Aural tuberculosis at the start of the 21st century. Literature review according to SWiM guidelines. Part 2: Treatment

OBJECTIVES

Systematic review of the scientific literature dedicated to treatment modalities and results for aural tuberculosis published since the start of the 21^st century.

MATERIAL AND METHODS

Search of the Medline, Cochrane and Embase databases for the period 2000 - 2020. Selection of articles in English, French and Spanish devoted to clinical cases and series documenting treatment of auricular tuberculosis. Extraction of data on pre-established files documenting treatment modalities and results. Reading of articles by two authors. Analysis performed according to SWiM guidelines, evaluating cure, tuberculosis-related death, treatment-related complications, improvement in facial palsy, and hearing sequelae rates.

RESULTS

One hundred and twenty eight articles: 118 case reports (159 patients) and 10 cohorts (177 patients) from 42 countries were analyzed. Female/male sex ratio was 1.2 with ages ranging from 1 month to 87 years. Medical treatment consisted in 5 to 24 months' antitubercular antibiotic treatment using 2 to 8 antibiotics. Mastoidectomy, tympanoplasty and facial nerve decompression were associated to medical treatment in 64.7%, 17.4% and 6.2% of cases, respectively. Overall rates of cure, death, treatment-related complications, facial sequelae and hearing sequelae were 96.8%, 2%, 9.5%, 35.8% and 75.5%. In case reports, BCG vaccination did not appear to protect against facial palsy and severe intracranial complications (P>0.6). There was no significant correlation (P>0.3) between death and the clinical variables tested, and facial nerve decompression did not appear to influence outcome for facial function (P=0.4).

CONCLUSION

Medical treatment is very effective but not without risk of death, complications and sequelae. It is the same as for pulmonary tuberculosis. Indications for and benefit of major auricular surgery during medical treatment deserve further studies.

Aural tuberculosis at the start of the 21st century. Literature review according to SWiM guidelines. Part 1: Clinical and diagnostic data

OBJECTIVES

Review of the scientific literature dedicated to clinical data and diagnosis modalities for aural tuberculosis published since the start of the 21st century.

MATERIAL AND METHODS

Search of the Medline, Cochrane and Embase databases for the period 2000-2020. Selection of articles in English, French and Spanish devoted to clinical cases and series documenting clinical data and diagnosis for aural tuberculosis of articles by two authors. Analysis performed according to SWiM guidelines. Extraction of data on pre-established files documenting clinical and diagnostic data.

RESULTS

In total, 173 articles: 163 case reports (228 patients) and 10 cohorts (177 patients) from 49 countries were analyzed. Female/male sex ratio was 1.05, with ages ranging from less than 1 month to 87 years. Tuberculosis involved another site in 35.1% of cases. Aural involvement was bilateral in 19.7% of cases. Clinical presentation corresponded to otitis media (prior antibiotic treatment and auricular surgery in 41.4% and 10.1% of cases, respectively) without any pathognomonic symptoms or signs. Associated severe locoregional complications were seen in 32% of cases, with 23.2% and 13% incidence of peripheral facial palsy and severe intracranial complications, respectively. Time to diagnosis ranged from less than 1 month to 384 months, and was longer than 12 months in 26.5% of case reports, without significant correlation (P=0.29) with severe revelatory locoregional complications. Incidence of Mycobacterium tuberculosis detection ranged from 33.4% of documented cases in auricular secretions to 64.6% in polyps, granulomas, and/or biopsies. In the case reports, diagnosis with certainty was done in 58.3% of cases, while it was based on involvement of another site and on indirect criteria or positive clinical progression after treatment in the other 10.1% and 31.6%, respectively.

CONCLUSION

Aural tuberculous must always be considered in case of unfavorable progression of otitis. Definitive diagnosis is based on multiple auricular sample sites, polymerase chain reaction, and γ interferon blood assay.

Intubation decision criteria in adult epiglottitis

OBJECTIVES

To identify contributive criteria in decision-making for intubation in acute epiglottitis, based on clinical and endoscopic data in adult patients, and to study clinical and biological characteristics and management.

MATERIALS AND METHODS

Diagnosis was established by flexible endoscopy showing epiglottic edema in association with general signs of sepsis in 28 patients consulting into two French hospitals between 2005 and 2016. Retrospective univariate and multivariate analysis between patients managed by intubation (Group I) or surveillance (Group S) was performed on clinical and endoscopic data.

RESULTS

Ten patients were intubated (36%). On univariate analysis, 4 variables were suggestively associated with intubation. On multivariate analysis, associations remained suggestive for dyspnea (OR=50.6; 95% CI=[2.7; 940.1]) and supraglottic edema extension (OR=42.2; 95% CI=[2.2; 799.5]). The area under the curve identifying intubated patients on these 2 criteria was 90.8%, testifying to high discrimination.

