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.

Functional evaluation of mandibular reconstruction with bone free flap. A GETTEC study.

OBJECTIVES: To assess the functional results of oromandibular reconstruction by free bone flap, in terms of swallowing, speech and esthetics. MATERIALS AND METHODS: A transverse multicenter study included 134 patients reconstructed by free bone flap between 1998 and 2016, with more than 6 months' follow-up, in 9 centers. A standardized questionnaire collected data on patients and treatment. Study endpoints comprised: weight loss, mouth opening, gastrostomy dependence, type of feeding, and DHI score. The impact of patient baseline characteristics on these functional criteria was explored by uni/multivariate analysis. RESULTS: Ninety of the 134 patients had cancer. Fibula flap was mainly used (80%). 94% of reconstructions were primary successes. 71% of patients had pre- or post-operative radiation therapy. 88% had less than 50% lingual resection. 97% recovered oral feeding. 89% had intelligible speech. 86% judged their esthetic appearance as good/average. 9% had dental prosthetic rehabilitation. Radiation therapy and extensive lingual resection significantly impacted swallowing function (P=0.04 and P=0.03, respectively). Radiation therapy and oropharyngeal extension significantly increased gastrostomy dependence (P=0.04 and P=0.02, respectively). CONCLUSION: Oromandibular reconstruction by free bone flap enabled return to oral feeding in most cases. More than 80% of patients were satisfied with their result in terms of speech and esthetics. However, the rate of dental rehabilitation was low and the rate of complications was high.

[Extensive oral condylomas treated by in situ cidofovir injection in an HIV patient]. / Traitement d'une condylomatose orale extensive par cidofovir intralésionnel chez un malade infecté par le VIH.

BACKGROUND: Human papillomavirus infections are difficult to treat and have a high rate of recurrence, especially in a setting of human immunodeficiency (HIV) infection. Moreover, there is no standard treatment for oral condylomas. PATIENTS AND METHODS: We report the partial success of in situ injections of cidofovir in an HIV patient, presenting extensive oral condylomas. The injections were well tolerated and the response was still present at one year while the immune status of the patient was unchanged. DISCUSSION: The efficacy of topical cidofovir against condyloma acuminata has been reported and the value of in situ cidofovir injections for the treatment of laryngeal papillomatosis is well established. This case report shows the need for further investigation of in situ cidofovir injections as an alternative treatment for human papillomavirus lesions that are difficult to treat because of both site and extension.

Organization of primary care pathway in head and neck oncology (short version): Organization of chemotherapy in head and neck oncology.

Chemotherapy may be indicated in head and neck cancer: as induction, associated with radiation therapy, or as a palliative solution, in case of local or locoregional progression if surgery and radiation therapy are contraindicated, and/or in case of metastatic progression. The most frequently used anticancer agents are platins, antimetabolites (5-fluorouracil, methotrexate) and taxanes. For several years now, in some indications, chemotherapy may be associated with targeted anti-EGFR antibody therapy. Prescription of chemotherapy and follow-up in head and neck cancer requires particular attention due to comorbidities related to alcohol abuse and smoking and frequent denutrition. Management thus requires close cooperation between the ENT physician, medical oncologists and radiation oncologists.

French Society of ENT (SFORL) guidelines for care pathway organization in head and neck oncology (short version). Early management of head and neck cancer.

Early management in oncology is based on coordination and high-quality exchange between the various health-care partners. The present guidelines are based on a literature search with levels of evidence. Treatment waiting time can be optimized by performing assessment as early as possible (Expert opinion), to limit the interval (ideally, less than 4 weeks) between first consultation and data collection. In the first specialist consultation, diagnostic work-up should be scheduled and the data required for management should be determined (Grade B). Work-up may be conducted on a day-care basis or with conventional admission (Expert opinion). The patient's medico-social context should be taken into account from the outset, with social work involvement whenever necessary (Expert opinion). Pain and nutritional management should be planned for (Grade A) and realistic therapeutic education be provided (Expert opinion). Community-hospital teamwork for supportive care should be optimized (Expert opinion). Management should be early and multidisciplinary, to shorten delay between diagnosis and treatment initiation.

Subcranial fronto-orbito-nasal approach for ethmoidal cancers surgical techniques and results.

