[Prevention and relief of pain induced by otolaryngology procedures]. / Prévention et soulagement des douleurs induites par les soins en ORL.

There are many types of pain induced in otolaryngology, stemming from medical acts, sinus drainage, packing of the nasal fossae, or complex bandaging after cancer surgery. In patients with impaired communication abilities resulting from impaired speech, greater attention must be paid to induced pain, sometimes requiring the use of behavioral evaluation scales. Preventing this pain means organizing medical acts and painful treatments by attempting to group them and informing the patient that the caregiver is listening to him and relieving his pain. Non-drug treatments should always be attempted, are based on a trusting relationship with the patient, a comfortable position, diverting his attention, and using bandaging that is less painful when removed. However, use of drug treatments often remains indispensable. The strong morphinics are used most often despite a pharmacokinetic profile that is poorly adapted and the undesirable side effects in case of repeated administration. Local anesthetics should be used whenever possible. Dissemination of nursing protocols for the use of MEOPA provides good pain relief providing that there are trained personnel in sufficient numbers. The intensity of pain induced by certain medical acts requires use of brief general anesthesia, which can often be done in the ambulatory situation and is preferable to deep sedation outside of the safety of the operating room.

[Use of methadone as analgesic]. / Utilisation de la méthadone comme antalgique.

Methadone is a synthetic opioid agonist which is mostly used for drug maintenance therapy in opioid addicts. It has also proven to be a powerful analgesic four times more powerful than oral morphine. The main indication is cancer pain as an alternative to oral morphine in case of tolerance or side effects due to accumulation of active metabolites. Methadone however shows wide inter-individual variability in half-life necessitating a carefully scheduled administration scheme. Side effects are similar for morphine and methadone. Methadone might be a safe and effective analgesic in patients with renal disease because its metabolites are almost exclusively excreted in the feces.

[Pain therapy]. / Traitement de la douleur.

NEW OPIOID ANALGESICS: Progress in pain reliet has recently been achieved with the introduction of new opioid analgesics such as tramadol and the pediatric preparation of codeine phosphate as well as powerful long-release opioids which can be administered per os, or percutaneously for transdermal fentanyl. CO-ANALGESICS: Other drugs, mainly antidepressants and anti-convulsants, can be usefully combined with analgesics. New serotonin uptake inhibitors and anticonvulsants (gabapentin and lamotrigin) have the advantage of better tolerance. None of these drugs has marketing approval in France for their pain relieving effects. The same is true for clonidine and neostigmine which, after spinal infusion, potentialize opioids and for ketamine which can relieve neuropathy pain by dissociative anesthesia. NEW ANTI-MIGRAINE DRUGS: New drugs have been developed for specific types of pain such as migraine. The new "triptans" are tolerated better than sumatriptan and is reimbursed by the national social security. REFRACTORY NEUROPATHY PAIN: Indications for electrical stimulation techniques conducted in a neurosurgery unit have been identified. Stimulators may be implanted in spinal or supra-spinal localizations. REGULATORY ASPECTS: New legislation has reorganized health care for pain relief in France. The new texts take into consideration personnel training, the health care network and progress in therapeutics.

Perceptual scaling of synthesized musical timbres: common dimensions, specificities, and latent subject classes.

To study the perceptual structure of musical timbre and the effects of musical training, timbral dissimilarities of synthesized instrument sounds were rated by professional musicians, amateur musicians, and nonmusicians. The data were analyzed with an extended version of the multidimensional scaling algorithm CLASCAL (Winsberg & De Soete, 1993), which estimates the number of latent classes of subjects, the coordinates of each timbre on common Euclidean dimensions, a specificity value of unique attributes for each timbre, and a separate weight for each latent class on each of the common dimensions and the set of specificities. Five latent classes were found for a three-dimensional spatial model with specificities. Common dimensions were quantified psychophysically in terms of log-rise time, spectral centroid, and degree of spectral variation. The results further suggest that musical timbres possess specific attributes not accounted for by these shared perceptual dimensions. Weight patterns indicate that perceptual salience of dimensions and specificities varied across classes. A comparison of class structure with biographical factors associated with degree of musical training and activity was not clearly related to the class structure, though musicians gave more precise and coherent judgments than did non-musicians or amateurs. The model with latent classes and specificities gave a better fit to the data and made the acoustic correlates of the common dimensions more interpretable.

