Closure without epiglottoplasty or tracheotomy after reconstructive frontal anterior laryngectomy.

Reconstructive frontal anterior laryngectomy (RFAL) is a partial laryngeal surgery technique for resecting early-stage (T1-T2) glottic squamous cell carcinoma. Indications comprise a lesion of the anterior commissure of the larynx that cannot be adequately exposed by endoscopy, and cases in which radiotherapy is refused or contraindicated. The initial RFAL technique included epiglottoplasty. Here we propose a technique without epiglottoplasty, with the advantage of avoiding need for tracheotomy in most cases. After the first stage of surgical excision, reconstruction consists in placing a vertical brace transepiglottically and below the cricoid. The epiglottis is thus left at its original height and secured in place to prevent flapping in the pharyngolaryngeal lumen. Transverse bracing is then performed through the thyroid wings: one of the key points of this surgery is to control tension to avoid risk of stenosis. The subhyoid muscles are sutured together to achieve satisfactory sealing. This technique offers satisfying functional results and oncological control. The most frequent complications are (1) secondary tracheotomy, which can be avoided by selecting patients who require a primary tracheotomy and optimizing the seal, and (2) stenosis, which can be limited by not bringing the cartilaginous structures too close together during bracing.

Sexual health at 5 years after diagnosis of head and neck cancer.

PURPOSE: Sexual health (SH) is an emerging concern in the assessment of quality of life in patients surviving head and neck cancer (HNC). Using data from the French National Prospective VICAN Survey, this study aimed to assess SH deterioration five years after HNC diagnosis and related factors. METHODS: Using univariate and multivariate analyses were performed in the 241 HNC survivors. We studied the factors associated between the sexuality and intimate life of these patients with demographic and medical data from the national epidemiological survey VICAN 5. RESULTS: Sexuality and body image were altered in 78.8% for men and 79.2% for women. This alteration in sexual quality of life affects both men and women. Dissatisfaction with the frequency of sexual intercourse was associated with being treated with radiotherapy (p=0.024), as well as decrease of sexual desire in patients treated with chemotherapy (p=0.044). Fatigue (p=0.002), impaired physical health (p=0.049), and high disease stage (p=0.001) remained significantly associated, after multivariate analysis, with decreased sexual desire. Among these 3 factors negatively influencing sexual quality of life, two are treatable with appropriate management. CONCLUSION: Five years after the diagnosis of HNC, a decrease in sexuality and body image are frequent and significantly impact the quality of life of survivors. These observations imply an adaptation of the management of the professionals involved.

Sex-related quality of life after total laryngectomy for cancer.

OBJECTIVES: Analysis of the quality of sexual life after total laryngectomy (TL) for cancer. MATERIAL AND METHODS: The Cochrane, PubMed, Embase, ClinicalKey and Science Direct databases were searched using the keywords: "total laryngectomy, sexual function, sexual behavior, sexual complications, sexual dysfunction, sexuality, intimacy". The abstracts of 69 articles were read by two of the authors and 24 articles were selected. The main endpoint was the impact of impairment of quality of sexual life after TL for cancer and the methods used to assess this. The secondary endpoints were the type of sexual impairment, associated variables and their treatment. RESULTS: The study population consisted of 1511 TL patients aged 21 to 90 years, with a male/female sex ratio of 7.49. One of the 7 validated Likert scales was used in 79% of the articles to evaluate impairment of sexual quality of life. Impaired quality of sexual life was reported by 47% of patients on average (range, 5-90%). Erectile and ejaculatory function and ejaculatory behavior of male patients decreased after TL. Other impairments comprised decreases in libido, frequency of sexual intercourse and satisfaction. Tracheostomy, advanced disease stage, young age and associated depression were factors for impairment. In all, 23% of patients reported lack of postoperative support in this area. CONCLUSION: The quality of sexual life is severely impacted by TL for cancer. The present data are a source of information and should be taken into account before carrying out TL. A common information tool needs to be developed. There is patient demand for improved management of sexuality.

Returning to work by thyroid cancer survivors 5 years after diagnosis: the VICAN survey.

