J. Paris

Diagnosis and treatment of juvenile nasopharyngeal angiofibroma

Abstract The aim of this retrospective study was to compare clinical and radiological findings and discuss optimal surgical approach in patients with juvenile nasopharyngeal angiofibroma (JNA). Forty-three cases of JNA were treated at our institution from 1975 to 1999. Thirty-three male patients aged between 8 and 25 years (mean 15.3) were included. Twenty-nine patients underwent primary surgical treatment at our institution and four were treated for recurrence following primary surgery elsewhere. Tumors were staged according to Fisch’s staging. Preoperative embolization was performed in 22 cases. Surgical techniques consisted of the transantral approach, lateral rhinotomy approach, transmaxillary via midfacial degloving approach, and the subtemporal preauricular infratemporal fossa approach. Tumors were classified stage I in seven cases, stage II in 11, stage III in 13 and stage IV in two. The mean delay between the initial symptom and surgery was 14 months overall, 18 months for stage I, 14 for stage II, 13 for stage III and 12 for stage IV. The transantral approach was used in 11 patients, lateral rhinotomy approach in 11 cases, transmaxillary via midfacial degloving approach in three patients, and pre-auricular infra-temporal approach in eight patients. Mean follow-up after surgery was 56 months. Six patients had recurrent tumors. Surgery is the gold standard for treatment of JNA. Modern imaging techniques allow accurate diagnosis and staging of JNA. Our experience and a review of the literature shows that the surgical approach should be selected according to tumor stage.

Management of invasive juvenile nasopharyngeal angiofibromas: The role of a multimodality approach - Commentary

OBJECTIVEJuvenile nasopharyngeal angiofibromas involving the cranial base and intracranial compartment are challenging tumors. We reviewed our experience of these tumors and analyzed the efficacy of a multimodality management. METHODSBetween 1981 and 2000, 15 extensive juvenile nasopharyngeal angiofibromas (Fisch Grade III or IV) were treated at our institution. The mean age of the patients was 14.5 years, and the mean interval between the first symptom and diagnosis was 12.9 months. Initial management included preoperative embolization of the external carotid artery feeders, followed by tumor removal. A maxillofacial procedure was performed in eight cases, a combination of maxillofacial and neurosurgical approach was performed in four cases, and a neurosurgical cranial base approach was performed in three cases. RESULTSTotal removal after the initial procedure was obtained in eight patients. Subtotal removal justified additional surgery in one case, gamma knife radiosurgery in two cases, and fractionated irradiation in four cases. True recurrences were observed in four cases at a mean interval of 37 months (range, 24–46 mo) and required tailored multimodality management. No cases of perioperative death were observed. One patient underwent hemiparesis after embolization in the early period of our experience. Permanent facial numbness was reported in four cases, moderate cosmetic problems were reported in three cases, and hyposmia was reported in three cases. Except for one patient who was lost to follow-up at 18 months, 12 patients were free of disease and two patients were free of tumor progression. All patients had normal or near-normal daily life at the last check-up, with a median follow-up period of 108 months (mean, 117 mo; range, 91–252 mo). CONCLUSIONExtensive juvenile nasopharyngeal angiofibromas are efficiently managed with a multimodal protocol in which preoperative embolization is followed by optimal surgical removal using various transcranial or transfacial approaches. Adjunctive gamma knife radiosurgery is a valuable option for intracavernous residual tumor. Our protocol offers long-term cure with acceptable morbidity.

Preoperative diagnostic values of fine-needle cytology and MRI in parotid gland tumors

The aim of this retrospective study was to assess and compare the diagnostic value of fine-needle cytology and MRI for the prediction of malignancy in parotid tumors. During an 11-year period, 148 patients underwent preoperative fine-needle aspiration cytology in our institution. Eighty-seven patients underwent a preoperative MRI study, and 54 had both MRI and cytology. The study compares results of cytology and MRI with histological reports. The sensitivity, specificity and accuracy for detecting malignant lesions were 87, 94 and 93% respectively for MRI, 81, 95 and 92% respectively for cytology and 100, 88 and 91% respectively for both studies combined. Fine-needle cytology provided better information than MRI concerning precise histological diagnoses. Conversely, the proportion of non-diagnostic smears reached 10%. Fine-needle cytology and MRI are simple, well-tolerated diagnostic means with an impact on the management of salivary gland tumors. The associated anatomic information obtained by MRI imaging makes it the test of first choice in an optimal medical environment.

