Free-flap reconstruction methods in head-and-neck oncologic surgery: A CROSS practice survey of members of the French GETTEC Head-and-Neck Tumor Study Group.

OBJECTIVE: To survey practices concerning the use of anticoagulants and antiplatelets in microvascular free-flap reconstruction following oncological surgery of the head and neck. METHODS: A survey of practices was carried out between September 2022 and March 2023. An online questionnaire was sent to members of the French GETTEC Head-and-Neck Tumor Study Group in all French centers practicing head-and-neck cancer surgery with reconstruction using microvascular free-flaps. The questionnaire asked surgeons about their practices regarding the use of intra- and postoperative anticoagulants and antiplatelets, preoperative management of comorbidities, and prevention of postoperative complications. RESULTS: Sixty-one percent of the 38 respondents (23/38) used intraoperative intravenous heparin injection, associated to flap irrigation with heparin for 76% of surgeons (29/38) and/or a heparin solution bath for 37% (14/38). Postoperative anticoagulation was used by 95% of surgeons (36/38), and antiplatelets by 40% (15/38). Postoperatively, 40% (15/38) carried out monitoring using an implantable micro-Doppler probe, associated to analysis of clinical characteristics of the flap. CONCLUSION: Reconstructive surgery using microvascular free-flaps involves numerous factors that can influence success. Prospective studies, particularly concerning the management of anticoagulants, could enable a national consensus on methods for free-flap reconstruction.

Cephalic vein transposition in head-and-neck reconstruction.

The advent of free flaps has made it possible to undertake increasingly complex reconstructive surgeries. Many of the patients have already undergone extensive prior surgery, primary free flap reconstruction and/or cervical irradiation. These treatments strongly impact anatomy and tissue quality. The reconstructive surgeon may be faced with a situation where the choice of recipient vessels is limited; in 7% of cases, no cervical vessels are available at all. For venous anastomosis, branches of the internal and external jugular vein are preferentially used, but may have been ligated or be unusable. Venous congestion is one of the most common causes of failure in these situations. The cephalic vein has been described as an alternative for second anastomosis in first line, but is rarely used for early free-flap salvage. Based on a case study, the technique of cephalic vein transposition is illustrated for early salvage of a double free flap for head-and-neck reconstruction. This technique is simple, reliable and rapid. It should be part of the armamentarium of the head and neck reconstructive surgeon.

Biomaterials and osteoradionecrosis of the jaw: Review of the literature according to the SWiM methodology.

OBJECTIVES: To systematically present and interpret the current literature on research and treatment perspectives for mandibular osteoradionecrosis (mORN) in the field of biomaterials. MATERIAL AND METHODS: A systematic review of the literature using the "Synthesis without meta-analysis" (SWiM) methodology was performed on PubMed, Embase and Cochrane, focusing on the implantation of synthetic biomaterials for bone reconstruction in mORN in humans and/or animal models. The primary endpoints were the composition, efficacy on mORN and tolerance of the implanted synthetic biomaterials. RESULTS: Forty-seven references were obtained and evaluated in full-text by two assessors. Ten (8 in humans and 2 in animal models) met the eligibility criteria and were included for analysis. Materials most often comprised support plates or metal mesh (5 of 10 cases) in combination with grafts or synthetic materials (phosphocalcic ceramics, glutaraldehyde). Other ceramic/polymer composites were also implanted. In half of the selected reports, active compounds (molecules, growth factors, lysates) and/or cells were associated with the reconstruction material. The number of articles referring to implantation of biomaterials for the treatment of mORN was small, and the properties of the implanted biomaterials were generally poorly described, thus limiting a thorough understanding of their role. CONCLUSION: In preventing the morbidity associated with some reconstructive surgeries, basic research has benefitted from recent advances in tissue engineering and biomaterials to repair limited bone loss.

Narrow-Band Imaging in oncologic otorhinolaryngology: State of the art.

