Search

Reconstruction of the oropharynx and the hypopharynx is difficult due to their wide diameters. We report eight cases of circumferential pharyngolaryngectomies for epidermoid carcinomas of the hypopharynx extended to the oropharynx and classified T4. Reconstruction was performed with a U-shaped free jejunal transplantation. This specific technique consists of a side to side anastomosis between two loops of jejunum. It facilitates reconstruction at the level of the oropharynx and diminishes postoperative complications.

Reconstruction of the oro and hypopharynx has specific difficulties due to their wide diameters. Seven patients underwent reconstruction with a free U-shaped jejunal transplant, after circular pharyngolaryngectomy for hypopharyngeal cancer invading the oropharynx. This transplant included a side-to-side anastomosis between the two limbs of the jejunal loop. This transplant allowed reconstruction of the upper digestive tract after wide carcinologic resection of the pharynx. The U-shaped jejunal transplant facilitated the upper anastomosis, especially at the upper part where the resection involved the oropharynx. It formed a reservoir behind the tongue, and avoided nasal reflux. The best indications are large resections involving the oropharynx.

A series of 23 patients with sphenoid disease were seen between 1992 and 1997. The most common symptom was headache. This headache was found to be nonspecific. Cranial nerve abnormalities were found in two patients. The different types of radiolographic images were analyzed, and compared with the surgical diagnosis. Twenty-one patients underwent surgical exploration by intranasal endoscopic sphenoidotomy. This approach allowed drainage and inspection of the sinus.

The histological examination of the salivary gland tumors is a very important step in the diagnostic approach of the lesions, on which depends the success of therapeutic outcome. Some surprises may occur; four examples were reported. In one case the lesion was not a tumor but a tuberculous lymphadenitis; another showed a Destombes Rosai Dorfman syndrome. Two other cases were found to be unusual tumors: a carcinosarcoma of the submandibular gland and a metastasis of a Merkel carcinoma in the submandibular gland.

Among a series of 520 parotidectomies performed between 1975 and 1995, we observed 88 cases of malignancy (17%). For this study, we excluded skin cancers which had invaded the parotid and glandular metastases of squamous cell carcinoma, malignant melanoma or kidney cancers, retaining only tumors with a glandular origin and lymphomas. Thus defined, our series comprised 60 patients, i.e. 12% of the operated parodids (31 confirmed cancers, 18 tumors with intermediary malignancy, including several in which the pathology report confirmed malignancy, and 11 lymphomas). We examined therapeutic management by histology and compared the outcomes. Relation with the facial nerve are discussed. Prognosis depends on histology, tumor stage and treatment.

One hundred and ninety seven patients with cancer of the hypopharynx underwent after circular resection, reconstruction with a free jejunal graft. The quality of free jejunal grafts is controlled by many investigations: clinical examination, radiography, electromyography, fibroscopy with biopsy. These investigations show that technically jejunal grafts must be short and linear to give the best functional results. Average resumption of oral intake was 14 days. Oral feeding was possible in 92% of cases. The free jejunal grafts with microsurgery are one of the more reliable procedures for reconstruction of pharynx and cervical esophagus after resection for cancer. (2 post-operative deaths and 8 grafts necrosis on 197 cases). The cumulative survival rate of 5 years was 35% for free jejunal graft. Survival depends on selection of the patients for local and nodes invasion. The quality of survival has improved. This operation must be reserved for the hypopharyngeal cancers which need a circular resection and do not invade the esophagus. The surgery is performed for a curative aim. The distant follow up of the patients is imperative: consultation every four months and then every six months: clinical examination, endoscopic, E.N.T., bronchial, and esophageal investigation. Chemotherapy and radiotherapy have specific indications.