CONCLUSION

Intubation must always be considered in epiglottitis. Dyspnea and supraglottic extension of the edema seem to be the two main criteria to be considered in airway control decision-making.

Rehabilitation following total laryngectomy: Oncologic, functional, socio-occupational and psychological aspects

GOAL

To review rehabilitation following total laryngectomy by an analysis of epidemiological, oncologic and functional data.

MATERIALS AND METHODS

This retrospective observational study focused on patients having undergone total laryngectomy or pharyngolaryngectomy between January 1, 2005 and December 31, 2016. Oncologic data notably comprised survival and relapse and predictive factors. The impact of the procedure on quality of life and the voice was analyzed by self-administered questionnaires (EORTC QLQ-C30 and H&N35, VHI 30). A satisfaction questionnaire was also sent to patients.

RESULTS

One hundred and thirty three patients were included. Overall specific 5-year survival was 65%. The relapse rate was 32%. Factors influencing survival were WHO performance status ≥2 (P<0.05), tumor location (P=0.07), metastatic lymphadenopathy (P=0.017) and positive resection margins (P=0.01). Quality of life was moderately degraded (global EORTC QLQ-C30 status: 61.4±23.9). Type of rehabilitation (P=0.03), tube feeding (P=0.03) and relapse (P<0.01) influenced quality of life. There were no differences in voice quality according to rehabilitation method, and no predictive factors for failure of voice rehabilitation. More than 90% of patients were satisfied with their hospital stay; 43%, however, were not satisfied with community caregiver training for laryngectomy patients.

CONCLUSION

Rehabilitation of laryngectomized patients is a current therapeutic challenge. A therapeutic education tool was designed to better meet patient expectations.

A rare location for a common tumor: Lingual lipoma

Lipomas are the most common benign tumors in human body but their occurrence in the oral cavity is very rare. They present as a slow growing, yellowish submucosal and painless mass. The treatment consists of a simple surgical excision. The histopathologic examination confirms the diagnosis. We present a case of tongue lipoma.

Maxillofacial brown tumours: Series of 5 cases

OBJECTIVES

Brown tumours are benign bone tumours secondary to hyperparathyroidism. The authors describe the various clinical features, diagnostic methods and treatment modalities for maxillofacial brown tumours.

MATERIAL AND METHODS

This multicentre retrospective study comprised 5 patients (four women and one man, between the ages of 29 and 70 years) with one or several maxillofacial brown tumours observed over a 16-year period from January 2000 to December 2016.

RESULTS

Four patients presented secondary hyperparathyroidism in a context of chronic renal failure, one patient presented primary hyperparathyroidism due to parathyroid adenoma. Three patients presented a mandibular brown tumour, and two patients presented a maxillary brown tumour. The diagnosis was based on histological examination and laboratory tests. Brown tumours were treated either surgically or conservatively. A favourable outcome was observed in all cases.

CONCLUSION

Brown tumours are rare lesions. This diagnosis must be considered in a context of giant cell tumour associated with hyperparathyroidism. Brown tumours should be treated conservatively.

Ptosis and vertical diplopia after ligation of ethmoidal arteries

The treatment of epistaxis is well codified, ligation of the ethmoidal arteries being the last resort. We report the case of a 25-year-old pregnant patient, who has had a ligation of the anterior and posterior ethmoidal arteries after a persistent epistaxis. Postoperatively, she presented a complete ptosis and an impaired eye elevation without any visual acuity disorders, evoking a lesion of the upper branch of the common oculomotor nerve (third cranial nerve). The patient totally recovered after 3 months. Anatomical study shows that the upper branch of the third cranial nerve is lying very close to the optic nerve and cannot be affected by surgery without any associated damage of the optic nerve. Thus, a vascular etiology seems to be the best explanation of the complication experienced by our patient. Ligation of the posterior ethmoidal artery should be done with caution.

Image-guided transoral approach in severe craniovertebral junction malformations at the golden age of endoscopy: Regarding 2 cases

INTRODUCTION

The image-guided transoral approach (IGTOA) provides a safe exposure to skull base midline lesions and the ventral aspect of the craniovertebral junction (CVJ). The IGTOA has several advantages: the head being placed in the extended position, it decreases the brainstem angulation during surgery; the approach being done through the avascular median pharyngeal raphe, not only lowers the bleeding risk but also provides a direct access to the bony pathology and granulation tissue accessible only via the ventral route. Wide field exposure and maneuverability are necessary to deal with the entire ventral brainstem compression in case of severe CVJ malformation to safely perform partial clivectomy and odontoidectomy.

PRESENTATION OF TWO CASES

We illustrate the cases of two patients, 52-year-old and 42-year-old males, who presented with an impressive craniovertebral junction malformation, confirmed on CT and MRI images. They first underwent surgery by IGTOA, later completed by occipitocervical fixation. For the two patients, outcomes were assessed respectively at 4 and 5 years and showed satisfactory results both clinically and radiologically.

