Dual innervation may occur in a partially denervated muscle.

INTRODUCTION: With a view to simplifying surgical techniques for selective laryngeal reinnervation, we addressed the question of whether it is feasible to receive additional innervation by a partially denervated muscle using an infrahyoid muscle model. METHODS: In 90 rats (6 groups of 15), phrenic nerve transfer was used to reinnervate the sternothyroid muscle. In some cases, residual innervation by the original nerve was present. Three months later we performed electromyographic studies, contraction strength measurements, histologic assessment, and retrograde labeling. RESULTS: Muscles reinnervated by the phrenic nerve had a greater "dual-response" rate (in terms of nerve latency, contraction strength, and retrograde labeling) than muscles in the control groups. DISCUSSION: The phrenic nerve can impart its inspiratory properties to an initially denervated strap muscle-even when residual innervation is present. The preservation of contractile potential confirmed the feasibility of dual innervation in a previously injured muscle. Muscle Nerve 59:108-115, 2019.

Tympanostomy tubes for serous otitis media and risk of recurrences.

OBJECTIVES: To determine the value of tympanostomy tubes (TTs) in the management of serous otitis media (SOM) and the risk factors for SOM recurrence. METHOD: This single-centre cohort study was performed in the University hospital of Amiens, France; and concerned 215 under-12 children having undergone at least one bilateral TT (Shepard grommet-type) placements for SOM. RESULTS: The mean TT retention time was 10 months. SOM recurred in 79 children (62.79%) and thus required a second TT placement (bilaterally in 90% of these cases). Overall, 29.3% of the patients underwent a total of two TT placements, 5.58% underwent three placements and 0.93% underwent four placements. After their first-ever TT placement, 17 children had complications: 10 cases of otorrhoea (4.6%), 4 cases of retraction pocket (1.9%) and 3 perforations of the tympanic membrane (1.4%). At last follow-up, the most common complications were tympanosclerosis (6.9%) and perforation of the tympanic membrane (6.5%). In a multivariate analysis, the only significant risk factors for SOM recurrence were age below 48 months at the time of TT placement, and a TT retention time below 9 months. In contrast, a history of allergy, gastro-oesophageal reflux, prematurity or passive smoking were not significantly associated with recurrence. CONCLUSION: Age at the time of TT placement and the TT retention time were significantly associated with SOM recurrence. The TT retention time and the number of TT placements were not associated with the risk of long-term complications.

Therapeutic Management of Pyriform Sinus Cancer.

Objective To analyze the survival rate of a nonselected pyriform sinus cancer population. Study Design Case series with chart review. Setting University hospital. Subjects and Methods A total of 122 patients were included in this study covering the 2002-2008 period. All patients had squamous cell carcinoma originating from the pyriform sinus. Survival and prognostic factors were analyzed. Results The 3- and 5-year overall survival rates were 39.7% and 2.4%, respectively. The 3- and 5-year survival rates without recurrence were 34% and 27%, respectively. The median survival rates by UICC stage were as follows: stage 1 and 2 patients, 60 months; stage 3, 40 months; stage 4, 19 months. Stage 4 patients had a lower median survival rate than other stages ( P = .039). The 5-year survival rate was 46% for patients having T3-T4 operable cancers treated by surgery vs 45% for patients treated by laryngeal conservation protocol (not significant). The 5-year survival rate for patients having nonoperable T4 cancers was 17.2%. The 3- and 5-year overall survival rates of N0 patients was significantly higher than N1 patients ( P = .042). N2 and N3 patients had 100% 5-year mortality. Conclusion This study showed that overall survival and therapeutic management depend on the initial stage of pyriform sinus cancer, notably on the N status. In particular, nonoperable T4 pyriform sinus cancer and N2 and N3 patients had a very poor prognosis. A laryngeal conservation protocol seemed as effective as surgical management in terms of survival.

Initial staging of head and neck squamous cell carcinoma. What is the place of bronchoscopy and upper GI endoscopy?

