1) Tuning fork tests are standard clinical tests used to evaluate hearing. The Rinne and Weber tests compare air and bone conduction to determine the type of hearing loss.
2) The Rinne test involves placing a vibrating tuning fork on the mastoid bone and then over the ear canal. A positive test indicates normal hearing while a negative test suggests conductive hearing loss.
3) The Weber test places a vibrating tuning fork in the middle of the head. If sound is heard equally, hearing is normal or there is bilateral deafness. If it lateralizes to the deafer ear, there is conductive hearing loss, while sensorineural hearing loss causes it to lateralize to the better hearing ear
Pure tone audiometry uses pure tones of single frequencies to test a patient's hearing thresholds through air and bone conduction testing. Air conduction testing evaluates the function of the outer, middle and inner ear by presenting tones from 250Hz to 8kHz through headphones. Bone conduction testing from 250Hz to 4kHz assesses inner ear function by presenting tones to the mastoid bone. The lowest intensity level at which the patient hears 50% of the tones is considered their threshold, which is plotted on a graph with frequency on the x-axis and decibels on the y-axis to evaluate the type, degree and configuration of any hearing loss.
The document discusses bone conduction hearing devices (BCHDs) and their components, functioning, advantages over conventional hearing aids, and surgical classifications. It provides details on the normal routes of bone conduction, components of acoustic and implantable hearing devices, pathophysiology of cochlear deafness addressed by implantable devices, and terminology used. It also outlines clinical indications and criteria for BCHDs as well as some limitations.
Digital hearing aids convert sound waves into digital code that can then be manipulated before being converted back to sound, allowing for more advanced sound processing than analog hearing aids. While analog hearing aids simply amplify sound waves, digital hearing aids can filter noise, adjust settings for different environments, and offer additional controls and saved profiles. However, analog hearing aids are generally cheaper than digital options. Both analog and digital hearing aids amplify sounds to improve hearing.
[1] O documento descreve a técnica de estratificação natural com resinas compostas para restaurar dentes anteriores fraturados. [2] A técnica envolve aplicar camadas incrementais de resinas de diferentes cores e opacidades para reproduzir a aparência natural do esmalte e dentina. [3] Imagens ilustram cada etapa do procedimento, desde a preparação do dente até o acabamento final, demonstrando como a técnica pode restaurar com sucesso a forma, cor e função do dente danificado.
1. The document discusses various techniques for administering local anesthesia, including infiltration, nerve blocks, and intraosseous injections.
2. It describes in detail the inferior alveolar nerve block and Gow-Gates techniques, including proper patient positioning, needle placement, and structures anesthetized.
3. Factors that influence diffusion of local anesthetic solutions and barriers that can slow anesthesia are examined, along with tips for minimizing pain during injection.
Otitis media with effusion, also known as glue ear, is the accumulation of fluid in the middle ear caused by eustachian tube dysfunction or infection. It is a common cause of hearing loss in children. Diagnosis is made through pneumatic otoscopy or tympanometry showing reduced mobility of the ear drum. Treatment involves initial watchful waiting, with myringotomy tubes placed for persistent or recurrent cases to improve ventilation and clear fluid. Complications can include ear drainage, tube displacement, blockage, or retained tubes.
1) Tuning fork tests are standard clinical tests used to evaluate hearing. The Rinne and Weber tests compare air and bone conduction to determine the type of hearing loss.
2) The Rinne test involves placing a vibrating tuning fork on the mastoid bone and then over the ear canal. A positive test indicates normal hearing while a negative test suggests conductive hearing loss.
3) The Weber test places a vibrating tuning fork in the middle of the head. If sound is heard equally, hearing is normal or there is bilateral deafness. If it lateralizes to the deafer ear, there is conductive hearing loss, while sensorineural hearing loss causes it to lateralize to the better hearing ear
Pure tone audiometry uses pure tones of single frequencies to test a patient's hearing thresholds through air and bone conduction testing. Air conduction testing evaluates the function of the outer, middle and inner ear by presenting tones from 250Hz to 8kHz through headphones. Bone conduction testing from 250Hz to 4kHz assesses inner ear function by presenting tones to the mastoid bone. The lowest intensity level at which the patient hears 50% of the tones is considered their threshold, which is plotted on a graph with frequency on the x-axis and decibels on the y-axis to evaluate the type, degree and configuration of any hearing loss.
The document discusses bone conduction hearing devices (BCHDs) and their components, functioning, advantages over conventional hearing aids, and surgical classifications. It provides details on the normal routes of bone conduction, components of acoustic and implantable hearing devices, pathophysiology of cochlear deafness addressed by implantable devices, and terminology used. It also outlines clinical indications and criteria for BCHDs as well as some limitations.
Digital hearing aids convert sound waves into digital code that can then be manipulated before being converted back to sound, allowing for more advanced sound processing than analog hearing aids. While analog hearing aids simply amplify sound waves, digital hearing aids can filter noise, adjust settings for different environments, and offer additional controls and saved profiles. However, analog hearing aids are generally cheaper than digital options. Both analog and digital hearing aids amplify sounds to improve hearing.