CONCLUSION

In patients with marked ventral compression, the IGTOA provides direct and guided access to the anterior aspect of the CVJ and effective means for odontoidectomy and clivectomy. This approach is more easily maneuverable compared to the endonasal endoscopic approach. The IGTOA approach is quite a complex technique, requiring multidisciplinary skills, but it should primarily be used in difficult situations. We suggest that endonasal endoscopy is over-utilized. We consider that endoscopy should not be routinely performed and kept only for well-selected cases.

Importance of malnutrition and associated diseases in the management of Zenker's diverticulum

OBJECTIVES

To study the impact of malnutrition on a population treated for Zenker's diverticulum and to look for the causes of persistence or recurrence of dysphagia after endoscopic surgery.

MATERIAL AND METHODS

This retrospective study included 30 patients with Zenker's diverticulum treated by endoscopy. All swallowing disorders and manifestations of malnutrition and postoperative improvement in and/or recurrence of symptoms were noted.

RESULTS

Nutritional status was evaluated for 26 patients. Before surgery, 54% suffered from malnutrition, which was severe in 31%; 28.6% of the cases with malnutrition showed postoperative complications, versus 8.3% of cases without baseline malnutrition. Ninety percent of patients (n=27) declared complete resolution of symptoms. Nine patients presented recurrence of dysphagia, including 6 with recurrence of Zenker's diverticulum and 3 with, respectively, inclusion body myopathy, esophageal hypertonia and central disease.

CONCLUSION

Malnutrition should be quantified and treated before and after surgery for Zenker's diverticulum to prevent complications and decrease mortality. Associated pathologies should be systematically screened for, especially in case of recurrence of swallowing disorder without recurrence of Zenker's diverticulum.

[Recurrence sites following definitive intensity-modulated conformational radiotherapy of squamous-cell carcinomas of the upper aerodigestive tract]

PURPOSE

The implementation of intensity-modulated radiotherapy (IMRT) in a centre requires regular critical review of medical practices and feedback to optimize the subsequent management of patients.

PATIENTS AND METHODS

We reviewed and determined through a retrospective single-centre study recurrence sites of 167 consecutive patients treated for head and neck squamous cell carcinoma excluding skin or sinuses. Patients had mostly stage III or IV locally advanced cancer (n=123).

RESULTS

Locoregional control rates at 1 and 2 years were respectively 87.9% (95% confidence interval [95%CI]: 81.6%-92.1%) and 77.6% (95%CI: 70.1%-83.5). Among 55 relapses, 20 patients (36.4%) had treatment failures. Patients treated with 70 Gy relapsed mainly in high risk volume (78%). Those treated with 66 Gy recurred regionally outside the irradiated volume (n=4) or in the irradiated high risk volume (n=3) or had isolated metastatic failure (n=3). Those irradiated with 50 Gy had regional relapse outside the irradiated volume (n=2) or isolated metastatic relapse (n=2). We noticed respectively 5.4%, 10.2% and 4.2% isolated metastatic, local, cervical lymph node relapse.

CONCLUSION

Our results are consistent with data from the literature. Corrective actions were performed to enhance our practices.

Bronchogenic cyst of the tip of the tongue: report of two cases

INTRODUCTION

Lingual bronchogenic cyst is a rare congenital malformation, classified as a choristoma. It is lined by respiratory epithelium. Extrathoracic sites are rare and the tongue is an exceptional site.

CASE REPORT

The authors report two cases of bronchogenic cyst of the tip of the tongue in newborn infants. These two initially asymptomatic lesions gradually increased in size, leading to feeding difficulties in one case. MRI demonstrated well-demarcated, solitary, unilocular cystic images. Surgical resection was easily performed and histological examination concluded on bronchogenic cyst. An aberrant right upper lobe tracheal bronchus was also present in one case.

DISCUSSION

Lingual choristomas are rare and defined histologically according to the type of epithelium. The embryological origin of lingual bronchogenic cysts remains controversial. MRI is the imaging examination of choice to characterize these lesions, but the definitive diagnosis is based on histological examination. Early, systematic surgical enucleation of all congenital lingual cysts must be performed to prevent obstructive and infectious complications.

Efficacy and safety of early G-CSF administration in patients with head and neck cancer treated by docetaxel-cisplatin and 5-fluorouracil (DCF protocol): a retrospective study

BACKGROUND

Induction chemotherapy with docetaxel-cisplatin and 5-fluorouracil (DCF) for locally advanced head and neck cancers (HNC) is associated with a high risk of severe neutropenia or febrile neutropenia (FN). We conducted a retrospective study to evaluate the efficacy and safety of administering granulocyte colony-stimulating factor (G-CSF) on day 3 (D3) during chemotherapy (early G-CSF stimulation) versus after the end of chemotherapy, as per current guidelines (i.e., after the end of 5-FU perfusion; D7), and its impact on patient outcomes.

