Preauricular transmandibular and transzygomatic approach for tumors of the infratemporal fossa revisited.

AIM: To demonstrate the surgical technique and results in patients operated on with a preauricular transmandibular transzygomatic approach. METHODS: This surgical technique was used in 21 patients with benign and malignant tumors of the infratemporal fossa (ITF), operated on between 1999 and 2011. RESULTS: Twenty-one patients were enrolled in the study. There were 6 patients with benign tumors and 15 with malignant ones. No patients with benign lesions show any disease recurrence 5 years after surgery and present excellent functional and cosmetic results. Postoperatively, a reduction of pain was noted in all patients with malignant lesions. Four patients in this group, who are alive 5 years after surgery, do not demonstrate any disease progression. CONCLUSION: The described approach provides an excellent exposure of the ITF and could be the procedure of choice in the management of ITF tumors.

Human papillomavirus and head and neck squamous cell carcinomas in the South-East of France: prevalence, viral expression, and prognostic implications.

CONCLUSION: Human papillomavirus (HPV) infection, especially by HPV 16, is frequently detected in oropharyngeal squamous cell carcinoma (OSCC). The expression of viral oncoproteins in tumoral tissues of OSCCs suggests the implication of HPV in tumorogenesis. It should now be systematically detected and considered in each patient's treatment and outcome. OBJECTIVES: To investigate the prevalence of HPV infection, the oncogenic role of HPV in patients from the South-East of France with head and neck squamous cell carcinoma (HNSCC), and the resulting clinical implications. METHODS: Biopsy samples from 200 patients with HNSCC were analyzed. For each patient, one or two biopsies of tumoral tissue were analyzed simultaneously with a biopsy of healthy tissue. Fresh frozen tissues were tested by molecular techniques for HPV DNA detection and genotyping as well as mRNA expression of oncoproteins E6 and E7. Expression of p16 was also analyzed by immunohistochemical staining. RESULTS: HPV DNA tested positive in 11.5% of biopsy samples. The HPV prevalence was higher in OSCCs (91.3 vs 27.3, p < 0.0001) and in patients not consuming tobacco (65.2% vs 95.4%, p < 0.0001). The estimated 3-year overall survival rates were 67.0% for HPV-infected patients versus 39.9% for non-infected patients. The high-risk HPV 16 was the most common type detected (65.2%). In 12 of 18 patients exhibiting DNA of high-risk HPV in their tumor tissue, the same viral genome was also present in normal tissue. E6 and E7 expression was found in 9 of 14 tumoral biopsies tested for these markers.

Endoscopic parathyroidectomy in primary hyperparathyroidism.

During the past decade, endoscopic video-assisted parathyroidectomy (EP) for primary hyper parathyroidism (PHPT) has gained wider acceptance. The endoscopic gasless procedure described by P. Miccoli (1997-1998) offers an attractive technique. A routine preoperative localization study was performed with both ultrasonography and 99m TC-Sestamibi scintigraphy for each patient with sporadic PHPT. The criteria to select patients eligible for EP included absence of significant nodular goiter, a previous neck surgery, a need for concomitant thyroidectomy, a significant obesity, and multiple enlarged parathyroid glands. The surgical outcome and the use of preoperative localization together with the operative strategy were evaluated. From 2005 to 2009, 59 out of 75 patients (78%) were potentially candidates for this approach. An enlarged parathyroid gland was located by both types of imaging for 34 patients (57%) and by 99 m Tc-Sestamibi scintigraphy for 46 patients (77%). Conversion was required in 11 cases (18%). Nine patients had a negative preoperative imaging study and five underwent a successful EP. The operating time ranged from 35 to 120 min (median 45 min). Usually patients were discharged home at 48 h. There were no cases of permanent hypocalcemia or recurrent laryngeal nerve palsy. Postoperative review showed that all calcium and parathyroid hormone levels remained normal at 3 months except for 1 patient with a double adenoma. EP is a quick, safe, and effective procedure in a selected group of patients. Our results show that this technique can be easily introduced into a general head and neck practice.

