Proposal for an algorithm to avoid neck dissection during salvage total laryngectomy. A GETTEC multicentric study.

OBJECTIVES: To identify the factors related to the presence of occult metastases before salvage total laryngectomy (STL) in rcN0 patients and to propose an algorithm to identify patients who do not require neck dissection (ND). PATIENTS AND METHODS: This multicentric retrospective study included five centers with recruitment from 2008 to 2018. Inclusion criteria were: i) having been treated for laryngeal squamous cell carcinoma in first intention by radiotherapy (either alone or potentiated or preceded by induction chemotherapy), ii) having received STL with or without ND, iii) having an rcN0 neck at the time of STL. RESULTS: 120 patients met the inclusion criteria. The overall rate of occult metastases was 9.1 %. The rate was significantly higher in patients with an initial positive cN+ lymph node status (p < 0.005) and in advanced stages with rcT3-T4 lesions at recurrence (p < 0.005). Patients with occult metastases recurred earlier than those without (p = 0.002). The overall survival of patients was the same with or without ND (p = 0.16). There were significantly more healing complications requiring revision surgery in the group with ND than in the group without (p = 0.048). CONCLUSION: ND does not confer a net survival benefit and is associated with significant complications. Patients without initial lymph node metastases who are rcT1-T2 at recurrence or rcT3-T4 with a recurrence period of more than 12 months could benefit from STL without ND. This decisional algorithm, which needs to be validated, would help avoid 58 % of ND procedures and their proven morbidity. DISCIPLINE: Head and neck surgery.

Airway management during transoral robotic surgery for head and neck cancers: a French GETTEC group survey.

PURPOSE: The aim of the survey was to define the indications for preventive tracheostomy in transoral robotic surgery (TORS) for head and neck cancers. METHODS: From October 2019 to January 2020, an online questionnaire was e-mailed to French surgical ENT teams with considerable experience of the TORS procedure (Gettec group). A descriptive analysis of the answers was performed. RESULTS: Eighteen French surgical teams answered the questionnaire. For 77.8% of the surgical teams, a past history of radiotherapy with residual edema was an indication for prophylactic tracheostomy, and for 88.9%, > 75 mg of antiplatelet medication or anticoagulation treatment was an indication. CONCLUSION: Early preventive tracheostomy during TORS can protect airway from uncommon but potentially life-threatening complications, such as transoral hemorrhage or airway edema. We recommend it in high-risk situations, such as a past history of radiotherapy or antiplatelet therapy associated with large resections. Further studies are needed to establish evidence-based recommendations.

Circulating Tumor Cells as a Prognostic Factor in Recurrent or Metastatic Head and Neck Squamous Cell Carcinoma: The CIRCUTEC Prospective Study.

BACKGROUND: This prospective multicenter study evaluated the prognostic value of circulating tumor cells (CTCs) in relapsing nonoperable or metastatic head and neck squamous cell carcinoma (rHNSCC) treated by chemotherapy and cetuximab. METHODS: In 65 patients suitable for analyses, peripheral blood was taken at day 0 (D0) D7, and D21 of treatment for CTC detection by CellSearch®, EPISPOT, and flow cytometry (FCM). Progression-free survival (PFS) was assessed with the Kaplan-Meier method and compared with the log-rank test (P < 0.05). RESULTS: At D0, CTCs were detected with EPISPOT, CellSearch, and FCM in 69% (45/65), 21% (12/58), and 11% (7/61) of patients, respectively. In the patients tested with all 3 methods, EPISPOT identified 92% (36/39), 92% (35/38), and 90% (25/28) of all positive samples at D0, D7, and D21, respectively. Median PFS time was significantly lower in (a) patients with increasing or stable CTC counts (36/54) from D0 to D7 with EPISPOTEGFR (3.9 vs 6.2 months; 95% CI, 5.0-6.9; P = 0.0103) and (b) patients with ≥1 CTC detected with EPISPOT or CellSearch® (37/51) (P = 0.0311), EPISPOT or FCM (38/54) (P = 0.0480), and CellSearch or FCM (11/51) (P = 0.0005) at D7. CONCLUSIONS: CTCs can be detected before and during chemotherapy in patients with rHNSCC. D0-D7 CTC kinetics evaluated with EPISPOTEGFR are associated with the response to treatment. This study indicates that CTCs can be used as a real-time liquid biopsy to monitor the early response to chemotherapy in rHNSCC. CLINICALTRIALSGOV IDENTIFIER: NCT02119559.

