[Information security in a radiotherapy centre: Controlling risks to better cope with them]

The dematerialization of data, the multiplication of sharing and exchanges between professionals, the increase of business software offer (patient files, human resources management, financial management, document management, etc.) question us about the security of information systems. This protection contributes to the quality of the care of patients in respect of their rights, to ensure the confidentiality, traceability and sustainability of digital personal health data and to strengthen the confidence of professionals in the system and its uses. But what security procedures are currently being undertaken in the radiotherapy centres?

Interest of video-assisted minimally invasive surgery in primary hyperparathyroidism

INTRODUCTION

Surgery is the only radical and definitive treatment for primary hyperparathyroidism. Exploration of the four parathyroid sites is giving way to minimally invasive techniques. The present study sought to compare two minimally invasive parathyroidectomy techniques, by classical cervicotomy (MIP-C) and by video-assistance (MIP-VA), in terms of success rate, complications rate, operating time, and patient and community physician satisfaction.

MATERIALS AND METHOD

A non-randomized retrospective comparative study included 112 patients presenting with primary hyperparathyroidism with identified parathyroid adenoma, operated on between January 2005 and October 2010. The two groups were constituted according to the surgeons' habitual practice: 54 cases of MIP-VA and 58 of MIP-C.

RESULTS

Results for MIP-VA and MIP-C were respectively: success, 96.3% vs. 100% (P=0.09); mean scar size, 1.47 vs. 3.43cm (P<0.01); hypocalcemia, 2 vs. 3 cases (P=0.1); theater time, 94.25 vs. 76min (P=0.02); and postoperative stay, 1.08 vs. 1.37 days (P=0.07). Patient satisfaction was comparable between groups, while 93.3% of community physicians found MIP-VA preferable to MIP-C, although only 39.3% had known the MIP-VA technique.

CONCLUSION

With efficacy, morbidity and patient satisfaction comparable to classical surgery, MIP-VA significantly reduced cervicotomy size and hospital stay. Community physicians considered it to be preferable to MIP-C.

Can hydrodynamic contact line paradox be solved by evaporation-condensation?

We investigate a possibility to regularize the hydrodynamic contact line singularity in the configuration of partial wetting (liquid wedge on a solid substrate) via evaporation-condensation, when an inert gas is present in the atmosphere above the liquid. The no-slip condition is imposed at the solid-liquid interface and the system is assumed to be isothermal. The mass exchange dynamics is controlled by vapor diffusion in the inert gas and interfacial kinetic resistance. The coupling between the liquid meniscus curvature and mass exchange is provided by the Kelvin effect. The atmosphere is saturated and the substrate moves at a steady velocity with respect to the liquid wedge. A multi-scale analysis is performed. The liquid dynamics description in the phase-change-controlled microregion and visco-capillary intermediate region is based on the lubrication equations. The vapor diffusion is considered in the gas phase. It is shown that from the mathematical point of view, the phase exchange relieves the contact line singularity. The liquid mass is conserved: evaporation existing on a part of the meniscus and condensation occurring over another part compensate exactly each other. However, numerical estimations carried out for three common fluids (ethanol, water and glycerol) at the ambient conditions show that the characteristic length scales are tiny.

Nodular recurrence and hypothyroidism following partial thyroidectomy for benign nodular thyroid disease in children and adolescents

OBJECTIVES

Diagnostic and therapeutic processing of a thyroid nodule in children and adolescents may require lobectomy-isthmusectomy (LI) or nodule-resection (NR). Very few data in the literature report the long-term evolution of the remaining thyroid lobe in a defined pediatric population. In this study, we aimed to answer the following questions: Does a nodule recurrence occur in the remainder lobe? Is a post-operative thyroxine treatment necessary?

MATERIAL AND METHODS

This retrospective study describes 28 patients under 18 who underwent LI (22 cases) or NR (6 cases) from January 2004 to March 2012. Ten of them were lost to follow up, 18 could be assessed (4 NR (22%) and 14 LI (78%) - mean follow-up 45±31 months). All patients benefited of post-operative thyroid ultrasonography, and regular endocrinologic follow-up. The following data were analysed: emergence of new thyroid nodules, evolution of pre-existing nodules, occurrence of post-operative hypothyroidism and requirement for completion thyroidectomy.

RESULTS

The mean age at the time of surgery was 14.3±1.9 years. Two patients (11%) had pre-existing nodules in the remaining thyroid gland, none of which showed an increase in size after surgery. De novo nodules developed in five patients (27.8%). Three patients who underwent LI (21.4%) needed thyroxine treatment for post-operative hypothyroidism. One patient (5.5%) needed completion thyroidectomy.

