Subcranial approach to tumors of the anterior cranial base.
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Craniotomy↗
Biomedical subjects
V Darrouzet
Publications and source records attributed to V Darrouzet.
Xenogeneic ossicular implants: an experimental study of heterotopic, demineralized, lyophilized, porcine implants in the guinea-pig.
This study was done to compare the outcome of porcine ossicular implants in the middle ear and the subcutaneous dorsal region of the guinea-pig to those of allo-implants implanted in parallel in the dorsal region. The implants were heteropic, xenogeneic, demineralized (HCl), lyophilized and sterilized. The evaluation was histological (light microscopy and scanning electron microscopy) and immunological (immunofluorescence staining). Fifty-four guinea-pigs were implanted in the middle ear and 14 of them were also implanted subcutaneously in the dorsal region with xeno-implants and allo-implants. The middle ear implants were found to be constantly reossified and coated with normal mucosa with only a minimal immune reaction. In contrast, the dorsal xeno-implants were found to be the target of mononucleic infiltration, fibrous encapsulation and an influx of immunoglobulins resulting in segregation. The corresponding allo-implants were found to be partially reoccupied and reossified. These findings highlight the value of HCl demineralization in the induction of non-species-specific Bone Morphogenetic Protein and the failure of attempts at immuno-despecification. It appears that the fate of the implant depends less on its antigenic load than on the site of implantation. In this regard the middle ear is apparently very advantageous. The very good short-term tolerance and recovery observed in the middle ear xeno-implant suggest that these implants offer sufficiently good results to warrant clinical testing.
Animals↗
New technique of side-to-end hypoglossal-facial nerve attachment with translocation of the infratemporal facial nerve.
OBJECT: The goal of this study was to assess the clinical results of hypoglossal-facial nerve attachment (HFA), which was primarily performed in patients following excision of tumors of the cerebellopontine angle. In six of the patients a new side-to-end procedure was used. METHODS: The authors have performed a retrospective study of 33 patients who underwent HFA, including 24 classic end-to-end, three May, and six side-to-end procedures. For the latter procedure, a hemihypoglossal-facial nerve attachment was performed by rerouting the intratemporal facial nerve; this avoided the jump-cable graft used in May's technique. The goal of the new procedure is to reduce the incidence of morbidity due to hemilingual paralysis (difficulty in chewing, speaking, and swallowing). The incidence of hemilingual paralysis was evaluated based on the findings of a questionnaire that was completed by the patients. The patient's facial mobility was assessed using the House and Brackmann grading system and the author's analytic scoring system. CONCLUSIONS: The HFA offers good functional results. Of the 28 cases evaluated, nine had House and Brackmann Grade III, 17 Grade IV, and only two Grade V at 18 months. When the new technique of side-to-end hemihypoglossal-facial nerve attachment was used, there was considerable reduction, if not complete disappearance, of lingual morbidity and the facial functional results were constant and satisfactory: there were five patients with House and Brackmann Grade III and one with Grade IV, and their mean percentage of facial mobility was 43.3%.
Adolescent↗
[Jugular bulb diverticular and facial paralysis].
The authors report a case where a woman presents a right jugular bulb procidence already known and responsible of a perception deafness. Secondarily, a right facial paralysis is appeared progressively and not regressive even with medical treatment. When the computed tomography as shown an intrapetrous diverticular, the facial paralysis treatment was surgical to decompress the facial nerve. The literature study shoes the rarity of this association facial paralysis and jugular bulb procidence (only two cases), more often responsible of deafness, tinnitus, and vertigo. The diagnosis is given by computed tomography. M.R.I. has not still be evaluated. Then the authors insist on the progressive character of the facial paralysis and on the necessity of a surgical treatment.
Adult↗
[Congenital cholesteatoma of the ear in the child. Clinical, follow-up and therapeutic analysis of a series of 34 cases].
Long a subject of debate, congenital cholesteatomas of the middle ear appear to be a specific clinical entity different from the much more frequent classical acquired cholesteoma. Characteristic features of congenital cholesteatomas are young age at diagnosis, typical peroperative presentation, satisfactory mastoid air cells in almost all cases, and associated congenital malformations, which may involve the otology system or not. Diagnosis is a difficult task due to the long latency period with no clinical manifestations. These congenital cholesteatomas appear to be more aggressive in a mastoid with functioning air cells. Thus open excision does not appear to be appropriate and should be reserved for selected cases. For us, the closed technique with two procedures is more adapted but requires good cooperation with the family. The risk of recurrence is however significant and at least comparable to that of acquired cholesteatomas in children. Follow-up should be persuade as long as possible. Functional results have been encouraging even though ossicular destruction is frequent. The quality of the auditory tube appears to be a determining factor.