Implantation metastasis following percutaneous endoscopic gastrostomy.

Since it was first described, the original percutaneous endoscopic gastrostomy (PEG) technique has proved to be a valuable adjunct in patients with head and neck tumours. This procedure is being increasingly utilized in the face of swallowing impairment related to head and neck carcinoma. Although generally well tolerated, it may be associated with complications. In this report, we document tumour implantation at the percutaneous endoscopic gastric site and review the report cases. It appears that implantation metastasis does alter prognosis.

[Control of the ratio of the flow rate of the substitution fluid to the blood removal rate during preoperative normovolemic hemodilution]. / Asservissement du débit d'administration du soluté de substitution à celui du prélèvement sanguin au cours de l'hémodilution normovolémique préopératoire.

Twenty-one patients (mean age 46 +/- 13 years) due to undergo abdominal or ENT surgery, presumed to give rise to an important blood loss were included in this study. None had any contra-indication to the use of normovolaemic haemodilution (NH). Mean initial haematocrit was 40.3 +/- 1.8%. Their estimated total blood volume was 4,867 +/- 857 ml. The patients were anaesthetized with thiopentone, fentanyl, vecuronium or atracurium. Maintenance was carried out with isoflurane (0.5% during NH). Usual haemodynamic monitoring was used throughout. The required haematocrit was decided on before starting NH. The amount of blood to be removed was calculated with usual mathematical formulae. A radial artery cannula (n = 7), or a subclavian or femoral venous cannula (n = 14) was used to remove blood, which was collected within a bag containing CPC-adenine. Six % hydroxyethyl starch (Elohes) was given through a short venous cannula some distance from the first one. An antiparallel double line set in a roller pump was used to carry out the NH. A mean 1,341 +/- 405 ml of blood were withdrawn so as to reach a mean haematocrit of 30.6 +/- 2.4%. NH was completed within 17 +/- 6 min. No major haemodynamic changes occurred during the procedure. No significant differences were observed between expected and observed final haematocrits. There was no effect of the volume of blood withdrawn on the error of haematocrit prediction (0.5 +/- 0.3%). However, a higher rate of blood removal could increase this error. This easy-to-use device seems to provide fast and identical rates of blood removal and replacement. The expected haematocrit may thus be reached reliably, even if this must be checked for the sake of safety.

[Evaluation and treatment of chronic pain after cervicofacial cancer surgery]. / Evaluation et traitement des douleurs chroniques après chirurgie carcinologique cervico-faciale.

When lasting pain occurs after surgery of head and neck cancer, tumoral recurrence should be considered. In addition to curative treatment, relief of pain is often provided by opioid analgesics. Doses vary according to tolerance and patient. Other than digestive routes of administration may be required. Here are two clinical reports: the first case with cervical epidural analgesia by ambulatory autoadministration device (Patient control analgesia), the other one with intrathecal in C7-T1 catheter with port access in which morphine was injected every 24 hours resulting in efficient analgesia, in metastatic Pancoast's syndrome. Surgical or radiotherapy sequelae sometimes bring about pain; bilateral cervicalgy described as burns associated with pain-related depression, 18 months after glotto-subglottic partial laryngectomy, requires psychological support and carbamazepine for desafferation pain removed within 6 months. When the only treatment left appears to be analgesia after surgery of head and neck cancer, follow-up in a multidisciplinary pain treatment centre allows a therapeutical management with optimum tolerance and efficiency.

[Ventilation with metallic tubes in CO2 laser surgery of the larynx]. / Ventilation par sonde métallique pour la chirurgie laryngée au laser CO2.

