Cytopathological analysis of salivary gland cancer: REFCOR recommendations by the formal consensus method

OBJECTIVE

To determine the indications for fine-needle cytology and the modalities of frozen section pathological analysis in the management of salivary gland cancer.

MATERIAL AND METHODS

The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group who drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group according to the formal consensus method.

RESULTS

Fine-needle cytology is recommended as part of the diagnostic work-up for a major salivary gland tumor suspicious for malignancy. Fine-needle cytology should be performed after MRI to avoid artifacts. Frozen section analysis is recommended to confirm the malignant nature of the tumor, to adapt the extent of resection and to indicate neck dissection. Whenever possible, the entire tumor and adjacent salivary or periglandular tissue should be sent for frozen section analysis.

CONCLUSION

Fine-needle cytology and frozen section analysis play an essential role in the management of salivary gland cancers.

Laryngeal graft after total laryngectomy in humans: A SWiM analysis

Evaluation of the results of laryngeal transplantation (LT) in humans. Analysis of 3 bibliographic databases with the keywords "larynx, transplantation, autograft". In total, 626 abstracts were read and 25 articles selected. The main objective was to analyze the characteristics of laryngeal transplant patients. The accessory objectives comprised analysis of operative technique, immunosuppressive treatment and results. Four articles were selected for analysis. Two patients were transplanted after total laryngectomy for laryngeal carcinoma and 2 after laryngeal trauma. Three of the 4 patients had true transplantation with arterial, venous and neural microanastomosis. Two patients were decannulated and the tracheostomy tube was maintained in the other 2. Three of the 4 patients had good-quality phonation and could feed without a gastric tube. One patient died of carcinoma progression and 1 patient had to be explanted 14 years after transplantation. The number of LTs reported is too small for scientific determination of the place of this intervention in laryngology. The published results could, at first sight, suggest that the future of LT is uncertain. However, several elements, also suggest that otolaryngologists should continue to take an interest in this technique.

Diagnostic imaging of salivary gland cancers: REFCOR recommendations by the formal consensus method

OBJECTIVE

To define the indications for each imaging modality in the screening, characterization, extension and follow-up of salivary gland tumors.

MATERIAL AND METHODS

The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group who drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group, according to the formal consensus method.

RESULTS

If a swelling of a salivary gland is palpable for 3 weeks, an ultrasound scan is recommended to confirm a tumoral lesion and rule out differential diagnoses. For a salivary gland tumor, MRI is recommended with diffusion-weighted and dynamic contrast-enhanced techniques. In the case of histologically proven malignancy or a highly suspicious lesion, a CT scan of the neck and chest is recommended to assess the tumor, lymph nodes and metastases. FDG-PET is not currently recommended in routine clinical practice for initial diagnosis, assessment of extension, evaluation of response to treatment, staging of recurrence, or follow-up of salivary gland tumors.

CONCLUSION

Assessing salivary tumors is based on MRI. Extension assessment is based on neck and chest CT.

Writing in the European Annals of Otorhinolaryngology Head & Neck Diseases. Dos and Don'ts!

Too many articles are still rejected by scientific medical journals due to lack of preparation of the manuscript and of knowledge of the modern editorial rules that govern scientific medical writing. Therefore, the editorial board of the European Annals of Otorhinolaryngology Heads & Neck Diseases summarized studies published by its members since 2020 in the columns of the scientific journal of the French Society of Otorhinolaryngology and the International Francophone Society of Otorhinolaryngology and data from the PubMed indexed literature dedicated to scientific medical writing in otolaryngology in the 21st century. The authors hope that this review, in the form of a list of "Dos and Don'ts", will provide authors with a practical guide facilitating publication of rigorous, reproducible and transparent scientific studies, in accordance with the movement toward better science that society as a whole has been fighting for since the beginning of this century.

Surgery of sublingual and minor salivary gland cancer: REFCOR recommendations by the formal consensus method

OBJECTIVE

To determine the indications and modalities for resection in the management of primary sublingual and minor salivary gland cancer, and the specific features of each primary location.

MATERIAL AND METHODS

The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group who drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group, according to the formal consensus method.

RESULTS

Histological evidence (submucosal biopsy) is recommended before surgical treatment of minor salivary gland carcinoma. Surgical treatment is recommended, with optimal oncologic margins, adapted to anatomical factors, histologic type and grade and functional consequences, with reconstruction if necessary.

CONCLUSION

Treatment of primary minor salivary and sublingual gland cancer is surgical, with wide resection margins. The modalities of resection and reconstruction are highly dependent on tumor location, extension and histologic type.

Systemic therapies for salivary gland carcinoma (excluding adenoid cystic carcinoma): REFCOR recommendations by the formal consensus method

OBJECTIVE

To determine the therapeutic indications for systemic medical treatment in the management of salivary gland carcinoma (excluding adenoid cystic carcinoma) according to the clinical situation.

MATERIALS AND METHODS

The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group who drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group, according to the formal consensus method.

