Critical review of diagnosis in rhinology and its therapeutical implications.

Diagnosis in rhinology is currently based on the concept of inflammation (chronic rhinosinusitis [CRS]) or the clinical concept of chronic nasal dysfunction (CND). The complementarity between these two approaches can be discussed by a critical review of the literature structured by the analysis of the fundamental and diagnostic bases and the therapeutic implications linked to each. The concept of CRS is based on the anatomical continuity of the nasal and sinus respiratory mucosa and molecular biology data, seeking to analyze the mechanisms of chronic inflammation and to identify proteins and biomarkers involved in the different supposed endotypes of chronic inflammation of this mucosa. The concept of CND seeks to analyze medical, instrumental or surgical diagnostic and therapeutic strategies, taking account of both inflammatory and non-inflammatory causes impacting the anatomy or physiology of each of the three noses (olfactory, respiratory and sinus) that make up the mid-face sinonasal organ of evolution-development (Evo-Devo) theory. Thus, the concept of CRS offers an endotypic approach, based on biological characterization of mucosal inflammation, while the concept of CND offers a compartmentalized phenotypic and pathophysiological approach to sinonasal diseases. The joint contribution of these two concepts in characterizing nasal functional pathology could in future improve the medical service provided to patients.

Allergic fungal rhinosinusitis and eosinophilic mucin chronic rhinosinusitis: Differential diagnostic criteria. A two-center comparative study following STROBE methodology.

OBJECTIVES: Allergic fungal rhinosinusitis (AFRS) and eosinophilic mucin chronic rhinosinusitis (EMRS) are two forms of chronic sinusitis distinguished by the presence (AFRS) or absence (EMRS) of fungal elements in sinus mucin. Detection of the fungal elements, however, is complex and it is difficult to say whether EMRS is in fact an entity distinct from AFRS. The aim of the present study, based on a retrospective series of AFRS and EMRS, was to identify the specific clinical and radiological elements distinguishing between the two. MATERIALS AND METHODS: A 2-center retrospective observational study following STROBE guidelines included patients managed for AFRS or EMRS between 2009 and 2022. Clinical, mycological, pathologic and radiological data were collected. Type of treatment and disease progression were also analyzed. Intergroup comparison used Student's test for mean values of quantitative variables, with calculation of P-values, and Pearson's Chi2 test or Fisher's exact test for categoric variables, with calculation of relative risk and 95% confidence intervals. RESULTS: The AFRS group comprised 41 patients and the EMRS group 34. Demographic data were comparable between groups. EMRS showed a higher rate of asthma (79.4 vs. 31.4%; P<0.001), more severe nasal symptomatology (rhinorrhea, P=0.01; nasal obstruction, P=0.001), and more frequent bilateral involvement (85.3 vs. 58.5%; P=0.021). AFRS showed more frequent complications (19 vs. 0%; P=0.006). Radiologically, mucin accumulation was greater in AFRS, filling the sinus in 84.2% of cases, versus 26.3% (P<0.001), with more frequent sinus wall erosion (19 vs. 5.8%; P=0.073). The recurrence rate was higher in EMRS: 38.2 vs.21.9% (P=0.087). CONCLUSION: The present retrospective study found a difference in clinical and radiological presentation between AFRS and EMRS, with EMRS more resembling the presentation of severe nasal polyposis.

Outpatient bilateral ethmoidectomy in a private non-profit structure: Retrospective study of 204 patients.

OBJECTIVES: The main objective of this study was to determine the rate of outpatient management in a population of patients undergoing bilateral ethmoidectomy. The secondary objectives were to evaluate the quality of outpatient management (rate of unscheduled overnight admission, readmission rate, complications) and to compare inpatient and outpatient groups to determine which elements of the phenotype and care pathway favored outpatient management. MATERIALS AND METHODS: A single-center observational study included 204 patients operated on for bilateral ethmoidectomy. Study variables comprised: type of care pathway (outpatient/inpatient), outpatient quality indicators (unscheduled admission, readmission, complications), care pathway, and population characteristics. RESULTS: One hundred and twenty (58.8%) outpatients were operated on. No deaths occurred. The unscheduled admission rate was 7.5%, and the readmission rate 4.1%; at the P<0.005 threshold, there were no significant differences between in- and out-patient groups. Outpatients had earlier surgery (P<0.005), and nasal packing rates and pain on VAS were lower (P<0.005). CONCLUSION: Ethmoidectomy could be carried out as an outpatient procedure in 58.8% of cases, with acceptable quality of care. Selection of patients and the organization of a dedicated care pathway seem to be elements favoring this management.

