Transalar transsphenoidal meningoencephalocele presenting in the form of recurrent meningitis: Report of two cases and discussion of the diagnosis and treatment

INTRODUCTION

Skull base meningoencephaloceles are rare congenital malformations. The two cases of transalar transsphenoidal malformation reported here differ from the classical transsphenoidal meningoencephalocele.

CASE REPORTS

Case 1 was a three-and-a-half-year-old boy and case 2 was a 36-year-old man. Both cases presented with clinical features of recurrent meningitis. Surgical management of case 1 was performed via an intradural infratemporal fossa craniotomy with reoperation 2years later. In the second case, surgery was initially performed via an endonasal approach and then via pterional craniotomy. Reoperation via Sekhar's transpetrosal approach was also a failure. Only closure of the trigeminal-pontine angle via a suboccipital retrosigmoid approach allowed repair of the defect.

DISCUSSION

Surgical access to the pterygopalatine fossa is complex due to its anatomical position and its anatomical relations with nerves and vessels. An endoscopic approach appears to be a valuable alternative to classical craniotomy.

CONCLUSION

In the two cases reported here, neurosurgery allowed lasting closure of the defect.

Cervical lymph node metastases and T1 squamous cell carcinoma of the lips

OBJECTIVE

The occurrence of cervical lymph node metastasis is a major prognostic factor for head and neck squamous cell carcinoma (SCC) of the lip. This study focuses on patients with T1 stage tumours,in order to describe the prevalence of metastatic lymphadenopathies.

METHODS

A multicenter retrospective study was performed in three tertiary care referral centers and included 59 patients surgically treated for T1 stage SCC of the lips from January 1996 to December 2006. This surgical treatment concerned the tumour, with cervical neck dissection when lymph node metastasis was suspected.

RESULTS

Cervical lymph node metastasis was found and histologically proven in 7 patients (11.9% of the cases, pN+ group; 95% confidence interval, 3.6 to 20.2%) during follow-up, never at the time of diagnosis. Metastasis appeared 13.3 ± 7.9 months (min. 5.3 months, max. 29.1 months) after the initial treatment and involved the IB level in all cases. Tumour progression was significantly longer in the pN+ group compared to patients with no lymph node metastases (sN-group). The pN+ group also had a significantly higher proportion of poorly or moderately differentiated tumours, and a significant decrease in overall survival, disease-free survival, and disease-specific survival.

CONCLUSION

Lymph node metastasis occurs in roughly 12% of T1 stage SCC of the lips, and the management of neck lymph node areas is necessary. A randomized trial is needed to determine the proportion of occult lymph node metastases in T1N0 patients and the impact of this therapeutic procedure on survival.

BRAF mutation in papillary thyroid carcinoma: predictive value for long-term prognosis and radioiodine sensitivity

OBJECTIVES

BRAF pV600E mutation is the most common oncogenic event and the most specific mutation for papillary thyroid carcinoma (PTC). Many studies over the last decade have shown a direct relationship between BRAF mutation and aggressive tumour characteristics, resulting in poor prognosis. However, several recent studies have suggested that BRAF mutation is not associated with poor prognosis of PTC. The present study was designed to evaluate the association between BRAF mutation with clinicopathological factors and tumour recurrence.

MATERIAL AND METHODS

In this retrospective study, BRAF mutation status was examined by direct sequencing on paraffin-embedded tumour specimens from 46 patients undergoing surgery for PTC in our institution from 1985 to 2000. The relationship between BRAF mutation and gender, advanced age, extrathyroid extension, multifocal tumour, cervical lymph node metastasis, tumour size and advanced pT stage of PTC and its predictive role for the risk of tumour recurrence were investigated with a median follow-up of 10.1 (±6.5)years.

RESULTS

BRAF mutation was detected in 20 of the 46 patients (43.5%) included in the study. No statistically significant correlation was demonstrated between the presence of BRAF mutation and the various clinicopathological factors studied. No significant difference in tumour recurrence rate or radioiodine sensitivity was observed between the two subgroups: mutant BRAF and wild-type BRAF.

CONCLUSION

Although BRAF mutation appears to play a role in local tumour progression, it is not a risk factor for poor prognosis or tumour recurrence in PTC.

Sialendoscopy: a new diagnostic and therapeutic tool

BACKGROUND

Sialendoscopy is a recently developed minimally invasive diagnostic and therapeutic procedure for the management of obstructive diseases of the salivary glands. This report describes our early experience with this new tool and compares our results with the literature data.

MATERIAL AND METHODS

This was a retrospective analysis of the 33 first cases treated at a teaching hospital from October 2009 to June 2011.

