[Results of fine needle aspiration biopsy, frozen section diagnosis and definite histological results in thyroid pathology. Report of 163 cases]

INTRODUCTION

In thyroid diseases, the place of fine needle aspiration biopsy still continues to be discussed: the sensibility and specificity vary greatly in the literature. Frozen section diagnosis is necessary to form a diagnostic strategy. The objective of this study was compare the results of fine needle aspiration biopsy, frozen section diagnosis, and definitive histologic results in a population of 163 patients and to draw conclusions about treatment.

MATERIAL AND METHOD

From 1994 to 1999, 163 patients (132 females and, 31 males) undergoing thyroid surgery were included in this retrospective study, after a standard preoperative work-up. Those with a single palpable nodule and hypofixation on scintigraphy underwent fine needle aspiration before surgery. These results were compared with the definitive histologic results.

RESULTS

A loboisthmectomy was performed in 88 cases (54%), a subtotal thyroidectomy in 34 cases (21%), and a total thyrodectomy in 41 cases (25%). In the latter group, an associated neck dissection was performed in 18 cases (11%); a frozen section diagnosis was obtained in all cases of thyroid nodules. This study demonstrated a single nodule in 97 cases (60%), multiple nodules in 27 cases (17%), multinodular goitre in 34 cases (21%), and 5 Basedow diseases (3%). Sixty-two cases (38%) of thyroid nodules underwent fine needle aspiration before surgery. In 25 cases (15%), definitive pathology showed a malignant lesion. The frozen section diagnosis had a sensitivity of 73% and a specificity of 99%, and the fine needle aspiration biopsy had a sensitivity of 40% and a specificity of 100%.

CONCLUSION

The authors propose fine needle aspiration biopsy in the following cases: a single palpable nodule and hypofixation on scintigraphy or a surgical contra indication; and direct surgery in symptomatic thyroid disease or if there are one or several full nodules > 2 cm. In near future, these indications will be modified with the increasing reliability of fine needle aspiration biopsy.

[One-stage surgery of middle ear cholesteatoma in adults: apropos of 180 cases]

OBJECTIVES

In order to evaluate the results of tympanoplasty in one stage middle ear cholesteatoma surgery, a retrospective study of 180 consecutive cholesteatomas operated on was undertaken.

METHODS

150 single procedures and 30 revision surgeries realized between 1992 and 1997 were analysed by studying anatomical and functional results with a mean follow-up of 24 months.

RESULTS

Among the 150 adult patients, 85 (57%) were previously operated on in other centres and presented a recurrence of cholesteatoma. Closed technique was performed in 110 cases (61%) and opened one in the remaining cases (41%). Ossiculoplasty was made in 101 cases (56%) with different materials (15 incus autografts, 14 teflon prosthesis, 35 hydroxyapatite (HA) composite prosthesis and 37 all in HA prosthesis): 91 cases in a one-stage procedure but 10 worse functional results required a closed revision procedure. Twenty cases were also revised after one year of follow up at least: six recurrences of cholesteatoma were operated on by using canal down mastoidectomy (4%), 14 limited residual cholesteatomas (9.3%) had a revision closed technique procedure. CT Scan followed up all the patients operated on by a closed technique. Postoperative air-bone gap (ABG) was 20 +/- 11.3 dB and 27 +/- 10.1 dB in closed and opened techniques, respectively (p < 0.05). ABG was 20 +/- 9.2 dB and 26 +/- 13 dB in type II and type III tympanoplasty, respectively (p < 0.05).

CONCLUSION

If the tympanic and posterior cavities are reasonably safe, middle ear cholesteatoma in adults can be well cured by a one-stage procedure including ossicular chain reconstruction with hydroxylapatite prosthesis covered with cartilage graft who achieved a valuable hearing restoration.

Chronic exposure to beta-hydroxybutyrate impairs insulin action in primary cultures of adult cardiomyocytes

Type 1 and type 2 diabetic patients often show elevated plasma ketone body concentrations. Because ketone bodies compete with other energetic substrates and reduce their utilization, they could participate in the development of insulin resistance in the heart. We have examined the effect of elevated levels of ketone bodies on insulin action in primary cultures of adult cardiomyocytes. Cardiomyocytes were cultured with the ketone body beta-hydroxybutyrate (beta-OHB) for 4 or 16 h, and insulin-stimulated glucose uptake was evaluated. Although short-term exposure to ketone bodies was not associated with any change in insulin action, our data demonstrated that preincubation with beta-OHB for 16 h markedly reduced insulin-stimulated glucose uptake in cardiomyocytes. This effect is concentration dependent and persists for at least 6 h after the removal of beta-OHB from the media. Ketone bodies also decreased the stimulatory effect of phorbol 12-myristate 13-acetate and pervanadate on glucose uptake. This diminution could not be explained by a change in either GLUT-1 or GLUT-4 protein content in cardiomyocytes. Chronic exposure to beta-OHB was associated with impaired protein kinase B activation in response to insulin and pervanadate. These results indicate that prolonged exposure to ketone bodies altered insulin action in cardiomyocytes and suggest that this substrate could play a role in the development of insulin resistance in the heart.

