Head and neck lymphatic malformation and treatment: Clinical study of 23 cases.

OBJECTIVES: Head and neck lymphatic malformation is a rare benign tumor, mainly affecting children under 1 year of age. Total resection is often difficult, and recurrence is frequent. Functional and esthetic sequelae are a major issue. MATERIALS AND METHODS: A single-center retrospective study recruited patients with head and neck lymphatic malformation managed surgically, with or without associated sclerosis by alcohol, bleomycin or aetoxisclerol, between January 1, 2004 and December 31, 2013. Local control, recurrence and complications rates were analyzed, as were swallowing disorder, tracheostomy and impaired phonation. RESULTS: Twenty-three patients, with a mean age of 15.80 years, were included. Location was suprahyoid in 17 cases (73.91%) and infrahyoid in 6 (26.09%). There were 11 macrocysts (47.82%), 2 microcysts (8.70%) and 10 mixed lesions (43.48%). Three patients showed spontaneous resolution; 12 patients (52.17%) underwent a single surgical procedure, 2 (8.7%) multiple procedures, 2 (8.7%) 1 surgical procedure and 1 sclerosis, 2 (8.7%) 1 surgical procedure and multiple scleroses, and 2 (8.7%) multiple procedures and multiple scleroses. The local control rate was 69.56%. There were 8 recurrences (34.78%), all in suprahyoid microcystic or mixed lesions. There were 2 complications (8.7%): 1 severe upper cervical edema following sclerosis of the floor of the mouth, and 1 postsurgical palsy of the marginal mandibular branch of the facial nerve. In 1 case (4.35%), a nasogastric tube was required for 6 days, without tracheostomy. CONCLUSION: Recurrence was frequent, with non-negligible functional and esthetic impact, especially in case of suprahyoid and microcystic lesion.

Paranasal sinus rhabdomyosarcoma: a rare tumor of poor prognosis.

INTRODUCTION: Rhabdomyosarcoma (RMS) is a rare sarcoma, in which paranasal sinus locations are exceptional in adults. CASE REPORT: We report a case of ethmoid metastatic RMS in a 48-year-old patient, discovered in connection with recurrent epistaxis associated with exophthalmia and ophthalmoplegia. The tumor was inoperable and chemotherapy based on adriamycin was initiated. The course was, however, marked by rapid worsening of symptoms and the patient's death. DISCUSSION: Paranasal sinus RMS shows no specific clinical signs, and diagnosis is mainly based on immunohistochemical analysis. The association of surgery and chemo-radiotherapy is the optimal attitude, but surgical resection is often impossible due to local extension. Prognosis in adults is poor.

Isolated hypoglossal palsy due to cervical osteophyte.

INTRODUCTION: Isolated hypoglossal nerve palsy is rare, and etiological diagnosis is difficult. We report a case of isolated hypoglossal compression by a cervical osteophyte in the hypoglossal canal exit. CASE STUDY: An 86-year-old woman with history of cervical spondylotic myelopathy consulted for a lesion of the free edge of the tongue with impaired elocution. Clinical examination found a bite lesion on the right free edge of the tongue with right lingual amyotrophy and associated left deviation on retraction. Isolated right hypoglossal palsy was diagnosed. Skull base CT found a cervical osteophyte compressing the hypoglossal nerve at the exit from the right hypoglossal canal. Surgery was contra-indicated by the patient's general health status. No motor recovery was observed at 6 months' follow-up, but the elocution disorders regressed under speech therapy. CONCLUSION: Hypoglossal palsy is infrequent, but generally a sign of skull base pathology. History-taking and careful examination guide rational selection of the radiological examinations required for etiological diagnosis.

Transoral robotic surgery for head and neck cancer: a series of 17 cases.

OBJECTIVES: Transoral robotic surgery (TORS) is an innovative surgical technique indicated for resection of selected head and neck cancers. The authors report their experience and discuss the indications, advantages and disadvantages of this technique. MATERIALS AND METHODS: Seventeen patients were operated by TORS in the Limoges University Hospital ENT department between March 2010 and January 2011. RESULTS: Tumour sites were the aryepiglottic fold (n=3), piriform sinus (n=2), lateral pharyngeal wall (n=3), posterior pharyngeal wall (n=2), base of tongue (n=3), vallecula (n=1), epiglottis (n=2) and arytenoid (n=2). One patient had two primary sites treated by TORS. This series comprised two stage I (11.7%), seven stage II (41.2%), six stage III (35.4%) and two stage IVa tumours (11.7%). Mean TORS set-up and operating times were 20.5 and 39.7 minutes, respectively. No major intraoperative complication was observed. One patient was reoperated on D5 for bleeding. Fifteen patients had clear surgical margins. Swallowing was restored on D2 for nine patients. The mean length of hospital stay was 10 days. Seven patients received adjuvant radiotherapy, seven patients were treated by chemoradiotherapy and three patients were submitted to simple clinical surveillance. CONCLUSION: TORS appears to provide new treatment options for head and neck cancers by extending the indications for endoscopic resection for selected cases of head and neck cancers. It allows effective cancer resection under excellent operating conditions with low morbidity and improved functional recovery. This new treatment modality needs to be evaluated in relation to other open surgery, endoscopic laser and chemoradiotherapy techniques.

