Radiological relationship of the ethmoid slit with the frontal sinus and the anterior ethmoidal artery and applications to the frontal sinus drillout.

PURPOSE: To compare two types of CT acquisition parameters: CT scan of the facial bone and CT scan of the sinuses, for studying the ethmoidal slit and its relationship with the frontal sinus and anterior ethmoidal artery. MATERIALS AND METHODS: Retrospective study of 145 scans of the sinuses and 79 of the facial bones performed between 2012 and 2016. On each scan, the visibility of the ethmoidal slits, their length, their distance from the ethmoidal artery, and their relationship with the anterior and posterior wall of the frontal sinus were studied. RESULTS: The ethmoidal slit was better visualized on CT scans of the facial bone (58.2%) than on those of the sinuses (43.1%) (p = 0.02). The distance between the anterior ethmoidal artery and the anterior part of the cribriform plate was 9.3 mm for CT scans of the facial bone and 8.4 mm for CT scans of the sinuses. The theoretical risk of damaging the glabellar soft tissue and that of damaging the meninges during a frontal sinusotomy was evaluated, respectively, at 9.6% and 26.1% for CT scans of the facial bone, and at 6.2% and 21.5% for sinus scans. CONCLUSIONS: CT scans of the facial bone are better than CT scans of the sinuses for identifying ethmoidal slits and their distance from the canal of the anterior ethmoidal artery. The identification of these elements is relevant for the surgeon during frontal sinus surgery and makes it possible to assess the risk of damaging the glabellar soft tissue or meninges. Performing a CT scan of the facial bone seems preferable to that of a CT scan of the sinuses in certain pathological situations, such as cerebrospinal rhinorrhea or revision surgeries of the frontal sinus.

The advantages of modified Thiel technique in head and neck surgical anatomy teaching.

PURPOSE: Thiel's body preservation method allows the donor body to retain color and soft tissue that are similar to those of a living individual. Since its initial description, the technique has not been developed much. Here, we propose a simpler protocol applied to the head and neck, making the technique easier, cheaper, and more accessible to a greater number of medical schools. METHODS: The modified Thiel technique was applied to three heads separated from the body, followed by 6 h of perfusion and 6 weeks of fixation. This technique was compared with formalin (three heads) and freeze (three heads) preservations during academic training in head and neck surgery. Anatomical dissections included a parotid gland dissection, a submandibular gland dissection, an otologic and an endonasal dissection. Twelve surgeons blindly assessed the three types of preservations using a standardized questionnaire. RESULTS: The modified Thiel technique made possible better quality of dissection and tissue identification, with the exception of endonasal dissection. Concerning the endonasal dissection, the modified Thiel technique ranked best for smell, but all other criteria ranked lower than the freezing method. For the submandibular and parotid gland dissections, the modified Thiel technique was ranked best, with statistically significant differences (p < 0.002) for all items. The modified Thiel technique also ranked significantly better during otologic surgery regarding the quality of the skin/eardrum, bone, and muscle, and the smell. CONCLUSION: This study demonstrated that the modified Thiel technique is an embalming technique which improves the quality of head and neck surgical anatomy education.

Endovascular management of a giant petrous internal carotid artery aneurysm in a child. Case report and literature review.

BACKGROUND: Aneurysms of the petrosal segment of the internal carotid artery are rare in children and are usually found secondary to trauma and infection or can have a congenital origin. Management includes endovascular therapy, surgery, and in rare cases observation. DISCUSSION: Here, we report our experience with a giant petrous internal carotid artery aneurysm in a 16-year-old boy successfully managed endovascularly by parent artery occlusion.

New detailed description of the anterior part of the cribriform plate using anatomic specimens and computed tomography.