[Auditory aspects of congenital malformations of the external and middle ears]

Auricular malformations are frequently associated to malformations of the external, the middle, and the inner ear in variable degrees. Asystematic audiometry must be performed in case of unilateral facial microsomia. This test which can be performed in very young patients can detect bilateral ear malformations necessitating auditory rehabilitation by surgery or external hearing aids. In major ear aplasia, air conduction hearing aids can rarely be proposed. In this case, bone conduction hearing aids using a mastoid transducer of through a bone anchored device yield the best auditory results with an excellent local tolerance.

[Predictive factors of outcome in 220 ossiculoplasties in adults]

OBJECTIVE

To define factors predictive of outcome after ossiculoplasty in adults.

MATERIAL AND METHODS

From 1992 to 1998, 220 ossiculoplasties were performed for chronic otitis media in 200 patients (100 men and 90 women), average age 53 years, age range 17 - 82 years. Ninety-four patients (47%) had not undergone prior surgery (99 ossiculoplasties) and 106 (53%) underwent revision procedures (121 ossiculoplasties). Average follow-up was 20 months. All patients were reexamined at consultations 3 and 12 months after surgery and 100 patients (50%) were reexamined at two years. The operations were classified in type II tympanoplasty when the patient presented a normal stapes (n=120), and a type III tympanoplasty when the stapes arch was absent (n=100). Perforations (n=200) were repaired by temporal aponeurosis in 160 cases (80%) and a tragal perichondrium in 40 cases (20%). The materials used included 23 incus autografts (10%), 105 hydroxyapatite composite Goldenberg prosthesis (48%), 55 all-hydroxyapatite Xomed prosthesis (25%) including 20 covered with a thinned tragal cartilage, 19 teflon Klein prosthesis (9%), 12 Ionos prosthesis (5%) and 6 Malleus prosthesis (3%). The results were analyzed from the microscopic aspect and audiometric data for frequencies 0,5 to 3 KHz.

RESULTS

Twenty prosthesis luxed or extruded (9%) within an average of 6 months, 15 (12.4%) after a revision procedure and 5 (5%, p<0,05) after an initial procedure. Fifteen perforations (15/200, 7.5%) occurred, 9 with temporal aponeurosis grafts (9/160, 5.6%) and 6 with perichondrium grafts (6/40, 15%, NS). The residual air-bone gap (ABG) was equal to 23 +/- 12,5 dB with 57% of ABG<20 dB at 12 months follow-up. The gain in air conduction was 14 +/- 16,5 dB and the change in air-bone gap 13 +/- 12,3 dB. Some factors could significantly improve functional results: presence of the stapes arch (n=120, p<0,05), first-intention procedure (n=99, p<0,05), and use of all-hydroxyapatite prosthesis in type II (p<0,05) or type III tympanoplasties.

CONCLUSION

Ossiculoplasty with all-hydroxyapatite prosthesis produced satisfactory results in type II or III tympaonoplasties.

[Tympanic grafts: surgical techniques and results of 260 cases]

PURPOSE OF STUDY

The aim of this retrospective survey was to define factors which may influence tympanic grafts results.

METHODS

260 surgical procedures were retrospectively analyzed between 1992 and 1997 by studying anatomical and functional results with a mean follow-up of 18 months.

RESULTS

Global rate of tympanic grafts reperforation was 9.2%. At 18 months, the air conduction gain was 9.5 +/- 11.5 dB, with an 13 +/- 7.7 dB air-bone gap (ABG) and 80% ABG inferior to 20 dB, the change in air bone gap was 9 +/- 10.3 dB. Several factors influencing the results were identified: second hand surgical procedures (40%) had worse functional results than patients from first hand procedures, inflammatory atrial mucosa or obstruction of the eustachian tube (more graft retraction), retracted malleus handle and/or stuck to the promontory (worse auditory results), temporal aponeurosis placed under malleus handle (more reperforation of the graft without hearing difference as to graft placement above malleus handle), association of canal wall-down technique (poor auditory results), surgeon experience (better auditory results).

