The Carcinologic Handicap Index (CHI): A disability self-assessment questionnaire for head and neck cancer patients

INTRODUCTION

The present prospective study sought to draw up and validate a self-assessment questionnaire for disability following head and neck cancer treatment.

MATERIAL AND METHOD

The Carcinologic Handicap Index (CHI) was designed empirically based on the Voice Handicap Index. It comprises 9 dimensions, self-assessed by the patient: pain, swallowing, feeding, respiration, phonation, hearing, vision, olfaction-gustation, and psychosocial. For each dimension, 4 items are scored in terms of frequency, providing dimension and global scores. The CHI was tested on 86 head and neck cancer patients (pathologic group: male predominance; mean age, 59 years) and 18 control subjects, for validation.

RESULTS AND DISCUSSION

Global internal coherence was 0.905 (Cronbach alpha); content validity (r, between questionnaire scores and corresponding visual analog scales) ranged between 0.6 and 0.8 except for the vision dimension and for total score compared to general health rating on VAS (r≤0.5: i.e., the pathology did not directly impair vision and was only one factor among others affecting general health status); temporal validity was satisfactory (r>0.7; P<0.0001) except on the respiration dimension (r=0.624, probably due to fluctuation in pulmonary congestion). Impact on swallowing, feeding and respiration varied with lesion site. There were no significant differences between patients and controls on the pain, hearing and vision dimensions.

CONCLUSION

The CHI showed acceptable psychometric qualities and can be considered as an authentic clinical tool for health professionals, assessing the impact of ENT pathology on quality of life, mainly in the functional domains directly affected by the pathology or treatment.

Surgical management of maxillary sinonasal inverted papilloma

OBJECTIVE

The extent of the surgery required when sinonasal inverted papilloma (IP) originates in the maxillary sinus is still the subject of debate. The principal aim of the study was to evaluate the efficacy of exclusive endoscopic removal or when combined with a limited vestibular anterior antrostomy of the maxillary IP.

METHODS

A retrospective analysis was carried out of 64 patients with IP treated in our university tertiary referral center from 1993-2007. Endoscopic removal of the IP was done for all patients, either exclusively or combined with an open approach. All patients were followed up for more than 1 year and the local control rate has been compared between patients with maxillary IP and others, and with both approaches.

RESULTS

The overall recurrence rate was 14% (9/64), for a mean follow up of 48 months (12-120 months). Twenty-three patients (23/64) had maxillary IP. Ten of them had endoscopic resection alone, 13 had a combined approach (1 with lateral rhinotomy). There were 4 recurrences (17%) three of which had had endoscopic surgery alone. We did not perform a medial maxillectomy in the first instance. There were no cases of epiphora or atrophic rhinitis. conclusion: We showed that the combined method (endoscopic assisted by a minimal vestibular approach) was an efficient and safe method to treat maxillary sinus IP. This approach could preserve the lacrimal duct and the inferior turbinate when these structures were not involved, even when there was a large maxillary sinus extension of the disease.

Endoscopic resection of sinonasal adenocarcinomas

OBJECTIVE

To evaluate the outcome and morbidity of endoscopic resection of sinonasal adenocarcinomas.

METHODS

This is a case series of 17 patients diagnosed with sinonasal adenocarcinoma that were resected endoscopically between 1999 and 2008.

RESULTS

The surgery constituted the first line of treatment for all patients. Five anterior skull base reconstructions were done. Post-operative meningoencephalitis and minimal epistaxis were the complications reported. The mean follow-up was 3 years [6-107 months]. To date, there have been two local recurrences at 6 months of an insufficient resection of a tumour classified pT4 and 25 months of a pT2 resected with safe margins. Another patient presented an unique metastasis in the parietal lobe 42 months after the resection of tumour pT4 extended to the frontal lobe. Two deaths unrelated to the disease were reported while thirteen patients remained free of disease (76.5%).

CONCLUSION

The endoscopic approach is a safe and effective treatment in selected cases of sinonasal adenocarcinomas. This procedure is less invasive than conventional surgery but requires an optimal preoperative imaging protocol and an experienced surgical team. These encouraging results have to be confirmed by a larger cohort and a longer follow-up.

[Ruptured pexis after supracricoid partial laryngectomy: a series of 5 cases]

OBJECTIVES

Supracricoid partial laryngectomies have a rare but a specific complication which is the rupture of the pexy. After cricohyoidoepiglottopexy or cricohyoidopexy, a separation can appear between the hyoid bone and the cricoid cartilage. Our objective was to define how to treat and to prevent this complication.