Recurrent transient facial nerve palsy on commercial air flights.

INTRODUCTION: Facial baroparesis is a rare event, usually associated with a favourable outcome. It is related to atmospheric pressure changes that are responsible for neuropraxia. Most cases of facial baroparesis have been reported in the context of underwater diving, but very few cases have been reported during commercial flights. CASE REPORT: We report the case of a patient who experienced several episodes of spontaneously resolving left facial palsy during long-haul flights. The work-up revealed bilateral facial nerve canal dehiscence visible on CT scan and clinical features of bilateral otitis media with effusion associated with hearing loss. DISCUSSION: The pathogenesis of this disease involves the combination of these two elements inducing ischaemia of the exposed facial nerve submitted to pressure variations. In most cases, ischaemia is rapidly reversible with complete recovery after landing or in response to Valsalva manoeuvres. It is therefore important not to miss this entity to avoid delayed or inappropriate management.

Radiological-audiological correlation in type II tympanoplasty with glass ionomer cement.

AIM: To assess the CT scan aspect of cement bridges used to repair incudostapedial joint discontinuity (ISD) and correlate these observations to audiometric data over time. MATERIAL AND METHODS: A retrospective study in 12 patients with cement rebridging for ISD compared pre- and post-operative pure-tone average thresholds, Hounsfield units (HU), and bridge size and position on postoperative CT scans. RESULTS: Mean pre- and post-operative air-bone gap (ABG) was 24.5 and 16dB, respectively. HU did not vary over time post-surgery, with no significant correlation between HU and time to postoperative CTnscan up to 24months (p=0.219). However, a "suggestive" correlation was found between postoperative ABG and HU (p=0.004, r=-0.7). High cement density correlated with good functional outcome: HU <500 indicating functional failure and >1000 indicating ABG closure. CONCLUSION: Immediate cement polymerization quality (high HU) was stable over time and a marker of ossiculoplasty success, correlating with good functional outcome. Particular care should be taken in preparing the cement, and solidification needs to be on dry mucosa-free ossicles.

Use of a navigation system in endonasal surgery: Impact on surgical strategy and surgeon satisfaction. A prospective multicenter study.

OBJECTIVES: Surgical navigation systems (SNS) are now widely used in endoscopic endonasal surgery. Benefit, however, has not been fully studied. The objective of this study was to evaluate the impact of an SNS in terms of performance of the surgical procedure and of surgeon satisfaction, in a prospective multicenter study. MATERIALS AND METHODS: A multicenter prospective study included patients undergoing endoscopic endonasal surgery using the electromagnetic DigiPointeur® (DGP) SNS in 16 French hospitals. An observation form, completed by the surgeon immediately at end of procedure, included type of procedure, and any changes in strategy or extent of surgery related to use of the SNS. Surgeon satisfaction was rated on an analog scale, with self-assessment of stress experienced during the procedure. RESULTS: The study included 311 patients operated on by 36 surgeons in 16 French hospitals. Ethmoidectomy was the most frequent procedure (90%); tumor resection was performed in 5.1% of cases. The SNS enabled more extensive surgery in 81% of cases, in particular by identifying and opening additional cells (57% of cases). Mean satisfaction was 8.6/10; surgeons reported decreased surgical stress thanks to the SNS in 95% of cases. CONCLUSION: In this observational study, the use of an SNS increased the extent of surgery in 81% of cases, and had a positive impact on the stress perceived by the surgeon in 95% of cases.

Day-surgery in otology: Impact study of a dedicated organizational model.

