[Treatments of hereditary hemorrhagic telangiectasia of the nasal mucosa]. / Indications et stratégies thérapeutiques des épistaxis dans la maladie de Rendu Osler.

UNLABELLED: 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.

[Vascular "tumors" and the rules of their surgical management]. / Les "tumeurs" vasculaires et les règles de prise en charge chirurgicale.

After defining vascular tumors and malformations, formerly called angiomas, the authors adopt the classification of the International Society for the Study of vascular Anomalies. The various groups of malformations, after definition of the subject and the problems raised, are illustrated by a number of clinical cases and the rules of surgical management are discussed. Capillary malformations, formerly called portwine stains, can be treated by dye laser, but sometimes tissue and orthognathic reconstructive surgery in the presence of a skeletal malformation. Lymphatic malformations (lymphangiomas), optimally assessed by CT or MRI, can be treated by a variety of approaches: sclerotherapy, surgery. Venous malformations raise very different problems in the cervicocephalic region and on the limbs and trunk, but always require a multidisciplinary approach with, according to the site, size and repercussions, Ethibloc percutaneous sclerotherapy, embolization, surgery. Arteriovenous malformations require complete surgical treatment, usually preceded by embolization; reconstruction consists of local flaps or skin expansion in simple cases, and revascularized free flaps in difficult cases. If the malformation is cosmetically and functionally acceptable, the authors propose conservative management. The first-line treatment of haemangiomas is pharmacological (corticosteroids, interferon), but surgery may be indicated in two situations: early and late. There is a renewed interest in early surgery, subtended by several factors including cosmetic concerns and the development of new technologies, including the Cavitron. Late surgery retains its classical cosmetic and functional indications. Two key-words dominate the rules of therapeutic management of all types of vascular malformations: a multidisciplinary approach and modesty.

The current management of cervico-cephalic venous malformations.

Venous malformations are often detected at birth and progressively increase in size if not treated. They can have severe aesthetic and functional consequences. Our purpose is to evaluate therapeutic results with Ethibloc. From 1982 to 1994, we have been using Ethibloc injections under fluoroscopic control in a group of 421 patients with malformations in cervicofacial veins. The diagnosis was made on the basis of clinical examinations as well as by using CT and MRI. In addition, 40 patients had a diagnostic angiogram. The therapeutic procedure consisted of direct puncture and opacification of venous the basis of lakes before injection of Ethibloc. Two hundred patients have been analyzed. In 139 patients treated with Ethibloc alone, the venous malformations were reduced significantly in size in 64%, while we obtained good results in 67% of the 61 patients treated with a combined procedure (Ethibloc followed by surgical excision). In those, Ethibloc effectively prevented extensive blood loss during surgery and delineated the malformations. Minor complications occurred such as fever or aseptic superficial abscesses. Ethibloc is safe, has no neurotoxicity, is efficient can be repeated many times and facilitates surgery. It must be used as the therapy of choice in venous malformations.

Direct intratumoral embolization of juvenile angiofibroma.

INTRODUCTION: Embolization is a well-established technique that facilitates the subsequent surgical removal of vascularized tumors such as juvenile angiofibroma. However, there is risk of a neurological accident during angiography and tumor embolization from the internal carotid artery. Direct intratumoral embolization may help prevent these potential side effects. METHOD: A group of 7 patients with juvenile angiofibroma vascularized through the branches of the internal carotid artery underwent direct tumoral embolization under general anesthesia. An injection made slowly with an intranasal or lateral percutaneous route with either a mixture of cyanoacrylate, lipiodal, and tungsten powder. Continuous radiographic control was used. RESULTS: This technique induced a marked devascularization and necrosis of the tumor. The technique provided useful perioperative visualization of the tumor. No neurologic sequelae were encountered. CONCLUSION: Direct intratumoral embolization deserves further consideration. This might be especially important in tumors with extracranial extension, cavernous sinus involvement, or those with small or multiple recurrences.

[Surgical indications in angiomas of the face]. / Indications chirurgicales dans les angiomes de face.

Hemangiomas are common vascular tumors of children. They always regress. Surgery takes place for late sequelae, such as cutaneous scarring and distortion of the facial structures. Early surgery is beneficial for the nasal cyrano hemangioma, of for some eyelid hemangiomas. Venous malformations need to be manage from childhood to adulthood as they slowly worsen. Percutaneous embolization with Ethibloc and surgery are performed in order to minimize, or to improve the skin, muscle and bone distortion. Arteriovenous malformations are the most dangerous vascular anomalies of the face. Superselective arterial embolization prepares the surgical excision of the nidus. Difficulties in covering the excised area are frequently solved by flaps or cutaneous expansion.

Percutaneous embolization with Ethibloc of lymphatic cystic malformations with a review of the experience in 70 patients.

