Consensus français sur la pratique de la chirurgie oncologique ORL pendant la pandémie de COVID-19

Dans le contexte de la pandémie de COVID-19, des conseils spécifiques semblent nécessaires concernant la prise en charge des patients atteints de cancers ORL. La règle est de limiter au maximum le flux de patients afin de réduire les risques de contamination par le virus SARS-Cov-2 aussi bien des patients que du personnel soignant, particulièrement exposé en ORL. L’objectif est de limiter le risque de perte de chance pour le patient et d’anticiper le flux de patients atteints de cancers à traiter à la fin de l’épidémie, en tenant compte du degré d’urgence, de la lourdeur de la chirurgie, du risque de contamination de l’équipe soignante (trachéotomie) et de la situation locale (saturation ou non de l’hôpital et des services de réanimation).

French consensus regarding precautions during tracheostomy and post-tracheostomy care in the context of COVID-19 pandemic

Tracheostomy post-tracheostomy care are regarded as at high risk for contamination of health care professionals with the new coronavirus (SARS-CoV-2). Considering the rapid spread of the infection, all patients in France must be considered as potentially infected by the virus. Nevertheless, patients without clinical or radiological (CT scan) markers of COVID-19, and with negative nasopharyngeal sample within 24h of surgery, are at low risk of being infected. Instructions for personal protection include specific wound dressings and decontamination of all material used. The operating room should be ventilated after each tracheostomy and the pressure of the room should be neutral or negative. Percutaneous tracheostomy is to be preferred over surgical cervicotomy in order to reduce aerosolization and to avoid moving patients from the intensive care unit to the operating room. Ventilation must be optimized during the procedure, to limit patient oxygen desaturation. Drug assisted neuromuscular blockage is advised to reduce coughing during tracheostomy tube insertion. An experienced team is mandatory to secure and accelerate the procedure as well as to reduce risk of contamination.

French consensus on management of head and neck cancer surgery during COVID-19 pandemic

In the context of the current pandemic, there is a need for specific advice concerning treatment of patients with Head and Neck cancers. The rule is to limit as much as possible the number of patients in order to reduce the risks of contamination by the SARS-Cov-2 virus for both patients and the caregivers, who are particularly exposed in ENT. The aim is to minimize the risk of loss of opportunity for patients and to anticipate the increased number of cancer patients to be treated at the end of the pandemic, taking into account the degree of urgency, the difficulty of the surgery, the risk of contaminating the caregivers (tracheotomy) and the local situation (whether or not the hospital and intensive care departments are overstretched).

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.

[Advances in the management of cervical lymphadenopathies of unknown primary with intensity modulated radiotherapy: Doses and target volumes]

The definition of nodal and/or mucosal target volumes for radiation therapy for lymphadenopathies of unknown primary is controversial. Target volumes may include all nodal areas bilaterraly and be pan-mucosal or unilateral, selective, including the sole oropharyngeal mucosa. This review presents current recommendations in light of changes in the TNM classification, Human papillomavirus status and therapeutic advances. We conducted a systematic review of the literature with the following keywords: lymphadenopathy; head and neck; unknown primary and radiation therapy. There are no direct comparative studies between unilateral or bilateral nodal irradiation or pan-mucosal and selective mucosal irradiation. Contralateral lymph node failure rates range from 0 to 6% after unilateral nodal irradiation and 0 and 31% after bilateral irradiation. Occurrence of a mucosal primary varies between 0 and 19.2%. Initial clinical presentation and Human papillomavirus status are critical to define mucosal target volumes. Intensity-modulated radiotherapy is recommended (rather than three-dimensional irradiation) to avoid toxicities. Systemic treatments have similar indications as for identified primary head and neck cancers. Failures do not appear superior in case of unilateral nodal irradiation but comparative studies are warranted due to major biases hampering direct comparisons. Human papillomavirus status should be incorporated into the therapeutic strategy and practice-changing TNM staging changes will need to be evaluated.

Tranexamic acid for epistaxis in hereditary hemorrhagic telangiectasia patients: a European cross-over controlled trial in a rare disease

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is a genetic disorder associated with abnormal angiogenesis and disabling epistaxis. Tranexamic acid (TA) has been widely used in the treatment of these severe bleeds but with no properly designed trial.

OBJECTIVES

To demonstrate the efficacy of TA in epistaxis in HHT patients and to explore its safety of use.

PATIENTS/METHODS

A randomized, placebo-controlled, double-blind, cross-over trial was conducted. Participants were randomized to receive TA (3 g a day) then placebo or the opposite sequence. The main analysis compared intra-individual mean duration of epistaxis under TA vs. placebo on a log scale. The primary outcome was the mean duration of epistaxis per month, assessed with specific grids to be completed by participants. The number of epistaxis episodes was recorded as a secondary outcome.

