Early detection of pharyngocutaneous fistulae after total laryngectomy by cytokine in drainage: A pilot study (DEFILAC)

BACKGROUND

The determination of cytokines in the postoperative drainage (POD) fluid could be a method for early detection of the development of a pharyngocutaneous fistula (PCF).

MATERIALS AND METHODS

We conducted a prospective two-center study involving 28 patients. PODs were collected on Day 1 (D1) and Day 2 (D2) postoperatively for determination of a cytokine panel and cytobacteriological examination.

RESULTS

Eleven (39%) patients presented with PCF on average 13 ± 5.5 days after surgery. Patients with PCF had higher IL-10 (121 vs. 40.3, p = 0.04, effect size (ES) = 0.98 [0.16, 1.79]) and TNFα level (21.2 vs. 2.2, p = 0.02, ES = 0.83 [0.03, 1.63]) on D2. An IL-10 threshold of 72 pg/mL on D2 was diagnostic of the occurrence of PCF with a sensibility of 70%, specificity of 88%.

CONCLUSION

The determination of cytokines in POD fluid on D2 is a reliable tool for predicting the development of a PCF after total laryngectomy.

Conditioned Media from Head and Neck Cancer Cell Lines and Serum Samples from Head and Neck Cancer Patients Drive Catabolic Pathways in Cultured Muscle Cells

BACKGROUND

The role of secreted factors from the tumor cells in driving cancer cachexia and especially muscle loss is unknown. We wanted to study both the action of secreted factors from head and neck cancer (HNC) cell lines and circulating factors in HNC patients on skeletal muscle protein catabolism.

METHODS

Conditioned media (CM) made from head and neck cancer cell lines and mix of sera from head and neck cancer (HNC) patients were incubated for 48 h with human myotubes. The atrophy and the catabolic pathway were monitored in myotubes. The patients were classified regarding their skeletal muscle loss observed at the outset of management.

RESULTS

Tumor CM (TCM) was able to produce atrophy on myotubes as compared with control CM (CCM). However, a mix of sera from HNC patients was not able to produce atrophy in myotubes. Despite this discrepancy on atrophy, we observed a similar regulation of the catabolic pathways by the tumor-conditioned media and mix of sera from cancer patients. The catabolic response after incubation with the mix of sera seemed to depend on the muscle loss seen in patients.

CONCLUSION

This study found evidence that the atrophy observed in HNC patients cannot be solely explained by a deficit in food intake.

Toxicity of induction chemotherapy in head and neck cancer: The central role of skeletal muscle mass

BACKGROUND

To assess the impact of nutritional status on tolerance to induction chemotherapy by docetaxel, cisplatin and 5-fluorouracil (ICT) in head and neck cancer (HNC).

METHODS

Ninety-two HNC patients were included. Toxicity was assessed according to common terminology criteria for adverse events. Nutritional status was assessed by body mass index (BMI), serum albumin, nutritional risk index (NRI), and CT scan (skeletal muscle mass index [SMI] at the first lumbar vertebral level).

RESULTS

Before treatment, average BMI was 22.7 ± 4.6 kg/m² , serum albumin 38.7 ± 5.8 g/L, NRI 97.6 ± 10.6, and SMI 36.4 ± 7.9 cm² /m² . After treatment, BMI was 23 ± 4.5, serum albumin 30.2 ± 7.1, and NRI 88.1 ± 9.2. During ICT, 52 (62%) patients developed at least one toxicity ≥ Grade 3. Pre-treatment SMI was the only predictive factor of toxicity irrespective of BMI (p = 0.04).

CONCLUSION

Low skeletal muscle mass is a predictive factor of toxicity to ICT in HNC.

Failure of anterior skull base reconstruction for sinonasal carcinoma: consequence on the postoperative follow up. A multicentre evaluation of management

BACKGROUND

Numerous techniques for closure of the anterior skull base in cancer patients have a high success rate but management of failure is poorly documented.

OBJECTIVES

To standardize the post-operative follow-up after reconstruction surgery of the anterior skull base after removal for sinonasal carcinoma.

MATERIALS AND METHODS

Retrospective review of failure of anterior skull base reconstruction between 2005 and 2018 in a multicenter setting.

RESULTS

Twenty four patients were included. Reconstruction failure was detected by a cerebrospinal (CSF) leak in 79.2%, by an infectious complication without CSF leak (i.e. meningitis) in 12.5%, and in 8.3% by extensive pneumocephalus. Failure was observed during the first week after surgery in 75% of patients, in the second week in 21%, and in 4% after day 15. The delay in discovery of the failure was associated with multilayer reconstruction (p=.03). Failure was treated surgically in 54% of the patients and medically in 46%, with a similar success rate (85 vs. 100%).

CONCLUSION AND SIGNIFICANCE

After carcinologic resection of the anterior skull base, monitoring should be systematic during the first postoperative week. Surgical management of failure is not always necessary.

