Experience of French patients with olfactory disorders.

OBJECTIVES: To assess the experience of subjects with olfactory disorders in their daily life and medical management, and their expectations and proposals for improvement. MATERIAL AND METHODS: A cross-sectional observational study was conducted over the period January 2020 to December 2021, with 300 subjects with olfactory disorders: 222 female, 78 male; mean age 46±15 years. In total, 126 were patients consulting in ENT, and 174 were members of the Anosmie.org patients' association. Participants filled out a questionnaire; free texts were analyzed thematically and coded for various qualitative variables. RESULTS: Olfactory disorders considerably impacted health, safety and quality of life. Non-COVID-19 acute etiologies (non-COVID-19 viral infection, cranial trauma) showed particularly high risk of psychological, social, safety-related and nutritional consequences. Almost all patients (94%) were dissatisfied with their medical management: 28% had received little explanation, and 23% felt their dysosmia was completely neglected, with no exploration and no etiology suggested. Patients wished above all to have follow-up and accompaniment. CONCLUSION: Despite significant impact on health and quality of life, olfactory disorders are neglected by the medical community. Patients should be given an ENT assessment with olfactometry, to establish diagnosis and prognosis. Global multidisciplinary management is necessary, including therapeutic education, and psychological, social and nutritional follow-up.

Writing in the European Annals of Otorhinolaryngology Head & Neck Diseases. Dos and Don'ts!

Too many articles are still rejected by scientific medical journals due to lack of preparation of the manuscript and of knowledge of the modern editorial rules that govern scientific medical writing. Therefore, the editorial board of the European Annals of Otorhinolaryngology Heads & Neck Diseases summarized studies published by its members since 2020 in the columns of the scientific journal of the French Society of Otorhinolaryngology and the International Francophone Society of Otorhinolaryngology and data from the PubMed indexed literature dedicated to scientific medical writing in otolaryngology in the 21st century. The authors hope that this review, in the form of a list of "Dos and Don'ts", will provide authors with a practical guide facilitating publication of rigorous, reproducible and transparent scientific studies, in accordance with the movement toward better science that society as a whole has been fighting for since the beginning of this century.

Maxillary ostium preservation in ethmoidectomy.

The paranasal sinuses play a role in producing and storing nitric oxide (NO). NO is a powerful antiviral and antibacterial gas which may be involved in the non-specific immune defenses of the respiratory tract. Conducted by the inspiratory current at the alveolar-capillary membrane, it increases pulmonary venous blood oxygenation. NO is actively released in the form of independent boluses in the respiratory tract, thanks to a sphincter function that can be identified during ethmoidectomy under general anesthesia. Safeguarding paranasal sinus physiology necessarily involves conserving this ostial sphincter function, which is essential to the respiratory role of the paranasal sinuses. Although it has not yet been demonstrated that the destruction of this ostial function has measurable consequences for respiratory function, it makes sense to avoid systematic antrostomy and to preserve this ostial function whenever possible, depending on the clinical conditions. This technical note describes step-by-step how to conserve the maxillary ostium, in the example of radical ethmoidectomy with mucosal ablation for nasal polyposis (nasalization). It is illustrated by two videos. The discussion focuses on the respective indications for ostial preservation and middle meatotomy (antrostomy).

Critical review of diagnosis in rhinology and its therapeutical implications.

Diagnosis in rhinology is currently based on the concept of inflammation (chronic rhinosinusitis [CRS]) or the clinical concept of chronic nasal dysfunction (CND). The complementarity between these two approaches can be discussed by a critical review of the literature structured by the analysis of the fundamental and diagnostic bases and the therapeutic implications linked to each. The concept of CRS is based on the anatomical continuity of the nasal and sinus respiratory mucosa and molecular biology data, seeking to analyze the mechanisms of chronic inflammation and to identify proteins and biomarkers involved in the different supposed endotypes of chronic inflammation of this mucosa. The concept of CND seeks to analyze medical, instrumental or surgical diagnostic and therapeutic strategies, taking account of both inflammatory and non-inflammatory causes impacting the anatomy or physiology of each of the three noses (olfactory, respiratory and sinus) that make up the mid-face sinonasal organ of evolution-development (Evo-Devo) theory. Thus, the concept of CRS offers an endotypic approach, based on biological characterization of mucosal inflammation, while the concept of CND offers a compartmentalized phenotypic and pathophysiological approach to sinonasal diseases. The joint contribution of these two concepts in characterizing nasal functional pathology could in future improve the medical service provided to patients.

Surgery for chronic rhinosinusitis with nasal polyps: An update.