[A new look on septoplasties: an anatomo-clinical study and surgical procedures of the 4 main septoplasties]. / Les septoplasties revisitées: étude anatomo-clinique et technique chirurgicale des 4 principales septoplasties.

The aim of a nasal septum surgery is functional and aesthetic aims. With a semiologic study the authors analyse four kinds of septoplasties which allows to correct the main septal deviations: erndoscopic septoplasty for posterior nasal obstruction, Cottle's septoplasty for septum's luxation and deviation on the premaxilla area, septoplasty with spreader grafts for dorsum cartilage deviations, extracorporeal septoplasty with a new septum cartilage frame for the complex deviations. The authors emphasize on the help given by videoendoscopy during the surgical procedures.

Bilateral paranasal sinus mucopyoceles in a child with cystic fibrosis.

Mucoceles of the paranasal sinuses are well-described complication of chronic sinusitis in adults. They are extremely rare in children and the main predisposing factor is cystic fibrosis (CF). We report a case of bilateral ethmoid and maxillary sinus mucopyoceles, associated with CF occurring in a six months old boy. The main symptom was a complete nasal obstruction. The marsupialization of mucocele was performed by endoscopic surgery. One year follow-up showed no recurrence.

Expression levels of thymidylate synthase, thymidylate phosphorylase and dihydropyrimidine dehydrogenase in head and neck squamous cell carcinoma: preliminary study.

INTRODUCTION: Pharyngo-laryngeal tumors classified as T3-4, N0-3, M0, are conventionally treated by mutilating surgery (total (pharyngo)-laryngectomy). Neo-adjuvant chemotherapy with 5-FU/platinum salt can be proposed in an attempt to preserve the larynx. The level of the response to chemotherapy ranges from 36 to 54% of cases. Thus, a large number of patients receive chemotherapy that is ineffective and not free from adverse effects. Three main enzymes are involved in the metabolism of 5-FU: thymidylate synthase (TS), thymidylate phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD). Several studies suggest that a high level of expression of these three genes correlates with a poor clinical response to 5-FU. The main purpose of our study was to look for a correlation between the levels of expression of the genes for sensitivity to 5-FU (TS, TP, DPD) within the tumor and the clinical response observed after three courses of chemotherapy combining 5-FU/platinum salt in patients presenting with advanced cancer of the pharyngo-larynx. METHODS: This was a prospective genetic study that had required approval from the Ethics Committee. The main assessment criterion was based on the assessment of the clinical response by an ENT panendoscopy and a cervical CT scan, after three courses of chemotherapy. The expression of the genes was determined by quantitative RT-PCR, using total RNA extracted from tumor biopsies taken during the initial panendoscopy. RESULTS: The means calculated, in our study, for the three genes of interest (TS, TP, DPD) were lower in the responder group than those in the non-responder group. DISCUSSION: Our preliminary findings reveal trends that confirm the hypothesis that the lower the level of expression of the sensitivity genes, the better the clinical response to chemotherapy. They now form part of a larger study that is currently in progress.

[Ophthalmic arteries originating from external carotid arteries]. / Artères ophtalmiques issues des carotides externes. A propos d'un cas.

The ophthalmic artery arises from the internal carotid at the level of the carotid siphon; in 3.5-5% of the population, it arises from the middle meningeal artery, a branch of the internal maxillary artery, terminal of the external carotid artery. We report a rare case of bilateral malformation in a 28-year-old patient. Our study covers the possible dual origin of orbital blood vascularization. This variation in the anatomic distribution is important to know, particularly if embolization is intended as inadvertent occlusion of the ophthalmic artery, because it may lead to permanent loss of vision.

