Aural tuberculosis at the start of the 21st century. Literature review according to SWiM guidelines. Part 2: Treatment.

OBJECTIVES: Systematic review of the scientific literature dedicated to treatment modalities and results for aural tuberculosis published since the start of the 21st century. MATERIAL AND METHODS: Search of the Medline, Cochrane and Embase databases for the period 2000 - 2020. Selection of articles in English, French and Spanish devoted to clinical cases and series documenting treatment of auricular tuberculosis. Extraction of data on pre-established files documenting treatment modalities and results. Reading of articles by two authors. Analysis performed according to SWiM guidelines, evaluating cure, tuberculosis-related death, treatment-related complications, improvement in facial palsy, and hearing sequelae rates. RESULTS: One hundred and twenty eight articles: 118 case reports (159 patients) and 10 cohorts (177 patients) from 42 countries were analyzed. Female/male sex ratio was 1.2 with ages ranging from 1 month to 87 years. Medical treatment consisted in 5 to 24 months' antitubercular antibiotic treatment using 2 to 8 antibiotics. Mastoidectomy, tympanoplasty and facial nerve decompression were associated to medical treatment in 64.7%, 17.4% and 6.2% of cases, respectively. Overall rates of cure, death, treatment-related complications, facial sequelae and hearing sequelae were 96.8%, 2%, 9.5%, 35.8% and 75.5%. In case reports, BCG vaccination did not appear to protect against facial palsy and severe intracranial complications (P>0.6). There was no significant correlation (P>0.3) between death and the clinical variables tested, and facial nerve decompression did not appear to influence outcome for facial function (P=0.4). CONCLUSION: Medical treatment is very effective but not without risk of death, complications and sequelae. It is the same as for pulmonary tuberculosis. Indications for and benefit of major auricular surgery during medical treatment deserve further studies.

Aural tuberculosis at the start of the 21st century. Literature review according to SWiM guidelines. Part 1: Clinical and diagnostic data.

OBJECTIVES: Review of the scientific literature dedicated to clinical data and diagnosis modalities for aural tuberculosis published since the start of the 21st century. MATERIAL AND METHODS: Search of the Medline, Cochrane and Embase databases for the period 2000-2020. Selection of articles in English, French and Spanish devoted to clinical cases and series documenting clinical data and diagnosis for aural tuberculosis of articles by two authors. Analysis performed according to SWiM guidelines. Extraction of data on pre-established files documenting clinical and diagnostic data. RESULTS: In total, 173 articles: 163 case reports (228 patients) and 10 cohorts (177 patients) from 49 countries were analyzed. Female/male sex ratio was 1.05, with ages ranging from less than 1 month to 87 years. Tuberculosis involved another site in 35.1% of cases. Aural involvement was bilateral in 19.7% of cases. Clinical presentation corresponded to otitis media (prior antibiotic treatment and auricular surgery in 41.4% and 10.1% of cases, respectively) without any pathognomonic symptoms or signs. Associated severe locoregional complications were seen in 32% of cases, with 23.2% and 13% incidence of peripheral facial palsy and severe intracranial complications, respectively. Time to diagnosis ranged from less than 1 month to 384 months, and was longer than 12 months in 26.5% of case reports, without significant correlation (P=0.29) with severe revelatory locoregional complications. Incidence of Mycobacterium tuberculosis detection ranged from 33.4% of documented cases in auricular secretions to 64.6% in polyps, granulomas, and/or biopsies. In the case reports, diagnosis with certainty was done in 58.3% of cases, while it was based on involvement of another site and on indirect criteria or positive clinical progression after treatment in the other 10.1% and 31.6%, respectively. CONCLUSION: Aural tuberculous must always be considered in case of unfavorable progression of otitis. Definitive diagnosis is based on multiple auricular sample sites, polymerase chain reaction, and γ interferon blood assay.

Positive predictive values of MRI and ultrasound-guided fine-needle aspiration biopsy for isolated parotid swelling in adults: A STARD comparative analysis.

