Geriatric assessment and quality of life for 2 years in older patients with head and neck cancer.

Due to the location and toxicity of treatments, head and neck cancer (HNC) has a major impact on quality of life (QoL). Objectiveto assess the effects of geriatric-assessment (GA)-driven interventions on QoL over 2 years in older adults with HNC.EGeSOR was a randomized study of HNC patients aged ≥65, receiving a pretreatment GA, a geriatric intervention and follow-up (intervention) or standard of care (control). The primary endpoint was QoL score (EORTC QLQ-C30, QLQ-HN35) over 24 months.475 patients were included (median age: 75.3; women: 31%; oral cancer: 44%). QoL scores improved over 24 months with various trajectories, without significant differences between the groups. 74% of patients (interventional group) did not receive the complete intervention. Cancer characteristics, functional status, and risk of frailty were associated with change in the Global Health Status QoL score.There is a need to develop alternative model of implementation such as patient-centered healthcare pathways. TRIAL REGISTRATION: NCT02025062.

Curative high-dose reirradiation for patients with recurrent head and neck adenoid cystic carcinomas: outcomes and analysis of patterns of failure.

BACKGROUND: To investigate the outcomes of patients who underwent curative reirradiation (reRT), with intensity-modulated radiation therapy (IMRT) or proton therapy (PT) for unresectable recurrent or second primary head and neck adenoid cystic carcinoma (HNACC). METHODS: Ten patients, mostly KPS 90%, were reirradiated (3/10 with IMRT and 7/10 with PT) at a median maximum dose to the CTV of 64.2 Gy from July 2011 to November 2021. Locations at the time of reRT were mainly the sinus (4/10) and the salivary glands (including the parotid and submandibular gland, 3/10). CTCAEv5 was used to assess acute and late toxicities. Follow-up was the time between the end of reRT and the date of last news. RESULTS: The median time between the two irradiations was 53.5 months (IQR: 18-84). After a median follow-up of 26 months (range, 12.5-51.8 months), six patients had developed a locoregional recurrence (LR), of which four occurred within the previously irradiated volume. Two and three-year locoregional failure-free survival (LFFS) and overall survival (OS) were 55.6% [95%CI: 31-99.7%], and 41% [18.5-94%] and 66.7% [42-100%] and 44.4% [21.4-92.3%], respectively. LFFS and OS were significantly better in the subgroup of sinus tumors (p = .013) and the subgroup of patients re-irradiated more than two years after the first course of irradiation (p = .01). Seven patients had impairments before the start of reRT, including hearing impairment (3/10) and facial nerve impairment (3/10). The most severe late toxicities were brain necrosis (2/10), osteoradionecrosis (1/10) and vision decreased (1/10). CONCLUSION: Curative reRT for HNACC is possible for selected cases, but the LR rate in the irradiated field and the risk of severe toxicity remain high. Improved selection criteria and more carefully defined target volumes may improve outcome in these patients. A further study including larger cohort of patients would be useful to confirm these results.

Proton therapy and/or helical tomotherapy for locally advanced sinonasal skull base adenoid cystic carcinoma: Focus on experience of the Institut Curie and review of literature.

BACKGROUND: Sinonasal adenoid cystic carcinomas (SNACC) have high propensity for skull base (SB) infiltration. Unresectability or incomplete surgical resection in such cases make radiotherapy treatment paramount. Curative dose escalation is challenging because of adjacent organs at risk, especially in locally advanced cases. METHODS: Eighteen patients that had locally advanced SB SNACC with unresectable or incomplete surgical resection treated by proton therapy and/or helical tomotherapy at Institut Curie between 3/2010 and 8/2020 were retrospectively included. RESULTS: After median follow-up of 52 months, 5-year OS, LRRFS, DMFS, DFS rates were, respectively, 47% (95%CI: 26-83), 50% (95%CI: 36-88), 39% (95%CI: 26-81), 33% (95%CI: 22-73). One patient had grade 4 late optic nerve disorder. Eight patients had grade 3 late toxicity including mainly hearing impairments. CONCLUSION: Proton therapy and helical tomotherapy are effective and safe methods for curative dose escalation of locally advanced SB SNACC, which are a poor prognosis subgroup. Available literature suggests carbon-ion therapy could be an efficient alternative.

Effectiveness of Geriatric Assessment-Driven Interventions on Survival and Functional and Nutritional Status in Older Patients with Head and Neck Cancer: A Randomized Controlled Trial (EGeSOR).