RESULTS

The success rate for diagnostic sialendoscopy was 94%. Sialolithiasis was found in 19 cases and salivary duct stenosis in 11; no canal anomaly was found in two cases. The success rate for stone removal was 79%, while treatment of strictures failed in four cases. Longer surgical experience led to shorter operating times and improved indications as well as better therapeutic outcomes. There were no complications.

CONCLUSION

Sialendoscopy is a safe technique that can easily be learned by surgeons familiar with endoscopic surgery. However, practical experience is needed to reduce operating times, lower failure rates and determine its precise indications.

[Role of hypnotherapy in the treatment of debilitating tinnitus]

OBJECTIVE

Hypnotherapy is currently used for tinnitus therapy in our university hospital. The aim of this study was to evaluate its efficacy.

MATERIAL AND METHODS

This study was performed on 110 patients suffering from distressing tinnitus. They were treated during five sessions with hypnotherapy, supplemented by instruction on self-hypnotherapy. A subjective evaluation was done by the practitioner at the end of the sessions of hypnotherapy. Then a questionnaire on psychologic distress (Wilson 1991) was sent retrospectively to the patients.

RESULTS

We received 65 responses which were used for this study. Before treatment, the mean value of the Wilson score was 54 (28-104). After treatment, it was: 31 (0-86). 69% of the patients felt an improvement > or = 5 points Wilson score. These results were compared with the evaluation carried out by the practitioner at the end of the sessions of hypnosis. There was a "significant correlation" between the evaluation of the felt benefice, analyzed by the practitioner at the end of the sessions of hypnosis, and by the patient questioned long after the treatment. These results had significant correlation with the evaluation made by the therapist at the end of the five sessions of hypnotherapy. They show, how effective (68% improvement) this therapeutic approach can be.

CONCLUSION

Hypnotherapy can be regarded as an effective treatment against distressing tinnitus.

[Thyroid differenciated carcinoma in children. Study from Normandy]

OBJECTIVE

Definition of a strategy for the management of thyroid differenciated carcinoma in children.

DESIGN AND SETTING

Retrospective cohort study from the Normandy area in France.

METHOD

Analysis of the medical records of 13 children and adolescents (age > 15 years), presenting with thyroid differenciated carcinoma in three Normandy French hospitals from 1994 to 2006, to determine the clinical features and treatment of the disease.

RESULTS

X of the patients were male and y were female, with a mean age at presentation of 11 years. Most frequently symptom was solitary nodes in the thyroid gland (69%). Most frequent histological type was papillary cancer (92%). Size of tumor was > 4 cm in 23% of cases. Children had undergone surgery with total thyroidectomy, radio-iodine treatment and suppressive hormonotherapy. We observed 46% post surgery complications. All patients were alive and none developed a recurrence.

CONCLUSION

Thyroid differenciated carcinoma in children and adolescents were more agressif with most frequently metastasis and recurrence than thyroid differenciated carcinoma of adults. Pronostic is good with 90% of survival at 20 years. We propose a coherent plan of treatment: 1. Thyroidectomy with cervical central lymph node dissection (group VI) completed bilateral selected head neck dissection compartments (groups IIa, III, IV) if macroscopic lymph node metastases in lateral cervical compartment. 2. Postoperative radioiodine is done in all tumor > T1N0 and completed with hormonotherapy.

[CT scan, MR imaging and anatomopathologic correlation in the glottic carcinoma T1-T2]

OBJECTIVES

Endoscopy and imaging are necessary to diagnose glottis carcinoma. Today, CT scan is the gold standard but MR imaging should be more sensitive for neoplastic invasion detection. The purpose of this study was to determine which exam to perform (CT scan or MRI) for neoplastic invasion.

MATERIAL AND METHODS

This prospective study span a 18 months period. Seven patients with glottis carcinoma (TI-T2) underwent CT and MR imaging before surgery. Findings at imaging and pathologic examination were compared.

RESULTS

Both CT and MR imaging were interesting, more specific (90%) than sensitive (74%). The anterior commissure, ventricles, subglottis, thyroid and arytenoid cartilages are the more difficult area analyzing.

CONCLUSION

CT imaging stays the gold standard. MR imaging is more effective on second intention to refine the data. Indications are being improved, with complete cure and more preserved laryngealfunctions.

Quality of life in head and neck cancers patients: predictive factors, functional and psychosocial outcome

The principal endpoints in head and neck cancer are survival with improvement of quality of life (QoL) in cancer patients. Patients treated for head and neck cancer suffer from a number of symptom domains: physical symptoms linked to diet and feeding, communication disorders, pain and their general state of health; psychological symptoms including depression, irritability, loss of self-esteem (occasionally feelings of shame), and social symptoms including relationship difficulties with partner (sexual disorders) or with other family members, loss of work, reduction in salary, and sense of uselessness, resulting in a negative impact on their daily life. At present, most tools only partially evaluate patient QoL, concentrating on the global impact of disease and its treatment on patients' physical and psychological condition. The "sociability" of individual patients is rarely evaluated, and the development of qualitative studies in this domain will enable improved understanding of the social factors involved in each patient's adaptability to disease, its treatment and after-effects.