OBJECTIVES: To evaluate positive predictive values (PPVs) of magnetic resonance imaging (MRI) and ultrasound-guided fine-needle aspiration biopsy (UFNAB) in patients with isolated parotid swelling. MATERIAL AND METHODS: Observational study following the STARD guideline, based on a cohort of 212 patients from 18 to 93years of age, with isolated parotid swelling (malignant: 16.9%; benign: 83.1%), consecutively operated on between 2015 and 2020, after work-up including MRI and UFNAB in an otorhinolaryngology department of a university hospital. The main endpoint was PPV for diagnosis of benign tumor, malignant tumor and the most frequent etiology. Secondary endpoints were correlations between PPVs and clinical factors for malignancy, and the impact on PPV of various situations: dynamic analysis on MRI; diagnostic disagreement between MRI and UFNAB; and UFNAB PPV according to MRI diagnosis. RESULTS: PPVs for MRI and UFNAB were respectively 45.4% and 88.8% for malignant tumor, 89.6% and 46.9% for benign tumor, and 88.1% and 85.2% for pleomorphic adenoma (the most frequent etiology). Tumor fixation and history of head and neck radiation therapy PPVs were the only one higher than the MRI one for malignant tumor. MRI PPV did not differ between groups with or without dynamic analysis. PPV for malignant tumor, benign tumor and pleomorphic adenoma on MRI and UFNAB was respectively 42.8% and 33.3%, 42.8% and 100%, and 36.3% and 50% in case of diagnostic discordance. When MRI suggested malignant tumor, UFNAB PPV was 51.8% for malignant tumor, 67.7% for benign tumor, and 37.5% for pleomorphic adenoma; when MRI suggested benign tumor, it was 32.2% for malignant tumor, 91.5% for benign tumor, and 88.5% for pleomorphic adenoma; and, when MRI suggested pleomorphic adenoma, it was 23.5% for malignant tumor, 93.9% for benign tumor, and 92% for pleomorphic adenoma. CONCLUSION: Systematic association of UFNAB to MRI did not fundamentally improve diagnostic accuracy. UFNAB appeared most valuable in case of history of radiation therapy, in case of tumor fixation, and when MRI diagnosis was uncertain and/or suggested malignant tumor and/or the apparent diffusion coefficient (ADC) was low. The contribution of UFNAB when MRI suggested benign tumor or especially pleomorphic adenoma was more limited.

Auditory and visual 3D virtual reality therapy as a new treatment for chronic subjective tinnitus: Results of a randomized controlled trial.

BACKGROUND: Subjective tinnitus (ST) is a frequent audiologic condition that still requires effective treatment. This study aimed at evaluating two therapeutic approaches: Virtual Reality (VR) immersion in auditory and visual 3D environments and Cognitive Behaviour Therapy (CBT). METHODS: This open, randomized and therapeutic equivalence trial used bilateral testing of VR versus CBT. Adult patients displaying unilateral or predominantly unilateral ST, and fulfilling inclusion criteria were included after giving their written informed consent. We measured the different therapeutic effect by comparing the mean scores of validated questionnaires and visual analog scales, pre and post protocol. Equivalence was established if both strategies did not differ for more than a predetermined limit. We used univariate and multivariate analysis adjusted on baseline values to assess treatment efficacy. In addition of this trial, purely exploratory comparison to a waiting list group (WL) was provided. RESULTS: Between August, 2009 and November, 2011, 148 of 162 screened patients were enrolled (VR n = 61, CBT n = 58, WL n = 29). These groups did not differ at baseline for demographic data. Three month after the end of the treatment, we didn't find any difference between VR and CBT groups either for tinnitus severity (p = 0.99) or tinnitus handicap (p = 0.36). CONCLUSION: VR appears to be at least as effective as CBT in unilateral ST patients.

Warthin's tumor of parotid gland: Surgery or follow-up? Diagnostic value of a decisional algorithm with functional MRI.