Prognosis in Head and Neck Cancer: Importance of Nutritional and Biological Inflammatory Status

OBJECTIVES

To determine the importance of nutritional status, social status, and inflammatory status in the prognosis of head and neck cancer.

STUDY DESIGN

Single-center retrospective study of prospectively collected data.

SETTING

Tertiary referral center.

METHODS

Ninety-two consecutive patients newly diagnosed for cancer of the upper aerodigestive tract without metastases were assessed at time of diagnosis for several prognostic factors. Nutritional status was assessed by the nutritional risk index, social status by the EPICES score, and inflammatory status by the systemic inflammatory response index. The primary endpoint was overall survival.

RESULTS

In multivariable analysis, the main prognostic factors were the TNM classification (hazard ratio [HR] = 3.34, P = .002, for stage T3-4), malnutrition as assessed by the nutritional risk index (HR = 3.64, P = .008, for severe malnutrition), and a systemic inflammatory response index score ≥1.6 (HR = 3.32, P = .02). Social deprivation was not a prognostic factor.

CONCLUSION

Prognosis in head and neck cancer is multifactorial; however, malnutrition and inflammation are important factors that are potentially reversible by early intervention.

Inspiratory stridor of newborns and infants admitted to a paediatric ENT outpatient clinic: diagnostic approach and therapeutic outcome

The main objective was to analyse the use of rigid laryngotracheoscopy under general anaesthesia (GA) and endoscopic surgery in the management of inspiratory stridor in patients referred to a paediatric ENT outpatient clinic. The secondary objective was to analyse the aetiological diagnoses made and their therapeutic management. This is a prospective study including all newborns and infants, corresponding to 190 patients, presenting for the first time in consultation for inspiratory stridor from January 2015 to December 2017. A consultation form was filled out after each consultation and added to a database; a management algorithm was used to determine which patients required a rigid laryngotracheoscopy. A 17.9% (n = 34) of the patients required rigid laryngotracheoscopy, of whom 12.6% (n = 24) underwent concomitant endoscopic surgery. A 65.8% (n = 125) of the patients were diagnosed with laryngomalacia, 21.1% (n = 40) with isolated posterior excess of mucosa, 9.5% (n = 18) with another diagnosis and 3.7% (n = 7) with a normal examination. The presence of comorbidity was associated (p < 0.001) with the use of rigid laryngotracheoscopy and endoscopic surgery.Conclusion: Rigid laryngotracheoscopy under GA was required in one in five to six patients. Conservative management with strict follow-up may be appropriate in a large number of patients, especially those with laryngomalacia. What is Known: • Previous research has established that laryngomalacia is the main aetiology of stridor. • Comorbidities are linked with a poor tolerance of stridor. What is new: • About one in five to six patients seen in consultation for stridor will require a trip to the operative room (and one in eight will require endoscopic surgery). • Laryngomalacia and isolated posterior excess of mucosa account for 85-90% of the patients seen in consultation for stridor.

Very painful acute frontal sinusitis revealing granulomatosis with polyangiitis

INTRODUCTION

Granulomatosis with polyangiitis (GPA) is a necrotizing vasculitis of small and medium-sized vessels comprising inflammation of the vessel wall and perivascular and extravascular granulomas, frequently presenting in the form of chronic sinusitis.

OBSERVATION

We report the case of a 27-year-old man who presented with very painful acute frontal sinusitis that was managed medically and surgically. The symptoms rapidly recurred despite treatment and CT scan demonstrated diffuse thickening of the sinus mucosa. Anti-proteinase 3 ANCA were positive. Biopsy of a pulmonary nodule confirmed the diagnosis of GPA. The patient was treated with corticosteroids in combination with rituximab, resulting in improvement of the clinical, laboratory and CT signs.

DISCUSSION

In the presence of persistent, acute, localized sinusitis despite appropriate treatment, associated systemic signs and/or the presence of other signs suggestive of GPA, the ENT surgeon must request a targeted work-up. In the absence of treatment, GPA can be fatal within a few months. However, with currently available treatment, remission is obtained in 80% of cases with a 75% 10-year survival rate.

Early corrected serum calcium value can predict definitive calcium serum level after total thyroidectomy in asymptomatic patients

INTRODUCTION

Hypocalcemia is the most common complication of thyroidectomy, requiring supplementation as well as prolonged hospitalization. Our study's objective was to determine a corrected calcium (CCa) level on day 1 after thyroidectomy predictive of no calcium and vitamin supplementation.

MATERIALS AND METHODS

A single-center prospective study conducted between January 2012 and July 2015 in 396 patients, consisting of 331 cases of total thyroidectomy, with seven completion surgeries. The data collected were age, sex, type of thyroid surgery, etiology, anatomical pathological analysis, and the need for calcium and vitamin supplementation therapy as well as its duration. CCa levels were analyzed 20 and 30 h after surgery then on days 2 and 3. To determine a cut-off value for CCa, a ROC curve analysis was performed. The population was described in terms of numbers and associated percentages for categorical variables, and mean.