[Laryngeal schwannomas]

Laryngeal schwannoma is a rare benign tumour of the larynx. Schwannomas derive from the Schwann cells. The majority occurs in supraglottic area and may arise at any age. Magnetic resonance imaging (MRI) is the best imaging tool for suggesting the diagnosis in the appropriate clinical context. Conservative surgery is the treatment of choice. These tumors have to be distinguished from neurofibromas. We report 2 cases of laryngeal schwannoma. The first one concerned an 8-month-old baby with a laryngeal stridor history which seemed to be related to laryngomalacia. The second case was a 22-year-old man with a 5-year history of dysphonia. On nasofibroscopic examination, a sub mucosal mass enlarged the posterior part of the right false vocal cord in both cases. Both CT scan and MRI sequences showed a well margined lesion in the same place. Histological biopsies identified a schwannoma. External surgeries were subsequently and successfully performed. Diagnosis (imaging), specific treatment (endoscopic or external surgery), and possible association of laryngeal schwannomas are discussed.

Les tumeurs malignes primitives des voies lacrymales

OBJECTIVES

To assess the clinical characteristics, the workup, therapeutic approach and pathological findings of primitive tumors of the lacrimal sac.

MATERIAL AND METHODS

Three cases were retrospectively reviewed from the database of our ENT department. They were analyzed and compared to cases reported in the literature.

RESULTS

One adenoid cystic carcinoma and two adenocarcinomas were observed, all were adults and the sex ratio was one man for 2 women. Clinically they presented neither significant lacrimal or rhinologic sign. A CT-scan and a MRI were performed along with a physical examination. An entire surgical resection was done with subsequent postoperative radiotherapy. Two patients died, and one is alive, free of disease.

CONCLUSION

Lacrimal tumors should be considered in the differential diagnosis of a banal chronic epiphora. The ENT practitioner must associate this factor to any clinical evaluation. The management of these lesions requires a complete surgical resection, routinely associated with postoperative radiation.

[Genetic deafness]

OBJECTIVES

The aim of this study was to review the different types of genetic deafness.

METHODS

We describe syndromic and isolated sensorineural deafness and transmission deafness.

RESULTS

Genetic sensorineural syndromic deafness represents 30% of cases of genetic deafness. A frequent cause is Pendred syndrome, which associates congenital sensorineural deafness with goitre and malformations of the inner ear which can be identified on computed tomography scan. Isolated deafness which is responsible for 70% of cases of genetic deafness is then outlined. Among the different types of isolated deafness, 80% are autosomal recessive disorders. A frequent form of autosomal recessive deafness is due to mutations in the connexin 26 gene. Lastly, we detail transmission deafness dominated by aplasia. Major aplasia is characterized by a malformation of the external ear associated with malformations of the middle ear whereas, minor aplasia corresponds to a malformation of the middle ear, sometimes associated with minor external ear malformations.

CONCLUSION

For each type of deafness we propose a systematic assessment.

Small cell neuroendocrine carcinoma of the nasal cavity and paranasal sinuses

INTRODUCTION

Small cell neuroendocrine carcinoma (SNEC) of the sinonasal tract is a rare disease.

OBJECTIVE

Report a descriptive study of a relatively large cohort of SNEC of the nasal cavity and paranasal sinuses.

METHOD

The medical records of 21 patients presenting with nasal and paranasal SNEC to various French hospitals, from 1989 to 2003, were analysed to determine the clinical features and current treatment of the disease.

RESULTS

Patient data were obtained from eight French hospitals. Twelve of the patients were male and nine were female, with a mean age at presentation of 55 years (range: 27 to 79 years). Patients' staging for nasal cavity malignancy was: T1, four; T2, three; T3, one; T4, 13; N0, 18; N2, three; M0, 20; and M1, one. None of the patients suffered from SNEC of the sinonasal tract with ectopic hormone production. Immunohistochemistry proved useful for diagnosis in 20 cases. Twelve cases were positive for cytokeratin, 14 for chromogranin, eight for neuron-specific enolase and 11 for neuron-specific synaptophysin. One patient had an adenocarcinoma and an inverted papilloma associated with neuroendocrine carcinoma. Patients underwent surgery (11 cases), radiotherapy (14 cases) and chemotherapy (12 cases). Recurrence occurred in 10 cases. Five patients had visceral metastases or cervical lymph node involvement. Nine of the patients died within four years of onset of the disease.

