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The ophthalmic artery arises from the internal carotid at the level of the carotid siphon; in 3.5-5% of the population, it arises from the middle meningeal artery, a branch of the internal maxillary artery, terminal of the external carotid artery. We report a rare case of bilateral malformation in a 28-year-old patient. Our study covers the possible dual origin of orbital blood vascularization. This variation in the anatomic distribution is important to know, particularly if embolization is intended as inadvertent occlusion of the ophthalmic artery, because it may lead to permanent loss of vision.

Granulocytic sarcoma rarely involves the orbit. It is the local proliferation of immature myeloid cells and occurs most often in patients suffering from myelodysplastic syndromes. We report a case of granulocytic sarcoma that revealed acute myeloid leukemia in a patient suffering from chronic myelomonocytic leukemia. At the time of diagnosis, the lesion involved the nasal fossae, the ethmoidal sinus, and the orbit, with subperiosteal tumoral infiltration toward the skin. The treatment involved surgery and radiotherapy. The patient died 3 months later of complications of the hematological disease. This observation is original for the occurrence of granulocytic sarcoma during chronic and well-known leukemia, the age of onset, and the fatal outcome in just a few weeks. In this observation, the ophthalmologist revealed the acute nature of the myelodysplastic syndrome.

Unlabelled: Amphicrine adenoma is an extremely rare tumor of the middle ear. We report three cases obtained over a twenty year period., The Aim of This Study: is to discuss our clinical cases and review the literature., Materials and Methods: Three cases of middle ear amphicrine tumour were reviewed., Results: During a 10 year period (1986-2006) three cases of middle ear amphicrine tumour were treated at our unit (2 male, 1 female). The presenting complaint was hearing loss in all 3 cases. Amphicrine adenoma is diagnosed by an immuno-histological examination of pathological specimens. Differential diagnosis can be difficult and one individual was initially treated as an adenocarcinoma by radiotherapy. This patient succumbed to cerebral mycosis two years post-radiotherapy. The other two patients have no evidence of recurrence eight and nine years post treatment., Conclusion: Historically, differential diagnosis between amphicrine adenoma and adenocarcinoma of the middle ear has been very difficult. Carcinoid tumour is considered to be a more agressive form of amphicrine adenoma. Tumour progression is through loco regional invasion. Complete excision by surgical management with long term follow up is the treatment of choice.

The incidence of benign paroxysmal positional vertigo (BPPV) of the horizontal and superior semicircular canals is much less than that of BPPV due to affection of the posterior semicircular canal. Their diagnosis is however much more difficult and still prone to controversies. The provocative manoeuvre of the BPPV of the horizontal canal (BPPV-HSC) is the manoeuvre of rotation of the head in dorsal position. A horizontal positional nystagmus is obtained. There are two forms of BPPV-HSC: the geotropic form and the ageotropic form. In the geotropic form, the liberatory manoeuvre is a "barbecue" rotation of 180 with 360 degrees towards the healthy side. In the ageotropic form, there is no universal liberatory manoeuvre. Moreover as some cases of neurological aetiology have been recognized, it is not appropriate to apply ineffective manoeuvres. The BPPV of the superior canal (BPV-SSC) is very rare. The provocative manoeuvre is the Dix and Hallpike's manoeuvre. It causes positional torsional and vertical nystagmus with an opposite direction to that obtained for a BPPV of the contra-lateral posterior canal. The liberatory manoeuvre is a Semont manoeuvre, which is identical to that we would make for a contra-lateral BPPV of the posterior canal.

We describe a case of laryngeal venous malformation, discovered by dysphonia. This malformation has a different histology and evolution compared to infant laryngeal hemangioma. The histological exam shows large and multiple vessels lined by regular endothelium. There is no spontaneous regression; this malformation can be stable or increase and induce a laryngeal obstruction. Although inconstant, a bluish colour, seen at endoscopy, suggests the presence of venous malformation. The diagnostic is confirmed by MRI, which shows local extension. We propose regular clinical and radiological supervision for asymptomatic venous malformations. Treatment is recommended only for symptomatic patients usually by laryngeal microsurgery or cervicotomy. Per cutaneous sclerosis is an interesting alternative therapy alone or prior to surgery. Regular follow-up is essential in order to detect frequent recurrences.

