Iatrogenic Cerebrospinal Fluid Leak in Endoscopic Sinus Surgery: Topographical Map and Influence of Skull Base Asymmetry.

BACKGROUND: Iatrogenic cerebrospinal fluid leak (iCSF-L) is a major complication of endonasal surgeries whose occurrence is always a potential adverse event due to anatomical variation/asymmetry of the skull base (SB). The aim of this manuscript is to provide a topographical map of iCSF-L and to investigate the role of SB asymmetry in iCSF-L occurrence. METHODS: In this retrospective study, the location of iCSF-L dural defect was studied and compared to patients affected by spontaneous and post-traumatic CSF-L. Considering only iCSF-L, after having collected the SB asymmetry data, the Keros, Gera, distance of the anterior ethmoidal artery from the SB, frontal sinus pneumatization, and Thailand-Malaysia-Singapore score classifications were compared to a control group of patients. RESULTS: A total of 153 CSF-Ls (103 spontaneous, 37 iatrogenic, and 13 traumatic) were included. A significant association was noted (p < 0.001) between the nature of the CSF-L and the areas involved. Considering iCSF-Ls, only the Gera classification was significantly different (p < 0.05) and the most reliable in predicting the risk of dural transgression (AUC = 0.719). CONCLUSIONS: ICSF-Ls present peculiar regional SB involvement with the cribriform plate, with the ethmoidal roof being the most involved. After having assessed the asymmetry of the SB, the Gera classification was the most reliable one.

Septal Nasopharyngeal "Kite Flap" for Long-Term Patency of Petrous Apex Cholesterol Granuloma.

Medial petrous apex cholesterol granuloma is a benign lesion which treatment is generally based on a trans-nasal marsupialization. When the artificial ostium is created, it is usually kept open with local flaps, like the septal nasopharyngeal "kite flap", a reliable local vascularized flap. Laryngoscope, 134:2111-2114, 2024.

How to perform prespecified subgroup analyses when using propensity score methods in the case of imbalanced subgroups.

BACKGROUND: Looking for treatment-by-subset interaction on a right-censored outcome based on observational data using propensity-score (PS) modeling is of interest. However, there are still issues regarding its implementation, notably when the subsets are very imbalanced in terms of prognostic features and treatment prevalence. METHODS: We conducted a simulation study to compare two main PS estimation strategies, performed either once on the whole sample ("across subset") or in each subset separately ("within subsets"). Several PS models and estimands are also investigated. We then illustrated those approaches on the motivating example, namely, evaluating the benefits of facial nerve resection in patients with parotid cancer in contact with the nerve, according to pretreatment facial palsy. RESULTS: Our simulation study demonstrated that both strategies provide close results in terms of bias and variance of the estimated treatment effect, with a slight advantage for the "across subsets" strategy in very small samples, provided that interaction terms between the subset variable and other covariates influencing the choice of treatment are incorporated. PS matching without replacement resulted in biased estimates and should be avoided in the case of very imbalanced subsets. CONCLUSIONS: When assessing heterogeneity in the treatment effect in small samples, the "across subsets" strategy of PS estimation is preferred. Then, either a PS matching with replacement or a weighting method must be used to estimate the average treatment effect in the treated or in the overlap population. In contrast, PS matching without replacement should be avoided in this setting.

[Salivary gland neoplasms]. / Tumeurs des glandes salivaires.

SALIVARY GLAND NEOPLASMS. Salivary gland tumors represent a heterogeneous group of lesions, with various anatomical locations. The most frequent site of involvement is the parotid, and the most frequent histology is pleomorphic adenoma, a benign tumor with the potential for recurrence and malignant transformation. Approximately one third of tumors are malignant, and the prognosis depends on the tumor histology and histoprognostic criteria. The diagnostic strategy focuses on determining the benignity or malignancy of these lesions to choose appropriate treatment. It is based on multiparametric magnetic resonance imaging (MRI) [associating morphological images with diffusion and perfusion sequences], and on fine needle aspiration. Surgery is almost always indicated to allow histological confirmation and treatment of the disease. The extent of resection, the need for elective neck dissection, and the indication of adjuvant therapy (postoperative radiotherapy) depend on the tumor histology.