[1] O documento descreve a técnica de estratificação natural com resinas compostas para restaurar dentes anteriores fraturados. [2] A técnica envolve aplicar camadas incrementais de resinas de diferentes cores e opacidades para reproduzir a aparência natural do esmalte e dentina. [3] Imagens ilustram cada etapa do procedimento, desde a preparação do dente até o acabamento final, demonstrando como a técnica pode restaurar com sucesso a forma, cor e função do dente danificado.
1. The document discusses various techniques for administering local anesthesia, including infiltration, nerve blocks, and intraosseous injections.
2. It describes in detail the inferior alveolar nerve block and Gow-Gates techniques, including proper patient positioning, needle placement, and structures anesthetized.
3. Factors that influence diffusion of local anesthetic solutions and barriers that can slow anesthesia are examined, along with tips for minimizing pain during injection.
Otitis media with effusion, also known as glue ear, is the accumulation of fluid in the middle ear caused by eustachian tube dysfunction or infection. It is a common cause of hearing loss in children. Diagnosis is made through pneumatic otoscopy or tympanometry showing reduced mobility of the ear drum. Treatment involves initial watchful waiting, with myringotomy tubes placed for persistent or recurrent cases to improve ventilation and clear fluid. Complications can include ear drainage, tube displacement, blockage, or retained tubes.
Hearing aids are electronic devices that amplify sound to help people with hearing loss. There are two main types - analog hearing aids amplify all sounds equally while digital hearing aids analyze sound and amplify different frequencies individually for clearer sound. Digital hearing aids break sound into 48 or more frequency bands and amplify each band as needed. Hearing aids come in several styles including custom-fit models that go completely in the ear canal or invisible models. Behind-the-ear models have the components behind the ear connected to an earpiece. Receiver-in-canal models place the microphone in the outer ear connected by a tube to a receiver in the ear canal.
1) O documento apresenta noções básicas de cirurgia odontológica, incluindo as etapas pré, trans e pós-operatórias e procedimentos como preparo do paciente e ambiente, anestesia, diérese, exérese e síntese.
2) As fases cirúrgicas incluem preparação do paciente e ambiente, realização do procedimento e cuidados pós-operatórios como limpeza e aplicação de gaze úmida.
3) A montagem da mesa cirúrgica e paramentação
Protocolo medicamentoso em odontologiaJose Gerardo
A empresa de tecnologia anunciou um novo smartphone com câmera aprimorada, tela maior e bateria de longa duração por um preço acessível. O dispositivo visa atrair mais consumidores em mercados emergentes com especificações sólidas a um preço baixo. Analistas esperam que o lançamento ajude a empresa a ganhar participação de mercado.
Empty Nose Syndrome (ENS) is a condition characterized by paradoxical nasal obstruction despite a widely patent nasal airway. It often results from nasal surgery involving resection of the turbinates. Diagnosis involves identifying a history of turbinate surgery and appropriate symptoms like dryness and improvement with a "cotton test" where cotton is placed in areas of deficit. Treatment planning involves using CT imaging and endoscopy to identify defects and testing placement of cotton or saline to identify locations for grafting. Surgical repair techniques involve implanting tissue like acellular dermis or autogenous tissue into locations identified as beneficial by the cotton test, such as the septum, lateral wall, or expanding the existing inferior turbinate. The
A dental assistant greets patients, prepares materials, schedules appointments, takes x-rays, and helps the dentist during procedures. The job requires graduating high school and completing an associate's degree or on-the-job training. Salaries range from $22,270 to $46,150 annually based on experience. The career has strong growth potential and a bright outlook as the number of dental assistants is expected to increase by 43.1% over the next decade.
voice rehabilitation in total laryngectomyENT Resident
This document discusses different voice rehabilitation options for laryngectomy patients including pseudowhisper, esophageal speech, electrolarynx, pneumatic artificial larynx, and voice prosthesis. It notes key selection criteria for these options such as patient dexterity, phonatory effort required, thickness of tissue, durability, and cost. Potential problems are also outlined for voice prosthesis including leakage, granulations, valve issues, and other medical complications.
Acoustic immittance measurements objectively assess middle ear function using tympanometry, acoustic reflex thresholds, and acoustic reflex decay. Tympanometry involves placing a probe in the ear canal to measure how acoustic admittance changes as pressure is varied. Normal tympanograms are Type A, while abnormal types include flat (Type B), negative pressure (Type C), stiff (Type As), and flaccid (Type AD). Acoustic reflex thresholds measure the lowest level needed to elicit the stapedius muscle reflex, providing information about the middle ear, cochlea, auditory nerve and brainstem. Acoustic reflex decay tests the sustainability of the reflex over 10 seconds of continuous stimulation.
This document discusses masking techniques used during audiological testing. Masking involves using noise in the non-test ear to prevent it from interfering with thresholds measured in the test ear. It explains that masking is necessary for bone conduction testing and varies depending on frequency, skull thickness, and transducer used. The document provides guidelines for when to mask air and bone conduction thresholds and describes different masking types, levels, and challenges like under, over, and dilemma masking. It emphasizes using inserts to reduce interaural attenuation when masking is difficult.
Certain medications like aminoglycoside antibiotics and chemotherapy drugs can cause permanent hearing loss or damage to balance functions. Audiometric monitoring of high frequencies above 8 kHz is the most effective way to detect this ototoxicity early. High frequencies are affected first, which can later degrade speech understanding if the hearing loss spreads to lower frequencies that are important for speech. Early detection allows for potential intervention to minimize ototoxic impacts.
