Free-flap reconstruction methods in head-and-neck oncologic surgery: A CROSS practice survey of members of the French GETTEC Head-and-Neck Tumor Study Group

OBJECTIVE

To survey practices concerning the use of anticoagulants and antiplatelets in microvascular free-flap reconstruction following oncological surgery of the head and neck.

METHODS

A survey of practices was carried out between September 2022 and March 2023. An online questionnaire was sent to members of the French GETTEC Head-and-Neck Tumor Study Group in all French centers practicing head-and-neck cancer surgery with reconstruction using microvascular free-flaps. The questionnaire asked surgeons about their practices regarding the use of intra- and postoperative anticoagulants and antiplatelets, preoperative management of comorbidities, and prevention of postoperative complications.

RESULTS

Sixty-one percent of the 38 respondents (23/38) used intraoperative intravenous heparin injection, associated to flap irrigation with heparin for 76% of surgeons (29/38) and/or a heparin solution bath for 37% (14/38). Postoperative anticoagulation was used by 95% of surgeons (36/38), and antiplatelets by 40% (15/38). Postoperatively, 40% (15/38) carried out monitoring using an implantable micro-Doppler probe, associated to analysis of clinical characteristics of the flap.

CONCLUSION

Reconstructive surgery using microvascular free-flaps involves numerous factors that can influence success. Prospective studies, particularly concerning the management of anticoagulants, could enable a national consensus on methods for free-flap reconstruction.

Increasing use of EQUATOR guidelines in the European Annals of Otorhinolaryngology, Head and Neck Diseases between 2020 and 2022: A SWiM review

OBJECTIVES

To evaluate the use of EQUATOR guidelines in scientific articles published in the European Annals of Otorhinolaryngology, Head and Neck Diseases between 2020 and 2022. The aim was also to translate the most widely used guidelines into French, in order to promote their dissemination and use in otorhinolaryngology and head and neck surgery.

METHOD

The SWiM guidelines were used. Articles published in the European Annals of Otorhinolaryngology, Head and Neck Diseases between January 1, 2020 and December 31, 2022 were retrieved from the PubMed bibliographic database. Editorials, Letters to the Editor and "What is your diagnosis" articles that did not meet any EQUATOR guidelines were excluded from the analysis.

RESULTS

Of the 149 eligible published articles, 21.5% (n=32/149) mentioned use of such a guideline. Guideline use by the European Annals of Otorhinolaryngology, Head and Neck Diseases author community progressed from 0% in 2020 to 8% in 2021 and 63% in 2022.

CONCLUSION

The analysis carried out in this article and the availability of the French version of the seven EQUATOR guidelines most widely used in the European Annals of Otorhinolaryngology Head & Neck Diseases could stimulate application and compliance by authors who submit their work to the journal of the French and international French-speaking societies of otorhinolaryngology.

Perception of endoscopic endonasal surgery training by French otolaryngology residents: A STROBE analysis of expectations

OBJECTIVES

To analyze the perception of endoscopic endonasal surgery training by French otolaryngology residents.

MATERIAL AND METHODS

A multicenter retrospective observational study was conducted from March to April 2023. Otolaryngology residents from 7 French regions filled out a 27-item questionnaire on their training in endoscopic endonasal surgery.

RESULTS

Out of 283 residents contacted, 126 (45%) filled out the questionnaire. Seventy-four (59%) had already partially or completely performed the surgeries specified in their diploma course. The level of mastery of the main steps of endonasal surgery and the level of autonomy were higher in the consolidation stage group than in the basic and advanced stages. Seventy residents (56%) felt they had gaps in their level of training. To improve training, 94 (75%) wished for more dissection sessions, surgical skills assessments each semester and simulation sessions. Eighty-nine (71%) felt they needed to find their own teaching aids and other methods to complete their training. One hundred and thirteen (90%) felt that the lack of funding available for congresses and training courses was detrimental.