OBJECTIVES: To describe the diagnostic performance of Narrow Band Imaging (NBI) combined with White Light Imaging (WLI) in the diagnosis of mucosal lesions at each location of the upper aerodigestive tract, for detection of primary tumor in case of carcinoma of unknown primary, for determination of intraoperative resection margins, and to describe its main diagnostic pitfalls. MATERIAL AND METHODS: A PubMed search was carried out according to the PRISMA method. RESULTS: Four hundred and seventy-seven articles published between 2007 and 2020 were identified, 133 of which met the study inclusion criteria and were assessed. CONCLUSION: The current literature seems to support the use of NBI in diagnosis and/or follow-up of (pre-)malignant head & neck tumors, and in the determination of intraoperative resection margins.

Observational study of the long-term impact of donor-site sequelae after head and neck reconstruction by free anterolateral thigh flap.

OBJECTIVE: Free anterolateral thigh flap has many applications in head and neck reconstruction surgery. The aims of the present study were: (1) to assess functional and esthetic sequelae of harvesting for oncologic purposes; and (2) to assess long-term impact of harvesting on quality of life according to patient and to physician. MATERIALS AND METHODS: Forty-one patients undergoing reconstruction by free anterolateral thigh flap following oncologic head and neck surgery were assessed by questionnaire at>6 months postoperatively. Donor site sequelae were assessed in consultation. Harvesting impact was assessed on 5-point Likert scales by patient and by surgeon. RESULTS: Thirty nine percent of patients showed≥1 sequelae. Donor site sequela impact on sport, daily living and work was assessed by patients as none or mild in 94%, 98% and 100% of cases, respectively. Sixty-one percent of patients and 58.5% of surgeons considered scar esthetics to be discreet or very discreet. CONCLUSION: Morbidity related to anterolateral thigh flap harvesting was low, and functional sequelae at the donor site were well tolerated. The scar was only moderately satisfactory, but could easily be hidden.

Biofunctionalization of 3D-printed silicone implants with immunomodulatory hydrogels for controlling the innate immune response: An in vivo model of tracheal defect repair.

The recent advances in 3D-printed silicone (PDMS: polydimethylsiloxane) implants present prospects for personalized implants with highly accurate anatomical conformity. However, a potential adverse effect, such as granuloma formation due to immune reactions, still exists. One potential way to overcome this problem is to control the implant/host interface using immunomodulatory coatings. In this study, a new cytokine cocktail composed of interleukin-10 and prostaglandin-E2 was designed to decrease adverse immune reactions and promote tissue integration by fixing macrophages into M2 pro-healing phenotype for an extended period of time. In vitro, the cytokine cocktail maintained low levels of pro-inflammatory cytokine (TNF-α and IL-6) secretions and induced the secretion of IL-10 and the upregulation of multifunctional scavenging and sorting receptor stabilin-1, expressed by M2 macrophages. This cocktail was then loaded in a gelatine-based hydrogel to develop an immunomodulatory material that could be used as a coating for medical devices. The efficacy of this coating was demonstrated in an in vivo rat model during the reconstruction of a tracheal defect by 3D-printed silicone implants. The coating was stable on the silicone implants for over 2 weeks, and the controlled release of the cocktail components was achieved for at least 14 days. In vivo, only 33% of the animals with bare silicone implants survived, whereas 100% of the animals survived with the implant equipped with the immunomodulatory hydrogel. The presence of the hydrogel and the cytokine cocktail diminished the thickness of the inflammatory tissue, the intensity of both acute and chronic inflammation, the overall fibroblastic reaction, the presence of oedema and the formation of fibrinoid (assessed by histology) and led to a 100% survival rate. At the systemic level, the presence of immunomodulatory hydrogels significantly decreased pro-inflammatory cytokines such as TNF-α, IFN-γ, CXCL1 and MCP-1 levels at day 7 and significantly decreased IL-1α, IL-1ß, CXCL1 and MCP-1 levels at day 21. The ability of this new immunomodulatory hydrogel to control the level of inflammation once applied to a 3D-printed silicone implant has been demonstrated. Such thin coatings can be applied to any implants or scaffolds used in tissue engineering to diminish the initial immune response, improve the integration and functionality of these materials and decrease potential complications related to their presence.

