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.

Use of a navigation system in endonasal surgery: Impact on surgical strategy and surgeon satisfaction. A prospective multicenter study.

OBJECTIVES: Surgical navigation systems (SNS) are now widely used in endoscopic endonasal surgery. Benefit, however, has not been fully studied. The objective of this study was to evaluate the impact of an SNS in terms of performance of the surgical procedure and of surgeon satisfaction, in a prospective multicenter study. MATERIALS AND METHODS: A multicenter prospective study included patients undergoing endoscopic endonasal surgery using the electromagnetic DigiPointeur® (DGP) SNS in 16 French hospitals. An observation form, completed by the surgeon immediately at end of procedure, included type of procedure, and any changes in strategy or extent of surgery related to use of the SNS. Surgeon satisfaction was rated on an analog scale, with self-assessment of stress experienced during the procedure. RESULTS: The study included 311 patients operated on by 36 surgeons in 16 French hospitals. Ethmoidectomy was the most frequent procedure (90%); tumor resection was performed in 5.1% of cases. The SNS enabled more extensive surgery in 81% of cases, in particular by identifying and opening additional cells (57% of cases). Mean satisfaction was 8.6/10; surgeons reported decreased surgical stress thanks to the SNS in 95% of cases. CONCLUSION: In this observational study, the use of an SNS increased the extent of surgery in 81% of cases, and had a positive impact on the stress perceived by the surgeon in 95% of cases.

Assessment and management of cervico-mediastinal goiter.

Cervico-mediastinal goiter is a particular entity from the point of view of thyroid surgery. Its volume, hardness and intrathoracic extension require the surgeon to adapt technique and perform a painstaking preoperative work-up, so as to draw up fully-fledged plan. CT is now indispensable, to anticipate risks and determine whether sternotomy is needed. Surgery seems to induce more postoperative complications than in conventional surgery, although they can be reduced by retrograde dissection of the inferior laryngeal nerve and downward dissection of the posterior side of the lobe to optimize control of adjacent structures. This surgery requires optimal teamwork between all of the specialties involved in patient management: medical, radiological, anesthesiological and surgical.

[Adult orbital tumors]. / Tumeurs de l'orbite de l'adulte.

Orbital tumors are a rather frequent pathology. Their diagnosis and treatment may be difficult. They can be benign or malignant. All the tissues of the orbit can give rise to a tumor, resulting in their large number. Among the benign tumors, we have meningiomas and cavernous hemangiomas, and for the malignant tumors, lymphomas, metastasis, ENT tumors and lacrimal gland tumors in the adult. Usually the signs are nonspecific, with proptosis, oculomotor disturbance, inflammatory signs, pain and sometimes a mass. Imaging (CT, MRI and color Doppler ultrasound) shows the tumor, its location, extent and possible metastases. Biopsy and anatomic and cytopathologic examination confirm the type of benign or malignant tumor. Based on these three elements: clinical appearance, imaging and histology, the tumor will be treated, usually by a surgical approach according to the recommendations of a multidisciplinary tumor conference. Radiation therapy and chemotherapy may supplement the treatment.

[Postoperative radiotherapy in N0 laryngeal cancer]. / Radiothérapie postopératoire des cancers laryngés classés N0.

PURPOSE: A retrospective study to re-assess the indications for postoperative radiation therapy in squamous cell carcinoma of the larynx staged N0 after gross resection. PATIENTS AND METHODS: Between January 1975 and December 2000, 166 patients with squamous cell carcinoma of the larynx were treated by total laryngectomy with or without neck dissection. Surgery was completed by external radiotherapy delivering 45 to 65 Gy to the tumour bed and 45 to 50 Gy to cervical lymphatic chains. Minimal follow-up was 36 months and median follow-up was 98 months. RESULTS: The rate of nodal recurrence was 6% (median time for relapse was 9 months). The survival rates at 1, 2, 3 and 5 years were 93.5, 84, 80 and 69% respectively, with a 8 year 3 month median survival. The univariate analysis showed 4 parameters, which significantly increased the risk of local recurrence: the medical necessity for immediate tracheotomy, the subglottic involvement, the involvement of the whole larynx and the presence of lymphatic embols in the neck dissection. There was no statistically significant difference between the patients with or without a neck dissection. Fifty-nine secondary cancers were observed, 15 of them occurring in the head and neck area. The late complications consisted of cervical subcutaneous fibrosis (7%), oesophageal stricture (4%), oeso-tracheal fistula (l%), hypothyroidism (3%), bone necrosis (1%). CONCLUSION: Prophylactic cervical radiotherapy in laryngeal cancers resulted in 6% cervical node recurrence rate. This value may represent the maximal rate to accept if one would favour new therapeutic strategies based on restricted indications for radiotherapy.

[Treatment of voice prosthesis leakage. Preliminary results]. / Traitement des fuites sur prothèse phonatoire. Résultats préliminaires.

