Les syndromes obstructifs des voies aériennes et digestives supérieures par hypertrophie adéno-amygdalienne chez l'enfant

L'hypertrophie adéno-amygdalienne (HAA) est la première cause d'obstruction des voies aériennes et digestives supérieures chez l'enfant. L'HAA est une pathologie courante qui peut revêtir plusieurs aspects cliniques. Le tableau clinique peut parfois être le témoin de complications variées. Après de brefs rappels anatomiques et physiologiques, nous proposons, au cours d'une revue de la littérature, de détailler les étiologies potentielles d'HAA ainsi que les principes de la prise en charge diagnostique et thérapeutique. Enfin, nous présentons une étude clinique portant sur la croissance staturo-pondérale des enfants ayant bénéficié d'un traitement chirurgical par adénoctonsillectomie.NANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF

De l’altération de la parole en cancérologie aux solutions

International audienc

Reconstruction hypopharyngée par lambeau musculo-cutané pédiculé de grand pectoral en fer a cheval après pharyngo-laryngectomie totale circulaire (à propos de 41 cas)

Les objectifs de ce travail étaient d'évaluer les résultats chirurgicaux, fonctionnels et carcinologiques de patients opérés d'une pharyngo-laryngectomie totale circulaire avec reconstruction de l'hypopharynx par lambeau musculo-cutané pédiculé de grand pectoral en fer à cheval . La qualité de vie après la chirurgie a également été étudiée. L'étude rétrospective monocentrique incluait 41 patients ayant bénéficié de la même technique de reconstruction hypopharyngée après pharyngo-laryngectomie totale circulaire pendant une période de 6 ans. Aucun décès péri-opératoire n'a été constaté. Des complications générales et locales sont intervenues chez respectivement 10% et 22% des patients. La durée moyenne d hospitalisation était de 19 jours. Les taux de sténoses du néopharynx et de fistules salivaires étaient respectivement de 39% et 22%. L alimentation et la réhabilitation vocale étaient considérées comme satisfaisantes pour 82% et 38% des opérés. Les résultats carcinologiques retrouvaient un taux de poursuite évolutive et de récidive de 48%, un taux de métastase de 24%, pour une survie à 1 et 3 ans de respectivement 68% et 29%. Le recul moyen était de 20 mois. Un questionnaire de qualité de vie validé soumis aux dix patients vivants au moment du recueil des données montrait que les patients étaient globalement satisfaits de leur qualité de vie. Les atouts du lambeau musculo-cutané pédiculé de grand pectoral en fer à cheval sont sa simplicité de réalisation par une seule équipe chirurgicale, sa fiabilité et sa faible morbidité. Les résultats en terme de qualité de déglutition sont cependant moins bons que ceux des principaux lambeaux libres décrits pour reconstruire l hypopharynx. Cette technique semble particulièrement adaptée aux patients à l état général altéré ; elle permet de conserver une qualité de vie acceptable chez ces patients malgré le mauvais pronostic carcinologique de la tumeur.NANTES-BU Médecine pharmacie (441092101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Development of a rat model of mandibular irradiation sequelae for preclinical studies of bone repair

International audienceRepairing mandibular bone defects after radiotherapy of the upper aerodigestive tract is clinically challenging. Although bone tissue engineering has recently generated a number of innovative treatment approaches for osteoradionecrosis, these modalities must be evaluated preclinically in a relevant, reproducible, animal model. The objective of the present study was to evaluate a novel rat model of mandibular irradiation sequelae, with a focus on the adverse effects of radiotherapy on bone structure, intraosseous vascularization, and bone regeneration. Rats were irradiated with a single 80 Gy dose to the jaws. Three weeks after irradiation, mandibular bone defects of different sizes (0, 1, 3 or 5 mm) were produced in each hemimandible. Five weeks after the surgical procedure, the animals were euthanized. Explanted mandibular samples were qualitatively and quantitatively assessed for bone formation, bone structure, and intraosseous vascular volume using micro-computed tomography, scanning electron microscopy, and histology. Twenty irradiated hemimandibles and 20 nonirradiated hemimandibles were included in the study. The bone and vessel volumes were significantly lower in the irradiated group. The extent of bone remodeling was inversely related to the defect size. In the irradiated group, scanning electron microscopy revealed a large number of polycyclic gaps consistent with periosteocytic lysis (described as being pathognomonic for osteoradionecrosis). This feature was correlated with elevated osteoclastic activity in a histological assessment. In the irradiated areas, the critical defect size was 3 mm. Hence, our rat model of mandibular irradiation sequelae showed hypovascularization and osteopenia