PURPOSE: Warthin's tumor is the second most frequent benign tumor of the parotid gland, with no risk of malignant evolution. That is why surgery should be avoided if the preoperative diagnosis is certain. The aim of the study was to assess the added value of a decisional algorithm for the preoperative diagnosis of Warthin's tumor. MATERIALS AND METHODS: This retrospective IRB-approved study included 75 patients who underwent standardised MRI with conventional sequences (T1- and T2-weighted images, and T1 post-contrast sequences with fat saturation) and functional sequences: diffusion (b0, b1000) and perfusion MR. Two independent readers reviewed the images using the decisional algorithm. The conclusion of each reader was: the lesion is or is not a Warthin's tumor. The MRI conclusion was compared with histology or with cytology and follow-up. We calculated the Cohen's kappa coefficient between the two observers and the sensitivity and specificity of the algorithm-helped-reading for the diagnosis of Warthin's tumor. RESULTS: Seventy-five patients; histology (n=61) or cytology and follow-up (n=14) results revealed 20 Warthin's tumors and 55 other tumors. Using the algorithm, sensitivity and specificity were 80-96%, and 85-100%, respectively for readers 1 and 2. The Cohen's kappa coefficient between the two observers was 0.79 (P<0.05) for the diagnosis of Warthin's tumor. CONCLUSION: Our decisional algorithm helps the preoperative diagnosis of Warthin's tumor. The specificity of the technique is sufficient to avoid surgery if a parotid gland tumor presents all the MRI characteristics of a Warthin's tumor.

Value and limits of non-robotic transoral oropharyngectomy for local control of T1-2 invasive squamous cell carcinoma of the tonsillar fossa.

BACKGROUND: An analysis of the value and limits of non-robotic transoral oropharyngectomy for local control of T1-2 squamous cell carcinoma of the tonsillar fossa. METHODS: A retrospective series of 111 T1 and 133 T2 (N0: 129; N1: 52; N2: 53; N3: 10). Induction chemotherapy and postoperative radiation therapy were used in 63.5% and 29.5% of cases, respectively. Actuarial analysis of local failure, impact of various variables upon local failure and consequences of local failure upon other oncological events and survival are documented. RESULTS: The 5-year actuarial local failure estimate was 10.4% and 14.2% for T1 and T2 tumors, respectively. The 5-year actuarial local failure estimate was significantly reduced when resection margins were safe or yielded dysplasia (P=0.008) and when induction chemotherapy achieved complete histologic regression (P=0.013). Salvage treatment achieved a 97.2% and 93.2% overall local control rate in T1 and T2 tumors, respectively. The 5-year actuarial nodal failure estimate was 35.1% in patients with local failure versus 10.8% without (P=0.0001). The 5-year actuarial metachronous second primary estimate was 7% in patients with local failure versus 33.2% without (P=0.016). The impact of local failure on survival (5-year actuarial survival estimate: 67.3% without and 46.4% with local failure) was not significant. CONCLUSION: In T1-2 squamous cell carcinoma of the tonsillar fossa, non-robotic transoral oropharyngectomy appeared to be highly effective in terms of local control. The high incidence of head and neck metachronous second primaries further advocates the use of this treatment option in order to reserve radiation therapy to such cases.

[Which choice would the radiation oncologist consider if facing an advanced stage laryngeal cancer?]. / Quel choix pour l'oncologue radiothérapeute atteint d'un cancer du larynx localement évolué ?

PURPOSE: To analyse the therapeutic decision considered by radiation oncologists put in a position of being diagnosed with an advanced stage cancer of the larynx accessible either to a total laryngectomy or to an organ preservation protocol. MATERIALS AND METHODS: Prospective analysis based on an anonymous survey filled by 104 radiation oncologists. RESULTS: A total of 30.7% of radiation oncologists surveyed did not consider any trade in their cure rate to preserve their larynx. The median percentage of cure that they were willing to trade was 10% (2-100%); and 0.9% of them were willing to trade 100% of their chance for cure in order to "avoid" total laryngectomy. A total of 16.3% of radiation oncologists would like to receive more information before making their decision. The additional information most frequently requested concerned the precise stage of the tumour and the potential remedial treatment in case of failure of the laryngeal preservation protocol. None of the analysed demographic variables influenced the choice to trade or not survival chance to preserve the larynx, the percentage of chance that radiation oncologists would consider exchanging, and/or the wish to receive additional information. CONCLUSION: This prospective study highlights that larynx preservation protocol is not the main therapeutic goal shared by all radiation oncologists put in a position of being diagnosed with an advanced stage cancer of the larynx. Total laryngectomy should remain a treatment option that as organ preservation protocols to be proposed and discussed.