Adolescent↗
[Multi-frequency tympanometry in experimentally-induced cochlear lesions in chinchillas and guinea pigs].
OBJECTIVES: To establish that susceptance-conductance tympanograms at a probe-tone frequency of 2 kHz reflects the status of the annular ligament (AL) and through it of the cochlea. METHODS: Experimental study in 5 chinchillas and 22 guinea pigs. Six validating experiments were used: blockages of the stapes and of the round window membrane (RWM), fistula of the RWM, fluid removal from the cochlea, injection of saline in the scala tympani (ST) and acoustic trauma (AT). Quantitative data (mean values of Y226, FR, Y2000, G2000 and B2000) and shape of the curves were analyzed before and immediately after lesions were done. RESULTS: Guinea pig was the most convenient provided bulla was vented and the same tip was used along the experiments. Only the shape of the curves are discriminant: 1/a supplementary sharp peak, centered around negative pressures, is observed in Y/G tympanograms in every case of RWM fistulas and in some case of AT. 2/injection of saline into ST induces immediate and reproducible Y2000, G2000, et B2000 curves modifications. 3/RWM and stapes blockages provoke foreseeable stiffening and sharpening of the tympanograms at 2 kHz. 4/on the contrary, fluid removal from the cochlea induces multiple peaks curves. CONCLUSIONS: Experimentally-induced modifications at the AL either direct (stapes blockage) or indirect by AT or decrease/increase of pressure load at the cochlear interface at the footplate result in noticeable, constant, reproducible changes of curves registered at 2 kHz. The stapes behaves both as the plotter of the curves and the interpreter of the inner ear pressure.
Acoustic Impedance Tests↗
[Multi-frequency impedance measurement and Meniere's disease. Analysis of the results of TEFLAG].
We present today our preliminary results of the TEFLAG test performed on 58 patients suffering from Meniere's disease. This test completed in 1993 has already led to a 4-stage classification of noise induced hearing losses. On the one hand, it is based on the morphological study of susceptance B curves, and on the other hand, on the study of the resonant frequency (RF) of the annular ligament of the stapes, provided by a multifrequential impedancemeter. The endolymphatic hydrops coming with the Meniere's disease practically always cohabits in the intercritical period with the decrease of the perilymphatic pressure of the scala vestibuli, which is shown in the morphology of Stage IV curves especially, and the decrease of the annular ligament rigidity. Inversely, during the vertigo or around, we mainly have stage I curves, and an increase of the stapes annular ligament resonant frequency (RF), testifying the labyrinthic hydrops, which is the physiopathological essence of the Meniere's disease.
Acoustic Impedance Tests↗
[Management of post-traumatic facial paralysis. A decision based on a series of 85 cases].
OBJECTIVE: To review patient selection and factors affecting the decision for surgical or non-surgical management of patients with trauma-induced facial nerve palsy. STUDY DESIGN: Retrospective review of 85 consecutive cases occurring over a 6-year period. METHODS: Between 1984 and 1990, 85 cases of facial nerve palsy following trauma were treated. Patient assessment included clinical, audiological, radiological and EMG examinations. Depending on test results, patients were either given medical treatment or underwent total facial nerve decompression surgery. RESULTS: Recovery was achieved in all 33 medically treated patients. Among the 52 surgically-treated patients (61.2%), 47 had immediate facial nerve palsy at admission (90.4%). Onset of facial palsy was delayed in 5 others, including 3 for whom the delay to onset was unknown. Surgical accesses used were the middle fossa and transmastoidal (60%), translabyrinthine (11%), and pure transmastoidal (29%) routes depending on hearing loss, location of fracture line and general patient condition. Lesions were predominantly found in the geniculate ganglion area. A nerve gap was found in only 13.5% of the cases. Two years post-operatively, 92.3% of the patients had grade I-III recovery. No grade V or VI cases were observed. DISCUSSION AND CONCLUSION: The rarity of severe nerve lesions encountered in surgically-treated patients raises the question of better candidate selection for surgery. At present, imaging techniques, particularly radiology, can help to choose the best indication. Immediate total facial palsy associated with a clear-cut fracture going through the Fallopian canal is perhaps the only case requiring surgery. When the delay of onset is unknown, an EMG indicating a total denervation process is the decisive argument.
