Tracheoesophageal fistula and pharyngoesophageal stenosis repair by double skin paddle radial forearm flap.

Tracheoesophageal fistula (TEF) constitutes a rare, but serious complication in laryngectomized patients, usually occurring after radiotherapy. TEF may occur spontaneously or may be due to enlargement of the TEF created for placement of a voice prosthesis. Surgical treatment of TEF can be complex, especially in the presence of a concomitant pharyngoesophageal stenosis (PES), and is associated with a high failure rate. In this article, we describe the surgical reconstruction technique for TEF associated with PES using a double skin paddle fasciocutaneous radial forearm free flap. The key points of this technique consist of correct positioning of the 2 skin paddles in order to reconstruct the anterior pharyngoesophageal wall and posterior tracheal wall, as well as de-epidermization of the intermediate part of the flap, which is then placed in the tracheoesophageal space.

Functional evaluation of mandibular reconstruction with bone free flap. A GETTEC study.

OBJECTIVES: To assess the functional results of oromandibular reconstruction by free bone flap, in terms of swallowing, speech and esthetics. MATERIALS AND METHODS: A transverse multicenter study included 134 patients reconstructed by free bone flap between 1998 and 2016, with more than 6 months' follow-up, in 9 centers. A standardized questionnaire collected data on patients and treatment. Study endpoints comprised: weight loss, mouth opening, gastrostomy dependence, type of feeding, and DHI score. The impact of patient baseline characteristics on these functional criteria was explored by uni/multivariate analysis. RESULTS: Ninety of the 134 patients had cancer. Fibula flap was mainly used (80%). 94% of reconstructions were primary successes. 71% of patients had pre- or post-operative radiation therapy. 88% had less than 50% lingual resection. 97% recovered oral feeding. 89% had intelligible speech. 86% judged their esthetic appearance as good/average. 9% had dental prosthetic rehabilitation. Radiation therapy and extensive lingual resection significantly impacted swallowing function (P=0.04 and P=0.03, respectively). Radiation therapy and oropharyngeal extension significantly increased gastrostomy dependence (P=0.04 and P=0.02, respectively). CONCLUSION: Oromandibular reconstruction by free bone flap enabled return to oral feeding in most cases. More than 80% of patients were satisfied with their result in terms of speech and esthetics. However, the rate of dental rehabilitation was low and the rate of complications was high.

French consensus on management of head and neck cancer surgery during COVID-19 pandemic.

In the context of the current pandemic, there is a need for specific advice concerning treatment of patients with Head and Neck cancers. The rule is to limit as much as possible the number of patients in order to reduce the risks of contamination by the SARS-Cov-2 virus for both patients and the caregivers, who are particularly exposed in ENT. The aim is to minimize the risk of loss of opportunity for patients and to anticipate the increased number of cancer patients to be treated at the end of the pandemic, taking into account the degree of urgency, the difficulty of the surgery, the risk of contaminating the caregivers (tracheotomy) and the local situation (whether or not the hospital and intensive care departments are overstretched).

Cystic form of cervical lymphadenopathy in adults. Guidelines of the French Society of Otorhinolaryngology (short version). Part 2-etiological diagnosis procedure: Clinical and imaging assessment.

INTRODUCTION: The authors present the guidelines of the French Society of Otorhinolaryngology (SFORL) for clinical and radiological assessment of cystic neck lymphadenopathy of unknown primary in adults. Most cases concern head and neck carcinoma metastasis, often in the oropharyngeal area, or less frequently differentiated thyroid carcinoma or non-keratinizing nasopharyngeal carcinoma. METHODS: A multidisciplinary task force was commissioned to carry out a review of the literature on the etiological work-up in cystic neck lymphadenopathy in adults: clinical examination, conventional imaging (ultrasound, CT, MRI) and metabolic imaging. Guidelines were drafted based on the articles retrieved, and graded A, B, C or expert opinion according to decreasing level of evidence. RESULTS: Oriented clinical examination, cervical and thyroid ultrasound scan and contrast-enhanced neck and chest CT scan are recommended in the assessment of cystic neck lymphadenopathy of unknown primary in adult patients. PET-CT is recommended prior to panendoscopy, to identify the primary tumor. CONCLUSION: Clinical and radiological assessment is fundamental for etiologic diagnosis of cystic neck lymphadenopathy in adult patients, and should be completed by cytological examination before in initiating treatment.