This update aimed to evaluate surgical indications in the management of chronic rhinosinusitis with nasal polyps (CRSwNP). It was conducted and reported according to the criteria stipulated by the Synthesis Without Meta-analysis (SwiM) guidelines. From the PubMed-National Library of Medicine database, 1098 articles were identified for the period 2006-2021 using the key words "nasal polyps" and "surgery". After screening and analysis, 39 publications were selected. The efficacy of surgery on functional improvement in CRSwNP, measured by the specific quality-of-life score SNOT-22, is established, and improvement in olfactory function is expected in 50% of patients. The rate of surgical revision is at least 10-15% at 4 years, but the disease can be controlled for several years, with the interval between primary surgery and symptomatic recurrence exceeding 10 years in some cases. The criteria for surgery are not clearly defined in the literature. However, several authors consider failure of ≥ 8 weeks' well-conducted local medical treatment and use of more than 2 courses of systemic corticosteroids as a reliable indication. No studies or meta-analyses are currently available to determine the superiority of one surgical technique over another.

O Rose thou art sick history of allergic rhinitis.

It was at the dawn of the 18th century that "hay fever" was first identified as such. The symptoms were exhaustively described in all their aspects by a physician who was particularly well-informed as he himself suffered from this catarrhal condition every year in the flowering season. But it then took many other discoveries to understand the pathophysiology, starting by identifying the role of pollens, conceptualizing the principles of the reaction and giving it the name of allergy, and then developing the first screening and identification tests of individual sensitization. This historical article describes the major discoveries and key actors that contributed to the current knowledge of pollinosis and, more broadly, of allergic rhinitis.

Keys for successful publication in Eur Ann Otorhinolaryngol Head Neck Dis: A STROBE analysis of peer reviews of articles submitted in 2020-2021.

OBJECTIVE: To evaluate reviewing and editorial decision for articles submitted to the European Annals of Otorhinolaryngology Head & Neck Diseases. MATERIALS AND METHODS: A retrospective analysis was made of reviewers' comments on 1,133 scientific articles (700 original articles, 96 literature reviews, and 337 case reports), originating from 69 countries, consecutively submitted on-line between January 1st, 2020 and December 31st, 2021. The main objective was to document the acceptance rate and decision time. Accessory objectives were to synthesize the main comments and to screen for correlations between acceptance and the main characteristics of first authors, articles and reviewers' comments. RESULTS: In total, 4.1% of submitted articles were accepted. Median decision time differed significantly (P<0.0001), at 1 month in case of refusal and 4 months in case of acceptance. Reviewers mentioned failure to adhere to the journal's authors' guide, to use the appropriate EQUATOR guidelines and to adopt the recommended P<0.005 significance threshold in 94.8%, 54.2%, and 39.9% of cases, respectively. On multivariate analysis, 3 variables significantly impacted acceptance, which increased from 1.3% to 44.6% (P<0.0001) when an appropriate EQUATOR guideline was used and from 0.3% to 57.4% (P<0.0001) when the significance threshold was set at P<0.005, and decreased from 10.5% to 1.1% (P=0.0001) when the article did not originate from a French-speaking country (member of the Francophonie organization). CONCLUSION: Adhesion to modern scientific medical writing rules increased acceptance rates for articles in the European Annals of Otorhinolaryngology Head & Neck Diseases. Teaching modern scientific medical writing needs to be enhanced in otorhinolaryngology.

Chronic respiratory rhinitis: Toward endoscopic diagnosis of nasal allergy? An observational study.

OBJECTIVE: The study objective was to assess the functional, endoscopic and tomodensitometric semiology of a cohort of patients with chronic respiratory rhinitis (CRR). The concept of CRR is based on the anatomical, pathophysiological and semiological individualization of the respiratory nose within the sinonasal organ, in which three noses are distinguished by the parallel study of evolution and development in the "evo-devo" theory of the origins of the nose, anterior base of the skull and middle third of the face. MATERIAL AND METHOD: A single-center retrospective study included a cohort of 28 patients (16 men and 12 women, aged 19 to 69years) with CRR. The main objective was to describe symptoms clinically, endoscopically and on CT. The secondary objective was to compare clinical symptomatology and CT data between CRR and a control group of 31 patients with nasal polyposis (NP). The endoscopic semiology of CRR was analyzed consensually on video recordings using a pre-established grid. The DyNaChron self-administered questionnaire was used to compare symptom intensity and deterioration in quality of life. Olfaction was compared using the Sniffin' Sticks test. CT opacities were compared between CRR and NP on Lund-Mackay sinus score and a specific ethmoid opacities score. RESULTS: In CRR, endoscopy found a constant association of inflammatory or edematous signs in the inferior or middle turbinates with signs of hypersecretion. Ethmoid opacities in CRR were discrete and significantly smaller than in NP (P<0.0001), and were mainly located in the medial compartment in contact with the olfactory cleft (P<0.0001). Allergological assessment was positive in 17 of the 28 cases of CRR. Chronic nasal dysfunction was similar in CRR and NP, but olfactory impairment was significantly lower in CRR (P<0.0001). CONCLUSION: The CRR entity clinically resembles atopic central compartment disease. In both entities, endoscopy reveals inflammatory lesions restricted to the nasal cavities without significant ethmoid opacity on CT, an observation which seems to contradict the pathophysiological united airway concept.