Vascularized lymph node transfer with submental free flap.

Limb lymphoedema is common in patients who have undergone inguinal or axillary lymph node dissection. Lymphoedema seriously impacts the patient's quality of life by inducing adipogenesis, fibrosis and repeated episodes of lymphangitis and cellulitis. Following failure of compression therapies, several curative or symptomatic surgical options have been proposed over recent decades, such as liposuction or lymphovenous anastomosis. Vascularized lymph node transfer techniques have recently been described, with promising results. Vascularized lymph node transfer with submental free flap appears to be the most reliable of these technique, associated with the lowest morbidity. The flap harvesting technique presents several specific differences compared to conventional submental free flap. A good knowledge of neck anatomy is essential and multimodal and multidisciplinary management is often required. In the light of a case report, we describe the basic submental free flap technique for vascularized lymph node transfer for the treatment of lower limb lymphoedema. This technique may be used by head and neck surgeons performing flap harvest, as well as plastic surgeon surgeons or gynaecologists ensuring long-term management of these patients.

Transoral robotic surgery of the tongue base for obstructive sleep apnea: Preliminary results.

INTRODUCTION: Obstructive sleep apnea syndrome (OSAS) is a major public health issue. Robotic tongue-base reduction surgery is being developed, but needs assessment. The present study reports clinical and polygraphic results at 6 months' follow-up. METHOD: Single-center prospective study of 8 patients undergoing transoral robotic surgery (TORS) for severe OSAS. RESULTS: Mean age was 47 years. M/F sex ratio was 5:3. Initial body-mass index ranged from 18 to 35kg/m2. Mean Epworth score was 12. Mean preoperative apnea-hypopnea index (AHI) was 47 (range, 36-60). At 6 months, only 1 patient did not meet usual success criteria (AHI<20 with>50% decrease); 2 patients had residual AHI between 10 and 20; the other 5 had non-significant event rates. CONCLUSION: TORS tongue-base reduction showed promising results, which need confirmation on long-term multicenter studies.

Functional outcome after long-term low-dose trimethoprim/sulfamethoxazole in chronic rhinosinusitis with purulence: a prospective study.

OBJECTIVE: Trimethoprim/sulfamethoxazole has been suggested as a treatment option for chronic rhinosinusitis with purulence. This study aimed to assess the functional and endoscopic outcomes after a three-month course of low-dose trimethoprim/sulfamethoxazole. METHODS: A prospective study was performed, comprising patients referred to a tertiary care medical centre with a diagnosis of chronic rhinosinusitis with purulence. Trimethoprim/sulfamethoxazole was prescribed at 960 mg/day for three months. Sinonasal complaints and endoscopic findings were documented, and bacteriological data were compared. RESULTS: Fifteen patients were included. Staphylococcus aureus was the most common bacterium cultured (86 per cent). Improvement in nasal function, as measured by the 22-item Sino-Nasal Outcome Test, was highly significant at three months (p < 0.0005). This improvement slightly decreased but remained significant at 6, 9 and 12 months. No side effects were noted. Endoscopic scores revealed similar and concordant improvements. CONCLUSION: Long-term low-dose trimethoprim/sulfamethoxazole therapy seems to be a safe option for selected patients. Additional randomised multicentre studies remain necessary.

Hypopharyngeal reconstruction using a circular stapler.

Distal anastomosis by tubed free flap is one of the main technical difficulties encountered during hypopharyngeal reconstruction. Although high flap survival probability can be achieved by experienced surgical teams, two complications are commonly observed at the flap-oesophagus junction: fistula and stenosis. Use of a circular stapler reduced the frequency of these complications by ensuring a perfectly circular and resistant suture line. Salivary stent placement is therefore unnecessary, allowing earlier resumption of feeding. The stapling procedure is simple, but a few technical skills are required, as the stapler is not specifically designed for this purpose. We describe the indications, surgical procedure and global results based on our series. We consider the forearm flap to be the gold standard for this reconstruction, but thicker flaps, such as pectoralis major flap, can also be used, but with poorer results in terms of healing and swallowing performance.