CONCLUSION

This study highlighted the overall satisfaction of residents with their training in endoscopic endonasal surgery. They expressed a desire for more dissection, simulation and evaluation.

Risk factors for laryngeal lesions in adult acute respiratory distress syndrome: A STROBE-compliant French case-control study

INTRODUCTION

The global SARS-CoV-2 pandemic led to an increased incidence of post-intubation laryngeal injuries in patients with acute respiratory distress syndrome (ARDS). The primary objective of this study was to identify risk factors for symptomatic laryngeal lesions in patients with Covid-19-related ARDS. The secondary objective was to analyze the progression of these laryngeal lesions.

METHODS

A 21 month nested case-control study was conducted in 3 university hospital centers of the Hospices Civils de Lyon (France). Cases encompassed all patients intubated for Covid-19-related ARDS who presented symptomatic laryngeal pathology. The control group consisted of all patients enrolled during the same period for Covid-19-related ARDS without evidence of laryngeal lesions (no specific ENT intervention). Uni- and multi-variate analyses were performed to identify risk factors for the occurrence of laryngeal lesions.

RESULTS

Forty-nine patients were included in the case group and 50 in the control group. The only significant risk factor for symptomatic laryngeal injury was the number of reintubations, with an odds ratio of 5.08 (95% CI, 1.40-22.12; P=0.013). No other predictive factors were identified among the variables analyzed: obesity, number of prone sessions, self-extubation, duration of intubation and number of days of curarization.

CONCLUSION

The number of reintubations was the sole independent risk factor associated with the development of symptomatic laryngeal lesions in patients managed for Covid-19-related ARDS.

Perception of environmental issues in the head-and-neck surgery room: A preliminary study

OBJECTIVES

To assess the perception of environmental issues in head-and-neck surgery rooms and to compare the perception of priority environmental issues according to health professionals' age-group, initial training and role in the operating room.

METHODS

A multicenter descriptive observational study was conducted in January 2023, contacting health professionals working in the operating rooms of 5 French centers. An anonymous online questionnaire explored the perception of environmental issues according to age, initial training and role in the operating room.

RESULTS

Sixty-nine percent of the 387 persons contacted (267/387) completed the entire questionnaire. Ninety-six percent of respondents (256/267) said that they felt concerned about climate change issues and 85% (226/267) felt well-informed. Ninety-three percent (251/267) were willing to make environmental efforts in the operating room. Priorities were to improve waste recycling and reduce the amount of waste for 95% (251/267) and 97% (259/267) of respondents respectively. Those under 40 years of age tended to feel better informed about climate issues (76% [75/99] versus 60% [100/168]; P=0.010).

CONCLUSION

Our study showed that the vast majority of health professionals working in head-and-neck surgery rooms in France felt concerned about climate issues and were ready to make an effort. Nevertheless, it seems important to carry out information campaigns dedicated to these environmental issues.

Surgical and instrumental options for chronic rhinitis: A systematic review and PRISMA meta-analysis

BACKGROUND

There is no consensus on the role of surgery in the treatment of chronic rhinitis (CR). Should it be considered when nasal symptoms are not controlled by medical treatment? Various targets (turbinates and secretory nerves) and techniques (surgical, laser, cryotherapy, radiofrequency and phototherapy) have been reported, but benefit varies between reports. The aim of this systematic review and meta-analysis was to evaluate results of surgical and instrumental procedures in CR care.

METHODS

Two systematic reviews of the US National Library of Medicine, Cochrane Library, Web of Science and Embase databases were conducted in October 15, 2021 (registration numbers CRD42021284257 and CRD42021295227). A database watch was performed until submission of the manuscript. The review focuses on total nasal symptom score (TNSS) and quality of life (QoL) after treatment. All controlled studies reporting nasal surgery/instrumental procedures in adult patients with CR were included.