PURPOSE: Return to work (RTW) following cancer diagnosis is a challenge for both the patient and society. As thyroid cancer (TC) incidence is increasing, this study aims to assess difficulties in returning to work and income changes in TC survivors 5 years post-diagnosis. METHODS: This study belongs to the national VICAN survey conducted in France among TC patients diagnosed between January and June 2010. Data were collected through phone interviews, medical surveys and from the national medico-administrative register in 2012 and 2015. We used multivariate logistic regressions to investigate TC impact on employment and income changes. RESULTS: Of 146 patients, 121(82.9%) were women; the mean age was 42 years (SD = 8.34), 119 (81.3%) were diagnosed at an early stage, and 142(97.6%) underwent thyroidectomy. At 5 years post-diagnosis, 116 (79.7%) of the TC survivors were professionally active, 22 (15.4%) were unemployed and 8 (4.90%) were receiving disability. Among the patients employed at the time of diagnosis (n = 122), 15 (12.3%) had not returned to work 5 years post-diagnosis. Between 2 and 5 years post-diagnosis, there was no significant improvement in rates of RTW. At 5 years post-diagnosis, 90 (61.6%) reported an income decline. All TC survivors who have not returned to work were women and declared higher fatigue. Moreover, in multivariate analyses, not returning to work was associated with weight gain (OR = 8.41 (1.21; 58.23)) and working arrangements (6.90 (1.18-38.48)), while income decline was associated with comorbidities (OR = 2.28 (1.07; 4.86)) and to be engaged in manual work (OR = 2.28 (1.07; 4.88)). CONCLUSION: This study highlights that, despite a good prognostic, up to 12.3% of TC survivors had not returned to work and 61.6% reported an income decline, 5 years post-diagnosis. Weight gain, fatigue, to be a woman and working-type arrangement were associated with higher probability of not returning to work. IMPLICATIONS FOR CANCER SURVIVORS: TC affects a young working population. Our study identified potentially vulnerable TC survivors and important modifiable factors which may help TC survivors to be professionally active and, therefore, increase their overall quality of life.

[Ethical considerations in ENT during the COVID-19 pandemic: Qualitative analysis of open-ended questions]. / Questionnements éthiques en ORL pendant la pandémie COVID-19 : étude qualitative de témoignages.

INTRODUCTION: The current new SARS-CoV-2 pandemic has had a profound impact on medical practice. The objective was to analyse the ethical questions raised by the French ENT community during the first wave of COVID-19 infections. METHODS: Four open-ended questions concerning ethical considerations in ENT were sent out in April 2020: (i) difficulties to care for COVID-19 positive patients; (ii) impact of the health crisis on COVID-19 negative patients; (iii) communication within the healthcare teams and with hospital staff; and (iv) management of information by the press, or national ENT societies. A thematic analysis was carried out and crossed with the epidemiological data of each respondent. RESULTS: Thirty-one responses from 13 different French Departments, including 21 from public institutions and 10 from private practice, median age of 45 and 17 men for 14 women, were analysed. The main ethical considerations concerned the management by ENTs of COVID-19 positive patients, the modification of practices in consultation and in the operating room, the fear of loss of chance for COVID-19 negative patients, the appropriate use of teleconsultations and teleworking and the consequences of fake-news for the population. CONCLUSION: In preparation of possible future pandemic outbreaks, key ethical aspects are to adapt patient management to local resources and infection prevalence, and circulate clear institutional guidelines.

French consensus regarding precautions during tracheostomy and post-tracheostomy care in the context of COVID-19 pandemic.

Tracheostomy post-tracheostomy care are regarded as at high risk for contamination of health care professionals with the new coronavirus (SARS-CoV-2). Considering the rapid spread of the infection, all patients in France must be considered as potentially infected by the virus. Nevertheless, patients without clinical or radiological (CT scan) markers of COVID-19, and with negative nasopharyngeal sample within 24h of surgery, are at low risk of being infected. Instructions for personal protection include specific wound dressings and decontamination of all material used. The operating room should be ventilated after each tracheostomy and the pressure of the room should be neutral or negative. Percutaneous tracheostomy is to be preferred over surgical cervicotomy in order to reduce aerosolization and to avoid moving patients from the intensive care unit to the operating room. Ventilation must be optimized during the procedure, to limit patient oxygen desaturation. Drug assisted neuromuscular blockage is advised to reduce coughing during tracheostomy tube insertion. An experienced team is mandatory to secure and accelerate the procedure as well as to reduce risk of contamination.

