Eggermont, J.J., Salamy, A., 1988b. Development of ABR parameters in a preterm and a term born population. Ear Hear 9, 283-9]. Here, we investigated the maturation of electrically evoked auditory brainstem responses (EABR) in 55 deaf children who recovered hearing after cochlear implantation, and proposed a predictive model of EABR maturation depending on the onset of deafness. The pattern of EABR maturation over the first 2 years of cochlear implant use was compared with the normal pattern of ABR maturation in hearing children.

METHODS

Changes in EABR wave V latency over the 2 years following cochlear implant connection were analyzed in two groups of children. The first group (n=41) consisted of children with early-onset of deafness (mostly congenital), and the second (n=14) of children who had become profoundly deaf after 1 year of age. The modeling of changes in EABR wave V latency with time was based on the mean values from each of the two groups, allowing comparison of the rates of EABR maturation between groups. Differences between EABRs elicited at the basal and apical ends of the implant electrode array were also tested.

RESULTS

There was no influence of age at implantation on the rate of wave V latency change. The main factor for EABR changes was the time in sound. Indeed, significant maturation was observed over the first 2 years of implant use only in the group with early-onset deafness. In this group maturation of wave V progressed as in the ABR model of [Eggermont, J.J., Salamy, A., 1988a. Maturational time-course for the ABR in preterm and full term infants. Hear Res 33, 35-47; Eggermont, J.J., Salamy, A., 1988b. Development of ABR parameters in a preterm and a term born population. Ear Hear 9, 283-9] of normal hearing children: a sum of two decaying exponential functions, one showing an early rapid decrease in latency and the other a slower decrease. Remarkably, the time-constants fell well within the ranges described by Eggermont and Salamy (i.e., 3.9 and 68 weeks), consistent with the time-course of the neurophysiological mechanisms presumably involved in auditory pathway maturation during the first 2 years of life: i.e., myelination and increased synaptic efficacy. In contrast, relatively little change in wave V was evident in children with late-onset deafness. In agreement with the notion that EABR maturation follows an apex-to-base gradient as described for ABR, we observed that wave V latencies were longer for the basal than the apical end of the implant electrode array and remained so throughout the study period, whatever the time of onset of deafness.

CONCLUSIONS

The findings in the early-onset of deafness group support the theory that auditory pathways remain "frozen" during the period of sensory deprivation until cochlear implant rehabilitation restores the normal chronology of maturational processes. In children with late-onset deafness, however, some maturational processes may occur before the onset of deafness, and thus less additional maturation is required during the first two years of implant use resulting in no significant EABR latency changes being observed in this period. The results suggest that the rehabilitation-induced plasticity of the auditory pathways is, in case of late auditory deprivation, unlikely to result in neurophysiological outcomes similar to those observed in children with early auditory deprivation.

SIGNIFICANCE

Changes in EABR wave V latency over the first 2 years of cochlear implant use were found to be well fitted by the sum of two decaying exponential functions in children with early-onset deafness. This is in line with the maturation of ABR wave V latency in normal-hearing children over the first two years of life. Further studies are needed to assess whether the differences observed in terms of auditory pathways maturation are associated with consistent differences in terms of language development.

[Guidelines for the clinical practice: aesthetic and functional rhinoplasty]

A multidisciplinary working group of experts met in 2006 in order to establish a list of recommendations concerning the aesthetic and functional rhinoplasties. These experts tried to answer various practical problems while relying, on one hand, on a critical analysis of the literature, and on the other hand, on a consensus within the group. Six topics were approached. The management of the preoperative consultation, the surgical environment, the contra-indications, the materials used, the management of the post operative period, some particular pathological situations. This collective reflexion thus did not relate to the surgical techniques but to the methodology of treatment of patients who are candidates for rhinoplasty. It comes out clearly from this collective work that surgical indication can only be addressed after having clarified all the technical and psychological aspects. The use of computer graphics is recommended. Cartilage autograft are recommended as a priority.

