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Ultrasonography (US) and Tc-99m sestamibi scintigraphy (SS) are usually performed as preoperative imaging modalities for patients with sporadic primary hyperparathyroidism (SPHP). Fine-needle aspiration (FNA) under US guidance for parathyroid hormone (PH) assay can enhance the diagnostic accuracy of US. The main aim of the present study was to compare positive predictive values between US-FNA and SS. The secondary aim was to draw up a decision-tree for FNA and SS. The single-center retrospective study included patients with previously non-operated SPHP. They underwent US-guided FNA, PET-CT SS, and 18 F-choline scintigraphy if the first two methods were inconclusive. PH washout level was considered pathological when greater than the serum PH level. Postoperative histology data were correlated to imaging data. In total, 117 patients were included, with a mean age of 64 years (range, 26–89 years). A single adenoma was identified on pathology in 101 patients (89%). FNA findings were pathologic for 64 patients (55%), with a mean PH level of 2,604 ng/L [range, 585–9,074 ng/L], higher than the serum level of 179 ng/L [range, 60–1,000 ng/L]. US-guided FNA showed sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of respectively 72%, 92%, 99% and 28%, compared to 89%, 42%, 93% and 32% for SS. The rate of error in locating the parathyroid gland was 8% for US-guided FNA versus 12% for SS. Comparison of the two methods showed better sensitivity for SS (P = 0.0052) and better specificity for FNA (P = 0.0143), with no significant difference in PPV or NPV. 18 F-choline scintigraphy detected the hyperfunctioning parathyroid in 11 out of the 15 patients. PPV did not significantly differ between FNA and SS. US-guided FNA performed by an experienced operator could be a simple first-line method for more than 50% of patients with non-operated SPHP, with 99% PPV. In case of negative or doubtful FNA findings, SS can be performed in second line. [ABSTRACT FROM AUTHOR]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.forsciint.2009.07.015 Byline: S. Duband (a)(b), A.P. Timoshenko (c)(d), R. Mohammedi (e), J.-M. Prades (c)(d), F.-G. Barral (e), M. Debout (a), M. Peoc'h (a)(b) Keywords: Hanging; Nasolaryngofibroscopy; Larynx; Vocal cords; Vocal cords position; Forensic interest Abstract: To evaluate laryngoscopic findings in hanging cases and to compare them with magnetic resonance imaging (MRI) and forensic autopsy results. Author Affiliation: (a) Department of Forensic Medicine, Saint-Etienne University Hospital Center, Bellevue Hospital, 42055 St-Etienne, Cedex 2, France (b) Department of Pathology, Saint-Etienne University Hospital Center, North Hospital, 42055 St-Etienne, Cedex 2, France (c) Department of Otolaryngology-Head and Neck Surgery, Saint-Etienne University Hospital Center, North Hospital, 42055 St-Etienne, Cedex 2, France (d) Department of Anatomy, Jacques Lisfranc Faculty of Medicine, Jean Monnet University, 15 rue Ambroise Pare, 42023 St-Etienne, Cedex 2, France (e) Department of Radiology, Saint-Etienne University Hospital Center, Bellevue Hospital, 42055 St-Etienne, Cedex 2, France Article History: Received 20 October 2008; Revised 16 July 2009; Accepted 21 July 2009

The pterygopalatine fossa and infratemporal fossa are spaces located under the skull base, housing important neurovascular structures. Surgical access to these spaces is challenging because of their deep location and complex anatomy. Their surgical access has been classically carried out through multiple craniofacial approaches until the advent of endoscopic endonasal surgery at the end of the XXth century. Our goal is to describe the transmaxillary-transsphenoidal-transpterygoid approach to the pterygopalatine and infratemporal fossae through endonasal endoscopic surgery based on anatomo-surgical dissection and an illustrative clinical case. We conclude that after careful radiologic evaluation of the feasibility of this technique, the endonasal endoscopic access to these spaces for tumor resection is efficient with reduced surgical morbidities. The endonasal approach is versatile and can be fashioned according to the nature and extent of the lesion. [ABSTRACT FROM AUTHOR]