Adénome pléomorphe parotidien: Etude Histopathologique

Objectifs Le role des effractions capsulaires dans la genese des recidives des adenomes pleomorphes de la parotide est aujourd’hui admis. Le but de ce travail retrospectif etait d’etudier les caracteristiques histopathologiques des adenomes pleomorphes afin d’identifier les mecanismes possibles de recidive et de preciser la strategie chirurgicale. Materiel et methode Une analyse histologique a ete realisee par relecture des lames provenant de 100 patients porteurs d’adenomes pleomorphes parotidiens primitifs operes dans notre institution entre mai 1992 et novembre 2002. Resultats La population etudiee a ete repartie en sous-groupes histologiques permettant une analyse plus precise : 56 % des patients ont ete classes hypo-cellulaires, 29 % hyper-cellulaires et 15 % classiques (repartition homogene entre stroma et contingent cellulaire). La finesse de la capsule a ete significativement correlee au type hypo-cellulaire. La frequence des pseudopodes et nodules satellites etait de 72 % sur la serie, sans influence des sous-types histologiques. Conclusion La frequence des pseudopodes et nodules satellites ainsi que la finesse capsulaire de certains types tumoraux justifient la pratique d’une exerese tumorale passant au large de la capsule afin de ne pas creer de ruptures capsulaires, source de recidive. Les parotidectomies exofaciales et totales constituent les interventions standards de la chirurgie parotidienne de l’adenome pleomorphe.

Apport du TEP scanner au [18F]-FDG dans les adénopathies cervicales primitives

Objectives To evaluate the usefulness of fusioning positron emission tomography withcomputed tomography (PET/CT) for the detection of head and neck carcinomas of unknown primary. Methods This prospective study included 20 patients with cervical lymph node of squamous.cell carcinoma of unknown primary after standard initial workup (nasofibroscopy and CT scan of the chest and head and neck). Patients underwent PET/CT and panendoscopy ofthe upper airways and upper digestive tract with PET/CT directed biopsies. The follow-up was 6 months minimum in all patients. Results A potential primary tumor was found in 10 of the 20 cases and confirmed by histology.in 7 cases (3 bases of tongue, 1 tonsillar pillar, 1 vallecula, 1 tonsillar fossa, 1 piriformsinus). Four of these seven patients presented a normal endoscopy (diagnosis was made with submucosal PET/CT directed biopsies). PET/CT was normal in 10 of 20 cases with 3 false negatives. The sensitivity of PET/CT was 70%, the specificity was 70% and the accuracy was 70%. Conclusion PET/CT seems to be of interest in the detection of head and neck carcinoma of unknown primary. PET/CT detected 15% of unknown primary tumors with treatmentrelated implications.

Intérêt de la TEP au 18FDG couplée à la TDM dans la surveillance post-thérapeutiquedes carcinomes épidermoïdesdes voies aérodigestives supérieures

Objectif Evaluer l’interet de la tomographie par emission de positons au 18-fluoro-2-deoxy-D-glucose dans la surveillance post-therapeutique precoce des carcinomes ORL. Methodes Cette etude prospective incluait 61 patients presentant un carcinome epidermoide evolue des voies aerodigestives superieures traite de facon curative. Un bilan standard (clinique + TDM + panendoscopie) ainsi qu’une TEP couplee a une TDM par fusion d’images (TEP/TDM) ont ete realises trois mois apres la fin du traitement. Les patients ont ete suivis six mois apres ce bilan. La TEP/TDM a ete evaluee a plusieurs niveaux : tumeur primitive, statut ganglionnaire, metastases et patient pris dans sa globalite. Resultats Pour la tumeur primitive, la TEP/TDM a presente une sensibilite, une specificite, une valeur predictive positive, une valeur predictive negative, et une valeur globale respectivement de 86,7 %, 82,6 %, 62 %, 95 % et 83,6 %. Pour le statut ganglionnaire : 100 %, 98,2 %, 80 %, 100 % et 98,3 %. Pour les metastases : 100 %, 92,2 %, 66,7 %, 100 % et 93,2 %. Au niveau patient : 88,8 %, 78,1 %, 64 %, 94,1 % et 81,4 %. La TEP/TDM aura ete plus performante que le bilan standard chez 22 % des patients. Conclusion La TEP/TDM presente un interet dans cette indication, en particulier pour son excellente valeur predictive negative.

