[Otolaryngological cancer pain at the after-effects stage]. / Douleur des cancers ORL au stade des séquelles.

The standards of pharyngolaryngeal tumor treatment have changed over the years in an attempt to prevent laryngeal mutilation (partial surgery, endoscopic surgery, sequential radiotherapy, and chemotherapy). Pain induced by these treatments is frequent and varies from one treatment to another. Chemoradiotherapy induces less pain but often more severe pain, since 20% of these situations are not controlled by strong opioids. Pain from mucositis, although nonspecific to otolaryngic cancer, is more frequent and more severe, and prevention and treatment remain poorly defined. Pain from postradiotherapeutic necrosis (mandibula, laryngeal cartilage, etc.) is less frequent, delayed, and extremely severe. Cervical and shoulder pain is present in more than one-third of patients and stems from a number of mechanisms (myofascial and articulatory). It is secondary to radiotherapy or surgery (XIth cranial nerve lesions during curage or flap reconstruction). Finally, pain coexists with disturbances of basic functions (speech, swallowing, etc.) and the disability generated by treatments. Management of pain, suffering, and the psychosocial impact is essential.

[Facial anesthetic blocks in the treatment of acute pain during ophthalmic zoster]. / Blocs anesthésiques faciaux dans le traitement de la douleur aiguë du zona ophtalmique.

BACKGROUND: Ophthalmic zoster is frequently accompanied by severe pain in the frontal and nasal divisions of the ophthalmic nerve. Treating this pain is often difficult, particularly in elderly patients, owing to iatrogenic effects and to interactions with the pre-existing diseases and treatments frequently present in this age group. The aim of our study was to consider the efficacy and toxicity of the frontal and nasal nerve blocks in the treatment of severe pain during acute ophthalmic zoster in the elderly. MATERIAL AND METHODS: A prospective study was conducted on 20 patients (mean age, 76 +/-7 years; range, 63-88) presenting with acute ophthalmic zoster with severe pain (less than 1 month since onset), which had resisted analgesic medication. All patients had a visual analogue score for pain (VAS) of 4 or more and received one or more anesthetic blocks of a compound of bupivacaine with adrenaline associated with clonidine at the frontal branch and sometimes the nasal branch levels of the ophthalmic nerve. Pain was measured daily by VAS for 5 days, and the blocks were repeated if the VAS was still 4 or higher. Patients were checked for local or systemic side effects. RESULTS: The number of anesthetic blocks per patient ranged from one to four (mean: 2.3 +/-0.7). All patients experienced less pain after the first injection. The mean preinjection VAS was 7.4 +/-1 and fell to 4.8 +/-1.0, 4.1 +/-1.1, 3.5 +/-1.0, 3.2 +/-0.6 and 2.8 +/-0.9 at day 1, day 2, day 3, day 4 and day 5, respectively (p<0.001). It was possible to reduce analgesic medication permanently in all patients. No local or systemic side effect was observed. CONCLUSION: Anesthetic blocks of the frontal and nasal branches, repeated if necessary, give fast and effective relief from the severe pain of acute ophthalmic zoster. They are fully tolerated and simple to administer, making them an excellent indication in the complementary treatment of the pain of hyperalgic acute zoster in the elderly.

[Validation of the combined SF36/MSQOL test of evaluation of quality of life in migraine patients in France]. / Validation de l'association SF36/MSQOL pour évaluer la qualité de vie des migraineux en France.

The impact of migraine on patients quality of life is great, even between attacks. The aim of this study was to assess the properties of a French language quality of life questionnaire, which associates the Medical Outcome Study Short Form (MOS SF 36) with the Migraine-Specific Quality of Life (MSQOL). Data were obtained from 110 consultant patients of neurology units located in three University hospitals in the center of France. The results indicated a good acceptability of the association of the two questionnaires with a 84p.cent response rate. The Principal Component Analysis showed no change in both SF-36 and MSQOL structures. It also suggested that the two questionnaires were complementary. The high values of the Cronbach alpha coefficients for each scale indicated a high level of internal consistency. The quality of life scores were correlated with external parameters such as frequency, intensity and length of migraine attacks, and social activity reduction due to these attacks. In conclusion, the association of the SF-36 with the MSQOL has the interest of associating generic and specific questionnaire, in a complementary way. This association has good psychometric properties, and can be used to evaluate migraineurs quality of life in French speaking countries.

A possible therapeutic solution for stomatodynia (burning mouth syndrome).

Stomatodynia is a difficult disease for both patients and clinicians. When facing true stomatodynia, i.e., idiopathic burning mouth, patients are offered poorly effective treatment. This open study reports the results of local application of clonazepam (0.5 or 1 mg) two or three times daily in 25 subjects who suffered from idiopathic stomatodynia. At the first evaluation, 4 weeks after the beginning of treatment, a visual analogue scale (VAS) that represented the intensity of pain decreased significantly from 6.2 +/- 0.3 to 3.0 +/- 0.5. At the second evaluation, 3 to 29 months after the first consultation, the VAS scores dropped significantly further to 2.6 +/- 0.5. Analysis of the individual results showed that 10 patients were totally cured and needed no further treatment, 6 patients had no benefit at all, and the remaining 9 patients had some improvement but were not considered to be cured since they did not wish to stop the treatment. Blood level tests that were performed 1 and 3 hours after the topical application revealed the presence of small amounts of the drug (3.3 ng/mL +/- 0.66 and 3.3 ng/mL +/- 0.52, respectively). The hypothesis that clonazepam acts locally to disrupt the neuropathologic mechanism that underlies stomatodynia is proposed. The risk factors that are recognized for this condition could decrease the density and/or ligand affinity of peripheral benzodiazepine receptors. This, in turn, could cause spontaneous pain from the tissues concerned.