RESULTS

Salivary gland carcinoma is rare and there is currently insufficient evidence to indicate chemotherapy at the localized stage. At the metastatic stage, initial management can be based on a phase of monitoring for indolent disease. Some histological subtypes (salivary duct carcinoma and adenocarcinoma) are more aggressive and require systemic treatment from the outset. To guide systemic treatment, it is recommended to perform immunohistochemistry and molecular biology analyses (overexpression of HER2 and androgen receptors, NTRK fusion, next-generation sequencing).

CONCLUSION

Salivary gland carcinoma is a rare tumor for which there are currently few effective medical treatments. It is therefore recommended to include patients in clinical trials.

Surgery of major salivary gland cancers: REFCOR recommendations by the formal consensus method

OBJECTIVE

To determine the role of surgery of the primary tumor site in the management of primary major salivary gland cancer.

MATERIAL AND METHODS

The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group, which drafted a non-systematic narrative review of the literature published on Medline, and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group, according to the formal consensus method.

RESULTS

Treatment of salivary gland tumor is mainly surgical. The gold standard for parotid cancer is a total parotidectomy, to obtain clear margins and remove all intraparotid lymph nodes. For low-grade tumors, partial parotidectomy with wide excision of the tumor is acceptable in the case of postoperative diagnosis on definitive histology. In the event of positive margins on definitive analysis, revision surgery should be assessed for feasibility, and performed if possible.

CONCLUSION

Treatment of primary major salivary gland cancer is based on surgery with clear resection margins, as far away as possible from the tumor. The type of surgery depends on tumor location, pathologic type and extension.

Lymph node surgery for salivary gland cancer: REFCOR recommendations by the formal consensus method

OBJECTIVE

To determine the indications for neck dissection in the management of parotid, submandibular or minor salivary gland cancers depending on the clinical situation: i.e., clinical lymph node involvement (cN+) or not (cN0); low or high risk of occult nodal metastasis; diagnosis of malignancy before, during or after surgery.

MATERIAL AND METHODS

The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group which drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group according to the formal consensus method.

RESULTS

In cN+ salivary gland cancer, ipsilateral neck dissection is recommended. In cN0 salivary gland cancer, ipsilateral neck dissection is recommended, except for tumors at low risk of occult nodal metastasis. If definitive pathology reveals a high risk of occult nodal involvement, additional neck treatment is recommended: ipsilateral neck dissection or elective nodal irradiation.

CONCLUSION

The rate of occult lymph node involvement, and therefore the indication for elective neck dissection, depends primarily on the pathologic grade of the salivary gland cancer.

Radiotherapy for salivary gland cancer: REFCOR recommendations by the formal consensus method

OBJECTIVE

To determine the indications for radiotherapy in salivary gland cancer and to specify the modalities and target radiation volumes.

MATERIAL AND METHODS

The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group which drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group, according to the formal consensus method.

RESULTS

Postoperatively, radiotherapy to the primary tumor site±to the lymph nodes is indicated if one or more of the following adverse histoprognostic factors are present (risk>10% of locoregional recurrence): T3-T4 category, lymph node invasion, extraglandular invasion, close or positive surgical margins, high tumor grade, perineural invasion, vascular emboli, and/or bone invasion. Intensity-modulated radiation therapy (IMRT) is the gold standard. For unresectable cancers or inoperable patients, carbon ion hadrontherapy may be considered.

CONCLUSION

Radiotherapy in salivary gland cancer is indicated in postoperative situations in case of adverse histoprognostic factors and for inoperable tumors.

Post-treatment monitoring of salivary gland cancer: REFCOR recommendations by the formal consensus method

OBJECTIVE

To determine the frequency and modality of post-treatment monitoring of primary salivary gland cancer.

MATERIAL AND METHODS

The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group who drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group, according to the formal consensus method.

RESULTS

Clinical monitoring should be adapted to the risk of recurrence: initially every 3 months and progressively spaced out, becoming annual after 5 years. Post-treatment head and neck and chest imaging is recommended at 3 months. Local and regional monitoring can then be carried out yearly or twice yearly with contrast-enhanced head and neck imaging. An annual chest CT scan is recommended for high-grade tumors. For lesions at high risk of late recurrence, very prolonged annual surveillance (up to 15 years) is recommended, including screening for pulmonary metastases.

CONCLUSION

Given the wide range of malignant salivary gland tumors, the modalities and frequency of post-treatment monitoring must be adapted to the expected course of the disease.

Carl Gussenbauer and the first artificial larynx after total laryngectomy

The aim of this historical vignette is to delve into the description and use of the first artificial larynx, developed by Carl Gussenbauer, and used after Theodor Billroth's first total laryngectomy, performed on December 31, 1873.

Keys for successful publication in Eur Ann Otorhinolaryngol Head Neck Dis: A STROBE analysis of peer reviews of articles submitted in 2020-2021

OBJECTIVE

To evaluate reviewing and editorial decision for articles submitted to the European Annals of Otorhinolaryngology Head & Neck Diseases.

