Saeed, SR

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The Journal of Laryngology & Otologyhttp://journals.cambridge.org/JLOAdditional services for The Journal of Laryngology & Otology:Email alerts: Click hereSubscriptions: Click hereCommercial reprints: Click hereTerms of use : Click hereA visit to Doctor Jean­Bernard Causse, Béziers and Professor Jacques Magnan, MarseilleShakeel R. SaeedThe Journal of Laryngology & Otology / Volume 112 / Issue 01 / January 1998, pp 110 ­ 111DOI: 10.1017/S0022215100140046, Published online: 29 June 2007Link to this article: http://journals.cambridge.org/abstract_S0022215100140046How to cite this article:Shakeel R. Saeed (1998). A visit to Doctor Jean­Bernard Causse, Béziers and Professor Jacques Magnan, Marseille. The Journal of Laryngology & Otology, 112, pp 110­111 doi:10.1017/S0022215100140046Request Permissions : Click hereDownloaded from http://journals.cambridge.org/JLO, IP address: 144.82.107.83 on 16 Oct 2012The Journal of Laryngology and OtologyJanuary 1998, Vol. 112, pp. 110-111JLO Travelling Fellowship 1996 ReportA visit to Doctor Jean-Bernard Causse,Beziers and Professor Jacques Magnan,MarseilleSHAKEEL R. SAEED, F.R.C.S., F.R.C.S. (ORL)Senior Registrar and Neuro-Otology Fellow,University Department of Otolaryngology-Head and Neck Surgery,Manchester Royal Infirmary,Manchester M13 9WL.IntroductionThe JLO Travelling Fellowships enable otolaryngologistsin training to visit overseas centres that provide experienceor expertise in areas not readily available in the UK. Myown interests are in otology and neuro-otology. I thereforeelected to visit two somewhat contrasting centres in theSouth of France: The Clinique Jean Causse which is a fewkilometres from Beziers and the Service d'Oto-Rhino-Laryngologie, Hopital Nord in Marseille.Clinique Jean Causse, BeziersThere can be few in our specialty who have not heard ofthe Causse Clinic. Now predominantly dedicated tosurgery of the ear, the original ENT clinic was foundedby Jean Rene Causse over 60 years ago and was situated inBeziers itself. Following a visit to John Shea in 1958, JeanRene Causse imported the stapedectomy operation toFrance at a time when George Portmann did the same inBordeaux. In 1975, Jean-Bernard joined his father at theBeziers clinic and three years later, having audited hisson's work (no dead ears in 1000 stapedectomies), JeanRene retired having undertaken over 10,000 ear proce-dures himself (Robinson, 1996). By 1985, a combination oftwo factors, the volume of work being undertaken and thefinancial situation that the French Health Service founditself in, necessitated a move from the Beziers site. Fiveyears from conception to inception, the new Causse clinicis a private venture dedicated to Jean Rene Causse. Nowsituated in Colombier, 7 km from Beziers the clinicofficially opened in 1990.The initial impression on visiting the clinic is one ofdisbelief. Set on the banks of the Midi canal, amongstrolling vineyards is a purpose built structure that looks asthough it landed on this inspirational site. This surreal auracontinues when you observe the work that is undertaken atthe clinic: here is an institution that has taken one aspect ofour specialty and developed it to a pinnacle of excellence.The clinic comprises a hotel, restaurant, library, confer-ence room, operating theatres, audiological booths andconsulting rooms in additional to the 90 ward beds.Currently there are over 20 doctors and 250 ancillarystaff employed by the institution. The daily workload isremarkable: around 30 operations and up to 300 outpatientvisits. Firmly at the helm of course is Jean-Bernard Causse.As he undertakes up to five procedures per morning list Ihad ample opportunity to observe him operating. Thewhole process is highly tuned and extremely efficient. Mostof the adult surgery is done under local anaesthesia withthe anaesthetist administrating appropriate intravenoussedatives. The degree of sedation however is such that thepatients tolerate the insertion of an oropharyngeal airwaysuggesting to my mind that this is a not far removed fromgeneral anaesthesia. The patient is already prepared anddraped and all the personnel in the operating room areacutely aware of their precise role. Each procedure isvideo recorded and Jean-Bernard takes great pleasure innot only furnishing the patient with a recording of theiroperation but also presenting a copy to the visitors that areinvariably present at each operation. With such a vastexperience of middle ear surgery (over 20,000 stapedec-tomies), Jean-Bernard makes the actual surgery lookeffortless. This of course is deceptive. The various stepsof the procedure are undertaken in precisely the samemanner each time and there is certainly economy ofmovement: this in itself is a great skill that develops withexperience but more importantly, when anatomical diffi-culties are encountered he is able to deal with them withconsummate ease. It is a lesson that we can all attempt toapply to whatever aspect of otolaryngology we areinvolved in. The laser stapedotomy is restricted to theposterior third of the footplate, and a vein graft is utilizedto make good the deficit between the 0.5 mm teflonprosthesis and the 0.88 mm stapedotomy. Jean-Bernardbelieves that the vein serves to emulate the function of theannular ligament of the footplate. Currently he alsoattempts to reconstruct the stapedial tendon mechanismby using connective tissue 'glue' from the vein graft to jointhe cut tendon to a polycel cuff around the neck of theprosthesis. The whole process takes about half an hour.Jean-Bernard leaves theatre to attend to administrativeaffairs by which time the next patient is ready for surgery:the whole thing runs like clockwork. The morning sessionends with a post-operative ward round (it was interestingto meet two post-operative patients from the UK!)followed by lunch with Jean-Bernard and his colleaguesin the clinic restaurant.The Causse clinic also has a prolific throughput ofsurgery for chronic ear disease. This aspect is headed byDr Benoit Gratacap, whose surgical skills reflect the ethos110JLO TRAVELLING FELLOWSHIP 1996 REPORT 111of the clinic without losing the individuality that makesevery surgeon