A cross-sectional comparative study: ChatGPT 3.5 versus diverse levels of medical experts in the diagnosis of ENT diseases

PURPOSE

With recent advances in artificial intelligence (AI), it has become crucial to thoroughly evaluate its applicability in healthcare. This study aimed to assess the accuracy of ChatGPT in diagnosing ear, nose, and throat (ENT) pathology, and comparing its performance to that of medical experts.

METHODS

We conducted a cross-sectional comparative study where 32 ENT cases were presented to ChatGPT 3.5, ENT physicians, ENT residents, family medicine (FM) specialists, second-year medical students (Med2), and third-year medical students (Med3). Each participant provided three differential diagnoses. The study analyzed diagnostic accuracy rates and inter-rater agreement within and between participant groups and ChatGPT.

RESULTS

The accuracy rate of ChatGPT was 70.8%, being not significantly different from ENT physicians or ENT residents. However, a significant difference in correctness rate existed between ChatGPT and FM specialists (49.8%, p < 0.001), and between ChatGPT and medical students (Med2 47.5%, p < 0.001; Med3 47%, p < 0.001). Inter-rater agreement for the differential diagnosis between ChatGPT and each participant group was either poor or fair. In 68.75% of cases, ChatGPT failed to mention the most critical diagnosis.

CONCLUSIONS

ChatGPT demonstrated accuracy comparable to that of ENT physicians and ENT residents in diagnosing ENT pathology, outperforming FM specialists, Med2 and Med3. However, it showed limitations in identifying the most critical diagnosis.

Consensus on the Objectives of an Educational Intervention for Patients with Oropharyngeal Dysphagia and Their Informal Caregivers: A Delphi Study

PURPOSE

In the absence of literature allowing for an evidence-based approach to therapeutic patient education (TPE) in Oropharyngeal Dysphagia (OD), this study aims to reach a consensus of experts on the content of a competency framework of an educational program for OD patients and their informal caregivers (ICGs).

METHODS

We used the Delphi consensus-building method. Four categories of experts were recruited: 12 patients, 17 ICGs, 46 healthcare professionals (HCP) (experienced in OD, not necessarily certified in TPE), and 19 experts in TPE (trained individuals to set up and run TPE programs not necessarily HCPs). The content of the questionnaire of the first round (R) was established according to the result of a scoping review and the opinion of an expert committee. We carried out three rounds. In R1 and R2, we collected the opinions on the relevance (7-point Likert-type scale) and on comprehensiveness (YES/No question and asking participants to propose additional content). Participants were also invited to leave comments on each objective. In R3, we asked the participants to give their opinion about the relevance of the objectives again and asked them to rank the themes from highest to lowest priority.

RESULTS

Objectives were considered relevant for all participants if they reached consensus when the interquartile (IQR) ≤ 1, and if the median indicated agreement (Mdn ≥ 6) (6= appropriate, 7 = totally appropriate). Following three rounds, the final content of the educational program is composed of 23 educational objectives organized in 13 themes with an agreement about relevance amongst all participants (Mdn ≥ 6; IQR ≤ 1). The comprehensiveness criterion received also a consensus (IQR ≤ 1). The participants ranked the theme "normal swallowing vs difficulty swallowing" as the highest priority.

CONCLUSION

This Delphi study resulted in a consensus, on the content of a competency framework of an educational program for OD patients and their ICGs. Further steps are needed to construct learning activities based on these objectives before testing their feasibility and efficacy.

Lipoinjection for Unilateral Vocal Fold Paralysis Treatment: A Systematic Review and Meta-Analysis

INTRODUCTION

Lipoinjection is one of the available treatments for unilateral vocal fold paralysis.

OBJECTIVE

To evaluate lipoinjection predictability, and analyze the differences in safety and efficacy of the different techniques.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS AND RESULTS

A systematic review on Medline, Cochrane, and Scopus databases included 49 articles analyzing the data of 1,166 patients, concerning technical details and voice parameters changes. Lipoinjection used a mean volume of 1.3 mL, 95% confidence interval (CI) (0.92, 1.69)-average overcorrection of 30%. Meta-analysis of pre- and postoperative voice parameters' means showed a significant improvement at 6 months of mean phonation time (preoperative: 5.12, 95% CI [4.48, 5.76]-6 months: 10.46, 95% CI [9.18, 11.75]), Jitter (preoperative: 2.71, 95% CI [2.08, 3.33])-6 months: 1.37, 95% CI [1.05, 1.70]), Shimmer (preoperative: 4.55, 95% CI [3.04, 6.07]-6 months: 2.57, 95% CI [1.69, 3.45]), grade (preoperative: 2.15, 95% CI [1.73, 2.57]-6 months: 0.12, 95% CI [0.97, 1.43]), breathiness (preoperative: 2.012, 95% CI [1.48, 2.55]-6 months: 0.99, 95% CI [0.58, 1.40]), and asthenia (preoperative: 1.90, 95% CI [1.33, 2.47]-6 months: 0.75, 95% CI [0.17, 1.33]) of GRBAS (Grade, Roughness, Breathiness, Asthenia and Strain), and Voice Handicap Index-30 (preoperative: 72.06, 95% CI [54.35, 89.76]-6 months: 26.24, 95% CI [19.58, 32.90]). Subgroup analysis by harvesting technique concluded in no statistically significant difference between them. Few complications were reported. Reintervention was only required for 86 patients.