RESULTS

A total of 118 randomized patients contributed to the statistical analysis. The mean duration of epistaxis per month was significantly shorter with TA than placebo (0.19 on the log scale; SD = 0.07; P = 0.005), corresponding to a decrease of 17.3% (15.7 min) in the duration of epistaxis per month (CI 95%, 5.5-27.6). The median number of epistaxis episodes per month was 22.1 episodes in the placebo arm vs. 23.3 episodes in the TA arm. No thrombophlebitis was observed.

CONCLUSIONS

In the ATERO study, we demonstrated a significant decrease in the duration of epistaxis in HHT patients taking TA. No safety issues were recorded in our cohort of patients.

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.

Cancer of the external auditory canal

INTRODUCTION

Cancer of the external auditory canal is a rare tumour with an annual incidence of one per one million inhabitants. The objective of this study was to evaluate the 5-year overall survival and disease-free survival rates in a series of patients with carcinoma of the external auditory canal and to compare our results concerning the clinical presentation, management and survival with those of the literature.

PATIENTS AND METHOD

Ten patients were included in this retrospective, single-centre study over a 20-year period. Data concerning age, symptoms, imaging, TNM stage according to the Pittsburgh classification, histology, management, sequelae, recurrences and survival were recorded.

RESULTS

The mean age of the patients of this series was 60.7 years. Seven patients had a squamous cell carcinoma. The other histological types were undifferentiated carcinoma, adenoid cystic carcinoma and neuroendocrine carcinoma. Staging was based on the Pittsburgh classification with one stage I, one stage III and eight stage IV tumours. Five-year overall survival rates were 100%, 50% and 0%, respectively. The mean 5-year overall survival rate was 35% and the mean 5-year disease-free survival rate was 24%.

CONCLUSION

Carcinoma of the external auditory canal is a difficult diagnosis when the tumour does not present as a fungating mass protruding from the external auditory canal. The Pittsburgh classification was used for TNM staging of these tumours, allowing comparison of our results with those of the literature. The clinical findings and survival rates observed in this study are comparable to those reported in the literature. These tumours are associated with a poor prognosis on the basis of our results and published data.

Radiofrequency tonsillotomy versus bipolar scissors tonsillectomy for the treatment of OSAS in children: a prospective study

INTRODUCTION

Tonsillotomy is an effective treatment for the management of obstructive sleep apnoea syndrome (OSAS) in children with tonsillar hypertrophy and appears to be associated with less pain and postoperative morbidity.

OBJECTIVE

To compare postoperative morbidity and short-term and intermediate-term efficacy of radiofrequency tonsillotomy (TT) and bipolar scissors tonsillectomy (TE) in children.

PATIENTS AND METHODS

Children with OSAS due to tonsillar hypertrophy were included in a prospective, non-randomized study between February 4, 2008 and March 20, 2010. Exclusion criteria were recurrent tonsillitis (≥ 3 episodes per year), clotting disorders and age less than 2 years. Postoperative complications, efficacy on OSAS, and operating times were evaluated. Pain was evaluated by the Postoperative Pain Measure for Parents score on D0, D1, D7 and D30.

RESULTS

One hundred and ninety-three children were included: 105 in the TE group (age: 4.75 ± 2.37 years) and 88 in the TT group (age: 4.88 ± 2.6 years). The pain score was significantly lower in the TT group than in the TE group during the first postoperative week (P<0.05). A significant difference was observed for the secondary postoperative bleeding rate (1 after TT versus 8 after TE). No significant difference was observed between the two techniques in terms of the efficacy on OSAS. At 1 year, the tonsil regrowth rate in the TT group was 4.5%.

CONCLUSION

Radiofrequency tonsillotomy is a safe technique for the treatment of obstructive tonsillar hypertrophy in children with good results on OSAS and a reduction of postoperative pain.

Initial staging of squamous cell carcinoma of the oral cavity, larynx and pharynx (excluding nasopharynx). Part I: Locoregional extension assessment: 2012 SFORL guidelines

OBJECTIVES

To set out good practice guidelines for locoregional extension assessment of squamous cell carcinoma of the head and neck (excluding nasopharynx, nasal cavities and sinuses).

MATERIALS AND METHODS

A critical multidisciplinary review of the literature on locoregional extension assessment of squamous cell carcinoma of the head and neck was conducted, applying levels of evidence in line with the French health authority's (HAS) literature analysis guide of January 2000.

CONCLUSION

Based on the levels of evidence of the selected articles and on work-group consensus, graded guidelines are set out for clinical, endoscopic and imaging locoregional extension assessment of head and neck cancer.