[Induction chemotherapy and laryngeal preservation in pharyngolaryngeal carcinomas. Study of a 124 serie's patients and patient's follow up with laryngeal preservation]. / Chimiothérapie d'induction et préservation laryngée dans les cancers du pharyngolarynx. Etude d'une série de 124 patients et suivi des patients en préservation laryngée.

OBJECTIVE: To try and determine the value of chemotherapy and its subsequent effect on laryngeal preservation in patients presenting with laryngeal and pharyngeal carcinomas. One group was initially treated with surgery and radiotherapy. The second group was treated with chemotherapy and subsequent salvage surgery and/or radiotherapy. Their survival rates and laryngeal preservation rates were compared. PATIENTS AND METHODS: From 251 patients the authors have retrospectively studied 124 patients with induction chemotherapy. The survival rate has been compared with a control group of 127 patients who was treated by initial surgery and radiotherapy. RESULTS: The survival rate at 5 years for the patients initially treated by surgery and radiotherapy was 64.1%. The survival for patients with a total clinical response following chemotherapy was 49.8% at 5 years. Survival with no total clinical response following chemotherapy treated by secondary radiotherapy was 25.7% at 3 years. The initial rate of laryngeal preservation is 32.2% but this rate fell to 22% after local recurrencies. CONCLUSION: The group with total clinical response after induction chemotherapy with laryngeal preservation have a non significantly difference in their survival compared with the group initially treated by surgery and radiotherapy. In contrary patients with non complete clinical response have a survival of 25.7% at 3 years. The rate of local recurrency of patients with laryngeal preservation is 32.5% and gives a finally rate of laryngeal preservation of 21%. These recurrencies decrease the survival rate.

[Adult laryngeal cavernous hemangioma: a case report]. / Malformation veineuse laryngée de l'adulte: à propos d'un cas.

We describe a case of laryngeal venous malformation, discovered by dysphonia. This malformation has a different histology and evolution compared to infant laryngeal hemangioma. The histological exam shows large and multiple vessels lined by regular endothelium. There is no spontaneous regression; this malformation can be stable or increase and induce a laryngeal obstruction. Although inconstant, a bluish colour, seen at endoscopy, suggests the presence of venous malformation. The diagnostic is confirmed by MRI, which shows local extension. We propose regular clinical and radiological supervision for asymptomatic venous malformations. Treatment is recommended only for symptomatic patients usually by laryngeal microsurgery or cervicotomy. Per cutaneous sclerosis is an interesting alternative therapy alone or prior to surgery. Regular follow-up is essential in order to detect frequent recurrences.

[Laryngeal Preservation with Induction Chemotherapy. Experience of two GETTEC Centers, Between 1985 and 1995]. / Préservation laryngée par chimiothérapie d'induction.

This is a retrospective study of laryngeal preservation in endolaryngeal cancer with induction chemotherapy and radiotherapy for good responders. Between 1985 and 1995, 104 patients were treated in Institut Gustave Roussy (87 patients) and in Limoges (17 patients). The overall survival for the whole population was 76% and 69% at 3 and 5 years respectively, with a 36% rate of laryngeal preservation. In this retrospective series of patients, the single prognostic factor affecting survival was arytenoid mobility before treatment (66% and 55% at 3 years vs 85% and 82% at 5 years; p<0.004). Loco-regional failures were higher (33% vs 15%, p<0.03), and laryngeal preservation was lower (18% vs 51%) among patients with a fixed arytenoid (49 pts), compared with patients with a non fixed arytenoid (55 pts) ). The percentages of patients with a fixed arytenoid could explain the conflicting results of the two randomized studies of laryngeal preservation in laryngeal cancer.

[Lymph node metastasis of cutaneous epidermoid carcinomas of the head and neck: prognostic factors and therapeutic strategies. Apropos of a series of 13 cases]. / Métastases ganglionnaires des carcinomes épidermoïdes cutanés cervico-faciaux. Facteurs pronostiques et modalités thérapeutiques. A propos d'une série de 13 cas.

UNLABELLED: Squamous cell skin carcinoma has a relatively low rate of metastasis (0.5 to 16%), but the prognosis of these metastases is poor (22% of survival at 5 years). PATIENTS AND METHODS: from a series of 243 patients, we studied 13 patients who were found initially to have metastases or who developed metastases later. Fifty-four percent (54%) of the patients presented initially with regional lymph node and parotid involvement in 54%. RESULTS: All patients underwent surgery with removal of the skin cancer and a neck dissection. Radiotherapy was performed later in 92% of the cases. The 2 years survival rate was 62% and mean survival by Kaplan Meier curve was 47 months. DISCUSSION: Poor criteria of these cutaneous tumors are defined: tumor size, histologic differentiation, perineural spread. Patients with severe criteria must have a neck dissection to control the first lymph node. Along the anatomic area of the cutaneous tumor, a parotidectomy, a submaxillary control or a neck dissection will be performed. Its involvement will be followed by a neck dissection. A comparative study of the literature is made. Poor prognostic criteria of these cutaneous tumors are defined, in addition to the initial management of the cervical and parotid lymph nodes.

