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In front of external otitis in spite of a well-conducted treatment, especially in immunodeficient patient, it is always necessary to look for an osteomyelitis of the skull base that requires an urgent parenteral antibiotic treatment of several weeks. Acute otitis media (AOM) is the most common bacterial infection of the child. In children under 2 years with purulent AOM, antibiotic therapy with amoxicilline is systematic for a period of 8-10 days. After 2 years of age and with mild symptoms of AOM, symptomatic treatment may be justified as first-line treatment. Chronic otitis media is frequent after an episode of AOM and becomes chronic only after 3 months of evolution. Grommets reduce the frequency of AOM episodes. All AOM complicated with meningitis requires monitoring by audiogram and MRI of the ear., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: Endolymphatic sac tumors (ELSTs) are, with a prevalence of up to 16%, a component of von Hippel-Lindau (VHL) disease. Data from international registries regarding heritable fraction and characteristics, germline VHL mutation frequency, and prevalence are lacking., Methods: Systematic registration of ELSTs from international centers of otorhinolaryngology and from multidisciplinary VHL centers' registries was performed. Molecular genetic analyses of the VHL gene were offered to all patients., Results: Our population-based registry comprised 93 patients with ELST and 1789 patients with VHL. The prevalence of VHL germline mutations in apparently sporadic ELSTs was 39%. The prevalence of ELSTs in patients with VHL was 3.6%. ELST was the initial manifestation in 32% of patients with VHL-ELST., Conclusion: Prevalence of ELST in VHL disease is much lower compared to the literature. VHL-associated ELSTs can be the first presentation of the syndrome and mimic sporadic tumors, thus emphasizing the need of molecular testing in all presentations of ELST. © 2015 Wiley Periodicals, Inc. Head Neck 38: 673-679, 2016., (© 2015 Wiley Periodicals, Inc.)

Background: Successful treatment of acromegaly improves disease-related cardiovascular mortality and morbidity, but its effects on autonomic modulation of the heart rate are unknown., Objectives: We documented treatment-induced changes in time-domain heart rate variability, taking into account the confounding effects of obstructive sleep apnea., Patients and Methods: Sixteen consecutive patients (12 males, aged 43 ± 12 y) with newly diagnosed acromegaly underwent overnight (12:00-7:00 am) cardiac Holter recordings coupled with polysomnography. Data were obtained before and 10 ± 6 months after successful treatment of acromegaly., Results: IGF-1 levels fell from 807 ± 333 to 207 ± 69 μg/L and normalized in all patients. Seven patients (44%) had obstructive sleep apnea (apnea-hypopnea index 33 ± 21/h) at baseline. Treatment had no significant effect on polysomnographic indices. After treatment, increases were noted in the normal-to-normal heart period (NN), SD-NN, the percentage of NN differing from the previous NN by greater than 50 msec, and the root mean square of successive differences in NN (each P < .05). These heart rate variability results were not influenced by the type of treatment, and there was no relationship between changes in NN and changes in the apnea-hypopnea index (P = .58)., Conclusion: Early after successful treatment of acromegaly, we observed increased parasympathetic modulation/decreased sympathetic modulation of the nighttime heart rate, an effect that seems unrelated to changes in sleep apnea status. Treatments aimed at normalizing IGF-1 may improve cardiovascular homeostasis through improved cardiac autonomic nervous system modulation.

Objective: To analyze the difference between the endolymphatic sac tumors (ELSTs) in sporadic cases and in von Hippel-Lindau (VHL) disease., Study Design: Retrospective case review in a tertiary referral center., Patients and Methods: Fourteen cases of ELST, occurring since 1998, were reviewed. We analyzed the initial symptoms, characteristics of the tumor, treatment, sequelae, and follow-up for each group., Results: The ELSTs were sporadic in 6 cases and associated with VHL disease in 8 cases. The mean age at the time of the first surgery was 26 years (range, 12-41). All except two of the patients presented with a unilateral tumor. The initial symptoms were hearing loss (n = 9), tinnitus (n = 7), and/or vertigo (n = 5). Hearing loss was more prevalent in the sporadic cases. Preoperative arteriography was performed for 4 patients, with embolization performed for 1 patient. The size of the tumor was significantly larger in the sporadic cases (31.7 mm) than in the cases of VHL disease (19.3 mm). The surgical approach was more extensive in the sporadic cases. The surgeons found 2 types of tumors. Cystic tumors with massive bleeding invading the surrounding structures (the dura mater or jugular bulb) were more common in the sporadic cases. Fibrous tumors that infiltrate the bone and have moderate bleeding were more common in the cases associated with VHL disease.Two patients with small lesions were not operated on but were followed for 6 years without tumor growth. They died of metastasis from gastric and kidney cancer. Four recurrences occurred during the 14 years of follow-up. Four facial palsies and 8 cases of profound deafness were encountered postoperatively., Conclusion: Sporadic tumors are more aggressive than those associated with VHL disease. Complete surgical resection should be the goal of treatment. Preoperative angiography with embolization is recommended. In some cases, embolization may be impossible, and preoperative or postoperative radiotherapy should be discussed.

