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Background Superior canal dehiscence (SCD) is a benign condition in which a surgical treatment may be considered depending on the patients’ tolerance of their symptoms. In this study, we aim to identify driving factors behind the patients’ choice of a surgical management over watchful waiting. Methods Sixty-two patients with cochlear and/or vestibular symptoms and a temporal bone high-resolution CT (HRCT) scan showing SCD were included in the study. All patients have been offered either surgical management or watchful waiting. Results Of these, 28 elected surgery and 34 declined it. The operated group showed more cochlear (6.6 vs. 2.4) symptoms than the non-operated group (P < 0.001) except for hypoacousis, but no significant difference (P = 0.059) was found for the number of vestibular symptoms between both groups (3.4 vs. 1.1). Footstep and eating hyperacousis were both present in 57.1% of operated vs. 3% of non-operated patients (P < 0.001). Oscillopsia with effort and with walking was found in 50% and 35.7% of operated patients, respectively, but none in the non-operated group (P < 0.001). Hearing tuning fork at malleolus and Valsalva and pneumatic speculum induced vertigo showed a statistically significant difference between the two groups (P = 0.003, P < 0.001, P = 0.010 respectively). Cervical vestibular-evoked myogenic potential (cVEMP) thresholds, air and bone conduction thresholds, and mean air-bone gap (ABG) were similar in the two populations (P > 0.05). The average dehiscence size was 4.7 mm (2.0 - 8.0 mm) and 3.8 mm (1.3 - 7.7 mm) in the operated and non-operated patients, respectively (P = 0.421). Conclusions The natures of cochleovestibular signs and symptoms were shown to be key factors in patients’ choice of a surgical management whereas paraclinical tests seem to be less significant in the patients’ decision for a surgical treatment.

Review the useful hearing preservation and tumor control outcomes of microsurgery (MS), stereotactic radiation (SR), conservative management (CM), and chemotherapy (ChT) for Neurofibromatosis type 2 vestibular schwannomas.Ovid MEDLINE was used to conduct a thorough search of English-language publications dating from 1948 to February 2013.Patients must have had useful hearing at diagnosis and treated with one of the 4 treatments as their primary therapy. All sporadic vestibular schwannoma cases were excluded.A total of 19 articles were reviewed. Hearing preservation was defined as unchanged or improved useful hearing. Tumor control was defined as no change in size or tumor regression for SR, CM, and ChT-treated cases, and as no recurrence for MS treated cases.Microsurgery seems to have the worse overall results, while SR has very good tumor control with poor useful hearing preservation. If a patient qualifies for CM, he is likely to show the most satisfactory results with the least treatment available. A close follow-up on ChT clinical trials and possible side-effects is warranted as preliminary short-term results are quite favorable. Additional long-term studies are required for a better understanding of this disease.

Radioactive iodine (RAI) remnant ablation in low-risk papillary thyroid cancer (PTC) is controversial. Current patient selection guidelines recommend the use of postoperative stimulated thyroglobulin (stim-Tg), neck dissections, and sonography but fail to include sentinel lymph node biopsy (SLNB). The objective of this study was to evaluate the correlation between SLNB status and postoperative stimulated thyroglobulin as a surrogate marker of clinical outcome.Retrospective chart review of low-risk PTC patients who underwent a total thyroidectomy with SLNB at the McGill Thyroid Cancer Center. SLNBs were obtained using methylene blue dye. Biochemical measurements were acquired between 4 and 12 weeks postoperatively. Statistical analyses were performed using logistic regression models and receiver operating characterisitc (ROC) curves. A P-value.05 was considered significant.Ninety-six patients were included in this study. The positive SLNB rate was 14.6%. The mean postoperative Tg level was 1.41 μg/L. There were no significant correlations between the SLNB and the covariates analyzed (age, gender, histology, tumor size, and thyrotropin levels). Patients with negative SLNB were significantly more likely to have a lower stim-Tg (P.0001). When postoperative Tg was analyzed as a categorical variable, a threshold of1 μg/L was significantly associated with a negative SLNB, with a sensitivity and specificity (determined by ROC curves) of 0.86 and 0.88, respectively.There exists a correlation between SLNB and postoperative Tg. This creates the possibility of a new approach to RAI administration among low-risk PTC patients incorporating SLNB to the current guidelines.