CONCLUSIONS

In this children and adolescents population, after performing LI or NR, remaining thyroid tissue stays free of nodules in 72.2% of the cases. A post-operative thyroxin treatment is necessary in 21.4% of cases after LI.

Cervical lymphadenopathies signaling thyroid microcarcinoma. Case study and review of the literature

BACKGROUND

Some lateral cervical lymphadenopathies may lead to the discovery of papillary microcarcinomas (PMC) of the thyroid that are not radiologically apparent. This relatively rare clinical situation raises questions about the diagnostic approach to chronic cervical lymphadenopathy and the impact of lymph node metastasis on PMC prognosis. PURPOSE OF THE ARTICLE: To study the epidemiologic, clinical, and prognostic criteria of cases of lymphadenopathy that signaled PMC.

PATIENTS AND METHODS

A retrospective study of 167 consecutive cases of PMC compared with 13 cases where a cervical mass signaled other forms of PMC.

RESULTS

The mean age was 48.5 years, the ratio of men to women was 5:8, and the mean PMC size was 5.5mm. These data did not differently significantly from those of the other PMC cases. The preoperative imaging found fluid content in six cases, with microcalcifications in three cases. All cases were treated by modified radical neck dissection on the side with the lymphadenopathy and total thyroidectomy with central neck dissection. The lymphadenopathy included a ruptured capsule in five cases and was accompanied by central lymph node metastases in three cases. Thyroid capsule involvement was significantly more common in cases of PMC discovered due to lymphadenopathy than in other cases of PMC (69% versus 9.7%, respectively; p<0.001). The mean follow-up was 7.3 years. There were no deaths due to PMC signaled by lymphadenopathy. Two cases of lymph node recurrence after 8 and 10 years were controlled by another surgery and radioactive iodine treatment.

CONCLUSION

Any chronic cervical mass should suggest the possibility of thyroid origin, especially in cases with cystic content or microcalcifications in subjects with no particular risk factors. An ultrasound of the thyroid should be done, as well as a fine needle aspiration biopsy of the lymphadenopathy with a thyroglobulin assay. Treatment is the same as for any thyroid carcinoma, and results in a good oncological outcome, despite the possibility of lymph node recurrences.

Writing an article for the European Annals of Otorhinolaryngology, Head and Neck Surgery: rights and responsibilities

Based on a review of the literature published on medical writing, the authors discuss the rules to respect in terms of both structure and substance to facilitate publication of studies in the European Annals of Otorhinolaryngology, Head and Neck Surgery. The main errors leading to an article's being rejected are detailed and analyzed.

Drying of a solution in a meniscus: a model coupling the liquid and the gas phases

A model simulating the drying of a solution in a meniscus in contact with a moving substrate is developed. It takes into account the hydrodynamics in the solution in the framework of the lubrication approximation, the vapor diffusion in the gas phase, and the variation of physical properties during drying. The free surface profile and spatial evaporation flux are not imposed a priori but result from the simulation of the mass transfer in the liquid/gas system (1.5-sided model). Several regimes are observed depending on the substrate velocity. For a large substrate velocity, the classical Landau-Levich regime is obtained. For smaller velocities, a drying front appears that is characterized by a strong concentration gradient and a peak in the evaporation flux. The coupling between the evaporation flux and the meniscus shape in this regime is analyzed. Another regime appears at a very low substrate velocity and seems to be driven by a competition between advection and diffusion. This macroscopic model simulates recent experimental results, namely, the dependence of the deposit thickness on the substrate velocity, which scales as 1/V in the regime dominated by evaporation.

Drying of colloidal suspensions and polymer solutions near the contact line: deposit thickness at low capillary number

Drying experiments with a receding contact line have been performed with silica colloidal suspensions and polyacrylamide (PAAm) polymer solutions. The experimental setup allows to control the receding movement of the contact line and the evaporation flux separately. Deposit thickness as a function of these two control parameters has been investigated. The different systems exhibit a similar behavior: in the regime of very low capillary numbers the deposit thickness scaled by the solute volume concentration and the evaporation rate is proportional to the inverse of the contact line velocity. Both the scaling exponent and the constant (which has the dimension of a length) do not depend on the system under study. The observation of this evaporative regime confirms some recent results obtained by Le Berre et al. on a very different system (phospholipidic molecules) and fully supports their interpretation. Following their approach, a simple model based on mass balance accounts for these results. This implies that this regime is dominated by the evaporation and that the deformation of the meniscus induced by viscous forces does not play any significant role. When increasing the velocity, another regime is observed where the thickness does not depend significantly on the velocity.