MATERIALS AND METHODS

A retrospective analysis was made of reviewers' comments on 1,133 scientific articles (700 original articles, 96 literature reviews, and 337 case reports), originating from 69 countries, consecutively submitted on-line between January 1st, 2020 and December 31st, 2021. The main objective was to document the acceptance rate and decision time. Accessory objectives were to synthesize the main comments and to screen for correlations between acceptance and the main characteristics of first authors, articles and reviewers' comments.

RESULTS

In total, 4.1% of submitted articles were accepted. Median decision time differed significantly (P<0.0001), at 1 month in case of refusal and 4 months in case of acceptance. Reviewers mentioned failure to adhere to the journal's authors' guide, to use the appropriate EQUATOR guidelines and to adopt the recommended P<0.005 significance threshold in 94.8%, 54.2%, and 39.9% of cases, respectively. On multivariate analysis, 3 variables significantly impacted acceptance, which increased from 1.3% to 44.6% (P<0.0001) when an appropriate EQUATOR guideline was used and from 0.3% to 57.4% (P<0.0001) when the significance threshold was set at P<0.005, and decreased from 10.5% to 1.1% (P=0.0001) when the article did not originate from a French-speaking country (member of the Francophonie organization).

CONCLUSION

Adhesion to modern scientific medical writing rules increased acceptance rates for articles in the European Annals of Otorhinolaryngology Head & Neck Diseases. Teaching modern scientific medical writing needs to be enhanced in otorhinolaryngology.

Guidelines of the French Society of ENT (SFORL): Drug-induced sleep endoscopy in adult obstructive sleep apnea syndrome

OBJECTIVES

To determine the indications, anesthesiological and surgical procedure and interest of drug-induced sleep endoscopy in the treatment of adult obstructive sleep apnea syndrome.

DESIGN

A redactional committee of 17 experts was set up. Conflicts of interest were disclosed and followed up throughout the process of drawing up the guidelines. The work received no funding from any firm dealing in health products (drugs or devices). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was applied to assess the quality of the data on which the guidelines were founded. It was stressed that strong recommendations should not be made on the basis of poor-quality or insufficient data.

METHODS

The committee studied 29 questions on 5 topics: indications and contraindications, anesthetic technique, surgical technique, interpretation and reporting of results, and management guided by results.

RESULTS

Expert review and application of the GRADE method led to 30 guidelines: 10 with high level of evidence (Grade 1+ or 1-), 19 with low level (GRADE 2+ or 2-) and 1 expert opinion.

CONCLUSION

Experts fully agreed on the strong guidelines formalizing the indications and modalities of drug-induced sleep endoscopy for adult obstructive sleep apnea syndrome.

Radiotherapy of salivary gland tumours

Primary tumours of the salivary glands account for about 5 to 10% of tumours of the head and neck. These tumours represent a multitude of situations and histologies, where surgery is the mainstay of treatment and radiotherapy is frequently needed for malignant tumours (in case of stage T3-T4, nodal involvement, extraparotid invasion, positive or close resection margins, histological high-grade tumour, lymphovascular or perineural invasion, bone involvement postoperatively, or unresectable tumours). The diagnosis relies on anatomic and functional MRI and ultrasound-guided fine-needle aspiration for the diagnostic of benign or malignant tumors. In addition to patient characteristics, the determination of primary and nodal target volumes depends on tumor extensions and stage, histology and grade. Therefore, radiotherapy of salivary gland tumors requires a certain degree of personalization, which has been codified in the recommendations of the French multidisciplinary network of expertise for rare ENT cancers (Refcor) and may justify a specialised multidisciplinary discussion. Although radiotherapy is usually recommended for malignant tumours only, recurrent pleomorphic adenomas may sometimes require radiotherapy based on multidisciplinary discussion. An update of indications and recommendations for radiotherapy for salivary gland tumours in terms of techniques, doses, target volumes and dose constraints to organs at risk of the French society for radiotherapy and oncology (SFRO) was reported in this article.

Surgical navigation in parotid sialolith extraction

Posterior parotid lithiasis may in some cases require a combined surgical approach associating sialendoscopy to an external intraoral or transfacial approach. This single-center retrospective study describes the surgical technique for parotid lithiasis extraction by a combined external and sialendoscopic approach with the help of CT-navigation. Five patients were included between November 2014 and July 2020. The sialolith was extracted in 100% of cases. Navigation and transillumination localizations matched consistently. No patients showed postoperative facial paresis. At 2 to 21 months' follow-up, there was no recurrence of sialolithiasis. Navigation can be a complement to transillumination, improving surgical comfort and safety, but does not replace first-line sialendoscopy. Visual control is required whenever possible after extraction. In combined procedures, it enables accurate identification of parotid sialoliths. In case of impassable stenosis, it could be a therapeutic alternative to parotidectomy.

