Review of olfactory cleft roof anatomy.

Progress in skull-base endoscopic surgery has improved our knowledge of olfactory cleft (OC) anatomy. This article presents a review of current knowledge concerning the OC roof: descriptive anatomy, radiological exploration, and endoscopic observation. The OC is a narrow area in the most superior part of the nasal cavity. Its roof is the thinnest structure separating the nasal cavities from the brain; it comprises three superimposed tissues: nasal mucosa, ethmoid cribriform plate (ECP), and dura mater. The ECP comprises the anterior ECP containing the ethmoidal slit (ES) medially and the cribroethmoidal foramen (CEF) laterally; and the posterior ECP, comprising the olfactory foramina. The OC roof is bordered anteriorly by the nasal bone roof, laterally by the lateral ethmoid masses, and posteriorly by the jugum and anterior wall of the sphenoid sinuses. Imaging is crucial for analyzing this wall, providing precise detailed information on conformation and anatomic relations with adjacent structures such as the anterior ethmoidal artery. Understanding OC roof anatomy and correct interpretation of imaging are essential for safety in present-day functional endoscopic sinus surgery and anterior skull-base oncologic surgery.

How to identify the anterior cribriform plate in the medial approach to the frontal sinus.

Draf III frontal sinusotomy is one of the most complex surgical procedures on the frontal sinus, designed to limit the risks of restenosis by ensuring unification of the two ostia and resection of the floor of the sinus. This procedure requires a good knowledge of anatomy and sufficient surgical expertise to avoid the risk of CSF leak and to limit the risk of restenosis. The surgeon can use various landmarks, consisting of foramina, bone grooves and arteries located on the anterior part of the cribriform plate to guide the procedure. The purpose of this technical note is to explain the use of these landmarks to ensure safe Draf III frontal sinusotomy via a medial approach.

How to perform subperichondrial and subperiosteal rhinoplasty.

Rhinoplasty, via either an open or a closed approach, is classically performed in the supraperichondrial plane, i.e. underneath the SMAS. Total subperichondrial and subperiosteal approaches, providing large exposure of all of the osteocartilaginous framework of the nose, have been described in recent years. This deeper dissection requires adaptation of surgical instruments to perform both subperichondrial and subperiosteal dissection, but also to perform osteotomies. New tools, such as the Rhinosculpture or piezoelectric motor are particularly useful in this context. Acquisition of this dissection technique, although it requires a long learning curve, is largely rewarded by the advantages of this technique in primary and secondary rhinoplasty. The objective of this technical note is to provide a detailed description of the operative technique and the instrumentation required.

How to perform microscopic/endoscopic resection of large petrous apex lesions.

The endoscope and microscope can be used conjointly in certain sites, such as middle ear cholesteatoma or for resection of cerebellopontine angle tumours. Petrous apex tumours are classically accessed via a lateral otological approach, or, for the most anterior tumours, via an endonasal endoscopic approach. Surgical access via a lateral incision is limited inferiorly by the superior bulb of the internal jugular vein, medially by the labyrinth, facial nerve and internal auditory canal, superiorly by the dura mater, and laterally by the internal carotid artery. Via an anterior endonasal approach, the corridor formed by the internal carotid artery and the paraclival dura limits access to the posterior part of the petrous apex, restricting this approach to certain cholesterol granulomas or small cholesteatomas. None of these approaches, on its own, is sufficient in the case of an extensive petrous apex lesion. The objective of this technical note is to describe the combined microscopic/endoscopic approach comprising sequential use of the microscope and the endoscope via a lateral approach for the management of large petrous apex lesions.

State of the art of endoscopic frontal sinus cerebrospinal fluid leak repair.

Frontal sinus cerebrospinal fluid leaks are rare and their surgical management is difficult. Up until recently, they could only be treated by open surgery with an osteoplastic flap. With the development of endoscopic surgery, less invasive techniques such as an exclusive endoscopic approach can now be used, ensuring a simpler postoperative course. However, these techniques require a thorough knowledge of frontal sinus anatomy and endoscopic CSF leak repair. This knowledge is essential both to ensure closure of the CSF leak and to preserve frontal sinus patency.

Associating portal embolization and artery ligation to induce rapid liver regeneration in staged hepatectomy.

