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Resume Objectif Le lambeau libre anterolateral de cuisse presente de multiples applications en reconstruction cervico-faciale. Les objectifs de cette etude etaient : premierement d’evaluer les sequelles fonctionnelles et esthetiques du prelevement d’un lambeau anterolateral de cuisse indique pour des raisons carcinologiques, puis secondairement d’evaluer le retentissement a long terme de ce prelevement sur la qualite de vie du point de vue du patient et du praticien. Materiels et methodes Quarante et un patients ayant beneficie d’une reconstruction cervico-faciale par lambeau libre anterolateral de cuisse, dans les suites d’un cancer de la tete et du cou, ont ete evalues par questionnaire a plus de 6 mois de la chirurgie. Les sequelles au site donneur ont ete evaluees en consultation. Le retentissement du prelevement du lambeau a ete evalue par des echelles de Likert a 5 points par les patients et les chirurgiens. Resultats Trente-neuf pour cent des patients presentaient une ou plusieurs sequelles. Le retentissement des sequelles au site donneur sur la pratique d’un sport, la vie quotidienne, et l’activite professionnelle etait juge nul a minime par le patient dans 94 %, 98 % et 100 % des cas respectivement. Soixante et un pour cent des patients et 58,5 % des praticiens jugeaient l’aspect esthetique de la cicatrice tres discret ou discret. Conclusion La morbidite liee au prelevement d’un lambeau anterolateral de cuisse est faible et les sequelles fonctionnelles au site donneur sont bien tolerees par les patients. La cicatrice est moyennement satisfaisante mais facilement dissimulable.

Resume Introduction Actuellement, le cancer localise de la corde vocale est traite par radiotherapie ou par chirurgie endoscopique. Ces deux modalites ont prouve leur interet chez le patient âge, la place exacte de chaque traitement est peu documentee. Cette etude evalue notre prise en charge des patients tres âges, atteints d’un cancer des cordes vocales. Materiel et methodes Etude retrospective monocentrique des patients âges de 75 ans ou plus, traites par radiotherapie ou chirurgie endoscopique a visee curative, pour un cancer localise de la corde vocale entre 2004 et 2018. Resultats Trente-trois patients, 27 hommes et 6 femmes, d’âge moyen 82,2 ans (76,1–93,1) ont ete inclus. Vingt-quatre patients ont ete traites par radiotherapie et 9 par chirurgie. Le seul facteur influencant le choix de traitement etait l’invasion de la commissure anterieure. La survie globale etait de 87 % a 2 ans et 62 % a 5 ans. Dix-neuf pour cent des patients ont recidive dans les 5 ans, necessitant des revisions chirugicales. Aucun deces lie au traitement n’a ete note. Le traitement par radiotherapie etait plus pourvoyeur de complications locales aigues, avec deux interruptions temporaires de traitement, et un traitement non mene a son terme. Le traitement par chirurgie etait plus pourvoyeur de dysphonies, retrouvees chez 80 % des patients operes. Conclusion Le traitement du cancer localise de la corde vocale du sujet âge peut se faire par radiotherapie ou par chirurgie endoscopique. L’âge ne doit pas modifier la prise en charge de ces patients. Le traitement chirurgical, plus court, est mieux tolere, mais plus nocif pour la voix et pourra etre privilegie chez les patients les plus comorbides.

Numerous studies proved that all pedicle screw constructs produce the best outcome in the surgical treatment of patients with scoliosis. However, the optimal amount and distribution of screws has not yet been defined. In recent studies on idiopathic scoliosis, the correlation between curve correction and implant density has been discussed with diversifying results. The aim of this study was to detect a possible correlation of sagittal and coronal curve correction in dependence of metal load and flexibility index. Twenty-six patients were included in this study with surgical correction by one surgeon between January 2014 and December 2017. Clinical data and radiographic images (preoperative, postoperative and one-year follow-up) were retrospectively analyzed and metal load, flexibility index, correction rate and correction index were consequently calculated. The Pearson correlation analysis was used for metal load—correction index and metal load—correction rate, correction of kyphosis—metal load and correction of lordosis—metal load. According to the mean metal load of 88%, patients were divided into two subgroups—a low-density group of 12 patients and a high-density group of 14 patients. Clinical and radiographic features were examined by an independent two-sided t-test. Eight patients were male, 18 patients female. Ten suffered from neuromuscular and 16 from idiopathic scoliosis. Mean age was 17.1 years. Correction rate directly postoperative was 70.43%, at the follow-up 67.90%. Mean correction index directly postoperative was 3.40 and at the follow-up 3.23. Pearson correlation of metal load—correction index directly postoperative was − 0.188 and one year postoperative − 0.189. The correlation between metal load—correction rate immediately after the surgery was 0.324 and at the follow-up 0.285. Correlation for correction of kyphosis—metal load postoperative was − 0.120 and one year later − 0.178. Pearson coefficient of lordosis—metal load directly after the surgical intervention was − 0.214 and at the follow-up − 0.220. Dependency of flexibility index and correction rate showed a positive trend (Pearson flexibility—correction rate direct 0.616; flexibility index—correction rate follow-up 0.516). A statistically significant difference between the high- and the low-density group was detected in the correction rate directly postoperative (p = 0.047). With an implant density over 70%, satisfactory surgical treatment can be achieved in idiopathic and neuromuscular scoliosis. No statistical significance between the high-density (88–100%) and the low-density (73–87%) group could be verified in curve correction, ICU stay and complications.

International audience; Purpose Radial forearm free flap (RFFF) being a workhorse flap in head and neck reconstruction, we investigated its donor site delayed consequences. Methods Multicentric case series evaluating 189 patients who underwent RFFF for carcinologic reasons at least 6 months before. Patients and surgeon's appreciation regarding the aesthetic and functional consequences of the flap harvest on their daily life were evaluated by questionnaires using likert scales. Medical data were collected from patients' charts retrospectively. Results Thirty percent of patients had at least one sequelae. Experiencing a graft necrosis did not worsen long-term results. Cosmetic satisfaction was significantly worst for women, according to patients' and surgeons' opinion. For 81% and 92% patients, respectively, the flap harvest had no impact on daily life nor sport practice. Ratio between the benefits of reconstruction and the sequelae at the donor site was judged ``excellent'' for 77% patients. Conclusions Although objectively important, RFFF morbidity has little impact in head and neck cancer patient's life.