Initial staging for squamous cell carcinoma of the mouth, larynx and pharynx (except nasopharynx). Part 3: general assessment. 2012 SFORL recommendations

OBJECTIVES

The French Society of Otorhinolaryngology (SFORL) set up a work group to draw up guidelines for initial staging of head and neck squamous cell carcinoma. Locoregional and remote extension assessment are dealt with in two separate reports. The present part 3 deals with the assessment of frequent associated symptoms and pathologies, requiring early treatment and the collection of data on a certain number of clinical and paraclinical parameters for therapeutic decision-making in the multidisciplinary team meeting.

MATERIALS AND METHODS

A multidisciplinary critical analysis of the literature was conducted. General assessment here covers screening, assessment and initial management of the following: usual risk factors (smoking, alcohol, HPV), the most frequent medical comorbidities, nutritional status, social and psychological status, dental status, pain and possible anemia. As oncologic management frequently associates surgery, radiation therapy and chemotherapy, the underlying examinations should be early, as part of initial staging. The levels of evidence for the examinations were estimated so as to grade guidelines, failing which expert consensuses were established.

RESULTS

The high rates of pain, malnutrition and anemia call for systematic screening and early management, especially as rapidly effective treatments exist. Assessing comorbidity and social and psychological status enables general health status to be assessed, along with possible contraindications to the usual treatments. Tracheal intubation problems may require intubation under flexible endoscopy or jet-ventilation by inter-cricothyroid catheterization from the diagnostic endoscopy stage. Assessment and adapted dental care should be conducted if radiation therapy is likely or certain.

CONCLUSION

Early management of symptoms and comorbidity and anticipation of subsequent treatment are intended to shorten initial staging time and to collate the data needed for therapeutic decision-making. This assessment should be performed at the same time as the locoregional and remote extension assessment, and is obviously to be adapted according to tumoral extension stage and the possible treatment options.

[Post intubation collected septic cricoarytenoid arthritis: case report]

We report a rare case of post intubation cricoarytenoid arthritis. A 18-year-old man admitted to emergency was easely intubated for 14 days for a non neck injury. Sixty-six days after intubation, he consulted for severe odynophagia with dyspnoea. Nasofibroscopic examination revealed a right arytenoid granuloma with oedema and inflammation, and bilateral arytenoid immobility. There was evidence on the CT scan of cricoarytenoid arthritis with fluid accumulation. Antibiotic treatment and two punctures for drainage allowed healing. There were cricoid and arytenoid calcifications. The patient recovered total and stable laryngeal mobility and function. This case is unusual, with features unlike those previously reported: intubation being the probable cause, the unusual clinical presentation with painless cricoid palpation, and the contrast between imaging findings during follow-up and the evolution under treatment. Indeed, there was an apparent discrepancy between the favourable clinical course and the CT-images revealing calcifications.

Lipoleiomyosarcoma of the larynx

BACKGROUND

Lipoleiomyosarcoma is a rare tumor consisting of well-differentiated liposarcoma and leiomyosarcoma. The ear-nose-throat location of lipoleiomyosarcoma has not been previously described.

METHODS AND RESULTS

A 37-year-old man with a dysphagia had a dyspnea after an endoscopy. A large tumor was exteriorized from the man's mouth. The lesion was pedicled to the epiglottis. A histologic examination determined that the tumor was a lipoleiomyosarcoma. MDM2 and CDK4 gene amplification were positive. Due to the risk of recurrence, a second intervention was performed to complete the excision.

CONCLUSION

These tumors develop in cavities slowly and gradually. The treatment of this lesion is surgical with a sufficient resection margin.

Canal wall up tympanoplasty for middle ear cholesteatoma in adults: modeling cartilage

OBJECTIVES

The authors report their experience with a variant cartilage tympanoplasty technique in a canal wall up (CWU) procedure for middle ear cholesteatoma, comparing reliability with other techniques. Functional results are analyzed according to ossicular chain status.

MATERIALS AND METHODS

A retrospective study was performed in adults operated on with CWU tympanoplasty for middle ear cholesteatoma. The surgical technique of "modeling" cartilage is described.

RESULTS

One hundred and nine patients were included (113 procedures). There were four recurrences (3.5%). Mean follow-up was 48 months (range, 24-96 months). In case of normal ossicular chain, postoperative pure-tone average air-bone gap was always less than 20dB, and less than 20dB following myringostapedopexy in 60% of cases with incus destruction.

CONCLUSION

Modeling cartilage is a reliable reconstruction technique to prevent recurrent cholesteatoma, and contributes to the quality of functional results in ossiculoplasty.

Residual cholesteatoma: prevalence and location. Follow-up strategy in adults

OBJECTIVES

To assess prevalence and location of residual cholesteatoma following closed "canal wall up" tympanoplasty (CWUT). The evolution of follow-up strategy is discussed.