This study assesses the efficacy of Geriatric Assessment (GA)-driven interventions and follow-up on six-month mortality, functional, and nutritional status in older patients with head and neck cancer (HNC). HNC patients aged 65 years or over were included between November 2013 and September 2018 by 15 Ear, Nose, and Throat (ENT) and maxillofacial surgery departments at 13 centers in France. The study was of an open-label, multicenter, randomized, controlled, and parallel-group design, with independent outcome assessments. The patients were randomized 1:1 to benefit from GA-driven interventions and follow-up versus standard of care. The interventions consisted in a pre-therapeutic GA, a standardized geriatric intervention, and follow-up, tailored to the cancer-treatment plan for 24 months. The primary outcome was a composite criterion including six-month mortality, functional impairment (fall in the Activities of Daily Living (ADL) score ≥2), and weight loss ≥10%. Among the patients included (n = 499), 475 were randomized to the experimental (n = 238) or control arm (n = 237). The median age was 75.3 years [70.4-81.9]; 69.5% were men, and the principal tumor site was oral cavity (43.9%). There were no statistically significant differences regarding the primary endpoint (n = 98 events; 41.0% in the experimental arm versus 90 (38.0%); p = 0.53), or for each criterion (i.e., death (31 (13%) versus 27 (11.4%); p = 0.48), weight loss of ≥10% (69 (29%) versus 65 (27.4%); p = 0.73) and fall in ADL score ≥2 (9 (3.8%) versus 13 (5.5%); p = 0.35)). In older patients with HNC, GA-driven interventions and follow-up failed to improve six-month overall survival, functional, and nutritional status.

Diode endovascular laser treatment in venous malformations of the upper aerodigestive tract.

PURPOSE: Venous malformations of the upper aerodigestive tract can cause pain, dysphagia, obstructive sleep apnea, and rarely bleeding. We studied 980-nm diode endovenous laser therapy. MATERIAL AND METHODS: This is a 2007-2014 retrospective study in our vascular anomalies center. Data on patients' clinical history, polysomnography, magnetic resonance imaging, and treatment were collected. Patients were contacted for Epworth Sleepiness Scale and Eating Assessment Tool (EAT-10) scores to evaluate sleepiness and dysphagia before and after laser therapy. RESULTS: We included 32 patients (mean age 41 years) presenting with obstructive sleep apnea (n = 18) and dysphagia (n = 13). With a mean follow-up of 39 months, average Epworth Sleepiness Scale score fell from 17.3 to 10.4 (p = 0.015), EAT-10 score from 8.2 to 3.5 (p = 0.002) and apnea-hypopnea index from 47.5 to 24.7 (p = 0.01). Of the sleep apnea patients, 89% required continuous positive airway pressure before and 50% afterward (p = 0.016). CONCLUSIONS: Diode endovascular laser treatment seems to be a safe and effective treatment option in venous malformations of the upper airways.

Value of systematic analysis of the olfactory cleft in case of cerebrospinal rhinorrhea: incidence of olfactory arachnoid dilatation.

To report on the presence of olfactory arachnoid dilatations (OAD), a previously undescribed radiologic feature of spontaneous cerebrospinal fluid (CSF) rhinorrhea originating from the cribriform plate of the ethmoid bone. The medical records of all patients treated between 2001 and 2011 at a tertiary care center for a spontaneous CSF rhinorrhea originating from the cribriform plate were retrospectively reviewed. The radiological work-up included high-resolution computed tomography and magnetic resonance imaging with at least the following sequences: T1, T2, and T2 with fast imaging employing steady state acquisition (FIESTA). Thirty cases were identified. The mean age at diagnosis was 49. Fourteen patients (47 %) had a body mass index (BMI) of 30 or more and 3 patients (10 %) had a BMI between 25 and 29.9. Five patients had a history of meningitis. The imaging work-up revealed a bone defect of the cribriform plate in 6 cases (20 %), associated to a typical meningocele in 14 cases (47 %). In ten patients (33 %), there was no defect of the cribriform plate, but ultrathin coronal T2-FIESTA sequences revealed an OAD, i.e. a dilatation of the arachnoid sheath of the olfactory fibers, in nine cases (30 %), or a "pseudo-polyp" outlined by a thin layer of arachnoid (1 patient, 3 %). Preoperative imaging should be carefully analyzed for the presence of OAD or "pseudo-polyp" in patients presenting with a CSF rhinorrhea without bony defect of the cribriform plate.

Petrous and sphenoid arachnoid cysts: diagnosis and management.