Introduction: Osteoma is a benign slow growing bone tumor with a prevalence of 3% of all benign paranasal sinuses tumors, with a peak incidence between the fourth and sixth decades, mostly involving frontal sinuses.(1) PRESENTATION OF CASE: We present a case of a large right ethmoidal sinus osteoma in a 12-year-old boy, complaining of frontal headaches and excessive lacrimation of the right eye. CT scan showed a very large tumor in the right anterior ethmoidal sinus (30mm×25mm×15mm)., Discussion: Large osteomas of the paranasal sinuses are usually resected by external approaches. However, the minimally invasive endonasal approach, which minimizes external facial scarring, is challenging for such large lesions in pediatrics. In the presented case, the osteoma was successfully resected exclusively by endoscopy-guided endonasal approach assisted by neuronavigation, with no peri or postoperative complications., Conclusion: An endoscopic approach assisted with neuronavigation may be a minimally invasive and safe procedure for managing large osteoma of the ethmoidal sinus in pediatrics patients., (Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Middle ear cholesteatoma is an aggressive form of chronic otitis media requiring surgical therapy. The surgical strategy depends on the location of the lesion, its extensions to the middle ear and mastoid, the anatomical conformation of the tympanomastoid cavities and the health status of the patient (as well as his or her interest in aquatic leisure activities). For several years, imaging of the ear has been a routine test in the preoperative work-up of the disease. National guidelines for the topic "Imaging of non-operated middle ear cholesteatoma" were prepared in October 2010, for the annual congress of the French Society of Otolaryngology Head and Neck Surgery (SFORL), by a panel of experts from the SFORL, represented by the French Association of Otology and Neuro-otology (AFON), and the French Radiological Society (SFR), represented by the French Society of Head and Neck Imaging (CIREOL). These guidelines are presented in the present article., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objectives: To report our centre's experience of outpatient tonsillectomy in children over a 7-year period and to evaluate the postoperative complication rate in this type of procedure compared to tonsillectomy performed in the context of conventional hospitalisation., Material and Methods: Retrospective review of medical charts., Results: From May 2002 to April 2009, 276 tonsillectomies were performed on an outpatient basis, i.e. 55.4% of all paediatric tonsillectomies, in children with a mean age of 5.28 years. Ninety-six children (34.8%) presented clinical OSAS. Development of an early postoperative complication (before H8) required conventional hospitalisation on D0 in six (2.1%) of these 276 children operated on an outpatient basis: early postoperative bleeding in four cases (1.4%), which required reoperation to control bleeding in three cases, refusal to feed in one case (0.3%), and a parental problem in one case (0.3%). Postoperative complications occurring after H8 required readmission in six cases (2.1%): pain and feeding difficulties in two cases (0.7%) on D1 and D5, respectively, bleeding in four cases (1.4%) with reoperation before H24 for one patient, D5 for two patients and D7 for one patient. Only one case of bleeding occurred between H8 and H24. No perioperative respiratory complications were observed in children with clinical OSAS., Conclusion: The results of this study show that, in line with international publications and meta-analyses, post-tonsillectomy complications between H8 and H24 postoperatively, mainly bleeding, are exceptional. Respiratory complications usually occur in high-risk clinical settings that are not eligible for outpatient surgery. Outpatient tonsillectomy is therefore a safe procedure in children presenting all of the required medical, social and organizational conditions., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

In vitro isotonic and isometric mechanical properties of the sternohyoid (SH) muscle, an upper airway dilator muscle, were studied in rats with a growth hormone (GH)-secreting tumour (GH tumour group; n = 10). The effects of muscle fatigue were also studied. Stress and shortening were measured in muscles contracting from zero load up to isometric load under tetanic conditions. Isometric stress and maximum unloaded shortening velocity were determined and compared with values obtained from control rats (n = 10). Crossbridge kinetics and energetics and mechanical efficiency were calculated from Huxley's equations. Compared with controls, isometric stress, mechanical efficiency, crossbridge number and crossbridge single force were lower in the GH tumour group. The probability of crossbridge being in the power stroke configuration was lower in the GH tumour group than in controls. Muscle fatigue significantly impaired maximal muscle efficiency and crossbridge single force in the GH tumour group but not in controls. In conclusion, mechanical and energetic properties of the SH muscle and crossbridge properties were worse in the GH tumour group than in controls. This may partly account for impairment of the upper airway dilator muscle function and the increased occurrence of obstructive sleep apnoea in acromegaly.

Objective: To compare the efficacy and safety of four radiofrequency generators (Ellman, Select Sutter, Coblator, Somnus) for the treatment of simple snoring., Materials and Methods: Multicenter, randomized, prospective single-blind study on 120 selected patients with simple snoring (apnea/hypopnea index <10/h of sleep). Snoring sound intensity was measured on a visual analog scale and the partner's short-term satisfaction rate was evaluated after two treatment sessions maximum. Discomfort, pain, and medication intake were compared., Results: Radiofrequency decreased the snoring sound intensity from 7.9 +/- 1.7 to 4.4 +/- 2.7 (P < 0.0001). The four radiofrequency generators had a statistically comparable efficacy. The Ellman generator caused less discomfort and required less anti-inflammatory drugs., Conclusion: Despite different technical characteristics, the four generators had a comparable efficacy with good safety. The Ellman generator induced the least discomfort.

Aim of the Study: Parotidectomy leaves a retromandibular hollow area in proportion with the amount of gland resected. Many surgeons perform primary reconstruction after superficial or subtotal parotidectomy in patients with exo-facial pleiomorphic focal adenoma. Many techniques have been proposed. We present a new technique of filling of the parotidectomy chamber by a second generation leucocyte and platelet concentrate, Platelet-Rich Fibrin (PRF, Choukroun's method)., Patients and Methods: 10 patients were included in this preliminary study. Subtotal parotidectomy was performed through classic procedure or lifting procedure. The macroscopic security margin of resection usually allowed performance of a SMAS flap. PRF was prepared following the original Choukroun's method., Results and Discussion: PRF slow resorption after filling of the exeresis cavity, offers a key aesthetic interest. The fibrin matrix of this biomaterial has many angiogenic and healing properties. Synergetic action of the fibrin and the platelets cytokines within PRF may improve revascularization and postoperative resumption of facial nerve function. The membrane formed by the fibrin dense fibrillary network, as well as the SMAS flap, may help to prevent the Frey's syndrome., Conclusion: We propose the use of PRF as a filling, healing and interposition material after parotidectomy for benign parotid tumors. Preliminary results are very encouraging. Longer prospective evaluation of this technique is necessary.

