Solid amorphous formulations for enhancing solubility and inhibiting Erlotinib crystallization during gastric-to-intestinal transfer

The objective of this study was to improve the solubility and inhibit the crystallisation during the gastric-to-intestinal transfer of Erlotinib (ERL), a small molecule kinase inhibitor (smKI) compound class, which is classified as class II drug in the Biopharmaceutical Classification System (BCS). A screening approach combining different parameters (solubility in aqueous media, inhibitory effect of drug crystallisation from supersaturated drug solutions) was applied to selected polymers for the development of solid amorphous dispersions of ERL. ERL solid amorphous dispersions formulations were then prepared with 3 different polymers (Soluplus®, HPMC-AS-L, HPMC-AS-H) at a fixed drug: polymer ratio (1:4) by two different production methods (spray drying and hot melt extrusion). The spray-dried particles and cryo-milled extrudates were characterized by thermal properties, shape and particle size, solubility and dissolution behavior in aqueous media. The influence of the manufacturing process on these solid characteristics was also identified during this study. Based on the obtained results, it is concluded that the cryo-milled extrudates of HPMC-AS-L displayed better performance (enhanced solubility, reduced ERL crystallization during the simulated gastric-to-intestinal transfer) and represents a promising amorphous solid dispersion formulation for oral administration of ERL.

Peripheral neck nerve tumor: A 73-case study and literature review

OBJECTIVES

Peripheral neck nerve tumors are rare and mostly benign neoplasms. The exceptional malignant forms are very aggressive, and diagnosis is difficult. The objective of this study was to evaluate diagnostic and therapeutic management and identify possible predictive factors.

MATERIAL AND METHODS

A retrospective study was conducted of 73 patients treated for peripheral neck nerve tumor between 1995 and 2015.

RESULTS

Mean age was 44years. The main presenting symptom was a cervical mass, isolated or associated with signs related to the affected nerve structure. Diagnosis was suspected by slow progression of a firm mass, featuring T1 hyposignal and T2 hypersignal on magnetic resonance imaging. Surgery was performed in 99% of cases, completed by adjuvant chemotherapy in case of malignant neuroblastic tumor. Type 1 neurofibromatosis and sudden increase in mass with or without associated pain suggested malignant transformation. Age below 10years suggested neuroblastic tumor.

CONCLUSION

Neck nerve tumors are very often benign with low degenerative potential. Surgery is the treatment of choice after risk/benefit analysis. However, there is no clearly defined consensus regarding the timing of surgery for these lesions.

Intraoperative bacterial analysis in nasal polyposis: Clinical and functional impact

BACKGROUND

The impact of Staphylococcus aureus on onset of nasal polyposis has been the focus of numerous studies, but there have been few studies of other germs found in the ethmoid of operated patients or of their impact on post-operative results.

MATERIAL AND METHODS

All patients undergoing endoscopic radical ethmoidectomy for nasal polyposis in the teaching hospital of Nantes (France) between 2006 and 2016 had intraoperative ethmoid cavity bacterial sampling. Phenotypic characteristics, pre- and post-operative symptoms and endoscopic findings were analyzed. Mann-Whitney tests and Kruskal-Wallis correlation analysis were used to assess clinical/bacteriological correlations.

OBJECTIVES

The main objective was to describe bacterial colonization of patients undergoing surgery for nasal polyposis, and to assess correlations with phenotypic features, functional results and postoperative clinical course.

RESULTS

One hundred and seven patients were included. A total of 26% were not infected, 55% mono-infected and 19% multi-infected. In 27.3%, staphylococci were isolated; in 30.5%, isolates were gram-negative bacilli. There were no significant correlations between presence or type of pathogen and symptom profile.

CONCLUSION

This study confirmed the high rate of pathogenic bacteria in nasal cavities in case of polyposis, with high frequencies of S. aureus but also of gram-negative bacilli, raising the question of their involvement in the inflammatory reactions underlying the nasal polyposis.

Assessment of swallowing function after circumferential pharyngolaryngectomy. A multicenter study by the GETTEC group

OBJECTIVE

Circumferential pharyngolaryngectomy is performed for advanced pharyngeal tumor or in a context of postradiation recurrence. Several free or pedicle flaps have been described for pharyngeal defect reconstruction, with choice at the surgeon's discretion. The aim of this study was to evaluate long-term swallowing function according to the type of flap used for reconstruction.

MATERIAL AND METHOD

A multicenter retrospective study was conducted from January to September 2016 within the French GETTEC head and neck tumor study group. All patients in remission after circumferential pharyngolaryngectomy were included and filled out the Deglutition Handicap Index (DHI) questionnaire and underwent swallowing function fiberoptic endoscopy assessment. 46 patients (39 men, 7 women) were included. Reconstruction used a tubularized forearm free flap (FFF group) in 19 cases, pectoralis major myocutaneous flap (PMMF group) in 15 cases and free jejunum flap (FJF group) in 12 cases.