Resume But Les pharyngolaryngectomies totale circulaires sont realisees pour des tumeurs evoluees du pharynx ou dans un contexte de recidive post-radique. Plusieurs procedes de reconstruction du pharynx par lambeau libres ou pedicules sont utilises et sont choisis selon l’operateur. Cette etude a pour but d’evaluer les resultats fonctionnels sur la deglutition a long terme de ces patients en fonction du type de lambeau utilise pour la reconstruction. Materiel et methode Une etude retrospective multicentrique a ete menee de janvier a septembre 2016 dans le groupe Gettec. Tous les patients operes d’une pharyngolaryngectomie totale circulaire et en remission etaient inclus et devaient remplir le questionnaire du deglutition handicap index (DHI) et avoir une fibroscopie de deglutition. 46 patients (39 hommes 7 femmes) ont ete inclus pendant cette periode. Le lambeau ante-brachial tubulise (groupe LABT) etait utilise dans 19 cas, le grand pectoral en fer a cheval (groupe LGP) dans 15 cas et le jejunum libre (groupe LJL) dans 12 cas. Resultats Le DHI moyen etait de 24 : 20 groupes LABT, 23 groupes LJL, 25 groupes LGP, sans difference significative ; 27 patients avaient une deglutition normale, 9 mixee, 8 liquide, 3 etaient alimentes par gastrostomie. La nasofibroscopie de la deglutition obtenait un pourcentage de patient avec une deglutition normale de salive et de yaourt significativement plus important pour les patients reconstruits avec un lambeau libre (LJL et LABT) par rapport au groupe LGP (p = 0,04). Conclusion Cette etude a montre que le type de lambeau de reconstruction d’une pharyngolaryngectomie totale circulaire n’a pas d’impact sur la qualite de la deglutition postoperatoire evaluee par le patient par autoquestionnaire du DHI.

Objective Free anterolateral thigh flap has many applications in head and neck reconstruction surgery. The aims of the present study were: (1) to assess functional and esthetic sequelae of harvesting for oncologic purposes; and (2) to assess long-term impact of harvesting on quality of life according to patient and to physician. Materials and methods Forty-one patients undergoing reconstruction by free anterolateral thigh flap following oncologic head and neck surgery were assessed by questionnaire at > 6 months postoperatively. Donor site sequelae were assessed in consultation. Harvesting impact was assessed on 5-point Likert scales by patient and by surgeon. Results Thirty nine percent of patients showed ≥ 1 sequelae. Donor site sequela impact on sport, daily living and work was assessed by patients as none or mild in 94%, 98% and 100% of cases, respectively. Sixty-one percent of patients and 58.5% of surgeons considered scar esthetics to be discreet or very discreet. Conclusion Morbidity related to anterolateral thigh flap harvesting was low, and functional sequelae at the donor site were well tolerated. The scar was only moderately satisfactory, but could easily be hidden.

International audience; Aims: Early glottic carcinoma is currently managed by radiation therapy or endoscopic surgery. Both are effective in elderly patients, but their respective indications are poorly determined. The present study assessed our management of very elderly patients with early glottic carcinoma. Material and methods: A retrospective single-center study included all patients aged 75 years and older at diagnosis, treated by radiation therapy or endoscopic surgery with curative intent for T1 or T2 glottic carcinoma between 2004 and 2018. Results: Records of 33 patients (27 men and 6 women; mean age, 82.2 years (range, 76.1-93.1 years)) were reviewed. 24 patients received radiation therapy and 9 endoscopic resection. The only factor for choice of treatment was anterior commissure involvement. Overall survival was 87% at 2 years and 62% at 5 years. 19% of patients relapsed within 5 years and had to undergo further treatment. There were no treatment-related deaths. Radiation therapy was associated with more acute local complications, with two temporary treatment interruptions and one uncompleted treatment. Surgical treatment was more likely to result in dysphonia, found in 80% of cases. Conclusion: Treatment of early glottic cancer in elderly subjects can consist in either radiotherapy or endoscopic surgery. Age should not affect management. Surgical treatment is shorter and better tolerated, although with poorer vocal outcome, and may be preferred in the most comorbid patients.

International audience; Objectives: To assess the factors associated with long-term quality of life (QoL) and patient concerns in elderly oral or oropharyngeal cancer (OOPC) patients after oncologic surgery and free-flap reconstruction. Methods: Patients aged over 70 years who were still alive and disease-free at least 1 year after surgery were enrolled in this cross-sectional multicentric study. Patients completed the EORTC QLQ-C30, -H&N35 and -ELD14 QoL questionnaires, and the Hospital Anxiety and Depression Scale (HADS). Patient needs were evaluated using the Patient Concerns Inventory (PCI). Factors associated with these clinical outcomes were determined in univariate and multivariate analysis. Results: Sixty-four patients were included in this study. Long-term QoL, functioning scales and patient autonomy were well-preserved. Main persistent symptoms were fatigue, constipation and oral function-related disorders. Salivary and mastication/swallowing problems were the main patient concerns. The mean number of patient concerns increased with the deterioration of their QoL. Psychological distress (HADS score ≥ 15) and patient frailty (G8 score

Resume Le transplant libre de fibula, est utilise en pratique courante pour les reconstructions mandibulaires en cancerologie ORL. La rehabilitation dentaire, finalite de la reconstruction, fait appel aux implants intra-oraux comme support d’une prothese adjointe ou conjointe. Le positionnement des greffons osseux fibulaires et des implants conditionnent l’osteointegration des implants et les possibilites de rehabilitation prothetique. Une pre-implantation de la fibula par des implants intra-oraux avant son prelevement en tant que lambeau libre va favoriser l’osteointegration des implants. La position des implants doit alors etre planifiee avec precision. La chirurgie virtuelle et les techniques de conception et fabrication assistees par ordinateur vont permettre de planifier la reconstruction puis de reproduire cette planification a l’aide de guides de coupe fibulaires et mandibulaires sur-mesure assurant ainsi le bon positionnement des fragments osseux fibulaires et des implants. La technique de pre-implantation fibulaire implique deux temps chirurgicaux (prefabrication et transfert du lambeau) et une planification preoperatoire precise. La pre-implantation dentaire des lambeaux libres de fibula, grâce a l’amelioration de la qualite de la cicatrisation osseuse des implants avant le transfert du lambeau, permet d’augmenter les possibilites de rehabilitation prothetique dans les reconstructions mandibulaires secondaires complexes.