Hearing Instrument Fitting Formulae History and OverviewLynn Royer
The document discusses the history of hearing instrument fitting formulae. Initial formulae attempted to mirror audiograms or provide gain to reach the most comfortable listening level. Over time, researchers realized fitting should be based on loudness perception and individual needs rather than just audiogram results. Modern digital instruments allow customizing gain by frequency to better address pathologies. Fitting formulae still often rely on norms from non-pathological ears rather than individual testing and needs.
[1] O documento discute considerações no atendimento a pacientes com necessidades especiais, incluindo medidas universais de prevenção, vias de transmissão de doenças, definições importantes e a importância da anamnese.
[2] É destacada a necessidade de conhecer a história completa do paciente para identificar seus cuidados requeridos, incluindo detalhes desde o nascimento.
[3] A anamnese deve ser direcionada e abordar aspectos clínicos, psicológicos e fonoaudiológic
Slides da minha vídeo aula postada no Youtube onde falo sobre a anatomia dental aplicada a endodontia, discutindo as principais características anatômicas das raízes e dos canais de cada um dos dentes.
Após discutir o tema, respondo junto com você várias questões de concurso público sobre o assunto, para que o conteúdo seja bem fixado;
Para assistir essa vídeo aula, acesse: https://youtu.be/9IIMLAQ7UTA
A review for Hearing loss causes and Hearing aids
ototoxicity has been left out other then a mention as it is separate topic. PPt prepared for in ward discussion with colleagues.
Revisão e resumo da disciplina de endodontia, para universitários e profissionais. Bem objetiva e clara. Para quem quiser, existe uma revisão atualizada e modificada 2019. https://pt.slideshare.net/jonathancgr/endodontia-reviso-completa-e-atualizada-2019
This document discusses immittance audiometry, which uses non-invasive and non-behavioral measures to assess middle ear function and detect pathology. It describes the instrumentation used, including a probe tone oscillator and microphone. Immittance refers to how easily energy flows through the outer and middle ear. Tympanometry measures how acoustic immittance changes with air pressure in the ear canal. Normal tympanograms show a peaked shape around -100mm H2O. Acoustic reflex thresholds detect the lowest sound level that elicits a middle ear muscle contraction. Reflex decay testing assesses the muscle's response over time. These measures help evaluate the ear's conductive system without requiring patient responses.
O documento descreve as técnicas e materiais utilizados para a abertura coronária em diferentes tipos de dentes, incluindo incisivos, caninos, pré-molares superiores e inferiores. Ele detalha os passos da abertura coronária, como ponto de eleição, forma de contorno, trepanação, remoção do teto da câmara pulpar e limpeza final.
The document discusses the history, components, types, needs, candidacy, and surgery of bone anchored hearing aids (BAHA), which transmit sound to the cochlea via bone conduction by bypassing abnormalities of the outer and middle ear through an implanted titanium fixture. It traces the development of BAHA from its origins in the 1950s to current digital processors. BAHA consists of a titanium screw surgically implanted in the skull that protrudes a titanium abutment connecting to an external sound processor.
This document provides information about middle ear implants (MEIs). It discusses the different types of MEIs, including piezoelectric, electromagnetic, and electromechanical designs. It also describes partial and total MEIs based on the placement of the processor. Several key advances in MEI development from the 1930s to present day are highlighted. Requirements for MEI candidacy include having a moderate to severe sensorineural or conductive hearing loss, symmetrical audiogram, and residual cochlear function.
- Anterior teeth are primarily selected based on esthetic requirements while posterior teeth are selected based on masticatory function and occlusion.
- Factors to consider in anterior tooth selection include morphology, size, color, placement based on anatomical landmarks and guides.
- Careful evaluation of the patient's existing dentition, facial characteristics, and preferences are important in selecting the right anterior teeth.
Hearing aids are electronic devices that amplify sound to help people with hearing loss. There are two main types - analog hearing aids amplify all sounds equally while digital hearing aids analyze sound and amplify different frequencies individually for clearer sound. Digital hearing aids break sound into 48 or more frequency bands and amplify each band as needed. Hearing aids come in several styles including custom-fit models that go completely in the ear canal or invisible models. Behind-the-ear models have the components behind the ear connected to an earpiece. Receiver-in-canal models place the microphone in the outer ear connected by a tube to a receiver in the ear canal.
1) O documento apresenta noções básicas de cirurgia odontológica, incluindo as etapas pré, trans e pós-operatórias e procedimentos como preparo do paciente e ambiente, anestesia, diérese, exérese e síntese.
2) As fases cirúrgicas incluem preparação do paciente e ambiente, realização do procedimento e cuidados pós-operatórios como limpeza e aplicação de gaze úmida.
3) A montagem da mesa cirúrgica e paramentação
Protocolo medicamentoso em odontologiaJose Gerardo
A empresa de tecnologia anunciou um novo smartphone com câmera aprimorada, tela maior e bateria de longa duração por um preço acessível. O dispositivo visa atrair mais consumidores em mercados emergentes com especificações sólidas a um preço baixo. Analistas esperam que o lançamento ajude a empresa a ganhar participação de mercado.
