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BACKGROUND: Consensus guidelines on the definition, investigation, and treatment of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) have been previously published in European Journal of Neurology and Journal of the Peripheral Nervous System. OBJECTIVES: To revise these guidelines. METHODS: Disease experts, including a representative of patients, considered references retrieved from MEDLINE and Cochrane Systematic Reviews published between August 2004 and July 2009 and prepared statements that were agreed in an iterative fashion. RECOMMENDATIONS: The Task Force agreed on Good Practice Points to define clinical and electrophysiological diagnostic criteria for CIDP with or without concomitant diseases and investigations to be considered. The principal treatment recommendations were: (i) intravenous immunoglobulin (IVIg) (Recommendation Level A) or corticosteroids (Recommendation Level C) should be considered in sensory and motor CIDP; (ii) IVIg should be considered as the initial treatment in pure motor CIDP (Good Practice Point); (iii) if IVIg and corticosteroids are ineffective, plasma exchange (PE) should be considered (Recommendation Level A); (iv) if the response is inadequate or the maintenance doses of the initial treatment are high, combination treatments or adding an immunosuppressant or immunomodulatory drug should be considered (Good Practice Point); (v) symptomatic treatment and multidisciplinary management should be considered (Good Practice Point).

Current research in affective neuroscience suggests that the emotional content of visual stimuli activates brain-body responses that could be critical to general health and physical disease. The aim of this study was to develop an integrated neurophysiological approach linking central and peripheral markers of nervous activity during the presentation of natural scenes in order to determine the temporal stages of brain processing related to the bodily impact of emotions. More specifically, whole head magnetoencephalogram (MEG) data and skin conductance response (SCR), a reliable autonomic marker of central activation, were recorded in healthy volunteers during the presentation of emotional (unpleasant and pleasant) and neutral pictures selected from the International Affective Picture System (IAPS). Analyses of event-related magnetic fields (ERFs) revealed greater activity at 180 ms in an occipitotemporal component for emotional pictures than for neutral counterparts. More importantly, these early effects of emotional arousal on cerebral activity were significantly correlated with later increases in SCR magnitude. For the first time, a neuromagnetic cortical component linked to a well-documented marker of bodily arousal expression of emotion, namely, the SCR, was identified and located. This finding sheds light on the time course of the brain-body interaction with emotional arousal and provides new insights into the neural bases of complex and reciprocal mind-body links.

Little is known about the genetic factors that contribute to nasal polyposis (NP). A genome-wide association study identified 10 single nucleotide polymorphisms (SNPs) associated with eosinophilia. As eosinophils play a key role in the pathogenesis of NP, we assessed if any of these SNPs contribute to genetic susceptibility of NP. We recruited 284 patients with NP in four participating hospitals in Belgium and 427 healthy controls, and genotyped 10 SNPs affecting eosinophilia (rs1420101 in IL1RL1, rs12619285 in IKZF2, rs4431128 in GATA2, rs4143832 in IL5, rs3184504 in SH2B3, rs2416257 in WDR36, rs2269426 in MHC, rs9494145 in MYB, rs748065 in GFRA2, and rs3939286 in IL33) using MALDI-TOF. A two-stage design was used while correcting for multiple testing. First stage analysis, involving 150 NP patients and 250 controls, identified rs3939286 nearby IL33 as a susceptibility factor for NP. Per at-risk A-allele, rs3939286 increased the risk for NP with an odds ratio (OR) of 1.60 (95% CI = 1.16-2.22; P = 0.0041). Second stage replication analysis in another 123 NP patients and 165 controls confirmed this association (OR = 1.43; CI = 1.00-2.06; P = 0.046). The combined analysis of both stages revealed an OR of 1.53 (CI = 1.21-1.96; P = 0.00041). Given the association of IL33 with NP, we also investigated rs1420101 in IL1RL1, which is the receptor for IL33. Although rs1420101 itself failed to associate with NP, a combined risk assessment of rs3939286 and rs1420101 further increased the risk for NP. We provide unprecedented genetic evidence suggesting a role for the IL33 pathway in the pathogenesis of NP.

Selective neck dissection (SND) is known to be a valid procedure to stage the clinically N0 neck but its reliability to control metastatic neck disease remains controversial. This study analysed if selective neck dissection is a reliable procedure to prevent regional metastatic disease in head and neck squamous cell carcinoma (HNSCC). We retrospectively analysed the medical records of 163 previously untreated patients with squamous cell carcinoma of the oral cavity, oropharynx, larynx and hypopharynx treated initially in our departement from January 1990 to December 2002. All patients had unilateral or bilateral SND, in combination with surgical resection of the primary tumour. SND was performed in 281 necks. Finally, 146 patients who underwent 249 SND (39 I-III, I-IV, 210 II-IV, II-V) had adequate follow-up and were assessed for the regional control. The median follow-up was 37 months (1-180 months). The end points of the study were neck control following SND and overall survival. Twenty-five percent (30/119) of patients staged cN0 had lymph node (LN) metastasis. Overall, regional recurrence was observed in 2.8% of the necks (7/249): 1.6% (4/249) in dissected field and 1.2% (3/249) in undissected field. Seventy-eight percent (194/249) of the necks were staged pN0 with a subsequent failure rate of 1.5% (3/194); 16% (39/249) were staged pN1 and postoperative radiotherapy (PORT) was proposed in 21 of these patients. The failure rate with PORT was 9.5% and 5.5% without PORT. Six percent (16/249) of the necks were staged pN2b and all had PORT with one subsequent recurrence. Extracapsular spread (ECS) was reported in 16.5% of positive SND specimens (9/55); all by one were treated by PORT with a subsequent failure rate of 22% (2/9). At 3 years, overall survival for the whole population was 70% and statistically highly correlated with pN stage (p<0.001). These results support the reliability of SND to stage the clinically N0 neck. SND is a definitive operation not only in

We investigated with fMRI the cortical correlates of recovery of semantic processing in a patient (DL) with left temporal damage. Names of animals, plant, and artifacts (semantic conditions) and reversed words (baseline condition) were auditorily presented to the patient and nine control subjects in a category monitoring task. Data analyses showed large differences between the patterns of domain-specific semantic activation observed in DL and the control subjects, which could be attributed to a cortical reorganization compensating for the damaged part of the semantic processing system in DL. Such reorganization relied on three main mechanisms, first, upholding of a subset of the structurally intact domain-specific regions, second, functional changes (both decreases and increases) of the domain specificity in several structurally intact regions that are normally engaged in the domain-specific network and, third, recruitment of supplementary domain-specific areas. Thus, in DL, animal-specific processing engaged supplementary areas in the left lingual gyrus and right cuneus, which correspond to animal-specific regions usually engaged in more demanding semantic tasks whereas the supplementary areas recruited for artifact-specific processing within the left superior/middle occipital lobe and right angular gyrus probably are endowed with a related but not domain-specific, semantic function. In contrast, no supplementary area contributed to plant-specific processing in DL. These findings suggest that the pattern of cortical reorganization consecutive to damage to the semantic processing network depends on the particular domain-specific function sustained by the damaged areas and the capacity of the remaining areas to assume this function.