PATIENTS AND METHODS

A retrospective study was run in adults operated on by CWUT for middle-ear cholesteatoma and who had undergone second look surgery and/or postoperative radiology (CT-scan, diffusion-weighted MRI).

RESULTS

One hundred and nine patients (113 ears) underwent the procedure. Mean follow-up was 48 months (range, 24-96 months). Twenty-nine residual cholesteatomas were found (25%), including 11 located in the anterior attic (38%). Follow-up included 77 second look operations (70%), and 71 radiological examinations (62 CT-scans and nine diffusion-weighted MRIs). Second look surgery was without benefit for the patient (no residual, no ossiculoplasty) in one third of cases.

CONCLUSION

Residual cholesteatoma in the anterior attic is a problem in CWUT. When postoperative auditory results are good, second look surgery should not be systematic but guided by high quality imaging.

Thyroid gland invasion in laryngopharyngeal squamous cell carcinoma: prevalence, endoscopic and CT predictors

OBJECTIVES

The authors studied the prevalence of histological thyroid gland invasion in laryngopharyngeal cancer and the preoperative endoscopic and CT signs predictive of this invasion.

PATIENTS AND METHODS

Retrospective study of patients with laryngopharyngeal squamous cell carcinoma (T3 and T4) treated by total laryngectomy or total laryngopharyngectomy associated with concomitant total thyroidectomy or ipsilateral lobectomy and isthmectomy.

RESULTS

Eighty-seven patients were included. Eleven patients (12.6%) presented thyroid gland invasion. Subglottic tumour extension greater than or equal to 10mm (P=0.008) and cricoid cartilage destruction on CT (P=0.001) were statistically correlated with histological thyroid gland invasion. An intact appearance of the laryngeal cartilages on CT was associated with a low probability of thyroid gland invasion.

CONCLUSION

Thyroid gland invasion must not be underestimated in patients with advanced laryngopharyngeal cancer. Preoperative CT is an essential part of the preoperative work-up. Thyroidectomy must not be performed systematically.

[Submental flap for auricule reconstruction]

OBJECTIVE

We present our experience in the use of submental flap in reconstruction of post-auricular excision defects.

MATERIAL AND METHODS

Three patients underwent reconstruction with submental flap.

RESULTS

The submental flap has been used in 3 patients for auricular defect reconstruction. All patients had a carcinoma involving the auricle. All the donor site defects were closed primarily. Outcomes were simple. In one case, we noticed a partial necrosis of the flap extremity.

CONCLUSION

The submental flap produces excellent skin color and contour. It leaves a very well-hidden donor site. The operative technique makes it easy to use. So, the submental flap has definite advantages over distant flaps and it is a useful addition to the reconstruction in head and neck surgery.

[Metastatic melanoma to the oropharynx]

INTRODUCTION

Metastatic mucosal melanoma to the oropharyngeal area is extremely rare. Only 0.6% to 3% of patients with cutaneous malignant melanoma will have metastases to the mucosa of the upper aerodigestive tract.

CASE REPORT

A 60-year-old woman presented with a past history of dorsal melanoma and metastatic inguinal node was referred to our department for odynophagia. Physical examination revealed a mass of the right tonsil. A cervico-facial computed tomography, a magnetic resonance imagery and PET-scanner were performed and showed the tumefaction located at the right tonsil. Biopsy was performed under general anesthesia. The histological examination revealed a metastatic melanoma. After discussion a palliative treatment with chemotherapy was begun. The patient died of disseminated disease 2 months after the beginning of the chemotherapy, only 4 months after the initial diagnosis.

DISCUSSION/CONCLUSION

The case presentation indicates that careful examination of the head and neck should be part of the routine follow-up examination in all melanoma patients. The discovery of mucosal metastasis in head and neck indicated widespread dissemination and a poor prognosis.

Cholesterol granuloma of the maxillary sinus

INTRODUCTION

Cholesterol granuloma (CG) can be found in several areas of the body. Maxillary sinus localization is considered rare.

CASE REPORT

A 37-year-old male presented with acute febrile sinusitis. Nasal endoscopy showed a nasal polyp at the middle meatus. Computed Tomography (CT scan) of the sinus showed complete opacity of the right maxillary sinus without calcification and partial opacification of frontal and ethmoidal sinuses. Functional endoscopic sinus approach was performed. Marsupialization of the cyst which a brownish fluid, which evoked the diagnosis of cholesterol granuloma.

CONCLUSION

The definite diagnosis is made by histology, although intra-operative finding could be suggestive. Complete excision is achievable by endoscopic approach.

[Epidermoid cysts of the fourth ventricle mimicking benign paroxysmal positional vertigo]

OBJECTIVE

To report a case of atypical positional vertigo revealing a fourth ventricle epidermoid cyst.

