The Prognostic Value of Olfactory Dysfunction in Patients with COVID-19: The COVIDORA Study.

BACKGROUND: Among all studies describing COVID-19 clinical features during the first wave of the pandemic, only a few retrospective studies have assessed the correlation between olfac-tory dysfunction (OD) and the evolution of disease severity. The main aim was to assess whether OD is a predictive factor of COVID-19 severity based on the patient's medical management (outpa-tient care, standard hospital admission, and ICU admission). METHODS: A national, prospective, mul-ticenter cohort study was conducted in 20 public hospitals and a public center for COVID-19 screen-ing. During the first wave of the pandemic, from 6 April to 11 May 2020, all patients tested positive for COVID-19 confirmed by RT-PCR underwent two follow-up ENT consultations within 10 days of symptom onset. The main outcome measures were the evolution of medical management (out-patient care, standard hospital admission, and ICU admission) at diagnosis and along the clinical course of COVID-19 disease. RESULTS: Among 481 patients included, the prevalence of OD was 60.7%, and it affected mostly female patients (74.3%) under 65 years old (92.5%), with fewer comor-bidities than patients with normal olfactory function. Here, 99.3% (290/292) of patients with OD presented with non-severe COVID-19 disease. Patients reporting OD were significantly less hospi-talized than the ones managed as outpatients, in either a standard medical unit or an ICU. Conclu-sions: As regards the clinical course of COVID-19 disease, OD could predict a decreased risk of hospitalization during the first wave of the pandemic.

Transverse Venous Sinus Stenosis in Patients With Nasal Cerebrospinal Fluid Leak and Idiopathic Intracranial Hypertension.

OBJECTIVE: Spontaneous nasal cerebrospinal fluid (CSF) leaks are frequently linked to idiopathic intracranial hypertension (IIH). The objectives of our study were: (1) to determine the rate of transverse venous sinus stenosis (TVSS) in patients with spontaneous nasal CSF leak and in patients with IIH without CSF (controls), and (2) to study the correlation between spontaneous nasal CSF leak and brain imaging features. STUDY DESIGN: A multicenter retrospective case-control study. SETTING: Six French tertiary hospitals. METHODS: Patients with spontaneous nasal CSF leaks and patients with IIH without nasal CSF leaks (controls) were included. The transverse venous sinus patency was analyzed by magnetic resonance imaging to identify possible stenosis or hypoplasia. RESULTS: Thirty-two patients with spontaneous nasal CSF leaks and 32 controls were included. TVSS was significantly more frequent in patients with spontaneous nasal CSF leaks than in controls (p = .029). Univariate analysis indicated that TVSS (odds ratio, OR: 4.2; 95% confidence interval, CI [1.352-14.915]; p = .017) and arachnoid granulations (OR: 3; 95% CI [1.065-8.994]; p = .042) were risk factors for spontaneous nasal CSF leak. In multivariate analysis, TVSS and arachnoid granulations were independent risk factors of nasal CSF leak (OR: 5.577, 95% CI [1.485-25.837], p = .016; and OR: 4.35, 95% CI [1.234-17.756], p = .029, respectively). CONCLUSION: This multicenter case-control study shows that TVSS is an independent risk factor for CSF leak in patients with IIH. Stenosis management by interventional radiology may be proposed postoperatively to increase the success of IIH surgical treatment or preoperatively to reduce the need for surgery.

Definition of severity and treatment response in chronic rhinosinusitis with nasal polyps: a Delphi study among French experts.

INTRODUCTION: The introduction of biotherapies has significantly changed the management of patients with chronic rhinosinusitis with nasal polyps (CRSwNP). These drugs are generally reserved for severe or recurrent CRSwNP. Thus, the concepts of severity of the disease and treatment response must be mastered by otorhinolaryngologists. However, a clear definition of these concepts in CRSwNP is missing. METHODS: This article focuses on definitions of severity and treatment response in CRSwNP by providing an expert consensus among French rhinologists, using a Delphi study. RESULTS: The severity assessment should seek the presence of uncontrolled asthma, olfactory disorders, nasal blockage, impaired quality of life (QOL) and cumulative annual dose of systemic corticosteroids.The treatment response should assess the presence of olfactory disorders, nasal blockage, QOL impairment, response to background therapy, resistance and/or dependence to oral corticosteroids, cumulative annual dose of systemic corticosteroids, response to surgery and to biologics.A failure after polypectomy should not be considered as a failure of surgical management of CRSwNP and must discuss the realization of an extended sinus surgery procedure before the prescription of biologics. CONCLUSION: Definitions of severity, control of CRSwNP, as well as therapeutic strategies to improve patients' QOL achieved high level of consensus.