PATIENTS AND METHODS

Patients ≥19 years old, with advanced HNC who received DCF induction chemotherapy (D and P 75 mg per meter squared (mg/m(2)) on day 1 and 5-FU 750 mg/m(2)/day from D1 to D5), were included in the analysis.

RESULTS

Data of 70 patients were analyzed from 01 January 2003 to 01 December 2010. Mean age was 56 years (range 45 to 77 years). Thirty-six patients (51.4 %) received pegfilgrastim on D7, and 28 (40 %) started G-CSF prophylaxis during chemotherapy; 12 (17.1 %) had daily filgrastim and 16 (22.9 %) pegfilgrastim on D3. Overall response rate (ORR) was 89.6 % (three early deaths due to infectious complications; 4.3 %). The 3-year overall survival (OS) rate was 72.8 %. FN rate was 14.3 % and chemotherapy delay was 12.9 %. In the D7 G-CSF arm, incidence of grade 3-4 neutropenia (p = 0.023), FN (p = 0.029), and cycle delays (p = 0.006) was statistically higher than the "early" G-CSF arm. A decrease of OS was observed at 2 years (from 85.1 to 63.5 %) of chemotherapy discontinuation or FN (p = 0.0348).

DISCUSSION

Early administration of G-CSF is safe and seems to be more effective than D7. Future prospective trials are required to confirm our results.

Adenocarcinoma of the ethmoid sinus: retrospective study of 42 cases

OBJECTIVES

Retrospective analysis of the oncological results and morbidity of ethmoid sinus adenocarcinoma surgery, and identification of survival factors.

MATERIAL AND METHODS

Forty-two patients were treated from 1990 to 2009. The study covered clinical presentation, medical imaging, histologic data, TNM grade, treatment, morbidity and overall recurrence-free survival.

RESULTS

Forty-one men and one woman, with mean age at diagnosis of 61.5 years, were included. 85.7% had been exposed to wood dust. Twenty patients (47.6%) were graded T4 at diagnosis. Thirty-three (78.5%) were treated by surgery followed by radiation therapy; nearly half of these showed recurrence. Overall specific 5-year survival was 44.2% at 5 years and recurrence-free 5-year survival 46.4%. The factors of poor prognosis found were cerebromeningeal or orbital invasion and local recurrence.

CONCLUSION

This series confirms the epidemiological literature on ethmoid adenocarcinoma and the influence of poor prognosis factors. Survival depended directly on local tumor control and seemed to be enhanced on an isolated transfacial approach.

Ultrasound-guided botulinum toxin injections for treatment of drooling

OBJECTIVES

To evaluate the efficacy of treatment of drooling by ultrasound-guided botulinum toxin injection of the salivary glands and to determine the optimal modalities of this procedure.

PATIENTS AND METHODS

This study is a retrospective review of patients treated for drooling by injection of 100 units of Botox(®) into the parotid and submaxillary glands between 2002 and 2008. Efficacy was evaluated by a quality of life questionnaire six weeks after the injections.

RESULTS

One hundred and eleven injection sessions were performed in 70 patients aged one to 84 years with a beneficial effect in 66% of cases. The most effective protocol was injection of 20 units of botulinum toxin into each submaxillary gland and 30 units of toxin into each parotid gland.

CONCLUSION

The treatment of drooling by Botox(®) injections into salivary glands is effective. The authors propose ultrasound-guided injection of both submaxillary glands and both parotid glands. These injections can be repeated in the case of recurrence of drooling.

A not so solitary fibrous tumor of the liver

Solitary fibrous tumor (SFT) is a rare neoplasm. Liver parenchyma is a rare location of SFT and, in this case, it usually follows a benign course. We report here the case of a 54-year-old man who presented a large SFT tumor of the right hepatic lobe. The tumor was surgically resected. Local recurrence occurred 6 years later as a 15 cm diameter liver tumor. Histological examination of the resected lesion showed features of an aggressive form of SFT. Two years later, the patient presented with complaints of neck pain and ensuing examinations revealed a tumor of the cranial base. A new surgical resection was performed and histological examination confirmed a metastasis of the SFT. Few weeks later, the patient presented an irreducible psoitis due to an iliac bone metastasis. He died within 1 month.

[Persistent stapedial artery with otosclerosis]

OBJECTIVES

A persistent stapedial artery is a rare vascular malformation. This diagnosis is based on CT scan and intraoperative findings.

MATERIAL AND METHODS

The case of a 19-year-old woman with a persistent stapedial artery found during stapes surgery is reported. This vascular malformation was explored with a CT scan showing the bilaterality of this anatomical variation and signs of associated otosclerosis.

RESULTS

This malformation was successfully coagulated with laser allowing the stapedotomy to be completed.