MATERIAL AND METHODS

We report a case of a thirty-year-old woman suffering from positional vertigo with downbeat nystagmus. Except for these symptoms, the physical examination was normal, apart from intermittent headaches. On videonystagmography, a decrease in the average speed of beats and lowered benefits obtained by slow motion were noted. MRI revealed a fourth ventricle epidermoid cyst.

RESULTS

Physical examination may provide several signs that are likely to enable the examiner to distinguish between central nervous system or peripheral vertigos. Atypical symptoms such as a downbeat nystagmus, a lack of reversal in nystagmus beats when returning to the sitting position and a lack of a latency period in vertigo and nystagmus occurrence during the Dix-Hallpike maneuver suggest a central nervous system etiology.

CONCLUSION

With atypical symptoms noted when questioning the patient or during physical examination, a central nervous system etiology should be mentioned and explored with cerebral MRI.

[Swallowing sound signal: description in normal and laryngectomized subjects]

OBJECTIVES

Recently, we described three sound components in the pharyngeal swallowing sound. The aim of the present study was to identify the origin of these components using modern techniques providing numeric, synchronized acoustic-radiological data in a normal population and in a partial supracricoid laryngectomized population (SCL group) and a total laryngectomized (TL group) population in pre- and postoperative situations.

PATIENTS AND METHODS

We enrolled 15 normal subjects (10 men and five women; mean age, 29.5+/-8 years), 11 patients in the SCL group (11 men; mean age, 62; range, 45-75 years), and nine patients in the TL group (three women, six men; mean age, 56; range, 39-73). An X-ray camera was connected to a video acquisition card to obtain acoustic-radiological data (2 images/s). The microphone was attached to each subject's skin overlying the lateral border of the cricoid. The subjects were asked to swallow 10 ml of a barium suspension. We performed the acoustic-radiological analysis using Visualisation and Cool Edit Pro software. Each sound component was associated with a specific position of the bolus and the moving anatomic structure. Three sound components were identified: the laryngeal ascension sound (LAS), the upper sphincter opening sound (USOS), and the laryngeal release sound (LRS). We quantified the total duration of the pharyngeal sound and its components, as well as the duration of the interval.

RESULTS

The average duration of the normal pharyngeal sound was 690+/-162 ms and was significantly decreased in the TL group (296+/-105 ms) and increased in the SCL group (701+/-186 ms). The USOS was present in 100% of the recordings. A typical profile of the swallowing sound for each group was obtained.

CONCLUSION

This study allowed us to determine the origin of the three main sound components of the pharyngeal swallowing sound with respect to movements in anatomic structures and the different positions of the bolus, and to describe the main variations induced by a partial and a total laryngectomy.

Anterior cerebrospinal fluid leaks in children and adults: five years experience

OBJECTIVES

To describe surgical experience in the repair of anterior skull base defects, we studied patients with congenital or acquired defects. According to a multidisciplinary evaluation, all subjects underwent surgery performed by an ENT surgeon in order to avoid craniotomy.

DESIGN

Retrospective study of patients who were treated for an anterior skull base defect between 2000 and 2005 at a tertiary referral centre.

MATERIALS AND METHODS

Twelve patients had surgery to correct anterior skull base defects. Four patients had spontaneous anterior basal defect and eight had a post-traumatic cerebrospinal fluid (CSF) leakage. The diagnosis was made with imaging studies: Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scans, possibly supplemented by a cisternography. The defects were repaired using the endoscopic endonasal approach excepted in frontal sinus location.

RESULTS

CT and MRI scans demonstrated the defect in all but two cases. In one of them, MR cisternography showed the intranasal sac and in the other CT cisternography demonstrated a CSF fistula without any bone defect at the ethmoid roof. After surgery, the follow-up period was at least 16 months (mean 26 months). Success rate at first attempt was 83%. Two adults needed a second surgical repair with successful outcome in one, increasing the success rate to 92% after the second attempt. One female patient, obese with a body mass index > 30 and hydrocephaly, had a recurrence of CSF leakage despite surgical revision. Postoperative imaging studies, CT scan or MRI, showed that the defect had successfully been repaired in 11 patients.

CONCLUSION

High-resolution CT scan, MRI with or without cisternography, should investigate osteo-meningeal defect. Our report confirms that endonasal surgical techniques are useful for treating meningoceles and meningo-encephaloceles. The external route is to be preferred when the lesion is located in the apex of the frontal sinus.

[Evolution of facial nerve prognosis in vestibular schwannoma surgery by translabyrinthine approach]

OBJECTIVES OF THE STUDY

To evaluate our results on the postoperative facial function, its pre and preoperative predictive factors, and the application of the surgical technique to lesions of decreasing size.

PATIENTS AND METHODS

A series of 248 patients operated of an unilateral vestibular schwannoma has been reviewed. We have compared the results gathered over two periods corresponding to the evolution of our surgical technique since 1998.

