[Ethmoidal mucocele after transpalpebral bony orbital decompression]. / Mucocèle ethmoïdale après décompression orbitaire osseuse transpalpébrale.

We report a case of a late ethmoidal mucocele occurring after transpalpebral bony orbital decompression. A 39-year-old man presented with a recurrence of a right-sided proptosis without signs of orbital inflammation. The patient had undergone bilateral transpalpebral bony orbital decompression for dysthyroid orbitopathy 2 years prior. Orbital CT scan showed a large mucocele in the supero-lateral right ethmoidal sinus with lateral extension to the medial rectus. The patient was therefore referred to an ear, nose and throat (ENT) surgeon, who performed an anterior ethmoidectomy with marsupialization and drainage of the mucocele via an endoscopic approach. A complete postoperative resolution of proptosis was observed without recurrence of the mucocele to date, approximately 6 months postoperative. Sinus complications occurring after orbital decompression may include sinusitis, hematoma, imploding antrum syndrome and mucoceles. Recurrent proptosis secondary to an ethmoidal mucocele is a rare event after bony orbital decompression surgery, with only two cases reported in the international literature. Management requires ophthalmologic diagnosis and collaboration between the ophthalmologist and otorhinolaryngologist.

[Surgery of mucocele of the paranasal sinuses: report of 52 cases with a middle term follow up]. / La chirurgie des mucocèles sinusiennes: notre expérience à propos de 52 cas suivis à moyen terme.

OBJECTIVE: To define indications and limitations of Functional Endoscopic Sinus Surgery (FESS) for mucoceles therapeutic management. PATIENTS AND METHODS: 52 cases of mucoceles were treated in our institution during the 8-year period 1993-2001. All patients underwent follow-up for a minimal period of 4 years, with a clinical (endoscopy) and imaging assessments, in order to diagnose recurrences. OUTCOMES: Distribution of mucoceles location was: fronto-ethmoid sinus (25 cases), maxillary sinus (10 cases), anterior ethmoid sinus (3 cases), posterior ethmoid sinus (8 cases), sphenoid sinus (4 cases) and nasal cavity (2 cases). Thirty eight patients had undergone a nasal (1 septoplasty, 2 rhinoplasties) or sinusal surgery in their history. Recurrences were reported in 2 cases (3.8%). These 2 patients presented primarily with nasal polyps (nasal polyposis or cystic fibrosis) and both recurrences involved fronto-ethmoid sinuses. DISCUSSION AND CONCLUSION: Mucoceles involve quite commonly the maxillary sinus and the frontoethmoid sinus. Exclusive FESS with large opening of the mucocele (marsupialization) is an efficient therapeutic procedure. FESS procedure should be a procedure of first choice for mucocele management as it is highly efficient and has a low morbidity. Nevertheless, latero-frontal sinus mucoceles might be difficult to cure with FESS. Recurrences most likely occur in patients with associated ethmoidal inflammatory diseases.

[Aesthetic parotidectomy: face lift incision and SMAS flap]. / Parotidectomie esthétique: incision dissimulée de lifting pré-capillaire et lambeau de SMAS.

INTRODUCTION: Traditional parotidectomy skin incision (bayonet-shaped incision) is adapted from an extirpative standpoint but not ideal cosmetically. There are three main drawbacks: Scar, retro-mandibular depression and Frey syndrome. The goal of this prospective study was to evaluate the feasibility of this facial incision for extirpative purposes and to define the clinical benefit in terms of scar and retromandibular depression. METHOD: Ten patients with parotid tumors were included during the period 2005-2006. All patients had benign tumours: 5 males and 5 females. Mean age was 49 yrs. (42-67). Investigated parameters were: "retromandibular depression", "skin scar" and "Frey syndrome". Analogic visual satisfaction scale (1-10) was used by patients to assess these data postoperatively at 15 days, 1 month and 6 months. RESULTS: This face lift approach allowed very good surgical exposure not only of the parotid area but the posterior submandibular region and over the sternocleidomastoid muscle. Postoperative lateral facial contour was symmetric and good in all cases. Six patients assessed this parameter 8/10 and 4 assessed 10/10. After removal of stitches the facial skin scar was considered good in 100% of cases. Six patients assed this parameter 9/10 and 4 assessed 10/10. No Frey syndrome was reported by any patients within 16 months postoperatively. CONCLUSION: Association of a face skin lift approach and a SMAS flap yields a very good cosmetic outcome after surgical parotidectomy. As aesthetic considerations are obvious in breast surgery, aesthetic considerations have a great place in parotid and head and neck surgery.