Peripheral Nerve Block Efficacy on Refractory Neuralgia Complicating Ramsay Hunt Syndrome: A Case Report.

Several case studies have suggested the usefulness of peripheral nerve blocks in the management of various types of chronic pain that are unresponsive to standard medical treatment. We report here the case of a patient with severe neuralgia, secondary to Ramsay Hunt syndrome that was refractory to standard drug therapy. As a last resort, a block of the terminal branches of nervus intermedius was performed. Despite transient facial paralysis, pain was markedly reduced for 3 months with self-reported improved quality of life. To our knowledge, this block has never been described previously.

Cetuximab pharmacokinetic/pharmacodynamics relationships in advanced head and neck carcinoma patients.

AIMS: Cetuximab associated with cisplatin and 5-fluorouracil is used to treat patients with inoperable or metastatic head and neck squamous cell carcinomas (HNSCC) up until disease progression or unacceptable toxicities. To date, no biomarkers of efficacy are available to select patients who will benefit from treatment. METHODS: An ancillary pharmacokinetics (PK) exploration was performed in the context of a prospective study investigating circulating-tumour cells vs progression-free survival (PFS). Cetuximab plasma concentrations were analysed according to a population PK model. Individual exposure parameters were confronted with soluble epidermal growth factor receptor (sEGFR) concentrations, tumour response and PFS. RESULTS: PK data (28 patients, 203 observations) were best described by a two-compartment model with linear elimination. Performance status (PS) significantly correlated to both cetuximab clearance and central volume of distribution with both parameters increasing by 33.3% (95% CI 1-65.6) for each 1-point increase of PS compared to PS = 0. Univariate analysis showed that patients with higher trough cetuximab concentrations at Day 7 (Cmin,D7 ) had better tumour response (P = 0.03) and longer PFS (P = 0.035). However, multivariate analysis revealed that only PS and tumour size at baseline remained significantly associated with PFS. Levels of sEGFR increased during cetuximab treatment but were not associated with PFS in the multivariate analysis. CONCLUSIONS: Our study prospectively indicates that PS is likely a confounding factor in the relationship between cetuximab PK and PFS, patients with a poor PS having lower cetuximab plasma exposure and lower PFS.

Oncological and functional outcomes of trans-oral robotic surgery for pyriform sinus carcinoma: A French GETTEC group study.

BACKGROUND: Pyriform sinus carcinomas (SCC) present specific functional and oncological issues. The recent advent of trans-oral robotic surgery (TORS), as a conservative procedure, has opened up new perspectives. OBJECTIVES: To present the oncological and functional outcomes of TORS for pyriform sinus SCC. MATERIALS AND METHODS: We included, retrospectively, all TORS procedures for pyriform sinus SCC performed between 2009 and 2017 in eight French tertiary referral centers. We excluded lesions involving the pyriform sinus that had developed from the oropharynx, larynx, or other anatomic sub-sites of the hypopharynx. RESULTS: We included 57 TORS procedures. Median hospital stay was 10 days. A preventive tracheotomy was performed in seven cases (12%), and all were successfully decannulated. Oral re-feeding was possible for 93%, after a median of 5 days. The main surgical complications were hemorrhages (three cases), all successfully handled, although 2 patients with heavy comorbidities died from blood loss in the days after. Adjuvant therapy was proposed in 31 cases (54%), including two cases of salvage surgery (total pharyngolaryngectomy). After a median follow-up of 23 months, overall and disease-free survival were, respectively, 84% and 74% at 24 months, and 66% and 50% at 48 months. At the end of follow-up, organ preservation rate was 96%. None of the surviving patients needed a tracheotomy and oral diet was possible for 96%. CONCLUSION: The functional and oncological outcomes of TORS for pyriform sinus cancer are encouraging, and this procedure can be considered safe for selected early or moderately advanced cases as a conservative treatment.