PURPOSE: Ethmoidal slit (ES) and cribroethmoidal foramen (CF) have been poorly studied, without any radiological description. They may ease cribriform plate's diseases. The objective was to describe the frequency, size, and computed tomography (CT) appearance of these foramina. METHODS: A two-part anatomoradiological study was performed: first on dry skulls using a surgical microscope and CT, second on patients CT scans. For each, foramina were searched for, described, and measured when possible. RESULTS: Thirteen dry macerated skulls were studied. The orbitomeatal plane was relevant for studying ES. With microscope, ES and CF were identified in, respectively, 92% and 100% of cases. Using CT, all ES and CF were visible, with a mean length and width of, respectively, 3.9 ± 1.7 mm and 0.9 ± 0.3 mm for ES and 1.6 ± 1 mm and 0.9 ± 0.3 mm for CF. CT scans from 153 patients were reviewed. ES and CF were identified in, respectively, 80% and 91% of cases, with a mean length and width of, respectively, 3.9 ± 0.8 mm and 0.8 ± 0.2 mm for ES. CONCLUSION: Large-sized ES was found frequently, and were clearly visible in patients CT scans. CF was markedly smaller, but seen in most patient scans. ES and CF could be areas of least resistance in the anterior part of the cribriform plate. CT might be helpful in understanding their pathological implications.

The forgotten foramina: a study of the anterior cribriform plate.

PURPOSE: The olfactory cleft has garnered interest since the advent of endoscopic skull base surgery. Its precise anatomy, however, is still partially unknown. According to Rouvière, an "ethmoidal foramen" is located in its antero-medial part and contains a process of the dura mater. In a more lateral and anterior location, a second foramen, the "cribroethmoidal foramen", contains the anterior ethmoidal nerve. The aim of this study was to verify the existence of these elements and to establish landmarks for surgery. METHODS: We performed an anatomical and histological study of eight olfactory clefts in four cadavers using both endonasal endoscopic and endocranial dissection. RESULTS: An ethmoidal and a cribroethmoidal foramen were found in, respectively, 100 and 75% of cases. Their mean length was, respectively, 4.1 and 1.8 mm. They were located, respectively, in mean at 5.3 and 5.8 mm from the anterior ethmoidal artery. CONCLUSION: Our anatomical study demonstrates the existence of both foramina. The ethmoidal foramen clearly represents an area of least resistance in the anterior part of the olfactory cleft, which could predispose to anterior skull base cerebrospinal fluid leaks and meningoceles.

Endovascular treatment of symptomatic vestibular aqueduct dehiscence as a result of jugular bulb abnormalities.

A new endovascular treatment consisting of stent-assisted coil implantation is described for jugular bulb abnormalities causing symptomatic vestibular aqueduct dehiscence. Three patients presenting with vertigo associated with pulsatile tinnitus or hearing loss were treated. This technique cured the vertigo and pulsatile tinnitus in all patients and preserved normal cerebral venous drainage with no side effects.

New treatment of vertigo caused by jugular bulb abnormalities.

OBJECTIVE: Jugular bulb abnormalities can induce tinnitus, hearing loss, or vertigo. Vertigo can be very disabling and may need surgical treatments with risk of hearing loss, major bleeding or facial palsy. Hence, we have developed a new treatment for vertigo caused by jugular bulb anomalies, using an endovascular technique. PATIENTS: Three patients presented with severe vertigos mostly induced by high venous pressure. One patient showed downbeat vertical nystagmus during the Valsalva maneuver. The temporal-bone computed tomography scan showed a high rising jugular bulb or a jugular bulb diverticulum with dehiscence and compression of the vestibular aqueduct in all cases. INTERVENTION: We plugged the upper part of the bulb with coils, and we used a stent to maintain the coils and preserving the venous permeability. RESULTS: After 12- to 24-month follow-up, those patients experienced no more vertigo, allowing return to work. The 3-month arteriographs showed good permeability of the sigmoid sinus and jugular bulb through the stent, with complete obstruction of the upper part of the bulb in all cases. CONCLUSION: Disabling vertigo induced by jugular bulb abnormalities can be effectively treated by an endovascular technique. This technique is minimally invasive with a probable greater benefit/risk ratio compare with surgery.

The Prognostic Value of Olfactory Dysfunction in Patients with COVID-19: The COVIDORA Study.