Unlabelled: Less than 150 cases of cerebro-spinal fluid leak with spontaneous defect of the roof of the temporal bone have been described in the international literature., The Aim of This Work: Is to define this pathology, to describe the clinical features, to suggest a diagnostic strategy, and to clarify the treatment method and the hypotheses on causation., Materials and Methods: This is a retrospective study of 3 cases., Results: At the first medical examination, the most common clinical feature is serous otitis media or otorrhea after myringotomy. Rhinorrhea is rarely pointed out by the patients but exists in our 3 observations. The diagnosis of cerebro-spinal fluid leak with spontaneous defect of the roof of the temporal bone needs; cerebro-spinal fluid leakage, absence of an otologic history or cranial trauma and a bony defect on CT scan. CT scan with millimeter slices is able to show the location and the size of the bony defect(s) of the roof of the temporal bone and often shows partial or total opacity of the middle ear cavities. MRI is able to show if this opacity exists in conjunction with meningeal hernia or cerebro-meningeal hernia. Surgical repair consists of placing an autologous graft over the bony defect by the middle fossa approach. The origin of a spontaneous defect of the temporal bone is discussed. We study the hypothesis in which arachnoïd granulations could be responsible for a temporal bone defect.

Unlabelled: Squamous cell skin carcinoma has a relatively low rate of metastasis (0.5 to 16%), but the prognosis of these metastases is poor (22% of survival at 5 years)., Patients and Methods: from a series of 243 patients, we studied 13 patients who were found initially to have metastases or who developed metastases later. Fifty-four percent (54%) of the patients presented initially with regional lymph node and parotid involvement in 54%., Results: All patients underwent surgery with removal of the skin cancer and a neck dissection. Radiotherapy was performed later in 92% of the cases. The 2 years survival rate was 62% and mean survival by Kaplan Meier curve was 47 months., Discussion: Poor criteria of these cutaneous tumors are defined: tumor size, histologic differentiation, perineural spread. Patients with severe criteria must have a neck dissection to control the first lymph node. Along the anatomic area of the cutaneous tumor, a parotidectomy, a submaxillary control or a neck dissection will be performed. Its involvement will be followed by a neck dissection. A comparative study of the literature is made. Poor prognostic criteria of these cutaneous tumors are defined, in addition to the initial management of the cervical and parotid lymph nodes.

Up until now, the questionnaires used to evaluate vertigo have been self-administered questionnaires that rate either symptoms and/or their consequences. In contrast, the European Evaluation of Vertigo scale (EEV) is a physician-administered questionnaire that only assesses symptoms of the vestibular syndrome: illusion of movement, duration of illusion, motion intolerance, neurovegetative signs, and instability. Twenty-six ear, nose, and throat (ENT) specialists participated in this validation study conducted among 123 patients suffering from different types of vertigo. The reliability, responsiveness and construct, convergent and discriminant validity of the EEV scale were assessed. Construct, convergent and discriminant validity was determined by comparing the scores on the EEV scale with those obtained using the following validated scales: patient diary and conventional scale designed by the DPHM, functional scale of the AAO-HNS, and SF-36 scale, a generic quality of life scale. With the exception of the "neurovegetative signs" item, the reliability of the EEV scale is good, particularly in terms of interrater reliability (r = 0.93 for the global score), and responsiveness is high (p < 0.01). EEV scale has good correlations with the items of patient diary, DPHM scale and "physical" dimensions of SF-36, from the first evaluation, whereas this scale has poor correlation at Day 0, with the items of AAO scale and the "psychological" dimensions of SF-36. These results confirm that EEV scale is exclusively a symptomatic scale and does not interfere with the psychism. The EEV scale is therefore a validated physician-administered questionnaire capable of monitoring the course of vertigo and of assessing the efficacy of anti-vertigo treatments.

Three questions are raised when a patient experiences sudden vertigo. Is it due to a disease of the vestibule? This would be suggested in case of a revolving nature of the vertigo, the presence of nystagmus and of vestibular ataxia. Are there associated otological (infection of the labyrinth, zoster neuritis) or neurological (ischemic vascular accidents of the cerebral trunk and of the cerebellum, cerebellar haemorrhage) signs? What is the evolution of the sudden vertigo? A single, isolated episode of vertigo will generally be related to vestibular neuritis. However, it may rather be a first episode of repeated vertigo, Ménière's disease, recurrent vertigo, migraine, or very rarely transitory ischemic accident.

