Cervical lymph node metastases and T1 squamous cell carcinoma of the lips.

OBJECTIVE: The occurrence of cervical lymph node metastasis is a major prognostic factor for head and neck squamous cell carcinoma (SCC) of the lip. This study focuses on patients with T1 stage tumours,in order to describe the prevalence of metastatic lymphadenopathies. METHODS: A multicenter retrospective study was performed in three tertiary care referral centers and included 59 patients surgically treated for T1 stage SCC of the lips from January 1996 to December 2006. This surgical treatment concerned the tumour, with cervical neck dissection when lymph node metastasis was suspected. RESULTS: Cervical lymph node metastasis was found and histologically proven in 7 patients (11.9% of the cases, pN+ group; 95% confidence interval, 3.6 to 20.2%) during follow-up, never at the time of diagnosis. Metastasis appeared 13.3 ± 7.9 months (min. 5.3 months, max. 29.1 months) after the initial treatment and involved the IB level in all cases. Tumour progression was significantly longer in the pN+ group compared to patients with no lymph node metastases (sN-group). The pN+ group also had a significantly higher proportion of poorly or moderately differentiated tumours, and a significant decrease in overall survival, disease-free survival, and disease-specific survival. CONCLUSION: Lymph node metastasis occurs in roughly 12% of T1 stage SCC of the lips, and the management of neck lymph node areas is necessary. A randomized trial is needed to determine the proportion of occult lymph node metastases in T1N0 patients and the impact of this therapeutic procedure on survival.

Treatment of earlobe keloids by surgical excision and cryosurgery.

BACKGROUND: The long-term results of keloid treatments remain poor. OBJECTIVE: To assess the long-term efficacy of a technique combining surgical excision and immediate cryosurgery in patients with ear keloids. METHODS: A retrospective study was performed between January 2001 and June 2011. All patients referred for treatment of an ear keloid and undergoing subsequent surgical excision followed by immediate freezing of the postoperative wound using cryosurgery were included. The primary end-point was the number of patients who achieved major flattening of the keloid (defined as a reduction of more than 80% of the keloid) at the time of the study after a minimum follow-up of 24 months after treatment. RESULTS: Sixty-six patients with a total of 97 keloids were included. Median follow-up time after treatment was 43 months. 'Major' flattening was observed in 69 keloids (71%). Fifty-six of these lesions (81%) were treated with one session and 13 (19%) required a second session after keloid recurrence. Fifteen lesions (15%) were considered 'treatment failure', including 11 keloids in eight patients who were lost to follow-up and four keloids which achieved less than 30% reduction of their surface. Thirteen other keloids were evaluated as displaying significant or moderate improvement. Treatment side-effects were partial amputation of the ear lobe in three patients with a very large keloid of the ear lobe and hypopigmentation in five patients. LIMITATION: Retrospective study. CONCLUSION: The combination of surgical excision and cryosurgery can be considered for the treatment of large ear keloids.

Acute mastoiditis in children: 10 years experience in a French tertiary university referral center.

Acute mastoiditis have been increasingly reported in the last decade, with bacteriologic modifications and new therapeutic guidelines. This study is a retrospective review of 36 children hospitalized for acute mastoiditis in a French tertiary university referral center from 1999 to 2009, to assess incidence, bacteriology of pathogens and management. There were 10 periosteitis and 26 subperiosteal abscesses. There was a trend toward increased incidence over the past 10 years. The mean age of the patients was 31.8 months. A total of 63.2% children received 7.2 days antibiotic prior to hospitalization for acute otitis media, with sensitive pathogens in 80%. The pathogens were Streptococcus pneumoniae (36.1%), S. pyogenes A (13.9%), Staphylococcus coagulase-negative (13.9%), Pseudomonas aeruginosa (8.3%), Fusobacterium necroforum (8.3%) and Haemophiluss influenzae (2.8%). Cultures were negative in 16.7%. All patients received intravenous antibiotics. Eleven patients underwent bilateral myringotomy with or without tympanostomy tubes. Mastoidectomy was performed in 24 patients. Decrease in the length of hospitalization and delay from admission to surgery were significantly correlated. We observed a trend in the increase of acute mastoiditis at our center. The pathogens were dominated by S. pneumoniae. F. necroforum and P. aerguginosae were pathogens found in children over 2 years of age. Mastoidectomy was performed in 92.3% of subperiostal abscesses. However, there has been a trend toward conservative nonsurgical treatment in recent reported studies and further prospective studies are warranted to evaluate the long-term sequelae.

