Stephane Ayache

Objective: This study was conducted with the aim of determining the contribution of otoendoscopy in the surgical management of cholesteatoma of the middle ear. Background: The anterior epitympanum and the retrotympanum are anatomic sites that are difficult to access under otomicroscopy. Otoendoscopy offers a large field of vision using direct vision and lateral vision endoscopes, particularly in the supratubal recess and sinus tympani, for which visualization is excellent with reduced surgical approaches. The objectives of the study were to evaluate otoendoscopy as a means of identifying residues of lesions after excision of the disease under otomicroscopy in the same stage of surgery and its impact on the frequency of residual cholesteatomas at the time of surgical revision. Study Design: Retrospective case review. Setting: Private hospital center. Patients: Patients operated on a tympanoplasty under otomicroscopy with or without an otoendoscopic exploration for a cholesteatoma or an uncontrollable tympanic retraction pocket. Interventions: Between 1994 and 2005, 350 patients underwent tympanoplasty for a cholesteatoma or an uncontrollable tympanic retraction pocket. The surgical procedures were divided into closed tympanoplasty via the transmeatal approach, closed tympanoplasty with antroatticomastoidectomy and open tympanoplasty. Tympanoplasty was initially performed systematically under otomicroscopy. After excision of the disease, the cavities of the middle ear were examined by otovideoendoscopy, with the aim of identifying any peroperative residue of the lesion, to determine its location, especially in the epitympanum and retrotympanum, and the quality of its excision under otovideoendoscopy. During surgical revision, the frequency and location of any residual cholesteatoma were systematically recorded to determine the prognostic value of the quality of excision under otovideoendoscopy. Main Outcome Measures: The repartition of the canal wall down, canal wall up, and transmeatic tympanoplasties was compared between the population operated with or without the otoendoscopy as a complementary exploration of the otomicroscopy in the same surgical time. The frequency and the location of a residual disease identified by the otoendoscopy and the frequency of a residual disease in a second surgical stage were evaluated. Results: Eighty patients (34%) who presented with an initial location of the disease at the epitympanum underwent complementary exploration by otovideoendoscopy. In this population, the frequency of open tympanoplasty was significantly lower. In 35 cases (44%), otoendoscopy revealed a residual lesion after an apparently total excision by otomicroscopy during closed tympanoplasty. The use of otoendoscopy did not produce a significant reduction in the number of residual cholesteatomas at the second stage of surgery compared to the population that underwent surgery under otomicroscopy alone. Nevertheless, the 35 residual lesions identified under otoendoscopy, as a complement to the microscope, during the first stage of surgery would have led systematically to a residual cholesteatoma at the second stage of surgery. Complementary exploration by otoendoscopy was performed on 85 patients (34%) who presented with a lesion of the retrotympanum. In this population, the frequency of open tympanoplasty was significantly reduced, while the techniques by the transmeatal approach were used in the majority of cases. In 65 cases (76%), a residual lesion was identified by otoendoscopy during the first stage of surgery in the sinus tympani or on the footplate of the stapes, between the crura of the stapes. Otoendoscopy did not produce a reduction in the frequency of residual cholesteatomas during surgical revision. Nevertheless, as for the epitympanum, the 65 residual lesions discovered under otoendoscopy would have led systematically to a residual cholesteatoma at the second stage of surgery if otoendoscopy had not been performed during the first stage. Conclusion: This study confirms the real value of otoendoscopy in the surgical management of cholesteatomas of the middle ear. It belongs entirely to the minimally invasive surgical procedures, while significantly reducing the frequency of open tympanoplasty and recourse to posterior tympanotomy and offering excellent access to numerous lesions by the transmeatal approach. Analysis using otoendoscopy reduces the incidence of residual cholesteatomas by identifying lesion extensions that are overlooked under otomicroscopy. Nevertheless, some residual cholesteatomas persist at the second stage of surgery. The quality of excision under otoendoscopy constitutes an important parameter in the decision regarding revision surgery. By targeting the at-risk regions where a residual lesion was discovered, it allows the control scanner to be read with greater accuracy, thus facilitating the decision on whether to perform surgical exploration.