Function evaluation of laryngeal reconstruction using infrahyoid muscle after partial laryngectomy in 37patients.

Treatment of small laryngeal cancerous lesions (T1 and T2) is based on partial endoscopic or open surgery and radiotherapy. In addition to the oncological imperative, these techniques must optimally preserve the functions of breathing, swallowing and phonation. OBJECTIVE: To analyze the above functions in patients treated with supracricoid laryngectomy and reconstruction using infrahyoid muscle. MATERIALS AND METHODS: Breathing, swallowing and phonation were analyzed in 37patients treated in two institutes between 2005 and 2015. All patients undergoing the above type of reconstruction with a minimum 1year's follow-up were included. Respiratory study noted any tracheotomy and measured peak inspiratory flow. Preservation of cricoarytenoid units and nasogastric intubation time, and DHI-30 self-administered questionnaire results were collected to analyze swallowing function. Phonation was assessed on the VHI-30 self-administered questionnaire. RESULTS: The rate of primary surgery without tracheotomy was 64.9% (13patients), with rapid resumption of oral feeding (mean intubation time, 13days). Mean VHI score was 28.3 and mean DHI 30score 2.7. Mean peak inspiratory flow was 203.3mL/min. CONCLUSION: Supracricoid laryngectomy with reconstruction using subhyoid muscle is an alternative technique for the treatment of small laryngeal cancerous lesions, providing uncomplicated functional outcome.

Impact of locoregional irradiation in patients with upfront metastatic head and neck squamous cell carcinoma.

OBJECTIVE: To evaluate the frequency of use, modalities and potential interest of locoregional irradiation (LRT) in patients with upfront metastatic head and neck squamous cell carcinoma (HNSCC). METHODS: Retrospective multicentric study. Were included all patients presenting an upfront metastatic HNSCC treated by platin-5FU- cetuximab based regimen, from 2008 to 2016. Patients with past history of cervical irradiation or HNSCC within the 5 years before metastasis diagnosis were excluded. RESULTS: 65 patients were included. 25 patients (38%) presented a response or stable disease with chemotherapy. Forty-one patients (63%) underwent a locoregional irradiation: 5 patients before chemotherapy (upfront RT), 13 patients with stable disease or response after chemotherapy (consolidation RT), and 23 patients with progressive disease. Median overall survival (OS) was 11.6 months, median progression free survival was 7.9 months. OS was significantly improved for patients who underwent LRT (median OS 16.1 vs 7.5 months, p < 0.01). Among patients who received LRT, OS trended to be better if LRT was performed as consolidation RT compared to upfront RT (median OS of 22.1 vs 15.5 months, p = 0.11). Among patients with stable disease or response after chemotherapy, there was a non-significant better OS for the 13 patients treated by LRT (median OS 22.1 vs 11.8 months, p = 0.21)). Radical dose was not associated with better locoregional control compared to palliative dose (p = 0.37). CONCLUSION: LRT is frequently performed during management of upfront metastatic HNSCC and associated with better OS. Non-progressive disease after firs-line chemotherapy seems a good way to select patients who would benefit from radical LRT.

Platinum rechallenge in recurrent head and neck squamous cell carcinoma after primary chemoradiation.