RESULTS

The database search yielded a total of 5628 articles; after eligibility screening, 2091 patients were included from 21 studies. QoL results favored surgery/instrumental procedures over medical treatment (SMD -1.27; 95% CI [-2.38; -0.16]; I2=97%), as did TNSS (SMD -1.40; 95% CI [-2.30; -0.50]; I2=98%). The small number of studies and their heterogeneity did not allow meta-regression to be performed.

CONCLUSION

This systematic review supports the use of surgical/instrumental procedures to improve nasal symptom score and QoL of adult patients with CR poorly controlled by medical treatment.

Recurrent peripartum alveolar soft-part sarcoma: Case report using CARE methodology

INTRODUCTION

Alveolar soft-part sarcoma (ASPS) is a rare malignant sarcoma with only a few cases reported in the sinus and head and neck region. It shows strong female predominance. Hormone-dependent recurrence was never reported.

CASE REPORT

A 35 year-old woman presented nasal cavity ASPS during her first pregnancy, middle-ear ASPS during the second, and a third ASPS in the sinus outside of any peripartum period, with unfavorable progression and metastasis, terminating in death.

DISCUSSION

Pathology analysis of the tumors showed positive immunolabeling for progesterone receptors in the two peripartum episodes. This was thus the first report of peripartum recurrence of ASPS with strong progesterone sensitivity, reinforcing the suspected biological link between ASPS and progesterone. This case report may be a preliminary finding suggesting progesterone blockers as a novel treatment for recurrent ASPS.

Deterioration experienced by French otolaryngology residents in their training during the COVID-19 pandemic: A STROBE analysis

OBJECTIVE

To evaluate the impact of the first three waves of COVID-19 on the academic and surgical training of ENT and Head and Neck Surgery residents in France.

MATERIAL AND METHODS

Observational, retrospective study. A 55-item survey of academic education and surgical training was sent to ENT residents in five major French regions (Île-de-France, Rhône-Alpes Auvergne, Occitanie, Grand Est, Grand Ouest) from August to October 2021.

RESULTS

Eighty-nine out of 135 residents (66%) responded. Two-thirds considered that surgical training was more affected than academic education, with reductions evaluated of 50-75%, 25-50% and 0-25% for the first three waves, respectively. Residents in Île-de-France, Rhône-Alpes Auvergne and Grand Est were the most affected by the first wave (75-100% reduction in surgical activity, in parallel to increased admissions). Otology, rhinology and functional exploration were the most affected, whereas pediatrics and oncology were spared. Seventy-one of the 89 residents (79.7%) felt that the first wave impacted their career, while this proportion decreased to 39.3% and 44.9% for the second and third waves, respectively.

CONCLUSION

The first wave of COVID-19, compared to the following two waves, severely impacted the surgical training of French ENT residents, especially in regions severely impacted by the pandemic, while academic education was relatively safeguarded by the implementation of e-learning alternatives.

Speech restoration with tracheoesophageal prosthesis after total laryngectomy: An observational study of vocal results, complications and quality of life

OBJECTIVES

To study voice prosthesis survival, complications, efficacy and impact on quality of life.

METHODS

A single-center observational study was performed in patients treated for squamous cell carcinoma of the larynx or hypopharynx by total (pharyngo)-laryngectomy between 2010 and 2015. Study data comprised: maximum phonation time (sec), number of and reasons for prosthesis exchanges (leakage through or around the prosthesis, expulsion or inclusion of the prosthesis), plus 2 quality of life questionnaires (QLQ-C30, QLQ-H&N35) and the Voice Handicap Inventory (VHI 30).

RESULTS

Forty-nine patients were included. The most common causes of prosthesis exchange were leakage through (73.2%) or around the prosthesis (18.5%). The median time between exchanges was 4 months. Global quality of life status on the QLQ-C30 was 63.5. Mean maximum phonation time was 7.4sec. Mean VHI was 46/120; 10 patients had a mild voice handicap, 12 moderate and 10 severe. No relation emerged between the number of prosthesis exchanges per year and quality of life. Voice handicap significantly decreased quality of life, with QLQ-C30 72.3 for the 22 patients with mild to moderate voice handicap and 44.2 for the 10 patients with severe voice handicap (P=0.001).