Free fibula transplant is routinely used for mandibular reconstruction in head and neck cancer. Dental rehabilitation, the objective of mandibular reconstruction, requires the use of dental implants as supports for fixed or removable dentures. Positioning of fibular bone grafts and implants determines implant osseointegration and the possibilities of dental rehabilitation. Prefabrication of a fibula free flap with dental implants prior to harvesting as a free flap can promote implant osseointegration. The position of the implants must then be precisely planned. Virtual surgery and computer-assisted design and prefabrication techniques are used to plan the reconstruction and then reproduce this planning by means of tailored fibula and mandible cutting guides, thereby ensuring correct positioning of fibular bone fragments and implants. The prefabricated fibula free flap technique requires two surgical procedures (prefabrication and flap transfer) and precise preoperative planning. Prefabricated fibula free flap with dental implants, by improving the quality of osseointegration of the implants before flap transfer, extends the possibilities of prosthetic rehabilitation in complex secondary mandibular reconstructions.

Objective Circumferential pharyngolaryngectomy is performed for advanced pharyngeal tumor or in a context of postradiation recurrence. Several free or pedicle flaps have been described for pharyngeal defect reconstruction, with choice at the surgeon's discretion. The aim of this study was to evaluate long-term swallowing function according to the type of flap used for reconstruction. Material and method A multicenter retrospective study was conducted from January to September 2016 within the French GETTEC head and neck tumor study group. All patients in remission after circumferential pharyngolaryngectomy were included and filled out the Deglutition Handicap Index (DHI) questionnaire and underwent swallowing function fiberoptic endoscopy assessment. 46 patients (39 men, 7 women) were included. Reconstruction used a tubularized forearm free flap (FFF group) in 19 cases, pectoralis major myocutaneous flap (PMMF group) in 15 cases and free jejunum flap (FJF group) in 12 cases. Results Mean DHI was 24: 20 in the FFF group, 23 in the FJF group and 25 in the PMMF group, without significant differences. 27 patients had normal swallowing, 9 mixed diet, 8 liquid diet and 3 were fed by gastrostomy. On endoscopy, free flaps (FJF and FFF) were associated with significantly greater rates of normal swallowing of saliva and yogurt than in the PMMF group (P = 0.04). Conclusion Type of flap reconstruction after circumferential pharyngolaryngectomy had no significant impact on postoperative swallowing function assessed on the self-administered DHI questionnaire.

Resume L’anatomie complexe de la tete et du cou necessite de posseder un large eventail de lambeaux pedicules ou libres afin d’assurer une reconstruction optimale des differentes pertes de substances secondaires au traitement du cancer. Le lambeau supraclaviculaire est un lambeau fasciocutane preleve aux depens des regions supraclaviculaire et deltoidienne. Il est vascularise par l’artere supraclaviculaire ; branche cutanee directe de l’artere cervicale transverse dans 93 % des cas ou de l’artere suprascapulaire dans 7 % des cas. L’artere supraclaviculaire est localisee dans un triangle delimite par le bord posterieur du muscle sterno-cleido-mastoidien en interne, la veine jugulaire externe en posterieur et la portion mediane de la clavicule en anterieure. Ce lambeau pedicule est fin, malleable, facile et rapide a prelever avec un pedicule fiable et une morbidite minime au niveau du site donneur. Il autorise des reconstructions innervees, en une etape, de nombreux types de defects cervico-faciaux. C’est une alternative aux lambeaux locoregionaux avec des resultats fonctionnels equivalents, qui doit faire partie integrante de l’arsenal therapeutique du chirurgien oncologue ORL.

But de la presentation L’objectif de cette etude est de decrire les caracteristiques des patients atteints de lymphomes extra-ganglionnaires de la tete et du cou (LEGTC), leur presentation clinique au diagnostic et de mettre en evidence la place de l’ORL dans leur prise en charge. Materiel et methodes Tous les dossiers des patients presentant un LEGTC entre le 01/01/2001 et le 31/12/2013 ont ete retrospectivement analyses. L’âge au diagnostic, le sexe, le type histologique (selon la classification 2009 de l’OMS), la localisation, le mode de presentation clinique, le delai entre les premiers symptomes et le diagnostic histologique, le mode de presentation clinique et la presence de symptomes B definis par une alteration de l’etat general, des sueurs ou de la fievre ont ete notes. La specialite (ORL ou autre) du premier medecin consulte pour le symptome ayant amene au diagnostic de lymphome et de celui qui realisait le prelevement a l’origine du diagnostic etait relevee pour chaque cas de lymphome. Resultats 67 cas de LEGTC ont ete diagnostiques : 39 hommes et 28 femmes, d’âge median 68 ans. Les lymphomes B (84 %) etaient beaucoup plus frequents que les plasmocytomes (7 %) et que les lymphomes T (6 %). Le sous-type histologique dominant etait le lymphome B diffus a grandes cellules (DLBCL) (54 %). Les localisations anatomiques etaient les amygdales (28 %), le rhino-sinus (19 %), la parotide (15 %) et le cavum (13 %). Les LEGTC etaient reveles soit par une masse (33 %) soit par une symptomatologie liee a la localisation de cette masse (52 %), rarement par des symptomes B (7 %). 55 % des cas n’avaient pas d’adenopathie cervicale associee ni de localisation extra-cervicofaciale. La symptomatologie etait plus bruyante pour les lymphomes agressifs de type Burkitt ou DLBCL, avec un delai entre les premiers symptomes et le diagnostic histologique tres court (3,9 mois en moyenne). Pour les lymphomes indolents (plasmocytomes, lymphomes B du manteau, lymphomes de MALT), la presentation clinique etait plus insidieuse, avec un delai beaucoup plus long (10,3 mois en moyenne). L’ORL etait le premier medecin consulte dans 67 % des cas et il realisait le prelevement a l’origine du diagnostic dans 97 % des cas. Conclusion Les LEGTC sont une pathologie rare (5 cas/an) dont la presentation clinique est tres polymorphe en fonction de la localisation et du type histologique. L’ORL doit savoir evoquer le diagnostic quelque soit la region anatomique afin d’organiser au mieux la prise en charge diagnostique.