UNLABELLED: Numerous voice prostheses have been developed since the early eighties. The device, located in the tracheo-esophageal wall, can generate local complications. The most frequent and the hardest to treat is peri-prosthetic salivary leakage. OBJECTIVE: To present a new management scheme for peri-prosthetic salivary leakage by BIOPLASTIQUE injection. PATIENTS AND METHOD: Five patients, with residual peri-prosthetic salivary leakage after different treatments were managed by peri-prosthetic injection of BIOPLASTIQUE, a medical silicone elastomere. The injection was performed under general anesthesia in four points around the prosthesis: above, below, left and right. RESULTS: Leakage disappeared after one or two injections in all patients. No technical problem was encountered. CONCLUSION: Although this method still has to pass the test of time, our preliminary results are encouraging. Such a procedure could be performed under local anesthesia in order to minimize its cost.

French Society of ENT (SFORL) guidelines for care pathway organization in head and neck oncology (short version). Early management of head and neck cancer.

Early management in oncology is based on coordination and high-quality exchange between the various health-care partners. The present guidelines are based on a literature search with levels of evidence. Treatment waiting time can be optimized by performing assessment as early as possible (Expert opinion), to limit the interval (ideally, less than 4 weeks) between first consultation and data collection. In the first specialist consultation, diagnostic work-up should be scheduled and the data required for management should be determined (Grade B). Work-up may be conducted on a day-care basis or with conventional admission (Expert opinion). The patient's medico-social context should be taken into account from the outset, with social work involvement whenever necessary (Expert opinion). Pain and nutritional management should be planned for (Grade A) and realistic therapeutic education be provided (Expert opinion). Community-hospital teamwork for supportive care should be optimized (Expert opinion). Management should be early and multidisciplinary, to shorten delay between diagnosis and treatment initiation.

Guidelines (short version) of the French Otorhinolaryngology - Head and Neck Surgery Society (SFORL) on patient pathway organization in ENT: The therapeutic decision-making process.

OBJECTIVES: The authors present the guidelines of the French Otorhinolaryngology - Head and Neck Surgery Society (SFORL) for patient pathway organization in head and neck cancer, and in particular for multidisciplinary team meetings. The present article concerns the therapeutic decision-making process. METHODS: A multidisciplinary work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group. The final version was established in a coordination meeting. The guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence. RESULTS: It is recommended that: an organ specialist should contribute to all multidisciplinary meetings on head and neck cancer; all members of the multidisciplinary meeting should have specific knowledge in head and neck cancer; any referring physician who does not follow the multidisciplinary meeting's advice should justify that decision; there should be sufficient time to prepare, discuss and sum up the cases dealt with in the multidisciplinary team meeting.

Early death during initial chemotherapy of squamous cell carcinoma of the oro- or hypopharynx.

Neoadjuvant chemotherapy produces high response rates in squamous cell carcinoma of the head and neck without increasing the survival time. Furthermore authors have observed a death rate of about 5% (up to 10%) during chemotherapy. A series of patients with an oro- or hypo-pharynx cancer, were retrospectively divided into two groups on the basis of a short (< or = 2 months) or long (> or = 2 years) survival time. Clinical, tumoral and usual biological data from either group were compared. By univariate analysis, obesity index, hemoglobin, albumin concentrations and mononuclear cell counts were lower in patients with a short survival time compared with those in the other group. On the contrary, polymorphonuclear cell and platelet counts were higher. Infection appeared to be more frequent for patients with a poor prognosis without being entirely responsible for early death. By multivariate analysis, obesity index and platelet count were both independent variables associated with prognosis. These results call for further investigation of cardiac function, inflammatory, nutritional and immunological status of patients with squamous cell carcinoma of the head and neck who were given initial chemotherapy, particularly Cisplatin and Fluorouracil.

Prognostic significance of routine clinical and laboratory data in advanced head and neck cancers.

Predictive factors for toxicity and response to chemotherapy in patients with advanced head and neck cancer are seldom reported. Therefore, from a short series of patients with a histologically proven cancer, who were treated by a neo-adjuvant protocol with cisplatin and fluorouracil, routine clinical and laboratory data were investigated. ALT (alanine aminotransferase) and Hb (hemoglobin) appeared to be predictive for efficacy. By multivariate analysis (principal component analysis), these laboratory data were involved in two independent axes: one which was considered as "inflammatory" and the other as "hepatic". Initial obesity indices were associated with the former. The predictive variables for toxicity (i.e. age, serum creatinine level, weight loss and plasma cisplatin) were probably biased in this series. Nevertheless cisplatin concentration regularly increased in each cycle. Hence it was dependent on the rank of the course. According to this preliminary study, it would be of interest to conduct future investigations on acquired protein-energy malnutrition, as well as on selected soluble mediators of cellular and humoral immune response.

[Acute Mastoiditis in Children: a series of 38 Cases]. / Les mastoïdites aiguës de l'enfant.