METHODS

One hundred and one supracricoid partial laryngectomies were performed in our department between 1980 and 2006. A retrospective analysis of the medical charts and operative files revealed that 5 patients have had a ruptured pexy. A review of the diagnosis, management, and outcome of these five cases is presented and discussed in this paper.

RESULTS

The diagnosis was done in the first post-operative month for all cases. Delay in decannulation time, swallowing disorders, local infection were associated with the rupture of the pexy. The separation between the hyoid bone and the cricoid cartilage was also suspected at neck palpation and in endoscopy. Lateral plain Xrays of the neck or CT scans were used to confirm the diagnosis. A medical treatment, a completion total laryngectomy and three revisions of the pexis were performed.

CONCLUSIONS

In our series, an antecedent of radiation before surgery appears to be a risk factor for the development of this specific complication. A revision of the pexis procedure is advocated in case of a major ruptured pexis.

[Endonasal endoscopic approach in the treatment of sino-nasal inverted papillomas]

INTRODUCTION

Sino-nasal inverted papilloma is a rare benign tumor of the nasal fossa and the paranasal sinuses for which the successful surgical treatment by an endonasal approach has been corroborated in the literature. Nevertheless, the authors aim in this study to evaluate the advantages and the limits of this approach, to analyse its failures and its recurrences, and to define the indications for using it with the external or dissimulated approach.

MATERIAL AND METHODS

42 patients presenting with a sino-nasal inverted papilloma and treated surgically over a ten year period were included in this retrospective study. The operative technique was chosen as a function of the endonasal and radiological examination results (CT scan and MRI). Follow-up was over one year for all patients.

RESULTS

Twenty eight patients were operated exclusively through an endoscopic endonasal approach. Fourteen patients were operated using a combined approach, associating either a vestibular (9 cases), a paralateral nasal (3 cases) or a fronto-orbital (2 cases) approach with endonsal endoscopy. In two cases, an associated squamous cell carcinoma was found. We observed a recurrence in 9.5% of the all cases and in 14.2% of the patients treated using a combined approach.

CONCLUSIONS

Endoscopic endonasal surgery is a validated surgical approach for the treatment of sino-nasal inverted papilloma in that total tumor removal is possible. This approach is particularly indicated in medially-situated papillomas without frontal or maxillary extension. In all other cases, associating an external or dissimulated approach is usually necessary.

[Pseudoaneurysm of the internal carotid artery revelated by epistaxis: report of two cases]

OBJECTIVES

Pseudoaneurysms of the carotid artery are a rare but serious cause of epistaxis. They can be rapidly life-threatening. Usually resulting of a surgery or a traumatism, pseudoaneurysms can express themselves by recurrent epistaxis. Management of these epistaxis is discussed.

METHODS

The authors present two cases and effect a review of the literature.

RESULTS

The first patient presented with a pseudoaneurysm few days after a transsphenoidal surgery. The second patient presented with a pseudoaneurysm fourteen years after a radio-surgical treatment of an ethmoidal and frontal epidermoid carcinoma. Diagnosis was suspected during nasal endoscopy and confirmed in both cases with angio-CT and arteriography. The first patient underwent a selective embolization. The second patient had to have a carotid occlusion due to a sudden severe haemorrhage, resulting from a pseudoaneurysm rupture following the embolization attempt.

CONCLUSION

Review of the literature confirms the indication of endovascular intervention. The optimal management is carotid occlusion, provided the patient can tolerate carotid test occlusion and the circle of Willis is satisfactory. In some cases, a preservative treatment may be possible, which could be either pseudoaneurysm embolization or the placement of a covered stent.

[Nasal polyposis: long term functional results in 203 patients treated by ethmoidectomy combined with intranasal corticotherapy]

OBJECTIVE

Evaluate the long term quality of life in patients after ethmoidectomy associated with intranasal corticotherapy for nasal polyposis on the appreciation of the intensity of nasal symptoms. MATERIAL ET METHOD: The authors report their experience about 203 patients treated by endonasal endoscopic ethmoïdectomy intranasal followed by a long term intransal corticotherapy, with a mean follow up of six years. In this prospective study, each symptom was evaluated using an analogic visual scale and a questionnaire. The evolution of asthma after surgery and the patients global satisfactory rate were noted.