OBJECTIVE: Mutations in genes encoding succinate dehydrogenase and its anchoring subunits (SDH genes) are at the origin of hereditary head and neck paraganglioma (PGL) and a subset of apparently sporadic pheochromocytoma. METHODS: We describe a family including three patients harbouring bilateral head and neck PGL diagnosed before 25 years of age. Multiple hypervascular hepatic lesions were subsequently discovered in two of them. In both, liver biopsy confirmed the diagnosis of PGL. In addition, in one patient, MRI disclosed multiple target-like lesions of the spine, highly suggestive of metastatic PGL. Family history was compatible with autosomal dominant inheritance with possible maternal imprinting. RESULTS: Combined single-strand conformation polymorphism and heteroduplex analysis followed by sequencing did not show any mutation of the coding parts of SDHB, SDHC, SDHD, RET or VHL genes. Screening of copy number alterations and loss of heterozygosity in the three affected family members showed no deletion or amplification of the SDH, RET and VHL genes. Furthermore, succinate dehydrogenase activity measured in a liver PGL sample was not significantly decreased in the affected patient as compared with controls, underscoring the exclusion of the SDH genes. CONCLUSIONS: To our knowledge, this is the first reported family of hereditary head and neck PGL with metastatic dissemination in the liver and the spine. A large body of evidence supports the absence of mutations in SDH, RET and VHL genes, which suggests the existence of a yet unknown gene at the origin of this particular form of familial PGL.

The objective of the study was to measure the subjective long-term effects of vocal therapy (more than 6 months) in 29 patients suffering from dysfunctional dysphonia. Four subjective measurements were used: one visual analog scale ranging from 0 (not efficient at all) to 100 (very efficient); one question "Is the speech therapy still efficient?," answered by yes or no; the GRB parameters of the GRBAS scale (evaluated by the patient); and the VHI-10. The results show that 76% of the patients consider that the vocal therapy they received is still efficient. On the vocal quality (G), roughness (R), and breathiness (B) parameters, we observe a high degree of satisfaction on the G parameter (median=77). The scores on the R and B parameters are lower (median R=12, S=5). Roughness is significantly correlated to the Grade (Spearman coefficient r=0.516, P=0.004), whereas breathiness is not (P=0.251, NS). The comparison of the results on the VHI-10 pre and post treatment shows a significant decrease in the grade of perceived handicap (medians 15 vs 11, P=0.017). The correlations between the judgment of the treatment's efficacy and the vocal quality is significant (r=0.623, P<0.001) as well as the correlation between the VHI-10 and the length of the treatment (r=0.416, P=0.035). The conclusion can be made that speech therapy plays an important role in long-term treatment of dysfunctional dysphonias.

When damaged perinatally, as in congenital hemiplegia (CH), the corticospinal tract usually undergoes an extensive reorganization, such as the stabilization of normally transient projections to the ipsilateral spinal cord. Whether the reorganization of the corticospinal projections occurring in CH patients is also accompanied by a topographical rearrangement of the hand representations in the primary motor cortex (M1) remains unclear. To address this issue, we mapped, for both hands, the representation of the first dorsal interosseous muscle (1DI) in 12 CH patients by using transcranial magnetic stimulation co-registered onto individual three-dimensional magnetic resonance imaging; these maps were compared with those gathered in age-matched controls (n = 11). In the damaged hemisphere of CH patients, the representation of the paretic 1DI was either found in the hand knob of M1 (n = 5), shifted caudally (n = 5), or missing (n = 2). In the intact hemisphere of six CH patients, an additional, ipsilateral, representation of the paretic 1DI was found in the hand knob, where it overlapped exactly the representation of the non-paretic 1DI. In the other six CH patients, the ipsilateral representation of the paretic 1DI was either shifted caudally (n = 2) or was lacking (n = 4). Surprisingly, in these two subgroups of patients, the representation of the contralateral non-paretic 1DI was found in a more medio-dorsal position than in controls. The present study demonstrates that, besides the well-known reorganization of the corticospinal projections, early brain injuries may also lead to a topographical rearrangement of the representations of both the paretic and non-paretic hands in M1.

Recently, a self-reported scale of activity limitations, the ACTIVLIM questionnaire, was developed and validated in patients with neuromuscular disorders (NMD). The purpose of this study was to investigate its sensitivity to change. One hundred thirty-two patients with NMD (mean age, range: 31, 6-80) were assessed twice, with 21+/-4 months in between, using the ACTIVLIM questionnaire. Mean score change, effect size, standardized response, mean paired t-test and an individual-level statistical approach were calculated for groups of patients according to their self-rated functional status evolution and for three main diagnostic groups (Ambulant and wheelchair-bound Duchenne muscular dystrophy patients, myotonic dystrophy patients, and patients with Charcot-Marie-Tooth neuropathy). The responsiveness indices showed that the change in activity measures was higher in patients who reported deteriorated functional status and in patients with Duchenne muscular dystrophy. The ACTIVLIM questionnaire showed a good sensitivity to change and could be useful in research settings to characterize the disease course of NMD.

We report a case of a 9-month-old baby admitted to the hospital because of low-grade fever, focal seizures in a context of watery diarrhea for 14 days' duration. The patient workup revealed a mild neutrophilic pleocytosis on cerebrospinal fluid (46 cells/mul), a positive stool culture for Salmonella pomona sensitive to ceftriaxone and ciprofloxacin, and a subdural empyema (SDE) on the cerebral MRI. The child received an intravenous third-generation cephalosporin for 4 weeks which resulted in cure. This case highlights an unusual extra-intestinal complication of non-typhoid salmonella infection. Involvement of the central nervous system with non-typhoidal salmonellosis is an important complication that can result in significant morbidity if not recognized and treated promptly. A focal intra-cranial infection must be considered in the differential diagnosis of any child presenting with focal seizures and gastroenteritis due to Salmonella. Appropriate diagnostic imaging of the head (cerebral CT scan with contrast and/or MRI) is mandatory to exclude the presence of an intra-cranial complication, even in the presence of negative CSF culture for Salmonella. Subfrontal and subtemporal SDE are sometimes missed on axial CT scans and better appreciated on MRI. Non-surgical treatment of small subdural empyemas with prolonged intravenous antibiotic therapy is a therapeutic option.

OBJECTIVE: Although numerous studies have shown that transsphenoidal surgery is the best initial treatment for Cushing disease offering 59-95% of success, fewer information is available on the long-term outcome in the subgroup of patients harboring ACTH-secreting macroadenomas. The aims of this study were to analyze our 10-year experience with transsphenoidal surgery in Cushing's disease and to examine whether remission rates were different between micro- and macroadenomas. PATIENTS AND METHODS: Forty consecutive patients with proven Cushing's disease (28 microadenomas, 12 macroadenomas [diameter: 10-25mm], 3 patients with no visible adenoma at MRI) underwent transsphenoidal surgery (TSS) assisted by neuronavigation in our center between 1996 and 2007. The diagnosis was made using standard endocrinological criteria including bilateral inferior petrosal sinus sampling (BIPSS) with CRH stimulation in all patients with discordant or equivocal biochemical and radiological testing. Morning serum cortisol was measured during the first week postoperatively, and a complete endocrine evaluation was made in all patients at 6-8 weeks. Remission at follow-up was defined as a normal postoperative 24-h urinary free cortisol (UFC) or continued need for glucocorticoid hormone replacement after TSS. RESULTS: Overall, 32/40 patients (80%) were in remission after one or more TSS. Interestingly, a very good remission rate (92%) was observed in the subset of macroadenomas, similar to that found in the group of microadenomas (84%, NS), while no post-surgical remission was observed in the 3 patients with no visible adenoma at MRI (p<0.01). Of the 8 patients not in remission after repeated TSS surgery, 3 underwent radiation therapy and three had bilateral adrenalectomy, allowing remission of their hypercortisolism. There was minor morbidity and no death. CONCLUSION: While our overall results are in accordance with other published series, we show here that ACTH-secreting pituitary macroaden