Intraoperative neuromonitoring of the laryngeal nerves during thyroidectomy is a reliable method to assess nerve function. After identification of the cricothyroid ligament, a bipolar electrode is selectively inserted through the ligament into the thyroarytenoid muscle (TAM) and cricothyroid muscle (CTM). Vagus nerve stimulation then allows precise monitoring of the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve (EBSLN) in the TAM and CTM, respectively. A significant muscle response (greater than 100 μV) is 100% predictive of preserved laryngeal mobility, while the absence of a muscle response is 70% predictive of vocal fold paralysis with 100% sensitivity and 98% specificity. A significant thyroarytenoid muscle response is only recorded ipsilateral to the stimulation with a shorter latency on the right side. A concomitant TAM and CTM response to vagus nerve stimulation or EBSLN stimulation is observed in more than 70% of cases. [ABSTRACT FROM AUTHOR]

The Eustachian (auditory) tube and tympanomastoid cavities form an anatomic and functional whole that cannot easily be divided, and is therefore known as the “tubotympanic system”. The system has been the focus of several studies, with complex and sometimes contradictory results, making an overview of its functioning difficult to obtain. The objective of the present article is to review the current state of knowledge, as an indispensable preliminary to understanding tubotympanic system dysfunction, and notably the development of chronic otitis. The system as a whole is covered by mucosa, which provides continuity, although with certain particularities from one area to another, and plays a primordial role. Thus, under physiological conditions, gas diffusion across the tympanomastoid mucosa largely ensures the equilibrium of pressure between the middle ear and outside environment, the tube orifice being very little involved. Under large rapid change in atmospheric pressure, the aeration function of the Eustachian tube comes into play, governed by a reflex mechanism. The system also has other functions that are essential to good middle-ear functioning: protection against nasopharyngeal secretions and pathogens and against certain physiological noises; middle-ear cavity clearance by mucociliary transport of pathogens, partly related to submucosal gland secretion; and immune defense. [ABSTRACT FROM AUTHOR]

Objectives There is paucity of data on the efficacy of volumetric modulated arc therapy (VMAT) in head and neck squamous cell carcinoma (HNSCC). The objective of the present study was to investigate outcomes and patterns of recurrence in locally advanced HNSCC treated by VMAT. Methods A retrospective study included all patients with stage III or IV HNSCC undergoing curative VMAT. Results From 2010 to 2013, 130 patients were treated for locally advanced oropharynx ( n = 55; 42%), hypopharynx ( n = 38; 29%), larynx ( n = 22; 17%) or oral cavity ( n = 15; 12%) SCC. Median age was 60 years (range, 39–85). Median follow-up was 18.1 months (range, 0–43.7). By end of follow-up, 60 patients (46%) had died. Two-year progression-free and overall survival were respectively 63.6% and 77.3% for laryngeal tumors, 60% and 60% for oral cavity tumors, 52.6% and 57.6% for oropharyngeal tumors, and 38.8% and 54.7% for hypopharyngeal tumors. Most recurrences were located within or marginal to radiation therapy fields. Conclusion This retrospective analysis is, to our knowledge, the largest study of the efficacy of VMAT in HNSCC. Recurrence patterns and outcomes were consistent with those previously reported for intensity-modulated radiotherapy. [ABSTRACT FROM AUTHOR]

Objectives Supracentimetric cervical lymph node metastasis is classically a poor prognostic factor for locoregional recurrence and survival in head and neck cancer. Causality, however, is more controversial for infracentimetric cervical lymph node metastases. The objective of this study was to evaluate the incidence and prognostic value of infracentimetric lymph node metastasis. Materials and methods Two hundred and forty-three neck dissections from 150 head and neck cancer patients were analyzed. A single pathologist exhaustively inventoried the number and size of all adenopathies in the surgical specimen. Results Cervical lymph node metastases were infracentimetric in 38% of cases, with 72% extracapsular spread (versus 91% for supracentimetric adenopathies; P < 0.01). Infracentimetric metastases were more often associated with other cervical lymph node metastases (mean 5.3 versus 3.9; P = 0.14). Fifty three percent of specimens showed only supracentimetric metastases (versus 13% infracentimetric metastases; P < 0.01). Disease-specific and failure-free survival were lower in case of infracentimetric metastasis, associated with supracentimetric metastasis or not, than in case of macrometastasis only. Conclusion Infracentimetric cervical lymph node metastasis is a factor of poor prognosis, and may represent a different, more aggressive lymphatic process. We suggest complete neck dissection by the surgeon and meticulous analysis by the pathologist, the results of which guide complementary therapy. Close surveillance of recurrence is also recommended. [ABSTRACT FROM AUTHOR]