BACKGROUND: Insufficient volume of the future liver remnant (FLR) is a major cause of unresectability in patients with bilobar colorectal liver metastases (CLM). The objective of this study was to evaluate the safety and efficacy of the novel associating portal embolization and artery ligation (APEAL) technique before extended right hepatectomy during a two-stage procedure for CLM. METHODS: All patients who had undergone extended right hepatectomy during two-stage surgery for CLM between 2012 and 2014 were identified retrospectively from a prospectively maintained database. In the first stage, right portal vein embolization, partial right hepatic artery ligation and devascularization of segment IVb along the round ligament without parenchymal transection were associated with clearance of the FLR and/or primary tumour resection. Liver volumetry was performed using OsiriX software on postoperative day (POD) 7 and 30. RESULTS: Ten patients underwent the APEAL procedure. During the first stage, APEAL was combined with colorectal resection in seven patients. The median (range) interval between the two stages was 45 (31-71) days. The FLR volume increased from 327 (214-537) cm(3) before surgery to 590 (508-1072) cm(3) on POD 7 and 701 (512-1018) cm(3) on POD 30. This corresponded to a FLR regeneration rate of 104 (42-185) and 134 (53-171) per cent respectively. There were no deaths. The overall morbidity rate was 60 per cent (6 of 10) after each procedure, with severe morbidity occurring in two and three of ten patients after the first and second procedures respectively. CONCLUSION: APEAL induces fast, safe, reproducible and effective FLR growth when an extended right hepatectomy is scheduled in patients with multiple bilobar CLM.

[Use of a free antero-lateral thigh flap for two-stage reconstruction of a large thoracic defect]. / Utilisation du lambeau antéro-latéral de cuisse selon la technique du chausson aux pommes pour la couverture d'une large perte de substance thoracique.

In case of extremely large thoracic full-thickness defects where no pedicled flap is available, very large free flaps are sometimes the only options. Dealing with such full-thickness defects where failure of the flap could be lethal, Servant and al described the concept of "two stage free flap" using Latissimus Dorsi muscular or myocutaneous flap. We present a reconstruction of a wide right posterior trunk radionecrosis with exposure of an underlying infected prosthesis using this two-stage free flap strategy with a fasciocutaneous antero-lateral thigh flap.

[Tolerance and efficacy of lipomodelling as an element of breast symmetry in breast reconstruction]. / Tolérance et efficacité du lipomodelage comme élément de symétrisation en reconstruction mammaire: à propos de 150 patientes.

AIM OF THE STUDY: Fat transfer significantly improved results in breast reconstruction. Final breast symmetry is very important in breast reconstruction, but sometimes, the result is not perfect with usual techniques. The aim of this study is to evaluate the tolerance and efficacy of lipomodelling as a complementary technique for breast symmetrisation. MEANS AND METHODS: In this study, 150 patients had controlateral breast symmetrisation after breast reconstruction, using or completed with fat transfer. Patients were clinically evaluated one year after surgery. Age, BMI, harvested, purified and transferred fat volumes, and postoperatory complications were recorded. Morphological outcomes were evaluated by the surgeon as: very good, good, average or bad. Patients rated their degree of satisfaction as: very satisfying, satisfying, poor or bad. RESULTS: We found out that 98.6 % of morphological results were good or very good, and 86.6 % of the patients were satisfied or very satisfied with the result. Complications were rare (2 % of cytosteatonecrotic lesions). CONCLUSION: Lipomodelling in native breast symmetrisation after reconstruction is a powerful technique because it allows to increase volume of a hypoplastic controlateral breast, to ameliorate its shape, and to finally enhance mammoplasty result by correcting persisting localized volume defects. It definitively is a major therapeutic tool for enhancing breast reconstruction outcomes.

[Morbidity of neck dissection submuscular recess (sublevel IIb) in head and neck cancer]. / Morbidité des curages ganglionnaires cervicaux en cancérologie ORL (secteur IIb).

OBJECTIVES: The impact of neck dissection on quality of life has often been considered less important than the oncological control. Dissection of level IIb doesn't improve oncologic control everytime, knowing that an injury of the spinal nerve can occur. The aim of our study was to assess the impact of neck dissection including level IIb on shoulder function and quality of life in N0 patients. MATERIALS AND METHODS: Fifteen patients with squamous cell carcinoma of the upper aerodigestive tract, clinical and radiological NO, were included. They were assessed by validated scales (QLQ-C30, H&N35 and DASH) and they underwent an examination of the shoulder. RESULTS: Almost half of the patients had pain in the shoulder. The functional scale score QLQ-C30 was statistically more altered (49.7%) than that of patients with cancer in general (74.9%, p = 0.00016) and of the general population 60 to 69 years (85.4%, p = 0). CONCLUSION: The results of our study underscore the morbidity on shoulder function after neck dissection. These findings, combined with the low prevalence of occult lymph node metastases in level IIb among T1-T2 patients, must question the systematic inclusion of this level in neck dissection.

Aspergillus vertebral osteomyelitis in immunocompetent subjects: case report and review of the literature.