Second or more surgical procedures on parotid are usually difficult and may induce injury on the facial nerve. The authors report their experience about 42 patients. The choice between a total parotidectomy or a surgical excision of a tumor depends on the number of surgical procedure, the type of initial procedure and the histological type of the tumor. Second surgical procedures for a wrong initial diagnosis (11 cases) were always a total parotidectomy with facial nerve preservation. The risk of a partial or total facial palsy is higher after several recurrences (3 of 8 cases). The facial nerve had to be resected in 3 of 9 cases of malignant tumors recurrences. The initial treatment of a tumor of the parotid must be radical so it can prevent for further surgical procedures and then avoid a facial nerve injury.

This study compared the results of the CT scan of the paranasal sinuses in nasal polyposis patients before and after a topical vasoconstrictor application on the nasal mucosa. No change have been observed either on the maxillary and ethmoidal sinuses, or the middle meatus. On the other hand, an important retraction was observed on the nasal mucosa, in particular on the inferior turbinate. Then, the application of a topical vasoconstrictor on the nasal mucosa does not seem necessary in order to explore the sinuses in patients with nasal polyposis.

Salvage oesophagoplasty using a free jejunal transplant is the ultimate reconstruction possible after repeated failures using the classic procedures of oesophagoplasty. The free jejunal transplant appears to be the best choice. Twenty-five free jejunal transplants were performed by the same surgeon for such reconstructions including 13 cases involving benign lesions and 12 cases of cancer. There were no post-operative death and none of the transplantations was a complete failure although three cases of stenosis and fistulization occurred. Several recommendations can be made: save the existing digestive tract, redissect the residual digestive plasty and pull it up. The residual digestive flap can be examined by opacification or endoscopically in order to evaluate its length. An arteriography of the pediculated plasty gives information on its vascularization. A free jejunal graft can safely cover 25 to 30 cm. When possible, residual plasties should be positioned subcutaneously. The reconstruction of the cervico-thoracic oesophagus usually requires a vascular bypass with a saphene graft. In difficult cases, it may be necessary to remove a part of the sternal manubrium and the head of the clavicular bone in order to avoid compressing the jejunal graft. When the length of the reconstruction is greater than 30 cm, a long jejunal transplant with two pedicules (1 pedicule revascularized from the cervical vessels and the other pedicule from the internal thoracic vessels) is needed. An alternative technique would be a free antebrachial flap (six cases operated with two post-operative deaths at 6 weeks and two fistulas).(ABSTRACT TRUNCATED AT 250 WORDS)

Cancers of the posterior wall of the oro or hypopharynx are rare and do not invade the larynx or the oesophageal orifice. Previously, these cancers were treated with radiotherapy alone, but since 1981 new techniques in reconstruction surgery have allowed a surgical approach. Cancerological non-mutilating exeresis is possible, but reconstruction is difficult since the flap must be very thin to allow normal food intake. In addition, flap reliability is extremely important due to the gravity of cervical salivary fistulation. We treated 15 patients with a lesion of the posterior wall of the pharynx using posterior pharyngectomy and reconstruction with a free antebrachial transplant which was revascularized and reinnervated. In two cases, the operation was performed in patients who had had previous radiotherapy. A branch of the external carotid and the internal jugular vein were used for vascular microanastomoses and reinnervation was obtained using the superficial cervical plexus. The transplant was placed over the prevertebral aponevrosis and sutured to the remaining pharyngeal mucosa. One postoperative death due to heart disease occurred at D + 11. All reconstructions were successful and two salivary fistulas on irradiated tissue closed spontaneously. Postoperative radiotherapy was performed in 11 cases (50-65 Gy) and was well tolerated. These results demonstrate that a highly flexible and thin free forearm transplant is perfectly adapted to reconstruction after posterior pharyngectomy. It is more reliable than local pediculated flaps.