BACKGROUND AND PURPOSE: Recent work demonstrated that application of peripheral nerve and cortical stimulation independently can induce modest improvements in motor performance in patients with stroke. The purpose of this study was to test the hypothesis that combining peripheral nerve stimulation (PNS) to the paretic hand with anodal direct current stimulation (tDCS) to the ipsilesional primary motor cortex (M1) would facilitate beneficial effects of motor training more than each intervention alone or sham (tDCSSham and PNSSham). METHODS: Nine chronic stroke patients completed a blinded crossover designed study. In separate sessions, we investigated the effects of single applications of PNS+tDCS, PNS+tDCSSham, tDCS+PNSSham, and PNSSham+tDCSSham before motor training on the ability to perform finger motor sequences with the paretic hand. RESULTS: PNS+tDCS resulted in a 41.3% improvement in the number of correct key presses relative to PNSSham+tDCSSham, 15.4% relative to PNS+tDCSSham, and 22.7% relative to tDCS+PNSSham. These performance differences were maintained 1 and 6 days after the end of the training. CONCLUSIONS: These results indicate that combining PNS with tDCS can facilitate the beneficial effects of training on motor performance beyond levels reached with each intervention alone, a finding of relevance for the neurorehabilitation of motor impairments after stroke.

This paper is about the computer use by teenagers, often estimated abusive by their family circle. In most cases, it is a "simple abundant use" more than a true addiction or a passion. The author describes the psychosocial mechanisms of such behaviours and the characteristics of each one. Finally, he describes how the adults, teachers and nursing staff can face up their responsibilities to contribute towards a safe use of multimedia in young people.

TOPIC: Olfactory dysfunction may be assessed in the clinic with psychophysical testing and electrophysiological recording. Chemosensory event-related potentials (CSERPs) constitute an objective method to assess chemosensory function. Olfactory and trigeminal stimuli activate chemoreceptors from the olfactory neuroepithelium and from the nasal mucosa to evoke an electrophysiological response respectively called olfactory (OERPs) and trigeminal ERPs (TERPs). The purpose of this study is to assess the usefulness and feasibility of these diagnostic tools in the rhinology clinic and to correlate these results to the olfactory disorder aetiology. MATERIALS AND METHODS: This study encompasses a cohort of 229 patients with a complaint of olfactory dysfunction from different origins. Orthonasal (Sniffing stick test with the treshold-discrimination-identification score: maximal score 48) and retronasal olfactory (maximal score 20) testing as well as CSERPs both after olfactory and trigeminal stimuli have been routinely performed. Olfactory dysfunction aetiologies were as follows: congenital (Cong.), chronic rhinosinusitis (CRS), idiopathic (Idiop.), post-medication (PM), neurologic (Neuro.), post-traumatic (PT) and post-infection (PI). RESULTS: Mean orthonasal and retronasal scores were respectively: 11.8 and 10.1 for Cong., 18.5 and 13.1 for CRS, 15.6 and 10.4 for Idiop., 15.3 and 10.2 for PM, 17 and 10.6 for Neuro., 15 and 9.9 for PT and 18.3 and 12 for PI. Correlations between orthonasal and retronasal scores were present for all subgroups except congenital and chronic rhinosinusitis subgroups. Orthonasal and retronasal scores were different (p < 0.05) when comparing CRS vs Cong., CRS vs PT and PT vs PI. Technical problems (olfactometer or olfactory stimulation, EEG amplifier,...) and patients discomfort (anxiety, stress,...) did not allow to draw any conclusion in 2 patients. Three patients after olfactory stimulus and 6 patients after trigeminal stimulus demonstrated too

Dacryocystorhinostomy (DCR) in children is indicated in cases of common congenital nasolacrimal duct obstruction (CNLDO) unresponsive to medical therapy, probing or intubation. The purpose of this manuscript is to evaluate the effectiveness of endonasal endoscopic pediatric DCR. The authors present a series of eight children (seven boys and one girl) who underwent a pediatric endonasal DCR between September 2007 and December 2008. The mean age was: 4.3 years (range: 8 months to 9 years old). Three children had a craniofacial abnormality. There were ten primary DCRs and one revision DCR. In nine cases, the indication was a pure primary low mechanical obstruction persistent after one or more probings. In the 10th case there was also a stenosis of the inferior canaliculus diagnosed during the DCR. The revision DCR was indicated because of the closure of the stoma created 3 years ago. A silicone intubation was put in place only in two cases: in case of a stenosis of the inferior canaliculus (3 months) and the other in case of revision DCR (1 month). The follow-up for primary DCRs was 10.5 months (range: 6-15) and for revision surgery 6 months (after the retrieve of the stent). In primary DCRs, there was a complete resolution of symptoms in nine out of 10 cases. The 10th case experienced a transient slight epiphora during a viral rhinitis. In case of revision DCR, the child was free of symptoms. In conclusion pediatric DCR is a very effective and safe procedure for the treatment of a low mechanical obstruction of the lacrimal pathway in children unresponsive to previous probings. Stenosis of the inferior canaliculus can give some slight intermittent epiphora despite a wide and patent stoma. Moreover craniofacial abnormalities are more common in children than in adults undergoing a DCR.

INTRODUCTION: Botulinum toxin type A (BoNT-A) injections are known to improve walking impairments and activity in spastic hemiparetic stroke patients presenting with a stiff-knee gait [Caty GD, Detrembleur C, Bleyenheuft C, Deltombe T, Lejeune TM. Effect of simultaneous botulinum toxin injections into several muscles on impairment, activity, participation, and quality of life among stroke patients presenting with a stiff knee gait. Stroke 2008;39(October (10)):2803-8]. The aim of the present study was to understand how the improvement of mechanical variables during gait is controlled by the central nervous system after BoNT-A injections. Therefore, we used Kinematic Segmental Coordination (KSC), i.e. the kinematic covariation law of elevation angles between lower limb segments, to assess their effect on gait control. As far as we know, this has never been studied before. METHODS: Twenty chronic hemiparetic stroke patients presenting with a stiff-knee gait performed an instrumented gait analysis at the same walking speed before and 2 months after BoNT-A injection in several spastic muscles. We used the kinematic recordings previously obtained by Caty et al. [Caty GD, Detrembleur C, Bleyenheuft C, Deltombe T, Lejeune TM. Effect of simultaneous botulinum toxin injections into several muscles on impairment, activity, participation, and quality of life among stroke patients presenting with a stiff knee gait. Stroke 2008;39(October (10)):2803-8] and computed KSC following Borghese's methodology. The treatment effect was tested using a repeated measures ANOVA. RESULTS: BoNT-A injections allowed a statistically significant improvement in KSC of both lower limbs (p=0.004). Moreover, the unaffected side KSC reached normal values after BoNT-A injections. CONCLUSION AND DISCUSSION: BoNT-A allowed an improvement in KSC of the affected lower limb and a normalization of KSC of the unaffected limb. This improvement could either be due to a mechanical effect or a central effect of B