OBJECTIVE: We reviewed retrospectively the clinical, radiological and therapeutic findings in 38 infants and children with acute mastoiditis. MATERIAL AND METHODS: From 1988 to 2001, 38 children (mean age 36 months) were treated for acute mastoiditis and periostitis or retroauricular abscess. RESULTS: Diagnosis was usually made on the basis of typical retroauricular signs (60% of the cases), but was sometimes delayed owing to inappropriate antibiotics in 16 cases (42%) or atypical presentation in 3 (8%). Twenty-four children (70%) had no otolaryngological history. Pneumococci were isolated in most of the cases (n=15, 57%) with 13% having penicillin-resistant pneumococci. Lateral sinus thrombophlebitis was the most frequent complication, observed in 3 children (8%). Mastoiditis revealed congenital or acquired cholesteatoma in 4 children, who were all four infected with Gram-negative bacteria. Intravenous antibiotic therapy was associated with antroatticotomy in 36 children. CONCLUSION: Despite emergence of new antibiotic resistance, the annual rate of mastoiditis has remained unchanged, remaining a serious complication of middle ear acute otitis. Cholesteatoma should be suspected in case of Gram-negative bacteria or in older children.

[Lips reanimation with temporalis myoplasty technique]. / Réanimation labiale par myoplastie du muscle temporal.

PURPOSE OF THE STUDY: The authors report their experience in lips reanimation with lengthening temporalis myoplasty for treatment of facial paralysis. MATERIALS AND METHODS: We studied 8 patients with permanent facial paralysis. The surgical technique allowed to transfer temporalis tendinous of coronoid process onto lips muscular strap, without aponevrotic relay. RESULTS: Functional and aesthetic results are exposed and so complications. Specialized facial physiotherapy rehabilitation is necessary in order to improve.

[Ethmoid adenocarcinoma: a series of 17 cases]. / Adénocarcinomes de l'ethmoïde. Notre expérience à propos d'une série de 17 cas.

INTRODUCTION: Ethmoid adenocarcinoma are and represent rare, 2.5 to 3% of head and neck cancers. The 5-year survival is around 50% for all stages. We present a series of 17 patients treated in our institution. OBJECTIVES: Expose the treatment of these patients and evaluate the results. METHODS: A retrospective study of 17 consecutive patients, treated between 1992 and 1999 for an ethmoid adenocarcinoma (15 T4 and 2 T2) and evaluated in 2002, with a mean follow-up of 5.8 years. RESULTS: In May 2002, 4 (23.53%) patients were alive and disease-free, 3 (17.65%) were alive with recurrence and 10 (58.82%) was died. The 5-year survival with Kaplan Meyer method is 41%. CONCLUSION: This series demonstrates the contribution of a combined approach for T3 and T4 tumors. The bifrontal approach induced an important morbidity in our series and should be replaced by the nasofrontal approach. Most teams agree that postoperative radiotherapy is necessary but the appropriateness of chemotherapy is still discussed. Some authors are of the opinion that it has no action on adenocarcinoma and others that it improves survival. It seems to have been efficient in our T4 patients.

[Role of super selective arteriography with embolization in the treatment of severe epistaxis: our experience apropos of 16 cases]. / Place de l'artériographie super sélective avec embolisation dans le traitement des épistaxis graves: notre expérience à propos de 16 cas.

Diagnostic angiography and super selective embolization of the internal maxillary artery were performed on 16 cases between 1990 and 1995. The patients (mean age, 49 years) were treated for severe posterior epistaxis, refractory to local haemostatic therapy (nasal packing alone for the most of them), hypertension was found to be the most frequent predisposing factor, 13 patients had their nose bleeding stopped. Among the 3 failures, were 2 cases of Osler-Weber-Rendu disease, which were subsequently significatively improved by this method. We conclude that angiography with super selective embolization is considered as a valuable diagnostic and therapeutic option in the management of patients with severe epistaxis.

[Our experience on Rendu-Osler disease. Apropos of 19 cases]. / Notre expérience de la maladie de Rendu-Osler. A propos de 19 cas.

We report a synthesis of our experience about the Osler-Weber-Rendu disease, based on a retrospective study of 19 cases collected from 1978 to 1995. Except the almost systematic recourse to anterior or posterior packings in 31% of cases, management of epistaxis in urgency has consisted of arteriography with embolization of the maxillary arteries. In this way, in two third of cases, the control of the epistaxis was obtained. In the other third, it was necessary to associate arteriography to a ligature of the ethmoidal arteries. As part of a preventive treatment of epistaxis we prefer, presently, to inject in situ a fibrin glue, which can be reviewed at the demand. These injections bring only exceptionally complications. The quality and duration of remission is judged satisfactory by the patients in 80% of the cases. Although no physio-pathological explanation can be brought, the intramuscular injections of fibrin glue could increase the duration of remission, which in this way, could diminish the frequency of injections in situ.

[Acoustic comparison of esophageal versus tracheoesophageal speech]. / Comparaison acoustique entre voix oesophagienne et voix trachéo-oesophagienne.

The authors present results of an acoustic criterions analysis made next to 57 subjects, who had undergone total laryngectomy or total pharyngolaryngectomy, between 6 months and 3 years before. The study allows to assess, next to 29 tracheoesophageal voices and 30 oesophageal voices, the fundamental frequency, the vocal extensive, the maximum phonation time, and the study of pauses (number and time) in a reference sentence. The acoustic advantages of phonatory prothesis are confirmed, but the oesophageal voice knowledge must not be forgotten.