Objectives To analyze histopathologic invasion of the anterior laryngeal commissure on surgical specimens from patients operated on for stage-2 squamous-cell carcinoma managed by supracricoid partial laryngectomy (SCL). Patients and methods Twenty-five patients with previously untreated stage-2 squamous-cell carcinoma were selected. Preoperative endoscopy confirmed anterior commissure involvement; CT found no cartilage lysis. SCL was performed in all cases: 15 anterior frontal SCLs with epiglottoplasty, 8 with cricohyoidepiglottopexy, and 2 with cricohyoidopexy. Histopathology analyzed resection margins (< 1 mm, 1–5 mm, > 5 mm), cartilage extension and vascular embolism. Mean time to observation was 18 months (range, 12–36 months). Results Resection margins were < 1 mm in 7 cases (28%), 1–5 mm in 9 and > 5 mm in 9 patients. Vascular emboli were found in 15 patients (60%). Twenty patients were free of medial thyroid cartilage involvement; 5 showed cartilage extension (20%), restricted to the internal cortical layer in 4 cases (stage T3) and transfixing in 1 (stage T4a). Mucosal extension appeared non-predictive of cartilage invasion. The T4a patient showed local laryngeal recurrence at 12 months. Conclusions In laryngeal commissure squamous-cell carcinoma, SCL enables pathologic analysis of the entire anterior commissure as organogenetically defined: medial thyroid wing, in which the three laryngeal regions are inserted. Microscopic cartilage invasion is poorly predicted by mucosal extension, and may affect 20% of initially T2 patients. [ABSTRACT FROM AUTHOR]

Aims Hyperthyroidism includes several clinical and histopathological situations. Surgery is commonly indicated after failure of medical treatment. The aim of this study was to analyze the indications and complications of surgery as well as endocrine results. Materials and methods Patients operated on for hyperthyroidism between 2004 and 2012 were included in a retrospective study. Total thyroidectomy was performed for Graves’ disease, toxic multinodular goiter and amiodarone-associated thyrotoxicosis; patients with toxic nodule underwent hemithyroidectomy. Pathologic analysis assessed surgical specimens; postoperative complications and resolution of hyperthyroidism were noted. Results Two hundred patients from 15 to 83 years old were included. One hundred and eighty-eight underwent primary surgery and 12 were re-operated for recurrent goiter (6 with subtotal thyroidectomy for multinodular goiter 25 years previously; 6 with hemithyroidectomy for solitary nodule 15 years previously). Eighty-two patients suffered from toxic multinodular goiter, 78 from Graves’ disease, 35 from solitary toxic nodules and 5 from amiodarone-associated thyrotoxicosis. Fourteen papillary carcinomas (including 11 papillary microcarcinomas) and 34 healthy parathyroid glands (17%) were identified in the pathological specimens. Postoperative complications comprised 4% permanent recurrent laryngeal nerve palsy (1 year follow-up), 9% hematoma requiring surgical revision, and 3% definitive hypocalcemia. Normalization of thyroid hormone levels was observed in 198 patients. Two recurrences occurred due to incomplete resection (1 case of Graves’ disease and 1 intrathoracic toxic goiter that occurred respectively 18 and 5 months after resection). Postoperative complications were more frequent in multinodular goiter (23%) than in Graves’ disease (13%) (ns: P > 0.05). Conclusion Surgical management of hyperthyroidism enables good endocrinal control if surgery is complete. Patients need to be fully informed of all possible postoperative complications that could occur, especially vocal ones. Long-term follow-up is necessary to detect recurrence, which can occur more than 20 years after partial thyroidectomy surgery. Surgery allows early diagnosis of 12.5% of papillary carcinomas. [ABSTRACT FROM AUTHOR]

Objectives The present study assessed the predictive value of [ 18 F]-FDG PET-CT (positron emission tomography with 18-fluoro-eoxyglucose radiotracer, coupled to computerized tomography) for response to induction chemotherapy in head and neck squamous cell carcinoma (HNSCC). Material and methods [ 18 F]-FDG PET-CT was systematically performed before treatment initiation and after the first cycle of chemotherapy. Results were compared with those of endoscopy and pathologic analysis of biopsy and surgical specimens. Results This preliminary study included 21 previously untreated HNSCC patients. A decrease of more than 30% in SUVmax (maximum standard uptake value) during induction was predictive of tumor response to chemotherapy ( P = 0.04). PET-CT measurement of hypermetabolic volume based on a predetermined SUV threshold (SUV = 2.5), on the other hand, proved non-predictive. Conclusion These preliminary findings are promising. A larger sample, however, would be required in order to determine a more precise SUVmax reduction cut-off threshold during induction. Other methods for determining metabolic volume thresholds will be investigated. If functional imaging proves contributive, it could enable early screening of non-responders, avoiding unnecessary intoxication. [ABSTRACT FROM AUTHOR]