[Saddle nose surgery: long term aesthetic outcomes of support grafts]. / Ensellures nasales. Résultats esthétiques à long terme des greffons de soutien.

UNLABELLED: Saddle nose surgery requires support grafts to improve the aesthestic of the nose such as the functional ventilation. Many kind of graft are available: Calvarial bone graft, iliac crest, septal cartilage, conchal cartilage, nasal hump, bony inferior turbinate. OBJECTIVES: To define the surgical strategy and long term aesthetic outcomes of rhinoplasty with support graft for saddle nose correction. MATERIAL AND METHOD: Retrospective study during the period 1985-2005: 160 patients underwent rhinoplasty with support graft for saddle nose correction. Patients were divided into 3 groups depending on the deformation (group I: Minor saddle nose; group II: Intermediate saddle nose; group III: Major saddle nose). Long term results were analysed at least 5 years after surgery, in 70 patients. RESULTS: An intranasal approach was performed in 92 cases, while an open approach was performed in 68 cases. A bony support graft was used in 85% of patients of group II and 94% of patients of group III. These grafts allowed a more rigid correction of the saddle nose than cartilage. For groups II and III patients, cartilage support grafts were not used because of the lack of quantity to correct the saddle nose. CONCLUSION: Calvarial bone support graft has a great role in saddle nose surgery. The postoperative aesthetic outcomes are interesting and its absorption is low.

Cervical paragangliomas: neurovascular surgical risk and therapeutic management.

Paragangliomas of the neck region arise most commonly in the carotid and vagal bodies. The goal of this retrospective study is to evaluate intraoperative vascular and neurological morbidity and to define the therapeutic strategy. During the period 1990-2004, 32 patients with 42 neck paragangliomas were referred to our institution (Head and Neck Service, Otolaryngology Federation, CHU La Timone, Marseilles, France). There were 29 carotid body tumors and 11 vagal body tumors. There were 14 men and 18 women. Forty paragangliomas were surgically excised. Mean age of patients with family history of paragangliomas was 34 years and that of patients without any familial history was 47 years. Only one patient had a malignant paraganglioma. A vascular repair procedure was performed in 10% and always occurred in carotid body tumors including the malignant one. Postoperative hypoglossal nerve deficit was reported in five cases (12.5%). Paralysis of vagus nerve was reported in 11 cases (27.5%), nine of whom were patients with vagal body tumors. Knowledge of number of paragangliomas and their location is of main importance and influences the therapeutic strategy. The goal of this strategy is to avoid major neurovascular morbidity and to optimize treatment of multiple or bilateral tumors. Early management of patients prevents progressive neurological deficit due to an enlarging tumor mass and minimizes neurovascular complications.

The silent sinus syndrome.

Silent sinus syndrome is a rare clinical entity typically characterized by spontaneous and progressive enophthalmos and hypoglobus caused by an alteration of the normal orbital architecture and function from maxillary collapse in the setting of the chronic maxillary sinus hypoventilation. The authors report an unusual case revealed by mild dental pain, present the imaging (before, during and after the development of the disease), discuss the different theories related to pathogenesis and comment the treatment.

Pediatric paranasal sinus mucoceles: etiologic factors, management and outcome.

OBJECTIVES: To study the local and general etiological factors of paranasal sinus mucoceles in the pediatric population and to evaluate and discuss the clinical management and the results of endonasal marsupialization. DESIGN: Retrospective study. PATIENTS AND METHODS: A series of 10 cases of paranasal sinus mucocele in children were managed. For imaging, CT-scan and, sometimes MRI were performed. An ophthalmologic evaluation was performed preoperatively in all cases, and post-operatively in case of preoperative trouble. All patients were treated with endoscopic surgical procedure. Authors also looked for etiological factors. RESULTS: Cystic fibrosis was found in 6 cases out of 10. Others etiological factors were trauma and inflammatory process; one case was strictly idiopathic. Three patients out of 10 had ophthalmologic trouble related with the mucocele. With a mean follow-up of 17 months, neither recurrence nor complication were noted. All patients with ophthalmologic complain were free of trouble after surgery. CONCLUSION: Paranasal sinus mucoceles in children are still rare. In our experience, 9 out of 10 patients had predisposing factors, especially cystic fibrosis. Imaging with CT-scan and MRI allow the physician to rule out other tumors such as meningoceles or rhabdomyosarcoma. Endoscopic endonasal surgery is nowadays the gold standard for the treatment of paranasal sinus mucoceles.

[Sinonasal hemangiopericytoma: a case report]. / Hémangiopéricytome sinusonasal: a propos d'un cas.