Perioperative practices in thyroid surgery vary from one specialty, institution, or country to the next. We evaluated the preoperative, intraoperative, and postoperative practices of thyroid surgeons focusing on preoperative ultrasound, vocal cord evaluation, wound drains, and hospitalization duration, among others.A survey was sent to 7 different otolaryngology and endocrine/general surgery associations.There were 965 respondents from 52 countries. Surgeon-performed ultrasound is practiced by more than one third of respondents. Otolaryngologists perform preoperative and postoperative vocal cord evaluation more often than endocrine/general surgeons (p.001). Sixty percent of respondents either never place drains or place drains50% of the time in thyroid lobectomies (43% for total thyroidectomies). Outpatient thyroid surgery is most frequently performed by surgeons in the United States (63%).This epidemiologic study is the first global thyroid survey of its kind and clearly demonstrates the variability and evolving trends in thyroid surgery. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1296-1305, 2017.

O ano de 2016 marca os 150 anos de nascimento de Georg Walther Groddeck, primeiro médico utilizar o referencial psicanalítico para o tratamento das doenças orgânicas. Groddeck se tornou mais conhecido no meio psicanalítico devido a sua contribuição para a formulação freudiana da segunda tópica por meio do conceito de Isso (Id). Freud reconhece sua contribuição em O Eu e o Isso de 1923, e admite em carta a Pfister que Groddeck provavelmente estaria certo em relação às determinações inconscientes das doenças orgânicas. Entretanto, para Groddeck, o seu Isso, herdeiro do Deus-Natureza de Goethe, não poderia se restringir aos limites a ele atribuídos por Freud na formulação de sua segunda representação tópica do aparelho psíquico. Anterior à formação da unidade biopsíquica do sujeito, o Isso de Groddeck, uma espécie de matriz de onde emana toda a existência somatopsíquica, determinaria tanto a saúde quanto a doença, a vida e a morte.

Molossid bats are considered as morphologically specialized for fast enduring flights within obstacle-free environments. The only European species of the family, the European free-tailed bat Tadarida teniotis, exhibits a similar flight behavior and is thus expected to demonstrate analogous morphological adaptations. The present report investigates external and muscular forelimb features that could be associated with open air high-speed flight patterns. For the scope of the study, we calculated standard external ecomorphological indices and carried out gross anatomical dissections on six adult specimens of T. teniotis from northern Greece. In this way, we qualitatively and quantitatively examined patterns of relative mass and strength in selected muscles. In terms of external morphology, T. teniotis possessed long and narrow wings with slightly pointed tips. Regarding forelimb muscular anatomy, the species is characterized by powerful wing adductors (e.g. pectorales), an enlargement of the coracoid head of biceps brachii, and equal mass of elbow joint flexors and extensors. These characteristics, partly shared by other molossids, may correlate to a powerful, controlled downstroke and a semi-extended elbow for fast enduring non-maneuverable flight.