Acute burn is a more or less profound destruction of the skin envelope. The depth of the injury determines the severity of functional and aesthetic sequelae. Local care prevents the infection, factor of deepening of the burn. Currently the dressing used in most Burns centers is a bandage covering a bacterial product applied to the burn. The advantage of this dressing is to prevent the occurrence of local infection. In contrast, open-air method of treatment is based on the notions that the wound is infected. His purpose is to reduce the effects of infection by creating an unfavourable environment to the growth and multiplication of bacteria. The principle of this method is the formation over the burned area of an eschar. The eschar acts as a natural dressing to protect the injured area against infection. The residual skin islets are preserved. The surgical cleavage of the eschar is easy; the deep surface of the crust defines the surgical plan. Deep tangential excisions are not necessary. The implementation of this technique is easy and it is particularly well suited to pediatrics. Treatment is not painful and the child's activities are not hampered by bandages. Respect of the children's quality of life and medical-economic efficiency of this method give it a prominent place in the treatment of burns in children.

Objectives/Hypothesis To evaluate the long-term outcome of patients with vocal fold nodules treated by surgery alone, or by a combination of surgery and voice therapy and to identify factors associated with long-term recurrent dysphonia. Study Design Retrospective study. Methods All patients who had undergone surgery for vocal fold nodules in a tertiary care hospital between 1996 and 2006 were contacted. After giving their consent, they were evaluated by videostroboscopic examination of vocal fold nodules and by a subjective questionnaire including the Voice Handicap Index (VHI). Results Sixty-two out of 90 patients (69%) (60 women, 2 men with a mean age of 33 years) answered the questionnaire at a mean interval of 9.5 years after surgery. Recurrent dysphonia was observed in 19 patients (30%) at a mean interval of 5.2 years after surgery and new benign vocal fold lesions (nodules or Reinke's edema) were observed in 11 patients (18%). Absence of postoperative voice therapy was significantly associated with a higher recurrence rate (P = 0.02) (56% of recurrent dysphonia without voice therapy versus 22% with voice therapy). Conclusions Postoperative voice therapy decreases the risk of recurrence. Vocal fold nodules can recur over a period of 5 years, consequently requiring follow-up for at least 5 years in clinical practice and in future prospective studies. Level of Evidence 2b (Individual retrospective cohort study). Laryngoscope, 123:1926–1930, 2013

Annales Francaises d'Oto-Rhino-Laryngologie et de pathologie cervico-faciale - Vol. 129 - N° 3 - p. 192-196

European Annals of Otorhinolaryngology, Head and Neck Diseases - Vol. 129 - N° 3 - p. 167-171

High-grade C1C2 luxation is a rare pathology. There is no clear evidence as to how to treat this deformity. There is only limited evidence about the different surgical techniques and possible approaches including advantages, disadvantages, and complications.This is an uncommon case of a 13-year-old child with progressive, tetraplegia due to congenital os odontoideum with translational instability between C1 and C2, and progressive luxation of C2. An irreducible dislocation of the C0/C1 complex caused significant compression at the cervicomedullary junction and neurologic deficit. In this paper we highlight the different types of os odontoideum, a review of existing evidence of surgical correction. We will discuss the different treatment strategies which could be applied and the current solution will be described.Continuous skeletal traction and translational reduction was achieved by a specially designed halo traction system including continuous skeletal traction in a wheelchair for 6 weeks. The surgical treatment consisted of a posterior only release, translational reduction and posterior instrumentation from C0 to C4 with a Y plate and homologous bone graft. Neurological deficits started to improve during halo traction. After surgery the patient was ambulatory without any assistance and reached a Frankel stage E. Postoperative X-rays and CT scan revealed complete reduction at the C1/C2 level and a decompressed cervicomedullary junction.Treatment of severe C1C2 luxation is difficult with limited evidence in the literature. The current case shows a successful treatment strategy to reduce the deformity and lists alternative approaches.

Annales Francaises d'Oto-Rhino-Laryngologie et de pathologie cervico-faciale - Vol. 129 - N° 2 - p. 140-143

Summary Neck pain affects a third of patients following head-and-neck cancer treatment, whether by radiation therapy or surgery. It is a disabling condition and the associated muscle contractures impair cervical motion. Type-A botulinum toxin is an analgesic and muscle relaxant, able to improve patients’ quality of life. We here report our experience with botulinum toxin in post-radiosurgical neck contracture. Patients and methods A single-center pilot study was run from January 2007 to July 2008, respecting the Declaration of Helsinki. All patients in complete remission from head-and-neck cancer with post-radiosurgical neck contracture impairing neck motion were included. Pain and functional impairment were assessed on a neck-function disability scale before and 1 month after botulinum toxin injection. Efficacy duration was measured. Complications at the injection site or related to drug diffusion were investigated. Results Nine consecutive patients (six male, three female; mean age, 61 years [range, 52–73 years]) were included. In six patients, the sternocleidomastoid muscle was injected and the muscular pedicle of a pectoralis major flap in three. Mean cervical disability score fell significantly from 33 to 23 ( P = 0.01). There were no complications. Efficacy was seen at a mean 6 days, and analgesia and muscle relaxation lasted for a mean 19 days. Conclusion In post-radiosurgical neck contracture, botulinum toxin injection is a simple and easy procedure able to improve neck motion and reduce neck pain in head-and-neck cancer patients. A phase-II prospective study to determine injection sites and dosage should help bear out these preliminary findings.

