Peri-operative management of endoscopic endonasal cerebrospinal fluid leak repair: an international survey.

PURPOSE: Peri-operative management of nasal cerebrospinal fluid (CSF) leaks is not consensual due to limited evidence. The main aim of this study was to identify key factors in peri-operative management of endoscopic endonasal CSF leak repair among international experts. METHODS: A 60-item survey questionnaire collected opinions of members of international learned societies of ENT surgeons and neurosurgeons on nasal packing, post-operative instructions, antibiotic prophylaxis, and CSF volume depletion. RESULTS: The survey had 153 respondents (124 otorhinolaryngologists and 29 neurosurgeons). A resting position was recommended by 85% (130/151) of respondents for extended CSF leak of the anterior skull base, mainly in Fowler's position (72% (110/153)). Nasal packing was used by 85% (130/153) of respondents; 33.3% (51/153) used it to stabilize the reconstruction, and 22.2% (34/153) to prevent bleeding. It was usually removed after 48 h in 44.4% of cases (68/153). CSF depletion was considered by 47.1% (72/153) of respondents in case of CSF leak recurrence and by 34.6% (53/153) in cases of increased intracranial pressure. All respondents gave specific postoperative instructions to patients including driving, running, swimming, diving restrictions and flighting restrictions. In subgroup analysis, ENT surgeons more often recommended a resting position than neurosurgeons (71% vs. 37.9% ; p = 0.0008) and prescribed more antibiotics (82.3% vs. 21.4% ; p < 0.0001). CONCLUSION: Although postoperative management after CSF closure remains challenging and not codified, this international survey revealed some points of consensus concerning resting position and restriction of post-operative activities. Prospective clinical studies must be undertaken to evaluate their efficiency.

Prevalence of anti-neutrophil cytoplasmic antibody-associated vasculitis in the south of France, using the capture-recapture method.

OBJECTIVES: This study aimed to estimate the prevalence of ANCA-associated vasculitis (AAV), ie granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA), in Southern France in 2018, and evaluate differences among Europeans and non-Europeans. METHODS: This population-based, cross-sectional study used four sources (hospitals, community-based physicians, laboratories, National Health Insurance) to identify adults ≥ 15 years diagnosed with GPA, MPA or EGPA, living in Hérault and Gard in 2018. Cases were defined using the ACR/EULAR classification criteria, and if necessary, the European Medicines Agency algorithm. Prevalence estimates were standardised to the world population and capture-recapture analysis was used to assess the comprehensiveness of the estimation. The influence of geographical origin was evaluated. RESULTS: 202 patients were selected, with 86 cases of GPA (42.6%), 85 cases of MPA (42.1%), and 31 cases of EGPA (15.3%). The standardised prevalence estimates per million inhabitants for 2018 were: 103 (95%CI 84 - 125) for AAV, 48 (95%CI 35 - 64) for GPA, 39 (95%CI 28 - 53) for MPA and 16 (95%CI 9 - 26) for EGPA, 36 (95%CI 25 - 50) for anti-PR3 positive AAV, 46 (95%CI 34 - 61) for anti-MPO positive AAV, and 16 (95%CI 9 - 26) for ANCA-negative AAV. The global estimation of comprehensiveness by capture-recapture analysis was 80.5%. The number of AAV cases was higher for non-European residents (P=0.001), particularly for MPA (P<0.0001). CONCLUSION: We provide a new estimate of AAV prevalence in France and show a higher prevalence of MPA in non-European patients.

Should the Impact of Postural Change of Intracranial Pressure After Surgical Repair of Skull Base Cerebrospinal Fluid Leaks Be Considered? A Preliminary Survey.