Objectives To compare the results obtained with canal wall up (CWU) tympanoplasty for cholesteatoma using cartilage or an hydroxyapatite (HA) PORP positioned on the head of the stapes and to analyse the impact of malleus removal and total reinforcement of the tympanic membrane with cartilage. Materials and methods Retrospective study of 128 cases (99 adults, 29 children) operated between 2003 and 2012 for cholesteatoma by CWU tympanoplasty with use of a cartilage graft (90 cases) or a PORP (38 cases) on the head of the stapes. Audiometric results were analysed according to the International Bureau for Audiophonology (BIAP) criteria and were submitted to statistical analysis. All ossiculoplasties were performed during the first operation and only 39% of patients required surgical revision. The malleus was preserved in 79 cases and sacrificed in 49 cases. Results With a follow-up of 2 years, the residual mean air-bone gap was 16.8 dB in the cartilage group (gain of 7.6 dB; P = 0.001) and 15.8 dB in the PORP group (gain of 8.5 dB; P = 0.002). The air-bone gap was less than 20 dB in 67.6% of cases in the cartilage group and 70.4% of cases in the PORP group. No significant difference was observed between the 2 techniques and no significant difference was observed according to whether or not the malleus was preserved in either the cartilage group or the PORP group. Conclusion These results confirm the value of cartilage graft placed on the head of the stapes as ossiculoplasty technique in cholesteatoma operated by CWU tympanoplasty, giving comparable results to those obtained with a PORP. Malleus removal did not induce any reduction of the quality of hearing obtained. Total reinforcement of the tympanic membrane with cartilage appeared to decrease the cholesteatoma recurrence rate (8.5%). [ABSTRACT FROM AUTHOR]

Summary: Objectives: The authors analyse the predictive diagnostic accuracy of fine-needle aspiration cytology (FNAC) and frozen section examination in adult patients operated for thyroid nodules. Patients and methods: The same pathologist performed macroscopic and cytological examination, followed by frozen section examination on each operative specimen. FNAC results were classified into three groups: benign, malignant or suspicious of malignancy. Frozen section examination was also classified into three categories: benign, malignant or suspicious of malignancy when not all criteria of malignancy were present. Results: One hundred and sixty-six (82%) of the 202 patients included in the study were females. Patients had a mean age of 51years. Thyroid carcinoma was diagnosed on final pathology in 22% of women and 25% of men. FNAC results were benign in 85% of cases, malignant in 9% of cases and atypical or suspicious in 6% of cases, with a specificity of more than 99% and a sensitivity, including and excluding microcarcinomas, of 36% and 48%, respectively. The diagnostic accuracy of FNAC was 84% and 89%, after excluding micro-carcinomas. Frozen section was benign in 85% of cases, malignant in 13% of cases and suspicious in 2% of cases, with a specificity of more than 99% and a sensitivity, including and excluding microcarcinomas, of 56% and 68%, respectively. The diagnostic accuracy of frozen section was 89% and 90%, after excluding microcarcinomas. The diagnostic accuracy of the combination of the two examinations was 94% after excluding microcarcinomas. Conclusion: FNAC and frozen section have a comparable predictive diagnostic accuracy. Frozen section is requested by the surgeon not only on the basis of preoperative FNAC, especially when it is suspicious, or even indeterminate, but also in the light of the macroscopic surgical findings. [Copyright &y& Elsevier]

Summary: Targeted endoscopic parathyroidectomy without gas insufflation is a relatively non-invasive means of discovering and resecting parathyroid adenomas in sporadic primary hyperparathyroidism. This standardized technique depends on the quality of the preoperative imaging: cervical ultrasound and sestamibi scintigraphy, and can be optimized by preoperative insertion of an ultrasound-guided “harpoon” and rapid peroperative parathyroid hormone analysis. Failure rates range between 1.7% and 4%. [Copyright &y& Elsevier]