From ethmoidal air cells to ethmoturbinal passages.

The concept of ethmoidal sinuses composed of ethmoidal air cells does not appear to fit with the embryological origin of the ethmoid. Post-natal formation of the paranasal sinuses, as visualized by MRI, appears to be fundamentally different from the embryological development of the ethmoid sinus. These two organs also appear to have very distinct functions: paranasal sinuses play a role in respiration and sanitization of the respiratory tract, while the ethmoid sinus plays a role in olfaction. However, human acquisition of bipedalism resulted in ethmoidal compartmentalization into olfactory clefts lined by olfactory mucosa and the ethmoidal labyrinth formed by a meshwork of ethmoturbinals that have lost their olfactory mucosa. Ethmoturbinals are septa that increase the surface area of olfactory mucosa in mammalian olfactory chambers. Embryological development of the human ethmoid sinus can be seen as the result of curved stacking of ethmoturbinal septa forming passages. Surgically, these passages can be accessed via the middle, superior and supreme meati. An ethmoidectomy technique following the ethmoturbinal passages can therefore be described. This structure of the ethmoidal labyrinth is both useful and necessary for the teaching of ethmoidal surgery.

Do the upper lateral nasal cartilages exist? The concept of septolateral cartilages.

BACKGROUND: In the cartilaginous nose, classical surgical anatomy describes 2 triangular upper lateral cartilages (ULCs) framing the lateral sides of the mid-third of the nasal pyramid, which articulate with to the superior edge of the quadrangular cartilage (QC) of the nasal septum. This anatomic arrangement in 3 distinct cartilage parts is, however, controversial. OBJECTIVE: The present study aimed to describe the articulation between the ULCs and the QC, avoiding dissection artefacts. MATERIALS AND METHODS: Six nasal pyramids were taken in monobloc from fresh cadavers and imaged on micro-MRI with 0.4mm slice thickness. Images were interpreted jointly by 2 head and neck surgeons and a radiologist. RESULTS: The cartilage skeleton supporting the mid-third of the nasal dorsum in all specimens presented as 2 septal plates backing onto the midline and curving on either side to form a continuous dome under the inferior aspect of the piriform aperture. CONCLUSION: Like the alar cartilages framing the tip of the nose, there are two continuous septolateral cartilages (SLCs) framing the mid-third of the nasal pyramid, likewise showing 2 cruras, medial and lateral, joined in a dome. The SLCs (also known as triangular cartilages) thus cannot be separated as 2 individual anatomic structures. These findings are in line with the shared embryological origin of all the elements composing the fibrocartilaginous nose in evo-devo theory.

Statistics in scientific articles published in the European Annals of Otorhinolaryngology Head & Neck Diseases.

OBJECTIVES: To evaluate biostatistics in scientific articles published in the European Annals of Otorhinolaryngology Head & Neck Diseases. MATERIALS AND METHODS: Retrospective analysis of 76 scientific articles published in 2018 and 2019. The main goal was to describe the percentage of articles using biostatistics and to explore for potential associations with the article's main characteristics. Secondary goals were, within the group of articles using statistical tests, to describe the type of statistics used, the assessment of normality in case of comparison of mean values, the p-value threshold for significance, the use of confidence intervals, and power analysis. RESULTS: Statistics were used in 73.7% of articles, without any significant association with main characteristics. Within the group of articles using statistics, the tests used were parametric, non-parametric and not specified in 77.7%, 51.4% and 1.8% of cases, respectively. Normality was checked in 14.2% of article using parametric tests to evaluate mean values. The p-value significance threshold was set at .05, .01, .005 levels and not defined in 60.7%, 1.8%, 1.8% and 35.7% of articles, respectively, while confidence intervals and power analyses were documented in 10.7% and 5.3%, respectively. CONCLUSION: This article underlines the need for better use of statistics in the European Annals of Otorhinolaryngology Head & Neck Diseases, to improve the quality of scientific articles published in the organ of written expression of the French and International French-speaking Societies of Otorhinolaryngology, and to support the ongoing move toward better medical science.