RESULTS

Mean CCa on 20 h after surgery was 2.09 mmol/L (p < 0.001) and 30 h was 2.06 mmol/L p = 0.02. CCa of less than 2.13 mmol/L was predictive of calcium and vitamin supplementation with 56% sensitivity and 97% specificity. On the evening of day 1, the cut-off value for CCa was 2.06 mmol/L with 67% sensitivity and 65% specificity.

CONCLUSION

This prospective study confirms that CCa on the first morning after surgery is reliable when it is more than 2.13 mmol/L. In total, analyzing CCa on day 1 after total thyroidectomy allows the discharge of 70% of patients on the first day after surgery, with no risk of hypocalcemia.

Frontal sinus schwannoma

INTRODUCTION

Nasal sinus schwannomas are rare tumors, particularly in the frontal sinus.

CASE REPORT

The authors report the case of a woman with left frontal sinus schwannoma discovered in a context of frontal sinusitis with orbital and ocular complications. The surgical procedure consisted of endonasal tumor resection and external drainage.

DISCUSSION

The pathogenesis of frontal sinus schwannomas remains unclear. These tumors can present with a wide range of clinical and radiological signs, making them difficult to diagnosis. Surgical resection of these tumors is also complex.

Which Assessment Method of Malnutrition in Head and Neck Cancer?

Objective

To assess the value of several diagnostic methods of nutritional status during the initial management of a head and neck cancer.

Study Design

Single-center prospective study.

Setting

Tertiary referral center.

Subjects and Methods

Ninety patients with head and neck cancer participated in the study. Assessment of their nutritional status was made with anthropometric, biological, body, and muscle measurements (the last by computed tomography: L3 muscle mass index [L3MMI]). Assessment of muscle performance (functional reflection of nutritional status) was made via the Short Physical Performance Battery test. The malnutrition thresholds were set according to the literature.

Results

Mean body mass index (BMI) was 24.6 ± 5.4 kg/m2. Mean weight loss and albumin levels were –4.5 ± 10.5 kg and 37.1 ± 5.2 g/L, respectively. Fourteen percent of patients were diagnosed as malnourished on the basis of BMI, 54% according to the Nutritional Risk Index (NRI), and 58% by L3MMI. There was 64% agreement between NRI and L3MMI ( P < .001). All patients identified as malnourished by BMI were considered as such by the other assessment methods; however, many malnourished patients had normal or high BMI. The Short Physical Performance Battery score was low particularly among patients considered to be the most undernourished by the other methods.

Conclusion

NRI and L3MMI are the best methods to identify patients as being malnourished. Functional muscle assessment can determine the severity of malnutrition.

Will the presence of the patient at multidisciplinary meetings influence the decision in head and neck oncology management?

OBJECTIVES

Multidisciplinary team meetings (MTM) are essential in the choice of a therapeutic strategy in head and neck cancer. In many centres patients attend MTMs and are examined by the team. The aim of this study was to assess the influence of the patient's presence on therapeutic decisions.

STUDY DESIGN

Prospective study of 119 consecutive patients.

METHODS

Two therapeutic situations were compared: the therapeutic decision taken following discussion of the patient's file in the MTM (D1) and the therapeutic decision taken after examination of the patient during MTMs (D2). Concordance between the two situations was measured.

RESULTS

Concordance between D1 and D2 was 97%. No factors likely to decrease concordance were identified. Decisions taken during MTMs were acted upon for 97% of the patients.

CONCLUSION

The presence of the patient during MTMs is not essential if the files are thoroughly presented and discussed.

Resistance of Gerbil Auditory Function to Reversible Decrease in Cochlear Blood Flow

The objective was to design in gerbils a model of reversible decrease in cochlear blood flow (CBF) and analyze its influence on cochlear function. In Mongolian gerbils injected with ferromagnetic microbeads, a magnet placed near the porus acusticus allowed CBF to be manipulated. The cochlear microphonic potential (CM) from the basal cochlea was monitored by a round-window electrode. In 13 of the 20 successfully injected gerbils, stable CBF reduction was obtained for 11.5 min on average. The CM was affected only when CBF fell to less than 60% of its baseline, yet remained >40% of its initial level in about 2/3 of such cases. After CBF restoration, CM recovery was fast and usually complete. Reduced CM came with a 35- to 45-dB threshold elevation of neural responses determined by compound action potentials. This method allowing reversible changes of CBF confirms the robustness of cochlear function to decreased CBF. It can be used to study whether a hypovascularized cochlea is abnormally sensitive to stress.