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.

The external pudendal artery free flap in women: Anatomical study of a novel flap for buccopharyngeal reconstruction.

BACKGROUND: Because of the widespread and high reliability of free flaps in head and neck reconstruction, the challenge today is to reduce donor site morbidity. The external pudendal artery (EPA) free flap has been described in men and provides a minimal functional and cosmetic impact. This study aimed to assess the feasibility of the EPA free flap in women for buccopharyngeal reconstruction. METHODS: A dissection of the inguinal region was performed bilaterally on fresh female cadavers. The anatomy of the EPA and its angiosome were described, along with the design of the EPA free flap. A computed tomography angiographic study of the flap perfusion was performed. RESULTS: Fourteen cadavers were dissected. The EPA was constant. Its diameter ranged from 1.12 to 2.96 mm (median 2.0 mm). The mean area of its angiosome was 167.3 ± 38.5 cm2. An axial fasciocutaneous flap was designed with a horizontal skin paddle measuring on average 9.2 × 6 cm and a pedicle length of 8.4 ± 1.9 cm. The mean flap thickness was 11.7 ± 6.8 mm and depended on individual factors. A primary closure was achieved in all cases with a scar hidden in the underwear. CONCLUSIONS: This anatomical study demonstrates that the EPA seems constant despite variations in its origin pattern. Its diameter and angiosome allow the design of an EPA free flap in women. A clinical study should confirm that this flap is suitable for the repair of buccopharyngeal defects and could be added to the armamentarium of the head and neck reconstructive surgeon.

Functional and oncological outcomes of salvage transoral robotic surgery: a comparative study.

PURPOSE: Transoral robotic surgery (TORS) as a first-line therapy has been well-documented but evidence is missing regarding salvage therapy. The aim of this study is to compare the oncological and functional outcomes of TORS as a primary and salvage therapy. METHODS: This retrospective monocentric study included 74 patients operated by a single surgeon and sorted out into two groups: primary treatment (PT) or Salvage treatment (ST) in case of previous history of radiation therapy. Patients were further stratified by tumour location: larynx and pharynx (lST vs lPT and pST vs pPT). RESULTS: Forty-eight patients were included in PT group (64.9%) and 26 in ST group (35.1%). ST patients had more frequent cTis/T1 tumours (57.7% vs 29.2%, p = 0.0164) and no clinical lymph disease (3.8% vs 37.5%, p = 0.0016). Tracheostomy was more often performed in the ST group (57.7% vs 16.7%, p = 0.0003) and the lST subgroup (88.9% vs 9.1%, p < 0.0001). Gastric feeding tube placement was more frequent in the ST group (76.9% vs 33.3%, p = 0.0003), the pST subgroup (64.7% vs 15.4%, p = 0.0009) and the lST subgroup (100% vs 54.5%, p = 0.0297). We observed a trend for more postoperative complications in the ST group (69.2% vs 47.9%, p = 0.0783). The overall survival was lower in the ST group (p = 0.0004), and in the pST subgroup (p < 0.0001). The disease-free survival rate was lower in the ST group (p = 0.0001), the pST subgroup (p = 0.0002) and the lST subgroup (p = 0.0328). CONCLUSION: This study confirms that survival and functional outcomes after salvage TORS are worse than in first line surgery.

Failure of anterior skull base reconstruction for sinonasal carcinoma: consequence on the postoperative follow up. A multicentre evaluation of management.

BACKGROUND: Numerous techniques for closure of the anterior skull base in cancer patients have a high success rate but management of failure is poorly documented. OBJECTIVES: To standardize the post-operative follow-up after reconstruction surgery of the anterior skull base after removal for sinonasal carcinoma. MATERIALS AND METHODS: Retrospective review of failure of anterior skull base reconstruction between 2005 and 2018 in a multicenter setting. RESULTS: Twenty four patients were included. Reconstruction failure was detected by a cerebrospinal (CSF) leak in 79.2%, by an infectious complication without CSF leak (i.e. meningitis) in 12.5%, and in 8.3% by extensive pneumocephalus. Failure was observed during the first week after surgery in 75% of patients, in the second week in 21%, and in 4% after day 15. The delay in discovery of the failure was associated with multilayer reconstruction (p=.03). Failure was treated surgically in 54% of the patients and medically in 46%, with a similar success rate (85 vs. 100%). CONCLUSION AND SIGNIFICANCE: After carcinologic resection of the anterior skull base, monitoring should be systematic during the first postoperative week. Surgical management of failure is not always necessary.