Resume Introduction La reconstruction de la pointe du nez est une chirurgie tres delicate car elle doit reconstruire trois plans anatomiques differents : le plan muqueux, le plan cartilagineux et le plan cutane avec des imperatifs fonctionnels et esthetiques. Chez les patients brules, elle est d’autant plus difficile que les sites donneurs sont reduits et la qualite de la peau mediocre. Elle fait le plus souvent appel a des lambeaux locoregionaux ou preleves a distance. Nous rapportons notre experience de la reconstruction des ailes du nez grâce a la technique de remodelage du tissu cicatriciel sous-cutane au moyen d’un lambeau d’enroulement greffe. Patients et methodes Etude retrospective de sept patients, cinq femmes et deux hommes, d’âge moyen 30 ans, ayant beneficie de cette technique entre 1991 et 2006. Six patients avaient des sequelles de brulure et une patiente presentait une hemiagenesie faciale congenitale. Resultats La reconstruction a ete bilaterale chez tous les patients brules ( n = 6). La greffe de peau a ete prelevee au niveau de la face interne de l’avant-bras ( n = 4), en retro-auriculaire ( n = 2) et dans le pli inguinal ( n = 1). Un patient a necessite une reprise chirurgicale pour une escarre de la pointe du nez. Les patients ont ete suivis en moyenne pendant cinq ans (de six mois a 15 ans), aucune obstruction nasale n’a ete rapportee. Conclusion Le lambeau dermique enroule greffe pour reconstruire les ailes du nez est une technique simple et fiable, realisable avec du tissu cicatriciel. Le comblement de la perte de substance et la reconstruction des plans anatomiques du nez se font en un seul temps operatoire. Les resultats fonctionnels et esthetiques sont satisfaisants. Cette technique est bien adaptee aux cas de sequelles de brulures, elle peut egalement etre utilisee en cas d’hemiagenesie narinaire mais aussi de mutilations par morsures ou accidents de la voie publique.

Background Exophthalmos is a protrusion of the eyeball due to an increase in orbital contents in a normal bony orbit. Exorbitism is a protrusion of the eyeball due to a decrease in capacity of the orbital container, with a normal orbital content volume such as seen in a congenital form termed nonsyndromic exorbitism. High myopia can enhance proptosis. The purpose of this study was to provide values for orbital measurements from computed tomography and to suggest computed tomography criteria for nonsyndromic exorbitism. Methods Seventy-three computed tomography scans were collected (57 of Graves' ophthalmopathy and 16 of nonsyndromic exorbitism). Thirty-two scans from nonproptotic patients constituted a control series. Nine measurements and two indexes, performed on a reference axial computed tomography slice transecting the neuro-ocular plane, were obtained from each scan. Results The angle between the sagittal axis and the lateral orbital wall, as well as the width of the ethmoid bone (midinterorbital distance), was found to be more open in the nonsyndromic exorbitism population. A lateral orbital wall angle greater than or equal to 42 degrees and a midinterorbital distance greater than 30 mm were chosen as cutpoints. The association of these two criteria allowed the authors to obtain a sensitivity of 62 percent, a specificity of 78 percent, a positive predictive value of 80 percent, and a negative predictive value of 86 percent for nonsyndromic exorbitism. Conclusions The different mechanisms of globe protrusion have to be taken into account before an orbital expansion/decompression procedure is planned. Only a preoperative morphological analysis of the orbital shape permits a precise analysis of the relative position of the ocular globe and orbital structures, in addition to clinical examination.

Background: Graves’ ophthalmopathy affects orbital contents and eyelids. Protrusion of the globe can also be the result of myopia and/or an abnormal orbit shape, which is responsible for nonsyndromic exorbitism. It is necessary to recognize these components of protrusion to treat patients adequately. The authors present a surgical strategy for treatment of the orbit and lids. Methods: Files of 84 patients treated from 1984 to 2003 were retrospectively reviewed. Sixty-eight patients were operated on for Graves’ ophthalmopathy and 16 for nonsyndromic exorbitism with or without myopia. The surgical strategy was adapted to the degree of emergency, the age of the patient, and the shape of the orbit measured using computed tomography. The accepted standard of treatment was a coronal approach with a two-wall expansion, with or without bone grafts, especially in cases of associated nonsyndromic exorbitism, with or without complementary ablation of the external part of the orbital floor. Lid surgery was performed at a second stage. Results: Nonsyndromic exorbitism patients were successfully treated in one step. No diplopia was present either preoperatively or postoperatively. In contrast, the treatment of the Graves’ ophthalmopathy patients justified one to three orbital expansion procedures per patient and/or one to seven procedures for levator palpebrae lengthening or reinsertion. Forty-three percent of preexisting diplopias were improved by the surgery. The overall postoperative incidence of de novo diplopia was 19 percent. In the Graves’ ophthalmopathy series, three patients (5 percent) finally underwent strabismus surgery. No major complication occurred. Conclusions: The treatment of Graves’ ophthalmopathy is challenging. A graded approach is justified. Patients have to be informed that several procedures may be necessary and, in cases of nonsyndromic exorbitism or myopia, that facial modifications might occur.

European Annals of Otorhinolaryngology, Head and Neck Diseases - Vol. 133 - N° 1 - p. 71-72

The purpose of this study was to report our experience with the free thoracodorsal artery perforator flap for reconstruction of the oropharynx and soft palate in head and neck cancer using a retrospective review of the medical charts of all patients undergoing oropharyngeal reconstruction by free thoracodorsal artery perforator flap during the same procedure as cancer resection between January 2011 and April 2013. Evaluation of speech, feeding and the presence of nasal emissions was performed 6 months after treatment in accordance with the Declaration of Helsinki. Nine patients were evaluated. Clear understanding of the patient was reported by the family and the examiner for seven patients, while understanding difficulties were reported for two patients (1 case of flap dehiscence and 1 technical error of flap fixation). The results indicated that, due to its complex anatomy and function, reconstruction of the soft palate remains a delicate procedure. The free thoracodorsal artery perforator flap allows functional soft palate reconstruction, while limiting donor site morbidity.

