Philippe Pasche

Supracricoid Partial Laryngectomy With Cricohyoidoepiglottopexy and Cricohyoidopexy for Glottic and Supraglottic Carcinomas

Objectives To review the patients operated in our department with supracricoid partial laryngectomy with either cricohyoidoepiglottopexy (CHEP) (59 cases) or cricohyoidopexy (CHP) (10 cases) technique, for primary or recurrent glottosupraglottic squamous cell carcinoma and compare the technique with other surgical or conservative approaches for treatment of laryngeal carcinoma.

Glial cell line-derived neurotrophic factor released by synthetic guidance channels promotes facial nerve regeneration in the rat

Regeneration of the human facial nerve after lesion is often limited, leading to severe functional impairments, in particular when repair is delayed for several months, when cross‐facial nerve grafts have to be performed, or in elderly patients. To improve the outcome, the potential accelerating and maturating effects of the neurotrophic factors glial cell line‐derived neurotrophic factor (GDNF) and neurotrophin‐3 (NT‐3) on nerve regeneration were assessed using an axotomy model of the rat facial nerve. One‐centimeter‐long synthetic guidance channels releasing the neurotrophic factors over several weeks were used to bridge an 8 mm nerve gap, a distance that does not allow regeneration in the absence of growth factors. Nerve cables regenerated in the presence of GDNF showed a large number of myelinated axons 6 weeks after grafting (871 ± 373, n = 5), whereas only 106 ± 86 (n = 5) myelinated axons were counted in the presence of NT‐3. Retrograde labeling with fluorogold revealed 981 ± 450 (n = 5) and 53 ± 38 (n = 5) retrogradely labeled motoneurons in the facial nucleus in the presence of GDNF and NT‐3, respectively. No regenerated axons or retrogradely labeled cells were observed in the absence of growth factors (n = 6). These results demonstrate that GDNF, as previously described for the sciatic nerve, a mixed sensory and motor nerve, is also very efficient in promoting regeneration of the facial nerve, an essentially pure motor nerve. GDNF may therefore be useful in improving facial nerve regeneration in the clinic.

Closure of large intrathoracic airway defects using extrathoracic muscle flaps

BACKGROUND Prospective assessment of pedicled extrathoracic muscle flaps for the closure of large intrathoracic airway defects after noncircumferential resection in situations where an end-to-end reconstruction seemed risky (defects of > 4-cm length, desmoplastic reactions after previous infection or radiochemotherapy). METHODS From 1996 to 2001, 13 intrathoracic muscle transpositions (6 latissimus dorsi and 7 serratus anterior muscle flaps) were performed to close defects of the intrathoracic airways after noncircumferential resection for tumor (n = 5), large tracheoesophageal fistula (n = 2), delayed tracheal injury (n = 1) and bronchopleural fistula (n = 5). In 2 patients, the extent of the tracheal defect required reinforcement of the reconstruction by use of a rib segment embedded into the muscle flap followed by temporary tracheal stenting. Patient follow-up was by clinical examination bronchoscopy and biopsy, pulmonary function tests, and dynamic virtual bronchoscopy by computed tomographic (CT) scan during inspiration and expiration. RESULTS The airway defects ranged from 2 x 1 cm to 8 x 4 cm and involved up to 50% of the airway circumference. They were all successfully closed using muscle flaps with no mortality and all patients were extubated within 24 hours. Bronchoscopy revealed epithelialization of the reconstructions without dehiscence, stenosis, or recurrence of fistulas. The flow-volume loop was preserved in all patients and dynamic virtual bronchoscopy revealed no significant difference in the endoluminal cross surface areas of the airway between inspiration and expiration above (45 +/- 21 mm(2)), at the site (76 +/- 23 mm(2)) and below the reconstruction (65 +/- 40 mm(2)). CONCLUSIONS Intrathoracic airway defects of up to 50% of the circumference may be repaired using extrathoracic muscle flaps when an end-to-end reconstruction is not feasible.

Abrasive esophageal cytology for the oncological follow-up of patients with head and neck cancer

Objectives: The occurrence of a second primary cancer in the esophagus in patients with head and neck squamous cell carcinoma is frequent and is associated with a poor prognosis. The aim of this study was to evaluate the yield of abrasive esophageal cytology as a means of screening for metachronous cancer of the upper aerodigestive tract.

Second primary squamous cell carcinoma arising in cutaneous flap reconstructions of two head and neck cancer patients

Early complications of myocutaneous flap transfers following surgical eradication of head and neck tumors have been extensively described. However, knowledge concerning long-term complications of these techniques remains limited. We report the cases of two patients with a prior history of squamous cell carcinoma of the head and neck (HNSCC), who developed a second primary SCC on the cutaneous surface of their flaps, years after reconstruction. Interestingly, it seems that the well-known risk of a second primary SCC in patients with previous head and neck carcinoma also applies to foreign tissues implanted within the area at risk. Given the important expansion of these interventions, this type of complication may become more frequent in the future. Therefore, long-term follow-up of patients previously treated for HNSCC not only requires careful evaluation of the normal mucosa of the upper aero-digestive tract, but also of the cutaneous surface of the flap used for reconstruction.