INTRODUCTION: Managing skull base cerebrospinal fluid (CSF) leaks is often challenging. Postoperative care, especially regarding postural restrictions and bedrest recommendations, is variable and continues to be based on empirical habits. METHODS: An electronic survey was submitted to French experts in skull base surgery to evaluate current practice of postoperative postural recommendations in patients treated for skull base CSF leaks. RESULTS: Thirty-nine experts completed the survey. Postoperative recommendations were heterogenous. They depended on the size of defects: half of the surgeons did not recommend any constraints of posture for small defects; 84% recommended bed rest for large defects. The most preferred bed-rest modality was Fowler's position (20°-30° tilt). Standing/walking during short periods was allowed in up to 73%. From a physiological viewpoint, head elevation decreases ICP and thus limits the risk of recurrence of CSF leak. However, ICP can fall below 0 in the standing position, favouring pneumocephalus. DISCUSSION: These results confirmed that postural recommendations for patients surgically treated for skull base CSF leaks remain variable. Recommendations should take into consideration the postural change in ICP. Fowler's position may represent the best compromise between risk of recurrence of CSF leak and the risk of pneumocephalus in large CSF leaks.

Endoscopic subperichondrial transseptal transsphenoidal approach is safe and efficient for non-extended pituitary surgery.

PURPOSE: To report the results of a series of patients undergoing the endoscopic subperichondrial transseptal (STRAS) approach for pituitary surgery and to evaluate the efficiency and the safety of this approach. METHODS: This is a single-centre retrospective study including all patients undergoing pituitary lesion resection through the STRAS approach from January 2002 to December 2017 by a multidisciplinary surgical team (ENT and neurosurgeon). Demographic data, tumour type, complication rate and pre- and post-operative visual, endocrine and tumour status were retrospectively analysed. RESULTS: 119 patients were included in the study, 80 (67%) presenting macroadenoma, 24 (20%) microadenoma (20%) and 6 (5%) giant adenoma. 61 (51%) patients had secreting adenoma and 51 (42%) patient had non-functioning adenoma. The STRAS approach allowed a good visualization of intrasphenoidal and intrasellar anatomical landmarks in all cases and no patient needed turbinate resection. No patient died or had neurological deficit. Endocrine remission or control was achieved in 90.5% of hormone-secreting microadenomas and in 84.2% of hormone-secreting macroadenomas. Gross-total resection was achieved for 39 patients (48.8%) of the 80 macroadenomas. Nasal complication rate was very low, with no septal perforation and two epistaxis (1.7%) medically treated. CONCLUSION: The STRAS approach is an elegant approach to the sphenoid sinus that enables a good exposure of the intrasphenoidal anatomical landmarks with a maximal preservation of the nasal mucosa. This approach allows an intrasellar work with great comfort and safety for the surgeon using a two-hand or a four-hand technique.

Multicenter study to assess endoscopic resection of 159 sinonasal adenocarcinomas.

PURPOSE: This study was designed to assess the efficacy and morbidity of the endoscopic endonasal approach for the treatment of sinonasal adenocarcinomas. METHODS: This was a retrospective, multicenter study of nine French tertiary referral centers, including untreated patients. All patients were operated by an endoscopic approach. Tumors were classified according to the UICC 2002. Demographic, therapeutic, histological, morbidity data, and the course of the disease were recorded. Survival rates were obtained using the Kaplan-Meier method. RESULTS: A total of 159 patients were included with a mean age of 69 years. There were 19T1, 62T2 (1M1), 36T3 (1N1), 26T4a, and 16T4b (1N2a-1N2c). The mean duration of hospitalization was 4.4 days. The histologic outcomes showed that the olfactory cleft, the posterior and anterior ethmoid sinus, and the sphenoid, maxillary, and frontal sinuses were invaded in 95, 64, 55, 19, 7, and 3 % of cases, respectively. Histologic margins were positive in 17 % (1T1, 4T2, 3T3, 2T4a, and 8T4b). In total, 130 patients received adjuvant radiotherapy on the primary tumor site (58 Gy), 24 cases were not irradiated, and 5 refused treatment. The mean follow-up was 32.5 ± 24 months. The complication rate was 19 %: 6 epistaxis, 3 meningitis, 6 CSF leaks, 2 dacryocystitis, and 8 septoplasties. The recurrence rate was 17.6 % (28 cases) within 23 ± 21 months. Eleven patients underwent a second surgical procedure. Nine patients died of their disease (3T2, 2T3, 4T4b). The global and disease-specific, recurrence-free survival rate at 3 years was 74 and 84 % respectively. CONCLUSIONS: The endoscopic approach seems to be efficient to remove sinonasal adenocarcinoma with low morbidity.