[Role of hypnotherapy in the treatment of debilitating tinnitus]. / Intérêt de l'hypnose dans le traitement des acouphènes invalidants.

OBJECTIVE: Hypnotherapy is currently used for tinnitus therapy in our university hospital. The aim of this study was to evaluate its efficacy. MATERIAL AND METHODS: This study was performed on 110 patients suffering from distressing tinnitus. They were treated during five sessions with hypnotherapy, supplemented by instruction on self-hypnotherapy. A subjective evaluation was done by the practitioner at the end of the sessions of hypnotherapy. Then a questionnaire on psychologic distress (Wilson 1991) was sent retrospectively to the patients. RESULTS: We received 65 responses which were used for this study. Before treatment, the mean value of the Wilson score was 54 (28-104). After treatment, it was: 31 (0-86). 69% of the patients felt an improvement > or = 5 points Wilson score. These results were compared with the evaluation carried out by the practitioner at the end of the sessions of hypnosis. There was a "significant correlation" between the evaluation of the felt benefice, analyzed by the practitioner at the end of the sessions of hypnosis, and by the patient questioned long after the treatment. These results had significant correlation with the evaluation made by the therapist at the end of the five sessions of hypnotherapy. They show, how effective (68% improvement) this therapeutic approach can be. CONCLUSION: Hypnotherapy can be regarded as an effective treatment against distressing tinnitus.

[Thyroid differenciated carcinoma in children. Study from Normandy]. / Cancers thyroïdiens différenciés de l'enfant. l'expérience normande.

OBJECTIVE: Definition of a strategy for the management of thyroid differenciated carcinoma in children. DESIGN AND SETTING: Retrospective cohort study from the Normandy area in France. METHOD: Analysis of the medical records of 13 children and adolescents (age > 15 years), presenting with thyroid differenciated carcinoma in three Normandy French hospitals from 1994 to 2006, to determine the clinical features and treatment of the disease. RESULTS: X of the patients were male and y were female, with a mean age at presentation of 11 years. Most frequently symptom was solitary nodes in the thyroid gland (69%). Most frequent histological type was papillary cancer (92%). Size of tumor was > 4 cm in 23% of cases. Children had undergone surgery with total thyroidectomy, radio-iodine treatment and suppressive hormonotherapy. We observed 46% post surgery complications. All patients were alive and none developed a recurrence. CONCLUSION: Thyroid differenciated carcinoma in children and adolescents were more agressif with most frequently metastasis and recurrence than thyroid differenciated carcinoma of adults. Pronostic is good with 90% of survival at 20 years. We propose a coherent plan of treatment: 1. Thyroidectomy with cervical central lymph node dissection (group VI) completed bilateral selected head neck dissection compartments (groups IIa, III, IV) if macroscopic lymph node metastases in lateral cervical compartment. 2. Postoperative radioiodine is done in all tumor > T1N0 and completed with hormonotherapy.

Endoscopic revision of external dacryocystorhinostomy failure.

OBJECTIVE: To evaluate the usefulness of endoscopic analysis and surgery of the lacrimal sac in cases of external dacryocystorhinostomy (DCR) failure. MATERIAL & METHOD: In a retrospective study, 17 endoscopic procedures in 17 patients during 11 years with recurrent lacrimal obstruction after external DCR were performed. Endoscopic analysis and procedures were carried out with a routine silicone tube catheterization for 3 to 6 months. RESULTS: In 13 patients, scar tissue was the cause of the obstacle, while in 3 patients an unsuitable location of the ostia and in 1 case an inflammatory polyp were found. After a long-term follow-up (56 months), the epiphora was controlled in 94% of the cases. The mean delay between the first DCR and the recurrence of epiphora was 22 months. CONCLUSION: A persistent or recurrent epiphora can be explored after an external procedure and treated by endoscopic procedure. The endonasal approach for DCR was considered safe, and effective particularly in patients with unsuccessful external DCR.

