Extended endoscopic endonasal approach to clival and paraclival tumors: Indications and limits.

OBJECTIVE: To report our experience with the Extended endoscopic endonasal approach (EEEA) for clival and paraclival tumors. DESIGN: Retrospective analysis of a consecutive series of patients. RESULTS: Eleven patients were considered: 3 chordomas, 3 meningiomas, 3 metastatic lesions, one chondroma and one chondrosarcoma. Gross total resection (GTR) was achieved in all chordomas and in chondromas with patients free of disease at the last follow-up. The chondrosarcoma was first operated on using a transfacial approach and endoscopy was performed for local progression with subtotal resection. The meningiomas were treated by a combination of transcranial and endoscopic approach due to their extension. The resection was subtotal and the residue treated by radiosurgery. Two patients with rhinopharyngeal carcinoma underwent palliative debulking. One metastatic melanoma that underwent GTR experienced remission. Two patients had postoperative cranial nerve palsy. No other complications were observed. CONCLUSIONS: EEEA allows a direct access to the skull base. Through a minimal access, it limits the incidence of neurological morbidities. For midline epidural clival tumors, EEEA allows a total excision. It also offers an excellent access to the clival component of intradural lesions. A combined approach permits good tumor control with minimal complications.

[Laryngeal amyloidosis: a clinical case and review of literature]. / Amyloïdose laryngée: revue de la littérature et cas clinique.

Amyloidosis consists of different forms of systemic or isolated organ lesions characterised by fibrillary protein deposits in extra-cellular tissue. The isolated involvement of the larynx is the most frequent form in the ENT sphere. We present a clinical case of a 67 year-old woman addressed for a sub-acute laryngitis resistant to conservative treatment, and finally diagnosed with laryngeal amyloidosis. We reviewed its physiopathology, the scientific literature as well as the different possibilities of management. Laryngeal amyloidosis is rare. A thorough additional work-up for the research of multifocal or systemic forms is highly recommended. The treatment aims at a minimal invasive endoscopic surgery with functional organ preservation.

[Skin cancers infiltrating the skull base]. / Cancers cutanés envahissant la base du crâne.

Squamous cell and basocellular carcinoma of the face have an excellent prognosis. Nevertherless, a small proportion therefore of these cancers differs by a much more aggressive behavior, caracterised by a tendency to infiltrate the deep facial soft tissues and facial bones. The invasion of the craniofacial skeleton and the intracranial structures follows the embryonic fusion lines or the facial sensitive or motor nerves, sometimes years after the initial treatment. The development of craniofacial surgery, reconstruction techniques and conformational radiotherapy allows us now to offer curative guided treatments, for these advanced staged tumors with a remaining limited prognosis. A therapeutic benefit implies a rigorous selection of these patients.

[Smile "forced" smile versus "spontaneous": comparison of 3 techniques of reconstructive surgery of the face. Myoplasty temporal muscle, hypoglossal facial anastomosis and gracilis muscle free flap]. / Sourire "contraint" versus sourire "spontané": comparaison entre 3 techniques de chirurgie réparatrice de la face. Myoplastie du muscle temporal, anastomose hypoglosso faciale et lambeau libre de muscle Gracilis.

The facial palsy cause serious consequences for patients. Studies have also shown that in these patients, the inability to produce an appropriate and spontaneous smile would be a key factor of depression. When facial palsy is considered complete and the nerve cannot be repaired, the patient can benefit from palliative surgery to regain a better quality of life in the aesthetic, functional, and psychological aspects. The hypoglossal-facial anastomosis (AHF), temporal myoplasty (MAT) and gracilis transposition (TG) are the major surgeries currently used for this purpose. The aim of our study is to assess quantitatively and qualitatively the effects of each of these surgeries on the lip mobility and production of smile. From this perspective, we proposed a protocol of an evaluation of facial motricity, of quality of life, and more particularly on the quality and the analysis of the smile. The results underline that there is no significant difference in the recovery of the facial motricity according to the surgery. Only the slower, deferred deadline of recovery at the patients AHF and TG who have to wait several months, it is for the same levels as that of the patients' MAT. A premature and intensive rehabilitation such as the patients of our protocol benefited from it what is nevertheless essential to a good recovery whatever is the surgery.