Contribution of 3D printing to mandibular reconstruction after cancer.

Three-dimensional (3D) printing is booming in the medical field. This technology increases the possibilities of personalized treatment for patients, while lowering manufacturing costs. To facilitate mandibular reconstruction with fibula free flap, some companies propose cutting guides obtained by CT-guided moulding. However, these guides are prohibitively expensive (€2,000 to €6,000). Based on a partnership with the CNRS, engineering students and a biomedical company, the authors have developed cutting guides and 3D-printed mandible templates, deliverable in 7days and at a lower cost. The novelty of this project is the speed of product development at a significantly lower price. In this technical note, the authors describe the logistic chain of production of mandible templates and cutting guides, as well as the results obtained. The goal is to allow access to this technology to all patients in the near future.

Intractable epistaxis: which arteries are responsible? An angiographic study.

PURPOSE: Epistaxis constitutes a significant proportion of the Otolaryngologist's emergency workload. Optimal management differs in relation to the anatomic origin of the bleeding. The outcome of our study was to determine which artery(ies) could be considered as the cause of severe bleeding in the context of severe epistaxis. METHODS: Fifty-five procedures of embolization preceded by angiography were reviewed. Medical records of interventionally treated patients were analysed for demographics, medical history, risk factors and clinical data. Angiographic findings were also assessed for active contrast extravasation (blush), vascular abnormality and embolised artery. RESULTS: Previous angiography showed an active contrast extravasation in only 20 procedures. The most common bleeding source was the sphenopalatine artery (SPA) followed by anterior ethmoïdal artery (AEA) and facial artery. Majority of multiple or bilateral extravasations occured in patients with systemic factors. CONCLUSIONS: A better understanding of the potential bleeding source might help and limit the risk of treatment failures. Our study confirms that the SPA is the most common cause of severe bleeding. We also emphasise the role of the AEA not only in traumatic context. Others arteries are rarely involved except in patients with comorbidities or frequent recurrences.

Induction chemotherapy before surgery for unresectable head and neck cancer.

OBJECTIVE: To preoperatively reduce tumour size in patients with locally advanced and/or non-resectable squamous cell carcinoma with induction chemotherapy in order to achieve surgical excision with clear margins and preserve quality of life. METHODOLOGY: In this study, 16 patients with locally advanced and/or non-resectable squamous cell carcinoma underwent induction chemotherapy with docetaxel, cisplatin, and 5-fluorouricil or paclitaxel, carboplatin, and cetuximab. RESULTS: Over 80% of patients responded to induction chemotherapy. Histological examination of the 14 surgical specimens showed a total absence of residual cancer cells in 37.5% of cases. CONCLUSION: Concurrent radiation and chemotherapy is the standard treatment for locally advanced head and neck squamous cell carcinoma; however, induction chemotherapy may be beneficial in select patients.

[Surgical treatement by intracapsular enucleation of cervical peripheral neural sheath tumors]. / Traitement chirurgical des tumeurs nerveuses périphériques bénignes cervicales par exérèse intracapsulaire.

Schwannomas and neurofibromas are benign tumors of the peripheral neural sheath tumors (PNST), representing 5% of soft tissue tumors. Cervical PNST are mainly located on the vagus nerve or in the sympathetic nervous system. The treatment is based on a tumor resection with preservation of nerve function. Classical surgery consists in total tumor removal after dissection of the nerve and is frequently complicated by nerve paralysis. The authors describe a simpler surgical technique consisting in a resection of the intracapsular enucleation of PNST that can limit the risk of nerve injury without increasing recidivism. The description of this surgical technique is illustrated by its use in a type I neurofibromatosis patient with a large vagal nerve neurofibroma.

Semi-free forearm flap for pharyngeal-esophageal reconstruction after radiation therapy.