Prognostic value of two tumour staging classifications in patients with sinonasal mucosal melanoma

INTRODUCTION

Sinonasal mucosal melanoma is a rare disease associated with a very poor prognosis. The purpose of this study was to assess the prognostic value of the 2 staging systems published in the literature for these tumours: the American Joint Committee on Cancer (AJCC) Cancer Staging Manual for mucosal melanoma of the head and neck published in 2009 (7th edition) and the AJCC Cancer Staging Manual for cancers of the nasal cavity and paranasal sinuses published in 2002 (6th edition) and the prognostic value of tumour site, either limited to the nasal cavities or with paranasal sinus invasion.

METHODS

A retrospective study was conducted on 18 patients treated between August 1998 and June 2014. Each lesion was staged according to the AJCC Cancer Staging Manual 2002 and 2009 and the following data were collected: age, sex, tumour site, initial symptoms, treatment modalities, follow-up, recurrences and overall survival. Patient survival, from the date of discovery of the melanoma until death, was analysed by Kaplan-Meier survival curves and between-group comparison of survival was performed with a log rank test.

RESULTS

The mean age at diagnosis was 72 years (range: 54-94) and the cohort comprised 11 women and 7 men. The median overall survival was 80 months, the 1-year overall survival was 82.6% and the 5-year overall survival was 54.5%. The AJCC 2002 staging system presented a statistically significant prognostic value (P=0.0476), while no statistically significant prognostic value was observed for the AJCC 2009 staging system (P=0.108). Paranasal sinus invasion was significantly associated with a poor prognosis (P=0.0039).

CONCLUSION

This study demonstrates the superiority of the non-specific AJCC 2002 Cancer Staging Manual. Medical and surgical management must take paranasal sinus invasion into account, as it constitutes a major prognostic factor.

Results of transnasal transostial sphenoidotomy in 79 cases of chronic sphenoid sinusitis

OBJECTIVE

This study was designed to retrospectively review the postoperative results of transnasal transostial sphenoidotomy in 79 patients with isolated chronic sphenoid sinusitis operated between 1995 and 2013 and evaluate the recurrence rate due to postoperative closure of the sphenoidotomy.

PATIENTS AND METHODS

Seventy-nine patients, 44 women and 35 men (M:F sex ratio: 0.79) aged 10 to 84 years (mean age: 48), were included. The most common presenting symptom was headache in 61% of cases. Visual disturbances were present in three cases. The diagnostic work-up comprised nasal endoscopy, computed tomography (CT) and magnetic resonance imaging (MRI) of the sinuses. The surgical indication was based on failure of antibiotic therapy and/or the nature and severity of sphenoid sinusitis. All patients were operated by endoscopic transnasal transostial sphenoidotomy. Samples were taken for histological, bacteriological and mycological examination.

RESULTS

No intraoperative or immediate postoperative complications were observed. Nature of the lesion: forty-seven patients (59.5%) presented nonspecific inflammatory lesions with negative bacterial or fungal culture and inflammatory mucosal changes, 19 patients (24%) had fungal sinusitis presenting as a fungus ball and 13 patients (16.4%) had documented bacterial sinusitis. Mean postoperative follow-up was 7.4 months (range: 6-48). No recurrence of the sinusitis or symptoms was observed in 71 cases (89.8%). Recurrence: eight cases (10.2%) of postoperative closure of the sphenoidotomy were observed, requiring one (6 cases) or several (2 cases) reoperations with a mean of 16.4 months after the initial procedure. Symptoms of recurrence consisted of varying degrees of headache, with similar symptoms to those of the first episode in 7 cases, and retro-orbital headache in 1 case. Reoperation was performed via a transnasal transostial approach in 6 cases and a transethmoidal approach in 2 cases.

CONCLUSION

The transnasal transostial surgical approach is a safe and effective procedure for the treatment of isolated sphenoid sinusitis. However, the recurrence rate due to postoperative closure of the sphenoidotomy observed in our series raises the question of postoperative maintenance of a patent and functional sphenoidotomy.

Malignant melanoma of the nasal septum, a rare tumor, occurring in a 54-year-old patient after hereditary retinoblastoma treatment

The authors report a case of a malignant melanoma of the nasal cavity that is a rare tumor and very aggressive, constituting 1% of all melanomas. It appeared in a patient 54 years after he was treated for a hereditary retinoblastoma. Its symptoms are nonspecific, and often marked by epistaxis. Its diagnosis is histological, supported by immunohistochemistry. Its prognosis is often unfavorable, and characterized by the occurrence of metastases and recurrences. Because of the risk of secondary cancer that exists in any survivor of hereditary retinoblastoma, we must think of possible mucosal melanoma of the nasal sinus in these patients in cases of chronic epistaxis. The prognosis of this tumor depends on its early diagnosis and surgical treatment.