[CT scan, MR imaging and anatomopathologic correlation in the glottic carcinoma T1-T2]. / Corrélation TDM, IRM et anatomopathologique dans les cancers glottiques T1-T2.

OBJECTIVES: Endoscopy and imaging are necessary to diagnose glottis carcinoma. Today, CT scan is the gold standard but MR imaging should be more sensitive for neoplastic invasion detection. The purpose of this study was to determine which exam to perform (CT scan or MRI) for neoplastic invasion. MATERIAL AND METHODS: This prospective study span a 18 months period. Seven patients with glottis carcinoma (TI-T2) underwent CT and MR imaging before surgery. Findings at imaging and pathologic examination were compared. RESULTS: Both CT and MR imaging were interesting, more specific (90%) than sensitive (74%). The anterior commissure, ventricles, subglottis, thyroid and arytenoid cartilages are the more difficult area analyzing. CONCLUSION: CT imaging stays the gold standard. MR imaging is more effective on second intention to refine the data. Indications are being improved, with complete cure and more preserved laryngealfunctions.

[Comparison of two antibioprophylaxis protocols in ear surgery]. / Comparaison de deux protocoles d'antibioprophylaxie dans la chirurgie de l'oreille.

INTRODUCTION: During surgical procedure, antibioprophylaxis is known to decrease bacterial proliferation and limit postoperative complications such as infections. In France, antibiotic prescription guidelines have been established for ear surgery, but applied with discrepancies. The purpose of the study was to evaluate the necessity of antibioprophylaxis in ear surgery. MATERIAL AND METHODS: Retrospective study of two consecutives series of ear surgery with two different antibioprophylaxis protocols. In the first series (n=100), antibioprophylaxis by amoxicillin and clavulanic acid was given only in cases of chronic otitis media with otorrhea and cholesteatoma (contaminated surgery). In the second series (n=107), no antibiotic was administered. The number of infected complications was evaluated by reviewing medical charts. RESULTS: The percentage of infected complications was 5% versus 6.5% in the second series (with no antibioprophylaxis), for all types of ear surgery, 9.4% versus 4.2% after ear contaminated surgery. No statistical difference was observed between the two series. CONCLUSION: In ear surgery, postoperative infected complications do not more frequently occur without antibioprophylaxis, either in otorrhea or in cholesteatoma surgery.

[Laryngeal schwannomas]. / Schwannomes du larynx.

Laryngeal schwannoma is a rare benign tumour of the larynx. Schwannomas derive from the Schwann cells. The majority occurs in supraglottic area and may arise at any age. Magnetic resonance imaging (MRI) is the best imaging tool for suggesting the diagnosis in the appropriate clinical context. Conservative surgery is the treatment of choice. These tumors have to be distinguished from neurofibromas. We report 2 cases of laryngeal schwannoma. The first one concerned an 8-month-old baby with a laryngeal stridor history which seemed to be related to laryngomalacia. The second case was a 22-year-old man with a 5-year history of dysphonia. On nasofibroscopic examination, a sub mucosal mass enlarged the posterior part of the right false vocal cord in both cases. Both CT scan and MRI sequences showed a well margined lesion in the same place. Histological biopsies identified a schwannoma. External surgeries were subsequently and successfully performed. Diagnosis (imaging), specific treatment (endoscopic or external surgery), and possible association of laryngeal schwannomas are discussed.

[Primary malignant tumors of the lacrimal sac and nasolacrimal duct]. / Les tumeurs malignes primitives des voies lacrymales.