CONCLUSION

Lipoinjection seems a safe therapeutic option for unilateral vocal fold paralysis, with available data showing an efficacy lasting 6 months to 1 year. Laryngoscope, 2021.

Smoking cessation intervention for patients with head and neck cancer: A prospective randomized controlled trial

AIMS

To evaluate the effectiveness of a brief smoking cessation intervention in head and neck cancer patients (HNCP).

STUDY DESIGN

A prospective randomized controlled trial that randomly assigns participants in two groups: a usual care group (UCG), and a standardized intervention group (SIG).

MATERIAL AND METHODS

Patients with a confirmed diagnosis of head and neck squamous cell carcinoma (HNSCC) and who are active smokers were prospectively approached by one of 4 trained Ear-nose-throat (ENT) residents. Participants were randomized into a UCG, and a SIG consisting of a brief perioperative smoking cessation intervention based on National Institute of Health (NIH) "5A's" model along with an informative motivational document and nicotine patch therapy (NPT) offered for 8 weeks in gradually decreasing doses.

OBJECTIVE

The evaluation of abstinence at 3, 6 and 12 months after enrollment.

RESULTS

56 subjects were randomized into the UCG (N = 29, 52%), and the SIG (N = 27, 48%). The overall smoking cessation rates were not statistically different between the two groups; we observed at 3 months cessation rates of 57.1% vs. 57.7% (p = 0.96); at 6 months, 42.9% vs. 24% (p = 0.148); and at 12 months, 33.3% vs. 20.8% (p = 0.318), for the UCG and the SIG respectively.

CONCLUSION

This study failed to show the effectiveness of a combined brief smoking cessation approach led by and ENT resident in HNSCC patients. A multifaceted approach addressing different pharmacological treatments, factors contributing to smoking maintenance, mainly alcohol dependence and mood disturbances and dealing with relapse risks through close face-to-face or phone call follow-ups may have better outcomes and should be evaluated in upcoming trials.

[Cervical plexus block as an alternative anesthetic approach for type I thyroplasty: a case report]

BACKGROUND

The role of type I thyroplasty (TIP) is well established as the treatment for glottal insufficiency due to vocal fold paralysis, but the ideal anesthetic management for this procedure is still largely debated. We present the case of a novel anesthetic approach for TIP using combined intermediate and superficial Cervical Plexus Block (CPB) and intermittent mild sedation analgesia.

CASE REPORT

A 51-year-old presenting with left vocal fold paralysis and obstructive sleep apnea was scheduled for TIP. An ultrasound-guided intermediate CPB was performed using the posterior approach, and 15 mL of ropivacaine 0.5% were injected in the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. Then, for the superficial CPB, a total of 10 mL 0.5% ropivacaine was injected subcutaneously, adjacently to the posterior border of the sternocleidomastoid muscle, without penetrating the investing fascia. An intermittent sedation analgesia with a target-controlled infusion of remifentanyl (target 0.5 ng.mL^-1) was used to facilitate prosthesis insertion and the fiberoptic laryngoscopy. This technique offered a safe anesthetic airway and good operating conditions for the surgeon, as well as feasible voice monitoring and optimal patient comfort.

CONCLUSION

The use of regional technique is a promising method for the anesthetic management in TIP, especially in patients with compromised airway.

Pediatric laryngeal inflammatory myofibroblastic tumour: Case report and systematic review of the literature

INTRODUCTION

Inflammatory myofibroblastic tumours (IMT) are rare benign neoplasms in the pediatric population, found most frequently in the lungs with rare reports of laryngeal involvement. The aim of this paper is to present a clinical case of laryngeal IMT followed by a systematic review on pediatric laryngeal IMT.

CASE REPORT

We present the case and the management of a 13-year-old boy with a laryngeal IMT MATERIAL AND METHODS: A comprehensive review of literature was conducted in September 2019 using Pubmed and Scopus. Included articles were reviewed for mean age at presentation, gender, main symptoms, treatment modality, histopathological features and follow-up RESULTS: Sixteen cases of pediatric laryngeal IMT were reported in the literature. The mean age of presentation was 7 years; endoscopic surgical resection was used in 87% of procedures, and the mean number of interventions needed to achieve remission was 1.6.