Objective: To estimate the frequency, mechanisms and predictive factors of sleep apnoea syndrome (SAS) in a large group of children and adults with type I (CMI) and II (CMII) Chiari malformation (CM)., Background: The anatomical and functional integrity of both respiratory circuits and lower cranial nerves controlling the upper airway is necessary for breathing control during sleep. These latter structures may be altered in CM, and a few investigations have reported CM related sleep disordered breathing., Methods: Forty-six consecutive unrelated patients with CM (40 CMI, six CMII), of which 20 were children (eight males) and 26 were adults (12 males), underwent physical, neurological and oto-rhino-laryngoscopic examination, MRI and polysomnography., Results: SAS was present in 31 (67.4%) of the patients with CM (70% of CMI, 50% of CMII, including mainly children). Sixty per cent of children with CM exhibited SAS, including 35% with obstructive (OSAS) and 25% with central (CSAS) sleep apnoea syndrome. SAS was observed in 73% of CM adults (57.7% OSAS, 15.4% CSAS). Severe SAS was found in 23% of CM adults. Multiple regression analysis revealed that age, type II Chiari and vocal cord paralysis predicted the central apnoea index., Conclusion: SAS is highly prevalent in all age groups of patients suffering from CM. CSAS, a rare condition in the general population, was common among the patients with CM in our study. Sleep disordered breathing associated with CM may explain the high frequency of respiratory failures observed during curative surgery of CM. Our results suggest that SAS should be systematically screened for in patients with CM, especially before surgery.

Objectives: The authors describe 28 pediatric cases of foreign body inhalation requiring treatment in intensive care units between 1987 and 1999. The purpose of this study was: (1) to analyze the circumstances, diagnostic difficulties and initial treatment of serious foreign bodies and (2) to compare our series with other literature descriptions and define principles for optimal prevention and initial treatment., Methods: Twenty-one children presented a penetration syndrome, which was responsible in 13 cases for asphyxia with cardiorespiratory arrest. All these children died, regardless of the initial treatment. Seven children were hospitalized for apparent asthmatic symptoms that did not respond to traditional treatment., Results: The inefficiency of external extraction methods like the Heimlich maneuver and the mean delay between clinical signs and initial treatment lead us to propose a new strategy for the emergency treatment of foreign bodies with asphyxia., Conclusions: We recommend that emergency teams promote the use of a laryngoscope and Magill forceps. Flexible endoscopy is still recommended as the appropriate diagnostic tool to eliminate doubt in the case of a first severe asthma attack.

Objective: To study the incidence, location, pre- and postoperative symptoms (hearing loss, tinnitus, vertigo, facial palsy), preoperative diagnostic imaging, and surgical treatment of labyrinthine fistulae (LF)., Design: Retrospective case review., Patients: Twenty-two cases of LF over 382 mastoid operations performed in a 168-month period., Main Outcome Measures: Clinical, imaging, and surgical correlation of extensive fistulae and bone fistulae., Results: LF prevalence was 5.8%. The main primary symptoms were otorrhea and hypoacusis. Only four patients presented vertigo as their main complaint. All patients underwent preoperative computed tomographic (CT) scans and preoperative audiometry. LF diagnosis was made before surgery for 100% of patients on the basis of CT scan. A second fistula was, however, misdiagnosed by imaging in two patients. With respect to surgical technique, a canal wall down procedure was performed in 77% and a conservative procedure was performed in 23%. Fistula was located in the horizontal semicircular canal in 100% of cases, and in 9%, a second fistula was operatively diagnosed. In 91% of cases, the matrix was removed, whereas it was left in the course of a canal down procedure in 9%. With a follow-up of 5.7 years, hearing remained unchanged in 80% of patients., Conclusions: Surgery with removal of the cholesteatoma matrix and sealing of the fistula with temporalis fascia is a safe procedure that can help preserve cochlear function. The choice of a canal down procedure would be influenced by cholesteatoma characteristics rather than by the finding of an LF.

Unresectable forms of HNSCC relapses occurring in a previously irradiated area are relatively common and may be difficult to manage from a therapeutic point of view. Full dose re-irradiation with concomitant chemotherapy constitutes an alternative to palliative chemotherapy. Indeed, the feasibility of this approach has been shown, and may be associated with a curative potential in a relatively low proportion of these relapses.

Objective: To present a case of squamous cell carcinoma developed on a thyroglossal duct cyst in an adult patient. Modalities of treatment and prevention are discussed., Patient and Methods: A 55-year-old woman had a thyroglossal duct cyst since childhood. Surgical resection had not been performed because of parental refusal., Results: Diagnosis of malignant degeneration was suggested by an increase in volume associated with cervical pain. Surgery was incomplete because of carotid artery and laryngeal involvement. Postoperative radiotherapy was given. At two years follow-up, local progression was controlled by palliative chemotherapy., Discussion: For most authors, the risk of recurrent infections is the main reason for surgical resection of a thyroglossal duct cyst during childhood. The risk of malignant degeneration is generally not put forward. It is rather uncommon for carcinoma to develop on a thyroglossal duct cyst. The risk is probably underestimated because surgery is generally performed early in childhood., Conclusion: This observation of malignant degeneration emphasizes the importance of surgical resection of thyroglossal duct cysts during childhood. We discuss treatment in the event of malignant degeneration.