CONCLUSION

Small cell neuroendocrine carcinoma of the sinonasal tract is an uncommon neoplasm with aggressive clinical behaviour. Recurrence is frequent and the prognosis is poor. However, the current treatment of these neuroendocrine neoplasms varies widely.

Traitement de cicatrices chéloïdes par « shaving » et cryochirurgie : résultats préliminaires

INTRODUCTION

Numerous treatments have been proposed in patients with keloid scars. Unfortunately, most exhibit poor efficacy. The preliminary results obtained in ten patients with large keloid scars treated by shaving followed by cryosurgery are reported.

PATIENTS AND METHODS

Ten patients with one or more keloid scars were treated by shaving of the keloid immediately followed by cryosurgery of underlying scar tissue using an impedance of 500 k Ohms. Minimum post-treatment follow-up was 12 months. "Major response" was defined as a reduction in keloid thickness of 80% to 100%, "moderate response" as an improvement of 50% to 80% or partial relapse, and failure as an improvement of less than 50% or complete relapse after treatment.

RESULTS

A total of 16 keloids in ten patients (7 men, 3 women) aged from 10 to 45 years old (mean age: 25 years) were treated. Keloids were localised on the lower lobe of the ear (n=10), on the ear lobe (n=3), on the neck (n=1), on the pubis (n=1), and on the presternal area (n=1). Mean duration of keloids was 3.1 years (18 months - 10 years). Mean follow-up was 23 months (12-56 months). "Major responses" were observed in 13 cases (82%) (3 cases required further treatment); "moderate response" was observed in 3 cases (18%).

CONCLUSION

These preliminary results are highly encouraging since all patients showed improvement. Shaving associated with cryosurgery appears to us to be a useful treatment for large keloids scars, particularly after otoplastic surgery.

[Oncology and quality of life. Study in head and neck cancer]

The principal endpoints in oncology are survival with improvement of quality of life in cancer patients.

OBJECTIVES

To give an accurate account of current literature on quality of life and head and neck cancers.

METHODS

Two keys words are used: "quality of life" and "cancer" enabling to trace articles in Medical and Human Science journals. Analysis and synthesis of these documents.

RESULTS

Quality of life is difficult to evaluate as it is a multidimensional concept with three main symptom domains: physical, psychological and social. Several quality of life evaluation scales have been developed enabling authors to estimate the effects of disease on patients as well as treatment-related symptoms. Reports on quality of life in ENT patients have offered improved knowledge on patient experience and aftereffects, and therapies have been adapted and improved in view of such studies.

CONCLUSION

Quality of life evaluation tools need to be improved. At present, most tools only partially evaluate patient quality of life, concentrating on the global impact of disease and its treatment on patients' physical and psychological condition. The "sociability" of individual patients is rarely evaluated, and the development of qualitative studies in this domain will enable improved understanding of the social factors involved in each patient's adaptability to disease, its treatment and after-effects.

Hamartoma of the middle ear: a case study

Hamartomas and teratomas are rare tumors in children. Its location in head and neck is quite exceptional. An unusual case of hamartoma in the middle ear is reported in a 5-month-old child. The tumor was isolated without associated malformation. Definitive diagnosis was made after surgery and based on histological results. At 2 years follow-up, no recurrence was observed. CT-scan is useful in order to reach a final diagnosis. Although rare, this type of tumor should be considered in the differential diagnosis of a middle ear mass during childhood.

[Ewing's sarcoma of the head and neck: a case report]

We report a case of Ewing's sarcoma located in the ethmoid sinus. The patient complained of facial pain, anosmia and visual defect. Diagnosis was established at microscopic examination with histoimmunochemistry and molecular biology. Treatment combined chemotherapy and surgical resection with skull base reconstruction and post-operative ratio and chemotherapy.

[Primary cauda equina epidermoid cyst. A case report]

A primary epidermoid cyst of the cauda equina was diagnosed in an eleven-year-old boy. The patient had a previous two months history of lumbar pain with unilateral L 4 radicular pain. The diagnosis of an epidermoid cyst of the cauda equina, suspected by MRI, was confirmed by histology following surgery. Wide tumor resection, as complete as possible, was performed with minimum trauma. Presence of an epidermoid cyst in the filum terminale is a rare finding, few cases have been reported in the literature. However, surgical treatment and favorable post-operative course are similar to that observed in intraspinal localizations. MRI is helpful for the preoperative and differential diagnosis and for post-operative follow-up.

[Management of cleft lip and palate in university hospital of Rouen]

Cleft lips and cleft palates are managed in the department of Pediatric surgery in Rouen for the last 30 years. From the antenatal diagnosis, the parents got in touch with the surgeon who will coordinate this management. Around thirty new patients are treated every year. The chronology of the treatment is of "classic" manner. The cleft lip is repaired at about 3 weeks of age and the palatoplasty is performed after the age of 1 year. In view to maintain the intimacy of the consultation we did not institute multidisciplinary consultations. The other members of the interdisciplinary team will intervene during the follow up depending on the form of the cleft and the encountered problems. The information and the files circulate freely and are discussed together.

