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Balance disorders presenting with symptoms of dizziness and vertigo are due to various diseases. Clinical approach gives the opportunity to identify emergency situations and most common causes, among them the first one being the benign paroxysmal positional vertigo. Oculomotor assessment is pertinent as major clinical orientation, particularly between peripheral and central diseases. These clinical findings support the respective indication of modern imaging and/or vestibular tests, focused on the direction of presupposed diagnosis. On elderly the risk of falls and their complications needs a specific evaluation.

La malattia di Meniere e una patologia specifica dell’orecchio interno, la cui diagnosi si basa sulla presenza di sintomi clinici cocleovestibolari identificati da Meniere nella sua descrizione originale. Questi sintomi si evolvono in crisi, piu o meno intense e piu o meno frequenti. I meccanismi fisiopatologici sono ancora discussi, ma e piu probabile il ruolo delle variazioni di pressione dei fluidi labirintici, che definiscono l’idrope endolinfatica. La diversita dei sintomi da un paziente all’altro e per uno stesso paziente e la loro evoluzione nel tempo giustificano la disposizione di precisi criteri diagnostici. Questi ultimi sono stati formalizzati, in particolare sotto forma di raccomandazioni delle varie societa scientifiche internazionali, tra cui la Societa francese di oto-rino-laringoiatria. Gli esami paraclinici hanno una duplice utilita. La prima e quella di quantificare l’impatto delle crisi sulle funzioni uditive e vestibolari, cosa che orienta le scelte terapeutiche. La seconda e, attraverso dei test specifici e un imaging specializzato, di identificare i cambiamenti caratteristici dell’idrope: test elettrofisiologici e, soprattutto, diagnostica attraverso risonanza magnetica. La strategia terapeutica e adattata al singolo caso, in base all’impatto individuale dei sintomi e alla loro evoluzione. Inizialmente basato su misure dietetiche e farmaci, il trattamento puo, talvolta, utilizzare delle modalita chirurgiche conservative o radicali: chirurgia del sacco endolinfatico, labirintectomia chimica o neurotomia vestibolare. Le indicazioni sono condizionate dalla storia naturale della malattia, che evolve verso un arresto delle crisi vertiginose, in un momento in cui l’udito si stabilizza a un livello relativamente basso, dopo alcuni periodi di fluttuazioni.

La enfermedad de Meniere es una afeccion especifica del oido interno cuyo diagnostico se basa en la presencia de los sintomas clinicos cocleovestibulares identificados por Meniere en su descripcion original. Estos sintomas evolucionan por episodios, mas o menos intensos y mas o menos frecuentes. Los mecanismos fisiopatologicos son motivo de debate, pero el papel de las variaciones de presion de los liquidos laberinticos, que define el sindrome de Meniere endolinfatico, es el mas probable. La diversidad de los sintomas de un paciente a otro y en un mismo paciente, asi como su evolucion en el tiempo justifica que se disponga de criterios diagnosticos precisos. Estos ultimos se han formalizado, en particular en forma de recomendaciones de distintas sociedades cientificas internacionales, como la Societe Francaise d⬢Oto-rhino-laryngologie. Las pruebas complementarias tienen una doble utilidad. La primera es cuantificar el impacto de los episodios agudos sobre las funciones auditiva y vestibular, lo que orienta las elecciones terapeuticas. La segunda es, mediante pruebas especificas y con pruebas de imagen especializadas, identificar las modificaciones caracteristicas del sindrome de Meniere: pruebas electrofisiologicas y resonancia magnetica, en particular. La estrategia terapeutica se adapta caso por caso, dependiendo del impacto individual de los sintomas y de su progresion. El tratamiento, que se basa inicialmente en medidas dieteticas y farmacos, puede consistir en ocasiones en modalidades quirurgicas conservadoras o radicales: cirugia del saco endolinfatico, laberintectomia quimica o neurotomia vestibular. Las indicaciones dependen de la historia natural de la enfermedad, que evoluciona hacia una desaparicion de los episodios de vertigo, en un momento en el que la audicion se estabiliza en un nivel relativamente bajo, despues de periodos de fluctuacion.