Patient Satisfaction After Non-surgical Rhinoplasty Using Hyaluronic Acid: A Literature Review.

BACKGROUND: Few studies have focused on assessing patient satisfaction after non-surgical rhinoplasty using hyaluronic acid (HA). The main objective of this study was to perform a systematic review assessing patient satisfaction after non-surgical rhinoplasty using HA. METHODS: We conducted a systematic review using the PRISMA model. All articles assessing patient satisfaction using self-questionnaires or scales (visual analogic scales, Likert scale) after non-surgical rhinoplasty were included. We also analyzed injection protocols and complications. The criteria for considering studies for the review were based on the population, intervention, comparison, outcome, timing and setting (PICOTS) framework. RESULTS: A total of 674 patients were included in eight studies. Mean age was 29.5 years old (min = 19, max = 67, sex ratio = 0.20). Rates of "satisfied" or "very satisfied" patients were 100% immediately after injection (n = 404/404 patients), 98.2% in the weeks following injection (n = 628/639 patients), 84.7% 3 months after injection (n = 333/393 patients) and 96.4% one year after injection (n = 60/62 patients). Duration of HA effectiveness ranged between 8 and 14 months. One local infection (0.001%) but no skin necrosis and no blindness were reported. Most of authors used less than 1 mL of HA per procedure. CONCLUSIONS: Provided precautions for use and indications are observed, and presuming good anatomical knowledge, non-surgical rhinoplasty is an interesting procedure associated with high satisfaction rates. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Multicentre evaluation of the interest in planned surgery for mandibular reconstruction with fibula free flap: a retrospective cohort study.

PURPOSE: The aim of this study was to determine the impact and cost-effectiveness of virtual surgical planning during fibula free flap mandibular reconstruction on peri- and postoperative data. METHODS: We conducted a retrospective cohort study from January 2012 to December 2016 in four French university centres. RESULTS: Three hundred fibula free flaps for mandibular reconstruction were performed in 294 patients. Surgeries were planned in 29.7% of cases (n = 89). There was no significant difference in the rate of negative-margins excision, median length of hospital stay, operative time, and early complications between planned and non-planned surgeries. Morphological analysis revealed a higher rate of centred occlusion in planned patients (satisfactory alignment of interincisal points: Planned 65.5% vs Non-Planned 33.3%, p = 0.006). CONCLUSION: In mandibular reconstruction by fibula free flap, the additional cost generated by virtual surgical planning does not seem to be balanced by savings resulting from a shorter operative course, a reduced hospital stay, or a reduction in postoperative complications. However, virtual surgical planning may provide a higher rate of centred occlusion. Long-term benefits should be assessed by further studies.

Contribution of narrow band imaging in delineation of laryngopharyngeal superficial cancer spread: a prospective study.

PURPOSE: The aim of this study was to assess the performance of Narrow Band Imaging (NBI) added to White Light (WL) in the delineation of laryngopharyngeal superficial cancer spread during office-based transnasal flexible endoscopy. METHODS: This bi-centric prospective study was conducted between October 2014 and December 2017. We included consecutive patients with laryngopharyngeal malignant tumors. Transnasal flexible endoscopy was performed by two endoscopists who were blinded to each other's assessments and who examined each patient independently. The first endoscopist only performed a WL examination, while the second endoscopist carried out both WL and NBI. The extent of tumor involvement was reported based on predefined anatomical sub-units. Biopsies in NBI + /WL- sub-units were subsequently performed during panendoscopy. RESULTS: Eighty-four patients were included in the study. A total of 72 NBI + /WL- sub-units were sampled in 38 patients, and 37 of the biopsies were positive (51.4%): 16 for invasive carcinoma, 17 for high-grade dysplasia/carcinoma in situ and 4 for low-grade dysplasia. Ultimately, 26.2% of patients had at least one positive biopsy in an NBI + /WL- sub-unit and, therefore, a better tumor delineation. The clinical T stage was upgraded in 4.8% of cases examined. CONCLUSION: Adding NBI to WL imaging during transnasal flexible endoscopy in patients presenting with laryngopharyngeal pre-malignant or malignant lesions improves the delineation of superficial cancer spread, thereby leading to better adapted treatments. Clinicaltrials.gov registration number: NCT02035735.

Is the dorsal vascular system sufficient to vascularize the entire teguments of the thumb?

