Biomedical subjects
Publications and source records attributed to W Pellet.
The authors report their experiences after operating on 279 patients with unilateral acoustic neuromas between 1976 and 1988, with 258 cases managed by the translabyrinthine approach and 21 cases by the middle fossa approach. The authors emphasize the necessity for total removal in order to avoid recurrences.
The authors describe a widened transcochlear approach for large tumors of the jugular foramen with intrapetrous, intracranial, and infratemporal extensions. This approach complements the transcochlear and infratemporal approaches by enlarging the route of access to the region with disinsertion of the sternocleidomastoid, digastric, and stylohyoid muscles, by removing petrous bone in order to displace the facial nerve, by resection of the auditory canal, and by subluxation of the temporomandibular joint and zygomatic process. The use of this approach is described in seven patients.
From 1973 until November 1984, 224 cerebello-pontine angle tumors, 180 of them isolated neurinomas, were operated on. In a large majority of cases (160) through the widened trans-labyrinthine approach, advocated by House and Hitselberger was used. Despite advances in diagnostic procedures two out of three of these neurinomas were discovered only when they were already quite big. The post-operative overall death rate was 5 p. 100, tumor removal was complete in 96 p. 100 of cases and the facial nerve continuity was respected in 87 p. 100 of cases. These overall results can be still improved because in the last 50 cases, no death occurred, the removal was always total and the facial nerve continuity was respected in 96 p. 100 of cases. The problem of hearing preservation, impossible by this approach, is discussed. The necessity of facial nerve preservation and total removal, in order to prevent recurrence, is emphasized. It often seems very difficult to preserve hearing and to completely remove the tumor and at the same time, have the highest chance of saving the facial nerve.
Based on a review of 38 cases of tumors of pontocerebellar angle, excluding acoustic neurinoma, and a literature review, clinical, radiologic and therapeutic characteristics of these lesions are described. Diagnosis depends on accurate pre-operative identification of the type of tumor. Based on frequency data it can be estimated that tumors of pontocerebellar angle are nearly always acoustic neurinomas : this infers that these other tumors of the angle represent a differential diagnosis where major orientation signs are radiologic. This is fundamental, since when considering all tumors of pontocerebellar angle those requiring a totally different approach to treatment than that for acoustic neurinomas must be distinguished from those for which inability to identify them is not of marked importance since their operatibility is identical.
One hundred consecutive operations using the enlarged trans-labyrinthic (ETL) approach for acoustic neurinoma performed by the same surgeon were analyzed to determine incidence of venous and/or meningeal prolapses. Findings showed that ETL approaches were normal in 51 cases : normal superficial sinusodural space--external auditory canal and on deep dissection a superior petrous sinus and jugular space separated from the internal auditory canal. Prolapse was observed in 49 approaches : 30 very narrow sinusodural spaces due usually to temporal meninges prolapse (76%) associated in 25% of cases with a prolapse of lateral sinus; 29 prolapses of jugular space and 10 of superior petrous sinus, detected mainly in the narrow sinusodural spaces. In these cases, superficial displacement of the temporal meninges and lateral sinus appears indispensable in order to recover normal operating conditions towards the labyrinth and pontocerebellar angle.
The authors describe the extended trans-cochlear approach and define its indications on the basis of a series of 10 cases operated by the transcochlear approach, 6 of which were extended. This approach has a well defined indication between the trans-cochlear approach described by W. House and the infra-temporal approach described by Fish.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
The authors report a series of 43 cases of cerebello-pontine angle tumours operated by an oto-neuro-surgical team. The approaches used were, once the supra-petrous approach, twice the posterior fossa, 12 times a combined trans-labyrinthine and posterior fossa approach, and 28 times the enlarged trans-labyrinthine route. This last approach, which is now being used exclusively for the last two years, is described in detail. Forty-three tumours operated on broke down into 40 neurinomas, 2 meningiomas and 1 malignant melanoma. The size of the tumours varied from 1 cm to 11 cm in diameter. Overall statistics show 9.3% of deaths and 65% of functioning facial nerves. The statistics for the nelarged trans-labyrinthine route (the last 28 cases) are: 10.7% of deaths and 75% of functioning facial nerves. In the enlarged trans-labyrinthine route, there is no complication and no mortality in the small and medium-sized tumours, i.e. up to 4 cm in diameter.
The authors, supporters of a tight oto-neuro-surgical collaboration, show their tactical evolution in front of acoustic neurinomas which they operated at first in two stages, trans-labyrinthine then sub-occipital, and now they approach only by trans-labyrinthine way. They report their experience and their results to the point of a first serie of 30 cases : 10 combined approaches in two stages, and 20 trans-labyrinthine approaches. The mortality (3 cases-10%) for this first serie is still raised. One patient, after a softening of the pons, maintained important sequelles. On the other hand, among the remaining 26 patients, 13 kept a normal facial motricity and 5 recovered but with syncinesis. These first results are still perfectible : among the 20 last cases only trans-labyrinthine approached the facial nerve preservation was realised in 72% of the cases. The most frequent surgical complication is a cerebro-spinal fluid leak (7 cases) which fortunately the most often spontaneously dry up (6 cases) but which justify a very attentive closure technic. The authors show the arguments which convinced them of the interest of the trans-labyrinthine approach such it is done by W. House.
The treatment of cancer pain by psychotropic drugs is a method which has been employed for a long time [8] and in which the results obtained have appeared very interesting from the beginning: there is a high percentage of success, rapid action, absence of addiction, and although there are sometimes unpleasant side-effects, they are reversible when the treatment is stopped. Even after several years of application, this therapy still sets some unsolved problems. Some consider that psychotropics are not real analgesics, but that they work on the emotional reaction rather than on the pain itself [3]. Still others consider that the results are obtained only at the price of a state of prostration of the patient similar to that obtained after lobectomy. Finally, this procedure is reproached as having unpredictable results and indications difficult to define. We think that what has, up to now, prevented these types of problems from being solved has been the absence of a really objective evaluation of the pain in the patients observed. We have wrestled with this problem for several years [1,2], and offer the following hypothesis: what is important in considering chronic pain is, above all, the infirmity conferred upon the patient. If "pain" in the broad sense of the term lends itself to objective evaluation with difficulty, it is not the same with respect to infirmity. A method of evaluation of the physical disability intended for routine practice in a cancer center has been used on a series of 100 patients. The results obtained in this series have been analyzed and give the answer to questions such as mechanism of action, indications of psychotropic drugs and prognosis of cancer pain.
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Tumours of the glomus jugulare always raise diagnostic and therapeutic problems. We decided to review the pathology and clinical findings whilst reporting a typical case found on our neurology unit. After a brief review of the embryology, anatomy and histology of the glomus jugulare, the authors report the case of a patient who presented a recurrent intracranial form with involvement of several cranial nerves, together with associated involvement of the carotid glomus. This was a familial disease. The patient was operated on with excellent results. The authors then present a clinical description of the various signs in glomus tumours,; depending more on the origin of the tumours than on the length of history. They then criticize the diagnostic interest of radiology, emphasizing the interest of angiography which may demonstrate a pathological vascular focus derived from the internal carotid artery together with the vertebro-basilar system. Retrograde jugulography also provides important information. The treatment of glomus jugulare tumours is, above all, surgical. They are approached through the ear in order to localise the intra-petrous part, or else, they may be approached through the skull. A combined otological and neuro-surgical approach to sometimes necessary for the lesion may involve both the petromastoid region and the posterior cerebral fossa. Radiotherapy is often advised after operation, in view of the importance of the vascular component of these tumours. The results of treatment are, on the whole, satisfactory.
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