Guidelines of the French Society of ENT (SFORL): Drug-induced sleep endoscopy in adult obstructive sleep apnea syndrome.

OBJECTIVES: To determine the indications, anesthesiological and surgical procedure and interest of drug-induced sleep endoscopy in the treatment of adult obstructive sleep apnea syndrome. DESIGN: A redactional committee of 17 experts was set up. Conflicts of interest were disclosed and followed up throughout the process of drawing up the guidelines. The work received no funding from any firm dealing in health products (drugs or devices). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was applied to assess the quality of the data on which the guidelines were founded. It was stressed that strong recommendations should not be made on the basis of poor-quality or insufficient data. METHODS: The committee studied 29 questions on 5 topics: indications and contraindications, anesthetic technique, surgical technique, interpretation and reporting of results, and management guided by results. RESULTS: Expert review and application of the GRADE method led to 30 guidelines: 10 with high level of evidence (Grade 1+ or 1-), 19 with low level (GRADE 2+ or 2-) and 1 expert opinion. CONCLUSION: Experts fully agreed on the strong guidelines formalizing the indications and modalities of drug-induced sleep endoscopy for adult obstructive sleep apnea syndrome.

Treatment of sleep apnea by ENT specialists during the COVID-19 pandemic.

The treatment of sleep disorders has been strongly impacted by the COVID-19 pandemic. When the lockdown is over, resumption of usual patient care will require precautions to limit the risk of contamination for patients and caregivers. In this document, the French Association of Otorhinolaryngology and Sleep disorders (AFSORL) and the French Society of Otorhinolaryngology (SFORL) put forward a summary of the measures for continuing the treatment of sleep apnoea syndrome in these new practice conditions. Emphasis is placed on teleconsultation, methods of nocturnal sleep studies, the conditions for treatment by continuous positive airway pressure (CPAP) ventilation, and the postponement of more invasive treatments.

Feasibility study of bilateral radical ethmoidectomy in ambulatory surgery.

OBJECTIVES: To assess the feasibility of bilateral radical ethmoidectomy in ambulatory surgery by risk analysis, and to calculate possible medico-economic savings. METHODS: This study was performed retrospectively over a 2-year period and prospectively for 1 year. It included all patients undergoing bilateral ethmoidectomy, associated to sphenoidotomy and/or septoplasty or not, in a university hospital department. Data were collected on demographics, disease etiology, previous surgery, operative details, postoperative course, complications and satisfaction assessed by questionnaire at days 1 and 30. Ambulatory surgery eligibility criteria were applied to this population, and an economic analysis compared savings between inpatient and outpatient management. RESULTS: Hundred and sixty-five patients were included. Surgical indications comprised nasal polyposis (87%), chronic sinusitis without nasal polyps (6%) or cystic fibrosis (7%). Seventy-five septoplasties were associated (45.5%). Operating time depended on associated septoplasty (P=0.005), surgeon experience (P<0.0001) and previous sinus surgery (P=0.041). Only 37% of the patients wished for same-day discharge; reasons for refusal were home-to-hospital distance and bleeding risk. Considering anesthesia contraindications, immediate complications and operating time, 107 patients were eligible for outpatient treatment, although only 13 patients underwent ambulatory surgery. Medical-economic savings with outpatient management would have been about €20,000 per year. CONCLUSIONS: Bilateral radical ethmoidectomy, associated to septoplasty or not, could be performed on an outpatient basis in more than 60% of cases, without increased risk, and with cost savings of 28.4%.

A study with pharyngeal and esophageal 24-hour pH-impedance monitoring in patients with laryngopharyngeal symptoms refractory to proton pump inhibitors.