[Analysis of the projection of the nasal tip]

The success of a rhinoplasty is conditioned by a detailed preoperative analysis of the morphology of the nose and face of the patient. A good knowledge of the characteristic reference marks and nasal proportions authorize a detailed description of the nose. The position of the nasal tip is one of the principal characteristics of the nose. It is expressed by the combination of its projection and its height. A reflexion on the position of the tip and its ideal position post-operatively enabled us to work out a conceptual approach aiming at guiding the surgical project. The drawing of two circles centered on the nasal pyramid is the expression of this concept. Thus, a detailed analysis of the nasal pyramid and a biomechanical approach are the key to a relevant surgical plan.

[Apology for the biplane cervico-facial face lift]

After a description of the physiopathology of facial ageing, the author specifies the interest of the biplane cervico-facial face lift to correct the tegumentary ptose of the lower third of the face. The various technical stages are described while insisting on the complementarity of the handing-over in tension of the SMAS (Superficial Musculo Aponevrotic System) and the redrap of the SACS (Superficial Adipo-Cutaneous System).

Le lambeau myo-muqueux de buccinateur en îlot: indications et limites dans la reconstruction des pertes de substance de la cavité buccale et de l'oropharynx

OBJECTIVE

To outline the indications and limits of the myo-mucosal buccinator island flap based on the facial artery in the reconstruction of deficits of the buccal cavity and lateral wall of the oropharynx following oncologic resection or radionecrosis.

METHOD

We retrospectively studied 40 patients. Flap is raised using a modified technique without Doppler or skin incision to identify the facial artery. This study identifies causes for failure and limits and indications for this flap.

RESULTS

We found a failure rate of 10% and an identical fistula rate. On the other hand success rate is over 95% when (1) permeability of the artery is confirmed preoperatively in post-neck dissection or post-radiation therapy patients and (2) the deficit does not cross the midline.

CONCLUSION

The myo-mucosal buccinator flap is a reliable technique. When specific indications are followed and the flap raised appropriately, the succes rate is 95%.

[Three-dimensional modeling of mandibular distraction]

Facial hemi-atrophy affects 1 in 4000 or 5000 children. We propose treating this deformation of the 1st branchial arch with the "bone distraction" lengthening technique first described by Ilizarov in the 1950s, which has already been employed with the mandible. We have modelled mandibular distraction in facial hemi-atrophy patients and discuss the benefits of such pre-surgical planning encompassing the assistance of pre- and post-operative as well as surgically coordinated orthodontic therapy. Using X scanner views of a 5 year-old girl patient, we have developed a distraction-simulation software, which makes the pathological side harmonious with the healthy side along the medial sagittal plane. In order to obtain facial symmetry, put bones in balance, and orient the occlusal plane horizontally, essential requisites of occlusal stability, it is necessary: to employ a 2 or 3-dimensional distractor, to pre-plan the distraction and screw positioning, to set up a fixed orthodontic treatment plan prior to beginning distraction therapy.

Decreased expression of keratinocyte beta1 integrins in chronically sun-exposed skin in vivo

BACKGROUND

Chronic exposure to ultraviolet (UV) radiation induces changes in the skin structure which are mostly found in the superficial dermis and at the dermal-epidermal junction. Keratinocytes and fibroblasts contribute both to the synthesis and to the degradation of the molecules important for the integrity of this skin site. While several studies have reported on alterations of dermal components and of the functions of fibroblasts in vivo and in vitro after UV exposure, recent data suggested that keratinocytes could be the main skin cell type involved in the photoageing process.

OBJECTIVES

In this study, we analysed the expression of two keratinocyte molecules namely, beta1 integrin (a proliferation marker) and involucrin (a differentiation marker) in sun-exposed and sun-protected facial skin of 16 healthy patients undergoing facial lifting.

METHODS

Methods included histology, immunohistochemistry and quantitative reverse transcriptase-polymerase chain reaction analysis.