Empty Nose Syndrome (ENS) is a condition characterized by paradoxical nasal obstruction despite a widely patent nasal airway. It often results from nasal surgery involving resection of the turbinates. Diagnosis involves identifying a history of turbinate surgery and appropriate symptoms like dryness and improvement with a "cotton test" where cotton is placed in areas of deficit. Treatment planning involves using CT imaging and endoscopy to identify defects and testing placement of cotton or saline to identify locations for grafting. Surgical repair techniques involve implanting tissue like acellular dermis or autogenous tissue into locations identified as beneficial by the cotton test, such as the septum, lateral wall, or expanding the existing inferior turbinate. The
A dental assistant greets patients, prepares materials, schedules appointments, takes x-rays, and helps the dentist during procedures. The job requires graduating high school and completing an associate's degree or on-the-job training. Salaries range from $22,270 to $46,150 annually based on experience. The career has strong growth potential and a bright outlook as the number of dental assistants is expected to increase by 43.1% over the next decade.
voice rehabilitation in total laryngectomyENT Resident
This document discusses different voice rehabilitation options for laryngectomy patients including pseudowhisper, esophageal speech, electrolarynx, pneumatic artificial larynx, and voice prosthesis. It notes key selection criteria for these options such as patient dexterity, phonatory effort required, thickness of tissue, durability, and cost. Potential problems are also outlined for voice prosthesis including leakage, granulations, valve issues, and other medical complications.
Acoustic immittance measurements objectively assess middle ear function using tympanometry, acoustic reflex thresholds, and acoustic reflex decay. Tympanometry involves placing a probe in the ear canal to measure how acoustic admittance changes as pressure is varied. Normal tympanograms are Type A, while abnormal types include flat (Type B), negative pressure (Type C), stiff (Type As), and flaccid (Type AD). Acoustic reflex thresholds measure the lowest level needed to elicit the stapedius muscle reflex, providing information about the middle ear, cochlea, auditory nerve and brainstem. Acoustic reflex decay tests the sustainability of the reflex over 10 seconds of continuous stimulation.
This document discusses masking techniques used during audiological testing. Masking involves using noise in the non-test ear to prevent it from interfering with thresholds measured in the test ear. It explains that masking is necessary for bone conduction testing and varies depending on frequency, skull thickness, and transducer used. The document provides guidelines for when to mask air and bone conduction thresholds and describes different masking types, levels, and challenges like under, over, and dilemma masking. It emphasizes using inserts to reduce interaural attenuation when masking is difficult.
Certain medications like aminoglycoside antibiotics and chemotherapy drugs can cause permanent hearing loss or damage to balance functions. Audiometric monitoring of high frequencies above 8 kHz is the most effective way to detect this ototoxicity early. High frequencies are affected first, which can later degrade speech understanding if the hearing loss spreads to lower frequencies that are important for speech. Early detection allows for potential intervention to minimize ototoxic impacts.
Hearing Instrument Fitting Formulae History and OverviewLynn Royer
The document discusses the history of hearing instrument fitting formulae. Initial formulae attempted to mirror audiograms or provide gain to reach the most comfortable listening level. Over time, researchers realized fitting should be based on loudness perception and individual needs rather than just audiogram results. Modern digital instruments allow customizing gain by frequency to better address pathologies. Fitting formulae still often rely on norms from non-pathological ears rather than individual testing and needs.
[1] O documento discute considerações no atendimento a pacientes com necessidades especiais, incluindo medidas universais de prevenção, vias de transmissão de doenças, definições importantes e a importância da anamnese.
[2] É destacada a necessidade de conhecer a história completa do paciente para identificar seus cuidados requeridos, incluindo detalhes desde o nascimento.
[3] A anamnese deve ser direcionada e abordar aspectos clínicos, psicológicos e fonoaudiológic
Slides da minha vídeo aula postada no Youtube onde falo sobre a anatomia dental aplicada a endodontia, discutindo as principais características anatômicas das raízes e dos canais de cada um dos dentes.
Após discutir o tema, respondo junto com você várias questões de concurso público sobre o assunto, para que o conteúdo seja bem fixado;
Para assistir essa vídeo aula, acesse: https://youtu.be/9IIMLAQ7UTA
A review for Hearing loss causes and Hearing aids
ototoxicity has been left out other then a mention as it is separate topic. PPt prepared for in ward discussion with colleagues.
Revisão e resumo da disciplina de endodontia, para universitários e profissionais. Bem objetiva e clara. Para quem quiser, existe uma revisão atualizada e modificada 2019. https://pt.slideshare.net/jonathancgr/endodontia-reviso-completa-e-atualizada-2019
This document discusses immittance audiometry, which uses non-invasive and non-behavioral measures to assess middle ear function and detect pathology. It describes the instrumentation used, including a probe tone oscillator and microphone. Immittance refers to how easily energy flows through the outer and middle ear. Tympanometry measures how acoustic immittance changes with air pressure in the ear canal. Normal tympanograms show a peaked shape around -100mm H2O. Acoustic reflex thresholds detect the lowest sound level that elicits a middle ear muscle contraction. Reflex decay testing assesses the muscle's response over time. These measures help evaluate the ear's conductive system without requiring patient responses.