While thyroidectomy is considered a safe surgery, dedicated tools facilitating tissue identification during surgery could improve its outcome. The most common complication following surgery is hypocalcaemia, which results from iatrogenic removal or damage to parathyroid glands. This research project aims at developing and validating an instrument based on optical microscopy modalities to identify tissues in real time during surgery. Our approach is based on a combination of reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) to obtain multi-scale morphological contrast images. The orthogonal field of views provide information to navigate through the sample. To allow simultaneous, synchronized video-rate imaging in both modalities, we designed and built a dual-band wavelength-swept laser which scans a 30 nm band centered at 780 nm and a 90 nm band centered at 1310 nm. We built an imaging setup integrating a custom-made objective lens and a double-clad fibre coupler optimized for confocal microscopy. It features high resolutions in RCM (2µm lateral and 20 µm axial) in a 500 µm x 500 µm field-of-view and a larger field-of-view of 2 mm (lateral) x 5 mm (axial) with 20 µm lateral and axial resolutions in OCT. Imaging of ex vivo animal samples is demonstrated on a bench-top system. Tissues that are visually difficult to distinguish from each other intra-operatively such as parathyroid gland, lymph nodes and adipose tissue are imaged to show the potential of this approach in differentiating neck tissues. We will also provide an update on our ongoing clinical pilot study on patients undergoing thyroidectomy.

Esta tese apresenta os resultados de estudos geofísicos e geológicos de superfície e sub-superfície realizados com objetivos hidrogeológicos na Bacia Hidrográfica do Baixo Rio Capivari (SP), na qual afloram rochas sedimentares neopaleozóicas do Subgrupo Itararé e intrusivas básicas associadas, numa área aproximada de 1560 Km² quadrados. Os levantamentos geológicos envolveram a aplicação de uma nova metodologia na pesquisa das rochas sedimentares da região, já efetuamos com sucesso em pesquisas petrolíferas. A aplicação do moderno conceito de sistemas deposicionais da estratigrafia genética para as rochas do Subgrupo Itararé na região permitiu caracterizar essa unidade através do Sistema Costeiro e do Sistema Deltaico. A utilização de métodos geofísicos de superfície teve conseqüências tanto geológicas quanto hidrogeológicas. As sondagens elétricas verticais (SEV) permitiram a elaboração de uma estratificação elétrica regional bem como conduziram à obtenção de uma tendência da distribuição espacial das litologias. Os levantamentos magnetométricos da componente vertical do campo detectaram os corpos de rochas básicas intrusivas, cujo conhecimento é importante para a hidrogeologia, e possibilitaram a eliminação de dúvidas na interpretação das colunas geoelétricas obtidas pelas SEV. Descrições litológicas de amostras e testemunhos de poços e perfilagens geofísicas associadas conduziram a uma interpretação mais segura das colunas geoelétricas através de SEV paramétricas, permitindo também a realização de correlações estratigráficas. Além disso verificou-se estreita correlação entre as litologias e os perfis geofísicos de poços, principalmente no caso do perfil de radiação gama natural. Do conjunto dos levantamentos efetuados concluiu-se que a geofísica contribuiu, dentro do conceito de sistemas deposicionais, para a caracterização das litologias do Subgrupo Itararé, sugerindo que a mesma possa vir a ser aplicada com sucesso em outras regiões dessa complexa unidade estratigráfica. Do ponto de vista hidrogeológico foram definidos os sistemas aqüíferos regionais bem como algumas de suas características hidráulicas. Dados de resistência transversal calculados a partir das SEV foram usados para a elaboração de um mapa de valores dessa grandeza geofísica, e mostraram boa correlação com valores de transmissibilidades hidráulicas. As SEV desempenham assim um importante papel na previsão do comportamento hidrogeológico dos poços que vieram a ser perfurados na região estudada. This paper presents the results of surface and sub-surface geophysical and geological studies with hydrogeologic objectives in the Hydrographic Basin of the Down Capivari River (SP), in which outcrop neopaleozoic sedimentary rocks of Itararé Subgroup and associated basic intrusives, in an area near 1560 Km². The geological works applicated a new methodology in the research of the regional sedimentary rocks, already applied with success in oil research. The use of the modern concept of depositional systems related with genetic stratigraphy for rocks of Itararé Subgroup in the region allowed the characterization in this unit of the Coastal System and Deltaic System. The use of surface geophysical methods conducted to a new geological and hydrogeological contribution. The vertical electrical souding (VES) permitted a construction of a regional electrical stratification and a spatial distribution of lithologies. The magnetometric works through the measurement of the vertical component of the field, detected the bodies of intrusive basic rocks, this knowledge being important to hydrogeology, and allowed the removal of doubts in the interpretation of geolectric columns given by VES. Lithological descriptions of samples and cores of wells and associated geophysical profiles lead to a better interpretation of the geoelectrical columbs through the use of parametric VES, and permitted also stratigraphic correlations. It was verified, also, a good correlation between lithologies and geophysical well-logs, mainly with the natural gross gama radiation profile. The set of works made permitted the conclusion that geophysics contributed, inside the concept of depositional systems, to the characterization of the lithologies of the Itararé Subgroup, suggesting that the methodology proposed can be applied in other regions of this complex stratigraphic unit. From hydrogeologic point of view were defined the regional aquifer systems and their hydraulic caracteristics. Transversal resistence values calculated from VES were used to make a isovalue map of that geophysical function, and exhibited a good correlation with the hydraulic transmissivity values. The VES have than an important role in the prediction of hydrogeological behavior of wells drilled in the studied region.