Summary: Objectives: To report a second case of cholesterol granuloma of the middle ear invading the cochlea. Material and methods: A 54-year-old woman, who had undergone right-side tympanoplasty with stapedectomy, complained of intermittent right-side otorrhea associated with cophosis. Otomicroscopy found anterior eardrum perforation with mucopurulent effusion. Computed tomography (CT) showed a lesion filling the tympanic cavity, exposing the tympanic facial nerve, with destruction of the ossicles; the vestibule and cochlea were ossified except for the basal turn. The petrous apex was normal. Magnetic resonance imaging (MRI) showed invasion of the cavity and basal turn of the cochlea by a mass in heterogeneous hypersignal on T-1 weighted images, non-enhanced by gadolinium injection, and hyperintensity on T2-weighted images. Cholesterol granuloma of the middle ear was suspected, with surgery indicated due to the facial nerve exposure and cochlear invasion. Results: A brownish-yellow compressive mass invading the basal turn of the cochlea, suggestive of cholesterol granuloma, was removed. Histologic examination confirmed diagnosis. Conclusion: Direct invasion of the otic capsule by cholesterol granuloma is extremely unusual. Surgery is indicated in such cases, to avoid onset of neurologic complications. [Copyright &y& Elsevier]

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Summary: Tympanoplasty now frequently uses cartilage to repair bone lysis in the external auditory canal (EAC) and to reinforce the tympanic membrane. Once in place, however, the cartilage may complicate ossiculoplasty by obstructing visualization of the stapedial region. Posterior tympanotomy, when included in the tympanoplasty procedure, may provide an interesting means of positioning the ossiculoplasty. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of the medical autopsy is to define the causes of a patient''s death. Although its rate has dramatically decreased, the post-mortem examination remains one of the basic tools for the assessment of medical care. The objective of this study was to identify the factors influencing the acceptance of medical autopsies. Methods: A prospective survey was performed using questionnaire that was administered to patients and health care professionals of the Saint-Étienne university hospital. The survey consisted in several questions relating to the autopsy practice (on one''s own body) and the knowledge of the procedure. Results: The population surveyed consisted of 186 individuals and 112 health care professionals, including physicians, residents and nurses. The results of the study overall showed a good acceptance of autopsy. Actually, 86% of the individauls and 94.6% of health professionals would not be opposed to their own autopsy (in order to identify the cause of the death, to help relatives bereavement, to foster medical research). The main reasons of medical autopsy opposition include religion belief, body integrity, dignity and respect. Only 42.5% of patients had previously received some information about autopsies, while 33.9% of health care professionals had received a specific formation. Conclusion: The rate of refusal of medical autopsy was low in this survey but information relative to this procedure remains insufficient. The current law imposes to look after a nonopposition to medical autopsy of the died individual, including asking his/her relatives that markedly limit the organ donation. Modification of the French bioethical law should be beneficial to increase both medical autopsy organ donation rates. [Copyright &y& Elsevier]

Background: Postoperative analgesia after oropharyngeal carcinoma surgery remains poorly studied. This study investigates the effects of mandibular nerve block (MNB) with ropivacaine 10 mg ml(-1) in conjunction with general anaesthesia (GA) on postoperative analgesia after partial glossectomy or transmandibular lateral pharyngectomy.Methods: In a randomized double-blind study, 42 patients (21 in each group) received an MNB by the lateral extra-oral approach (MNB group) or a deep s.c. injection of normal saline (control group). Both groups received a standardized general anaesthetic. Postoperative analgesia included fixed dose of i.v. acetaminophen and morphine via a patient-controlled analgesia device. Consumption of morphine and supplemental analgesics and pain scores at rest were measured.Results: The mean cumulative morphine consumption was reduced by 56 and 45% at 12 and 24 h after operation in the MNB group. The administration of analgesic rescue medications was delayed in the MNB group. The visual analogue scale (VAS) pain scores were comparable in the two groups during the first 24 h. Adequate analgesia (mean VAS < or = 3) was observed throughout the study period in the MNB group, but only from 4 h after operation onwards in the control group. The number of patients who experienced severe pain (VAS > 7) during the first postoperative day was lower in the MNB group than in the control group (3 vs 10. respectively, P < 0.05).Conclusions: In this study, MNB performed before GA for oropharyngeal carcinoma surgery improved postoperative analgesia, resulting in reduced morphine consumption at 24 h and severe pain in fewer patients. [ABSTRACT FROM AUTHOR]