CONCLUSIONS

Pediatric laryngeal IMT are rare benign proliferations with only 16 reported case in the medical literature. The diagnosis of this entity remains a challenge and the standard of care is surgery with clear margins.

Cervical plexus block as an alternative anesthetic approach for type I thyroplasty: a case report

Background

The role of type I thyroplasty (TIP) is well established as the treatment for glottal insufficiency due to vocal fold paralysis, but the ideal anesthetic management for this procedure is still largely debated. We present the case of a novel anesthetic approach for TIP using combined intermediate and superficial Cervical Plexus Block (CPB) and intermittent mild sedation analgesia.

Case report

A 51-year-old presenting with left vocal fold paralysis and obstructive sleep apnea was scheduled for TIP. An ultrasound-guided intermediate CPB was performed using the posterior approach, and 15 mL of ropivacaine 0.5% were injected in the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. Then, for the superficial CPB, a total of 10 mL 0.5% ropivacaine was injected subcutaneously, adjacently to the posterior border of the sternocleidomastoid muscle, without penetrating the investing fascia An intermittent sedation analgesia with a target-controlled infusion of remifentanyl (target 0.5 ng.mL^-1) was used to facilitate prosthesis insertion and the fiberoptic laryngoscopy. This technique offered a safe anesthetic airway and good operating conditions for the surgeon, as well as feasible voice monitoring and optimal patient comfort.

Conclusion

The use of a regional technique is a promising method for the anesthetic management in TIP, especially in patients with compromised airway.

Profiling of Oropharyngeal Dysphagia in an Acute Care Hospital Setting

PURPOSE

To identify the main complaints, diagnostic tools, as well as the treatment plan in patients presenting with oropharyngeal dysphagia in the acute care settings.

METHODS

The electronic medical chart of 100 consecutive hospitalized patients who presented an oropharyngeal dysphagia were retrospectively reviewed from January 2017 to January 2019.

RESULTS

The mean age of patients was 76.03 (standard deviation = 16.06) years old with 71% of patients being males. The most common admission diagnosis was pneumonia (30%), followed by stroke (28%). The swallowing evaluation was performed on the regular floor in 85% of patients and in the intensive care unit in 15% of patients. The main reasons for the swallowing evaluation are suspicion of aspiration by the medical or nursing teams (60%), systematic evaluation (20%), ear, nose and throat (ENT) complaints by the patient (14%), and aspiration pneumonia (6%). Fiberoptic endoscopic evaluation of swallowing with sensitivity testing was the most common diagnostic tool used alone in 88% of patients. Diet and postural modifications were prescribed to 71% and 62% of the patients, respectively. Swallowing exercises were performed in 43% of patients. Overall, otolaryngologist interventions resulted in an increased rate of patients getting oral intake compared to nonoral feeding routes (P = .05).

CONCLUSIONS

This study adds knowledge about the causes and characteristics of oropharyngeal dysphagia in an acute tertiary medical setting. It also provides insights regarding the role, and the consequences of a swallowing intervention led by an ENT specialist in collaboration with the members of the health team.

Repetitive Voice Evaluation in Dysphonic Teachers: Office Versus Home

INTRODUCTION

A patient's voice can vary from one moment to another, and these variations cannot be captured by a one-time assessment. Multiple assessments may give a more holistic idea of the severity of the patient's dysphonia and by asking the patient to do the recordings he becomes involved in his therapeutic plan from the beginning.

AIM

This study aims to evaluate the added value of a repetitive assessment outside the speech therapist's (SLP) clinic, to have a broader vision of the voice disorder and identify parameters that change after working hours to be able to explain this disorder and find solutions for it.

METHODOLOGY

Twelve dysphonic Lebanese teachers, aged between 20 and 60 years, recorded their voices once at the SLP's office, and five other times at home every day after working hours. The recordings included a standardized text and a sustained /ɑ/. For perceptive evaluation of voice quality, six SLPs (three experts and three naïve) analyzed the recordings using the GRBAS scale. For self-assessment, patients filled two self-assessment grids at the office: (SSVS: subjective assessment for vocal overwork) and the Lebanese Voice Handicap Index (VHI-10lb) questionnaire. They responded orally to a third scale ranging from 0 to 100 assessing the severity of dysphonia every day after completing the repetitive home recordings. For objective evaluation of the acoustic parameters, PRAAT software was used.