Balance disorders presenting with symptoms of dizziness and vertigo are due to various diseases. Clinical approach gives the opportunity to identify emergency situations and most common causes, among them the first one being the benign paroxysmal positional vertigo. Oculomotor assessment is pertinent as major clinical orientation, particularly between peripheral and central diseases. These clinical findings support the respective indication of modern imaging and/or vestibular tests, focused on the direction of presupposed diagnosis. On elderly the risk of falls and their complications needs a specific evaluation.

El implante auditivo del tronco del encefalo es una modalidad de rehabilitacion de la audicion cuyas indicaciones son escasas. Se trata de situaciones en las que el implante coclear es imposible o ineficaz: presencia de tumores de las vias auditivas, osificaciones cocleares y malformaciones de la coclea y del nervio auditivo. La principal es la neurofibromatosis tipo 2. Las indicaciones se establecen despues de llevar a cabo una evaluacion pluridisciplinaria y la colocacion del portaelectrodos (cuya configuracion se adapta a la anatomia del tronco del encefalo) se efectua durante una intervencion por un equipo otoneuroquirurgico. Los resultados obtenidos desde el punto de vista funcional son variables y, en el mejor de los casos, pueden alcanzar los que se logran con un implante coclear.

L’impianto uditivo del tronco cerebrale e una modalita di riabilitazione dell’udito le cui indicazioni sono rare. Si tratta delle situazioni dove l’impianto cocleare e impossibile o inefficace: presenza di tumori delle vie uditive, ossificazioni cocleari e malformazioni della coclea e del nervo uditivo. La principale e la neurofibromatosi di tipo 2. Le indicazioni sono poste dopo una valutazione pluridisciplinare e il posizionamento del portaelettrodi, la cui configurazione e adattata all’anatomia del tronco cerebrale, e eseguito durante un intervento da parte di un’equipe oto-neuro-chirurgica. I risultati ottenuti dal punto di vista funzionale sono variabili e possono raggiungere, nei casi migliori, quelli ottenuti con un impianto cocleare.

L’otorinolaringoiatra (ORL) dispone oggi, con la TC e con la risonanza magnetica (RM), di strumenti molto efficaci per lo studio dell’orecchio medio. Questo articolo presenta le rispettive indicazioni della TC e della RM nelle patologie dell’orecchio medio. La TC e molto spesso l’esame di prima intenzione. L’anatomia radiologica dell’orecchio medio alla TC e il trattamento delle immagini con le ricostruzioni 3D per lo studio della catena degli ossicini sono presentati in modo sintetico. Questo articolo analizza anche in dettaglio, per lo specialista ORL, il vantaggio delle differenti sequenze utilizzate in RM nell’esplorazione dell’orecchio medio. La scintigrafia e la RM hanno un ruolo complementare nella caratterizzazione e nella valutazione dell’estensione delle lesioni dell’orecchio medio. In questo articolo e sviluppato il controllo dopo il trattamento chirurgico delle otiti croniche e, piu in particolare, delle forme colesteatomatose. Nell’otosclerosi la TC e utile per la valutazione iniziale e per la diagnosi delle complicanze postoperatorie. Il ruolo della TC nell’esplorazione dei traumi del temporale e della RM nella valutazione delle brecce del tegmen e importante. Le lesioni vascolari e le varianti anatomiche vascolari presentano un rischio chirurgico e devono essere individuate alla TC e in angio-RM.

La finalidad de este articulo consiste en describir los aspectos esenciales de las tecnicas quirurgicas referentes a las protesis auditivas implantables que estan disponibles en la actualidad. Cuando se ha considerado util recordar la anatomia quirurgica, se ha hecho hincapie en los puntos fundamentales. Se revisaran los implantes cocleares, los implantes auditivos del tronco del encefalo, las protesis auditivas osteointegradas y, por ultimo, los implantes de oido medio. Se detallaran las indicaciones, los principios de funcionamiento y los resultados. Se ha previsto un apartado especial para algunas indicaciones especiales que pueden requerirse una modificacion de la tecnica estandar. Asimismo, se describen las complicaciones, que, por desgracia, son una parte integrante de las tecnicas quirurgicas.

