Use of a scapular free flap for reconstruction of the cricoid cartilage in pharyngolaryngeal oncology.

A newly developed technique for cricoid reconstructive surgery is presented and discussed. This method allows us to increase the number of patients presenting with squamous cell carcinoma who may benefit from partial laryngectomy. The method is based on the transfer of a vascularized scapular flap to reconstruct half a resected cricoid. Two alternatives may be used whether anterior laryngectomy preserves the half posterior cricoid and both arytenoids or a hemilateral laryngectomy leaves one arytenoid and half the cricoid. Complementary radiotherapy may be performed after surgery. Satisfactory results are reported from an initial series of three patients.

[Undifferentiated osteogenic carcinoma of the thyroid]. / Carcinome indifférencié ostéogénique de la thyroïde.

A case of osteogenic thyroid carcinoma in a 68 years old male patient is reported. The WHO histopathological classification of such exceptional tumor is reminded. A review of the literature and the treatment modalities are discussed. Several etiological hypotheses are discussed.

Immunologic alterations in patients with sensorineural hearing disorders.

The autoimmune etiology suspected for some forms of hearing loss, supported by the clinical efficacy of steroid therapy, is thought to involve immune complexes, autoantibodies directed to the inner ear and/or cellular effectors. We report a study performed in 57 individuals with sudden deafness (n = 17, group 1) or progressive sensorineural hearing impairment (n = 40, group 2). A severe depletion in CD3+ and CD4+ peripheral lymphocytes was observed in group 1 and a marked decrease of CD8+ cells levels was observed in both groups. Group 2 patients frequently had anti-nuclear and anti-thyroid antibodies, while anti-cochlear antibodies were found in both groups (respective incidences, 75 and 71%). Anti-cartilage antibodies, found with a similar frequency in both groups, were not correlated with anti-cochlear antibodies. These data suggest that different immune disorders are involved in the development of sudden and progressive deafness, while both types of sensorineural hearing impairment involve immune abnormalities.

Restricted expression of Ki-67 in cholesteatoma epithelium.

Proliferative sites within the overgrowing epithelium of cholesteatoma are still ill defined. In this study, we used the monoclonal antibody Ki-67 on frozen cut sections from 23 cholesteatoma samples obtained at surgery from 20 patients. This reagent has been reported to stain the nucleus of proliferating tumor cells and the cytoplasm of growing keratinocytes. In this series of samples, flat superficial layers of epithelium were consistently negative for Ki-67 or displayed a faint staining of the basal layer. By contrast, the deepest areas of epithelial recesses appeared brightly stained with Ki-67. The latter were often in the close vicinity of inflammatory cells present in the underlying mucosa. This observation suggests that cholesteatoma growth is initiated within the deep epithelial folds of overgrown tympanic skin, and that it might be triggered or sustained by inflammatory cytokines.

[An original technique of reconstruction of the cricoid cartilage by vitalized scapular flap. Application to pharyngolaryngeal carcinology]. / Technique originale de reconstruction du cartilage cricoïde par lambeau vitalisé de scapulaire. Application en carcinologie pharyngo-laryngée.

A personal technique for cricoid reconstructive surgery is presented and discussed. A transfert of a free living scapular flap by microvascular anastomoses is used for reconstructing half cricoid resection. We can with this technique increase the number of partial laryngectomy in patients with squamous cell carcinoma. Two techniques are possible: The half anterior laryngectomy conserves only the half posterior cricoid and the twice arytenoids. The half lateral laryngectomy conserves one arytenoid and a half cricoid.

[Malignant transformation of juvenile-type laryngeal papillomatosis]. / Transformation maligne de la papillomatose laryngée de type juvénile.

Juvenile laryngeal papillomatosis is characterized by benign budding tumors, developing from the endolaryngeal epithelium. Because the evolution of these tumors is unpredictable, choice of the best therapy is difficult. We report two cases where invasive juvenile laryngeal papillomatosis, progressively colonized the trachea and bronchi. Malignant transformation occurred without carcinoma predisposing factors. In both cases patients died after pulmonary dissemination. We discuss the role of the human papilloma virus and the high interest of viral typing, for an early diagnosis of possible degeneration. The choice of the best therapy, chemotherapy, CO2 laser, alpha interferon or auto-vaccination will depend on the type on the papilloma virus.

Osteogenic anaplastic carcinoma of the thyroid.

An unusual osteogenic anaplastic carcinoma of the thyroid developed in a 68-year-old man and showed follicular and osteosarcomatous components. Seven months after surgery and 70 mCi 131I treatment, a local tumor recurrence was found and showed an intense uptake of 99mTc-MDP on the bone scan. After a second operation, pathologic and immunostaining analysis revealed no more thyroid carcinoma but only osteosarcomatous cells. Chemotherapy was ineffective and the patient died with diffuse pulmonary metastases 26 months after the diagnosis. The importance of osteogenic sarcomatous differentiation is proven by the bone scan. Osteosarcoma of the thyroid is a rare but well known tumor. Usually these tumors do not contain any cells originating from the thyroid epithelium and only comprise sarcomatous components. Ten cases of undifferentiated carcinoma of thyroid origin with osteogenic component have been reported. These tumors have been recently included in undifferentiated carcinomas in the second edition of the WHO classification. The evolution and pathologic findings favor the hypothesis of a transdifferentiation of the thyroid cell into osteogenic cells.

[Mechanical sutures in ORL cancers, value, indications, techniques and results apropos of 30 cases]. / Les sutures mécaniques en carcinologie O.R.L., intérêt, indications, techniques, résultats à propos de 30 cas.