RESULTS

Results reveal significant difference between the scores of the voices recorded in the office compared to the home repetitive assessment for the G and R of the perceptual evaluation with P < 0.01, as well as for the Jitter, the fundamental frequency, and the harmonic-to-noise ratio with P < 0.05. The recordings made at home revealed a more severe dysphonia. The self-evaluation scales 1 and 2 (VHI-10Ib, SSVS) did not correlate with the results of the objective and perceptual analysis, whereas the results of the oral self-assessment 3 seem to be in agreement with the results of Jitter (P < 0.05), and Grade of dysphonia (P < 0.05).

CONCLUSIONS

In teachers, the severity of dysphonia is more pronounced when the voice is recorded after working hours. Daily self-evaluation allows the patient to be more aware of his vocal disorder and voice fluctuations and might improve participation and compliance with therapy. It may also be used to monitor the response to speech therapy.

Laser-assisted surgery of the upper aero-digestive tract: a clarification of nomenclature. A consensus statement of the European Laryngological Society

Acronyms and abbreviations are frequently used in otorhinolaryngology and other medical specialties. CO₂ laser-assisted transoral surgery of the pharynx, the larynx and the upper airway is a family of commonly performed surgical procedures termed transoral laser microsurgery (TLM). The abbreviation TLM can be confusing because of alternative modes of delivery. Classification and definition of the different types of procedures, performed transorally or transnasally, are proposed by the Working Committee for Nomenclature of the European Laryngological Society, emphasizing the type of laser used and the way this laser is transmitted. What is usually called TLM, would more clearly be defined as CO₂ laser transoral microsurgery or CO₂ TOLMS or CO₂ laser transoral surgery only (with a handpiece) would be defined as CO₂ TOLS. KTP transnasal flexible laser surgery would be KTP TNFLS. Transoral use of the flexible CO₂ wave-guide with a handpiece would be a CO₂ TOFLS. One can argue that these clarifications are not necessary and that the abbreviation TLM for transoral laser microsurgery is more than sufficient. But this is not the case. Laser surgery, office-based laser surgery and microsurgery are frequently and erroneously interchanged for one another. These classifications allow for a clear understanding of what was performed and what the results meant.

Voice Quality and Gender Stereotypes: A Study of Lebanese Women With Reinke's Edema

PURPOSE

Women with Reinke's edema (RW) report being mistaken for men during telephone conversations. For this reason, their masculine-sounding voices are interesting for the study of gender stereotypes. The study's objective is to verify their complaint and to understand the cues used in gender identification.

METHOD

Using a self-evaluation study, we verified RW's perception of their own voices. We compared the acoustic parameters of vowels produced by 10 RW to those produced by 10 men and 10 women with healthy voices (hereafter referred to as NW) in Lebanese Arabic. We conducted a perception study for the evaluation of RW, healthy men's, and NW voices by naïve listeners.

RESULTS

RW self-evaluated their voices as masculine and their gender identities as feminine. The acoustic parameters that distinguish RW from NW voices concern fundamental frequency, spectral slope, harmonicity of the voicing signal, and complexity of the spectral envelope. Naïve listeners very often rate RW as surely masculine.

CONCLUSIONS

Listeners may rate RW's gender incorrectly. These incorrect gender ratings are correlated with acoustic measures of fundamental frequency and voice quality. Further investigations will reveal the contribution of each of these parameters to gender perception and guide the treatment plan of patients complaining of a gender ambiguous voice.

Survival of T4aN0 and T3N+ laryngeal cancer patients: a retrospective institutional study and systematic review

OBJECTIVE

We aim to assess the correlation of tumor and nodal staging to survival in pT3N+ and T4aN0 laryngeal cancer with subgroup analysis within stage IVa (pT4N0 and pT3N2).

STUDY DESIGN

Retrospective cohort study with systematic review of the literature.

SETTING

Hotel Dieu de France University Hospital (tertiary referral center).

SUBJECTS AND METHODS

Laryngeal cancer patients' registries were reviewed from 1998 to 2012 selecting pT3N+ and pT4aN0 patients treated by primary total layngectomy. Overall survivals were compared using Log rank and Kaplan-Meier analysis. A systematic review was performed by 2 reviewers including all the articles reporting the outcome of these categories of patients. Online databases, including PubMed and EMBASE, were used. Reference sections of identified studies were examined for additional articles.

RESULTS

Thirteen T3N+ patients and 19 T4aN0 patients treated by primary total laryngectomy were included. Five-year overall survival for T3N+, T3N2 and T4aN0 was respectively 33%, 32.1% and 73.7%. Due to the small sample, the difference was not significant. The systematic review revealed three articles reporting overall survival outcome for the T4N0 group and 6 articles for the T3N+. At 5years, the survival ranged from 62.5% to 73% in T4N0 and from 32.2% to 77% in T3N+.