The authors report the case of a 63 years old man who presented a voluminous exteriorized keratocyst of the jaw. We have first made a punction of the cyst in order to facilitate the operation. Anatomopathological examination of the liquid found epithelial cells. We collected the keratocyst by a non interrupting mandibulotomy via cervical incision.

A retrospective oncological study was performed in 25 woodworkers, in whom an adenocarcinoma of the ethmoid sinuses was discovered between March 1985 and December 1993. All patients were males with a mean age of 57 years, and a mean duration of wood dust exposure of 24 years. Signs of nasal obstruction, drainage, and discomfort were present in all cases. Ophthalmological findings were a poor prognosis indicator. It was possible to precisely evaluate treatment and outcome in 23 cases. The majority of tumors were classified as T3 or T4 (72%), with extension beyond the ethmoid sinuses; all were in contact with the roof of the ethmoidal sinuses. Extension was predominantly into the orbital and intracranial cavities as compared with extension posteriorly or into the maxillary sinuses. Treatment was identical in the 25 patients: a) combined surgery including a paranasal and a neurosurgical approach, b) postoperative radiotherapy. Results were expressed in terms of morbidity related to surgery and the oncologic outcome. Operative morbidity and mortality were substantially reduced with reconstruction of the roof of the ethmoidal sinuses. Meticulous excision, in addition to postoperative radiotherapy, resulted in a decreased rate of local recurrence (26%). On the other hand, metastasis were encountered more frequently (30%). Radiotherapy was insufficient when macroscopic excision was incomplete. Chemotherapy was used as palliative treatment in the event of a recurrence and/or metastases. Survival rate was 68% at 3 years, and 48% at 5 years. Most complications and recurrences arose within the first two years. Exophthalmos, intracranial extension, incompleteremoval, and extensive class T4 tumors were associated with a poor prognosis. Optimal therapy for malignant tumors of the ethmoid sinuses requires combined transfacial and neurosurgical approaches that allow precise assessment of tumor extension and adequate excision, yielding an improved oncologic outcome. Followed by radiotherapy, this association can result in a remission. Patient prognosis depends essentially on management of the initial lesion.

Since 1985, we have been using the so-called "hammock" technique in myringoplasty through the retro-auricular approach, with a temporal fascia graft positioned under what is left of the tympanum. The main feature of this technique lies in the creation of a cephaled tympano-meatal flap by a partial disinsertion of 4 to 5 millimetres of the cephalad part of the Gerlach annular labrurm, taking care to leave 2 millimetres of the labrum attached above the junction of the ephalad wall and the lower wall of the external auditory canal (anterior lower anchoring point). At the end of the operation, the graft is fixed both to the cephalad and to the caudad wall of the bony-external auditory canal like a hammock. This technique makes it possible to verify systematically the tympanic opening of the Eustachian tube. The use of biological glue is desirable, but not essential. The graft is stable enough for the implantation of Politzer's manoeuvre as from the seventh day and for Valsalva's manoeuvre from then on. Out of 213 operation, including all kinds of pathologies, 98% of good results were obtained as from the end of the first month, and 94.6% after three months.

Enlarging tracheoesophageal fistula after tracheoesophageal prosthesis for voice rehabilitation remains a major challenge. The authors analyze the results of treatment of 15 severe enlarging tracheoesophageal fistulas among 28 cases (52%) of tracheoesophageal voice rehabilitation which occurred during a 4 years period of time. Among these 15 cases, a spontaneous closure occurred in 3 cases (20%), a two layers closure was performed in 4 cases (26%) and a closure using a tracheal ascension associated with the design of a new tracheostoma was performed on 8 cases (53%). The authors describe the surgical technique and discussed the advantages of surch technique.

A disorder of the internal ear of unknown origin, Menière's disease is not characterised by vertigo but rather by the associated auditory symptoms and a chronic course. The first differential diagnosis is the acoustic neurinoma. Study of auditory evoked potentials, which is reliable and inexpensive, can preclude the use of more expensive imaging techniques. Menière's disease can be invalidating in patients who are often young and active. Treatment remains symptomatic and empiric. Destructive surgery can be a solution if it respects audition. Overall management remains the basis of treatment.