Questo articolo ha lo scopo di descrivere l’essenziale delle tecniche chirurgiche riguardo agli ausili uditivi impiantabili attualmente disponibili. Quando e stato giudicato utile richiamare l’anatomia chirurgica, l’accento e stato posto sui punti essenziali. Saranno passati in rassegna gli impianti cocleari, gli impianti uditivi del tronco cerebrale, gli ausili uditivi ad ancoraggio osseo e, infine, gli impianti dell’orecchio medio. Sono ricordati le indicazioni, i principi di funzionamento e i risultati. Sono affrontate le varianti chirurgiche. E stato previsto uno sviluppo per le indicazioni particolari quando puo derivarne una modificazione della tecnica standard. Analogamente sono trattate le complicanze, parte purtroppo integrale delle tecniche chirurgiche.

Resume Les chutes du sujet âge sont sources de complications parfois graves. Le depistage en consultation est fonde sur l’interrogatoire et un certain nombre de tests. Dans certains cas, ceux-ci conduisent a realiser des explorations plus ciblees du point de vue cardiovasculaire, neurologique, ophtalmologique ou ORL. Grâce aux techniques de posturographie statique et dynamique, il est possible d’analyser plus precisement le risque de chute et d’orienter les mesures therapeutiques.

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El otorrinolaringologo (ORL) dispone en la actualidad, gracias a la tomografia computarizada (TC) y a la resonancia magnetica (RM), de unas herramientas que ofrecen un gran rendimiento para el estudio del oido medio. En este articulo se presentan las indicaciones respectivas de la TC y de la RM en las enfermedades del oido medio. La TC suele ser la prueba de primera eleccion. La anatomia radiologica del oido medio en la TC y el tratamiento de las imagenes con las reconstrucciones 3D volumetricas para el estudio de la cadena osicular se presentaran de forma resumida. De igual manera, en el articulo se detalla la utilidad para el ORL de las distintas secuencias utilizadas en RM para la exploracion del oido medio. La TC y la RM tienen un papel complementario en la caracterizacion y el estudio de extension de las lesiones del oido medio. Tambien se describe la vigilancia tras el tratamiento quirurgico de las otitis cronica y, en especial, de las formas colesteatomatosas. Cuando se trata de la otospongiosis, la TC es util para el estudio inicial y el diagnostico de las complicaciones postoperatorias. El papel de la TC en la exploracion de los traumatismos del hueso temporal y el de la RM en la exploracion de las dehiscencias del tegmen es considerable. Las lesiones vasculares y las variantes anatomicas vasculares presentan un riesgo quirurgico, por lo que deben detectarse en la TC y la angio-RM.

Resume Introduction La neurofibromatose de type 2 (NF2) est une maladie genetique, a transmission autosomique dominante caracterisee par la presence de schwannomes vestibulaires bilateraux. Etat des connaissances Les autres manifestations de la NF2 incluent des meningiomes, des schwannomes, des ependymomes, localises en intracrânien ou intrarachidien, ainsi que des lesions cutanees et ophtalmologiques. En l’absence de schwannome vestibulaire bilateral, un ensemble de criteres permet neanmoins de diagnostiquer la NF2. L’expression phenotypique de la maladie est variable. Les principaux facteurs de mauvais pronostique sont un âge precoce a l’apparition des premiers symptomes et un nombre eleve de tumeurs au diagnostic. Le produit du gene NF2 , Merlin/Schwannomin est aussi implique dans le developpement de la majorite des schwannomes et meningiomes sporadiques. Perspectives et conclusion La prise en charge des patients NF2 necessite une equipe oto-neurochirurgicale experimentee, dans le cadre de « cliniques NF2 ». Une surveillance clinique et paraclinique annuelle prolongee est souhaitable. Un protocole de depistage familial est propose. Classiquement, seules les tumeurs symptomatiques sont traitees. Certains proposent une attitude active precoce sur les schwannomes vestibulaires afin de preserver l’audition. Lorsqu’un traitement est indique, la chirurgie est le traitement de reference des tumeurs. L’implant auditif du tronc cerebral a une place de choix dans la rehabilitation de l’audition des patients NF2.