Oncologic outcomes with transoral robotic surgery for supraglottic squamous cell carcinoma: Results of the French Robotic Surgery Group of GETTEC.

BACKGROUND: Transoral robotic surgery (TORS) is an option to treat supraglottic squamous cell carcinomas (SCCs). We studied the oncologic outcomes after TORS for supraglottic laryngectomy (SGL). METHODS: We conducted a multicenter observational study of SGL using TORS for patients with supraglottic SCC with at least 2 years of follow-up. RESULTS: One hundred twenty-two patients were included in our study. Mean follow-up was 42.8 months. Local control was 94.3% at 2 years and 90.2% at 5 years. Overall survival and disease-free survival were 86.9% and 95.1% at 2 years, and 78.7% and 94.3% at 5 years, respectively. Sixty-three patients (51.6%) received adjuvant radiotherapy. For 16 of them, this was due to close or positive margins. CONCLUSION: Local control rate after TORS SGL was at least equivalent to what has been described in the literature for open or transoral laser surgery, or with radiotherapy. Using TORS seems to be an effective therapeutic treatment of early-stage and intermediate-stage supraglottic SCCs.

[Cyto-histological correlation in the management of parotid gland tumors: A retrospective study of 160 cases]. / Corrélation cyto-histologique dans la prise en charge des tumeurs parotidiennes : étude rétrospective de 160 cas.

INTRODUCTION: The aim of this study was to correlate the cytological and histological results and evaluate the diagnostic performance of fine-needle aspiration cytology (FNAC) in the management of parotid gland tumors. METHODS: This retrospective study included 160 patients with a parotid gland tumor who underwent fine-needle aspiration and parotidectomy surgery between January 2005 and August 2016 at the Limoges university hospital center. RESULTS: On 160 fine-needle aspirations performed, fine-needle aspiration diagnoses were: 77 benign lesions, 35 malignant lesions and 48 non-diagnostic cases. Final histological diagnosis revealed there were 113 benign lesions and 47 malignant lesions. A hundred and one cytological diagnoses were accurate over 112 contributive fine-needle aspirations: seven false-negative cases and 4 false-positive cases were observed. The sensitivity, specificity, and accuracy were 82, 95 and 90% respectively for fine-needle aspiration, and 83, 95 and 92% respectively for association of fine-needle aspiration and magnetic resonance imaging. Diagnostic concordance between fine-needle aspiration and final histology for malignant lesions was 78%. A greater number of contributive fine-needle aspirations was observed among experimented operators. DISCUSSION: Fine-needle aspiration is a reliable, safe and effective diagnostic tool that allows good differentiation between malignant and benign diagnosis in the preoperative management of parotid gland tumors. The association of fine-needle aspiration and magnetic resonance imaging (MRI) can improve diagnostic performance.

Clinical outcomes with transoral robotic surgery for supraglottic squamous cell carcinoma: Experience of a French evaluation cooperative subgroup of GETTEC.

BACKGROUND: Transoral, minimally invasive, organ preservation surgeries are increasingly used to treat laryngopharyngeal carcinomas to avoid the toxicity associated with combined chemoradiotherapy (CRT) regimens. This study investigated the efficiency, safety, and functional outcomes of using transoral robotic surgery (TORS) to perform supraglottic laryngectomy (SGL). METHODS: This was a multicenter study using a case series with planned data collection from 2009 to 2012 for patients with supraglottic squamous cell carcinomas (SCCs) who underwent an SGL using TORS. RESULTS: Eighty-four of the 262 patients underwent TORS for a supraglottic SCC. Within 24 hours of surgery, 24% of the patients began an oral diet. The median use of a feeding tube was 8 days for 76% of other patients. Definitive percutaneous gastrostomy feeding was necessary for 9.5% of the patients. Twenty-four percent of the patients did require a tracheostomy, and the median use was 8 days. One percent of the patients had a definitive tracheostomy. Aspiration pneumonia was observed in 23% of the patients during the postoperative course, and was responsible for the death of 1 patient. Postoperative bleeding occurred in 18% of the patients. Based on the pathology results, 51% of the patients received adjuvant radiation therapy. CONCLUSION: TORS for SGL, in the intermediate stage of SCC, provides a safe procedure with good functional outcomes and fast recovery times; however, adverse events are possible. Consequently, this technique requires good selection criteria for the patients to reduce the risk of postoperative complications. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1097-E1101, 2016.