The objective of this review is to compare the symptomatological evolution following conservative management (CM) or microsurgery (MS) in patients with intralabyrinthine schwannomas (ILS). A thorough systematic review of the English and French literature from 1948 to February 2014 was performed using Ovid Medline. An ancestor search was also completed. The major inclusion criterion consisted of a diagnosis of ILS with magnetic resonance imaging. Patients with a classic vestibular schwannoma, cases of incidentaloma during surgery or an autopsy were the main exclusion criteria. Thirty-one studies met our selective criteria. Descriptive data were collected from the articles. Clinical outcomes regarding the hearing loss, tinnitus, vertigo, dizziness and aural fullness were stated as improved, unchanged or worse at the last follow-up. All data were then separated into two different groups according to the management option: CM and MS. The data were analyzed using a Pearson χ (2) test and Fisher's exact test. This meta-analysis suggests that MS has a statistically significant favorable outcome regarding symptom relief compared to CM in patients with ILS suffering from tinnitus, vertigo and dizziness. Hearing level was not compared between treatment groups, as MS leads to anacusis. An indicative bias was the main limitation of this study, as patients suffering from intractable vertigo with moderate-to-severe hearing loss were referred to MS. Therefore, in the presence of a serviceable hearing, we suggest that CM should be the treatment of choice.

Human papillomavirus (HPV)-positive head and neck squamous cell carcinomas (HNSCC) have been shown to have a significantly better prognosis and response to current treatment modalities. Current guidelines recommend systematic HPV-DNA and/or p16 testing on HNSCCs, although treatment approach should not be directed by test results. The objectives of this study were to (1) assess whether HPV-DNA and/or p16 status are systematically evaluated across North American otolaryngologists-head and neck surgeons and (2) whether the status is used to direct treatment approach.A 15-question online survey was sent to three associations: the Association of Oto-rhino-laryngology-Head and Neck Surgery of Quebec, the Canadian Society of Otolaryngology-Head and Neck Surgery, and the American Head and Neck Society.Sixty-seven percent of respondents systematically test for HPV-DNA and/or p16 on HNSCC sites, while 58.3% report using test results to direct treatment for oropharyngeal cancers. A lack of official guidelines was the primary reason (81.8%) physicians did not use test results to direct treatment. Academic centre physicians (83.3%) and physicians with ⩾50% oncologic practice (87.6%) were more likely to test for HPV-DNA and/or p16 in HNSCC compared to non-academic centre physicians (39.7%) and physicians with50% oncologic practices (51.4%) (p0.001). Cost of the tests (69.2%), lack of relevance (46.1%) and time constraints (30.8%) were the primary reasons HPV-DNA and/or p16 were not tested.The majority of North American respondents in this survey systematically test for HPV-DNA and/or p16 in HNSCC sites, and most indicate that test results influence their treatment approach for oropharyngeal cancers.

