Biomedical subjects
Publications and source records attributed to A Pech.
The authors report their experiences after operating on 279 patients with unilateral acoustic neuromas between 1976 and 1988, with 258 cases managed by the translabyrinthine approach and 21 cases by the middle fossa approach. The authors emphasize the necessity for total removal in order to avoid recurrences.
The authors report on 11 cases of congenital cholesteatomas, treated between 1979 and 1988. In all cases, there was a long-standing history of deafness. The diagnosis revealed 6 cophoses, 5 cases of mixed deafness, 9 cases of impairment of the facial nerve (7 cases of paralysis including 4 with sudden onset and 2 hemispasms), 2 facial neuralgias with facial hypesthesia, one Gradenigo-Lannois syndrome, 2 leaks of the C.S.F. (1 nasal, 1 very abundant auricular leak). In 6 cases, the surgical approach route was trans-cochlear, and in 5 cases surpa-petrosal, two of which were extended to a petrectomy. Of the 5 cases of partial deafness, only one was preserved. In 5 cases, the facial nerve was destroyed at the level of the ganglion of the facial nerve, a region where a frankly epidermal tissue is always found. In 4 cases the facial nerve was repaired (three hypo-glosso-facial anastomoses and one end-to-end suture, after re-routing). The authors share the opinion of Fisch that the origin of the intra-petrosal congenital cholesteatoma always occurs at the level of the ganglion of the facial nerve.
Diagnostic and surgical features of lateral cervical chemodectomas are discussed in relation to a personal series of 16 patients with carotid body tumors and 10 with tumors of the intravagal glomus. Clinically, these affections are poor in symptomatology, those of the carotid glomus presenting as an isolated cervical tumor, intravagal glomus tumors as parapharyngeal masses of the restrostyloid type. Arteriographic findings are discussed in detail, as they constitute the only pathognomonic signs, enable differentiation between the two tumor sites, and supply essential pre-operative data: location of the pedicles, possible invasion of arterial walls, and the limits of the tumor. Surgical approach should be wide to enable control of the distal end of the internal carotid artery, if necessary under the base of the cranium, excision of the tumor usually being possible by employing the sub-adventitial resection technique.
The superficial temporal fascia is formed by a fine fibro-muscular layer situated between the subcutaneous plane of the temporal region and the temporal muscle aponeurosis. The superficial temporal artery and its branches run within the fascia which acts as a veritable vessel carrying sheet. The therefore useful in that in minimises esthetic and functional complications at the donor site. This reliable, polyvalent arterialised aponeurotic type flap behaves above all as a covering or interpositional flap. Our clinical experience involves 20 cases, in addition to the applications already published: covering material in cases of loss of facial substance, otopoiesis, organisation of open techniques, we propose its use during oro-bucco-pharyngoplasty and for sealing the base of the skull.
Study of a personal series of 10 cases of thyroid cancer in children and a review of the literature reveals what we consider to be the 3 problems which are posed by this pathology in children: 1. The frequency of isolated cervical adenopathy in the initial symptomatology may be confused with congenital swelling or inflammatory adenopathy. 2. The surgical management depends on the histological nature: total thyroidectomy, lymph node excision, risk to the parathyroid gland and IRAtherapy all depend on the histological data. 3. Finally, the long term prognosis of these cancers is unknown. Schematically, differentiated cancers including papillary carcinomas have a good or indeed excellent prognosis, while medullary carcinomas have a prognosis which will imminently depend on the extrathyroid involvement, the quality of thyroidectomy and lymph node clearance. This highlights the problem of screening for subclinical disease in familial forms of the disease.
The surgical approach should be adapted to the type of correction needed. There is no room of standard technics. The various selection criteria that have to be considered are: the structure of the alar cartilages and the infra-and suprastructural characteristics thereof, determining the upper triangle of the lobule; the relative incidence of the abnormalities encountered in rhinoplastic practice; an analysis of the failures leading to secondary rhinoplastic operations, among which the most frequent are lobule and/or irregularities and drooping apex or insufficient projection thereof. Currently, the authors' conclusions are that: Most of the times, the upper triangle of the lobule is overdeveloped: reduction is carried out by resecting a superior strip laterally, while additionally trimming the cupulae, if necessary. Much more rarely, a globally hypertrophied lobule will be found that requires management by section-reconstruction of the cupulae. In case of a "normal", excessively projected lobule, the technic of choice is apex retraction. Primary apex projection defects should be recognized and treated with molding grafts. The nose tip should be prevented from drooping by means of columellar supporting grafts.