RESULTS

Mean DHI was 24: 20 in the FFF group, 23 in the FJF group and 25 in the PMMF group, without significant differences. 27 patients had normal swallowing, 9 mixed diet, 8 liquid diet and 3 were fed by gastrostomy. On endoscopy, free flaps (FJF and FFF) were associated with significantly greater rates of normal swallowing of saliva and yogurt than in the PMMF group (P=0.04).

CONCLUSION

Type of flap reconstruction after circumferential pharyngolaryngectomy had no significant impact on postoperative swallowing function assessed on the self-administered DHI questionnaire.

International consensus (ICON) on assessment of oropharyngeal dysphagia

OBJECTIVE

To present international recommendations regarding the proper evaluation of oropharyngeal dysphagia (OD), both objectively and subjectively (self-evaluation).

METHODS

Following a thorough review of the literature, 5 experts in the field from 4 different continents answered separately a questionnaire regarding the work-up of OD. Individual answers were presented and discussed during the world ENT conference that was held in Paris in June 2017. This article will present the recommendations issued from that meeting.

RESULTS

For the initial objective assessment of OD, it is recommended to perform either a functional endoscopic evaluation of swallowing (FEES) or a videofluoroscopic swallowing study (VFSS). FEES is the more popular investigation given its increased ease of use and accessibility. When evaluating for the presence of aspiration during the objective evaluation of OD, it is recommended to perform either a FEES or a VFSS. In this case, FEES is the favored investigation given its likely increased sensitivity. In order to highlight the presence of oropharyngeal food residue following the deglutition process, it is recommended to perform either a FEES or a VFSS; FEES likely being the more sensitive investigation while VFSS allows a better quantification of the amount of pharyngeal residue. Is it also recommended to objectify the quality of the deglutition process by means of a score during the objective evaluation of OD. Finally, it is recommended to utilize a self-evaluation questionnaire during research studies exploring the deglutition process.

Sinonasal mucosal melanoma: A 44-case study and literature analysis

OBJECTIVES

Sinonasal mucosal melanoma is a rare disease, representing 4% of nasal cavity and paranasal sinus malignancies. The aim of this study was to assess the clinical characteristics, progression and treatment of this disease and to identify prognostic factors.

MATERIAL AND METHODS

This retrospective review presents a cohort of 44 patients treated for a melanoma arising from the nasal cavity and paranasal sinuses, in the ENT Head and Neck Surgery Department of the University Hospital of Nantes (France) between 1988 and 2015.

RESULTS

Mean age at diagnosis was 71.2 years. The main signs at diagnosis were epistaxis and unilateral nasal obstruction. 25% of patients were initially classified as T4. Surgical treatment was performed in 42 patients. Postoperative radiotherapy was performed in 19 cases and adjuvant immunotherapy in 14 cases. Mean follow-up was 50 months. Cumulative overall survival was 71.5% at 1 year and 33% at 5 years. Clinically, headache, facial pain and trigeminal V2 nerve anesthesia were significant factors for poor prognosis. Exclusively nasal involvement was a factor for better overall survival than sinus involvement. Adjuvant radiation therapy showed a non-significant trend toward improved local control.

CONCLUSIONS

Mucosal melanoma of the sinonasal cavities has poor prognosis due to high metastatic potential. Surgical resection followed by radiation therapy is the main treatment. There is no consensus regarding new systemic adjuvant treatments in this indication, unlike for primary cutaneous melanoma.

Perturbation of a radially oscillating single-bubble by a micron-sized object

A single bubble oscillating in a levitation cell is acoustically monitored by a piezo-ceramics microphone glued on the cell external wall. The correlation of the filtered signal recorded over distant cycles on one hand, and its harmonic content on the other hand, are shown to carry rich information on the bubble stability and existence. For example, the harmonic content of the signal is shown to increase drastically once air is fully dissociated in the bubble, and the resulting pure argon bubble enters into the upper branch of the sonoluminescence regime. As a consequence, the bubble disappearance can be unambiguously detected by a net drop in the harmonic content. On the other hand, we perturb a stable sonoluminescing bubble by approaching a micron-sized fiber. The bubble remains unperturbed until the fiber tip is approached within a critical distance, below which the bubble becomes unstable and disappears. This distance can be easily measured by image treatment, and is shown to scale roughly with 3-4 times the bubble maximal radius. The bubble disappearance is well detected by the drop of the microphone harmonic content, but several thousands of periods after the bubble actually disappeared. The delay is attributed to the slow extinction of higher modes of the levitation cell, excited by the bubble oscillation. The acoustic detection method should however allow the early detection and imaging of non-predictable perturbations of the bubble by foreign micron-sized objects, such as crystals or droplets.

Theoretical model of ice nucleation induced by acoustic cavitation. Part 1: Pressure and temperature profiles around a single bubble

This paper deals with the inertial cavitation of a single gas bubble in a liquid submitted to an ultrasonic wave. The aim was to calculate accurately the pressure and temperature at the bubble wall and in the liquid adjacent to the wall just before and just after the collapse. Two different approaches were proposed for modeling the heat transfer between the ambient liquid and the gas: the simplified approach (A) with liquid acting as perfect heat sink, the rigorous approach (B) with liquid acting as a normal heat conducting medium. The time profiles of the bubble radius, gas temperature, interface temperature and pressure corresponding to the above models were compared and important differences were observed excepted for the bubble size. The exact pressure and temperature distributions in the liquid corresponding to the second model (B) were also presented. These profiles are necessary for the prediction of any physical phenomena occurring around the cavitation bubble, with possible applications to sono-crystallization.