BACKGROUND: Among all studies describing COVID-19 clinical features during the first wave of the pandemic, only a few retrospective studies have assessed the correlation between olfac-tory dysfunction (OD) and the evolution of disease severity. The main aim was to assess whether OD is a predictive factor of COVID-19 severity based on the patient's medical management (outpa-tient care, standard hospital admission, and ICU admission). METHODS: A national, prospective, mul-ticenter cohort study was conducted in 20 public hospitals and a public center for COVID-19 screen-ing. During the first wave of the pandemic, from 6 April to 11 May 2020, all patients tested positive for COVID-19 confirmed by RT-PCR underwent two follow-up ENT consultations within 10 days of symptom onset. The main outcome measures were the evolution of medical management (out-patient care, standard hospital admission, and ICU admission) at diagnosis and along the clinical course of COVID-19 disease. RESULTS: Among 481 patients included, the prevalence of OD was 60.7%, and it affected mostly female patients (74.3%) under 65 years old (92.5%), with fewer comor-bidities than patients with normal olfactory function. Here, 99.3% (290/292) of patients with OD presented with non-severe COVID-19 disease. Patients reporting OD were significantly less hospi-talized than the ones managed as outpatients, in either a standard medical unit or an ICU. Conclu-sions: As regards the clinical course of COVID-19 disease, OD could predict a decreased risk of hospitalization during the first wave of the pandemic.

Predictive factors for lateral occult lymph node metastasis in papillary thyroid carcinoma.

Management of lateral no necks in papillary thyroid carcinoma (PTC) is very controversial. The aim of this study was to find predictive factors of lateral neck involvement in N0 PTC to help the clinician in his decision to treat the lateral compartment. We retrospectively analysed 173 patients who underwent thyroidectomy and lateral prophylactic neck dissection for PTC >10 mm. Predictive factors for occult lateral lymph node metastasis including sex, age, tumour size, multifocality and bilaterality, tumour extracapsular spread, vascular invasion and presence of a tumour capsule were examined by multivariate analysis. There were three independent predictive factors for occult lateral lymph node metastases in multivariate analysis: tumour extracapsular spread (p < 0.0001), vascular invasion (p < 0.001) and age <45 years (p < 0.027). When none of these factors was present, the risk of occult metastases was <5 %. The risk increased up to 56 % when at least two of these factors were present. These findings suggest that, in patients older than 45 years with neither tumour extracapsular spread nor vascular invasion on histopathological examination, occult lymph node metastases are very uncommon. In that case further discussion regarding the risks and benefits of lateral nodal dissection may be warranted.

Hypoxia Differentially Affects Chondrogenic Differentiation of Progenitor Cells from Different Origins.

Background and Objectives: Ear cartilage malformations are commonly encountered problems in reconstructive surgery, since cartilage has low self-regenerating capacity. Malformations that impose psychological and social burden on one's life are currently treated using ear prosthesis, synthetic implants or autologous flaps from rib cartilage. These approaches are challenging because not only they request high surgical expertise, but also they lack flexibility and induce severe donor-site morbidity. Through the last decade, tissue engineering gained attention where it aims at regenerating human tissues or organs in order to restore normal functions. This technique consists of three main elements, cells, growth factors, and above all, a scaffold that supports cells and guides their behavior. Several studies have investigated different scaffolds prepared from both synthetic or natural materials and their effects on cellular differentiation and behavior. Methods and Results: In this study, we investigated a natural scaffold (alginate) as tridimensional hydrogel seeded with progenitors from different origins such as bone marrow, perichondrium and dental pulp. In contact with the scaffold, these cells remained viable and were able to differentiate into chondrocytes when cultured in vitro. Quantitative and qualitative results show the presence of different chondrogenic markers as well as elastic ones for the purpose of ear cartilage, upon different culture conditions. Conclusions: We confirmed that auricular perichondrial cells outperform other cells to produce chondrogenic tissue in normal oxygen levels and we report for the first time the effect of hypoxia on these cells. Our results provide updates for cartilage engineering for future clinical applications.

Multicenter study to assess surgical treatments of 452 sinonasal intestinal-type adenocarcinomas: A REFCOR study.