CONCLUSIONS

A persistent stapedial artery is not a contraindication to stapedotomy because it can be safely coagulated during the same procedure.

Long term outcome of 135 high grade non-Hodgkin’s lymphoma of the head and neck (HN NHL) treated with high dose CHOP regimen and involved field radiotherapy

7550

Background: We present the results of a prospective study conducted by the GOELAMS group and evaluating long-term clinical outcome in a series of 135 patients with a HN NHL undergoing chemotherapy and radiotherapy. Methods: From 1986 through 1998, 135 patients aged from 17 to 69 years were enrolled in a prospective multicenter study for primary treatment of HN localized stage I/II high-grade NHL. Treatment regimen consisted in 3 VCAP + 40 Gy locoregional irradiation. Results: The median age was 48.5 years (17–69) with 36 patients being 60 or over. The main localization was Waldeyer’s ring (57) including tonsil (35), nasopharynx (14), whole Waldeyer (8), neck (49), nasal cavities (14), thyroid (8) salivary gland (5), mandibular bone (2). According to the WFC, histological subtype were as F (21%), G (57%) and H (20%) and unclassified (2%). Ann Harbor classification included 80 stage 1 and 55 stage II. The IPI score was 0 (49.7%), 1 (22.3%), 2 (10.4%), 3 (2.3%) undetermined (16.3%). PS>2 and bulk (≥ 5 cm) were observed in 7.5% and 43% of patients respectively. 94% achieved CR. 2 patients died during treatment. Relapses occurred in 23/127 (18.1%) at a median time of 31 months (5.5–80). 16 of these relapses occurred before 3 years of CR, 5 between 3 and 6 years and 2 after 6 years of CR. With a median follow up of 65 month (7–146) OS and EFS were 81.5% and 77% respectively. In univariate analysis age≥ 60, extension, PS≥2, Bulk≥5 cm, erythrocyte sedimentation rate≥ 40, high serum LDH,IPI≥2 and salivary gland or panwaldeyer localization significantly decrease EFS (P = 0.055, 0.017, 0.006, 0.0001, 0.04, 0.028, 0.014 and 0.043 or 0.0001 respectively). In multivariate analysis only the bulk≥5 cm, the erythrocyte sedimentation rate≥40 and the localization to salivary gland significantly decrease EFS (P = 0.004, 0.004 and 0.033 respectively). Conclusions: This study underlines the high efficiency of this protocol in treating HN NHL. HN NHL localized to the salivary glands or with a bulk ≥ 5 cm should be included in new therapeutic trials in order to improve their outcome.

No significant financial relationships to disclose.

Treatment of epistaxis in rendu-osler-weber disease by in situ ethibloc® injections

After a brief review of Rendu-Osler-Weber disease, we present the results from a series of 13 patients treated by Ethibloc injections for epistaxis. Based on a review of the literature, typical treatments are presented along with discussion of their efficacy and side effects. In our series, 90% of patients improved after only one injection. All patients reported a decrease in hemorrhage, especially patients with recurrent epistaxis. Five of nine patients reported a decrease in the length of the bleeding episodes. Improvement was reported by 85% of patients within one month following Ethibloc injection. Fifty percent of these patients have persistent good results at 4 Year follow-up. Our results indicate that Ethibloc injections are safe and effective as an alternative treatment for patients that have failed standard treatment options.

Surgical anatomy of the infratemporal fossa using the transmaxillary approach

In this study we evaluated the ability of the transmaxillary route to expose the elements of the infratemporal fossa (ITF). Five adult cadaver heads were dissected on both sides, after making a paralateronasal incision. The maxillary branch of the trigeminal nerve served as a superior landmark to progress into the retroantral space and pterygopalatine fossa. The maxillary artery, lateral pterygoid muscle, pterygoid venous plexus, foramen rotundum and foramen ovale were identified. Distances between those elements and angle of approaches of the foramen ovale and foramen rotundum were measured in the horizontal plane. In all cases, the anterior loop of the maxillary artery and the sphenopalatine artery were located in the proximal retroantral fatty space and could be ligated without optic magnification. The maxillary nerve could be followed up to the foramen rotundum at a 44 mm mean distance from the opening. The mean angle of vision to the foramen rotundum was 31 degrees. Under the greater sphenoid wing and lateral to the pterygoid process, desinsertion and partial resection of the lateral pterygoid muscle were required to identify the pterygoid venous plexus and foramen ovale. The pterygoid venous plexus was organized as a compact network of channels between and superior to the muscle fibers; it was in close relation with the foramen ovale. Access to the foramen ovale was deep (mean 56 mm) and narrow (20 degrees). Our results indicate that the transmaxillary approach is a minimally invasive procedure that gives an appropriate window to the structures of the retroantral space and to the pterygomaxillary fissure and pterygopalatine fossa. Monitoring of the retropterygoid portion of the infratemporal fossa by this route is inadequate.