RESULTS

Immediate and 1 year postoperative facial function is significantly better among patients operated after 1998 (satisfactory in 75 and 88% respectively). This trend marked by the improvement of the results since 1998 has to be discussed according to other predictive factors. One of predictive factor is the decrease of the size of the lesion during the same period. The other factors are the hearing level, deafness duration, trigeminal nerve involved, vestibular status and ABR desynchronization.

CONCLUSION

The positive predictive factors are usually correlated with the size of the tumour This implies the necessity of an early diagnosis of the schwannomas. The second predictive factor of the facial function is the use of a soft surgical technique.

Métastase thyroïdienne d'un cancer rénal

INTRODUCTION

Intrathyroid metastases are uncommon. Clinically, the distinction may be difficult with thyroid malignant tumor.

CASE REPORT

A 76-year-old woman was referred to our department for an evaluation of a dysphonia. She had a past history of renal cancer 6 months ago. A multinodular goiter was noticed at the palpation. Left recurrent laryngeal nerve palsy was observed; there was no cervical lymph node. Fine-needle aspiration was not contributive. Computed tomography confirmed the multinodular goiter. Total thyroidectomy was performed and final histologic examination revealed a metastasis of a renal cancer.

CONCLUSION

Even if intrathyroid metastasis are rare, the practitioner must suggest the diagnosis if the patient had a thyroid tumor and a past history of cancer. A fine-needle aspiration can help the diagnosis. The surgical management is recommended for isolated metastasis to the thyroid gland especially in renal cancer.

Neuro-endocrine adenoma of the middle ear: a case study

Neuroendocrine adenomas are rare tumors, which can appear in the middle ear. Approximately a hundred cases have been reported in the literature. We report the case of a 58-year-old man who consulted for an abnormal sensation of fullness in the right ear. The otoscopic examination showed a retrotympanic tumefaction. The CT scan and MRI of the middle ear demonstrated a well-defined tissue mass without any osteolysis. We performed surgical exeresis by transcanal procedure with a cartilage graft tympanoplasty. Microscopic examination and immunohistochemistry revealed an endocrine adenoma of the middle ear. Neuroendocrine adenomas can develop in a number of different sites. When they appear in the middle ear they usually produce hypoacousia. The otoscopic examination shows non-specific findings with only retrotympanic swelling. Surgical exeresis enables histologic and immunohistochemically analysis of the surgical specimen. The adenoma is composed of two cellular types: neuroendocrine (which closely resemble carcinoid tumors) and glandular. Regular clinical and radiologic follow-up is necessary since recurrence is possible. The formal diagnosis of neuroendocrine adenomas of the middle ear requires histologic and immunohistochemically confirmations since the clinical symptoms are non-specific. Surgical excision with removal of the ossicular chain is the treatment of choice in order to prevent recurrence.

[Differenciated thyroid carcinomas with laryngo-tracheal invasion]

OBJECTIVES

Analyze the diagnosis and treatment of differentiated thyroid carcinomas with laryngo-tracheal invasion.

MATERIALS AND METHODS

Among the 117 patients operated for a differentiated thyroid carcinoma in the ENT department of Tours Hospital (France) between January 1990 and December 2003, seven presented laryngo-tracheal invasion and were included in this retrospective study.

RESULTS

Laryngo-tracheal resection resulted in a thyroid cartilage-shaving in two patients. We performed a resection of one side of the thyroid cartilage in one patient, a thyro-tracheal resection-anastomosis with a partial cricoidectomy in one patient, a partial vertical laryngectomy extended to the first tracheal ring in one patient and a total laryngectomy in one patient. No laryngo-tracheal resection was done in one patient. Early complications were swallowing disorders (n = 2), transitory hypoparathyroidism (n = 1), definitive recurrent nerve paralysis (n = 2), subcutaneous emphysema and hematoma (n = 1) and Claude Bernard-Horner's syndrome (n = 1). Locoregional recurrences (n = 2) and distant metastasis (n = 2) were discovered six months to four years after the laryngo-tracheal resection. With a mean follow-up of 40 month, four patients were alive (two disease free) two patients had died and one was lost of follow-up at three months.

CONCLUSION

The frequency of locoregional recurrences and distant metastasis is higher for the differentiated thyroid carcinomas with laryngo-tracheal invasion than the others. In these cases, we performed macroscopic carcinological surgery preserving laryngeal functions as much as possible.

[Chondrosarcoma of the cricoid]

OBJECTIVE

Chondrosarcoma of the larynx is a rare neoplasm generally observed on the cricoid. The purpose of this study was to define the most appropriate surgical management depending on tumor extension and histological grade.