OBJECTIVE: To evaluate platinum rechallenge efficacy and tolerance in patients presenting recurrent head and neck squamous cell carcinoma (HNSCC) after platinum-based chemoradiation. MATERIALS AND METHODS: We retrospectively included all patients treated from 2007 to 2016 by platinum-based polychemotherapy for recurrence of HNSCC previously treated by primary or postsurgical platinum-based chemoradiation. The primary end-point was disease control rate (DCR) on platinum rechallenge. RESULTS: Forty-five patients were included. Median disease-free interval (DFI) after chemoradiation was 5.7 months. DCR on platinum rechallenge was 40%. Progression-free survival at recurrence was 3.7 months and overall survival 5.0 months. DCR in patients with recurrence within 6 months of chemoradiotherapy was 47.8%. DFI>4.5 months was associated with better DCR: 28.5% versus 54.8%; P=0.0311. CONCLUSION: Platinum rechallenge provided good DCR in recurrent HNSCC after chemoradiation.

Impact of head and neck cancer on partner's sociability.

INTRODUCTION: "Sociability" is defined as the range of experiences linking the subject to others. This is the first study to focus specifically on the impact of head and neck cancer on the sociability of patients' partners. METHOD: Data were collected via a dedicated questionnaire sent to patients' partners. The main endpoint was partner's self-assessment of the impact of the patient's disease on the partner's everyday life. The impact on sociability was analyzed with respect to: the circle of friends (friendship environment), unknown environment, known outside environment, necessary environment, and solitary activities. RESULTS: Two hundred and seventy partners responded. Their everyday activities were impacted by the patient's disease in 71.5% of cases. The friendship environment was badly affected in 46.4% of cases. The unknown environment was affected in 44.0% of cases. Social practices related to the known outside environment were affected in 67.8% of cases, and the necessary environment in 26.0%; the number of solitary activities increased in 35.6% of cases. Social impact on patients' partners was thus considerable.

[Advances in the management of cervical lymphadenopathies of unknown primary with intensity modulated radiotherapy: Doses and target volumes]. / Évolutions dans la prise en charge des métastases ganglionnaires cervicales sans cancer primitif retrouvé : doses et volumes cibles de la radiothérapie avec modulation d'intensité.

The definition of nodal and/or mucosal target volumes for radiation therapy for lymphadenopathies of unknown primary is controversial. Target volumes may include all nodal areas bilaterraly and be pan-mucosal or unilateral, selective, including the sole oropharyngeal mucosa. This review presents current recommendations in light of changes in the TNM classification, Human papillomavirus status and therapeutic advances. We conducted a systematic review of the literature with the following keywords: lymphadenopathy; head and neck; unknown primary and radiation therapy. There are no direct comparative studies between unilateral or bilateral nodal irradiation or pan-mucosal and selective mucosal irradiation. Contralateral lymph node failure rates range from 0 to 6% after unilateral nodal irradiation and 0 and 31% after bilateral irradiation. Occurrence of a mucosal primary varies between 0 and 19.2%. Initial clinical presentation and Human papillomavirus status are critical to define mucosal target volumes. Intensity-modulated radiotherapy is recommended (rather than three-dimensional irradiation) to avoid toxicities. Systemic treatments have similar indications as for identified primary head and neck cancers. Failures do not appear superior in case of unilateral nodal irradiation but comparative studies are warranted due to major biases hampering direct comparisons. Human papillomavirus status should be incorporated into the therapeutic strategy and practice-changing TNM staging changes will need to be evaluated.

[Information quality in general public French-speaking websites dedicated to oral cancer detection]. / Qualité de l'information des sites francophones destinés au public pour le dépistage des cancers oraux.

INTRODUCTION: The goal set by the French highest national authorities in the 2014-2019 Cancer Plan is to "heal more sick persons by promoting early diagnosis through screening". Screening requires information. Nowadays, Internet allows for access to information "in one click". The aim of our study was to evaluate the quality of information found on the Internet. MATERIALS AND METHODS: Several sites dedicated to oral cavity cancer screening were selected on Google. The quality of health information found in these sites was evaluated by the DISCERN questionnaire. The quality of decision support provided by the sites was evaluated by the IPDAS checklist. RESULTS: Twenty-seven sites were selected. The average DISCERN score was 25.1/75 (15/75 to 40/75). Eighteen sites (66.6%) had very poor, 8 sites (29.6%) had poor and 1 site had average information quality. IPDAS scores ranged from 11.1 to 38.1. Eight sites (29.6%) had less than 20%, 14 sites (51.9%) had between 20 and 30% and 5 sites (18.5%) had 30% or more validated criteria. No site achieved the pass mark. DISCUSSION: The quality of general public French-speaking website dedicated to oral cancer detection is very bad. The role of health professionals such as general practitioners and head and neck surgeons, remains essential.