Laryngeal stenosis after supracricoid partial laryngectomy

The purpose of this study was to review the incidence, risks, management, and outcomes of nontumoral laryngeal stenosis after supracricoid partial laryngectomy (SCPL) in a case series of 376 consecutive SCPLs performed at 1 institution from 1975 to 1995 with a minimum of 3 years of follow-up. Post-SCPL nontumoral symptomatic laryngeal stenosis was defined as an inability to decannulate patients before the 60th postoperative day (group 1) or the development of dyspnea (in patients without local recurrence) after an initial period of prolonged, successful decannulation (group 2). Of 376 SCPLs performed, nontumoral symptomatic laryngeal stenosis developed in 14 (3.7%). There were 7 patients (1.85%) in group 1 and 7 patients (1.85%) in group 2. In univariate analysis, none of the following variables appeared to be statistically related to the risk of immediate stenosis (group 1): age, gender, comorbidity, diabetes mellitus, symptomatic gastroesophageal reflux, arteritis, preoperative radiotherapy, arytenoid cartilage disarticulation, type of reconstruction performed, and postoperative radiotherapy. A delayed laryngeal stenosis (group 2) was statistically more likely to occur if the reconstruction performed at the time of SCPL was a cricohyoidopexy (p = .01). Successful management of the laryngeal stenosis without permanent tracheostomy was achieved in 5 group 1 patients and 3 group 2 patients. We believe that stenosis in group I patients arose through technical error, whereas group 2 patients seemed to suffer from problems of healing, mainly cicatricial narrowing of the airway at the site of the cricohyoidal impaction, or pexis. As a result, whereas laryngeal stenosis in group 1 patients was usually more easily correctable through dilation, laser incision, or resection of redundant tissue or revision of the impaction, laryngeal stenosis in group 2 patients presented a more difficult and frustrating complication. The management and outcomes of these patients are presented.

Vertical partial laryngectomy versus supracricoid partial laryngectomy for selected carcinomas of the true vocal cord classified as T2N0

From an inception cohort of 204 patients with squamous cell carcinoma of the true vocal cord classified as T2N0 and a minimum of 3 years of follow-up, the authors compare the oncological and functional outcomes following vertical partial laryngectomy (group 1; 85 patients) and supracricoid partial laryngectomy (group 2; 119 patients). The 10-year actuarial survival estimate was 46.2% for group 1 and 66.4% for group 2. Survival was statistically more likely to be reduced (p = .019) in group 1 than in group 2. The 10-year actuarial local control estimate was 69.3% for group 1 and 94.6% for group 2. Local recurrence was statistically more likely to occur (p < .0001) in group 1 than in group 2. Salvage treatment resulted in an overall 94.1% local control rate and a 78.1% laryngeal preservation rate for group 1 and an overall 99.2% local control rate and a 94.9% laryngeal preservation rate for group 2. The 10-year actuarial nodal control estimate was 81.7% for group 1 and 93.7% for group 2. Nodal recurrence was statistically more likely to occur (p = .028) in group 1 than in group 2. The 10-year actuarial estimate for patients without distant metastasis was 84.6% for group 1 and 95.1% for group 2. Distant metastasis was statistically more likely to occur (p = .05) in group 1 than in group 2. The hospital mortality rate was 1.2% for group 1 and 0.8% for group 2. The incidence of permanent gastrostomy was 0% for group 1 and 2.4% for group 2. The incidence of permanent tracheostomy was 1.2% for group 1 and 2.4% for group 2. The incidence of completion laryngectomy due to functional problems was 1.2% for group 1 and 0.8% for group 2.

[Indications for the Schmid-Meyer frontal-temporal flap for nasal reconstruction. Four clinical cases]

The fronto-temporal flap described by Schmid and modified by Meyer is a tubular flap with an internal supraciliary pedicle which allows the transposition of the temporal skin with the addition of ear cartilage on the tip of the nose or the ala nasi. This meticulous reconstruction requires four stages which are workable under local anesthesia. Four clinical cases allow to specify the advantages and the drawbacks of this technique. They place this technique in the therapeutic possibilities between the composite grafts and various local and distant flaps.

Swallowing disorders in paralysis of the lower cranial nerves: a functional analysis

Deficits of the lower cranial nerves (nerves IX, X, XI, and XII) occurring after treatment of skull base tumors may cause disabling swallowing disorders. To assess the mechanisms of swallowing disorders involved in such cases, we performed functional examinations: a videoendoscopic swallowing study and simultaneous manometry and videofluoroscopy in 7 patients. This study shows that the main mechanism of the swallowing disorders was a disturbance of the pharyngeal stage, including a decrease of pharyngeal propulsion, reduced laryngeal closure, and cricopharyngeal dysfunction, which led to aspiration. Decreased pharyngeal propulsion was found in 6 patients, with a very high correlation between fiberoscopy and simultaneous manometry-fluoroscopy. The responsibility of the upper esophageal sphincter in swallowing disorders was more difficult to assess. The role of the upper esophageal sphincter and pharyngeal propulsion in the onset of the problem is discussed in regard to the cricopharyngeal myotomy.