Second or more surgical procedures on parotid are usually difficult and may induce injury on the facial nerve. The authors report their experience about 42 patients. The choice between a total parotidectomy or a surgical excision of a tumor depends of the number of surgical procedure, the type of initial procedure and the histological type of the tumor. Second surgical procedures for a wrong initial histological diagnosis (11 cases) were always a total parotidectomy with facial nerve preservation. The risk of a partial or total facial palsy is higher after several recurrences (3 of 8 cases). The facial nerve had to be resected in 3 of 9 cases of malignant tumors recurrences. The initial treatment of a tumor of the parotid must be radical so it can prevent for further surgical procedures and then avoid a facial nerve injury.

Twelve patients with nasal polyposis were examined with magnetic resonance imaging (MRI) prior to surgical ethmoidectomies (20 ethmoidectomies). MRI signal was analyzed in correlation with surgical findings in order to define the semiology of nasal and sinuses polyps. One of the most important point of this semiology is based on the analysis of sequences after administration of gadolinium. MRI seems an interesting method for analysing the extension of nasal polyposis and could be useful for ENT surgeons before an endoscopic nasal surgery.

The aim of this study was to define the most interesting parameters useful for a clinical application of acoustic distortion products (mainly, F1 and F2 primaries frequencies and levels). The most interesting F1 and F2 primaries level in order to separate subjects with a normally-hearing function and patients with a sensorineural hearing loss is 50 dBHL. This result can be explained by some physiological properties of cochlear mechanisms.

The authors present their experience concerning combined transfacial and neurosurgical procedures in the treatment of carcinomas of the ethmoid sinuses. 109 ethmoid-spheno-orbital tumors were treated at our department from 1982 to 1990: 85 were located into the ethmoidal and/or sphenoidal sinuses; 78 of these were malignant. Among the 65 ethmoidal carcinomas which were operated through a combined route, 48 underwent an induction chemotherapy and 19 a post-operative radiotherapy. The surgical technique is detailed, mostly the intra-cranial approach and the reconstruction of the cranial basis. Clinical results, and particularly the actuarial survival rates are discussed. The 5-year actuarial survival rate is 40% for all first hand ethmoidal adenocarcinomas. The figure reaches 52% for the patients without intra-cranial extension. At last, the 5-year actuarial survival rate is 100% for patients having a complete clinical response to induction chemotherapy.

The free neurovascular antebrachial transplant was described by Yang-Guofan in 1978. In 1981, we brought the description of this free transplant to Europe. Forty-three antebrachial grafts were made to reconstruct the cervicocephalic extremity. We had various indications: floor of the mouth and base of the tongue: 18 cases, facial structures: 7 cases, posterior wall of the pharynx: 9 cases, rescue surgery for esophagoplasty: 6 cases, mandible: 2 cases (using a bone rod taken from the radius), internal aspect of the cheek: 1 case. All grafts were revascularized. In 41 cases, the indications were carcinological, the last 2 cases being benign lesions. The early postoperative mortality included 1 case, not related to the nature of the operation (neoplasm). There was no failure of free transplants. Surveillance was ensured every half-hour during 12 hours, then every 3 hours. Discriminating sensation was recovered in 39 of 43 cases. Mandibular bone reconstructions were knit at the 3rd month. The main disadvantage of removing this graft is esthetic, as it leaves a considerable scar on the forearm. The free antebrachial transplant provides an effective solution to the reconstructions of the cervicocephalic extremity, when a narrow, thin, supple, reinnervated, compound transplant is needed.

Four hundred and thirty-two patients with a carcinoma of the true vocal cord, treated with a partial laryngectomy from 1972 through 1984, were retrospectively analyzed. All patients were staged as NO, MO. Survival and death rates were not presented. A three-year minimum follow-up was achieved in 97% of the cases. Local and cervical recurrences were presented and analyzed. Factors such as local tumor extent, impaired mobility of the true vocal cord, invasion of conus elasticus or thyroid cartilage, and positive margins of resection enhance the outcome of local and cervical recurrences. This present report underscores that thyrotomies, hemilaryngectomies, and cricohyoidoepiglottopexies should be adapted to the exact tumor location and the laryngeal mobilities. Cervical lymph node recurrence is less likely to happen if local control is achieved. The role and rationale for an associated elective ipsilateral cervical and paratracheal lymph chain dissection are presented and advocated.

