[Anosmia and COVID-19]

Anosmia associated or not with dysgeusia seems to be a frequent symptom in cases of infection with SARS-CoV-2 responsible for COVID-19. It can be the initial symptom of the disease or remain isolated in pauci-symptomatic patients. Waiting for scientific confirmation and in the context of the current pandemic, it seems essential to consider any patient with a new anosmia as being infected with SARS-CoV-2 until proven otherwise. These patients should therefore isolate themselves and remain alert to the occurrence of other symptoms suggestive of the infection and/or be tested. Topical and systemic corticosteroids and nose washes are contraindicated. The natural course of anosmia seems to be favorable in most cases.

Mutations in the polyglutamylase gene TTLL5, expressed in photoreceptor cells and spermatozoa, are associated with cone-rod degeneration and reduced male fertility

Hereditary retinal degenerations encompass a group of genetic diseases characterized by extreme clinical variability. Following next-generation sequencing and autozygome-based screening of patients presenting with a peculiar, recessive form of cone-dominated retinopathy, we identified five homozygous variants [p.(Asp594fs), p.(Gln117*), p.(Met712fs), p.(Ile756Phe), and p.(Glu543Lys)] in the polyglutamylase-encoding gene TTLL5, in eight patients from six families. The two male patients carrying truncating TTLL5 variants also displayed a substantial reduction in sperm motility and infertility, whereas those carrying missense changes were fertile. Defects in this polyglutamylase in humans have recently been associated with cone photoreceptor dystrophy, while mouse models carrying truncating mutations in the same gene also display reduced fertility in male animals. We examined the expression levels of TTLL5 in various human tissues and determined that this gene has multiple viable isoforms, being highly expressed in testis and retina. In addition, antibodies against TTLL5 stained the basal body of photoreceptor cells in rat and the centrosome of the spermatozoon flagellum in humans, suggesting a common mechanism of action in these two cell types. Taken together, our data indicate that mutations in TTLL5 delineate a novel, allele-specific syndrome causing defects in two as yet pathogenically unrelated functions, reproduction and vision.

Intranasal trigeminal function in patients with empty nose syndrome

OBJECTIVES/HYPOTHESIS

Trigeminal nerve mediates the perception of nasal airflow. This study examines whether impaired intranasal trigeminal function is a part of the paradoxical nasal obstruction sensation in patients with empty nose syndrome (ENS).

STUDY DESIGN

Prospective case-control study in a tertiary hospital.

METHODS

Three groups were examined: 1) ENS patients with previous bilateral near total inferior turbinectomy, 2) patients who underwent near total inferior turbinate removal (ITR) without ENS symptoms, and 3) control participants. All participants examined with active anterior rhinomanometry, olfactory testing (extended Sniffin' Sticks test), and trigeminal testing (lateralization task using menthol and odorless solvent).

RESULTS

Seventy-one participants were included (21 ENS patients, 18 ITR patients, and 31 controls). Analyses revealed that ENS patients had significantly lower scores on trigeminal lateralization testing than the ITR group and controls. The ENS group had also significantly lower scores in olfactory testing than controls. No statistical differences were found in rhinomanometry between groups. The gender factor was not associated with the chemosensory testing; however, this was not the case with the age factor, as trigeminal test results were negatively correlated.

CONCLUSIONS

This study demonstrates significantly impaired intranasal trigeminal function in ENS patients when compared with ITR patients and controls. Further prospective studies are needed to clarify the role of preoperative trigeminal function of these patients and the contribution of surgery to this impairment.

LEVEL OF EVIDENCE

3b. Laryngoscope, 127:1263-1267, 2017.

Extended endoscopic endonasal approach to clival and paraclival tumors: Indications and limits

OBJECTIVE

To report our experience with the Extended endoscopic endonasal approach (EEEA) for clival and paraclival tumors.

DESIGN

Retrospective analysis of a consecutive series of patients.

RESULTS

Eleven patients were considered: 3 chordomas, 3 meningiomas, 3 metastatic lesions, one chondroma and one chondrosarcoma. Gross total resection (GTR) was achieved in all chordomas and in chondromas with patients free of disease at the last follow-up. The chondrosarcoma was first operated on using a transfacial approach and endoscopy was performed for local progression with subtotal resection. The meningiomas were treated by a combination of transcranial and endoscopic approach due to their extension. The resection was subtotal and the residue treated by radiosurgery. Two patients with rhinopharyngeal carcinoma underwent palliative debulking. One metastatic melanoma that underwent GTR experienced remission. Two patients had postoperative cranial nerve palsy. No other complications were observed.

CONCLUSIONS

EEEA allows a direct access to the skull base. Through a minimal access, it limits the incidence of neurological morbidities. For midline epidural clival tumors, EEEA allows a total excision. It also offers an excellent access to the clival component of intradural lesions. A combined approach permits good tumor control with minimal complications.

[Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome): clinical manifestations and multidisciplinary management]

Hereditary hemorrhagic telangiectasia (HHT), or Osler- Weber-Rendu syndrome, is a rare genetic disorder with autosomal dominant inheritance, characterized by recurrent epistaxis, mucocutaneous telangiectasia and visceral arteriovenous malformations (AVMs), which may lead to severe complications. The diagnosis of HHT is often delayed due to the rarity of the disease, and the variety of clinical manifestations. The management of HHT includes systematic screening for visceral AVMs at regular intervals, preventive interventions to reduce the risk of complications, and symptomatic measures. A multidisciplinary standardized program in specialised centers may improve the management of patients with HHT.

Transthyrohyoid access to the larynx for endoscopic resection of early-stage glottic cancer

BACKGROUND

The effectiveness of transoral microsurgery for early-stage glottic cancer relies on the possibility to obtain adequate exposure of the lesion. The purpose of this study was to design a new surgical technique allowing efficient endoscopic removal of these tumors in patients with unsatisfactory transoral exposure.

METHODS

A minimal invasive access to the glottis, made through the thyrohyoid membrane and the preepiglottic space, was used for endoscopic resection of an early-stage glottic tumor in a patient with a medical history of previous radiotherapy and unsatisfactory endoscopic exposure of the lesion.

RESULTS

This approach provided excellent exposure of the glottis and allowed endoscopic resection with adequate surgical margins. The surgical procedure and the postoperative period were uneventful. Functional outcomes were back to baseline after 1 month.

CONCLUSION

This technique represents an attractive solution for patients presenting with early-stage glottic tumors that cannot be exposed transorally and have contraindications to alternative therapeutic procedures. © 2016 Wiley Periodicals, Inc. Head Neck 38:1286-1289, 2016.

Vestibular Schwannoma: The Evolution of Hearing and Tumor Size in Natural Course and after Treatment by LINAC Stereotactic Radiosurgery

OBJECTIVE

To review the natural course of tumor size and hearing during conservative management of 151 patients with unilateral vestibular schwannoma (VS), and to evaluate the same parameters for the part of the group (n = 84) who were treated by LINAC stereotactic radiosurgery (SRS).

METHODS

In prospectively collected data, patients underwent MRI and complete audiovestibular tests at inclusion, during the conservative management period and after SRS. Hearing was graded according to the Gardner-Robertson (GR) scale and tumor size according to Koos. Statistics were performed using Kaplan-Meier survival analysis and multivariate analyses including linear and logistic regression. Specific insight was given to patients with serviceable hearing.

RESULTS

During the conservative management period (mean follow-up time: 24 months, range: 6-96), the annual risk of GR class degradation was 6% for GRI and 15% for GR II patients. Hearing loss as an initial symptom was highly predictive of further hearing loss (p = 0.003). Tumor growth reached 25%. For SRS patients, functional hearing preservation was 51% at 1 year and 36% at 3 years. Tumor control was 94 and 91%, respectively.

CONCLUSION

In VS patients, hearing loss at the time of diagnosis is a predictor of poorer hearing outcome. LINAC SRS is efficient for tumor control. Patients who preserved their pretreatment hearing presented less hearing loss per year after SRS than before treatment, suggesting a protective effect of SRS when cochlear function can be preserved.

Stricture prevention after extended circumferential endoscopic mucosal resection by injecting autologous keratinocytes in the sheep esophagus

BACKGROUND

During the past decades, endoscopic mucosal resection (EMR) has been developed to treat early intramucosal esophageal cancers and dysplastic Barrett's esophagus. The primary drawback of this method is severe postsurgical esophageal stricture formation. The purpose of this preclinical study was to assess strategies for prevention of this major complication by injecting autologous keratinocytes in the EMR mucosal defect in the sheep model.

METHODS

Circumferential, 6-cm-long EMRs were performed in the esophagus of nine sheep. Autologous keratinocytes were harvested 2 weeks before EMR and cultured. Circumferential resection consisted of two opposite hemicircumferential mucosectomies allowing a widespread resection of 24 cm(2). Immediately after EMR, autologous keratinocytes were endoscopically injected in the mucosal defect. Animals were sacrificed after 6 months.

RESULTS

Circumferential EMRs were successfully performed in all animals. There were no intra- or postoperative complications. None of the animals developed strictures. All animals were sacrificed at 6 months as planned. Histological examinations showed fibrotic changes in 10 % (range 0-25 %) of the circumferential muscularis propria interna layer and 7.2 % (range 0-25 %) in the muscularis propria externa layer at the midportion of the EMR. No circumferential transmural fibrosis was identified.

