Supracricoid partial laryngectomy with crico-hyoido-epiglottopexy for glottic carcinoma with anterior commissure involvement.

Glottic cancers discovered at an early stage (T1-T2) can be treated with either radiotherapy or surgery. The aim of our study is to analyse survival and functional results of supra-cricoid partial laryngectomy (SCPL) with crico-hyoido-epiglottopexy (CHEP) as surgical treatment for glottic carcinoma with anterior commissure involvement. We performed a retrospective study (1996-2013) which included patients who underwent SCPL-CHEP for glottic squamous cell carcinoma with involvement of the anterior commissure. Before surgery, all patients underwent staging including head, neck and chest CT-scan with contrast injection as well as suspension laryngoscopy under general anaesthesia. A total of 53 patients were included. The median follow-up period was 124 months. Tumour resection was complete in 96.2% of cases. The overall, specific and recurrence-free survival rates at 5 years were, respectively, 93.7%, 95.6% and 87.7%. The average period of hospitalisation was 18 days. The average time elapsed before decannulation and before restoration of oral feeding were 15 and 18 days, respectively. SCPL-CHEP is an important option for laryngeal surgical preservation. It allows adequate disease control as well as good functional results as long as the indications are well respected and the surgical techniques are mastered.

Neurovascular complications following carotid body paraganglioma resection.

OBJECTIVE: The present consecutive case series reports our experience in the management of carotid body paraganglioma and aims to assess whether the Shamblin classification or tumor size are predictive of early and late postoperative neurovascular complications. MATERIAL AND METHODS: A retrospective study included 54 carotid body tumor resections in 49 patients, between 1980 and 2011. Data comprised early (<1month) and late (18 months) postoperative neurovascular complications. RESULTS: Early postoperative complications occurred in 31 cases, including 30 cases of cranial nerve deficit (56%). Cranial nerve deficit occurred in 83% of Shamblin III carotid body paragangliomas and was associated with significantly larger mean tumor size (4±1.4cm versus 2.9±1.3cm; P<0.01). Shamblin III tumor and tumor size>3.2cm emerged as predictive factors for early postoperative peripheral neurological complications. Eight patients (17%) showed no cranial nerve deficit recovery, even after 18 months' follow-up; no predictive factors could be identified for this. CONCLUSION: Surgical resection remains the only curative treatment in carotid body paraganglioma, with low vascular morbidity. However, early postoperative nerve deficit remains frequent (56%), although mostly temporary, with 17% definitive sequelae at 18 months. Tumor size and Shamblin classification are predictive of early neurovascular complications.

[Vestibular disorders and nausea during head and neck intensity-modulated radiation therapy]. / Nausées et troubles vestibulaires lors de la radiothérapie conformationnelle avec modulation d'intensité de la tête et du cou.

PURPOSE: We studied whether there is a relationship between nausea and vestibular disorders in patients treated with intensity modulated radiation therapy (IMRT) for head and neck cancer. PATIENTS AND METHODS: We performed a prospective single-centre study that enrolled 31 patients. A videonystagmography was carried out before and within 15 days after radiation therapy for each patient. Nausea was assessed at baseline, every week, and at the post-radiotherapy videonystagmography visit. RESULTS: Twenty-six patients had benefited from a complete interpretable videonystagmography. For 14 of these patients vestibular damage was diagnosed post-radiotherapy. During irradiation, six patients felt nauseous, but without dizziness. In univariate analysis, we found a relationship statistically significant between the average dose received by the vestibules and vestibular disorder videonystagmography (P=0.001, odds ratio [OR]: 1.08 [1.025-.138]), but there was no relationship between vestibular disorder videonystagmography and nausea (P=0.701). CONCLUSIONS: Irradiation of the vestibular system during IMRT does not seem to explain the nausea.

Optimal enlargement of the frontal sinus approach.

