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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.

Before they give their results, the authors, whose experience of sclerosis of oesophageal varices under the oesophagoscope has so far involved 157 patients, deal specifically with the problems facing the anaesthetist and resuscitator when this technique is used, tolerance of the product injected and possible accidents. Firstly, they point out the unsuitability of the patients referred to them by their medical or surgical colleagues. By implication therefore, treatment should only be undertaken with the assistance of a team of experienced resuscitators and every precaution taken to mitigate the effects of possible accidents to these patients who are particularly at risk. These cases are mainly characterized by serious haemorrhages (seven cases described, one resulting in death). Oesophageal injury is, on the other hand, the exception where trained personnel are involved (2 minor mucosal tears out of more than 800 oesophagoscopies). Finally, secondary parietal oesophageal necrosis occurs. Quininaemia assessment after injection of quinine-urea confirms that the product is being efficiently eliminated. Overall results reveal a survival rate of 61 p. 100 after more than a year and 20 p. 100 after more than than three years. These figures underline the limitations of therapeutic possibilities and the serious prognosis for this result of portal hypertension. This leads the authors to express a wish that the procedure should be used as a measure to prevent haemorrhage as soon as the presence of varices is realized. On the other hand, they reject on practical grounds emergency sclerosis of oesophageal varices, as a direct heamostatic method, since, according to their statistics, this almost invariably results in failure.

Invasion of the hyothyroepiglottic (HTE) space, or pre-epiglottic space, constitutes an important element in selecting the type of therapy in cancer of the larynx (functional surgery, radiotherapy), the oropharynx and the hypopharynx. Clinical examination and standard X-ray films provide insufficient information. High frequency real time ultrasonography offers a reliable means for exploring the pre-epiglottic space, as evidenced by this study carried on 34 histologically-confirmed cases taken among 77 cases of carcinoma of the upper digestive and respiratory tracts. Advantages presented by this method over CT-scanning and MR imaging in this particular pathological are simplicity, rapidity and low cost, combined with good performance.

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.

Following a brief review of anatomical features, the risk of injury to the recurrent nerve is discussed as a function of the type of operation performed: subtotal thyroidectomy, ablation of a retrosternal goitre, lobectomy, and total thyroidectomy. Particular attention has to be paid to the risk of anomaly in the nerve pathway: early division or a nerve branching directly from the Xth nerve without a recurrent pathway. Paralysis may be due to simple stretching of the nerve, when regression occurs in approximately three months. Paralysis of the recurrent nerve occurred in 1.69% of cases (7 definite, including 2 of necessity), in a series of 1 184 recurrent nerve exposures.

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.

The atuhors analyze the case of a three-year-old child suffering from an abnormal condition of the left internal ear, revealed by copious discharge of cerebro-spinal fluid at the onset of 5 attacks of meningitis. A direct approach to the plate and the bony and aponeurotic contents of the oval fossa made it possible to seal this off and this was checked surgically eighteen months later. On this occasion a general survey was carried out into the usual circumstances in which such a discovery is made, pathological concepts and treatment for these accidents. It would appear that unusual permeability may be found either in the internal auditory meatus or in the cochlear aqueduct. Therapeutic procedure depends on circumstances. Blocking the oval fossa is not always effective and should be reserved for cases in which abnormalities impair function. Choice between blocking the internal auditory meatus and eradication of the cochlear aqueduct depends to some extent on the information supplied by tomography, but more on the pathogenetic conclusions reached.

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.

In the E.N.T. area, gastro-oesophageal reflux (GOR) is manifested as atypical pharyngitis or laryngitis. E.N.T. examination is frequently negative. The diagnosis rests on demonstration of the reflux which is clinically obvious in most cases. It must be confirmed by exploratory methods, the main one being oesophageal pH measurement. Fibroscopy is useful to exclude an associated oesophagitis. GOR is very frequent in children and indeed unavoidable during the first weeks of life. It may produce inflammatory E.N.T. symptoms, but also obstructive apnoea and nocturnal cough. Management essentially consists of hygienic and dietetic measures. It is highly effective as regards both GOR and its atypical E.N.T. manifestations.

Vascular sarcomas (haemangio-endotheliomas) are tumours which are very rarely encountered in the facial mass. Only 10 cases have been found in the literature. Two cases are described: the first patient was operated on in 1968 for a localization in the left side of the ethmoid and presented 9 year later with a recurrence on the right side symmetrical with the first which remained apparently cured; a year later, there was a recurrence on the right then diffuse pulmonary metastases. The second case was that of a patient with an ethmoid localization cured by radiotherapy and surgery 20 years before, but presenting with a recurrence in the ganglia 10 years later and a parapharyngeal recurrence developing over the past 6 years. In connection with these two cases, the diagnostic difficulties involved in distinguishing these tumours from epitheliomas and sarcomas of the facial mass, which sometimes show considerable vascularization, from other vascular tumours, benign haemangioendotheliomas, glomus tumours and, in particular, haemangio-pericytomas, are described. The possibility of a long survival should be noted for some rare facial localizations: this is in contrast with the usually very rapid development of vascular sarcomas in other localizations.