[Adenoid cystic carcinomas invading the skull base. Apropos of 4 cases and review of the literature]. / Carcinomes adénoïdes kystiques envahissant la base du crâne. A propos de 4 observations et revue de la littérature.

Head and neck adenoid cystic carcinomas may invade the adjacent skull base by bone lysis and/or by perinervous and perivascular spread within the skull base foramina. Neurosurgical decision making is not well defined regarding the extent of intracranial tumor component removal, as neurosurgical expertise is limited for this peculiar type of tumors. The issue is to decide whether a radical supposedly locally curative surgery should be attempted, or if a large non disfigurating surgery is mandatory, keeping in mind the frequency of local recurrences and of distant metastases. Over a 13-year period, four adenoid cystic carcinomas invading the skull base were operated on at our institution: two tumors originated in the parotid gland, one in the sphenoid sinus, and one in the ethmoid sinus. Surgical removal was total in one case, subtotal in three cases. Post-operative irradiation was delivered in the four patients (two neutron irradiation, two conventional). One patient with advanced metastatic disease was submitted to chemotherapy. Three patients died from local tumor progression and distant metastases within three years after the intracranial tumor extension has been diagnosed. The patient with an ethmoid tumor is still alive seven years after surgery without any evidence of local tumor progression nor distant metastases. Surgery remains the gold standard treatment for adenoid cystic carcinomas invading the skull base. However, in our opinion a large tumor removal, without or with bone osteotomies, but without sacrifice of cranial nerves, cavernous sinus, internal carotid artery, and of the orbit allows patient survival with an acceptable comfort and absence of psychological distress due to disfigurating surgery nor surgically induced neurological functional deficit. Post-operative irradiation may sometimes stabilize locally the lesions. The place of chemotherapy has, yet, to be determined.

[Proposal for a predictive clinical scale in dysphagia]. / Proposition d'une échelle clinique prédictive du risque de fausses-routes.

The compiling of a predictive clinical scoring system for the risk of a false passage (FP) has its origins in the limitations of tests which explore only the cough reflex, known to be absent or faulty in 40% of patients investigated for problems of deglutition. A raised clinical score is based on the results of an exhaustive prospective study of 140 patients tested for the first time by videofluoroscopy for FP, this being the reference investigation for false passages. Discriminant analysis allowed the most selective variables to be identified and retained. We have identified 2 categories of patients, according to whether or not they have had any ENT past history. The score is obtained by adding the weighted values for the selected clinical signs. For those patients with an ENT past history, 5 clinical variables were retained: the absence of adhesions = 14, the presence of a velar reflex = 8, the capacity for voluntary deglutition = 8, glottic obstruction = 6, the absence of primitive reflexes = 6, giving a total score for the variables of between 0 and 42. If the total exceeds 32 or is less than 26, there is no FP; for scores between 32 and 26, videofluoroscopy is required to give more precise evidence of the risk. When this scoring system was applied prospectively to a series of 105 patients, a correct predictive result was obtained in 54 patients (51.4%), an equivocal result in 42 patients (40%), and a false result in 9 patients (8.6%), 3 of which (2.8%) were false negatives. The predictive score for FP allows evaluation of the risks of FP in at-risk patients, and adaptation of the treatment strategy according to the type of disordered physiology expected from the cause; thus videofluoroscopy can then be reserved for cases where treatment fails, so that the precise deglutition problem can be pinpointed.

[Nutritional status and clinical score of 95 patients examined by radiovideoscopy for deglutition]. / Etat nutritionnel et score clinique de 95 patients explorés en radiovidéoscopie de la déglutition.

Ninety five consecutive patients were examined. One performed swallowing videoradioscopy, swallowing clinical score calculation and nutritional assessment with four different methods: Body Mass Index (BMI), arm muscle circumference, dual frequency bioelectrical impedance analysis and serum albumin level. The easiest and the most reliable method for nutritional assessment, comparing to the others, was BMI, where only weight ant height were necessary to measure. So, the prevalence of protein-energy malnutrition was 24.2%, unlinked neither with the presence of videoradioscopy swallowing disorders nor with clinical swallowing score level. The score level was inversely correlated with the presence of videoradioscopy swallowing disorders, and correlated with feeding types: the highest for per os normal feeding, the lowest for patients with parenteral nutrition. The presence of videoradioscopy swallowing disorders was inversely correlated with feeding types. Swallowing clinical score was validated.