EGFR Expression and KRAS and BRAF Mutational Status in Intestinal-Type Sinonasal Adenocarcinoma.

Accumulation of molecular alterations, including EGFR overexpression and mutations in KRAS and BRAF, contribute to colorectal carcinogenesis. Since intestinal-type adenocarcinoma (ITAC) of the nasal cavity and paranasal sinus has morphologic and phenotypic features that are usually indistinguishable from colorectal cancer (CRC), it is likely that both tumor types share equivalent genetic alterations. Data from a series of 43 patients treated surgically for ITAC in Montpellier, France between November 1998 and December 2012 were collected. Tumors were characterized for mutations in KRAS and BRAF as well as EGFR overexpression. Kaplan-Meier survival curves were constructed using overall survival as the primary end points. Patient survival was analyzed using the hazards ratio. Twenty seven tumors (63%) showed EGFR positivity and 30% exhibited a high expression level (+2/+3). KRAS mutations were detected in 43% of cases. BRAF mutations were identified in 3.6% of specimens. Patients with age superior to 60 years, metastatic status, and KRAS mutations had significant overall survival values (p = 0.026, p = 0.001 and p = 0.03, respectively). Our results indicate that KRAS mutations and EGFR expression are frequent in ITAC and that KRAS mutations predict good patient prognosis in ITAC. Finally, EGFR directed molecular treatments could be investigated in a subset of patients affected by ITAC.

Endoscopic transsphenoidal surgery for non-functioning pituitary adenoma: Learning curve and surgical results in a prospective series during initial experience.

Background: To report the initial experience of surgery for non-functioning pituitary adenoma (NFPA) from a neurosurgeon in a dedicated residency training endoscopic transsphenoidal (ETS) program, and detail the surgical and clinical outcomes during this period. Methods: A prospective series of all patients operated for NFPA, using an ETS approach, during the three first years of experience of a newly board-certified neurosurgeon was analysed. Clinical, radiological and peri-operative data were collected. Extent of resection (EOR) was determined by formal volumetric analysis. Impact of the learning curve and predictive factors of gross total resection (GTR) were determined. Results: Fifty-three patients with NFPA were included in this prospective cohort which was divided in two periods of time ("First period": 30 first cases, and "second period": 23 following cases). Baseline characteristics of the patients in the two periods were similar. Overall occurrence of complication was 22% and was not significantly different in the two periods of time. No patient had severe neurological complication. Gross total resection was achieved in 70% of patients. Mean Extent of resection was 96%. In a multiple linear regression model, a higher EOR was positively correlated with experience (p = 0.018) and negatively correlated with Knosp Score equal to 4 (p < 0.001). Predictive factors for GTR were Higher Knosp grade (p = 0,01), higher pre-operative volume (p = 0.03), and second period of time (p = 0.01). Conclusion: NFPA surgery can be safe and efficient during the learning period. Dedicated intensive learning, careful patient selection and multidisciplinary work are key to shorten the learning curve and achieve satisfactory results.

Diagnostic Value of Patient-Reported and Clinically Tested Olfactory Dysfunction in a Population Screened for COVID-19.