An uncommon case of dyspnea with unilateral laryngeal paralysis in acromegaly.

A 61-year-old man with obstructive sleep apnea syndrome and normal BMI complained of dyspnea. Nasofibroscopy revealed a global and major oedema of the glottis and supraglottis and also a paralysis of the left vocal fold. CT-scan pointed out a spontaneous hyperdensity of the left arytenoid cartilage. A tracheostomy was performed. Clinical examination revealed large hands and macroglossy with high IGF1 rate. MRI confirmed a supracentimetric pituitary adenoma. To our knowledge, this is the first description of a case of acute respiratory distress due to unilateral larynx paralysis leading to acromegaly diagnosis. This is due to submucosal hypertrophy and vocal cord immobility.

Influence of musculoskeletal pain on workers' ergonomic risk-factor assessments.

This study compares the ergonomic risk-factor assessments of workers with and without musculoskeletal pain. A questionnaire on the musculoskeletal pain experienced in various body regions during the 12 months and seven days preceding the data collection was administered to 473 workers from three industrial sectors. The Ergonomic Workplace Analysis method, developed by the Finnish Institute of Occupational Health (FIOH), was then used by the workers and an ergonomics expert to assess the workstations. The ergonomic quality of the workstations and the need for change were also assessed by the expert and the workers at the workstation, using visual analog scales (VAS). Results show that the workers in this study were exposed to significant musculoskeletal disorder (MSD) risk factors, according to the FIOH assessment and the high percentages of reported pain. The results also show that those who reported pain in the seven days prior to the assessment evaluated their workstations more negatively than subjects who reported no pain, while the expert found no difference between the two groups' exposure to MSD risk factors.

Initial multi-institutional experience with transoral robotic surgery.

OBJECTIVE: To assess the initial experience for transoral robotic surgery (TORS), as observed in the French TORS group. STUDY DESIGN: A multi-institutional prospective cohort study. SETTING: Seven tertiary referral centers. SUBJECTS AND METHODS: One hundred thirty consecutive patients who were scheduled for a TORS between October 2008 and March 2011 were included. The operative times, conversion rates, morbidity, and alternatives were described. The serious adverse effects encountered were analyzed, and recommendations for avoiding them are specified. RESULTS: Most of the patients (65%) had a laryngeal (supraglottic) and/or hypopharyngeal resection. Thirty-nine of the 130 patients receiving TORS would have had a transoral laser resection as their alternative surgery. The tumor exposure was suboptimal in 26% of the cases. Six of the 130 patients needed conversion to an open approach. There were 15 postoperative hemorrhages and 2 deaths due to posthemorrhage complications in patients with significant comorbidities at 9 and 18 days after the surgery. The median setup and procedure times were 52 ± 46 and 90 ± 92 minutes, respectively. The learning curve was characterized by better selection and management of potential patients. CONCLUSION: The visualization offered by the robotic assistance allowed transoral resections of tumors that were difficult to resect or unresectable by laser surgery. Self-assessment of surgical exposure and a decrease in the need to convert to an open procedure over time suggested improvement in TORS-related surgical skills. Nevertheless, strict patient selection is essential. Even with a minimally invasive approach, some patients will need a tracheostomy for safety reasons.

Transoral robotic surgery for the treatment of head and neck cancer of various localizations.