PATIENTS AND METHODS

Three males and one female were treated for chondrosarcoma of the cricoid between 1990 and 2003 in the Ear, Nose and Throat department in Tours, France. There were three grade I tumors and one grade II tumor. Tumor resection by thyrotomy was performed in two patients, total laryngectomy in one and laser desobstruction in one.

RESULTS

The patient who underwent total laryngectomy remained in complete remission at five years. Among the two patients who had thyrotomy, one remained in remission at three years and the other experienced recurrence at four years and underwent a second operation. He died five years later due to another disease. Total follow-up was nine years. The patient treated by laser therapy achieved stabilization at twelve months.

CONCLUSION

Computed tomography and histological grading enable choosing the best surgical procedure. Partial laryngeal surgery is indicated for small or low-grade chondrosarcomas. For large or high-grade tumors, total laryngectomy must be performed. In the event of patient refusal, laser desobstruction can provide clinical stabilization.

[Isolated tracheo-oesophageal fistula in neonates]

INTRODUCTION

Congenital isolated tracheo-oesophageal fistulae without oesophageal atresia account for about 4% of tracheo-oesophageal malformations. An Otolaryngologist, even with a paediatric practice, is unlikely to treat a lot of cases during his career. We report 3 cases and discuss the investigations and management of the fistulae.

PATIENTS AND METHODS

Three neonates with an isolated congenital tracheo-oesophageal fistula were treated between 1997 and 2002. We describe their presentation, investigation and treatment. We present radiology, endoscopic and surgical images for one case.

RESULTS

The mean age at diagnosis of congenital isolated fistula was 6.7 days. In retrospect, the symptoms were usually present from birth. A barium swallow had demonstrated the tracheo-oesophageal fistula in 2 infants. In all three cases the fistula was clearly visualized by tracheoscopy. The most distal fistula was 25 millimetres below the true vocal cords. The closure of the fistula was made by cervicotomy in all cases. Our results are discussed with regards to the literature.

CONCLUSION

Congenital tracheo-oesophageal fistulae are rare malformations. Diagnostic delay is common. Tracheo-oesophageal endoscopy is the investigation of choice. Good results are obtained with surgery treatment via a cervical approach. The management of such fistulae requires medical teams familiar with neonatal endoscopy and cervical surgery.

[Intrapetrous cholesteatoma. A retrospective study of seven operated cases]

INTRODUCTION

Intrapetrous cholesteatoma can be recalled with regard of facial paralysis, mixed deafness, cholesteatoma visible under an otoscopy and some characteristic signs in imaging. Its treatment is a real dilemma between its complete exeresis and the preservation of the facial nerve.

METHODOLOGY

We studied the diagnostic and therapeutic aspects of the 7 operated cases from 1994 to 2004.

RESULTS

We noted 5 men and 2 women with an average age of 37.29 years. One case was primitive. We observed 6 translabyrinthic lesions, 5 supralabyrinthic lesions and 2 infralabyrinthic lesions. The surgical approach was: translabyrinthic (1 case), translabyrinthic and suprapetrous (2 cases), suprapetrous (1 case), suprapetrous and petrectomy (1 case), petrectomy (2 cases). The diversion of the facial nerve was often associated. After the surgical operation the activity of the facial nerve was conserved in 4 patients and improved in 2 patients. The facial nerve paralysis that appeared on a patient after being operated on, totally recovered after 7 months. In spite of the appropriate surgical approach, the residual lesions were not rare (2 cases). This situation imposes a clinical and radiological follow-up for life.

CONCLUSION

Intrapetrous cholesteatoma is rare. The X-ray confirmed the diagnosis. The new MRI techniques allow to detect recurrences and residues. A second surgical operation can be necessary.

[Treatments of hereditary hemorrhagic telangiectasia of the nasal mucosa]

Hereditary Hemorrhagic Telangiectasia is a systemic autosomal dominant disorder involving blood vessels. The most common symptom is recurrent epistaxis. The treatments of these epistaxis are numerous but such treatments are often symptomatic and their effects are often not sustained. Some of these treatments may be complicated by visceral vascular malformations. The aim of this study is to propose a treatment plan for these patients with hierarchical organisation of therapeutic options taking into account of their previous therapy.

METHOD

H. Plauchu organized in Paris, december 2002 a meeting with any medical specialists of this disease. They have analysed variety of therapies that have been proposed for epistaxis control in Hereditary Haemorrhagic Télangiectasia.

RESULTS

Most common use packing of nasal fossa and then hyperselective embolization of the internal maxillary and facial arteries for severe epistaxis. For chronic epistaxis, best treatment use sclerotics products (Ethibloc) and laser. After discussion, primary embolization could be useful to reduce vascularization of nasal fossa.

CONCLUSION

Treatment of epistaxis in Hereditary Haemorrhagic Telangiectasia could increase in few years. Use of an index card of for epistaxis in the disease of Rendu-Osler could help to find treatment of choice.