[Ewing's sarcoma of the ethmoid bone. Case report]

Ewing's sarcoma is rarely located at the base of the skull. We report a case of ethmoid Ewing's sarcoma. Diagnosis was established on microscopic examination. A complete surgical resection was performed, followed by cranial base reconstruction. During the postoperative period, a combined course of chemotherapy and radiotherapy was performed. We also present a review of the literature.

[Wegener's granulomatosis involving head and neck: retrospective analysis of 16 patients]

Based on a retrospective analysis of patients with Wegener's granulomatosis (WG), the aim of our study was to compare our finding with those previously reported in the literature. We also reviewed the characteristic features of WG, particularly otorhinolaryngology features. Sixteen consecutive patients were followed over a period of 23 years. There were 8 men and 8 women, all Caucasians, aged between 13 and 74 years (mean 42 years). Initial ENT signs and symptoms were observed in 62.5% of the cases, and occurred in 94% during disease progression with predominant rhino-sinusal (75%) and otological (38%) or laryngotracheal (25%) localizations. Later, the disease primarily affected the lower respiratory tract (87.5%) and the kidneys (50%). Articular (40%), ocular (25%), cardiovascular (25%), neurological (25%), and cutaneous (19%) localizations were also observed. The mean delay to diagnosis was 40 months, more than 1 year in 7 patients. A definitive diagnosis could not be made for 5 patients because of lack of histological evidence, but clinical and biological arguments suggested diagnosis of WG. Antineutrophil cytoplasmic antibodies (ANCA) were assessed in 13 patients and were positive in all. The role of ENT biopsies was significant to our study (31%). The ENT specialist can play a very important role in the diagnosis of Wegener's granulomatosis.

Post-intubation vocal cord paralysis: the viral hypothesis. A case report

After digestive surgery, a 20-year-old man presented dysphonia and fever. Indirect laryngoscopy revealed a left vocal cord paralysis with no structural lesion. IgM and IgG were positive for cytomegalovirus and negative for human immunodeficiency virus, herpes simplex virus, varicella zoster virus and Epstein-Barr virus. The patient recovered spontaneously with a normal voice, and the mobility of vocal cord recovered within 3 months. The aetiology of post-intubation vocal cord paralysis (VCP) remains controversial. Vocal cord paralysis with cytomegalovirus has been reported in two cases associated with acquired immunodeficiency syndrome. Vocal cord paralysis secondary to viral disease has also been described in other circumstances. panied by polyneuritis, especially in immunocompromised patients. We report the case of a patient with transitory unilateral post-intubation vocal cord paralysis which could have been related to a virus infection.

[Adenocarcinoma of the ethmoid sinuses: results of a retrospective study in Rouen]

Ethmoid adenocarcinoma is a rare tumour of the ethmoidal sinuses. The authors report on the clinical features, treatment and follow-up results in 19 cases. Risk factors were those regularly encountered. Delay to diagnosis was long due to the nonspecific clinical features and course. Nasal endoscopy was essential for follow-up. Computed tomography and magnetic resonance imaging were also required to assess tumour spread. Our results suggest that radiotherapy following surgery should be preferred. Survival rate is generally low for this type of tumor. We had 77% survival at 5 years.

[Parathyroid cysts: reprot of 2 cases and review of the literature]

Although parathyroid cysts are rarely described in the literature, they should be considered in the differential diagnosis of cysts occurring in the anterior compartment of the neck. We report two cases. The presence of elevated parahormone in the clear fluid aspirate is the diagnostic criterion. Parathyroid cysts may be functional, probably resulting from cystic formation of a parathyroid adenoma, or non function with their own epithelial lining, probably arising from remnants of the pharyngeal pouch or Kursteiner's canal. Search for both hypercalcemia and hypophosphoremia are needed. Fine needle aspiration provides the diagnosis and is also the treatment of choice for non-functional parathyroid cysts. Aspiration of functional cysts can reduce the hormone level to normal prior to surgical removal.

Treatment of an acyclovir and foscarnet-resistant herpes simplex virus infection with cidofovir in a child after an unrelated bone marrow transplant

Herpes simplex virus (HSV) causes serious problems in immuno-compromised patients such as those receiving a bone marrow transplant (BMT) for a hematological malignancy. Resistance to acyclovir (ACV) is a growing major concern. Foscarnet is a non-thymidine kinase-dependent agent, but the emergence of ACV and foscarnet-resistant HSV requires a new therapeutic approach. We describe a girl treated with cidofovir for a life-threatening ACV-resistant HSV infection after an unrelated BMT for a relapse of an acute myeloblastic leukemia (AML).

