[Montgomery thyroplasty implant under local anesthesia for unilateral laryngeal paralysis]. / Thyroplastie avec implant de Montgomery sous anesthésie locale dans les paralysies laryngées unilatérales.

OBJECTIVES: Based on an inception cohort of 63 patients with unilateral vocal fold paralysis consecutively treated with thyroplasty and Montgomery's implant under local anesthesia during the years 1997-2002, we recorded i) morbidity and mortality, ii) evolution of dysphonia and swallowing impairment and iii) a prospective analysis of selected speech and voice parameters in an attempt to determine their evolution during the first 12 postoperative months and to search for potential statistical relationships with the following variables (age, gender, side of the paralysis, etiology of the paralysis, time between onset of paralysis and thyroplasty, position of the paralyzed true vocal fold, nerve involved, associated pneumonectomy, prior intracordal injection of autologous fat and surgeon). RESULTS: The overall complication rate was 8%. Minor complications occurred in 6.5% of the patients and included 4 cases of laryngeal edema successfully treated with oral steroids. Major complications occurred in 1.5% of the patients. Intralaryngeal hematoma requiring temporary tracheotomy was the major complication. Swallowing was improved in 93.5% of the patients. Immediate improvement of speech and voice was noted in all. Secondary degradation of speech and voice occurred in one patient. At revision thyroplasty lateral displacement of the implant was noted and successfully repositioned. At one month post-operatively, the values of maximum phonation time, speech rate, group phrasing standard deviation of the fundamental frequency, jitter and shimmer were statistically improved while the fundamental frequency did not vary significantly. At 12 months post-operatively the noise to harmonic ratio was improved while the other parameters remained stable. No significant statistical relationship was found between the post-operative speech and voice parameters and the variables under analysis. CONCLUSION: Based on the current series and a review of the medical literature, thyroplasty with Montgomery's implant under local anesthesia appears to be an easy, effective and safe procedure that might be used in all patients with unilateral laryngeal nerve paralysis.

[Cancer of the ethmoid sinus]. / Cancer de l'ethmoïde.

Ethmoid sinuses are located at the level of the anterior skull base. Seventy to 80% of the ethmoid sinus malignant tumors are adenocarcinomas. Wood dust exposure is a carcinogen agent to ethmoid adenocarcinoma. More than 90% of patients with ethmoid adenocarcinoma are woodworkers. Craniofacial computed tomography scan and magnetic resonance imaging are always performed before treatment. It is always a multidisciplinary treatment including surgical resection followed by external radiation therapy. Some authors recommend a neoadjuvant chemotherapy. A total ethmoidectomy including the cribriform plate through a transcranial subfrontal approach is the best surgical technique. Local recurrence is the most frequent cause of failure; 5-year survival of patients with ethmoid adenocarcinoma is around 50%. A regular follow-up including clinical and radiological examination is always required.

[Replacement of tracheo-esophageal Provox prosthesis]. / Remplacement de l'implant phonatoire Provox: anesthésie locale ou anesthésie générale?

OBJECTIVES: To compare anesthesic techniques used between 1992 and 1997 at Laënnec Hospital for replacement by tracheo-esophageal Provox prosthesis: local and general anesthesia. Theoretical financial cost for replacement was estimated according to anaesthetic techniques. PATIENTS AND METHODS: Provox in situ lifetime was calculated in 58 patients who underwent 115 and 49 replacements under general and local anaesthesia respectively. Age, sex, surgical and radiotherapy backgrounds, complications and anaesthetic techniques were studied as potential factors correlated with Provox in situ lifetime. Theoretical financial cost for replacement was estimated according to anaesthetic techniques. RESULTS: In 1992, 12% of Provox prosthesis were inserted under local anaesthesia and 54% in 1997. Provox in situ lifetime was either not influenced by anaesthetic techniques or other factors under analysis. The theoretical financial cost was estimated at 14, 341 FFrs and 6,048 FFrs for replacement under general and local anaesthesia respectively. CONCLUSION: Due to increased control of health care costs, we advocated local anaesthesia for Provox prosthesis replacement if control endoscopy is not required.

