[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.

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.

[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.

[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.

[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.

[Epidemiology of postoperative infections in cervicofacial surgery]. / Epidémiologie des infections post-opératoires en chirurgie cervico-faciale.

Post-operative infections are studied about 150 patients distributed in five groups according to type of surgery (total pharyngolaryngectomy, hemilaryngectomy, bucco-pharyngectomy, cordectomy, cervicotomy). An antibiotic prophylaxis by penicillin G and metronidazole was prescribed for all groups excepted the last. Only sixteen patients (seven of whom in bucco-pharyngectomy group) developed a local infection, therefore these antibiotics are indicated until mucosa cicatrisation. Systematic bacteriologic study of cervical drains is useless because they are frequently positive with non-pathogenic germs and in case of local infection the responsible germ is different of the germ obtained by culture of drain.

[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 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.

[Partial pharyngo-laryngectomy with subtotal esophagectomy and 1-stage coloplasty]. / Pharyngo-laryngectomie partielle avec oesophagectomie sub-totale et coloplastie en un temps.

A patient with cancer of both the hypopharynx and esophagus was treated by partial pharyngolaryngectomy, subtotal esophagectomy and a reconstructive one-stage coloplasty. Surgical and carcinologic problems raised by this technique are discussed.

[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.

[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.

[High frequency injection ventilation in laryngeal surgery. Methods and indications]. / La ventilation par injection à haute fréquence dans la chirurgie du larynx. Réalisation et indications.

High frequency injection ventilation was employed in 150 patients during endoscopy or laryngeal surgery. Lower mean intratracheal pressures are obtained that by conventional injection ventilation, and the respiratory pathways are protected to a greater degree. The reduced diameter of the tracheal approach provided by the use of a small transglottic catheter or a small intercricothyroidal tube enables the operative zone to be well exposed. For optimal efficacy, the method requires a frequency, equal to or less than 150 per minute, a short insufflation period, and sufficient exposure of the respiratory tract. General anesthesia is required.

[Partial vertical surgery of the larynx : results as a function of anesthesia and the employ of tracheotomy (author's transl)]. / Anesthésie, trachéotomie dans la chirurgie partielle verticale du larynx.

Postoperative course and complications were studied as a function of the type of anesthesia, and the employ of a tracheotomy tube and gauze drainage of the laryngeal cavity, following partial vertical surgery on the larynx of 238 patients. Findings demonstrated that a general anesthetic by intubation with total skin closure without tracheotomy and gauze drainage of the laryngeal cavity, reduced the incidence of local infections complications and the duration of hospitalization. Without insisting on the advantages of this type of anesthesia and the value of immediate suturing, the authors note that these simple techniques markedly reduce the hospitalization period at a time when emphasis is being placed on the economic impact of the duration of this period.

[Tracheotomy in the surgical treatment of carcinomas of the pharyngo-larynx (author's transl)]. / Trachéotomie dans le traitement chirurgical des épithéliomas du pharyngo-larynx.

The authors studied the local postoperative course and period of hospitalisation after 890 total and partial pharyngo-laryngectomies according to whether the operation was started under general anaesthesia by intubation or after tracheotomy under local anaesthesia. The authors show the improvement in postoperative course as well as the decrease in the period of hospitalisation when intubation was used first.

[Criteria for choice of an anesthetic technic for laryngeal laser microsurgery using the laser in adults]. / Critères de choix d'une technique anesthésique pour la micro-chirurgie laryngée au laser de l'adulte.

Laryngeal microsurgery by means of the laser involves anesthetic constraints regarding mainly the mode of ventilation during operation. The principal techniques and different anesthetic protocols are discussed. The two main criteria for the choice of method appear to be the permeability of the laryngeal passage and the patient's general condition and history. The two principal methods proposed are high frequency jet ventilation and ventilation controlled by a protected intubation tube.

[Use of the CO2 laser in the emergency treatment of dyspnea in laryngeal cancer]. / Utilisation du laser CO2 dans le traitement d'urgence des dyspnées des cancers du larynx.

Occlusion of the larynx of neoplastic origin was treated by CO2 laser in seven patients between Marc 1982 and April 1983. Temporary tracheotomy was avoided in all 7 cases but treatment had to be repeated in two patients. Specific anesthetic techniques necessary when using the laser in hypercapneic patients are described, and the advantages, limitations and complications of this therapy are discussed.

[Induction chemotherapy in cancer of the upper respiratory and digestive tract. Preliminary results of the protocol combining cisplatin, 5-fluorouracil and bleomycin (CFB)]. / Chimiothérapie d'induction dans les cancers des voies aéro-digestives supérieures. Résultats préliminaires du protocole Cisplatyl, 5 fluoro-uracile, bléomycine (C.F.B.).

Prognosis in cancer of the upper respiratory-digestive tract (URDT) is dominated by the importance of local and regional spread, of second localizations or metastases and of any underlying clinical condition. Stable results are obtained using local and regional treatment (surgery and/or chemotherapy) alone, and the use of chemotherapy has been evaluated since 1965, neo-adjuvant cancer chemotherapy being adapted in 1970 for cancer of URDT. From november 1982 to december 1983, 184 patients with epidermoid cancer of URDT were treated by combined therapy with Cisplatin, 5 Fluoro-uracil, Bleomycin as a continuous infusion. Results are presented of the different tumoral responses as a function of localization and stage, excluding any glandular responses.

[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.

[Induction chemotherapy in cancers of the respiratory and digestive tracts by continuous infusions combining cisplatinum (C), fluorouracil (F), bleomycin (B) or C and F]. / Chimiothérapie d'induction dans les cancers des voies aéro-digestives par perfusions continues associant cisplatinum (C), fluoro-5-uracile (F), bléomycine (B) ou C, F.

A series of 344 patients with squamous cell carcinoma (oropharynx, larynx, hypopharynx, or buccal cavity) were treated between November 1982 and January 1985 by chemotherapy. This involved either cisplatinum (C) on day 1 followed by continuous infusion of 5-fluorouracil (F) and bleomycin (B) from day 1 to day 4 or C combined with F as continuous infusion from day 1 to day 4. Tumoral response was 61% and nodal response 61%. Among the 234 patients operated upon, 31 (13%) were free from tumoral cells in the specimen and 25 (48%) with residual tumor. Toxicity of cancer chemotherapy was markedly minimized with the second regimen involving continuous administration of Cisplatin over 24 hours for a period of 4 days. Tolerance was improved mainly in the digestive and renal spheres: cardiovascular complications related to essential hyperhydration during administration of single-dose Cisplatin on day 1 were non-existent with this new continuous mode of administration. This new procedure should optimize results and improve the comfort of patients.