Cystic lymphatic malformations (CLM) are superficial vascular hemodynamically inactive malformations of the lymphatic compartment. We propose a new approach which uses a sclerosing agent as an alternative to surgical resection. In the past nine years we treated 70 patients with CLM. Fifty-five percent were younger than five years of age with a male preponderance and most (80%) of the CLM were located in the maxillofacial region. They usually presented with functional impairment from the mass effect; others had infections, bleeding, or inflammation. The CLM were injected under fluoroscopic control with a sclerosing agent, Ethibloc, which dries up the pockets and reduces the mass. On follow-up the results were good in 62%, unchanged in 5%, and continued progression in 20%. Fifteen percent underwent surgery failures (24%) occurred in mixed forms of cystic and cellular lymphangiomas. Complications were minors. Percutaneous embolization is useful for CLM, with minimal risk, absence of scar, and it avoids surgery. It should be the first line of treatment for these lesions.

[Surgical indications in angioma of the face]. / Indications chirurgicales dans les angiomes de face.

Hemangiomas are common vascular tumors of children. They always regress. Surgery takes place for late sequelae, such as cutaneous scarring and distortion of the facial structures. Early surgery is beneficial for the nasal cryano hemangioma, or for some eyelid hemangiomas. Venous malformations need to be manage from childhood to adulthood as they slowly worsen. Percutaneous embolization with Ethibloc and surgery are performed in order to minimize, or to improve the skin, muscle and bone distortion. Arteriovenous malformations are the most dangerous vascular anomalies of the face. Superselective arterial embolization prepares the surgical excision of the nidus. Difficulties in covering the excised area are frequently solved by flaps or cutaneous expansion.

[Arteriovenous malformations]. / Malformations artério-veineuses.

Arteriovenous malformations (AVM) are the most dangerous of vascular malformations, being haemodynamically active. These malformations proceed in two phases: a phase of quiescence which may last throughout life, and an unpredictable phase of activity sometimes triggered by a trauma or by hormonal variations (puberty, pregnancy, oral contraceptives). Treatment must be careful usually limited, and considered in the phase of activity. A multidisciplinary consensus is necessary.

[Cystic lymphatic malformations of the head and neck. Role of interventional radiology]. / Malformations lymphatiques kystiques cervico-faciales. Place de la radiologie interventionnelle.

Cystic lymphatic malformations are hemodynamically inactive vascular malformations of the lymphatic compartment. Over a 9 years period, 52 patients with superficial cystic lymphatic malformations of the head and neck underwent embolization by direct injections of Ethibloc (Ethicon, Ethnon Laboratories, Neuilly/France) under fluoroscopic control. Results were graded as excellent or good in 57% of patients after embolization alone. Treatment was completed by surgery in 19% of patients. Embolization was considered a failure in 24% (12 patients), although 10 of these patients showed regression of the cystic component after embolization. This safe, efficacious percutaneous technique has emerged as the first treatment to be considered for cystic lymphatic malformations.

[Treatment of epistaxis in Rendu-Osler disease by intramucosal injection of ethibloc]. / Le traitement des épistaxis de la maladie de Rendu-Osler par injection intramuqueuse d'éthibloc.

The authors relate their one-year experience in percutaneous embolization of 12 patients presenting with severe epistaxis because of a Rendu Osler disease. Using Ethibloc a sclerosing substance derived from maize in direct intramucosal injection seems to be a promising technique. Ethibloc is still used successfully in percutaneous treatment of superficial venous angiomas.

[Results and indications of curietherapy of the eustachian tube with iridium 192 in chronic otitis in the adult]. / Résultats et indications de la curiethérapie de la trompe d'eustache à l'iridium 192 dans l'otite chronique de l'adulte.

Between January 1985 and January 1988, 56 patients received radioactive implant therapy of the Eustachian tube with Iridium 192 in the context of tympanoplasty for chronic otitis with tubal dysfunction. After reviewing the method used, we present the results by category of chronic otitis and attempt to propose its indications. Tubal dysfunction was assessed on clinical and otoscopic data and tubal manometry in each patient. A randomised study would appear to be necessary to confirm the interesting results obtained in chronic mucous otitis, in the sequelae of chronic otitis, in evolving retraction pockets and finally for certain manifestly discharging cavities.

[Endoscopic surgery of the turbinates. Preliminary results]. / La chirurgie endoscopique des cornets. Etude préliminaire.

Turbinate surgery has become more precise thanks to miniaturisation and improvements in optical systems, therby allowing endoscopic surgery throughout the procedure including its posterior portion. Endoscopic turbinate surgery includes surgery of the hypertrophied middle turbinate "concha bullosa" which requires diagnosis for successful treatment (septoplasty, endonasal ethmoid surgery). Endoscopy has improved inferior turbinate cauterisation which has become more complete and precise especially for the posterior portion of the turbinate. It allows the use of new techniques: the YAG laser and the CO2 laser. Endoscopy allows good control during resection of the tail of the inferior turbinate and ensures hemostasis in the event of hemorrhage occurring during this procedure.