BACKGROUND: The authors report their experience with the subfronto-orbito-nasal approach (SFON) for the treatment of 30 patients suffering from ethmoidal cancers over the past 3 years. The advantages and pitfalls of this technique are described and compared with other classic approaches. METHODS: Among 156 patients suffering from ethmoidal cancers and treated between January 1984 and January 1998, 30 patients were operated on using the SFON approach during the past 3 years. There were 27 males and 3 females, ranging in age from 15 to 77 years. Histologic composition of the lesions was as follows: 15 adenocarcinomas, 6 esthesioneuroblastomas, 3 melanomas, 2 epidermoid carcinomas, 1 nondifferentiated carcinoma, 1 neuroendocrine carcinoma, 1 villous carcinoma, and 1 cystic adenoid carcinoma (cylindroma). According to the authors' classification, 7% were T1, 6% T2, 22% T3, 38.5% T4a, and 26.5% T4b. All patients were operated on through a SFON approach, followed by removal of the tumor and reconstruction of the skull base with a pericranial flap. RESULTS: Since the mean follow-up was of short duration (12 months, ranging from 3 to 29 months), significant carcinologic results could not be obtained. However, a detailed analysis of the surgical procedure was performed. No patient died or had major complications related to the SFON approach. One cerebrospinal fluid (CSF) fistula and four oculomotricity dysfunctions were observed. Definitive anosmia was reported in all cases. CONCLUSION: The advantages of the procedure include a wide exposure of the anterior skull base through a limited approach, the possibility of modifying the approach according to the size and location of the lesion, total resection of tumors, simplified skull base reconstruction technique, and reduction of postoperative confusion and hospital stay.

Electromyographic activity of strap and cricothyroid muscles in pitch change.

The EMG activity of the cricothyroid muscle (CT) and the three extrinsic laryngeal muscles (thyohyoid, TH; sternothyroid, ST, and sternohyoid, SH) were recorded throughout the voice range of one female and one male subject, both untrained singers. The voice range was examined using rising and falling glissandos (production of a sustained sound with progressive and continuous variation of fundamental frequency). Muscle activity was observed at various pitches during the glissandos. The strap muscle activity during the production of glissandos appears to be synergistic. At the lowest frequency, the CT is inactive but strap muscles (TH, ST, SH) are active. As frequency increases, strap muscle activity decreases while the CT controls frequency in the middle of the range. At higher frequencies the strap muscles once again become active. This activity might depend on the vocal vibratory mechanism involved. The role of the strap muscles at high pitches is a widely debated point but it seems that in some way they control the phenomena relevant to the rising pitch. The phasic-type strap muscle activity contrasts with the tonic-type activity of the CT. The CT closely controls the frequency, while the straps are not directly linked to the pitch but rather to the evolution of the frequency of voice production (speaking voice, singing voice, held notes, glissandos, trillo, vibrato, etc.).

[Oculopharyngeal myopathies: value of myotomy of the superior sphincter of the esophagus. Apropos of a case]. / Myopathies oculopharyngées: intérêt de la myotomie du sphincter supérieur de l'oesophage. A propos d'un cas.

Since 3 years, a 74 year-old man suffered of swallowing impairment, weight loss, bilateral ptosis and proximal muscular weakness. Electron microscopy disclosed intranuclear tubular filaments and confirmed the diagnosis of oculopharyngeal muscular dystrophy. Upper oesophageal sphincter myotomy was performed with complete improvement. Four months after surgery, swallowing disorders were not recurrent and weight gain was substantial.

[Lesions to lips, oral and nasal cavities, pharynx, larynx, trachea and esophagus due to endotracheal intubation and its alternatives]. / Lésions liées à l'intubation oro- et nasotrachéale et aux techniques alternatives: lèvres, cavités buccale et nasales, pharynx, larynx, trachée, oesophage.