After recalling the main anatomical characteristics of the frontal sinuses, the authors describe the frontal craniotomy surgical procedure and its variants. A bicoronal skin incision is performed. An inferior-based pericranial flap is created, with its limits situated away from the osteotomies. Osteotomies are performed with an oscillating saw. The inferior osteotomy is horizontal, tangentially following the supraorbital margin as far as the lateral limit of each sinus. The osteotomy is continued medially as far as the nasion, passing an average of 3mm above the floor of the medial part of the sinuses, immediately above the frontonasal ducts. The superior osteotomy is performed in a vertical coronal plane through the summit of the sinuses. It is arc-shaped, concave downwards, joining the lateral extremities of the inferior osteotomy. The posterior wall of the sinus can be resected to perform frontal sinus cranialization, allowing access to the midline anterior cranial fossa. The posterior wall of the sinus is removed with a high-speed burr in the same way as the anterior wall. At the end of the procedure, the bone flap is sutured with nylon suture material and the pericranium is sutured over the bone flap.

Thyroglossal duct surgery. Sistrunk procedure.

Midline cysts of the neck are the most common congenital malformations of the neck. They arise along the thyroglossal duct. The presence of a fistula is the result of either spontaneous (suppuration) or surgical fistulisation (simple incision or incomplete excision). The cyst and/or fistula are located between the base of the tongue and the thyroid gland, predominantly adjacent to the hyoid bone. This midline site can be explained by embryological development of the thyroid gland. Treatment is surgical. Many techniques have been described, but Sistrunck procedure (described in 1920), based on embryological studies, remains the reference technique with a recurrence rate of less than 3%, provided surgery is performed correctly, comprising resection of the body of the hyoid. Risk factors for recurrence are: surgery during the inflammatory phase, cyst rupture during dissection, multiple thyroglossal ducts and a technical error during the surgical procedure.

Role of near-infrared fluorescence imaging in the resection of metastatic lymph nodes in an optimized orthotopic animal model of HNSCC.

OBJECTIVES: To study the role of near-infrared fluorescence imaging in the detection and resection of metastatic cervical lymph nodes in head and neck cancer. MATERIALS AND METHODS: CAL33 head and neck cancer cells of human origin were implanted in the oral cavity of nude mice. The mice were followed up after tumor resection to detect the development of lymph node metastases. A specific fluorescent tracer for αvß3 integrin expressed by CAL33 cells was injected intravenously in the surviving mice between the second and the fourth month following tumor resection. A near-infrared fluorescence-imaging camera was used to detect tracer uptake in metastatic cervical lymph nodes, to guide of lymph-node resection for histological analysis. RESULTS: Lymph node metastases were observed in 42.8% of surviving mice between the second and the fourth month following orthotopic tumor resection. Near-infrared fluorescence imaging provided real-time intraoperative detection of clinical and subclinical lymph node metastases. These results were confirmed histologically. CONCLUSION: Near infrared fluorescence imaging provides real-time contrast between normal and malignant tissue, allowing intraoperative detection of metastatic lymph nodes. This preclinical stage is essential before testing the technique in humans.

The role of tonsillectomy in the initial diagnostic work-up of head and neck squamous cell carcinoma of unknown primary.

OBJECTIVE: The aim of the present study was to determine the value of tonsillectomy in the initial diagnostic work-up of head and neck squamous cell carcinoma of unknown primary (HNSCCUP). MATERIAL AND METHODS: A single-center retrospective study (1999­2012) included 45 patients. All cases underwent physical examination, panendoscopy and contrast-enhanced neck and chest CT scan; 27 (60%)also underwent 18-FDG PET scan. Imaging was systematically performed before panendoscopy. In 34 cases (75%), histologic tonsil samples ipsilateral to the HNSCCUP were collected (28 tonsillectomies and 6 biopsies) during panendoscopy. Categoric variables were compared on Chi-square test. RESULTS: Clinical examination and CT did not identify any primary tumor. In 13 cases (38%), invasive squamous cell carcinoma (SCC) was diagnosed on histological samples (12 tonsillectomies, 1 biopsy). For these 13 cases, lymph nodes were located in the upper or middle jugular group, and in 3 cases lymph nodes were cystic on CT scan. In 7 cases (26%), there was an abnormal tonsillar 18-FDG uptake ipsilateral to the cervical lymphadenopathy; tonsillectomy was performed, and SCC was found in 5 of these cases:i.e., 18-FDG PET showed sensitivity and specificity of respectively 55.5 and 88.8%. CONCLUSION: Tonsillectomy has a role in the initial diagnostic work-up of HNSCCUP. It is especially useful when lymph nodes are located in the upper and/or middle jugular group with a cystic aspect on CT.