'Canalization' of the frontal sinus: a functional approach for the management of post-traumatic sinusitis with lateral bony septa. Report of two cases and long-term follow-up

The patency of the naso-frontal duct is a key issue in the surgical management of chronic frontal sinusitis. Most of the current operative techniques only provide access to the paramedian portions of the frontal sinus. A canalization approach that allows a functional frontal sinus to be maintained while providing good access to the most lateral areas of the sinus is described herein. Two cases of severe post-traumatic frontal sinusitis, operated on successfully by canalization method based on the conservation of the frontal sinus and the maintenance of the patency of the naso-frontal duct, using both open and endonasal approaches, are reported. One patient was followed-up for 8 years and the other for 7 months. Canalization requires validation in a larger series. This approach provides an alternative to both cranialization and strictly endoscopic methods in lateralized frontal sinus retentions and allows mucocele to be avoided.

Theoretical model of ice nucleation induced by inertial acoustic cavitation. Part 2: Number of ice nuclei generated by a single bubble

In the preceding paper (part 1), the pressure and temperature fields close to a bubble undergoing inertial acoustic cavitation were presented. It was shown that extremely high liquid water pressures but quite moderate temperatures were attained near the bubble wall just after the collapse providing the necessary conditions for ice nucleation. In this paper (part 2), the nucleation rate and the nuclei number generated by a single collapsing bubble were determined. The calculations were performed for different driving acoustic pressures, liquid ambient temperatures and bubble initial radius. An optimal acoustic pressure range and a nucleation temperature threshold as function of bubble radius were determined. The capability of moderate power ultrasound to trigger ice nucleation at low undercooling level and for a wide distribution of bubble sizes has thus been assessed on the theoretical ground.

Vascular imaging with contrast agent in hard and soft tissues using microcomputed-tomography

Vascularization is essential for many tissues and is a main requisite for various tissue-engineering strategies. Different techniques are used for highlighting vasculature, in vivo and ex vivo, in 2-D or 3-D including histological staining, immunohistochemistry, radiography, angiography, microscopy, computed tomography (CT) or micro-CT, both stand-alone and synchrotron system. Vascularization can be studied with or without a contrast agent. This paper presents the results obtained with the latest Skyscan micro-CT (Skyscan 1272, Bruker, Belgium) following barium sulphate injection replacing the bloodstream in comparison with results obtained with a Skyscan In Vivo 1076. Different hard and soft tissues were perfused with contrast agent and were harvested. Samples were analysed using both forms of micro-CT, and improved results were shown using this new micro-CT. This study highlights the vasculature using micro-CT methods. The results obtained with the Skyscan 1272 are clearly defined compared to results obtained with Skyscan 1076. In particular, this instrument highlights the high number of small vessels, which were not seen before at lower resolution. This new micro-CT opens broader possibilities in detection and characterization of the 3-D vascular tree to assess vascular tissue engineering strategies.

Direct comparison of current cell-based and cell-free approaches towards the repair of craniofacial bone defects - A preclinical study

For craniofacial bone defect repair, several alternatives to bone graft (BG) exist, including the combination of biphasic calcium phosphate (BCP) biomaterials with total bone marrow (TBM) and bone marrow-derived mesenchymal stromal cells (MSCs), or the use of growth factors like recombinant human bone morphogenic protein-2 (RhBMP-2) and various scaffolds. Therefore, clinicians might be unsure as to which approach will offer their patients the most benefit. Here, we aimed to compare different clinically relevant bone tissue engineering methods in an "all-in-one" study in rat calvarial defects. TBM, and MSCs committed or not, and cultured in two- or three-dimensions were mixed with BCP and implanted in bilateral parietal bone defects in rats. RhBMP-2 and BG were used as positive controls. After 7 weeks, significant de novo bone formation was observed in rhBMP-2 and BG groups, and in a lesser amount, when BCP biomaterials were mixed with TBM or committed MSCs cultured in three-dimensions. Due to the efficacy and safety of the TBM/BCP combination approach, we recommend this one-step procedure for further clinical investigation.

STATEMENT OF SIGNIFICANCE

For craniofacial repair, total bone marrow (BM) and BM mesenchymal stem cell (MSC)-based regenerative medicine have shown to be promising in alternative to bone grafting (BG). Therefore, clinicians might be unsure as to which approach will offer the most benefit. Here, BM and MSCs committed or not were mixed with calcium phosphate ceramics (CaP) and implanted in bone defects in rats. RhBMP-2 and BG were used as positive controls. After 7 weeks, significant bone formation was observed in rhBMP-2 and BG groups, and when CaP were mixed with BM or committed MSCs. Since the BM-based procedure does not require bone harvest or cell culture, but provides de novo bone formation, we recommend consideration of this strategy for craniofacial applications.