TUMEURS DES GLANDES SALIVAIRES. Les tumeurs des glandes salivaires représentent un groupe hétérogène de lésions, de localisations anatomiques variées. L'atteinte la plus fréquente est parotidienne, et l'histologie est le plus souvent l'adénome pléomorphe, tumeur bénigne avec un potentiel de récidive et de transformation maligne. Environ un tiers des tumeurs sont malignes ; le pronostic dépend alors de l'histologie tumorale et de critères histopronostiques. La démarche diagnostique s'attache à déterminer la bénignité ou la malignité de ces lésions pour un choix thérapeutique adapté. Elle se fonde sur l'imagerie par résonance magnétique (IRM) multiparamétrique (associant des images morphologiques à des séquences de diffusion et de perfusion) et sur la cytoponction à l'aiguille fine. La chirurgie est presque toujours indiquée pour permettre la confirmation histologique et traiter la maladie. L'étendue de la résection, la réalisation d'un curage cervical et d'un traitement adjuvant (radiothérapie postopératoire) dépendent de l'histologie tumorale.

Expression, Prognostic Value and Correlation with HPV Status of Hypoxia-Induced Markers in Sinonasal Squamous Cell Carcinoma.

(1) Background: In head and neck squamous cell carcinoma, tumor hypoxia has been associated with radio/chemoresistance and poor prognosis, whereas human papillomavirus (HPV)-positive status has a positive impact on treatment response and survival outcomes. The aim of this study was to evaluate the expression and the potential prognostic value of hypoxia-induced endogenous markers in patients treated for squamous cell carcinoma of the nasal cavity and paranasal sinuses (SNSCC), and their correlation with HPV status. (2) Methods: In this monocentric study, patients treated in a curative intent for a SNSCC were screened retrospectively. Protein expression of CA-IX, GLUT-1, VEGF, VEGF-R1, and HIF-1α was determined by immunohistochemical staining, scored, and then correlated with overall survival (OS) and locoregional recurrence free survival (LRRFS). HPV status was assessed and correlated with hypoxic markers. (3) Results: 40 patients were included. A strong expression of CA-IX, GLUT-1, VEGF, and VEGF-R1 was detected in 30%, 32.5%, 50%, and 37.5% of cases, respectively. HIF-1α was detected in 27.5% of cases. High CA-IX expression was associated in univariate analysis with poor OS (p = 0.035), but there was no significant association between GLUT-1, VEGF, VEGF-R1, and HIF-1α expression, and OS/LRRFS. There was no correlation found between HPV status and hypoxia-induced endogenous markers (all p > 0.05). (4) Conclusions: This study provides data on the expression of hypoxia-induced endogenous markers in patients treated for SNSCC and underlines the potential role of CA-IX as a prognostic biomarker for SNSCC.

Survival outcomes, prognostic factors, and effect of adjuvant radiotherapy and prophylactic neck dissection in salivary acinic cell carcinoma: A prospective multicenter REFCOR study of 187 patients.

BACKGROUND: Acinic cell carcinomas (AciCCs) are malignant tumours of the salivary glands. The aim of this work was to analyse data from the national REFCOR multicenter cohort (i) to investigate the prognostic factors influencing survival outcomes in AciCC, (ii) to assess the impact on survival of postoperative radiotherapy (RT) in patients treated for AciCC without high-grade transformation and (iii) to explore the prognostic impact of prophylactic neck dissection (ND) in patients treated for AciCC of the major salivary glands. PATIENTS AND METHODS: Data from all the patients treated for salivary AciCC between 2009 and 2020 were extracted from the REFCOR database. Survival outcomes and prognostic factors influencing Disease-Free Survival (DFS) and Overall Survival (OS) were investigated using univariate and multivariate analyses. Propensity score matching was used to assess the impact of postoperative RT and prophylactic ND on DFS. RESULTS: A total of 187 patients were included. After a median follow-up of 53 months, their 5-year OS and DFS rates were 92.8% and 76.2%, respectively. In multivariate analysis, male sex, older age, higher T and N status, and high grade were independently associated with a worse DFS. In the subpopulation analysed after propensity score matching, patients with cN0 AciCC without high-grade transformation who were treated by surgery and RT did not have an improved DFS compared to patients who were treated by surgery alone (hazard ratio (HR) = 0.87, p = 0.8). Factors associated with nodal invasion were T3-T4 status and intermediate/high histological grade. After propensity score matching, prophylactic ND was associated with a trend toward a better DFS (HR = 0.46, p = 0.16). CONCLUSIONS: These results suggest that (i) long-term follow-up (>5 years) should be considered in patients with AciCC, (ii) treatment by surgery alone could be an option in selected cN0 patients with AciCC without high-grade transformation and (iii) prophylactic ND may be considered preferentially in patients with T3-T4 status and/or intermediate/high histological grade.

