Transoral robotic surgery for squamous cell carcinomas of the posterior pharyngeal wall.

Posterior pharyngeal wall squamous cell carcinomas (SCCs) are rare and have an associated poor prognosis. Progress in transoral resection techniques, in particular, transoral robotic surgery (TORS), have renewed the role of surgery in their treatment. This article presents the oncological and functional results obtained by the French Group of Head and Neck Robotic Surgery for TORS for posterior pharyngeal wall SCC-curative surgery. This retrospective, multicentre study presents data collected between September 2009 and November 2013 for patients treated with TORS for posterior pharyngeal wall SCCs. Analysis of patient characteristics, tumour and treatment details were completed. Kaplan-Meier analysis was used to calculate overall survival rates and recurrence-free survival rates. Student's t test and Chi2 test were also calculated. 23 patients were included (mean age of 62 years). 12 patients had a prior HNSCC. Ten patients had pT1 cancers. The overall two-year survival rate was 59%, but 89% for pT1 compared to 28% for pT2-T3 (p = 0.01). It was noted that TORS was simple to perform, but generated significant post-operative dysphagia. Two cases of spondylodiscitis were reported as specific post-operative complications of TORS. In conclusion, TORS is a treatment solution for selected posterior pharyngeal wall SCCs. It provides a possible alternative to medical treatment for early pT1 lesions and is often the only remaining curative solution in patients previously treated with radiotherapy. In cases of bulky resection, or when there is a past medical history of radiotherapy, a tissue reconstruction by forearm free-flap may be indicated.

Partial pharyngolaryngectomy with free flap for an unusual pharyngeal stenosis: surgical experience and literature review.

This report describes the case of a middle-aged man who attempted suicide, which resulted in laryngeal webbing and pharyngeal stenosis. The patient was compromised at the level of respiration, necessitating a tracheostomy. Alimentation was also affected, and feeding was done through a gastrostomy tube. Unfortunately, the fibrous tissues were resistant to dilatation and laser treatment. Hence, he underwent a modified partial horizontal supraglottic laryngectomy (PHSL) and pharyngectomy to excise all of the fibrous tissues formed after the incident. The resulting defect was closed with a radial forearm flap (RFF), which is an innovative means of reconstruction after PHSL. The postoperative results were satisfactory. The patient could achieve full oral intake without aspiration at 10 days and the cannula was removed at 3 weeks. This surgical technique could be applied in supraglottic cancers with extension to the pharynx, with repair of the defect by RFF, thus preserving the function of the larynx.

Laryngeal graft after total laryngectomy in humans: A SWiM analysis.

Evaluation of the results of laryngeal transplantation (LT) in humans. Analysis of 3 bibliographic databases with the keywords "larynx, transplantation, autograft". In total, 626 abstracts were read and 25 articles selected. The main objective was to analyze the characteristics of laryngeal transplant patients. The accessory objectives comprised analysis of operative technique, immunosuppressive treatment and results. Four articles were selected for analysis. Two patients were transplanted after total laryngectomy for laryngeal carcinoma and 2 after laryngeal trauma. Three of the 4 patients had true transplantation with arterial, venous and neural microanastomosis. Two patients were decannulated and the tracheostomy tube was maintained in the other 2. Three of the 4 patients had good-quality phonation and could feed without a gastric tube. One patient died of carcinoma progression and 1 patient had to be explanted 14 years after transplantation. The number of LTs reported is too small for scientific determination of the place of this intervention in laryngology. The published results could, at first sight, suggest that the future of LT is uncertain. However, several elements, also suggest that otolaryngologists should continue to take an interest in this technique.

Efficacy and safety of photodynamic therapy with temoporfin in curative treatment of recurrent carcinoma of the oral cavity and oropharynx.