Carbon dioxide laser debulking for obstructing endolaryngeal carcinoma: a 10-year experience

The results of the carbon dioxide (CO2) laser debulking procedure for obstructing endolaryngeal carcinoma were analyzed in terms of efficiency, complications, secondary tracheotomy rate, and peristomal recurrence rate in a series of 50 patients consecutively managed at our department. The CO2 laser was used to reestablish a safe airway without resorting to tracheotomy and without performing a transoral resection. Our series included 42 patients in a pre-definitive treatment group (group 1) and 8 patients in a palliation group (group 2). Complications included death, pneumonia from inhalation, and cutaneous burns in 2 patients, 1 patient, and 1 patient, respectively. Thirty-two percent of patients required a repeat laser treatment to maintain the airway. Overall success rates of 92.8% and 87.5% were achieved in group 1 and group 2 patients, respectively. None of the variables under analysis could predict the success of the CO2 laser debulking procedure. The overall incidences for secondary tracheotomy were 4.7% and 0% in group 1 and group 2 patients, respectively. Peristomal recurrence was not encountered in patients managed with definitive therapy with curative intent.

Role of videoendoscopy in assessment of pharyngeal function in oropharyngeal dysphagia: comparison with videofluoroscopy and manometry

OBJECTIVE

The purpose of the current report is to evaluate the ability of videoendoscopic swallowing study in assessing pharyngeal propulsion and aspiration episodes when compared with videofluoroscopy and manometry.

STUDY DESIGN

Prospective study.

METHODS

Thirty-four patients with oropharyngeal dysphagia underwent videoendoscopy of swallowing to assess pharyngeal propulsion as pathologic or nonpathologic, and aspiration. These features were compared with those found on manometry and videofluoroscopy, which were considered as the reference examinations. Sensitivity, specificity, and positive and negative predictive values of videoendoscopy were estimated, with their 95% confidence intervals.

RESULTS

A total agreement between videoendoscopy and videofluoroscopy was found in 76.4% of cases for pharyngeal propulsion and in 82.3% for aspiration. This rate for pharyngeal propulsion reached 82.3% between videoendoscopy and manometry. Moreover, in 24 cases (70.5%) in which videofluoroscopy and manometry agreed for pharyngeal propulsion, 22 were assessed similarly through fiberoscopy. When using fluoroscopy and manometry as reference examinations, videoendoscopy detected nearly 90% (95% confidence interval [CI] = 0.80, 1.0) of impaired pharyngeal propulsion. Concerning aspiration, 70% (95% CI = 0.54, 0.85) of events detected by videoendoscopy were also observed on videofluoroscopy. Sensitivity, specificity, and positive and negative predictive values of videoendoscopy reached a higher rate (90% to 92.8%) when agreement was found between fluoroscopy and manometry.

CONCLUSIONS

Videoendoscopy is an examination that can be used to detect inexpensively pharyngeal propulsion disorders and aspiration episodes.

Local failure after supracricoid partial laryngectomy: symptoms, management, and outcome

The medical files of 15 patients with local recurrence after supracricoid partial laryngectomy consecutively managed at Laënnec Hospital were reviewed. The clinical symptoms and the laryngeal computed tomography appearance of local recurrence, as well as the salvage treatment performed, are presented. The main presenting symptom was dyspnea. None of the local recurrences was considered to be unresectable. One patient refused any form of salvage treatment. Radiation therapy and salvage total laryngectomy were the options retained for local salvage. A minimum 5-year follow-up was always achieved. In patients who underwent salvage total laryngectomy, perioperative or postoperative death and postoperative pharyngocutaneous fistula were not encountered. The 5-year survival was 33.3%. The local control rate was 66.6%. The percentage of patients who experienced nodal recurrence was 26.6%, and the distant metastasis estimate was 53.3%. The cause of death was distant metastasis in eight patients, local recurrence in two, and intercurrent disease in one. Peristomal recurrence was not encountered. Overall, 80% local control and 6.6% laryngeal preservation rates were achieved.

Supracricoid partial laryngectomy with cricohyoidoepiglottopexy for "early" glottic carcinoma classified as T1-T2N0 invading the anterior commissure

PURPOSE

"Early" glottic squamous cell carcinoma classified as T1-T2N0 with anterior commissure invasion is conventionnaly managed with vertical partial laryngectomy (VPL) or radiation therapy (RT). At our insitution, in the early 1980s, vertical partial laryngectomy was progressively replaced by supracricoid partial laryngectomy with cricohyoidoepiglottopexy (SCPL-CHEP). The medical files and operative charts of 62 patients with "early" glottic carcinoma classified as T1-T2N0 invading the anterior commissure, consecutively managed with cricohyoidoepiglottopexy, were retrospectively reviewed to ascertain whether any conclusions could be drawn regarding this treatment modality.