OBJECTIVES: To assess the clinical characteristics, the workup, therapeutic approach and pathological findings of primitive tumors of the lacrimal sac. MATERIAL AND METHODS: Three cases were retrospectively reviewed from the database of our ENT department. They were analyzed and compared to cases reported in the literature. RESULTS: One adenoid cystic carcinoma and two adenocarcinomas were observed, all were adults and the sex ratio was one man for 2 women. Clinically they presented neither significant lacrimal or rhinologic sign. A CT-scan and a MRI were performed along with a physical examination. An entire surgical resection was done with subsequent postoperative radiotherapy. Two patients died, and one is alive, free of disease. CONCLUSION: Lacrimal tumors should be considered in the differential diagnosis of a banal chronic epiphora. The ENT practitioner must associate this factor to any clinical evaluation. The management of these lesions requires a complete surgical resection, routinely associated with postoperative radiation.

Small cell neuroendocrine carcinoma of the nasal cavity and paranasal sinuses.

INTRODUCTION: Small cell neuroendocrine carcinoma (SNEC) of the sinonasal tract is a rare disease. OBJECTIVE: Report a descriptive study of a relatively large cohort of SNEC of the nasal cavity and paranasal sinuses. METHOD: The medical records of 21 patients presenting with nasal and paranasal SNEC to various French hospitals, from 1989 to 2003, were analysed to determine the clinical features and current treatment of the disease. RESULTS: Patient data were obtained from eight French hospitals. Twelve of the patients were male and nine were female, with a mean age at presentation of 55 years (range: 27 to 79 years). Patients' staging for nasal cavity malignancy was: T1, four; T2, three; T3, one; T4, 13; N0, 18; N2, three; M0, 20; and M1, one. None of the patients suffered from SNEC of the sinonasal tract with ectopic hormone production. Immunohistochemistry proved useful for diagnosis in 20 cases. Twelve cases were positive for cytokeratin, 14 for chromogranin, eight for neuron-specific enolase and 11 for neuron-specific synaptophysin. One patient had an adenocarcinoma and an inverted papilloma associated with neuroendocrine carcinoma. Patients underwent surgery (11 cases), radiotherapy (14 cases) and chemotherapy (12 cases). Recurrence occurred in 10 cases. Five patients had visceral metastases or cervical lymph node involvement. Nine of the patients died within four years of onset of the disease. CONCLUSION: Small cell neuroendocrine carcinoma of the sinonasal tract is an uncommon neoplasm with aggressive clinical behaviour. Recurrence is frequent and the prognosis is poor. However, the current treatment of these neuroendocrine neoplasms varies widely.

[Treatment of keloids with shaving and cryosurgery: preliminary reports]. / Traitement de cicatrices chéloides par "shaving" et cryochirurgie: résultats préliminaires.

INTRODUCTION: Numerous treatments have been proposed in patients with keloid scars. Unfortunately, most exhibit poor efficacy. The preliminary results obtained in ten patients with large keloid scars treated by shaving followed by cryosurgery are reported. PATIENTS AND METHODS: Ten patients with one or more keloid scars were treated by shaving of the keloid immediately followed by cryosurgery of underlying scar tissue using an impedance of 500 k Ohms. Minimum post-treatment follow-up was 12 months. "Major response" was defined as a reduction in keloid thickness of 80% to 100%, "moderate response" as an improvement of 50% to 80% or partial relapse, and failure as an improvement of less than 50% or complete relapse after treatment. RESULTS: A total of 16 keloids in ten patients (7 men, 3 women) aged from 10 to 45 years old (mean age: 25 years) were treated. Keloids were localised on the lower lobe of the ear (n=10), on the ear lobe (n=3), on the neck (n=1), on the pubis (n=1), and on the presternal area (n=1). Mean duration of keloids was 3.1 years (18 months - 10 years). Mean follow-up was 23 months (12-56 months). "Major responses" were observed in 13 cases (82%) (3 cases required further treatment); "moderate response" was observed in 3 cases (18%). CONCLUSION: These preliminary results are highly encouraging since all patients showed improvement. Shaving associated with cryosurgery appears to us to be a useful treatment for large keloids scars, particularly after otoplastic surgery.

[Genetic deafness]. / Surdités d'origine génétique.

