Comparison of radial forearm flap and thoracodorsal artery perforator flap donor site morbidity for reconstruction of oral and oropharyngeal defects in head and neck cancer.

INTRODUCTION: Reconstruction of the oral cavity and oropharynx after tumour resection often involves the use of free flaps, but donor site morbidity must be taken into account. The radial forearm flap, the flap most commonly used in this setting, leaves a readily visible scar on an exposed region of the body. The thoracodorsal artery perforator flap (TDAP), which possesses the same plastic qualities as the radial forearm flap, leaves a scar that is hidden in the axilla. The purpose of this study was to evaluate the cosmetic results of radial forearm and thoracodorsal artery perforator free flap donor sites. MATERIAL AND METHODS: The medical charts of all patients undergoing reconstruction by a radial forearm or thoracodorsal artery perforator free flap between January 2011 and December 2011 were retrospectively reviewed. The Patient and Observer Scar Assessment Scales and the Vancouver Scar Scale were used to evaluate the quality of the scars. RESULTS: Reconstruction was performed by radial forearm flap in 4 cases and TDAP flap in 7 cases. The PSAS score was significantly lower in the TDAP group than in the radial forearm group (P=0.03), and the OSAS score was higher in the radial forearm group (21.5 versus 14). The Vancouver Scar Scale was significantly higher for radial forearm flap scars than for TDAP scars (8 versus 2.7, P=0.005). CONCLUSION: This is the first study to compare radial forearm and thoracodorsal artery perforator free flap donor site scars. It demonstrates the minimal TDAP donor site morbidity and the high level of patient satisfaction.

Craniofacial fibrous dysplasia surgery: a functional approach.

BACKGROUND: Craniofacial fibrous dysplasia has not only esthetic but functional impact. Surgery is controversial, ranging from conservative to radical. It involves elevated hemorrhage risk, and should be progressive, based on an individual risk/benefit analysis with the aim of improving quality of life. CASE REPORTS: Three patients (one male, two female; mean age, 35 years) with evolutive orbital-temporal maxillary dysplasia were treated between 2008 and 2009 in our department. All showed exophthalmia and nasal obstruction. In one patient, symptomatology was aggravated by a frontal sinus cyst within the dysplasia. Another had associated auditory canal obstruction inducing recurrent external otitis. Optic nerve decompression was achieved on a combined coronal and endonasal approach, assisted by neuronavigation. Complementary remodelling resection, dacryocystorhinostomy and internal optic nerve decompression were performed. Functional results showed 70 % improvement on a subjective scale for eye tension and nasal obstruction. Surgery was feasible in all patients, with no complications. CONCLUSION: Current surgical management allies esthetic and functional concerns. Remodeling resection is the reference technique. The coronal approach is a good primary option for optic nerve decompression. Endonasal surgery with neuronavigation improves nasal ventilation and lacrimal canal permeability.

Botulinum toxin in the treatment of post-radiosurgical neck contracture in head and neck cancer: a novel approach.

UNLABELLED: Neck pain affects a third of patients following head-and-neck cancer treatment, whether by radiation therapy or surgery. It is a disabling condition and the associated muscle contractures impair cervical motion. Type-A botulinum toxin is an analgesic and muscle relaxant, able to improve patients' quality of life. We here report our experience with botulinum toxin in post-radiosurgical neck contracture. PATIENTS AND METHODS: A single-center pilot study was run from January 2007 to July 2008, respecting the Declaration of Helsinki. All patients in complete remission from head-and-neck cancer with post-radiosurgical neck contracture impairing neck motion were included. Pain and functional impairment were assessed on a neck-function disability scale before and 1 month after botulinum toxin injection. Efficacy duration was measured. Complications at the injection site or related to drug diffusion were investigated. RESULTS: Nine consecutive patients (six male, three female; mean age, 61 years [range, 52-73 years]) were included. In six patients, the sternocleidomastoid muscle was injected and the muscular pedicle of a pectoralis major flap in three. Mean cervical disability score fell significantly from 33 to 23 (P=0.01). There were no complications. Efficacy was seen at a mean 6 days, and analgesia and muscle relaxation lasted for a mean 19 days. CONCLUSION: In post-radiosurgical neck contracture, botulinum toxin injection is a simple and easy procedure able to improve neck motion and reduce neck pain in head-and-neck cancer patients. A phase-II prospective study to determine injection sites and dosage should help bear out these preliminary findings.

[Surgical treatment of severe sleep apnea syndrome by maxillomandibular advancing or mental tranposition]. / Traitement chirurgical du syndrome d'apnées du sommeil sévère par avancée maxillo-mandibulaire ou par transposition génienne.