O documento descreve as técnicas e materiais utilizados para a abertura coronária em diferentes tipos de dentes, incluindo incisivos, caninos, pré-molares superiores e inferiores. Ele detalha os passos da abertura coronária, como ponto de eleição, forma de contorno, trepanação, remoção do teto da câmara pulpar e limpeza final.
The document discusses the history, components, types, needs, candidacy, and surgery of bone anchored hearing aids (BAHA), which transmit sound to the cochlea via bone conduction by bypassing abnormalities of the outer and middle ear through an implanted titanium fixture. It traces the development of BAHA from its origins in the 1950s to current digital processors. BAHA consists of a titanium screw surgically implanted in the skull that protrudes a titanium abutment connecting to an external sound processor.
This document provides information about middle ear implants (MEIs). It discusses the different types of MEIs, including piezoelectric, electromagnetic, and electromechanical designs. It also describes partial and total MEIs based on the placement of the processor. Several key advances in MEI development from the 1930s to present day are highlighted. Requirements for MEI candidacy include having a moderate to severe sensorineural or conductive hearing loss, symmetrical audiogram, and residual cochlear function.
- Anterior teeth are primarily selected based on esthetic requirements while posterior teeth are selected based on masticatory function and occlusion.
- Factors to consider in anterior tooth selection include morphology, size, color, placement based on anatomical landmarks and guides.
- Careful evaluation of the patient's existing dentition, facial characteristics, and preferences are important in selecting the right anterior teeth.
Ce diaporama a été construit dans le cadre du plan Ecoantibio2017; il est le fruit d’un partenariat entre plusieurs structures et de l’implication d’un noyau d’individus de bonne volonté, qu’ils soient ici remerciés.
Ce diaporama est libre de droit et de reproduction, il a vocation à être utilisé largement et à bon escient ; il peut être allégé selon les besoins et les contextes de présentation.
Merci de citer les structures ayant conçu ce diaporama lors de toute présentation ou reproduction, même partielle.
Les sources utilisées sont mentionnées dans les commentaires ou sur les diapositives.
Value Of Ear Endoscopy In Cholesteatoma Surgery.Pptaliabbas07
This document discusses the value of ear endoscopy in cholesteatoma surgery. It finds that ear endoscopy can be used as an adjunct to the microscope to provide educational, diagnostic, and therapeutic benefits. A study of 942 patients undergoing cholesteatoma surgery found that endoscopy assisted in the identification and removal of residual cholesteatoma in 19% of primary cases and 14% of second look procedures. The conclusions are that endoscopy is a complementary tool that can help confirm thorough cholesteatoma removal, assess the adequacy of tympanoplasty, and aid in second look explorations when used alongside the microscope.
The document summarizes a study on subglottic stenosis in children with neurological disorders. It finds that children with neurological disorders made up 22% of the 178 children studied. These children tended to be older, have more severe stenosis, and require a two-stage procedure more often than children without neurological disorders. The two-stage procedure and treatment for gastroesophageal reflux resulted in better airway protection and ability to be re-fed for children with neurological disorders.
This document summarizes a study on congenital middle ear cholesteatomas in children. The study compared 61 cases of congenital cholesteatoma to 261 cases of acquired cholesteatoma in children. Key findings included that congenital cholesteatomas were more likely to present asymptomatically or with serous otitis media. Congenital cholesteatomas also tended to have a closed "cystic" pattern located in the anterior superior quadrant, while acquired cholesteatomas had a more open "infiltrate" pattern. Earlier diagnosis of congenital cholesteatoma led to better surgical results and hearing outcomes.
This document discusses tropical otolaryngology practices in sub-Saharan Africa. Some common diseases seen include rhinoscleroma, noma, and Burkitt's lymphoma. Rhinoscleroma is a chronic infection of the nose caused by Klebsiella that presents in three stages and is difficult to treat. Noma is a devastating gangrenous disease of the face seen in undernourished children and leads to severe tissue destruction. Burkitt's lymphoma has the highest incidence of childhood cancer in sub-Saharan Africa, usually presenting as a maxillary tumor. Common otologic disorders include chronic otitis media, which frequently leads to complications in children such as acute mastoiditis. Due to increased travel
This case report from Senegal describes a giant cylindroma of the parotid gland in a 27-year-old woman. The tumor had been growing for 10 years and rapidly progressed in the last year. Due to a lack of diagnostic resources, the tumor measured 9x8 cm before surgical removal. A radical parotidectomy and neck dissection were performed, but reconstruction failed due to flap necrosis, requiring a second surgery. Histopathology found a cylindroma, which is a malignant epithelial tumor. The patient died of cerebral metastases four months later, demonstrating the challenges of diagnosing and treating large salivary gland tumors in under-resourced settings.
This document reports a case of a 39-year-old woman in Senegal with a giant recurrent ameloblastoma tumor measuring 20x12x13cm in her left mandible that had regrown after a previous partial surgery. A CT scan showed the tumor had destroyed parts of the mandible, maxilla and palate bones. The patient underwent a radical resection of the left mandible, part of the maxilla and palate. The pathological examination found it was a follicular ameloblastoma without signs of malignancy. This case highlights the challenges of diagnosing and treating recurrent giant ameloblastomas in areas with limited medical resources.