Between 1980 and 1987, 63 lung cancers associated with upper aero-digestive tract carcinomas were operated on 50% of the primary malignancies of the upper aero-digestive system were laryngeal. These tumors developed synchronously in 13% and metachronously in 87%. The operative mortality rate was 3%. The five years survival rate was 30%. Our results were found identical to those observed in a single lung cancer series. Coin lesion of the lung should be therefore considered as a second primary cancer. Thus, the best treatment is surgical resection. When the option exist, the lung cancer should be treated before the upper airway cancer to avoid the impact of previous irradiation and/or surgical treatment of the upper airway cancer upon the post-thoracotomy management.

When confronted with complete chemotherapy-induced histological/clinical regression of a tumor, should the initial therapeutical strategy be modified? Such situations occur more and more frequently. Additional treatment must be carried out in all instances. Indeed, a correlation between complete clinical and histological regression was demonstrated in 66% of cases by histological examination of surgical specimens. It is doubtless recommended to avoid mutilating surgery and to continue chemotherapy for another year. However, whenever partial surgery had been programmed initially, the same indications and excision limits should be maintained. Combination chemical and surgical treatments yield better local results. Nonetheless, this is not always the case and the patient's tolerance to chemotherapy and background should influence the final decision. Radiotherapy then constitutes a choice alternative.

The authors assessed ganglionic failure in a series of 432 cases of N0 M0 epidermoid carcinomas of the glottic floor following partial laryngeal surgery. The overall of ganglionic failure was 7.8%. This rate of failure is related to 64.7% death rate, i.e. 5.1% of the 432 patients under study. This retrospective study differentiates between primary ganglionic failure and secondary ganglionic failure. Primary ganglionic failure is the first local/regional carcinologic event to develop after treatment of any glottic lesion. Secondary ganglionic failure is related to isolated local failures. The percentage of primary ganglionic failure was 5.1%. It was responsible for deaths occurring in 54.5% of cases. The percentage of secondary ganglionic failure was 2.7% and it was responsible for deaths occurring in 83.3% of cases. Factors promoting ganglionic failure (real tumor extension, tumor infiltration, altered laryngeal mobility, local control and efficacy of retakes of local failures) are discussed. The importance of prophylactic surgical procedures guarding from ganglionic failure, such as the ipsilateral jugular-carotid and recurrent nerve approaches is emphasized. Although such procedures can be of aid in cases of T2 or T3 N0 M0 epitheliomas of the glottic floor, they present no alternative in the course of retake operations of local failures.

Many procedures are used for reconstruction of a pharyngeal gutter after circular pharyngolaryngectomy, interrupter of digestive continuity. The operation chosen was used of third part of jejunum for reconstruction, and its indications and limitations are described. The choice was based on anatomic data from dissection of 100 cadavers and values for different measurements performed (length of transplant, height of mesentery, caliber and length of vessels), and more particularly on constancy and reliability of vascularization of this digestive segment. To these advantages are added bacteriologic, technical, histologic and physiologic reasons. Results are analyzed of 11 operations carried out in the same department, from among a larger group comprising now 45 cases. Postoperative course was usually uncomplicated with rapid restoration of deglutition (a mean of 11.77 days in 9 of the 11 cases). Preoperative radiotherapy is not a contraindication and postoperative radiotherapy should be given routinely as a complement to surgery. It is usually well tolerated and transplant necrosis is not provoked. Nevertheless, the seriousness of this type of lesion is underlined by the high incidence of carcinologic failures, with an elevated risk of local and regional recurrence and of distant metastases.

