Vocal fold scars: current concepts and future directions. Consensus report of the Phonosurgery Committee of the European Laryngological Society.

Scarring of the vocal folds leads to a deterioration of the highly complex micro-structure with consecutively impaired vibratory pattern and glottic insufficiency. The resulting dysphonia is predominantly characterized by a reduced vocal capacity. Despite the considerable progress in understanding of the underlying pathophysiology, the treatment of scarred vocal folds is still an unresolved chapter in laryngology and phonosurgery. Essential for a successful treatment is an individual, multi-dimensional concept that comprises the whole armamentarium of surgical and non-surgical (i.p. voice therapy) modalities. An ideal approach would be to soften the scar, because the reduced pliability and consequently the increased vibratory rigidity impede the easiness of vibration. The chosen phonosurgical method is determined by the main clinical feature: Medialization techniques for the treatment of glottic gap, or epithelium freeing techniques for improvement of vibration characteristics often combined with injection augmentation or implantation. In severe cases, buccal mucosa grafting can be an option. New developments, include treatment with anxiolytic lasers, laser technology with ultrafine excision/ablation properties avoiding coagulation (Picosecond infrared laser, PIRL), or techniques of tissue engineering. However, despite the promising results by in vitro experiments, animal studies and first clinical trials, the step into clinical routine application has yet to be taken.

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.

Prognostic value of the status of resection margins after endoscopic laser cordectomy for T1a glottic carcinoma.

OBJECTIVES: The small size of endoscopic laser cordectomy (ELC) specimens frequently leads the histopathologist to assess excision margins as pathologic. The present study sought to assess the prognostic value of margin status in terms of overall and of recurrence-free survival in a population of T1a glottic carcinoma operated on by ELC. MATERIAL AND METHODS: Sixty-four records of T1a squamous-cell carcinoma treated between 1996 and 2006 were retrospectively analyzed. Overall and recurrence-free survival for the group with negative margins (group 1) and with positive margins (group 2) were analyzed following Kaplan-Meier. The influence of resection margin histologic status was assessed on Log Rank test. RESULTS: Six female and 58 male patients were included. Forty (62.5%) had negative margins (group 1) and 24 (37.5%) positive margins (group 2). Overall five-year survival was 97% (95% in group 1 and 100% in group 2). Five-year recurrence-free survival was 94% (91.7% in group 1 and 95% in group 2). There was no significant difference in overall or recurrence-free survival according to resection margin histologic status. CONCLUSIONS: The present results show that margins considered positive after laser resection do not significantly impact carcinologic course, while still requiring close surveillance. The most generally recommended attitude is control endoscopy with biopsy at 10 weeks.

A schwannoma of the hypoglossal nerve presenting as a malignant tumour of the oral floor.

OBJECTIVES: We describe a case of an unusual schwannoma of the hypoglossal nerve presenting clinically as a malignant tumour of the floor of the oral cavity. CASE REPORT: A 77-year-old woman presented with a bulky tumour located between the left anterior floor of mouth and the ventricular portion of the tongue. The tumour was ulcerated, painful and presented with a necrotic aspect. Neurological examination revealed a mild left hemiparesis of the tongue. MRI and CT showed a circumscribed tumour with a broad necrotic centre. The patient underwent a transoral excision of the tumour under general anaesthesia. CONCLUSION: Schwannomas are generally managed by complete surgical excision but they can mimic primary or metastatic cancer in the head and neck, preoperative diagnosis is therefore necessary to avoid a wide excision.

[Role of diffusion weighted MR in the diagnosis of parotid tumours]. / Apport des séquences d'IRM de diffusion au diagnostic des tumeurs parotidiennes.

OBJECTIVE: To evaluate the contribution of sequences of diffusion for the diagnosis of nature of the tumours of the parotid. METHODS: Retrospective study based on 29 patients all operated of a parotid tumour They had a MRI in conventional acquisition (T1, T1 Gadolinium, T2) and in sequences of diffusion. An ADC cartography (apparent coefficient of diffusion) and an ADC ratio between the tumoral area and the healthy controlateral parotid were successively analyzed by two experienced radiologists. We calculated the effectiveness of these MRI sequences, focusing more particularly on the diagnosis of the malignant tumours. We also determined the sensitivity and the specificity of the sequences of diffusion, with their positive and negative predictive values. RESULTS: On the 7 malignant tumours, 3 had been classified wrongly like benign thanks to the only cartography of diffusion. We obtained a sensitivity of this examination for the diagnosis of malignity of 57%. Out of the 22 benign tumours, 1 only was classified wrongly like malignant. The specificity of the diffusion for the diagnosis of malignity thus rose with 95%, its positive predictive value with 80% and its negative predictive value to 87%. It should be noted that all the malignant tumours had an ADC ratio lower or equal to 1.8. CONCLUSIONS: The histological characteristics of the malignant tumours of the parotid are very variable. Generally, they have large nuclei associated with a hypercellularity involving a decrease of the ADC. The results of this MRI sequence are encouraging even if they remain not very reliable in front of cystic or necrotic tumours.