An original submandibular approach technique sparing the cervical branch of the facial nerve.

Many articles and anatomy textbooks accurately describe the anatomy and anatomical variations of the marginal mandibular branch of the facial nerve (VII). This is not, however, true for the cervical branch, damage to which results in paralysis of the platysma and, because of its insertions at the lower lip and labial commissure, in disfigurement, especially when smiling. This may be mistaken for paralysis of the marginal mandibular branch of the facial nerve. Precise anatomical description of the cervical branch of the facial nerve allows certain technical safeguards to be determined which, if adhered to, should reduce the risk of injury, especially during surgical excision of the submandibular gland on a transcervical approach.

Assessment of nutritional status at the time of diagnosis in patients treated for head and neck cancer.

OBJECTIVE: To evaluate the nutritional status at the time of diagnosis of patients treated for head and neck cancer. MATERIAL AND METHODS: Single-centre prospective study. Nutritional assessment comprised: clinical interview, physical examination, and a laboratory work-up. Clinical interview assessed: reference weight, diet, calorie intake, causes of weight loss, use of dietary supplements. A subjective global assessment of nutritional status (Detsky index) was established on the basis of clinical interview. The patient's height and weight were determined and serum albumin was assayed. Weight loss, body mass index, and Buzby index were then calculated. Two groups of malnourished patients were distinguished: moderately malnourished (group 1), severely malnourished (group 2). Variables were compared between the two groups by Chi(2) test. RESULTS: One hundred and sixty-nine patients were included in the study: 145 had a history of smoking and alcohol abuse, 82 (48.5%) were malnourished and 47 of them were classified in group 1. All patients of group 1 had a normal or pureed diet. 21 (69%) patients of group 2 had a pureed or liquid diet. The mean daily calorie intake was 31kcal/kg/24h for group 1 and 20kcal/kg/24h for group 2. The main causes of weight loss were pain and dysphagia. Dietary supplements were not used by any of the patients in group 1 and by four (13%) patients in group 2. The concordance between the Detsky index and objective nutritional status was 92% for the overall population. Malnutrition was significantly more frequent among males (P=0.01), alcohol users (P=0.02), elderly subjects (P=0.01), patients with pharyngeal tumour (P=0.03), and patients with advanced tumour stage (P=0.01). CONCLUSION: The prevalence of malnutrition among patients with head and neck cancer is high. Assessment of nutritional status and appropriate management must be part of the initial work-up of these patients.

[Treatment of head and neck squamous cell carcinoma of an unknown primary (HNCCUP): oncologic analysis of 35 cases]. / Traitement des adénopathies cervicales malignes en apparence primitive (AMAP): résultats carcinologiques à propos de 35 cas.