Unlabelled: Obstructive sleep apnea syndrome is a very common disease. Nasal continuous positive airway pressure is a useful and efficient treatment but compliance depends on several factors including the degree of nasal obstruction., Objectives: The aim of this study was to evaluate the effects of surgical correction of nasal obstruction on compliance to nasal continuous positive airway pressure in obstructive sleep apnea syndrome., Material and Methods: This retrospective study (from March 1998 to March 2000) included ten patients suffering from a severe obstructive sleep apnea syndrome (apnea-hypopnea index greater than 30 per hour) treated by nasal continuous positive airway pressure for at least three months and presenting an anatomic nasal obstruction limiting the use of nasal continuous positive airway pressure. Surgical procedures included one septoplasty, two inferior turbinectomies and seven septoplasties with turbinectomies., Results: The post-operative polysomnography showed that surgical correction of nasal obstruction had no effect on obstructive sleep apnea syndrome severity (no significative change of apnea hypopnea index after surgery) but allowed the use of lower nasal continuous positive airway pressure levels (7.1 mmHg after surgery versus 10 mmHg before) and improved compliance to treatment (six compliant patients after surgery versus no compliant patient before). These results were compared with those published in the literature., Conclusion: An examination of the nose has to be performed before initiating nasal continuous positive airway pressure. If nasal continuous positive airway pressure cannot be tolerated because of nasal obstruction, surgery is required to improve compliance and tolerance to treatment.

Wegener's granulomatosis (WG) is a severe and potentially lethal granulomatosis. Even though no specific radiological criteria exist, CT may suggest the correct diagnosis at an early stage. Recent improvement in the prognosis is related to earlier diagnosis, allowing the initiation of efficient and specific treatment before any severe complications occur. We reviewed a series of WG cases in order to establish the CT diagnostic criteria.

Introduction: In order to meet the evolution of pneumococcus resistance to beta-lactam antibiotics, a new formulation of amoxicillin (AMX) and clavulanic acid (CA), with twice as much AMX (1 g/125 mg vs. 500 mg/125 mg) was developed for the treatment of acute pneumonia in patients at risk. This formulation can also be used in the treatment of acute maxillary sinusitis using a 1 g/125 mg regimen twice-daily., Objectives: Compare the sinusal penetration of AMX and CA (1 g/125 mg twice-daily vs. 500 mg/125 mg three times a day) when administered at both regimens to demonstrate equivalent pharmacokinetic and pharmacodynamic behaviour of the former when compared to the latter., Methods: Concentrations of AMX and CA were measured in the anterior ethmoid, maxillary, posterior ethmoid sinus and in the middle nasa concha in 62 patients undergoing surgery for nasosinusal polyps. Patients randomised in two groups corresponding to 2 oral regimens, received either 1 g/125 mg twice a day or 500 mg/125 mg three times a day for 4 days. The last dose in both groups was administered 1 h 30, 3, 5 or 8 hrs prior to surgery. Serum samples were taken simultaneously to tissue samples. AMX and CA were measured by high performance liquid chromatography. Exogenous and above all endogenous blood contamination were taken into account with the hematocrit as well as blood and tissue haemoglobin concentrations. Comparisons of tissue concentrations were made for each sampling time, according to values obtained for a specific tissue with both doses on one hand, and on the other to values obtained with a specific dose in different tissues. The calculated pharmacodynamic parameters, which are considered to be predictive for bacteriological and clinical efficacy, result directly from tissue concentrations of AMX. tissue inhibitory quotients (IQtissue = Tissue concentration/MIC). time above MICs for serum and tissue concentrations (T > MIC)., Results: As regards AMX, whatever the dose, at 1 h 30 and at 3 hrs, tissue concentrations did not differ significantly whatever the tissue studied (from 1.1 to 2.5 micrograms/g). Conversely, at 5 and 8 hrs, they were greater than after the 1 g/125 mg regimen given twice-daily (0.06-0.7 vs. 0.7-1.8 micrograms/g). If we consider a given dose, the comparison between the various tissues showed identical concentrations in the four tissues studied at each sampling time, except in two cases with the dose of 500 mg/125 mg 3 times a day. T > MIC for serum and tissue showed higher values than those required for AMX/pneumococcus association (40-50%) with, nevertheless, greater tissue values for the 1 g/125 mg dose given twice-daily when MIC was of 1 microgram/ml (40-52% vs. 50-66%). The maximum tissue inhibitory quotients were also greater with the twice-daily 1 g/125 mg dose, when calculated with MIC 50 or 90 of S. Pneumoniae, H. influenzae, M. catarrhalis or S. pyogenes. As for CA, concentrations were equivalent for both doses at each sampling time and greater than those required in vitro during respectively 4 and 5 hours for beta-lactamases H. influenzae and M. catarrhalis., Discussion-Conclusion: A least an equivalence between both dose regimens was observed, with occasionally a superiority of the twice-daily 1 g/125 mg dose, in terms of pharmacokinetics, tissue penetration and pharmacodynamics for both AMX and CA. This new regimen therefore appears more appropriate for the treatment of acute maxillary sinusitis in adults.

In 1999, all clinical Staphylococcus aureus isolates from patients admitted to a Belgian University hospital were tested for decreased vancomycin susceptibility. Three vancomycin-intermediate Staphylococcus aureus (VISA) and four hetero-VISA strains were detected among 2145 isolates tested. They emerged from strains that belonged to locally endemic methicillin-resistant S. aureus (MRSA) genotypes in three patients who had received repeated courses of vancomycin therapy. A cystic fibrosis patient with MRSA/VISA-associated broncho-pulmonary exacerbation was successfully treated by continuous vancomycin infusion plus fusidic acid followed by oral minocycline-fusidic acid. Two other patients had VISA recovered from specimens of undetermined clinical significance. Emergence of VISA variants of endemic MRSA strains in Belgium warrants active microbiological surveillance and careful monitoring of vancomycin therapy. Therapy with high-dose vancomycin administered by continuous infusion in combination with other antimicrobials may be a therapeutic option worth investigating for VISA infection.