MATERIALS AND METHODS

Survival, local control, nodal recurrence, distant metastasis, and metachronous second primary tumor estimate was analyzed using the Kaplan-Meier life table method.

RESULTS

The 3- and 5-year actuarial survival estimate was 93.3% and 86.5%, respectively. The 3- and 5-year actuarial local control estimate was 98.2%. The only patient with local recurrence was successfully salvaged with RT resulting in an overall 100% local control rate and laryngeal preservation rate. The 3- and 5-year actuarial nodal recurrence estimate was 1.8%. The 3- and 5-year actuarial distant metastasis estimate was 0% and 2%, respectively. Aspiration related completion total laryngectomy and permanent tracheostomy never occurred.

CONCLUSION

The present retrospective study suggests that cricohyoidoepiglottopexy for glottic carcinoma classified as T1-T2 invading the anterior commissure resulted in higher local control rates and overall laryngeal preservation rate when compared with historical series using either VPL or RT. Further series are warranted to confirm our results.

Dysphagia in oculopharyngeal muscular dystrophy: a series of 22 French cases

Twenty-two patients (mean age = 67.9 years) with oculopharyngeal muscular dystrophy (OPMD) were referred for dysphagia from 1987 to January 1995. Six patients had suffered aspiration pneumonia, and three had significantly lost weight, while 19 complained of discomfort during swallowing but without weight loss. Swallowing was assessed by fiberscopy during swallowing (last eight patients), videofluoroscopy (12 cases) and manometry (19 cases). Twelve patients underwent a cricopharyngeal (CP) myotomy: 10 showed improvement, one had a partial improvement, and the procedure failed in one (mean follow-up = 29.6 months). In the other cases, CP myotomy was postponed, refused or contraindicated. Of the 22 patients, three died from OPMD consequences. Factors associated with favorable outcome were adequate residual pharyngeal propulsion and no weight loss. In a majority of cases, CP myotomy constitutes an effective treatment of dysphagia with adequate residual propulsion but does not modify the final prognosis and is contraindicated in cases with pharyngeal aperistalsis.

Hearing impairment in infants after meningitis: detection by transient evoked otoacoustic emissions

OBJECTIVE

To evaluate the feasibility and cost-effectiveness of using transient evoked otoacoustic emissions (TEOEs) to assess hearing in infants recovered from meningitis.

METHODS

Recordings of TEOEs and visual reinforcement audiometry (VRA) were performed in a prospective study of 39 children aged 6 to 24 months recovering from a purulent meningitis. Patients with no TEOEs, or whose VRA findings were abnormal, were also tested by impedance audiometry and recording of auditory brain-stem responses (ABRs) after treatment of any secretory otitis media. Costs were compared with those of a previous protocol including VRA, impedance audiometry, and ABR for all children.

RESULTS

A total of 29 children had TEOEs in both ears and normal VRA findings. Ten children lacked TEOEs in one or both ears; 9 of them had otitis media with effusion. Further examination by VRA and ABR led to the diagnosis of bilateral sensorineural hearing loss in 2.6% (1/39) of patients and unilateral sensorineural hearing loss in 7.7% (3/39) of patients. Cost analysis revealed that this protocol costs about half the previous one.

CONCLUSION

Recording TEOEs appears to be a feasible and cost-effective hearing screening test for infants recovered from meningitis. If TEOEs are absent, impedance audiometry, ABR recordings, and audiometric evaluation techniques are needed to distinguish between conductive and sensorineural hearing loss and to assess hearing thresholds precisely.

Supracricoid hemilaryngopharyngectomy conversion to Pearson's near-total laryngectomy: a case report

BACKGROUND

Pearson's near-total laryngectomy was initially advocated in patients with extended glottic carcinoma and hypopharyngeal carcinoma. More recently, the utility of near-total laryngectomy for supraglottic pharyngeal, base of tongue, and other cancers such as thyroid cancer with anterior tracheal wall invasion has also been reported.

METHODS

The purpose of this case report was to demonstrate the feasibility of this procedure in the setting of severe aspiration after supracricoid hemilaryngopharyngectomy.

RESULTS

The first case of successful conversion from supracricoid hemilaryngopharyngectomy to Pearson's near-total laryngectomy in a patient with severe and recurrent aspiration is presented.

CONCLUSIONS

This case report suggests that when partial laryngopharyngectomy results in severe and recurrent aspiration, rather than having to convert the patient to a total laryngectomy with tracheoesophageal puncture, a near-total laryngectomy is a reasonable option with acceptable functional results.