The olfactory bulb collects the sensory afferents of the olfactory receptor cells located in the olfactory neuroepithelium. The olfactory bulb ends with the olfactory tract and is closely related to the olfactory sulcus of the frontal lobe. Many studies demonstrated that olfactory bulb volume assessed with magnetic resonance imaging is related to the olfactory function both in normal and pathological conditions. It has been shown that olfactory bulb volume changes with the degree of olfactory dysfunction, that it decreases with the duration of the olfactory loss and that patients with qualitative disorder such as parosmia have smaller olfactory bulbs than patients without parosmia. In this review, we will discuss the actual knowledge regarding olfactory bulb function, practical ways to measure olfactory bulb volume and olfactory sulcus depth, and report systematic observations regarding these measurements related to various causes of olfactory dysfunction, e.g. infection of the upper respiratory tract, head trauma, or neurodegenerative disease. Measurement of olfactory bulb volume may provide valuable information for patients with olfactory dysfunction.

Previous studies showed that early blind humans develop superior abilities in the use of their remaining senses, hypothetically due to a functional reorganization of the deprived visual brain areas. While auditory and tactile functions have been investigated for long, little is known about the effects of early visual deprivation on olfactory processing. However, blind humans make an extensive use of olfactory information in their daily life. Here we investigated olfactory discrimination and identification abilities in early blind subjects and age-matched sighted controls. Three levels of cuing were used in the identification task, i.e. free-identification (no cue), categorization (semantic cues) and multiple choice (semantic and phonological cues). Early blind subjects significantly outperformed the controls in odour discrimination, free-identification and categorization. In addition, the larger group difference was observed in the free-identification as compared to the categorization and the multiple choice conditions. This indicated that a better access to the semantic information from odour perception accounted for part of the improved olfactory performances in odour identification in the blind. We concluded that early blind subjects have both improved perceptual abilities and a better access to the information stored in semantic memory than sighted subjects.

AIMS: Emotional facial expression (EFE) decoding impairment has been repeatedly reported in alcoholism (e.g. Philippot et al., 1999). Nevertheless, several questions are still under debate concerning this alteration, notably its generalization to other emotional stimuli and its variation according to the emotional valence of stimuli. METHODS: Eighteen recently detoxified alcoholic subjects and 18 matched controls performed a decoding test consisting in emotional intensity ratings on various stimuli (faces, voices, body postures and written scenarios) depicting different emotions (anger, fear, happiness, neutral, sadness). Perceived threat and difficulty were also assessed for each stimulus. RESULTS: Alcoholic individuals had a preserved decoding performance for happiness stimuli, but alcoholism was associated with an underestimation of sadness and fear, and with a general overestimation of anger. More importantly, these decoding impairments were observed for faces, voices and postures but not for written scenarios. CONCLUSIONS: We observed for the first time a generalized emotional decoding impairment in alcoholism, as this impairment is present not only for faces but also for other visual (i.e. body postures) and auditory stimuli. Moreover, we report that this alteration (1) is mainly indexed by an overestimation of anger and (2) cannot be explained by an 'affect labelling' impairment, as the semantic comprehension of written emotional scenarios is preserved. Fundamental and clinical implications are discussed.

OBJECTIVE: The aim of this study was to evaluate long-term results of endoscopic surgery for supraglottic carcinoma. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care university hospital. SUBJECTS AND METHODS: From 1992 to 2004, 45 patients diagnosed with supraglottic squamous cell carcinoma (two Tis, nine T1N0, 27 T2N0, two T2N1, one T2N2, four T3N0) underwent different types of endoscopic supraglottic laryngectomies according to the European Laryngological Society (ELS) classification: three limited excision (type I); 27 medial without resection of the preepiglottic space (type IIb); one medial with resection of the preepiglottic space (type IIIa); three medial with resection of the preepiglottic space (type IIIb); nine lateral (type IVa); two lateral (type IVb). RESULTS: Overall survival was 93 +/- 4 percent (SE) after three years and 89 +/- 6 percent (SE) after five years. The median follow-up is 3.7 years. Patients with clinically N0 necks were found to have positive nodes in eight (19%) cases. Two cases of postoperative hemorrhage were controlled by electrocautery. All of the patients without previous treatment for larynx cancer regained swallowing function within five days to three weeks after surgery. Mean duration of hospitalization was 12.5 days. CONCLUSION: Endoscopic partial laryngectomies, as defined by the ELS classification, for selected supraglottic squamous cell carcinoma proved to be an excellent alternative to radiotherapy and open neck surgery.

In July 1999, the European Laryngological Society (ELS) has accepted a proposal for the classification of different laryngeal endoscopic cordectomies. This is actually a common classification system used as a tool for surgical training, documentation and comparison of results. The same harmonization work is deemed necessary for the treatment of supraglottic lesions. The ELS is proposing a classification of the different laryngeal endoscopic supraglottic partial laryngectomies. This classification comprises four types of supraglottic laryngectomies: Type I, limited excision of small size superficial lesions of the free edge of the epiglottis, the ary-epiglottic fold, the arytenoid, or the ventricular fold or any other part of the supraglottis; Type II, medial supraglottic laryngectomy without resection of the pre-epiglottic space, suitable for T1 lesions of either the suprahyoid or the infrahyoid laryngeal surface of the epiglottis (Type IIa, superior hemi-epiglottectomy or Type IIb, total epiglottectomy, respectively); Type III, medial supraglottic laryngectomy with resection of the pre-epiglottic space, suitable for T1-T2 tumors of the infrahyoid endolaryngeal epiglottis without (Type IIIa) or with (Type IIIb) extension to the ventricular fold, necessitating its excision; finally, Type IV, lateral supraglottic laryngectomy, suitable for tumors of the threefolds' region, which may include the ventricular fold (Type IVa) or the arytenoid (Type IVb), when involved. As in the cases of endoscopic cordectomies, these operations are similarly classified according to the surgical approach used and the degree of resection completed in order to facilitate their use in daily clinical practice.

There has been an ongoing confusion among pathologists in their attempt to accurately identify lesions of Reinke's space. Nodules, polyps and Reinke's edema fall in the same basket and differentiation between them relies largely on the clinical description of the pathologic specimen by the operating surgeon than on their distinct pathologic features. By revising the pertinent literature, the need for an establishment of the aforementioned term still remains and is further stressed out, as confusion among the various pathologic descriptions of these lesions still exists. This is further verified by a study conducted in the Department of Otorhinolaryngology-Head and Neck Surgery of the University Hospital of Louvain at Mont-Godinne, Belgium, involving 323 operative specimens obtained from 200 patients with macroscopic picture. Statistical analysis showed lack of agreement between surgical and histopathologic diagnosis in almost a third of the cases (Cohen's kappa coefficient of 0.683 +/- 0.037, P < 0.001). We, therefore, propose the term "exudative lesions of Reinke's space" to include Reinke's edema, polyps and nodules. These lesions share common histologic features, which are located in the Reinke's space and whose macroscopic appearance is largely dependent upon the presence and duration of certain causative factors.