A pharmacokinetic study was carried out to determine moxifloxacin concentrations in sinus tissue, after oral moxifloxacin 400 mg once daily for 5 days to patients with chronic sinusitis, undergoing elective sinus surgery. Patients were randomly allocated to one of seven treatment groups, in which tissues were sampled 2, 3, 4, 6, 12, 24 or 36 h post-dose. A control group with non-infected nasal polyps was also included. Forty-eight patients (13 female, 35 male, mean age 47.1 years) were allocated to one of each active treatment group (n = 42) or to the control group (n = 6). Tissue and plasma samples were taken simultaneously and stored frozen until assayed by HPLC. Thirty-nine patients were fully valid for pharmacokinetic analysis. The geometric mean moxifloxacin plasma concentration increased from 2.32 mg/L at 2 h to a maximum of 3.37 mg/L at 4 h post-dose, decreasing to 0.37 mg/L at 36 h post-dose. The moxifloxacin concentration in sinus mucosa was consistently greater than that in plasma being 4.56-5.73 mg/kg from 2 to 6 h and 2.81-1.25 mg/kg from 12 to 36 h post-dose. The elimination rates in plasma and sinus tissues were similar. The tissue/plasma ratio was c. 200% between 2 and 6 h, and up to 328.9% at 36 h. Results were similar whatever the site of tissue sampling (maxillary sinus, anterior ethmoid sinus or nasal polyps). Tissue levels exceeded the MIC(90) of all pathogens commonly causing acute sinusitis (e.g. 5-30 x MIC for Streptococcus pneumoniae: 0.25 mg/L). These results sup-port the use of moxifloxacin 400 mg once daily as a regimen for the treatment of sinus infections.

Hemangiomas are tumors. Hemangiomas near the geniculate ganglion or in the internal acoustic meatus are well known but rare. We present two cases of hemangiomas located at the porus acusticus, an even more rare site. MRI showed a millimeter-sized tumor, located in the porus acusticus, developing perpendicular to the axis of the acoustico-facial nerves, surrounding them. They were hyperintense on T1-weighted images, strongly hyperintense on T2-weighted images with a characteristic progressive and marked enhancement after injection of gadolinium DTPA. Similar signal abnormalities were present in the adjacent temporal bone, and CT scan demonstrated a honeycomb appearance with intratumoral bony spicules. These imaging criteria allows differentiation between hemangioma and neurinoma. We hypothesize that this location is related to the presence of a rich vascular plexus of the dura mater in this area.

Insulin-like growth factor-I (IGF -I) is likely to be an indicator of somatotropin (ST) administration in the horse. To investigate the different ways ST administration may be detected, the following aspects of IGF -I concentrations in plasma were studied: (i) the daily variation; (ii) variation following a treadmill test; (iii) concentrations at rest and after exercise; and (iv) concentrations in plasma from two young horses and two adults treated with methionyl equine somatotropin (e ST). In the population of horses at rest, IGF -I mean concentration (SEM) was 261 (104) ng ml(-1). In post race samples, IGF -I mean concentration was 187 (100) ng ml(-1). All of these data indicate that exercise does not modify IGF -I concentration in plasma. The magnitude of the increase in IGF -I following administration of e ST differed according to the age of the horses. The critical value of 700 ng ml(-1)was exceeded for 1 day in adult horses and for at least 11 days in young horses. These results show that IGF -I has potential as an indirect marker of ST administration in horses., (Copyright 2001 Harcourt Publishers Ltd.)

The insulin-like-growth-factor-I (IGF-I) peptide is known to be a marker for growth hormone administration. The development of a quantification method by electrospray ionization mass spectrometry (ESI-MS) coupled with high-performance liquid chromatography (HPLC) is required. This paper describes a method to quantify IGF-I using the internal standard R3 IGF-I in its oxidized forms. A deconvolution software was used to quantify the set of multi-charged molecules recorded on an ESI ion trap mass spectrometer. The results (i.e., linearity, reproducibility and concentration range) were obtained on standard samples and the described LC-ESI-MS method should be applicable to biological samples.

Background: The purpose of this study was to analyze the tolerance and efficacy of full dose reirradiation combined with chemotherapy in patients with head and neck carcinoma (HNC) with a high risk of recurrence after salvage surgery., Methods: Between 1991 and 1996, 25 patients having a recurrence or a second primary tumor in a previously irradiated area (> 45 grays [Gy]) were entered in this prospective study. All of them received salvage surgery and had a positive surgical margin and/or lymph node involvement with capsular rupture (N+R+). Adjuvant radiochemotherapy was given, delivering 60 Gy per 30 fractions with concomitant hydroxyurea and 5-fluorouracil. The median total cumulative dose of the 2 irradiations was 118 Gy. The median follow-up after the second irradiation was 66 months., Results: During the reirradiation course, Grade 3 and 4 mucositis were observed in 40% and 12%, respectively. Analysis of late effects (> 6 months after reirradiation) showed that 16% of the patients had osteoradionecrosis and 40% had Grade 2-3 cervical fibrosis (Radiation Therapy Oncology Group scoring system). The patterns of failure were as follows: local only (n = 9), lymph node only (n = 2), local and lymph node only (n = 1), and metastatic (n = 4). The 4-year survival rate after reirradiation was 43% (95% confidence interval, 25-62)., Conclusions: Full dose reirradiation combined with chemotherapy after salvage surgery in high risk patients with HNC was feasible with an "acceptable" toxicity and led to a relatively good 5-year survival rate. These results prompted the authors to initiate a multicentric randomized trial that is ongoing (GETTEC-GORTEC 99-01) to evaluate the benefit of adjuvant radiochemotherapy in these types of patients., (Copyright 2001 American Cancer Society.)