After a review of the literature concerning oncogenes expression of in head and neck carcinomas, the authors studied RAN extraction, in vitro transduction and two dimensional analysis of oncoproteins in head and neck carcinomas. The results between the tumoral tissue and normal tissue were compared significantly more oncoproteins spots were found in the tumoral tissue analysis.

Tumors of the amygdaline region were up until now most often treated by transmandibular buccopharyngectomy (TMBP) with a systematic sacrifice of the mandibular angle. This exercise justified by wide carcinological imperatives, a larger surgical facility and simple immediate postoperative follow-up, in fact systematically shows a substantial esthetic and functional prejudice. This principle was reinforced by the occurrence of osteitis during the first attempts of osseous reconstruction using steel wires opposite the mandibular angle (Dargent, Charachon, 1963). In 1989, Gehanno and Beauvillain published a mandibular conservation technique by vertical paramedian osteotomy, right in front of the mental nerve, shifted from the future field of radiation, with osteosynthesis by titanium plates. This technique appeals to us because it is easy to use, reliable and carcinologically safe. We have currently adopted it with satisfaction for 8 of our patients over an 18-month period, without any case of osteitis and with both good esthetic and functional results.

We report the case of a 78 year old man with unilateral persistent headache and associated bilateral kerato-conjunctivitis and minor skin lesions. Chronic ethmoiditis was diagnosed on a CT scan, and endoscopically controlled endonasal ethmoidal biopsy gave the diagnosis of sarcoid and hence the treatment. A nodular type isolated pulmonary lesion, atypical for sarcoidosis, also disappeared on steroid therapy. A review of the literature showed this to be an exceptionally rare form of the disease.

The authors describe their septoplasty technique of performing an extramucosal dissection with excision, revision and replacement of the cartilaginous septum during difficult rhinoplasties. They analyse the main septal deformations which may benefit from this technique and the functional and esthetic results.

Sudden deafness is a medical emergency, for which etiopathology is ill-known and no therapeutic consensus exists. This study is aimed at demonstrating that a greater audiometric gain can be achieved if trimetazidine, a major cellular anti-ischemia agent, is associated with hemodilution, than when the treatment is based on hemodilution only. 42 patients suffering from sudden deafness were all treated with hemodilution before their 7th day of deafness, half of them being given 3 tablets of trimetazidine daily in addition and the other half placebo, during one month. The results of this double-blind trial demonstrate an additional audiometric gain of 10% in the trimetazidine group for all frequencies, as well as a higher percentage of total recovery, ie. 63% vs. 47% in the placebo group. No particular sensitivity to treatment was noted according to the shape of the audiometric curve or in the case of initial cophosis, known to be of poor prognosis. The statistic significance was not established due to the small number of cases. The association of trimetazidine and hemodilution therefore seems to be an interesting therapeutic approach for sudden deafness, owing to the clinically appreciable audiometric improvement we have noted.

A typical case of naso-orbital-cerebral mucormycosis is described. This rare but serious disease mainly occurs in fragile patients, notably diabetics or those undergoing an immunosuppressant treatment. The cases recorded are therefore increasingly frequent. Mucorales, normally saprophytic, germinate in the nasal cavities due to an infection and then colonize the sinuses, the orbit, followed by the meninges. The diagnosis must be made before meningeal impairment when faced with a peri-orbital edema, the beginning of exophtalmy or oculomotor paralysis in high-risk patients with sinusal opacity. The diagnosis is based on the histology and the mucology which must be directed by the clinician: indeed, the histology of the naso-sinusal mucosa samples must be performed using special stains. The mycological samples must also be taken from special environments. Once the diagnosis is confirmed, the required treatment with high doses of intravenous Amphotericine B must be administered immediately, otherwise the evolution is fatal.

The authors reemploy the technique using the temporal muscle to fill in large surgical cavities after tumoral surgery of the middle 1/3 of the face. The purpose of this technique is to prevent crust formation after radiotherapy, and to improve esthetic results by preventing further cutaneous retraction. They expose their own technique, the results and the indications from 8 cases.

A technique of jet ventilation under general anesthesia (Alfaterinse suxamethonium) was used in 67 patients, in 55 cases for multiple endoscopic examinations in a single stage, usually laryngoscopy in suspension followed by oesophagoscopy, and in 12 cases, for an operation on the larynx. Arterial gasometry (PaO2 and PaCO2) proved the efficacy of the method, the major risk remaining, in the opinion of the authors, the possibility of excessive pressure which may be avoided by strict supervision.