OBJECTIVE: To define clinical, histological and radiological features of sinonasal hemangiopericytoma (SNHPC) and to describe its therapeutic management. PATIENTS AND METHODS: A case of SNHPC (47 year old man) of the left nasal cavity underwent endoscopic sinus surgery at our institution. This case is reported and discussed with a review of the literature. DISCUSSION: SNHPC is a low grade malignant vascular tumour. The intra-nasal location is very rare. This unusual tumour of the nasal cavity has a specific clinical behaviour and prognosis. Diagnosis is confirmed by histological studies with immunohistochemical methods. Vimentin and SMA markers are reported positive in 98% and 92% of cases, respectively. Work up includes MRI and CT scan in order to assess the tumour extent. Angiography is useful to assess the vascularization and preoperative embolization reduces the intra-operative bleeding of large tumours. The gold standard treatment is surgery and the aim is to perform a wide excision with tumour free margins. Surgery can be performed by endoscopic techniques in patients without extra-nasal extension. Radiotherapy is advised for cases of suspect or positive margins. Post-treatment follow up focuses on lifelong endoscopic surveillance. Metastases are rare but recurrences can occur many years postoperatively. The treatment of recurrence is also surgical.

[Microinvasive endonasal surgery: contribution of endoscopy to maxillofacial surgery]. / Chirurgie endonasale micro-invasive: apport de l'endoscopie en chirurgie maxillo-faciale.

Video-assisted endonasal endoscopic surgery is used for a constantly increasing number of indications, replacing more invasive external approaches. Indications include chronic bacterial and fungal sinusitis, nasosinus polyposis, mucocele, inverted papilloma, and lacrimal duct stenosis. This microinvasive technique offers the advantage of preserving the physiological properties of the mucosa while assuring proper ventilation of the nasal and sinus cavities. We discuss the technical basis of this new surgical option used by ear-nose-throat specialists and maxillofacial surgeons. We focus on turbinai, septal, maxillary, and lacrimal surgery but do not discuss the more specific rhinology areas such as ethmoidectomy, sphenoidotomy or frontal surgery. The main procedures are described together with indications and expected results.

Cavernous sinus thrombosis secondary to non-invasive sphenoid aspergillosis.

The sphenoid localization of aspergillosis is a rare sinusal disease, often latent or asymptomatic. The neurological complications are the result of invasive forms occurring in most cases for the immunocompromised or diabetic patients. Nevertheless, non-invasive sphenoid aspergillosis may cause also several complications and affect the vital prognosis of nonimmunocompromised patients. This report is about two cases of cavernous sinus thrombosis secondary to a non-invasive sphenoid aspergillosis. The authors refer to the clinical and radiological findings and therapeutic approach of this rare complication.

Preoperative diagnostic values of fine-needle cytology and MRI in parotid gland tumors.

The aim of this retrospective study was to assess and compare the diagnostic value of fine-needle cytology and MRI for the prediction of malignancy in parotid tumors. During an 11-year period, 148 patients underwent preoperative fine-needle aspiration cytology in our institution. Eighty-seven patients underwent a preoperative MRI study, and 54 had both MRI and cytology. The study compares results of cytology and MRI with histological reports. The sensitivity, specificity and accuracy for detecting malignant lesions were 87, 94 and 93% respectively for MRI, 81, 95 and 92% respectively for cytology and 100, 88 and 91% respectively for both studies combined. Fine-needle cytology provided better information than MRI concerning precise histological diagnoses. Conversely, the proportion of non-diagnostic smears reached 10%. Fine-needle cytology and MRI are simple, well-tolerated diagnostic means with an impact on the management of salivary gland tumors. The associated anatomic information obtained by MRI imaging makes it the test of first choice in an optimal medical environment.

[Recurrences of pleomorphic adenomas of the parotid: development of concepts]. / Récidives des adénomes pléiomorphes parotidiens. Evolution des concepts.

OBJECTIVES: The aim of this study was to examine the surgical and pathological factors that led to recurrent parotid pleomorphic adenomas. The study also tried to determine best practice for the treatment of recurrence. In addition the study looked at the correlation between fine needle cytology and definitive histology. MATERIAL AND METHOD: Histological study was undertaken on 100 pleomorphic adenomas surgically removed from patients in our institution between 1992 and 2002. Study of diagnostic value of fine needle cytology aspiration and MRI for pleomorphic adenoma diagnosis was performed in 181 patients operated on for parotid tumors. RESULTS: Hypocellular pleomorphic adenomas often have a thin capsule and constitute the most frequently encountered histological type in recurrence. Pseudopodias are considered as an additional factor in recurrence. In our series, cytological study had an excellent diagnostic value with a sensitivity of 92% and a PPV of 96%. MRI study had a sensitivity of 83% and a PPV of 89%. CONCLUSIONS: According to these findings, enucleation surgery on a pleomorphic adenoma should not be performed anymore. Parotidectomy techniques (total or lateral) constitute the surgical treatment of choice. Fine needle aspirate cystology in a useful diagnostic procedure. Management of recurrences is based on surgery with total parotidectomy and facial nerve preservation. Role of radiotherapy is still indeterminate.