Transoral robotic removal of submandibular sialolith combined with sialendoscopic assistance

Treatment of symptomatic impacted and palpable submandibular lithiasis generally involves a combined transoral and sialendoscopic approach with an excellent success rate, and a low morbidity. Nevertheless, the approach of proximal or hilar lithiasis may in some cases represent a real challenge and cause major surgical discomfort, which could increase the risk of damage to the lingual nerve. This article details the surgical technique and advantages of submandibular lithiasis removal by transoral robotic surgery combined with sialendoscopy, together with a case video.

Narrow-Band Imaging in oncologic otorhinolaryngology: State of the art

OBJECTIVES

To describe the diagnostic performance of Narrow Band Imaging (NBI) combined with White Light Imaging (WLI) in the diagnosis of mucosal lesions at each location of the upper aerodigestive tract, for detection of primary tumor in case of carcinoma of unknown primary, for determination of intraoperative resection margins, and to describe its main diagnostic pitfalls.

MATERIAL AND METHODS

A PubMed search was carried out according to the PRISMA method.

RESULTS

Four hundred and seventy-seven articles published between 2007 and 2020 were identified, 133 of which met the study inclusion criteria and were assessed.

CONCLUSION

The current literature seems to support the use of NBI in diagnosis and/or follow-up of (pre-)malignant head & neck tumors, and in the determination of intraoperative resection margins.

Guidelines of the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL), part I: Primary treatment of pleomorphic adenoma

INTRODUCTION

The authors present the guidelines of the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL) for the diagnosis and treatment of pleomorphic adenoma (PA) of the salivary glands.

METHOD

A review of the literature was performed by a multidisciplinary task force. Guidelines were drafted based on the articles retrieved and the workgroup members' individual experience. Guidelines were graded A, B, C or expert opinion by decreasing level of evidence.

RESULTS

In clinically suspected salivary gland PA, MRI should be performed, including head and neck lymph node levels. Fine needle aspiration cytology is particularly recommended for tumours difficult to characterise by MRI. Frozen section biopsy should be performed to confirm diagnosis and adapt the surgical procedure in case of intraoperative findings of malignancy. Complete resection of the parotid PA should be performed en bloc, including margins, when feasible according to tumour location, while respecting the facial nerve. Enucleation (resection only in contact with the tumour) is not recommended. For the accessory salivary and submandibular glands, complete en bloc resection should be performed.

Guidelines of the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL), part II: Management of recurrent pleomorphic adenoma of the parotid gland

INTRODUCTION

The authors present the guidelines of the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL) for the management of recurrent pleomorphic adenoma (RPA) of the parotid gland.

METHOD

A review of the literature was performed by a multidisciplinary task force. Guidelines were drafted, based on the articles retrieved and the work group members' individual experience. There were then read and re-edited by an independent reading group. The proposed recommendations were graded A, B or C on decreasing levels of evidence.

RESULTS

Complete resection under neuromonitoring is recommended in case of RPA. The risks of progression and malignant transformation, which are higher the younger the patient, have to be taken into consideration. The risk of functional sequelae must be explained to the patient. MRI is recommended ahead of any surgery for parotid RPA, to determine extension and detect subclinical lesions. Radiotherapy should be considered in case of multi-recurrent pleomorphic adenoma after macroscopically complete revision surgery at high risk of new recurrence (microscopic residual disease), in case of RPA after incomplete resection, and in non-operable RPA.

French Society of ENT (SFORL) guidelines. Management of acute Bell's palsy

AQFThe authors present the guidelines of the French Society of ENT and Head and Neck Surgery (SFORL) regarding the management of Bell's palsy in adults. After a literature review by a multidisciplinary workgroup, guidelines were drawn up based on retrieved articles and group-members' experience, then read over by an independent group to edit the final version. Guidelines were graded A, B, C or "expert opinion" according to decreasing level of evidence. Thorough ENT and neurological clinical examination is recommended in all patients presenting with peripheral facial palsy to confirm diagnosis of Bell's palsy. MRI with gadolinium enhancement should explore the entire course of the facial nerve, if possible within the first month. ENMG should be performed to assess prognosis for recovery. In confirmed Bell's palsy, corticosteroid therapy should be implemented as early as possible (ideally within 72h) at a dose of 1mg/kg/day for 7-10 days. Antiviral therapy should be associated to steroids in patients with severe and early-onset disease and in Ramsay-Hunt syndrome. Isolated antiviral therapy is not recommended. To date, there is no evidence that surgical facial nerve decompression provides benefit.

Consensus français sur la pratique de la chirurgie oncologique ORL pendant la pandémie de COVID-19

Dans le contexte de la pandémie de COVID-19, des conseils spécifiques semblent nécessaires concernant la prise en charge des patients atteints de cancers ORL. La règle est de limiter au maximum le flux de patients afin de réduire les risques de contamination par le virus SARS-Cov-2 aussi bien des patients que du personnel soignant, particulièrement exposé en ORL. L’objectif est de limiter le risque de perte de chance pour le patient et d’anticiper le flux de patients atteints de cancers à traiter à la fin de l’épidémie, en tenant compte du degré d’urgence, de la lourdeur de la chirurgie, du risque de contamination de l’équipe soignante (trachéotomie) et de la situation locale (saturation ou non de l’hôpital et des services de réanimation).