Objectives:1) Evaluate systematic testing of human papillomavirus (HPV) and p16 status on head and neck cancer in North America. 2) Assess if HPV or p16 status is used to influence treatment in this population.Methods:An online survey was sent to three professional associations: the American Head & Neck Society, the Canadian Society of Otolaryngology, and the Quebec Association of Otolaryngology. Inclusion criteria were physicians practicing in North America. Incomplete surveys were disregarded. Chi-square analyses were conducted.Results:There was a response rate of 20% with a total of 216 complete responses. Most respondents were otolaryngologists (196; 90.7%), English-speaking (178; 82.4%), and practicing in an academic setting (138; 63.9%). Routine HPV or p16 testing was performed by 146 respondents for the oropharynx, 69 for oral cavity, and 44 for other subsites. Most physicians (113; 77.4%) test for both HPV and p16, while 58.3% indicated that HPV/p16 status influences their treatment approach for o...

The objective of this study is to describe the superior canal dehiscence syndrome (SCDS) and its vestibule-cochlear manifestations, while analyzing dehiscence size, audiogram and vestibular-evoked myogenic potential (VEMP) changes following dehiscence obliteration. We conducted a prospective study in a tertiary referral center. All Patients diagnosed and surgically treated for SCDS were operated through a middle fossa craniotomy (MFC). Clinical and radiological data were collected. The main outcome measures were Air-bone gaps, Pure-tone average (PTA), speech discrimination scores (SDS) and VEMP thresholds and were correlated to dehiscence size. 28 patients were included in this study with a mean dehiscence size of 4.68 mm. Phonophobia and imbalance were the most debilitating cochlear and vestibular symptoms, respectively. At 2 months postoperatively, low-frequency air-bone gaps showed a statistically significant improvement (p < 0.001). SDS and PTA did not show any statistically significant changes 2 months postoperatively (p = 0.282 and p = 0.295, respectively). VEMP threshold differences between operated and contralateral ears were statistically significant preoperatively (p < 0.001) and non-significant 2 months postoperatively (p = 0.173). Dehiscence size only showed a statistically significant correlation with preoperative total cochlear symptoms, while remaining insignificant with all other variables measured. Air-bone gaps, VEMP and computerized tomography remain essential tools in diagnosing and following SCDS. Dehiscence size is an independent factor in the analysis of SCDS, with cochlear symptomatology being associated to dehiscence sizes. Finally, it is shown that overall symptomatology, audiometric results and VEMP thresholds return to normal values post-obliteration, confirming the continuing success of the MFC approach for SCDS obliteration.

Objective: 1) To retrospectively assess the usefulness of preoperative thyroglobulin (Tg) levels in predicting sentinel lymph node (SLN) biopsy (SLNB) status. 2) To evaluate the correlation between preoperative Tg levels and the overall number of positive SLNs. 3) To compare primary tumor (T) classification in patients according to SLNB outcome.Method: Data from patients operated for well-differentiated thyroid carcinoma (WDTC) at the McGill University Thyroid Cancer Center were collected from January 2007 to January 2012. Statistical analyses were performed using a Mann-Whitney-Wilcoxon test, a Pearson correlation coefficient and a Pearson χ2 test.Results: Preoperative Tg levels and SLNB results were available in 74 patients (51 negative and 23 positive SLNBs). Mean preoperative Tg levels for negative and positive SLNB groups were 105.2 and 85.9 ng/mL, respectively, yielding no statistically significant difference (P = .143). Moreover, no statistically significant correlation was found between Tg levels ...