AIM: Day surgery (DS) in otology in France is insufficiently implemented compared to other countries of comparable socio-economic level. The aim of the present study was to evaluate changes in surgical practice in "major otology" cases in a hospital center after launching a dedicated ENT DS unit. MATERIAL AND METHODS: This new unit, designed in collaboration with the surgeons, was inaugurated in 2014. Number of procedures, patient demographics, surgery durations, and rates of crossover from DS to conventional management were recorded prospectively for the year before and the year after the launch. All otologic surgery procedures with at least tympanomeatal flap elevation were included; minor surgeries such as grommet insertion were excluded. RESULTS: Between the two time periods, major otology day cases increased from 106 to 153 procedures (+43%). In 2013, the DS rate was 27%, versus 56% in 2015. Otosclerosis surgeries represented 7% in 2013 and 15% in 2015, and type II and III tympanoplasties 3% and 24% respectively. Difference in patient age between DS and conventional surgery was lower in 2015. Crossover rates were 10% in 2013 and 21% in 2015, mainly due to nausea/vertigo (56%) and surgery ending too late in the day (33%). CONCLUSION: Major otologic cases are suitable for DS. Launching this dedicated unit with its specific organization enabled a very significant increase in DS rates, probably due to greater patient satisfaction and surgeons' growing confidence. The main pitfall was in scheduling, with surgery ending too late in the day for discharge home; this has since been corrected.

Evaluation of the prevalence and specificities of asymptomatic paranasal sinus aspergillosis: retrospective study of 59 cases.

STUDY OBJECTIVES: To calculate the prevalence of asymptomatic localized paranasal sinus aspergillosis (or fungus ball) in the general population and to compare asymptomatic and symptomatic fungus balls (FB) in order to determine their specificities. MATERIAL AND METHOD: Retrospective study including 59 patients operated for FB between 2006 and 2011 in a single unit. Patients were divided into two groups: asymptomatic patients (group 1, n=10), and symptomatic patients (group 2, n=49). All patients in group 1 were identified by systematic screening for a site of infection prior to cataract surgery during this period (n=6198). All patients were treated by endonasal surgery. Calculation of the prevalence of asymptomatic FB was based on standardization of the source population (normal distribution, 95% confidence interval). The two groups were then compared (clinical context, age, history of root canal treatment, topography, recurrence rate), after randomization test by Student's test and Chi(2) test. RESULTS: The prevalence rate of asymptomatic FB in our study was 1.6/1000 in the population over the age of 55 years. A statistically significant difference was demonstrated between the two groups in terms of the following parameters: more advanced age for patients of group 1, constant history of root canal treatment in group 1, constant maxillary topography in group 1, and higher recurrence rate in group 2. Mean follow-up was 18.7 months (range: 3-49 months). DISCUSSION: This study, the first to determine the prevalence of asymptomatic FB, suggests the existence of very slowly progressive, minimally symptomatic forms, raising the problem of the surgical indications in these patients. CONCLUSION: The prevalence of asymptomatic fungus balls is 1.6/1000. Prospective studies are necessary to justify conservative management in these patients.

French Otorhinolaryngology Society guidelines for day-case nasal surgery.

OBJECTIVES: The French Otorhinolaryngology Society (SFORL) set up a work group to draw up a consensus document on day-case surgery in four rhinologic procedures: endoscopic middle meatal antrostomy (French National Health Insurance (CCAM) code GBPE001), septoplasty (GAMA007), and reduction of nasal bone fracture using a direct approach (LAEA007) and using a closed technique (LAEP002). MATERIALS AND METHODS: Methodology followed the French Health Authority (HAS) "Methodological Bases for Drawing Up Professional Guidelines by Formalized Consensus" published in January 2006; the method chosen was the short version of the RAND/UCLA Appropriateness Method (without editorial group), as the work group topic was highly specialized, with few experts available. RESULTS: Ahead of any day-case sinonasal surgery, it is recommended that patient eligibility criteria be respected and hemorrhagic risk assessed; preference should be given to short procedures involving little variation in surgery time and minimizing blood-loss, and associated procedures (e.g., septoplasty+turbinectomy) should be avoided. The patient and family should be informed of specific hemorrhagic, orbital and/or neuromeningeal risks, onset of which may preclude discharge home. Uni- or bilateral postoperative nasal packing is not a contraindication to day-case management. CONCLUSION: All four procedures may be performed on a day-case basis. Eligibility criteria should be systematically respected, but hemorrhagic risk, which is very specific to the sinonasal organ, is to be assessed on a case-by-case basis, as it is a major issue in this kind of management for a non-negligible number of patients.