RESULTS

There is a global improvement of the nasal symptoms with a mean postoperative individual scores calculated at 32% for nasal obstruction, at 34% for rhinorrhea and at 51% for anosmia. No impact on asthma or improvement of asthma was encountered in 92% of the patients. The patients global satisfactory rate of this medico-surgical approach of the disease is 93.6%. A positive correlation was found between the severity of the olfactory disorders and the oral corticosteroid therapy.

CONCLUSION

Endoscopic endonasal ethmoïdectomy followed by intranasal corticotherapy represents a valuable protocol in treating patients with severe nasal polyposis.

Endoscopic sinus surgery for sinonasal haemangiopericytomas

Haemangiopericytomas are rare peri-vascular tumours with variable malignant potential. The nasal cavity and the paranasal sinuses are most often involved in the head and neck. Five cases of haemangiopericytomas treated by a strict endonasal endoscopic approach are presented. Bleeding and nasal obstruction are the most frequent symptoms. Computed tomography (CT) scan and magnetic resonance imaging (MRI) allowed pre-operative assessment. Angiography with embolization was needed in two of the five cases. None of our patients presented with malignant histology. Our five cases were operated on, and a total tumour excision was performed through the endoscopic endonasal approach. We had one recurrence with a mean follow-up of 4.5 years. We suggest that when the tumour is purely intranasal or strictly located in the ethmoid or sphenoid sinus, it can be removed via an endonasal approach under endoscopic guidance in experienced hands.

[Allergic rhinitis in children]

The diagnosis of allergic rhinitis (AR) in children is mainly based upon history which leads to distinguish between seasonal (periodic or intermittent) pollinic AR and perrenial (permanent or chronic) AR. The consequences of an AR can be severe with major nasal discomfort, repercussion on quality of life and school attendance, and impact on facial bone growth. In addition it can be complicated by asthma. Specific desensitization is the only treatment which may modify the immune response towards allergens. However it must be compared with the other treatments including local or general antihistaminic drugs and intranasal corticosteroids, the choice resting upon the severity of the symptoms, the respiratory repercussion, and the age of the child.

Value of investigation in the diagnosis of allergic fungal rhinosinusitis: results of a prospective study

The authors report a prospective study in which the aim was to analyse the usefulness of different criteria in optimizing the diagnosis of allergic fungal rhinosinusitis. From 1995 to 1998, 165 patients were operated on for chronic rhinosinusitis. Investigations used in this study for the diagnosis of allergic Aspergillus rhinosinusitis consisted of an analysis of clinical, radiological, immuno-allergic criteria. Fourteen patients presented with allergic Aspergillus rhinosinusitis. One hundred and fifty-one patients did not present any of the necessary criteria for the diagnosis of allergic Aspergillus rhinosinusitis. The results show that the characteristic macroscopic appearance, the maxillary sinus localization, and the presence of positive specific IgE to Aspergillus fumigatus are arguments that reinforce the diagnostic certitude of allergic fungal sinusitis. No specific clinical or radiological criteria orients a diagnosis of chronic rhinosinusitis toward that of allergic fungal rhinosinusitis. The other immuno-allergic tests do not contribute to the diagnosis of allergic fungal rhinosinusitis. pathological, mycological, and

Evaluation of some velar functions before and after surgical treatment of snoring

The aim of this prospective study was to evaluate velar function before and after uvulopalatopharyngoplasty for isolated snoring and for sleep apnoea. It is based on the analysis of oral and nasal airflow during phonation by an EVA workstation of 24 patients before and after the surgical intervention. The results show (1) quantitative and qualitative airflow abnormalities before the operation, (2) an increase in the percentage of nasal airflow flow after the operation, and (3) a change in the airflow sequence, which is improved after the surgical procedure. In conclusion, this work confirms a modification of velar function after uvulopalatopharyngoplasty and raises the problem of contra-indications to this intervention.

[Allergic rhinitis]

Allergic rhinitis is one of the commonest diseases. The main allergens responsible are respiratory allergens. Pollinic or seasonal allergic rhinitis is currently distinguished from perannual or nonseasonal rhinitis, generally related to sensitization to allergens of the home environment. The diagnostic approach of allergic rhinitis is based on a careful clinical examination, in order to eliminate other causes of nasal dysfunction, and on complementary investigations, most importantly allergic skin tests. Several types of drugs, topically or systemically administered are currently available to treat allergic rhinitis. Surgical techniques should be reserved to patients who resist to medical treatment or to correct nasal architectural abnormality.

