F. Jégoux

Évidement cervical dans les carcinomes de la cavité orale classes N0

Objectifs La prise en charge des patients porteurs de carcinomes classes N0 reste controversee. Le but de cette etude a ete d’evaluer l’efficacite de l’evidement selectif dans le traitement des patients porteurs de carcinomes de la cavite orale classes N0. Materiel et methodes Une analyse retrospective de 77 patients ayant presente un carcinome epidermoide de la cavite orale entre 1988 et 2001 a ete realisee. Le traitement ganglionnaire a ete une surveillance dans 7 cas, un evidement cervical dans 56 cas, une radiotherapie seule dans 14 cas. 77 evidements cervicaux dont 62 selectifs et 15 radicaux modifies ont ete realises. Resultats Le nombre moyen de ganglions examines par evidement a ete de 10,7. Le taux de metastases occultes (cN0pN+) a ete de 32,5 %. Une rupture capsulaire a ete detectee dans 7,8 % des cas. Le suivi moyen a ete de 43 mois. Le taux global de controle ganglionnaire parmi les patients sans recidive locale a ete de 2,4 %. Une recidive ganglionnaire est survenue dans 2,9 % des cous cN0pN0. L’efficacite globale de l’evidement cervical a ete de 94 %. Aucun des 11 patients traites par evidement selectif sans radiotherapie postoperatoire n’a recidive. Parmi les T1T2pN0 il n’y a pas eu de difference en termes de survie ou de recidive, qu’il y ait eu de la radiotherapie postoperatoire ou pas. La radiotherapie a pu etre evitee chez 27 % des patients traites par evidement cervical. La survie globale a 1, 3 et 5 ans a ete de 89,3 %, 77,7 % et 63.2 %. Conclusions L’evidement selectif est un moyen efficace de diagnostic de l’envahissement et de traitement ganglionnaire des tumeurs de la cavite orale classees N0.

Management of post-traumatic cerebrospinal fluid (CSF) leak of anterior skull base: 10 years experience.

Abstract Conclusion: Anterior skull base cerebrospinal fluid (CSF) leak should be surgically repaired with an endonasal approach first for less morbidity. Pretherapeutic topographical diagnosis increases the success rate of surgical repair. Objectives: We aimed to evaluate our efficiency in taking care of post-traumatic anterior skull base CSF leak, since no consensual algorithms for diagnosis and treatment have been established. Methods: Data from 40 patients treated for post-traumatic CSF leak of the anterior skull base between January 1997 and December 2008 were retrospectively reviewed. Twenty-nine patients were treated with surgery, with an endonasal approach in 14 patients and a neurosurgical approach in 15 patients. A wait and see policy was applied in 11 patients. Results: The overall risk of reccurence was 22.5%. Recurrence was represented by the presence of CSF rhinorrhea in 12.5% and the appearance of meningitis in 10% of patients. The overall risk of postoperative anosmia was 27.5%. A wait and see policy led to a higher risk of developing meningitis than surgical repair (p = 0.0003). The absence of pretherapeutic topographical diagnosis led to a higher risk of recurrence of CSF rhinorrhea (p = 0.01). The endonasal approach resulted in less postoperative anosmia (p = 0.006).

Micro-CT scan, electron microscopy and optical microscopy study of insertional traumas of cochlear implants

PurposeKnowledge of cochlear trauma resulting from the implantation of electrodes is important for the development of atraumatic surgical techniques. The purpose of this study was to demonstrate the advantages of micro-CT scanning, back-scattered electron microscopy (BSEM) and optical microscopy (OM) in understanding the mechanisms of cochlear trauma due to cochlear implantation.MethodOur study involved six petrous bones removed from fresh human cadavers: one control specimen plus five other specimens that were surgically implanted with Neurelec Digisonic SP EVO® electrode arrays. All six specimens underwent glycol methyl methacrylate embedding, were examined via micro-CT scan and were then sectioned for histological analysis of undecalcified samples via BSEM and OM.ResultsThe 2D micro-CT scan reconstructions did not display cochlear microtrauma due to a limited resolution and the loss of information caused by the metallic artifacts of the intracochlear electrodes. The 3D reconstructions displayed the quality of the electrode array positioning in the cochlea and enabled determining the axes on which to section the specimens for histological examination. BSEM afforded a clear view of the damage to the osseous structures of the cochlea, but did not display the soft tissue injuries. OM enabled viewing and grading the histological lesions resulting from insertion.ConclusionIn our opinion, the combination of 3D micro-CT scan reconstructions and histological analysis using OM appears to be the best method to analyze this type of trauma.

