Residual cholesteatoma: its prevention by surgery with endoscopic guidance]

In comparing two series of 72 operated cholesteatomas covered by a systematic surgical second look between 12 and 18 months, the authors have observed a distinct regression of residual cholesteatomas since oto-endoscopy came into use (from 47.7% to 10.7%). This new approach, with a minimum amount of practice, makes it possible to perform true endoscopy-guided surgery of the entire tympanic cavity, and reduces the indications of later tympanotomy.     

Nanocomposite Foams of Polypropylene and Carbon Nanotubes: Preparation,Characterization, and Evaluation of their Performance as EMI Absorbers

Highly expanded nanocomposite foams of polypropylene and carbon nanotubes (PP/CNT) are formed using supercritical carbon dioxide (scCO₂) technology. The foaming parameters (temperature, pressure) are investigated to establish their influence on the morphology of the resulting foams and their impact on the electrical conductivity. As promising electromagnetic‐interference (EMI) absorbers, the EMI shielding performance of the foams is determined, and a preliminary relationship is established between foam morphology and the EMI shielding performance. The best candidates are highly expanded foams with a volume expansion of >25, containing 0.1 vol% CNTs; they are able to absorb more than 90% of the incident radiation between 25 and 40 GHz.

     

Congenital cholesteatoma of the petrous bone. Etiopathogenic discussions apropos of 11 cases

The authors report on 11 cases of congenital cholesteatomas, treated between 1979 and 1988. In all cases, there was a long-standing history of deafness. The diagnosis revealed 6 cophoses, 5 cases of mixed deafness, 9 cases of impairment of the facial nerve (7 cases of paralysis including 4 with sudden onset and 2 hemispasms), 2 facial neuralgias with facial hypesthesia, one Gradenigo-Lannois syndrome, 2 leaks of the C.S.F. (1 nasal, 1 very abundant auricular leak). In 6 cases, the surgical approach route was trans-cochlear, and in 5 cases surpa-petrosal, two of which were extended to a petrectomy. Of the 5 cases of partial deafness, only one was preserved. In 5 cases, the facial nerve was destroyed at the level of the ganglion of the facial nerve, a region where a frankly epidermal tissue is always found. In 4 cases the facial nerve was repaired (three hypo-glosso-facial anastomoses and one end-to-end suture, after re-routing). The authors share the opinion of Fisch that the origin of the intra-petrosal congenital cholesteatoma always occurs at the level of the ganglion of the facial nerve.     

Contraceptive methods used by female diabetic patients

A questionnaire was used to study the contraceptive habits of ambulatory diabetic patients ages 16-50 (n=209) who were followed in the diabetology department of the Hotel-Dieu Hospital in Paris from June 1982 to December 1983. 64% of the patients were using contraceptives; 23% used none despite regular sexual intercourse and 13% had abandoned contraceptive use beforehand. This distribution was correlated to the type of diabetes and the parity. Microprogestagens and IUD were used most often (26% and 32%, respectively). The comparison with results of the broad study by the INED-INSEE in 1978 underscored the near absence of estroprogestagens and the lower percentage of microprogestagens used by diabetics than that compared with combined pills by the female French population. This is probably due to the poor gynecological tolerance which characterized this group. Microprogestagen users revealed the greatest incidence of amenorrhea (39%) and of menstrual disorders (33%). 19 contraceptive failures were noted, 6 of them with an IUD. 1/3 of the women did not use the method they chose initially, but 3/4 of them were generally satisfied. In conclusion, the frequent absence of effective contraception should be pointed out, particularly among the nulliparous, and the high percentage of IUDs inserted in these patients. Contraceptive advice is essential for diabetics in view of the importance of spacing each pregnancy. (author's modified)     

Functional outcome after gamma knife surgery or microsurgery for vestibular schwannomas