RESULTS

Sun-exposed skin displayed the characteristic morphological and molecular features of dermal photoageing, compared with sun-protected skin, including dermal elastosis, diminished fibrillin and type VII collagen expression. Analysis of the epidermis in sun-exposed vs. sun-protected skin showed no histological differences, but dramatic changes in the expression of beta1 integrin and involucrin. In sun-exposed skin, expression of beta1 integrin protein by epidermal basal cells was reduced, paralleling a downregulation of beta1 integrin mRNA, whereas involucrin protein expression was greatly enhanced in the superficial epidermal cell layers. Interestingly, the ratio between involucrin and beta1 integrin protein expression was consistently increased in sun-exposed skin sites.

CONCLUSIONS

Collectively these results demonstrate that epidermal homeostasis is impaired by chronic UV exposure, and define beta1 integrin expression as a molecular marker of the epidermal photoageing process.

Computer-assisted navigation system in pediatric intranasal surgery

OBJECTIVES

To introduce a computer-assisted navigation system and to evaluate its application in pediatric sinusonasal surgery.

METHODS

A commercially available wireless passive marker system that allows the calibration and tracking of virtually any instrument was adapted to children and used during pediatric endoscopic sinusonasal surgery.

RESULTS

The headset localizer that was initially used in computed tomographic scanning was not well accepted by children. Correlation of the preoperative computed tomographic scan to the actual patient was made possible by a laser device. Setup time was able to be decreased from an initial 20 minutes to 3 minutes. The average recording accuracy was 1.1 mm. The advantages of the system became apparent as experience increased in cases involving sinus polyposis, choanal atresia, nasopharyngeal fibroma removal, tumor biopsy, and minimally invasive maxillary, frontal, and sphenoidal surgery.

CONCLUSIONS

The computer-assisted navigation system was used first as a control system and then, as experience increased, as a true surgical guide. Indications for its use also increased. Pediatric intranasal surgery was performed using 2 complementary guides: an endoscopic view and a computed tomographic view of the instrument's position.

Skin ageing: clinical and histopathologic study of permanent and reducible wrinkles

Wrinkles are modifications of the skin associated with cutaneous ageing and develop preferentially on sun-exposed skin. The aim of the study was to analyse the clinicopathological features of wrinkles, among the different types of skin relief modifications. Despite its importance in dermato-cosmetology and skin ageing, few studies have been specifically devoted to wrinkles. In the present study, we analyzed the histological features of the pre-auricular wrinkle compared to retro-auricular skin, obtained from sixteen patients undergoing facial surgery; skin samples were immediately processed for routine histology and histochemical staining. Four types of skin depressions could be defined according to their depth: folds, permanent wrinkles, reducible wrinkles and skin micro-relief. Two different types of pre-auricular wrinkles were observed: (i) permanent wrinkles which were conserved after sampling and, (ii) reducible wrinkles which required in vivo staining to be visible at histology. Histological analysis of the epidermis and dermis of the skin forming the pre-auricular wrinkle revealed a normal skin morphology, identical to that of the skin immediately adjacent to the wrinkle. This was particularly striking for the reducible wrinkles which could not be individualized in the absence of in vivo staining. Both types of wrinkles comprised skin modifications observed in sun-exposed skin, however, in the upper dermis, permanent wrinkles showed a more pronounced accumulation of basophilic fibers, i.e. actinic elastosis, than reducible wrinkles did. These data suggest that the development of wrinkles could be secondary to actinic elastosis and to the disappearance of microfibrils and collagen fibers at the dermal-epidermal junction.