Surgery of the facial skeleton or the tongue may be envisaged in case of failure of continuous positive pressure ventilation for severe sleep apnea syndrome defined by a apnea-hyponea index greater than 30/h. We present here our results in patients treated by maxillo-mandibular advancing and mental transposition. We define the surgical indications. Between January 1993 and June 1997, 41 patients, mean age 49 years, with severe sleep apnea syndrome (mean apnea-hyponea index =58.5/h) were treated by maxillo-mandibular advancing (21 cases) or mental transposition (20 cases) depending on the cephalometric work-up including lateral teleradiography and sagittal magnetic resonance imaging of the tongue. Functional outcome was good in both groups. Objective success (postoperative apnea-hyponea index <20) was 70.5 % after bimaxillary advancing (mean apnea-hypopnea index =17), but only 25 % after mental transposition (mean apnea-hyponea index =44.5). Maxillomandibular advancing is a major procedure which can be effective in sleep apnea patients with severe craniofacial skeletal anomalies. Its applications in apneic patients with no skeletal anomaly remains a subject of debate. Conversely, there would appear to be very few indications for mental transposition.

[Tongue base reduction with hyoid-epiglottoplasty. A surgical alternative in severe sleep apnea syndromes]. / Basiglossectomie avec hyo-épiglottoplastie. Une alternative chirurgicale pour les syndromes d'apnées du sommeil sévères.

We present preliminary results and indications of tongue base reduction with hyo-epiglottoplasty for the treatment of severe obstructive sleep apnea syndrome (OSAS) due to isolated hyolingual abnormalities. The procedure consists in a subtotal resection of the tongue base after identification and derouting of the lingual neurovascular bundle. Hypopharyngeal enlargement, epiglottis verticalization, floor of the mouth tension and hyoid bone repositioning are also performed during the procedure. 14 severe OSAS male patients (mean apnea-hypopnea index of 71) were treated in our institution from November 1992 to February 1996. Indications were determined after a cephalometric analysis and a magnetic resonance imaging evaluation. Results were evaluated on clinical and polysomnographic criteria. No neurovascular complications occurred. Clinical results were excellent but success rate based on polysomnography was 50%. These preliminary results led us to change some of the steps in the technique. We also identified a predictive factor of success on the cephalometrics: an oropharyngeal area greater than 25 cm2.

[A new technique of gene transposition in the surgical treatment of sleep apnea syndrome]. / Nouvelle technique de transposition génienne dans le traitement chirurgical du syndrome d'apnée du sommeil.

Pharyngotomy appears to be insufficient for the treatment of severe sleep apnea. For patients who refuse or abandon mechanical ventilatory assistance, surgery can be used to widen the retrobasilingual space adapting it to the cephalometric profile defined by cineradiography and MRI in combination with velopharyngeal plasty. For patients with no maxillomandibular or lingual malformation, the pharyngotomy can be combined with an anterior transposition of the genial insertions of the tongue without rotation. A method different from that described by Riley and Powel is proposed. The details of the surgical procedure are exposed. The operation is indicated in snorers with sleep apnoea with an Apnea Index Superior to 30 who refuse nocturnal ventilatory assistance and who do not have a hypertrophied tongue (Surface less than 30 cm2) or maxillomandibular retroposition.

[Attic emptying in cholesteatoma and precholesteatoma states. Technique, indications and results]. / L'évidement attical dans les états cholestéatomateux et précholestéatomateux. Technique, indications, résultats.

A surgical procedure different from the open or closed technique is presented. The attic is emptied through the meatus after a retromeatal access to the antromastoidal cavities. By blocking the aditus ad antrum, the procedure produces an antrio-attic microcavity with no recessus. Results of resection of epidermal lesions are quite satisfactory with a low rate of residual pathology. Retraction pouches do not develop because the mastoid is excluded and no attic recessus is formed. Surveillance of the cavity is easy and the disadvantages of functional sequellae inherent in open techniques are avoided. The preliminary results would confirmed the quality of the procedure. In 22 cases, there were 3 residual perles on the windows and 2 retraction pouches (anterior and posterosuperior). This technique is indicated in precholesteatoma states with poor prognosis and cholesteatomas of the attic. For more advanced lesions, this technique is less reliable and the open procedure is required.

[Treatment of velopharyngeal stenosis after pharyngotomy for chronic snoring. Apropos of 13 cases]. / Traitement des sténoses vélopharyngées après pharyngotomie pour rhonchopathie chronique. A propos de 13 cas.

