Postoperative follow-up of juvenile nasopharyngeal angiofibromas: assessment by CT scan and MR imaging.

The purpose of this study was to assess the radiological findings after surgical removal of juvenile nasopharyngeal angiofibromas (JNA). The postoperative CT and MRI scans of ten patients were reviewed. The cured group included six patients. The non-controlled group included six patients with eight recurrences. Two patients belonged to both groups as they were also followed and cured after surgery for relapse. Four recurrences were asymptomatic and diagnosed by imaging. The imaging patterns were matched to the patients clinical status and endoscopic findings. In the cured group, non-enhanced residual soft tissue masses were seen in all cases. In the non-controlled group, recurrence was always demonstrated on early postoperative CT or MR as a dramatically enhanced mass. The recurrence was located in the lateral or superior aspect of the nasopharynx (n = 3), deep to the fossa of Rosenmuller (n = 4) or out of the nasopharynx (n = 1). In two cases a remaining enhanced mass disappeared spontaneously on iterated examinations. Because of numerous asymptomatic relapses, a radiological workup is recommended four months after surgery, even in patients with normal endoscopy, to rule out posterolateral or extranasopharyngeal recurrences. Spontaneous evolution of residual masses must be appreciated on iterated imaging examinations.

[Hypoglossal-facial anastomosis. A report of 60 cases]. / Anastomose hypoglosso-faciale. A propos de 60 cas.

The authors report their experience of 60 cases of hypoglosso-facial anastomosis. The results of this retrospective series were analysed by the same examiner according to the House and Brackmann classification. The surgical technique is rapidly described, with emphasis on the important points. The results are analysed as a function of the interval between the anastomosis and facial paralysis: better and more rapid results are obtained when surgery is performed early (80% of grade 3 with immediate surgery versus 50% in very late surgery after more than 4 years). However, grade 3 or 4 can be obtained in every case, even in the case of very late surgery. Other favourable prognostic factors were revealed by this study: specialized rehabilitation and especially the patient's psychological must be integrated in this nerve transfer. In view of these good results and the limited adverse effects (atrophy of the hemi-tongue, eye-mouth synkinesias), hypoglosso-facial anastomosis must be part of the therapeutic strategy of total, permanent facial paralysis.

Objective evaluation of dysphonia: preliminary results of a device allowing simultaneous acoustic and aerodynamic measurements.

Voice quality analysis was performed in 88 normal speakers and 157 dysphonic speakers using a device that allows simultaneous study of acoustic and aerodynamic parameters during pronunciation of a sustained /a/. We compared the results with those of voice quality grading by a jury. The Mann-Whitney test showed significant differences between the grades of dysphonia for all the parameters chosen. Comparison of results (using discriminant factorial analysis) with perceptual evaluation by a jury showed concordance in 66.1%. Based on these preliminary results, the authors conclude that their protocol overlooks some relevant voice parameters like middle-term variations. Further study will be undertaken to take into account this type of variations.

Juvenile nasopharyngeal angiofibroma: comparison of blood loss during removal in embolized group versus nonembolized group.

PURPOSE: This retrospective study was performed to assess the beneficial effect of preoperative embolization of juvenile nasopharyngeal angiofibromas (JNA) in terms of blood loss during surgery. METHODS: Intraoperative blood loss in a group of 7 patients who underwent 10 procedures for JNA without preoperative embolization was compared with the blood loss of 13 patients who underwent 16 procedures after embolization of one or both external carotid arteries. RESULTS: Mean blood loss was 5380 ml in patients without embolization and 1037.5 ml in those with embolization. This difference was not statistically significant because of the high standard deviation in the nonembolized group. However, when data were analyzed by tumor stage, a significant difference was noted between the embolized and the nonembolized patients with high-grade tumors but not between those with low-grade tumors. CONCLUSION: Preoperative embolization of the branches of the external carotid appears to facilitate removal of high grade tumors. The benefit of embolization in those with low-grade tumors is less clear cut, probably because there is less vascularity in low-grade tumors and so removal is easier.