Therapeutic options for recurrent carcinoma of the upper aérodigestive tract (UADT) are limited. The prognosis of these tumours remains poor with significant rate of recurrence and a lower median survival time. Photodynamic therapy (PDT) is a relatively new therapeutic alternative which combines the use of a photosensitising agent and light to induce a cytotoxic effect on the tissues. This is a retrospective single-centre study carried out in patients with a recurrence of an oral cavity or oropharyngeal carcinoma or a second appearance of tumour in a previously irradiated area. There were no metastases in lymph nodes or other organs. Laser treatment was carried out 96 h after temoporfin (Foscan(®)) injection. In our series we had 14 cases with a complete response, 1 partial response. Overall survival at 1 year was 72 % and 36 % at 5 years. Disease-specific survival at 1 year was 82 % and 45 % at 5 years. Recurrence-free survival at 1 year was 52 % and 34 % at 5 years. Side effects mainly described are pain in the area of illumination, well controlled. PDT with Foscan(®) gives useful results in terms of survival and improvement in quality of life with few adverse events or severe complications. The fact that it has low toxicity and that treatment sessions can be repeated mean it should be considered in the therapeutic armamentarium for recurrent carcinoma of the UADT.

Management of the neck in the setting of definitive chemoradiation: is there a consensus? A GETTEC study.

BACKGROUND: The management of the neck remains controversial in the definitive chemoradiation setting of advanced N2-3 head and neck squamous cell carcinoma. Most published data favor omission of neck dissection (ND) after complete response for N2-3 or selective ND for residual disease METHODS: We studied the patterns of care in the French-Belgian Groupe d'Etude des Tumeurs de la Tête Et du Cou (GETTEC) through a questionnaire-based survey. RESULTS: Eighteen percent of institutions never performed up-front ND, 20% rarely, 40% sometimes, 14% often, and 8% systematically. Induction chemotherapy was indicated in 30% of the cases, and most ND were performed either between induction and radiation or after chemoradiation for residual disease. Response to chemoradiation was assessed by computed tomographic scan and positron emission tomography in 72% of cases. Selective ND was more common than radical ND. CONCLUSIONS: Omission of ND based on computed tomographic scan and positron emission tomography-based complete response to chemoradiation is the most common strategy for advanced nodal disease among centers. However, neck management strategies vary among institutions, and some institutions continue advocating systematic ND before irradiation. The new treatment options and the changing epidemiology, namely docetaxel-based induction chemotherapy and human papilloma virus-related head and neck squamous cell carcinoma having better response profiles and prognosis, are adding to the nonconsensual approach. The best therapeutic index in terms of neck management remains to be defined in this evolving context.

[Management of ear, nose, and throat diseases in district hospital centers in Madagascar]. / Prise en charge de la pathologie ORL dans les centres hospitaliers de district à Madagascar.

The purpose of this report is to describe the experience of a specialized medico-surgical ENT team sent to hospital centers in Atalaha and Tulear, Madagascar by a nonprofit organization called "Terre rouge" from the Reunion Island. In three separate short-term missions, a total of 93 patients received care. Discussion focuses on the particular pathological, cultural, and pedagogical features of the Island and on the resources that were deployed during the missions. Providing ENT care in district hospitals in Madagascar requires adaptation to the difficult climatic conditions, poor hospital facilities (infrastructure, equip ment, and personnel), and advanced stage of diseases. To ensure continuous access to ENT care, it will be necessary to provide practical and didactic training for healthcare personnel in the country.

Surgical activity during the Covid-19 pandemic: Results for 112 patients in a French tertiary care center, a quality improvement study.

BACKGROUND: After the emergence of Covid-19 in China, Hubei Province, the epidemic quickly spread to Europe. France was quickly hit and our institution was one of the first French university to receive patients infected with Sars-COV2. The predicted massive influx of patients motivated the cancellation of all elective surgical procedures planned to free hospitalization beds and to free intensive care beds. Nevertheless, we should properly select patients who will be canceled to avoid life-threatening. The retained surgical indications are surgical emergencies, oncologic surgery, and organ transplantation. MATERIAL AND METHODS: We describe the organization of our institution which allows the continuation of these surgical activities while limiting the exposure of our patients to the Sars Cov2. RESULTS: After 4 weeks of implementation of intra-hospital protocols for the control of the Covid-19 epidemic, 112 patients were operated on (104 oncology or emergency surgeries and 8 liver transplants). Only one case of post-operative contamination was observed. No mortality related to Covid-19 was noted. No cases of contamination of surgical care personnel have been reported. CONCLUSION: We found that the performance of oncological or emergency surgery is possible, safe for both patients and caregivers.