Rendu-Osler disease is an hereditary disease due to a predominantly antosomic heredity. The statistics given for 50 cases include 27 males 7 p. 100 of which had no familial antecedents. Clinically, Rendu-Osler disease begins in adulthood (44 p. 100) and often in late adulthood. In fact, it does not become really severe until about the age of 50 or 60. Epistaxis is the most frequent accident and proves fatal in more than 10 p. 100 of cases. Treatment of the nasal symptoms, whether this involves surgical excision followed by grafting or plesiocurietherapy using irridium wires, is very disappointing. The future alone will prove whether embolization gives more permanent results.

A right and left comparative study of the venous drainage of the lateral trapezius muscle musculocutaneous flap was performed on 16 cadavers. The variability of this drainage explains the precautions required in the use of this flap.

The usual landmarks of thyroid surgery are often altered with a goiter. The surrounding tissue may also be subject to variation. Different anomalies the surgeon may encounter are presented along with their management: the recurrent nerve, the external laryngeal nerve, the parathyroids and an intrathoracic goiter. Each case of thyroid surgery must be considered individually, and the ENT surgeon must devote particular attention to assure perfect postoperative vocal cord function.

The authors report the case of a patient with a glomus jugulare tumor. After embolization of the external carotid artery branches feeding the tumor, a complete removal had been performed by a combined otoneurological approach. Although clearly defined and cleavable at the jugulare foramen, the chemodectoma had invasive characteristics in its intrapetrous extension, indicative post operative radiotherapy. In addition a review of publications support preoperative embolization and otoneurosurgical cooperation.

In numerous chronic osteitic and diffuse cholesteatomatous chronic otitis, the surgeon is obliged to form a Transmeatal partial or radical cavity usually with considerable mastoidectomy.

Some chronic otites result in local or diffuse attico-antral osseous outgrowths. These may complicate all sorts of chronic otites: cholesteatomatous or otherwise, suppurative or merely inflammatory, with the tympanum open or closed. They should be distinguisged from tympanosclerosis and condensation or osseous eburnation lesions. They seem to result from post-inflammatory irritation causing metaplastic bone growth or from an exostosis. The key to their diagnosis lies in radio-tomography. From the surgical point of view, diffuse attico-antral forms are particularly dangerous and deadly. It is essential that the kopho-surgeon should be aware of their existence which, as far as we know, does not seem to have been noted so far.

Vertigo results from sensory conflicts that are usually intralabyrinthine or between two labyrinths. Symptomatic treatments rests on the reduction of these conflicts by vestibuloplegic drugs. However, this treatment should not last for more than 48 or 72 hours since in established vestibular lesions central compensation demands that the centres be informed. The use of sedative drugs in vertigo, therefore, should be reduced, and vestibular rehabilitation is recommended in most cases. Only Meniere's disease escapes this rule, being a self-limited process.

The authors report their experience treating nine patients with swallowing disorders following partial surgery of the laryngo-pharynx. GAX collagen (Phonagel), resistant to collagenase was injected into the laryngeal structures to protect the trachea, yielding a satisfactory long term result. A description of the injection technique is given particularly with functional reconstructive laryngectomies and hemipharyngolaryngectomies. The results concerning functional improvement and weight gain are evaluated over a five month period.

A case of giant cell tumor of the temporal bone is reported. The surgical difficulties encountered in this case are presented and therapeutic modalities for this tumor, consisting of radical surgery and post operatoire radiotherapy, one defined and discussed. Comments are made concerning this rare tumor location, its occurrence in young adults, and difficulties in establishing a histologic diagnosis.

The authors begin by recalling the various tumoral conditions responsible for severe epistaxis. They differentiate between: angiomas and pseudo-tumoral angiomatous formations, vascular or so-called vascular tumours and hypervascularized tumours. In an emergency, immediate tamponage is essential. Treatment is also preventive: a gentle clinical examination and biopsies in the operating theatre. Particular stress should be laid on the contribution of super-selective arteriography which enables embolization to be carried out during the investigation. Embolization is particularly advocated, notably in cases of naso-pharyngeal fibroma, when there is a tumoral projection obstructing the pterygo-maxillary fossa or when there is considerable vascularization stemming from a branch of the external carotid other than the internal maxillary. Whatever the situation, any embolization, if it is to be permanently effective should be followed within 48 to 72 hours by surgical excision.