Isolated lateral semicircular canal aplasia: Functional consequences

INTRODUCTION

Lateral semicircular canal aplasia is a malformation of the inner ear, usually associated with vestibular and cochlear malformations in the context of congenital malformation syndromes. We report a rare case of a young patient with isolated lateral semicircular canal aplasia and no associated vestibular symptoms.

CLINICAL CASE SUMMARY

A 20-year-old man with no personal or family history presented with persistent unilateral tinnitus for three years with no associated vestibular symptoms. Moderate unilateral right sensorineural hearing loss was detected. Magnetic resonance imaging demonstrated isolated aplasia of the right lateral semicircular canal. Videonystagmography revealed right hyporeflexia. Vestibular evoked myogenic potentials were absent after stimulation on the right side and normal on the left side.

DISCUSSION

Although the morphological abnormalities appeared to be isolated on imaging, the patient presented functional signs of global cochlear, semicircular canal and otolithic lesions, probably related to a developmental disorder of the membranous labyrinth. Functional investigations must be performed in the presence of isolated semicircular canal aplasia, even when it is an incidental finding, to exclude more extensive labyrinthine lesions.

Extranodal non-Hodgkin lymphoma of the sinonasal cavities: A 22-case report

OBJECTIVE

To determine presenting features, management and prognosis in extranodal non-Hodgkin lymphoma of the sinonasal tract.

MATERIAL AND METHODS

A retrospective study between 2004 and 2013 in the University Hospital Center of Nantes (France) recruited patients with lymphoma discovered by sinonasal involvement. Epidemiologic, diagnostic, clinical and prognostic criteria were analyzed, with survival studied on the Kaplan-Meier estimator and Log-rank test.

RESULTS

Twenty-two patients were included: 14 male, 7 female, with a mean age of 65 years at diagnosis. All had non-Hodgkin lymphoma, with strong predominance of diffuse large B-cell lymphoma (77%). Seven patients had risk factors for lymphoma (infection by HIV, EBV or chronic lymphocytic leukemia). A majority (68%) had advanced tumor at diagnosis (stage IV on the Ann Arbor classification). Most were located in the craniofacial bones (68%), mainly involving the maxillary or ethmoidal sinuses. The most frequent presenting symptoms were unilateral nasal obstruction, mucopurulent rhinorrhea, recurrent epistaxis or diplopia. Treatment consisted in chemotherapy, in some cases associated to radiotherapy. Overall survival was 82% at 12 months and 73% at 36 months. Recurrence-free survival was 76% at 12 months and 64% at 36 months.

CONCLUSION

Lymphoma is an aggressive pathology; revelation by sinonasal involvement is rare. Recommended treatment is chemotherapy, possibly associated to radiotherapy. Prognosis depends on histologic type, Ann Arbor stage at diagnosis and the therapeutic options available for the individual patient.

Prediction of the acoustic and bubble fields in insonified freeze-drying vials

The acoustic field and the location of cavitation bubble are computed in vials used for freeze-drying, insonified from the bottom by a vibrating plate. The calculations rely on a nonlinear model of sound propagation in a cavitating liquid [Louisnard, Ultrason. Sonochem., 19, (2012) 56-65]. Both the vibration amplitude and the liquid level in the vial are parametrically varied. For low liquid levels, a threshold amplitude is required to form a cavitation zone at the bottom of the vial. For increasing vibration amplitudes, the bubble field slightly thickens but remains at the vial bottom, and the acoustic field saturates, which cannot be captured by linear acoustics. On the other hand, increasing the liquid level may promote the formation of a secondary bubble structure near the glass wall, a few centimeters below the free liquid surface. These predictions suggest that rather complex acoustic fields and bubble structures can arise even in such small volumes. As the acoustic and bubble fields govern ice nucleation during the freezing step, the final crystal's size distribution in the frozen product may crucially depend on the liquid level in the vial.

Full-thickness nasal defect: place of prosthetic reconstruction

Extensive rhinectomy or full-thickness defects are not uncommon, in particular in the treatment of skin cancer. The present study lays out the principles of choice and creation of prostheses for nasal reconstruction. Prosthetic nasal reconstruction in France depends on a specialist prescription drawn up under the "Ocular and Facial Prostheses" rubric of the official List of Products and Procedures. National health insurance cover is 100% on condition that the prosthesis is produced by an approved prosthetist. The present study describes production stages, forms and means of fixation, and the timeline of implantation. Nasal prosthetic repair is simple, fast and functional, allowing social rehabilitation despite full respect of carcinologic margins, and without ruling out subsequent multilayer reconstruction. Benefits and drawbacks, and the factors determining repair options according to pathologic context are discussed. Nasal prostheses are an integral option in the repair of full-thickness nasal defects and total rhinectomies. The head and neck surgeon needs expertise in indications and techniques of reconstruction, so as to prescribe nasal prostheses as the context demands.