Study of 168 cases of ear surgery, from September 1979 to September 1981. Various anaesthetic protocols were compared with a view to decreasing per-operative bleeding: --in 9 cases: Fluothane --in 11 cases: Alfatesine --in 89 cases: Neuroleptanalgesia --in 39 cases: Narcozep. The various proposals for controlled hypotension are discussed and the conclusion is drawn that, regardless of the method used, the percentage of failures was essentially identical and seemed to be related more to errors in assessment of the duration of the operation than to the drug used. A corollary to this attitude was the possibility of a 25% rate in delayed post-anaesthetic recovery.

This is an analysis of 4 patients with suspicion of centro-facial granulomatosis. Diagnosis is difficult, mainly based upon clinical data, without precise histopathological presentation. The main differential diagnosis is Wegener's granulomatosis. The etiology of centrofacial granulomatosis is still unknown but multiple theories have been proposed: systemic disease, lymphoma. In one case, the initial histopathological diagnosis was undifferentiated carcinoma and the patient received chemotherapy (i.e., Adriamycin, Vincristine, Bleomycin and Steroids). A complete response was achieved. The interest of chemotherapy in the treatment of centro-facial granulomatosis is discussed.

The authors report a series of 63 cases, all operated, of bronchial cancer associated with upper airway cancer. The laryngeal portion of the upper airways was the site of cancer in 50% of cases. The two cancers occurred synchronously in 13% and at different times in 87% of cases. Operative mortality was 3%. Post-operative complications were dominated by bronchopulmonary congestion. Long-term survival was similar to that in series of operated bronchial cancer alone and was 70% at one year and 30% at five years. These results should lead to all isolated pulmonary lesions being considered as second primary cancers with early surgical resection being proposed.

Of a total of 219 partial laryngectomies performed, 119 were cordectomies, 30 hemilaryngectomies and 70 supraglottic laryngectomies. Results of each type of operation are presented with emphasis on problems of local recurrences, evidence of validity of procedure selected and of its indications. Analysis of results, with the reservation that indications were sometimes wide but always reasonable, showed an extremely low incidence of recurrences, the quality of the resection (limited or insufficient) having finally little incidence on the latter, except perhaps in the supraglottic laryngectomies. It is suggested, therefore, that no attempt should be made to "recover" a histologically detected insufficient excision by complementary radiotherapy not required in principle. This assists follow up review and allows secondary therapy if an unfavorable course is noted.

The pre-epiglottic space is located superficially at the junction of the larynx, oropharynx and hypopharynx. When it is invaded by a neighbouring cancer, the latter rises to stages 3 or 4 of the TNM classification. The space is explorable by percutaneous ultrasonic scanning of the neck. The present paper gives the first description of the normal sonographic anatomy of the pre-epiglottic space, based on 16 healthy volunteers. It also gives the first description of invasion of that space, based on 18 patients operated upon for ENT (ear, nose and throat) cancers. In 5 of these 18 patients, invasion of the pre-epiglottic space was proven at histology. There were 3 positive and no false negative results, but 3 false positive results were obtained at the beginning of the series. The accuracy of ultrasounds in this study was 83 per cent.

Five fluoro-uracil (5-FU) is a cytotoxic drug which has been extensively used for chemotherapy since 1957. Ischaemic heart disease resulting from its administration is rare. Spontaneous angina during infusions of 5-FU was observed in two patients with electrocardiographic changes suggesting coronary spasm. After treatment, clinical examination, electrocardiogram, echocardiogram, stress test, coronary angiography with left ventriculography were all normal. An Ergonovine test was performed in one patient but failed to elicit coronary spasm. In the other patient, intravenous trinitrin and diltiazem were ineffective in preventing the ischaemic changes. A review of the literature is presented (51 cases). The pathophysiology of 5-FU-induced ischaemic heart disease is not fully understood. In 9 cases, coronary angiography was normal and coronary spasm was suggested as a possible cause. However, antispastic drugs are usually ineffective. It has been shown experimentally that 5-FU has a direct toxic effect on the myocardium.