One of the risks of laryngeal laser surgery is the ignition of the disposable plastic endotracheal tubes used for ventilation. In 1985, Hunton and Oswal (Anaesthesia, 40: 1210, 1985) developed a metallic tube which is now available in France. In this study, the tube has been tested on 30 patients undergoing this type of surgery. The tube was sterilized in glutaraldehyde before re-using it. There never was any problem with placing the tube and surgical conditions were satisfactory. There was neither incident due to the laser, nor any difficulties with the use of high-frequency jet-ventilation. The blood gas values were satisfactory (mean PaO2: 19.4 +/- 4.2 kPa; mean PaCO2 5.0 +/- 0.46 kPa). After a use in 30 consecutive patients, the tube was not damaged. The advantages and disadvantages of this tube are discussed, considering the other types of special laser surgery endotracheal tubes. This metallic tube is not flammable, can be used several times, occupies only a small space and does not hurt tissues. Moreover, it is cheaper than disposable tubes when the price is calculated per patient. It would therefore seem that Hunton and Oswal's metallic tube, used with high-frequency jet-ventilation is a good alternative for tubes used today.

[Percutaneous endoscopic gastrostomy. Indications and results in 31 patients]. / Gastrostomie percutanée endoscopique. Indications et résultats chez 31 patients.

Nutritional assistance was indicated in 31 patients with an ENT tumour at different stages of treatment and different stages of the disease. These patients presented with disorders of deglutition with false passages (68%), aspiration pneumonia (10%), dysphagia (35%) or denutrition (17%). We used an endoscopic percutaneous gastrotomy kit produced by the Bioser company (pull technique). In 29 patients, the tube was inserted under general anaesthesia in the operating theatre to prevent dyspnoea during introduction of the tube in these patients with alteration of the airway-gastrointestinal tract junction or because the tube was inserted at the beginning of anaesthesia for ENT surgery. The tube was able to be inserted in every case, with cardiac arrest in one patient who was effectively resuscitated without sequelae, two obstructions of the cuff requiring advancement of the tube with a bougie, 2 ruptures of the thread and one case of dyspnoea. Two patients subsequently developed a wound abscess which was drained and one patient required removal of the tube. Follow-up of the patients demonstrated the good tolerance of this tube which was maintained for an average of 2.9 +/- 0.5 months (0.1 to 9 months) without any major complications. 3 benign wound infections, 4 inflammatory reactions, 4 minimal leaks, 1 case of hyperthermia, 12 cases of abdominal distension and 2 cases of displacement of the tube were observed. The weight gain was equal to 4%. The authors believe that this technique of endoscopic gastrostomy should be preferred to surgical gastrostomy.

[Percutaneous endoscopic gastrostomy. Indications and follow-up in 30 patients]. / Gastrostomie percutanée endoscopique. Indications et suivi chez 30 patients.

The indications and results of percutaneous endoscopic gastrostomy (PEG) were reviewed in 30 consecutive patients, most of whom had problems of deglutition secondary to the treatment of ENT neoplasia. The procedure was successful in all patients but some difficulty was encountered in 4 cases. There were no major complications or fatalities. The benign complications were all amenable to medical therapy and did not require ablation of the gastric tube. In general, PGE was well tolerated and an easy to use method of nutritional assistance, allowing most patients to gain weight. In the authors' experience, this technique has an important role to play in the nutritional assistance of patients with problems of deglutition due to neurological disease or ENT neoplasia. The relative innocuity of PEG gives it a great advantage over surgical gastrostomy.

[Early death after chemotherapy via central venous catheterization in tumors of the upper respiratory and digestive tracts]. / Décès précoces après chimiothérapie par cathéter central dans les tumeurs des voies aéro-digestives supérieures.

Between 1987 and 1988, 1 100 patients were treated by continuous, ambulatory chemotherapy. 35 of these patients died within 90 days of the insertion of the catheter. One death would appear to be related to the catheter, 5 deaths (0.5%) were related to the chemotherapy and 29 deaths were related to progression of the malignant disease. The mortality rate associated with ambulatory chemotherapy via a central catheter would appear to be negligible when compared to deaths related to the progression of the malignant disease.

