[Transsexualism: from diagnosis to management]. / Transsexualisme: du diagnostic à la prise en charge thérapeutique.

The transsexualism or gender dysphoria is a pathology during which an individual does not recognize himself in his sexual identity and wishes to change it: in that it must be differentiated from the sexual ambiguities (hermaphrodism, pseudohermaphroditism) in which the sexual phenotype is not clearly established. In France the number of transsexuals is estimated at approximately 50,000 people. Since 2009 the transsexualism is not any more considered as a mental illness, it remains regarded as a long term illness. The objective of this article is to present the recent evolutions concerning the management of transsexual patients seeking feminization.

Endoscopic resection of sinonasal adenocarcinomas.

OBJECTIVE: To evaluate the outcome and morbidity of endoscopic resection of sinonasal adenocarcinomas. METHODS: This is a case series of 17 patients diagnosed with sinonasal adenocarcinoma that were resected endoscopically between 1999 and 2008. RESULTS: The surgery constituted the first line of treatment for all patients. Five anterior skull base reconstructions were done. Post-operative meningoencephalitis and minimal epistaxis were the complications reported. The mean follow-up was 3 years [6-107 months]. To date, there have been two local recurrences at 6 months of an insufficient resection of a tumour classified pT4 and 25 months of a pT2 resected with safe margins. Another patient presented an unique metastasis in the parietal lobe 42 months after the resection of tumour pT4 extended to the frontal lobe. Two deaths unrelated to the disease were reported while thirteen patients remained free of disease (76.5%). CONCLUSION: The endoscopic approach is a safe and effective treatment in selected cases of sinonasal adenocarcinomas. This procedure is less invasive than conventional surgery but requires an optimal preoperative imaging protocol and an experienced surgical team. These encouraging results have to be confirmed by a larger cohort and a longer follow-up.

[Ruptured pexis after supracricoid partial laryngectomy: a series of 5 cases]. / Les lâchages de pexie dans les laryngectomies partielles supracricoidiennes: à propos de 5 cas.

OBJECTIVES: Supracricoid partial laryngectomies have a rare but a specific complication which is the rupture of the pexy. After cricohyoidoepiglottopexy or cricohyoidopexy, a separation can appear between the hyoid bone and the cricoid cartilage. Our objective was to define how to treat and to prevent this complication. METHODS: One hundred and one supracricoid partial laryngectomies were performed in our department between 1980 and 2006. A retrospective analysis of the medical charts and operative files revealed that 5 patients have had a ruptured pexy. A review of the diagnosis, management, and outcome of these five cases is presented and discussed in this paper. RESULTS: The diagnosis was done in the first post-operative month for all cases. Delay in decannulation time, swallowing disorders, local infection were associated with the rupture of the pexy. The separation between the hyoid bone and the cricoid cartilage was also suspected at neck palpation and in endoscopy. Lateral plain Xrays of the neck or CT scans were used to confirm the diagnosis. A medical treatment, a completion total laryngectomy and three revisions of the pexis were performed. CONCLUSIONS: In our series, an antecedent of radiation before surgery appears to be a risk factor for the development of this specific complication. A revision of the pexis procedure is advocated in case of a major ruptured pexis.

[Major orbital complications of acute maxillary sinusitis of dental aetiology]. / Complications orbitaires majeures des sinusites maxillaires aiguës d'origine dentaire.

OBJECTIVES: To demonstrate the importance of searching for a dental aetiology when confronted with an orbital cellulitis secondary to an acute unilateral maxillary sinusitis and to diagnose and treat as soon as possible in order to avoid visual sequelae. CASE REPORT: Two cases are presented. The first case of a 35 year-old man who was diagnosed and treated late, for an orbital abscess secondary to a sinusitis of dental origin. The patient presented with visual signs such as diplopia and impaired occulomotoricity. The clinical diagnosis was concluded by an emergency sinus CT scan. Treatment consisted of an urgent surgical drainage associated to broad spectrum antibiotics with a high spectrum against Gram +cocci and anaerobes. Dispite this treatment regimen and two subsequent surgeries, the evolution was pejorative ending in a unilateral blindness. The second case is of a 45 year-old immunodeficient woman, presenting with the same pathology but without visual signs and whose evolution was satisfactory after adapted surgical and medical treatments. DISSCUSSION: The presence of visual and ocular signs warn on the gravity of the infection and indicate the need for urgent surgery. Sinus CT scan is essential to highlight the association between the orbit and the causal dental infection. For that, it must include the alveolar processes of the maxilla to show the dental lesion which is usually missed clinically. Functional endoscopic sinus surgery achieves two goals here; one diagnostic by the direct exploration of the nasal sinus cavities and the other therapeutic by the possible drainage all the paranasal sinuses.