Velopharyngeal stenosis is a rare complication of pharyngotomy (UPPP) for chronic snoring. Its treatment is hard because of its recidivant feature. The aim of this study was to determine a therapeutic strategy accorded to each stenosis from clinical and anatomical features of 13 velopharyngeal stenosis. Therapeutic behavior was function of patients complains, of the ground (associated chronic rhinosinusitis and obstructive sleep apnea) and clinical findings (partial or total stenosis, tonsil remainders, short or long residual soft palate). From these data, treatment was medical (1 case) or surgical (12 cases), searching lateral velopharyngeal mucosa recovery in order to avoid recidive of stenosis. This aim needed locoregional mucosal grafts in 4 patients with short soft palate. Patients complains were improved in all cases and there was no patient with recurrence of stenosis. The best treatment of velopharyngeal stenosis still remains a preventive one, by respecting a severe surgical technique during pharyngotomy for chronic snoring.

[Analysis of results of pharyngotomy in the surgical treatment of sleep apnea syndrome. Apropos of 150 cases]. / Analyse des résultats de la pharyngotomie dans le traitement chirurgical du syndrome d'apnée du sommeil. A propos de 150 cas.

The indications and limitations of simple veloamygdalotomy as surgical cure for sleep apnoea were analyzed on the basis of results obtained in the first 150 cases treated prospectively by pharyngotomy. Clinical and polysomnographic results were analyzed as possible factors predicting success or failure. With a success rate of 80%, pharyngotomy is a simple and effective treatment for patients with minor forms of sleep apnoea (initial apnoea/hypopnoea index < 20) and no severe obesity. It appears unreasonable to propose isolated pharyngotomy if the initial index is < 30 since the success rate in the cases is only 27%. Nasal repermeation does not improve overall results significantly. The lack of patient compliance to diagnostic and therapeutic modalities is an unavoidable reality due to human, social and economic implications.

[Primary non-Hodgkin lymphoma of the nasal fossae and sinuses. Apropos of 8 cases]. / Les lymphomes non hodgkiniens primitifs des fosses nasales et des sinus. A propos de 8 cas.

The authors report their experience about 8 cases of nasal lymphomas diagnosed and treated between 1987 and 1993. Behind ordinary symptoms, a very bad forecast lymphoma may be hidden. Histological diagnosis is sometimes difficult and needs voluminous fresh fragments. During the evolution of this affection, local temporary nasal and paranasal remissions are often noted after chimiotherapy and/or radiotherapy, but rapidly appear visceras secondary localisations, suggesting an underestimation of the nasal and paranasal sinuses localisations among the treated non-Hodgkin's lymphomas population.

[Ambulatory laser and turbinectomy in the treatment of nasal obstruction. Apropos of 68 cases]. / Analyse du laser ambulatoire et de la turbinectomie dans le traitement de l'obstruction nasale. A propos de 68 cas.

The purpose of this prospective study was to compare subjectively and objectively the efficiency of laser vaporisation against surgical procedure in treatment of nasal obstruction related to vasomotor rhinitis. 40 inferior nasal turbinates laser vaporisations were compared to 28 surgical inferior turbinectomies. This trial was based on rhinomanometric data before and after laser or surgical management and on appreciation of individual nasal comfort. The results obtained with conventional surgery were slightly better than laser vaporisation; however this new procedure succeed in 75% of cases with a mean of one year follow-up. The rhinomanometric++ findings appeared especially contributing when significant disorders exist before treatment.

[Parotid metastases: value of imaging. Review of the literature, apropos of 4 cases]. / Métastases parotidiennes: intérêt de l'imagerie. Revue de la littérature, a propos de 4 cas.

Parotid gland is a very unusual site of metastasis. Four proven cases are described. The tumor was occult in three cases out of four. In one case, an extra neck primitive tumor was suspected. Two kinds of metastases are described: firstly, metastases within the salivary gland with look like pleomorphic adenoma and are secondary to hematogenous spread; secondly, lymph node metastasis (two cases). Their diagnosis appear easier as they are not usually completely surrounded by parenchyma. They can reveal either occult head and neck tumor or visceral tumor.

[Physiopathologic value of cephalometric teleradiography study and magnetic resonance imaging in sleep apnea syndromes. Therapeutic deductions]. / Intérêt physio-pathologique d'une étude céphalométrique par téléradiographie et IRM dans le syndrome d'apnée du sommeil. Déductions thérapeutiques.

A cephalometric study was carried out on 98 patients assigned to 3 groups including 48 patients with sleep apnea, 25 patients with chronic rhonchopathy without apnea, and 25 controls, respectively. 44 patients benefited from lateral teleroentgenographic investigations and 54 had sagittal-median NMR sections visualized. Various distance, angle and area measurements were obtained. The authors found that anomalies were the more severe that snoring was associated with sleep apnea. These arguments speak for an evolutional character of the disease. The various cephalometric anomalies were primarily related to the hyoglossal apparatus, more rarely to the maxillary-mandibular basal bones. After this analysis, the authors propose a therapeutic strategy for the management of chronic snoring associated with sleep apnea.