French consensus regarding precautions during tracheostomy and post-tracheostomy care in the context of COVID-19 pandemic

Tracheostomy post-tracheostomy care are regarded as at high risk for contamination of health care professionals with the new coronavirus (SARS-CoV-2). Considering the rapid spread of the infection, all patients in France must be considered as potentially infected by the virus. Nevertheless, patients without clinical or radiological (CT scan) markers of COVID-19, and with negative nasopharyngeal sample within 24h of surgery, are at low risk of being infected. Instructions for personal protection include specific wound dressings and decontamination of all material used. The operating room should be ventilated after each tracheostomy and the pressure of the room should be neutral or negative. Percutaneous tracheostomy is to be preferred over surgical cervicotomy in order to reduce aerosolization and to avoid moving patients from the intensive care unit to the operating room. Ventilation must be optimized during the procedure, to limit patient oxygen desaturation. Drug assisted neuromuscular blockage is advised to reduce coughing during tracheostomy tube insertion. An experienced team is mandatory to secure and accelerate the procedure as well as to reduce risk of contamination.

French consensus on management of head and neck cancer surgery during COVID-19 pandemic

In the context of the current pandemic, there is a need for specific advice concerning treatment of patients with Head and Neck cancers. The rule is to limit as much as possible the number of patients in order to reduce the risks of contamination by the SARS-Cov-2 virus for both patients and the caregivers, who are particularly exposed in ENT. The aim is to minimize the risk of loss of opportunity for patients and to anticipate the increased number of cancer patients to be treated at the end of the pandemic, taking into account the degree of urgency, the difficulty of the surgery, the risk of contaminating the caregivers (tracheotomy) and the local situation (whether or not the hospital and intensive care departments are overstretched).

COVID-19 and rhinology, from the consultation room to the operating theatre

The purpose of this article is to give rhinologists advice on how to adapt their standard practice during the COVID-19 pandemic. The main goal of these recommendations is to protect healthcare workers against COVID-19 while continuing to provide emergency care so as to prevent loss of chance for patients. We reviewed our recommendations concerning consultations, medical prescriptions and surgical activity in rhinology.

Oncologic outcomes, prognostic factor analysis and therapeutic algorithm evaluation of head and neck mucosal melanomas in France

BACKGROUND

Head and neck mucosal melanoma (HNMM) is aggressive and rare, with a poor prognosis because of its high metastatic potential. The two main subtypes are sinonasal (sinonasal mucosal melanoma [SNMM]) and oral cavity (oral cavity mucosal melanoma [OCMM]). Consensual therapeutic guidelines considering the primary tumour site and tumour-node-metastasis (TNM) stage are not well established.

MATERIAL & METHODS

Patients with HNMM from the prospective national French Rare Head and Neck Cancer Expert Network database between 2000 and 2017 were included. Clinical characteristics, treatment modalities, outcomes and prognostic factors were analysed.

RESULTS

In total, 314 patients were included. The 5-year overall survival (OS) and progression-free survival (PFS) rates were 49.4% and 24.7%, respectively, in the surgery group; no long-term survivors were observed when surgery was not feasible. Moreover, even after surgery, a high recurrence rate was reported with a median PFS of 22 months. In multivariate analysis, Union for International Cancer Control (UICC) stage and tumour site correlated with PFS and OS. Postoperative radiotherapy (PORT) improved the PFS but not OS in patients with small (T3) SNMM and OCMM tumours. Nodal involvement was more frequent in patients with OCMM (p < 10^-4), although, as in SNMM, it was not a significant prognostic predictor.

CONCLUSION

Even early HNMM was associated with poor oncologic outcomes due to distant metastases despite surgical resection with clear margins. Lymph node metastases had no impact on the prognosis, suggesting treatment de-escalation in cervical node management. PORT might be useful for local control.

Assessment of swallowing function after circumferential pharyngolaryngectomy. A multicenter study by the GETTEC group

OBJECTIVE

Circumferential pharyngolaryngectomy is performed for advanced pharyngeal tumor or in a context of postradiation recurrence. Several free or pedicle flaps have been described for pharyngeal defect reconstruction, with choice at the surgeon's discretion. The aim of this study was to evaluate long-term swallowing function according to the type of flap used for reconstruction.

MATERIAL AND METHOD

A multicenter retrospective study was conducted from January to September 2016 within the French GETTEC head and neck tumor study group. All patients in remission after circumferential pharyngolaryngectomy were included and filled out the Deglutition Handicap Index (DHI) questionnaire and underwent swallowing function fiberoptic endoscopy assessment. 46 patients (39 men, 7 women) were included. Reconstruction used a tubularized forearm free flap (FFF group) in 19 cases, pectoralis major myocutaneous flap (PMMF group) in 15 cases and free jejunum flap (FJF group) in 12 cases.