Importance: Recent studies have suggested that olfactory dysfunction and gustatory dysfunction are associated with coronavirus disease 2019 (COVID-19). However, olfaction has been evaluated solely on reported symptoms, after COVID-19 diagnosis, and in both mild and severe COVID-19 cases, but rarely has it been assessed in prospectively unselected populations. Objective: To evaluate the diagnostic value of a semiobjective olfactory test developed to assess patient-reported chemosensory dysfunction prior to testing for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients attending a COVID-19 screening facility. Design, Setting, and Participants: This prospective diagnostic study with participants and observers blinded to COVID-19 status was conducted in a COVID-19 screening center of a tertiary university hospital in France from March 23 to April 22, 2020. Participants were 854 consecutively included health care workers or outpatients with symptoms or with close contact with an index case. Exclusion criteria were prior chemosensory dysfunction, testing inability, or contraindications (n = 45). Main Outcomes and Measures: Participants were interviewed to ascertain their symptoms and then underwent Clinical Olfactory Dysfunction Assessment (CODA), an ad hoc test developed for a simple and fast evaluation of olfactory function. This assessment followed a standardized procedure in which participants identified and rated the intensity of 3 scents (lavender, lemongrass, and mint) to achieve a summed score ranging from 0 to 6. The COVID-19 status was assessed using reverse transcriptase-polymerase chain reaction to detect the presence of SARS-CoV-2 in samples collected via nasopharyngeal swab (reference standard) to calculate the diagnostic values of patient-reported chemosensory dysfunction and CODA. Results: Of 809 participants, the female to male sex ratio was 2.8, and the mean (SD) age was 41.8 (13.0) years (range, 18-94 years). All participants, if symptomatic, had mild disease at the time of testing, and 58 (7.2%) tested positive for SARS-CoV-2. Chemosensory dysfunction was reported by 20 of 58 participants (34.5%) with confirmed COVID-19 vs 29 of 751 participants (3.9%) who tested negative for COVID-19 (absolute difference, 30.6% [95% CI, 18.3%-42.9%]). Olfactory dysfunction, either self-reported or clinically ascertained (CODA score ≤3), yielded similar sensitivity (0.31 [95% CI, 0.20-0.45] vs 0.34 [95% CI, 0.22-0.48]) and specificity (0.97 [95% CI, 0.96-0.98) vs 0.98 [95% CI, 0.96-0.99]) for COVID-19 diagnosis. Concordance was high between reported and clinically tested olfactory dysfunction, with a Gwet AC1 of 0.95 (95% CI, 0.93-0.97). Of 19 participants, 15 (78.9%) with both reported olfactory dysfunction and a CODA score of 3 or lower were confirmed to have COVID-19. The CODA score also revealed 5 of 19 participants (26.3%) with confirmed COVID-19 who had previously unperceived olfactory dysfunction. Conclusions and Relevance: In this prospective diagnostic study of outpatients with asymptomatic or mild to moderate COVID-19, systematically assessed anamnesis and clinical testing with the newly developed CODA were complementary and specific for chemosensory dysfunction. Olfactory dysfunction was suggestive of COVID-19, particularly when clinical testing confirmed anamnesis. However, normal olfaction was most common among patients with COVID-19.

Recurrent pleomorphic adenoma: results of surgical treatment.

BACKGROUND: Recurrent parotid pleomorphic adenoma surgery increases the risk of facial nerve injury, and there is also a risk of ulterior recurrence. METHODS: Postoperative results from 62 consecutive patients operated for recurrent pleomorphic adenoma were analyzed. It was the first recurrence for 49 patients (79%), the second or more for 13 patients (21%). RESULTS: Total parotidectomy was performed in 69.4% of cases. Skin resection was performed in 47 patients (75.8%). Resection of a facial nerve branch was performed in seven patients (11.3%). Pathologic examination findings revealed carcinoma ex pleomorphic adenoma in 10/62 cases (16.1%) and microscopic multinodular disease in 39 patients (62.9%). Nine patients had preoperative facial palsy, 95% had postoperative facial paralysis ≥ grade II (House-Brackmann scale), and 11.3% still had ≥ grade III facial palsy after 1 year. Six patients developed another recurrence after our intervention (9.68%). Moreover, carcinoma was discovered after a new intervention in 40% of these patients. Initial partial parotid surgery [hazard ratio (HR) = 8.477, P = 0.008], microscopic multinodular recurrent disease (HR = 11.717, P = 0.005), and ≥ 1 recurrence number (HR = 10.608, P = 0.01) were associated with increased risk of ulterior recurrence. CONCLUSION: Surgery is recommended in pleomorphic adenoma recurrence because of the high rate of carcinoma ex pleomorphic adenoma (16.1%). Nevertheless, a definitive facial paralysis ≥ grade III rate of 11.3% is reported after multiple nerve dissection. New recurrence after surgery is less frequent if the initial treatment for pleomorphic adenoma is total parotidectomy.