Cochlear implantation through the round window with a straight slotted electrode array: optimizing the surgical procedure

The question addressed here is how optimizing the quality of insertion through the round window with the lower morbidity, when using a straight and slotted electrode array of regular length. This retrospective analysis includes all cases implanted with a cochlear implant Digisonic SP (Neurelec-Oticon Medical) since 2004. We checked the operative charts, the depth of insertion, and the follow-up. For comparisons, contingency tables were used and a Chi-square test was performed. A p value <0.05 was considered significant. 126 cases of patients with non-malformed cochleas were implanted through the round window. The mean age was 53.8 ± 16.2 for adults and 3.6 ± 2.6 for children (24 cases). The mean follow-up was 33 ± 22 months. The straight electrode array had either a square or a soft pointed tip (n = 84). Full insertion was achieved in 79 out of 84 cases with a soft tip vs. 18 out of 42 square tips (χ (2) = 41.41, DOF = 1, p < 0.0001). Two cases were stuck at the round window niche by a prominent crista fenestrae. In all cases but one, the chorda tympany was preserved. In one case, a misrouting to the vestibule required a revision surgery. Implantation through the round window with a straight and slotted electrode array with a soft tip (Digisonic SP, Neurelec-Oticon Medical) can lead to a full insertion in 94 % of cases. Drilling out a prominent crista fenestrae is recommended.

Mucosal melanoma of the nasal cavity and paranasal sinuses

Mucosal melanoma of the nasal cavity and paranasal sinuses is a rare disease, but its incidence appears to be increasing. The mean age at diagnosis is between 65 and 70 years. Unilateral nasal obstruction and epistaxis are the most common presenting complaints. Melanoma arises in the septum or lateral wall of the nasal cavity in the great majority of cases. The histological diagnosis is based on specific immunohistochemical labelling and is usually established at an advanced stage of disease: stage T3 or T4 tumours according to the 7th edition of the American Joint Committee on Cancer (AJCC) classification of tumours. First-line treatment consists of surgery. The place of intranasal endoscopic surgery remains controversial due to the difficulty of controlling surgical margins and should be reserved for experienced teams. Adjuvant radiotherapy is usually performed due to its efficacy on local and regional disease control. Five-year overall survival of mucosal melanoma of the nasal cavity and paranasal sinuses in the most recent series does not exceed 40%. Local recurrence is observed in about 50% of cases and metastatic disease is common. The quality of initial tumour resection with negative surgical margins is the most important prognostic factor for tumours confined to the nasal cavity. Hopes for improvement of survival are based on early diagnosis, progress in radiotherapy techniques and cell and gene therapy that are currently under evaluation.

Long-term benefit and sound localization in patients with single-sided deafness rehabilitated with an osseointegrated bone-conduction device

OBJECTIVE

Investigation of long-term satisfaction and correlation with audiometric measurements after osseointegrated bone-conduction device (OBCD) surgery for patients with single-sided deafness (SSD).

PATIENTS

Thirty-six patients implanted with an OBCD for SSD.

STUDY DESIGN

Retrospective review in a university medical center.

INTERVENTION

Rehabilitative. The patients were implanted after a test with an OBCD worn on a headband during 15 days in a daily use. The patients were implanted if the test gave us satisfaction.

MAIN OUTCOME MEASURES

A series of audiometric tests, including speech perception in noise, prosthetic gain, and sound localization measurements, with and without OBCD on headband before surgery and on the transcutaneous implant remote from the surgery. Assessment of benefit and satisfaction using the modified Entific Medical System Questionnaire (EMSQ), the Abbreviated Profile of Hearing Aid Benefit (APHAB), and the Glasgow Benefit Index (GBI).

RESULTS

The mean follow-up is 2.2 years. Approximately 64% of the patients use their OBCD more than 8 hours per day and 82% more than 4 hours per day. Mean satisfaction score is 7.3/10. The APHAB and GBI show a significant benefit (APHAB ease of communication before and after implantation, +21; GBI total score, +17). These results show an improvement in speech perception in noise with the OBCD, but no differences between the preoperative and postoperative tests. There is no improvement in sound localization. A high level of satisfaction is correlated with good results on the pre operative speech perception in noise.

CONCLUSION

The OBCD is an effective way of rehabilitation for SSD. The BAHA improves the speech perception in noise but provided no significant improvement in sound localization as revealed in the postoperative test. With 3 questionnaires we noticed an improvement in the quality of life with the OBCD.

[Balloon catheter dilatation for frontal sinus ostium stenosis: surgical technique and preliminary report]

OBJECTIVES

To report early clinical experience with balloon dilation of the frontal recess ("Balloon Sinuplasty"), to describe surgical technique, to assess its feasibility and effectiveness.

MATERIAL AND METHODS

This prospective, multiinstitutional case series describes all patients who underwent balloon sinuplasty for frontal sinus ostium stenosis from May 2011 to December 2011.