[Percutaneous endoscopic gastrostomy. Indications and follow-up in 52 patients]. / Gastrostomie percutanée endoscopique. Indications et suivi chez 52 patients.

A nutritional support was indicated in 52 patients, most of whom had deglutition problems linked with post-therapeutic after-effects of neoplasia of the ORL sphere. Assistance was possible in all the cases, with difficulty in 9 cases. There were only three major complication (two of which necessitated the removal of the tube) and no fatalities. Benign, more numerous complications were all medically curable and did not necessitate the removal of the tube. The follow-up of the patients showed remarkable tolerance to, and nonproblematic use of, the GPE tube as a nutritional aid leading, in the majority of cases, to a weight gain, even when ambulatory. Our experience suggests that this technique deserves a prime place as a nutritional aid for cases of deglutition problems, of neurological origin, and in ORL cancers. Its relative safety must undoubtedly make it preferable to the surgical technique.

[Esophagectomy and pharyngectomy in cancers of the upper respiratory and digestive tracts and the esophagus. Results apropos of 16 cases]. / Oesophagectomie et pharyngectomie dans les cancers des voies aéro-digestives supérieures et oesophagiens. Résultats à propos de seize cas.

A series of 16 squamous cell carcinomas of the pharynx with an extension to the cervical esophagus, or multiple primaries of the pharynx and esophagus is presented. The surgical procedure consisted of an oesophagectomy associated with either total pharyngolaryngectomy, or partial pharyngectomy, or transmandibular resection. 13 patients received neo-adjuvant chemotherapy: CDDP-5-FU. Postoperative complications occurred in less than 20% without any postoperative death. One-year and five-year actuarial survival rates were respectively 20% and 13.3%. The mean survival was 9.5 +/- 3.7 months. 75% of the deaths were due to local or cervical lymph node recurrences. Neo-adjuvant chemotherapy could improve the prognosis of these pharyngo-oesophageal carcinomas.

[Percutaneous and implantable catheters in cancers of the upper respiratory and digestive tracts. Apropos of 600 cases]. / Cathéters percutanés et cathéters implantables dans les cancers des voies aérodigestives supérieures. A propos de 600 cas.

For two years, 600 catheters (234 silicone catheters, 153 tunnelisation cuffed catheters and 188 total implantable systems) were place for chemotherapy in patients with head and neck cancer. Percutaneous catheters remain for 152 days and total implantable systems for 188 days. Total complications decrease with greater experience of physicians and using improved catheters.

[Continuous ambulatory chemotherapy in cancer of the upper respiratory and digestive tract]. / Chimiothérapie continue ambulatoire dans les cancers des voies aéro-digestives supérieures.

Chemotherapy of the upper respiratory and gastrointestinal tracts is currently based on Cis-platinum-5 FU administered by continuous infusions which, up until 1985, were performed in hospital during a 4 days admission. These infusions can now be administered on an outpatient basis over a period of 6 days. More than 600 patients have been treated in this way. The improvement in the results observed on a population of 86 operable patients confirms the value of prolonged continuous infusions. The clinical and psychological acceptability of this method, which allows the patient to maintain his autonomy and sometimes his occupation, is an important advance which could promote extension of this approach, particularly in view of its economic advantages.

[Comparative use of thiopental and methohexital in patients anesthesized for E.N.T. endoscopy. Apropos of 60 cases]. / Utilisation comparée du thiopental et du méthohexital chez les patients anesthésiés pour endoscopie O.R.L. A propos de 60 cas.

The clinical effects of methohexital versus thiopental are studied in 60 randomized patients anaesthetized for E.N.T. endoscopy or laser surgery of the larynx. Thiopental is injected by I.V. bolus (5 mg/kg) and methohexital is administered by continuous infusion (0.1 mg/kg/min). Fentanyl is the analgesic and succinyl-choline is used for curarisation. All patients are ventilated by a conventional ventilator or by high frequency ventilation. Side-effects, extubation time, and recovery estimated by the Newman-test modified by Weber are studied. The only difference between methohexital and thiopental is a better recovery-score at 30 minutes for the methohexital group.