[The role of laryngeal kinesthetic feedback in the control of pitch in speech production]. / Mise en évidence du rôle de la proprioception laryngée dans le contrôle de la courbe mélodique lors de la production de parole.

OBJECTIVES: Pitch change during voice production is under the control of auditive and kinesthetic feedback phenomenona. The aim of the study was to determine the role of larynx kinesthetic feedback in speech production control. MATERIALS AND METHODS: To validate our laryngeal model, five porcine larynges were excised and placed on a test bench consisting of a blower and a laser photoglottometer for measurement of vocal cord vibration. We applied vibratory stimuli to the cricothyroid muscles to determine whether vibrators supplied by a generator alter the biomechanics of the larynx. Fundamental frequency (F0) was recorded under three conditions--larynx on vibration--larynx on vibration with vibrators activation--larynx on rest and vibrators activation. Once validated, 7 male and 7 female, mean age 29 years, were enrolled. Vibrators were positioned on cricothyroid muscles, cricoid and thyroid cartilages. Masking noise was used. Fundamental frequency, intensity and speech time production was measured during speech production under three conditions--normal speech, vibrators activation, and masking activation. RESULTS: The preliminary study demonstrated that larynx on vibration with vibrators activation doesn't alter the vocal fold F0. For the human trial, between normal speech and vibrators activation conditions, we found a significant difference (p= 0.045 for male, p= 0.010 for female) in intonation, and no significant difference for intensity and speech time. Between normal speech and masking activation conditions, no significant differences were measured for any condition. CONCLUSION: Use of the vibrators is a reliable method to allow the evaluation of larynx kinesthetic feedback in speech production control.

[Remodeling of the nasal lobule using cartilaginous grafts on tip projection]. / La restructuration du lobule du nez par greffons cartilagineux.

OBJECTIVES: Nasal tip projetion and definition are essential parameters which should be considered in the preoperative rhinoplasty plan. Jonhson and Toriumi have defined a technique of rhinoplasty to restructure the lobule using columellar strut and tip grafts. The aim of this study was to define the influence of this procedure on nasal tip projection, using the Goode method (objective measurement of the tip projection). METHODS: Forty patients underwent primary rhinoplasty, by open approach, with remodeling of the lobule using cartilagenous grafts, according to Jonhson and Torium technique. Goode ratio was calculated to assess tip projection preoperatively and postoperatively, based on photographic analysis. Moreover, postoperatively, all patients were clinically evaluated at 2, 4 and 6 months, and based on photographs of face at 2 and 6 months. RESULTS: Five hypoprojected preoperative nasal tips (Goode ratio (GR): 0,45 to 0,51) had a normal nasal tip projection postoperatively (GR: 0,55 to 0,59). Among the eight normal projected preoperative nasal tips (GR: 0,56 to 0,60), six had a normal postoperative nasal tip projection while two showed a hyperprojection (GR: 0,62 and 0,63). Among the 27 hyperprojected preoperative nasal tips (GR: 0,62 to 0,75), 17 showed a normal projection of the nasal tip postoperatively while 10 remained hyperprojected despite a decreased Goode ratio. CONCLUSION: Restructuration of the lobule, using cartilagenous grafts, is a reliable and reproducible technique allowing satisfying aesthetic results and objective measurements of the changes in nasal tip projection using the Goode method.

[Endoscopic medialization with Vox implant: our experience]. / Médialisation endoscopique de la corde vocale par injection de Vox-implant : notre experience.

OBJECTIVE: The purpose of this work is to analyze our preliminary results on the endoscopic vocal cords medialization by Bioplastique. MATERIAL AND METHOD: This was a retrospective study on 39 cases of unilateral laryngeal paralysis, treated with the injection of Vox-implant between May 2004 and August 2006. The evolution of the swallowing disorders was followed by video fluoroscopy. The phoniatric evaluation was based on an auto evaluation questionnaire: Voice Handicap Index 10 (VHI-10). RESULTS: Of the 19 patients who presented with swallowing disorder, 18 gave a normal video fluoroscopy test. In only one case, a second injection, one year later was necessary to completely cure the patient from fluid aspirations. Thirty two patients were satisfied with the post-operative vocal results. The Wilcoxon matched pairs test gave a statistically significant difference between pre and post-operative VHI-10 (p< 0,001). The voice handicap improved approximately 53%. CONCLUSION: Bioplastic Vox-lmplant profits from a simple injection technique, it is well tolerated and gives a good voice quality. It allows moreover a fast and simple resolution of the problem, can be repeated, and in case of failure or insufficiency a thyroplasty remains possible.

