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We report a case of branchial cyst of unusual location. A asymptomatic 41-year-old man had a nontender deeply located left neck mass. Sonography, CT scan, and MRI showed a cystic lesion posterior to the sternocleidomastoid muscle. The diagnosis of branchial cyst much debated because of this atypical location was confirmed by histologic analysis after surgical resection. During organogenesis, the important caudal proliferation of the second branchial arch generates a transient cavity, the cervical sinus, which finally becomes obliterated. The incomplete obliteration of which can result in a sinus, fistula or cyst. Such cysts typically lie at the level of the mandibular angle, anterior to the sternocleidomastoid muscle. This location has been regarded as a major diagnosis criteria, but it is not absolute. The sternocleidomastoid muscle develops apart from the branchial apparatus, caudally and anteriorly. As a result the cysts which are located on an inferior portion of the cervical sinus can lie posterior to this muscle.

Nasal secretory eosinophilia was evaluated in inflammatory chronic rhinitis by a cytometric method. Thirteen control subjects and 97 patients (nasal polyps = 44; chronic sinusitis = 26; chronic rhinitis = 27) took part in this study. Secretory eosinophilia was low in the control group (0.3 +/- 0.2 to 1.3 + 0.8%), compared to: 13.8 +/- 8.2 to 15 +/- 7.6% in idiopathic chronic rhinitis, 16.3 +/- 7.3 to 22.7 +/- 10.2% in perennial allergic rhinitis, 18.5 +/- 6 to 25.3 +/- 6.1% in nasal polyps, 23.1 +/- 1.1 to 25.9 +/- 8.6% in nasal polyps with asthma, 27.3 +/- 7.1 to 30.3 +/- 7.8% in aspirin triad. The NARES syndrome was clearly individualized with a secretory eosinophilia between 48 +/- 16.9 and 58.8 +/- 10.7%. Nasal cytometry is a new method that confirms the role of secretory eosinophilia as an interesting marker in the study of inflammatory chronic rhinitis. Nevertheless reference values would be established only after a better knowledge of cell kinetics in nasal secretion under normal and pathological conditions.

Possible sinus surgery complications are reviewed. The difficult anatomy and its relationship with the orbit, the optic nerve and the olfactory fossa are the main reason of complication. However by technical improvement of imaging and endoscopy, as well as by surgical skill refinement the complication rate decreases. In the patient's interest, and to avoid medico-legal suits, some recommendations are suggested.

Biological adhesives are made of human plasma and bovine heterologous proteins. These entail a poorly documented risk of sensitization. We report about two allergic accidents caused by the injection of Tissucol in the pituitary mucosa of patients suffering from the Rendu-Osler-Weber disease. The clinical picture of the first case was that of a serum sickness, and leukocytoclastic vasculitis was demonstrated. The second case was a delayed hypersensitivity accident, which was confirmed by the subsequent allergological investigation. Although the responsibility of thrombin seems to be evidenced in these two cases, it nevertheless remains exceptional. However, the risk of sensitization following repeated injections of heterologous proteins in a mucosa with a particularly high immunological responsiveness must be well-known. The increasing use of these biological products will probably result in a growing number of accidents, and we must now contemplate the possibility of screening this sensitization before using biological adhesive. Finally, the possibility of latent sensitization by the ingestion of beef must also be considered.

The mucus membranes of the nasal chambers may be compared to a local immune system which has been called the NALT. The submucosa contains a lymphoid infiltration of T-helpers, T-suppressors and a set of plasma cells capable of synthetizing four IgG subgroups, IgM, IgA and IgD. The IgA plasma cells are most numerous. There is no local synthesis of IgE. Macrophages and langerhans' giant cells are present. The epithelium is an immunological entity which is composed, in addition to secretory cells, of uliated cells, lymphocytes, and M cells. The epithelium is able to synthesize secretory component and allows the transport of IgA and IgM into the secretions. The NALT has multiple immunological functions: antigenic information, humoral immune response, and expression of local cellular immunity. Modifications in T lymphocyte subpopulations are observed in allergic rhinitis. Secreted interleukins modify the local efflux and affluence of effector cells (mastocytes and eosinophils). Abnormalities of the NALT are characteristic of deficiency in humoral IgA and IgG subgroups. The possible presence of alterations of cellular immunity in chronic rhinosinusitis has been suggested.