Adductor spasmodic dysphonia: case reports with acoustic analysis following botulinum toxin injection and acupuncture.

We analyzed frequency and duration parameters of voice and speech in two men with adductor spasmodic dysphonia (SD). One was treated with botulinum toxin injection; the other received acupuncture therapy. Improvement after acupuncture therapy in terms of standard deviation of fundamental frequency, acoustic perturbation measurements, durational measurements of voice and speech, and spectrographic analysis was comparable to the results achieved with botulinum toxin injection. Voice and speech parameters were stable 1 year after acupuncture therapy.

Cisplatin-based neoadjuvant chemotherapy and combined resection for ethmoid sinus adenocarcinoma reaching and/or invading the skull base.

OBJECTIVE: To review our experience with cisplatin-based neoadjuvant chemotherapy before en bloc resection via a combined neurosurgical and transfacial approach for ethmoid sinus adenocarcinoma reaching and/or invading the skull base. DESIGN: Case series. SETTING: A tertiary care center and university teaching hospital. PATIENTS: Twenty-two patients with primary untreated ethmoid sinus adenocarcinoma reaching and/or invading the skull base consecutively treated between 1984 and 1992 with cisplatin-based neoadjuvant chemotherapy and combined neurosurgical and transfacial approach. MAIN OUTCOME MEASURES: Statistical analysis of survival, local control, nodal recurrence, distant metastasis, and metachronous second primary tumor incidence based on the Kaplan-Meier actuarial method. Univariate analysis was performed to analyze the relationships between various factors, survival, and local recurrence. Clinical response, histological response, toxic effects of chemotherapy, and postoperative course were also reported. RESULTS: The Kaplan-Meier 3-year survival, local control, nodal recurrence, and distant metastasis estimates were 68.1%, 65.7%, 5.3%, and 10%, respectively. Metachronous second primary tumor was not encountered in our series. Survival was statistically more likely to be reduced in patients with intrasphenoidal tumor extent (P = .04) and local recurrence (P = .01). Local recurrence was statistically more likely in patients with intrasphenoidal tumor extent (P = .002) and no response to cisplatin-based neoadjuvant chemotherapy (P = .03). CONCLUSIONS: The results achieved suggest that cisplatin-based neoadjuvant chemotherapy before combined neurosurgical and transfacial approach should be further investigated for the treatment of ethmoid sinus adenocarcinoma reaching and/or invading the skull base.

[Exclusive chemotherapy in T1-T3N0 cancers of the vocal cord with complete clinical response after neoadjuvant treatment with a cisplatin-fluorouracil combination]. / Chimiothérapie exclusive dans les cancers de la corde vocale T1-T3N0 en réponse clinique complète après traitement néo-adjuvant cisplatine-fluorouracile.

OBJECTIVES: Evaluation of cisplatin-fluorouracil exclusive chemotherapy for invasive squamous cell carcinoma of the glottis staged as T1-T3N0 with a complete response after cisplatin-fluorouracil neo-adjuvant chemotherapy. METHODS: A retrospective analysis of the files of 69 patients with a well-differentiated untreated invasive squamous cell carcinoma, staged as T1-T3N0 with a complete response after cisplatin-fluorouracil neo-adjuvant chemotherapy is presented. Actuarial analysis (Kaplan Meier method) of survival and local failure is presented among the group of 25 patients treated with exclusive chemotherapy and the group of 44 patients in whom the local treatment (partial laryngeal surgery or radiation therapy) initially planned was maintained. RESULTS: Three-year survival and local control estimate was 91.8% and 69.3%, respectively after exclusive chemotherapy and 92.5% and 97.2% if the local treatment was performed as initially planned. Patients with local recurrence after exclusive chemotherapy were always salvaged with partial laryngeal surgery or radiation therapy resulting in an overall 100% local control and laryngeal preservation rate. CONCLUSION: Exclusive chemotherapy for T1-T3N0 glottic carcinomas with a complete response after cisplatin-fluorouracil neo-adjuvant chemotherapy should be considered especially in patients in whom preservation of voice is of utmost importance.