[Adenocarcinomas of nasal cavities and paranasal sinuses: Diagnostic pitfalls in sinonasal glandular lesions]. / Adénocarcinomes des fosses nasales et des sinus : pièges diagnostiques des lésions glandulaires naso-sinusiennes.

Among primitive adenocarcinoma of nasal cavity and paranasal sinus, the 2005 WHO classification distinguishes two main categories: intestinal type adenocarcinoma (ITAC) and low-grade non-intestinal adenocarcinoma, entities with different clinical and epidemiological characteristics. Low-grade adenocarcinoma shows a respiratory type phenotype (CK20-/CK7+/CDX2-/villin-) and ITACs, an intestinal type profile (CK20+/CK7-/CDX2+/villin+). Because of histological, ultrastructural and phenotypical similarities between ITAC and colorectal adenocarcinomas, several studies have discussed a possible common pathway in carcinogenesis. But the review of literature shows conflicting results, suggesting different pathways of pathogenesis. Differential diagnoses of sinonasal intestinal-type adenocarcinoma are mainly respiratory epithelial adenomatoid hamartomas, inverted schneiderian papillomas, salivary glands-type carcinoma and more rarely metastasis of adenocarcinoma.

Endoscopic treatment of sinonasal papilloma: a 12 year review.

CONCLUSION: Endoscopic surgical management is recommended as a viable treatment option for sinonasal papilloma, with comparable results to those treated by an external approach. An external approach is still indicated in cases where the papilloma is not accessible endoscopically, or where there is extrasinus invasion. Long-term follow-up is essential for recurrence detection. OBJECTIVES: The goal of this study was to highlight our experience with endoscopic surgery for the management of sinonasal papilloma. PATIENTS AND METHODS: A retrospective study of all patients who underwent endoscopic surgery for the treatment of sinonasal papilloma over a 12 year period at the Gui de Chauliac Hospital, Montpellier, France. RESULTS: A total of 55 patients were included in this study; 32 patients (58%) were treated exclusively by an endoscopic approach and 23 (42%) were treated by a combined approach. Minimal follow-up was 3 years. The overall recurrence rate was 7%. All recurrences occurred at the initial site and the average delay between surgery and recurrence was 30 months (14 months to 4 years).

Multicenter assessment of exclusive endoscopic endonasal approach for the treatment of 53 olfactory neuroblastomas.

BACKGROUND: Given the particularities of olfactory neuroblastoma (ONB) and the lack of studies on the subject, a multicenter collaborative study was conducted to assess treatment strategy. METHODS: Fifty-three patients with ONB were included from the French Rare Head and Neck Cancer Expert Network (REFCOR) database: 16T1, 8T2, 19T3, and 10T4. All cases were treated endoscopically with skull base removal and repair in 26 cases (49%) and without external craniotomy. RESULTS: The overall survival (OS) and disease-free survival (DFS) rates at 5 years were 87% and 71%, respectively, with mean follow-up of 45.4 ± 26.5 months. The complication rate was 18.8% with 4 cases of meningitis. Pathological analysis showed positive margins in 26.8%, notably on the dura-mater and periorbita, without impairment of OS or DFS. Forty-eight patients received adjuvant radiotherapy on T ± N. Ten patients had a recurrence (18.9%). Six patients died of their disease. Prophylactic neck irradiation seemed to reduce the recurrence rate. CONCLUSION: Exclusively endoscopic treatment proved efficient and reliable in a large controlled series.

The diagnostic accuracy of reverse transcription-PCR quantification of cytokeratin mRNA in the detection of sentinel lymph node invasion in oral and oropharyngeal squamous cell carcinoma: a comparison with immunohistochemistry.