[Study of the platysma coli muscle vascularisation by the facial artery. Implication during the elevation of the musculo-cutaneous platysma coli muscle flap]

AIM OF THE STUDY

The purpose of this study was to assess the vascularity of the platysma muscle by the branches of the facial artery, in order to determine the best means of harvesting a musculo-cutaneous flap while ensuring maximum vascular security.

PATIENTS AND METHODS

Ten platysma muscles were dissected on 4 fresh specimens and one formaldehyde-preserved specimen. The dissection was performed after injection of the facial artery in 6 cases, while 4 muscles were dissected without any previous injection.

RESULTS

The vascular supply of the platysma muscle comes essentially from the branches of the submental artery and from branches descending straight from the facial artery. Other collateral branches contribute to this vascularization, but their importance is minor. All these arteries reach the muscle, entering its visceral aspect, then proceed to the sternal notch in a radial axis.

CONCLUSION

The size of the flap has to be defined within a quadrilateral figure with its base formed by the mandibular edge and its apex by the inferior limit of the flap. It is essential to preserve the maximum possible muscular thickness, especially on the medial side of the flap. If the facial artery needs to be ligated, this has to be done as it enters the submandibular space in order to protect most of the collateral branches destined to the muscle. The vascularization is then taken back by the homo- and contro-lateral facial vascularisation in an inverted flow in the remaining segment of the facial artery.

Physical aging of glassy PMMA/toluene films: influence of drying/swelling history

Gravimetry experiments in a well-controlled environment have been performed to investigate aging for a glassy PMMA/toluene film. The temperature is constant and the control parameter is the solvent vapor pressure above the film (i.e. the activity). Several experimental protocols have been used, starting from a high activity where the film is swollen and rubbery and then aging the film at different activities below the glass transition. Desorption and resorption curves have been compared for the different protocols, in particular in terms of the softening time, i.e. the time needed by the sample to recover an equilibrium state at high activity. Non-trivial behaviors have been observed, especially at small activities (deep quench). A model is proposed, extending the Leibler-Sekimoto approach to take into account the structural relaxation in the glassy state, using the Tool formalism. This model well captures some of the observed phenomena, but fails in describing the specific kinetics observed when aging is followed by a short but deep quench.

Surgical management of carotid body tumors

BACKGROUND

Carotid body tumors (CBT) should be considered when evaluating every lateral neck mass.

METHODS

A retrospective study was conducted of 52 patients with 57 CBT. The surgical approach and complications were reviewed. All patients were operated on without preoperative embolization.

RESULTS

Multifocal paraganglioma (PG) were detected in six cases. A succinate dehydrogenase subunit D (SDHD) mutation was discovered in four patients. Vascular peroperative complication occurred in one case. Vascular reconstruction was decided peroperatively in five cases (8.8%). Vascular reconstruction was 0% for Shamblin 1 or 2 tumors, but 28.5% for Shamblin 3. A postoperative nerve paresis was reported in 24 patients (42.1%) and vagal nerve paralysis persisted in four cases (7.01%). The rate of serious complications, e.g., permanent nerve palsy, preoperative and postoperative complications, was 14.03%; it was 2.3% for Shamblin 1 or 2 tumors and 35.7% for Shamblin 3. One patient had malignant PG with node metastasis and was not referred for radiotherapy. No recurrence or metastasis was reported after 6-year follow-up.

CONCLUSION

Early surgical treatment is recommended in almost all patients after preoperative evaluation and detection of multifocal tumors. Surgical excision of small tumors was safe and without complication, but resection of Shamblin 3 tumors can be challenging. Routine preoperative embolization of carotid body paragangliomas is not required.

[Voice handicap evaluation after supracricoid partial laryngectomy]

The importance of patient self-impressions has been emphasized in determining the success of cancer treatment. The supracricoid partial laryngectomy (SCPL) is recognized as a suitable procedure for the treatment of T1b and T2 glottic carcinoma. The aim of this surgical procedure is the preservation of a physiologic phonation with optimal oncologic control.

METHOD

Measurements included Voice handicap Index (VHI), Voice Related Quality of'Life (VRQL), subjective (GRBAS) and objective analysis.