RESULTS

Eight adult patients underwent a total of 11 frontal balloon sinuplasty in the clinical setting. The mean age was 46 +/- 12. All procedures were performed under general anesthesia. No complications occurred. Six of the eight patients were deemed cured with a follow-up range of 1-7 months. For 2 patients the procedure was unsuccessful.

CONCLUSIONS

Balloon dilatation of the frontal recess is a safe and feasible technique with a comparable efficacy to conventional surgical treatment modalities. There is a need for randomised controlled trials and cost-effectiveness studies.

Unstable distortion-product otoacoustic emission phase in Menière's disease

The presence of endolymphatic hydrops as a marker of Menière's disease (MD) suggests abnormal pressure in the intralabyrinthine compartments of patients and excessive stiffness of sound-sensitive structures. Otoacoustic emissions (OAEs) have been reported to respond to changes in the ear's stiffness, including those produced by intracranial pressure steps, by a characteristic phase shift around 1 kHz, thereby suggesting a noninvasive means of monitoring MD. Here, body tilt was used for modulating intracranial pressure in forty-one patients with definite MD who were tentatively measured at two stages, with and without active symptoms. Their distortion-product OAEs (DPOAEs) were dynamically monitored around 1 kHz every few seconds in response to body tilt. In a control sample of thirty normal ears, the maximum phase rotation of DPOAEs produced by body tilt was between -18° and +37°. In MD ears with the complete set of symptoms, the posture-induced phase shifts in 32 out of 35 tests fell outside the normative interval, and in 10 tests, although DPOAEs were well above noise floor, their phase was always so abnormally erratic that body tilt produced hardly any additional effect. When MD ears were asymptomatic, nine out of 32 posture tests were abnormal. The excessive DPOAE phase shift is consistent with either a too stiff cochlear partition or a displacement of the operating point of outer hair cells by endolymphatic hydrops.

Tropisetron and paracetamol association in post-operative patients

Studies in animals and in healthy volunteers have demonstrated the central serotonergic analgesic mechanism of action of paracetamol involving the inhibition of this analgesia by tropisetron, a 5-HT3 antagonist. This randomized, double-blind, controlled study aims at studying this interaction in post-operative patients after ear surgery. Thirty-six patients are included in two parallel groups with intravenous paracetamol (1 g) and either tropisetron (T, 5 mg/mL) or placebo (c, NaCl 0.9%) administered at the end of surgery. Numerical pain evaluations are performed every 30 min, six times after awakening. The difference between the sums of numerical scales of both groups [9 ± 10 (T) vs. 6 ± 7 (c)] is not significant, but the tropisetron group displays higher pain scores despite additional rescue analgesia. The limits of this trial call for a much larger study to investigate further this pharmacodynamic interaction.

Sinonasal mucosal melanomas

OBJECTIVES

Sinonasal mucosal melanomas account for approximately 1% of all melanomas. These tumors are particularly aggressive, with a recurrence rate between 37 and 54% and a 5-year survival rate between 20 and 46%. Metastases are frequent. The main objective of this study was to analyze all of our cases of sinonasal mucosal melanomas and determine any prognostic factors.

PATIENTS AND METHODS

All our cases of sinonasal mucosal melanoma over a period of 10 years were included. Ten cases were analyzed. The mean age was 71 years (range: 61-85 years) for seven women and three men. The clinical, radiological, anatomopathological, and surgical data as well as the characteristics of disease progression were analyzed. These data were compared to those reported in the literature.

RESULTS

The mean follow-up was 36.3 months (range: 2-96 months). The 5-year overall survival was 40%. Seven patients developed local recurrences after a mean follow-up of 16 months (range: 2-27 months) with associated metastases in three cases. Analysis of the prognostic factors showed that tumors classified as T1 and limited to the nasal fossae had a better prognosis.

CONCLUSION

Sinonasal mucosal melanomas are rare tumors with a high mortality rate. Treatment of these tumors requires extensive surgical treatment associated with external radiotherapy.

Osteoma of the internal auditory canal

OBJECTIVE

Osteoma occurs almost exclusively in the head and neck region, only rarely developing into the internal auditory canal. We report an incidental finding of a case in the radiological evaluation of a patient with left hemifacial spasm.

PATIENTS AND METHODS

A 79-year-old woman consulted for left hemifacial spasm associated with left anacusis. Symptoms occurred up to 30 years prior to the first radiological investigations. Computed tomographic (CT) and magnetic resonance (MRI) images were taken.

RESULTS

MRI demonstrated a left internal auditory canal lesion with spontaneous hypointense signal on T1- and T2-weighted images. CT showed the lesion as a typically dense and opaque osteoma. It measured 0.6 cm in maximum size. No surgery was performed because of the slow-growing features of the lesion. Clinical monitoring was recommended.

CONCLUSION

Osteomas are diagnosed incidentally in asymptomatic patients. Our case was symptomatic and raised the question of surgical management. This article discusses the presentation and management associated with this exceptional osteoma location.