Role of magnetic resonance imaging in predicting late facial motor function after removal of vestibular schwannomas by the translabyrinthine approach.

Facial motor function was assessed in 61 patients 18 months after surgical resection, by the translabyrinthine approach, of vestibular schwannoma involving both the cerebellopontine angle (CPA) and the auditory canal. Pre-operative magnetic resonance imaging (MRI) was performed to measure the maximum extracanalicular diameter of the tumour between the porus and the farthest extension in the CPA on transverse slices and to calculate extracanalicular tumour volume. Post-operative facial motor function was graded according to the House and Brackmann system. There was a statistically significant relationship between late facial motor function and extracanalicular diameter. The best cut-off point for good and poor results was 20mm. There was no relationship between the tumour volume and the late post-operative facial motor function grade. In this study the best pre-operative radiological predictor of the late facial motor function in patients operated on by the translabyrinthine approach was the maximum diameter measured by MRI.

[Reconstructive anterior frontal laryngectomy. Long-term results in T2 glottic cancers]. / La laryngectomie frontale antérieure reconstructive. Résultats à long-terme dans les T2 du plan glottique.

Between 1982 and 1992, we performed near total laryngectomy with epiglottic reconstruction in 142 patients with state T1 and T2 according to the 1987 Union Internationale contre le Cancer. In this paper, we report our experience with 61 T2 patient who were followed-up 5 years or until death. Actuarial survival was 83%. Actuarial tumor control was obtained in 91%. There were no post-operative mortalities and follow-up was usually simple. All patients underwent decanulation and were able to eat by normal track. The main drawback of this technique is speech disability. We use near total laryngectomy with epiglottic reconstruction in certain T2 patients selected according to local extension. This choice is justified by good functional results and an excellent local control. The contraindications are age over 75 years, poor patient cooperation, cardiac or pulmonary disease, fixation of the arytenoids, subglottic extension of more than 1 cm in front and 0.5 cm laterally, and extensive involvement of the ventricular folds or anterior commissure.

[Objective vocal evaluation of dysphonia by simultaneous measurement of acoustic and aerodynamic parameters with the EVA device]. / Evaluation vocale objective des dysphonies par la mesure simultanée de paramètres acoustiques et aérodynamiques à l'aide de l'appareillage EVA.

Authors present the analysis of the voice in 88 normal subjects and 159 dysphonic patients by simultaneously measurements of Jitter (acoustical short-term indicator of aperiodicity) and "Glottal Leakage" (aerodynamic parameter calculated by the ratio of Oral Airflow and Intensity). All the measurements were performed, with EVA apparatus, on the most stable part of a steady-state vowel /a/. The reference method was the rating by a jury along a global perceptual scale. Statistical tests confirm that Jitter and "Glottal Leakage" are relevant to evaluate the quality of the voice. Discriminant analysis allows to find out a fairly-good rate of discrimination of 63.1% (Randomly rating would have been 25%) The authors conclude on the interest of such a protocol and present suggestions to improve it by taking in count phénomena during the vocal attack and middle-term variations.

[Surgical anatomy of the parathyroid glands. Apropos of 200 cases. Practical implications]. / Anatomie chirurgicale des glandes parathyroïdes. A propos de 200 cas. Implications pratiques.

An operative procedure aimed at decreasing the risk of post-surgery hypothyroidism was proposed on the basis of parathyroid gland surgical anatomy described from a retrospective study of 200 thyroidectomies performed by the same operator It is almost always possible to visualize 1 or parathyroids during thyroid procedures. This fact makes it possible to reduce the rate of definitive hypoparathyroidism to less than 5% in surgery for invasive cancer of the thyroid and to 1% for non-invasive cancers requiring total thyroidectomy and uni or bilateral mediastinorecurrent curettage.