Septorhinoplasty by disarticulation.

Septorhinoplasty by disarticulation is an esthetic and functional solution for naturally occuring nasal pyramid dysmorphia, releasing the anatomic traces of growth-related stresses. Disarticulating the septolateral cartilage from its bony framework via a closed approach to the septal pocket is associated to Rethi's external approach in order to disarticulate the fibrocartilaginous nasal dorsum, while conserving its integrity, under the bony dorsum. The bony pyramid is then disarticulated down to the nasion, after resecting any bone hump, by 2 paramedian and 2 low lateral osteotomies in the basal groove. The lateral sides of the bony pyramid are then fractured at their posterior edges by percutaneous pinching to close the open roof and realign them along the midline. The septolateral cartilage, reduced as necessary at the inferior and anterior edges, is thereafter repositioned on the premaxillary bone. Traction on its anterior edge restores rectilinear frontal and lateral tension in the fibrocartilaginous dorsum, fully conserved from its attachment to the nasion. This technique corrects any septal deformity and restores frontal and lateral dorsum straightness.

Simulation-based training in endoscopic endonasal surgery: Assessment of the cyrano simulator.

PURPOSE: Endoscopic endonasal surgery requires many skills: a learning program was developed with progressive steps, on a surgical simulator (Cyrano) designed to train junior surgeons in the acquisition of basic endoscopic surgery skills and to assess their progress. The main objective of this study was to establish the construct validity of these exercises and to refine objective criteria to establish students' level. MATERIAL AND METHODS: Thirty volunteers with varying experience in endoscopic endonasal surgery were blindly evaluated on 4 modules according to objective and subjective criteria. RESULTS: Ten beginner, 11 intermediate and 9 expert level participants were included. For each exercise, at least one criterion was discriminant for level of expertise. Weighted scores succeeded in discriminating groups. Interpretation of a single criterion must remain cautious and evaluation should rather rely on composite scores, which better reflect the participants' level. Useful criteria and their reference values are specific of each exercise. Face and content validity were rated at 3.92/5 and 4.59/5 respectively (5-level Likert scale). CONCLUSION: The construct/face/content validity of the proposed modules have been verified. Most of the modules tested here were physically not realistic, but they were all rated as highly relevant for surgical training by the participants.

The relationship between spontaneous cerebrospinal fluid leak and idiopathic intracranial hypertension.

Surgical treatment of spontaneous cerebrospinal fluid (CSF) leak is now performed by ENT surgeons, endonasal endoscopy being preferred to craniotomy as less invasive. However, it is often the symptom of underlying idiopathic intracranial hypertension, which lies outside the traditional sphere of ENT competence. Surgery is a necessary step, but should not obscure the need to treat the underlying pathology. This treatment is complex, and requires multidisciplinary team-work between otorhinolaryngologist, ophthalmologist, neurologist, neurosurgeon, radiologist, dietician, endocrinologist and psychotherapist. The present update details this multidisciplinary management to which the ENT surgeons must be attentive before and after spontaneous CSF leak repair.

Septoplasty by disarticulation.

The difficulty of correcting nasal septum deformities using the classical Killian or Cottle techniques or derivatives has led in recent years to new suggestions such as extracorporeal septoplasty or various apposition grafts to counteract refractory deformity of the quadrangular cartilage. Naturally occurring septal deformities result from conflicts in growth between the quadrangular cartilage, perpendicular ethmoidal plate and vomer, which each have their own different evo-devo origin. Septoplasty by disarticulation consistently restores a level septum by completely resolving the growth conflicts. Conserving the quadrangular cartilage is essential for the stability of the nasal pyramid on condition that 1) the lateral flare of the superior edge of both the component septolateral cartilages that suspend it at the roof of the piriform orifice and 2) the height of its anterior edge are respected. The anterior edge is always high enough (except in case of fracture or malformation to project the retrolobular nasal dorsum in proportion to the height of the alar cartilage when it is repositioned on its natural premaxillary base.

COVID-19 and rhinology, from the consultation room to the operating theatre.

The purpose of this article is to give rhinologists advice on how to adapt their standard practice during the COVID-19 pandemic. The main goal of these recommendations is to protect healthcare workers against COVID-19 while continuing to provide emergency care so as to prevent loss of chance for patients. We reviewed our recommendations concerning consultations, medical prescriptions and surgical activity in rhinology.

Spontaneous arytenoid dislocation and crico-arytenoid instability.