[Endonasal endoscopic approach in the treatment of sino-nasal inverted papillomas]. / Voie endonasale endoscopique dans le traitement des papillomes inversés naso-sinusiens.

INTRODUCTION: Sino-nasal inverted papilloma is a rare benign tumor of the nasal fossa and the paranasal sinuses for which the successful surgical treatment by an endonasal approach has been corroborated in the literature. Nevertheless, the authors aim in this study to evaluate the advantages and the limits of this approach, to analyse its failures and its recurrences, and to define the indications for using it with the external or dissimulated approach. MATERIAL AND METHODS: 42 patients presenting with a sino-nasal inverted papilloma and treated surgically over a ten year period were included in this retrospective study. The operative technique was chosen as a function of the endonasal and radiological examination results (CT scan and MRI). Follow-up was over one year for all patients. RESULTS: Twenty eight patients were operated exclusively through an endoscopic endonasal approach. Fourteen patients were operated using a combined approach, associating either a vestibular (9 cases), a paralateral nasal (3 cases) or a fronto-orbital (2 cases) approach with endonsal endoscopy. In two cases, an associated squamous cell carcinoma was found. We observed a recurrence in 9.5% of the all cases and in 14.2% of the patients treated using a combined approach. CONCLUSIONS: Endoscopic endonasal surgery is a validated surgical approach for the treatment of sino-nasal inverted papilloma in that total tumor removal is possible. This approach is particularly indicated in medially-situated papillomas without frontal or maxillary extension. In all other cases, associating an external or dissimulated approach is usually necessary.

[Treatment of simple snoring by radiofrequency velar coblation]. / Traitement du ronflement simple par coblation vélaire.

OBJECTIVES: Short- and long-term evaluation of the efficacy and safety of radiofrequency velar coblation for simple snoring. MATERIAL AND METHODS: From February 2000 to May 2004, 175 patients underwent a single radiofrequency session for velar coblation. All patients suffered from snoring without sleep apnea. They presented modifications of the velo-pharyngeal region but did not have tonsillar or basilingual hypertrophy. Outcome was assessed in terms of pain, changes in snoring, secondary effects and complications at three months and one, two, and three years. Secondary uvulectomy was performed in 28 patients. RESULTS: At three months, snoring had decreased in 82% of patients with complete resolution in 12%. Outcome remained unchanged in 70% of patients at one, two, and three years. After uvulectomy, snoring declined in 96% of patients with complete resolution in 48%. Post-treatment pain lasted less than five days in 68% of patients. Mean duration was three days. Fifteen patients developed pharyngeal paresthesia which regressed at one year. Two patients had a nasal voice and three developed necrosis of the uvula. CONCLUSION: Velar coblation is a simple treatment for snoring which can be performed in a single session. The best results are achieved in patients whose body mass index is below 25 and after secondary uvulectomy.

[Levofloxacin in the treatment of acute and bacteriologically documented sinusitis with high risk of complications]. / Efficacité et tolérance de la lévofloxacine dans le traitement des sinusites aiguës bactériologiquement documentées et à risque de complications.

OBJECTIVES: The authors had for aim to evaluate the efficacy and tolerance of oral levofloxacin (500 mg once a day during ten days), as a treatment for acute bacterial sinusitis at risk for complications in adult patients. PATIENTS AND METHODS: This was a prospective, multicenter, open, non-comparative, efficacy and tolerance study of levofloxacin in acute sinusitis at risk for complications, radiologically confirmed, and with documentation of the bacterial origin by fiberoptic rhinoscopy. RESULTS: Two hundred and thirty-one patients were included and 174 patients had an X ray confirmed sinusitis. The localization was frontal in 81% patients, sphenoidal in 9.2%, ethmoidosphenoidal in 2.3%, and 7.5% patients had a pansinusitis. One hundred and thirty-three patients had a probable or proven bacterial infection, involving: Streptococcus pneumoniae (26.0%), enterobacteriaceae (19.7%), Haemophilus influenzae (17.3%), Staphylococcus aureus (15.0%), streptococci other than S. pneumoniae (7.9%), and Branhamella catarrhalis (5.5%). One hundred and one patients constituted the per protocol population. Clinical success was observed in 94.1 % patients (95/101), and 85.1% (86/101), respectively 7 to 14 days and three to four weeks after the end of treatment, with consistent success rates according to the localization of the infection, and the various pathogens involved. The tolerance data was as expected for levofloxacin. CONCLUSIONS: The results of this study show that levofloxacin, (one 500 mg tablet QD during ten days) is efficient in over 94% patients with bacteriologically documented sinusitis at risk for complications.

