COVID-19 and ENT Pediatric otolaryngology during the COVID-19 pandemic. Guidelines of the French Association of Pediatric Otorhinolaryngology (AFOP) and French Society of Otorhinolaryngology (SFORL).

OBJECTIVE: Joint guidelines of the French Pediatric Otolaryngology Society (AFOP) and of the French Society of otorhinolaryngology-head and neck surgery (SFORL) on the management of paediatric otolaryngology patients in the context of the COVID-19 pandemic. METHODS: A nation-wide workgroup drew guidelines based on clinical experience, national and local recommendations and scientific literature. Proposals may have to be updated on a day-to-day basis. RESULTS: In children, incidence of symptomatic COVID-19 (1-5%) is low and of good prognosis. The indications for nasal flexible endoscopy should be drastically limited. If undertaken, full Personal Protective Equipment (PPE) including FFP2 masks are required, as well as use of a sheath. Saline nose wash done by caregivers other than parents at home should require PPE. Unless foreign body tracheobronchial aspiration is clinically obvious, CT-scan should be performed to confirm indication of endoscopy. Surgical indications should be limited to emergencies and to cases that cannot be delayed beyond 2 months (especially endonasal, endopharyngeal laryngo-tracheobronchial procedures). Postponement should ideally be a group decision and recorded as such in the medical file. Surgical techniques should be adapted to limit the risk of viral dissemination in the air, avoiding the use of drills, microdebriders, monopolar cautery or lasers. Continuous suction should be placed near the operating field. In case of confirmed Covid-19 cases, or suspected cases (or in some centres systematically), PPE with FFP2 mask should be worn by all staff members present in the operating room.

Role of the ENT specialist in the diagnosis of pediatric obstructive sleep apnea-hypopnea syndrome (POSAHS). Part 3: sleep recordings.

OBJECTIVES: The authors present the clinical practice guidelines of the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL) concerning the role of the ENT specialist in the management of pediatric obstructive sleep apnea hypopnea syndrome (POSAHS). Part 3 is dedicated to the place of sleep recordings in the diagnosis of POSAHS. METHODS: A multidisciplinary work group was commissioned to carry out a review of the scientific literature on the above topic. Based on the articles retrieved and the group members' individual experience, guidelines were drafted and graded as A, B or C or Expert Opinion by decreasing level of evidence, then reviewed by an editorial group independent of the work group. RESULTS: Sleep recordings are presented according to the American Sleep Disorders Association's classification as type 1, 2, 3 or 4. Their modalities, interpretation, indications, advantages and limitations are detailed.

Laryngeal lesion associated with epidermolysis bullosa secondary to congenital plectin deficiency.

INTRODUCTION: Epidermolysis bullosa (EB) is a congenital disease characterized by fragility of epithelial structures. The skin is the organ primarily affected, resulting in the formation of skin blisters. Some forms of EB may also present mucosal lesions. CASE REPORT: We report the case of a girl with epidermolysis bullosa simplex (EBS) associated with muscular dystrophy secondary to congenital plectin deficiency. She presented severe respiratory tract lesions extending from the oral cavity to the larynx. In particular, we describe our medical and surgical management of the laryngeal lesions, responsible for several episodes of respiratory distress and feeding difficulties. DISCUSSION: Epidermolysis bullosa simplex associated with muscular dystrophy is a rare hereditary form of EB, as fewer than 50 cases have been reported in the literature. This form is characterized by mucosal lesions involving the upper aerodigestive tract, with consequences for feeding, phonation and breathing. Special care must be taken when performing diagnostic and therapeutic procedures to avoid worsening the lesions of this very fragile mucosa. Tracheotomy is a harmful procedure in these patients and should only be considered as a last resort.

French Society of Otorhinolaryngology and Head and Neck Surgery (SFORL) guidelines concerning the role of otorhinolaryngologists in the management of paediatric obstructive sleep apnoea syndrome: Follow-up protocol for treated children.

OBJECTIVES: The authors present the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL) clinical practice guidelines concerning the role of otorhinolaryngologists in the management of paediatric obstructive sleep apnoea syndrome (OSAS). This chapter is devoted to the follow-up protocol for children treated for OSAS. METHODS: A multidisciplinary task force was commissioned to carry out a review of the scientific literature on this topic. On the basis of the articles selected and the personal experience of each member of the task force, guidelines were drafted and graded as A, B or C or expert opinion according to a decreasing level of scientific evidence, and were then reviewed by a reading committee, independently of the task force. The final guidelines were established at a consensus meeting. RESULTS: Short-term, medium-term and long-term clinical follow-up and complementary investigations are necessary in view of the risk of residual OSAS, and the risk of recurrence of OSAS related to adenoid and tonsillar regrowth following adenotonsillectomy, the treatment most commonly performed. The modalities of follow-up after surgery, continuous positive airway pressure (CPAP) ventilation, orthodontic treatment, myofascial rehabilitation, and drug therapy are described. The indications for nasal endoscopy and sleep studies as part of follow-up are specified.