Tumeurs parapharyngées : diagnostic et traitement

OBJECTIVES Parapharyngeal space tumors are rare and usually benign. Their treatment is surgical and many approaches have been described. We report our experience in managing these neoplasms. Two points are developed more fully: the correlation between imaging and surgical observation and the reliability of the cervical approach. MATERIAL AND METHODS A retrospective review of primary parapharyngeal space tumors treated at the Rennes University Hospital between 1992 and 2004 is presented. Nine patients were included, all treated surgically with a cervical approach without parotidectomy. RESULTS Eight MR imaging and seven CT scans were done. Two retrostyloid tumors and six prestyloid tumors, all independent of the deep lobe of the parotid gland, were found. They were benign in all cases (five salivary tumors and four schwannomas). Two patients treated for a pleomorphic adenoma presented recurrence and were reoperated successfully. The average follow-up was 66 months. None of the patients died. Definitive postoperative complications occurred only for neurogenic tumors. CONCLUSION The cervical approach is safe and allows the surgical excision of retrostyloid and prestyloid tumors, independent of the deep lobe of the parotid gland. Large tumor (8cm in our study) excision can be done with few complications. An attentive study of preoperative imaging is necessary to choose the best surgical approach.

Chirurgia dei carcinomi della cavità orale: exeresi e riparazione

I carcinomi del pavimento orale richiedono, in un gran numero di casi, un trattamento chirurgico. Questo intervento chirurgico deve interessare sia l’area tumorale che le aree linfatiche. Il trattamento dell’area tumorale comporta sempre un tempo di exeresi e, in seguito, un tempo di riparazione. Il tempo di exeresi deve essere adattato all’estensione del tumore sia a livello dei tessuti molli che a livello dell’osso. In caso di interruzione ossea, la riparazione della continuita ossea, soprattutto se l’interruzione e anteriore, e indispensabile per evitare delle sequele morfologiche e funzionali molto pesanti.

Cirugía de los cánceres de la cavidad oral: resección y reparación

Los carcinomas del piso de la boca requieren cirugia en un porcentaje muy elevado de casos. Este tratamiento quirurgico debe englobar el lecho tumoral y las areas ganglionares. El tratamiento del lecho tumoral siempre incluye un tiempo de reseccion, seguido de un tiempo de reparacion. El tiempo de reseccion debe adecuarse a la extension del tumor tanto a nivel de los tejidos blandos como del hueso. En caso de interrupcion osea, la reparacion de la continuidad osea, sobre todo si la interrupcion es anterior, es indispensable para evitar la aparicion de secuelas morfologicas y funcionales muy graves.

Envahissement et résection mandibulaire dans le traitement des cancers de la cavité orale

Le traitement des cancers de la cavité orale est basé sur la chirurgie d’exérèse, éventuellement suivie d’une irradiation. L’objectif est à la fois carcinologique, en optimisant le contrôle locorégional et la survie, mais aussi fonctionnel en limitant le plus possible les altérations de la qualité de vie. La chirurgie des tumeurs de la cavité orale, en particulier du plancher, intéresse la mandibule soit directement lorsqu’elle est envahie [1], soit indirectement lorsque sa résection est nécessaire pour obtenir des marges de sécurité. Lorsque l’envahissement est franc et massif, le diagnostic de celui-ci ne pose pas de problème en imagerie et le traitement unanimement admis est la résection segmentaire mandibulaire large. Dans les situations où la mandibule est peu ou pas envahie, le diagnostic préopératoire est difficile et entrave la planification du geste chirurgical sur la mandibule. Par ailleurs, dans cette situation, il n’y a pas de consensus sur les indications (site anatomique, taille tumorale, distance de la mandibule, irradiation préalable) et le type de résection mandibulaire (segmentaire ou marginale). Il existe donc de nombreuses controverses concernant les moyens diagnostiques, le rôle pronostique de l’envahissement mandibulaire, les indications et les modalités de mandibulectomie. Nous proposons de synthétiser la littérature actuelle des bases rationnelles sur ce sujet essentiellement constituée d’études rétrospectives.