[MIF in head and neck cancer: a new therapeutic target ?]. / Le MIF dans les cancers des voies aéro-digestives supérieures: une nouvelle thérapie ciblée?

Macrophage migration inhibitory factor is a critical proinflammatory cytokine produced by cells of innate and adaptive immune system. MIF plays a key role in cell cycle regulation and in the pathogenesis of many cancers. Recently, MIF has been studied in the upper aerodigestive tract cancer for its involvement in tumor progression, invasion, proliferation and cell motility. In addition, MIF appears to be a mediator in angiogenesis and in the development of metastasis and locoregional lymph node, which are often associated with a poor prognosis. The mechanisms of action responsible for MIF involvement in tumor progression are not completely elucidated. However, the main effects of MIF are mediated by the CD74 receptor. MIF binding to its receptor is responsible for the activation of several signaling pathways (ERK1/2 - MAPK, JAB1 - CSN5, PI3K - Akt), the inhibition of p53 and the stimulation of angiogenic factors including VEGF and IL-8. The overexpression of MIF also causes a reduction of the anti-tumor activity of the immune system. Finally, MIF could be an interesting biomarker in the diagnosis and monitoring of upper aerodigestive tract cancers. In this paper, we assess the state of knowledge of MIF involvement in upper aero-digestive tract cancers and we analyze the therapeutic perspectives.

Esteem 2 middle ear implant: our experience.

INTRODUCTION: The Esteem is a totally implantable hearing system that uses piezoelectric technology. It is indicated in case of moderate to severe stable sensorineural hearing loss with a minimum discrimination score of 60% and a middle ear which is anatomically and functionally intact. Its two components (sensor and driver) are positioned and fixed in the mastoid cavity and coupled respectively to the incus body and capitulum with cement. STUDY DESIGN: Retrospective study. SETTINGS: Tertiary referral center. MATERIALS AND METHODS: Pure-tone average (PTA) gain in the implanted ear was calculated at 1, 2, and 4 KHz, word recognition score (WRS) gain at 50 dB SPL, and average WRS (AWRS) gain at 40, 55, and 70 dB SPL. WRS was also evaluated in silence and noise. All patients were asked to fill in the abbreviated profile of hearing aid benefit (APHAB) questionnaire pre- and postoperatively as well as an Esteem questionnaire. RESULTS: Thirteen patients received implants between May 2008 and April 2010. Five minor complications occurred (1 temporary partial facial palsy, 1 secondary healing difficulty, and 3 revision surgeries for poor and deteriorating functional results and progressive gain loss after use of a heart defibrillator). Two patients (15%) suffered major complications and their implants had to be removed 4 months postoperatively because of a Staphylococcus aureus wound infection. One patient underwent reimplantation 6 months later. Mean PTA gain was 25 ± 11 dB, mean WRS gain at 50 dB SPL was 64 ± 33%, and mean AWRS gain was 40 ± 20%. WRS in silence and with a signal-noise ratio of 10, 0, and -5 dB was 91 ± 11, 85 ± 14, 71 ± 19, and 64 ± 30%, respectively. The APHAB questionnaire revealed 84% of satisfaction improvement compared to the previous classic hearing aid. CONCLUSION: The totally implantable hearing device Esteem 2 can offer good functional and satisfaction results. Careful selection of patients is required, however, based on hearing tests, exclusion of middle ear ventilation problems, and CAT-scan middle ear anatomy. Specific surgical training and experience are also needed. The implant is safe and only associated with classic auditory implant complications.

[Chronic maxillary rhinosinusitis of dental origin: report of 2 cases]. / Rhinosinusites chroniques maxillaires d'origine dentaire : à propos de 2 cas.

Chronic maxillary rhinosinusitis of dental origin represents approximately 5 % of chronic maxillary rhinosinusitis. The diagnosis of this pathology is often delayed and mainly based on endoscopy and medical imaging. Its treatment is complex and requires the involvement of several teams. This article discusses two cases of chronic maxillary rhinosinusitis secondary to dental treatment. A literature review on the epidemiology, diagnosis, treatment and complications are also introduced.