Micro-CT Analysis of Radiation-Induced Osteopenia and Bone Hypovascularization in Rat

International audienceTreatment of carcinomas of the upper aerodigestive tract often requires external radiation therapy. However, radiation affects all the components of bone, with different degrees of sensitivity, and may produce severe side effects such as mandibular osteoradionecrosis (ORN). Intraosseous vascularization is thought to be decreased after irradiation, but its impact on total bone volume is still controversial. The aim of this study was to compare intraosseous vascularization, cortical bone thickness, and total bone volume in a rat model of ORN versus nonirradiated rats, using a micro-computed tomography (micro-CT) analysis after intracardiac injection of a contrast agent. The study was performed on 8-week-old Lewis 1A rats (n = 14). Eleven rats underwent external irradiation on the hind limbs by a single 80-Gy dose. Three rats did not receive irradiation and served as controls for statistical analysis. Eight weeks after the external irradiation, all the animals received a barium sulfate intracardiac injection under general anesthesia. All samples were analyzed with the micro-computed tomography system at a resolution of 5.5 µm. The images were later processed to create 3D reconstructions and study vascularization, bone volume, and cortical thickness. Data from irradiated and nonirradiated rats were compared using the Kruskal–Wallis test. No animal died after irradiation. Nineteen irradiatedtibias and six nonirradiated tibias were included for micro-CT analysis. The vessel percentage was significantly lower inirradiated bones (p = 0.0001). The distance between the vessels, a marker of vascular destruction, was higher after irradiation (p = 0.001). The vessels were also more altered distally after irradiation (p = 0.028). Cortical thickness wasseverely decreased after irradiation, sometimes even reduced to zero. Both trabecular and cortical structures were destroyed after irradiation, with wide bone gaps. Finally, both total bone volume (p = 0.0001) and cortical thickness (p = 0.0001) were significantly decreased in irradiated tibias compared to nonirradiated tibias. These results led to multiple spontaneous fractures in the irradiated group, and the destruction of intraosseous vessels observed macroscopically with the radiographic preview. This study revealed the impact of radiation on intraosseous vasculature and cortical bone with a micro-CT analysis in a rat ORN model. Hypovascularization and osteopenia are consistent with the literature, contributing amorphological scale with high resolution. Visualization of the vasculature by micro-CT is an innovative technique to see thechanges after radiation, and should help adjust bone tissue engineering in irradiated bone

International consensus (ICON) on assessment of oropharyngeal dysphagia.

OBJECTIVE: To present international recommendations regarding the proper evaluation of oropharyngeal dysphagia (OD), both objectively and subjectively (self-evaluation). METHODS: Following a thorough review of the literature, 5 experts in the field from 4 different continents answered separately a questionnaire regarding the work-up of OD. Individual answers were presented and discussed during the world ENT conference that was held in Paris in June 2017. This article will present the recommendations issued from that meeting. Results: For the initial objective assessment of OD, it is recommended to perform either a functional endoscopic evaluation of swallowing (FEES) or a videofluoroscopic swallowing study (VFSS). FEES is the more popular investigation given its increased ease of use and accessibility. When evaluating for the presence of aspiration during the objective evaluation of OD, it is recommended to perform either a FEES or a VFSS. In this case, FEES is the favored investigation given its likely increased sensitivity. In order to highlight the presence of oropharyngeal food residue following the deglutition process, it is recommended to perform either a FEES or a VFSS; FEES likely being the more sensitive investigation while VFSS allows a better quantification of the amount of pharyngeal residue. Is it also recommended to objectify the quality of the deglutition process by means of a score during the objective evaluation of OD. Finally, it is recommended to utilize a self-evaluation questionnaire during research studies exploring the deglutition process