Pharyngeal diverticulum: Iatrogenic complication of anterior cervical spine surgery.

INTRODUCTION: Dysphagia is a common presenting complaint and can often be due to pharyngoesophageal diverticulum, including Zenker's diverticulum. Iatrogenic pharyngeal diverticulum, occurring after anterior cervical spine surgery, is a rare cause of dysphagia. CASE REPORT: We report the case of a 51-year-old man, with a history of anterior cervical fusion about ten years previously, who complained of chronic dysphagia and disabling episodes of aspiration. Anterolateral pharyngeal diverticulum in contact with the cervical screw plates was diagnosed on barium swallow and upper gastrointestinal endoscopy. DISCUSSION: Pharyngeal diverticulum differs from Zenker's diverticulum in terms of its position and its origin. It may occur early or late after anterior cervical spine surgery. Treatment consists of endoscopic or open surgery via a neck incision. In our case, appropriate treatment allowed complete resolution of the patient's symptoms with no complications following rigorous postoperative surveillance.

Role of supracricoid partial laryngectomy with cricohyoidoepiglottopexy in glottic carcinoma with anterior commissure involvement.

OBJECTIVES: To analyze oncologic and functional outcomes after supracricoid laryngectomy with cricohyoidoepiglottopexy (SCL-CHEP) in glottic carcinoma with anterior commissure (AC) involvement, to determine predictive factors, and to compare results with those reported for other therapeutic strategies. MATERIAL AND METHODS: A retrospective analysis included all patients who underwent SCL-CHEP for glottic squamous cell carcinoma with anterior commissure involvement in our institution, between 2000 and 2014. Swallowing function was evaluated on the DOSS (Dysphagia Outcomes and Severity Scale). RESULTS: Fifty-three patients were included. Three-year overall, cause-specific and recurrence-free survival rates were 86, 95 and 80%, respectively. There were 5 cases of local recurrence (9%), all treated by total laryngectomy. Smoking was the only predictive factor of recurrence-free survival (P=0.02). Mean DOSS score was 5.5±0.9. DOSS scores≥6 (normal oral feeding) were recovered by 59% of patients. T-stage≥2 was the only predictive factor for DOSS score (P=0.04). CONCLUSION: In glottic carcinoma with anterior commissure involvement, SCL with CHEP provided a local control rate of more than 90%, which is higher than reported with endoscopic surgery or external radiotherapy. However, contrary to LSC, salvage of local recurrence can often be obtained by conservative treatments after endoscopic surgery. Therefore, total-laryngectomy-free survival rates after SCL-CHEP and endoscopic surgery are finally comparable.

[Reirradiation of head and neck cancers]. / Réirradiation des cancers des voies aérodigestives supérieures.

Locoregional relapse in previously irradiated region for head and neck tumours is associated with a bad locoregional and distant prognosis. Reirradiation might be exclusive, or feasible in addition with surgery and/or chemotherapy, according to histopronostic factors. Data show that reirradiation is feasible with some severe toxicity due to the bad prognosis of this situation. Hyperfractionnated regimen with split course or normofractionnated regimen without split course are possible with similar efficacy. If tumour size is small, stereotactic ablative radiotherapy may be considered, and if the treatment centre has proton therapy, it could be proposed because of better organs at risk sparing. There is no standard regarding reirradiation schedules and several trials have to be done in order to determine the best technique. Nevertheless, it is agreed that a total dose of 60Gy (2Gy per fraction) is needed. Other trials testing the association with new systemic agents have to be performed, among them agents targeting the PD1/PD-L1 axis.