Microvascular radial forearm fasciocutaneous free flap in hard palate reconstruction.

THE AIM OF THIS STUDY: To report the reconstruction of palatal defects by microvascular radial forearm fasciocutaneous free flap (RFFF) and to report patient's quality of life outcomes after this procedure. MATERIAL AND METHODS: During the period 1990-2002, 30 cases of palatal defects were reconstructed using RFFF in our institution. RFFF allowed restoration of a vestibular sulcus to maintain dental prostheses. Outcome measurements included post-operative assessment of speech, swallowing and diet evaluation 6 months, 1 year and 2 years after reconstruction. Quality of life outcomes were measured 1 and 2 years post-reconstruction. RESULTS: RFFF surgery was successful in 28 cases. Six months after resection 28 patients reported satisfactory speech and swallowing. Two years after surgery, 92% (n=26) of patients resumed a normal diet. All patients underwent dental evaluation and 68% (n=19) of patients required dental rehabilitation over a post-operative period of 3-18 months. Patients self assessed their quality of life on a scale of 0-2. First year post-operatively, 21 patients reported a good quality of life (score=2). After the second year, 26 patients reported a good quality of life and the remaining two patients reported an intermediate quality of life (score=1) because they did not resume a normal diet. CONCLUSION: RFFF for palatal reconstruction is a reliable technique and provides a definitive separation between oral and sinusonasal cavities. Furthermore, it improves quality of life by improving speech, swallowing and chewing. It should be considered an integral component of head and neck cancer therapy and rehabilitation.

[Comparison of magnetic resonance imaging with histopathological correlation in laryngeal carcinomas]. / Comparaison dans les cancers du larynx entre l'imagerie par résonance magnétique et les coupes histologiques après laryngectomie.

Apart from a clinical examination including direct laryngoscopy and biopsy, pretherapeutic staging for local extension of laryngeal carcinoma requires computed tomography. The role of magnetic resonance imaging (MRI) remains controversial. The aim of this study was to determine its value for detecting invasion of the main laryngeal structures. Histological findings were compared with axial MRI slices to remain in the same plane. A double-blind study of 10 areas of the larynx was performed: vocal muscle, anterior and posterior paraglottic spaces, anterior and posterior laryngeal commissures, anterior and posterior subglottic area, arytenoid, thyroid, and cricoid cartilages. MRI appeared to be the method of choice to detect neoplastic cartilage, and subglottic and commissural invasion. MRI allows a treatment strategy adapted to the areas involved by the laryngeal carcinoma.

Fos expression in the rat brain after exposure to gravito-inertial force changes.

The immediate-early genes constitute useful neurobiological tools for mapping brain functional activity after sensory stimulation. We immunohistochemically investigated Fos protein expression in the brain of rats exposed to gravito-inertial force changes. Experiments were performed in hypergravity rats born and housed for 60 days in terrestrian gravity (1xg) and thereafter exposed for 90 min to 2xg or 4xg in a centrifuge, and in hypogravity rats born and housed for 60 days at 2xg and submitted for 90 min to 1xg. Data from these two experimental groups were quantified by light microscopy and compared to those from two groups of control rats born and permanently housed in either 1xg or 2xg environments that never had to adapt to novel gravito-inertial environments. Results showed a low basal Fos expression in the controls and a strong Fos staining in the experimental rats. Only the hypergravity rats displayed Fos-positive cells in vestibular-related brainstem regions (medial, inferior, and superior vestibular nuclei (VN); group y; dorsomedial cell column (DMCC) of the inferior olive (IO)). By contrast, many suprabulbar areas were strongly labeled in both the hyper- and hypogravity rats, as shown by the numerous Fos-positive cells in mesencephalic (colliculus, laterodorsal periaqueductal gray, autonomic nuclei), diencephalic (hypothalamic and thalamic nuclei), and telencephalic (parietal, temporal, entorhinal and visual cortices) structures. These spatial patterns of Fos expression suggest that an increase in gravito-inertial force activates otolith-vestibulo-olivar pathways and various suprabulbar structures underlying the corticovestibular interactions, which govern the multiple representations of vestibular information in the cortex. A decrease in gravito-inertial force has the opposite effects on the vestibulo-olivar structures as a result of otolith system disfacilitation which, in turn, modifies the activity of complex neural pathways. Exposure to both hyper- and hypogravity environments likely induces neurovegetative and/or stress effects that could account for Fos labeling in autonomic nuclei and in nervous structures involved in the hypothalamo-pituitary-adrenal axis.

Fos expression in the cat brainstem after unilateral vestibular neurectomy.