Submandibular diagnostic and interventional sialendoscopy: new procedure for ductal disorders

We present our initial experience with submandibular sialendoscopy, a new therapeutic approach for disorders of Wharton's duct. We review the sialendoscopes used and discuss their respective merits. We evaluated and treated 129 consecutive patients with suspected ductal disorders. Diagnostic sialendoscopy was used for classifying ductal lesions as sialolithiasis, stenosis, sialodochitis, or polyps. Interventional sialendoscopy was used to treat these disorders. The type of endoscope used, the type of sialolith fragmentation and/or extraction device used, the total number of procedures, the type of anesthesia, and the number and size of the sialoliths removed were the dependent variables. The outcome variable was the endoscopic clearing of the ductal tree and resolution of symptoms. Diagnostic sialendoscopy was possible in 131 of 135 glands (97%), with an average (+/-SD) duration of 28 +/- 15 minutes. Interventional sialendoscopy was attempted in 110 cases, with an average duration of 71 +/- 41 minutes, with a success rate of 82%. Multiple sialendoscopies were necessary in 25% of cases. General anesthesia was used in 12% of cases. Submandibular gland resection was performed in 4%. The average size of the stones was 4.9 +/- 2.9 mm. Multiple sialoliths were found in 31 cases (29%). Sialolith fragmentation was required in 26%. Larger and multiple stones often required longer and multiple procedures and general anesthesia, and more often resulted in failures. Semirigid endoscopes had a higher success rate (85%) than flexible sialendoscopes (54%). Complications were mostly minor, but were encountered in 10% of cases. Diagnostic sialendoscopy is a new technique for evaluating salivary duct disorders that is associated with low morbidity. Interventional sialendoscopy allows the extraction of sialoliths in most patients, thus preventing open gland excision.

[Cervical and pharyngeal inflammatory pseudo-tumors, a report of two cases: clinical course and treatment]

The authors report two new cases of inflammatory pseudotumours, sited in the pharynx and neck--sites in which no previous cases have so far been reported in the literature. The aetiology and clinical course of these rare benign tumours remain little understood even today. Their treatment is also not clearly described. This is most often surgical, although medical treatment is often very effective, and is sometimes appropriate. The authors begin by describing these two clinical cases, and then use the literature to give an account of the clinical course and treatment of inflammatory pseudotumours.

[Genetic deafness:the primary cause of sensorineural hearing loss in children]

Genetically-transferred hearing impairments account for more than 50% of cases of pediatric sensorineural hearing defects. Multiple clinical aspects are involved in genetic hearing impairment, including the involvement of other organs, genetic inheritance, and the degree and age at onset of hearing loss. Diagnosis relies on family history, on the systematic investigation of the symptomatology including an associated syndrome, and audiometry testing in parents and siblings. Analysis of the connexin 26 gene is also indicated, as it is frequently involved in this disorder. Further genetic analysis in affected families will aid in detecting other as yet unidentified genes responsible for hearing impairment.

Specificity of parotid sialendoscopy

OBJECTIVE

To present our initial experience with sialendoscopy of the parotid duct.

STUDY DESIGN

METHODS

Diagnostic and interventional sialendoscopy procedures were performed in 79 and 55 cases, respectively. Diagnostic sialendoscopy was used to classify ductal lesions into sialolithiasis, stenosis, sialodochitis, and polyps. Interventional sialendoscopy was used to treat these disorders. The type of endoscope used, the type of sialolithiasis fragmentation and/or extraction device used, the total number of procedures, the type of anesthesia, and the number and size of the sialoliths removed were the dependent variables. The outcome variable was the endoscopic clearing of the ductal tree and resolution of symptoms.

RESULTS

Diagnostic sialendoscopy was possible in all cases, with an average duration of 26+/-14 minutes and no complications. Interventional sialendoscopy was successful in 85% of cases, with an average duration of 73+/-43 minutes (+/- standard deviation). Multiple procedures were performed in 45% of cases, general anesthesia was used in 24%, and parotidectomy in 2%. Multiple sialoliths were found in 58% of ducts and associated with more procedures under general anesthesia and longer operations. The average size of sialoliths was 3.2+/-1.3 mm; larger stones were associated with more procedures under general anesthesia, longer and multiple procedures, use of fragmentation, and sialendoscopy failures. Sialolithiasis fragmentation was required in 10% of cases, with a success rate of 70%. Semirigid sialendoscopes performed better than flexible ones. Complications were mostly minor but were encountered in 12% of cases.