Adolescent↗
The widened retrolabyrinthe approach: a new concept in acoustic neuroma surgery.
For many years, the retrolabyrinthine approach has been limited to functional surgery of the cerebellopontine angle (CPA). As a result of the increased surgical exposure, particularly the opening of the internal auditory meatus (IAM), the widened retrolabyrinthine technique permits tumor excision from both the CPA and the IAM, regardless of the histological nature of the tumor. The authors have treated 60 acoustic neuromas of varying sizes via this approach (6% intrameatal tumors; 30% > 25 mm in diameter). The postoperative mortality rate was 0%. The risk of fistula formation was 3.3%, and 3.3% of the patients suffered from postoperative meningitis. The results for facial nerve function were equivalent to those obtained previously via a widened translabyrinthine approach and those in a series treated via a suboccipital approach (80% with Grades I and II, 15% with Grade III, and 5% with Grades V and VI). One patient (1.7%) required a secondary hypoglossal-facial nerve anastomosis and had attained a Grade IV result 6 months later. Postoperatively 21.7% of these patients maintained socially useful hearing and 20% had mediocre hearing. Socially useful hearing was preserved in 50% of a subgroup of 20 patients who had both good preoperative hearing and a tumor that involved less than half of the IAM regardless of its volume. Additionally, 15% had mediocre hearing that could be improved with hearing aids. Because of its efficacy in preserving hearing, the authors favor the retrolabyrinthine over the occipital approach, with the latter being considered less subtle and more aggressive.
Adult↗
[Endocranial complications of cholesteatoma: apropos of 8 cases].
The authors present a recent series of 8 cases of intracranial complications secondary to cholesteatoma. The series is made up of 3 temporal lobe abscesses, 1 parietal lobe abscess, 1 cerebellar abscess, 1 extradural abscess, one lateral sinus thrombo-phlebitis with subdural abscess and one meningitis on its own. Otological management with removal of the cholesteatoma was by open or closed technique, depending on the local anatomical conditions. It was supplemented by multiple antibiotic therapy, in turn guided by the bacteriological cultures and by any known epidemiological information. It was necessary to needle the abscess by a neurosurgical approach in two cases. The results of bacteriological samples taken for analysis from the intracranial abscesses are often negative, which limits their clinical value. In such cases, the choice of antibiotics rests on epidemiological information. The authors emphasise the progress that has been made towards the early diagnosis of intracranial complications. Appropriate combined medical and surgical treatment leads to complete cure without neurological sequelae in most cases.
Adult↗
[Acute vertigo caused by ischemia of the postero-inferior cerebellar artery or PICA. Apropos of 2 cases].
Based on two cases and a review of the recent literature, we would like to draw attention to the fact that a cerebellar infarction, localised to the territory of the PICA, can present with just a single clinical feature-acute rotary vertigo. Cerebellar vascular accidents remain a little known cause of acute vertigo, often masquerading as a peripheral vestibular disturbance. The main differential diagnosis is vestibular neuronitis. The prognosis is usually good, but the risk of a late recurrence or of a further cerebro-vascular episode is difficult to predict. This uncommon aetiology should not be ignored because of the risk of progression towards a sort of pseudo-tumoral infarct, in which the risk of a fatal outcome remains ever present. In most cases, however, sequelae are few or absent.
Acute Disease↗
[Temporo-sphenoidal giant cell tumors, apropos of a case].
The authors report an extremely rare case: a bony giant cell tumour in the temporo-sphenoidal region presenting with hearing loss and vertigo. The main characteristics of these tumours are given, together with a literature review. This is the 5th published case of this tumour in the temporo-sphenoidal region. The treatment of these tumours is essentially surgical, and the authors emphasise the use of Sekhar's approach.
Adult↗
[Hypoglosso-facial anastomosis: results and technical development towards end-to-side anastomosis with rerouting of the intra-temporal facial nerve (modified May technique)].