OBJECTIVES

evaluate voice problems after SCPL, provide correlations between patients' daily activities, VHI, and subjective evaluation of the dysphonia.

PATIENTS

53 patients were assessed more than 1 year after SCPL. 26 patients, less than 60 years of age and professionally active were included. The mean age was 48 years (43 to 59 years). Eleven patients had professional activities in the communications industry requiring a compulsory daily use of their voices.

RESULTS

57.6% of the active patients underwent a cessation or an adaptation of their professional activities. The mean VHI was 52.22. It was respectively 36.3, 50.03 and 52.42 according to the grade 1, 2, 3 of dysphonia. Correlations between VHI and the time laps since intervention (p: 0.047). discontinuation of professional activities (p: 0.037), and grade of dysphonia (p: 0.049) were found.

CONCLUSION

VHI allows an evaluation of the voice problems after SCPL. A significant impact on voice is reported after SCPL and may influence the patient's life, with potential disturbance of their professional activities. Potential post surgical voice impact must be considered when the therapeutic options are discussed.

[Importance of tussometry in unilateral laryngeal paralysis]

Cough is a physiological gesture witch requires a perfect laryngeal competence. Tussometry was described as a reliable and reproducible method of analysis based on the measure of oral air flow rate during cough. This test allows to quantify the efficiency of laryngeal occlusion in normal situation and in case of unilateral laryngeal paralysis. The measure of the time lag between the beginning of the cough and the maximal air flow rate (peak value time) is the most reliable parameter (8). Present study is designed to asses the reproducibility of tussometry realized on a vocal analysis workstation EVA II and to test the efficiency of intracordal injection of autologus fat in case of unilateral laryngeal paralysis following thoracotomy. 10 control subjects were recorded at two moments. 6 patients presenting unilateral laryngeal paralysis following thoracic surgery were recorded before and after injection of autologus fat in the paralysed vocal cord. Reproducibility of tussometry is good (r = 0.96). The mean peak value time is significantly improved (p = 0.048). In conclusion, tussometry is a reliable routine test on EVA III workstation. Intracordal autologus fat injection improves occlusive function of larynx during cough in case of unilateral paralysis.

[Nasal involvement in Crohn's disease: report of a case and diagnostic difficulties of systemic diseases affecting the nose]

The authors describe the case of a 32 years old man with Crohn's disease who has developped sinonasal and tracheal localizations. The review of the literature, quite poor, allows to find some cases of nasal involvement in Crohn's disease and few associations between this illness and others systemic diseases as Wegener's disease or relapsing polychondritis. Among these diseases, we can find atypical conditions mixing different features of the most classical systemic diseases, which are called "overlap syndromes". The case we report illustrate these questions relative to the diagnosis. To conclude, it may be important to point at the difficulties of the anatomopathological diagnosis and the interest of the iterative biopsies. Regular follow-up can help us to identify systemic disease with the research of new extra-sinonasal symptoms.

Endoscopic surgical treatment of sinonasal polyposis-medium term outcomes (mean follow-up of 5 years)

BACKGROUND

Between 30 and 50% of patients with sinonasal polyposis (SNP) will require surgical treatment.

OBJECTIVE

To determine the medium term risks and benefits of endonasal ethmoidectomy in SNP.

METHOD

132 cases of SNP have been retrospectively studied before and after endoscopic nasal surgery with a mean follow-up of 5 years. Functional symptoms and appearances on endoscopic examination were recorded on graded scales. Non-parametric statistical analyses for matched series were used in the assessment of data.

RESULTS

Post-operative normalisation of nasal function was obtained in 62% of cases. Each of the four main nasal symptoms (nasal obstruction, rhinorrhoea, facial pain and anosmia) was improved (p = 0.001). Patients with associated asthma or ASA triad had higher scores for nasal obstruction and rhinorrhoea (Fisher's exact test; p < 0.02). The pre-operative clinical stage of SNP correlated neither with recurrence nor with functional outcomes (Fisher's exact test; p > 0.05). The requirement for steroid treatment of concurrent asthma was also reduced post-operatively (p = 0.001). The association with asthma and its level of treatment was not related to the frequency of recurrence of SNP (Chi2; p > 0.6).

CONCLUSIONS

Functional outcomes for patients with SNP and asthma were significantly improved by endoscopic surgical treatment, even if the appearance of the nasal mucosa did not always return to normal.

[Combined approach (endoscopic and external) for the treatment of sinusal mucoceles]

AIM OF THE STUDY

Determination of the best surgical approach in the treatment of mucocoeles of the sinuses according to their localization.