Protrusion of the optic nerve into the ethmoid and sphenoid sinus: prospective study of 150 CT studies.

Damage to the optic nerve is a serious complication of intranasal sinus surgery. Protrusion of the optic canal into the sphenoid sinus is a major risk factor. In this prospective study of 150 CT studies, we found this anatomical variation in 8% of cases. It was consistently associated with pneumatisation of the ipsilateral anterior or clinoid process. Protrusion of the optic nerve into the posterior ethmoid cells was never observed. CT is a useful part of the preoperative investigation of patients undergoing intranasal sinus surgery. Axial and coronal images obtained or by direct acquisition by reconstructions are necessary to show the position of the optic nerve.

Effect of heavy smoking on nasal resistance.

Smoking is a part of our sociocultural environment. Its medical consequences are probably still underestimated. In this prospective clinical study, we explored the relationship between heavy smoking and nasal resistance. Anterior rhinomanometry was performed in 26 smokers and 26 non-smokers. Each group contained 13 men and 13 women. Analysis of variance of nasal resistance measurements using age and weight as covariables showed no significant difference between sexes. In contrast, a highly significant increase was noted between smokers and non-smokers. Age and weight had no influence on these results. Rhinomanometry proved to be an excellent method of detection for these modifications. Similar studies on the effects of passive smoking and of atmospheric and occupational pollutants should follow in the near future.

[Intra-sphenoidal prolapse of the internal carotid artery. Computed tomography of 300 sinuses]. / Procidence intra-sphénoïdale de l'artère carotide interne. Etude tomodensitométrique de 300 sinus.

OBJECTIVES: Endonasal sphenoidotomy is a high risk operation: fatal complications due to direct lesion to the internal carotid artery have been reported. We conducted a prospective analysis of carotid prolapse within the sphenoid cavity in order to draw attention to this dangerous anatomic variant. METHODS: Tomodensitometry of the sinuses was performed in 150 patients (mean age 35 years; range 20-70) with inflammatory nasal symptoms of less than one year duration (mean 5.2 months). Cases with benign or malignant tumours, polyposis or a past history of sinus trauma were excluded. Transversal sections were analyzed by one radiologist and one ear-nose-throat specialist. The diagnosis of carotid prolapse was defined as an intrasphenoid protrusion of the artery at least as long as one-third of its circumference. Results of the analysis were expressed as percent for 300 sinuses. RESULTS: Prolapse of the internal carotid was found in 20.3% of the sinuses (n = 61). In all cases a thin (> 1 mm) bony structure surrounded the artery. No prolapse was observed into the posterior ethmoid cells. CONCLUSIONS: Intrasphenoid prolapse of the internal carotid artery is a major risk factor in nasal and sinus surgery. The high incidence (1 out of 5 sinuses) indicates the need for routine preoperative imagery to reduce surgical risk.

Major complications of sinus surgery: a review of 1192 procedures.

Based on this review of 1192 intranasal sinus procedures under endoscopic control with video assistance, the risk of major complications was estimated to be about 1.3 per cent. Ethmoidectomy was the most hazardous procedure. Operation by a right-handed surgeon standing on the right side of the patient was an added risk factor. We stress ways of achieving prevention, peroperative recognition of cerebrospinal fluid leaks and proper management of complications.

Difference in the height of the right and left ethmoidal roofs: a possible risk factor for ethmoidal surgery. Prospective study of 150 CT scans.

A prospective study of 150 CT scans showed that the right ethmoidal roof was lower than the left in 8.6 per cent of cases. The reverse situation, i.e. the right higher than the left, was observed in only 1.2 per cent of cases. This finding could account for the higher reported incidence of endocranial complications associated with right ethmoidectomy. Coronal CT scans allowing comparison of the right and left ethmoidal roofs should always be made before undertaking intranasal ethmoidectomy.