French Society of ENT (SFORL) guidelines (short version) on the roles of the various treatment options in childhood obstructive sleep apnea-hypopnea syndrome.

OBJECTIVE: The authors present the guidelines of the French Society of ENT and Head & Neck Surgery (SFORL) on the role of the ENT physician in childhood obstructive sleep apnea-hypopnea syndrome (OSAHS). This section of the guidelines concerns the roles of the various medical and surgical treatment options. METHOD: A multidisciplinary work-group was entrusted with a review of the scientific literature on the topic. Based on the retrieved articles and the group members' own experience, guidelines were drawn up, then read over by a reading group independent of the work-group. An editorial meeting then produced the final text. RESULTS: Adenotonsillectomy is the reference treatment for childhood OSAHS with adenotonsillar hypertrophy. Respiratory assistance is recommended in children with severe OSAHS without nasal and/or oropharyngeal obstacle, after surgery in case of persistent OSAHS, in case of contraindications to surgery, in complex obstruction related to pharyngolaryngeal or laryngeal pathology or comorbidity, or as an alternative to tracheotomy. Nasal route corticosteroids may be used in childhood OSAHS in with associated nasal obstruction.

Evaluation of the efficacy of tongue-lip adhesion in Pierre Robin sequence.

OBJECTIVE: Tongue-lip adhesion may be used to relieve obstructive sleep apnoea in infants with Pierre Robin sequence (PRS), but only a few studies have objectively evaluated its efficacy. The purpose of this study was to evaluate the results of tongue-lip adhesion by polysomnography. MATERIEL AND METHODS: A single-centre retrospective study was conducted in infants with PRS treated by tongue-lip adhesion from 2004 to 2015, in whom at least laryngotracheal endoscopy and polysomnography were performed. The variables collected were the syndromic diagnosis, demographic data, respiratory management before tongue-lip adhesion, symptoms, and additional airway interventions. Obstructive sleep apnoea was classified into 3 groups according to severity. Polysomnography was performed one month after tongue-lip adhesion. Statistical analysis was performed with Wilcoxon signed-rank test with a limit of statistical significance of P<0.005. RESULTS: Thirty-seven subjects in whom tongue-lip adhesion was performed at a mean age of 45 days (8 to 210 days) were included. Thirty-one patients had isolated PRS and 6 patients had associated anomalies. All patients had confirmed severe obstructive sleep apnoea. All patients required respiratory support prior to surgery: 8 intubated patients, 15 patients with noninvasive ventilation and 14 patients with nasopharyngeal airways. Eight patients had bradycardia before tongue-lip adhesion. All parameters were improved on postoperative polysomnography: oxygen saturation, hypercapnia, apnoea-hypopnoea index, bradycardia (P<0.005). Only 8 patients had persistent severe obstructive sleep apnoea and required tracheostomy (n=5) or noninvasive ventilation (n=3). No significant correlation was observed between treatment success and any predictive variables. CONCLUSION: Tongue-lip adhesion improved airway obstruction in all infants with PRS and resolved obstructive sleep apnoea in 29 patients. However, 8 patients required additional airway interventions.

Desmoid tumours of the head and neck in children: Review of management.

OBJECTIVE: Desmoid tumours of the head and neck in children are rare, local invasive and potentially fatal tumours. The purpose of this review is to discuss the management of these tumours in the light of a case series and a review of the literature. MATERIAL AND METHODS: This retrospective study summarised the medical data of children treated for desmoid tumours of the head and neck between 1976 and 2014. RESULTS: Five of the 6 children were treated by radical surgical resection, with positive surgical margins (R1) in 2 cases, followed by recurrence requiring further resection. One child with a very advanced lesion was treated by weekly methotrexate and vinorelbine chemotherapy for 18months, allowing 93% reduction of tumour volume without recurrence. CONCLUSIONS: Desmoid tumours of the head and neck in children are more aggressive than their adult counterparts and are associated with high morbidity and mortality and a high recurrence rate. CT and MRI imaging assessment should preferably be performed before biopsy. External beam radiotherapy must be avoided in children as it is less effective than in adults, and is responsible for long-term cosmetic and functional sequelae and even a risk of second tumours. Treatment is surgical whenever radical resection is possible. In patients presenting an excessive risk of morbidity and mortality, chemotherapy devoid of long-term adverse effects (such as methotrexate in combination with a Vinca alkaloid) can be proposed. Long-term follow-up must be ensured due to the risk of recurrence.