CONCLUSIONS

Prevention of stricture formation after extensive (6-cm long) circumferential EMR of the sheep esophagus can be achieved by injecting autologous keratinocytes into the wound of the resected mucosal segment.

Standardizing the diagnosis of inhalation injury using a descriptive score based on mucosal injury criteria

INTRODUCTION

Inhalation injury is an important determinant of outcome in patients with major burns. However the diagnostic criteria remain imprecise, preventing objective comparisons of published data. The aims were to evaluate the utility of an inhalation score based on mucosal injury, while assessing separately the oro-pharyngeal sphere (ENT) and tracheobronchial tree (TB) in patients admitted to the ICU with a suspicion of inhalation injury.

METHODS

Prospective observational study in 100 patients admitted with suspicion of inhalation injury among 168 consecutive burn admissions to the ICU of a university hospital. Inclusion criteria, endoscopic airway assessment during the first hours. ENT/TB lesion grading was 1: oedema, hyperemia, hypersecretion, 2: bullous mucosal detachment, erosion, exudates, 3: profound ulcers, necrosis.

RESULTS

Of the 100 patients (age 42±17 years, burns 23±19%BSA), 79 presented an ENT inhalation injury ≥ENT1 (soot present in 24%): 36 had a tracheobronchial extension, 33 having a grade ≥TB1. Burned vibrissae: 10 patients "without" suffered ENT injury, while 6 patients "with" had no further lesions. Length of mechanical ventilation was strongly associated with the first 24 hrs' fluid resuscitation volume (p<0.0001) and the presence of inhalation injury (p=0.03), while the ICU length of stay was correlated with the %BSA. Soot was associated with prolonged mechanical ventilation (p=0.0115). There was no extubation failure.

CONCLUSIONS

The developed inhalation score was simple to use, providing a unified language, and drawing attention to upper airway involvement. Burned vibrissae and suspected history proved to be insufficient diagnostic criteria. Further studies are required to validate the score in a larger population.

Partial Cricotracheal Resection in Children Weighing Less than 10 Kilograms

OBJECTIVES: To assess the long-term outcome, safety, and efficacy of partial cricotracheal resection (PCTR) for subglottic stenosis in a group of children and infants weighing less than 10 kg at the time of the surgery.

STUDY DESIGN: Historical cohort study.

SETTING: Academic tertiary medical center.

SUBJECTS AND METHODS: Thirty-six children weighing less than 10 kg at the time of the surgery were compared to a group of 65 children who weighed more than 10 kg. The Kaplan Meier method and Cox regression were carried out to detect differences in decannulation time and rates and to examine the influence of various parameters (i.e., comorbidities, type of surgery, and complications requiring revision surgery) at the time of decannulation. Evaluation of the long-term outcome was based on questionnaires assessing breathing, voice, and swallowing.

RESULTS: Decannulation rate was 92 percent (33/36) for the group of children weighing less than 10 kg. No significant differences were found between the two body weight groups with respect to the aforementioned covariates. The median follow-up period was nine years (range, 1–23 yrs). Questionnaire responses revealed completely normal breathing and swallowing in 72 percent and 90 percent of the children, respectively. Seventy-one percent of the patients considered their voice to be rough or weak.

CONCLUSION: PCTR in infants and children weighing less than 10 kg is a safe and efficient technique with similar long-term results when compared to results seen in older and heavier children.

Proposal of a new classification for optimising outcome assessment following partial cricotracheal resections in severe pediatric subglottic stenosis

OBJECTIVE

Creation of a patent subglottic airway after partial cricotracheal resection (PCTR) may not always result in successful decannulation due to associated parameters such as co-morbidity and/or glottic involvement. We classified patients after incorporating these additional parameters into the original Myer-Cotton classification to assess whether this could better predict the outcome measures after PCTR.

METHODS

One hundred children with Myer-Cotton grade III or IV subglottic stenosis who underwent PCTR between 1978 and 2008 were identified from a prospectively collected database. The patients were classified into four groups based on the association of co-morbidity and/or glottic involvement. Delay in decannulation, revision open surgery and rates of decannulation were the outcome measures compared between the groups.

RESULTS

There were 68 children with Myer-Cotton grade III and 32 children with grade IV stenosis. Based on the new classification, there were 36 children with isolated SGS, 31 with associated co-morbidity, 19 with associated glottic involvement and 14 children with both co-morbidity and glottic involvement. A trend towards less optimal results was noticed with the association of co-morbidity and/or glottic involvement. Statistical significance was reached for maximum decannulation failure in the group with both co-morbidity and glottic involvement. Delayed decannulation significantly correlated in the group with associated glottic involvement.

CONCLUSION

This new classification is relatively simple and aimed at providing more accurate and uniform prognostic information to both patients and surgeons when dealing with the whole spectrum of severe SGS.