To determine the place of bronchoscopy and upper GI endoscopy in the initial staging of head and neck squamous cell carcinoma (HNSCC). A 10-year retrospective study was conducted on a series of 838 patients. As part of initial staging of the tumor, all patients were examined by neck and chest CT scan, 487 patients were examined by bronchoscopy and 588 patients were examined by upper GI endoscopy. Esophageal cancer was detected in 4.25 % of cases and lung cancer in 6.35 % of cases. Chest CT scan was statistically superior to bronchoscopy to detect second lung cancers (p < 0.05). On multivariate analysis, oral cancers (p = 0.009) and multiple (synchronous) HNSCC (p = 0.009) were associated with the presence of a second lung cancer. Systematic bronchoscopy (performed by a pulmonologist) might not to be indicated for initial staging of HNSCC, particularly in the presence of normal chest CT scan. In case of abnormal Chest CT scan, patients should be referred to a pulmonologist. However, as oral cancers and multiple (synchronous) HNSCCs were statistically associated with the presence of a second lung cancer in this study, bronchoscopy might be indicated in these cases in order to detect rare small proximal bronchic lesions which might be invisible on chest CT scan in these patients at risk. More, systematic upper GI endoscopy (performed by a gastroenterologist) for initial staging of HNSCC might also not to be indicated in a majority of cases.

Serious spontaneous epistaxis and hypertension in hospitalized patients.

The aim of the study was to evaluate the role of hypertension in patients hospitalized for serious spontaneous epistaxis. This 6-year retrospective study was based on 219 patients hospitalized in a University Hospital ENT and Head and Neck surgery department for serious spontaneous epistaxis. The following parameters were recorded: length of hospital stay, history of hypertension, blood pressure (BP) recordings (on admission, during hospitalization and on discharge), epistaxis severity criteria, including medical and/or surgical management of epistaxis (blood transfusion depending on blood count, embolization, surgery), medications affecting clotting. Epistaxis was classified into two groups: serious and severe. No significant differences were observed between the two groups in terms of age, sex ratio, history of epistaxis and BP characteristics including history of hypertension, mean BP on admission, mean arterial pressure on discharge and number of patients in whom BP was difficult to control. Patients with more severe epistaxis had a similar exposure to anticoagulant and platelet antiaggregant medications as patients with less severe epistaxis. Overall, on univariate logistic regression analysis, no factors were independently associated with severity of epistaxis. The pathophysiology of serious spontaneous epistaxis remains to be unclear. It concerns elderly patients (>60-70 years old) with a history of hypertension in about 50% of cases. Serious spontaneous epistaxis may also be the presenting sign of underlying true hypertension in about 43% of patients with no history of hypertension. However, hypertension per se does not appear to be a statistically significant causal factor and/or a factor of severity of serious spontaneous epistaxis.

'Aggressive papillary' thyroid microcarcinoma.

The objective of this study is to highlight the fact that papillary thyroid microcarcinoma can be aggressive, requiring therapeutic management similar to that of other differentiated thyroid cancers. This 8-year retrospective study concerned 187 surgical patients managed in an ENT and Head and Neck surgery department for thyroid cancer. 65 patients were found to have papillary microcarcinoma. 41 microcarcinomas were considered to be aggressive because of the presence of several risk factors such as larger than 5 mm, multifocal microcarcinomas, capsular effraction, vascular embolus, tumour extension beyond the thyroid parenchyma and metastatic lymphadenopathy. All patients with aggressive papillary microcarcinoma were treated by total thyroidectomy and (131)I. Ipsilateral recurrent laryngeal and lateral cervical lymph node dissections were performed in ten patients, ipsilateral cervical lymph node dissection was performed in six patients and bilateral recurrent laryngeal and lateral cervical lymph node dissections were performed in three patients. No recurrence or metastasis was observed (follow-up ranging from 6 months to 8 years). The optimal management of thyroid papillary microcarcinoma is still controversial. "Aggressive" papillary thyroid microcarcinoma is not rare and may justify aggressive treatment depending on the presence or absence of prognostic risk factors.

Detection of enterovirus RNA in postoperative thyroid tissue specimens.