To compare the long-term outcome of hearing and tumor control of small vestibular schwannomas treated with conservative management or radiation therapy.A thorough search for English-language publications and "in-process" articles dating from 1948 to January 2011 was performed using Ovid MEDLINE.The principal criteria were patients with no microsurgical intervention before their treatment, a follow-up of at least 5 years, and a useful hearing level at diagnosis.Fourteen studies met our criteria. Hearing preservation outcome (worse, unchanged, and better) and tumor size outcome (growth, unchanged, and regression) data were collected from the articles, as well as all other significant observations. No studies using fractionated stereotactic radiotherapy met our criteria. Stereotactic radiation was the only radiation therapy analyzed.The data were analyzed using the Pearson χ2 test.Current data on conservative management and stereotactic radiation do not provide enough evidence to make a clear conclusion on the outcome of useful hearing preservation in a long-term manner. In this study, however, stereotactic radiation is shown to have better tumor control rates than conservative management. Additional studies reporting long-term follow-ups of patients are required so as to provide the medical field with a better understanding of vestibular schwannoma treatment therapies.

From the link between the works of Freud, Ferenczi and Groddeck, this study attempts to show that psychoanalysis, since their first developments, provides evidence for the formulation of a psychoanalytic psychosomatic. In the first chapter, when we approach psychoanalytic concepts that are in the intersection between the psychic and somatic, we present evidences suggesting that somatic changes that affect somatic functions and/or structures are produced when, under impact of a traumatic situation, added by the insufficiency of the specific action, the discharge of the affection occurs of a totally unconscious way, running a cumulative excitement that found no other way of expression. This means of discharge, which is based upon the acting, not on the word, can come up from phylogenesis after the failure of the ontogenesis to equip the individual with more consistent reactions to him face limit-situations of reality. Prevented from acting against the object, the natural aggressiveness -inherent to the instincts of preservation of the species- acts in the way to disrupt the psychic functioning or, if it is sufficiently protected by the cleavage of the ego, disorganizing the somatic structures. On that regression beyond the psychic limits, selfdestructiveness, remnant of the original masochism, expressed a force even more basic in the formation of living being, as sought to show in the second chapter. Identified by Freud at both the psychological level as in the somatic level, the death drive extends the roots of unconscious to the biological level, considering the existence of an undifferentiated region between soma and psyche, where the variations of a level impact on the other. This hypothesis is supported: (1) by Ferenczi, who introduced changes in analytical technique with the aim of promoting a regression able to access content from traumatic experiences, and reached archaic and undifferentiated contents, that remains detained in the body as a memory without words, at the margin of language and the further development of the ego, producing psychical and somatic suffering, (2) by the location of the It at the psychic apparatus, connected directly with the somatic forces. By tracing the origin of It until the thought of Groddeck, in the third chapter, we find an unconscious-It that precedes the psychosomatic existence. For Groddeck, the lack of symbolic significance of organic diseases are due to the split between soma and psyche inherent at the explanatory model, for which the disease and the sickness organs are not seen as symbols that can be decoded and resized from the symbolic nature of unconscious. Finally, we show that, in despite the work of Freud provides explanations for the psychosomatic phenomenon in a psychoanalytic perspective it is Groddeck and Ferenczi that provide the clinical features that allow rescuing the psychosomatic phenomenon to become synonymous with lack of symbolization. Despite Freud have remained away of this issue and skeptical about the resolution of the psychosomatic disease through analysis, some of his assertions in his last years show that the creator of metapsychology not remained totally unrelated to that possibility. A partir da articulação entre as obras de Freud, Ferenczi e Groddeck, este trabalho procura mostrar que, desde os seus primeiros desenvolvimentos, a psicanálise oferece elementos para a formulação de uma psicossomática psicanalítica. No primeiro capítulo, ao abordarmos conceitos psicanalíticos que se constituíram na intersecção entre o psíquico e o somático, apresentamos elementos que permitem supor que as alterações somáticas que atingem funções e/ou estruturas do corpo são produzidas quando, sob impacto de uma situação traumática, somado à insuficiência da ação específica, o afeto se descarregar de modo totalmente inconsciente, veiculando uma excitação acumulada que não encontrou outra possibilidade de expressão. Tal via de descarga, que tem como base o ato, e não a palavra pode ser evocada a partir da filogênese quando a ontogênese falha em equipar o indivíduo com reações mais condizentes ao enfrentamento de situações-limite da realidade. Impedida de se atualizar contra o objeto, a agressividade natural, inerente aos instintos de conservação da espécie, atua no sentido de desorganizar o funcionamento psíquico, ou, se este estiver suficientemente protegido pela clivagem do ego, desestruturar o funcionamento somático. Nessa marcha regressiva para além dos limites psíquicos, a auto-destrutividade, resquício do masoquismo original, expressa uma força ainda mais fundamental na constituição do vivo, como procuramos mostrar no segundo capítulo. Identificada por Freud tanto no nível psíquico como no nível somático, a pulsão de morte estende as raízes do inconsciente ao registro biológico, e permite considerar a existência de uma região indiferenciada entre soma e psique, onde as variações de um registro repercutem sobre o outro. Essa hipótese é corroborada: (1) por Ferenczi, que ao empreender modificações na técnica analítica com o objetivo de promover uma regressão capaz de acessar conteúdos derivados de experiências traumáticas, acessa conteúdos arcaicos e indiferenciados, que se mantêm imobilizados no corpo como lembranças sem palavras, à margem da linguagem e do desenvolvimento posterior do ego, produzindo sofrimentos somato-psíquicos; (2) pela localização do Isso no extremo do aparelho, em conexão direta com as forças somáticas. Ao rastrearmos a origem do Isso até o pensamento de Groddeck, no terceiro capítulo, encontramos um Isso-inconsciente precedendo toda a existência psicossomática. Para Groddeck, a falta de significação simbólica das doenças orgânicas deve-se à cisão entre soma e psique inerente ao próprio modelo explicativo, para o qual a doença e os órgãos doentes não são vistos como símbolos que podem ser decodificados e redimensionados a partir da natureza simbólica do próprio inconsciente. Para finalizar, procuramos mostrar que, apesar da obra de Freud fornecer elementos para a explicação do fenômeno psicossomático na perspectiva psicanalítica, é Groddeck e Ferenczi que fornecem os elementos clínico-conceituais que permitem resgatar o fenômeno psicossomático de se tornar sinônimo de ausência de simbolização. Apesar de Freud ter se mantido afastado dessa temática, e cético em relação à resolução da doença somática pela via analítica, algumas de suas afirmações em seus últimos anos indicam que o criador da metapsicologia não se manteve totalmente alheio a essa possibilidade.