[A voluminous exteriorized odontogenic keratocyst]. / A propos d'un volumineux kératokyste odontogénique extériorisé.

The authors report the case of a 63 years old man who presented a voluminous exteriorized keratocyst of the jaw. We have first made a punction of the cyst in order to facilitate the operation. Anatomopathological examination of the liquid found epithelial cells. We collected the keratocyst by a non interrupting mandibulotomy via cervical incision.

[Adenocarcinoma of the ethmoid sinus in woodworkers. Retrospective study of 25 cases]. / Adénocarcinomes de l'ethmoïde chez les travailleurs du bois. Etude rétrospective de 25 cas.

A retrospective oncological study was performed in 25 woodworkers, in whom an adenocarcinoma of the ethmoid sinuses was discovered between March 1985 and December 1993. All patients were males with a mean age of 57 years, and a mean duration of wood dust exposure of 24 years. Signs of nasal obstruction, drainage, and discomfort were present in all cases. Ophthalmological findings were a poor prognosis indicator. It was possible to precisely evaluate treatment and outcome in 23 cases. The majority of tumors were classified as T3 or T4 (72%), with extension beyond the ethmoid sinuses; all were in contact with the roof of the ethmoidal sinuses. Extension was predominantly into the orbital and intracranial cavities as compared with extension posteriorly or into the maxillary sinuses. Treatment was identical in the 25 patients: a) combined surgery including a paranasal and a neurosurgical approach, b) postoperative radiotherapy. Results were expressed in terms of morbidity related to surgery and the oncologic outcome. Operative morbidity and mortality were substantially reduced with reconstruction of the roof of the ethmoidal sinuses. Meticulous excision, in addition to postoperative radiotherapy, resulted in a decreased rate of local recurrence (26%). On the other hand, metastasis were encountered more frequently (30%). Radiotherapy was insufficient when macroscopic excision was incomplete. Chemotherapy was used as palliative treatment in the event of a recurrence and/or metastases. Survival rate was 68% at 3 years, and 48% at 5 years. Most complications and recurrences arose within the first two years. Exophthalmos, intracranial extension, incompleteremoval, and extensive class T4 tumors were associated with a poor prognosis. Optimal therapy for malignant tumors of the ethmoid sinuses requires combined transfacial and neurosurgical approaches that allow precise assessment of tumor extension and adequate excision, yielding an improved oncologic outcome. Followed by radiotherapy, this association can result in a remission. Patient prognosis depends essentially on management of the initial lesion.

[Is laryngeal papillomatosis always juvenile?]. / La papillomatose laryngée est-elle toujours juvénile?

After recording an increased frequency of adult-onset recurrent respiratory papillomatosis, the authors propose a multicentric investigation. The aim of the investigation is to determinate the frequency of the new cases and their clinical form. The preliminary results confirm the increased frequency of the adult-onset form and show the possibility of a clinical form change.

[Closure of esotracheal fistula after phonation implants. Technique and results of tracheal ascension]. / Fermeture des fistules oesotrachéales après pose d'implant phonatoire. Technique et résultat de l'ascension trachéale.

Enlarging tracheoesophageal fistula after tracheoesophageal prosthesis for voice rehabilitation remains a major challenge. The authors analyze the results of treatment of 15 severe enlarging tracheoesophageal fistulas among 28 cases (52%) of tracheoesophageal voice rehabilitation which occurred during a 4 years period of time. Among these 15 cases, a spontaneous closure occurred in 3 cases (20%), a two layers closure was performed in 4 cases (26%) and a closure using a tracheal ascension associated with the design of a new tracheostoma was performed on 8 cases (53%). The authors describe the surgical technique and discussed the advantages of surch technique.

Ewing's sarcoma of the mandible: a case report.

The authors report the case of an 8-year-old boy with a Ewing's sarcoma localized to the mandible. The therapeutic modalities consisting of induction chemotherapy, surgical removal of the involved portion of the mandible with reconstruction using a parascapular osteo-cutaneous free flap, and maintenance chemotherapy are described. Emphasis is placed on the importance of performing a wide resection and the use of a multidisciplinary team approach in the treatment of these unusual tumours.