[Pseudoaneurysm of the internal carotid artery revelated by epistaxis: report of two cases]. / Pseudo-anévrysmes de l'artère carotide interne révélés par une epistaxis. A propos de deux cas.

OBJECTIVES: Pseudoaneurysms of the carotid artery are a rare but serious cause of epistaxis. They can be rapidly life-threatening. Usually resulting of a surgery or a traumatism, pseudoaneurysms can express themselves by recurrent epistaxis. Management of these epistaxis is discussed. METHODS: The authors present two cases and effect a review of the literature. RESULTS: The first patient presented with a pseudoaneurysm few days after a transsphenoidal surgery. The second patient presented with a pseudoaneurysm fourteen years after a radio-surgical treatment of an ethmoidal and frontal epidermoid carcinoma. Diagnosis was suspected during nasal endoscopy and confirmed in both cases with angio-CT and arteriography. The first patient underwent a selective embolization. The second patient had to have a carotid occlusion due to a sudden severe haemorrhage, resulting from a pseudoaneurysm rupture following the embolization attempt. CONCLUSION: Review of the literature confirms the indication of endovascular intervention. The optimal management is carotid occlusion, provided the patient can tolerate carotid test occlusion and the circle of Willis is satisfactory. In some cases, a preservative treatment may be possible, which could be either pseudoaneurysm embolization or the placement of a covered stent.

Short course therapy with cefuroxime axetil for acute otitis media: results of a randomized multicenter comparison with amoxicillin/clavulanate.

BACKGROUND: Otitis media is a common infection of childhood. Increasing antibiotic resistance rates among the principal causative pathogens, Streptococcus pneumoniae and Haemophilus influenzae, are associated with failure of first line agents. OBJECTIVE: This open, randomized, multicenter study compared the clinical efficacy of a short 5-day course of cefuroxime axetil (CAE) suspension with that of amoxicillin/clavulanate (A/CA) suspension for 8 or 10 days. METHODS: Children age 6 to 36 months with acute otitis media with effusion, diagnosed by tympanocentesis and microbiologic culture, were randomized to receive CAE (30 mg/kg/day in two divided doses for 5 days) or A/CA 40 mg/kg/day in three divided doses for 10 days (A/CA-10). In French centers A/CA was given at 80 mg/kg/day in three divided doses for 8 days (A/CA-8). Patients were assessed 1 to 4 days after completing the course (posttreatment) and followed up at 21 to 28 days after completing the course. RESULTS: Of the 716 patients randomized, 252 were treated with CAE, 255 with A/CA-10 and 209 with A/CA-8. In the clinically evaluable population, the proportions of patients with clinical cure at posttreatment were 175 of 203 (86%), 181 of 205 (88%) and 145 of 164 (88%) in the CAE, A/CA-10 and A/CA-8 groups, respectively, demonstrating equivalence among the three treatments. For patients <18 months old, clinical cures were 111 of 134 (83%), 116 of 131 (89%) and 83 of 99 (84%) in the CAE, A/CA-10 and A/CA-8 groups, respectively; equivalence was also demonstrated. At follow-up, 130 of 175 (74%) CAE, 121 of 172 (70%) A/CA-10, and 112 of 142 (79%) A/CA-8 had maintained cure. A total of 837 pretreatment pathogens were isolated from middle ear fluid in 73% (522 of 716) patients, the majority of isolates were S. pneumoniae (30%) and H. influenzae (27%). The most common adverse events were gastrointestinal, the incidence of drug-related diarrhea being higher in the A/CA-10 group (18%) than in either the CAE or A/CA-8 groups (10%). CONCLUSIONS: A 5-day course of CAE, given twice daily, was shown to be equivalent to the two regimens of A/CA for treatment of acute otitis media with effusion in children.

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.

Functional endoscopic sinus surgery and 109 mycetomas of paranasal sinuses.