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Resume La toux accompagne frequemment les pathologies naso-sinusiennes qu’elles soient isolees ou qu’elles atteignent simultanement les voies respiratoires hautes et basses. La toux s’observe egalement au cours des tumeurs pharyngo-laryngees, des laryngites chroniques et des troubles du carrefour aero-digestif ou elle est frequemment associee a une dysphagie, une dysphonie, une dyspnee ou une odynophagie.

We report the MRI findings of six unusual lesions of the internal auditory canal: three haemangiomas, one lipoma, one metastasis and one traumatic neuroma. We compare the findings to those of 20 intracanalicular schwannomas. We noted the site and size of the tumour, its signal intensity, borders and the homogeneity of enhancement were studied on T1-weighted images before and after intravenous contrast medium and T2-weighted images. Most schwannomas were homogeneous lesions, isointense on T1- and T2-weighted images, and strongly enhancing. Spontaneous high signal on T1-weighted images, heterogeneous contrast enhancement and extranodular enhancement were helpful for recognising lesions other then schwannomas; site, size and signal on T2-weighted images were not. All the haemangiomas had a specific pattern of contrast enhancement, with an anterior core intensely enhancing portion and a posterior portion which enhanced moderately or not at all.

The cause of sudden sensorineural hearing loss (SHL) remains unknown, even though studies have evidenced two main hypotheses: a latent virus infection due to herpesvirus and a local decrease in cochlear blood flow caused by vasospasm and/or hyperviscosity. Clinical evaluation and diagnostic tests should always be performed, to rule out an acoustic neuroma, revealed in 5–26% of cases by a sudden deafness. The two main major prognostic factors are the severity of hearing loss and the time from onset to treatment, suggesting that two groups of patients are susceptible to benefit from therapy: patients with a hearing loss of less than 40 dB, managed within 2 months from the onset, and patients with a hearing loss of more than 40 dB, treated within 1 month after the onset of deafness. Steroids appear to be the only treatment available with a significant beneficial effect on SHL.

To present three pediatric cases of auditory brainstem implantation (ABI) and review literature data concerning this topic.The first two children had a neurofibromatosis type II with bilateral sensorineural deafness; in both cases, the implant was inserted during the surgical removal of a vestibular schwannoma; the third patient had profound deafness due to bilateral cochlear nerve insufficiency associated with inner ear malformation.Two postoperative complications were observed: patient 1 had a persistent fever which required the replacement of the fat graft used to seal the translabyrinthine approach; patient 3 had a CSF leakage requiring additional surgery and lumbar external drainage. In our three patients, the numbers of active electrodes were 6/22 (Cochlear ABI 24M ABI), 11/12 (Medel Opus II ABI) and 11/12 (implant Medel), respectively. Due to additional major surgical procedures and to disappointing functional results of the ABI, patient 1 stopped wearing her implant 18 months after implantation. Nine months after surgery, patient 2 achieved open-set speech recognition and was very satisfied with the implant. Six months after implantation, patient 3 (cochlear nerve deficiency), who was 3.5 years-old at the time, clearly reacted to some environmental sounds but was not yet able to achieve speech recognition.ABI has now entered the list of treatments that can be proposed in pediatric profound sensorineural deafness. Its major risks of complications are CSF leakage and non-auditory side effects. Its outcomes are worse and less predictable than cochlear implants. Thus, its indications must remain restricted to cases meeting the following conditions: absence of alternative option to restore hearing, patients and parents high level of motivation and realistic expectations.