PURPOSE: Simultaneous lesions of both proper digital arteries of the thumb are common in hand trauma surgery. The purpose of this anatomical study was to determine if the dorsal arterial network could be sufficient to ensure the vascularization of the thumb skin sheath. METHODS: We carried out a cadaveric study on 22 hands. The ulnar and radial proper digital arteries of the thumb were ligated at the base of the first phalanx. Red dye was injected into the radial artery and blue dye into the ulnar artery at the wrist level. Visual evaluation of skin staining and systematic photographs was done at 1, 3 and 10 min after injection of dyes. RESULTS: Staining of the thumb sheath was obtained in 100% of the dissections and complete in 91.91% of cases. Staining originated from mixed radial and ulnar artery origins in 81.82% of cases. It was incomplete in 9.09% of cases with a missing on the dorsoradial edge of the proximal phalanx. In one dissection, the whole hand skin was only stained red, and in another dissection only stained blue. CONCLUSION: The dorsal vascular network ensures the substitution of the skin vascularization in more than 90% of cases when ligating the proper digital arteries of the thumb. A clinical impression of good skin vascularization after injury of both proper digital arteries might lead the surgeon not to perform systematic revascularization, but the risk of variable damages of adjacent tissues due to an interruption of one major arterial system requires a palmar arterial anastomosis whenever possible.

Cytokine Signature and Involvement in Chronic Rhinosinusitis with Nasal Polyps.

Cytokines are well known to play a central role in chronic rhinosinusitis with nasal polyps (CRSwNP), particularly in maintenance of the inflammatory response and the recruitment of eosinophils. The pathophysiological concepts concerning the involvement of inflammatory cytokines in CRSwNP have gradually evolved. Although the Th2 cytokines environment associated with an eosinophilic infiltration has retained a central role in the genesis of polyps, the role of other cytokine subpopulations has also and more recently been detailed, leading to a specific and complex signature in CRSwNP. The purpose of this review is to summarize the current state of knowledge about the cytokine signature in CRSwNP, the role of cytokines in the pathogenesis of this disease and in the intercellular dialog between epithelial cells, fibroblasts and inflammatory cells. Knowledge of this precise cytokine signature in CRSwNP is fundamental in the perspective of potential targeting biotherapies.

Risk Factors for Pharyngocutaneous Fistula After Total Pharyngolaryngectomy.

PURPOSE: To evaluate the risk factors of pharyngocutaneous fistula after total pharyngolaryngectomy (TPL) in order to reduce their incidence and propose a perioperative rehabilitation protocol. MATERIALS AND METHODS: This was a multicenter retrospective study based on 456 patients operated for squamous cell carcinoma by total laryngectomy or TPL. Sociodemographic, medical, surgical, carcinologic, and biological risk factors were studied. Reactive C protein was evaluated on post-op day 5. Patients were divided into a learning population and a validation population with patients who underwent surgery between 2006 and 2013 and between 2014 and 2016, respectively. A risk score of occurrence of salivary fistula was developed from the learning population data and then applied on the validation population (temporal validation). OBJECTIVE: To use a preoperative risk score in order to modify practices and reduce the incidence of pharyngocutaneous fistula. RESULTS: Four hundred fifty-six patients were included, 328 in the learning population and 128 in the validation population. The combination of active smoking over 20 pack-years, a history of cervical radiotherapy, mucosal closure in separate stitches instead of running sutures, and the placement of a pedicle flap instead of a free flap led to a maximum risk of post-op pharyngocutaneous fistula after TPL. The risk score was discriminant with an area under the receiver operating characteristic curve of 0.66 (95% confidence interval [CI] = 0.59-0.73) and 0.70 (95% CI = 0.60-0.81) for the learning population and the validation population, respectively. CONCLUSION: A preoperative risk score could be used to reduce the rate of pharyngocutaneous fistula after TPL by removing 1 or more of the 4 identified risk factors.

The specific branches leading to the genioglossus muscle: three-dimensional localisation using skin reference points.