CONCLUSION

A first surgical procedure, normal malleus handle and atrial mucosa, no mastoidectomy or canal wall-up technique, a temporal aponeurosis graft placed above malleus handle are predictive factors for anatomical and/or functional good results.

Temporal modulation of nephrotoxicity, feeding, and drinking in gentamicin-treated rats

Gentamicin-induced nephrotoxicity varies temporally, with a peak being observed when this antibiotic is administered during the resting period and a trough when given during the activity period of rats. These nychthemeral variations are modified by fasting and by restricted feeding schedules. In this study, food and water intakes of adult female Sprague-Dawley rats were measured during pretreatment (Days 1 to 5) and during treatment (Days 6 to 10) with gentamicin (80 mg/kg/day, i.p.) injected at 1300 or 0100h. A significantly higher level of serum creatinine was observed when gentamicin was administered at 1300 h compared to 0100 h, and a significantly lower creatinine clearance was found in rats treated with gentamicin at 1300 h compared to those treated with saline at the same time. Gentamicin treatment at 1300 or 0100 h resulted in a decrease in the 24-h food intake. In addition, in the gentamicin-treated group at 0100 h, the maximal food intake observed at late dark during the pretreatment period decreased during treatment, and early dark rather than late dark maximal intake occurred. Our data demonstrate that gentamicin induces a nephrotoxicity that varies temporally, and that gentamicin treatment inhibits food intake and alters its nocturnal variations.

Surgical treatment of the high jugular bulb in patients with Ménière's disease and pulsatile tinnitus

The aim of this retrospective study was to evaluate the functional results of surgical lowering of the high jugular bulb in the treatment of patients with Ménière's disease and pulsatile tinnitus. Fifteen patients with disabling Ménière's disease associated with pulsatile tinnitus and a high and medial jugular bulb were included in this study. As treatment a complete mastoidectomy was performed, after which the jugular bulb was freed by an infralabyrinthine and subfacial approach. The bulb was then displaced downwards with surgical wax. Functional results of surgery were assessed by a questionnaire according to the 1995 guidelines of the United States American Academy Committee on Hearing and Equilibrium, audiometric and vestibular tests, and by magnetic resonance and computed tomographic imaging with vascular sequences. Surgical treatment was contraindicated in two cases: one had hypoplasia of the contralateral sigmoid sinus and the other a small petrous hemangioma located around the jugular bulb that was discovered peroperatively. Among the 13 patients treated by definitive surgery, attacks of vertigo were reported as disabling in 12 cases preoperatively (92%) versus 1 (8%) after surgical treatment. No significant change in hearing was observed after surgery. Tinnitus had been reported in all patients preoperatively and decreased in intensity in four (31%) and disappeared in three (23%) after surgery.

Hormonal modulation of inner ear fluids

In the cochlea, hormones such as antidiuretic hormone and adrenocorticosteroid hormones are supposed to modulate the endolymph osmolality acting on the labyrinthine water permeability, on the one hand, and on the Na+, K(+)-ATPase, on the other hand. To test the hypothesis that these hormones are involved in the inner ear fluids homeostasis, the electrochemical composition of cochlear fluids was studied in control Long Evans rats, Brattleboro rats that are genetically deprived of antidiuretic hormone, and in adrenalectomized Long Evans rats. The results demonstrated that: i) in Brattleboro rats, the endocochlear K gradient was absent whereas the endocochlear potential and the Cl concentration gradients were maintained; the K gradient was restored by the dDAVP administration; ii) in adrenalectomized rats, no modification of the electrochemical composition of endolymph occurred; the injection of bumetanide (10 mg/kg) induced a larger decrease of the endocochlear potential in adrenalectomized rats than in control animals. These results suggest that the cellular transport systems involved in the endolymph secretion may be altered by different hormones such as antidiuretic hormone and/or adrenocorticosteroid hormones. Nevertheless, the hormonal modulation of the inner ear fluid homeostasis remains to be further documented.

[Digital necrosis associated with fenoxazoline poisoning. Apropos of a case and review of the literature]

We report the case of a 53 year-old woman with paroxystic hypertension and digital ischemia. The only triggering factor was chronic intoxication by a nasal vasoconstrictor:fenoxazoline. The worsening of the lesions required amputation of the third phalanx of the 3rd and 5th finger and the pulp of the 4th finger of the left hand. The review of literature exhibits association between fenoxazoline intoxication and paroxystic hypertension, myocardial ischemia or stroke, but association between fenoxazoline intoxication and digital ischemia has never been reported. We emphasize the extreme caution necessary with the prescription and the chronic consumption of this kind of drug.