BACKGROUND: Intraosseous arachnoid cysts are rare and difficult to diagnose. The purpose of this study was to describe the clinical and radiological semiology of petrous and sphenoid arachnoid cysts and to propose a specific management strategy. METHODS: This was a retrospective, descriptive study of patients with arachnoid cysts, which utilized CT, MRI, and the patients' medical histories. RESULTS: Ten patients were included in this study. On CT, the lesions were lytic with bony delineation. On MRI, the lesions exhibited the same signals as cerebrospinal fluid and were not enhanced after contrast. On fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted sequences, the arachnoid cysts' signal disappeared, which is a key feature for eliminating the diagnosis of cholesteatoma. Two patients underwent surgery because of misdiagnosis, either with a meningocele or a cholesteatoma. CONCLUSION: MRI FLAIR and diffusion-weighted sequences, together with osseous CT scans, help to distinguish arachnoid cysts from meningoceles and avoid unnecessary surgeries with potential complications.

Critical analysis of recurrences of esthesioneuroblastomas: can we prevent them?

Esthesioneuroblastoma (ENB) involving the anterior skull base is a rare malignant tumour derived from the olfactory epithelium. The gold standard of surgical treatment is currently craniofacial resection (CFR), which allows efficient removal of the tumour but entails significant morbidity. To reduce morbidity combined with good visualization of tumour limits removal, endonasal endoscopy resection (EER) has developed. The objective of this work was (1) to describe the EER surgical procedure, the morbidity, and the limitations of this endoscopic approach as compared with CFR, (2) analyse recurrences to define risk factors of recurrences and (3) to discuss a therapeutic decision algorithm. Retrospective series of 18 patients with ENB endoscopically treated in a university tertiary referral centre over 13 years. Fifteen of those underwent radiotherapy. Epidemiological data, clinical and imaging findings, histology, treatment modalities and outcome of patients were studied. Mean follow-up was 31 months. Morbidity was mainly related to radiotherapy. Three recurrences were detected: one bone and one sylvian metastasis, and a local recurrence in a patient not irradiated. One recurrence spread through leptomeningeal propagation. Dural extension and frontal invasion were significantly associated with recurrences (p = 0.001 and p = 0.019, respectively). Patients with dural extension or frontal invasion should receive aggressive treatment. With a low rate of perioperative morbidity and efficient local control, EER seems to be a promising approach for selected cases of ENB.

Minimally invasive video-assisted thyroidectomy: tips and pearls for the surgical technique.

BACKGROUND: The objectives of this study were first to show principles of the minimally invasive video-assisted thyroidectomy (MIVAT), based on a video highlighting critical steps, and second to discuss tips and pearls to assist surgical teams that would like to start using this technique. METHODS: Based on a video, we described tips and pearls of a MIVAT. RESULTS: MIVAT includes 5 main steps: (1) skin incision and identification of the common carotid artery, (2) dissection and ligation of the upper pedicle, (3) identification of the inferior laryngeal nerve and parathyroid glands, (4) isthmectomy and lobe extraction, and (5) closure. DISCUSSION: Coordination between the surgeon and the 2 assistants is of paramount importance for the performance of MIVAT. Appropriate material is also required. The magnification and tissue contrast emphasizes the identification of the vessels, the superior and inferior laryngeal nerves, and parathyroid glands, on a large-view screen.

Comparison of 3 procedures for hypoglossal-facial anastomosis.

OBJECTIVE: We aimed to evaluate rehabilitation of complete facial palsy with 3 procedures for hypoglossal-facial anastomosis: end-to-end ("original"), partial end-to-end with interpositional jump grafting ("jump") and the new partial end to end without grafting ("modified"). METHODS: A medical jury reviewed videos of 36 patients with complete facial palsy who underwent surgery from 1998 to 2008 by original (n = 13), jump (n = 13), and modified (n = 10) procedures. The jury of 5 ear, nose, and throat surgeons who were blinded to the procedure evaluated rehabilitation by 3 facial nerve grading systems-House and Brackman (HB), Sunnybrook, and Freyss scales-and 3 subjective scores for the face at rest and during voluntary and emotional motions. RESULTS: Recovery time was shorter with the modified and original procedures than jump procedure (5, 6, and 8 mo, respectively). All patients achieved at least good results. Scores on the HB scale (I-VI) were mainly III. HB and Sunnybrook scores did not differ by procedure. Freyss score was better for the modified procedure than original and jump procedures. Scores for the face at rest did not differ by procedure, but those during voluntary and emotional movements were worse for the jump procedure than for other procedures. Synkinesis was more severe with the original procedure than other procedures. CONCLUSION: The 3 procedures give satisfactory results for rehabilitation after surgery for facial palsy. The original procedure should be performed in patients with strong mimic or long-standing facial palsy. The jump procedure is delicate and entails risk of weak reinnervation. The modified procedure is a good compromise in terms of muscle tone and side effects.