CONCLUSIONS

Diagnostic sialendoscopy is a new technique for evaluating salivary duct disease, a technique which is associated with low morbidity. Interventional sialendoscopy allows the extraction of sialoliths in most patients, preventing open gland excision.

[Hearing impairment in children: early diagnosis is essential]

Diagnosis of hearing impairment is possible during the first days of life. Hearing tests are noninvasive and should not be delayed when hearing loss is suspected. Among children's hearing impairments, conductive hearing loss is the most frequent; it is generally acquired and reversible. At the opposite pole, sensorineural hearing loss has more severe consequences because it is irreversible and often present from birth. Early diagnosis and treatment are necessary in all cases to prevent speech delay. In cases with sensorineural hearing impairment, hearing aid fitting, or even cochlear implantation, and intensive speech therapy will help deaf children learn speech, with the view of optimal social and professional integration.

[Role of epitheses in the rehabilitation of substance losses of the face]

Epithesis with bone anchoring can be usefully envisaged for the rehabilitation of losses of facial substance when reconstructive surgery is impossible, either for local or general reasons. It is important to ensure that patients are offered both methods, the advantages and disadvantages of which are analysed in this paper.

[Reconstruction and ear prosthesis: what are the indications?]

There are two procedures available for treatment of the agenetic pinna: reconstructive plastic surgery using costal cartilage, and bone-anchored prostheses. Both techniques are described, and the indications clarified. It is important to emphasise that all of the possible alternatives must be within the repertoire of the surgeon, so that the treatment can be adapted to suit the individual case.

[Submental myocutaneous island flaps: anatomical study and prospective use]

The authors describe a myocutaneous cervical island flap based on the submental vessels. The anatomy based on 12 fresh cadaver dissection is outlined the submental arteries were injected with methylene blue, and the flap design and technique were studied. The flap has a long, reliable pedicle and cutaneous dimension measured 10 x 5 cm. The flap has an excellent skin color match and wide are of rotation and can extend to the whole homolateral face, the whole oral cavity, the whole homolateral oropharyngeal. The donor site scare dissimulated under the mandible is perfectly acceptable.

Chronic tympanic membrane perforation: an animal model

Acute perforations in the tympanic membranes (TM) of animals are not good models for assessment of materials used as graft membranes or of substances with the potential to activate tympanic membrane healing mechanisms for closing perforations. Most acute TM perforations heal spontaneously, in both animals and humans. Acute TM perforation models are not analogous to the pathologic human problem of long-standing TM perforation. Bilateral subtotal symmetric perforations, with each animal serving as its own control provide a suitable model. Fourteen dogs were operated. Subtotal perforation of TM in right ears were soaked with 2% glutaraldehyde to develop an animal model for persistent tympanic membrane perforation. Subtotal myringectomy was performed on left ears, without chemical treatment of the rim. Perforations were standardized in size. The healing pattern was evaluated weekly for a 15-week period. Six of the right ears and 14 of the left ears completely healed within 15 weeks. Statistically, the mean delay of closure was higher in the treated group than in the non-treated group, and the two groups were different according the closure rate criterion. Histologic analyses of persistent TM perforations and of healed cases were performed.

A clinical study of human type IV collagen as tympanic membrane grafting material. Preliminary noncomparative study

OBJECTIVE

To evaluate tolerance for this middle-ear implant and its effectiveness in eardrum healing under various pathologic conditions.

SETTING

A 12- to 18-month follow-up case series at an institutional referral center offering hospitalized care.

PATIENTS

Twenty-six eligible volunteers suffering from tympanic perforation or tympanic pocket retraction class II and III in Tos' classification.

INTERVENTION

Patients underwent implantation with the type IV collagen film (film called "MTY" from the French membrane tympanique). The surgical procedure was similar to those using the temporal aponeurosis or the tragal perichondrium.