OBJECTIVE: ERTL (Epreuves de Repérage de Troubles de Langage) tests have been designed as a screening test to detect rapidly language disorders. To evaluate the effectiveness of these tests, we have compared them to the form P (NEEL-P) tests for the examination of language in 6 children with a 22q11 microdeletion. MATERIALS AND METHOD: 6 children aged from 4 years and 4 months to 5 years and 4 months, 4 boys and 2 girls have been tested. These tests have been performed in two sessions lasting between 1 and 1 1/2 hour. RESULTS: They are consistent in both tests. ERTL has identified all the children with a disorder. CONCLUSION: These fast tests should be used more often to detect children requiring additional and more complex language and neuropsychological evaluations.

BACKGROUND AND PURPOSE: The purpose of this study was to study the effect of Botulinum toxin type A (BoNT-A) injections in spastic upper limb muscles on impairment, activity, participation and quality of life in chronic stroke patients. METHODS: BoNT-A (Dysport) was injected into several upper limb spastic muscles in a group of 20 patients. Neurological impairment (muscle tone and strength, dexterity, SIAS), activity (ABILHAND), participation (SATIS-Stroke), and quality of life (SF36) were assessed before and 2 months after the injections. RESULTS: BoNT-A injections improved muscle tone, but had no impact on dexterity, manual ability, social participation, and quality of life. CONCLUSIONS: In this study, BoNT-A injections in spastic upper limbs significantly reduced neurological impairments, but had no functional impact.

OBJECTIVES: We report on the auditory abilities and speech performance in quiet and noise of 35 children with sequential bilateral cochlear implantation after 3 years of bilateral implant use. METHODS: Testing was done in bilateral and both unilateral listening conditions. The assessments took place before the second implantation and at several time intervals after fitting. As different auditory tests were used, the children were categorized by their age at the second implantation: younger or older than 6 years. RESULTS: The pure tone averages for the bilateral condition were significantly better than those for either unilateral condition after 12 months of bilateral implant use and remained so from that test interval onward. The speech recognition outcomes in quiet and noise also improved significantly for almost all children after 36 months, although a linear regression analysis showed a beneficial effect of younger age at first implantation on the speech-in-noise results. CONCLUSIONS: Bilateral cochlear implantation offered advantages to all children in comparison with the first implant--even the children who received the second implant after the age of 6 years. Compared to the younger children, the older children needed a longer adjustment period to gain bilateral benefit. However, they obtained similar results after 2 years of bilateral implant use.

The optimal timing and extent of neck dissection in the context of chemoradiation for head and neck cancer remains controversial. For some institutions, it is uncertain whether neck dissection should still be performed upfront especially for cystic nodes. For others, neck dissection can be performed after chemoradiation and can be omitted for N1 disease as long as a complete response to chemoradiation is obtained. The question is debated for N2 and N3 disease even after a complete response as the correlation between radiological and clinical assessment and pathology may not be reliable. Response rates are greater than or equal to 60% and isolated neck failures are less than or equal to 10% with current chemoradiation protocols. Some therefore consider that systematic upfront or planned neck dissection would lead to greater than or equal to 50% unnecessary neck dissections for N2-N3 disease. Positron-emission tomography (PET) scanning to assess treatment response and have shown a very high negative predictive value of greater than or equal to 95% when using a standard uptake value of 3 for patients with a negative PET at four months after the completion of therapy. These data may support the practice of observing PET-negative necks. More evidence-based data are awaited to assess the need for neck dissection on PET. Selective neck dissection based on radiological assessment and peroperative findings and not exclusively on initial nodal stage may help to limit morbidity and to improve the quality of life without increasing the risk of neck failure. Adjuvant regional radiation boosts might be discussed on an individual basis for aggressive residual nodal disease with extracapsular spread and uncertain margins but evidence is missing. Medical treatments aiming at reducing the metastatic risk especially for N3 disease are to be evaluated.

OBJECTIVE: To examine the effects of sequential bilateral cochlear implantation (CI) on the life of young children after 36 months of bilateral implant use. METHOD: Thirty-five children were assessed prior to and 3 until 36 months after activation of the second CI. Main outcome measures were: the Categories of Auditory Performance (CAP), Speech Intelligibility Rating (SIR), communication mode, classroom placement, parent reports and the Würzburg questionnaire. Results were analysed separately for children younger and older than 6 years at the time of the second implantation. RESULTS: At the 3-year test interval, 80% of the younger children attended mainstream schools and were comprehensible for all listeners. They all used oral communication and almost 70% of them could have a conversation over the telephone. After 3 years of bilateral implant use less than 50% of the older children obtained the highest score on the SIR and CAP. Approximately 70% of them was integrated in mainstream schools and used oral communication. All parents reported a more natural communication and an improved quality of life. CONCLUSIONS: Sequential bilateral implantation seems to offer a wide range of participation benefits to all children and facilitates the social intercourse with their hearing environment.

OBJECTIVE: To investigate the subjective benefits of bilateral cochlear implantation in 33 young children after 18 months of second implant use. METHOD: The Wurzburg questionnaire inquiring into a range of hearing functions was filled out by the parents. Additional data concerning the daily life and well-being of the children were gathered with an open-ended questionnaire and the Categories of Auditory Performance. Results were analyzed separately for children younger and older than 6 years at the time of the second implantation. RESULTS: After 18 months of bilateral implant use 30% of the younger and 6% of the older children made the transition to an auditory-oral communication. In this period, 15% of all children switched to mainstream schools. The parents reported an evolution of their children's auditory abilities, which included a better sound and speech perception. Multiregression analysis revealed that early hearing aid fitting and the age at the second cochlear implantation significantly contributed to the variance of the Wurzburg results. CONCLUSIONS: The results indicate a wide range of positive subjective changes associated with bilateral cochlear implantation, even in older children. This progress led to a better and easier communication and a better integration in the normal-hearing world.

OBJECTIVES:: In this study, procedures for measuring sound localization, sound lateralization, and binaural masking level differences (BMLDs) in young children were developed. Sensitivity for these tasks was assessed in large groups of children between 4 and 9 yr of age to investigate potential developmental trends. DESIGN:: Sound localization was measured in the sound field, with a broadband bell-ring presented from one of nine loudspeakers positioned in the frontal horizontal field. A group of 33 children between 4 and 6 yr of age and 5 adults took part in this experiment. Sound lateralization based on interaural time differences was measured with headphones in 49 children between 4 and 9 yr of age and 10 adults. A low-frequency stimulus containing harmonics 2 to 5 from a click train with a rate of 160 Hz was used. In the BMLD test, the same filtered click train was presented diotically or dichotically (phase reversed or time delayed) in a broadband (200 to 1000 Hz) frozen noise to 23 children between 4 and 6 yr of age and 10 adults. For comparison with literature, additional measurements with a 500-Hz sinusoid were administered to adults. All tasks were adapted to the interest and attention span of young children. RESULTS:: Children of 5 yr of age did not perform significantly different from adults on the sound localization task, but mean absolute errors were larger for the 4 yr olds. Also on the BMLD task, 5-yr-old children performed at the adult level, whereas the 4-yr-old children obtained significantly less binaural unmasking compared with the adults. Concerning sound lateralization, a small but significant difference between adults and children existed, but no age effects were apparent in the 4- to 9-yr-old group. Overall, the variation was relatively large in the 4-yr-old group, with some of the children performing at adult level, in all three tasks. CONCLUSIONS:: The results of this study show that the modified procedures are suitable for testing children