But de la presentation Comparer l’evolution clinique entre le traitement conservateuret la resection chirurgicale chez les patients atteints d’un schwannome intralabyrinthique (SIL). Materiel et methodes Une revue systematique des articles publies entre 1948 et fevrier 2014 a ete effectuee a l’aide de la base de donnees Ovid Medline. La symptomatologie initiale, le type de traitement et les issues cliniques sur l’audition, l’acouphene, les vertiges et les etourdissements ont ete recueillis. Deux groupes ont ete formes : traitement conservateur (TC) et microchirurgie (MC). La relation entre le type d’intervention et les issues cliniques a ete analysee avec le test de Fisher. Resultats Trente et un articles ont rencontre les criteres de selection, comptabilisant 66 patients. Le groupe TC est compose de 44 patients et le groupe MC comprend 22 patients. Une difference statistiquement significative favorisant la MC a ete demontree concernant l’acouphene ( p p p = 0,001). L’audition n’a pas ete comparee, car la MC induit une anacousie. Conclusion Dans un contexte ou l’incidence des SIL est limitee, les etudes descriptives rapportees ne permettent pas la comparaison entre le TC et la MC. Cette meta-analyse suggere un avantage clinique de la MC par rapport au TC, concernant l’amelioration de l’acouphene, des vertiges et des etourdissements. Toufefois, le biais d’indication est une des principales limitations, car la chirurgie est generalement indiquee lorsque la severite des symptomes est plus importante. Des etudes observationnelles ayant des suivis a plus long terme pourront etablir davantage de liens entre le traitement et les issues cliniques.