Dysphagia of greater than 48 h duration is an indication for indirect laryngoscopy and when odynophagia and otalgia occur simultaneously, the possibility of subluxation of the arytenoids demands an urgent ENT assessment. The potential seriousness of laryngeal lesions following intubation obliges us to use the smallest compatible endotracheal tube. The occurrence of pain cervical surgical emphysema and fever suggests a pharyngeal lesion necessitating the suspension of oral feeding and the initiation of antibiotic therapy with anaerobic activity, while awaiting possible surgical intervention. There is no argument to use a tooth-guard for each intubation, but tooth fragility must be researched. The incidence of nasal fossa trauma is reduced with the use of nasal packs impregnated with local anaesthetic containing a vasoconstrictor. This allows the introduction of a small flexible lubricated tube. Laryngeal mask-induced sore throat is more common than the more serious injuries. The classical technique of introducing a laryngeal mask of appropriate size (4 for women, 5 for men) in which the cuff is inflated to a leak pressure of 20 cm H(2)O reduces this frequency. The facial mask may cause injuries especially with prolonged use. The incidence of pulmonary aspiration, linked to the action of drugs, raised intra-abdominal pressure; an emergent situation or difficult intubation is decreased with the performance of the Sellick maneuver at intubation, rapid induction and the neutralization of gastric acidity. A meticulous technique of insertion of the, individualized anaesthesia, particular vigilance at the time of decurarisation and position changes and a calm awakening assure its optimal use, unless the Proseal laryngeal mask modifies this point of view.

[Comparative study of 2 chemotherapy induction protocols. Cisplatinum-methotrexate-bleomycin and oncovin-methotrexate-bleomycin]. / Etude comparative de deux protocoles de chimiothérapie d'induction. Cisplatinum-méthotrexate-bléomycine, oncovin-méthotrexate-bléomycin.

A prospective randomized study was conducted in 77 patients with stages III and IV epidermoid carcinomas of the buccal cavity, oropharynx, and pharyngolaryngeal regions to compare effects of two induction chemotherapy regimens: cisplatinum, methotrexate, bleomycin, and oncovin, methotrexate, bleomycin. Tumoral response and complications were analyzed as a function of the regimen, the tumoral site, and the stage. Chemotherapy including cisplatinum provided a tumoral response in 58.8 p.cent of stage III pharyngolaryngeal epitheliomas as against 38.4 p.cent with oncovin, methotrexate, bleomycin, but with a higher frequency of complications.

[Criteria for choice of an anesthetic technic for laryngeal laser microsurgery using the laser in adults]. / Critères de choix d'une technique anesthésique pour la micro-chirurgie laryngée au laser de l'adulte.

Laryngeal microsurgery by means of the laser involves anesthetic constraints regarding mainly the mode of ventilation during operation. The principal techniques and different anesthetic protocols are discussed. The two main criteria for the choice of method appear to be the permeability of the laryngeal passage and the patient's general condition and history. The two principal methods proposed are high frequency jet ventilation and ventilation controlled by a protected intubation tube.

[Intrinsic muscles of the human larynx. Histoenzymological characteristics of the muscle fibers]. / Muscles intrinsèques du larynx de l'homme. Caractéristiques histoenzymologiques des fibres musculaires.

ATPasic, oxidative, and glycogenolytic activities were demonstrated in human laryngeal intrinsic muscles (a total of 15) employing a series of histoenzymatic investigational techniques. Staining methods applied to 10 of the muscles revealed the presence of motor plates on the fibers, either with or without associated ATPase activity. These findings enabled clarification of the different muscle fiber populations, enzymatic equipment, and type of innervation of the laryngeal muscles. Certain of these muscles (cricothyroid, thyroarytenoid, and posterior cricoarytenoid) possess remarkable particularities in relation to known skeletal muscles, and the significance of these features is discussed.

[Correction of defects in the projection of the tip of the nose after surgery]. / Correction des défauts de projection de la pointe du nez après chirurgie.

Dropping of the tip of the nose after surgery is mainly the result of either too extensive resection of the alae or excessive resection of the septum. In the first case, the resulting round or hooked nose can be corrected by an auto or homologous cartilage graft. In the second case, following surgery to obtain functional improvement, the presence of an osteocartilaginous hump can be exploited to support the tip, or a conventional flap can be employed, composed of alar chondromucosal tissue. These remarks are but one particular feature of secondary surgery to the nose, a delicate surgery in full expansion.

[Value of computed tomography in tumors of the pharyngolarynx]. / Intérêt de la tomodensitométrie dans les tumeurs du pharyngo-larynx.

A study was conducted of 27 case-reports to assess the value of computed tomography for investigation of pharyngolaryngeal cancer spread. Analysis was by comparison of clinical, endoscopic, conventional radiologic, computed tomography, and definitive operative specimen histologic findings. Certain laryngeal structures were studied more particularly: the anterior commissure, the pre-epiglottic spaces, the subglottic region, and the thyroid cartilage. Findings demonstrated that the CT Scan is of no value for the study of the anterior commissure and the pre-epiglottic spaces, but is of major interest for detection of subclinical lesions of the subglottic region and thyroid cartilage.