The emergency in the treatment of sudden hearing loss. A controversial dogma? Does the delay in instigation of treatment in cases of sudden hearing loss affect the outcome? 109 patients were included in this study. Sudden hearing loss is a much discussed subject in the literature. The authors agree on the concept of therapeutic emergency. This retrospective study aims to analyze the value of precocity in starting treatment on hearing improvement. The therapeutic time delay does not appear to be a significant factor and sheds doubt on the rule of therapeutic emergency. The authors remain nevertheless prudent on these conclusions. A larger number of cases should be studied. The question of a national versus placebo study is also laid.

The recurrential nerve palsy (RNP), the hypocalcemy and bleeding are traditional complications of the thyroid surgery. The objective is to bring back the postoperative rates of complications and to compare them with the patient's history and the goiter features (CT-scan extensions and weight) in order to identify predictive factors of these complications. One hundred and seventeen patients with a goiter below the subclavicular vessels on the cervicothoracic CT-scan and with a benign extemporane histopathology were operated between february 1997 and January 2004 and included in this retrospective study. The initial clinical assessment reports the respiratory and digestive functional signs, researches a palpable mass and studies the mobility of the vocal folds. The post-operative complications rates (RNP hypocalcemy and bleeding) are analyzed according to the patient's history and the goiter extensions in order to correlate these factors with the complications occurence. Five unilateral RNP occurred and two of them remained permanent, particularly for patients with thyroid surgery history (NS). The right/left or anterior/posterior extensions did not seem determining factors. Nevertheless the volume of the goiter suspected by the tracheal latero-deviation seems to play a role but without statistical confirmation. Among the thirty-four hypocalcemies, six were defined like permanent, without correlations with the surgical history nor the systematic identification of parathyroid glands. The volume and the younger age of the patient tend nevertheless to support the hypocalcemy. Three post-operative bleeding cases were reported, which one needed a reoperation, with a correlation with thyroid surgical history. None the factors among volume, extension or the age of the patient seem to play a role. The cervico-thoracic CT-scan is essential since echography does not manage to identify the lower pole of the gland. It helps to define the goiter and to analyze its extensions, very usefull to predict surgical difficulties in the preoperative information of the patient. Complications occurrence seems related on the volume and the thyroid surgical history.

Objectives: To describe the features of an oropharyngeal and hypopharyngeal myxoma.Materials and methods: Case report of a 34-year-old patient operated upon for a dual-location tumour, and review of the literature.Results: The myxoma is a rare tumour. Various head and neck locations have been described, but not (to our knowledge) a tumour in both the oropharynx and the hypopharynx. Multiple synchronous locations must be searched for, particularly regarding cardiac myxoma.Conclusion: The myxoma is a rare, benign tumour, even rarer in the head and neck. Surgical treatment must be complete in order to avoid recurrences, and should be performed after assessment for cardiac involvement.

Cervical liposuction belongs to aesthetic surgical procedures. It gives a new oval of the face, which is a characteristic of beauty and youth. The aim is the reduction of sub-mental and sub-maxillary fat accumulation. This procedure is reliable and not invasive. This article reports on the indications of this procedure, insisting on the physiopathology of fat tissue, technical procedures, results and complications, through the experience of authors.

To report, compare the clinical signs and the radiological signs of retrosternal goitre (cervico-thoracic goitre) and try to establish a correlation between clinical signs and radiological extent. One hundred and seventeen patients with a goitre beyond the sub-clavian vessels in cervico-thoracic CT-scan and with a benign histopathology examination after thyroid surgery in the head and neck department, University Hospital, Amiens, France between February 1997 and January 2004 were included in this retrospective study. The initial clinical assessment includes the respiratory and swallowing functional signs, palpable mass and mobility of the vocal cords. A correlation is analyzed between the extent of the goitre, the anatomic relations with the trachea and oesophagus and clinical signs. Dyspnea is the commonest of the functional signs (39.3%) for young subjects (p < 0.05), due to tracheal compression regardless of the side of extension of the goitre. Dysphagia (16.2%) is not correlated with the extent of the goitre in this series. A cervical palpable mass is present in 69.2% of cases. The cervico-thoracic CT-scan is the key examination of the assessment of a retrosternal goitre making it possible to appreciate its features, its anatomic relations and its tracheal involvement sometimes announced by respiratory disorders, the presence of a dysphagia should alert to the possibility of posterior extension which can not be felt during the cervical palpation.