BACKGROUND: Transoral robotic surgery (TORS) is a recent endoscopic technique to resect selected head and neck cancers. STUDY DESIGN: In total, 13 patients underwent TORS procedure for resection of head and neck cancers of various localizations, within the ENT Department of Limoges University Hospital Center between March and October 2010. RESULTS: Tumor localizations were aryepiglottic fold (n = 3), pyriform sinus (n = 2), posterior pharyngeal wall (n = 2), base of tongue (n = 2), lateral pharyngeal wall (n = 2), vallecula (n = 1), and epiglottis (n = 1). Average TORS setup time was 23 minutes. Average TORS operative time was 45 minutes. Average hospital stay was 8.4 days. CONCLUSIONS: TORS is a new technique that permits excellent resection of selected head and neck cancers with poor morbidity. Future reports on long-term oncologic and functional outcomes are needed to assess the risks and benefits of this approach compared with external approaches and nonsurgical alternatives.

Pattern of lateral neck metastases in N0 papillary thyroid carcinoma.

BACKGROUND: Indication and extent of lateral prophylactic neck dissection (PLND) in papillary thyroid carcinoma (PTC) is very controversial. METHODS: We retrospectively analysed 131 patients who underwent thyroidectomy and prophylactic lateral neck dissection from level II to V for PTC. RESULTS: 140 PLND were performed. The occult lymph node metastases (OLNM) overall rate was 18.6%. The incidence of node involvement was 10% at level III and 6.4% at level IIa. Level IV and level Vb were both concerned by 5.7% OLNM. Only 2.9% of level IIb contained OLNM. None of the level Va ND revealed OLNM. CONCLUSIONS: OLNM from PTC occurs commonly in level IIa, III, IV and Vb. Incidence in other levels is low. For surgeons that usually perform PLND, we believe that a selective neck dissection of levels IIa, III, IV and Vb in N0 neck PTC is sufficient for the clearance of occult metastases.

Peripheral facial paralysis and bilateral carotid pseudoaneurysms of petrous localization: a case report.

Carotid pseudoaneurysms of petrous localization are rare. They are mostly due to trauma, tumoral or infectious diseases, or a result of iatrogenic complications after skull base surgery. Symptoms such as facial paralysis are exceptional and have rarely been described in the literature until now. We report the case of a 64-year-old woman, who developed left peripheral facial paralysis induced by two carotid pseudoaneurysms in their intrapetrous section. The treatment is endovascular, despite the high morbidity rate. She was first put on antiplatelet medications, before the left carotid aneurysm was bypassed thanks to a self-expanding pipeline-type stent with flow diversion. The left peripheral facial paralysis was due to the compression exerted by the left carotid aneurysm, probably a congenital malformation. The progressive palsy recovery was fist due to the aneurysmal thrombosis, then to the secondary fibrosis.

Transethmoidal drainage of frontal brain abscesses.

BACKGROUND: The frontal lobe is the second most common location for brain abscess after the temporal lobe. Since the advent of computed tomography and magnetic resonance imaging scanning, diagnosis has become easier, but the prognosis of brain abscess is still poor. Treatment is based on antimicrobial therapy and neurosurgical evacuation, but controversy still remains as to the merits place of each. METHODS: This study describes 2 cases of patients with frontal abscesses treated by endonasal transethmoidal sinus surgery (ESS) and reviews the literature on this topic. RESULTS: Follow-up revealed no cerebrospinal fluid leak in both patients, complete abscess drainage in one patient, and incomplete drainage in the other. CONCLUSIONS: ESS drainage of frontal abscesses is feasible in intracerebral and epidural abscesses if they have a thick shell and are in contact with the skull base. The procedure is minimally invasive and relatively simple. It allows for rapid microbial identification and an effective drainage.

Endoscopic treatment of pharyngo-esophageal diverticulum in child.

Pharyngo-esophageal diverticula are extremely rare among children. Treatment in adults usually consists of endoscopic resection of the crico-pharyngeal muscle but application of this surgical procedure in children has not been reported before. We report the case of a 5-year-old boy whose recurrent pulmonary infection and chronic low weight led to diagnosis of a pharyngeal diverticulum. The diverticulum was removed by endoscopic CO(2) laser surgery. No relapse occurred during the 4-year follow-up period after surgery.