Nasopharyngeal tuberculosis

Rhinopharyngeal tuberculosis is a rare pathological condition. It is most often associated with lymph node and pulmonary lesions, but it may be an isolated finding. The authors report a recent case of an isolated rhinopharyngeal tuberculosis in a 64-year-old female. A review of the literature is presented. They emphasize the clinical presentation, that, in all aspects, may resemble a malignant tumour of the nasopharynx, as well as the difficulty of obtaining a pathological and bacteriological diagnosis.

[Does allergic fungal sinusitis exist? Preliminary results of a prospective study]

Allergic aspergillar sinusitis is a very controversial clinical feature. We present results of a prospective study aimed at evaluating the reality of allergic aspergillar sinusitis in a nosologic and clinical point of vue. During a 5 months period, 31 patients underwent surgery: 21 sino-nasal polyposis, 5 chronic sinusitis without polyposis, 5 chronic sinusitis with radiologic images evocative of mycosis. The study was carried out using clinical criteria (per-operative discovery of glue-like, thickened and viscous aspect of the secretions), pathologic criteria (the presence of elements consitutive of allergic mucin), mycological criteria (direct examination and culture), and immunoallergic criteria (specific IgE for Aspergillus fumigatus, serology for Aspergillus fumigatus and Aspergillus flavus (IgM, IgG), skin tests for Aspergillus fumigatus). In three cases we suspect an allergic aspergillar sinusitis (one patient presenting a bilateral chronic sinusitis and two patients presenting a sinonasal polyposis). In two patients presenting a sinonasal polyposis, a allergic fungal sinusitis was suspected, fungal identification was not possible.

[Adenoid cystic carcinoma of the larynx. A case report and review of the literature]

Laryngeal adenoïd cystic carcinoma (ACC) is a rare disease due to the poor distribution of the accessory salivary glands in this area. The authors describe a case of ACC arising from the sus glottic area and underline the difficulty of such a diagnosis, which is in fact an histologic finding. The signs of discovery of a laryngeal ACC are not different from other tumors of the area, except pain frequently evoked in these tumors. Laryngeal ACC arises exceptionally before the age of 20 years and no risk factor is known. The most frequent localization is in the sub-glottic area, but sus glottic and glottic localizations have been reported. Evolution is marked by the onset of cervical lymph adenopathies and systemic metastasis most often located in the lung. The treatment comprises wide surgical exerisis followed by radiotherapy. Other reports seem to indicate that the pronostic of the laryngeal location of this disease is worse than in other areas of the head and neck.

Mucoceles of the paranasal sinuses: uncommon location

Mucoceles are the most common lesions causing expansion of the paranasal sinuses. The sinuses most commonly involved are, in decreasing order of frequency, frontal sinus, ethmoid sinuses, maxillary sinus and sphenoid sinus. We reviewed 46 cases of surgically proven mucoceles and the purpose of this study was to report five cases of mucoceles in an uncommon location.

[Bilateral closure of the nasal cavity. An original surgical technique of treatment of severe recurrent epistaxis in Rendu-Osler disease]

In the Rendu Osler disease, epistaxis are seen in 80 to 90% of patients, and the multiple treatments that have been proposed have each shown their failure to achieve satisfactory results. We propose, in the case of abundant epistaxis, a bilateral closure of the nasal cavity. This technique has been initially described by Young in 1967 in the treatment of chronic atrophic rhinitis. This operation was carried out in two patients who presented with serious daily epistaxis, poorly tolerated, and refractory to several treatments. Neither of these patients has presented a post-operative bleeding episode with a one year and six months follow-up respectively. Anatomically, the results are satisfactory in both patients, with total closure of the nasal cavity. Functionally, both patients are satisfied, with an appreciable improvement in the quality of life despite total nasal obstruction.

The holmium:YAG laser for treatment of inferior turbinate hypertrophy

Chronic hypertrophic rhinitis is sometimes refractory to local, as well as general, medical treatment. Before undertaking surgical reduction of the inferior turbinates, there is indisputably a place for cauterization or laser vaporization of the inferior turbinate mucosa. The authors present a study of 46 patients treated by the holmium:YAG laser for chronic hypertrophic rhinitis. The results after only one laser session are satisfactory in 89.1% at 6 months' follow-up and in 52.2% with mean follow-up of 16.2 months. No major secondary effects were observed.

