Comparison between caloric and canal impulse rotatory test.

It has been suggested that the rotatory test using videonystagmoscopy can also be applied for identification of vestibular canal paresis. In this study, we test this hypothesis by comparing the results of a canal impulse rotatory test with those of the caloric test using the method described by Freyss. Our study indicates that only in 38% of all tested patients, the same results between the two tests have been obtained. Furthermore, when the group with abnormal findings is observed separately, in 24% patients only these two test methods lead to the same results. Consequently, the canal impulse rotatory test cannot replace the caloric test.

Comparison between caloric and canal impulse rotatory test.

It has been suggested that the rotatory test using videosnystagmoscopy can also be applied for identification of vestibular canal paresis. In this study, we test this hypothesis by comparing the results of a canal impulse rotatory test with those of the caloric test using the method described by Freyss. Our study indicates that only in 38% of all tested patients, the same results between the two tests have been obtained. Furthermore, which the group with abnormal findings is observed separately, in 24% patients only these two test methods lead to the same results. Consequently, the canal impulse rotatory test cannot replace the caloric test.

[Giant pleomorphic adenoma of the parotid gland: a case report and review of the literature]. / Adénome pléomorphe géant de la parotide: a propos d'un cas et revue de la littérature.

We report the case history of a 72-year-old patient who had a giant parotid adenoma that developed over 12 years. Worrisome clinical signs started to develop when the tumor had reached the size of 50 cm and a weight of 2.6 kg. Histology reported a benign tumor of the parotid gland. We discuss this case in relation to the to similar cases in the literature, highlighting clinical and histological difficulties encountered in patients with giant tumors of the parotid.

[Atelectasis of the maxillary sinus. Analysis of progression stages. Apropos of 4 cases]. / Processus atélectasique du sinus maxillaire. Analyse des stades évolutifs. A propos de 4 cas.

We analyzed atelectasic processes occurring in the maxillary sinus. Several publications in the literature have tempted to analyze the pathogenesis. Clinically the processes are often silent and only revealed when the major opthalmological complication, enophthalmia, becomes patent. In other cases there is a long history of chronic sinusitis. There is a spectacular retraction of the maxillary sinus walls leading to collapse of the orbital floor and enophthalmia. We report four cases of maxillary sinusitis with atelectasia of the sinus walls at different stages of progression. These observations and data in the literature emphasize the importance, whatever the state of development, of endoscopic osteal decompression to avoid ophthalmological complications.

[Atypical involvement of undifferentiated carcinomas of the nasopharyngeal type. Apropos of 3 cases]. / Localisations atypiques des carcinomes indifférenciés de type nasopharyngé. A propos de 3 cas.

We report 3 cases of undifferentiated carcinomas of nasopharyngeal type (UCNT) found in unusual sites and compare them with histologically identical tumors found in the nasopharynx. Using viral serology and viral marquers found in the tumor cells, we looked for a link with the Epstein Barr Virus (EBV) which exists in the nasopharyngeal site. It appears that UCNT found in unusual sites have a poorer prognostic than the same nasopharyngeal tumors; no link was found with EBV. The number of published cases is too small to form a conclusion, therefore, we propose a systematic search for EBV, presenting our protocol, each time is discovered UCNT in an unusual site.

[Use of endoscopy in pituitary surgery]. / Utilisation de l'endoscopie dans la chirurgie pituitaire.

Endoscopy has changed many of surgical procedures concerning nasal and paranasal cavities. It has been proposed for transnasal removal of pituitary adenomas. The authors report their experience concerning four pituitary macroadenomas operated with the neurosurgical team of Sainte-Anne hospital. The endonasal trans-septal route seemed to be more anatomical and less traumatic than the rhinoseptal sublabial route. The 30 degrees rigid Hopkins endoscope was a good help for controlling the absence of any tumor remnant in the supra and parasellar regions after complete removal of the tumor performed through the endoscope or with the operating microscope. The authors discuss the advantages and limitations of such endoscopic procedures in the light of recent literature.