Surgical pitfalls encountered with the semi-implantable middle ear transducer ossicular stimulator (MET-Otologics)

OBJECTIVE

To determine whether surgical pitfalls can be anticipated through a preoperative CT-Scan in case of middle ear implantation with a semi-implantable middle ear ossicular stimulator from Otologics (SIMOS). A second outcome measure was to assess the auditory gain obtained in the series.

MATERIALS AND METHODS

A retrospective analysis of 19 consecutive surgical procedure for a SIMOS implantations was achieved. Preoperative Ct-Scans were analyzed and several measurements of the mastoid were taken out from axial transverse views, ie. the distance between the incus and the cortical mastoid bone [d(i-c)], the distance between the sigmoid sinus and the incus [d(i-ss)], the distance between the sigmoid sinus and the cortical bone of the mastoid [d(c'-ss)]. On coronal images, the dura of the middle fossa was described as procident if it was lower than the head of malleus and/or body incus. Auditory gain was calculated on pure tone and speech audiometry with bisyllabic words.

RESULTS

All cases were successfully implanted. d(i-c) was on average at 33.1 +/- 2.6 mm in cases easy to implant. One case of contracted mastoid was difficult and led to the impaction of the sigmoid sinus. In this case the distance d(i-c) was shorter at 25 mm than the average minus 2 standard deviations of the others (27.9 mm). Also d(ss-c') was lower at 7 mm than the average minus 2 standard deviations of the others (7.6 mm). Two other cases led to difficult surgical procedures because of a low middle fossa dura. This too low middle fossa dura could be identified on preoperative coronal CT-scans in these two cases. Audiometric gains were remarkable, with an average of 39 +/- 16 dB. In case of severe sensorineural hearing loss the average gain was higher at 46 +/- 9 dB. Two revision-procedures were required, one for a device failure, the second because of skin alteration due to systemic inflammatory disease requiring corticosteroids. Mean follow-up was 50 +/- 22 months.

CONCLUSION

The SIMOS is a powerful middle ear implant that can undoubtedly give a huge audiometric gain. The implantation procedure requires a precise microsurgical operation that can be hampered by anatomical conditions of the petrous bone. A thorough examination of preoperative CT-scan is highly recommended in order to obtain measurements of the mastoid in axial views, and the analysis of the position of the middle fossa dura in coronal views.

Effects of glycerol intake and body tilt on otoacoustic emissions reflect labyrinthine pressure changes in Menière's disease

It is known that by influencing stapes stiffness thus the ear's impedance, changes in intracranial and intralabyrinthine pressure induce a characteristic phase shift in otoacoustic emissions (OAE) around 1 kHz in human ears. Thus, if the regulation of pressure in intralabyrinthine compartments were abnormal in Menière patients, OAEs might help detect it. Body tilt, which acts on intracranial pressure, and administration of an osmotically active substance provide two simple ways of manipulating intralabyrinthine pressure. Here, 14 patients with typical signs of an attack of unilateral endolymphatic hydrops were submitted to postural changes and a glycerol test. Their OAEs initially collected in upright position served as references, then OAEs were measured in supine position, and back to the upright posture one and 3h after glycerol intake. Twenty control subjects were also tested for body tilt. The main effect of body tilt and glycerol was a phase rotation of OAEs peaking around 1 kHz. Its frequency dependence matched the one due to a pressure-related change in stapes or basilar membrane stiffness predicted by the ear model of Zwislocki (1962). The average glycerol-induced phase shifts were similar in size in Menière vs. asymptomatic ear and audiometric thresholds were stable after glycerol intake in line with the model predicting little change in the magnitude of the transfer function. These data support a simple conductive pressure-related mechanism explaining the action of glycerol on inner ear responses. The fact that the mean postural shift was three times larger in Menière than asymptomatic and control ears suggests an additional effect in allegedly hydropic ears.

Acute abscess of the base of the tongue: a rare but important emergency

BACKGROUND

Acute posterior lingual abscess is rare, but may potentially compromise the airway acutely.

OBJECTIVE

Lingual abscesses call for prompt and aggressive management because they are potentially life-threatening infections. Anterior lingual abscess (the most common) and posterior third lingual abscess must be differentiated.

CASE REPORT

A young man who experienced the beginnings of dyspnea and total aphagia presented to the Emergency Department. A posterior lingual abscess was identified on computed tomography scan.

DISCUSSION

Multi-antimicrobial therapy is the cornerstone of treatment. Surgical drainage is also of critical importance for preventing deeper spread of the infection.

CONCLUSION

We present this case to increase awareness among emergency physicians and head and neck surgeons of the clinical findings of acute abscess of the base of the tongue, which can be difficult to diagnose clinically. Imaging of the oral cavity and pharynx is the key to the diagnosis, and the key to choosing the best surgical strategy.

