Hamartoma of the middle ear: a case study

Hamartomas and teratomas are rare tumors in children. Its location in head and neck is quite exceptional. An unusual case of hamartoma in the middle ear is reported in a 5-month-old child. The tumor was isolated without associated malformation. Definitive diagnosis was made after surgery and based on histological results. At 2 years follow-up, no recurrence was observed. CT-scan is useful in order to reach a final diagnosis. Although rare, this type of tumor should be considered in the differential diagnosis of a middle ear mass during childhood.

[Ewing's sarcoma of the head and neck: a case report]

We report a case of Ewing's sarcoma located in the ethmoid sinus. The patient complained of facial pain, anosmia and visual defect. Diagnosis was established at microscopic examination with histoimmunochemistry and molecular biology. Treatment combined chemotherapy and surgical resection with skull base reconstruction and post-operative ratio and chemotherapy.

Comparison between anatomy and resistance of upper airway in normal subjects, snorers and OSAS patients

Upper airway (UA) anatomical abnormalities are frequently observed in obstructive sleep apnea syndrome (OSAS). The correspondence between UA anatomical modifications and UA resistance (UAR) had not been studied. We aimed to determine if cephalometric characteristics could be related to segmental UAR. In twenty-five patients (21 males) (15 OSAS patients, 10 snorers) and 10 control subjects (8 males), segmental UAR were measured in supine position and cephalometry was performed. Inspiratory and expiratory UAR were calculated at peak flow. Length of the soft palate (LP), posterior airway space (PAS), distance from hyoid bone to mandibular plane and to posterior pharyngeal wall were different between the groups (P<0.01). Inspiratory and expiratory, total and segmental, UAR were higher in OSAS (P<0.001). Segmental UAR were correlated with PAS and distance from hyoid bone to mandibular plane and to pharyngeal posterior wall (P<0.05). In conclusion, OSAS patients had higher UAR depending on anatomical variables, especially the place of the hyoid bone.

[Wegener's granulomatosis involving head and neck: retrospective analysis of 16 patients]

Based on a retrospective analysis of patients with Wegener's granulomatosis (WG), the aim of our study was to compare our finding with those previously reported in the literature. We also reviewed the characteristic features of WG, particularly otorhinolaryngology features. Sixteen consecutive patients were followed over a period of 23 years. There were 8 men and 8 women, all Caucasians, aged between 13 and 74 years (mean 42 years). Initial ENT signs and symptoms were observed in 62.5% of the cases, and occurred in 94% during disease progression with predominant rhino-sinusal (75%) and otological (38%) or laryngotracheal (25%) localizations. Later, the disease primarily affected the lower respiratory tract (87.5%) and the kidneys (50%). Articular (40%), ocular (25%), cardiovascular (25%), neurological (25%), and cutaneous (19%) localizations were also observed. The mean delay to diagnosis was 40 months, more than 1 year in 7 patients. A definitive diagnosis could not be made for 5 patients because of lack of histological evidence, but clinical and biological arguments suggested diagnosis of WG. Antineutrophil cytoplasmic antibodies (ANCA) were assessed in 13 patients and were positive in all. The role of ENT biopsies was significant to our study (31%). The ENT specialist can play a very important role in the diagnosis of Wegener's granulomatosis.

Post-intubation vocal cord paralysis: the viral hypothesis. A case report

After digestive surgery, a 20-year-old man presented dysphonia and fever. Indirect laryngoscopy revealed a left vocal cord paralysis with no structural lesion. IgM and IgG were positive for cytomegalovirus and negative for human immunodeficiency virus, herpes simplex virus, varicella zoster virus and Epstein-Barr virus. The patient recovered spontaneously with a normal voice, and the mobility of vocal cord recovered within 3 months. The aetiology of post-intubation vocal cord paralysis (VCP) remains controversial. Vocal cord paralysis with cytomegalovirus has been reported in two cases associated with acquired immunodeficiency syndrome. Vocal cord paralysis secondary to viral disease has also been described in other circumstances. panied by polyneuritis, especially in immunocompromised patients. We report the case of a patient with transitory unilateral post-intubation vocal cord paralysis which could have been related to a virus infection.