Aspergillus spondylodiscitis (AS) is rare in immunocompetent (IC) patients. A 65-year-old diabetic IC male subject presented with cervical AS 18 months after otomycosis. Two serological tests, mastoidectomy and biopsy of the sphenoid bone, were negative. A prevertebral biopsy identified A. flavus. The patient was successfully treated with voriconazole. Forty-three cases of AS in IC patients have been published. A predisposition was found in 84 % of cases. Fever was reported in 20 % of cases, whereas neurological defects were present in 41 %. Serology was inconsistently positive (5/7) and diagnosis was confirmed by biopsy or surgery. A. fumigatus was the most frequently isolated species (74 %). All episodes were medically treated, associated with surgery in 57 % of cases, and 73 % of patients fully recovered. AS must be discussed in IC patients presenting with risk factors, including diabetes mellitus. Biopsy is necessary to confirm diagnosis, since serology offers low sensitivity. Nevertheless, the prognosis is good.

Laryngeal paraganglioma mimicking a laryngeal haemangioma.

Paraganglioma are uncommon neuroendocrine tumours arising from extra-adrenal chromaffin cells of the autonomic nervous system. In the head and neck region, these neoplasms most commonly arise from the carotid body, the vagus nerve, and the jugulotympanic area. We present the case of a 69-year-old woman who suffered from dyspnoea and dysphonia for six months. A biopsy diagnosed a laryngeal haemangioma and a resection of the tumour was performed using supraglottic pharyngolaryngectomy. Definitive histopathological examination revealed a laryngeal paraganglioma. Laryngeal paraganglioma and haemangioma must be evoked when confronted with a submucosal vascular laryngeal tumour. In such cases biopsies should be avoided. Exhaustive imaging is a key factor in the diagnosis and should include an MRI and an arteriography in order to rule out other differential diagnoses. To our knowledge this is the first case focusing on this issue.

Evaluation of the chemical model of vestibular lesions induced by arsanilate in rats.

Several animal models of vestibular deficits that mimic the human pathology phenotype have previously been developed to correlate the degree of vestibular injury to cognate vestibular deficits in a time-dependent manner. Sodium arsanilate is one of the most commonly used substances for chemical vestibular lesioning, but it is not well described in the literature. In the present study, we used histological and functional approaches to conduct a detailed exploration of the model of vestibular lesions induced by transtympanic injection of sodium arsanilate in rats. The arsanilate-induced damage was restricted to the vestibular sensory organs without affecting the external ear, the oropharynx, or Scarpa's ganglion. This finding strongly supports the absence of diffusion of arsanilate into the external ear or Eustachian tubes, or through the eighth cranial nerve sheath leading to the brainstem. One of the striking observations of the present study is the complete restructuring of the sensory epithelia into a non sensory epithelial monolayer observed at 3months after arsanilate application. This atrophy resembles the monolayer epithelia observed postmortem in the vestibular epithelia of patients with a history of lesioned vestibular deficits such as labyrinthectomy, antibiotic treatment, vestibular neuritis, or Ménière's disease. In cases of Ménière's disease, aminoglycosides, and platinum-based chemotherapy, vestibular hair cells are destroyed, regardless of the physiopathological process, as reproduced with the arsanilate model of vestibular lesion. These observations, together with those presented in this study of arsanilate vestibular toxicity, suggest that this atrophy process relies on a common mechanism of degeneration of the sensory epithelia.

Psychosocial quality of life in hereditary haemorrhagic telangiectasia patients.

OBJECTIVES: The aim of this study was to evaluate psychosocial quality of life (PQoL) in patients with Hereditary Haemorrhagic Telangiectasia (HHT). STUDY DESIGN AND SETTING: A retrospective study was performed on PQoL in HHT patients presenting with epistaxis. One hundred fifteen patients were interviewed using a questionnaire designed by two sociologists and a head and neck surgeon. Changes over time were assessed according to information on psychosocial well-being, social life, family support, occupation, and medical and demographic data regarding age, gender and patient appearance. RESULTS: Analysis of Psychosocial Quality of Life (PQoL) revealed no statistical difference in relation to gender, marital status, household income or place of residence (rural or urban); however, a significant difference was observed with age. Elderly patients had a poorer PQoL than younger patients. Workers had a better PQoL than unemployed patients. Epistaxis and professional duties were correlated: workers with less than one episode of epistaxis per month were more active. Frequent episodes of epistaxis and abundant bleeding decreased PQoL. These patients felt different and often experienced a desire to withdraw compared to others. CONCLUSION: Epistaxis in hereditary haemorrhagic telangiectasia patients was associated with the impairment of many PQoL criteria, together with relationship modifications.

[Bladder necrosis after an immediate post-operative mitomycin C instillation]. / Nécrose vésicale dans les suites d'une instillation postopératoire précoce (Ipop) de mitomycine C.

Administration of intravesical chemotherapy by mitomycin C decreases the risk of recurrence in non-muscle-invasive bladder tumours. We report the case of a man, who presented a full bladder necrosis after an immediate adjuvant mitomycin C instillation. The failure of resection of the necrotic area led us to perform a total cystectomy with an intestinal reconstruction. A review of the literature showed four other cases of necrosis of the bladder or of lower urinary tract. In all cases the rules of early instillation were observed.