Objective: The objective of the study was to define timing of surgical treatment in management of massive hemoptysis. Methods: We performed a retrospective review of all patients admitted for massive hemoptysis in the intensive care unit of our thoracic surgery department. Treatment was managed according to the patient's status, the etiology of bleeding, the findings of bronchoscopy and computed tomographic scan. Therapeutic measures available were medical treatment, tracheal intubation (single or double lumen tube), interventional endoscopy, arterial embolisation and surgical treatment. Results: Between September 1996 and December 2001, 43 patients were treated (nine females and 34 males with mean age of 54 years, range from 32 to 79). The mean red cell blood transfusion per patient was 1.57 Units. The patients were classified into three groups: Group 1, 11 patients were operated on immediately close to the bleeding crise (five pneumonectomy and six lobectomy); Group 2, five patients for whom operation was delayed from the 7th to the 22nd day after cessation of bleeding (five lobectomy); Group 3, 27 patients were treated by non-surgical methods (medical treatment, endobronchial treatment, percutaneous embolisation). Fifteen patients underwent an arterial embolization, which was complete in 13 cases. Among the five patients of group 2, cessation of bleeding was obtained by bronchial embolisation in four cases. Considering the whole series, 10 (23%) patients died: three (19%) patients in group 1, zero in group 2, seven (26%) in group 3. In two patients who were suffering from tumor necrosis, hemoptysis relapsed leading to death. Conclusion: Emergency thoracotomy for massive hemoptysis is at high risk. In case of bleeding from the arterial bronchial vessels, embolization may enable to postpone surgery and operate secondarily. In case of bleeding from the pulmonary vessels (tumor necrosis), surgical treatment must be immediate. An algorithm for management is proposed. (C) 2002 Elsevier Science B.V. All rights reserved.

Cysts and bursae of the nasopharynx are uncommon and seldom symptomatic when compared with malignant tumors of this region. However, it is noteworthy that in the presence of symptoms, a good knowledge of their radiological appearance is useful to establish the correct diagnosis. Cysts of Rathke's pouch, pharyngeal bursa of Luschka, Tornwaldt's cysts, retentional cysts of the seromucinous glands, oncocytic cysts, intra-adenoid cysts, branchial cysts, prevertebral or retropharyngeal abscess and pseudocysts of the nasopharynx will be discussed in this paper.

Les kystes ou les bourses du nasopharynx (kyste de la poche de Rathke, bourse pharyngienne de Luschka, kyste de Tornwaldt, kystes rétentionnels oncocytiques ou des glandes séromucineuses, kyste intra-adénoïde, kyste branchial, abcès rétropharyngé ou prévertébral) sont présents chez 31 % de la population. Nous allons décrire dans cette revue iconographique leur mode de révélation clinique, leur aspect en imagerie en s’aidant au besoin des données histologiques. Après un bref rappel de l’embryologie et de la classification de ces kystes, seront exclus de cette revue les pseudokystes du nasopharynx tels les tératomes, hamartomes, méningo-encéphalocèles et les polypes antrochoanaux qui sont différenciables des autres formations kystiques, soit en raison de leur contenu, soit en raison de leur communication avec les méninges ou les sinus. La muqueuse nasopharyngée est constituée de tissu épithélial, de glandes salivaires accessoires et de tissu lymphoïde. Chacun de ses composants peut être à l’origine de lésions kystiques qui sont séparés en fonction de leur position médiane ou latérale et/ou en fonction de leur origine congénitale ou acquise. Pour pouvoir les identifier et les différencier des lésions invasives de l’espace muqueux pharyngé ou de l’espace parapharyngé, une bonne connaissance de la topographie et de la sémiologie radiologique des kystes nasopharyngiens est nécessaire.