Bilateral cochlear implants (CIs) may offer deaf children a range of advantages compared to unilateral CIs. However, speech perception in noise is mainly facilitated by better-ear effects and much less by interaural comparisons or true 'binaural' hearing. Little is known about the development of the binaural auditory system with CIs provided at a young age. It is possible that, as with adults, binaural sensitivity exists but is not accessed due to technical limitations in electrical stimulation methods. In this paper, we present results on binaural hearing in children with bilateral CIs. Binaural masking level differences (BMLDs) were measured for a 180-degree phase shift in a 125-Hz sinusoid, presented in a 50-Hz-wide noise band and modulating a 1000-pps carrier pulse train. Stimuli were presented to a single electrode in the middle of the electrode array at both ears. Eight children between 6 and 15 years of age participated in this study. Six children had a significantly better detection threshold when the signal was out of phase (dichotic) between two ears than when it was in phase (diotic), with a mean difference (BMLD) of 6.4 dB. The present results show that children with bilateral CIs are sensitive to binaural cues in electrical stimuli, similar to adults, even when implants are provided at a later age and with a longer delay between implantations.

Differentiation of progenitor cells into neurons in the olfactory bulb depends on olfactory stimulation that can lead to an increase in olfactory bulb volume. In this study, we investigated whether the human olfactory bulb volume increases with increasing olfactory function due to treatment of chronic rhinosinusitis. Nineteen patients with chronic rhinosinusitis were investigated before and after treatment. For comparison, additional measurements were performed in 18 healthy volunteers. Volumetric measurements of the olfactory bulb were based on planimetric manual contouring of magnetic resonance scans. Olfactory function was evaluated separately for each nostril using tests for odour threshold, odour discrimination and odour identification. Measurements were performed on two occasions, 3 months apart. In healthy controls, the olfactory bulb volume did not change significantly between the two measurements. In contrast, the olfactory bulb volume in patients increased significantly from the initial 64.5 +/- 3.2 to 70.0 +/- 3.5 mm(3) on the left side (P = 0.02) and from 60.9 +/- 3.5 to 72.4 +/- 2.8 mm(3) on the right side (P < 0.001). The increase in olfactory bulb volume correlated significantly with an increase in odour thresholds (r = 0.60, P = 0.006, left side; r = 0.49, P = 0.03, right side), but not with changes in odour discrimination or odour identification. Results of this study support the idea that stimulation of olfactory receptor neurons impacts on the cell death in the olfactory bulb, not only in rodents but also in humans. To our knowledge, this is the first longitudinal study that describes an enlargement of the human olfactory bulb due to improvement of peripheral olfactory function.

A dacryocystocele refers to a sterile cystic dilatation of the lacrimal sac resulting from a complete obstruction of the lacrimal pathway above and below the lacrimal sac. In most cases, it is a congenital disorder that typically occurs in neonates. It is characterized by a bluish cystic swelling just below the medial canthus accompanied by epiphora. In some cases, there is also an intranasal expansion beneath the inferior turbinate. When this expansion is large and bilateral, it can lead to respiratory distress in neonates since they are obligate nasal breathers. Although congenital dacryocystoceles may resolve with conservative measures, many become infected and require systemic antibiotic treatment, and most require early surgical intervention. Herein, the authors report a rare case of dacryocystocele in an adult that was successfully managed with an endonasal endoscopic dacryocystorhinostomy. The pre-operative images and the intra-operative findings are shown, and the available literature is reviewed.

STUDY AIM: To assess the physiological variables among Upper Esophageal Sphincter Nadir (UESN), Hypopharyngeal Peak Pressure (HPP) and Pharyngo-Esophageal Pressure Gradient (PEPG) for Videofluoromanometry (VFM). PATIENTS & METHOD: Exploratory non-randomised prospective study comparing UESN, HPP and PEPG of three cohorts of individuals presumably presenting very distinctive "manometric signatures" based on McConnel's Piston Model of swallowing: 11 non-dysphagic volunteers called the Control Group (CG), 10 dysphagic patients presenting a Myotonic Dystrophy (MD), at various stages of evolution, and 10 patients presenting a CricoPharyngeal Barr (CPB), with no post-swallow pharyngeal residue at a previous Modified Barium Swallow (MBS). VFM tests are performed using solid-state three unidirectional transducers produced by Gaeltec Inc. The simultaneous display storage of the standard fluoroscopic swallow of 10 ml liquid barium with UESN and HPP measurements, continuously recorded on a 3-channel polygraph, is performed using a Kay-Pentax Swallowing Work Station. PEPG calculations are subsequently made. RESULTS: Significant different HPP and PEPG values were observed between the three cohorts. MD patients presented HPP and PEPG below 100 mmHg while CPB patients presented HPP and PEPG above 200 mmHg. The CG presented HPP and PEPG between 100 and 200 mmHg. UESN values revealed no significant difference between the three cohorts. A reading scale is proposed. The aim of the scale is to make a link between HPP or PEPG values and physiopathological (not diagnostic) conditions. Patients presenting an HPP or PEPG below 100 mmHg indicate a High probability of Pharyngeal Propulsion Impairment while patients presenting an HPP or PEPG above 200 mmHg are more likely to have an Increased Flow Resistance with appropriate Propulsion Response. Pros and cons for calculation of the PEPG, representing a possibly unnecessary step, are discussed. CONCLUSIONS: In our study, the use of HPP or PEPG

OBJECTIVE: To determine the epidemiology and the clinical and therapeutic outcomes of conjunctival nevi and to identify the clinical variables statistically associated with operative excision. DESIGN: Prospective, observational, noncomparative case series. PARTICIPANTS: Two hundred fifty-five patients with the clinical diagnosis of conjunctival nevus. METHODS: Consecutive cases of conjunctival nevi managed at a single institution were studied to identify the clinical risk factors for operative excision. MAIN OUTCOME MEASURES: Reasons for operative excision. RESULTS: Of the 255 patients who were periodically observed for a mean of 5.3 years (range, 1-11), nevi were clinically diagnosed in 140 females and 115 males and modified operative excision was performed in 75 patients (29%). The decision of operative excision was made by the surgeon in 13 cases (17%) and by the patient in 62 cases (83%). In those 13 patients, the operative decision was prompted by our concern for possible malignant transformation based on suspicious biomicroscopic features in 10 patients (13%) and photographically documented tumor growth in 3 patients (4%). For the other 62 patients who elected to undergo surgery, their reasons for excision included patient's concern for cancer in 34 cases (45%), cosmetic arguments in 9 cases (12%), and patient's request owing to lesion-induced ocular surface irritation in 19 cases (25%). Comparison between groups showed that the clinical factors at initial visit that were statistically predictive of surgical excision were the older age of the patient (P = 0.001), the largest basal tumor diameter (P<0.001), tumor location (P = 0.023), and presence of clear cysts (P = 0.013), of intrinsic vasculature (P<0.001), of prominent feeder vessels (P<0.001), and of corneal involvement (P = 0.008). None of the excised lesions showed histopathologically malignant features. CONCLUSIONS: In our series, documented tumor growth of conjunctival nevus remained relatively a uncom