CONCLUSION

Voice restoration by tracheoesophageal prosthesis after total (pharyngo)-laryngectomy is a reliable technique that decreases voice handicap and, despite potentially serious complications, has little negative impact on quality of life.

[An atypical presentation of atherosclerosis in psoriasis: "Porcelain aorta"]

BACKGROUND

Several recent epidemiological studies have shown an increase in cardiovascular morbidity and mortality in patients with psoriasis; such increase is greater in the event of severe and early psoriasis.

PATIENTS AND METHODS

We report the case of a 42-year-old patient with severe skin psoriasis ongoing since childhood and presenting with porcelain aorta, a little-known sign of atherosclerosis. This is the first publication reporting this association.

DISCUSSION

Porcelain aorta results from atherosclerotic calcification of the aortic arch. For long asymptomatic, it can manifest itself in various complications. This observation highlights the importance of cardiovascular risk assessment and of screening for complications thereof in patients presenting psoriasis.

[Juvenile hyaline fibromatosis]

BACKGROUND

Juvenile hyaline fibromatosis and infantile systemic hyalinosis are two rare autosomal recessive diseases arising from mutation in the capillary morphogenesis factor-2 gene. They are characterized by accumulation of hyaline material, in the skin in the first instance and in other organs in the second. We describe a case of juvenile hyaline fibromatosis.

CASE REPORT

A 2-year-old girl presented gingival hyperplasia, skin papules, subcutaneous nodules and joints and bones lesion. A diagnosis of juvenile hyaline fibromatosis was suggested and this was confirmed by histopathology and genetic analyses. The patient presented frequent episodes of diarrhoea, which is evocative of infantile systemic hyalinosis.

DISCUSSION

This case clearly illustrates the wide phenotypic range of juvenile hyaline fibromatosis. Diagnosis must be made as soon as possible to avoid cosmetic and functional handicap.

A family outbreak due to an emm-type 11 multiresistant strain of Streptococcus pyogenes

Four cases of Streptococcus pyogenes infection due to an emm-type 11 strain, including one with a fatal outcome, occurred within a seven-member family. All strains shared biotype 5, pyrogenic exotoxin genes speB and speC, and resistance to kanamycin, tetracycline, macrolides and lincosamides. The identity of SmaI pulsed-field gel electrophoresis patterns confirmed their clonal origin. This highlights the ability of S. pyogenes to spread rapidly among family members. This first report of a family outbreak due to emm11 S. pyogenes reinforces the importance of surveillance of close family contacts of individuals with invasive streptococcal disease, and provides further support for antibiotic prophylaxis among the elderly.

[Lepromatous leprosy revealed by a swollen hands syndrome]

Osteoarticular pathology in leprosy is common and described at all stages, but rarely as the most evident clinical manifestation. We report a case of borderline lepromatous leprosy with initial and disabling hands edema. The swollen hands syndrome is probably due to chronic Mycobacterium leprae tenosynovitis.

[Splenic lymphoma with villous lymphocytes revealed by purpura pigmentosa progressiva associated with cryoglobulinemia and chronic hepatitis C infection]

BACKGROUND

Splenic lymphoma with villous lymphocytes is occasionally associated with chronic hepatitis C infection. Antiviral hepatitis C therapy has been recently reported to be efficacious against splenic lymphoma with villous lymphocytes. We report a new case revealed by cutaneous symptoms.

CASE REPORT

A 53-year-old patient with arthritis and neuropathy of the lower limbs consulted for vascular purpura on both legs. The blood picture showed an increase in villous lymphocytes leading to a diagnosis of splenic lymphoma with villous lymphocytes. Histologic examination of a cutaneous biopsy specimen showed thrombosis of the superficial dermal vessels, associated with cryoglobulinemia with renal and neurologic failure, a satellite of hepatitis C virus infection. The patient was treated with interferon, ribavirin and plasmapheresis.