Evaluation of new bone formation in irradiated areas using association of mesenchymal stem cells and total fresh bone marrow mixed with calcium phosphate scaffold

The consequences of the treatment of the squamous cell carcinomas of the upper aerodigestive tract (bone removal and external radiation therapy) are constant. Tissue engineering using biphasic calcium phosphate (BCP) and mesenchymal stem cells (MSC) is considered as a promising alternative. We previously demonstrated the efficacy of BCP and total fresh bone marrow (TBM) in regenerating irradiated bone defect. The aim of this study was to know if adding MSC to BCP + TBM mixture could improve the bone formation in irradiated bone defects. Twenty-four Lewis 1A rats received a single dose of 20 Gy to the hind limbs. MSC were sampled from non-irradiated donors and amplified in proliferative, and a part in osteogenic, medium. 3 weeks after, defects were created on femurs and tibias, which were filled with BCP alone, BCP + TBM, BCP + TBM + uncommitted MSC, or BCP + TBM + committed MSC. 3 weeks after, samples were removed and prepared for qualitative and quantitative analysis. The rate of bone ingrowth was significantly higher after implantation of BCP + TBM mixture. The adding of a high concentration of MSC, committed or not, didn't improve the bone regeneration. The association BCP + TBM remains the most efficient material for bone substitution in irradiated areas.

Physicochemical characterization of D-mannitol polymorphs: the challenging surface energy determination by inverse gas chromatography in the infinite dilution region

Nowadays, it is well known that surface interactions play a preponderant role in mechanical operations, which are fundamental in pharmaceutical processing and formulation. Nevertheless, it is difficult to correlate surface behaviour in processes to physical properties measurement. Indeed, most pharmaceutical solids have multiple surface energies because of varying forms, crystal faces and impurities contents or physical defects, among others. In this paper, D-mannitol polymorphs (α, β and δ) were studied through different characterization techniques highlighting bulk and surface behaviour differences. Due to the low adsorption behaviour of β and δ polymorphs, special emphasis has been paid to surface energy analysis by inverse gas chromatography, IGC. Surface energy behaviour has been studied in Henry's domain showing that, for some organic solids, the classical IGC infinite dilution zone is never reached. IGC studies highlighted, without precedent in literature, dispersive surface energy differences between α and β mannitol, with a most energetically active α form with a γ(s)(d) of 74.9 mJ·m⁻². Surface heterogeneity studies showed a highly heterogeneous α mannitol with a more homogeneous β (40.0 mJ·m⁻²) and δ mannitol (40.3 mJ·m⁻²). Moreover, these last two forms behaved similarly considering surface energy at different probe concentrations.

Management of somatic pain induced by treatment of head and neck cancer: Postoperative pain. Guidelines of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL)

OBJECTIVE

To present the guidelines of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL) concerning the management of somatic pain induced by the treatment of head and neck cancer, and in particular the management of early and late post-surgical pain.

METHODS

A multidisciplinary work group conducted a review of the scientific literature on the study topic. An editorial group subsequently read the resulting guidelines before validation.

RESULTS

It is recommended to prevent onset of pain caused by malpositioning on the operating table, as well as pain related to postoperative care. During surgery, it is recommended to spare nerve and muscle structures as far as possible to limit painful sequelae. Management of early postoperative pain upon tumor resection and flap harvesting sites requires patient-controlled analgesia by morphine pump. Physical therapy is recommended after flap harvesting to minimize painful sequelae.

CONCLUSION

Preventive and curative measures should be undertaken for appropriate management of post-surgical pain in the treatment of head and neck cancers.

[Influence of pressure- and volume-controlled ventilation on pulse pressure variations: randomized study]

OBJECTIVE

Pulse pressure variation (ΔPP) has been demonstrated to be an accurate dynamic parameter to predict fluid responsiveness. However, the impact of different ventilator modes on this parameter is unknown. We compared ΔPP values calculated alternatively during pressure- and volume-controlled ventilation.

STUDY DESIGN

Double-blind randomized study, cross-over design.

PATIENTS

Patients in intensive care unit after a cardiac surgery.

METHOD

Patients were ventilated alternatively in both ventilator modes (according to the randomization): volume-controlled ventilation (VVC) and pressure-controlled ventilation (VPC). Other parameters of ventilation were identical. ΔPP values were calculated for each patient in both ventilator modes.

RESULTS

Among the 26 patients analyzed, mean ΔPP value was de 14.0±7.3% in VVC and 11.8±6.2% in VPC (P<0,0001). On Bland-Altman representation, mean bias was +2.2±2.3% and inferior and superior limits of agreement were respectively -2.3 and 6.7%. Arterial blood pressure and central venous pressure were not modified.

CONCLUSION

ΔPP values obtained with both ventilator modes were not interchangeable. On average, ΔPP decreases by more than two points in the passage VVC to VPC for a given patient, all others things being equal.

Heterogeneity in meta-analyses of treatment of acute postoperative pain: a review

BACKGROUND

Heterogeneity and its causes must be assessed using meta-analyses (meta-analysis). Especially in meta-analysis dealing with treatment of acute postoperative pain, the type of surgery is a source of heterogeneity. We aimed to assess whether the type of surgery is considered a source of heterogeneity in meta-analysis and how it is taken into account in meta-analysis evaluating the efficacy of treatment of acute postoperative pain. We further compared meta-analysis that pooled trials of surgeries with highly heterogeneous postoperative pain levels, the heterogeneous group, with meta-analysis that pooled trials involving surgeries with homogeneous pain levels, the homogenous group.