Preoperative combined 18-fluorodeoxyglucose positron emission tomography and computed tomography imaging in head and neck cancer: does it really improve initial N staging?

CONCLUSION: In our experience PET-CT cannot yet reliably predict the need for surgical neck dissection in patients with N0 neck. According to the results of PET-CT the neck dissection should be extended towards unusual lymph node areas. OBJECTIVE: To analyze the value of PET-CT for the initial N staging, comparing PET-CT data with histopathological results of the modified radical neck dissection. METHODS: Fifty patients with previously untreated head and neck squamous cell carcinoma were eligible for inclusion in this study. Modified radical unilateral or bilateral neck dissection was performed in all patients. PET-CT findings and histological findings were compared to determine their diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value. RESULTS: In all, 105 levels had pathologically diagnosed metastases: PET-CT was positive in 87 levels and negative in 18 levels. Also, 399 levels had negative postoperative histology findings: PET-CT was positive in 24 levels and negative in 375 levels. The false-positive over-staged and the false-negative under-staged rates were 27% and 12%, respectively.

Randomized phase III trial comparing induction chemotherapy followed by radiotherapy to concomitant chemoradiotherapy for laryngeal preservation in T3M0 pyriform sinus carcinoma.

CONCLUSIONS: Conventional radiotherapy with concurrent cisplatin is significantly superior to induction cisplatin fluorouracil chemotherapy followed by radiotherapy in terms of laryngeal preservation in patients with T3 hypopharyngeal carcinoma. Despite a high rate of laryngeal preservation no survival benefit was recorded in this selected population. OBJECTIVES: To compare conventional radiotherapy with concurrent cisplatin to induction chemotherapy with cisplatin fluorouracil followed by conventional radiotherapy. The primary end point was the preservation of the larynx. The secondary end points included toxicity, causes of death, and survival rates. PATIENTS AND METHODS: Seventy-one adult patients with previously untreated resectable T3 pyriform sinus squamous cell carcinoma were enrolled in the multicenter prospective randomized phase III trial. They were evaluated for organ preservation, survival rates, and toxic reactions. RESULTS: The rates of laryngeal preservation at 2 years were 68% for the induction chemotherapy (IC) group and 92% for the chemoradiotherapy (CR) group (p = 0.016). At 2 years, the event-free survival rates were 36% and 41% for the IC group and CR group, respectively.

Sphenopalatine and anterior ethmoidal artery ligation for severe epistaxis.

OBJECTIVES: We describe the surgical treatment of severe epistaxis and evaluate the recurrence of bleeding in a nonrandomized retrospective trial. METHODS: We performed a retrospective study comparing bilateral endoscopic ligation of the sphenopalatine artery alone (ELSPA) and bilateral endoscopic ligation of the sphenopalatine artery with concomitant bilateral external ligation of the anterior ethmoidal artery (ELSPEA) in the management of persistent epistaxis. Clinical and hematologic information, preoperative and surgical care, and short- and long-term outcomes were analyzed. The main outcome measure was recurrence of epistaxis in the short- and long-term follow-up periods. RESULTS: Forty-five patients were enrolled in the study. There were 20 patients in group A (ELSPA) and 25 in group B (ELSPEA). Three patients in group A and no patients in group B had long-term (more than 2 weeks after surgery) rebleeding. The difference between the two groups was not statistically significant (p > 0.05). CONCLUSIONS: We conclude that ELSPA and ELSPEA are effective, well-tolerated, reliable procedures if performed by an experienced surgeon. Their failure can be explained by anatomic lateral nasal wall variations and perioperative technical difficulties. They can be appropriate methods to treat severe recurrent epistaxis refractory to repeated nasal packing.

Papillary thyroid microcarcinoma: incidence and prognostic factors.