The present study sought to describe clinical presentation in extranodal lymphoma of the head and neck (ELHN), with the aim of improving diagnostic management. Material and methods A single-center retrospective observational study was conducted over the period 2001–13. Age, gender, histologic type, location, type of clinical presentation, time interval between symptom onset and histologic diagnosis and presence of specific symptoms were recorded, as were the specialty of the physician initially consulted and of the physician taking the diagnostic sample. Results Sixty-seven cases of ELHN were diagnosed: 39 male and 28 female patients, with a median age of 68 years. B-cell lymphoma (84%) was more frequent than plasmacytoma (7%) or T-cell lymphoma (6%). Location was mainly palatine tonsil (28%), nasal fossa and sinus (19%), nasopharynx (14%) or parotid (13%). Revelation often involved a mass (33%), and only rarely any specific symptoms (9%). Time interval from symptom onset to diagnosis was short in aggressive lymphoma and longer in low-grade lymphoma (mean 4 and 10 months respectively). The physician initially consulted was an ENT specialist in 67% of cases, and an ENT specialist performed diagnostic sampling in 97% of cases. Conclusion ELHN is a rare pathology (5 cases per year in our department) of highly variable clinical presentation depending on location and histologic type. The ENT physician should be prepared for diagnosis regardless of anatomic location, so as to optimize diagnostic management.

Summary Subperiostal orbital hemorrhage is a rare condition. It usually occurs as a result of trauma or because of a vascular disorder. We present a case of subperiostal orbital hemorrhage induced by effort for vomiting. Case A 41-year-old pregnant patient (30 weeks of amenorrhea), with no prior history, was referred to the ENT emergency by her gynecologist for unilateral ptosis and proptosis secondary to efforts for vomiting. Clinical examination and CT scanner showed a subperiostal hematoma of the orbital roof. The hematoma resolved in ten days without sequels, under simple surveillance. Discussion Non-traumatic subperiostal orbital hemorrhage remains rare. Clinical examination and orbital CT scan allow making the diagnosis. If the optic nerve is not compressed, clinical surveillance during hematoma resorption is sufficient.

Summary Background Some studies have suggested that a lowprotein diet slows the deterioration of renal function in patients with chronic renal failure (CRF). The effects of a low-protein diet on renal function and growth, have not been assessed in a large, prospective randomised trial in children with CRF. Methods A 2-year prospective, stratified, and randomised multicentre study recruited 191 patients aged 2–18 years. After a run-in period of at least 6 months, patients were stratified into either a progressive or non-progressive category based on the change in creatinine clearance in this period. The patients were also stratified into three renal-disease categories and then randomly assigned to a control or diet group. In the diet group, the protein intake was the lowest, safe WHO recommendation-ie, 0·8–1·1 g/kg daily adjusted for age. All patients were advised to have a calorie intake of at least 70% of the WHO recommendations. Glomerular filtration rate (GFR) was measured every 2 months by creatinine clearance; dietary compliance was checked by urinary urea-nitrogen excretion and dietary diaries (weighing method). 112 patients completed an optional third year of the study. Findings The low-protein diet did not affect growth. However, there was no effect of diet on the mean decline in creatinine clearance over 2 years (diet vs control: progressive group −9·7 [SD 8·0] vs −10·7 [11·8] mL/min per 1·73m 2 ; non-progressive group −2·5 [7·5] vs −4·3 [10·0] mL/min per 1·73 m 2 ). Patients classified as having progressive disease were older and had a lower creatinine clearance and a higher blood pressure at randomisation, and had a greater decrease in creatinine clearance than non-progressive patients. On multivariate regression analysis proteinuria (partial R 2 =0·259) and systolic blood pressure (partial R 2 =0·087) were independent predictors of the change in GFR. Similar results were found after the study was extended for a third year. Interpretation A low-protein diet for 3 years did not affect the decrease in renal function in children with CRF. Proteinuria and blood pressure explain a large part of the variability of, and may be causally related to the decline in the GFR.

Subcutaneous emphysema is a rare and well-known complication of dental procedures. Many cases go unrecognized and resolve spontaneously, while others may require specific surgical management to prevent complications. We present a case of cervicofacial and mediastinal emphysema which occurred during a routine dental procedure and a review of the literature on differential diagnosis and management.

Skin grafts are commonly used in head and neck recon-struction surgery. Muscle flap coverage [1] or closure ofa flap harvesting site [2] (e.g., antebrachial radial flap)may require split-thickness autograft. Harvesting, however,involves considerable postoperative pain, and healing islong, often leaving an unsightly or pathological scar outsideof the head-and-neck region [3].Reducing the scars left by reconstruction surgery shouldbe a constant concern. It helps improve patients’ quality oflife. In this perspective, we here present a harvesting tech-nique for split-thickness skin graft from the scalp in headand neck surgery.The scalp is routinely used as a split-thickness skin graftdonor region in burn surgery [4]. It avoids leaving an extrascar, which is completely hidden and invisible once the hairgrows back.

But de la presentation Les fistules oesotracheales iatrogenes sur un terrain post-radique ne repondent pas a un traitement medical. Une fermeture chirurgicale en trois plans avec interposition d’un lambeau est toujours necessaire. Cette etude rapporte notre experience du lambeau supra-claviculaire pedicule dans la fermeture des fistules oesotracheales en terrain post-radique. Materiel et methodes Etude retrospective unicentrique des cas de fistules oesotracheales iatrogenes chez des patients laryngectomises en contexte de cicatrisation difficile apres radiotherapie. Resultats Deux patients, un homme et une femme de 58 et 66 ans, anciens alcoolo-tabagiques et laryngectomises totaux ont presente une fistule oesotracheale iatrogene dans les suites d’une dilatation oesophagienne compliquee et au cours de la pose d’une prothese phonatoire. Dans les deux cas la fermeture de la fistule a pu etre obtenue grâce a l’interposition d’un lambeau supra-claviculaire pedicule desepidermise entre l’œsophage et la trachee. La desepidermisation de la palette cutanee permet son enfouissement dans le mediastin. Conclusion La fermeture des fistules oesotracheales apres radiotherapie est complexe. La connaissance de differents lambeaux est indispensable surtout lorsque le muscle grand pectoral a deja ete utilise. Le lambeau supra-claviculaire pedicule merite d’etre reconnu dans cette indication. La technique de prelevement est simple, rapide. C’est un lambeau fiable dont la taille et la longueur peuvent facilement etre adapte a la perte de substance. Son point de rotation situe dans la region sus-claviculaire lui permet de descendre facilement dans le mediastin. La desepidermisation de la palette cutanee permet son enfouissement dans le mediastin. La morbidite au niveau du site donneur est tres faible. Il s’agit de la premiere description de l’utilisation de ce lambeau pedicule dans les fermetures de fistules oesotracheales.