Reconstruction of the pharynx and upper esophagus uses various procedures, including pedicled or free flap. Pharyngoplasty with free forearm flap provides excellent functional results. In radiation-related pharyngeal stenosis, recipient vascularization is often poor, especially in the venous system. The authors describe pharyngeal reconstruction with semi-free forearm flap, pedicled on the cephalic vein, to minimize the risk of venous thrombosis, which is the main factor of free forearm flap necrosis. Taking the case of a laryngectomy with complete pharyngeal stenosis after radiation therapy and iterative neck surgery, the technique of pharyngeal-esophageal reconstruction by semi-free forearm flap is described in a context of impaired vascularization.

Surgical treatment options for maxillary sinus fungus balls.

OBJECTIVE: 1) To evaluate the effectiveness and side-effects of endoscopic surgical treatment for maxillary sinus fungus balls, and to describe approaches to limiting recurrence of the disease and surgical complications. 2) To compare the results of this nasal endoscopic treatment with the results of treatment using a vestibular approach to the anterior wall of the maxillary sinus as described in the literature. PATIENTS AND METHODS: An institutional retrospective review was conducted for patients undergoing treatment for a maxillary sinus fungus ball using endonasal surgery alone from January 2005 to December 2010. RESULTS: A total of 100 patients were included in the study (58 women and 42 men, average age 54 years). The median follow-up time was 32 months. Three patients had a recurrence after our team performed endonasal surgery. No patients experienced complications. CONCLUSION: Our results are consistent with previous findings, indicating that the postoperative complication rate for endonasal surgery is low by comparison with the vestibular approach. Both techniques have similar outcomes. The nasal endoscopic route offers similar rates of success with a negligible complication rate.

[Balloon catheter dilatation for frontal sinus ostium stenosis: surgical technique and preliminary report]. / Technique de dilatation ostiale par ballonnet ("balloon Sinuplasty") dans les obstructions du canal naso-frontal: expérience préliminaire et notes techniques.

OBJECTIVES: To report early clinical experience with balloon dilation of the frontal recess ("Balloon Sinuplasty"), to describe surgical technique, to assess its feasibility and effectiveness. MATERIAL AND METHODS: This prospective, multiinstitutional case series describes all patients who underwent balloon sinuplasty for frontal sinus ostium stenosis from May 2011 to December 2011. RESULTS: Eight adult patients underwent a total of 11 frontal balloon sinuplasty in the clinical setting. The mean age was 46 +/- 12. All procedures were performed under general anesthesia. No complications occurred. Six of the eight patients were deemed cured with a follow-up range of 1-7 months. For 2 patients the procedure was unsuccessful. CONCLUSIONS: Balloon dilatation of the frontal recess is a safe and feasible technique with a comparable efficacy to conventional surgical treatment modalities. There is a need for randomised controlled trials and cost-effectiveness studies.

[Learning curve in sialendoscopy: Our first 101 procedures]. / Courbe d'apprentissage en sialendoscopie : nos 101 premières procédures.

OBJECTIVE: To present our learning curve in diagnostic and interventional sialendoscopy for obstructive salivary diseases. MATERIALS AND METHODS: Monocentric descriptive retrospective study from March 2009 to July 2011. Clinical and demographic data were collected. We are particularly interested in arising technical issues, the use of combined approach, operative time, functional improvement as well as parameter changes over time. RESULTS: 92 operations were performed to explore 101 glands (63 parotid glands against 38 submandibular). We found 39.6% of stones and as many stenosis. The rate of complete stone removal was 65% and dilation was effective in 75% of stenosis. The median of the visual analog scale for pain was 1/10 and functional improvement was effective in 77%. The removal of the gland did not exceed 3.3%. No major complication was noted. Since the initiation of this activity, the median operative time was steady while procedures were more complex, with increased interventional sialendoscopy procedure often requiring combined approach. In about 25% of cases, we have been faced with technical issues. These have evolved over time: initially failure to enter the papilla, difficulty of removing large stones today. CONCLUSION: The learning curve in sialendoscopy allows rapid empowerment and acquisition of expertise in security. Mastery of this technique allows for innovative approaches, complementary to conventional procedure, without compromising neither the operative time nor the functional benefit.