OBJECTIVE: The aim of our study was to perform an oncologic analysis of patients treated for head and neck squamous cell carcinoma of an unknown primary (HNCCUP). PATIENTS AND METHODS: 35 cases were included in our monocentric restrospective study (1999-2010). All patients had a complete clinical exam as well as head, neck and chest CT scans. The primary tumour remained undetected after panendoscopy 25 patients underwent a routine tonsillar biopsy ipsilateral to the lymphadenopathy. In 9 cases (36%), an invasive squamous cell carcinoma was detected on pathological examination. These patients were excluded from further study. Kaplan-Meier method was used for survival analysis. Univariate and multivariate analysis were also performed using Cox's regression model. RESULTS: The therapeutic management of patients' majority (73%) consisted of lymphadenectomy with frozen section examination which confirmed the presence of an invasive squamous carcinoma in the resected lymph node(s). This was followed by ipsilateral neck dissection and radiotherapy or radiochemotherapy. Patients with unresectable lymph node(s) underwent exclusive radiochemotherapy. Specific survival rates at 1, 3 and 5 years were respectively 77%, 52% and 47%. The median survival time was 3 years. The comparison of univariate and multivariate survival curves confirmed that the lymph node status is an important factor for survival (HR 8.3 [2.03-33.96]). CONCLUSION: Our results are consistent with those found in the medical literature. HNCCUP has a poor prognosis which correlates with the lymph node status.

Treatment of cervical paragangliomas.

OBJECTIVE: Review of the treatment of cervical paraganglioma. MATERIAL AND METHODS: Review of the literature based on a Medline database. RESULTS: The treatment of choice consists of a multidisciplinary approach based on a detailed clinical, laboratory and radiological work-up. Vascular reconstruction may be necessary when the tumour invades the artery wall. The main complication of surgery is damage to cranial nerves involved in speech and/or swallowing. Treatment of bilateral tumours must be conducted in two stages. The first side to be operated depends on the sites and size of the tumours, as the primary objective is to avoid bilateral vagus nerve palsy. Radiotherapy has been used to treat paragangliomas for several years and achieves tumour stabilization in the majority of cases. Potential indications reported in the literature are: inoperable tumours, recurrence after surgery, some bilateral tumours and malignant tumours. CONCLUSION: Surgery is the standard treatment for cervical paraganglioma. Radiotherapy can be proposed when surgery is contraindicated.

Salvage surgery after radiotherapy for oropharyngeal cancer. Treatment complications and oncological results.

AIMS: Surgery is the only available curative treatment option following failure of radiation therapy for oropharyngeal cancer. This study was designed to analyse the postoperative morbidity and survival rate in patents undergoing salvage surgery. MATERIAL AND METHODS: Single-centre retrospective study in a tertiary referral centre. RESULTS: One hundred and five patients were included, with tumour recurrence in 72 cases, and disease progression in 33 cases, despite radiotherapy. Seventy-seven tumours were located in the tonsillar fossa or glossotonsillar sulcus. Ninety-four tumours were classified as rT2-T3 and 83 were classified as rN0. Segmental mandibulectomy was performed in 77 cases. Cervical lymph node dissection was performed in 96 cases. Pharyngeal reconstruction was performed with a myocutaneous flap in 90 cases. Forty-one local complications were observed, including 12 orocutaneous fistulae and/or neck abscesses, associated with carotid artery rupture in three cases. Twenty patients experienced general complications. The mean decannulation and feeding times were 20 and 30 days, respectively. The 5-year disease-free survival was 21%. On univariate analysis, survival was poorer in patients with disease progression (P=0.01); survival was also correlated with tumour site (P=0.02), rT status (P=0.03), rN (P=0.048), and quality of resection (P=0.04). On multivariate analysis, tumour size (P=0.03) and the interval between the end of radiotherapy and surgery (P=0.02) were the two main prognostic factors for survival. CONCLUSION: The results of this study confirm the high local complication rate of salvage surgery for oropharyngeal cancer and the poor overall survival.

[Lateral transmandibular route for deep-lobe parotid tumor excision]. / Abord transmandibulaire latéral pour l'exérèse des tumeurs du lobe profond de la parotide.

The parapharyngeal space may be a site for tumors, especially for those developed in the deep parotid lobe. The surgical route to parapharyngeal space tumors is a challenge because of neighbor anatomic structures and the specific risk of mandibular nerve damage. The aim of this study was to describe an original lateral transmandibular route, setting aside the mandible angle and preserving the mandibular nerve.