CONCLUSION

In advanced stage laryngeal cancer, T4aN0 tends toward a better survival than T3N+ especially when compared to T3N2 although they are grouped in the same TNM stage IVa.

European Laryngological Society: ELS recommendations for the follow-up of patients treated for laryngeal cancer

It is accepted that the follow-up of patients who had treatment for laryngeal cancer is a fundamental part of their care. The reasons of post-treatment follow-up include evaluation of treatment response, early identification of recurrence, early detection of new primary tumours, monitoring and management of complications, optimisation of rehabilitation, promotion smoking and excessive alcohol cessation, provision of support to patients and their families, patient counselling and education. Controversies exist in how these aims are achieved. Increasing efforts are being made to rationalise the structure and timing of head and neck cancer follow-up clinics. The aim of this document is to analyse the current evidence for the need to follow up patients who have been treated for LC and provide an up to date, evidence-based statement which is meaningful and applicable to all European Health Care Systems. A working group of the Head and Neck Cancer Committee of the ELS was constituted in 2009. A review of the current published literature on the management and follow-up of laryngeal cancer was undertaken and statements are made based on critical appraisal of the literature and best current evidence. Category recommendations were based on the Oxford Centre for Evidence-Based Medicine. Statements include: length, frequency, setting, type of health professional, clinical assessment, screening investigations, patient's education, second primary tumours, and mode of treatment considerations including radiotherapy, chemo-radiation therapy, transoral surgery and open surgery. It also addresses specific recommendations regarding patients with persistent pain, new imaging techniques, tumour markers and narrow band imaging.

T4a laryngeal cancer survival: retrospective institutional analysis and systematic review

OBJECTIVES/HYPOTHESIS

To assess the survival outcomes of a homogeneous group of pT4a laryngeal cancer patients treated at our institution by primary total laryngectomy and neck dissection with adjuvant therapy when indicated, and to systematically review studies reporting overall survival outcomes in T4a laryngeal cancer.

STUDY DESIGN

Systematic review of PubMed and Embase databases.

METHODS

Records of 108 laryngeal cancer patients treated by total laryngectomy were reviewed. pT4a cases treated by primary total laryngectomy between 1998 and 2010 were included. Overall and disease-free survival at 2 and 5 years were reported. A systematic review was performed including all published studies reporting overall survival outcomes by treatment modality in T4 laryngeal cancer patients.

RESULTS

Thirty cases met the inclusion criteria. At 2 years, overall and disease-free survival were 81.3% and 78%, respectively. The 5-year overall and disease-free survival rates were 60%. The systematic review retrieved 24 articles. Overall survival at 2 years ranged from 12% to 21.2% with radiotherapy, <30% to 65% with chemoradiotherapy, and from 30% to 100% with surgery. At 5 years, it ranged from 0% to 75% with radiotherapy, 16% to 50.4% with chemoradiotherapy, and 10% to 80.9% with surgery.

CONCLUSIONS

Primary total laryngectomy provides a high survival rate for pT4a laryngeal cancer patients. Randomized controlled trials including homogenous patients are still needed before shifting to organ preservation protocols in these patients.

LEVEL OF EVIDENCE

NA.

New trends in the management of head and neck cancers

Head and neck cancers affect more than half million person a year worldwide. More than 40% have an advanced stage at diagnosis. The incidence in Lebanon according to the statistics of the Ministry of Public Health was 268 new cases in 2007. The tumors and their treatment modalities have an important impact on the quality of life because they influence communication, breathing and4 swallowing. Treatment modalities are evolving to more conservative approaches for better functional results without impeding survival. We present in this review the state of the art of the management of head and neck cancer in 2011 with emphasis on the most recent advances in the assessment, treatment and follow-up.

Reliability of Frozen Section Analysis in Transoral Laser Microsurgery of Upper Aerodigestive Tract Advanced Malignant Tumors

Objective

Transoral laser microsurgery (TLM) for endoscopic excision of head and neck cancers of the upper aerodigestive tract has become an accepted treatment modality. As in any excision of head and neck tumors, the persistance of tumor at the surgical margins influences the outcome. One of the frequent criticisms of endoscopic resection is that the laser use makes interpretation of the surgical margins difficult due to the thermal effect. The goal of this study is to assess the reliability of frozen section after laser excision in locally advanced tumors.

Methods

The charts of patients with T2 and T3 tumors, who underwent TLM between January 2000 and 2008, using the CO2 laser AcuBlade system were reviewed. Frozen section margin results obtained during TLM were compared with margins after formalin fixation.