A Pott's Puffy Tumour (PPT) is a rare clinical entity, which, traditionally has been described as an acute abscess with periosteitis secondary to osteomyelitis of the external table of the frontal bone of the skull, complicating an acute frontal sinusitis. The aim of this article is to present a case of progressively evolving PPT, which emerged during the course of a common rhinitis, in a patient who, thirty years previously, had undergone a reconstruction of the frontal sinus involving osteosynthesis. The patient was treated with antibiotic therapy coupled with external access surgery using the Cairn Unterberger approach. This allowed the drainage of pus, the removal of infected osteosynthetic material and a complete debridement of osteomyelitic bone from the affected area. Frontal sinus obliteration was undertaken using methyl methacrylate, preferable in this case to hydroxyapatite, due to the direct communication with the neighbouring sinus cavities and the presence of defective bone in the superior orbit. A review of literature available on Medline up to January 2008 reveals that this is the third published case of PPT complicating a frontal reconstruction.

We report two cases of postoperative unilateral hypoglossal nerve palsy following uncomplicated orotracheal intubation for plastic surgery. Both patients underwent a long procedure and were installed in a non physiological position. These two factors might have played an important role in the mechanism of nerve damage. Furthermore, other etiologies of neurological injury like a difficult airway or anatomical anomalies were not present. The aim of these two case reports is to sensitize the anesthetists to hypoglossal nerve palsy and to highlight a potential clinical problem of positioning during plastic surgery.

In combination with psychophysical testing and electrophysiological studies, magnetic resonance imaging plays a role in the clinical evaluation of patients with an olfactory dysfunction. Quantitative measurements of olfactory bulb volume and of olfactory sulcus depth, and the morphological depiction of structural abnormalities, make synergistic contributions to the accurate radiological diagnosis of smell dysfunction. Moreover, the plasticity of our olfactory system can be demonstrated by temporal changes in OB volumetric measurements. In this paper, we provide an outline of how to measure olfactory bulb volume and olfactory sulcus depth, with numerous illustrative cases of patients with congenital anosmia, post-infectious or posttraumatic olfactory loss and sinonasal-related olfactory dysfunction.

Wegener's granulomatosis (WG) is one form of idiopathic autoimmune vasculitis. The disease has a predilection for the upper and lower respiratory tracts (lungs, nose, sinus), and kidneys. WG may be systemic, severe, and potentially lethal, but it may also be limited to the otolaryngological area or to the eyes and the orbits. Obstruction of the lacrimal pathway is a possible complication of the disease that affects approximately 7% of patients with WG. It usually occurs as a direct extension of sinonasal disease and typically is a late manifestation. Management of such a condition is generally viewed as difficult. We report the case of a patient with a quiescent WG limited to the otolaryngological area. This patient presented a bilateral obstruction of the nasolacrimal ducts caused by bilateral extensive adhesions in the nasal cavity. Because she had several episodes of left-side acute dacryocystitis which necessitated several courses of broad-spectrum antibiotics, she successfully underwent an endonasal endoscopic dacryocystorhinostomy using a diode laser and powered instrumentation. The authors describe the clinical case, the surgical technique, and review the literature.

OBJECTIVES: Post-traumatic olfactory loss (PTOL) is the third most common aetiology for olfactory disorders. Mechanisms that lead to post-traumatic olfactory disorders include sinonasal affections, damage to the olfactory nerve and lesions of the cerebral olfactory centres. The purpose of this review is to present an update of this condition and to present a cohort study of 90 patients. METHODOLOGY: A review of the literature was made on Medline Pubmed up to May 2009 and a review was also conducted of patients with post-traumatic olfactory loss. RESULTS: The degree of olfactory impairment was related to the severity of head trauma and was particularly frequent in cases of occipital impact. Typically, patients experienced a sudden onset of olfactory symptoms and were more severely affected than in other aetiologies. Results from orthonasal and retronasal testing, chemosensory event-related potentials and olfactory bulb (OB) volume confirmed previous findings: patients are usually anosmic, OB volume correlates with the degree of olfactory loss (better correlation with retronasal scores than with orthonasal scores) and olfactory event-related potentials were recorded in only 18 patients. CONCLUSIONS: Accuracy in the evaluation of PTOL patients is based on the expertise and the time spent by the clinician on defining the complaint. Failing treatment, complete evaluation of the PTOL patients may help in counselling for the recovery prognosis, and appropriate counselling must be given to secure the environment and alimentation.

PURPOSE: Report a case of a patient, who benefitted from the I-gel, during an elective urological surgery and who presented severe laryngeal hemorrhage at the time of its withdrawal. CLINICAL FEATURES: A 71-year-old male patient had been admitted in the operating room for the insertion of a ureteral stent. He had a history of usual interstitial pneumonia (UIP) requiring corticosteroids and oxygen therapy and a severe obstructive sleep apnea syndrome treated with nasal continuous positive airway pressure (NCPAP). After intravenous induction of anesthesia, a size 5 I-gel (Intersurgical, Wokhingam, UK) was easily inserted in the first attempt. Anesthesia was maintained with sevoflurane. As soon as the procedure ended, the I-Gel was removed. After two minutes, the patient presented a respiratory distress and started spitting significant quantity of blood. Oropharyngeal fiberscopy was performed in emergency and highlighted active bleeding of the left aryepiglottic fold. Hemostasis was obtained by local compression. The patient was transferred to the intensive care unit. He was extubated the following day without complications. No additional procedure was necessary to stop the bleeding. CONCLUSION: Authors reported the first severe complication associated with the use of size 5 I-gel. Additional studies have to be carried out to specify the advantages and risks associated with the use of this recent material.

Background: Diagnostic criteria for chronic inflammatory demyelinating polyneuropathy ( CIDP) have variable sensitivity and specificity. Newly published criteria by Koski et al combine clinical and electrophysiological components, either of which suffices to establish the diagnosis. European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria require mandatory electrophysiology, as do other sets of criteria. Methods: The value of the two above-mentioned sets of criteria, on 151 patients with CIDP, and 162 controls with axonal neuropathy, from four European centres was assessed. Results were compared with Van den Bergh and Pieret's criteria and those of the American Academy of Neurology (AAN). The utility of more extensive nerve-conduction studies was ascertained. Results: Koski et al's criteria had a sensitivity of 63% and specificity of 99.3%. With unilateral, right-sided, forearm/foreleg, four-nerve studies, EFNS/PNS criteria offered a sensitivity of 81.3% and specificity of 96.2% for "definite/probable'' CIDP. Van den Bergh and Pieret's criteria had a sensitivity of 79.5% and specificity of 96.9%. AAN criteria were poorly sensitive (45.7%) but highly specific (100%). "Possible'' electrophysiological CIDP as per EFNS/PNS criteria were poorly specific (69.2%). More extensive studies increased the diagnostic sensitivity of EFNS/PNS criteria (96.7%) but reduced the specificity (79.3%). Conclusions: In our patient populations, the EFNS/PNS criteria were the most sensitive and allowed identification of a highly significantly greater number of patients than Koski et al's criteria. The latter were comparable in specificity with the "definite/probable'' EFNS/PNS electrodiagnostic subcategories. More extensive nerve-conduction studies improved diagnostic yield but resulted in loss of specificity.