METHODS

The meta-analysis reports available in Issue 3, 2011 of the electronic database of the Cochrane library and pooling results of randomized or quasi-randomized controlled trials that assessed the efficacy of treatment of acute postoperative pain alone were considered. A survey of experts established a rating of the postoperative pain levels for the type of surgery. For each meta-analysis, the different pain level ratings associated with the trials included in the meta-analysis were considered and the standard deviation (sd) of these ratings calculated. From the distribution of sd values, we defined the heterogeneous and homogeneous groups.

RESULTS

Sixty-one meta-analyses were included; all assessed heterogeneity. Twenty-six meta-analyses considered the type of surgery as a subgroup (50% vs 38% in the homogeneous group vs heterogeneous group). Forty-four reports discussed the type of surgery as a source of clinical heterogeneity (85% vs 62% for the homogeneous vs heterogeneous group). Twenty-nine meta-analyses compared 'postoperative pain from dental surgery' to 'other type of surgery'.

CONCLUSIONS

Meta-analyses evaluating treatment of postoperative pain should explore clinical heterogeneity associated with the type of surgery for better implications for practice.

Adenoid cystic carcinoma of the paranasal sinuses: retrospective series and review of the literature

OBJECTIVES

Adenoid cystic carcinomas (ACC) are rare malignant tumours arising in the major and minor salivary glands. Involvement of the nasal cavity and paranasal sinuses is rare and poorly described. The purpose of this study was to define the clinical and prognostic criteria of ACC of the paranasal sinuses based on the review of a series of 25 cases.

MATERIAL AND METHODS

Single-centre retrospective study of 25 cases of ACC of the paranasal sinuses managed between 1998 and 2011, evaluating epidemiological, clinical, diagnostic and prognostic criteria. Factors influencing survival (Kaplan-Meier/Log Rank test) and the patient's quality of life (EORTC QLQ-C30 questionnaire) were also analysed.

RESULTS

Most patients (72%) had a locally-advanced tumour (stage T3 or T4) at diagnosis. Tumour sites, in decreasing order of frequency, were the maxillary sinus, nasal cavities and ethmoid sinus. The most common presenting complaints were maxillary pain or heaviness, unilateral blocked nose, and repeated epistaxis. When the tumour was resectable, treatment comprised a combination of surgery and adjuvant radiotherapy. The 5-year overall survival rate was 63% and the 5-year disease-free survival rate was 43%. The TNM stage at diagnosis (P=0.03), the histological subtype (P=0.023), the possibility of combined surgery and radiotherapy (P=0.03), and local control (P=0.05) were significant factors of improved 5-year overall survival. Positive surgical margins were associated with a trend towards poorer 5-year disease-free survival (ns).

CONCLUSIONS

ACC are rare malignant tumours associated with a poor prognosis, characterized by a high recurrence rate. Recommended treatment is a combination of surgery and adjuvant radiotherapy whenever possible. Five-year survival varies as a function of TNM stage, histological subtype, treatment options and local control.

[Karapandzic flap for reconstruction of extensive defects of the lower lip]

OBJECTIVE

To discuss advantages and disadvantages of Karapandzic flap for reconstruction of extensive defects of the lower lip.

METHODS

Two clinical observations and a review of the literature are presented.

RESULTS

The Karapandzic flap requires only one operating time. The tissue used to reconstruct the lower lip is very close to the resected lip. The functional result is satisfactory, the lips being continent, allowing speech and feeding. The main advantage of this technique is the preservation of the labial sphincter, which is vascularized, mobile and sensitive. The aesthetic result is acceptable. This flap keeps the vermilion, but with rounded commissures that corrects spontaneously. The main disadvantage of this flap is the microstomia, requiring only rarely further surgery.

CONCLUSION

The Karapandzic flap is a good option for reconstruction of extensive defects of the lower lip. It recreates the labial sphincter, while maintaining its vascularization and innervation. Functionality is maintained, with an aesthetically acceptable result despite the presence of residual microstomia proportional to the defect.

Leptomeningeal carcinomatosis from ethmoid sinus adenocarcinoma

INTRODUCTION

Adenocarcinoma of the ethmoid is an aggressive tumor, with potential extension to surrounding structures. Leptomeningeal extension is a rarely reported entity.

CASE REPORT

A carpenter, aged 55, developed multifocal cranial nerve-related symptoms 1 week after resection of adenocarcinoma of the ethmoid, evolving towards deteriorated general health status and death 10 weeks later. Brain MRI showed diffuse contrast enhancement of the cranial nerves, and repeated cerebrospinal fluid (CSF) examination found increased protein concentration associated with decreased glucose concentration, without malignant cells. The diagnosis of carcinomatous meningitis was based on the association of clinical, CSF and brain MRI data.