PATIENTS AND METHODS

A retrospective study has been carried out including forty three cases of sinus mucocoeles, surgically treated from 1990 to 1997. These were in descending order, frontal (n = 19), maxillary (n = 10), ethmoïdo-frontal (n = 9), sphenoidal (n = 3) and ethmoidal (n = 2). Surgical treatment was achieved with an exclusive endoscopic approach in 28 cases whereas 15 of them underwent endoscopic surgery associated with an external approach (also called combined technique). Short term complications and recurrence were recorded after a minimum of 6 years follow-up, according to the type of surgery performed and the topography of the mucocoele.

RESULTS

Recurrence of mucocoeles is prevented in 95.8% of cases by an exclusive endoscopic treatment in ethmoïdo-frontal, maxillary, sphenoidal and ethmoidal sites. On the other hand, the recurrence rate in mucocoeles involving the frontal sinuses without ethmoidal involvement, was significantly higher when the mucocoele was operated on by an exclusively endoscopic method (25%, p < 0.001) rather than by a combined technique (0%).

DISCUSSION AND CONCLUSION

Ethmoido-frontal, maxillary, sphenoidal and ethmoidal mucocoeles are excellent indications for an exclusively endoscopic endonasal surgery. An external approach, combined with endoscopic surgery, is suitable in frontal mucocoeles, especially in distal sites and in case of recurrence.

[Recurrent benign tumors of parotid gland: the role of the surgery]

Parotid gland tumor recurrences can prove problematic both in terms of facial nerve trauma during surgery and for the possible transformation into malignancy. Between 1981 and 2001 a total of 40 patients (23 women, 17 men; average age 48; age range 20-79 years) underwent surgery for recurrent parotid gland tumors. The average time between the first and the second surgical procedures was approximately 10 years. Five subjects underwent surgery several times for the same pathology. The Authors feel that MRI imaging is an essential tool for the evaluation of infiltrations into the soft tissues. The following surgical procedures were performed: enucleation in 2 cases; exofacial partial parotidectomy (PP) in 1; lower polar PP with functional neck dissection in 1; total parotidectomy (TP) with preservation of the facial nerve in 31 cases; TP with functional neck dissection in 2; TP with sectioning of the facial nerve in 2 and TP with transmandibular buccopharyngectomy and myocutaneous gran dorsal muscle flap in 1 case. Histology proved positive for the following: pleomorphous adenoma in 21 cases, adenocarcinoma in 11, aggressive fibromatosis in 2, cystadenolymphoma in 1, parotiditis in 1, lipoma in 1, cystic lymphoid hyperplasia in 1, histiofibrosarcoma in 1 and neurofibrosarcoma in 1. The surgical technique used was retrograde dissection of the facial nerve starting from one of the peripheral branches. Post-operatively, whenever a facial paralysis was encountered it proved difficult to recover. Paralysis of the nerve was permanent only in the 2 subjects where sectioning proved necessary because of infiltration by carcinoma. In 6 subjects recovery of the paralysis took one year, in 4 it took 6 months and in 2 other cases 3 months. In 22 cases there was only a slight paralysis of some branches which recovered during the post-operative period. We do not have definitive data on 4 subjects either because the period of time since surgery is still too short or because they did not come in for subsequent check-ups. The results of our study show that total parotidectomy should be the treatment of choice in case of benign parotid gland tumors and in particular for pleomorphic adenoma.

[Our experience with papillary microcarcinoma of the thyroid]

INTRODUCTION

Papillary microcarcinoma (PMC) of the thyroid gland is high incidence pathology. Most of cases are related to a good prognosis. Conversely, numerous cases are reported with an aggressive course. Prognosis factors are age, size of tumour, multifocality, capsular invasion and cervical lymphadenopathy.

MATERIAL AND METHOD

We have conduced a retrospective study about 4,208 consecutive thyroidectomies over a period of 16 years. 251 cases of papillary cancers were analysed including 64 PMC (25.5%).

RESULTS

90% of PMC were incidentally found and 59% were diagnosed during surgical procedure. Multifocality improved the sensibility of histological diagnosis (P = 0.04). In 78%, total thyroidectomy was performed associated with a selective neck dissection in 47%. In case of extemporaneous diagnosis all partial thyroidectomy was convert into total thyroidectomy. In case of delayed diagnosis and in the absence of unfavourable prognosis factor, no other surgical procedure was carried out. A 7 years mean follow-up revealed only one case of recurrence successfully treated with Iodine 131 ablation. There was no case of death due to PMC.