[Surgical approach of the petrous vertical segment and upper cervical internal carotid]. / Approche chirurgicale du segment vertical pétreux et cervical haut de la carotide interne.

The main obstacle to successful management of aneurysms involving the high cervical internal carotid artery (ICA) is to obtain an adequate exposure. In this report we describe our experience in 5 patients presenting carotid aneurysms at the skull base, intermediately below the carotid foramen. Exposure is achieved in two stages. The cervical stage consists in resection of the styloid processes and muscles followed by anterior displacement of the mandibular condyle. This exposes the vertical segment of the petrous ICA. The petrous stage consists in partial petrectomy exposing the jugular bulb and the third segment of the facial nerve. Using this route, the vertical intrapetrous segment of the ICA can be drilled away without damaging the middle ear. In our series, no vascular complications occurred. Damage involving the facial glossopharyngeal and vagal nerves is discussed. This approach appears to be a suitable alternative to the conventional infratemporal approach which sacrifices the middle ear.

Near total laryngectomy with epiglottic reconstruction: long-term results in 57 patients.

INTRODUCTION: Extended partial laryngectomy procedures may offer patients the potential for a cure with preservation of voice. This report characterizes our patients managed with near laryngectomy and reconstructed with epiglottic tissue. MATERIALS AND METHODS: A total of 57 patients with T1 or T2 glottic carcinoma undergoing total laryngectomy with epiglottic reconstruction were reviewed retrospectively. This group included 15 patients with T1 lesions and 42 patients with T2 lesions. In the standard operation the specimen includes the thyroid ala, both vocal cords, both false vocal cords, and one arytenoid cartilage. The epiglottis is mobilized and delivered inferiorly for reconstruction of the glottic larynx. RESULT: Tumor control was obtained in 93% of T1 patients and 79% of T2 patients. All patients tolerated decannulation. After a mean duration of 12 days (range 5 to 22 days), all patients were able to swallow. Voice evaluation revealed 5 patients had whispery voices, 25 were difficult to understand in a noisy environment, and 27 were easily understood. DISCUSSION: This technique is an effective approach to cancer therapy with cure rates comparable to total laryngectomy. The main limitation of this technique is that voice recovery is unpredictable.

[Cholesteatoma of the middle ear in children. Apropos of 80 cases and review of the literature]. / Le cholestéatome de l'oreille moyenne chez l'enfant. A propos de 80 observations et revue de la littérature.

Cholesteatoma occurs in 10% of cases of chronic otitis in children. In most children, the clinical form is very similar to acquired cholesteatoma in the adult. However, we observed certain clinical variations in our retrospective series of 80 cases seen in our unit over the past 8 years. In most all cases, otorrhoea and hypoacousia were the presenting signs. The tympanic membrane was fully intact in 10% of the cases raising the possibility of congenital pathogenesis. An analysis of the correlations between per-operative observations and tomodensitometric results was conducted. Closed tympanoplasty, with a second operation 11 months later, was performed in 84% of the cases. Residual cholesteatoma was observed in 41% of the second operations and relapse occurred in 16%. These anatomic and functional findings, compared with those in the literature, demonstrate that no major difference in the published series. Presently the most important point is to separate acquired and congenital forms, which differ in terms of pathogenesis and clinical presentation, but are treated in the same manner. Progress in the treatment of cholesteatoma of the middle ear in children will come from prevention through earlier diagnosis of pathological manifestations in the ear nose and throat, in particular blocked Eustachian tubes, and through follow-up and treatment of pre-cholesteatomous states, as well as further advances in fundamental research.

[Surgical treatment of subglottic angioma in infants. Technique and indications]. / Le traitement chirurgical des angiomes sous-glottiques du nourrisson. Technique et indications.