BACKGROUND: The role of gastroesophageal reflux in chronic laryngeal symptoms is difficult to establish. The aim of this study was to characterize pharyngeal and esophageal pH-impedance reflux patterns in a group of patients with suspected laryngopharyngeal reflux and to determine predictive factors of response to proton pump inhibitors. METHODS: Patients with chronic pharyngolaryngeal symptoms were evaluated with a symptom score questionnaire, laryngoscopy, and 24-hour pharyngeal and esophageal pH-impedance monitoring at baseline and after 8-week treatment with esomeprazole 40 mg b.i.d. Response to treatment was defined by a diminution of more than 50% of the score for the primary symptom. Reflux patterns and baseline impedance values were compared to those obtained in 46 healthy subjects. KEY RESULTS: Twenty-four patients were included (17 women, median age 54 years), all previously refractory to antisecretory therapy. Symptom scores were 46 (32-62) and 40 (27-76) off and on therapy, respectively (P=.1). There was no significant difference between patients and controls for pH-impedance reflux parameters and baseline values off and on therapy in distal and proximal esophagus and in the pharynx. Median numbers of pharyngeal reflux were 0 and 0 off and on therapy, respectively. Only two patients were responders to treatment, both with excessive distal reflux but no pharyngeal reflux. Only one patient had abnormal pharyngeal reflux but did not respond to proton pump inhibitors. CONCLUSIONS: Patients with suspected laryngopharyngeal reflux refractory to therapy do not exhibit abnormal pharyngeal or esophageal pH-impedance reflux. In these patients, laryngopharyngeal reflux is unlikely.

Design and assessment of an anatomical diagram for sinonasal malignant tumour resection.

BACKGROUND: The aim of our work was to design and assess the comprehensibility of an anatomical diagram for recording surgical and pathological results after the removal of sinonasal malignant tumours by endoscopic endonasal surgery. METHODOLOGY: To create the first version of the diagram, we determined the functional and technical specifications for its use. The anatomical structures that appear on it were selected from the pathological reports of previous interventions. The comprehensibility of the diagram was tested by two successive multicentre labelling tests. Successive modifications led to the creation of a definitive version of the diagram. RESULTS: A diagram of the sinonasal cavities in exploded view was created from 47 selected anatomical structures. Labelling tests led to modifying the diagram by the overall restructuring and removal of the least recognized structures. In the labelling test of version 2, the mean global identification rate was 97.1 plus/minus 4.9% for 36 participants and all tested structures achieved a specific identification rate equal to or greater than 75%. CONCLUSIONS: This diagram of the sinonasal cavities is a comprehensible validated tool that allows the resection and invasion of sinonasal malignant tumours to be recorded. This three-dimensional diagram facilitates the understanding of the size, location and extensions of tumours. It may improve case presentations and communication in multidisciplinary team meetings.

Early and late surgical site infections in ear surgery.

A retroauricular approach is routinely used for treating chronic otitis media. The incidence of surgical site infections after ear surgery is around 10% in contaminated or dirty procedures. This observational prospective study describes surgical site infections after chronic otitis media surgery with the retroauricular approach and investigated their potential predictive factors. This observational prospective study included patients suffering from chronic otitis media and eligible for therapeutic surgery with a retroauricular approach. During follow-up, surgical site infections were defined as "early" if occurring within 30 days after surgery or as "late" if occurring thereafter. The data of 102 patients were analysed. Concerning early surgical site infections, four cases were diagnosed (3.9%) and a significant association was found with preoperative antibiotic therapy, wet ear at pre-operative examination, class III (contaminated) in the surgical wound classification, NNIS (National Nosocomial Infection Surveillance) index > 1, and oral post-operative antibiotic use. Seven late surgical site infections were diagnosed (7.1%) between 90 and 160 days after surgery and were significantly correlated to otorrhoea during the 6 months before surgery, surgery duration ≤60 minutes, canal wall down technique and use of fibrin glue. Surgical site infections after chronic otitis media surgery seem to be associated with factors related to the inflammatory state of the middle ear at the time of surgery in early infections and with chronic inflammation in late infections.

Nasal irrigation: From empiricism to evidence-based medicine. A review.