Correlation between the rate of asymmetry volume of maxillary sinuses and clinical symptomatology in the silent sinus syndrome: A retrospective study about 13 cases.

OBJECTIVES: The "silent sinus syndrome" (SSS) also known as imploding antrum syndrome or chronic maxillary sinus atelectasis consists of painless enophthalmos and inward retraction of the ipsilateral maxillary sinus walls. The aims of the present study were: i) to look for a correlation between the level of volume asymmetry of the maxillary sinuses and the presence of ophthalmological and rhinosinusitis signs, ii) to determine the benefits of a middle meatal antrostomy in SSS cases, and iii) to evaluate the preventive role of neuronavigation surgery in the morbidity of this specific surgery. MATERIALS AND METHODS: We retrospectively analyzed the data of 13 patients operated on for a SSS by middle meatal antrostomy, with the aid of neuronavigation in 7 cases. The median follow up was 30 months. No reconstruction of the orbital floor was performed. Morphometric analysis and modeling of the sinus volume from the preoperative CT scanners were performed to assess the impact of the loss of sinus volume on the symptoms. RESULTS: all patients displayed a retraction of the orbital floor. There was a significant correlation between the magnitude of the decrease in sinus volume and clinical manifestations. Surgical treatment allowed rhinosinusitis symptom disappearance in 53% of patients. Ophthalmological symptoms did not decrease, but stayed stable after the surgical treatment. When neuronavigation surgery was performed, no complications were observed. CONCLUSION: SSS symptoms correlated with the reduction of volume of the maxillary sinuses. This measure may be related to the severity of the disease. The middle meatal antrostomy seemed sufficient to stop the evolution of the SSS, avoiding the occurrence of severe enophthalmos. Neuronavigation surgery helped preventing serious eye complications.

[Modified butterfly cartilage tympanoplasty: retrospective study on 26 patients]. / Tympanoplastie transcanalaire type "butterfly" modifiée: etude rétrospective sur 26 patients.

OBJECTIVE: To assess the results of inlay butterfly tympanoplasty on dry perforation. STUDY DESIGN: Retrospective case study. PATIENTS: 26 patient (14 male, 12 female), mean age 38 years, ranged from 9 to 73. Mean follow up: 20 months. SURGERY: Inlay cartilage butterfly tympanoplasty performed under general or local anesthesia according to the technique originally described by Eavey, with our specific modifications (use of a dermatological punch). RESULTS: 92.3% of perforation closure was obtained; 2 residual perforations and 1 non-epithelialisation were observed. No iatrogenic cholesteatoma was observed. The mean preoperative to post operative four-tone air bone gap improved from 27.67 to 20.1 (mean gain 7.5). CONCLUSION: Inlay butterfly cartilage tympanoplasty is a safe, efficient and easy technique. This technique need more prospective evaluation, and its place among other techniques of tympanoplasty needs to be precised.

[Laryngeal pemphigus]. / Le pemphigus laryngé.

The pemphigus vulgaris is a serious bullous disease of the adult. The pharyngolaryngeal localization has rarely been described. The oral and genital localizations are often inaugural. We report the case of a 45 year old female who presented a laryngeal pemphigus which evolved during several years before its cure. The bullous dermatosis are serious affections capable of being stressfull to life. Their diagnosis and treatment must be done quickly. The discovery of painful pharyngolaryngeal lesions, erosive or bullous, must lead to a biopsy with immunofluorescence histological examination in order to diagnose the pemphigus vulgaris and conduct quickly the treatment.

[Normative data of the Biolfa(R) olfactory test]. / Valeurs normatives du test olfactométrique Biolfa(R).