How to replace codeine after tonsillectomy in children under 12 years of age? Guidelines of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL).

The authors present the guidelines of the French Oto-rhino-laryngology--Head and Neck Surgery Society (SFORL) regarding pain management in children and adults following tonsillectomy. A multidisciplinary work group was entrusted with a literature review. Guidelines were drawn up based on the articles retrieved and the group members' experience. They were read over by an editorial group independent of the work group. A coordination meeting drew up the final version. Guidelines were graded A, B or C or as professional agreement in decreasing order of level of evidence. At home, non-steroid anti-inflammatory drugs (NSAIDs) are recommended in association with paracetamol in elevated respiratory risk and especially obstructive sleep apnea syndrome; in elevated hemorrhagic risk (hemostasis disorder, surgical problems, etc.), tramadol is recommended. Two other treatment schedules (modified NSAIDs and corticosteroids) have not undergone dedicated study and should be assessed. Management of post-tonsillectomy pain in children is founded on individual risk/benefit analysis.

Guidelines (short version) of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL) for the management of post-tonsillectomy pain in adults.

OBJECTIVES: The present clinical practice guidelines cover the entire field of management of post-tonsillectomy pain. Given the French and European regulatory restrictions on the use of codeine, an update appears necessary to clarify the management of post-tonsillectomy pain in adults. METHOD: A work group approached the issue of pain management, following the chronological pathway from initial consultation to postoperative period. As exhaustive a study of the literature as possible assessed the pain impact of the various surgical techniques and the efficacy of the various analgesia schedules. RESULTS: Guidelines on the management of post-tonsillectomy pain in adults were drawn up and graded, based on the levels of evidence of selected articles and on work group consensus. The guidelines stress the importance of patient information and seek to harmonize practice, reduce the risk of postoperative complications and above all improve control of post-tonsillectomy pain in adults.

[Congenital piriform aperture stenosis and odontogenic disorders]. / Sténose congénitale de l'orifice piriforme et troubles de l'odontogenèse.

PURPOSE: We had for objective to assess odontogenic disorders associated to a congenital piriform aperture stenosis and to study their various presentations. METHODS: Twelve patients presenting with a congenital piriform aperture stenosis, 1 week to 3 months of age, were retrospectively included from 1998 to 2008. All patients underwent an initial CT scan to evaluate the temporary dental germs. RESULTS: Deciduous dental germs were abnormal in 75% of the cases. Thirty-three percent had a single median maxillary central incisor. DISCUSSION: The concept of solitary median maxillary central incisor syndrome makes for a more pathophysiological approach of this type of disease, with various clinical presentations, corresponding to various levels of severity of a same pathological process.

[Esophageal atresia]. / Devenir à moyen et long terme des enfants atteints d'atrésie de l'œsophage.

Most of the children operated for esophageal atresia will survive the neonatal period. However, medium-term and late complications are frequent in this population. Gastroesophageal reflux disease is observed in 26 to 75% of the cases and can be responsible for peptic esophagitis, anastomotic stenosis, and Barrett esophagus, which is a risk factor for adenocarcinoma of the esophagus. Dysphagia is frequently observed, sometimes several years after the surgery, affecting up to 45% of children at the age of 5 years. Growth retardation is present in nearly one-third of children at the age of 5 years. Ear, nose, and throat and respiratory complications are also very frequent but tend to improve with time. Tracheomalacia is found in 75% of these children at birth, sometimes responsible for severe complications (malaise, bradycardia). Respiratory symptoms are dominated by chronic cough, wheezing, and infections reported in 29% of the children by the age of 5 years. Restrictive, obstructive syndromes and bronchial hyperactivity can be observed, but usually remain moderate. All these complications can influence the patient's quality of life, which is moderately impaired compared to healthy controls. The high frequency of late sequelae in esophageal atresia justifies regular and multidisciplinary follow-up through adulthood.

Endonasal endoscopic approach for removal of intranasal nasal glial heterotopias.