[Metachronous sinonasal squamous-cell carcinoma after pharyngolaryngectomy]

OBJECTIVE

Three laryngectomized patients developed metachronous sinonasal squamous-cell carcinoma. We reviewed their files to search for clinical features useful for early diagnosis of this localization.

CASE REPORTS

Two of the patients, a textile worker and a food processing worker, had occupation exposure risk factors for sinonasal squamous-cell carcinoma. The anatomic modifications created by laryngectomy contributed to late diagnosis of the metachronous tumor at an advanced stage. Surgery was performed in all three patients. Local recurrence was observed at one year in two patients.

DISCUSSION

Sinonasal fibroscopy should be part of the surveillance scheme in laryngectomized patients to enable early diagnosis and treatment of metachronous tumors.

Anévrysme de l’artère carotide interne dans sa portion extracrânienne

INTRODUCTION

Extracranial aneurysm of the internal carotid artery is an exceptional finding.

CASE REPORT

An 89-year-old woman consulted for a peritonsillar mass. Physical examination revealed a parapharyngeal pulsatile mass in the oropharynx. Computed tomography (CT) provided the diagnosis of extracranial internal carotid artery aneurysm. Endovascular or surgical treatment were declined. Anticoagulation medication was given.

DISCUSSION

We reviewed the CT and magnetic resonance imaging findings and the clinical manifestations of extracranial internal artery aneurysm. Endovascular treatment is an alternative to open surgery.

[Acute mastoiditis in children: clinical and bacteriological study of 17 cases]

OBJECTIVE

Acute mastoiditis (AM) represents the most frequent complication of acute otitis media (AOM) in children. In the literature, its incidence is stable but with an impressive increase in pneumococci with reduced sensitivity to penicillin (PRSP). The aim of this study was to assess the incidence of AM in the area of Tours and the prevalence of PRSP.

METHOD

This was a retrospective study of children admitted to the regional paediatric centre in the Tours area, between January 1994 and May 2001. The coded AM files were analysed, excluding all the sub-acute forms or those complicating a cholesteatoma. The criteria studied concerned the clinical signs on admission, the imaging data and the bacteriological samples and the results of treatment.

RESULTS

Seventeen children (8 boys, 9 girls) were admitted for an AM during the study period. Their mean age was of 3.2 years (range: 6 months to 13 years). In 24% of cases, the mastoiditis existed on admission and in 59% of cases it complicated an AMO already treated with antibiotics. In 3 cases (18%), the AM was complicated on admission with peripheral facial paralysis in one case and thrombosis of the lateral sinus in 2 cases. The germ responsible was identified in 14 cases (82%) with a predominance of pneumococci (11 cases). Eight were PRSP-type. Scan of the pars petrosa identified a subperiosteal abscess in 13 cases. Fourteen mastoidectomies were performed and the mean duration of antibiotic therapy was of 23 days. The outcome was always good.

CONCLUSION

Over the past 7 years, the incidence of AM has been estimated at 1.2/100 000 children aged under 15 per year. The prevalence of PRSP is high but does not change the principles or the results of the treatment of AM.

[Basilingual rhabdomyoma treated by endoscopy]

Rhabdomyoma in adults is a rare benign neoplasm of the skeletal muscles generally arising in the pharyngolaryngeal region. These slow-growing tumors remain asymptomatic for a long period. We report a case of basilingual rhabdomyoma. Computed tomography and magnetic resonance imaging demonstrated a well-encapsulated tumor with a line of cleavage between the base of the tongue muscles. Deep transmucosal biopsies were obtained. Well-differentiated skeletal muscle cells with large eosinophilic granulular cytoplasm and cross striations gave the histologic diagnosis. Complete endoscopic resection was successful. The differential diagnoses of rhabdomyoma in adults are myoblastoma or Abrikossof tumor, rhabdomyosarcoma and hibernoma. The risk of late recurrence implies long-term clinical and radiologic follow-up.

[Epidemiology of otitis media with effusion]

Acute otitis media (AOM) and otitis media with effusion (OME) are very common in the young children. The relation ship between these two pathologies has not been completely established. The AOM incidence ranges between 22 to 74%. The OME which persists after onset of AOM is more frequent (20% at 2 months) than the chronic OME which concern 4.4 to 10% of the child population before the age of five. The highest age specific incidence for all episodes of AOM is one year of age. AOM and OME are most likely to occur in the winter. The OME risk factors are: the first episode of OMA before 6 month of age, the males sex, no breastfeeding, day-care centers, low socio-economic conditions and familial genetic predisposition. Passive-smoke exposure and allergy are discussed. The epidemiology assesses the actual state of these pathologies to settle, with the family, the optimum choices for the prevention.