Primary total laryngectomy and pharyngolaryngectomy in T4 pharyngolaryngeal cancers: Oncologic and functional results and prognostic factors.

OBJECTIVES: The aims of this study were to assess oncologic and functional outcome in primary total laryngectomy or pharyngolaryngectomy (TL/TL/TPL) for laryngeal or hypopharyngeal cancer with extra-laryngeal extension (T4) and to determine the predictive factors of these results. MATERIAL AND METHODS: A retrospective analysis was performed on the computerized medical records of all patients undergoing primary TL/TPL for T4 larynx or hypopharynx squamous cell carcinoma between 2000 and 2014 at our institution. Predictive factors of oncologic and functional outcome were investigated on univariate and multivariate analysis. RESULTS: Sixty-three patients (58 men, 5 women; mean age, 68.8±9.7 years) were included. Overall and disease-specific survivals were 69% and 80% at 3 years, and 56% and 69% at 5 years, respectively. On multivariate analysis, gender (female, P<0.001), ASA score (ASA≥3; P=0.006) and vascular embolism (P=0.006) had significant pejorative impact on overall survival. Six months after end of treatment, 90% of patients had recovered independent oral feeding and 83% of those with tracheoesophageal voice prostheses had recovered an intelligible voice. CONCLUSION: Primary TL/TPL remains the gold standard treatment for T4 larynx or hypopharynx cancer. It provides satisfactory oncologic and functional outcomes.

Transoral-transcervical oropharyngectomy without mandibulotomy, associated to fasciocutaneous radial forearm free-flap reconstruction, for oropharyngeal cancer: Postoperative course, oncologic and functional results, and prognostic factors.

OBJECTIVE: To analyze postoperative course, oncologic and functional results and prognostic factors of transoral-transcervical oropharyngeal cancer surgery without mandibulotomy, associated to radial forearm free-flap reconstruction. MATERIAL AND METHODS: Retrospective analysis of computerized medical records of all patients who underwent this type of surgery in our institution between 2004 and 2014. Predictive factors of oncologic and functional results were investigated on univariate and multivariate analyses. RESULTS: Forty-four patients (37 male, 7 female; mean age, 62.3±9.3years) were included. Three-year overall, disease-specific and recurrence-free survival was 90%, 92% and 79%, respectively. Functional scores were satisfactory (normal or slight impairment) for feeding, speech and oral opening functions in 86%, 93% and 100% of cases, respectively. ASA score≥III had significantly negative impact on overall survival (P=0.005) and on feeding (P=0.01) and speech (P=0.01). CONCLUSION: Transoral-transcervical oropharyngeal cancer surgery without mandibulotomy provided excellent oncologic and functional outcomes; it is an advantageous alternative to the conventional conservative transmandibular oropharyngectomy.

Virtual planning and guided surgery in fibular free-flap mandibular reconstruction: A 29-case series.

INTRODUCTION: Virtual planning and guided surgery (VPGS) has been recently developed for mandibular reconstruction, but benefit remains to be assessed. The aim of this study was to analyze the impact of VPGS on operative time and postoperative course. MATERIAL AND METHODS: All patients who underwent fibula free-flap mandibular reconstruction between 2013 and 2014 in our institution were included in a retrospective study. Operative times and postoperative course were compared between patients who underwent conventional surgery in 2013 and those who underwent VPGS in 2014. RESULTS: A total of 29 patients were included: 11 in 2013 and 18 in 2014. Taking all types of mandibular defect together, ischemia time was significantly decreased by VPGS (75min, vs 150min for conventional surgery; P<0.001), whereas overall operative time was not significantly reduced (481 and 516min, respectively; P=0.4). VPGS had no impact on postoperative course: local or general complications, time to decannulation and nasogastric tube removal, or length of stay. CONCLUSION: VPGS significantly reduced fibula free-flap ischemia time. Long-term functional and esthetic benefit remains to be evaluated.