[Diagnosis management of Warthin tumour: clinical presentation, fine needle cytology and MRI]. / Approche diagnostique des tumeurs de Warthin: clinique, cytoponction et IRM.

OBJECTIVES: Warthin tumour is the second most frequent benign tumour of the parotid gland after pleomorphic adenoma. The aim of this retrospective study was to define clinical, cytological and MRI characteristics in order to work out a therapeutic strategy. MATERIAL AND METHOD: During the period May 1991-January 2003, 53 patients with Warthin tumors were treated in our institution. Clinical data were reported from medical records reviewing. Histological diagnoses were compared with FNAB and MRI results. RESULTS: Warthin tumours represented 13% of all parotid lesions of our series. Mean age of patients was 58 year-old. Sex ratio was 3.8 men and 1 woman. Sensitivity of FNAB for Warthin tumour diagnosis was 75% while positive predictive value was 71%. Six cases of false positive patients were reported: 2 acinic cells carcinomas, 2 pleomorphic adenomas, 1 dermoid cyst, 1 branchial cyst. CONCLUSIONS: Surgical management is based on partial parotidectomy that may be adapted to the tumour location. Because of elderly patients, benign nature and low risk of malignant transformation of Warthin tumours, one might prompt to adopt a conservative strategy, avoiding surgery in some cases. Despite diagnosis of Whartin tumour on FNAB and MRI, one must be cautious in recommending conservative treatment in order to avoid ignoring a surgical tumour.

[Functional outcomes after translabyrinthine approach for vestibular schwannomas]. / Résultats de l'exérèse par voie translabyrinthique élargie des schwannomes vestibulaires.

PURPOSE: The aim of this paper is to present the functional outcomes after translabyrinthine approach (TLA) for vestibular schwannoma (VS). We analyzed data from 95 patients who had undergone surgery on between 1991 and 2001. METHODS: This retrospective study of clinical and radiological data concerned 95 patients operated on by TLA for a unilateral vestibular schwannoma, excluding NF2 patients and those who have been operated on after a gamma-knife treatment. Results were evaluated with at least 2 Years follow-up and compared with recent data in the literature. RESULTS: Complete tumor removal was achieved in 84% of cases. The facial nerve was normal at the end of the operative procedure in 85%. Facial nerve function was evaluated in 90 patients with two Years follow-up: 62% were grade I or II according to the House and Brackmann scale, 21% were grade III and 16.5% grade IV to VI. CSF leakage was noted in 8.4% including rhinorrhea in 4.2%. No deaths occurred during this period. CONCLUSION: The results related here show that TLA is a safe and efficient procedure for the removal of large acoustic neuromas.

[Preserving hearing function after Gamma Knife radiosurgery for unilateral vestibular schwannoma]. / Préservation de l'audition dans le traitement par radiochirurgie Gamma Knife des schwannomes vestibulaires unilatéraux.

OBJECTIVE: The majority of the patients still lose hearing function in spite of the technical advances in microsurgery. We wanted to evaluate preservation of hearing function potential after Gamma Knife Surgery. MATERIAL AND METHOD: In Marseille, we performed 1000 Gamma-Knife procedures for vestibular schwannomas between July 1992 and January 2002. This population included 175 patients undergoing first intention surgery for a unilateral schwannoma with functional preoperative hearing (Gardner and Robertson 1 or 2) who were studied with a follow-up longer than 3 Years. Univariate and multivariate analysis was performed. RESULTS: Numerous parameters significantly influenced the probability of functional hearing preservation at 3 years. The overall rate of preservation was 60%. The main parameters of predictability were limited hearing loss (Gardner and Robertson stage 1 versus 2) before radiosurgery, presence of tinnitus as the initial symptom, young age and the small tumor size. Preservation of functional hearing at 3 years was 77.8% when the patient was initially in stage I, 80% when the patient's first symptom was tinnitus, and 95% when the patient had both. In these patients, the probability of functional preservation at 5 years was 84%. CONCLUSION: We report a large population of patients treated by radiosurgery with initial functional hearing. These results demonstrate that a large percentage of selected patients can preserve functional hearing after Gamma Knife Surgery, their chances of functional preservation being greater than after microsurgery or simple surveillance.

