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.

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.

Economic analysis of the contribution of sialendoscopy in managing non-tumoral principal salivary gland pathology in the Réunion Island: Economic evaluation following the CHEERS methodology

GOALS

Cost analysis of the contribution of sialendoscopy in the treatment of non-tumoral pathologies of the main salivary glands, in Réunion Island, a French overseas territory.

OBJECTIVES

Calculation and comparison of median pricing (i.e., median payment to the healthcare establishment) per patient before and after the introduction of sialendoscopy, in the only regional establishment practicing sialendoscopy and in the whole of Réunion Island. Material and method A multicenter retrospective cost study was conducted over an 8-year period, before and after the introduction of sialendoscopy (period A: 2011-2014 and period B: 2015-2018), according to the CHEERS guidelines for economic studies, and included inpatients with non-tumoral pathology of the main salivary glands, whether treated by sialendoscopy or not.

RESULTS

Two hundred sixty-five patients were included, 139 of whom were treated by sialendoscopy: 74 in 2011-2014 and 191 in 2015-2018. Between the two periods, median pricing in the only center practicing sialendoscopy did not vary significantly: €3468 vs. €3368 (i.e., +2.9% (P=0.1)). In the Island as a whole, pricing increased significantly: €598 vs. €2332, (i.e., +390% (P<0.0001)).

CONCLUSION

Sialendoscopy is cost-effective in France in the public healthcare sector if outpatient management is optimal, but significantly increases the public health budget. It makes it possible to recruit and manage previously untreated patients (small stones, salivary strictures, etc.).

Medical analysis of the contribution of sialendoscopy in managing non-tumoral main salivary gland pathology in Reunion Island: Observational study following STROBE guidelines

GOALS

To perform a medical analysis of the contribution of sialendoscopy in the treatment of non-tumoral pathologies of the main salivary glands, in Reunion Island, a French overseas territory.

MATERIAL AND METHOD

A multicenter retrospective observational study was conducted for an 8-year period, before and after introduction of sialendoscopy (2011-2014 and 2015-2018), following STROBE guidelines.

OBJECTIVES

To compare populations treated before (period A) and after (period B) the introduction of sialendoscopy in terms of clinical characteristics, and analyze the characteristics of patients treated by sialendoscopy.

RESULTS

Two hundred and sixty-five patients were included: 74 in 2011-2014 and 191 in 2015-2018; 139 had sialendoscopy. Populations A and B were comparable except for the proportion of parotids treated (9% vs. 31%, respectively; P<0.0001), and smaller stones (11mm vs. 7.4mm, respectively; P=0.003). One hundred and ten pure sialendoscopies and 29 combined routes (20.8%) were performed: 63% submandibular and 37% parotid. Median age was 46 years. The M/F sex ratio was 0.96. Thirty-seven patients presented stenosis. There were 10 cases of papillary catheterization failure (7.1%), and 16 false routes or creation of false channels (11.5%), including 9 during the learning period. The rate of crossover to gland resection decreased: 10.45% for 2015-2016 and 5.56% for 2017-2018.

CONCLUSION

Although follow-up ranged between 12 and 55months (median, 30months), sialendoscopy appeared to be a useful and reliable technique, with a role in therapeutic strategy for the management of non-tumoral salivary pathologies in Reunion Island.

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.

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.

[Target volumes in cervical lympadenopathies of unknown primary: toward a selective customized approach? On behalf of REFCOR]

The treatment of carcinomas of unknown primary revealed by cervical lymphadenopathy is based on neck dissection and nodal and pan-mucosal irradiation to control the neck and avoid the emergence of a metachronous primary. The aim of this review was to assess diagnostic and therapeutic approaches and criteria that may be used for a customized selective approach to avoid severe toxicities of pan-mucosal irradiation. A literature search was performed with the following keywords: cervical lymphadenopathy, unknown primary, upper aerodigestive tract, cancer, radiotherapy, squamous cell carcinoma, variants. The diagnostic workup includes a head and neck scanner or MRI, ((18)F)-FDG PET CT, a panendoscopy and tonsillectomy. Squamous cell carcinoma represents over two thirds of cases. The number of metastatic cervical nodes, nodal level, and histological variant (associated with HPV/EBV status) may determine the primary site origin and might be weighted for the determination of radiation target volumes on a multidisciplinary basis. A selective customized approach is relevant to decrease radiation toxicity only if neck and mucosal control is not impaired. Although no recommendation can yet be made in the absence of sufficient level of evidence, the relevance of systematic pan-mucosal irradiation appears questionable in a number of clinical situations. Accordingly, a customized selective redefinition of target volumes may be discussed and be prospectively evaluated in relation to the therapeutic index obtained.

Altered quality of life in Rendu-Osler-Weber disease related to recurrent epistaxis

OBJECTIVES

Development and validation of an epistaxis-specific quality-of-life questionnaire (EQQoL) to evaluate the impact on quality of life of epistaxis, during hereditary hemorrhagic telangiectasia (HHT).

STUDY DESIGN

Prospective clinical study using QoL instruments administered twice in HHT patients.