Laser arytenoidectomy in the management of bilateral vocal cord paralysis in children.

OBJECTIVE: To analyse the efficacy of CO(2) laser arytenoidectomy in the management of bilateral vocal cord paralysis in children. METHODS: Retrospective series of 17 patients who underwent laser arytenoidectomy for bilateral vocal cord between 1995 and 2008 in a tertiary care institution. All patients had bilateral laryngeal paralysis, in isolation (n=5) or associated with concomitant airway conditions (n=12). All cases had anterior prolapse of the arytenoids with partial obstruction of the airway on inspiration. 12/17 patients (70.5%) were tracheotomy-dependant, 2/17 were in-extubatable, and 3/17 had severe airway limitation, effort dyspnea and poor sleep pattern. Main outcome measures were decannulation rate for patients with tracheotomy, occurrence of aspiration and quality of voice. RESULTS: The mean age was 2.8 years old. 9/12 patients with tracheotomy (75%) were decannulated with a median delay of 2 months (2 days to 18 months). Both of the intubated patients were extubated with a median delay of 36h. One of the decannulated patients who re-presented with a residual dyspnea after the arytenoidectomy was improved by a further laser cordotomy. 2/17 patients (11.7%) had post-operative persistent aspirations (with pneumopathies in one case), 5/17 patients were dysphonic, 3 improved with speech therapy and 2 with intracordal lipoinjection. CONCLUSIONS: Laser arytenoidectomy is effective for improving the breathing in children presenting with a bilateral vocal fold paralysis associated with obstructive arytenoid prolapse. Results are good as a first-line surgery or following laryngo-tracheal surgery. Voice outcomes are satisfactory. However, aspiration is a rare complication.

Endoscopic transsphenoidal approach to petrous apex cholesteatoma.

The purpose of this report is to present indications and risks of endoscopic transsphenoidal approach to treat petrous apex cholesteatoma. This is a retrospective analysis of two cases of petrous apex cholesteatoma presenting with double vision who underwent an endoscopic transsphenoidal approach at Lariboisiere Hospital, Paris, France. Control of the lesion was satisfactory in both cases. However, a minor pontic stroke resulted in transient hemiparesis in the case with dehiscent dura around the petrous apex cholesteatoma. To our knowledge, there are the first cases of petrous apex cholesteatoma reported to be removed by an endoscopic transsphenoidal approach, using image guidance system, with minimal morbidity.

Our experience in the management of petrous bone cholesteatoma.

We present the management of a series of petrous bone cholesteatomas. We performed a retrospective analysis on 28 patients with petrous bone cholesteatoma who underwent surgery between 1991 and 2008 at Lariboisiere Hospital, Paris, France. Main outcome measures included age of patients, surgical approaches, complications, and recurrence. The mean age was 47 years. Five were congenital cholesteatomas and 23 were acquired ones. Seventeen patients had undergone previous mastoid surgery elsewhere. Ninety-six percent of patients presented with hearing loss and 37.5% with facial nerve palsy. The surgical approaches varied according to the classification. Postoperatively, four patients developed facial nerve palsy; two patients, XII nerve paresis; one patient, X nerve paresis; and eight patients, deafness. The mean follow-up was 5 years. Twenty patients had no long-term recurrence. Two cases of petrous apex cholesteatoma presenting with double vision were removed by an endoscopic transsphenoidal approach. Control of the lesion was satisfactory in both cases. However, a minor pontic stroke resulted in transient hemiparesis in the case with dehiscent dura around the petrous bone cholesteatoma. Petrous bone cholesteatoma surgery is difficult. Lateral transtemporal and middle fossa approaches are classically used to remove petrous bone cholesteatoma. Recent progresses in endoscopic surgery, using image guidance system, allow removal of the petrous apex cholesteatoma by an endoscopic transsphenoidal approach with minimal morbidity.