CONCLUSION

This study confirms the good prognosis of PMC treated according to usual criterions.

[Inflammation and laryngitis]

1.

DISTINCT ENTITIES

Unlike inflammation or the middle ear or nasal or sinus cavities, there is no direct link between acute and chronic inflammation of the larynx. Chronic laryngitis is a distinct nosological entity. Patients with recurrent allergic laryngitis do not necessarily develop chronic laryngitis as is observed in patients with nasal allergy. 2.

RESEARCH

There is no research data on infections of the larynx comparable to that available for the middle ear or the nasal cavities. This is probably related to the difficulty of accessing the laryngeal mucosa and the risks related with this condition. 3.

CLINICAL TRIALS

While fundamental research remains to be conducted, their is a large body of clinical trials on the topic, although one must be prudent concerning the terms used. 4. NOSOLOGOGY: In French the term "croup" designates diphtheritic croup and must be distinguished from the more general term used in English. Clinical trials must be interpreted with caution since it is often difficult to ascertain which type of laryngitis is concerned. 5.

GRAVITY SCORES

Widely used in the English literature, gravity scores are not generally used in French pediatric ENT units and have no real equivalent in French. 6.

DYSPHONIA AND DYSPNEA

Dysphonia is the leading sign of chronic laryngitis. Dyspnea is the leading sign of acute laryngitis. Dyspnea is more frequent in children and is related to disease severity. 7.

BACTERIA AND VIRUSES

Epiglottitis (supraglottic laryngitis) is related to bacterial infections while subglottic laryngitis is related to viral infections requiring antibiotics in combination with corticosteroids. 8. H. INFLUENZAE: The most common causal agent of epiglottitis, type B Haemophilus influenzae, is not the only culprit. 9.

ADULTS

Epiglottitis can also occur in adults where it is as severe as in children. 10.

SYSTEMIC CORTICOSTEROIDS

Emergency administration of systemic and inhaled glucocorticoids in the hospital setting is the basic treatment for glotto-subglottic laryngitis. Dosage must be high, more than 0.3 mg/kg dexamethasone for 48 hours, followed by oral corticosteroids.

[Basilingual rhabdomyoma treated by endoscopy]

Rhabdomyoma in adults is a rare benign neoplasm of the skeletal muscles generally arising in the pharyngolaryngeal region. These slow-growing tumors remain asymptomatic for a long period. We report a case of basilingual rhabdomyoma. Computed tomography and magnetic resonance imaging demonstrated a well-encapsulated tumor with a line of cleavage between the base of the tongue muscles. Deep transmucosal biopsies were obtained. Well-differentiated skeletal muscle cells with large eosinophilic granulular cytoplasm and cross striations gave the histologic diagnosis. Complete endoscopic resection was successful. The differential diagnoses of rhabdomyoma in adults are myoblastoma or Abrikossof tumor, rhabdomyosarcoma and hibernoma. The risk of late recurrence implies long-term clinical and radiologic follow-up.

[Laryngomucoceles and subtotal C.H.E.P. reconstructive laryngectomy. Report of 6 cases]

We conducted a retrospective analysis of 131 patients who underwent subtotal CHEP laryngectomy for a tumor of the larynx between 1990 and 1999 in order to determine the incidence of laryngomucocele after surgery.

RESULTS

Five patients developed laryngomucocele late after surgery. A sixth patient underwent surgery in another unit. Laryngomucocele developed progressively or was disclosed by acute episodes of dyspnea, requiring tracheotomy again in two cases. One patient developed bilateral mucocele. Three patients had cervicotomy, and three others were treated by CO(2) laser endoscopic marsupialization.

DISCUSSION

We discuss the pathophysiology of late laryngomucocele after subtotal laryngectomy and various techniques that can be used to avoid this complication.

CONCLUSION

Although exceptional, laryngomucocele generally requires surgical removal by cervicotomy or CO(2) laser endoscopic marsupialization to prevent acute respiratory failure.

Intramuscular hemangioma of posterior neck muscles

Intramuscular hemangiomas of the head and neck are rare tumors, sparsely reported. They usually present themselves as a mass which enlarges suddenly. A case of intramuscular hemangioma involving the posterior neck muscles is presented. Computed tomography scanning, magnetic resonance imaging and angiography revealed the vascular nature of this lesion. Surgery consisted of a wide excision. The patient is free of disease after a 4-year follow-up.