[Pleomorphic adenoma of the parotid: histopathological study]. / Adénome pléomorphe parotidien. Etude histopathologique.

OBJECTIVES: Capsular ruptures play a major role in recurrences of parotid pleomorphic adenomas. The aim of this retrospective study was to define histomorphological characteristics of pleomorphic adenoma in order to define possible recurrence mechanisms and to set a clear surgical management. MATERIAL AND METHOD: Histological study was performed after reviewing of slides originating from 100 patients with pleomorphic adenomas of the parotid gland. These patients were treated in our institution during the period May 1992 - November 2002. RESULTS: The studied population was distributed into 3 histological subtypes for better analysis. Hypocellular (stroma rich) pleomorphic adenoma was reported in 56%, hypercellular pleomorphic adenoma was reported in 29% and "classic" in 15%. Thinness of capsule was significantly related to hypocellularity. Pseudopodias and satellite nodules were reported in 72% of this series. CONCLUSION: Due to capsular characteristics, surgical excision should avoid dissection in the vicinity of the tumor in order to avoid capsular bare area, so minimizing the risk of surgical induced recurrence. According to these findings, enucleation surgery for pleomorphic adenoma should not be performed anymore. Parotidectomy techniques (total or lateral) constitute the surgical procedures of choice.

[A case of nasal septum schwannoma: endoscopic resection]. / Le schwannome du septum nasal. A propos d'un cas.

OBJECTIVES: To define clinical and radiological characteristics of nasal septal schwannoma, and to propose endoscopic surgery. PATIENT AND METHODS: We report a case of an isolated schwannoma of the anterior part of the nasal septum, without involvement of any local structure. The only preoperative symptom was nasal obstruction. Imaging study included a CT scan and an MRI study. RESULTS: Schwannoma is a sheath tumor originating from Schwann cells of peripheral nerves. It rarely occurs in nasal and paranasal sinuses and its development on the nasal septum is extremely rare. Complete removal of the tumor was performed by endoscopic sinus surgery technique. Limits of the excision were free of tumor and the histological type was Antoni type A Schwannoma. After a year of follow up, the patient is free of recurrence. CONCLUSION: The Schwannoma of the nasal septum is a rare tumour whose clinical and radiological diagnosis by CT scan and IRM is relatively easy. Its treatment is surgical and the endoscopic surgery can be proposed in the forms slightly extensive.

[Primary cancer of the parotid gland: an anatomoclinical approach]. / Cancers primitifs de la parotide: approche anatomo-clinique.

BACKGROUND: Carcinoma of the parotid gland presents a wide variety of clinical presentations, behaviors and prognoses. The aim of this study was to define the characteristic clinical presentations and the prognostic factors of these tumors. MATERIAL AND METHOD: Sixty-six patients with carcinoma of the parotid gland seeing during the 1985-2003 period were included in this study. Mean patient age was 55 years; the sex-ratio was 1. RESULTS: The most common histological types of this series were mucoepidermoid carcinoma and adenoid cystic carcinoma. Stage I tumors were reported in 59% the series while only 18% the patients of this series had stage III and IV disease. Pain was reported in 45% all patients. Facial nerve clinical involvement was reported in 11% all patients. DISCUSSION: Both tumoral stage and histological grading are independent prognostic factors influencing the therapeutic strategy. Clinical course and tumor growth distinguished between malignant tumors with benign clinical behavior and malignant tumors with malignant clinical behavior. A preoperative workup with physical examination, fine needle cytology and MRI helps to define the preoperative diagnostic and to adapt the therapeutic strategy.

[Sphenoid sinusitis]. / Sinusites sphénoïdales.

Sphenoid sinusitis is uncommon, with an incidence of about 2.7%. Failure to diagnose and treat sphenoid sinus disease has been shown to lead to serious neurologic sequellae. Plain radiographs play a limited role in the management of sinusitis. CT scan can provide a positive diagnosis by the visualization of mucosal thickening, air-fluid level and complete opacification of the sinusal cavities. In addition, CT can provide more information about the anatomy and abnormalities of the sphenoid sinus. MRI is used in cases of suspected tumors or neurologic involvement. The most common presenting symptom is headache that arise characteristically, but rarely, from the vertex. Sphenoiditis has a high risk of severe neurologic involvement, cavernous sinus thrombosis being one of the most serious complications.