[Rhino-orbito-cerebral mucormycosis, surgical treatment, state of the art]. / Mucormycoses rhino-orbito-cérébrales - Traitement chirurgical, état de l'art.

Rhino-orbito-cerebral mucormycoses constitute a severe fungal infection. These infections mostly arise in immunosuppressed patients. The surgery aiming at resecting necrosed hurts showed its interest in term of survival for lung and cutaneous mucormycosis. However, treatment of rhino-orbito-cerebral location of mucormycosis is not well defined. Transnasal endoscopic surgery allows local control of the disease, better post-operative outcomes than transfacial approaches and less sequelae. However, transfacial approaches are sometimes necessary to allow cutaneous resection or exenteration, the indications of which still remain controversial. The retrospective study of 22 patients with mucormycosis allowed to show that radical surgical treatment allowed local control of the disease with an improved survival. Further prospective studies (PHRC MICCA, current) are required to standardize the management of this rare but potentially lethal pathology.

Surgical management of inverted papilloma: approaching a new standard for surgery.

BACKGROUND: Inverted papilloma surgery is currently performed primarily with an endoscopic approach, a technique that has a recurrence rate of 12%. However, a recent study reported a recurrence rate of 5% with a strategy based on subperiosteal dissection of the tumor, with limited indications for using an external approach. The aim of this work was to evaluate whether different teams using the same surgical concepts could reproduce the excellent results that were recently reported. METHODS: This study is a retrospective chart review of 71 consecutive patients with inverted papilloma who were treated during the last 10 years. RESULTS: In all, 80% of the patients were treated using a purely endoscopic approach. The mean follow-up period was 31.6 months. The recurrence rate was 3.3% for cases with at least a 12-month follow-up. CONCLUSIONS: This work confirms the results described in recent literature and further supports transnasal endoscopic surgery to manage inverted papilloma.

Ethmoid sinus osteoma: diagnosis and management.

BACKGROUND: Ethmoid sinus osteomas are uncommon, benign, osteogenic tumors. The purpose of this retrospective study was to describe their usual clinical presentation and to discuss their surgical management. METHODS: The medical records of 25 patients treated for ethmoid osteoma between March 2001 and December 2010 were retrospectively reviewed. RESULTS: The average tumor size was 18.5 ± 14 mm. Only 3 patients were asymptomatic, 14 had a history of frontal sinusitis (complicated with orbital cellulitis in 4 cases), and 4 patients presented with diplopia. An endoscopic approach was performed in 19 cases, a coronal approach in 4 cases, and a combined approach (endoscopic + coronal) in 2 cases. No recurrence was reported. CONCLUSION: Ethmoid sinus osteoma can be asymptomatic and detected incidentally on CT scans, but often causes frontal sinusitis and orbital complications. The endoscopic approach offers the possibility of safe removal with cosmetic advantages compared to coronal approach.

Minimally invasive video-assisted thyroidectomy: Learning curve in terms of mean operative time and conversion and complication rates.

BACKGROUND: The purpose of this study was to evaluate the learning curve for minimally invasive video-assisted thyroidectomy (MIVAT). METHODS: Fifty consecutive patients were prospectively included in groups corresponding to their surgical order (10 patients in each group). RESULTS: The mean operation times between 2 neighboring groups were 33.9 minutes longer in group 1 than in group 2 (p = .01) and 25.8 minutes longer in group 3 than in group 4 (p = .002). The conversion rate for technical difficulties in group 1 was 6% (3 of 50). The definitive complication rate was 2% (1 of 50). CONCLUSIONS: In terms of operative time, 10 patients represented the early stage of the learning curve, and 30 patients represented the number of procedures required to reach an advanced level of skill. Considering the low conversion and complication rates, improved aesthetic results and postoperative course, MIVAT should become a tool in the repertoire of high-volume thyroid surgeons.

Juvenile nasopharyngeal angiofibroma: does the external approach still make sense?