[Peripheral tuberculous lymphadenitis: diagnosis and management]. / Lymphadénite tuberculeuse cervicale et réaction paradoxale: diagnostic et traitem.

Tuberculous lymphadenitis is a frequent presentation of extrapulmonary tuberculosis. It corresponds to about 10% of tuberculosis cases in adults in developed countries, on the rise because of HIV, migrants and immunosuppressive therapy. The clinical diagnosis is often difficult and differential diagnosis is extensive. The patient presents with a history of painless swelling of one or a group of cervical lymph nodes. The mass may be present for 3 weeks to 8 months before the first consultation. The treatment of choice is an oral antimycobacterial treatment and is not surgical. This article reviews the specific clinical manifestations, diagnositc tools and treatment of tuberculous lymphadenitis through two cases.

[Ear reconstruction in case of microtia]. / Reconstruction du pavilion de l'oreille en cas de microtie.

Microtia is a uncommon pathology that is defined by a hypoplasia of the pinna. Multiple reconstructives surgeries have been developed. Nowadays, autologous rib cartilage reconstruction and Medpor implant reconstruction are the most widely used techniques. The authors present these two alternatives that significantly improve the quality of life of young patients with this visible abnormality.

[Children born with a cleft: treatment at the CHUV in Lausanne]. / Prise en charge des fentes labio-maxillo-palatines au CHUV.

A cleft can be labial, labial-maxillary, unilateral or bilateral labial-maxillary-palatal, or isolated palatal. A multidisciplinary team includes several specialists who will handle the diverse problems of children born with a cleft. This team will follow the child through each developmental stage and assemble an optimal treatment plan, thus reducing the onus on the family. Depending on the type of cleft and the age of the child, feeding, speech, ORL, dental, orthodontic, esthetic and possibly also psychological problems will be taken care of. This is why cleft treatment starts at the time it is diagnosed, before or after birth, and ends when the child is fully grown. It requires a complete interdisciplinary team and the collaboration with obstetricians and geneticians.

[Principles of the reconstruction of nasal defects]. / Principes de la reconstruction des pertes de substance nasale.

This article describes the principles of reconstruction for nasal tissue defects having a tumoral or traumatic cause, and describes results as they may actually be obtained. A brief historic resume dating back to Indian antiquity and Italian renaissance shows the main steps of reconstruction. The diagnostic approach, resection margins as well as timing of reconstruction are briefly detailed. The reconstruction principles aim to independently restore the three layers of the nasal pyramid, namely mucosa, bony and cartilaginous support, as well as skin coverage. The frontal or Indian flap remains the most widely used, and requires three surgical steps in order to obtain the needed finesse for a natural and almost invisible reconstruction. Some cases of complex reconstructions are shown.

Repair of non-circumferential cervical trachea defects by three different latissimus dorsi flaps. A comparative studyin an experimental setting.

BACKGROUND: Large intrathoracic airway defects may be closed using a pedicled latissimus dorsi (LD) flap, with rewarding results. This study addresses the question of whether this holds true for extrathoracic non-circumferential tracheal defects. METHODS: A cervical segment of the trachea of 4 x 1 cm was resected in 9 white male pigs. The defect was stented with a silicone stent for 3 months and closed either by an LD flap alone (group a, n = 3), an LD flap with an attached rib segment covered by pleura (group b, n = 3), or an LD flap reinforced by a perforated polylactide (MacroPore) plate (group c, n = 3). The trachea was assessed by rigid endoscopy at 3 and 4 months and histologically at 4 months postoperatively. RESULTS: The degree of stenosis at the level of the reconstruction at 4 months was 25, 50 and 75% in group a, 15, 50 and 60% in group b, and 20, 95 and 95% in group c, respectively. The percentage of the defect covered by columnar epithelium was 100% in all animals of group a, 60, 100 and 100% in group b, and 10, 0 and 0% in group c. Resorption of the rib was seen in all animals of group b and obstructive inflammatory polyps were found in 2 animals of group c. CONCLUSION: Pedicled LD flaps provided less satisfactory results for closure of large non-circumferential extrathoracic airway defects than observed after intrathoracic reconstruction. A pedicled rib segment added to the LD flap did not improve the results obtained from LD flap repair alone, and an embedded MacroPore prosthesis may result in severe airway stenosis due to plate migration and intense inflammatory reaction protruding into the tracheal lumen.