The authors propose a method, simple and practical, for quantitative cytological analysis of nasal secretions. A representative sample of secretions was collected in each nasal cavity by the washing-blowing technic. Homogenization using mucolytics was the first step in the laboratory. After cytocentrifugation and May-Grundwald-Giemsa staining, the light microscope (x 100) was used for the differential leukocyte count. The two factors Friedman's test (sample and experimentation) showed no analytic variability of the measure (p less than 0.05) for the analysed parameters. 534 specimens were obtained on 254 patients and 13 control subjects. All the parameters could be analysed for the two nasal cavities on 127 patients (47.6%), for only one nasal cavity on 62 patients (23.2%), at all 189 positive results (70.8%). The mean volume collected after a 7 ml washing-blowing test was 5 ml. The total leukocyte count varied between 6,833 +/- 1,424 and 44,638 +/- 31,226 per ml in the control group, between 125,246 +/- 36,108 and 498,245 +/- 367,328 per ml in the patient group. The mean eosinophil count varied between 0.3 +/- 0.2% and 1.3 +/- 0.8% in the control group, between 15.1 +/- 2.4% and 18.2 +/- 2.6% in the patient group. The neutrophil count was over 90% in the control group, between 75 and 80% in the patient group. The mean lymphocyte count was about 5% in the two groups, the monocyte count about 1%. So the washing-blowing technic enables a quantitative analysis of nasal secretions. Nasal cytometry seems to be an interesting method for studying the inflammatory secretory cells compartment.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report 100 ethmoidectomies performed on 50 patients between 01/87 and 09/89. 75% have been treated anteriorly by systemic corticosteroids. 65% have had prior sinus surgery. Follow-up time ranged from 12 to 34 months (mean: 18 months). A regular treatment with intranasal steroid sprays was taken post-operatively by 96% of patients until three months and 48% until 18 months. 72% of patients considered the symptoms relief as satisfactorily (score of satisfaction greater than 8/10). Severe nasal obstruction, noted in 88% cases pre-operatively, reappeared in 26% 18 months post-operatively. Anosmia, encountered in 72% pre-operatively, disappeared post-operatively in one half of the cases with a good conservation of olfaction 18 months later. Anterior and/or posterior rhinorrhea, sneezing were also satisfactorily controlled. Results on facial pain were not significant. Endoscopic evaluation was performed by a physician who was not the surgeon. A normoplastic mucosa covered the ethmoid cavities in 40%. Localized oedema was observed in 38%. An asymptomatic recurrence, discovered on endoscopic examination, was present in 11%. The symptomatic recurrence rate was 11%. A CTscan control, performed the day of the endoscopic examination and analysed few weeks later, reinforced the degree of objectivity. A complete marsupialization of the ethmoid labyrinth without any remaining cell was confirmed in only 30%. Frequence and aspects of the opacities in the great sinuses were the same pre- and post-operatively. So, this study shows that the insufficiencies of the ethmoidectomy are 1) the difficulty to perform a complete marsupialization of the ethmoid 2) persistent opacities in the great sinuses 3) persistence of the mucosa disease after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Non-allergic rhinitis with eosinophilic syndrome (NARES) accounts for 14% of rhinitis. It is defined by a syndrome of nasal hyper-reactivity over more than three months, the absence of any atopic factor, and an eosinophilia of nasal secretions 20% greater than the leukocytes. The main features are evidenced by the authors on the basis of 20 observations. The symptoms are significantly more marked than in other forms of rhinitis. Olfactive disorders occur very frequently. The symptoms often fail to respond to anti-histamines and even corticoids. The frequency of a micropolyposis starting in the meatus is confirmed by endoscopy and a CT-scan reveals the frequency of hyperplasia of the sinusal mucosa (affecting first and foremost the ethmoid cells). Hyperadrenergy is frequently evidenced by papavenire IDR and by the isoprenaline IV test. Two cases revealed the coexistence of an intolerance to aspirin and a bronchial hyper-reactivity, evidenced by the Carbachol test. The histological and immunofluorescent examination of the pituitary mucosa evidenced an eosinophilic infiltration in 40% of cases. This infiltrate is often labelled by the BB10 monoclonal antibody. The evolution of NARES appears to involve three stages: secretory eosinophilia with a healthy mucosa, eosinophilic mucosa infiltration, and in situ activation of the eosinophils. An evolution towards an eosinophilic PNS and then a triad was observed in two cases. Hopothèses are put forward by the authors to explain the local nasal influx of eosinophils.