DISCUSSION/CONCLUSION

Leptomeningeal dissemination of adenocarcinoma of the ethmoid is rare; diagnosis is guided by clinical signs. MRI reveals neurological spread, but the presence of malignant cells in the CSF is sufficient for diagnosis. Due to poor prognosis, the only currently available treatments are palliative.

[Parapharyngeal tumors: management and postoperative results]

OBJECTIVES

Parapharyngeal space tumours are rare and mostly benign, and their access is difficult. The aim of the study was to define the optimal treatment of these tumours.

MATERIAL AND METHODS

Clinical retrospective study, with histological, treatment, prognosis analysis of the parapharyngeal space tumours occurred between 1994 and 2012 and the surgical approach considerations.

RESULTS

35 patients were included with a male sex ratio predominance (51.43%, p = ns). The mean age of diagnosis was 49 years. The majority of tumours were benign (75.76%, p < 0.001). 54.5% originated from salivary gland with a majority of pleomorphic adenomas (42.42%). The second most frequent aetiology found was schwannoma (21.21%). 2 patients refused the treatment. Accidentally discovered were frequent (28.57%). In the symptomatic forms, dysphagia dominated (25.71%). Oropharyngeal (20%) and/or cervical (17.14%) mass were rare. A CT scan and a MR imaging were performed in 82.86% and 71.43% of the cases. A fine needle aspiration cytology was achieved in 10 cases with a positive predictive value of 60%. The cervical submandibular trans digastric approach was the most accomplished (40%). Other approaches were also used: Trans oral (25.71%), parotidectomy (14.71%), combined trans oral and cervical or parotidectomy (14.71%) and the cervical approached associated to a mandibulotomy (5.71%). A complementary treatment was proposed in 85.7% of the cases of malignant tumours. Post-operative complications were dominated by Horner's syndrome (n = 3), a temporary facial palsy (n = 5), definitive (n = 1), a velar insufficiency (n = 1), persistent pain (n = 6).

CONCLUSIONS

The presence of 25% of malignant tumours and 40% of pleomorphic adenomas require removal of parapharyngeal tumours, even if non symptomatic.

[Ethmoidal metastasis revealing lung adenocarcinoma]

OBJECTIVES

Ethmoidal cancers are rare and are mostly primitive adenocarcinomas. Sinuso-nasal metastases from adenocarcinoma occurring in other localisations are exceptional. We report a case of a patient presenting with an ethmoidal metastasis revealing a pulmonary adenocarcinoma.

CASE REPORT

A 57 years-old patient consulted for a right fronto-orbital pain which had appeared 3 weeks prior, associated with a central scotoma of the right eye and a third and fifth cranial nerve palsy. MR-imaging revealed a right ethmoidal tumour invading the orbit. Pathology results were in favour of a metastasis from a secondary adenocarcinoma. The CT-scan disclosed a pulmonary tumour of the right apex with liver and spleen metastasis.

CONCLUSION

Ethmoidal metastases are rare and often diagnosed in patients presenting with a previously known tumour. We report the first case of a pulmonary adenocarcinoma revealed by an ethmoidal metastasis. We emphasize the point that in ethmoidal tumours, pathological investigations are important for diagnosis.

Experimental study of sono-crystallisation of ZnSO4·7H2O, and interpretation by the segregation theory

Power ultrasound is known to enhance crystals nucleation, and nucleation times can be reduced by one up to three orders of magnitude for several organic or inorganic crystals. The precise physics involved in this phenomenon still remains unclear, and various mechanisms involving the action of inertial cavitation bubbles have been proposed. In this paper, two of these mechanisms, pressure and segregation effects, are examined. The first one concerns the variations of supersaturation induced by the high pressures appearing in the neighbourhood of a collapsing bubble, and the second one results from the modification of clusters distribution in the vicinity of bubble. Crystallisation experiments were performed on zinc sulphate heptahydrate ZnSO(4)·7H(2)O, which has been chosen for its pressure-independent solubility, so that pressure variations have no effect on supersaturation. As observed in past studies on other species, induction times were found lower under insonification than under silent conditions at low supersaturations, which casts some doubts on a pure pressure effect. The interfacial energy between the solid and the solution was estimated from induction times obtained in silent conditions, and, using classical nucleation theory, the steady-state distribution of the clusters was calculated. Segregation theory was then applied to calculate the over-concentrations of n-sized clusters at the end of the collapse of a 4 μm bubble driven at 20 kHz by different acoustic pressures. The over-concentration of clusters close to the critical size near a collapsing bubble was found to reach more than one order of magnitude, which may favour the direct attachment process between such clusters, and enhance the global nucleation kinetics.

[Obstructive hypertrophic cardiomyopathy and caesarean section under combined spinal and epidural anaesthesia with prophylactic vascular ligation: regarding a case]

We report the case of a caesarean section under combined spinal and epidural anaesthesia in a pregnant 32-year-old woman with an hypertrophic obstructive cardiomyopathy. In these patients, variations of the ventricular load conditions may induce a cardiac inefficacy. In this context, the post-partum haemorrhage is a feared complication, prevent in part by oxytocine intravenously. However, its injection can be associated with haemodynamic instability, even at a low dose, and it does not spread post-partum haemorrhage. The arterial ligation according to the technique of Tsirulnikov is an alternative that we reported. This technique is followed by a good obstetrical prognosis.