Otorhinolaryngologists' personal treatment preferences (total laryngectomy or laryngeal preservation) when faced with advanced stage laryngeal cancer.

OBJECTIVE: To analyse the treatment options that otorhinolaryngologists would consider if faced with advanced stage laryngeal cancer amenable to total laryngectomy or an organ preservation protocol. MATERIAL AND METHODS: Prospective study conducted in a French Teaching Hospital based on questionnaires filled in by 163 otorhinolaryngologists in 2012, studying the percentage chance of cure that they would be prepared to trade-off to preserve their larynx, defining the additional information that they would like to receive and identifying any statistical associations between these parameters and various medical and socioeconomic variables. RESULTS: A total of 42.3% of otorhinolaryngologists would not consider the slightest trade-off to preserve their larynx and preferred to undergo total laryngectomy. In the group of otorhinolaryngologists who would consider a larynx preservation protocol (57.6%), the percentage chance of cure that they would be willing to trade-off to preserve their larynx ranged between 5 to 100% (median: 15%) and 4.2% of them were willing to trade-off all chances of cure (100%) to avoid total laryngectomy. The percentage of otorhinolaryngologists who would not consider trading off the slightest chance of survival to preserve their larynx increased from 29.3 to 49.5% (P=0.01) when they participated in multidisciplinary consultation meetings. In the group of otorhinolaryngologists who would consider a larynx preservation protocol, the median percentage survival trade-off that they would consider in order to preserve their larynx (i) decreased from 20 to 10% (P=0.004) when they participated in multidisciplinary consultation meetings and (ii) increased regularly with their number of years of practice (P=0.03) and their age (P=0.025). Finally, 25.1% of otorhinolaryngologists wanted to receive additional information, although none of the variables analysed affected this desire for more information. CONCLUSION: Treatment options considered by otorhinolaryngologists faced with advanced stage laryngeal cancer were almost equally divided between total laryngectomy and larynx preservation. Number of years of practice and regular participation in head and neck cancer multidisciplinary consultation meetings were variables that significantly influenced this choice.

Total laryngectomy or laryngeal preservation for advanced laryngeal cancer. Impact of the functional risk upon the patient's preferences.

OBJECTIVE: To analyse, based on an anonymous questionnaire, the treatment decision envisaged and the impact of the medical information delivered in patients facing the diagnosis of an advanced laryngeal cancer amenable to total laryngectomy or a laryngeal preservation protocol. MATERIAL AND METHODS: Prospective study conducted in a French teaching hospital based on questionnaires filled in by 269 patients attending the otorhinolaryngology clinic. RESULTS: A total of 28.6% of patients would not consider any trade-off of cure to preserve their larynx; 1.4% of patients were willing to trade all chances of cure in order to avoid total laryngectomy. The median percentage of cure that patients were ready to loose in order to preserve their larynx was 33% (range: 5 to 100%); 47.9% of patients wanted to receive additional information before making their decision with a significant increase among patients with a level of education beyond secondary school (P=0.0006) and among patients with a family history of cancer (P=0.038). The additional information most frequently requested concerned the complications related to the laryngeal preservation protocol (34.1%) and the cure rate (28.6%). After receiving information about the risk of tracheostomy and permanent gastrostomy following the laryngeal preservation protocol, the percentage of subjects who would not consider any trade-off in order to preserve their larynx increased to 31.2% and 56.1%, respectively. CONCLUSION: Laryngeal preservation is not a major objective of treatment shared by patients filling a questionnaire devoted to the choice of treatment when facing an advanced laryngeal cancer. Specific information concerning the expected results and the inherent risks involved in the various treatment options must be provided in every case.

Cystic lesions of the pterygoid process.

INTRODUCTION: Cystic lesions of the pterygoid process are rare: there are only four case reports in PubMed. CASE REPORT: Two new cases (one schwannoma and one cystic lymphangioma) are reported, with clinical, radiological and therapeutic aspects. DISCUSSION: A literature review presents the semiology, radiology and treatment of cystic lesions of the pterygoid process.