PURPOSE: The objective was to assess the local oncological outcomes of endoscopic versus external surgical treatment of sinonasal intestinal-type adenocarcinomas (ITAC) and the factors of recurrence. METHODS: a retrospective non-randomized case-control multicenter study was carried out, including 452 untreated sinonasal ITACs recruited from 10 tertiary referral centers. The tumors were re-classified according to the UICC 2017 (pT). Survival curves were obtained using the Kaplan-Meier method. Univariate analysis was done with the log-rank test. Multivariate analysis was performed with a Cox model adjusted for age, T stage, and radiotherapy. A binary logistic regression compared surgical complications and performed two supplementary analyses on positive margins. RESULTS: We compared 195 and 257 patients operated by the external and endoscopic approach, respectively. The mean follow-up was 59.2 ± 48.7 months. Post-operative margins were invaded in 30.6 versus 18.9% of patients, respectively (p = 0.007). The overall recurrence rate was 33.8 versus 24.6%, respectively (p = 0.034). There was a significant difference in favor of the endoscopic approach regarding local recurrence-free survival thanks to better surgical margins in univariate and multivariate analysis (Odd Ratio = 2.01 (1.2-3.36) p = 0.0087). The complication rate (Odds Ratio = 3.4 (1.79-6.32) p < 0.001) was significantly lower in the endoscopic group. The histological positivity of signet-ring cells shows a statistically significant difference in recurrence-free survival (p = 0.0028). CONCLUSION: the oncological control of ITAC is better through the endoscopic approach, with negative margins and the absence of signet-ring-cells, two independent factors of recurrence.

Occult lymph node metastases increase locoregional recurrence in differentiated thyroid carcinoma.

OBJECTIVES: The impact of occult lymph node metastasis (OLNM) on locoregional recurrence (LRR) and survival in patients with NO differentiated thyroid carcinoma is unclear, because no large study has been carried out. A retrospective study was conducted in our department to assess the influence of OLNM. METHODS: We included 201 patients treated by prophylactic neck dissection for NO differentiated thyroid carcinoma between 1974 and 2006. The incidence of OLNM and predictive factors for recurrence and survival were assessed. RESULTS: The incidence of OLNM was 20%. Necks were involved at levels VI, III, II, IV, V, and I, in decreasing order of frequency. After a mean follow-up of 9 years, the rate of LRR was 8.9% and the rate of distant metastasis was 3.4%. An age of greater than 55 years and the presence of OLNM were predictive factors for LRR. An age of greater than 55 years and the presence of LRR were predictive factors for distant metastasis. The presence of distant metastasis was the only factor that significantly and independently influenced the disease-specific survival. CONCLUSIONS: We found that OLNM occurred in only 20% of NO patients. The presence and especially the number of OLNMs on neck dissection were major risk factors for LRR in this study, but did not affect the disease-specific survival.

Pattern of lateral neck metastases in N0 papillary thyroid carcinoma.

BACKGROUND: Indication and extent of lateral prophylactic neck dissection (PLND) in papillary thyroid carcinoma (PTC) is very controversial. METHODS: We retrospectively analysed 131 patients who underwent thyroidectomy and prophylactic lateral neck dissection from level II to V for PTC. RESULTS: 140 PLND were performed. The occult lymph node metastases (OLNM) overall rate was 18.6%. The incidence of node involvement was 10% at level III and 6.4% at level IIa. Level IV and level Vb were both concerned by 5.7% OLNM. Only 2.9% of level IIb contained OLNM. None of the level Va ND revealed OLNM. CONCLUSIONS: OLNM from PTC occurs commonly in level IIa, III, IV and Vb. Incidence in other levels is low. For surgeons that usually perform PLND, we believe that a selective neck dissection of levels IIa, III, IV and Vb in N0 neck PTC is sufficient for the clearance of occult metastases.

Failure of anterior skull base reconstruction for sinonasal carcinoma: consequence on the postoperative follow up. A multicentre evaluation of management.

BACKGROUND: Numerous techniques for closure of the anterior skull base in cancer patients have a high success rate but management of failure is poorly documented. OBJECTIVES: To standardize the post-operative follow-up after reconstruction surgery of the anterior skull base after removal for sinonasal carcinoma. MATERIALS AND METHODS: Retrospective review of failure of anterior skull base reconstruction between 2005 and 2018 in a multicenter setting. RESULTS: Twenty four patients were included. Reconstruction failure was detected by a cerebrospinal (CSF) leak in 79.2%, by an infectious complication without CSF leak (i.e. meningitis) in 12.5%, and in 8.3% by extensive pneumocephalus. Failure was observed during the first week after surgery in 75% of patients, in the second week in 21%, and in 4% after day 15. The delay in discovery of the failure was associated with multilayer reconstruction (p=.03). Failure was treated surgically in 54% of the patients and medically in 46%, with a similar success rate (85 vs. 100%). CONCLUSION AND SIGNIFICANCE: After carcinologic resection of the anterior skull base, monitoring should be systematic during the first postoperative week. Surgical management of failure is not always necessary.