[Endoscopic staple diverticulostomy for Zenker's diverticulum]. / Traitement endoscopique des diverticules de Zenker à la pince autosuturante.

OBJECTIVE: Retrospective study to evaluate the efficacy and safety of endoscopic stapled diverticulotomy of patients with Zenker's diverticulum. METHODS: Twenty-two patients with Zenker's diverticulum were evaluated. All patients had a preoperative barium swallow, which confirmed the Zenker diverticulum. SURGICAL PROCEDURE: Patients underwent an attempted endoscopic resection of the Zenker diverticulum using the endoscopic stapling technique. If unsuccessful, an open approach was then taken. All patients were seen in follow-up within one and then at six months after surgery and had a barium swallow during the first month. RESULTS: The patient's mean age was 74 years. The operation lasted a mean of 20minutes. Conversion to open surgery was required in five patients, which lasted a mean 20minutes. No postoperative morbidity or mortality was recorded. In two patients with a small diverticulum (2cm), persistent discomfort with no dysphagia or regurgitation was noted. The barium swallow demonstrated a persistent diverticulum without a neck. CONCLUSION: Endoscopic staple diverticulotomy is an excellent first-intention method to surgically correct Zenker's diverticulum in many patients. It is a technique with a significantly shorter operative time, hospital stay, time to resumption of oral feeding and lower mortality and fewer morbidity complications.

[Surgery or radiotherapy for oropharyngeal HPV-positive tumours?] / Chirurgie ou radiothérapie pour les cancers viro-induits ?

Oropharyngeal carcinomas related to the human papilloma virus (HPV; usually HPV16) exhibit biological differences in terms of carcinogenesis and are of relatively better prognosis (in the absence of tobacco consumption) compared to tobacco-related cancers. The therapeutic strategies between these two forms of cancers of the upper aerodigestive tract related to different risk factors are however identical, except therapeutic trial. In the absence of a sufficient level of evidence to define a specific strategy for induced HPV carcinomas, the analysis of the recent literature nonetheless allows us to suggest ways to guide the clinician in his therapeutic choice. Given the relative good prognosis HPV+ oropharyngeal cancers, an important goal is to avoid if possible a multimodal treatment that increases the sequelae and could degrade the quality of life. For the early stages I/II, it may be desirable to propose minimally invasive surgery if radiotherapy is avoidable or an exclusive conformal radiation therapy by intensity modulation in the opposite case. For the advanced stages III/IV, the recommendations are similar to those of cancers not related to HPV. Current trials should provide answers on the relevance of therapeutic deflation (absence of chemotherapy in the event of capsular rupture, dose reduction or irradiation volumes, etc.).

Salvage surgery for recurrence of laryngeal and hypopharyngeal squamous cell carcinoma: A retrospective study from 2005 to 2013.

OBJECTIVES: Salvage surgery is the gold-standard treatment for locoregional recurrence of laryngeal and hypopharyngeal cancer following radiation therapy. Imperfect oncologic and functional results, however, require patient selection. The main objective of the present study was to determine preoperative factors for survival. Secondary objectives were to study 5-year overall and disease-free survival, general and locoregional complications, and functional results in terms of feeding and tracheotomy closure. PATIENTS AND METHOD: A retrospective multicenter study included 52 patients treated by salvage surgery for recurrence of laryngeal or hypopharyngeal squamous cell carcinoma after radiation therapy between 2005 and 2013. RESULTS: Factors associated with improved 3-year overall survival on univariate analysis comprised laryngeal primary (P=0.001), laryngeal recurrence (P=0.026), rT1, rT2 or rT3 rather than rT4 tumor (P=0.007), previous chemotherapy (P=0.036), and neck dissection during salvage surgery (P=0.005), the last of these being confirmed on multivariate analysis. Five-year overall survival was 36.0% (range, 27.6-44.4%), for a median 23.04 months (95% CI, 19.44-26.64). Five-year disease-free survival was 23.5% (range, 16.0-31.0%), for a median 8.04 months (95% CI, 2.04-14.04). CONCLUSION: Salvage surgery for laryngeal or hypopharyngeal cancer is difficult, and survival is not good. Laryngeal primary and recurrence location, moderate tumor volume and extension (

[Transorbital fiberoptic intubation: a predictable difficult intubation in cephalic surgery]. / Intubation transorbitaire: une intubation difficile prévisible en chirurgie céphalique.