Retropharyngeal hematoma occurs rarely. It is located just in front of the cervical spine. Many circumstances can lead to its development. A trauma and/or anticoagulants are often key factors. The assessment must be made extremely carefully as such a hematoma can induce an airway compromise. Trauma being a key factor, it can also present with cervical spine fractures, increasing the risks. Two different cases of retropharyngeal hematomas are reported. The first case required surgical management with tracheotomy, per-oral drainage and naso-gastric tube feeding. A total recovery was obtained in 2 weeks. The second patient underwent medical treatment (methylprednisolone), and recovery was obtained in 6 days. Surgery for retropharyngeal hematoma is not always mandatory. It becomes necessary when a major dysphagia or dyspnea occurs. In other cases, medical treatment and close observation are usually sufficient.

Tinnitus of venous origin is a rare occurrence. It represents roughly half of cases of vascular tinnitus. The choice of treatment is not easy, even when the diagnosis is certain. Reassurance of the patient is often sufficient. Nevertheless, a surgical treatment is sometimes performed — usually ligature of the internal jugular vein. We present the case of a patient with a right venous pulsatile tinnitus and a history of 5 years of ineffective medical and surgical treatments. Ligature of the internal jugular vein was not chosen in this case: a computed tomographic scan showed filled mastoid cells, and mastoidectomy was performed instead. The tinnitus disappeared immediately after surgery and has not recurred during a 2-year follow-up. The bilateral preoperative sensorineural and conductive hearing loss also disappeared. Pulsatile tinnitus of venous origin is usually treated with ligature of the internal jugular vein. Mastoidectomy is an interesting alternative in selected cases.

The benign positional vertigo of the horizontal canal seems to find its origins in a canalolithiasis. The diagnosis is usually easy when its characteristics are perfectly known. A horizontal nystagmus does not always mean that the vertigo is of a central origin. This canal is exclusively connected, via the brainstem, to the external and internal oculomotor muscles so that the movement obtained by its stimulation can only be horizontal! This is quite different from what is obtained for the posterior canal, which is connected to various oculomotor muscles. Specific therapeutic maneuvers have to be carried out to be efficient: if properly performed, the otoconias, heavy particles sensitive to gravity, are easily mobilized. This paper describes the pathophysiology of the positional vertigo of the horizontal canal, diagnosis of its two presentations, and therapeutic possibilities.

OBJECTIVES To assess the prevalence, presentation, treatment, and evolution of Menière's disease in elderly patients (> or = 65 yr old). STUDY DESIGN Retrospective clinical study and case report. SETTING A neuro-otology referral center at the university hospital in Bern, Switzerland, and a neurotologic practice in Geneva, Switzerland. PATIENTS Patients were selected from the hospital clinic and otolaryngologic practice registers. Among 8423 neurotologic checkups performed between 1988 and 1998, 432 (5.1%) patients had definite Menière's disease and 66 (15.3%) of these patients were > or = 65 years old. INTERVENTION The files of these 66 patients were analyzed. RESULTS Menière's disease in the elderly had 2 modes of presentation: reactivation of longstanding Menière's disease (40.9%) and de novo Menière's disease (59.1%), where the first dizzy spells, tinnitus, and hearing loss appeared after 65 years of age. Drop attacks occurred in 11.1 and 25.6% of the cases, respectively, and could be responsible for misdiagnosis of strokes of the brainstem. The patients were treated by mild antivertiginous drugs (betahistine, cinnarizine). Twenty-seven patients (41%) underwent surgery: transtympanic ventilation tubes (19 patients), sacculotomy (4 patients), vestibular neurectomy (3 patients), surgical labyrinthectomy (1 patient). The vertigo spells disappeared in 73.3 to 100% of the cases according to the type of surgery performed. CONCLUSION Our study shows that Menière's disease in the elderly is not at all uncommon. It can appear as a de novo disease or as a reactivated longstanding disease. Drop attacks are more frequent than reported in general patient populations with Menière's disease and can mimic a stroke of the brainstem. Medical and surgical treatments have to be cautious because many of these elderly patients are fragile.