The authors report their experience in closure of the pharynx following total laryngectomy or total pharyngolaryngectomy by mean of the TA 55 instrument. The technique is described stressing the particular point of good presentation of the mucosa and the importance of the crossing of the lines of staples when two clips are used. An analysis of 30 cases studies is presented with the results as of the date of removal of the nasogastric catheter and the percentage of fistula. This technique appears to be rapid, safer than conventional methods of closure and less complications have been encountered in this series.

[Reconstruction of the mandibular symphysis using a revascularized free flap of the scapula. Surgical technic]. / Reconstruction de la symphyse mandibulaire par lambeau libre revascularisé de scapulaire. Technique chirurgicale.

In cases of surgically removed mandibular symphysis malignancies, the bone and mouth floor were reconstructed using osteo-musculo-cutaneous flaps. In our experience, the latter provide the best results. Removed in dorsal decubitus, they allow floor replacement. During the dissection of the tumor site, we also preserve labial and chin structures, which favours a good restoration of phonation and swallowing.

[Reconstruction of the mandibular arch using free vascularized iliac and scapular grafts. Arguments in favor of using scapular grafts]. / Reconstruction de la symphyse mandibulaire par transferts osseux vascularisés libres iliaques et scapulaires. Arguments en faveur de l'utilisation du lambeau scapulaire.

In 12 cases of surgically removed mandibular symphysis malignancies, the bone and mouth floor were reconstructed using osteo-musculocutaneous flaps from the iliac crest or free osteo-cutaneous scapular flaps. In our experience, the latter provide the best results. Removed in dorsal decubitus, they allow floor replacement. During the dissection of the tumor site, we also preserve labial and clin structures, which favours a good restoration of phonation and swallowing.

Immunohistologic analysis of the cholesteatoma matrix in children.

The immunohistological characteristics of retraction pockets, cholesteatoma matrix and granulomatous tissue were compared in 14 samples from pediatric cholesteatoma. The junction between epidermis and the middle ear mucosa appeared as the most inflammatory area, displaying the characteristics of delayed type hypersensitivity. CD1 + Langerhans cells were observed in all epidermic areas, but expressed class II molecules only in the vicinity of polymorphonuclear infiltrates. Numerous mast cells and IgA producing cells were also observed, suggesting that defenses from the mucosal immune system are summoned and contribute to the pathogenesis of cholesteatoma.

[External ear and abnormality of the urinary tract: a comparative study of 2 series (100 and 150 cases)]. / Oreille externe et malformation de l'appareil urinaire: étude comparée de deux séries (100 et 150 cas).

Pinnal anomalies were observed in 46% of 150 children with urinary tract malformation. This ear feature was only recorded in 16 cases among 100 control children. The observation of abnormalities of the auricle (flattened structure of the pinna, deformed shape of the helix) should thus prompt to investigate a possible urinary tract malformation (vesico-renal reflux, mega-ureter). The identification of this disorder should occur as early as possible in order to perform corrective surgery before irreversible kidney damage. Any urinary disorder associated to atypical morphology of the external ear should lead to abdominal echography. Urinary infections, sometimes mistaken for upper respiratory tract infections, will sometimes provide a diagnostic lead, confirmed by cyto-bacteriological examination of urine. These observations further confirm the concomitant development of the external ear and urinary tract during embryogenesis.

[New concepts of the course of cholesteatoma from the immunohistological study of 96 samples]. / Nouvelles conceptions de l'évolution du cholestéatome à partir de l'étude immuno-histologique de 96 prélèvements.

The immunohistological characteristics of retraction pockets, cholesteatoma matrix and granulomatous tissue have been compared. Langerhans cells, epidemic folds and sub-epithelial tissue were labelled with specific markers (HLA II, adhesion receptors, KI 67). The junction between epidermis and sub-epithelial tissue of middle ear mucosa appeared as the most inflammatory area, displaying characteristics of delayed type hypersensitivity phenomenon. CD1+ Langerhans cells appear to express class II molecules only in the vicinity of polymorphonuclear infiltrates. Epidemic proliferation seems to able place mainly in the deepest recesses of the epidermis.

[Use of the Galea flap in ORL]. / Utilisation de la Galéa en ORL.

We use the Galeal pericranial flap with the temporal vessels. Its high vascular content and its low esthetic and functional after effects are very interesting. The dissection between the outside of the flap and the subcutaneous tissue is difficult. The Galeal epicranial flap can cover wounds of orobuccopharynx, otopoiesis and loss of facial substance. We use it for arranging open technic and also for sealing the skull base.

[Osteosynthesis using a screwed plate in fractures of the mandibular condyle]. / L'ostéosynthèse par plaque vissée dans les fractures du condyle mandibulaire.

The surgical treatment of sub-condylar fractures allows rapid reestablishment of the bite, temporo-mandibular joint function and facial appearance. A pre-auricular approach is used involving dissection of the facial nerve and its upper branch. Surgical reduction is performed under direct vision. Fixation is via a plate with 4 screws. The condylar fragment needs to be large enough to accept at least two screws and hence this needs to be confirmed preoperatively by CT scan examination. In the adult we feel that fixation is indicated for low displaced sub-condylar fractures. We do not feel that surgery is indicated for recent trauma in children.

[Skull vault bone graft in augmentation septorhinoplasty]. / Apport du greffon osseux de voûte crânienne dans les septorhinoplasties d'addition.

We describe our technique of augmentation rhinoplasty with bone grafting. Degloving is used as the surgical access in collapsed noses, and midcolumellar incision allows further buildup of the nasal contour. A V cutting is made on the dorsum to receive the graft. A split skull graft is taken with a drill and an osteotome. The sculpted bone implant is maintained in position with a miniaturized screw. We compare various bone grafts and types of surgical access.