Horizontal partial laryngectomy for supraglottic squamous cell carcinoma.

Between 1981-1999, 75 patients treated for supraglottic SCC with horizontal supraglottic laryngectomy (HSL) at the Otolaryngology Head and Neck Surgery Department of Lausanne University Hospital were retrospectively studied. There were 16 patients with T1, 46 with T2 and 13 with T3 tumors. Among these, 16 patients (21%) had clinical neck disease corresponding to stage I, II, III and IV in 12, 39, 18 and 6 patients, respectively. All patients had HSL. Most patients had either elective or therapeutic bilateral level II-IV selective neck dissection. Six patients (8%) with advanced neck disease had ipsilateral radical and controlateral elective II-IV selective neck dissections. Adjuvant radiotherapy was given to 25 patients (30%) for either positive surgical margins (n=8), pathological nodal status (n=14) or both (n=3). Median follow-up was 48 months (range, 24-199). Five-year disease-specific survival and locoregional and local control were 92, 90 and 92.5%, respectively. Among five patients who were diagnosed with local recurrence, one had a total laryngectomy (1.4%); the others were treated by endoscopic laser surgery. Two patients had both a local and regional recurrence. They were salvaged with combined surgery and radiotherapy, but eventually died of their disease. Cartilage infiltration seems to influence both local control (P=0.03) and disease-specific survival (P=0.06). There was a trend for worse survival with pathological node involvement (P=0.15) and extralaryngeal extension of the cancer (P=0.1). All patients except one recovered a close to normal function after the treatment. Aspiration was present in 16 patients (26%) in the early postoperative period. A median of 16 days (7-9) was necessary to recover a close to normal diet. Decannulation took a median of 17 days (8-93). Seven patients kept a tracheotomy tube for up to 3 months because of persistent aspiration. There was no permanent tracheostomy or total laryngectomy for functional purposes. Horizontal supraglottic laryngectomy remains an adequate therapeutic alternative for supraglottic squamous cell carcinoma, offering an excellent oncological outcome. The postoperative functional morbidity is substantial, indicating the need for careful patient selection, but good laryngeal function recovery is the rule. The surgical alternative is endoscopic laser surgery, which may offer comparable oncological results with less functional morbidity. Nevertheless, these two different techniques need to be compared prospectively.

Comparison of once- versus twice-daily use of beclomethasone dipropionate aqueous nasal spray in the treatment of allergic and non-allergic chronic rhinosinusitis.

The aim of the study was to assess the efficacy and safety of nasal aqueous beclomethasone dipropionate (BDP), 400 micro g/day, given via a metered pump in a once-daily or twice-daily regimen following a double-blind, parallel group design over a 12-week period. Adult patients (n=112) with allergic or non-allergic chronic rhinosinusitis recorded their nasal and ocular symptoms for the 7-day run-in period and for the first 4 weeks of treatment. At baseline and after 4 weeks the airways' resistance via active anterior rhinomanometry and the volume and area section via acoustic rhinometry were measured. Morning serum cortisol was measured at baseline and at week 12. Adverse events were to be reported at each visit. Of the 112 randomised patients, three did not enter the ITT analysis and another 13 in total discontinued the treatment. Significant improvements over the baseline were reported in both groups for the primary variable sum of nasal scores (-53.7% in the once-daily group and -59.7 in the twice-daily group), as well as for each nasal and ocular symptoms, without differences between the groups. Because of a wider variability than expected, the 95% confidence interval (C.I.) for the difference between the least square means exceeded the pre-defined limit of +/-10% of the reference mean. Similar improvements in both groups were also reported for the nasal airway patency's parameters. The total number of drug-related adverse events was 26 in the once-daily group and 32 in the twice-daily group, with most of the events consisting of local effects at the site of application. No signs of adrenal suppression were observed, and serum morning cortisol values did not significantly change. The once-daily BDP dosing (400 micro g/day) therefore has a similar efficacy and safety profile as the same daily dose given in a twice-daily regimen.

Treatment of early stage squamous-cell carcinoma of the glottic larynx: endoscopic surgery or cricohyoidoepiglottopexy versus radiotherapy.