Gastric pull-up reconstruction after treatment for advanced hypopharyngeal and cervical esophageal cancer.

OBJECTIVES: In advanced hypopharyngeal and cervical esophageal carcinoma, the choice of reconstruction technique after total circumferential pharyngolaryngectomy (TCPL) remains controversial. We studied results of digestive tract reconstruction using gastric pull-up, concomitant or secondary to TCPL or after failure of reconstruction. MATERIAL AND METHODS: Twenty-four patients treated by gastric pull-up after TCPL for advanced hypopharyngeal or cervical esophageal carcinoma between December 1998 and January 2011 were retrospectively reviewed. RESULTS: Two-year survival was 37.5% (n=9). Thirty-day mortality was 4.1% (n=1), but 3 more patients died before discharge. Perioperative morbidity was 54.1% (n=13), including 9 fistulas (37.5%). Seventeen patients (71%) recovered oral feeding. CONCLUSION: Gastric pull-up is an interesting reconstruction technique after TCPL with invasion of the esophageal mouth, allowing comfortable oral feeding, but with non-negligible morbidity and mortality. Long-term survival is not high, partly due to the unfavorable prognosis of advanced hypopharyngeal and cervical esophageal tumor. The present high rate of fistula raises doubts for this surgery as second-line reconstruction after primary failure.

Retropharyngeal liposarcoma: A rare cause of dysphagia.

INTRODUCTION: Liposarcoma is a rare malignant mesenchymal tumour. Very few cases of retropharyngeal liposarcoma have been reported in the literature. SUMMARY: A 30-year-old woman with no notable history reported swallowing disorders for the past year associated with dysphonia. Nasal endoscopic examination demonstrated a tumour arising from the left lateral pharyngeal wall, ascending as far as the junction of the free margin of the epiglottis, aryepiglottic fold, and pharyngoepiglottic fold and obliterating the ipsilateral pyriform sinus with preservation of cord mobility. The rest of the physical examination was normal. The preoperative assessment was completed by gadolinium-enhanced MRI of the neck. Open surgery was performed. Definitive histological examination concluded on dedifferentiated liposarcoma with negative resection margins. Following staging chest computed tomography that did not reveal any metastases, the multidisciplinary consultation meeting decided to deliver adjuvant volumetric modulated arc therapy. No recurrence was observed nine months post-treatment. DISCUSSION: Retropharyngeal liposarcoma is a rare tumour. The authors report the first case of a dedifferentiated histological subtype in this site. A review of the literature completes this case report by providing a description of prognostic factors and the various treatments.

Facial reanimation by muscle-nerve neurotization after facial nerve sacrifice. Case report.

INTRODUCTION: Recovering a certain degree of mimicry after sacrifice of the facial nerve is a clinically recognized finding. The authors report a case of hemifacial reanimation suggesting a phenomenon of neurotization from muscle-to-nerve. CLINICAL CASE: A woman benefited from a parotidectomy with sacrifice of the left facial nerve indicated for recurrent tumor in the gland. The distal branches of the facial nerve, isolated at the time of resection, were buried in the masseter muscle underneath. The patient recovered a voluntary hémifacial motricity. The electromyographic analysis of the motor activity of the zygomaticus major before and after block of the masseter nerve showed a dependence between mimic muscles and the masseter muscle. DISCUSSION: Several hypotheses have been advanced to explain the spontaneous reanimation of facial paralysis. The clinical case makes it possible to argue in favor of muscle-to-nerve neurotization from masseter muscle to distal branches of the facial nerve. It illustrates the quality of motricity that can be obtained thanks to this procedure. CONCLUSION: The authors describe a simple implantation technique of distal branches of the facial nerve in the masseter muscle during a radical parotidectomy with facial nerve sacrifice and recovery of resting tone but also a quality voluntary mimicry.