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.

Major difficulties in laryngeal reconstruction are due to laryngeal nerves. A study was conducted of 100 larynges from fresh subjects after vascular injection. Vascularization of superior laryngeal nerves is derived essentially from superior laryngeal and ascending pharyngeal arteries. Inferior laryngeal nerves obtain their vascular supply from inferior thyroid and main carotid arteries. Histomorphometric study of laryngeal nerves used semi-automatic techniques: microscope, numerical table, computer, printer. The number of fibers per nerve varied between 511 and 2.244, the number of nerve fasculi between 3 and 14, and the diameter of myelinated fibers between 2 and 12 micron. Fibers of left inferior laryngeal nerve had a mean diameter (8.9 to 10.2) greater than those of right inferior laryngeal nerve (5.1 to 5.2 micron). Nerve tissue represented 60% to 66% of total. The left recurrent was longer than right nerve but had larger fibers providing more rapid conduction. Cartography of laryngeal nerves from 2 mm serial sections confirmed their plexis structure, this study providing new and objective precisions on laryngeal nerve structure.

In this paper are considered the etiology, the clinical findings and the management of anaesthesia for a certain number of ENT emergencies, situations of respiratory distress which may lead rapidly to death, or be the cause of severe complications, e.g. -haemorrhage (epistaxis or tonsilar haemorrhage, haemorrhage from carcinoma..), -dyspnea of the adult, neonatal dyspnea and dyspnea of infants and children, -foreign bodies, burns and perforations of the esophagus.

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.

Our propose is to present a case of peripheral ameloblastoma revealed by a glue-ear. This lesion is rare: thirty-one peripheral ameloblastoma have been reported whereas this case seems to be the first case described in the infratemporal fossa. Microscopic examination is necessary for the diagnosis. The resection was realized through the soft palate.

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 significance of the absence or presence of lymphadenopathy is not the same in relation to the site of the primary tumour. This study involved 574 cases, including 213 carcinomas of the piriform fossa and 361 laryngeal carcinomas, and revealed errors of omission (No - N+) in carcinomas of the piriforme fossa (50% cases) and the possibility of errors of commission (N not equal to - N - in carcinomas of the larynx. This merely confirmed the high level of lymphatic affinity of carcinomas of the piriform fossa, but at the same time emphasised the relative reliability of the clinical assessment of relevent classifications.

Surgical diathermy excision was employed to treatment 138 cases of buccopharyngeal cancer, either as initial followed by irradiation therapy, or as complementary treatment to radiotherapy in unsuccessful cases. Results were favorable in 34 patients with tonsillar carcinoma and 38 cases of soft palate cancer, but the method was only moderately effective for recurrences in these regions. In 36 cases of tongue cancer, and 30 with cancer of the floor of the mouth, this therapeutic procedure was particularly effective for treating patients not responding to radium needle implantation.

The principle of prefabricated transplants consists in the manufacturing of compound transplants complete with a vascular pedicle containing an artery, a vein, a muscle and its nerve, some cell tissue, bone tissue, cartilage, periosteum and innerved skin. This transplant is constructed and modeled in accordance with its intended use, around the preselected vascular pedicle, whence the term prefabricated. Neovascularization revascularizes these different structures. The free transplants together with their vasculonervous pedicles are excised five weeks after manufacture and then transplanted to the recipient site. Experimentally, we grafted 15 free prefabricated transplants in Wistar rats. One failure was observed due to thrombosis of the anastomoses. Experimental data from macroscopic, arteriographic, microangiographic, and histological examinations, with injection of a staining material, show that neovascularization develops at the level of the transplant. The emphasis is on creating free transplants selectively using various tissues and selected vascular pedicles. These transplants constitute a useful prospective alternative for very elaborate reconstructive surgery.

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.

Angio-immunoblastic lymphadenopathy is a recently demarcated clinico-anatomical entity. A new case underlines the importance of this lesion in E.N.T. The lesion often progresses like a neoplasm, even though the clinical, biochemical and histological features make one consider it today to be an expression of an immune disorder. Nevertheless, the relationship with malignant lymphoma is discussed and the histological arguments which show an association or an evolution towards malignancy are exposed. The difficulties of treatment are particularly underlined on the basis of this ambivalence; and especially on the basis of the dilemma posed by the necessity for an effective therapy, justified by the invasive and extensive nature of the lesion, and the risks represented by the use of chemotherapy in a patient whose immunity is already disturbed. A statistical analysis of the therapeutic results, from data collected from the literature, illustrates this difficulty but does not allow a universally acceptable attitude to be defined.

An up to date report on the surgical technique used in the treatment of pharyngo-oesophageal diverticulum by one-stage diverticulectomy. The authors emphasise the possible difficulties associated with diverticula surrounded by peridiverticulitis, the approach to diverticula with mediastinal extension and practical points which make it possible to simplify the posterative course. The place of myotomy of the cricopharyngeal muscle without ablation of the sac in the treatment of small asymptomatic diverticula is discussed.

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.