Objectives: To determine the incidence of Staphylococcus aureus isolates with reduced susceptibility to glycopeptides among all clinical isolates collected consecutively in two French hospitals between November 1998 and April 1999., Methods: Methicillin-resistant and -susceptible S. aureus isolates were screened on vancomycin- or teicoplanin-supplemented agar plates. Glycopeptide MICs were determined by the E test procedure with a high inoculum and by an agar dilution technique. Glycopeptide-intermediate S. aureus isolates were identified as homogeneously or heterogeneously resistant to vancomycin by performing population analysis., Results: Of the 640 isolates recovered from 518 patients, three from the same patient and two from two different patients showed homogeneous or heterogeneous intermediate resistance to vancomycin., Conclusion: The incidence of glycopeptide-intermediate S. aureus (homogeneously or heterogeneously resistant) in a non-selected patient population, i.e. regardless of predisposing factors and glycopeptide therapeutics, remains low in the two French hospitals involved in the study, representing 0.6% of isolates.

Chondromyxoid fibroma is a rare benign tumor that usually occurs in the long bones. A 50-year-old patient presented with chondromyxoid fibroma of the nasal bone with extension into the frontal and ethmoidal sinuses. This is the fourth case reported to date in the literature. The clinical manifestations of the tumor were very limited, and the appearance at rhinoscopy was misleading. Radiologic imaging showed a soft tissue lesion invading the adjacent bony structures and the dura mater. Surgery was performed by a combined team of otorhinolaryngologists and neurosurgeons, and total excision of the tumor was achieved. The histologic diagnosis of this tumor is difficult because of its similarities to chondrosarcoma. [Editorial comment: The authors concisely review management of this rare tumor, emphasizing that complete surgical excision, rather than curettage, is required for long term control.]

A Staphylococcus aureus strain with low-level heteroresistance to vancomycin (designated MER) but susceptible to methicillin was isolated from an outpatient with conjunctivitis who did not receive any glycopeptide antibiotics. Incubation of the parent strain, MER, with increasing concentrations of vancomycin led to rapid selection of a stable progeny homogeneously resistant to vancomycin. Electron micrographs of strain MER showed enhanced cell wall thickness and abnormal septations typically seen with methicillin-resistant S. aureus having intermediate susceptibility to vancomycin.

The usual treatments for primary snoring are uvulopalatopharyngoplasty (UPPPP) and laser assisted uvulopalatoplasty, their morbidity is known, particularly considerable postoperative pain. We have performed a prospective study on a population of 23 patients with primary snoring (respiratory disturbance index =6 +/- 1) to 1) evaluates by means of questionnaires the short term (2 month) efficacy of the application of radiofrequency energy at the level of the soft palate, and 2) assess the morbidity associated with this treatment in this population. In the group of patients receiving treatment at three sites in a maximum of three sessions, the short term satisfaction rate was 75 %. The postoperative pain was of minor importance and the use of major analgesics was necessary in 2 cases only. We conclude that this treatment with radiofrequency energy seems to be an effective treatment for primary snoring at short term. The morbidity, specially the pain seems to be distinctly inferior compared to UPPP or laser treatment. Further prospective studies on a larger number of patients and with a longer follow-up are absolutely necessary to confirm these results.

The mdx mouse is a widely used animal model of human muscular dystrophy. Although diaphragm muscle exhibits severe muscle weakness throughout the life of the animal, the limb muscle function of mdx mice spontaneously recovers by 6 mo of age. Pharyngeal dilator muscles such as sternohyoid (SH) contribute to upper airway patency during breathing. We hypothesized that SH muscle function was impaired in 6-mo-old mdx mice. Mechanical properties and myosin heavy chain (MHC) composition were investigated in isolated SH from 6-mo-old control (C, n = 10) and mdx (n = 10) mice. As compared with C, peak tetanic tension (Pmax) and maximum shortening velocity were 50% and 16% lower in mdx mice (p < 0.001 and p < 0.05, respectively). Peak mechanical power was lower in mdx than in C (19.0 +/- 3.2 versus 57.4 +/- 5.1 mW g(-)(1), p < 0.001). Both C and mdx SH were composed exclusively of fast myosin isoforms. As compared with C, mdx SH presented a higher proportion of IIX-MHC and a reduction in IIB-MHC (each p < 0.001). In conclusion, our results demonstrated severe SH muscle dysfunction in 6-mo-old mdx mice, that is, at a time when limb muscle function has recovered. Thus, SH muscle of the mdx mouse may be an excellent muscle for studying Duchenne muscular dystrophy.

Pharyngeal and diaphragm muscles contract and relax in synergy, which is why it was decided to compare their mechanical performance throughout the overall load continuum. The effects of fatigue were also studied. The isotonic mechanics of rat sternohyoid (SH; n=10) and diaphragm (D; n=10) were investigated in vitro. Force and length were measured in muscles contracting from zero load up to isometry. Maximum isometric tension (Pmax), peak mechanical work (Wmax), maximum unloaded shortening velocity (vzL) and mechanical efficiency (eff(max)) were recorded. Data were obtained both at baseline and after fatigue. SH muscles had a lower Pmax (96.0+/-13.7 versus 119.5+/-22.7 mN x mm(-2); p<0.05), a lower Wmax (5.5+/-1.2 versus 8.0+/-2.1 mJ x g(-1); p<0.01), a lower eff(max) (56.0+/-6.9 versus 62.6+/-5.8%; p<0.05) and a higher vzL (4.8+/-0.4 versus 3.4+/-0.4 initial length (L0) x s(-1); p<0.001) than D muscles. Wmax occurred at a higher relative load in SH (40% Pmax) than in D (30% Pmax). Fatigue did not modify eff(max) in SH muscles, whereas it significantly improved eff(max) in D muscles. These findings suggest that under control conditions, economy of force generation was less efficient in sternohyoid than in diaphragm muscles. Fatigue in sternohyoid muscles induced unfavourable mechanical behaviour. This may partly explain pharyngeal dilator muscle failure in the presence of increased loads. Whether these findings are relevant to human sleep apnoea syndrome has yet to be determined.