[Occupational exposure to wood dust and nasal sinus cancer]

OBJECTIVES

To determine the clinical, histological, epidemiological and occupational data related to exposure to wood dust in a series of 100 nasal sinus malignant tumors.

MATERIAL AND METHODS

We conducted a retrospective and descriptive study of cases diagnosed between 1st January 1981 and 31 December 2000, in the Auvergne region of France. Individual, medical, and occupational data were collected from a questionnaire completed by the patient (or the patient's family in case of death) and from the medical documents available.

RESULTS

Forty-six cases (46 men), with an average age of 63+/-9.2 years [range, 43-82], had been exposed to occupational wood dust before the diagnosis. Fifty-four cases (30 men, 24 women), with an average age of 64.3+/-8.7 years [range, 40-96], had never been exposed. The average annual incidence increased, either for the total population or for the two subgroups distinguished on the basis of occupational exposure to wood dust. The majority of the patients presented different functional symptoms at the time of the diagnosis. For the 46 patients exposed to wood dust, the tumors were primarily ethmoid adenocarcinomas (92%). For the 54 non-exposed patients, the tumors observed were mainly epidermoid carcinomas (57%), then adenocarcinomas (15%). On the 46 patients exposed to wood dust, 85% were carpenters or cabinetmakers. For the majority of the patients, wood dust exposure started before the age of 20 (average age: 17+/-4.5) and the longest exposure began before 1981. The exposure time to wood dust before diagnosis was in the majority of cases greater than 20 years (mean exposure time: 37 years+/-11.4). Only 15% were exposed at the time of the diagnosis (mean time between the end of the exposure to the diagnosis was 11 years+/-2.8). Of the 54 non-exposed patients, no professional risk factor was evidenced.

CONCLUSION

Epidemiologic data, such as the increasing incidence, and clinical and professional data, such as the occupational exposure to wood dust, were in agreement with the French and European literature. It is still probably too early to appreciate the effectiveness of prevention, established in France since 1980, on nasal sinus tumor incidence.

Manifestations salivaires dans la Maladie Fibrosclérosante Multiple à IgG4

OBJECTIVES

To report a case of IgG4-related multifocal fibrosclerosis, revealed by a multifocal salivary involvement.

MATERIAL AND METHODS

A 59-year-old man, with chronic pancreatitis, was managed for fibrotic involvement of the 2 submaxillary glands and the 2 parotids. Clinical, radiological, and histologic features were retrospectively studied.

RESULTS

Pathological features of submandibular gland revealed a chronic sclerosing sialadenitis. Retroperitoneal fibrosis in computed tomography and high rate of IgG4 are objectived. The diagnosis of IgG4-related multifocal fibrosclerosis is evoked. The patient's state improved with corticosteroid therapy.

CONCLUSION

Salivary involvement in IgG4-related multifocal fibrosclerosis must be recognized in salivary medical pathology.

[Adenoid cystic carcinoma of the external auditory canal]

OBJECTIVES

To report a case of adenoid cystic carcinoma of the external auditory canal with petrous involvement.

MATERIAL AND METHODS

A 50-year-old woman was referred to our department for the management of a necrotizing external otitis. Computed tomography and biopsy revealed an adenoid cystic carcinoma of the external auditory canal.

RESULTS

The patient was treated by complete surgical excision. A radiation therapy completed the treatment. Follow-up time was 19 months without evidence of recurrence. Adenoid cystic carcinoma of the external auditory canal is a rare tumor. It's a special type of carcinoma developing from the ceruminous glands. Histogenesis is difficult and unsettled. The most important survival factor is removal of the tumor with histologically free margins.

CONCLUSIONS

Lack of specific clinical and radiological signs makes the diagnostic challenging. The adenoid cystic carcinoma is a rare neoplasm of the external auditory canal. An initial aggressive wide "en bloc" surgical resection is mandatory.

Rapidly developing leptomeningeal carcinomatosis following anterior skull base surgery: a case report

Leptomeningeal carcinomatosis is rare in evolution of head and neck cancers. Prognosis is poor and treatment is through supportive care. We report an atypical rapid post-operative leptomeningeal carcinomatosis after skull base resection for an ethmoidal adenocarcinoma. The anterior skull base resection was near-total and we suspect a seeding of subarachnoid space either before surgery, either during surgical extirpation or from the residual intracranial nodule. It is the first description of rapid LMC after surgery (less than 1 month). Post-operative MRI diagnosed the LMC through the detection of contrast enhancing leptomeningeal nodules at bilateral second and eighth cranial nerves and at bilateral interpedoncular area. A strong index of suspicion along with clinical and radiological correlation is essential to arrive at a correct diagnosis. Otolaryngologists should be aware of the possibility of leptomeningeal carcinomatosis, before or after surgery, in a patient presents with an appropriate constellation of neurologic symptoms and a history of cancer.