Experimental reinnervation of a strap muscle with a few roots of the phrenic nerve in rabbits

In order to compare application of the roots of the phrenic nerve to the ansa hypoglossi for laryngeal muscle neurotization, 1 or more roots from the phrenic nerve were implanted into the right sternothyroid (RST) muscle of rabbits (n = 36). Controls were intact animals (in which RST innervation is provided by the ansa; n = 6) and denervated ones (n = 6). At 66 +/- 2 days (mean +/- SE) after neurotization, during quiet breathing, inspiratory electromyographic activity and isometric contraction force were observed in all reinnervated RST muscles (n = 24). During maximal inspiratory effort, electromyographic activity and force increased. In animals reinnervated by the C4 root alone, forces (46.22 +/- 7.8 g) were significantly higher than in intact animals (10.83 +/- 5.0 g). Retrograde labeling proved the phrenic origin of the neurotization. Electromyography of the diaphragm was recorded. We conclude that in rabbits, neurotization of a strap muscle by 1 or 2 roots of the phrenic nerve allows inspiratory contraction, even during quiet breathing. Such inspiratory activity is not observed in sternothyroid muscles of intact animals innervated by the ansa hypoglossi.

Cervical anatomy of phrenic nerve roots in the rabbit. European Group for Research on the Larynx

The cervical anatomy of the different nerve contributions that constitute the phrenic nerve (phrenic nerve roots and accessory phrenic nerve) were studied in rabbits. In 55 dissections, 6 main root arrangement types were observed. The roots that issued from the fourth and fifth cervical nerves (C4 and C5 roots) were constant. The C4 root was either short or long. The C6 root was at times absent, or sometimes double. An accessory phrenic nerve was present in 43% of the right and 28% of the left dissections. The distribution of the phrenic nerve roots often displayed left-right asymmetry. We conclude that a better knowledge of the cervical anatomy of the phrenic nerve is useful both in physiological studies involving diaphragm denervation and in experimental laryngeal reinnervation.

[Maxillary ameloblastoma. Illustration apropos of a clinical case]

The authors report a case of maxillary ameloblastoma presenting as nasal obstruction. An histopathologic description is done. The difference of clinical course between intra-osseous and extra-osseous (peripheral) ameloblastoma are recalled. The desmoplatic histologic type, recently described in medical literature, is exceptional. Surgery remains the adapted treatment in most cases.

Infiltrating lipoma of the head and neck: a report of one pediatric case

Infiltrating lipomas are rare benign tumors. Several cases have previously been reported in the oral cavity but only three cases have been reported to date in children. We report a case of a 7-year-old child with an infiltrating lipoma of the neck and a posterior extension to the fourth and fifth cervical roots and the vertebral artery. The absence of any neurological signs, negative clinical and radiological examination results, as well as, the surgical risk of total removal and high rate of recurrence suggested a period of watchful waiting. After 5 years, the patient's clinical and radiological characteristics remain stable. A review of the literature regarding this pathology in the head and neck area, in both children and adults is also presented.

[Bilateral laryngeal movement disorder and synkinesia: value of botulism toxin. Apropos of a case]

Several years after a subtotal thyroidectomy complicated by bilateral vocal cord paralysis, the patient presented with progressive dyspnea due to laryngeal synkinesis. The impairement of the ventilation status, in spite of laser arytenoidectomy, followed by contralateral posterior transverse cordotomy, suggested a botulinum toxin injection in the intrinsic adductor laryngeal muscles. The rapid improvement in ventilation without phonatory impairement is discussed in the following report.

[Middle ear cholesteatoma in children. Criteria for surgical procedure in 57 cases]

Fifty five children with 57 cholesteatomas (2 bilateral cholesteatomas) were operated on by the same surgeon. The median period of follow-up was 87 months. Fifteen cases were lost to follow-up (26%). An ossicular erosion was present in 76% of cases. In the first stage, an "intact canal wall technique" (ICWT) was carried out in 44% and a "canal wall down technique" (CWDT) in 56%. A planned second stage was carried out in 76% of ICWT and 56% of CWDT. The incidence of residual cholesteatoma was 29% and the incidence of recurrent cholesteatoma was 11%. A third stage was carried out in 6 cases (11%) without residual or recurrent cholesteatoma. Finally a CWDT was performed in 65% and a ICWT in 35%. The hearing results were significantly better with ICWT but this was due to a better preoperative hearing level. Whatever the surgical technique, the hearing results were better in the presence of an intact stapes. The surgery was individualized. Although ICWT is our priority technique, it was feasible, in our experience, only in a minority of cases because of difficult ablation, insufficient eustachian tube function and very advanced sigmoid sinus or very low lying tegmen plate. Minimal postoperative cavity problems were encountered, even in children where in our experience the mastoidal pneumatisation is limited.