DISCUSSION

Vascular purpura, often associated with cryoglobulinemia, may reveal chronic hepatitis C infection. The efficacy of interferon and ribavirin treatment for splenic lymphoma with villous lymphocytes associated with hepatitis C infection has already been documented, and results in remission of cryoglobulinemia and lymphoma as well a eradication of viral load in 78% patients.

[Cerium-induced granulomatous dermatitis]

BACKGROUND

The presence of inorganic foreign bodies in granulomatous cutaneous lesions is not infrequent. In this paper, we describe the first case of cerium-induced cutaneous granulomatous dermatitis.

CASE REPORT

A 57-year-old woman seriously burned four years ago presented with papulonodular lesions affecting only the burned areas treated with topical cerium nitrate-silver sulfadiazine cream (Flammacérium). Biopsies revealed sarcoidal granuloma associated with exogenous particles. Electron probe X-ray microanalysis demonstrated a high cerium content. Screening for systemic sarcoidosis was negative. The patient was treated with hydroxychloroquine. After four months of follow-up, clinical and histological evidence of decreased infiltrate was noted.

DISCUSSION

Cerium nitrate-silver sulfadiazine cream (Flammacérium) is widely used for the topical treatment of burns. The main effect of cerium is to create superficial calcification, which decreases wound colonization and prevents the formation of granulation tissue (no hypertrophic scar formation) in burns. Prior to our case, no cutaneous side-effects of cerium had been encountered. Inoculation of foreign matter may or may not induce granuloma formation or sarcoidosis in different subjects, according to their immunologic status. The favorable outcome in this case could in fact be due to a change in the pattern of cytokinin production (TH1=> TH2) rather than the effects of hydroxychloroquine therapy.

[Neutrophilic dermatosis of the hands. A localized subset of Sweet's syndrome: 3 cases]

INTRODUCTION

The term "pustular vasculitis of the hands" described by Strutton for an acute eruption of the hands was recently revisited. "Neutrophilic dermatosis of the hands" has been preferred. We observed 3 new cases.

OBSERVATIONS

Two women and a man, without notable past history, consulted for an acute and painful eruption of both hands with fever. Clinical examination showed erythematous papular or nodular or bullous lesions developed on thenar and hypothenar eminences, and on the finger. Histological findings were predominantly neutrophilic infiltration in the dermis, papillary dermal edema, with or without the presence of leukocytoclastic vasculitis. Diagnosis was Sweet's syndrome. No disease was associated. With indometacine (50-100 mg per day), all the lesions disappeared rapidly without relapse.

DISCUSSION

These 3 cases add to 19 other cases (review of literature) which confirm the existence of a homogenous entity that we think it a localized subset of Sweet's Syndrome, with a fast healing. Our observations are specific by the first localization on thenar and hypothenar eminences and by the excellent response to treatment with a non steroidal antiinflammatory agents such indometacine (50-100 mg per day). This treatment could be proposed as a first line therapy.

[Dermatological aspects in the risk of biological warfare]

The possible cutaneous manifestations of infectious biological warfare are multiple and vary depending on the agent used. An ulcerous and/or necrotic syndrome and/or regional lymphadenitis syndrome are possible with anthrax, tularaemia, bubonic plague and emission of trichotecene mycotoxins. A vesiculo-pustular syndrome with fever is provoked by smallpox, melioidosis and glanders. A purpural and/or haemorrhagic syndrome is seen during haemorrhagic fever viruses and septicaemic plague. These cutaneous manifestations are excellent markers that orient and alert when they occur in a context of a situation at risk, when several cases are observed in a usually non-exposed population and with extra-dermatological syndromes. They permit the early initiation of treatment.