The objective of this study was to define the prognostic factors of papillary microcarcinoma of the thyroid (PMCT), and to analyse their epidemiologic and histopathologic characteristics. Our series included 57 patients diagnosed with PMCT between 1994 and 2003 among 944 patients who underwent thyroid surgery. All the surgical specimens were examined in the same department of pathology using the same technique. The prognostic factors were elaborated from the results of the histological examination. The epidemiological and histopathological characteristics were also evaluated. Two sub-groups were distinguished: patients with node disease and/or with metastasis (17 patients) and patients without node disease and metastasis (40 patients). The architecture of PMCT was papillary in 14% of cases, follicular in 35% of cases and mixed in 49% of cases, with no significant difference between any two groups. Histopathologic characteristics such as the vascular extension, infiltration into the adjacent parenchyma or in the thyroid capsule are all indicative of a poor prognosis. Two categories of PMCT, with and without the risk of metastatic spread, can be identified from these prognostic factors.

Malleus head fixation: histopathology revisited.

CONCLUSIONS: Malleus head fixation is a rare but not exceptional pathology. It may be apparently congenital or acquired, and can be associated with stapes fixation. In the acquired secondary process two histological types of malleus head fixation were found: the first corresponded to non-tympanosclerotic bone remodeling and the second to localized tympanosclerosis. OBJECTIVE: To describe the histopathologic features of malleus head fixation and to correlate them with its clinical appearance. MATERIAL AND METHODS: Ten patients with surgically proven malleus head fixation were included in this series. A fixed malleus head was resected via a transcanal approach in six patients, and attic bony fragments fixing the malleus head were removed via a mastoidectomy without disruption of the ossicular chain in four. Histopathologic studies were performed for both types of malleus head fixation. RESULTS: Three types of acquired malleus head fixation were defined in accordance with the surgical and histopathological findings. Histologically, the first type presented with normal bone tissue, the second was characterized by non-tympanosclerotic bone remodeling and the third presented with a localized tympanosclerotic focus in the tympanic cavity.

Microsurgical anatomy of intralaryngeal distribution of the inferior laryngeal nerve.

The functional results of a partial laryngeal surgery or a laryngeal reinnervation depend on the precise knowledge of the intra laryngeal anatomy of the inferior laryngeal nerve (ILN). Ten human larynges without known laryngeal disorders were obtained from human cadavers for ILN microdissection. Intra laryngeal ILN branching patterns were determined bilaterally. The lengths of the vertical, genu and oblique segments of the anterior division of ILN and the distance between the nerve within the paraglottic space and the cricothyroid articulation (CTA) were measured with a digital microcaliper. The mean lengths of the vertical, genu and oblique segments were 10.82, 5.89 and 9.29 mm, respectively. The mean distance between the nerve in the paraglottic space and the CTA was 11.20 mm. Key anatomical landmarks of the abductor division (vertical and genu segments of ILN) were the lateral border of posterior cricoarytenoid (PCA) muscle and the superior ligament of the CTA. The two-branch pattern for the lateral border of the PCA muscle has been the most frequent (50%). A branch of interarytenoid muscle (IA) originated from the genu segment. One or two branches for the PCA muscle has been identified in 75% of cases from the IA neural plexus on the front side of PCA muscle. The adductor division for the thyroarytenoid muscle and the lateral cricoarytenoid muscle was the oblique segment of the nerve. We conclude that abductor and adductor divisions of intra laryngeal ILN can be readily identified and the knowledge of key landmarks allows preservation of the ILN during partial surgery of the larynx and possibly selective muscle reinnervation.

Extended and standard supraglottic laryngectomies: a review of 110 patients.