A clinical trial of continuous cisplatin-fluorouracil induction chemotherapy and supracricoid partial laryngectomy for glottic carcinoma classified as T2.

BACKGROUND: Vertical partial laryngectomy (VPL) and radiation therapy (RT) are the recommended conventional conservative options for glottic carcinoma classified as T2. In series presenting more than 100 patients with a minimum 3-year follow-up, however, local recurrence rates were reported as 22-43.5%. The authors' experience with a new strategy based on continuous cisplatin-fluorouracil induction chemotherapy (IC) and supracricoid partial laryngectomy with cricohyoepiglottopexy (CHEP) is presented. METHODS: A retrospective analysis of 67 patients who presented with untreated moderately to well differentiated invasive glottic carcinoma classified as T2, managed from 1983 to 1991 with IC and CHEP, was conducted. Statistical analysis of survival, local control, nodal control, distant metastasis, and metachronous second primary tumor incidence was based on the Kaplan-Meier actuarial method. Univariate analysis was performed to analyze the relationships between various factors and survival, local recurrence, and nodal recurrence. Clinical response, histologic response, IC toxicity and postoperative course were reported. RESULTS: The Kaplan-Meier 5-year survival, local recurrence, nodal recurrence, distant metastasis, and metachronous second primary tumor estimate were 92.3%, 5.6%, 1.5%, 1.8%, and 5.6%, respectively. Overall laryngeal preservation was achieved in 65 patients (97%). Ultimate local control was achieved in all patients but one. Nodal recurrence was statistically more likely in patients presenting with a local recurrence. Analysis of the specimens demonstrated complete histologic response to IC in 25 (37.3%) patients. A strong statistical relation (P < 0.0001) was noted between complete clinical response after IC and complete histologic response. CONCLUSIONS: The change from the prevailing treatment modalities of RT and VPL to a new multimodal strategy (IC+CHEP) did not decrease survival and allowed for an increase in laryngeal preservation rate. The high rate (37.3%) of complete histologic response suggests that IC deserves further consideration in the management of patients with glottic carcinoma classified as T2. The favorable results achieved in this series, when compared with historic controls, should stimulate prospective clinical trials comparing the two surgical procedures (CHEP vs. VPL with or without IC) for resection of Stage II glottic carcinoma.

Ethmoid sinus carcinomas: results and prognosis after neoadjuvant chemotherapy and combined surgery--a 10-year experience.

From June 1982 to June 1992, 144 ethmoido-sphenoido-orbital tumors have been referred to the neurosurgical department of Ste Anne Hospital. One hundred five of them were malignant lesions, among which 83 were included into our therapeutic protocol (1) neo-adjuvant chemotherapy (CDDP + 5-FU), (2) combined surgical procedure (subfrontal and transfacial), (3) postoperative radiotherapy. Fifty nine percent of the patients had no response to chemotherapy; 19% had a partial response (reduction of the tumoral volume > 50% and < 100%), 22% had a complete response. One patient had an immediate and transient postoperative rhinorrhea responsible for meningitis (acinetobacter) that was cured after a 3-day treatment. Four patients had postoperative meningitis without any cerebrospinal fluid leakage; they were also cured. Five patients had a local suppuration that was treated by subcutaneous drainage (n = 1) or the removal of the cranial basis graft (n = 4). Oncologic results are presented for only adenocarcinomas (n = 63) because they represent the only population of this series large enough to assure significant statistical figures. The global actuarial survival rate was 53% at 3 years and 42.5% at 5 years. The 5-year actuarial survival rate was 80% for T1 tumors, 60% for T2, 40% for T3, and 25% for T4. Patients with an intracranial extension had a 3-year survival rate of 19%; none survived after 4-year follow-up. Neo-adjuvant chemotherapy seemed to influence the survival: 100% survival rate at 5 and 10 years for the complete responders. We discuss the opportunity of intraorbital exenteration, the indications, and the limits of combined surgery. We emphasize the importance of neo-adjuvant chemotherapy and of combined surgical procedures, even when the patients are complete responders to chemotherapy: complete responders who had only a transfacial approach have a 5-year actuarial survival rate of 80% (instead of 100% when a combined procedure was performed). Those who were not operated primarily recurred within 3 years and then had to be operated. We propose to follow such a combined surgery for all large ethmoidal cancers (T3 and T4) and for small tumors (T1 and T2) developed superiorly and posteriorly. Anterior T1 and T2 tumors should be operated through a single transfacial route.