Evolution of bacterial resistance shortens antibiotic treatment in ENT infections. The efficacy and tolerance of amoxicillin-clavulanate (ACA), with and without associated short steroid therapy, was evaluated in acute sinusitis of adults at a dosage of 1.5 g/d for 5 d vs. 10 d. This multicentre, randomized, double-blind, placebo-controlled study included 433 patients, 417 of whom were suitable for intent-to-treat (ITT) analysis. The therapeutic success rate in the ITT population, assessed according to strict clinical and radiological criteria, was respectively, 80% and 85% in the 5-d and 10-d treatment groups. Due to the statistical risks that were evidenced, the 2 durations of treatment could not be considered equivalent. The analysis of medical history shows that some risk factors (recurrence of sinusitis, previous surgical sinus drainage) seem to promote therapeutic failure and that 5-d treatment is inappropriate in these patients. The persistence of therapeutic success on day 30 was not influenced by the initial duration of treatment. The efficacy and good tolerance of ACA in acute sinusitis in adults were confirmed. Further studies will be needed to define the indications of short treatments better, which seem to be indicated in the absence of specific risk factors.

The authors report a series of eight cases of isolated tracheoesophageal fistula without esophageal atresia (or an H type fistula), treated in three pediatric ENT departments. This is a rare malformation whose diagnosis requires investigation for associated anomalies. The clinical signs are mainly respiratory but also digestive and the symptomatology can be severe. The diagnosis can be made with a barium swallow combined with cineradiography, but a tracheoesophageal endoscopy remains the investigation of choice. The treatment is surgical. In most cases, the fistula is accessible by a right or left cervicotomy, depending on the surgeon's practice, with a much lower postoperative morbidity as compared to a thoracotomy. The postoperative management was straightforward in most of our cases. We discuss the role of gastro-esophageal reflux with respect to postoperative morbidity as well as systematic treatment for reflux peri-operatively. The pros and cons of the various surgical approaches are also discussed.

Gastroesophageal reflux is generally a benign condition, which resolves spontaneously, and which is usually manifested by digestive signs. More recently, laryngotracheal conditions such as laryngospasm, laryngomalacia and recurrent laryngitis, have been ascribed to gastroesophageal reflux. However, there is not a single common mechanism linking these two pathologies and different theories are postulated. Diagnosis of gastroesophageal reflux is based essentially on prolonged pH monitoring, where a negative result unfortunately cannot rule out reflux responsibility. Thus, in the end, in the face of a sufficient body of evidence, it is the effectiveness of the anti-reflux treatment which will make it possible to establish a link between gastroesophageal reflux and the laryngotracheal manifestations observed.

Results of CT and MRI explorations in 8 patients with cerebrospinal fluid (CSF) fistulae are reported and compared with surgical findings in 7. Sensitivity of MRI (CISS and fast T2 spin-echo sequences) was excellent giving perfect correlations with surgical findings in 7/7 cases. CT and MRI were found to provide complementary information suggesting they should be used in combination as first intention explorations of suspected CSF fistulae. Computerized cisternography should be used if MRI is contraindicated or if a clinically and biologically proven CSF fistulae is not visualized by CT or MRI.

Diarrhea due to infection with Microsporidium (M) or Cryptosporidium (C) raises significant therapeutic challenges in HIV-infected patients. The usefulness of protease inhibitor therapy was evaluated in 20 HIV-positive patients with positive tests for M and/or C. There were 17 men and three women with a mean age of 42.5 years (range, 26-64 years). Two patients had category B disease and 18 category C disease according to the 1993 CDC classification scheme (CD4 count before therapy, 72/mm3; mean viral burden, 4.6 log). Seventeen patients had chronic diarrhea (due to M in 12 cases and to C in five), and the remaining three patients were asymptomatic M carriers. Clinical symptoms resolved after addition to the antiretroviral regimen of indinavir (n = 17) or saquinavir (n = 3). Mean weight gain was 10.5 kg. Karnofsky's index improved. Twelve patients, including one of the three who were asymptomatic at baseline, had negative follow-up stool cultures. The mean CD4 count increase was 125/mm3, and the mean viral burden decrease was 1.285 log. These data suggest that protease inhibitors may be capable of eradicating M and/or C infection refractory to other treatments. The reason for this effect may involve partial restoration of immune function due to inhibition of HIV replication.

We present a case of osteoid osteoma of the petrous bone presenting with progressive sensorineural hearing loss. CT showed a dense homogeneous mass at the promontory surrounded by a thin bony border. On MRI this lesion gave intermediate signal intensity on T1- and T2-weighted spin-echo images and enhanced intensely with gadolinium. Surgical removal and pathological study proved the diagnosis.

Considerable interest has been shown in recent years about hyperfractionated and accelerated radiation therapy for head and neck squamous cell carcinomas. The first randomized trial showing an advantage for hyperfractionation in terms of tumor control was the European Organization for Research and Treatment of Cancer 22791 trial. More recently, accelerated radiotherapy has been tested in many studies showing that high total doses of radiation could be delivered in overall treatment time shorter than conventional radiation therapy. The benefit of accelerated radiation therapy has been reported in some recently completed randomized trials, which suggests that rapid repopulation of surviving tumor cells during radiation therapy is a major determinant to obtain cure in this type of cancer.