Nose and sinus pathology is frequently related to a chronic inflammation, the mechanisms of which involve different cell types that form the MALT, or effector cells. B-lymphocytes are three times more numerous than the T-lymphocytes, where the CD4+ cells predominate over the CD8+ cells. IgA's are mainly secreted by the plasmocytes. In IgA deficiency, a relative increase in IgG or IgD plasmocytes has been recorded. Antigenic information is obtained from cells presenting the antigen. Langerhans-like cells have been described. Two different populations of mast cells have been identified, whilst on the contrary eosinophilic cells are normally absent. The particularities of capillary vascularization and the extent of the nerve fibre network contribute to the creation of a micro-environment interacting with the lymphocytes. The phenomena of cellular interaction are described through the dynamic evolution of the IgE-dependent response in allergic rhinitis.

The immunohistological characteristics of retraction pockets, cholesteatoma matrix and granulomatous tissue have been compared. Langerhans cells, epidemic folds and sub-epithelial tissue were labelled with specific markers (HLA II, adhesion receptors, KI 67). The junction between epidermis and sub-epithelial tissue of middle ear mucosa appeared as the most inflammatory area, displaying characteristics of delayed type hypersensitivity phenomenon. CD1+ Langerhans cells appear to express class II molecules only in the vicinity of polymorphonuclear infiltrates. Epidemic proliferation seems to able place mainly in the deepest recesses of the epidermis.

The authors report a case of non traumatic rhinorrhea due to an empty sella turcica. Such an intra sellar arachnoidocele compress the pituitary gland against the posterior wall, erode the floor and lead to CSF rhinorrhea through the sphenoidal sinus. Diagnosis and treatment are best accomplished by a team approach involving otolaryngologist, neurosurgeon and neuroradiologist. CT Scan and IRM explain the diagnosis. Treatment can be accomplished by a transeptal transphenoidal approach with localization and repair of the leak in the absence of increased intracranial pressure.

This study was conducted in order to assess the activity of trimetazidine dosed at 60 mg/day in patients presenting degenerative loss of hearing. Ten centers participated in this multicenter double-blind placebo-controlled trial which spanned 6 months. Included were 251 patients (118 women, 133 men) presenting with pure perception bilateral symmetrical deafness concerning predominantly the acute frequency range. 228 patients terminated the study, including 115 in the trimetazidine group and 113 in the placebo group. The evolution over a 6-month treatment period was significantly better with trimetazidine as regards the following parameters: audibility as assessed by pure-tone audiometry, namely at the acute frequency range (p = 0.002), intelligibility as assessed by speech audiometry (p = 0.008), subjective evaluation of hearing loss and its impact on the patient's social life. Results confirm the value of trimetazidine hearing loss management, based on clinical, subjective criteria as well as audiometric ones. Parameters reflecting best trimetazidine's efficacy were intelligibility and the psychological/behavioral impact of the impairment, allowing for better social integration of the subject.