Perfusion in ENT imaging.

UNLABELLED: Perfusion MRI is an essential part of characterizing salivary gland tumors. The shape of the curves can provide a guide as to the type of lesion: benign (ascending plateau) or malignant (descending plateau), and can also occasionally strongly suggest a histological type such as a Warthin tumor (intense, rapid contrast enhancement with washout>30%). Perfusion imaging (CT or MRI) for other head and neck tumors is currently being developed and is being assessed. It should be a tool to assist in choosing the most appropriate initial treatment (chemotherapy, radiotherapy or surgery) and should also allow poor responders to conservative treatment to be identified and recurrences to be detected in post-treatment damaged tissues. AIMS: (a) to determine when to perform perfusion MRI; (b) to determine the type of perfusion to carry out: CT, T1-weighted MRI; (c) to determine how to position the region of interest to plot the perfusion curve; (d) to know how to interpret MRI curves for salivary gland tumors; (e) to know how to interpret the information obtained from perfusion CT or MRI for the upper aerodigestive tract.

First bite syndrome.

Based on a review of the indexed medical literature (PubMed database), the authors describe the clinical features leading to the diagnosis of first bite syndrome, the pathophysiology of this syndrome and analyse the various treatment options available to otorhinolaryngologists to manage this syndrome.

Late recurrence or secondary location? Towards a better understanding of the physiopathology of inverted papilloma.

INTRODUCTION: Inverted papilloma (IP) is the most frequent benign tumor of the nasal cavities. Recurrence is found in 12 to 14% of cases, mainly at the primary site, although also exceptionally in remote locations. The present paper discusses the physiopathogenesis of IP on the basis of a report of late second occurrence of IP at a remote location and a review of the literature. CASE REPORT: A man, who had undergone surgery in 1997 for ethmoid IP at the age of 56, presented 11 years later with nasal cavity IP at a second (frontal) location, discovered serendipitously during systematic follow-up and managed surgically without complication. DISCUSSION AND CONCLUSION: The physiopathology of nasal cavity IP remains unexplained. No reliable histologic or biological markers predict risk of recurrence or of malignant transformation. The sole treatment is total surgical resection. The risk of local recurrence, often due to incomplete resection, is well known, but that of a secondary location is less so, and regular very long-term follow-up is justified.

Intraparotid Kimura disease.

INTRODUCTION: Intraparotid locations are extremely rare in Kimura disease, especially in Europe. CASE REPORT: A 31-year-old man presented with intraparotid Kimura disease, managed by parotidectomy. DISCUSSION/CONCLUSION: The case was analyzed in the light of a review of the literature, focusing on the diagnostic and anatomopathologic problems encountered, and the physiopathology and treatment of this pathology. Any parotid mass found in a patient of Far-Eastern origin showing hypereosinophilia should suggest a diagnosis of intraparotid Kimura disease.

Inverted papilloma of the middle ear.

INTRODUCTION: Inverted papilloma (IP) of the middle ear is a very rare lesion, as less than 20 cases have been reported in the literature. CASE REPORT: The authors report the case of a 73-year-old male with IP of the middle and external ear that had already been operated many times. Treatment consisted of creating a large resection cavity. No recurrence was observed on clinical examination or MRI with a follow-up of 2 years. DISCUSSION AND CONCLUSION: This case is analysed in the light of a review of published cases with a discussion of the pathophysiological and treatment problems raised by these lesions.

Sinus mucocele: natural history and long-term recurrence rate.