OBJECTIVES: The aim of this study was to review the different types of genetic deafness. METHODS: We describe syndromic and isolated sensorineural deafness and transmission deafness. RESULTS: Genetic sensorineural syndromic deafness represents 30% of cases of genetic deafness. A frequent cause is Pendred syndrome, which associates congenital sensorineural deafness with goitre and malformations of the inner ear which can be identified on computed tomography scan. Isolated deafness which is responsible for 70% of cases of genetic deafness is then outlined. Among the different types of isolated deafness, 80% are autosomal recessive disorders. A frequent form of autosomal recessive deafness is due to mutations in the connexin 26 gene. Lastly, we detail transmission deafness dominated by aplasia. Major aplasia is characterized by a malformation of the external ear associated with malformations of the middle ear whereas, minor aplasia corresponds to a malformation of the middle ear, sometimes associated with minor external ear malformations. CONCLUSION: For each type of deafness we propose a systematic assessment.

Transalar transsphenoidal meningoencephalocele presenting in the form of recurrent meningitis: Report of two cases and discussion of the diagnosis and treatment.

INTRODUCTION: Skull base meningoencephaloceles are rare congenital malformations. The two cases of transalar transsphenoidal malformation reported here differ from the classical transsphenoidal meningoencephalocele. CASE REPORTS: Case 1 was a three-and-a-half-year-old boy and case 2 was a 36-year-old man. Both cases presented with clinical features of recurrent meningitis. Surgical management of case 1 was performed via an intradural infratemporal fossa craniotomy with reoperation 2years later. In the second case, surgery was initially performed via an endonasal approach and then via pterional craniotomy. Reoperation via Sekhar's transpetrosal approach was also a failure. Only closure of the trigeminal-pontine angle via a suboccipital retrosigmoid approach allowed repair of the defect. DISCUSSION: Surgical access to the pterygopalatine fossa is complex due to its anatomical position and its anatomical relations with nerves and vessels. An endoscopic approach appears to be a valuable alternative to classical craniotomy. CONCLUSION: In the two cases reported here, neurosurgery allowed lasting closure of the defect.

[Oncology and quality of life. Study in head and neck cancer]. / Qualité de vie en cancérologie. Application aux cancers des voies aérodigestives supérieures.

UNLABELLED: The principal endpoints in oncology are survival with improvement of quality of life in cancer patients. OBJECTIVES: To give an accurate account of current literature on quality of life and head and neck cancers. METHODS: Two keys words are used: "quality of life" and "cancer" enabling to trace articles in Medical and Human Science journals. Analysis and synthesis of these documents. RESULTS: Quality of life is difficult to evaluate as it is a multidimensional concept with three main symptom domains: physical, psychological and social. Several quality of life evaluation scales have been developed enabling authors to estimate the effects of disease on patients as well as treatment-related symptoms. Reports on quality of life in ENT patients have offered improved knowledge on patient experience and aftereffects, and therapies have been adapted and improved in view of such studies. CONCLUSION: Quality of life evaluation tools need to be improved. At present, most tools only partially evaluate patient quality of life, concentrating on the global impact of disease and its treatment on patients' physical and psychological condition. The "sociability" of individual patients is rarely evaluated, and the development of qualitative studies in this domain will enable improved understanding of the social factors involved in each patient's adaptability to disease, its treatment and after-effects.

Treatment of an acyclovir and foscarnet-resistant herpes simplex virus infection with cidofovir in a child after an unrelated bone marrow transplant.

Herpes simplex virus (HSV) causes serious problems in immuno-compromised patients such as those receiving a bone marrow transplant (BMT) for a hematological malignancy. Resistance to acyclovir (ACV) is a growing major concern. Foscarnet is a non-thymidine kinase-dependent agent, but the emergence of ACV and foscarnet-resistant HSV requires a new therapeutic approach. We describe a girl treated with cidofovir for a life-threatening ACV-resistant HSV infection after an unrelated BMT for a relapse of an acute myeloblastic leukemia (AML).

Transvenous versus perinervous stimulation of the phrenic nerve to assess the diaphragmatic strength in rabbits.