INTRODUCTION: Supra-selective stimulation of the branches destined for the horizontal part of genioglossus muscle (GGh) could be a target of choice in the treatment of mild-to-severe obstructive sleep apnea syndrome. The main aim of our study was to assess a percutaneous method for the three-dimensional localisation of the terminal branches destined to GGh. MATERIALS AND METHODS: Twenty cadaveric hypoglossal nerves were dissected and included in the injection protocol. The distance between the posterior edge of the mandibular symphysis and the hyoid bone on the sagittal midline as the approximated distance of the geniohyoid muscle (dGH) was measured before any dissection. Methylene blue mixed with a thickening agent, was injected. The injection point was defined in relation to dGH, in an orthonormal coordinate system. For each dissection, we recorded the theoretical and the real (X, Y, Z) coordinates of GGh motor points and measured their distance to each other. RESULTS: X was accurately estimated. Y and Z were overestimated by + 5.34 ± 5.21 mm ([Formula: see text]) and + 4.79 ± 3.99 mm ([Formula: see text]) on average, respectively. We found a more significant difference between the theoretical and real Y and Z coordinates in the subgroup BMI < 25 kg/m2 (8.6 ± 4.5 mm and 6.9 ± 2.5 mm, respectively, p = 0.0009), and of Z in subgroup with dGH ≥ 50 mm (6.89 ± 3.26 mm, p = 0.0494). CONCLUSIONS: X can be estimated accurately using the relationship [Formula: see text]. Y seems to be related to BMI and Z may be estimated with the relationship [Formula: see text]. This three-dimensional localisation could be very helpful to facilitate placement of cuff electrodes to manage refractory sleep apnea.

The super thin external pudendal artery (STEPA) free flap for oropharyngeal reconstruction - A case report.

The radial forearm flap is one of the most used micro-anastomotic flaps in cervicofacial reconstruction in a carcinological context. This flap is an ideal in terms of reliability and fineness; it has, however, some disadvantages in terms of the functional and aesthetic complications of its donor site. In alternative to a radial forearm free flap, we report the use of the free super thin external pudendal artery flap (STEPA flap) for an oropharyngeal reconstruction. The aim was to decrease the donor site morbidity. A 71-years-old man with a T2N0M0 oropharyngeal squamous cell carcinoma has undergone surgical treatment. A left STEPA free flap was performed to reconstruct a defect about 8 × 6 cm2 . This flap was designed as a half-scrotal free flap sized 9 × 7 cm2 and was inset after tunneling of the pedicle at the floor of the mouth. A surgical revision was needed on the 15th day postoperative for disunion. There was no skin flap failure. After 12 month of follow-up, no complication was observed at the donor site and no erectile dysfunction was recorded. Its characteristics in terms of fineness, flexibility, ease of conformation, and pedicle length are similar to those of the radial forearm flap with less aesthetic and functional sequelae of the donor site. The STEPA flap may be a promising free flap in oropharyngeal or oral cavity reconstruction.

An innovative reconstruction procedure of total nasal resurfacing with a bipedicled propeller perforator flap.

BACKGROUND: A forehead frontal flap is the treatment of choice for complex nasal defects. However, in patients with contra indications for such frontal flaps, few alternatives are available. METHODS: We developed a three-stage, nasal reconstruction procedure using a bipedicled, propeller perforator flap based on the modiolus perforators. Here, we describe the flap, the harvesting thereof, and the 6-month outcomes after placement. RESULTS: The flap did not exhibit any sign of necrosis or congestion. Six months after reconstruction, the patient had not suffered any esthetic or functional sequela. CONCLUSION: Although the indications for our new flap are less numerous than those for a frontal flap, our flap is a useful alternative when frontal flap placement is not feasible (or the patient refuses such a flap) and when placement of a free flap is too risky.

Cost-effectiveness of trans-nasal endoscopic sphenopalatine artery ligation vs arterial embolisation for intractable epistaxis: Long-term analyses.

OBJECTIVES: Trans-nasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular arterial embolisation both provide excellent success rates for intractable epistaxis. Recent economic models suggest that TESPAL could be a cost-saving strategy. Our main aim was to perform cost-effectiveness analyses on TESPAL compared with embolisation to treat patients with epistaxis. DESIGN: We performed retrospective, monocentric, comparative analyses on patients referred to our centre and treated with embolisation or TESPAL. SETTING: This economic evaluation was carried out from a payer's perspective (ie French National Health Insurance) within a time horizon of 12 months. PARTICIPANTS: Thirty-seven TESPAL procedures and thirty-nine embolisation procedures to treat intractable epistaxis were used in the analyses. MAIN OUTCOME MEASURES: The primary outcome is presented as the cost per 1% of non-recurrence. Effectiveness was defined as avoiding recurrence of epistaxis during the 1-year follow-up. Cost estimates were performed from the payer's perspective. RESULTS: Hospitalisation costs were higher for embolisation compared with TESPAL (5972 vs 3769 euros). On average, hospitalisation costs decreased by 41% when a patient was treated by TESPAL compared with an embolisation strategy (P = 0.06). The presence of comorbidities increased hospitalisation costs by 79% (P = 0.04). TESPAL enabled 1867€ to be gained in intractable epistaxis. CONCLUSIONS: The outcomes from our decision model confirm that TESPAL is more cost-effective for patients with intractable epistaxis.