[Measurement of pH of the rhinopharynx in children with gastroesophageal reflux]. / Mesure du pH du rhinopharynx chez l'enfant atteint de reflux gastro-oesophagien.

The relationship between gastro-oesophageal reflux and inflammatory airway pathology is well known as regards the trachea and bronchi. It is disputed by some authors but clearly established by others as regards the pharynx and larynx (recurrent laryngitis, subglottic stenosis, laryngospasm). A number of authors have empirically observed that gastro-oesophageal reflux is associated in some cases with chronic inflammation of the rhinopharynx and middle ear. We studied the 24-hour pH of the rhinopharyngeal mucosa in 3 groups of children: 3 healthy children acting as controls, 1 child with known gastro-oesophageal reflux but without rhinopharyngeal pathology, and 2 children with both gastro-oesophageal reflux and mucosal obstruction of the nose and pharynx unascribable to the usual causes. Minimal to considerable variations of rhinopharyngeal pH were observed in children of the third group, while controls had a remarkably stable 24-hour pH (6.7 to 7.4 depending on the subject). Owing to the small number of cases studied, these results should be regarded as preliminary and devoid of significant value concerning the real impact of the acid reflux on rhinopharyngeal pathology.

[An approach to tumors of the face by degloving. An elegant treatment of inverted papillomas and various sinus cancers. Values. Limitations and extension]. / Abord des tumeurs de la face par "degloving". Une solution élégante au traitement des papillomes inverses et de certains cancers des sinus. Intérêts. Limites et extension.

Degloving constitutes a hidden route of access to the middle third of the face. It combines a bilateral sublabial incision with a rhinoplastic approach, whereby all the soft tissues of the face can be undermined subperiosteally, leaving no external scar. This method offers an extended bilateral route of access to lesions of the nasal cavities and ethmoid/sphenoid/maxillary sinuses, deep to the clivus. Its exposing features at least compare with conventional technics, including bone resection or the creation of a valve. This procedure may be associated with other neurosurgical approaches in the treatment of extended lesions of the basis of the skull. Its use is particularly recommended in the treatment of inverted papillomas, although it applies as well to malignant tumors of the sinuses under certain conditions. We present here a review of our experience.

[Mastoidectomy and seromucous otitis]. / Mastoïdectomie et otite séro-muqueuse.

Twenty-nine children presenting with chronically recurring serous otitis media, or with serous otitis media complicated by retracted eardrum, underwent either unilateral or bilateral mastoidectomy. For 23 of the children (26 surgical cases) whose follow-up extended over a sufficiently long period of time, results were assessed by otoscopic eardrum inspection, audiometry, and tympanometry. Long-standing recovery of serous otitis media, accompanied by a return to normal of the tympanic membrane, the tympanometric and audiometric parameters, was achieved in 2/3 of cases. These data compare well with results obtained by other authors, and they are telling as regards the efficacy of mastoidectomy for stabilizing the inflammatory process and restoring normal tubal function, in some cases of chronic serous otitis media.

[Submucosal resection of the inferior nasal turbinates]. / La résection sous-muqueuse des cornets inférieurs.

Nasal obstruction is frequently related to hypertrophy of the bony inferior nasal conchae. Medical management and/or isolated correction of deviation of the nasal septum are often inadequate. Surgical management, although it has raised controversy, becomes the only therapeutical course. Submucosal resection of the conchae was performed in 104 patients between 1986 and 1988. Subjective analysis of postoperative data shows 82% of successful surgery cases yielding good nasal repermeabilization with some minor unpleasant effects, such as nasal crusts or discharge in 46% of cases. The authors describe the surgical technique as well as its indications, and its advantages as compared to medical treatment, cauterization or subtotal resection of the conchae in incapacitating nasal obstruction cases.

[Current role of total esopharyngo-laryngectomy in cervico-facial cancerology. Apropos of 11 cases]. / Place actuelle de l'oesopharyngo-laryngectomie totale en cancérologie cervico-faciale. A propos de 11 cas.

Eleven patients underwent total esophagopharyngolaryngectomy for cancer, with colic or gastric digestive reconstructive surgery. Postoperative course is analyzed, contraindications and indications outlined and other methods of pharyngeal reconstruction discussed. An extension to the technique is proposed to include tumors requiring a circular pharyngolaryngectomy. Improvement in the very poor prognosis of these tumors can only be envisaged by the use of enlarged surgery combined with chemotherapy and radiotherapy.