The case of an osteoid osteoma of the middle ear in a 42 year old man is reported. No former case has now been reported in the literature for this localization. The suspected diagnosis of osteoid osteoma was based on the pain and the findings of bone computerize tomography. In our case, the osteoid osteoma was totally painless and the diagnosis was made after surgical findings by histological studies. Some clinical and imaging points, pathologic findings and differential diagnosis are also discussed.

Purpose: To study the predictive value of pretreatment potential doubling time and labeling index, as measured by flow cytometry in patients with head and neck squamous cell carcinoma treated with conventional radiotherapy., Methods and Materials: 70 patients with a squamous cell carcinoma of the oropharynx and 4 patients with another involved head and neck site were entered in this prospective study. The duration of the S phase (TS), the labeling index (LI), and the potential doubling time (Tpot) were obtained by flow cytometry measurements of a tumor biopsy obtained after i.v. injection of 200 mg bromodeoxyuridine to the patient. The treatment consisted of 70 Gy in 7 weeks, 2 Gy per fraction and five fractions per week., Results: The mean and median LI were 7.7% (standard deviation, SD: 5.0) and 6.3%, respectively. The mean and median TS were 9.3 h (SD: 3.6) and 8.3 h, respectively. The mean and median Tpot were 5.6 days (SD: 5.4) and 4.6 days, respectively. No significant relationship was found between the Tpot or LI and the tumor stage (T), nodal status (N), histological grade, and the site of the primary within the oropharynx. The only parameter significantly associated with an increased risk of local relapse was the tumor stage (p < 0.001). The mean Tpot for the group of tumors that relapsed locally was 5.3 days (SD: 3.3), compared to 6.1 days (SD: 4.08) for those who did not relapse locally (NS). Two parameters were significantly associated with a decrease in disease-free (DFS) and overall survival, namely the tumor stage (p < 0.005, and p < 0.001, respectively, for DFS and overall survival) and nodal involvement (p = 0.02 and (p < 0.005, respectively, for DFS and overall survival). The TS, LI, DNA index, and Tpot were not significantly associated with local relapse, DFS, and survival, either in the univariate or in the multivariate analysis., Conclusions: The method used to evaluate tumor cell kinetics did not provide clinically relevant kinetic parameters for this type of cancer. The classic prognostic factors (tumor stage and nodal status) were strongly associated with clinical outcome.

Alpha 2-HS glycoprotein (AHSG) is a human serum glycoprotein synthesized by liver cells. It is a natural inhibitor of the insulin receptor tyrosine kinase activity. We produced this protein in insect cells by using a recombinant baculovirus expressing the whole coding sequence of the protein. By analyzing AHSG on isoelectric focusing and on sodium dodecyl sulfate (SDS) gels, followed by immunoblot, AHSG produced in insect cells was found to be phosphorylated and to possess the connecting peptide between the A and the B chains. The same features were found in the protein produced by Hep3B, a human liver cell line that synthesizes AHSG. By contrast, no phosphorylation could be detected in AHSG present in normal human plasma, and the connecting peptide was clipped. As the protein produced in insect cells is active on insulin receptors, in contrast to the plasma protein, our results suggest that the biological activity of the protein may be associated with its single chain form together with its phosphorylation.

From 1992 to 1993, 46 patients with very locally advanced (74% T4) head and neck carcinomas and extensive cervical involvement (82% N2-3) were treated at the Institute Gustave Roussy with a very accelerated radiotherapy regimen: 62 Gy in three weeks with two daily 1.75 Gy fractions. Early mucosal reactions were severe but manageable in this population of patients with frequent alteration of initial performance status. Nearly every patient experienced a grade 3 or 4 (WHO) mucositis and 80% required tube feeding. Follow-up is not sufficient to draw firm conclusion about late reactions but they do not seem different from those induced by conventional radiotherapy. The overall 2-year survival rate of 49.4% and loco-regional control rate of 67% seem superior to the results of conventional radiotherapy for such advanced tumors. These results have led to a multi-center randomized controlled trial comparing this regimen of accelerated radiotherapy with conventional fractionated radiotherapy.

alpha-Agglutinin of Saccharomyces cerevisiae is a cell wall-associated protein that mediates cell interaction in mating. Although the mature protein includes about 610 residues, the NH2-terminal half of the protein is sufficient for binding to its ligand a-agglutinin. alpha-Agglutinin20-351, a fully active fragment of the protein, has been purified and analyzed. Circular dichroism spectroscopy, together with sequence alignments, suggest that alpha-agglutinin20-351 consists of three immunoglobulin variable-like domains: domain I, residues 20-104; domain II, residues 105-199; and domain III, residues 200-326. Peptide sequencing data established the arrangement of the disulfide bonds in alpha-agglutinin20-351. Cys97 is disulfide-bonded to Cys114, forming an interdomain bond between domains I and II. Cys202 is bonded to Cys300, in an atypical intradomain disulfide bond between the A and F strands of domain III. Cys227 and Cys256 have free sulfhydryls. Sequencing also showed that at least two of three potential N-glycosylation sites with sequence Asn-Xaa-Thr are glycosylated. At least one of three Asn-Xaa-Ser sequences is not glycosylated. No residues NH2-terminal to Ser282 were O-glycosylated, whereas Ser282, and all hydroxy amino acid residues COOH-terminal to this position were modified. Therefore O-glycosylated Ser and Thr residues cluster in the COOH-terminal region of domain III, and the O-glycosylation continues into a Ser/Thr-rich sequence that extends from domain III to the COOH-terminal of the full-length protein.