Results

Sixty-seven patients fulfilled the inclusion criteria. 20 had supraglottic tumors, 22 had oral cavity tumors, 13 had oropharyngeal tumors and 12 had hypopharyngeal tumors. Fifty-nine had no prior treatment, seven had prior radiation therapy and one had prior open surgery. The mean number of frozen margins per surgery was 4. Histological examination on the formalin-fixed tissue confirmed frozen section in 97% of the cases. In 3% of the frozen sections, the diagnosis of invasive carcinoma was missed. None of these patients had significant locoregional disease progression.

Conclusion

Frozen section analysis of margins is reliable during TLM when performed by an experienced team. It enables a one-stage approach reducing the need of a planned second procedure.

Knotting of nasogastric tube around a nasotracheal tube: An unusual cause of hypercapnia in a 3-month-old infant

A 3-month-old boy was admitted to the intensive care unit because of septic shock; he required immediate intubation and placement of a nasogastric tube. A confirmatory chest radiograph showed that the nasogastric tube was looping in the hypopharynx and needed to be repositioned. During removal of the nasogastric tube, the infant experienced hypercapnia and respiratory distress. These complications were due to looping and knotting of the nasogastric tube around the nasotracheal tube.

Relaxation Thyroplasty for Mutational Falsetto Treatment

Mutational falsetto voice is considered to be a psychogenic disorder associated with the rejection of adulthood. The initial treatment must include speech therapy and psychotherapy. However, delayed treatment and denial of the problem can cause the disorder to become recalcitrant to behavioral treatment. Modified relaxation (type III) thyroplasty was proposed by Isshiki to shorten the vocal folds and release tension by incising and depressing the anterior segment of the thyroid cartilage. This procedure is called relaxation thyroplasty by a medial approach (anterior commissure retrusion) in the European Laryngological Society classification system. It results in a lowering of the vocal pitch. The surgery can be performed under local or general anesthesia. It should only be considered for cases not improved by speech therapy and psychological counseling. Our series included 7 male patients with a mean age of 21 years who underwent modified relaxation thyroplasty after failure of behavioral management. The assessment of outcomes was based on changes in the fundamental frequency of the voice and the Voice Handicap Index. The mean fundamental frequency was lowered from 187 Hz to 104 Hz (p < 0.001), and the mean Voice Handicap Index was improved from 70 to 21. There were no postoperative complications. The voice results were consistent over a mean follow-up of 17 months. Modified relaxation Isshiki (type III) thyroplasty is a successful treatment option for lowering vocal pitch in cases of mutational falsetto voice recalcitrant to conservative therapy.

Laryngeal Kaposi sarcoma: case report and literature review

PROBLEM/OBJECTIVE

Kaposi sarcoma is the most frequently-occurring neoplasm in AIDS patients. Laryngeal localization is infrequent. We discuss the management options for laryngeal Kaposi sarcoma based on a literature review.

CASE REPORT

A 42 year old, HIV-positive male receiving HAART therapy presented with mild hoarseness and sore throat. Fiberoptic laryngeal examination identified a small purple lesion in the right ventricular fold. He underwent biopsy under general anaesthesia. The lesion was histologically diagnosed as a Kaposi sarcoma. Systemic treatment was pursued, but 6 weeks later the patient developed severe dysphagia and acute airway obstruction when the lesion became glotto-supraglottic and obstruced the airway. Transoral tumour vaporization with a CO2 laser was performed in the emergency department. Post-operative chemotherapy was administered. Three months later, the patient was completely asymptomatic and the laryngeal examination was normal.

CONCLUSION

Transoral CO2 laser vaporization combined with chemotherapy is a valid option for managing obstructive laryngeal Kaposi sarcoma.

Bacterial flora in normal adult maxillary sinuses

BACKGROUND

Conflicting data exist about the presence of bacteria in healthy maxillary sinus cavities. This study was designed to determine the bacterial flora and to quantify the level of bacterial presence in healthy maxillary sinus cavities.

METHOD

Subjects included 34 patients undergoing Lefort I osteotomy for orthognathic surgery. All patients were preoperatively evaluated by a questionnaire and a complete physical examination including sinus endoscopy. Our exclusion criteria were presence of sinonasal symptoms, asthma, antibiotic treatment in the past 3 months, treatment with local steroids, previous sinonasal surgery, traumatic surgery, and an abnormal CT scan or sinus endoscopy. Washes were obtained from maxillary sinuses before surgery through an antral puncture. The sinus was irrigated with sterile saline followed by aspiration with a syringe attached to the trocar. Basic sterility rules were rigorously applied. Specimens were transported to the laboratory in an air-free syringe. Time between collection of materials and inoculation of the specimen did not exceed 15 minutes. Specimens were inoculated for aerobic and anaerobic organisms.