The authors describe a widened transcochlear approach for large tumors of the jugular foramen with intrapetrous, intracranial, and infratemporal extensions. This approach complements the transcochlear and infratemporal approaches by enlarging the route of access to the region with disinsertion of the sternocleidomastoid, digastric, and stylohyoid muscles, by removing petrous bone in order to displace the facial nerve, by resection of the auditory canal, and by subluxation of the temporomandibular joint and zygomatic process. The use of this approach is described in seven patients.
There are two major indications for Tissucol: 1. Stabilization of structures separated by the operative procedure or of graphs, in particular cartilaginous, whether placed along the crest of the nose or at the level of the columella in sagittal position between the mesials, or frontal position under their lower edges. 2. The construction of grafts. a) Mixing of bone powder and Tissucol provides "laminated" graphs which, when placed laterally and below iliac bone grafts, avoid the grooves which all too often form along the edges of such grafts. b) Coherent moulding graphs can be obtained using Tissucol with crushed cartilage (from septum or auricular concha).
Results of the use of grafts in primary and secondary rhinoplasty are reported, the grafts being either of cartilage (concha auriculae, nasal septum, alar cartilage), bone (mastoid, ilium) or connective tissue (temporal aponeurosis). The distinction is made between modelling grafts of softened cartilage, supporting grafts of non-softened cartilage and mastoid bone, of bone reconstruction and of cartilaginous filling grafts.
The authors describe a study of the labio-columellar region and of the alae of the nose in corrective rhinoplasty excluding malformations. Esthetic characteristics and the anatomical structure of this junctional area between the mobile nose and the facial plane are revealed. Surgical problems are analyzed with study in succession of surgical approaches, maxillo-septal angle, the columella, the maxilla, the muscular layer and the alo-jugal junction. Surgical techniques which can be divided into inferior septoplasties, columelloplasty and labio-columelloplasty have precise indications in accordance with the type of formation of the labio-columellar region. A technique of nostril resection with the absence of damage to and shortening plasty of the muscle layer is described.
Forty patients with suspected tumoral syndrome of ponto-cerebellar angle were investigated by NMR imaging. The method proved to be reliable, less invasive (lack of irritation and absence of iodized contrast) and as rapid as CT scan imaging for the diagnosis of presence and extension of an VIIIth nerve neurinoma. It also allowed avoidance of computerized gas meatography during screening for intracanal neurinomas.
Exploration of acoustic neurinoma, the most frequent benign tumor of posterior fossa, now includes magnetic resonance imaging, and an C.G.R. supraconductor apparatus (0.5 Tesla) has been in use since March 1986. This equipment provides high resolution frontal sections, not only of posterior fossa but of the two pontocerebellar angles and even the contents of the two IAC (thin, contiguous 4 mm sections in 256 x 256 matrix). A total of 43 patients were examined, 37 with surgically confirmed acoustic neurinoma and 2 with tumor recurrence. The neurinoma appears on the first echo as a hyposignal in relation to brain stem in sequences predominant in T1 and as a hypersignal in relation to peripontic CSF in sequences predominant in T2. Short sequences predominant in Tl (partial saturation or short ET and RT spin-echos) appear to be most effective for detection of acoustic neurinoma. Comparison of MRI and CT scan imaging showed that firstly, all cases detected by conventional scanography were correctly analyzed by MRI, with superiority for MRI for preoperative screening due to the frontal sections obtained without interference and, secondly, the non-invasive confirmation of diagnosis in doubtful or negative cases requiring computerized gaz meatocisternography. No false negative or false positive results were reported in our series or those documented in the literature using this new imaging technique, but high performance apparatus is necessary (thin sections ans powerful principal magnetic field of at least 0.5 resla). Improvements in this method could be obtained by the availability of more rapid programmes, the use of surface coils and the injection of paramagnetic substances (galodinium chelates) presently under study. NMR imaging is a reliable and non-invasive imaging method capable of replacing the scanner for study of acoustic neurinoma as soon as more apparatuses become available.
Mandibular reconstruction in 6 patients was by free flap from iliac crest in pelvi-mandibulectomies. The different technics proposed for mandibular reconstruction are described with emphasis on the specificity of repair surgery in cervicofacial oncology. In this precise indication stress is placed on the limitations of conventional graft and endoprosthesis procedures and the need to transfer a vascularized bone fragment. Among the technics for transfer of vascularized bone, preference is accorded to the composite flap from iliac crest as against the osteo-musculo-cutaneous flap, and details for removal of the former are given. The osteo-musculo-cutaneous flap from iliac crest appears to be the procedure of choice for reconstruction of bone in all cases where mandibular reconstruction is necessary after loss of continuity.
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