[Hard palate B cell lymphoma with spontaneous regression]. / Régression spontanée d'un lymphome B à grandes cellules du palais.

INTRODUCTION: Non-Hodgkin lymphomas are common cancers that can develop in the upper aero-digestive tract. We describe a case of a large B-cell palatine lymphoma with spontaneous clinical regression. CASE: A 58-year-old female patient presented with a sub-mucosal lesion of the hard palate. CT scan and magnetic resonance imaging revealed a lesion invading the right posterior palatine canal. At the second consultation, 15 days after performing the biopsy, the lesion had disappeared. PET scan proved the absence of lesion. Lymph node biopsy supported the diagnosis of large B-cell lymphoma. DISCUSSION: Large B-cell lymphoma of the hard palate is a rare disease. Only 27 cases have been described in the international literature. The anatomopathological analysis is often difficult to perform. The final diagnosis is often made by immunochemistry. The usual treatment is R-CHOP chemotherapy (cyclophosphamide, adriamycin, vincristine, prednisone combined to rituximab) with a 5-year survival rate at 55%.

Maxillary sinusitis caused by the migration of a silastic implant used for an orbital floor reconstruction: a case report.

OBJECTIVE: The authors report on a patient whose unilateral chronic maxillary sinusitis was caused by the migration of a silastic implant used for orbital floor repair. CASE REPORT: A 32-year-old woman presented with a three-year history of right-sided maxillary discomfort that was associated with a purulent discharge. Her medical history included chronic allergic rhinitis and the placement of a silastic implant after a right orbital floor fracture at the age of 14. The silastic implant was then removed endoscopically in a right maxillary sinus meatotomy. The symptoms improved within three weeks after surgery. CONCLUSION: Orbital implant migration is a rare cause of chronic unilateral sinusitis, and it must be suspected on the basis of a careful anamnesis, appropriate clinical examination, and sinus computed tomography. Misdiagnosing such a condition may increase patient morbidity by leading to inappropriate treatment.

Acromegaly presented as a cause of laryngeal dyspnea.

Acromegalic patients can develop obstructive sleep apnea syndrome or upper airflow obstruction. The development of dyspnea is unusual and the fixation of both vocal cords is exceptional. We report the case of a patient with bilateral vocal cord paralysis. Fiberoptic laryngoscopy and computed tomography (CT) of the neck showed a supra-glottic stenosis due to a swelling of the soft tissue. A tracheostomy was first performed. Thereafter, micro-laryngoscopy using laser vaporisation of the supra-glottic soft tissue was attempted but failed to remove the tracheostomy canula. Finally, blood tests and cerebral MRI revealed an acromegaly. The patient underwent a trans-sphenoidal resection of the pituitary adenoma. Fifteen months later, fiberoptic laryngoscopy showed bilateral restoration of vocal cord mobility and the tracheostomy canula was successfully removed after 18 months. Vocal cord fixation is probably due to hypopharyngeal and laryngeal soft tissue swelling and can be reversible after successful treatment of the adenoma.

Importance of clinical and radiological follow-up in head and neck cancers.

PROBLEMS/OBJECTIVES: To evaluate the relevance of routine head and neck ultrasonography (US), computed tomography (CT), chest X-ray, and standard clinical examination for the early detection of recurrences, second primary tumours, and distant metastases in the followup of patients treated for head and neck cancers. METHODOLOGY: Retrospective cohort study. RESULTS: One hundred ninety-five patients were reviewed. Seventy-one recurrences appeared during the follow-up period. Five recurrences were diagnosed during head and neck US and CT. Sixty-four recurrences were diagnosed based on patients' complaints or standard clinical examination. Two lung malignancies were diagnosed during the annual chest Xray. CONCLUSION: Systematic head and neck US and CT exams revealed recurrent cancers with poor efficiency and should be performed only after clinical suspicion of recurrence or second primary tumours. The value of an annual chest X-ray remains debatable. Routine clinical follow-up is clearly crucial for the detection of early recurrences and second primary tumours.