Randomized trial of induction chemotherapy in larynx carcinoma

We conducted a randomized study in patients with previously untreated advanced (T3) larynx carcinoma to compare total laryngectomy followed by radiotherapy to induction chemotherapy, followed by radiotherapy in good responders, and by total laryngectomy plus radiotherapy in poor responders. A total of 68 patients were included in the study, 36 in the induction chemotherapy group and 32 in the no chemotherapy group. 15 of the 36 patients in the induction chemotherapy group did not have a laryngectomy. Survival and disease-free survival were significantly worse in the induction chemotherapy group than in the no chemotherapy group (P = 0.006 and P = 0.02, respectively). The 2-year survival rates were 69% in the induction chemotherapy group and 84% in the no chemotherapy group. Larynx preservation for patients, selected on the basis of having responded to induction chemotherapy, cannot be considered a standard treatment at the present time.

[Spheno-ethmoidal rhinoscleroma. Report of a case and review of the literature]

We report an unusual case of spheno-ethmoidal rhinoscleroma. This chronic granulomatous disease occurs sporadically in Western Europe. Culture is necessary for diagnosis showing the causative organism of rhinoscleroma, Klebsiella rhinoscleromatis. Immunocytochemistry is used in any suspicious case with a negative culture. Antibiotics are the mainstay of therapy for several weeks, using ciprofloxacine or rifampicin, until the nasal biopsies demonstrated no Klebsiella organism.

Transvenous versus perinervous stimulation of the phrenic nerve to assess the diaphragmatic strength in rabbits

Diaphragmatic strength can be measured by transdiaphragmatic pressure during phrenic nerve stimulation. In order to avoid phrenic nerve dissection, a transjugular approach of the phrenic nerve can be performed. The objective of this study was to verify the identity of perinervous and transvenous techniques of phrenic nerve stimulation to assess diaphragmatic force. In intact (n = 9) or right phrenicotomized (n = 12) rabbits, we compared esophageal pressure (Peso) induced by supramaximal perinervous stimulation of the phrenic nerve with that obtained by transvenous stimulation of the phrenic nerve. Electromyography (EMG) of the thoracic muscles was studied in four animals. We found no difference between Peso induced by perinervous (PNS) and transvenous (TVS) unilateral or bilateral phrenic nerve stimulation. During unilateral stimulation, no EMG activity was recorded in the non stimulated diaphragm, or in the middle part of the esophagus, or in ipsi- and contralateral accessory inspiratory muscles. We conclude that in rabbits, unilateral or bilateral TVS of the phrenic nerve is functionally equivalent to PNS, whatever the side of stimulation; Peso is not altered by esophageal contraction in TVS. Transvenous stimulation can replace perinervous stimulation in experimental studies, when cervical access is difficult.

Selective resection of the phrenic nerve roots in rabbits. Part II: Respiratory effects

This study evaluates the delayed respiratory consequences of selective resection of one or several roots of the right phrenic nerve in rabbits. A total of 50 animals were operated on according to five modalities of root resection. A total of 11 animals served as control. The breathing pattern was analysed 8 weeks after surgery. Transdiaphragmatic pressure was measured during transjugular supramaximal stimulation of the phrenic nerve, unilaterally or bilaterally and during prolonged tracheal occlusion (PImax). No difference was observed between the esophageal pressure observed during bilateral phrenic nerve stimulation (BilPeso) in control animals when compared to animals with resection of the highest root of the right phrenic nerve (16.2 +/- 1.0 versus 14.5 +/- 1.0 cmH2O (mean +/- SE). Resection of the two highest or of the two lowest roots of the right phrenic nerve resulted in a similar BilPeso (11.3 +/- 0.8 versus 11.1 +/- 1.2 cmH2O). Preservation of only the accessory phrenic nerve (PN) resulted in a low value of BilPeso (9.8 +/- 1.0 cmH2O) similar to that obtained with complete denervation of the right hemidiaphragm. Ventilation and PImax were not different between the denervated or intact rabbits during quiet breathing. We conclude that in rabbits: (1) Diaphragmatic function is preserved after resection of the highest root of the phrenic nerve. (2) Diaphragmatic function is altered if only the APN is preserved.