OUTCOME MEASURE

Anatomic criteria was determined by otoscopy, and functional audiometric criteria was determined by air-borne gap measurements and by effects on cochlear function.

RESULTS

Twenty-two of 26 patients were completely healed after 6 months, with no subsequent evolution. Nineteen of 26 subjects underwent a 1-year postoperative audiometric follow-up examination: 13 (68%) had an air-borne gap less than 10 dB, four (21%) had between 11 and 20 dB, and two (11%) had between 21 and 30 dB. Adverse effects included one patient whose MTY fell into the middle ear, three patients with transient myringitis, and one patient with otitis media with effusion.

CONCLUSIONS

A human type IV collagen film may be a possible alternative to autologous tissue in tympanic membrane reconstruction. This new biomaterial was tested on patients with various diseases common in clinical otology, and demonstrated a good biocompatibility of MTY in the different pathologic conditions of chronic otitis media. A future randomized, controlled trial will randomly allocate patients to receive either MTY collagen film or tissue from the temporal aponeurosis.

[Study of the ototoxicity of amikacin and netilmicin using provoked acoustic oto-emissions and high-frequency audiometry]

To compare the ototoxicity of amikacin and netilmicin, tone audiometry, high-frequency audiometry, early auditory evoked potentials, and evoked otoacoustic emission testing were used to evaluate 30 patients (15 under amikacin and 15 under netilmicin). Ototoxicity was not significantly different in the two groups.

[Reconstruction of the external ear]

The authors after a short morphological description of the microtia, expose the surgical evolution which had led to the actual auricular reconstruction technique, using a costal cartilage framework. This technique requiring several steps is exposed in the typical case of microtia. It is the preferential method. The difficult reconstructions due to the poor quality of the skin are exposed by degree of complexity: in these cases, tissue expansion, fascia temporalis superficialis can be useful and finally auricular prostheses, attached to bone-integrated implants, can be recommended. The functional surgery of the middle ear is also replaced in the context of the auricular reconstruction which is done around 8 years old.

Minnesota Multiphasic Personality Inventory in tinnitus disorders

The relation between Minnesota Multiphasic Personality Inventory (MMPI) and tinnitus was examined in 100 subjects with tinnitus disorders. The overall profile of tinnitus sufferers on the MMPI was normal. Higher scores on the depression scale were obtained in males. High hypochondria scores were related to long duration of tinnitus. High psychoasthenia scores were associated with hearing loss. Despite an analogy previously described between chronic pain and tinnitus, the psychometric parameters of tinnitus and of headaches are quite different.

Evoked otoacoustic emissions and sensorineural hearing loss

Following Kemp's original studies, several others have confirmed the existence of otoacoustic emissions. Their clinical relevance remains, however, to be clarified. The various published studies have concerned small series. This study sought to specify otoacoustic emission characteristics in relation to sensorineural hearing loss (148 ears of 76 subjects). The results show that the presence of otoacoustic emissions drops as a function of hearing loss and that there is a highly statistically significant correlation between otoacoustic emission threshold and hearing loss at the 1000-Hz frequency. Otoacoustic emissions are never found when hearing loss at 1000 Hz exceeds 40 dB hearing level and when the mean audiometric hearing loss (at 500, 1000, 2000, and 4000 Hz) exceeds 45 dB hearing level. The main practical conclusion is that otoacoustic emission presence indicates middle frequency functional integrity of the outer hair cells of Corti's organ. Absence of otoacoustic emissions is harder to interpret.

Experimental study of collagen as eardrum graft support in dogs

This experimental study involving dogs tested type IV human collagen as a biomaterial for use in the tympanic membrane reconstruction. A loss of substance was induced for the two tympanic membranes, and a type IV collagen graft made to one side. The kinetics of receiver fibroblast colonisation of the graft, as well as in the case of resorption, were studied. Anatomopathological examination revealed the process of reconstitution. This animal study prepares the way for studies on man.