BACKGROUND: Both surgery and radiotherapy are recognized treatments of T1-T2 squamous cell carcinoma of the larynx. We retrospectively analyze and compare the oncological outcome of patients treated in a single institution, either by endoscopic surgery or partial supracricoid laryngectomy versus radiation therapy. METHODS: The medical records of 156 patients treated between 1983 and 1996 with either surgery (n = 75) or radiotherapy (n = 81) were reviewed. Male to female ratio, median age, and T-stage distribution were comparable. RESULTS: With a median follow-up time of 59 months, the 5-year cause-specific survival rate of 93% was identical for both groups. The actuarial incidence of metachronous second primaries was 7% at 5 years. Local control at 5 years remained 84% after surgery and 77% after radiotherapy. Anterior commissure infiltration was shown to represent a negative predictive factor of local control for radiotherapy (p =.01). Salvage treatment brought ultimate local control to 96% of patients after surgery and 94% after radiation therapy with long-term laryngeal preservation rate altered significantly (p =.05) in the group of patients who received radiotherapy (90.1% vs 97.4%). CONCLUSION: The treatment of laryngeal cancer is always a compromise between oncological efficiency and preservation of function. Our data suggest that, assuming proper selection of patients, radiation therapy and surgery yield similar local control and survival rates. The functional disadvantages after surgery are moderate and clearly counterbalanced by a significant decrease in long-term laryngeal preservation rate after radiotherapeutic treatment.

[Treatment of laryngeal cancer: cordectomy or crico-hyoido-epiglottopexy versus radiotherapy]. / Traitement du cancer laryngé: cordectomie ou crico-hyoïdoépiglottopexie versus radiothérapie.

INTRODUCTION: Both radiotherapy and endoscopic or open functional surgery are recognised treatments for laryngeal cancer stage I and II. A comparison between two groups of patients treated with either modality may clarify the indications for both treatments. METHODS: Over a period of 13 years two separate series of patients were treated for laryngeal cancer (stage I and II) by either surgery (n = 72) or radiotherapy (n = 81). We have analysed and compared the two groups. RESULTS: Statistical analyses show a better local control among patients treated with surgery, when the anterior commissure was involved (p < 0.01) or with extension of the tumour (T2). However, long-term survivals were not significantly different in the two groups. As postradiation recurrence was diagnosed at an early stage, salvage (requiring total laryngectomy in many cases) was efficient but contributed to an appreciable difference in the long-term laryngeal preservation rate between the two groups (91% after radiotherapy and 99% after surgery). CONCLUSION: The treatment of laryngeal cancer must always compromise between oncological efficiency and functional preservation. With anterior commissure involvement (T1b) or more extensive disease (T2), surgery appears to be better. Therefore, preservation of perfect laryngeal function should be subordinate to oncological safety.

[Reconstruction of the anterior mouth floor by surgical flap microanastomosis: oncologic and functional results]. / Reconstruction du plancher buccal antérieur par lambeaux microanastomosés: résultats oncologiques et fonctionnels.

INTRODUCTION: The purpose of this retrospective study was to evaluate oncological and functional results after reconstruction of the anterior floor of the mouth using free flaps. METHODS: From 1992 to 1998, 30 patients with squamous cell carcinoma of the anterior floor of the mouth underwent surgical excision and primary reconstruction with either free forearm- or bone-composed flaps. Functional assessment included evaluation by the Karnofsky scale, Performance Status Scale for Head and Neck Cancer (PSS-HNC), articulation test and videofluoroscopic examination. RESULTS: 16 patients underwent reconstruction with a free forearm flap, 13 with an iliac crest flap and 1 with a fibula flap. The most serious local complication was partial flap necrosis in two cases. Local control was 90% at 24 months and the specific survival rate was 92% at five years. Functional evaluation was performed on 19 patients: PSS-HNC median score for diet was 70 (range 50-100), the score for speech was 70 (range 50-100) and the score for "eating in public" was 65 (range 25-100). Patients with a major mobile tongue resection had a lower score compared to patients with minor or no mobile tongue resection. Videofluoroscopy showed swallowing alterations following large resections of soft tissues. DISCUSSION: Our study confirms that wide resection of mobile tongue is associated decreased rehabilitation quality. Mandibulectomy does not influence rehabilitation.