BACKGROUND: Nasal Glial Heterotopias also called Nasal Gliomas (NG) are rare congenital tumours of the midline frontonasal space arising from a normal neurectodermal tissue entrapped during the closure of the anterior neuropore. Historically, such tumours were approached using a frontal craniotomy. The study aims to evaluate a fully endonasal endoscopic approach for intranasal NG removal. METHODS: We report a retrospective study of intranasal and mixed NG treated using endonasal endoscopic techniques and computer assisted navigation system from 1997 to 2010 in two tertiary referral centres of Paediatric Otolaryngology. All tumours were investigated using two imaging modalities: craniofacial MRI and CT-scan. RESULTS: Fifteen patients were included (0 to 14 years of age). All tumours were totally removed and no recurrence was observed after a mean follow-up of 32 months. A skull base plasty was done in 13 cases to cover a bony defect or to treat a cerebrospinal leak. Nasal packing was usually removed 24 hours after surgery and all children were discharged home after 2 to 4 days. CONCLUSION: Removal of intranasal NGs using an endonasal endoscopic approach and a dedicated computer assisted navigation system is a safe and efficient procedure. Early management is recommended to treat neonatal airway obstruction.

[Congenital diaphragmatic hernia: respiratory and vascular outcomes]. / Hernie de coupole diaphragmatique : devenir respiratoire et vasculaire pulmonaire.

Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly associated with a variable degree of pulmonary hypoplasia (PH) and persistent pulmonary hypertension (PPH). Despite remarkable advances in neonatal resuscitation and intensive care, and new postnatal treatment strategies, the rates of mortality and morbidity in the newborn with CDH remain high as the result of severe respiratory failure secondary to PH and PPH. Later, lung function assessments show obstructive and restrictive impairments due to altered lung structure and lung damage due to prolonged ventilatory support. The long-term consequences of pulmonary hypertension are unknown. Other problems include chronic pulmonary aspiration caused by gastro-oesophageal reflux and respiratory manifestations of allergy such as asthma or rhinitis. Finally, failure to thrive may be caused by increased caloric requirements due to pulmonary morbidity. Follow-up studies that systematically assess long-term sequelae are needed. Based on such studies, a more focused approach for routine multidisciplinary follow-up programs could be established. It is the goal of the French Collaborative Network to promote exchange of knowledge, future research and development of treatment protocols.

[Role of duplex Doppler for superficial "angiomas"]. / Place de l'échodoppler dans les "angiomes" superficiels.

Diagnosis of superficial vascular anomalies, previously called "angiomas", is basically clinical. Ultrasound and duplex Doppler imaging is a simple and helpful tool to confirm the clinical diagnosis and/or to suggest further required imaging modalities. The purpose of this work is to demonstrate the usefulness of duplex Doppler and ultrasound for exploring vessel and soft tissue components of vascular anomalies.

Fluoroscopic guidance of Arndt endobronchial blocker placement for single-lung ventilation in small children.

BACKGROUND: Thoracoscopic surgery may require single-lung ventilation (SLV) in infants and small children. A variety of balloon-tipped endobronchial blockers exist but the placement is technically challenging if the size of the tracheal tube does not allow the simultaneous passage of the fibreoptic scope and the endobronchial blocker. This report describes a technique for endobronchial blocker insertion using fluoroscopic guidance in children undergoing SLV. METHODS: After approval from the local Medical Ethics Committee and parental consent, 18 patients aged 2 years or younger scheduled for thoracic surgery requiring SLV were prospectively included. Following induction of anesthesia, a 5 Fr endobronchial blocker (Cook) Arndt endobronchial blocker) was inserted first into the trachea under direct laryngoscopy. Correct placement in the main bronchus was assessed by fluoroscopy and tracheal intubation next to the endobronchial blocker. Optimal position and balloon inflation was verified using a fibreoptic scope. The duration and number of insertion attempts as well as age, weight and size of the tracheal tube were recorded. RESULTS: Eighteen patients were studied. Median (range) age and weight were 12 (0.2-24) months and 11.2 (4-15) kg, respectively. SLV was successfully achieved in all patients using a 5 Fr endobronchial blocker outside a 3.5-4.5 mm ID tracheal tube within 11.2 (+/-2.2) min. No side effects were observed during the procedure. CONCLUSION: Fluoroscopic-guided insertion of extraluminal endobronchial blocker is an effective and reliable tool to place Arndt endobronchial blockers in small children.

[Maternal and foetal anaesthesia for ex utero intrapartum treatment (EXIT) procedure]. / Anesthésie maternofoetale pour "ex utero intrapartum" traitement (EXIT) procédure: à propos de deux cas.

The ex utero intrapartum treatment (EXIT) procedure is a surgical procedure maintaining utero-placental circulation during caesarean section. Anaesthetic implications are described: foetal transplacental anaesthesia to avoid first breathing and to permit surgical procedure on obstructed foetal airway, deep maternal haemodynamically stable anaesthesia to relax uterine smooth muscle during a long caesarean procedure but avoiding post-partum haemorrhage. Volatile anaesthesia with sevoflurane seems to be adequate for these aims. Two cases are described.