RESULTS

Mean DHI was 24: 20 in the FFF group, 23 in the FJF group and 25 in the PMMF group, without significant differences. 27 patients had normal swallowing, 9 mixed diet, 8 liquid diet and 3 were fed by gastrostomy. On endoscopy, free flaps (FJF and FFF) were associated with significantly greater rates of normal swallowing of saliva and yogurt than in the PMMF group (P=0.04).

CONCLUSION

Type of flap reconstruction after circumferential pharyngolaryngectomy had no significant impact on postoperative swallowing function assessed on the self-administered DHI questionnaire.

Transoral robotic surgery of the tongue base for obstructive sleep apnea: Preliminary results

INTRODUCTION

Obstructive sleep apnea syndrome (OSAS) is a major public health issue. Robotic tongue-base reduction surgery is being developed, but needs assessment. The present study reports clinical and polygraphic results at 6 months' follow-up.

METHOD

Single-center prospective study of 8 patients undergoing transoral robotic surgery (TORS) for severe OSAS.

RESULTS

Mean age was 47 years. M/F sex ratio was 5:3. Initial body-mass index ranged from 18 to 35kg/m². Mean Epworth score was 12. Mean preoperative apnea-hypopnea index (AHI) was 47 (range, 36-60). At 6 months, only 1 patient did not meet usual success criteria (AHI<20 with>50% decrease); 2 patients had residual AHI between 10 and 20; the other 5 had non-significant event rates.

CONCLUSION

TORS tongue-base reduction showed promising results, which need confirmation on long-term multicenter studies.

Transnasal Endoscopic Sphenopalatine Artery Ligation Compared With Embolization for Intractable Epistaxis: A Long-term Analysis

Background Transnasal endoscopic sphenopalatine artery ligation (TESPAL) and selective embolization both provide excellent treatment success rate in the management of intractable epistaxis. Few long-term studies comparing these approaches have been previously published. Recommendations often present these techniques as alternatives, but there is no clear consensus. Objective The purpose of this study was to evaluate and compare the clinical efficacy of sphenopalatine artery ligation versus embolization to control intractable epistaxis. Methods We performed a retrospective study including all patients referred to our tertiary medical center for severe epistaxis and treated by surgical ligation and/or embolization. The patients were classified into 2 groups: those who underwent TESPAL only and those who underwent endovascular embolization only. We evaluate and compare long-term clinical outcomes after surgical ligation or embolization for the control of intractable epistaxis in terms of effectiveness (recurrence rate) and safety (complication rate). Results Forty-one procedures of supraselective embolization and 39 procedures of surgical ligation for intractable epistaxis are reported and analyzed. No significant difference was observed between the groups in terms of demographic factors, comorbidities, or average length of hospital stay. The 1-year success rate was similar (75%) in both groups. Complications (minor and/or major) occurred in 34% cases in the embolization group and in 18% in the surgical group ( P = .09, ns). Bilateral embolization including facial artery was the only treatment method associated with a significant risk of complications ( P = .015). Conclusion TESPAL seems to provide a similar control rate with a decrease in the number of complications compared to selective embolization in the context of intractable epistaxis. Further studies are required.

Ultrasound-guided fine-needle capillary cytology of parotid gland masses coupled with a rapid-on-site evaluation improves results

OBJECTIVE OF THE STUDY

To test whether a direct-on-site microscopic examination of fresh, unstained puncture slides by the radiologist decreases the rate of false-negative cases on ultrasound-guided fine-needle cytology of parotid gland masses.

PATIENTS

Thirty parotid gland masses from 28 patients were punctured under ultrasound guidance. The same group was used as its control group.

METHODS

After one or two passes, the material was spread on slides and air-dried (control group, without microscopic examination). For the study group, it was thus analyzed unstained under the microscope. A sample was considered adequate if at least six clusters of parotid cells were found per slide on at least two slides. For the study group, new punctures were obtained and slides prepared until this condition was fulfilled.

RESULTS

Of the 30 evaluated masses, 100% benefited from a cytological diagnosis after microscopy. Twenty-four were adequate in the control group, while 30 were adequate in the study group. The maximum number of punctures to obtain an adequate sample was six. On-site direct microscopy significantly increased the number of adequate specimens by 20% (P=0.03, CI [1.63-20%]).

CONCLUSION

Direct and systematic examination of slides by a radiologist avoided the risk of false-negative results caused by having insufficient sample material.

Transoral robotic surgery for squamous cell carcinomas of the posterior pharyngeal wall

Posterior pharyngeal wall squamous cell carcinomas (SCCs) are rare and have an associated poor prognosis. Progress in transoral resection techniques, in particular, transoral robotic surgery (TORS), have renewed the role of surgery in their treatment. This article presents the oncological and functional results obtained by the French Group of Head and Neck Robotic Surgery for TORS for posterior pharyngeal wall SCC-curative surgery. This retrospective, multicentre study presents data collected between September 2009 and November 2013 for patients treated with TORS for posterior pharyngeal wall SCCs. Analysis of patient characteristics, tumour and treatment details were completed. Kaplan-Meier analysis was used to calculate overall survival rates and recurrence-free survival rates. Student's t test and Chi² test were also calculated. 23 patients were included (mean age of 62 years). 12 patients had a prior HNSCC. Ten patients had pT1 cancers. The overall two-year survival rate was 59%, but 89% for pT1 compared to 28% for pT2-T3 (p = 0.01). It was noted that TORS was simple to perform, but generated significant post-operative dysphagia. Two cases of spondylodiscitis were reported as specific post-operative complications of TORS. In conclusion, TORS is a treatment solution for selected posterior pharyngeal wall SCCs. It provides a possible alternative to medical treatment for early pT1 lesions and is often the only remaining curative solution in patients previously treated with radiotherapy. In cases of bulky resection, or when there is a past medical history of radiotherapy, a tissue reconstruction by forearm free-flap may be indicated.