1. Dr Ali ABBAS
Sce d’ORL du Dr. Polonovski
Centre Hospitalier de Versailles
André Mignot
2. J0 zona coude
J2 méningite liquide clair : PCR VZV + à 48h
J0 gentamicine 3 mg/kg, J1 gentamicine 6 mg/kg (600 mg/94 kg)
et J2 gentamicine 6 mg/kg
Bilatéralement: J1 matin acouphènes, J1 soir hypoacousie, J2 matin
surdité subtotale, J2 soir vertige
J4 (Sce ORL): surdité subtotale bilatérale (85 dB aiguës) et aréflexie
vestibulaire bilatérale
7j de corticoïdes IV 1 mg/kg, 15j Zovirax 30 mg/kg
Durant hospitalisation en orl: aggravation surdité bilatérale:
cophose (surdité profonde à 100 dB aiguës et 70 dB graves),
persistance aréflexie vestibulaire bilatérale
Cs externe ORL CHU Avicenne pour implant cochléaire en
urgence: hypothèse ototoxicité
Conclusion du Sce ORL Mignot: labyrinthite bilatérale par
ototoxicité immédiate à la gentamicine pour méningite post-
zostérienne
3. Aucun cas décrit de surdité et atteinte
vestibulaire profonde et bilatérale après
méningite post-zostérienne
Relecture des transmissions IDE: chronologie
en faveur ototoxicité immédiate: suite à la
première injection de gentamicine à 3 mg/kg:
début par acouphènes
Doses suivantes de gentamicine > 6mg/kg
Indication gentamicine PL liquide clair:
suspicion de listériose mais gravité de l’état
clinique?
4. Syndrome de Ramsay-Hunt associant paralysie
faciale périphérique et surdité perception:
polynévrite ou labyrinthite mais pas de cas
bilatéral ni d’atteinte par méningite [1]
Méningite post-zostérienne: pas d’atteinte du
VIII, pas d’atteinte bilatérale [2]
1. Ohtani F, Furuta Y, Aizawa H, Fukuda S. Varicella-zoster virus load and cochleovestibular symptoms in Ramsay
Hunt syndrome. Ann Otol Rhinol Laryngol. 2006;115:233-8.
2. Gregoire SM, van Pesch V, Goffette S, Peeters A, Sindic CJ. Polymerase chain reaction analysis and oligoclonal
antibody in the cerebrospinal fluid from 34 patients with varicella-zoster virus infection of the nervous system. J
Neurol Neurosurg Psychiatry. 2006;77:938-42.
5. Cumulative, destruction CCE:
phosphorylation par radicaux libres oxydants :
gentamicine agit comme un chélateur du fer, active
la peroxydation des lipides membranaires et induit
la formation de radicaux libres [1]
apoptose gène régulateurs CCE [2]
Incidence: 3-33% en moyenne 15% patients en
courte durée (selon audiométrie haute fq) [3]
1. Fetoni AR, Sergi B, Ferraresi A, Paludetti G, Troiani D. alpha-Tocopherol protective effects on gentamicin
ototoxicity: an experimental study.Int J Audiol. 2004 Mar;43(3):166-71.
2. Nagy I, Bodmer M, Brors D, Bodmer D. Early gene expression in the organ of Corti exposed to gentamicin.
Hear Res. 2004;195:1-8
3. Fausti, S.A., Henry, J.A., Helt, W.J., Phillips, D.S., Frey, R.H., NoVsinger,D., Larson, V.D., Fowler, C.G., 1999.
An individualized, sensitive frequency range for early detection of ototoxicity. Ear Hear. 20, 497–505.
8. Aminoglycosides lèsent de façon dose-
dépendante l'organe de Corti, et tout
particulièrement les cellules ciliées externes
puis internes
Les CCE de la base de la cochlée (ondes aiguës)
et de la première rangée sont d'abord attaquées
suivent les autres rangées de CCEs et les CCIs
avec des doses plus fortes, les dégâts se
propagent régulièrement vers l'apex (ondes
graves).
9. Surface de l'organe de Corti d'une cochlée
de rat (base). Cette figure rappelle
l'organisation des cellules ciliées sur
l'animal témoin.
Echelle: 12 µm; MEB
Atteinte progressive des cellules ciliées
Début de l'atteinte des CCEs par un
antibiotique d la famille des aminosides.
C'est la 1ère rangée des CCEs (o) qui est la plus
fragile, comme on le voit ici ; aucune CCI (i) ne
manque.
Chez l'homme, une telle atteinte provoque une
surdité légère ou moyenne, accompagnée de
problèmes de discrimination fréquentielle.
10. Une dose plus forte détruit toutes les
CCEs, entraînant la perte du mécanisme
actif (stéréocils fusionnés)
Chez l'homme, un tel organe de Corti
fonctionne avec 60 dB de perte, et la
discrimination fréquentielle est très
fortement altérée.
Avec un dosage encore plus fort, les CCIs
disparaissent à leur tour. Seuls quelques
cils fusionnés (flèche rouge) sont visibles
çà et là.
p = piliers de Corti ; d = cellules de Deiters.