Supracricoid partial laryngectomy with cricohyoidoepiglottopexy and cricohyoidopexy for glottic and supraglottic carcinomas.

OBJECTIVES: To review the patients operated in our department with supracricoid partial laryngectomy with either cricohyoidoepiglottopexy (CHEP) (59 cases) or cricohyoidopexy (CHP) (10 cases) technique, for primary or recurrent glottosupraglottic squamous cell carcinoma and compare the technique with other surgical or conservative approaches for treatment of laryngeal carcinoma. METHODS: From hospital charts, we retrospectively reviewed 69 patients who had undergone supracricoid partial laryngectomy with the CHEP or CHP technique between 1983 and 1996 for primary or recurrent glottosupraglottic squamous cell carcinoma in our department. Statistical evaluation of oncological and functional results were conducted. Results were compared with other surgical and conservative treatment for glottosupraglottic carcinoma of the larynx that were published previously in the literature. RESULTS: Sixty-nine patients had CHEP or CHP for glottosupraglottic carcinoma of the larynx. Thirteen percent of the patients received adjuvant radiotherapy. Minimum follow-up was 2 years or until death. Five-year actuarial survival (Kaplan-Meier method) was 68%. Global local control was achieved in 84% of cases. Among previously untreated patients (n = 54), local control rate was 94.5%. After 1 year, 92.7% of patients achieved normal swallowing and respiration. Salvage total laryngectomy had to be performed in four patients (5.7%) for persistent aspiration and in five patients (7.2%), who were previously treated with radiotherapy, for local recurrence. No permanent tracheostomy or gastrostomy was required. CONCLUSIONS: Our experience with supracricoid partial laryngectomy with either CHP or CHEP suggests that this technique is a valuable alternative to radiotherapy for T2-T4 glottosupraglottic carcinomas, particularly those with extension and invasion of the anterior commissure. It allows for preservation of a good laryngeal function without altering the long-term survival, keeping total laryngectomy as a salvage procedure.

[Long-term complications of radiotherapy after mandibular reconstruction with vascularized bnoe graft]. / Complications post-actiniques à long terme après reconstructions mandibulaires par lambeau libre microanastomosé.

INTRODUCTION: The use of vascularised composite free flaps (VCFF) has become a widely accepted method for primary reconstruction of mandibular defects. Adjuvant or neo-adjuvant radiotherapy (RTH) increases susceptibility to trauma and infections. The aim of this study is to compare the incidence of local complications after mandibular reconstruction with vascularised composite free flaps, related to pre- or postoperative radiotherapy. The effects of these complications on functional rehabilitation with a dental prosthesis fixed on bone implants are also studied. METHODS: Between 1990 and 1999, 49 vascularised composite free flaps were used for mandibular reconstructions (41 iliac crest flaps and 8 fibula flaps). 31 patients (63%) underwent preoperative (8) or postoperative (23) radiotherapy. Short (6-12 months) and long-term (over 12 months) outcomes are analysed separately. The incidence of complications depending on the timing of radiotherapy (neo vs adjuvant) was compared. RESULTS: In the first 12 months the complication rates among the irradiated and non-irradiated patients were 26 and 11% respectively. During short-term evaluation complications were seen in 26% of the irradiated patients and 11% of the non-irradiated group. After 12 months the rate of complications rises to 45% for the irradiated and 18% for the non-irradiated patients. 27% of irradiated patients presented with fistula, 27% with exposed metallic plates and 9% developed osteoradionecrosis of the graft. Dental implants were inserted in 29 grafts, among which 9 had secondary radiotherapy. 90% of the non-irradiated patients and 56% of the irradiated patients chewed with the dental prosthesis fixed on bone implants. DISCUSSION: Regardless of pre- or postoperative timing, radiotherapy clearly augments complications, the incidence of which increases with time. Only in one patient did osteoradionecrosis necessitate removal of the dental prostheses. Inability to chew is linked more to the amount of resection of the mobile tongue than to complications of radiotherapy. We therefore recommend systematically placing dental implants during the initial surgery, unless large soft tissue resection preventing adequate swallowing is required.

Abrasive esophageal cytology for the oncological follow-up of patients with head and neck cancer.