Mycetomas of paranasal sinuses are more frequently diagnosed with the widespread use of nasal endoscopy and computed tomography (CT). We present a series of 109 cases treated by functional endoscopic sinus surgery (FESS) with a mean follow-up of 29 months. All localizations were seen, and contrary to what was initially thought, seven cases presented in multiple sites. Several clinical presentations were found, from a pansinusal involvement to a simple mycetoma hanging in a superior meatus. A heterogeneous sinus opacity with microcalcifications on CT scan is very suggestive of the diagnosis, but a homogeneous opacity may be encountered even with bone lysis. FESS was performed in all cases to obtain a wide opening of the affected sinuses, permitting a careful extraction of all fungal material. In the postoperative period, no medical treatment is prescribed. With a mean follow-up of 29 months, only four recurrences were seen. This study reinforces the interest in FESS for cases of mycetoma of the paranasal sinuses.

[ENT and neurosurgical team approach to malignant ethnoido-frontal tumors]. / Abord mixte O.R.L. et neuro-chirurgical des tumeurs malignes ethmoïdo-frontales.

The authors describe a surgical technique of total ethmoidectomy by mixed frontal and paralateronasal duct for excision of the ethmoidal bloc tumors. This technique requires a surgical team aware of neurosurgical and ORL problems. The authors report their experience on a series of six patients, surgically managed from 1983 to 1990.

[Postoperative external irradiation of epidermoid epitheliomas of the larynx and hypopharynx. Analysis of tumor control factors in and outside of the neck]. / Irradiation externe postopératoire des épithéliomas épidermoöides du larynx et de l'hypopharynx. Analyse de facteurs du contrôle tumoral dans et hors du cou.

The authors present a retrospective analysis of 138 patients with squamous cell carcinoma of the hypopharynx and larynx treated with post-operative irradiation. Overall tumoral control rate within the treated areas was 73.9%, uncorrected actuarial survival rates at 3 years and at 5 years were respectively 49.4 and 37.6%. The clinical status (TNM-UICC, 4th edition, 1987) seems to be the main determinant for the prognosis in terms of cervical tumoral control. Patients with N0-N1 nodal stage presented 14/88 (15.9%) cervical failures, while patients staged as N2-N3 presented 22/50 (44%) tumoral recurrences within the treated areas (P less than 0.001). Pyriform sinus tumors were found to present cervical relapses in 13/32 cases (40.6%). This recurrence rate was significantly higher than cervical failure risk in other tumoral sites (P less than 0.05). Cervical relapse (P less than 0.0001), N2-N3 nodal stage and pyriform sinus localization (P less than 0.05) were all found to increase metastasis rate. On the other hand, our results show that the use of post-operative irradiation reduces the prognostic influence of the primary tumor volume; in the same manner, the use of modulated post-operative external irradiation permits the control of microscopically positive surgical margins. In conclusion, the initial staging alone is sufficient to safely evaluate the risk of cervical relapse or metastatic spread; the use of these clinical parameters for selecting patients who could benefit from adjunctive chemotherapy is discussed.

The holmium:YAG laser for treatment of inferior turbinate hypertrophy.

Chronic hypertrophic rhinitis is sometimes refractory to local, as well as general, medical treatment. Before undertaking surgical reduction of the inferior turbinates, there is indisputably a place for cauterization or laser vaporization of the inferior turbinate mucosa. The authors present a study of 46 patients treated by the holmium:YAG laser for chronic hypertrophic rhinitis. The results after only one laser session are satisfactory in 89.1% at 6 months' follow-up and in 52.2% with mean follow-up of 16.2 months. No major secondary effects were observed.

Nasopharyngeal tuberculosis.

Rhinopharyngeal tuberculosis is a rare pathological condition. It is most often associated with lymph node and pulmonary lesions, but it may be an isolated finding. The authors report a recent case of an isolated rhinopharyngeal tuberculosis in a 64-year-old female. A review of the literature is presented. They emphasize the clinical presentation, that, in all aspects, may resemble a malignant tumour of the nasopharynx, as well as the difficulty of obtaining a pathological and bacteriological diagnosis.

Predictive factors of a complete response to and adverse effects of a CDDP-5FU combination as primary therapy for head and neck squamous carcinomas.