Parapharyngeal Lipoma Causing Obstructive Sleep Apnea Syndrome

A 53-year-old man with increasing snoring over a 1-year period was seen with excessive daytime sleepiness (Epworth score, 20/24). Relevant in the medical history was essential hypertension controlled with medication. The patient also mentioned a painless cervical mass that had increased in size during the previous 6 months. The patient did not have odynodysphagia, hoarseness, or dysphonia. Physical findings revealed a nonobese man (body mass index [BMI], 25.3 kg/m) with a soft, nontender mobile mass in the right neck measuring about 10 5 cm under the sternocleidomastoid muscle. Indirect laryngoscopy showed a slight narrowing on the right lateral pharyngeal wall with intact mucosa. The rest of the ear, nose, and throat examination was within normal limits. Magnetic resonance imaging of the head and neck confirmed a well-defined mass with uniform fat signal intensity, measuring 9 4 5 cm compatible with a cervical lipoma (Fig 1). OSAS was confirmed with nocturnal polysomnography, showing an apnea-hypopnea index (AHI) of 32.35/h (normal, 10/h) and baseline and minimal O2 saturations of 91% and 74%, respectively. Treatment with nasal continuous positive airway pressure (CPAP) monitoring of 7-cm water was successfully initiated, and a surgical procedure was planned. The mass was surgically removed, and the histopathologic examination confirmed the diagnosis of lipoma. After surgery, the snoring disappeared and daytime sleepiness markedly improved (Epworth score, 10/24). A polysomnographic study 2 months after surgery showed the resolution of obstructive apnea, with an AHI of 8.9/h, a baseline O2 saturation of 93%, and a minimal O2 saturation of 84%. CPAP treatment then was stopped.

Local delivery of glial cell line-derived neurotrophic factor improves facial nerve regeneration after late repair.

Facial nerve regeneration is limited in some clinical situations: in long grafts, by aged patients, and when the delay between nerve lesion and repair is prolonged. This deficient regeneration is due to the limited number of regenerating nerve fibers, their immaturity and the unresponsiveness of Schwann cells after a long period of denervation. This study proposes to apply glial cell line‐derived neurotrophic factor (GDNF) on facial nerve grafts via nerve guidance channels to improve the regeneration.

Accelerated postoperative radiation therapy with weekly concomitant boost in patients with advanced head and neck cancer

Purpose/Objective: To assess the feasibility and efficacy of accelerated weekly 6 fractionated 66-Gy postoperative radiation therapy (RT) using a single fraction regimen from Monday to Thursday and a concomitant boost in the Friday afternoon sessions in patients with advanced head and neck cancer (AHNC). Materials/Methods: Between December 1997 and June 2002, 89 (male to female ratio: 68/21; median age: 60 years [range: 36-81]) consecutive patients (refusing to participate or ineligible for the EORTC 22931 study comparing postoperative RT vs. RT plus chemotherapy) with pT1-pT4 and/or pN0-pN3 AHNC (28 oropharynx, 26 oral cavity, 18 hypopharynx, 6 larynx, 5 unknown primary, 4 salivary gland, and 2 paranasal sinus) were included in this prospective study. Postoperative RT was indicated because surgical margins were not free of tumor (n = 22) or for T4 tumors (n = 4) in 26 (29%) patients; or because of extranodal infiltration with (n = 33) or without (n = 30) positive surgical margins in 63 (71%) patients. Median interval between surgery and RT was 6 weeks (3-15). RT consisted of 66 Gy (2 Gy/fr) in 5 weeks and 3 days. Median RT duration was 39 days (range: 35-67). Prophylactic percutaneous endoscopic gastrostomy was applied in 26 (29%) patients. Median follow-up was 21 months (range: 2-59). Results: All but one patient (not finishing the treatment because of non treatment-related reasons at 56 Gy) received the planned total dose without unplanned interruption. Acute morbidity was acceptable: grade 3 mucositis in 20 (22%) patients, grade 3 dysphagia in 22 (25%) patients, grade 3 skin erythema in 18 (20%) patients. Median weight loss of was 2 kg (range: 0-14.5). No grade 4 toxicity was observed. Considering the late effects, grade 0, 1, 2, or 3 xerostomia was observed in 15 (17%), 57 (64%), 11 (12%), and 6 (7%) patients, respectively; grade 0, 1, 2, and 3 edema in 29 (33%), 46 (52%), 12 (13%), and 2 (2%) patients, respectively. Median time to locoregional relapse was 10 months (range: 2-21); only 4 (4%) local and 9 (10%) regional relapses were observed, and 18 (20%) patients developed distant metastases (all locally controlled but with regional relapses in 4 cases). The 2-year overall, cause-specific, and disease-free survival rates were 70%, 75%, and 63%, respectively; and 2-year actuarial-local and locoregional control rates were 94% and 80%, respectively. Distant metastasis probabilities at 2 and 4 years were 20% and 38%, respectively. Univariate analyses revealed that pT-stage, 3 or more lymph node metastases, and extranodal extension in 2 or more lymph nodes were Related Articles in ScienceDirect significant. Multivariate analysis (Cox model) revealed that pT-stage (pT1, 2 vs. pT3, 4) and extranodal extension (0, 1 vs. 2 or more) were the two factors independently influencing the outcome. Conclusions: We conclude that reducing the overall treatment time using postoperative accelerated RT by weekly concomitant boost (6 fractions per week) is easily feasible with excellent local control. Acute and late RT-related morbidity is highly acceptable. Given the disease progression pattern (distant metastases), adjuvant chemotherapy should be considered.