[Congenital cyst and fistula of the face and neck]

The authors propose an update on cervicofacial congenital cysts and fistulas' symptomatology. Embryological data, epidemiology and clinical manifestations are described. A reminder of the therapeutic principles is proposed as well as the evolution of these congenital pathologies, which may or may not involve the branchial system. branchial.

[Ossiculoplasty with a partial Spiggle & Theis titanium prosthesis in cholesteatoma: functional results]

OBJECTIVES

To report the functional results of ossicular reconstruction achieved with a specific partial prosthesis in tympanoplasty for cholesteatoma.

MATERIALS AND METHODS

Forty-four patients presenting cholesteatoma of the middle ear were involved in a retrospective study. Tympanoplasties were performed by the same surgeon over a 30-month period. The patients underwent ossiculoplasty with the shortest nondivisible partial titanium Spiggle & Theis prosthesis. Twenty-eight procedures were canal wall-up tympanoplasties and 17 were canal wall-down procedures; 27 were primary tympanoplasties and 18 were revisions. Audiometric data were evaluated before and after surgery, with a mean follow-up of 13.4 months.

RESULTS

Improvement of the air-bone gap was 6+/-12.2dB. The overall success rate was 56% and 67% using the Glasgow Benefit Plot and a postoperative air-bone gap lower than 20dB, respectively. There was no significant functional difference between canal wall-up and canal wall-down procedures. Hearing results were better in primary tympanoplasties than in revisions (p=0.004). The extrusion rate was 2.2%.

CONCLUSION

The functional results observed in this study confirm that this partial titanium Spiggle & Theis prosthesis is a valuable biomaterial for ossicular reconstruction in primary tympanoplasty for cholesteatoma.

Reconstruction of circumferential pharyngolaryngectomy using a ‘horseshoe-shaped’ pectoralis major myocutaneous flap

Eighteen patients underwent a circumferential pharyngolaryngectomy reconstruction post pharyngolaryngectomy. All tumours showed pharyngo-oesophageal junction invasion or circular involvement of the hypopharynx, requiring total, circumferential pharyngolaryngectomy. A pectoralis major myocutaneous flap was directly sutured to the pre-vertebral fascia. A Montgomery® salivary bypass tube was introduced into the oesophagus, and a nasogastric tube was placed within it. No post-operative complications occurred for 14 patients and only minor ones for the other four. Average post-operative stay was 12 days. For 15 patients, feeding returned to normal throughout the follow-up period. No fistulae were noted and neopharyngeal stenosis occurred in three patients (16 per cent). Thirteen had complete resection with normal margins. Thirteen were still alive after one to three years of follow up. The local recurrence rate was 16 per cent.

The use of a pectoralis major myocutaneous flap with Spriano's technique provides a simple, reliable method for circumferential hypopharyngeal resection. It has been applied to a wide range of patients, especially elderly ones and those with poor general status, as well as to cases in which widespread involvement was detected during surgery.

Atrial fibrillation and anticoagulation

Atrial fibrillation (AF) increases the risk of ischemic stroke due to the formation of a thrombus within left atrium. Thus, adjusted-dose (optimal INR: 2-3) anticoagulant therapy such as warfarin dramaticaly decreases this risk of embolic events both in primary and secondary prevention but slightly increases the risk of bleeding, particularly in the elderly. This explains that, although the benefit has been clearly demonstrated, the anticoagulant therapy remains underused. The efficacy of low doses of aspirin is less clear but it may be appropriate in younger patients with lone AF because of a low risk of embolic events. The combination of low doses of warfarin and aspirin should not be given. In case of contraindication to warfarin and aspirin, some others drugs such as indobufen or dipyridamole may be given but the most promising drug is ximelagatran, a direct thrombin inhibitor, which appears to be as effective than warfarin with a lower incidence of bleedings. For patients in AF who require urgent cardioversion, intravenous unfractionated heparin remains the anticoagulant of choice but an approach combining low-molecular-weight heparin and transesophageal echocardiography has been proposed. For each patient the decision of treatment must be tightly correlated to the benefit-risk ratio.

Definition of a solvent system for spherical crystallization of salbutamol sulfate by quasi-emulsion solvent diffusion (QESD) method

In this paper we describe how the spherical crystallization process by QESD method can be applied to a water-soluble drug, salbutamol sulfate. The type of solvent, antisolvent, and emulsifier and the concentration of emulsifier to be used for the production of spherical particles with a size range 80-500 microm are determined. Furthermore, the solvent/antisolvent ratio and the temperature difference between them (Delta T) are studied. It was observed that, in the case of salbutamol sulfate, the Delta T value has no influence on the formation of spherical particles. A very large metastable zone of salbutamol sulfate in water could explain this phenomenon. Finally, the influence of emulsifier concentration and of maturation time on the size of spherical particles is studied. The results show that these two parameters must be fixed to control the size of the recovered particles.