Use of a moulded aponeurotic graft, shapened and then made rigid by heat and formalin, is a seductive method of tympanic reconstruction because of its simplicity and availability. Indications for and results of the application of this method are analyzed based on experience of 158 cases, with sufficient follow up in 90. The principal indication for use is large perforations, when it is possible to exteriorize the whole canal and almost all the tympanic remains, while doubt exists as to its advantages for treatment of small perforations. Its essential advantage is in fact the ease with which the graft can be positioned on external surface of malleus and inside the remains of tympanic membrane. Overall anatomical results were very satisfactory (83.5%) if one includes in failures of treatment the apparent lateralizations of graft. Functional results were poorer, with rarely complete recovery of hearing and a certain number of labyrinthizations possibly due to injury to handle of malleus or even perforation of canal. Secondary degradation of favorable results may develop because of some degree of lateralization of the newly formed tympanic membrane. These could perhaps be avoided by the technical artifices proposed by other authors.

The authors analyse 247 cases of haemorrhagic oesophageal varices treated using sclerosing injections of Quinine-Urea between 1964 and 1977. Portal hypertension as a result of intrahepatic block accounted for 83% of the patients (alcoholic cirrhosis 65%, meta-icteric 12%) and cavernomas 11%. Sclerosing injections were used in patients refused by surgeons (85%) or after the failure of surgery (15%). Only 11 cases were treated during the period of active haemorrhage, and the others during the following weeks. Tolerance of treatment so long as all safety factors were employed routinely in order to deal with any possible haemorrhagic complications. Deaths due to the method totalled 2.8%, including those due to worsening of the underlying disease. Overall results were of 69% survival of more than one year, 40% at more than 3 years and 24% at more than five years. For alcoholic cirrhosis, these figures were respectively 62, 30 and 18%. The prognosis in cases of cavernoma was much better; 80% survival at more than 5 years.

On the basis of clinical impressions only, the authors had felt the carcinomas of the larynx and hypopharynx were probably graver in young subjects than in the elderly, and that age was a determinant factor in therapeutic decisions. 585 records including 216 carcinomas of the piriform fossa and 369 carcinomas of the larynx were studied over a period of 8 years. This study failed to reveal any difference related to age between populations aged less than 60 years and more than 60 years, both with regard to the prevalence of carcinomas whatever the siten the presence or absence of nodes, histological spread, loco-regional prognosis and actuarial survival. The latter parameter was studied by establishing the distribution between patients aged less than 55 and those 55 and over to obtain equivalent groups in terms of numbers. Overall, the prognosis seemed to be rather better in the younger patients, which would imply a therapeutic attitude independent of age.

Degloving constitutes a hidden route of access to the middle third of the face. It combines a bilateral sublabial incision with a rhinoplastic approach, whereby all the soft tissues of the face can be undermined subperiosteally, leaving no external scar. This method offers an extended bilateral route of access to lesions of the nasal cavities and ethmoid/sphenoid/maxillary sinuses, deep to the clivus. Its exposing features at least compare with conventional technics, including bone resection or the creation of a valve. This procedure may be associated with other neurosurgical approaches in the treatment of extended lesions of the basis of the skull. Its use is particularly recommended in the treatment of inverted papillomas, although it applies as well to malignant tumors of the sinuses under certain conditions. We present here a review of our experience.

Experience with 79 adult patients treated for thyroid cancer. The authors study different parameters of these cancers, particularly sex and age, circumstances of discovery and histological distribution. The state precisely their operative procedure and arguments on account of total thyroidectomy.