But de la presentation La rehabilitation de la cavite buccale et de l’oropharynx apres exerese tumorale est souvent obtenue par l’utilisation de lambeaux libres. La rancon cicatricielle au niveau du site donneur doit etre prise en compte. Le lambeau antebrachial radial, le plus utilise, laisse une cicatrice visible et facilement exposee au regard. Le lambeau thoraco-dorsal perforant (TDAP) qui possede les memes qualites plastiques que le lambeau antebrachial permet d’obtenir une cicatrice camouflee dans le creux axillaire. Le but de cette etude est d’evaluer le resultat esthetique des sites donneurs de lambeaux libres antebrachial radial et thoraco-dorsal. Materiel et methodes Tous les dossiers des patients ayant beneficies d’une reconstruction par un lambeau libre antebrachial ou thoraco-dorsal entre janvier 2011 et decembre 2011 ont ete retrospectivement analyses. Le Patient and Observer Scar Assessment Scale (PSAS et OSAS) et le score de Vancouver ont ete utilises pour evaluer la qualite des cicatrices. Resultats Une reconstruction par un lambeau antebrachial radial a ete realisee dans 4 cas, par un lambeau TDAP dans 7 cas. Le score PSAS du groupe TDAP est significativement inferieur a celui du groupe antebrachial ( p = 0,03). Le score OSAS est plus eleve dans le groupe antebrachial (21,5 vs 14). Le score de Vancouver est significativement plus eleve pour les cicatrices du lambeau antebrachial que pour celle du TDAP, 8 versus 2,7 ( p = 0,005). Conclusion Cette etude est la premiere qui compare les cicatrices des sites donneurs de lambeau libre antebrachial et thoracodorsal. Elle demontre la faible rancon cicatricielle liee au prelevement d’un lambeau thoraco-dorsal perforant et la satisfaction des patients. Elle incite a discuter l’interet de ce lambeau lors de chaque reconstruction.

In 1988 the European Study for Nutritional Treatment of Children with Chronic Renal Failure started its multicentre randomized trial to investigate the influence of protein intake on the progression of renal failure. A total of 284 children had been registered. Of these 221 were accepted for the study. The data from 105 patients after 1 year of study are vailable for preliminary analysis. Fifty children were randomized for the diet group and 55 for the control group. Both groups were comparable concerning age, glomuerlar filtration rate (GFR) and height standard deviation score for chronological age at the start of the study period and the distribution of primary renal diseases and sex. Limits for protein and energy intake were set according to the safe levels and recommendations given by the World Health Oraganization. The compliance with dietary prescriptions as calculated from dietary diaries was good. A low-protein diet did not do any harm to the children with respect to length gain and weight gain. The progression of renal failure was minimal in the diet group (mean loss of GFR 3.6 ml/min per 1.73 m2 per year) as well as in the control group (2.3 ml/min per 1.73 m2 per year). The differences between the diet group and the control group were statistically not significant when either all patients or only subgroups of various primary renal diseases were analysed. When only patients with a good compliance were considered (documented by dietary diaries or by urea nitrogen excretion) the same results were obtained. In summary, reduction of protein intake was accepted by the majority of patients. There was no significant influence on growth, weight gain and progression of renal failure within the 1 st year of study.

But de la presentation Dans un service d’ORL, l’extravasation d’une chimiotherapie, d’une perfusion de metabolites ou de produits de contraste iode peut etre a l’origine d’une necrose cutanee au niveau du site de perfusion. L’atteinte tissulaire va dependre de la toxicite du produit, allant du simple inconfort a la necrose cutanee. Le but de cette etude est de rappeler l’importance du depistage et de la prise en charge en urgence des extravasations iatrogenes. Materiel et methodes Etude retrospective unicentrique de 2010 a 2013 de tous les cas d’extravasation iatrogene survenus dans l’hopital et pris en charge dans le service d’ORL habitue a la reconstruction en cancerologie. Le type de produit extravase, le delai de prise en charge et le type de traitement ont ete analyses. Resultats Dix patients ont subi une extravasation au niveau d’une chambre implantable (n = 4) ou d’un site peripherique (n = 6). Il s’agissait d’un produit vesicant (n = 5), d’un produit irritant (n = 2) ou d’un produit de contraste iode (n = 3). Le delai de prise en charge a ete de 15 jours en moyenne, variant de 1 h a 3 mois. Une surveillance a ete instauree chez 4 patients, dont 3 ayant eu une extravasation de produit iode. Un patient a beneficie d’une aspiration-lavage avec une canule de lipoaspiration de la zone de diffusion au serum physiologique isotonique sous anesthesie loco-regionale une heure apres un accident perfusionnel avec un vesicant permettant d’arreter l’evolution de la necrose cutanee. Les patients (n = 5) pris en charge tardivement ont necessite une chirurgie d’exerese avec reconstruction par lambeau local. L’obtention de marges saines a ete obtenue par de grandes excisions cutanees avec rancon cicatricielle. Un patient dont l’excision etait insuffisante a presente un effet recall lors de la poursuite de sa chimiotherapie. Conclusion Le diagnostic de l’extravasation doit etre precoce et la prise en charge urgente pour limiter la necrose, le syndrome de loges et les sequelles fonctionnelles. Une fois la gravite reconnue, le traitement chirurgical par aspiration-lavage permet l’elimination du toxique et la preservation du revetement cutane. Dans notre serie, seul un patient a beneficie d’une prise en charge optimale apres extravasation de produit vesicant ce qui a permis d’eviter l’extension de la necrose cutanee et l’apparition de complications fonctionnelles. En cas de necrose installee, les techniques de chirurgie plastique permettent une couverture cutanee au prix de sequelles esthetiques. Tout service d’ORL disposant d’une canule de lipoaspiration doit pouvoir assurer le traitement en urgence de ces accidents.