Diaphragmatic strength can be measured by transdiaphragmatic pressure during phrenic nerve stimulation. In order to avoid phrenic nerve dissection, a transjugular approach of the phrenic nerve can be performed. The objective of this study was to verify the identity of perinervous and transvenous techniques of phrenic nerve stimulation to assess diaphragmatic force. In intact (n = 9) or right phrenicotomized (n = 12) rabbits, we compared esophageal pressure (Peso) induced by supramaximal perinervous stimulation of the phrenic nerve with that obtained by transvenous stimulation of the phrenic nerve. Electromyography (EMG) of the thoracic muscles was studied in four animals. We found no difference between Peso induced by perinervous (PNS) and transvenous (TVS) unilateral or bilateral phrenic nerve stimulation. During unilateral stimulation, no EMG activity was recorded in the non stimulated diaphragm, or in the middle part of the esophagus, or in ipsi- and contralateral accessory inspiratory muscles. We conclude that in rabbits, unilateral or bilateral TVS of the phrenic nerve is functionally equivalent to PNS, whatever the side of stimulation; Peso is not altered by esophageal contraction in TVS. Transvenous stimulation can replace perinervous stimulation in experimental studies, when cervical access is difficult.

Randomized trial of induction chemotherapy in larynx carcinoma.

We conducted a randomized study in patients with previously untreated advanced (T3) larynx carcinoma to compare total laryngectomy followed by radiotherapy to induction chemotherapy, followed by radiotherapy in good responders, and by total laryngectomy plus radiotherapy in poor responders. A total of 68 patients were included in the study, 36 in the induction chemotherapy group and 32 in the no chemotherapy group. 15 of the 36 patients in the induction chemotherapy group did not have a laryngectomy. Survival and disease-free survival were significantly worse in the induction chemotherapy group than in the no chemotherapy group (P = 0.006 and P = 0.02, respectively). The 2-year survival rates were 69% in the induction chemotherapy group and 84% in the no chemotherapy group. Larynx preservation for patients, selected on the basis of having responded to induction chemotherapy, cannot be considered a standard treatment at the present time.

Selective reinnervation of the abductor and adductor muscles of the canine larynx after recurrent nerve paralysis.

Functional rehabilitation of the larynx after unilateral vocal cord paralysis was attempted in the dog by selective reinnervation of the laryngeal muscles. The intralaryngeal branches of the right recurrent nerve were dissected. The adductor branch was anastomosed with the ansa cervicalis; the abductor branch was anastomosed with the trunk of the phrenic nerve either within the larynx or through the recurrent nerve, the adductor branch of which was sectioned. Results could be analyzed in seven dogs: mobility of the vocal cord was checked, and electromyography, stimulation of the nerves, and histologic studies were performed. Functional reinnervation of both the adductor and abductor muscles was obtained in only one case, with good abduction. Adduction was recorded in five cases. False-positive results emphasize the necessity of collecting several types of data before concluding that functional reinnervation has been accomplished. The reliability of the procedure can and must be improved.

Experimental reinnervation of a strap muscle with a few roots of the phrenic nerve in rabbits.

In order to compare application of the roots of the phrenic nerve to the ansa hypoglossi for laryngeal muscle neurotization, 1 or more roots from the phrenic nerve were implanted into the right sternothyroid (RST) muscle of rabbits (n = 36). Controls were intact animals (in which RST innervation is provided by the ansa; n = 6) and denervated ones (n = 6). At 66 +/- 2 days (mean +/- SE) after neurotization, during quiet breathing, inspiratory electromyographic activity and isometric contraction force were observed in all reinnervated RST muscles (n = 24). During maximal inspiratory effort, electromyographic activity and force increased. In animals reinnervated by the C4 root alone, forces (46.22 +/- 7.8 g) were significantly higher than in intact animals (10.83 +/- 5.0 g). Retrograde labeling proved the phrenic origin of the neurotization. Electromyography of the diaphragm was recorded. We conclude that in rabbits, neurotization of a strap muscle by 1 or 2 roots of the phrenic nerve allows inspiratory contraction, even during quiet breathing. Such inspiratory activity is not observed in sternothyroid muscles of intact animals innervated by the ansa hypoglossi.