[Adenocarcinoma of the ethmoid sinuses: results of a retrospective study in Rouen]

Ethmoid adenocarcinoma is a rare tumour of the ethmoidal sinuses. The authors report on the clinical features, treatment and follow-up results in 19 cases. Risk factors were those regularly encountered. Delay to diagnosis was long due to the nonspecific clinical features and course. Nasal endoscopy was essential for follow-up. Computed tomography and magnetic resonance imaging were also required to assess tumour spread. Our results suggest that radiotherapy following surgery should be preferred. Survival rate is generally low for this type of tumor. We had 77% survival at 5 years.

[Aging and deafness]

The hearing loss that appears with ageing or presbyacusis should not lead to withdrawal from communication an elderly person. The disorder should be recognised early. The first warning sign is difficulty for understanding in a noisy environment. When an individual indicates this problem, measurements of auditory functions should first be made and regular followed-up should be scheduled or therapeutic measures taken. Such measures generally include a hearing aid that amplifies the affected frequencies and speech therapy to learn lip reading. Some patients may profit from psychological follow-up during this new learning process. The family physician is crucial in the rehabilitation in encouraging the patient to seek medical help as soon as hearing loss begins.

Experimental reinnervation of a strap muscle with a few roots of the phrenic nerve in rabbits

In order to compare application of the roots of the phrenic nerve to the ansa hypoglossi for laryngeal muscle neurotization, 1 or more roots from the phrenic nerve were implanted into the right sternothyroid (RST) muscle of rabbits (n = 36). Controls were intact animals (in which RST innervation is provided by the ansa; n = 6) and denervated ones (n = 6). At 66 +/- 2 days (mean +/- SE) after neurotization, during quiet breathing, inspiratory electromyographic activity and isometric contraction force were observed in all reinnervated RST muscles (n = 24). During maximal inspiratory effort, electromyographic activity and force increased. In animals reinnervated by the C4 root alone, forces (46.22 +/- 7.8 g) were significantly higher than in intact animals (10.83 +/- 5.0 g). Retrograde labeling proved the phrenic origin of the neurotization. Electromyography of the diaphragm was recorded. We conclude that in rabbits, neurotization of a strap muscle by 1 or 2 roots of the phrenic nerve allows inspiratory contraction, even during quiet breathing. Such inspiratory activity is not observed in sternothyroid muscles of intact animals innervated by the ansa hypoglossi.

Cervical anatomy of phrenic nerve roots in the rabbit. European Group for Research on the Larynx

The cervical anatomy of the different nerve contributions that constitute the phrenic nerve (phrenic nerve roots and accessory phrenic nerve) were studied in rabbits. In 55 dissections, 6 main root arrangement types were observed. The roots that issued from the fourth and fifth cervical nerves (C4 and C5 roots) were constant. The C4 root was either short or long. The C6 root was at times absent, or sometimes double. An accessory phrenic nerve was present in 43% of the right and 28% of the left dissections. The distribution of the phrenic nerve roots often displayed left-right asymmetry. We conclude that a better knowledge of the cervical anatomy of the phrenic nerve is useful both in physiological studies involving diaphragm denervation and in experimental laryngeal reinnervation.

Infiltrating lipoma of the head and neck: a report of one pediatric case

Infiltrating lipomas are rare benign tumors. Several cases have previously been reported in the oral cavity but only three cases have been reported to date in children. We report a case of a 7-year-old child with an infiltrating lipoma of the neck and a posterior extension to the fourth and fifth cervical roots and the vertebral artery. The absence of any neurological signs, negative clinical and radiological examination results, as well as, the surgical risk of total removal and high rate of recurrence suggested a period of watchful waiting. After 5 years, the patient's clinical and radiological characteristics remain stable. A review of the literature regarding this pathology in the head and neck area, in both children and adults is also presented.