Chemosensory pathways: from periphery to cortex. The aim of this article is to summarise the anatomy of the chemosensory pathways. The vomeronasal organ, the olfactory system, the trigeminal system and the gustatory system will be reviewed in succession. For each of these systems, we will provide a description of the anatomy of the pathways sending the sensory message from the peripheral receptor to the cortical areas, passing through different relays in the nervous system. Particular emphasis will be paid to the anatomical features of the structures involved in chemosensory perception. This will help us to understand better how these systems interact and influence our social lives, our memories and our behaviour, and to evaluate patients with chemosensory dysfunction better.

The physiological basics of the olfactory neuro-epithelium. All living organisms can detect and identify chemical substances in their environment. The olfactory epithelium is covered by a mucus layer which is essential for the function of the olfactory neurons that are directly connected to the brain through the cribriform plate. However, little is known about the composition of this mucus in humans and its significance for the diagnosis of olfactory disorders. The olfactory epithelium consists of four primary cell types, including the olfactory receptor cells essential for odour transduction. This review examines the anatomical, histological and physiological fundamentals of olfactory mucosa. Particular attention is paid to the biochemical environment of the olfactory mucosa that regulates both peri-receptor events and several protective functions.

Background and Purpose-Microplasmin is a recombinant truncated form of human plasmin. It has demonstrated efficacy in experimental animal models of stroke and tolerability in healthy volunteers. We tested the tolerability of microplasmin in patients with acute ischemic stroke. Methods-In a multicenter, double-blind, randomized, placebo-controlled Phase II trial, 40 patients with ischemic stroke were treated with either placebo or active drug between 3 and 12 hours after symptom onset in a dose-finding design. Ten patients received placebo, 6 patients received a total dose of 2 mg/kg, 12 patients received a total dose of 3 mg/kg, and 12 patients received a total dose of 4 mg/kg. We studied the pharmacodynamics of microplasmin and its effect on the clinical and hemodynamic parameters of the patients. MRI was used as a surrogate marker and matrix metalloproteinases serum concentrations were used as markers of neurovascular integrity. The study was underpowered to detect clinical efficacy. Results-Microplasmin induced reversible effects on markers of systemic thrombolysis and neutralized alpha(2)-antiplasmin by up to 80%. It was well tolerated with one of 30 treated patients developing a fatal symptomatic intracerebral hemorrhage. No significant effect on reperfusion rate or on clinical outcome was observed. Matrix metalloproteinase-2 levels were reduced in microplasmin-treated patients. Conclusions-Microplasmin was well tolerated and achieved neutralization of alpha(2)-antiplasmin. Further studies are warranted to determine whether microplasmin is an effective therapeutic agent for ischemic stroke. (Stroke. 2009; 40: 3789-3795.)

There is ample evidence front randomized trials that for patients with stroke, stroke unit care is superior to care ill general medical or neurological wards. This evidence, which has been adopted by international guidelines has to be implemented into daily stroke care. This consensus document prepared by the Belgian Stroke Council provides a set of minimum criteria to meet international standards for stoke care. It is intended to provide help ill the creation of stroke units in centers who do not currently have one and to provide a benchmark for centres already having organised stroke care.

Objective: A 'case scenario' study on clinical decisions in progressing Parkinson's disease (PD) was developed to complement scientific evidence with the collective judgment of a panel of experts. Methods: The opinions of 9 experts in movement disorders on the appropriateness of 9 common pharmacological treatments for 33 hypothetical patient profiles were compared to those of 14 general neurologists. Before rating the case scenarios, all participants received a document integrating European and US guidelines for the treatment of patients with advanced PD. Case scenarios showing disagreement or with inconsistencies in appropriateness ratings were discussed at a feedback meeting. A tool for interactive discussion on the clinical case scenarios included was developed based on the outcome of the study. Results: Current guidelines are often insufficient to adequately guide the management of patients with progressing PD. The case scenario study did not reveal major differences in opinions between experts it? movement disorders and general neurologists about the appropriateness of certain drug choices for specific case scenarios. However in about 1 out of 5 treatment decisions where experts stated appropriateness or inappropriateness, the general neurologists panel had no or dispersed opinions. Conclusions: This study reveals more uncertainty about treatment of advanced PD in general neurologists compared with experts in movement disorders and underlines the need for additional support for guiding treatment decisions in clinical practice.

Objective: Training to perform a serial reaction-time task (procedural motor learning) with one hand results in performance improvements in the untrained as well as in the trained hand, a phenomenon referred to as intermanual transfer. The aim of this study was to investigate the neurophysiological changes associated with intermanual transfer associated with learning to perform an eminently different task involving fine force control within the primary motor cortex (M1). We hypothesized that intermanual transfer of learning Such a task would reveal intracortical changes within M1. Methods: Speed (time to complete each sequence) and accuracy (% of accuracy errors) of motor performance were measured in both hands before and after right (dominant) hand practice. Transcranial magnetic stimulation (TMS) was used to characterize recruitment curves (RC), short intracortical inhibition (SICI), intracortical facilitation (ICF) and interhemispheric inhibition (IHI) from the left to the right M1. Results: Practice resulted in significant improvements in both speed and accuracy in the right trained hand and in the left untrained hand. RC increased in the left M1, SICI decreased in both M1s, and IHI from the left to the right M1 decreased. No changes were identified in ICF nor in RC in the right M1. Conclusions: Our results suggest that some neurophysiological mechanisms operating in the M1 controlling performance of an untrained hand may contribute to optimize the procedure for selecting and implementing correct pinch force levels. Significance: These results raise the hypothesis of a contribution of modulation of SICI and IHI, or an interaction between both to intermanual transfer after learning a sequential pinch force task. (C) 2009 Published by Elsevier Ireland Ltd. on behalf of International Federation of Clinical Neurophysiology.

Medical therapy and smell dysfunction. Olfactory dysfunction is deemed to be a significant contributor to poor quality of life in different nasal inflammatory conditions like common cold, allergic rhinitis, and acute and chronic rhinosinusitis with and without nasal polyps (NP). The mechanism underlying olfactory impairment in inflammatory sinonasal disease relates to either the obstruction of the olfactory cleft due to congestion of the nasal mucosa, the presence of secretions or polyps inside the nasal cavity, or to dysfunction of the sensory mucosa of the olfactory bulb resulting from local inflammation. The reduction of smell capacity in nasal inflammatory conditions may have an acute or gradual onset, often with resolution of smell dysfunction after adequate medical treatment or surgery. In contrast to the well documented effects of surgery for rhinosinusitis on smell dysfunction, the available information about the effects of medical treatment is limited. Most studies have looked at corticosteroids, evaluating the restoration of olfactory capacity as a primary or secondary study outcome parameter. Both nasal and systemic corticosteroids have a beneficial effect on olfactory dysfunction, with systemic treatment being the most powerful. This review aims to provide an overview of current knowledge about medical treatment for rhinosinusitis and its effects on smell.