OBJECTIVES: To evaluate the feasibility of the Biolfa(R) olfaction test and establish normative values. PATIENTS AND METHODS: The new Biolfa(R) olfaction test includes a quantitative test to measure the olfactory threshold of three substances in a concentration range from 1 to 9 and a semi-quantitative test to assess olfactory "acuteness" for eight substances. Substances used for this test entail non-significant trigeminal stimulation. A population of 28 women and 24 men without olfactory dysfunction were tested. RESULTS: The olfactory threshold obtained with the quantitative test ranged from 5.86 to 9.54 for women, and from 6.4 to 9.6 for men. Analysis of the thresholds identified with the semi-quantitative test enabled establishing normative values for recognition of the eight substances. These values were reported on a diagram to allow partial translation of each subject's olfactory "acuteness". Olfactory threshold and smell identification ability were statistically superior for women. CONCLUSION: The Biolfa(R) olfaction test is the first allowing determination of both the olfactory threshold and quantification of smell identification ability. Normative values were obtained in this study to detect disease states.

[Is sudden sensorineural hearing loss a therapeutic emergency? Early results in a prospective cohort of 136 patients]. / Les surdités brusques sont-elles une urgence thérapeutique?

Idiopathic sudden sensorineural hearing loss is one of the most controversial issues in otology. A prospective cohort study including 136 sudden hearing losses seen at the ENT emergency referral center of Lariboisiere Hospital during an 18-month period was conducted. Patients were hospitalized and a corticotherapy course was administered, eventually associated with an antiviral treatment, low molecular weight dextran or sedative. At the end of the 5-day hospitalization, 74% of the patients had recovered, at least partially, with a mean gain of 22 dB. The outcome was considered satisfactory, i.e. superior to 50% of the initial loss, in 30% of the patients. After 1 month, 86% of the patients recovered at least partially with a mean gain of 30 dB. The outcome was considered satisfactory in 44% of the patients. A prognosis analysis showed that vertigo, age of the patient and anacusis are pejorative factors. Ascending audiogram shapes seem to involve a better prognosis. The therapeutic delay is not correlated with the quality of the outcome, which questions the classical notion of therapeutic emergency.

Lymphocele of the thoracic duct presenting as a left supraclavicular mass: a case report and review of the literature.

Surgical injuries and blunt trauma are the main causes of thoracic duct lesions. Cervical chylous fistula and chylothorax occur frequently after lesions of the cervical portion of the thoracic duct. On the other hand, thoracic duct cyst is a very rare entity, especially in its cervical portion. The authors reported a case of thoracic duct cyst, presenting as an asymptomatic left cervical mass. Diagnosis was suggested by computerized axial tomography and confirmed by histological analysis, after surgical removal of the cyst. After review of the literature, the authors recommended surgical treatment of cervical thoracic duct cysts in order to prevent potential complications as traumatic or spontaneous rupture.

Conservative surgery in T3-T4 pharyngolaryngeal squamous cell carcinoma: an alternative to radiation therapy and to total laryngectomy for good responders to induction chemotherapy.

OBJECTIVE: To evaluate the possibility of preservation of the larynx after neoadjuvant chemotherapy by performing a conservative surgery instead of total laryngectomy initially planned, in patients with previously untreated laryngeal and piriform sinus squamous cell carcinoma (SCC). STUDY DESIGN: Retrospective study. METHODS: A total of 115 patients treated at Tenon Hospital with induction chemotherapy from 1985 to 1995, all with initial indication of radical surgery, were available for the study. The clinical tumor response was evaluated after three cycles of chemotherapy. According to this response, to preserve laryngeal functions, some patients had a modification of the treatment initially planned: radiation therapy essentially for complete responders, and conservative surgery for some partial responders. RESULTS: Of 69 patients with laryngeal cancer, 14 were treated by partial laryngectomy and 19 by radiation therapy; of 46 patients with piriform sinus cancer, 8 were treated by partial surgery and 12 by radiation therapy; the other patients were treated as was initially planned (total laryngectomy with partial pharyngectomy). Overall survival rates, estimated by the Kaplan-Meier method, were not statistically different between the three treatment groups. The laryngeal functions were preserved in 54% of the patients who were alive at 3 years. CONCLUSION: This report is a retrospective study, but these results suggest the possibility of using conservative surgery, instead of initially planned total laryngectomy, for good responders to induction chemotherapy with a small residual tumor.