Regulation of osteosarcoma cell lung metastasis by the c-Fos/AP-1 target FGFR1.

Osteosarcoma is the most common primary malignancy of the skeleton and is prevalent in children and adolescents. Survival rates are poor and have remained stagnant owing to chemoresistance and the high propensity to form lung metastases. In this study, we used in vivo transgenic models of c-fos oncogene-induced osteosarcoma and chondrosarcoma in addition to c-Fos-inducible systems in vitro to investigate downstream signalling pathways that regulate osteosarcoma growth and metastasis. Fgfr1 (fibroblast growth factor receptor 1) was identified as a novel c-Fos/activator protein-1(AP-1)-regulated gene. Induction of c-Fos in vitro in osteoblasts and chondroblasts caused an increase in Fgfr1 RNA and FGFR1 protein expression levels that resulted in increased and sustained activation of mitogen-activated protein kinases (MAPKs), morphological transformation and increased anchorage-independent growth in response to FGF2 ligand treatment. High levels of FGFR1 protein and activated pFRS2α signalling were observed in murine and human osteosarcomas. Pharmacological inhibition of FGFR1 signalling blocked MAPK activation and colony growth of osteosarcoma cells in vitro. Orthotopic injection in vivo of FGFR1-silenced osteosarcoma cells caused a marked twofold to fivefold decrease in spontaneous lung metastases. Similarly, inhibition of FGFR signalling in vivo with the small-molecule inhibitor AZD4547 markedly reduced the number and size of metastatic nodules. Thus deregulated FGFR signalling has an important role in osteoblast transformation and osteosarcoma formation and regulates the development of lung metastases. Our findings support the development of anti-FGFR inhibitors as potential antimetastatic therapy.

Spontaneous intra-parotid pseudoaneurysm of the external carotid artery.

INTRODUCTION: The authors report a case of spontaneous intra-parotid pseudoaneurysm of the external carotid artery, never previously described in the literature. CASE REPORT: A 59-year-old woman presented with a palpable, non-pulsatile, 2 cm retromandibular left parotid mass with no triggering factors. This mass was considered to be a mixed tumour, although it did not present the typical features on MRI. At surgery, the lesion in the lower pole of the parotid gland was found to be pulsatile, in favour of pseudoaneurysm of the external carotid artery. The external carotid artery was ligated to remove the lesion. Definitive histological examination confirmed the diagnosis of pseudoaneurysm. DISCUSSION: Pseudoaneurysms of extracranial arteries are rare, most commonly involve the internal carotid artery and are essentially secondary to trauma. Review of MRI images demonstrated hyperintense arterial blood flow within the hypointense mass on T2-weighted sequences. The presence of this sign must therefore be investigated in the context of atypical images of a parotid mass. Although rare, and despite the absence of trauma, the diagnosis of pseudoaneurysm of the external carotid artery or one of its branches should therefore be considered in the presence of an atypical parotid mass.

French Society of ENT (SFORL) guidelines for care pathway organization in head and neck oncology (short version). Early management of head and neck cancer.

Early management in oncology is based on coordination and high-quality exchange between the various health-care partners. The present guidelines are based on a literature search with levels of evidence. Treatment waiting time can be optimized by performing assessment as early as possible (Expert opinion), to limit the interval (ideally, less than 4 weeks) between first consultation and data collection. In the first specialist consultation, diagnostic work-up should be scheduled and the data required for management should be determined (Grade B). Work-up may be conducted on a day-care basis or with conventional admission (Expert opinion). The patient's medico-social context should be taken into account from the outset, with social work involvement whenever necessary (Expert opinion). Pain and nutritional management should be planned for (Grade A) and realistic therapeutic education be provided (Expert opinion). Community-hospital teamwork for supportive care should be optimized (Expert opinion). Management should be early and multidisciplinary, to shorten delay between diagnosis and treatment initiation.

Guidelines (short version) of the French Otorhinolaryngology - Head and Neck Surgery Society (SFORL) on patient pathway organization in ENT: The therapeutic decision-making process.