Limited resection in partial surgery for carcinoma of the larynx leads to discussion of three surgical attitudes: total surgical resection as a matter of principle, additional treatment by radiotherapy, or waiting, with the need for strict surveillance. The present study reports the results of this latter attitude adopted in 23 cases out of 24 of limited resection in a group involving 119 partial laryngectomies (vertical or horizontal) consisting of: 57 cordectomies, 20 hemilaryngectomies, 42 supraglottal laryngectomies. Results of analysis show that there was no recurrence and patients were well with a 3 year follow-up in 19 cases of limited resection out of 24. Overall survival following limited resection was identical to that seen after satisfactory resection, but there was a marked difference with insufficient resection (X2 significant) Following partial laryngeal surgery involving a limit resection, it is felt to be legitimate to temporise as long as the patient can be seen regularly. Such an approach would not seem to modify the overall survival in these patients.

The authors report on 48 patients operated by hemi-laryngo-pharyngectomy for spinous carcinoma of the piriform sinus. They try to precise the indications by analysing the factors influencing survival and relapses. They compare surgery to the other methods. In a second part, they report 3 cases of posterior pharyngectomy by bilateral cervical incision.

Facial mucormycosis is a rare fungal infection which spreads rapidly and has a severe prognosis. It mainly affects insulin-dependent diabetics and immunodeficient subjects. We report about a case of mucormycosis of the facial structures in a diabetic patient, and lay particular stress on the diagnosis difficulties, on treatment and on evolution, which led to healing, leaving an extensive bony sequestrum which preserved the contents of the orbits.

Nasal obstruction is frequently related to hypertrophy of the bony inferior nasal conchae. Medical management and/or isolated correction of deviation of the nasal septum are often inadequate. Surgical management, although it has raised controversy, becomes the only therapeutical course. Submucosal resection of the conchae was performed in 104 patients between 1986 and 1988. Subjective analysis of postoperative data shows 82% of successful surgery cases yielding good nasal repermeabilization with some minor unpleasant effects, such as nasal crusts or discharge in 46% of cases. The authors describe the surgical technique as well as its indications, and its advantages as compared to medical treatment, cauterization or subtotal resection of the conchae in incapacitating nasal obstruction cases.

In a certain number of cases, extensive carcinomas of the hypopharynx require total pharyngeal resection, circular, and hence the restoration of continuity by a plastic procedure. Amongst the numerous procedures used (tubular flaps, substitution using a hollow organ), the authors opted for the use of free jejunal transplant with vascular microanastomoses in a single stage. Four cases very different in terms of their indications are reported. The postoperative course was in general very uncomplicated and characterised by the absence of either abdominal or pharyngeal infection. Swallowing became possible on about the 14th day. Vascular permeability was confirmed by arteriography in three cases and was felt to be satisfactory. This is, however, major surgery with a long operation (between 6 and 10 hours) and which at best requires the cooperation of two teams of surgeons. Indications should be considered with caution and in the present study involved only cases of widely extended pharyngeal carcinomas, with the exclusion of oesophageal involvement going beyond the pharyngo-oesophageal sphincter.

A study was carried out at Hôpital Boucicaut to determine the incidence of iatrogenic biological thyroid dysfunction in patients treated for cancer of the upper digestive and respiratory tracts, and to define the risk profile (tumor localisations, practical therapeutical procedures). Two studies were conducted: a prospective on including 18 patients and a retrospective one including 58 patients. Only partial results are currently available. They permit emphasizing the frequency of biological thyroid dysfunction associated both with combination surgical and radiotherapeutical regimens and radiotherapy or radiotherapy alone for the treatment of lesions of the piriform sinus, although they fail to provide conclusive evidence regarding the real frequency of this type pathology or the time of its occurrence.