Epistaxis of carotid origin usually calls for adventurous and complicated techniques such as trapping, embolization or releasable balloons. But there is an O.-R.-L. technique which is no less effective: the direct rhino-sinusal approach to the sphenoidal sinus followed by tenting or occlusion through the fascia lata. This tamponage, when applied very close to the source of the bleeding, has proved very effective and only cuts off the carotid axis progressively and is generally well-tolerated. To set against theoretically possible risks of extensive thrombosis are the indisputable practical advantages. In particular, any O.-R.-L. practitioner well versed in surgery of the sinuses can follow this procedure. Several cases are described.

With the advent of modern otology, cophosurgeons anxious to compare their results soon became aware of the need for a "T.N.M" type of classification for the ear. The classification described here by the authors is, in principle, a classification of the "T.N.M" type: that is, a purely descriptive classification without prognostic, pathogenetic or therapeutic pretensions. This "O.P.A.C." classification is based on a description of 4 main characteristics: 1) the existence and characteristics of potential otorrhoea, described under the letter C; 2) the characteristics of potential perforation of the tympanum, described under the letter P; 3) the appearance of the middle ear, excluding the ossicular chain, described under the letter A; 4) the condition of the ossicular chain when the surgeon has completed his exploration of the lesions, described under the letter C. Two years experience seems to have proved the convenience and usefulness of this purely clinical classification, providing otologists with a common language. While they are aware of the objections and criticisms to which it may give rise, the authors hope, on time, to improve in this classification.

A patient presented with a facial nerve neurinoma of unusual size and which gave particularly clear radiological images. The curious feature of this observation is that there was no pre-operative facial paralysis as happens in about 15 p. 100 of cases.

All the methods available to O.-R.-L. practitioners for the treatment of epistaxis in Rendu-Osler disease are reviewed. In an emergency, gentleness is essential. Over the long term, procrastination for as long as possible is advisable. Super-selective arteriography and embolization are of great value in an emergency and can give some good long-term results. In fact, there is not one exclusive curative therapy. Estrogenotherapy has its advocates. Saunder's dermoplasty gives variable results, but these can be improved upon if a broad access route is used and dermoplasty extended to above and behind the nasal fossae. Because of its aggressive nature, irradiation must be kept as a last resort.

Epistaxis due to rupture of the carotid, usually occurs as a result of cranial or closed cranio-facial traumatism. Heamorrhage is secondary to the formation of post-traumatic arterial aneurysms or arterio-venous fistulas. Frequently, the lesion is along the intra-cavernous pathway of the internal carotid. Rupture of a spontaneous arterial aneurysm in the sphenoidal sinus is, however, extremely rare. Carotid arteriography is the main method of investigation, and this method alone is capable of detecting the carotid lesion. In addition to obvious cases, it should be requested in cases of severe, copious and recurrent epistaxis when interrogation of the patient reveals the merest hint of trauma, often a long time previously. Immediate treatment consists of anterior bilateral and naso-pharyngeal tampnage. This allows enough time for arteriography to be carried out under the most favourable conditions and also testing for carotid substitution. In order to ensure permanent thrombosis of the aneurysmal pocket or the arteriovenous fistula, most methods resolve themselves into occlusion of the carotid axis. Cervical ligature of the carotid on its own, and isolated trapping have given way to techniques employing either a combination of trapping and embolization, or the placing of a balloon probe without trapping. At present, Serbinenko is advocating using balloons released when arteriography is carried out, obliterating the fistula and left in position permanently. Finally, there is the method by which the sphenoidal sinus is approached para-lateronasally after ethmoidectomy: this is an effective method which is much less incursive than the endo-cranial approach.

Two groups of patients were treated by plesiocurietherapy. The first group of 17 patients received only one exposure to radium (between 1949 and 1960). The second group received one or more doses of irridium 192 (between 1960 and 1973). The average period for stabilization of the disease was 13,2 months with radium and 20,4 months with irridium. Unfortunately, this does not give a permanent cure and, for irridium 192, the percentage of successes is only 30 p. 100 after 5 years. Logically, radiotherapy with irridium 192 should only be used when other methods have failed. The progressive accumulation of radio-lesions may, in fact, make the use of other techniques impossible.