[Management of breach of the tegmen isolated or associated with cephalocele]

This is a retrospective report of 41 tegmen breaches observed in 2 different populations : 27 patients among a series of 252 cases of operated chronic otitis (6.7%) and 14 patients admitted for management of tegmen breach and dura mater involvement. The most frequent cause was chronic otitis (36 cases, including 6 due to iatrogenic causes); there were also 2 cases of petrus fracture, 2 cases of intracranial hypertension and 1 idiopathic case. Computed tomography revealed a bony breach in 97% of the cases. Encephalo-meningocele was associated in 11 cases (31%). In these cases, MRI confirmed the preoperative diagnosis. Treatment via the mastoid route allowed removal of the infectious process and via the suprapetrous route allowed closure of the breaches in the bone and dura mater as well as treatment of associated cephaloceles, except in case of major infection where the cephalocele was closed in a second operation.

Antidiuretic hormone restores the endolymphatic longitudinal K+ gradient in the Brattleboro rat cochlea

In the cochlea, endolymph is hyperosmotic to plasma and perilymph. To test the hypothesis that antidiuretic hormone is involved in the modulation of endolymph secretion, the electrochemical composition of cochlear fluids, endolymph and perilymph, was studied in three groups of anaesthetized rats: control Long Evans rats, homozygous Brattleboro rats that are genetically deprived of antidiuretic hormone, and Brattleboro rats that were treated with antidiuretic hormone (dDAVP, 0.5 microgram/100 g body weight/24 h during 8 days). Endolymph was sampled from the scala media at each turn of the cochlea and perilymph from the scala vestibuli. In Long Evans rats, the endocochlear potential, the endolymphatic K+ and Cl- concentrations decreased from base to apex of the cochlea as previously reported in guinea pigs and Sprague Dawley rats. In Brattleboro rats, the endocochlear potential and the Cl- concentration gradients were still present, whereas the K+ concentration gradient were still present, whereas the K+ concentration gradient was absent. This K+ gradient was restored by the administration of dDAVP, which increased the K+ concentration at the base of the cochlea. This work indicates that the K+ secretion in endolymph, and thus the osmolality, may be locally modulated by the antidiuretic hormone, probably via V2 receptors.

Is the endolymphatic K secretion electrogenic?

The endolymphatic potential is assumed to result from active K transport into the endolymphatic compartment and passive K diffusion in the opposite direction. However, in several in vivo experiments, changes in the endolymphatic potential differed from those in the endolymphatic K concentration. Moreover, in in vitro experiments, a negative endolymphatic potential was observed in the presence of ouabain without K gradient between the two compartments. These observations suggest that the coupling between the K transport and the genesis of the endolymphatic potential is not tight. Several factors may separately influence the endolymphatic potential and the K transport such as the acid-base equilibrium, the integrity of Reissner's membrane, the hormonal status, and the Na transport.

Postlaryngectomy voice restoration. A prospective study in 83 patients

From July 1985 until May 1990, 83 patients underwent a total laryngectomy. We prospectively studied voice restoration in 81 of them (two died postoperatively). Esophageal voice was used by 19 patients; a tracheoesophageal procedure (myomucosal shunt, primary or secondary puncture with Blom-Singer prosthesis) by 41; and 21 patients had no voice restoration. Results were assessed according to voice quality and usage. Tracheoesophageal speech had a success rate of 73% (good voice, daily use) after 1 month, while esophageal voice proved to have only a 5% success rate. Thirty patients (37%), however, remained without a substitute voice. The reasons for their exclusion are presented; they include a high rate of refusal.

Cholesterol granulomas of the middle ear cavities: MR imaging

Symptomatic cholesterol granuloma developed in the middle ear cavities in three cases. At computed tomography (CT) after the administration of contrast material, the granulomas appeared as nonspecific, nonenhanced soft-tissue masses with variable bone erosion. These features are indistinguishable from those of other similar clinical entities, especially cholesteatoma, paraganglioma, and endaural brain hernia. At magnetic resonance (MR) imaging, cholesterol granulomas had a more characteristic appearance. In two cases, the granulomas were depicted as areas of high signal intensity with both T1- and T2-weighted sequences. In the third case, an expansile mastoid cholesterol cyst exhibited medium signal intensity on T1-weighted images, with only a small hyperintense area and a hypointense area located in the cystic wall. Correlations between CT, MR, and microscopic findings show that MR imaging is far superior to CT in tumoral characterization, which is crucial for planning surgical approaches. MR imaging has limitations, however, particularly its inability to depict subtle bone abnormalities.