PURPOSE: The main goal of sentinel lymph node (SLN) detection in head and neck squamous cell carcinomas is to limit neck dissections to pN+ cases only. However, intraoperative + diagnosis cannot be routinely done using the current gold standard, serial step sectioning with immunohistochemistry. Real-time quantitative reverse transcription-PCR (RT-PCR) is potentially compatible with intraoperative use, proving highly sensitive in detecting molecular markers. This study postoperatively assessed the accuracy of quantitative RT-PCR in staging patients from their SLN. EXPERIMENTAL DESIGN: A combined analysis on the same SLN by serial step sectioning with immunohistochemistry and quantitative RT-PCR targeting cytokeratins 5, 14, and 17 was done in 18 consecutive patients with oral or oropharyngeal squamous cell carcinoma and 10 control subjects. RESULTS: From 71 lymph nodes examined, mRNA levels (KRT) were linked to metastasis size for the three cytokeratins studied (Pearson correlation coefficient, r = 0.89, 0.73, and 0.77 for KRT 5, 14, and 17 respectively; P < 0.05). Histopathology-positive SLNs (macro- and micrometastases) showed higher mRNA values than negative SLNs for KRT 17 (P < 10(-4)) and KRT 14 (P < 10(-2)). KRT 5 showed nonsignificant results. KRT 17 seemed to be the most accurate marker for the diagnosis of micrometastases of a size >450 mum. Smaller micrometastases and isolated tumor cells did not provide results above the background level. Receiver operating characteristic curve analysis for KRT 17 identified a cutoff value where patient staging reached 100% specificity and sensitivity for macro- and micrometastases. CONCLUSION: Quantitative RT-PCR for SLN staging in cN(0) patients with oral and oropharyngeal squamous cell carcinoma seems to be a promising approach.

Geometric and mechanical evaluation of 3D-printing materials for skull base anatomical education and endoscopic surgery simulation - A first step to create reliable customized simulators.

INTRODUCTION: Endoscopic skull base surgery allows minimal invasive therapy through the nostrils to treat infectious or tumorous diseases. Surgical and anatomical education in this field is limited by the lack of validated training models in terms of geometric and mechanical accuracy. We choose to evaluate several consumer-grade materials to create a patient-specific 3D-printed skull base model for anatomical learning and surgical training. METHODS: Four 3D-printed consumer-grade materials were compared to human cadaver bone: calcium sulfate hemihydrate (named Multicolor), polyamide, resin and polycarbonate. We compared the geometric accuracy, forces required to break thin walls of materials and forces required during drilling. RESULTS: All materials had an acceptable global geometric accuracy (from 0.083mm to 0.203mm of global error). Local accuracy was better in polycarbonate (0.09mm) and polyamide (0.15mm) than in Multicolor (0.90mm) and resin (0.86mm). Resin and polyamide thin walls were not broken at 200N. Forces needed to break Multicolor thin walls were 1.6-3.5 times higher than in bone. For polycarbonate, forces applied were 1.6-2.5 times higher. Polycarbonate had a mode of fracture similar to the cadaver bone. Forces applied on materials during drilling followed a normal distribution except for the polyamide which was melted. Energy spent during drilling was respectively 1.6 and 2.6 times higher on bone than on PC and Multicolor. CONCLUSION: Polycarbonate is a good substitute of human cadaver bone for skull base surgery simulation. Thanks to short lead times and reasonable production costs, patient-specific 3D printed models can be used in clinical practice for pre-operative training, improving patient safety.

Fourth branchial pouch sinus: from diagnosis to treatment.