But de la presentation De nombreuses techniques ont ete proposees pour les reconstructions de l’oropharynx apres resection d’un cancer. Les qualites plastiques du lambeau antebrachial radial en font le lambeau de choix de ces reconstructions. L’exposition au regard du site de prelevement et la morbidite non negligeable a son niveau ont incite les chirurgiens a chercher des alternatives. Le lambeau anterolateral de cuisse (ALT) est utilise par de nombreuses equipes pour les reconstructions de l’oropharynx. Nous preferons utiliser le lambeau perforant thoraco-dorsal, dont le site donneur, autofermant, est camoufle dans le creux axillaire alors que la fermeture du site donneur de l’ALT doit faire appel a une greffe de peau lorsque la palette depasse 9 cm et la cicatrice est visible a la face anterieure de la cuisse. Le but de cette etude est de rapporter notre experience de l’utilisation du lambeau libre thoraco-dorsal perforant dans les reconstructions de l’oropharynx et du voile en cancerologie. Materiel et methodes Tous les dossiers des patients ayant beneficie d’une reconstruction de l’oropharynx par un lambeau libre thoraco-dorsal perforant dans le meme temps qu’une chirurgie d’exerese carcinologique entre janvier 2011 et avril 2013 ont ete retrospectivement analyses. L’evaluation de l’elocution, de l’alimentation, de la presence de fuites nasales a ete realisee 6 mois apres la fin du traitement. Resultats Neuf patients ont ete evalues. La comprehension se fait de facon claire par la famille et par l’examinateur chez 7 patients. Des difficultes de comprehension sont notees chez deux patients (1 decrochage du lambeau et 1 faute technique d’amarrage). Conclusion Le voile a une anatomie et une fonction complexes dont la reconstruction reste un challenge. Le lambeau thoracodorsal libre autorise des reconstructions velaires fonctionnelles tout en limitant la morbidite du site donneur. Il est une alternative au lambeau antebrachial et au lambeau anterolateral de cuisse.

Due to the complex anatomy of the head and neck, a wide range of pedicled or free flaps must be available to ensure optimal reconstruction of the various defects resulting from cancer surgery. The supraclavicular artery island flap is a fasciocutaneous flap harvested from the supraclavicular and deltoid regions. The blood supply of this flap is derived from the supraclavicular artery, a direct cutaneous branch of the transverse cervical artery in 93% of cases or the supraclavicular artery in 7% of cases. The supraclavicular artery is located in a triangle delineated by the posterior border of the sternocleidomastoid muscle medially, the external jugular vein posteriorly, and the median portion of the clavicle anteriorly. This pedicled flap is thin, malleable, and is easily and rapidly harvested with a reliable pedicle and minimal donor site morbidity. It can be used for one-step innervated reconstruction of many types of head and neck defects. It constitutes an alternative to local flaps, while providing equivalent functional results and must be an integral part of the cancer surgeon's therapeutic armamentarium.

Introduction Reconstruction of the oral cavity and oropharynx after tumour resection often involves the use of free flaps, but donor site morbidity must be taken into account. The radial forearm flap, the flap most commonly used in this setting, leaves a readily visible scar on an exposed region of the body. The thoracodorsal artery perforator flap (TDAP), which possesses the same plastic qualities as the radial forearm flap, leaves a scar that is hidden in the axilla. The purpose of this study was to evaluate the cosmetic results of radial forearm and thoracodorsal artery perforator free flap donor sites. Material and methods The medical charts of all patients undergoing reconstruction by a radial forearm or thoracodorsal artery perforator free flap between January 2011 and December 2011 were retrospectively reviewed. The Patient and Observer Scar Assessment Scales and the Vancouver Scar Scale were used to evaluate the quality of the scars. Results Reconstruction was performed by radial forearm flap in 4 cases and TDAP flap in 7 cases. The PSAS score was significantly lower in the TDAP group than in the radial forearm group (P = 0.03), and the OSAS score was higher in the radial forearm group (21.5 versus 14). The Vancouver Scar Scale was significantly higher for radial forearm flap scars than for TDAP scars (8 versus 2.7, P = 0.005). Conclusion This is the first study to compare radial forearm and thoracodorsal artery perforator free flap donor site scars. It demonstrates the minimal TDAP donor site morbidity and the high level of patient satisfaction.

Summary Introduction Surgical reconstruction of the nasal tip is a very delicate procedure, as it must rebuild three different anatomical planes: mucosa, cartilage and skin with functional and aesthetic requirements. This procedure is even more difficult in burns patients, due to more limited donor sites and poor skin quality. Numerous flap options are available to reconstruct defects of the tip of the nose. The authors report their experience of nasal alar reconstruction by a scar tissue remodelling technique using a rolled dermal flap with overlying full-thickness skin graft. Patients and methods The medical charts of seven patients (five women and two men with a mean age of 30) treated between 1991 and 2006 were retrospectively reviewed. Six patients presented sequelae of a facial burn and one patient had congenital facial hemiagenesis. Results Reconstruction was bilateral for all burns patients and unilateral for the patient with facial hemiagenesis. The skin graft was raised from the medial aspect of the forearm in four cases, the retroauricular region in two cases and the groin in one case. One patient required a second surgical procedure for necrosis of the nasal tip. No nasal obstruction was reported with a mean follow-up of five years (range: six months to 15 years). Conclusion The rolled dermal flap with overlying full-thickness skin graft is a simple and reliable procedure for reconstruction of the nasal alae. Filling of the nasal alae defect and reconstruction of all anatomical planes are achieved in a single surgical procedure. The aesthetic and functional results were satisfactory, with minimal scarring of the donor site. This technique is very suitable for the treatment of burn sequelae and can also be used to treat nasal hemiagenesis and nasal mutilation by biting or facial trauma.