OBJECTIVES: The authors present the guidelines of the French Otorhinolaryngology - Head and Neck Surgery Society (SFORL) for patient pathway organization in head and neck cancer, and in particular for multidisciplinary team meetings. The present article concerns the therapeutic decision-making process. METHODS: A multidisciplinary work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group. The final version was established in a coordination meeting. The guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence. RESULTS: It is recommended that: an organ specialist should contribute to all multidisciplinary meetings on head and neck cancer; all members of the multidisciplinary meeting should have specific knowledge in head and neck cancer; any referring physician who does not follow the multidisciplinary meeting's advice should justify that decision; there should be sufficient time to prepare, discuss and sum up the cases dealt with in the multidisciplinary team meeting.

Fra-2/AP-1 controls adipocyte differentiation and survival by regulating PPARγ and hypoxia.

Adipocyte cell number is a crucial factor for controlling of body weight and metabolic function. The regulation of adipocyte numbers in the adult organism is not fully understood but is considered to depend on the homeostasis of cell differentiation and apoptosis. Herein, we show that targeted deletion of the activator protein (AP-1)-related transcription factor Fra-2 in adipocytes in vivo (Fra-2(Δadip) mice) induces a high-turnover phenotype with increased differentiation and apoptosis of adipocytes, leading to a decrease in body weight and fat pad mass. Importantly, adipocyte cell numbers were significantly reduced in Fra-2(Δadip) mice. At the molecular level, Fra-2 directly binds to the PPARγ2 promoter and represses PPARγ2 expression. Deletion of Fra-2 leads to increased PPARγ2 expression and adipocyte differentiation as well as increased adipocyte apoptosis through upregulation of hypoxia-inducible factors (HIFs). These findings suggest that Fra-2 is an important checkpoint to control adipocyte turnover. Therefore, inhibition of Fra-2 may emerge as a useful strategy to increase adipocyte turnover and to reduce adipocyte numbers and fat mass in the body.

[Free flap reconstruction after oral and oropharyngeal advanced stage carcinoma surgery]. / Reconstruction par lambeau libre après chirurgie des cancers de la cavité buccale et de l'oropharynx de stade avancé.

INTRODUCTION: The aim of the study was to evaluate the survival and locoregional recurrence in patients with advanced oral and oropharyngeal squamous cell carcinoma treated by surgery with free flap reconstruction followed or not by radiochemotherapy. POPULATION AND METHODS: A retrospective study was performed on 188 patients treated by surgery with microvascular reconstruction with or without postoperative radiochemotherapy for an advanced stage squamous carcinoma of the oral cavity and/or of the oropharynx. All patients underwent free flap reconstruction. The study parameters were survival and recurrence rates. RESULTS: The 5-year overall survival, disease specific survival, and disease free survival rates were 54%, 65%, and 61% respectively. A high level of comorbidity was the only factor that influenced the survival rate. The overall recurrence rate was 34%. Only 9% of patients having recurred were treated successfully. The survival rate after locoregional recurrence and metastasis was 6% at 2 years. DISCUSSION: Surgery and postoperative radiochemotherapy allows for an acceptable survival rate for patients with advanced oral and oropharyngeal squamous cell carcinoma.

Patient information ahead of thyroid surgery. Guidelines of the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL).

OBJECTIVE: The authors present the guidelines of the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL) on patient information ahead of thyroid surgery. METHODS: A multidisciplinary medical team was tasked with a scientific literature review on this topic. The texts retrieved were analyzed by an independent committee. A joint meeting drew up the final guidelines. The strength of the recommendations (grade A, B or C) was based on levels of evidence. RESULTS: It is recommended that the results of preoperative exploration and the indications for surgery should be explained to the patient. Patients should be informed as to the type of surgery, surgical objectives, risks and consequences. It is mandatory to obtain the patient's written consent before surgery. CONCLUSION: Appropriate medical information is a critical step in patient management.