Surdité totale
11. Pas de safe dose de gentamicine: pic (« ototoxicité ») et
résiduel (néphrotoxicité) non contributifs pour prédire
début et sévérité oto- et vestibulotoxicité [1]
Ototoxicité de la gentamicine potentialisée par
diurétiques de l’anse et chimiothérapie (cisplatine):
thérapie associée ou successive
Ototoxicité retardée car élimination intra-cochléaire
lente: accumulation des aminoglycosides intra-
lysosomales des CCE dont l’élimination cellulaire est
lente [2]
Utilisation gentamicine intratympanique maladie
Menière: vestibulotoxicité plus qu’ototoxicité, atteinte
des cellules des macules sacculaires du vestibule [3]
1. Black FO, Pesznecker S, Stallings V. Permanent gentamicin vestibulotoxicity. Otol Neurotol. 2004 ;25:559-69.
2. Dulon D, Hiel H, Aurousseau C, Erre JP, Aran JM. Pharmacokinetics of gentamicin in the sensory hair cells of
the organ of Corti: rapid uptake and long term persistence. C R Acad Sci III. 1993 Jul;316:682-7
3. Cohen-Kerem R, Kisilevsky V, Einarson TR, Kozer E, Koren G, Rutka JA. Intratympanic gentamicin for
Menière's disease: a meta-analysis.Laryngoscope. 2004;114:2085-91.
12.
13. Méningite liquide clair BG+ (listeria) avec gravité
(GcS <8, choc, signes de localisation)
Pneumopathie nosocomiale tardive acquise sous
VM>7j ou précoce avec ATB ou hospit antérieure
Infection urinaire communautaire grave avec
hypotension
Péritonite communautaire et angiocholite aiguë
communautaire grave
Cellulite gangréneuse
Infection sur cathéter
Sepsis sans porte d’entrée suspectée
Réévaluation systématique des ATB à 48h
SFAR. Antibiothérapie probabiliste des états septiques graves. Conférence d’experts 2004
http://sfar.org/t/IMG/pdf/antibioprobabcexp.pdf
14. Drug Vestibulotoxicity Hearing Toxicity Toxic Level
Amikacin not toxic 13.9%
Azithromycin not known occasional Very high dose
required
Capreomycin yes
Chloramphenicol yes sporadic reports only
Dibekacin yes yes
Dihydrostreptomycin minor toxic very toxic
Erythromycin yes High IV doses only
Gentamicin 8.6% minor Usually 2 weeks
Metronidizole toxic (rarely) unknown
Neomycin minor very toxic In topical ear drops
Netilmicin Yes 2.4%
Polymyxin B In ear drops
Streptomycin very toxic minor
Tobramycin Yes minor in 6% Less toxic than
Gentamicin
Vancomycin nontoxic none to moderate synergistic with
gentamicin
http://www.dizziness-and-balance.com/disorders/bilat/gentamicin%20toxicity.htm
15. 3 patients sur 2184: ototoxicité par gentamicine
en 1 prise
plus bactéricide et réduction néphrotoxicité et
ototoxicité et
Ototoxicité moindre à condition d’une courte
période (pas d’article sur pharmacocinétique
humaine, uniquement animale): dose 5mg/kg
1 semaine plus acceptée vs 3 mg/kg/j
2 semaines
Nicolau DP, Freeman CD, Belliveau PP, Nightingale CH, Ross JW, Quintiliani R. Experience with a once-daily
aminoglycoside program administered to 2,184 adult patients. Antimicrob Agents Chemother. 1995;39:650-5
17. Mutations gène mitochondrial ARNr 12S responsable de tableaux
cliniques syndromiques avec atteinte multiples et de surdités isolées non
syndromiques [1]
La plus connue des surdités non syndromiques: la susceptibilité
ototoxique aux aminoglycosides (<5% surdités isolées génétiques)
L’évoquer quand:
Surdité familiale transmise par la mère (ADNmit)
Notion d’ototoxicité après traitement par aminosides même à doses
faibles
En 2007: 50 gènes responsables de surdité mitochondriale non
syndromiques +/- associée prise aminoglycosides [2]
3 mutations de l’ ARNr connues avec susceptibilité ototoxique aux
aminoglycosides [3]:
- mutation A1555G: la plus connue
- mutations C1494T et delT961Cn
1. Génétique et maladies ORL, Rapport SFORL 2005. 136-40
2. Kokotas H & al. Mitochondiral deafness. Clin Genet 2007;71: 379-91
3. Fichel-Ghodsian N. Pharmacogenomics 2005;61:27-36
18. Mutation A1555G dans le gène ARNr 12S
mitochondiral associé à susceptibilité
ototoxique aux aminoglycosides
Cible des aminoglycosides: ARNr bactérien
Mutation A1555G: modification 3D ARNr 12S
le rendant plus proche de l’ARNr bactérien
donc plus sensible à l’action des
aminoglycosides qu’un ARNr normal
Génétique et maladies ORL, Rapport SFORL 2005
19. Première famille décrite 1993 [1]
Mutation responsable de surdités de
perception primitives ou de surdités post-
aminoglycosides : études chinoises et
espagnoles: prévalence et incidence variable
d’une étude à l’autre: 1/1173 NN américains
[2], 10 à 15% surdités isolées espagnoles, 2 à
25% patients chinois sourds post-
aminoglycosides dont 50% porteurs de la