Cochlear implant in adults is a procedure, dedicated to rehabilitate severe to profound hearing loss. Because of technological progresses and their applications for signal strategies, new devices can improve hearing, even in noise conditions. Binaural stimulation, cochlear implant and hearing aid or bilateral cochlear implants are the best opportunities to access to better level of comprehension in all conditions and space localisation. By now minimally invasive surgery is possible to preserve residual hearing and use a double stimulation modality for the same ear: electrical for high frequencies and acoustic for low frequencies. In several conditions, cochlear implant is not possible due to cochlear nerve tumour or major malformations of the inner ear. In these cases, a brainstem implantation can be considered. Clinical data demonstrate that improvement in daily communication, for both cochlear and brainstem implants, is correlated with cerebral activation of auditory cortex.

Neurofibromatosis 2 (NF2) is a rare autosomal dominant disease whose hallmark is the development of bilateral vestibular schwannomas.Other features of NF2 include schwannomas, meningiomas, ependymomas, localized along the central nervous system, schwannomas of the peripheral nerves, cutaneous and ophthalmological manifestations. NF2 can be diagnosed in patients without bilateral vestibular schwannoma with sets of diagnostic criteria. Disease phenotype is variable among patients. Main negative prognostic factors are a young age at onset of symptoms and a high number of tumors at diagnosis. NF2 tumor suppressor gene encodes Merlin/Schwannomin, and is also involved in most sporadic schwannomas and meningiomas. Its functions remains largely unknown.Treatment and follow of NF2 patients up require oto-neurosurgical teams experienced in NF2. Yearly and life time surveillance is mandatory. A clinical screening protocol is suggested. Classically, only symptomatic lesions are to be treated. Some authors advocate an early proactive strategy against vestibular schwannoma in order to preserve hearing. When a treatment is advisable, surgery remains the treatment of choice for tumors. Auditory brainstem implant must be taken into account in hearing rehabilitation.

To expose the results obtained at short and middle terms and the tolerance of over pressure treatment with Meniett in Menière disease.A pressure treatment using Meniett device was initiated for 53 patients suffering of unilateral or bilateral active Menière's disease, despite medical treatment and physiotherapy.Retrospective analysis of the data demonstrate i) no complications due to the tympanostomy tube, ii) with a 4 months follow up after the treatment, a total control or reduction of vertigo in respectively 65% and 24.5% of the initially treated patients.The overpressure treatment with Meniett has been well tolerated. It can be repeated in case of recurrence of the symptoms. It is an interesting alternative for the treatment of Menière disease.

To evaluate results of cochlear implantation in patients with far-advanced otosclerosis.Sixteen patients with far-advanced otosclerosis had undergone unilateral (n = 13) or bilateral (n = 3) cochlear implantation. Surgical difficulties, incidence of complications and postoperative benefit were analyzed.A full electrode insertion was achieved in all patients without surgical difficulties. All patients demonstrated excellent benefit of cochlear implantation. Binaural implantation still improves speech performances, compared to unilateral implantation. In case of residual cochlear function of one nonoperated side, a stapes surgery, performed during the same surgical time as cochlear implantation, can improve speech scores and restore bilateral hearing. Facial nerve stimulation occurred only in 1 patient.Cochlear implantation is the method of choice for rehabilitation of patients with otosclerosis, presenting profound or total hearing loss. Patients obtain excellent benefit with a low rate of complications.