Use of fluorescent in-situ hybridisation in salivary gland cytology: A powerful diagnostic tool

OBJECTIVE

Salivary gland cytology is challenging because it includes a diversity of lesions and a wide spectra of tumours. Recently, it has been reported that many types of salivary gland tumours have specific molecular diagnostic signatures that could be identified by fluorescent in-situ hybridisation (FISH). The aim of the present study was to demonstrate the feasibility and efficiency of FISH on routine cytological salivary gland smears.

METHODS

FISH was conducted on 37 cytological salivary gland smears from 34 patients. According to the cytological diagnosis suspected, MECT1/MAML2 gene fusion and rearrangements of PLAG1, MYB, or ETV6 were analysed. The presence and percentages of cells that had gene rearrangements were evaluated. Results were compared with the histological surgical samples, available from 26 patients.

RESULTS

The PLAG1 rearrangement was observed in 12/20 (60%) cases of pleomorphic adenoma. MECT1/MAML2 gene fusion was observed in 1:2 mucoepidermoid carcinomas but was not observed in five other tumours (two pleomorphic adenomas, one Warthin's tumour, one mammary analogue secretory carcinoma [MASC] and one cystic tumour). MYB rearrangement was observed in 4/4 adenoid cystic carcinomas. ETV6-gene splitting identified one MASC.

CONCLUSION

Overall, FISH had a specificity of 100% and a sensitivity of 66.7%. When FISH and cytological analyses were combined, the overall sensitivity was increased to 93.3%. It can thus be concluded that when the FISH analysis is positive, the extent of surgery could be determined with confidence pre-operatively without needing a diagnosis from a frozen section.

Morphological concordance between CBCT and MDCT: a paranasal sinus-imaging anatomical study

PURPOSE

Cone-beam computed tomography (CBCT) is an imaging technique, first developed for use during oral and pre-implant surgery. In sinonasal surgery, CBCT might represent a valuable tool for anatomical research given its high spatial resolution and low irradiation dose. However, clinical and anatomical evidence pertaining to its efficacy is lacking. This study assessed the morphological concordance between CBCT and multislice detector computed tomography (MDCT) in the context of sinonasal anatomy.

METHODS

We performed an anatomical study using 15 fresh cadaver heads. Each head underwent both CBCT and MDCT. Two independent reviewers evaluated 26 notable anatomical landmarks. The primary outcome was the overall morphological concordance between the two imaging techniques. Secondary objectives included assessment of inter-rater agreement and comparison of the radiation doses received by different parts of the anatomy.

RESULTS

Overall morphological concordance between the two imaging techniques was excellent (>98 %); the inter-rater agreement for CBCT was approximately 97 %, which is highly similar to MDCT, but achieved using a significantly decreased irradiation dose.

CONCLUSION

Our preliminary study indicates that CBCT represents a valid, reproducible, and safe technique for the identification of relevant sinonasal anatomical structures. Further research, particularly in pathological contexts, is required.

French Society of ENT (SFORL) guidelines for care pathway organization in head and neck oncology (short version). Early management of head and neck cancer

Early management in oncology is based on coordination and high-quality exchange between the various health-care partners. The present guidelines are based on a literature search with levels of evidence. Treatment waiting time can be optimized by performing assessment as early as possible (Expert opinion), to limit the interval (ideally, less than 4 weeks) between first consultation and data collection. In the first specialist consultation, diagnostic work-up should be scheduled and the data required for management should be determined (Grade B). Work-up may be conducted on a day-care basis or with conventional admission (Expert opinion). The patient's medico-social context should be taken into account from the outset, with social work involvement whenever necessary (Expert opinion). Pain and nutritional management should be planned for (Grade A) and realistic therapeutic education be provided (Expert opinion). Community-hospital teamwork for supportive care should be optimized (Expert opinion). Management should be early and multidisciplinary, to shorten delay between diagnosis and treatment initiation.

Guidelines (short version) of the French Otorhinolaryngology - Head and Neck Surgery Society (SFORL) on patient pathway organization in ENT: The therapeutic decision-making process

OBJECTIVES

The authors present the guidelines of the French Otorhinolaryngology - Head and Neck Surgery Society (SFORL) for patient pathway organization in head and neck cancer, and in particular for multidisciplinary team meetings. The present article concerns the therapeutic decision-making process.