[Apropos of 2 cases of mucocele with major ophthalmologic complications treated by endoscopic endonasal surgery]. / A propos de deux cas de mucocèle avec complications ophtalmologiques majeures traitées par chirurgie endo-nasale endoscopique.

We report two cases of frontal and ethmoidal mucocele revealed by severe ophtalmologic complications and present the clinical data and computed tomography and magnetic resonance imaging results together with the treatment. The surgical approach and technique are discussed. Recovery of ophtalmologic deficiency was excellent.

Neoadjuvant chemotherapy with carboplatin/5-fluorouracil in head and neck cancer.

In a prospective, randomized, multicenter study, neoadjuvant chemotherapy (CT) with carboplatin and 5-fluorouracil (5-FU) followed by locoregional treatment (LRT) was compared with locoregional treatment alone in the treatment of patients with head and neck cancer. This study, which includes 324 patients, was conducted from January 1988 to July 1991. The aim of this study was to evaluate the impact of the carboplatin/5-FU regimen both on the incidence of mutilating surgery and on the survival rate. Chemotherapy consisted of three cycles of carboplatin 400 mg/m2 day 1 and 5-FU 1 g/m2 days 1-5, repeated every 3 weeks. Patients with a complete tumor response then received radiotherapy alone, instead of the treatment planned initially. Three hundred patients were analyzed: 79 had tumors of the oral cavity, 106 oropharyngeal tumors, and 115 pharyngolaryngeal tumors. One hundred fifty patients underwent CT+LRT; 150 patients had LRT alone. Grade 3 and 4 toxicity rates were minimal in the CT+LRT group; toxicity was mainly hematologic (24% neutropenia, 19% thrombocytopenia). There were 3 toxic deaths (2%), 2 due to septicemia and 1 due to cardiac toxicity. One hundred forty-three patients were evaluable for efficacy. The tumor objective response rate was 63% and complete response rate was 31% (35% for oropharyngeal, 34% for pharyngolaryngeal tumors, 22.5% for oral cavity tumors), which led to a 29% decrease in the rate of mutilating surgery. Conservative treatment was performed in 57% of patients in the CT+LRT group vs. 24% in the LRT group (p = 0.001). There was no significant difference between survival curves in the CT+LRT and LRT groups. At 4 years, overall survival rates were 56 and 46%; disease-free survival rates were 33 and 30% in the CT+LRT and the LRT groups, respectively. The survival rates were not significantly different in the two groups. The locoregional recurrence rates were 35% in the CT+LRT arm and 25% in the LRT arm (p = 0.04), with median follow-up of 25 months. The rates of secondary localization and distant metastasis were not significantly different in the two groups.

Neoadjuvant combination of carboplatin and 5-FU in head and neck cancer: a randomized study.

A prospective, randomized, multicenter study of patients with oropharyngeal and pharyngolaryngeal tumors compared locoregional treatment alone with neoadjuvant chemotherapy with carboplatin/5-fluorouracil (5-FU) followed by locoregional treatment. The aim of the study was to evaluate the role of chemotherapy on survival and on the need for mutilating surgery. Since 1988, 219 patients (105 with oropharyngeal and 114 with pharyngolaryngeal tumors) have entered the study. All patients randomized to neoadjuvant chemotherapy received three cycles of carboplatin 400 mg/m2 day 1 and 5-FU 1 g/m2/d as a continuous infusion days 1 through 5 every 3 weeks. Neoadjuvant chemotherapy was given to 108 patients. The 268 evaluable courses induced a low rate of grade 3 or 4 toxicity. Four patients (3.6%) died of major complications. The complete response (CR) rate was 31%, which represented a decrease in mutilating surgery of 30%. (Patients with CRs had radiotherapy alone instead of radiosurgical treatment as originally planned.) The objective response rate was 61%. Survival curves for the chemotherapy and chemotherapy-naive groups were not significantly different. The rate of nodal recurrence was significantly higher in the chemotherapy group, however, and chemotherapy did not decrease the rate of second primary tumors or distant metastases. Thus, the justification for neoadjuvant chemotherapy may be a decreased rate of mutilating surgery. These preliminary results are encouraging, but follow-up is as yet too short to allow definite conclusions.