Retrospective analysis of detailed patient and tumour factors associated with a complete response to combination inductive chemotherapy with CDDP-5FU (96 or 120 hour continuous infusion) was performed using data from 147 patients with a previously untreated squamous cell carcinoma of the oral cavity, oropharynx or pharyngo-larynx following completion of two (29 patients) or three (118 patients) cycles. Adverse reactions to chemotherapy were documented for all 164 patients included in the study. Eight drug-related deaths occurred due to: acute myocardial infarction (five patients), peptic ulcer disease (two patients) and severe neutropenia with sepsis (one patient). Severe non-lethal complications included marrow depletion (14 patients), peptic ulcer (two patients), thrombophlebitis (seven patients), angina pectoris (two patients), stroke (one patient), pulmonary oedema (one patient) and convulsions (one patient). Six patients refused further treatment because of untoward side effects and tumoral progression was observed in three cases. Separate response rates for the primary site and nodes were determined and analysis of respective predictive factors of response was performed. Complete response was obtained in 31 per cent at the primary site versus 18 per cent for the nodes (p < 0.05). The combined (primary site + nodes) overall complete response rate was 22 per cent. Among 11 factors studied (age, sex, performance status, primary site, tumour differentiation, initial resectability, 5FU dosage per cycle, number of cycles, T, N and TN stages), only performance status, N stage, resectability and number of cycles were associated with a combined complete response. Multivariate analysis showed performance status, N stage, TN stage and resectability to be significant predictive factors of a combined complete response.(ABSTRACT TRUNCATED AT 250 WORDS)

Mucoceles of the paranasal sinuses: uncommon location.

Mucoceles are the most common lesions causing expansion of the paranasal sinuses. The sinuses most commonly involved are, in decreasing order of frequency, frontal sinus, ethmoid sinuses, maxillary sinus and sphenoid sinus. We reviewed 46 cases of surgically proven mucoceles and the purpose of this study was to report five cases of mucoceles in an uncommon location.

[Pristinamycin in the outpatient treatment of acute sinusitis in adults]. / Place de la pristinamycine dans le traitement des sinusites aiguës de l'adulte en ville.

TWO MAIN GERMS: The risk of severe complications of acute bacterial sinusitis warrants empirical antibiotic therapy targeted against the two main causal agents: S. pneumoniae and H. influenzae. PRISTINAMYCIN VS CEFUROXIME AXETIL: A double-blind placebo-controlled randomized multicentric study conducted with two treatment arms including 310 patients has demonstrated that pristinamycin, 2 g/d for 8 days, has a clinical efficacy equivalent to cefuroxime axetil, 500 mg/d. IN CLINICAL PRACTICE: Pristinamycin is an interesting alternative to beta-lactams for the first intention treatment of purulent acute sinusitis in adults. Its efficacy against penicillin-resistant pneumococci and H. influenzae is a further reason for its use in case of failure after conventional treatments.

[Inflammation and acute pharyngo-tonsillitis]. / Inflammation et pharyngo-amygdalites aiguës.

1. FACTS: Despite several studies, it has been impossible to establish a correlation between bacteriological and clinical findings in erythematous pultaceous sore throat. 2. A RULE: Antibiotics should be prescribed for group A streptococcal sore throat alone. 3. INFLAMMATION AND INFECTION: In acute tonsilitis, inflammation is perfectly proportional to infection; 4. INFLAMMATORY CYTOKINES: Their extremely important role in the pathogenesis of different inflammatory processes has been demonstrated in acute tonsilitis. 5. RECOMMENDATION: Based on the fact that no clinical argument can confirm or infirm the streptococcal cause, it is recommended to use a rapid diagnostic test in all adults or children with sore throat. 6. A QUESTION: No data are available demonstrating the benefit of non-steroidal antiinflammatory drugs at antiinflammatory doses or of general corticosteroid treatment of acute sore throat. Nevertheless, in non-A hemolytic streptococcal where antibiotic treatment is not indicated, wouldn't it be useful to prescribe symptomatic antiinflammatory treatment?

[Total esophagectomy by stripping without thoracotomy in cancer of the pharynx, esophagus and cardia. 34 cases]. / L'oesophagectomie totale par "stripping" sans thoracotomie dans les cancers du pharynx, de l'oesophage et du cardia. Trente-quatre observations.

Total oesophagectomy by stripping without thoracotomy was performed in 34 cancer patients to reduce operative mortality and morbidity in those with impaired respiratory function. The carcinoma was located in the pharynx in 20 cases, on the cardia in 9 cases and on the lower oesophagus in 5 cases. Reconstruction in the posterior mediastinum was effected with the descending colon in 32 patients. The operative mortality rate was 11.8% and fistulization developed in 20.6% of the cases. Eight patients (26.5%) required post-operative endoscopic dilatation. Ninety per 100 of the patients who survived surgery resumed satisfactory feeding. Thus, these patients with high operative risk who underwent oesophagectomy by stripping without thoracotomy benefited from tumoral excision and normal feeding with results comparable to those of other types of oesophagectomy.