Mediastinal tracheostomy: unilateral resection of the anterior chest wall.

Since the first reliable mediastinal tracheostomy described by Grillo et al. in 1966, many new techniques have been described in order to reduce the number of complications. We here report the case of a 55-year-old man who was referred for surgery with post-radiochemotherapy recurrence of a double neoplasm of the pharyngolarynx extending to the proximal trachea and the medial part of the oesophagus. Through a median sternotomy, a pharyngolaryngoesophagectomy was performed with an extended tracheal resection. The reconstruction of the upper digestive tract was performed with a gastric pull-up. The mediastinal tracheostomy was performed with a pectoralis major muscular flap through a right unilateral resection of the manubrium, the right clavicular head and the right first and second costal cartilages. Historically, the mediastinal tracheostomy was performed through a large bilateral resection of the anterior chest wall, in order to prevent the tension on the tracheocutaneous sutures. Nowadays, with the possibility of various pedicled flaps, bilateral resection no longer seems to be necessary. This unilateral resection leads to a reduction in post-operative sequelae.

Initial assessment of a neck mass in children.

OBJECTIVE: To propose national recommendations for the initial assessment of a mass in the neck in children. METHODS: Comprehensive review of the available literature and consensus discussion with national experts in the field. RESULTS: Consensus guidelines are proposed concerning the work up of children presenting with a mass in the neck.

Initial work-up in head and neck squamous cell carcinoma.

OBJECTIVE: To propose national guidelines for the initial assessment of head and neck squamous cell carcinoma. METHODS: Comprehensive review of the literature and consensus discussion with national experts in the field. RESULTS: Consensus guidelines are proposed concerning the work-up of patients with a presumed diagnosis of a squamous cell carcinoma of the upper aero-digestive tract.

Physiotherapy in obstructive sleep apnea syndrome: preliminary results.

Apneic patients have hypotonia of the lingual and supra-hyoid muscles. The dysfunction of theses muscles leading to a collapse of the upper airway is responsible for the apnea. The goal of this study, designed as a before-after trial, is to determine the effect of lingual and supra-hyoid muscle strengthening on obstructive sleep apnea. Thirty-four patients with obstructive sleep apnea were included (consecutive sample). Only 16 patients completed the study. The treatment consisted of 30 sessions of transcutaneous neuromuscular stimulation administered to the submental region associated with muscular exercises. The effect on apneic events was analyzed with a polysomnography before and after the treatment. Thirteen patients could be analyzed for the statistical studies. The mean apnea-hypopnea index (AHI) decreased from 32.9 to 20.6 (Wilcoxon rank test: P = 0.017). Seven patients ended the study with an AHI of less than 10, and three more patients decreased their AHI by more than 50%. This treatment significantly decreased the AHI in most of the patients. A larger study with more patients and with a long-term follow-up is necessary to determine the place of physiotherapy in the treatment of obstructive sleep apnea.

A comparison of survival lifetime of the Provox and the Provox2 voice prosthesis.

The Provox (Atos Medical AB, Hörby, Sweden) voice prosthesis was developed between 1988 and 1990 and has been used at our centre with regular success since 1993. Since 1996, a second generation of Provox (Provox2) has been used, which can be inserted by an anterograde technique. The aim of this study is to compare the survival lifetime of both voice prostheses. The survival time of the two voice prostheses were compared retrospectively in 152 devices placed in 38 patients. A Kaplan-Meier analysis was performed to determine the survival lifetimes and a log rank test was performed to compare the two curves. Clinical factors affecting the lifetime were also analysed with a Kaplan-Meier plot. The median survival lifetime of the Provox and Provox2 were 303 and 144 days respectively. The Kaplan-Meier estimation shows that this difference is statistically significant (p=0.02). It is considered an early failure if it occurs within the first three months. There was a larger number of early failures with the Provox2 than with the Provox (p=0.04). Neither the gender nor the age affected the lifetime of the devices. Radiotherapy seemed to lengthen the lifetime of the first valve. The survival lifetime of the second generation Provox2 valve is shorter than the lifetime of the first generation Provox. This could be due to the difference in elasticity of these valves that could lead to a different level of colonization and invasion of the valves by micro-organisms.