Immediate early genes are generally expressed in response to sensory stimulation or deprivation and can be used for mapping brain functional activity and studying the molecular events underlying CNS plasticity. We immunohistochemically investigated Fos protein induction in the cat brainstem after unilateral vestibular neurectomy (UVN), with special reference to the vestibular nuclei (VN) and related structures. Fos-like immunoreactivity was analyzed at 2, 8, and 24 h, and 1 and 3 weeks after UVN. Data from these subgroups of cats were quantified in light microscopy and compared to those recorded in control and sham-operated animals submitted to anesthesia and anesthesia plus surgery, respectively. Results showed a very low level of Fos expression in the control and sham conditions. By contrast, Fos was consistently induced in the UVN cats. Asymmetrical labeling was found in the medial, inferior, and superior VN (ipsilateral predominance) and in the prepositus hypoglossi (PH) nuclei and the beta subnuclei of the inferior olive (betaIO) (contralateral predominance). Symmetrical staining was observed in the autonomic, tegmentum pontine, pontine gray, locus coeruleus and other reticular-related nuclei. As a rule, Fos expression peaked early (2 h) and declined progressively. However, some brainstem structures including the ipsilateral inferior VN and the bilateral pontine gray nuclei displayed a second peak of Fos expression (24 h-1 week). By comparing these data to the behavioral recovery process, we conclude that the early Fos expression likely reflects the activation of neural pathways in response to UVN whereas the delayed Fos expression might underlie long-term plastic changes involved in the recovery process.

Pilomatrixoma of the head and neck in children: a study of 38 cases and a review of the literature.

OBJECTIVES: To describe the clinical presentations and discuss the guidelines for surgical management of pilomatrixoma involving the head and neck in children. DESIGN: Retrospective study. SETTING: A tertiary care center. PATIENTS: Thirty-three patients, with a mean age of 4.5 years, underwent surgical treatment for pilomatrixoma (n = 38) between 1989 and 1997. INTERVENTION: All patients were treated surgically. In 34 cases, a direct approach was used to achieve complete removal of the lesion with (n = 11) or without (n = 23) skin resection. In the remaining 4 cases, an indirect approach via a parotidectomylike incision was used. RESULTS: In 88% of cases, the presenting symptom was a hard, slow-growing, subcutaneous tumor. The lesion was associated with pain and inflammation in 7 cases (18%) and abscess or ulceration in 4 cases (11%). Twenty-nine patients presented with single nodules and 4 presented with multiple occurrences. The lesions were located on the face (cheek, eyelid, or forehead) in 20 cases (53%), on the neck in 8 cases (21%), in the parotid region in 8 cases (21%), and on the scalp in 2 cases (5%). CONCLUSIONS: Pilomatrixoma is a rare, benign skin tumor, but practitioners should be aware of its clinical features. Diagnosis is usually easy based on clinical findings, but computed tomographic scan is helpful, especially in cases involving tumors located in the parotid region. Spontaneous regression is never observed. Complete surgical excision, including the overlying skin, is the treatment of choice.

Short-term changes in neck muscle and eye movement responses following unilateral vestibular neurectomy in the cat.

The purpose of this study was to investigate changes in neck muscle and eye movement responses during the early stages of vestibular compensation (first 3 weeks after unilateral vestibular neurectomy, UVN). Electromyographic (EMG) activity from antagonist neck extensor (splenius capitis) and flexor (longus capitis) muscles and eye movements were recorded during sinusoidal visual and/or otolith vertical linear stimulations in the 0.05-1 Hz frequency range (corresponding acceleration range 0.003-1.16 g) in the head-fixed alert cat. Preoperative EMG activity from the splenius and longus capitis muscles showed a pattern of alternate activation of the antagonist neck muscles in all the cats. After UVN, two motor strategies were observed. For three of the seven cats, the temporal activation of the individual neck muscles was the same as that recorded before UVN. For the other four cats, UVN resulted in a pattern of coactivation of the flexor and extensor neck muscles because of a phase change of the splenius capitis. In both subgroups, the response patterns of the antagonist neck muscles were consistent for each cat independently of the experimental conditions, throughout the 3 weeks of testing. Cats displaying alternate activation of antagonist neck muscles showed an enhanced gain of the visually induced neck responses, particularly in the high range of stimulus frequency, and a gain decrease in the otolith-induced neck responses at the lowest frequency (0.25 Hz) only. By contrast, for cats with neck muscle coactivation, the gain of the visually induced neck responses was basically unaffected relative to preoperative values, whereas otolith-induced neck responses were considerably decreased in the whole range of stimulation. As concerns oculomotor responses, results in the two subgroups of cats were similar. The optokinetic responses were not affected by the vestibular lesion. On the contrary, otolith-induced eye responses showed a gain reduction and a phase lead. Deficits and short-term changes after UVN of otolith- and semicircular canal-evoked collic and ocular responses are compared.