[Cerebral pneumocephalus after epidural anesthesia: a rare complication?]. / La pneumatocèle cérébrale après anesthésie péridurale: une complication rare?

A case is reported of pneumoencephalus occurring after an accidental dural puncture during a cervical epidural puncture using the loss of resistance technique. Six ml of air were injected intrathecally. The patient recovered spontaneously within five days. This complication may occur more frequently than commonly admitted. It may be difficult to differentiate between headache due to pneumoencephalus and that by stretching of the meninges due to cerebrospinal fluid leakage. Only a CT scan can help to answer this question.

[A rare cause of obstruction of the intubation tube]. / Une cause rare d'obstruction de la sonde d'intubation.

A case is reported of endotracheal tube obstruction due to impaction of a turbinate. This complication occurred during a first attempt of nasotracheal intubation in an ASA 1 18-year-old patient. Once the tube had been inserted into the trachea, manual ventilation was impossible. The diagnosis was made on removal of the completely obstructed tube. Differential diagnosis was sudden severe bronchospasm or a herniated cuff. Anaesthesiologists should be aware of this rare complication when carrying out nasotracheal intubation. Means of prevention are proposed.

[Cervical epidural anesthesia]. / Anesthésie péridurale cervicale.

Cervical epidural anaesthesia (CEA) results in an effective sensory blockade of the superficial cervical (C1/C4) and brachial plexus (C5/T1-T2). It is used both intraoperatively and in the treatment of postoperative or chronic pain. The approach to the epidural space at the C7-T1 interspace is not technically difficult. Patients are placed in the sitting position, increasing the negative pressure in the epidural space, with the head flexed on the thorax, in order to open the lowest cervical interspace. A 18-gauge Tuohy needle is inserted by a midline approach into the C6-C7 or C7-T1 interspace. A catheter may be inserted and left in place for postoperative analgesia. Local anaesthetics are administered either alone, or in combination with opiates. The CEA blocks the cardiac sympathetic fibers and consequently decreases heart rate, cardiac output and contractility. The mean blood pressure is unchanged or decreased, depending on peripheral systemic vascular resistance changes. The baroreflex activity is also partly impaired. Sympathetic blockade also decreases myocardial ischaemia. The cardiovascular changes induced by CEA are also partly due to the systemic effect of the local anaesthetic. The respiratory effects are minimal and depend on the extent of the blockade and the concentration of the local anaesthetic. A moderate restrictive syndrome occurs. Since the phrenic nerves originate from C3 to C5, ventilation may be impaired by CEA. Extension of the block may also impair intercostal muscle function, with a risk of respiratory failure when a CEA is used in patients with compromised respiratory function. The potential specific complications, mainly cardiovascular and respiratory, are the exacerbation of the effects of CEA. Side effects such as bradycardia, hypotension and acute ventilatory failure in relation to respiratory muscle paralysis, may be observed. Close monitoring of haemodynamics, respiratory rate and level blockade is required. Cervical epidural anaesthesia may be used either alone, or in combination with general anaesthesia depending on the surgical procedure. This technique seems to be effective in carotid artery surgery since sensitive and reliable information on cerebral function may be obtained. It is also for shoulder and upper limb surgery as well as for pharyngolaryngeal surgery, providing efficient operative anaesthesia and postoperative analgesia. CEA is used for relief of chronic pain in the head and neck or cancer pain due to Pancoast-Tobias syndrome. It seems to be effective for treating pain in patients with unstable angina pectoris or acute myocardial infarction.

[Locoregional anesthesia by peri-dural route in neck surgery]. / L'anesthésie loco-régionale par voie péri-durale en chirurgie cervicale.

Principal anatomical "targets" and physiological consequences of cervical epidural anesthesia are outlined, technic and aims of the method discussed and 53 patients (class ASA I and II) receiving major cervical surgery, mainly for cancer, reviewed. Effectiveness of cervical epidural anesthesia was rated as excellent for total pharyngo-laryngectomy, with or without flaps, total laryngectomy, lymph node curettage and thyroidectomy, moderate for reconstructive laryngectomy and only fair for transmaxillary buccopharyngectomy. Advantages of the method concern principally the postoperative period: immediate awakening (92% of cases) in the operating room whatever the duration of surgery, avoiding intensive care, and pain relief for at least 48 hours (85% of cases) by maintenance of catheter. Contraindications include hypocoagulability, local or general infection and impossibility of adjusting heart rate, and the method is not applicable for all patients in whom general anesthesia with assisted ventilation is contraindicated.