OBJECT: Microsurgical excision is an established treatment for vestibular schwannoma (VS). In 1992 the authors used a patient questionnaire to evaluate the functional outcome and quality of life in a series of 224 consecutive patients. In addition, starting with gamma knife surgery (GKS) in 1992, the authors decided to use the same methodology to evaluate prospectively the results of this modality to compare the two alternatives. METHODS: Among the 500 patients who were included prospectively, the authors only evaluated patients in whom GKS was the primary treatment for unilateral VS. Four years of follow up was available for the first 104 consecutive patients. Statistical analysis of the GKS and microsurgery populations has shown that only a comparison of Stage II and III (according to the Koos classification) was meaningful in terms of group size and preoperative risk factor distribution. Objective results and questionnaire answers from the first 97 consecutive patients were compared with the 110 patients in the microsurgery group who fulfilled the inclusion criteria. Questionnaire answers indicated that 100% of patients who underwent GKS compared with 63% of patients who underwent microsurgery had no new facial motor disturbance. Forty-nine percent of patients who underwent GKS (17% in the microsurgery study) had no ocular symptoms, and 91% of patients treated with GKS (61% in the microsurgery study) had no functional deterioration after treatment. The mean hospitalization stay was 3 days after GKS and 23 days after microsurgery. All the patients who underwent GKS who had been employed, except one, had kept the same professional activity (56% in the microsurgery study). The mean time away from work was 7 days for GKS (130 days in the microsurgery study). Among patients whose preoperative hearing level was Class 1 according to the Gardner and Robertson scale, 70% preserved functional hearing after GKS (Class 1 or 2) compared with only 37.5% in the microsurgery group. CONCLUSIONS: Functional side effects happen during the first 2 years after radiosurgery. Findings after 4 years of follow up indicated that GKS provided better functional outcomes than microsurgery in this patient series.     

Surgical removal of unilateral vestibular schwannomas after failed Gamma Knife radiosurgery

One of the primary criticismes of vestibular schwannoma (VS) radiosurgery is that the risk of surgical morbidity is increased for patients whose tumor progresses after the procedures. We reviewed the French experience of operated patients after failed Gamma Knife radiosurgery. From July 1992 to January 2002, 25 out of the 1000 treated patients underwent another treatment procedure for a gamma knife failure. Excluding the NF2 patients, 21 patients have been operated and the present study shows the data collected for 20 of them. In order to analyze the difficulties observed during the surgery, a questionnaire was filled by the surgeons. The mean interval between radiosurgery and removal was 36 Months, from 10 to 83 Months. The mean increase in Volume was 559% (37 to 3036%, median 160%). Evolution of the Koos grading was found from 8 grade II, 10 grade III et 2 grade IV to 10 grade III and 10 grade IV. Patients have been operated for radiological tumor growth in 7 cases and for clinico-radiological evolution in 13 cases. In 9 cases, the surgeon considered that he had to face unusual difficulties mainly because of adhesion of the tumor to neurovascular structures. Tumor removal was total in 14 cases, near total in 4 cases and subtotal in 2 cases. One case of venous infarction was noticed at the second day following surgery responsible of hemiparesis and aphasia that gradually recovered. At last follow-up examination, facial nerve was normal (House and Brackmann grade I and II) in 10 cases while it was a grade III in 7 cases and grade IV and V in 3 cases. We recommend that the decision for surgical removal of growing vestibular schwannoma after Gamma Knife treatment should be done after a sufficiently long follow-up period. Our results show that the quality of removal and of facial nerve preservation might be impaired by radiosurgery in half of cases. However these results do not support a change in our policy of radiosurgical treatment of small to medium size vestibular schwannoma.     

Surgical management of vestibular schwannomas secondary to type 2 neurofibromatosis

To evaluate the results of Gamma Knife radiosurgery treating vestibular schwannomas (VS) secondary to type 2 neurofibromatosis (NF2) we reviewed our clinical experience. Among the VS that have been treated between July 1992 and January 2002, we could analyze retrospectively the data of 50 VS from 37 patients. Fourteen patients had the mild phenotype while 23 were affected by the severe form. Before radiosurgery, one or two microsurgery attempts had been undertaken in 16 VS. Tumor Volume ranged from 120 to 14405 mm3 (mean: 3468 mm3) at the time of treatment; 12 tumors were Koos stade 4. Median clinical and radiological follow-up was 62 Months and ranged from 27 to 123 Months. The 5-Year and 10-Year actuarial survival rates without failure justifying tumor removal were 90 and 85% respectively. The 5-Year actuarial survival rate without hearing decreasing was 36% when selecting the cases of useful hearing (Gardner I & II) at the time of treatment. Severe phenotype (p=0.05) and dose (>12 Gy) delivered at the tumor margin (p=0.032) were correlated to hearing deterioration at univariated analysis. Permanent facial neuropathy occurred in 2%. Even though the level of tumor control and hearing preservation is not the same as for sporadic VS, these results show that Gamma Knife radiosurgery is a valuable alternative treatment for VS in NF2 patients. Future orientation of early proactive radiosurgical treatment of intracanalicular VS will probably improve these results.