[Middle ear cholesteatoma in children. Criteria for surgical procedure in 57 cases]

Fifty five children with 57 cholesteatomas (2 bilateral cholesteatomas) were operated on by the same surgeon. The median period of follow-up was 87 months. Fifteen cases were lost to follow-up (26%). An ossicular erosion was present in 76% of cases. In the first stage, an "intact canal wall technique" (ICWT) was carried out in 44% and a "canal wall down technique" (CWDT) in 56%. A planned second stage was carried out in 76% of ICWT and 56% of CWDT. The incidence of residual cholesteatoma was 29% and the incidence of recurrent cholesteatoma was 11%. A third stage was carried out in 6 cases (11%) without residual or recurrent cholesteatoma. Finally a CWDT was performed in 65% and a ICWT in 35%. The hearing results were significantly better with ICWT but this was due to a better preoperative hearing level. Whatever the surgical technique, the hearing results were better in the presence of an intact stapes. The surgery was individualized. Although ICWT is our priority technique, it was feasible, in our experience, only in a minority of cases because of difficult ablation, insufficient eustachian tube function and very advanced sigmoid sinus or very low lying tegmen plate. Minimal postoperative cavity problems were encountered, even in children where in our experience the mastoidal pneumatisation is limited.

[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.

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.

[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.

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.

[The treatment of laryngeal stenosis in the child. 156 cases (author's transl)]

156 cases of laryngeal stenosis in the child were seen over a 10 year period. 40 were congenital and 116 acquired, chiefly after intubation. Congenital stenosis improved spontaneously in 60 % of cases. When tracheotomy was necessary, treatment was similar to that of acquired stenosis. For post-intubation stenosis analysis of the underlying pathology revealed the existence of risk factors: coma, cardiac surgery with extracorporeal circulation, laryngaeal pathology being responsible in 75 % of cases. Awareness of these risk factors was felt to be one of the essential elements in the prevention of post-intubation stenosis. Treatment varied in accordance with the degree of progression of the stenosis. In recent progressive forms medical and endoscopic treatment (51 cures without treacheotomy, 11 after tracheotomy for 2 to 10 weeks). In forms with scar tissue, tracheotomy associated with endolaryngeal calibration (21 cases) or laryngotracheal enlargement surgery (21 cases). A number of precautions are suggested in order to improve the prevention of stenosis with scar tissue. Indications of the various therapeutic methods are discussed according to whether the stenosis is due to scar tissue or is congenital. With regard to procedures involving laryngotracheal widening (28 in all : 21 for stenosis after intubation and 7 for congenital stenosis), emphasis placed upon the need to select amongst several types of operation according to the site and extent of the lesions.

[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.

[Recurrent deforming juvenile nasosinusal polyposis and latent mucoviscidosis]

Three children from a family of eight, had a cystic fibrosis diagnosed by Sweat test. Two of these had a nasal polyposis wigh widening of the nose, ethmoid and intercanthal distance. Every cases of this rare type of nasal polyposis in children observed since 1953 (Sweat test) and related in the litterature, had cystic fibrosis. It is concluded that cystic fibrosis may be the one only, cause of nasal polyposis with widening of the nose.

[Ataxia and deafness secondary to meningitis in children: the role of labyrinth diseases]

A study is made of post meningitic ataxia from 9 purulent meningitis observations in children. This ataxia is accompanied by a bilateral vestibular destruction syndrome in 6 of the 7 patients examined. The labyrinthic origin of the ataxia accounts for its pure static aspect, its regressive evolution and the frequency of associated deafness. The study of sightless walking on unstable ground (mattress) gives a clinical sight of the vestibular impairment long after the acute phase. In the same way, the study of post-meningitis deafness shows that, most of the time, it is accompanied by an impairment or the suppression of the vestibular reactions. The frequency of the inner ear impairment, after purulent meningitis is certainly underestimated for two reasons: on the one hand, the ataxia remains unknown most of the time because of the excellent vestibular compensation; on the other hand, the deafness can be slight or localized only on one side. Consequently it seems important to undertake in each purulent meningitis convalescent, a clinical examination of standing and walking positions, together with an examination of the hearing and vestibular functions, as soon as age allows it. Lastly, with regard to a pathogenic theory of purulent meningitis, the role of a possible viral component of the infection in the cochleo-vestibular impairment is called into question.