The pathophysiology of nasal polyposis is yet unclear, but chronic disturbances of the inflammatory pathways may be suspected. Immunological investigations were performed in 3 series of patients: 37 with nasal polyps, 22 with chronic sinusitis, and 15 controls with healthy nasal and sinusal mucosa. Patients with nasal polyps had up to ten times more eosinophil density than patients with sinusitis or healthy mucosa. The average of mast cells and IgE or IgA, M, G plasma cells were not different in the various group. Deposited immune complexes were always absent. These results gave us the opportunity to discuss recent pathogenic theories.

Inverted papillomas are a benign tumors arising from the external wall of the nasal cavity. Sinus extension is easy to evaluate pre-operatively by using the CT-scan. Lateral rhinotomy is therefore not the only way to removing these tumors. Vestibular and endonasal approaches can be considered. Surgical treatment must however remove the tumor tissue completely since recurrence results directly from insufficiency and must be completed by an histological analysis of the whole tissue after its removal in view of its frequent association with carcinoma.

The authors describe two clear-cut cases of hypopharyngeal lateral diverticulum. They have found only 22 published cases. They discuss the nosological limits of the physiological pharyngeal expansions visible under high pressure pharyngography, those of kinetic pharyngoceles which are often forced hernias, finally, the very real but uncommon presence of true lateral diverticula. The passage of barium Therapeutic indications are discussed. The surgical technique is simple.

334 patients with functional cochleovestibular symptomatology were treated with trimetazidine (40 mg daily) or with placebo in a double-blind study. The decrease in subjective symptoms (tinnitus, hypoacusis, vertigo, disturbances of equilibrium, neurovegetative disturbances, bad discrimination in background noise) was significantly more important with trimetazidine than with placebo. Objective signs such as index deviation, walking tests and positive Romberg test were also significantly more improved with trimetazidine. Puretone audiometry in patients with perceptive hypoacusis showed an improvement of auditory level with trimetazidine; progression with trimetazidine is significantly better than that with placebo, at frequencies equal to or above 2 000 Hz. Overall and cardiovascular clinical acceptability is similar in both groups. This study underlines the therapeutic efficacy of trimetazidine in cochleovestibular syndromes, especially on functional symptomatology.

An ectopic thyroïd gland causing hypothyroïdism was found in a 7 years old girl. The treatment was stopped six months later, nevertheless the growth rate was not affected. Sudden mechanical airway obstruction caused by the lingual goiter needed at the age of 16 years a surgical management. A thyröid nodule auto-transplantation was performed with a rather good success. Special comments about some physiopathological aspects of this original case.

The conventional histopathology of the sinus is a criterium for the therapeutic indication, since it is possible to distinguish between granulomatous chronic sinusitis, chronic sinusitis with oedema and nasal polyposis. Each one of these clinical pictures has his own etiology and requires a specific therapeutic approach.

Non allergic rhinitis with eosinophilia syndrome is not an uncommon diagnosis, since eosinophilia in nasal secretions from 20% up to 90% of total cells, is detected in 15% of rhinitis. Nasal symptoms include sneezing paroxysms, profuse watery rhinorrhea, in adults or in children. All immunological tests are negative. Tomodensitometry may detect evolution towards sinusal polyposis, and bronchial challenges with carbamylcholine may detect bronchial hyper-reactivity. We conclude to the possibility for NARES to be a link between common vasomotor rhinitis and nasal polyposis with asthma and intolerance to aspirin. The diagnosis needs to be firmly established by the study of nasal eosinophilia during a nasal challenge with a perennial allergen (house dust mite). The first has to be unchanged, and the second has to be negative. As eosinophils are potent pro-inflammatory cells endowed with cytotoxicity, precise studies upon the characteristics of eosinophils in the nasal secretions and in the pituitary mucosa of patients with NARES, have to be carried on.