different. There is considerable emphasis onfunction and therefore maintenance of the posterior canalwall, reconstruction of the scutum and ossiculoplasty areconsidered just as important as disease exenteration. Theuse of the laser is certainly a useful adjunct in chronic earsurgery.As a background to such surgical expertise lies animmense generosity of spirit. The unit is geared to a steadythroughput of visitors from all over the world and all aremade to feel welcome. The enthusiasm of the medical staffis striking and the hospitality unparalleled. I would imploreany trainee interested in otology to visit the clinic to seehow, in an appropriate environment this aspect of ourspecialty can be taken to great heights.Service d'Oto-Rhino-Laryngologie, Hopital Nord inMarseilleThe Hopital Nord is one of the University Hospitals inMarseille. Overlooking the urban sprawl of northernMarseille the hospital serves all specialties of medicinewith over 700 adult beds. Its sister paediatric hospital isabout a kilometre away. The service d'oto-rhino-laryngo-logie et chirgurie cervico faciale is headed by ProfessorJacques Magnan whose interests are predominantlyotology and neuro-otology. Professor Magnan has writtenextensively on various aspects of craniobase surgery but itis his interest in the use of rigid endoscopes in neuro-otology that prompted me to visit his department. Myrequest to do so was well received and both ProfessorMagnan and his colleague Andre Chays had clearly goneto the trouble of ensuring that the operating scheduleduring my visit would allow me to observe the utilization ofendoscopes in the posterior cranial fossa. Both Magnanand Chays hold the view that rigid endoscopes are anadjunct to the conventional techniques of posterior fossasurgery. Having observed their work, I would have toagree. The improved illumination is certainly one factorbut the key difference is the manner in which theendoscope allows the surgeon to almost 'walk around'the cerebellopontine angle (CPA) and beyond. For bothvestibular neurectomy and vascular decompressions theCPA is approached through a mini posterior fossacraniotomy (2 cm X 1 cm) in the angle between theposterior margin of the mastoid process and a lineextrapolated from the root of the zygoma. The skin andperiosteal incisions are staggered and do not impinge onthe musculature of the neck at the craniobase: thiseliminates one of the factors supposedly implicated in theheadaches frequently seen after the retrosigmoid orsuboccipital approaches. The bone dust from the cranio-tomy is collected for use during closure and once the bonework is complete, an anteriorly based dural flap is cutexposing the posterior fossa. There is rarely a need forcerebellar retraction as hypocapnoeic anaesthesia seems to'slacken' the field well. Using 0° and 30° 6 cm x 4 mmendoscopes and television monitoring the CPA contentsare visualized: the ability to see all the cranial nerves fromIII to XII as well as the vasculature is quite remarkable.Professor Magnan is a proponent of vascular compressionsyndromes and he uses the endoscopes to accuratelyconfirm the diagnosis as well as decompress the cranialnerve in question. This exposure also allows section of thevestibular nerve utilizing the endoscope to define the planebetween the cochlear and vestibular components of theeighth nerve. The indications for endoscopy in vestibularschwannoma surgery are less clear. There are instanceswhere a 30° scope will allow improved visualization of thefacial nerve anterior to the tumour but more importantly,the endoscope can be used to search for remnants oftumour particularly at the lateral end if the internalauditory meatus in the retrosigmoid approach. When wedo reach the goal of being able to establish the growth rateof a vestibular schwannoma from a tissue sample, then nodoubt endoscopic biopsy will come into its own. Closure ofthe craniotomy is meticulous with suturing of the duralflap, insertion of a polyurethane (Neuro-Patch, B. Braun,Melsungen) disc that is cut to size, followed by insertion offibrin glue-bone dust pate to make good the bony deficit.CSF leakage has not been an issue with this method andpreventing adhesions between the dura and soft tissues ofthe scalp may be another reason why post-operativeheadaches are not a problem. I observed several nervesections and vascular decompressions during the visit and Iwas immensely impressed. The anatomy of the CPA isvaried and complex and the endoscope give an insight intothis complexity that in my opinion cannot be matched byconventional microscopic means. Since my return I havehad an opportunity to utilize rigid endoscopes during CPAand petrous apex surgery on several occasions and this is atechnique that I shall continue to develop - being able tovisualize and remove hidden matrix medial to the internalcarotid artery during surgery for a petrosal cholesteatomawas certainly illuminating! Finally, as in Beziers, thehospitality in Marseille was superb. There was ampleopportunity to discuss various otological issues and inparticular, the newly formed European Academy ofOtology and Neuro-Otology. Professor Magnan has beeninstrumental in getting this project off the ground and theinaugural meeting is to be held in Courchevel in February1998. The Academy has generated support internationallyand will no doubt continue to develop in years to come.Throughout my visit Professor Magnan and his team mademe feel very welcome and if endoscopic CPA surgery wasnot enough, they had one more ace up their sleeve: theMarseille bouillabaisse was the best I have ever tasted!Finally, I would like to express my gratitude to the JLOfor funding the visit to the two departments and to DrJean-Bernard Causse and Professor Jacques Magnan fortheir hospitality and enthusiasm to teach.ReferencesRobinson, J. M. (1996) The Beziers story. ENT News 5(3):16-17.

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A visit to Doctor Jean-Bernard Causse, Beziers and Professor Jacques Magnan, Marseille

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A visit to Doctor Jean-Bernard Causse, Beziers and Professor Jacques Magnan, Marseille

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