The authors report their experience with 31 hypoglosso-facial anastomoses mainly carried out after removal of tumours of the cerebello-pontine angle, 26 were available for evaluation: at 18 months there were 5 of grade II, 19 of grade IV and 2 of grade V. Only one patient was dissatisfied with the result. 24 of the patients had received their hypoglosso-facial anastomosis using the clinical technique of Korte. In 3 cases the operation was by the technique of May. The authors suggest a variation of May's technique: it was carried out on the last 4 patients. It consists of a hemi-hypoglosso-facial anastomosis with rerouting of the mastoid portion of the facial nerve, without using a nerve graft. The aim of this technique is to reduce the sequelae of hemi-lingual atrophy and paralysis (which gives trouble with articulation, mastication and deglutition). The authors' experience confirms that these sequelae are greatly reduced, if not abolished. The functional results in terms of facial movements were satisfactory and consistant: 43.7% were quantified--with 3 of grade II and one of grade IV on the House Brackmann scale.
Adolescent↗
[Cholesteatoma of the middle ear in children. Clinical, developing and therapeutic study in a series of 215 consecutive cases].
A retrospective study of 215 cases of cholesteatoma in 199 children operated on from 1985 to 1996 was conducted. Mean age of the children was 9.6 years. Bilateral cholesteatoma was present in 32 cases (8%). The cause was congenital in 32 cases (16%), iatrogenic in 24 cases (11%) and secondary or acquired in 63%. The surgical procedure was a closed technique in 88%, an open technique with or without ossiculoplasty in 10%, and exclusion of the ear using the Rambo technique in exceptional cases (1%). The facial nerve was exposed in 17%. A labyrinth fistula was discovered in 4%, and an intracranial suppuration in only 0.5%. A secondary open procedure was required in 5 cases (2.5%) and secondary exclusion 3 times (1.5%). The ossicular chain was interrupted in 24.2% of the cases and ossicular rehabilitation was performed in 68% of the cases (39% type II, 29% type III), including 49% during the first procedure. At least 2 operations were needed in 62% of the children and 21% had 3 operations. Residual cholesteatomas were observed in 21.5% of all children in the series, 33% in those with a second operation. Recurrence rate was 10%. Mean hearing loss was 28 dB for a mean gain of 4 dB. Post-operative hearing capacity was socially useful in 64% of the cases, including 12% who had normal hearing. Labyrinthization was observed in 15 cases, including 4 cases with total hearing loss. These result are in general agreement with data in the literature. Our strategy is based on a closed procedure for cholesteatomy and systematic re-evaluation at 1 year. The open technique is useful for very extensive lesion on a narrow mastoid, either as second intention procedure or more rarely as a first intention procedure. Management in children differs from that in adults since in adults the destruction has usually progressed further in a mastoid which accepts an open procedure more readily.
Adolescent↗
[Decalcified, lyophilized, sterile heterotopic porcine ossicular xenografts. Experimental evaluation in the guinea pig].
Using the guinea pig middle ear model, we assessed decalcified, lyophylized, sterile heterotopic porcine ossicular xeno-implants based on a histology (optic and electron scan microscope) and immunologic (immunofluorscence) methods. Implants were placed in the middle ear and others in the dorsal subcutaneous area. Allo-implants were compared as controls. Implants were placed in the middle ear in 54 animals and skin implants in 14. Under the influence of BMP, the implant ossified in all cases in the middle ear. Intense immune recruitment was not observed. Inversely, there was a mononuclear infiltration reaction to the skin implants with formation of a fibrous capsule, immunoglobulin and complement influx and consequently sequestration. The allo-implants were partially reossified. These findings confirm the value of decalcification with hydrochloric acid for BMP induction, independent of species and the failure of attempted immune despecification. Implant outcome is not dependent on its antigen load, which is high compared with its weight, but on the site of implantation. The middle ear appears to be a privileged site of implantation.
Animals↗
[Clinical case: apropos of a case of unilateral bifocal, temporal and occipital cholesteatoma].
A 23 year-old woman presented a double located cholesteatomas in the temporal and occipital bones. The two locations were anatomically well separated. No other case was found in the literature. This was a fortuitous association of an acquired temporal cholesteatomas and a congenital occipital one. A single surgical treatment with only one surgical access.
Adult↗
[The unique trans-fronto-nasal approach. A new approach to benign expansive bone tumors of the anterior floor of the skull base].
We report our experience with a new access route for benign expansive bone tumors of the anterior floor of the skull. From 1991, we used a unique transfrontonasal route, adapted from Raveh's technique for trauma surgery of the anterior floor, to access all tumors in this region. The images presented here show the advantages of this technique: overall vision allows permanent intraoperative control. In addition, the absence functional or esthetic sequelae favor this route for benign tumors.
Adolescent↗