CONTEXT: Autoimmune thyroiditis is a very common disease. A genetic predisposition and environmental factors such as viruses are thought to contribute to the development of autoimmune thyroiditis. Enteroviruses, which are involved in other autoimmune diseases, are attractive candidates. OBJECTIVE: To investigate the presence of enteroviral genome sequences in postoperative thyroid tissues with lymphocytic infiltration, a common histological feature of thyroiditis. SUBJECTS AND METHODS: Postoperative thyroid specimens collected prospectively from 86 patients were blindly frozen at -80 degrees C. The presence of EV genome sequences in the samples was blindly investigated by real-time RT-PCR. Clinical data, histological findings and levels of anti-TPO antibodies were collected. RESULTS: EV-RNA detection was positive (up to 36 cycles) or weakly positive (37-39 cycles) in 22 out of 86 patients (25%). EV-RNA (positive or weakly positive signal) was detected in 5 out of 27 (18.5%) thyroid specimens with lymphocytic infiltration, and in 17 out of 59 (29%) thyroid specimens without lymphocytic infiltration (P = 0.4). No correlation was observed between EV-RNA detection in thyroid and the presence of anti-TPOAb. EV-RNA was detected in 3 out of 11 patients histologically diagnosed as thyroiditis (27.3%) and in 18 out of 74 patients (24.3%) with thyroid tumours (multinodular goitre, adenoma and carcinoma) (P = 0.5) and in one patient with a normal thyroid. CONCLUSION: EV-RNA can be detected in thyroid tissue from patients with various thyroid diseases, but there is no relationship between the presence of EV-RNA and thyroiditis. Further studies are needed to clarify the role of EV in thyroid diseases.

Otoendoscopy in cholesteatoma surgery of the middle ear: what benefits can be expected?

OBJECTIVE: This study was conducted with the aim of determining the contribution of otoendoscopy in the surgical management of cholesteatoma of the middle ear. BACKGROUND: The anterior epitympanum and the retrotympanum are anatomic sites that are difficult to access under otomicroscopy. Otoendoscopy offers a large field of vision using direct vision and lateral vision endoscopes, particularly in the supratubal recess and sinus tympani, for which visualization is excellent with reduced surgical approaches.The objectives of the study were to evaluate otoendoscopy as a means of identifying residues of lesions after excision of the disease under otomicroscopy in the same stage of surgery and its impact on the frequency of residual cholesteatomas at the time of surgical revision. STUDY DESIGN: Retrospective case review. SETTING: Private hospital center. PATIENTS: Patients operated on a tympanoplasty under otomicroscopy with or without an otoendoscopic exploration for a cholesteatoma or an uncontrollable tympanic retraction pocket. INTERVENTIONS: Between 1994 and 2005, 350 patients underwent tympanoplasty for a cholesteatoma or an uncontrollable tympanic retraction pocket.The surgical procedures were divided into closed tympanoplasty via the transmeatal approach, closed tympanoplasty with antroatticomastoidectomy and open tympanoplasty. Tympanoplasty was initially performed systematically under otomicroscopy.After excision of the disease, the cavities of the middle ear were examined by otovideoendoscopy, with the aim of identifying any peroperative residue of the lesion, to determine its location, especially in the epitympanum and retrotympanum, and the quality of its excision under otovideoendoscopy.During surgical revision, the frequency and location of any residual cholesteatoma were systematically recorded to determine the prognostic value of the quality of excision under otovideoendoscopy. MAIN OUTCOME MEASURES: The repartition of the canal wall down, canal wall up, and transmeatic tympanoplasties was compared between the population operated with or without the otoendoscopy as a complementary exploration of the otomicroscopy in the same surgical time. The frequency and the location of a residual disease identified by the otoendoscopy and the frequency of a residual disease in a second surgical stage were evaluated. RESULTS: Eighty patients (34%) who presented with an initial location of the disease at the epitympanum underwent complementary exploration by otovideoendoscopy. In this population, the frequency of open tympanoplasty was significantly lower.In 35 cases (44%), otoendoscopy revealed a residual lesion after an apparently total excision by otomicroscopy during closed tympanoplasty.The use of otoendoscopy did not produce a significant reduction in the number of residual cholesteatomas at the second stage of surgery compared to the population that underwent surgery under otomicroscopy alone. Nevertheless, the 35 residual lesions identified under otoendoscopy, as a complement to the microscope, during the first stage of surgery would have led systematically to a residual cholesteatoma at the second stage of surgery.Complementary exploration by otoendoscopy was performed on 85 patients (34%) who presented with a lesion of the retrotympanum. In this population, the frequency of open tympanoplasty was significantly reduced, while the techniques by the transmeatal approach were used in the majority of cases.In 65 cases (76%), a residual lesion was identified by otoendoscopy during the first stage of surgery in the sinus tympani or on the footplate of the stapes, between the crura of the stapes. Otoendoscopy did not produce a reduction in the frequency of residual cholesteatomas during surgical revision. Nevertheless, as for the epitympanum, the 65 residual lesions discovered under otoendoscopy would have led systematically to a residual cholesteatoma at the second stage of surgery if otoendoscopy had not been performed during the first stage. CONCLUSION: This study confirms the real value of otoendoscopy in the surgical management of cholesteatomas of the middle ear. It belongs entirely to the minimally invasive surgical procedures, while significantly reducing the frequency of open tympanoplasty and recourse to posterior tympanotomy and offering excellent access to numerous lesions by the transmeatal approach. Analysis using otoendoscopy reduces the incidence of residual cholesteatomas by identifying lesion extensions that are overlooked under otomicroscopy. Nevertheless, some residual cholesteatomas persist at the second stage of surgery. The quality of excision under otoendoscopy constitutes an important parameter in the decision regarding revision surgery. By targeting the at-risk regions where a residual lesion was discovered, it allows the control scanner to be read with greater accuracy, thus facilitating the decision on whether to perform surgical exploration.