mutation [3]
1. Prezant & al. Mitochondrial ribosomal RNA mutation associated with both antibiotic_induced and
non-syndromic deafness. Nat Genet1993;4;289-94
2. Génétique et maladies ORL, Rapport SFORL 2005
3. Tang HY & al. Genetic susceptibility to aminoglycoside ototoxicity: how many are at risk? Genet
Med 2002;4:336-45
20. Surdité de perception fréquences aiguës moyenne
à profonde, évolutive, non congénitale, parfois
profonde et rapide <30 ans [1]
Surdité plus sévère après pris d’aminoglycosides
Pas d’atteinte vestibulaire habituellement [2]
Absence d’anomalie radiologique
Succès implant cochléaire [3]
1.Fichel-Ghodsian N. Mitochondrial deafness. Ear Hear 2003; 24:303-13
2. Nogucchi & al. Audiovestibular findings in patients with mitochondrial A1555G mutation. Laryngoscope 2004;
114:344-8
3. Sinnathuray & al. A review of cochlear implantation in mitochondrial sensineural hearing loss. Otol Neurotol
2003;24:418-26
21. Variation intra et inter-familiale âge de début
surdité (surdité congénitale à surdité révélée à
l’âge adulte)
Pénétrance variable intra et inter-familiale (de
non atteint à surdité profonde)
Atteinte cochléaire « isolée » (vestibulotoxicité)
Surdité isolée de perception aggravée ou
déclenchée par prise d’ aminoglycosides
Génétique et maladies ORL, Rapport SFORL 2005
22. Moins connues
Surdité de perception après administration
immédiate d’ aminoglycosides
Même site très conservé de l’ARNr 12S
Génétique et maladies ORL, Rapport SFORL 2005
23. 20% patients non sédatés se plaignent de vertiges, oscilloscopie et
instabilité. Confirmé par test clinique d’ Halmagyi , malgré doses
sériques et créatinémie normales[1]
Instabilité et vertiges induit aux mouvements de tête plusieurs
jours après [2]
Utilisation gentamicine en intra-tympanique pour vestibuloplégie
dans le cadre du traitement de la maladie de Menière [3]
3 patients A1555G sur 13 cas avaient des vertiges: atteinte
ototoxique et vestibulotoxique des aminosides chez les patients
porteurs de la mutation A1555G [4]
1. Shiyama G, Ishiyama A, Kerber K, Baloh RW. Gentamicin ototoxicity: clinical features and the effect on the human
vestibulo-ocular reflex. Acta Otolaryngol 2006;126:1057-61.
2. Seemungal BM, Bronstein AM. Aminoglycoside ototoxicity: Vestibular function is also vulnerable. BMJ. 2007
10;335:952.
3. Smith WK, Sandooram D, Prinsley PR. Intratympanic gentamicin treatment in Meniere's disease: patients' experiences
and outcomes. J Laryngol Otol. 2006;120:730-5
4. Gallo-Terán J, Arellano B, Morales-Angulo C, Modamio-Høybjør S, Moreno-Pelayo MA, Ramírez-Camacho R, del
Castillo I, Moreno F. Prevalence of the A1555G mutation in the mitochondrial DNA in patients with cochlear or
vestibular damage due to aminoglycoside-induced ototoxicity. Acta Otorrinolaringol Esp. 2004;55:212-7
24. action des antioxydants sur les radicaux libres
produits par la gentamicine dans l’organe de
Corti [1,2]
Aspirine: ototoxicité 3% avec aspirine vs 13%
placebo: chez 195 patients sous gentamicine:
3 g d’aspirine 14 jours p=0.013[2]
N-Acetylcysteine: plus néphroprotecteur
qu’otoprotecteur [3]
1. Sha SH , Qiu JH, Schacht J. Aspirin to prevent gentamicin-induced hearing loss. N Engl J Med.
2006;354:1856-7
2. Chen Y, Huang WG, Zha DJ, Qiu JH, Wang JL, Sha SH, Schacht J. Aspirin attenuates gentamicin ototoxicity:
from the laboratory to the clinic. Hear Res. 2007;226:178-82
3. Tepel M. N-Acetylcysteine in the prevention of ototoxicity. Kidney Int. 2007;72:359-63.
25. Bilan pré-implantation en cours avec accord d’indication
chirurgicale d’implant cochléaire dans les 3 mois
Actuellement audioprothèses bilatérales (contours d’oreille)
amélioration de 30% sur les ondes conversationnelles
(discussion possible mais pas en groupe)
En cours de rééducation vestibulaire, difficile car bilatérale
(pas de compensation de l’oreille interne controlatérale)
Impact social et économique (arrêt de travail)
Cs Dr S.Marlin (généticienne Salpêtrière pour diagnostic
génétique mutation mitochondriale +/- dépistage fratrie
(frère): contre-indication des aminosides alors pour son frère
26. Arrêt des aminoglycosides dès premiers signes
cochléo-vestibulaires: expertise ORL par
audiométrie et vidéonystagmographie
Poursuite gentamicine dose 5 mg/kg/j
acceptée mais en 1 prise et dose maximale
quotidienne 600 mg (patients obèses), ne pas
dépasser 1 semaine
Suivi ORL des patients ayant eu > 1 semaine
d’aminoglycosides
Penser aux mutations mitochondriales en cas
de surdité après 1 dose d’aminoglycosides