Les polypes antrochoanaux ou polype de Killian: Diagnostic et prise en charge thérapeutique

Le polype antraochoanal (PAC) ou polype de Killian est une pathologie unilaterale benigne maxillo-antrale qui atteint plus frequemment l’enfant et dont la physiopathologie ne reste que partiellement expliquee. Son diagnostic est avant tout clinique avec une symptomatologie dominee par l’obstruction nasale et la rhinorrhee unilaterale. Mais dans de rares cas son expression peut etre plus frustre voire atypique. Son diagnostic est alors facilite par la tomodensitometrie et plus rarement par l’IRM. Sa prise en charge therapeutique est exclusivement chirurgicale et la methode video-endoscopique endonasale est a privilegier en premiere intention. La bimeatotomie maxillaire par voie endoscopique avec exerese du pedicule du polype est une technique de choix. La coagulation du pied d’implantation du polype peut y etre associee. En cas de recidive ou lors d’une exerese incomplete par voie endonasale, l’intervention de Caldwell-Luc doit etre preferee.Antrochonal polyp is a unilateral and benign tumor of the maxillary sinus occurring in children. Its physiopathology remains unclear. Nasal presenting symptoms are unilateral obstruction and nasal discharge. In rare cases, presenting symptoms may be atypical. Radiographic examination with CT-scan and more rarely MRI helps the diagnosis. Surgery remains the mainstay of treatment and the endoscopic approach should be used in first intention. Double maxillary meatotomy by endoscopic approach procures a good exposure and permits a complete resection of the pedicle of the polyp. The insertion of the pedicule should be coagulated. In cases with recurrence or in cases of incomplete resection, an external approach (Caldwell-Luc) should be preferred.

La restructuration du lobule du nez ar greffons cartilagineux

OBJECTIVES: Nasal tip projetion and definition are essential parameters which should be considered in the preoperative rhinoplasty plan. Jonhson and Toriumi have defined a technique of rhinoplasty to restructure the lobule using columellar strut and tip grafts. The aim of this study was to define the influence of this procedure on nasal tip projection, using the Goode method (objective measurement of the tip projection). METHODS: Forty patients underwent primary rhinoplasty, by open approach, with remodeling of the lobule using cartilagenous grafts, according to Jonhson and Torium technique. Goode ratio was calculated to assess tip projection preoperatively and postoperatively, based on photographic analysis. Moreover, postoperatively, all patients were clinically evaluated at 2, 4 and 6 months, and based on photographs of face at 2 and 6 months. RESULTS: Five hypoprojected preoperative nasal tips (Goode ratio (GR): 0,45 to 0,51) had a normal nasal tip projection postoperatively (GR: 0,55 to 0,59). Among the eight normal projected preoperative nasal tips (GR: 0,56 to 0,60), six had a normal postoperative nasal tip projection while two showed a hyperprojection (GR: 0,62 and 0,63). Among the 27 hyperprojected preoperative nasal tips (GR: 0,62 to 0,75), 17 showed a normal projection of the nasal tip postoperatively while 10 remained hyperprojected despite a decreased Goode ratio. CONCLUSION: Restructuration of the lobule, using cartilagenous grafts, is a reliable and reproducible technique allowing satisfying aesthetic results and objective measurements of the changes in nasal tip projection using the Goode method.