Mitomycin C: an alternative conservative treatment for refractory esophageal stricture in children?

BACKGROUND AND STUDY AIMS: Mitomycin C is an antiproliferative agent that has been used successfully as an adjunct treatment in ophthalmological procedures, in the management of laryngeal and tracheal stenosis, and more recently to prevent the recurrence of caustic esophageal strictures in children. The aim of this study was to assess the efficacy and safety of local application of mitomycin C to refractory esophageal strictures in children. PATIENTS AND METHODS: We performed a preliminary prospective study of local application of mitomycin C in four children, aged between 1 year and 6 years, who had refractory esophageal strictures. Two of the children presented with strictures caused by caustic ingestion and the other two children had anastomotic strictures following surgical repair of congenital esophageal atresia. The patients had required between four and ten esophageal dilations over a 5-24-month period before mitomycin C application. After an endoscopic dilation, mitomycin C was applied onto the dilation wound using a rigid endoscope. RESULTS: No complications were observed after the procedure. One child required a second application of mitomycin C 2 weeks after the first application because of recurrence of dysphagia. All the children remained asymptomatic and none of them required further dilation over a mean follow-up period of 24 months. Radiological control examinations revealed that there was no recurrence of the esophageal strictures and esophageal biopsies performed during follow-up showed no signs of dysplasia. CONCLUSIONS: Local application of mitomycin C is a potential alternative to iterative dilations, surgery, or stent placement for the treatment of refractory esophageal strictures in children. However, prospective, long-term assessment of outcomes is needed before any definitive conclusion can be drawn about the usefulness of mitomycin C in these patients.

Thyroid alar cartilage graft in paediatric laryngotracheal reconstruction.

OBJECTIVE: To evaluate the potential indications of thyroid alar cartilage (TAC) graft in the paediatric laryngotracheal reconstruction (LTR) population based on observations obtained in a case series of 27 consecutive infants referred to our tertiary care center. METHODS: Thyroid alar cartilage grafting was performed for limited Myer grade II and grade III subglottic stenosis requiring a single-stage laryngoplasty and for laryngeal enlargement after translaryngotracheal resection of endolaryngeal tumors. The evolution of the grafted area was evaluated prospectively during endoscopic follow-up. RESULTS: Twenty-five patients (92.5%) were successfully extubated after a mean of 5.1 days. No perioperative or postoperative complications were observed. The mean duration of graft harvesting was 7.7 min. Follow-up of the grafted area revealed one case of partial necrosis without prolapse into the lumen. The mean duration of graft epithelialization was 18.1 days (range: 12-30 days). Development of granulation tissue was observed in eight patients (32%) with a mean duration of granulation tissue persistence of 61.5 days (range: 7-155 days). Endoscopic follow-up did not demonstrate any pharyngolaryngeal asymmetry or feeding difficulties. CONCLUSION: This study demonstrated that the use of thyroid alar cartilage grafting is feasible for pediatric laryngotracheal reconstruction. The indications of thyroid alar cartilage graft should be reserved for moderated subglottic stenosis. The use of TAC reduced the operative time and cosmetic sequelae significantly. The healing of the grafted area was similar to those obtained with other types of graft. The TAC removal did not induce laryngeal deformation but longer follow-up is necessary to confirm this.

[Severe laryngomalacia: surgical indications and results in 33 patients]. / Prise en charge chirurgicale des laryngomalacies sévères. Une série de 33 cas.

INTRODUCTION: Laryngomalacia is the most common course of stridor in children: with a 50% to 75% incidence. About 50% to 60% of congenital laryngeal anomalies that present with stridor are due to laryngomalacia. In most cases, the disease followed a benign course but the prognosis is less favorable in 10% to 15% of cases. These patients may require surgical intervention. MATERIALS AND METHODS: This prospective study included 33 patients referred to our institution from May 1998 to May 2003 for severe laryngomalacia. The diagnosis of severe laryngomalacia was based on clinical and if necessary paraclinical data. An endoscopic laser resection of arytenoid mucosal excess associated if necessary with suprahyoid epiglottectomy was performed in all patients. RESULTS: Mean age of the children was 7.5 Months (range, 2 weeks-4 Years). Ninety-six percent of the patients had complete resolution of symptoms before the fourth postoperative week. Ninety one percents of the patients had effective oral feeding within the first Month (48% immediately after surgery). The average hospital stay was 6 days (range, 3 to 14). Weight gains were found to be satisfactory in all cases since children were discharged the hospital. CONCLUSION: Endoscopic laryngeal surgery is an appropriate therapy for treatment of severe forms of laryngomalacia. It is a safe and effective surgical procedure.