INTRODUCTION: Arytenoid dislocation is a rare occurrence, for which the pathophysiology is still unclear. METHODS: We report here an unusual case of spontaneous arytenoid dislocation, which casts doubts on the prevailing classical theory of hemarthrosis. RESULTS AND CONCLUSIONS: This case and a review of the literature suggest that arytenoid dislocation could be linked to congenital or acquired arytenoid instability, thus facilitating arytenoid dislocation after even minor trauma. Once the diagnosis is established, we recommend to first attempt reduction, followed by speech therapy, though underlying diseases should be researched.

Is palato-premaxillary subduction a characteristic of Binder's syndrome?

OBJECTIVES: Binder's syndrome is a rare malformative syndrome, defined clinically. CT study of a patient with this morphotype found palato-premaxillary joint subduction on a sagittal slice. The objective of the present study was to analyze this joint in a control population free of Binder's syndrome. MATERIAL AND METHODS: Fifty adult Caucasian patients who had undergone sinus CT scan between 2013 and 2016, showing normal nasolabial angle and with good visualization of the palato-premaxillary joint on a single sagittal slice, were selected. Joint analysis by 3 observers classified the patients in 2 groups: A, showing approximation between primary and secondary palate, and S, showing subduction. Alongside the observers' subjective analysis, the following parameters were compared: posterior palato-premaxillary angle (A1), superior palato-premaxillary angle A2, and the distance (d) of the premaxilla above the secondary palate. RESULTS: Fifty patients were included: 43 in group A and 7 in group S. A1 angle differed significantly between groups: 111.95±10.22° in group A, versus 130.53±10.0° in group S; P=0.0015. Values for A2 and d did not differ according to group. CONCLUSION: Two forms of palato-premaxillary joint, showing approximation or subduction, were found in the control population. Approximation was more frequent. Palato-premaxillary subduction does not in itself characterize Binder's syndrome.

Maxillary sinus pain with radiolucent sinuses due to agenesis of the membranous ostium.

INTRODUCTION: The absence of opacities on CT scan usually eliminates paranasal sinus disease as a cause of facial pain. The authors report a case, which constitutes an exception to this general rule, corresponding to a new aetiology of sinus pain. CASE REPORT: A 16-year-old boy presented with very painful "recurrent acute sinusitis" triggered by pressure changes (altitude, diving, surfing), with no sinus opacity on CT scan. Surgical exploration demonstrated absence of a primary or accessory maxillary ostium. Middle meatus antrostomy relieved the patient's pain. DISCUSSION: The pathophysiology of this case of recurrent acute pseudo-sinusitis and the efficacy of antrostomy can be explained by the evo-devo theory of the origin and function of the paranasal sinuses. This case illustrates the absence of communication in the ethmoid of the membranous sac lining the maxillary sinus, formed by degeneration of the maxillary erythropoietic bone marrow. Under stable environmental conditions, the continuous production of nitric oxide by the sinus epithelium is eliminated by simple transmembrane diffusion, but is insufficiently eliminated in the case of rapid pressure changes, inducing sometimes very severe sinus pain, mimicking sinusitis. This case report paves the way for more detailed studies on the role of the paranasal sinuses in facial disease and respiratory physiology.

Intestinal and non-intestinal nasal cavity adenocarcinoma: Impact of wood dust exposure.

The aim of the present study was to investigate the role of wood dust exposure in intestinal (ITAC) and non-intestinal type (non-ITAC) nasal adenocarcinoma, so as to improve understanding of the oncogenic mechanisms in the light of the recent literature and of evo-devo concepts. MATERIALS AND METHODS: All consecutive patients operated in our institution for nasal adenocarcinoma diagnosed on anatomopathology between May 2004 and February 2014 were included. Surgical specimens were examined twice by independent pathologists, blind to wood dust exposure status. Clinical and demographic data, including wood dust exposure, were collected for the two groups (ITAC and non-IATC). RESULTS: 90 patients (84 ITAC, 6 non-ITAC) were included. No non-ITAC patients had history of wood dust exposure, versus 83/84 cases (99%) in ITAC (mean exposure duration: 30±16 years; range 2-65 years). Only 12 ITAC patients (18%) were still exposed at diagnosis. ITAC may develop long after the end of wood dust exposure (up to 60 years). Eight patients (12%) had exposure durations of less than 5 years. Latency between onset of exposure and onset of disease did not decrease with exposure duration. CONCLUSION: Exposure to wood dust, even for short periods of time, incurs a risk of developing ITAC, usually after a long latency period. Any exposure requires lifetime follow-up, to ensure prompt treatment. Factors leading to the development of nasal ITAC and non-ITAC are probably different. The analogy with Barret's esophagus and esophageal adenocarcinoma may shed light on the oncogenesis of nasal ITAC.