The purpose of this study was to compare functional and oncological results of extended and standard supraglottic laryngectomies. One hundred ten patients with supraglottic carcinoma were treated. A standard supraglottic laryngectomy (SSL), a laterally extended supraglottic laryngectomy (LESL) and an anteriorly extended supraglottic laryngectomy (AESL) were performed on 32, 47 and 31 patients, respectively. Indications for postoperative radiotherapy included positive surgical margins (23% of patients) and/or node metastasis (63% of patients). Local recurrence occurred in 13% of SSL, 15% of LESL and 17% of AESL patients. Pulmonary complications due to aspiration were observed in 6% of SSL, 15% of LESL and 19% of AESL. The overall 5-year cure rates were 63% for SSL, 45% for LESL and 47% for the AESL procedures. Extended supraglottic laryngectomies provided as good a local tumor control as SSL. Extension to the hypopharynx (LESL) and to the vallecula (AESL) showed more frequent pulmonary complications and reduced cure rates.

Malleus removal and total cartilage reinforcement in intact canal wall tympanoplasty for cholesteatoma.

This study analyzes the morphological and hearing results obtained from intact canal wall cholesteatoma surgery by removing the malleus, reinforcing the whole tympanic membrane with cartilage, and performing an ossiculoplasty with a hydroxyapatite prosthesis. The results were compared to those obtained in intact canal wall cholesteatoma surgery by preserving the malleus manubrium, partially reinforcing the tympanic membrane with cartilage, and predominantly using an ossicle to perform the ossiculoplasty. One- or two-stage intact canal wall procedures were performed in 390 adult patients (416 ears) who had a nonoperated middle ear cholesteatoma. Recurrent and residual cholesteatoma rates were evaluated. Hearing results were analyzed according to the Committee on Hearing and Equilibrium Guidelines of the American Academy of Otolaryngology-Head and Neck Surgery. There was a statistically significant decrease in the recurrence rate in patients who had total cartilage reinforcement of the tympanic membrane versus patients who had partial tympanic membrane cartilage reinforcement. This technique using a hydroxyapatite prosthesis for ossiculoplasty gave good hearing results.

Concomitant chemoradiotherapy in pyriform sinus carcinoma.

OBJECTIVES: To test the effectiveness of concurrent chemoradiotherapy in patients with pyriform sinus carcinoma and to demonstrate the feasibility of an organ preservation approach. DESIGN: Clinical trial phase 2. SETTING: University Hospital Center, St-Etienne, France. PATIENTS: The study population comprised 46 male patients with resectable stage III and IV pyriform sinus carcinoma. METHODS: Two successive chemoradiation regimens were investigated. In protocol 1 (24 patients), carboplatin was given on days 1 through 5 and 28 through 33, with an area under the curve dose of 5 mg/mL for 1 minute per day and bifractionated radiotherapy (160 rad [1.6 Gy]/fraction) delivered on days 1 through 16 and 28 through 38. A treatment break was planned on days 16 through 27. In protocol 2 (22 patients), chemotherapy was given with the same dose of carboplatin on days 1 and 21, and fluorouracil (750 mg/m(2) per day) on days 1 through 7 and 21 through 28. Radiotherapy with a single fraction of 180 rad (1.8 Gy)/d was delivered during the first 2 weeks and then 150 rad (1.5 Gy) twice a day during the next 3 weeks. MAIN OUTCOME MEASURES: Patients were evaluated for tumor response, toxic reactions, and organ preservation and survival rates. Statistical analysis of disease-free survival and overall survival was performed using the Kaplan-Meier method. RESULTS: A complete response was noted in 21 (88%) of the 24 patients following protocol 1 and 16 (73%) of the 22 patients following protocol 2. After 2 years of follow up, 16 patients (67%) (protocol 1) and 12 patients (55%) (protocol 2) retained their larynx without evidence of disease. During therapy, 15 patients (63%) (protocol 1) and 19 patients (86%) (protocol 2) required unplanned hospitalization for toxic effects. The overall survival and disease-free survival rates at 2 years were 58% (protocol 1) vs 53% (protocol 2) and 39% (protocol 1) vs 41% (protocol 2) (P =.80), respectively. CONCLUSION: Concomitant chemotherapy and bifractionated radiotherapy, although toxic, leads to good locoregional control and therefore to a significant level of laryngeal preservation.