Subglottic angiomas, frequently observed in new-borns, can have an unfavourable course due to laryngeal dyspnea. Although the natural course is towards spontaneous involution, different therapeutic approaches depend upon the lesion's sensitivity to corticotherapy. The authors report 24 cases of angioma observed over the last six years at the Hôpital d'Enfants de la Timone in Marseille, France. The relative importance of corticotherapy, intubation, laser and tracheotomy were analyzed and the role of surgical exeresis was analyzed with precision. Four observations were presented in detail. Based on the data in the literature, indications for this therapeutic method would be rather limited, but could offer rapid curative care without complications.

[Functional results of the surgery of unilateral acoustic neuroma]. / Les résultats fonctionnels de la chirurgie des neurinomes de l'acoustique unilatéraux.

The authors sent a circumstantial questionnaire to 224 surviving patients out of a 228 unilateral acoustic neurinoma operated on from June 83 to December 90 range of patients in order to assess their complaints. Seventy-two per cent of these neurinomas were Stade III or IV of Koos. Translabyrhintine approach was used for 85% and suprapetrous approach for 15%. The post-operative mortality rate is 1.75%. At the end of the procedure, the removal seemed total in 99% of cases and the anatomical facial nerve continuity was preserved in 94% of cases. Our patients kept or recovered a normal (Grade I of House--52%) or almost normal (Grade II of House--14%) facial motion in 66% of cases. A normal facial rest stretching with a complete eyelid closure but an asymmetrical facial mimic (Grade III of House) were in 20% of cases, and a more important facial palsy with incomplete eyelid closure was in 4% of cases (Grade IV of House). Patients needed an hypoglosso-facial anastomosis in 10% of cases. Always, this anastomosis restored a good facial motion near the Grade III of House. Hearing preservation was achieved for 45% of the attempts (through a suprapetrous approach) but hearing so preserved was functional (pure tone loss less than 50 db) in 37.5% of cases (5% of all the patients of this series) and only 61% of these patients kept or recovered a normal or almost normal facial motion. Varying, often regressive, complications were observed: C.S.F. leakages (7.5%) through the operative wound in two third of cases, owing to a pressure raising due to meningitis or C.S.F. circulatory constraint and usually cured by lumbar punctures and, if need be, antibiotics and, in one third of cases, through the tympanic cavity then nostril because of a hole remaining on the petrous drilled wall and usually needing a reintervention, swallowing difficulties (3%), due to a contralateral vagus nerve palsy in half of cases, postoperative hematomas (1.75%), fatal in one out of two times, brain traumatism (1.75%), meningitis (0.4%). The answers of patients were proper enough to be used for this study in 80% of cases (178). Their subjective answers about facial motion agreed with our objective assessment in 84% of cases that is emphasizing the difficulties of all attempt to this type of valuation. Our patients point out balance troubles in 67% of cases.(ABSTRACT TRUNCATED AT 400 WORDS)

Hydroxyapatite in experimental laryngotracheal reconstruction.

Current concepts in laryngotracheal reconstruction include lumen augmentation with interposition of autogenous costal cartilage. In an effort to reduce potential increased morbidity at the donor site, the use of porous hydroxyapatite was compared with autogenous costal cartilage in an experimental study. Ninety-nine New Zealand rabbits were randomly operated on to receive autogenous costal cartilage (n = 32), hydroxyapatite covered by a perichondrium graft (n = 33), or hydroxyapatite alone (n = 34). Rabbits were killed at 3 months after the surgery. Clinically (n = 85), no difference was found among the groups. Histologically (n = 81), grafts (n = 54) in the group receiving autogenous costal cartilage were greater than in those receiving the hydroxyapatite. Concerning the value of epithelial layer covering the graft, the rate of inflammation, the cricoid-graft interface, and the graft viability, no difference was noted among the groups. In the group in which no graft was found (n = 27), a fibrous bridge maintaining a cricoid distraction was noted in 23 cases. This study shows the possible value of hydroxyapatite in the animal model, but before clinical application, the natural course of the fibrous bridge must be documented.