Human anti-thyroid peroxidase single-chain fragment variable of Ig isolated from a combinatorial library assembled in-cell: insights into the in vivo situation

In an attempt to explore the natural variable heavy and light chain (VH/VL) pairing of autoantibodies involved in Graves' disease, we constructed a phage-displayed Ab library obtained by in-cell PCR of thyroid-infiltrating cells. We report here the molecular cloning and characterization of human single-chain fragment variable regions (scFv) specific for thyroid peroxidase (TPO) generated from this library. On the basis of the nucleotide sequences, three different scFvs were obtained (ICA1, ICB7, and ICA5). All were encoded by genes derived from the VH1 and Vlambda1 gene families. Using BIACORE for epitope mapping and kinetic analysis, we showed that these scFvs exhibited high affinity (Kd = 1 nM) for TPO and recognized three different epitopes. The biological relevance of these scFvs as compared with serum anti-TPO autoantibodies was assessed by competition studies. Sera from all the 29 Graves' disease patients tested were able to strongly inhibit (60-100%) the binding of the 3 scFvs to TPO. These data demonstrate that the in-cell PCR library generated human anti-TPO scFvs that retained the VH/VL pairing found in vivo and that the different epitope specificities defined by these scFvs overlapped with those found in the sera of patients with autoimmune thyroid disease.

[Substernal goiter. Report of 212 cases]

AIM OF THE STUDY

The aim of this retrospective study was to report the results of the surgical treatment in a series of 210 patients operated on for substernal goiters.

PATIENTS AND METHOD

From 1982 to 1996, 210 patients with substernal goiters, including 80% of women, were operated on via a cervical approach in 208 cases, via a sternotomy in two cases. Two patients with operative contra-indications were not operated on. Twenty-five were operated on for a substernal recurrence of a goiter. In 160 cases, extraction of the substernal portion was easy. In 48 cases, removal of the substernal portion was facilitated by the discovery of the recurrent nerve at its entering into the larynx and a downward dissection of the tracheal attachments of the lobe. The complete dissection of the cervical portion made easier the ascension of the substernal portion even in very large substernal components.

RESULTS

Three papillary carcinomas were diagnosed. A transient laryngeal nerve palsy occurred in 7.2% of the patients and a transient hypoparathyroidism in 13.4%, A definitive laryngeal nerve palsy occurred in 1.2% of the patients, and a persistent hypoparathyroidism in 2.1%. Of the 25 patients who underwent surgery for recurrence of a goiter, three (12%) developed a transient laryngeal nerve palsy, one (4%) a permanent nerve palsy, four (20%) a transient hypoparathyroidism and one (4%) a persistent hypocalcemia.

CONCLUSION

CT scan and MRI are the best explorations to evaluate intrathoracic extension of substernal goiters. Thyroidectomy was performed via a cervical incision in 208 patients and via a sternotomy in two patients only. The complete dissection of the cervical portion with discovery of the recurrent nerve at its entering into the larynx, facilitates the ascension of the substernal portion even in very large substernal goiters.

[Pleomorphic adenoma of the nasal septum: a case report]

We report on a case of pleomorphic adenoma involving the nasal septum, in a caucasian woman aged 23, who presented with nasal obstruction and epistaxis. A swelling of the anterior part of the nasal septum was observed and a biopsy demonstrated the existence of a pleomorphic adenoma. CT scan and MRI investigation showed the lesion to be limited, and removal was therefore possible using an endonasal approach. No recurrence has been found after 22 months.

[Imaging of the hypopharynx, oropharynx and parapharyngeal spaces]

Progress in upper aerodigestive imaging improved pathologic staging and therapeutic choices. Imaging, especially CT scan is now indispensable for staging the upper aerodigestive cancers. Some anatomic areas must be explored with special attention because of their importance for therapeutic decision.

Modified subtotal laryngectomy with cricohyoidoepiglottopexy--long term results in 81 patients

BACKGROUND

Standard treatment of early glottic carcinoma is radiotherapy, but involvement of the anterior commissure leads to a reduced cure rate. We investigated retrospectively whether our modified subtotal laryngectomy had improved results for early glottic carcinomas involving the anterior commissure, without causing excessive disability to laryngeal functions.

METHODS

Eighty-one patients with T1 or T2 glottic carcinoma involving the anterior commissure were reviewed. Follow-up was at least 3 years. Speech was assessed by subjective evaluation and a computer-assisted voice analysis device.