[Diagnostic management of unilateral sensorineural hearing loss in adults]. / Prise en charge diagnostique d'une surdité de perception unilatérale de l'adulte.

Adult unilateral hearing loss is a frequent complaint observed by the E.N.T. specialist. With a pure tone audiometry, we can recognize a conductive hearing loss from a sensorineural hearing loss. In case of a conductive hearing loss, a temporal bone computed tomography is the first choice procedure. For the sensorineural hearing loss, the standard screening test is the brainstem evoked response auditory (BERA), which can be completed by a magnetic resonance imaging (MRI). The BERA have a false negatives level of 2 to 15% according to the studies, which means that a checking must be done 6 months later. The improvement of MR examination offers a better detection of very small tumours (2-3 mm). The cost of a MRI is equivalent to the cost of 2 BERA. In conclusion, we propose MRI as the only investigation to be performed in case of an unilateral sensorineural hearing loss.

Clinical aspects of early and late hypocalcaemia afterthyroid surgery.

AIM: This study aimed to evaluate hypocalcaemia (time-course) and need for calcium administration after thyroid surgery in 135 consecutive cases (69 bilateral subtotal thyroidectomies, 50 unilateral lobectomies, 13 total thyroidectomies and three isthmectomies) for benign lesions and for differentiated carcinoma in 89% and 11% respectively. RESULTS: In unilateral lobectomy, two parathyroid glands were identified and preserved in 72%, and one gland in 28% of the patients; calcaemia decreased by 10% on average in the early post-operative period (P<0.001). Calcium treatment (average: 2.3 days) was administered to 34% of the patients, these patients had lower nadir post-operative calcaemia than those who did not receive calcium: 2.03 vs 2.14 mmol/l (P<0.001). Their calcaemias reverted to normal within 1 week after surgery and remained normal thereafter without further calcium administration. In bilateral procedures, four parathyroid glands were preserved in 40%, three in 42%, two in 16%, and only one in 2% of the cases. Calcaemia decreased by 15% on average (P<0.001), and early hypocalcaemia was common and severe in some patients: nadir post-operative calcaemia <2.0 mmol/l in 61%, and <1.75 mmol/l in 6% of the cases. Post-operative hypocalcaemia was more pronounced after total than subtotal thyroidectomy (1.86+/-0.19 vs 1.98+/-0.14 mmol/l P=0.014), and also after lymph node dissection (1.83+/-0.11 mmol/l). Serum parathormone (PTH) decreased from 36 ng/l before surgery to 17 ng/l in the week thereafter (P=0.001). There was a linear relationship between the number of preserved parathyroid glands and early hypocalcaemia. The percentage of patients requiring calcium treatment was: 24 h (15%), 2-7 days (26%), 8-180 days (33%), >1 year (9%). DISCUSSION: The number of parathyroid glands preserved in situ did not help predict the duration of post-surgical calcium treatment, nor the final outcome of hypocalcaemia. However, when total calcium levels were compared in patients having had one or two glands preserved vs three or four parathyroid glands, it was possible to show that despite prolonged calcium administration, late calcaemias remained significantly lower during the first 6 months in patients with a smaller number of parathyroid glands. Hypoparathyroidism, defined functionally on the basis of requirement of calcium supplementation 1 year after surgery, occurred in 8.6% of patients after bilateral lobectomy (despite measurable but inappropriately low-PTH concentration). This outcome could have been predicted earlier (after 3 to 6 months) and the patients perhaps given the benefit of definitive vitamin D treatment earlier, in order to avoid late and prolonged hypocalcaemia. Evaluation after 1 year showed that only one patient out of 82 bilateral lobectomies (1.2%) had permanent hypoparathyroidism and needed calcium whereas hypocalcaemia was persistent in one out of four patients who had undergone a staged procedure (i.e. heterolateral lobectomy years after a previous operation).