Randomized study of 5 fluorouracil and cis platin as neoadjuvant therapy in head and neck cancer: a preliminary report.

A randomized prospective study of 5 fluorouracil (5-FU) and Cis platin preceding definitive local treatment for squamous cell carcinoma of the head and neck region was initiated in September 1986. Seventy-five patients were stratified by site (oral cavity-12, oropharynx-28, larynx-16, hypopharynx-19), and by Stage (Stage II-20, Stage III-43, Stage IV-12) and randomized to receive definitive local treatment (surgery and post-operative radiation or radiation alone) or chemotherapy followed by definitive local treatment. Chemotherapy consisted of three cycles of 120 hr 5-FU infusion 1 g/m2/day plus Cis platin 100 mg/m2 on day 1 on each cycle. Response to chemotherapy was complete in 17 patients (46%) for an overall response rate of 68%. All the patients have completed therapy with a median follow-up of more than 12 months. After local treatment, the complete response rate is 84% for the control group and 86% in the chemotherapy group. Actuarial disease-free survival at 1 year is 61% in the control group and 73% in the chemotherapy group (p = 0.25). These preliminary results show that in spite of initial tumor response, neoadjuvant chemotherapy does not improve long-term control and survival.

[Several principles of jurisprudence on the medicosurgical error]. / Quelques principes de jurisprudence sur la faute médico-chirurgicale.

When medical responsibility is questioned in a court, the fault notion is more often the center of interest of the debates. The fault reproached to the doctors are of different kinds: clumsiness, imprudence, error in the diagnosis, surpassing of their competences, dereliction of duty to inform the patient of the risks or on the medical evident consequences of a surgical intervention etc. The principles which have motivated the decisions dispensed by civil, administrative and penal jurisdictions are exposed in some of these cases.

[Postoperative iatrogenic lesions of the external branch of the accessory spinal nerve]. / Lésions iatroènes post-opératoires de la branche externe du spinal.

Iatrogenic lesions of the spinal nerve are rare and generally occur during cervicotomy for aetiological assessment of adenopathy. The spinal nerve is essentially damaged at two sites: the supraclavicular fossa (where the nerve is very superficial) and in the antero-lateral triangle of the neck (where the nerve approaches the sterno-cleido-mastoid muscle). The lesion of the spinal nerve essentially presents in the form of paralysis of the trapezius; which should be examined systematically postoperatively and at subsequent consultations, as the clinical signs may only develop after a certain latency period. The spinal nerve lesion requires early surgical repair (graft, suture) which gives the best results when it is associated with long-term, patient physiotherapy. Legally, the practitioner is generally condemned due to failure to obtain informed consent, which emphasises the importance of preoperative consultations during which the patients should be warned of the possibility of a lesion to this nerve.

[Drug ototoxicity. Medicolegal aspects]. / L'ototoxicité médicamenteuse. Aspects médico-légaux.

Drug ototoxicity is a preoccupying iatrogenic complication. Experimental studies over recent years, in particular a pharmacokinetic study of the elimination of aminoglycosides, have enabled the authors to define rules of prescription for parenteral aminoglycosides designed to reduce to a minimum the risk associated with their use. New aminoglycosides such as Netromycin appear to be associated with reduced toxicity. The medico-legal consequences of this complication are still rare, although more precise rules of prescription tend to make the experts more rigorous. The experimental evidence of cochleovestibular toxicity of aminoglycosides applied locally in the presence of a perforated tympanum leaves no room for doubt. The principal factor seems to be the duration of treatment. The prescription of a local aminoglycoside in the presence of a perforated tympanum would only appear to be justified from a legal point of view when absolutely indicated by antibiotic sensitivity tests.