To summarize the indications and evaluate the Auditory Brainstem Implant (ABI) performances in neurofibromatosis type 2 (NF2) and other otologics indications, as postmeningitis ossified cochlea.Main and first indication of ABI is NF2. Emergent indications are bilateral total ossified cochlea, vestibular schwannoma with controlateral lesions, cochlear nerve aplasia or inner ear's malformations. The pre-operative evaluation includes clinical, radiological, lipreading, and psychological status. A translabyrinthine or retrosigmoid approach is performed, depending on tumoral or not tumoral status. The auditory perception with the ABI is evaluated by testing, the words recognition in open-set lists, and the speech understanding with usual sentences.In NF2 patients, best results are obtained in cases of smaller vestibular schwannoma and none, or short term, auditory deprivation. Negative prognostic factors are duration of total hearing loss (10 years), tumor size (30 mm), difficulties in electrode array placement, complications during post-operative course and number of active electrodes (10). In cases of postmeningitis total deafness with totally ossified cochlea, results demonstrate a good benefit reaching these obtained with cochlear implant in post-meningitis deafness.These results show a clear benefit of ABI in NF2 patients, with or without previous tumor removal, in case of small tumor with a short duration of hearing loss. In case of postmeningitis ossified cochlea, results potentially reach those of cochlear implants.

Vertigo and dizziness are the most common complications of cochlear implantation. Data of a multicentric study about clinical aspects and cost utility were collected for vertigo and dizziness: incidence, clinical and treatment were analyzed among 469 adults and children. Results demonstrated that 16% of adults and 3% of children experienced dizziness postoperatively. In a few cases a specific mechanism as perilymphatic fistula was identified. In other cases the mechanism underlying delayed vertigo remains speculative and endolymphatic hydrops was suggested.

Skull base osteomyelitis is an uncommon but severe condition generally secondary to necrotizing otitis externa. The aim of this study was to determine the patients demographics, clinical and radiological findings, and outcomes of this condition.We prospectively follow 5 patients with a diagnosis of skull base osteomyelitis between 2004 and 2005. Clinical, biologic and imaging data were collected, and also follow-up during treatment.The five patients were men and the average age at presentation was 75 years (63-89). All except one had a previous diabetes mellitus, with a more or less recent clinical story of otitis externa. All of them suffered of headaches and cranial nerve(s) deficits, particularly facial nerve. Diagnosis was made on MRI with gadolinium injection and fat saturation, and Pseudomonas aeruginosa identified as pathogen in all cases. One patient deceased of cranial nerves palsy complication. In 4 cases we found previously a too short or non adapted treatment of necrotizing otitis externa.In the setting of headache, cranial nerves deficit and abnormal skull base imaging on MRI with Fat sat, osteomyelitis should be consider as the likely diagnosis. This complication should be avoided by optimal management of necrotizing otitis externa.

* orthophonistes, centre referent implant cochleaire adulte d'Ile de France et surdite genetique de l'adulte du Pr O.Sterkers, groupe hospitalier Pitie-Salpetriere bâtiment Paul Castaigne 50-52 bd Vincent Auriol 75013 Paris ** orthophoniste, Dr en neurosciences, service ORL du Pr G. Lamas, groupe hospitalier PitieSalpetriere 50-52 bd Vincent Auriol 75013 Paris ***Docteur, Unite d’Otologie, Implants Auditifs et Chirurgie de la Base du Crâne, Hopital PitieSalpetriere, AP-HP, Paris. **** Professeur, Unite d’Otologie, Implants Auditifs et Chirurgie de la Base du Crâne, Hopital PitieSalpetriere, AP-HP, Paris.

To evaluate the benefit of cochlear implantation in older adults aged 60 Years and over.Fifty-six profoundly or totally hearing-impaired patients, aged 60 Years and over, were studied retrospectively. At the end of the preoperative evaluation, 28 patients received a cochlear implant. The mean age was 66 Years and the median follow-up was 22.5 Months. Speech perception scores before and after implantation were analyzed in order to evaluate the benefit of cochlear implantation. The speech perception score before implantation was compared to that of the non-implanted patients.There was a significant improvement of the dissyllabic words and sentences scores after implantation. The patients who are over 70 Years performed as well as those who are younger (between 60 and 70 Years). One patient developed a postoperative vertigo due a perilymphatic fistula. There was no flap-related problems. In the non-implanted group (mean age: 68 Years), 18 patients declined the cochlear device because they thought the subjective benefit of their hearing aid was sufficient and 5 patients declined because of surgical risk. The mean age, the cause and the duration of the deafness, and the speech perception scores were similar between implanted and non-implanted patients.This study demonstrates the beneficial effect of cochlear implantation in the elderly. These results suggest that a similar benefit could have been obtained in the patients who declined surgery. An early implantation could reduce the duration of the deafness and preserve binaural sound perception allowing increased performance in older people.