RESULTS

Three-year overall survival rate and 3- and 5-year actuarial survival rates were, respectively, 90.1%, 95%, and 90.8%, with no difference between the different T stages involved (p > 0.46). The local recurrence rate was 7.4%. Speech recovered in all patients and was evaluated as satisfactory in 86% of cases.

CONCLUSION

For early glottic carcinomas involving the anterior commissure, subtotal laryngectomies appear to be more effective than radiotherapy, and our modified technique simplifies the procedure.

[Repeat surgery for thyroid nodules (excluding cancer and hyperthyroidism)]

Second procedures for recurrent thyroid disease are known to carry a high risk of iatrogenic damage, particularly to the inferior laryngeal nerves and parathyroid glands. This risk has been clearly evaluated for the primary procedure, but is less clearly for second procedures. A series of 117 patients with solitary or multiple cold thyroid nodules were evaluated (excluding those patients re-operated for recurrent thyroid carcinoma or goitre associated with hyperthyroidism) to determine the operative risks. The level of transient and permanent recurrent laryngeal nerve palsy was 2.56% and 1.7% respectively. The level of transient and permanent hypocalcaemia was 12.9% and 4.62% respectively. The frequency of re-operation for recurrent disease involving the pyramidal lobe following total thyroidectomy (6 cases) highlights the importance of removing it during the primary procedure. The number of cases of cancer discovered at re-operation was 4.3% (5 cases out of 117).

[Pyolaryngocele: a rare cause of respiratory distress]

Pyolaryngocele is an unusual diagnosis, occurring as a complication of a laryngocele, witch may be discovered because of an episode of acute respiratory distress needing urgent medical care. This is a case report with confirmation of the diagnosis by CT scan, which needed surgical treatment.

[Is laryngeal papillomatosis always juvenile?]

After recording an increased frequency of adult-onset recurrent respiratory papillomatosis, the authors propose a multicentric investigation. The aim of the investigation is to determinate the frequency of the new cases and their clinical form. The preliminary results confirm the increased frequency of the adult-onset form and show the possibility of a clinical form change.

[Horizontal supraglottic laryngectomy. Technique, indications, oncologic results and early functional results. Apropos of 87 cases]

In this article, we advocate supraglottic laryngectomy with bilateral neck dissection for the treatment of supraglottic carcinomas with preserved laryngeal mobility. Post-operative results and follow-up of 87 patients are discussed. This technique allows an excellent loco-regional control of the disease with preservation of laryngeal function. Radiation therapy is preserved for treatment of metachronous (2nd primary) in cases with satisfactory local control without neck metastases. All stage 5-year overall survival rate was 55% with a 68.5% disease survival rate. Five-year local control of the disease and regional control of neck nodes were respectively 94% and 92%. Five-year disease survival rate for N- population was 71% Vs 61% for N+ population. Five-year disease survival rate according to the tumor classification was 70% for T1, 75% for T2, 69% for T3 and 54% for T4. In the post-operative follow-up, the median of time to decanulation was 17 days, that of nasogastric tube removal was 19 days, that of hospital stay 38 days.

[Aberrant intra-petrous internal carotid artery: apropos of a case]

This article illustrates a case of an aberrant pathway of the petrous portion of an internal carotid artery presenting as a cholesteatoma. This is a case of a 53 y.o man presenting with unilateral otalgia and vertigo. Otoscopic examination revealed a whitish retro-tympanic mass accompanied by a conduction hearing loss mimicking a cholesteatoma. An exploratory tympanotomy was performed. The surgical procedure was interrupted after needle aspiration of the mass suggesting an aberrant course of the petrous portion of the internal carotid artery. Authors report a review of the literature with an emphasis on the differential diagnosis, clinical and paraclinical diagnostic work-up. A thorough knowledge of this anomaly is required to avoid an iatrogenic risk during any otological surgery.

[Cervical paragangliomas. Results apropos of a series of 33 patients]

During the period 1971-1993, 33 patients were treated for cervical chemodectomas, 41 tumors were diagnosed. Seven patients had multicentric tumors. All patients expect one with bilateral carotid tumor were treated surgically. A carotid resection was performed in 4 patients. Six patients were given radiation therapy: five patient after surgery and one treated by irradiation alone. During the follow-up period one patient died of bone metastasis 6 year after a partial surgery and radiation therapy, and one had local recurrence treated with irradiation. The surgical management is the major treatment of these tumors, it revealed no postoperative cerebrovascular accident and limited complications secondary to unavoidable nerves sacrifice. Radiation therapy is performed only on particular cases: surgery contra-indications and nonradical resection.