PATIENTS AND METHODS

In total, 109 patients who had epistaxis and a clinical diagnosis of HHT according to Curacao criteria were included. Invoice of the questionnaire in 2004 and 2006 included SF-36, Jenkins` sleep scale and the new epistaxis-specific13-item EQQoL.

RESULTS

EQQoL uptake rate was 98%, mean score 58/100 +- 27, and Cronbach alpha 0.96. EQQoL was sensitive to change with a strong correlation with the course of epistaxis. Factorial analysis showed that EQQoL was clearly distinct from SF-36 and Jenkins sleep scales. In stepwise multivariate ordinal logistic regression, frequency and duration of epistaxis were both associated with lower EQQoL. Conversely, visceral involvement and comorbidity had independent impact on SF-36 scores, but not on EQQoL.

CONCLUSIONS

This new epistaxis-specific EQQoL questionnaire provides complementary information on the impact of HHT on patients quality of life relative to the SF-36 generic questionnaire. After international validation, the EQQoL might prove a useful tool for treatment evaluation.

[Role of imaging in the pre-treatment assessment and post-treatment follow-up of sinonasal malignancies]

Malignant sinonasal tumors are the most frequent facial malignancies in adults. Assessment of these tumors requires a multidisciplinary approach and imaging plays a major role to define the precise tumor location, volume and extension and to plan post-treatment follow-up. MRI provides superior differentiation between tumor and surrounding tissues and depiction of intracranial or perineural extension. CT is a useful complement to demonstrate bone erosion or extension into the skull base.

Nasal polyposis: is there an inheritance pattern? A single family study

BACKGROUND

Nasal Polyposis (NP) is defined as a chronic inflammatory disease of sinonasal mucosa leading to diffuse formation of benign polyps. Although family histories are frequently suggested in medical literature, no specific study focused on this point has been reported. The purpose of this study is to determine whether a hereditary factor could be implied for NP in a family where several members were affected. We included 99 members of this family.

METHODS

All patients were assessed for conditions known to be associated with the development or presence of NP. Concerning NP, patients were screened with a validated questionnaire and selected patients had a medical examination by an Ear, Nose and Throat practitioner.

RESULTS

Thirteen patients had a personal history of NP without asthma, aspirin intolerance, Churg Strauss syndrome, cystic fibrosis, Young's syndrome, bare lymphocyte syndrome, or primary ciliary dyskinesia. Within this family, 19.7% of those older than 17 years were affected by NP, as compared with the national French prevalence of 2.1%.

CONCLUSIONS

Regarding the pedigree, we discuss different modes of inheritance. The presence of consanguineous unions in this family suggests the possibility of a common ancestor and thus a recessive autosomal mode of inheritance.

[Peak Nasal Inspiratory Flow: learning curve for the measurement method and reproducibility]

OBJECTIVES

A prospective study on the learning curve and reproducibility of PNIF measurement with 18 different operators.

MATERIAL AND METHODS

Five hundred twenty-eight patients in two groups were prospectively enrolled in this study from September 2003 to April 2004. The learning curve of the technique was monitored after five patients had been measured. Reproducibility was evaluated with all patients after two consecutive measurements.

RESULTS

The technique was acquired by all operators after the fifth patient. The mean PNIF measurements in controls and patients were 86.02+/-36.96 l/min and 89.59+/-41.97 l/min, respectively. Reproducibility (PNIF2-PNIF1=5.51+/-24.93 l/min) was obtained for all operators, whatever the number of measurements taken.

CONCLUSIONS

The study confirms the good reproducibility and the easy training in PNIF measurement.

Paranasal sinus fungus ball: epidemiology, clinical features and diagnosis. A retrospective analysis of 173 cases from a single medical center in France, 1989-2002

Over the last decade, we have observed a high frequency of Aspergillus rhinosinusitis in french medical centers. The epidemiological data, clinical presentations, radiology, mycology and histology results of 173 consecutive patients with paranasal sinus fungus balls who were admitted from 1989 to 2002 have been reviewed. The most common symptoms included purulent nasal discharges and nasal obstructions, with the maxillary sinus being the most common site of infection (152 cases, 87.8%). Computed tomography scans (CT scan) were performed in 92% (159/173) of the cases and heterogeneous opacities were observed in 132 patients (83%). Histology examinations were performed in all cases and proved positive in 162 patients. Fungi were recovered, mainly Aspergillus fumigatus, from samples of 50 patients, while specimens from the remaining 123 patients were negative. Since no specific clinical sign could be found, a diagnosis of fungus ball is frequently made after a long term symptomatic period. CT scan findings of metallic or calcified densities within an opacified sinus cavity are highly suggestive of a fungus ball, but mycological and histological studies are essential to confirm the diagnosis. Treatment consisted of functional endonasal sinus surgery and was successful in 172 out of 173 cases.

[Diffuse nasal polyposis and comorbidity: study of 65 cases treated by endonasal endoscopic surgery]

INTRODUCTION

Nasal polyposis is an inflammatory disorder which pathophysiology remains unclear. Several clinical associations are described according to co-morbidities (asthma, allergy...).