Evaluation of new bone formation in irradiated areas using association of mesenchymal stem cells and total fresh bone marrow mixed with calcium phosphate scaffold

International audienceThe consequences of the treatment of the squamous cell carcinomas of the upper aerodigestive tract (bone removal and external radiation therapy) are constant. Tissue engineering using biphasic calcium phosphate (BCP) and mesenchymal stem cells (MSC) is considered as a promising alternative. We previously demonstrated the efficacy of BCP and total fresh bone marrow (TBM) in regenerating irradiated bone defect. The aim of this study was to know if adding MSC to BCP + TBM mixture could improve the bone formation in irradiated bone defects. Twenty-four Lewis 1A rats received a single dose of 20 Gy to the hind limbs. MSC were sampled from non-irradiated donors and amplified in proliferative, and a part in osteo-genic, medium. 3 weeks after, defects were created on femurs and tibias, which were filled with BCP alone, BCP + TBM, BCP + TBM + uncommitted MSC, or BCP + TBM + committed MSC. 3 weeks after, samples were removed and prepared for qualitative and quantitative analysis. The rate of bone ingrowth was significantly higher after implantation of BCP + TBM mixture. The adding of a high concentration of MSC, committed or not, didn't improve the bone regeneration. The association BCP + TBM remains the most efficient material for bone substitution in irradiated areas

Bone marrow cell extract promotes the regeneration of irradiated bone.

Mandibular osteoradionecrosis is a severe side effect of radiotherapy after the treatment of squamous cell carcinomas of the upper aerodigestive tract. As an alternative to its treatment by micro-anastomosed free-flaps, preclinical tissular engineering studies have been developed. Total bone marrow (TBM) associated with biphasic calcium phosphate (BCP) significantly enhanced bone formation in irradiated bone. One mechanism, explaining how bone marrow cells can help regenerate tissues like this, is the paracrine effect. The bone marrow cell extract (BMCE) makes use of this paracrine mechanism by keeping only the soluble factors such as growth factors and cytokines. It has provided significant results in repairing various tissues, but has not yet been studied in irradiated bone reconstruction. The purpose of this study was to evaluate the effect of BMCE via an intraosseous or intravenous delivery, with a calcium phosphate scaffold, in irradiated bone reconstruction. Twenty rats were irradiated on their hind limbs with a single 80-Gy dose. Three weeks later, surgery was performed to create osseous defects. The intraosseous group (n = 12) studied the effect of BMCE in situ, with six combinations (empty defect, BCP, TBM, BCP-TBM, lysate only, BCP-lysate). After four different combinations of implantation (empty defect, BCP, TBM, BCP-TBM), the intravenous group (n = 8) received four intravenous injections of BMCE for 2 weeks. Five weeks after implantation, samples were explanted for histological and scanning electron microscopy analysis. Lysate immunogenicity was studied with various mixed lymphocyte reactions. Intravenous injections of BMCE led to a significant new bone formation compared to the intraosseous group. The BCP-TBM mixture remained the most effective in the intraosseous group. However, intravenous injections were more effective, with TBM placed in the defect, with or without biomaterials. Histologically, highly cellularized bone marrow was observed in the defects after intravenous injections, and not after an in situ use of the lysate. The mixed lymphocyte reactions did not show any proliferation after 3, 5, or 7 days of lysate incubation with lymphocytes from another species. This study evaluated the role of BMCE in irradiated bone reconstruction. There were significant results arguing in favor of BMCE intravenous injections. This could open new perspectives to irradiated bone reconstruction