[Cisplatin-fluorouracil chemotherapy in epidermoid cancers of glottic origin staged as T2]. / Chimiothérapie cisplatine-fluorouracile dans les cancers epidermoides à point de départ glottique classes T2.

A retrospective analysis of 94 patients presenting well-differentiated untreated invasive glottic squamous cell carcinomas, staged as T2 according to the 1987 Union Internationale contre le Cancer staging classification system, managed at our institution from March 1982 to April 1991 with cisplatin-fluorouracil neo-adjuvant chemotherapy, was conducted. Following neo-adjuvant chemotherapy, partial laryngeal surgery, and radiation therapy were performed in 85.1% (80/94) and 4.2% (3/94) of cases, respectively. Perioperative chemotherapy (fluorouracil) and postoperative chemotherapy (cisplatin-fluorouracil) was performed in 68.7% (55/80) and 63.7% (51/80) of patients who underwent surgery, respectively. Following neoadjuvant chemotherapy, one patient (1.1%) refused any form of treatment, and "exclusive" chemotherapy was performed in 9.6% (9/94) of cases. A 3-year follow-up was always achieved and 66 patients (70.2%) presented with a 5-year follow-up. A complete clinical response was achieved in 32.9% of cases following neo-adjuvant chemotherapy. A complete histological response was noted in 31.2% (25/80) of patients treated with partial laryngeal surgery following neo-adjuvant chemotherapy. A strong statistical relation was noted between complete clinical response and complete histological response (p < .0001). Chemotherapy related death never occurred in our series however chemotherapy related toxicity lead to reduction in the drug dosages and chemotherapy arrest in 14.3% and 3.6% of cases, respectively. The Kaplan-Meier 5-year survival, local recurrence, nodal recurrence, distant metastasis, and second primary estimate was 84.9%, 8.4%, 1.1%, 2.2%, and 10%, respectively. The overall local recurrence rate varied from 25% following neo-adjuvant chemotherapy and radiotherapy, to 33.3% following "exclusive" chemotherapy, and 3.7% following neo-adjuvant chemotherapy and partial laryngeal surgery. Overall local control and laryngeal preservation was achieved in 98.9% and 97.8% of patients respectively. Our data suggests that the use of neo-adjuvant cisplatin-fluorouracil induction chemotherapy deserves further consideration in the management of glottic carcinomas staged as T2.

[Combined approach to malignant tumors of the ethmoid and other paranasal sinuses. Principles and results]. / Les abords combinés des tumeurs malignes de l'ethmoïde et autres sinus paranasaux Principes et résultats.

The authors present their experience concerning combined transfacial and neurosurgical procedures in the treatment of carcinomas of the ethmoid sinuses. 109 ethmoid-spheno-orbital tumors were treated at our department from 1982 to 1990: 85 were located into the ethmoidal and/or sphenoidal sinuses; 78 of these were malignant. Among the 65 ethmoidal carcinomas which were operated through a combined route, 48 underwent an induction chemotherapy and 19 a post-operative radiotherapy. The surgical technique is detailed, mostly the intra-cranial approach and the reconstruction of the cranial basis. Clinical results, and particularly the actuarial survival rates are discussed. The 5-year actuarial survival rate is 40% for all first hand ethmoidal adenocarcinomas. The figure reaches 52% for the patients without intra-cranial extension. At last, the 5-year actuarial survival rate is 100% for patients having a complete clinical response to induction chemotherapy.

[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.