The authors have studied real tumoral extension in 432 cases with N0 M0 epidermoid carcinoma of the glottic floor treated by partial laryngeal surgery over the period extending from 1972 to 1984. This retrospective study defines the limits and the errors of preoperative assessment of local extension. Clinical examination and direct suspension laryngoscopy are needed. T classification cannot be used as a sole reference in the selection of the surgical technique. The difficulties encountered in the evaluation of real tumor extension in this type of neoplasia calls for great caution on the part of the surgeon in selecting the procedure for partial laryngeal surgery. The study of the incidence of local failures in cases of real tumor extension emphasizes the need for an appropriate surgical technique for the local management of tumoral extension. The authors identify the respective place held by such techniques as thyrotomy associated with internal subperichondrial degloving and partial vertical laryngectomy with cartilage resection, and its many variants, and partial horizontal subcricoid laryngectomy (of the cricohyoepiglottopexy-type).

Lingual candidiasis is a condition arising from a multiple of causes, some of which are well known (thrush, etc...). Two cases of chronic lingual mycotic granuloma are presented, one of which was due to a candida, the diagnosis being confirmed by pathological examination and electrosyneresis. The course of this granuloma leads to the appearance of a true epidermoid carcinoma, as illustrated by the description of other cases that have been reported. Current therapy for the granuloma itself mainly depends on the employ of ketoconazole, but the unfavorable course of the affection raises the question of the need for associated surgery.

Acute epiglottitis is much less frequent in adults than in children. Three personal cases are reported and clinical findings associated with epiglottitis in adults are reviewed; sudden onset of acute respiratory failure is outlined. Mechanical desobstruction of airway may be required promptly, tracheostomy being often preferred to tracheal intubation. Overall prognosis has been evaluated from 130 cases reported in the literature in the last twenty years: the mortality rate, reaching 24,6 per cent in 73 cases published between 1958 and 1973, has been reduced to 5 per cent in 60 most recent cases. This improvement reflects a better understanding of the disease and as more properly defined therapy.

Inappropriate secretion of antidiuretic hormone or Schwartz-Bartter syndrome is considered to be a paraneoplastic endocrine syndrome, most frequently associated with a small cell anaplastic carcinoma of the lung. The authors present a case of sub-glottal laryngeal carcinoma discovered several months after the onset of clinical (disturbances of conscious level) and laboratory (hyponatraemia, hypochloraemia, blood hypo-osmolarity which preservation of urinary sodium output) manifestations which form the original features of this syndrome, the criteria of which are reviewed. The y conclude by the need for complete examination, not excluding unusual sites of primary tumour.

Malignant teratomas of the thyroid in the adult are rare. A personal case is presented. It brings the total number of cases found in the literature to nine, and illustrates the terrible prognosis of these tumours regardless of the treatment used (extensive surgery, radiotherapy, chemotherapy). Teratomas in the adult thus differ from those in the newborn and child. The latter are much more common and recurrences virtually non-existent. The histogenesis of these tumour is discussed. It may dysgenetic heterotypism, but no definite conclusions may be offered.

About a homogeneous statististic of 158 parotidectomies, authors study repartition parameters of parotid gland tumors. They insist on particular surgical and evolutive problems in relation to histology sometimes very difficult.

A Case of chordoma of the base of the skull is reported. It had been present with minimal symptoms for six years during which the clinical picture was limited to nasal obstruction and headache. Comparison of initial X-rays and the preoperative assessment revealed progressive destruction of the base of the skull which indicated the likelihood of considerable difficulties in excision. Surgical treatment posed the problem of the approach and emphasised the absence of encapsulation and the incomplete nature of the operation. The development of new symptoms (diplopia, dysphagia) resulted in complementary radiotherapy. The authors take the opportunity to point out the polymorphous clinical nature of these tumours in relation to their site and the criteria of the histological diagnosis. The possibilities of treatment are discussed. Abstention from treatment is formally rejected and, on the contrary, the emphasis is placed upon the need for early treatment. The consequences of excision should be limited by using a minimal surgical technique when possible. Complementary radiotherapy is necessary and may be repeated, up to certain limits, in the case of recurrence if the first irradiation is felt to be effective. There is no parallel between histological appearances and the response to treatment. The possibilities of chemotherapy would appear to be limited.