Management of the difficult adult airway is a crucial problem in anaesthesia. It is the first cause of anaesthetic mortality and morbidity. We report here the case of a patient who could only be intubated through the orbital cavity. We discuss our technique of intubation compared to the other rare procedures described in the literature. We also focus on our anaesthetic protocol and the interest of preserving spontaneous ventilation for intubation. Use of short acting anaesthetic drugs can help to achieve such conditions.

[Traumatic luxation of the stapes: radiology and surgical outcome]. / Luxation traumatique de l'étrier dans le vestibule: aspect radiologique et conduite à tenir.

OBJECTIVES: To describe the value of high resolution computed tomography scan (HRCT scan) in post traumatic hearing loss. METHOD: HRCT scan of the temporal bone in millimetric cut with axial and coronal views was performed. RESULTS: CT scan confirmed pneumolabyrinth with intact stapes depressed deeply into the vestibule. Surgical exploration was performed and the stapes was gently removed from the vestibule. CONCLUSION: CT scan confirmed the diagnosis and studied the stapes integrity. Hearing deteriorated postoperatively is increased in case of stapes fracture. When a luxation of the stapes into the vestibule is suspected, it is important to determine how deeply and whether it is fractured. When such a case is encountered, high resolution CT scan of the temporal bone must be performed to confirm the diagnosis and to confirm integrity of the stapes.

Morbidity and mortality revue of the French group of transoral robotic surgery: a multicentric study.

Transoral robotic assisted surgery (TORS) represents an innovative endoscopic therapeutic alternative in the treatment of head and neck tumors. Many publications favor this surgery, especially in terms of functional results. The aim of this study was to investigate the TORS morbidity and mortality and to identify the risk factors for complications. It is a multicenter retrospective study. All head and neck tumor patients treated by TORS were included in the study over a period of 5 years (2009-2014). The studied parameters were the intraoperative and post-operative complications including hemorrhage, fistula, tracheotomy, aspiration pneumonia and death. The parameters were correlated with age, tumor location, tumor stage, endoscopic exposure and patient's co-morbidities. 178 patients were included in the study. Malignant tumors classified as T1 were found in 169 cases (n = 51), T2 (n = 100), T3 (n = 16) and T4 (n = 2). The tumor locations were distributed as follows: larynx (n = 84), oropharynx (n = 51), and hypopharynx (n = 43). Fifty-three patients followed post-radiation therapy. We observed 12 intraoperative complications including 6 hemorrhage, 3 pharyngeal fistulas and 3 external surgical conversions. Postoperatively, we detected 33 hemorrhage, 27 aspiration pneumonia, 9 tracheostomy, 2 pharyngostomes, 2 cervical spondylitis and 2 deaths. The risk factors identified were (i) anticoagulant and/or antiplatelet therapy for hemorrhage, (ii) tumoral stage and the laryngeal location for aspiration pneumonia and (iii) laryngeal location for tracheostomy. Higher age over 65 years has been identified as a risk factor for all post-operative complications. TORS is a safe technique for the treatment of head and neck tumors. We identified some risk factors for complications which should systematically be studied in order to reduce its morbidity.

Conformal radiotherapy for paranasal sinus and nasal cavity tumors: three-dimensional treatment planning and preliminary results in 40 patients.