BACKGROUND: Fourth branchial pouch sinus (FBPS) is rare and frequently unknown to clinicians. Misdiagnosis is common and definitive surgery is often made difficult by previous episodes of infection and failed attempts at excision. The purpose of this paper is to clarify the diagnostic criteria and the methods used for the surgical management of FBPS. MATERIALS AND METHOD: From a series of 265 head and neck cysts and fistulae, 7 cases of FBPS were retrospectively reviewed. The surgical technique is detailed. RESULTS: Six cases were located on the left side and one on the right. CT scanning showed an air-filled structure on both sides of the lesser horn of the thyroid cartilage in 2 cases out of 4, and barium swallow found a FBPS in 1 case out of 3. Direct pharyngoscopy allowed confirmation of the diagnosis in all cases and permitted catheterization of the tract with the spring guidewire of a vascular catheter which helped surgical location and subsequent dissection. The recurrent laryngeal nerve was systematically dissected to avoid inadvertent damage. A hemi-thyroidectomy was performed in one case. A transient laryngeal paralysis (lasting 9 months) was noted in a 3-week-old newborn operated on. None of the 7 cases had a recurrence after complete resection of the FBPS (3.7 years average follow-up). CONCLUSION: Symptoms on the right side do not exclude the diagnosis of a FBPS. Endoscopy is the key investigation. It allows confirmation of the diagnosis and catheterization of the tract, which aids the surgical dissection. Total removal of the sinus tract tissue with dissection and preservation of the recurrent laryngeal nerve is recommended. EBM RATING: A-1.

Evaluation of calcium alginate nasal packing (Algostéril) versus Polyvinyl acetal (Merocel) for nasal packing after inferior turbinate resection.

Nasal packing is commonly used to control postoperative bleeding in patients undergoing endonasal surgical procedures. Bleeding and pain on packing removal are frequently reported. The principal objective of this study was to investigate the efficacy and safety of Algosteril to control post-operative nasal bleeding. The secondary objective was to assess nasal bleeding and pain on packing removal, and to evaluate the endoscopic appearance of nasal mucosa 9 days after the procedure. This open, multicenter, randomized, controlled study was conducted on 50 patients undergoing partial bilateral inferior turbinectomy, packed with Algosteril on one side versus Polyvinyl acetal tampon (Merocel) on the other side following a left/right randomization. Both nasal packs effectively prevented post-operative bleeding. However, bleeding on packing removal was statistically less frequent and less severe with Algosteril than with Polyvinyl acetal (p = 0.016). In addition, pain was statistically lower with Algosteril than with Polyvinyl acetal (p = 0.0001). A trend to a better healing of the wound on day 9 was observed with Algosteril, leading us to further investigations. Algosteril nasal packing is as effective as Polyvinyl acetal in preventing postoperative bleeding following partial inferior turbinate resection. Its removal, however, is less traumatic for the nasal mucosa and less painful for the patient, therefore improving patient's comfort.

Atypical presentations of sinonasal inverted papilloma: Surgical management and influence on the recurrence rate.

BACKGROUND: Sinonasal inverted papilloma (SNIP), classically, is a unilateral benign tumor of the nasal lateral wall. Numerous variations have been observed, depending on location, bilateral presentation, or association with nasal polyposis. OBJECTIVE: The aim of this work was to describe atypical presentations of SNIPs with their management specificities and to assess their influence on the recurrence rate in a large case series. METHODS: A retrospective single center study of 110 patients treated for SNIP. Atypical inverted papillomas were identified according to the following criteria: (1) unusual location (frontal, posterior, anterior), (2) bilateral involvement, and (3) association with nasal polyposis. Surgical management was detailed, and the influence of each atypical group on recurrence was assessed by using Kaplan-Meier survival curves and the log-rank test. RESULTS: Distribution of atypical presentations was as follows: frontal sinus localization (10.9%); posterior localization, including sphenoid sinus (9%); nasal anterior localization (3.6%); bilateral involvement (3.6%); and nasal polyposis association (10%). The surgical approach was endoscopic (74.5%), external (5.5%), or combined endoscopic and external (20%). Except for nasal anterior localization, all the groups were associated with a higher recurrence rate, without reaching statistical significance. CONCLUSION: Recurrence rates for these atypical presentations arise from their specific surgical challenges. The choice of the surgical technique is guided by tumor location and extension, and by the surgeon's experience; the main objective is a complete resection. The endoscopic endonasal approach is the most frequent procedure.