Always frequent and often misleading, chronic sinusitis are multifactorial. Consequently, the role of teeth apical infection is largely underestimated. The difficulties of interpretation of the sinus radiographic imaging are well established, particularly in the study of the dental with sinus border. The clinical circumstances in which the responsibility of teeth can be involved, are studied. Diagnosis insufficiency are frequent, and inadequate procedures can be undertaken. The particular conditions to obtain good polycyclicidal tomographs pictures are described and demonstrated. In special cases, with the eventual contribution of the bacterial-sensitivity evaluation, these sinusal-dental tomographs allow a relevant diagnosis.

Deep tonsillar flora were identified in tonsils removed from 48 patients, children and adults, with chronic tonsillitis and recurrent sore throats or obstructive hypertrophy. Most specimens (38/48) cultured multiple germs (2 to 5 different species) with aerobic and anaerobic Gram+ and Gram-forms, some being beta-lactamase producers. Of the total of 135 strains isolated, 104 were aerobic and 31 anaerobic. The species of aerobic germs most frequently isolated were: Apart from alpha-hemolytic streptococci of undertermined group (38 strains), Haemophilus sp. : 14 (including 3 beta-lactamase + strains), Staphylococcus aureus: 15 (including 11 beta-lactamase + strains), Streptococcus A : 10, Enterobacteriaceae : 6, Neisseria sp. : 8 (including 1 beta-lactamase + strain). And among the anaerobic germs: Peptococcus : 3, Veillonella alc : 10, Fusobacterium nucleatum : 9, Bacteroides melaninogenicus : 6, Other Bacteroides : 2. Of the 127 strains tested, 102 were sensitive to amoxicillin and 121 to amoxicillin and clavulanic acid combination. The presence of a beta-lactamase producing bacterium in 1 of 3 specimens suggests the risk of failure of treatment with penicillin, prescribed classically for this type of affection.

Cases of deafness due to Paget's disease can be separated into two types : (1) deafness of a mainly mixed type in which progressive aggravation occurs particularly in the inner ear, and (2) perceptional deafness which progresses without involvement of the transmission apparatus. Among 35 hospitalized patients with Paget's disease, 21 of whom suffered cranial involvement, 18 cases of deafness related to the bone disease were discovered by means of systematic examinations. The deafness was of the mixed type in 11 cases and of the perceptional type in the other 7. Of the 11 patients with the mixed type of deafness with an ankylosis syndrome of the ossicles, 3 were operated upon : one of them underwent an operation to mobilize the stapes, and the two others underwent total stapedectomy followed by venous interposition and the positioning of a Teflon piston. The long-term results were frankly disappointing and did not suggest that these attempts at surgical treatment should be followed up. Calcitonin was employed in 9 patients (6 with mixed deafness and 3 with perception type deafness), with comparative audiograms in 5 cases, and was also not very effective : this lack of effect was a result of the long duration of the Paget's disease and of the deafness in the patients treated. The value of hormonal treatment in cases of deafness associated with Paget's disease will probably be in the prevention of this complication.

The NARES is a new entity in rhinology. The incidence is more than 15% among all types of rhinitis. The clinical picture is a somewhat variable nasal hyper-reactivity, with frequent hyposmia. Three cases are recorded, which fit for classical criteria of diagnosis: negative allergic tests, more than 20% of local eosinophilia. The authors point out the absence of variation of eosinophilia after nasal challenge with an extract of house dust mite D. Ptéronyssinus. Nasal endoscopy and the computerized tomography show a propensity towards micropolyposis in 2 cases. A bronchial hyper-reactivity to carbamylcholine is detected twice. A cutaneous intolerance to aspirin is proved in one case. A state of adrenergic hyper-reactivity is established in the three patients. The authors suggest that NARES is precursor of the aspirin triad. A dysfunction of the autonomic nervous system, characterized by an adrenergic hyper-reactivity, leads to a neurogenic inflammation of the nasal mucosa. Eosinophils are attracted, and infiltrate the mucosa. Then the eosinophil-derived chemical mediators maintain a chronic inflammatory state. The best therapeutical means are discussed.