Two cases of progressive bilateral hearing loss associated with superficial hemosiderosis of the central nervous system are reported. This is a rare disease caused by repetitive hemorrhage in subarachnoid spaces with hemosiderin deposits on the brain surface and cranial nerves. MRI provided the etiologic diagnosis in both cases based on typical low-density signals from the brain, the brainstem, and the cerebellar surfaces on T1 and T2 sequences. In one case a fourth ventricle ependymoma, which was the probable cause of hemosiderosis, was also discovered. Based on a literature review, we discuss the pathophysiological hypotheses, the modalities for treating hearing loss including cochlear implantation despite retrocochlear sensorineural hearing loss.

To investigate the surgical techniques and speech performance of multichannel auditory brainstem implant (ABI) in patients with bilateral acoustic neuromas (neurofibromatosis type 2).The nucleus 21 channel auditory brainstem implant was implanted into the lateral recess of the fourth ventricle through the translabyrinthine approach in 7 patients after removal of the tumor. The accurate placement of electrode array was ensured by the electromyogram monitoring of the 7th and 9th nerves and the electrically evoked auditory brainstem responses (EABR). Initial switch-on occurred six weeks postoperatively. Speech evaluation was performed every 3 months for the first year and annually thereafter.During the surgery, the lateral recess could be found and the typical EABR could be recorded in 6 cases. They later reported a significant benefit from the device. Two of the cases have achieved functional open-set speech understanding. In contrast, one patient with no EABR because of difficulty of the anatomic location during the surgery had no sensations postoperatively.The multichannel ABI could effectively restore auditory sensations in patients deafened by bilateral acoustic neuromas. The accurate location of the cochlear nucleus complex during surgery was the key factor for the success of the operation.

Otogenic pneumocephalus is uncommon. Typical causes include trauma, tumor, infection, and nasosinusal or mastoid surgery but spontaneous otogenic pneumocephalus is very exceptional. We report a case of spontaneous otogenic pneumocephalus located in the left temporal lobe revealed by sudden onset aphasia. The temporal pneumatocele was cured through an epidural subtemporal approach with needle puncture of the aeroma and duroplasty. Two years after surgery, no recurrence was observed and the patient remained symptom free.

The principal objectives of acoustic neuroma surgery in the order of priority are absence of mortality and neurological morbidity, total removal of the lesion, preservation of facial function, and preservation of hearing. The aim of this work was to evaluate the selection criteria and the therapeutic strategy for hearing preservation in acoustic neuroma management. This retrospective study included 436 consecutive patients referred to our department for an acoustic neuroma. The population comprised 365 patients (84%) treated surgically, 66 patients (15%) managed conservatively, and 5 irradiated patients (1%). The mean age was 54 years (range: 13-87). The mean follow-up period was 24 months (range: 1-120). The surgical approaches were translabyrinthine in 294 (81%), retrosigmoid in 37 (10%), and through the middle fossa in 34 cases (9%). Approaches preserving the labyrinth were employed in patients aged less than 60 years with lesions measuringor=2 cm and a serviceable hearing (pure tone average50 dB and speech discrimination scoreor=50%). A serviceable hearing was preserved in 53% of the cases with a serviceable hearing in 44% of the cases. Postoperative normal or subnormal facial function was obtained in 72 to 98% of cases depending on tumor size. Two cases (0.5%) of recurrence were reported. In conclusion, our surgical strategy based on age, tumor size and pre-operative hearing function permitted hearing preservation in 50% of selected cases, a high rate of facial function preservation and a low risk of recurrence.