Endonasal Lacrimal Transposition to Expand Pre-Lacrimal Medial Maxillectomy Approach.

EPLA lacrimal transposition facilitates management of maxillary sinus/pterygopalatine fossa lesions and overcomes limitations such as the Simmen type I recess or IPMS pedicled on the medial wall, without increasing peri-operative morbidity. Laryngoscope, 133:2090-2094, 2023.

Surgical Management of Sinonasal Cancers: A Comprehensive Review.

Surgery plays an important role in the treatment of sinonasal cancer. Many surgical approaches have been described, including open, endoscopic, or combined approaches. The choice is based on several criteria: general criteria related to the oncological results and morbidity of each technique, specific criteria related to the tumor (tumor extensions, tumor pathology), the patient, or the surgeon himself. The aims of this review are (i) to provide a complete overview of the surgical techniques available for the management of sinonasal malignant tumors, with a special focus on recent developments in the field of transnasal endoscopic surgery; (ii) to summarize the criteria that lead to the choice of one technique over another. In particular, the oncological outcomes, the morbidity of the different techniques, and the specificities of each histologic subtype will be discussed based on a comprehensive literature review.

Laparoscopic resection of a giant retroperitoneal melanotic schwannoma.

BACKGROUND: Retroperitoneal schwannomas are extremely rare, as they account for only 3% of retroperitoneal tumors. Clinical symptoms are nonspecific and of late onset, meaning that these tumors are diagnosed at an advanced stage. Surgical resection is required for histological diagnosis and to prevent possible malignant transformation. Celioscopy offers numerous benefits, reducing postoperative pain and speeding up the patient's return to autonomy, but it can pose a real challenge due to the size of these lesions. CASE PRESENTATION: We report a case of laparoscopic resection of a very large right-sided retroperitoneal schwannoma, with a particular histological form. CONCLUSION: Surgical resection in a single unit remains the golden rule, and a laparoscopy can be proposed when the diagnosis is beyond doubt. The large size of the retroperitoneal melanotic schwannomas, a common feature, increases surgical difficulties but is not a contraindication to this approach.

Anatomical study of the medial patello-femoral ligament: landmarks for its surgical reconstruction.

PURPOSE: The aim of this dissection study was to describe the anatomical insertions of the medial patello-femoral ligament (MPFL), and to assess its relationship with surrounding structures to improve its surgical reconstruction. METHODS: Twelve knees (7 cadavers) were included for the study. Measurements and general features of the MPFL were assessed: lengths, widths and insertions. RESULTS: The MPFL was found in all knees, presenting a triangular shape, and extending from the medial part of the patella to its femoral insertion (its length was of 59 ± 6.6 mm), distal to the adductor tubercle. The mean femoral insertion of the MPFL was 7.2 ± 2.7 mm proximal and 7.4 ± 4.0 mm posterior to the medial femoral epicondyle (MFE). It was also at a mean 11 ± 2.8 mm distal and 1.3 ± 2.1 mm posterior to the adductor tubercle, and 22 ± 6.4 mm anterior to the posterior condyle. We did not find any double-bundle organization on the patellar insertion. The width of the MPFL was 8.8 ± 2.9 mm at the femoral insertion, 27 ± 5.9 mm at the patellar insertion, and 12 ± 3.1 mm in the middle of the MPFL. The vastus medialis obliquus was found to be inserted on the superior part of the MPFL. CONCLUSION: The adductor tubercle appeared to be a better landmark than the MFE for the femoral tunnel positioning during surgical reconstructions of the MPFL because it was easier to identify and its relationship with the femoral insertion of the MPFL was constant (10 mm below).