METHODS

A multidisciplinary work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group. The final version was established in a coordination meeting. The guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence.

RESULTS

It is recommended that: an organ specialist should contribute to all multidisciplinary meetings on head and neck cancer; all members of the multidisciplinary meeting should have specific knowledge in head and neck cancer; any referring physician who does not follow the multidisciplinary meeting's advice should justify that decision; there should be sufficient time to prepare, discuss and sum up the cases dealt with in the multidisciplinary team meeting.

Sialendoscopy learning curve: comparing our first and last 100 procedures

OBJECTIVES

Sialendoscopy is a relatively new minimally invasive technique that permits direct salivary tree visualization and is important in obstructive sialadenitis management and treatment. The present study aimed to examine the sialendoscopy learning curve between March 2009 and March 2013.

METHODOLOGY

We compared the first and last 100 sialendoscopies performed in our department with regard to anaesthesia type, operating time, success rate, technical difficulty, major complications, and clinical improvement.

RESULTS

General anaesthesia rates were 63% and 38% (P = 0.0004) among the first and last 100 sialendoscopies, respectively. Among the first and last 100 procedures, respectively, average operating times were 39 and 25 minutes (P = 0.00055) for diagnostic sialendoscopies and 68 and 65 minutes (P = 0.35) for interventional sialendoscopies. Successful stone extraction rates were 65% and 90.2% (P = 0.0058) among the first and last 100 procedures, respectively, while the corresponding rates of successful stenosis dilation were 92.5% and 97.1% (P = 0.27). Technical difficulty was encountered in 25% and 17% (P = 0.164) of the first and last 100 sialendoscopies, respectively. Neither group experienced major complications. All patients tolerated the procedures well and had excellent outcomes.

CONCLUSION

Progressive learning regarding sialendoscopy enabled more frequent operation under local anaesthesia, thus better meeting the requirements of a minimally invasive technique. We were able to decrease the operative time in diagnostic sialendoscopy. These two factors support the inclusion of diagnostic sialendoscopy into the diagnostic panel in obstructive glandular diseases.

Clinical outcomes of transoral robotic surgery for supraglottic squamous cell carcinoma: experience of a french evaluation cooperative subgroup of gettec

BACKGROUND

Transoral, minimally invasive, organ preservation surgeries are increasingly used to treat laryngopharyngeal carcinomas to avoid the toxicity associated with combined chemoradiotherapy regimens. This study investigated the efficiency, safety, and functional outcomes of using transoral robotic surgery (TORS) to perform supraglottic laryngectomy (SGL).

METHODS

This was a multicenter study using a case series with planned data collection from 2009 to 2012 for patients with supraglottic squamous cell carcinomas (SCC) who underwent SGL using TORS.

RESULTS

Eighty-four (84) of 262 patients underwent TORS for supraglottic SCC. Within 24 hours of surgery, 24% of the patients started on an oral diet. The median use of a feeding tube was 8 days for 76% of other patients. Definitive percutaneous gastrostomy feeding was necessary for 9.5% of the patients. 24% of the patients did require a tracheostomy, and the median use was 8 days. One percent (1%) of the patients had a definitive tracheostomy. Aspiration pneumonia was observed in 23% of the patients during the postoperative course, and was responsible for the death of one patient. Postoperative bleeding occurred in 18% of the patients. Based on the pathology results, 51% of the patients received adjuvant radiation therapy.

CONCLUSION

TORS for SGL in intermediate stage SCC is a safe procedure with good functional outcomes and fast recovery times. However, adverse events can occur. Consequently, this technique requires good patient selection criteria to reduce the risk of postoperative complications.

Long-term carcinologic results of advanced esthesioneuroblastoma: a systematic review

Surgical resection followed by radiotherapy can be considered like the optimal treatment modality for limited esthesioneuroblastoma. However, therapeutic management of locally advanced tumors remains a challenge. The aim of our study was to access and compare the oncologic results of the different treatment modalities in advanced esthesioneuroblastoma. We performed a systematic review using the Medline, and Cochrane database in accordance with PRISMA criteria and included all the cases of advanced esthesioneuroblastoma published between 2000 and 2013. We also retrospectively included 15 patients with an advanced esthesioneuroblastoma managed at our tertiary care medical center. Long-term survival rates defined as the time from diagnosis or randomization to the date of death or last follow-up were evaluated for each treatment with Kaplan-Meier survival curve analyses. 283 patients have been included. The mean follow-up was 78 months. Five-year highest survival rates were obtained in patients treated by surgery associated with radiotherapy. Ten-year highest survival rates were obtained in patients treated by the association of surgery, radiotherapy and chemotherapy (p = 0.0008). Within the surgical group, 5-year highest survival rates were obtained in patients treated by endoscopic resection (p = 0.003). Surgical resection combined with radiotherapy offers the gold standard of care. Adjuvant chemotherapy seems to improve the long-term survival in patients with locally advanced esthesioneuroblastoma. Endoscopic resection in advanced tumors should be discussed on a case-by-case basis.