OBJECTIVE: To define the natural history, clinical signs, treatment and the modalities of medium- and long-term follow-up of patients operated for sinus mucocele. PATIENTS AND METHOD: Retrospective study of all patients operated for sinus mucocele between January 1993 and December 2009 (n=68). Demographic data, symptoms, medical imaging findings, surgical treatment and results were recorded. RESULTS: The mean age of patients in this series was 53 years (range: 27-82 years, sex ratio: 3/2). The most common site was fronto-ethmoidal. Fifty-one patients (75%) had a history of sinus surgery, essentially for nasal polyposis. Only 15% of mucoceles occurred spontaneously. Presenting symptoms, in decreasing order of frequency, were facial pain or headache (38%), ocular or orbital complications (28%), while 20% of patients were asymptomatic. Surgery was performed by endonasal endoscopic sinus surgery (n=57, 84%) or via a combined, transfacial and endonasal approach, associated with navigation after January 2003. The mean follow-up was 7 years (range: 4 months-16 years). During this follow-up period, 23.5% of patients developed recurrence or a second mucocele after a mean interval of 4 years. CONCLUSION: This study demonstrates the high recurrence rate of mucocele, particularly in multi-operated patients with chronic sinusitis. Long-term, regular, clinical and radiological follow-up is necessary to detect asymptomatic lesions prior to the onset of complications.

Extraosseous plasmacytoma of the lacrimal duct.

OBJECTIVE: Extraosseous plasmacytoma (EOP) is a rare plasma cell proliferative disorder that commonly affects the head and neck region. We report the first case of a plasmacytoma of the lacrimal duct. METHODS: A 66-year-old man presented with an isolated plasmacytoma of the right lacrimal duct and was treated surgically. RESULTS: The tumour grew slowly for a few months. CT scan and MRI showed a right lateral nasal mass extending from the right lacrimal duct toward the floor of the right maxillary sinus. The lesion was removed completely by endoscopic nasal surgery. DISCUSSION: EOP accounts for up to 3% of all plasma cell tumours. Management of this rare lesion involves surgery and radiotherapy with or without adjuvant chemotherapy. Guided by a literature review, we discuss the diagnostic and therapeutic management of EOP.

Olfactory system and emotion: common substrates.

THE AIM OF THE REVIEW: A large number of studies suggest a close relationship between olfactory and affective information processing. Odors can modulate mood, cognition, and behavior. The aim of this article is to summarize the comparative anatomy of central olfactory pathways and centers involved in emotional analysis, in order to shed light on the relationship between the two systems. ANATOMY OF THE OLFACTORY SYSTEM: Odorant contact with the primary olfactory neurons is the starting point of olfactory transduction. The glomerulus of the olfactory bulb is the only relay between the peripheral and central olfactory system. Olfactory information is conducted to the secondary olfactory structures, notably the piriform cortex. The tertiary olfactory structures are the thalamus, hypothalamus, amygdala, hippocampus, orbitofrontal cortex and insular cortex. THE IMPACT OF ODORS ON AFFECTIVE STATES: Quality of life is commonly impaired in dysosmic patients. There have, however, been few publications on this topic. EMOTION AND OLFACTION: COMMON BRAIN PATHWAYS: There are brain structures common to emotion and odor processing. The present review focuses on such structures: amygdala, hippocampus, insula, anterior cingulate cortex and orbitofrontal cortex. The physiology and anatomy of each of these systems is described and discussed.

Pneumosinus dilatans associated with nasal polyposis.

OBJECTIVE: Pneumosinus dilatans (PSD) and pneumocele involve the expansion of one or more paranasal sinuses. We present the first cases of frontal PSD and pneumocele associated with nasal polyposis. We also attempt to explain the development of these rare pathologies through this unexpected association. METHODS: Two cases are described. A 31-year-old man presented with chronic rhinosinusitis for many years and a left frontal protrusion. Physical examination found nasal polyposis and CT scan showed an abnormally enlarged left frontal sinus without bone destruction. The second patient was a 17-year-old man who presented with a left frontal protrusion and orbital encroachment associated with chronic rhinosinusitis. Physical examination also found nasal polyposis and CT scan showed an abnormally enlarged left frontal sinus with focal thinning of the bony sinus walls. DISCUSSION: Focal or generalized thinning of the bony sinus walls differentiates pneumocele from PSD; otherwise, these two entities share the same physiopathological and clinical courses. Many explanations have been proposed for their development including increases in intra-sinus pressure, weakening of bone by tumor invasion, intracranial hypotension, spontaneous drainage of a mucocele, and congenital or hormonal causes. Yet, its physiopathology remains unknown. These two cases support the pressure mechanism of development.