Functional endoscopic sinus surgery and 109 mycetomas of paranasal sinuses

Mycetomas of paranasal sinuses are more frequently diagnosed with the widespread use of nasal endoscopy and computed tomography (CT). We present a series of 109 cases treated by functional endoscopic sinus surgery (FESS) with a mean follow-up of 29 months. All localizations were seen, and contrary to what was initially thought, seven cases presented in multiple sites. Several clinical presentations were found, from a pansinusal involvement to a simple mycetoma hanging in a superior meatus. A heterogeneous sinus opacity with microcalcifications on CT scan is very suggestive of the diagnosis, but a homogeneous opacity may be encountered even with bone lysis. FESS was performed in all cases to obtain a wide opening of the affected sinuses, permitting a careful extraction of all fungal material. In the postoperative period, no medical treatment is prescribed. With a mean follow-up of 29 months, only four recurrences were seen. This study reinforces the interest in FESS for cases of mycetoma of the paranasal sinuses.

[Metastatic cervical adenopathies of unknown primary site. Long-term course]

We conducted a retrospective study of 34 patients treated by radical neck dissection followed by radiotherapy for one or several cervical adenopathies without a primary tumor. Mean follow-up was 48 months. During follow-up, 6 patients developed a presumed primary tumor, and 11 patients presented with recurrent lymph nodes. We found no statistically significant predictive factor, as to either clinical characteristics or the histological nature of the adenopathies. On the other hand, the number of metastatic lymph nodes found on the surgical specimen was correlated with the risk of lymph node recurrence. Among the prognostic factors with an unfavorable effect on survival, the dimensions of the adenopathy, its fixed characteristic and its TNM status, were identified. In this series, the appearance of a primary tumor did not seem to worsen the prognosis. On the other hand, the appearance of lymph node recurrence predicted poorer survival rates. The results are discussed and compared with those found in the literature.

[Partial lower turbinectomy in children: indications, technique, results]

Inferior turbinate surgery has been proposed as a treatment modality in severe childhood hypertrophic rhinitis refractory to medical treatment. The authors present a series of 38 children treated in the otorhinolaryngology department of the Timone University Hospital, Marseille, and the Rangueil University Hospital, Toulouse. Thirty eight children between 9 and 16 years of age (27 males and 11 females) underwent a bilateral inferior turbinectomy, and followed-up for a period of 6 months to 4 years. Allergy was fund in 19 patients, asthma in 11 patients, and an underlying sinus pathology associated in 9 patients. Turbinate surgery was isolated in 16 cases, and in 22 cases, it was associated with an adenoidectomy, a septoplasty, and/or an ethmoidectomy. The authors discuss the operative indications, and describe the turbinectomy technique in children. Post-operative complications are rare (no crusting rhinitis, one non symptomatic synechia). One case of nasal bleeding was noted after nasal packing removal. Functional obstructive symptoms were improved in near 90% of cases. Asthma was improved or disappeared in 27.3% of cases, and no cases of worsening asthma was noted. The authors conclude that this type of turbinectomy is efficient and non-iatrogenic when a precise indication and a rigorous technique are applied.

[The voice of the child, morphological evolution of the larynx and its acoustic consequences]

From a review of the literature, the authors analyze the role of laryngeal modifications in the evolution of a child's voice. The modifications found are topographic (laryngeal descent in the neck), morphologic (increase in volume modification of laryngeal shape), and histologic (lamina propria differentiation), each responsible for acoustic modifications. The chronological evolution of the voice integrates these modifications in a global context of development, where the central nervous system is of primary importance.

[Efficacy of partial inferior turbinectomy in the treatment of nasal obstruction. Retrospective study apropos of 71 patients]

Longtime discredited, practiced with reticence even today, the inferior turbinectomy represents the treatment of choice in patients with persistent chronic nasal obstruction despite medical treatment or cauterization. Between January 1989 and December 1995, 81 patients underwent an isolated bilateral inferior turbinectomy (without an associated septal or sinus intervention). This retrospective study analyzes the short and long-term results in 71 patients with a one year minimum follow-up. Turbinectomy was in all cases always partial and managed under endoscopic guiding. Mean follow-up was 33 months, based on a patient's questionnaire. No cases of crusting rhinitis were observed. 81,7% of patients were improved by the surgical intervention. In asthmatic patients, no worsening of the asthma was noted, whereas in 28,5% of these cases, there was an improvement or disappearance. Non serious adverse effects appear after surgery as rhinorrhea (16%) and post nasal drip (18,4%). The surgical turbinate reduction represents an option in the care of patients with chronic nasal obstruction associated with inferior turbinate hypertrophy.