Cartilage tympanoplasty: postoperative functional results.

We evaluated auditory performance following cartilage tympanoplasty for the management of tympanic membrane retraction pockets. We performed a 230-patient retrospective study over a 10-year period (1990-2000) and compared pre-operative and postoperative audiograms. Postoperative audiograms were better in 49% of cases, identical in 16% and worse in 11%. Cartilage tympanoplasty for the management of tympanic membrane retraction pockets has a good postoperative functional outcome. Cartilage graft is useful for reconstruction of the eardrum and tympanic bone defects.

[Management of the papillary microcarcinoma of the thyroid gland]. / Microcarcinomes papillaires de la thyroïde: quelle attitude thérapeutique?

OBJECTIVES: To study the management and treatment of papillary microcarcinoma of the thyroid. MATERIAL AND METHODS: Retrospective study of 57 patients operated on their thyroid gland between 1995 and 2004. All patients had a frozen section of the specimen. Procedure varied according to histology results and presence of adenopathy. RESULTS: Procedure planned initially was a total thyroidectomy in 75% of patients (the other 25% were planned as hemi-thyroidectomy). Frozen section was positive in 46% of patients. We proceeded with 16 selective neck dissections (levels 2-3-4) and 10 bilateral "level 6" . Microcarcinomas were unique in 77% of cases. Extra-capsular spreading was noted in 39% of cases. Adjuvant Iodine 131 was administered to 36 patients (63%). Follow-up included clinic visits, ultra-sound and Tg levels. With a follow-up of 3 to 12 years, no recurrence or metastasis has been identified. CONCLUSION: Treatment of papillary microcarcinomas of the thyroid is controversial. If surgery is chosen as treatment, the extent both regarding the thyroid itself and the cervical nodes is debated. Because of the excellent prognosis, some authors have recommended, when risk factors are absent, to limit the treatment to the thyroidectomy. Others, because of the risk of local recurrence and distal metastasis, have recommended a very aggressive approach.

Early hearing screening: what is the best strategy?