PURPOSE: To assess the possibility to deliver a high and homogeneous irradiation with respect to maximal tolerated dose to the visual pathways for paranasal sinus and nasal cavity tumors. METHODS AND MATERIALS: Forty patients with advanced stage malignant tumors were treated with postoperative (30) or primary (10 patients) conformal radiotherapy (CRT). Five patients were previously irradiated. Six to 15 individually shaped isocentric noncoplanar field arrangements, using a multileaf collimator were designed. Dose-volume histograms (DVH) for the planning target volumes (PTV) and the optic pathways were analyzed in 31 cases. RESULTS: Median and maximal delivered doses to the PTV were 60 (+/-3) and 66 (+/-4) Gy. Dose distributions for critical organs are detailed. Median follow-up was 19 months (3 to 48). Local, nodal, and metastatic recurrences occurred in 8, 2, and 7 cases, respectively. Major prognostic factor for local recurrences was central nervous system (CNS) involvement. One patient died of meningitis. Two patients developed cataract, and 1 patient ipsilateral blindness due to vascular glaucoma. CONCLUSION: CRT for locally advanced paranasal sinus and nasal cavity tumors enables the delivery of high homogeneous doses to the PTV with respect to critical organs, with a low toxicity and a high local control.

Cervical necrotizing fasciitis: 10 years' experience at a single institution.

OBJECTIVE: To evaluate clinical and microbiologic characteristics, modalities of treatment and outcome of patients with cervical necrotizing fasciitis admitted to our institution. DESIGN: Retrospective clinical investigation. PATIENTS AND METHODS: We reviewed the charts of 20 consecutive patients hospitalized in our Intensive Care Unit between January 1987 and June 1998 with the diagnosis of cervical necrotizing fasciitis. RESULTS: All the patients required mechanical ventilation. Four of them had mediastinal involvement. The organisms most commonly implicated included Streptococcus, Prevotella, and Peptostreptococcus species. Patients with adequate surgery had a better outcome than those with inadequate surgical procedures. Because no evidence-based recommendations exist in the field of head and neck infections, hyperbaric oxygen was not used as adjunctive therapy. Of the 20 patients, 3 (15 %) died. CONCLUSION: The main finding of this study is that prompt, rather than delayed, surgical débridement correlates with a decrease in morbidity and mortality. However, no definite conclusion is justified due to the relatively small number of patients. Immediate radical débridement, and early redébridement if needed, appropriate antibiotics and intensive care support are critical in controlling these life-threatening infections.

Major cellulitis following percutaneous tracheostomy.

Percutaneous tracheostomy, a technique that can be performed at the bedside in the intensive care unit (ICU), is increasingly used for critically ill ventilator-dependent patients. Based on many clinical studies, this procedure appears to be simple, rapid and safer than conventional surgical tracheostomy. This technique produces a stoma tissue tract that fits snugly around the cannula, and this could explain the low incidence of infective complications. However, we report two cases of life-threatening cellulitis, a serious complication that has rarely been reported previously.

Ulcerated cutaneous epithelioid hemangioendothelioma.

Epithelioid hemangioendothelioma described first by Weiss and Enzinger in 1982 is an uncommon vascular tumor usually involving soft tissue, less frequently the lung and the liver and exceptionally the skin. We herein report a 52-year-old woman who presented an isolated moderately painful persistant ulceration of the concha of her left ear. Histopathological findings showed strands and nests of epithelioid endothelial cells typical of cutaneous epithelioid hemangioendothelioma. Immunohistochemical stainings confirmed the vascular nature of the tumor. Surgical excision by ear amputation was performed. In a review of the literature, to our knowledge, this clinical presentation as ulceration has never previously been reported.

[Diagnostic criteria for progressive necrotizing external otitis. Are scintigraphic findings reliable?]. / Critères diagnostiques des otites externes nécrosantes progressives. Faut-il remettre en question la scintigraphie?

OBJECTIVES: Determine the role of 99m technetium scintigraphy for diagnosis in progressive necrotizing external otitis and assess the diagnostic criteria of this disease. METHOD: A retrospective study was conducted in 16 patients hospitalized for suspected progressive necrotizing external otitis. Patient characteristics, clinical features, imaging findings and disease course were recorded in order to evaluate the classical criteria of diagnosis. RESULTS: The clinical course and complementary test results showed that 99m technetium scintigraphy lacked specificity for progressive necrotizing external otitis. These findings are in disagreement with those reported in the literature. CONCLUSION: Patient characteristics and clinical course are key elements for early diagnosis of this disease. Scintigraphy findings are contributive only when bone lysis (which occurs late) can be evidenced. A prospective study would be required to confirm the lack of specificity of scintigraphy in progressive necrotizing external otitis.