RESULTS

After applying the selection criteria, 14 patients (28 sinuses) remained. Eight (57.1%) were men with a mean age of 22.7 years; 82.14% of the specimens were sterile. Bacterial organisms were recovered in only four patients with two different coagulase-negative staphylococci in the same patient: one in each sinus with 200 UFC/mL in the left sinus and 10 UFC/mL in the right sinus, one Citrobacter fundii (70 UFC/mL) and two polymorphic floras.

CONCLUSION

This descriptive study shows the large predominance of sterile maxillary sinus cavities in asymptomatic adults with endoscopically normal mucosa.

[Intra-uterine fetal death by knife: case report]

INTRODUCTION

Opened injuries by knife are rare in pregnant women and are responsible of foetal death in most cases.

OBSERVATION AND COMMENTARY

We report a case of a 27-years woman, in her 8th months of pregnancy, victim of three knife punchs in her right iliac fossa. An emmergent laparotomy revealed deep wounds in the uterus and its right vascular pedicles, and a right external iliac artery lesion. Hysterectomy was performed and the extracted fetus was dead. He had two wounds in skull and back. Foetal death is common in opened knife injuries especially at the end of pregnancy. On one hand, the fetus has an abdominal situation that expose him to penetrating lesions. On the other hand, the uterus is richly vascularized during this period of pregnancy, thus any uterine or pedicular wound could result in a maternal hemorrhagic shock and hence a poor foetal and maternal prognosis.

CONCLUSION

Knife injuries in pregnant women could compromise the foetal prognosis. Managmanent should be early and requires a close collaboration between resuscitators, obstetricians and vascular surgeons.

Impact of the lunar cycle on the incidence of intracranial aneurysm rupture: myth or reality?

OBJECTIVE

To analyze the impact of the lunar cycle and season on the incidence of aneurysmal subarachnoid hemorrhage (SAH).

PATIENTS AND METHODS

The medical records of 111 patients who were admitted over a 5-year period to our department because of aneurysmal SAH were retrospectively reviewed. The date of aneurysm rupture was matched with the corresponding season and moon phase.

RESULTS

An incidence peak for aneurysm rupture (28 patients) was seen during the phase of new moon, which was statistically significant (p < 0.001). In contrast, no seasonal variation in the incidence of SAH was observed.

CONCLUSION

The lunar cycle seems to affect the incidence of intracranial aneurysm rupture, with the new moon being associated with an increased risk of aneurysmal SAH.

[Pregnancy in rudimentary uterine horn: diagnostic and therapeutic difficulties]

Ectopic pregnancy in a rudimentary uterine horn is extremely uncommon. Implantation of one embryo in the uterine cavity and of another in a rudimentary uterine horn is an extremely uncommon form of twin pregnancy. The authors report three cases of pregnancies in a rudimentary uterine horn. One was associated to a heterotopic pregnancy in the other eutrophic horn. Through these three cases, they report the risks incurred and the difficulties of the assumption of responsibility of this type of pathology, on the diagnostic as well as therapeutic level. But generally underline the interest of echography especially endovaginale and the coelioscopy in the early diagnosis of this type of uterine malformation.

[Severe neonatal myasthenia with arthrogryposis]

Maternal myasthenia gravis has been associated with the presence of neonatal myasthania and sometimes fetal congenital anomalies. The purpose of this paper is to present an infant with multiple deformations born to a mother with myasthenia gravis. The infant presented with arthrogryposis multiplex and pulmonary hypoplasia. The new born died within the first day of life. Twenty-seven other cases of neonatal myasthenia with arthrogryposis have been reported. Twenty-two of them were stillborn or died. The surviving children needed ventilatory assistance for a long period.

[Pelvic lymphocele: report of a case and review of the literature]

Lymphadenectomy for pelvic cancer can lead to complications, particularly lymphocele. We report a case of pelvic lymphocele, which occurred in a patient who underwent surgery for stage IIa cervical carcinoma after preoperative radiotherapy. The intervention consisted in colpohysterectomy, with lymphadenectomy without peritonisation. Five months later she developed dysuria and pelvic pain. Ultrasound and computed tomography showed a pelvic lymphocele complicated by renal insufficiency. Kidney function was re-established after intraperitoneal marsupialisation. One year later the patient was in good clinical condition with no disorder of kidney function.