Transethmoidal drainage of frontal brain abscesses.

BACKGROUND: The frontal lobe is the second most common location for brain abscess after the temporal lobe. Since the advent of computed tomography and magnetic resonance imaging scanning, diagnosis has become easier, but the prognosis of brain abscess is still poor. Treatment is based on antimicrobial therapy and neurosurgical evacuation, but controversy still remains as to the merits place of each. METHODS: This study describes 2 cases of patients with frontal abscesses treated by endonasal transethmoidal sinus surgery (ESS) and reviews the literature on this topic. RESULTS: Follow-up revealed no cerebrospinal fluid leak in both patients, complete abscess drainage in one patient, and incomplete drainage in the other. CONCLUSIONS: ESS drainage of frontal abscesses is feasible in intracerebral and epidural abscesses if they have a thick shell and are in contact with the skull base. The procedure is minimally invasive and relatively simple. It allows for rapid microbial identification and an effective drainage.

New landmarks in endonasal surgery: from nasal bone to anterior cribriform plate including branches of anterior ethmoidal artery and nerve and terminal nerve.

BACKGROUND: Despite the development of anterior skull base surgery, the anatomy of the nasal bone and anterior cribriform plate remains unclear. A recent study confirmed 2 distinct foramina in the anterior part of cribriform plate: the ethmoidal slit (ES) and the cribroethmoidal foramen (CF). The aim of this study was to specify their content, their anatomic relationship to the frontal sinus and skull base, and their potential value in skull base surgery. METHODS: Dissections were performed on 36 cadaver heads. Macro- and microscopic examinations were carried out. Microcomputed tomography scans contrasted with osmium were performed to identify vessels and nerves. Histology with neural, meningeal, or luteinizing hormone-releasing hormone immunomarkers was performed on the content of the foramina. Finally, endonasal surgical dissections were carried out. RESULTS: The ES and the CF were observed in all cases. They measured a mean of 4.2 and 1.6 mm, respectively. The ES contained dura mater, arachnoid tissues, lymphatics, and the terminal nerve. The CF contained the anterior ethmoidal nerve and artery. This foramen continued forward with the cribroethmoidal groove, which measured a mean of 2.5 mm. This groove was under the frontal sinus and in front of the skull base. We also described a "cribroethmoidal canal" and a "nasal bone foramen." CONCLUSION: The clinical applications of this new anatomic description concern both cribriform plate and frontal sinus surgeries. Identifying the terminal nerve passing through the ES is a step forward in understanding pheromone recognition in humans.

[Ten years of advances in head and neck surgery, how does this influence postoperative radiotherapy?] / Dix ans de progrès en chirurgie des tumeurs de la tête et du cou, quel impact sur la radiothérapie postopératoire ?

Minimal invasive surgery and reconstructive surgery tend to become the standard in France in the management of head and neck tumors. The use of endoscopic approaches (through endoscopic endonasal/transoral approaches±robot-assisted) instead of open surgery and the use of reconstructive surgery using autologous (flaps) or heterologous materials aim to reduce surgical morbidity by making-up for the loss of substance to restore the function. The impact of these substantial changes in surgical techniques has not been assessed with respect to postoperative radiotherapy practice. Endoscopic endonasal approaches result, however, in piecemeal resection, which, along the analysis of resection margins (a key prognostic factor), make the interpretation of the quality of resection more complex for radiation oncologists. The definition of tumour sub-volumes to be irradiated and doses to these sub-volumes then requires accurate histosurgical mapping and close multidisciplinary consultation between surgeons, pathologists, radiologists and radiation oncologists. Similarly, the increasing use of various types of flaps (of soft tissue or bone flaps), adapted to the patient and tumor anatomy, is associated with substantial modifications to the operating bed. The delineation of tumour volumes in postoperative radiotherapy is made more complex. Tremendous multidisciplinary efforts should now be initiated to fully take advantage of surgical advances and to further optimize the therapeutic index by making radiotherapy also less toxic, i.e. "mini-morbid".