Nasal irrigation plays a non-negligible role in the treatment of numerous sinonasal pathologies and postoperative care. There is, however, a wide variety of protocols. The present review of the evidence-based literature sought objective arguments for optimization and efficacy. It emerged that large-volume low-pressure nasal douche optimizes the distribution and cleansing power of the irrigation solution in the nasal cavity. Ionic composition and pH also influence mucociliary clearance and epithelium trophicity. Seawater is less rich in sodium ions and richer in bicarbonates, potassium, calcium and magnesium than is isotonic normal saline, while alkaline pH and elevated calcium concentration optimized ciliary motility in vitro. Bicarbonates reduce secretion viscosity. Potassium and magnesium promote healing and limit local inflammation. These results show that the efficacy of nasal irrigation is multifactorial. Large-volume low-pressure nasal irrigation using undiluted seawater seems, in the present state of knowledge, to be the most effective protocol.

External versus endoscopic approach in the management of 131 sinonasal inverted papillomas.

BACKGROUND: Incidence of inverted Papilloma (IP) is around 0.5% to 4% of all nasal tumours. It is characterised by its propensy for local invasiveness, recurrence and malignant transformation. The treatment of reference is surgery. The aim of our study was to compare our oncologic outcome and morbidity between the open and the endoscopic approach to remove inverted papillomas. MATERIAL AND METHOD: This retrospective study includes all primary and benign cases operated between 1985 and 2012. We assessed epidemiologic data, medical history, tumour location, morbidity of treatment, pathological outcomes, patient's follow-up and rate of recurrence. The mean time of surgery, of follow-up and recurrence delay were compared. RESULTS: 131 patients were included: 77 operated by lateral rhinotomy or mid-facial degloving and 54 by endoscopic approach (± associated with a limited Caldwell-Luc or a frontal incision). The mean time of surgery for the endoscopic approach was 76 ± 46 min (10-240 min) vs 163 ± 46 min (60-300 min) for the open approach (p< 10(-5)). The uncinate process was included in most of the IP (97/131; 74%), including its horizontal and/or vertical parts. The mean follow-up in endoscopic group was 43 ± 32 months (12-177 months) vs 73 ± 48 months (12-221 months) for the open approach group (p< 10(-4)). The recurrence rates are not significantly different for both groups: 9% (7/77) after open approach vs 7.4% (4/54) after endoscopic approach (p> 0.05). Also, the mean delay of recurrence was not different between both group (p> 0.05) and the propensy of recurrence didn't depend on the degree of dysplasia. There were fewer complications in the endoscopic group (13%) than in the open approach group (57%). CONCLUSION: According to several authors we found no statistical difference on the oncological outcome between surgery via open versus endoscopic approach to remove IP. Endoscopic surgery offers less complications and morbidity than external approach.

Respiratory epithelial adenomatoid hamartomas and olfactory function.

INTRODUCTION: Respiratory epithelial adenomatoid hamartoma can occur alone or associated with several diseases with very different pathological processes. Our hypothesis is that REAH is a non-specific reaction of the nose when olfaction is impaired. MATERIAL AND METHOD: This is a retrospective study including all patients with HERA operated in an academic ENT department. Data analysis focused on the pre and post-operative olfaction, corticosteroids consumption, histological results of the polyps, the evolution of the disease allowing a comparison of HERA with or without polyps and comparison of data literature. RESULTS: 28 patients suffered from REAH of which 18 are associated with polyps. Nineteen patients had inflammatory disease with a 9 year interval between initial diagnosis and surgery of REAH. Olfactory function was improved after surgery (p < 0.01). The cell content of the polyps showed eosinophilic infiltration in 8 patients which 6 were correlated with inflammatory disease. Lymphoplasmacytic infiltration was present in 10 patients which 8 were correlated with inflammatory disease. Nasal corticosteroid consumption decreased after surgery (p < 0.02). The mean follow-up after surgery was 34 ± 43 months. Polyp recurrence rate was 11% (3 patients), and 0% for REAH. CONCLUSION: In most cases, olfactory function, cellular infiltration and polyp recurrence rate are not correlated with the pathophysiological inflammatory processes that coincides with REAH. Therefore, the co-existence of nasal polyposis with REAH is probably overestimated.