[Vesico-uterine fistula of obstetrical origin. Report of 3 cases]

Vesico-uterine fistulae (VUF) lead to an abnormal breech between the bladder and the womb. They are responsible for urinary incontinence and/or cyclic hematuria. They are rare and, in most cases, lead to complications following caesarean deliveries. We report observations of 3 vesico-uterine fistulae treated over a 5 years period at university maternity based at Casablanca, Morocco; they all occurred following caesarean deliveries. These patients were consulted for urinary leakage occurring few weeks up to many years following surgical traumatism. Diagnosis was evoked clinically in all cases and confirmed by intravenous urography and/or hysterography. These VUF were successfully treated by simple breech suture at laparotomy. Treatment is very simple and efficient when the diagnosis is made early and fistula simple. Surgery is recommended after medical treatment failure aiming at fistula drainage.

[Prevalence of urinary incontinence in Moroccan women. Report of 1,000 cases]

An inquiry concerning the prevalence of urinary incontinence for the moroccan women has been archived about 1000 women aged more than 18 years to study prevalence, epidemiology and risk factors of urinary incontinence. 271 women among the 1000 women said that they had suffered from the mictional disorder at least one time during the last month, let 27.1%; 48.7% of the incontinent women are from 30 to 60 years; 22.5% are less than 30 years old, and 8.85% are more than 75 years old. Among these 271 women, 49.44% suffered from leakage after making an effort; 42.80% an imperiosity, and 7.76% spontaneous leakage. Seventy per cent among these women had level of study at least medium; 85.97% among these women suffered the discomfort; but 8.48% of them had been consulted for this disorder, 78.96% are able to consult a medical and to have a clinical or paraclinical exams. The elements who are responsible of this disorder are: menopause, parity, the use of forceps, the weight of first child birth over 3.5 kg, the perineal tearing. Among the medical antecedents we find: chronic bronchitis, urinary infections, chronic constipation, diabetes, and in the other way among surgical antecedents are: hysterectomy and prolapsus cure.

[Current profile of obstetrical vesicovaginal fistulas at the maternity unit of the University of Casablanca]

Obstetrical vesicovaginal fistulas are secondary to dystocia. Late and inappropriate treatment are still a health public problem in under development countries. In five years (1993-1997), twelve vesicovaginal fistulas were repertored in the department of obstetrics and gynaecology of Casablanca (Morocco) with a frequency of 0.33@1000 deliveries and 2.4 new cases a year. 80% of the cases occurred after a long labour without efficient obstetrical care. Most of the cases (75%) were simple with an easy surgical treatment. All the fistulas were resolved after one or two surgical procedures realised by vaginal route in eight cases (2/3). During these last decades, with the efforts in obstetrical care in our country, we are assisting in a diminution of the frequency of this pathology and specially the number of complicated fistulas.

[Mammary tuberculosis: a series of 14 cases]

OBJECTIVES

We examined cases of mammary tuberculosis in order to determine the different modes of presentation and analyze diagnostic difficulties.

METHODS

Retrospective analysis of 14 cases of mammary tuberculosis treated at the Ibn Rochd University Hospital in Casablanca over a 16 year period.

RESULTS

Patient age ranged from 16 to 65 years. Contact with a contaminated person was recognized in 2 cases. The predominant clinical presentation was a tumor formation (12 cases) which sometimes simulated cancer. Axillary nodes were observed in 10 cases with 1 case of fistulization. Mammography suggested cancer in 3 cases. The diagnosis of mammary tuberculosis was based on pathology findings in 14 cases (2 biopsies, 12 peroperative specimens) and isolation of bacilli from pus in one case. Medical treatment was given. Surgery was associated as needed (abscess drainage, residual lesions). Except for one death due to tuberculous meningoencephalitis, clinical course was favorable with ad integrun breast recovery.

DISCUSSION

Mammary tuberculosis is uncommon and often produces a pseudoneoplastic presentation. Pathology confirmation is required for diagnosis.

[Maternal complications of cesarean section: retrospective analysis of 3,231 interventions at the Casablanca University Hospital, Morocco]

We carried out a retrospective analysis of 3,231 cases of cesarean section between 1994 and 1997, to assess the maternal mortality and morbidity associated with this intervention. The frequency of cesarean delivery was 12.4%. The indications for cesarean section were of three types: elective indications (627 cases, 19.4%), emergency indications (454 cases, 14.1%), failure of normal labor (2,150 cases, 66.5%). Nine maternal deaths were noted (2.8 per thousand), one of which was directly linked to surgery. The peroperative complications were primarily major hemorrhagia (39 cases, 1.2%), visceral lesions such as bladder rupture (3 cases, 0.1%) and intestinal lesions (3 cases, 0.1%). Postoperative morbidity was predominated by infectious complications, particularly endometritis (5.1%). Thromboembolism was reported in 7 cases (0.2%). Cesarean section is used to preserve the life of both the mother and the child. However, maternal morbidity and mortality rates are higher with cesarean section than with vaginal delivery and therefore its indications must be justified.