OBJECTIVES: The occurrence of a second primary cancer in the esophagus in patients with head and neck squamous cell carcinoma is frequent and is associated with a poor prognosis. The aim of this study was to evaluate the yield of abrasive esophageal cytology as a means of screening for metachronous cancer of the upper aerodigestive tract. STUDY DESIGN: We retrospectively reviewed the results of abrasive esophageal cytology performed twice yearly for the screening of patients with prior head and neck cancer. METHODS: From 1987 to 1996, 320 patients treated for head and neck cancer underwent 1,673 abrasive cytology examinations of the esophagus during a mean follow-up period of 4 years. Cytological results were classified as negative, suspect, or positive for malignancy. RESULTS: Twenty-five patients without symptoms had one or more suspect or positive cytologic findings, leading to 29 endoscopic examinations. These revealed 20 premalignant or early malignant lesions of the esophagus (2 dysplasias, 18 squamous cell carcinomas), 2 glandular carcinomas, and 10 clinically unsuspected oral or pharyngeal carcinomas. In seven patients, positive cytological results were associated with clinically visible head and neck cancer. Of the 34 patients with suspect cytological results for malignancy, 10 had no evidence of tumor at endoscopy and 24 had no endoscopic examination because of refusal or because suspected cells were not found in additional examinations. Negative results on cytological examination were found for 254 patients throughout their follow-up, and none of them developed esophageal cancer during a mean follow-up period of 3 years. CONCLUSIONS: For patients with head and neck cancer, abrasive sponge cytology is useful for detecting esophageal cancer at an early stage. In addition, it may reveal unsuspected second primaries or recurrences in the head and neck region.

The anterior mandibular positioning device for the treatment of obstructive sleep apnoea syndrome: experience with the Serenox.

Anterior mandibular positioning devices are seldom used at present in the treatment of obstructive sleep apnoea syndrome (OSAS). The aim of our study was to evaluate the efficiency, the side-effects and the patient compliance with one type of device made in Switzerland, the Serenox. This device is designed to keep the mouth closed with the mandible forward, avoiding the vibration of the soft palate. Between January 1996 and October 1997, 15 patients with OSAS were treated using a Serenox. One of them stopped using the device after 6 weeks due to the persistence of temporomandibular joint pain. Serenox was successful in 13 of the remaining 14 patients. The median pretreatment apnoea/hypopnoea index (AHI) of 36.25/h was decreased to 5.5/h after treatment (P < 0.002). Snoring and daytime sleepiness were notably reduced. The side-effects were frequent but mild and disappeared after a few weeks of adaptation. In conclusion, 87% (13/15) of the patients were treated successfully. Indications for the use of a mandibular positioning device include snoring, upper airway resistance syndrome and light to mild OSAS without severe obesity.

Mucosal wound healing after nasal surgery. A controlled clinical trial on the efficacy of hyaluronic acid containing cream.

In the present clinical trial the efficacy of a new nasal cream containing hyaluronic acid (Rhinogen) on mucosal wound healing has been evaluated in comparison to an ointment (H.E.C.), which is commonly prescribed for this disorder in Switzerland. A total of 56 patients recovering from surgical operation of the nasal cavities participated in this study. In both treatment groups (Rhinogen n = 27 patients, H.E.C. n = 29 patients) respiration and the condition of the nasal mucosa clearly improved. The statistical comparison between the two treatments showed a significant difference in favor of Rhinogen. With regard to the improvement in respiration, the Rhinogen-treated group showed a faster and greater progress than did the H.E.C.-treated group. Furthermore, hyaluronic acid prevented extensive crust formation during the first week of wound healing. The analysis of the efficacy of the treatments, judged by both the patients and the investigator, showed the overall superiority of Rhinogen (patients: p = 0.0041, investigator: p = 0.0023) after 6 weeks of treatment. Furthermore, Rhinogen scored significantly better than H.E.C. with respect to the organoleptic parameters of smell and sensation of cooling. Both treatments were well tolerated. No adverse reactions were reported or observed for Rhinogen, whereas three patients in the H.E.C.-treated group complained of sore throat and burning sensation when the ointment flowed down into the pharynx. In conclusion, this study confirms the therapeutic benefit of hyaluronic acid in mucosal wound healing.