Selective resection of the phrenic nerve roots in rabbits. Part I: Cartography of the residual innervation

Partial unilateral diaphragmatic paralysis remains poorly understood. This study evaluates the residual innervation of the diaphragm after selective resection of one or several roots of the right phrenic nerve in rabbits. Forty-seven animals were operated on according to five root resection modalities. Seven animals served as control. Eight weeks after surgery, the different regions of each hemidiaphragm were analyzed. Electromyographic activity was measured during quiet inspiration and the following histomorphometric parameters were studied: mean fiber area, fiber area dispersion, and ratio large diameter over small diameter. The results obtained from the two measurements were similar. When the accessory phrenic nerve was spared, the crural diaphragmatic region was preserved; denervation was encountered in anterior and lateral parts of the hemidiaphragm. When the highest root of the right phrenic nerve was resected, denervation denervation was limited to the sternal region. When resection of the two highest roots was performed, partial denervation was observed in each region, with residual innervation in the posterior hemidiaphragm. When resection of both the lowest roots was performed, denervation was maximal in the costal region; sternal region remained intact. No contralateral innervation was observed. We conclude that in rabbits: 1) resection of a single root of the phrenic nerve preserves consistent residual innervation. 2) somatotopy of the diaphragm innvervation follows an anteroposterior distribution.

[Total unilateral deafness in children. Etiologies and long-term consequences]

A retrospective study of 72 children with a profound (average hearing loss > 90 dB) unilateral sensorineural hearing loss (PUSNHL) was carried out in the ENT department at the Rouen hospital in 1988 and 1994. This study intended to investigate the etiologies, how it was recognized, the age of the onset and the results of the medical evaluation of these PUSNHL. We found, in 2 cases, that vestibular lesions of the healthy ear were present before the onset of a hearing loss on this side, turning the PUSNHL into a bilateral deafness. We tried to correlate the etiologies, age of onset of the PUSNHL, status of the opposite ear and possible scholar problems in the group of the 42 children followed-up for more than 2 years (mean follow-up time = 7 years). Among children suffering from PUSNHL, we specified a group with higher risk of school failures, allowing ENT physicians to propose more accurate management to these children.

[Management of caustic burns of the esophagus in children]

The authors describe their therapeutic approach to caustic burns of the esophagus in pediatric patients. Initially, early endoscopic evaluation is carried out under general anesthesia using a stiff tube then a fiberoptic endoscope. During this procedure, severity of esophageal damage is determined: stage I: mild burn requiring no treatment; stages II and III: severe burn with a risk of subsequent esophageal stricture requiring insertion of a nasogastric stent. A repeat endoscopy is performed after approximately 25 days to evaluate healing. If healing has occurred, the nasogastric tube is removed and dynamic esophagography is performed 2 to 7 days later. Patients with strictures should be treated with repeated endoscopic dilatation at gradually increasing intervals. Surgery is indicated only in patients with complications or multiple strictures after failure of dilatation; trans-mediastinal colon esophagoplasty with removal of the burned esophagus is the method of choice.

[Caustic stenoses of the esophagus]

Oesophageal stenosis is a frequent complication of caustic burns, especially when deep injuries are present, due to the presence of scar tissue. After the treatment of initial complications and after an initial endoscopic evaluation, a few preventive measures can be decided to protect the upper part of the gastrointestinal tract. These measures include complete parenteral nutrition for some, and calibrating nasogastric tube for others; corticosteroid treatment is discussed. When stenosis is present, endoscopic dilatations can be performed. If they failed or instead of them, surgical replacement can be proposed with gastro or coloplasty. Resection of burned oesophagus prevents the risk of mucocele or cancer.

[Ingestion of caustics by children. Report of 23 deep lesions. Therapeutic attitude and long-term results]

In children, 23 caustic injuries of oesophagus with deep lesions (second or third degree of burn) were treated in pediatric ENT department (Pr ANDRIEU--Rouen) during a 19 years long period. Endoscopy in emergency, nasogastric tube for stent and repeated dilatations were the bases of the treatment. 14 second degree burns and 7 third degree burns were complicated of 9 stenosis and one death. The mean duration of total treatment was 43 months. The mean number of dilatations was 38 months. 4 stenosis were definitely cured. 8 children had normal feeding. Mean following was 8 years with good long term results.

Selective reinnervation of the abductor and adductor muscles of the canine larynx after recurrent nerve paralysis

Functional rehabilitation of the larynx after unilateral vocal cord paralysis was attempted in the dog by selective reinnervation of the laryngeal muscles. The intralaryngeal branches of the right recurrent nerve were dissected. The adductor branch was anastomosed with the ansa cervicalis; the abductor branch was anastomosed with the trunk of the phrenic nerve either within the larynx or through the recurrent nerve, the adductor branch of which was sectioned. Results could be analyzed in seven dogs: mobility of the vocal cord was checked, and electromyography, stimulation of the nerves, and histologic studies were performed. Functional reinnervation of both the adductor and abductor muscles was obtained in only one case, with good abduction. Adduction was recorded in five cases. False-positive results emphasize the necessity of collecting several types of data before concluding that functional reinnervation has been accomplished. The reliability of the procedure can and must be improved.