Tonsillar lymphoma and AIDS.

A case of a patient presenting unilateral tonsillar enlargement, whereby non-Hodgkin lymphoma (NHL) and AIDS were diagnosed, is presented. The clinical and pathological aspects of this pathology, its pathogenicity and treatment are reviewed.

Laryngeal aspergillosis in an acquired immunodeficiency syndrome patient.

Aspergillosis is a rare infection. It varies considerably in its virulence depending on whether or not the patient affected is immunodepressed. The serious form is characterized by vascular invasion with haematogenic dissemination, tissue infarction and necrosis. The most often affected site is the lung. A laryngeal localization is exceptional and usually results from dissemination from a lower airways portal of entry. Diagnosis is difficult: cultures are only positive in 50 per cent of cases, while in 60 per cent of cases the characteristic histological features reminiscent of sprigs of mistletoe are only found on postmortem examination. In view of the high morbidity and mortality in acquired immunodeficiency syndrome (AIDS) sufferers, this condition must be treated early and aggressively. Treatment is based essentially on amphotericin B and itraconazole.

An unusual localisation of Kaposi's sarcoma: the external auditory canal.

The epidemic form of Kaposi's sarcoma is associated with human immunodeficiency virus infection. Cutaneous and mucosal manifestations are frequently reported in the ENT sphere, mostly involving the oral cavity. The external and middle ear are only rarely concerned with only one case of a mastoid lesion without extension to the external auditory canal (EAC) being reported to this day. The present article describes the first case of involvement of the EAC with extension to adjacent structures. This patient presented other Kaposi lesions and had been treated by systemic hormonal therapy. Thereafter local injection of a cytotoxic agent was given without effect. Finally, radiotherapy resulted in a 50% regression of the tumour mass. The epidemiologic factors and therapeutic modalities with their results are described.

Elevated CEA in breast cancer patients with overlooked medullary thyroid carcinoma.

After mastectomy and radiation for breast cancer, two patients were found to have persistent elevated CEA in their serum. This finding was erroneously attributed to occult metastases for the first patient and to local recurrence for the second. Overlooked medullary thyroid carcinoma (MTC) was the causal disease in both patients. A review of the literature stresses the frequency of CEA elevation in serum of MTC patients. A thorough search for any possible cause of elevated levels of CEA is advocated, particularly by thyroid sonogram with a needle aspiration biopsy when a nodule is discovered and by calcitonin assay in the serum.

Wound dressing in major head and neck cancer surgery: a prospective randomized study of gauze dressing vs sterile vaseline ointment.

A total of 207 patients were randomized in a prospective comparative study of standard gauze dressing vs sterile vaseline ointment. 179 patients were evaluable. All patients received antimicrobial prophylaxis. The two groups (86 standard and 93 vaseline) were comparable as far as age (mean, 57 yr; range, 21-84), genders (155 males/24 females), weight (mean, 66 kg; range, 40-69), type of surgery, previous or concomitant anticancer treatment. Severity of surgery was identical, as was the severity of cancer, in the two groups. Wound infection within 20 days of surgery occurred in 31.2% (29/93) of the vaseline group and 24.4% (21/86) in the standard group (NSS). Bacteremia occurred in three patients from the vaseline group and in four patients from the standard group. Bronchopneumonia occurred in 10 patients from the vaseline group and 14 patients in the standard group. The spectrum of microorganisms recovered was similar in the two groups. The need for antimicrobial treatment (empiric or for documented infections) within 20 days after surgery was 34.4% (32/93) in the vaseline group and 36.0% (31/86) in the standard group. The median delay to infection (range in days) in the vaseline group was 9 (5-15) for wound and 6 (1-12) for bronchopneumonia. For the standard group the corresponding delays were 8 (4-15) and 7 (2-19). Vaseline dressing was not associated with an increased risk of infection as compared to the standard gauze dressing.