OBJECTIVE

To analyze the efficacy of a standardized surgical procedure in 65 patients with nasal polyposis, enrolled in three categories according to the presence of co-morbidities (asthma, allergy...).

STUDY DESIGN

Open prospective study of non-randomized cases from a single institution.

METHODS

An inception cohort of 65 consecutive patients with nasal polyposis observed from January 1994 to December 1997. The same surgical procedure was performed in all patients. At the end of the study, an evaluation was performed to collect all the information concerning nasal and bronchial symptoms, asthma conditions, and medical treatment.

RESULTS

60 patients have finally completed the study. Polyposis was isolated in 29 patients, asthma was present in 21 patients, associated with aspirin intolerance in 10 patients (ASA Triad). Nasal obstruction and olfactory dysfunction was improved in 37 and 42 patients, respectively (p<0.0001), without a statistical significance between all groups. After surgery, topical treatment with steroids and local recurrences were more frequently observed in the ASA Triad group without statistical significance.

CONCLUSION

Nasal polyposis appears to be less controlled in the ASA Triad group compared to isolated nasal polyposis, although such conclusion is not statistically significant.

[Retropharyngeal and lateral pharyngeal abscesses in children]

OBJECTIVE

Review of the diagnostic and management of retropharyngeal and lateral pharyngeal abscesses in children.

PATIENTS AND METHODS

Retrospective study of 5 children's cases hospitalized during year 2003.

RESULTS

Diagnosis included CT scan which is often helpful to differentiate cellulitis from abscesses. First medical management consists in an intravenous broad-spectrum antibiotics. Surgical drainage may be considered in cases of failure or clinical aggravation. Closed observation is mandatory in all cases to prevent major complication.

CONCLUSION

Retropharyngeal and lateral pharyngeal abscesses in children are life-threatening infectious. Therapeutic consists in intravenous broad-spectrum antibiotics associated, if necessary, with surgical drainage in cases of persistent abscess.

[Epistaxis and hospitalization: a retrospective observational study over 4 years of 260 patients]

OBJECTIVE

Epistaxis is a frequent emergency for which guidelines and treatment are well known. Nevertheless few studies have evaluated the factors that may influence the decision for hospitalisation. Through a retrospective study we have searched to define potential factors which lead to taking such a decision.

METHODS

Retrospective analysis of charts of 260 patients hospitalized for epistaxis. For each patient we have reviewed several data including, age, associated pathologies, current treatment, duration of the stay, complications, recurrences etc...

RESULTS

If the severity of the bleeding is one of the major factor, socio-economic factors are also taken into account and may influence the decision to hospitalize. Age, associated pathologies (hypertension, hemopathy) and their treatment (anti-coagulant) also play a role in this decision. Furthermore an obvious strategy in the choice of the different treatment may help to reduce the length of stay and the morbidity of each treatment.

CONCLUSION

We propose some modifications to our strategy to improve the management of epistaxis. This includes the use of endoscopic techniques for diagnosis and treatment.

[Adenoid cystic carcinoma (CAC) of the naso-sinonasal cavities: report of 5 cases, review of the literature]

Adenoid cystic carcinoma is a rare tumour which mainly affects the major and accessory salivary glands. We report 5 new cases affecting the nose and sinuses, and based on these review the literature to determine how this disorder can be better treated, given the significant morbidity and mortality of the condition.

Pneumosinus dilatans: a report of three new cases and their surgical management

Pneumosinus dilatans is a rare pathology that primarily involves the frontal sinus. We report three new cases, with special attention given to the pathophysiology and histologic data. Surgical management is reported.

[Laryngeal schwannoma. Diagnostic and therapeutic approach. Apropos of 2 cases]

Laryngeal schwannoma is an uncommon benign tumor. We report two clinical cases and discuss the different types of clinical symptoms revealing the tumor. Difficulties encountered in obtaining a histological diagnosis are presented. The contribution of imaging is also analyzed according to the different surgical techniques used to manage the tumor depending on its size and localization. We stress the importance of long-term follow-up as recurrences may occur several years after surgical removal.

[Asthma and polyposis]

For many years, the association between asthma and naso-sinus pathology has been noted in the literature. The role of sinus infections on the triggering or aggravation of asthma has been well established. More recently attention has been drawn to the association of the chronic inflammatory rhino-sinus pathologies such as polyposis, with asthmatic illness. Its research and identification are essential in care of the asthmatic patient, since recent work has shown the value of control of polyposis for the stability and improvement of the asthmatic illness. The authors report and analyse the diagnostic and therapeutic methods for polyposis in asthmatics.

[Hemifacial atrophy. A case report associated with linear scleroderma]

The authors report a case of facial hemiatrophy, secondary to linear scleroderma, and review the various possible causes of facial hemiatrophy. The various treatments proposed to correct facial hemiatrophy are described. The advantages and disadvantages of each technique together with their indications as a function of the severity of the lesions are then discussed. Free flap currently appears to be the treatment of choice in severe forms and the main question concerns the choice of flap. The authors prefer an inverted dermal fat flap because of its advantages (absence of long-term ptosis, better facial contours) and the absence of laparotomy.