OBJECTIVES: A discussion concerning the relevance of universal newborn hearing screening has been conducted in France since the end of the 1990s. As a contribution to the choice of strategy to be implemented, we evaluated and compared the results of this screening and its impact on the parent-infant relationship as a function of the time at which screening was performed: during the infant's stay in the maternity unit, in the first strategy (strategy 1), or 2 months after birth, in the second strategy (strategy 2). PATIENTS AND METHOD: Five thousand seven hundred and ninety infants participated in the study: 3202 were included in the first strategy and 2588 were included in the second strategy. Within this population, 143 mother-infant pairs were submitted to psychological assessment. We compared the number of infants screened, the number of first positive tests, the number of false-positive tests and the number of infants not reviewed after screening. Adverse effects on the parent-infant relationship were evaluated in terms of maternal anxiety and the quality of early interactions. RESULTS: A statistically significant difference in favor of newborn screening was demonstrated for the number of infants screened: 95.72% for the first strategy [95.0%; 96.4%], 64.18% for the second strategy [62.3%; 66.0%]; the number of first positive tests: 1.11% during newborn screening [0.7%; 1.5%], 3.13% in the second strategy [2.3%; 4.0%]; the number of false-positive tests: 0.29% in the first strategy [0.10%; 0.49%] and 2.65% in the second strategy [1.88%; 3.42%]; and the number of infants not reviewed after screening: 8.8% during newborn screening [0.0%; 18.4%] and 38.5% in the second strategy [25.2%; 51.7%]. Analysis of the results of the psychological assessment showed that screening per se did not have any impact on maternal anxiety or on the quality of early interactions, regardless of the screening strategy used. However, the result of the test had a significant impact. Announcement of a positive result increased maternal anxiety and induced a deterioration of the mother's psychological state which affected the quality of early interactions. As the number of positive results is significantly lower in newborn hearing screening, there are consequently fewer psychological side effects with this strategy than with the second strategy. CONCLUSION: This study demonstrates that universal newborn hearing screening is the most efficient strategy.

Superior approach to the inferior laryngeal nerve in thyroid surgery: anatomy, surgical technique and indications.

GOALS OF THE STUDY: To describe the anatomical bases of the surgical access to the higher part of the thyroid lobe, with first location of the inferior laryngeal nerve at its laryngeal penetration, to discuss the advantages and disadvantages of this surgical technique and to determine the operational indications. POPULATION AND METHOD: A prospective study of surgical anatomy performed over a period of 18 months was conducted. A total of 25 (22 women and 3 men) patients with cervicothoracic goitre underwent total thyroidectomy. Thyroid lobectomies were performed using the technique of "capsular thyroidectomy", with first location and complete dissection of the inferior laryngeal nerve. A neurostimulator was systematically used for the location of the inferior laryngeal nerve and also the external laryngeal nerve. RESULTS: The first detection of the inferior laryngeal nerve at the top of the thyroid lobe was positive in 49/50 cases. A superior parathyroid gland was found in 75% of cases and an inferior parathyroid gland in 37.5% of cases. The external laryngeal nerve was stimulated and respected in 12,5% of cases. No voice trouble, no laryngeal palsy and no definitive hypoparathyroidism occurred after surgery. CONCLUSION: Safeguarding of the inferior laryngeal nerve is the principal and obligatory stake in thyroid surgery. Locating the inferior laryngeal nerve at the level of its laryngeal penetration at the superior pole of the thyroid region is necessary in cases of particular situations: huge cervicothoracic goitres, re-operative procedures and various anatomical variations. The use of a neurostimulator secures this technique.

[Lemierre syndrome: unusual, but still possible]. / Le syndrome de Lemierre: exceptionnel, mais encore possible.

Lemierre syndrome is a rare disease, which was life-threatening before the antibiotics era. We report here two cases with favorable outcome. Clinical features are stereotypic: tonsillis, cervical pain revealing deep vein thrombosis, and pulmonary septic metastasis. The most frequent causal germ on blood cultures is Fusobacterium necrophorum but other anaerobial bacteries can be found. Cervical Doppler-ultrasonography, and thoracic tomodensitometry are useful. Medical treatment is antibiotic therapy and anticoagulation.