OBJECTIVE: The aim of this study was to review recent management of juvenile nasopharyngeal angiofibroma (JNA) in our institution during the past 10 years and to analyze the shift in surgical paradigm based on the rate of endoscopic approach and Radkowski staging. STUDY DESIGN: Case series with chart review. SETTING: The study was conducted from April 2000 to August 2010 in a tertiary care university hospital (Lariboisière, Paris, France). SUBJECTS AND METHODS: All patients referred for a JNA were included in the study. Medical files and imaging data were retrospectively analyzed. Surgical management was then evaluated for 2 different periods (group 1, n = 31, consecutive patients operated on from April 2000 to June 2005, and group 2, n = 41, from July 2005 to August 2010). RESULTS: Seventy-two patients were operated on, with a mean age of 16.25 years (range, 9-33 years). The rate of the endoscopic approach was significantly higher in group 2 than in group 1 (82.9% vs 45%). Rates of recurrence and complications were similar. Recurrences (ie, residual disease growing and treated by redo) were noted in 6 cases or 8.3% (group 1, n = 3; group 2, n = 3; P > .05). CONCLUSION: Progress in skull base anatomy, instrumentation, cameras, and surgical strategy allows for expansion of the indications for endoscopic removal of JNA. This approach may have a better outcome in terms of blood loss, hospital stay, and local sequelae. Still, an external approach should be considered only for selected cases due to massive intracranial extension or optic nerve or internal carotid artery entrapment by the tumor.

Endoscopy skull-base resection for ethmoid adenocarcinoma and olfactory neuroblastoma.

STATEMENT OF PROBLEM: Olfactory neuroblastoma (ON) and ethmoid adenocarcinoma (AC) are rare sinonasal malignancies that often involve the skull base. Standard surgical treatment is craniofacial resection (CFR), which allows for efficient removal but entails significant morbidity and mortality. Because expanded endoscopy nasal approaches are newly developed, we aimed to describe the procedure in patients with ON and AC and compare it with CFR in terms of efficiency and morbidity. METHODS: This work reports on a retrospective series of 16 patients with AC and ON treated endoscopically with anterior skull-base resection in a single institution over 9 years. Invasion of the frontal sinus, massive extension to the cerebral parenchyma, spread of the tumour above the orbits or lysis of anterior facial skeleton were contraindications for endoscopy resection. RESULTS: Of the 16 patients, 11 had AC and 5 ON. In total, 37.5% (6) exhibited skull-base invasion. All patients had postoperative radiotherapy. In the early postoperative period, one patient experienced delayed seizure due to a minor subdural hematoma. Two delayed complications were observed: one encephalocele related to inappropriate postoperative care, which required revision surgery, and one extended radionecrosis. Five-year disease-free survival was 83% and 5-year recurrence-free survival 58%. Local control rate was 91% for AC and 100% for ON. CONCLUSIONS: With low perioperative morbidity and efficient local control, ethmoidectomy combined with anterior skull-base resection is a promising approach for managing selected cases of AC and ON. These findings need further investigation with prolonged follow-up.

Unilateral rhinorrhea after translabyrinthine surgery due to parasympathetic hypersensitive syndrome: differentiation from cerebrospinal fluid leakage.

INTRODUCTION: Unilateral rhinorrhea after translabyrinthine surgery for vestibular or facial schwannoma usually suggests cerebrospinal fluid (CSF) leakage and requires specific measures, including revision surgery. OBJECTIVE: To draw attention to the possibility of postoperative unilateral rhinorrhea with concomitant hyperlacrimation and hypersialorrhea without a CSF origin and reflecting more a neuroplastic phenomenon. STUDY DESIGN: Retrospective study in a tertiary care center university clinic. PATIENTS AND INTERVENTION: For 1 case of intratemporal facial schwannoma and 2 cases of vestibular schwannoma, surgery was by a translabyrinthine approach with sacrifice of the facial nerve and hypoglossofacial anastomosis in the first case. Postoperative unilateral hydrorhinorrhea associated with various degrees of lacrimation and/or salivary hypersecretion occurred mainly during exercise or under stressful situations. CONCLUSION: With unilateral rhinorrhea after translabyrinthine surgery for vestibular or facial schwannoma, concomitant symptoms such as lacrimation or hypersialorrhea may not be explained by CSF leakage through the eustachian tube. Misinterpretation may lead to detrimental revision surgery. The pathophysiogenetic mechanism suggests a neuroplastic phenomenon involving a denervation hypersensitivity reaction of the autonomous system. A simple diagnostic test with a nasal anticholinergic agent may be beneficial.

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.