[Lymphadenopathies associated with carcinoma of the larynx (author's transl)]. / Les adénopathies des épithéliomas du larynx. Fréquence et pronostic.

On the basis of 287 cases of carcinoma of laryngeal origin, treated by total or horizontal sub-glottal laryngectomy, the authors study the prognosis in lymphadenopathies. This prognosis is envisaged in the light of the international nomenclature NO, N1, N2, N3, in relation to the size of the nodes and, finally, in relation to the surgical or radiotherapeutic treatment given to the node areas. The authors emphasise the need for bilateral surgery to the node areas, this procedure being all the more extensive when the lymphadenopathy is larger. On the basis of this size, a choice must be made between radical dissection, extended cellulo-adenectomy (or functional excision).

[Musculocutaneous flaps of pectoralis major. Anatomical and technical aspects, results, and literature review (author's transl)]. / Notre expérience des lambeaux musculo-cutanés de grand pectoral. Anatomie, technique. Résultats, revue de la littérature.

After a review of reports in the published literature on the employ of musculocutaneous flaps of pectoralis major, and a brief historical outline, the techniques employed, indications, advantages, and results obtained are discussed. Surgery for cancer, particularly in the buccopharyngeal region, could be partly transformed by this excellent reparative procedure because of the wide surgical scope it allows, and the spectacular functional results obtained.

[Recovery total glossectomy with immediate reconstruction by means of a musculocutaneous flap : functional results and perspectives (author's transl)]. / Glossectomies totales de rattrapage avec reconstruction d'emblée par lambeaux musculo-cutanés. Résultats fonctionnels, perspectives.

A surgical procedure is proposed for treating recurrent or non-sterile cancer of the tongue whenever satisfactory excision of the tumor can be accomplished. The technique involves a recovery total glossectomy associated, as shown to be necessary following its application in 3 cases, with a transmaxillary buccopharyngectomy. This operation has become valid following the use of musculocutaneous flaps, which enable reconstruction of the tongue with good quality functional results.

[Use of the CO2 laser in the emergency treatment of dyspnea in laryngeal cancer]. / Utilisation du laser CO2 dans le traitement d'urgence des dyspnées des cancers du larynx.

Occlusion of the larynx of neoplastic origin was treated by CO2 laser in seven patients between Marc 1982 and April 1983. Temporary tracheotomy was avoided in all 7 cases but treatment had to be repeated in two patients. Specific anesthetic techniques necessary when using the laser in hypercapneic patients are described, and the advantages, limitations and complications of this therapy are discussed.

[Cancer of the mobile tongue. Therapeutic development and results]. / Cancers de la langue mobile. Evolution des thérapeutiques et résultats.

The authors analyse the results of treatment of 84 squamous cell carcinomas of the mobile portion of the tongue treated between 1961 and 1982. 64% of the patients treated were Stage I or II. The local recurrence rate was 13% at 5 years (6/43) for T1, T2. Recurrences were more frequent after interstitial radium therapy (17% at 5 years: 5/28) than after partial glossectomy performed at the outset (6.6% : 1.15). The treatment of stage NO remains controversial. The frequency of lymph node recurrences remains proportional to lymph node involvement by histology (NO, N-: no recurrences; NO, N+: 18.1%: 6/33) but seemed to be independent of the initial treatment of the regional nodes: no treatment, neck dissection with or without subsequent external radiotherapy. It is important to emphasize that lymph node recurrences contralateral to the tumour always occurred in the presence of initial homolateral lymphadenopathy with capsular rupture. Other oncological failures were frequent (35% : 20/56) at 5 years, grouping together visceral metastases (14.3% : 8/56) and second primary cancers in the upper respiratory/digestive tract (21.4% : 12/56).

[Effects of the CO2 laser on mandibular bone. Preliminary study]. / Effets du laser CO2 sur l'os mandibulaire. Etude préliminaire.

A study of the effects of the CO2 laser on bone was undertaken using human mandibles obtained from cadavers. Different series of shots were used, varying the power and duration of the shots, as well as the latent period between two impacts with intermittent shooting. For a given impact duration, the depth of penetration increased in proportion to power up to 25 watts. Beyond, penetration was less deep but more extensive. For a given intensity, the duration of the shot did not result in any variation in penetration. These findings and their possible clinical implications are discussed.