Velopharyngeal function after free thoracodorsal artery perforator flap in lateral and superior oropharyngeal cancer.

The purpose of this study was to report our experience with the free thoracodorsal artery perforator flap for reconstruction of the oropharynx and soft palate in head and neck cancer using a retrospective review of the medical charts of all patients undergoing oropharyngeal reconstruction by free thoracodorsal artery perforator flap during the same procedure as cancer resection between January 2011 and April 2013. Evaluation of speech, feeding and the presence of nasal emissions was performed 6 months after treatment in accordance with the Declaration of Helsinki. Nine patients were evaluated. Clear understanding of the patient was reported by the family and the examiner for seven patients, while understanding difficulties were reported for two patients (1 case of flap dehiscence and 1 technical error of flap fixation). The results indicated that, due to its complex anatomy and function, reconstruction of the soft palate remains a delicate procedure. The free thoracodorsal artery perforator flap allows functional soft palate reconstruction, while limiting donor site morbidity.

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

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

OSAS and upper pharynx surgery: Does basilingual collapsus always rhyme with failure?

OBJECTIVE: Drug-induced-sedation endoscopy (DISE) has proved superior to awake clinical examination for diagnosis of upper-airway obstruction sites and surgical planning. Our question is: does multilevel obstruction on DISE systematically entail failure for surgery limited to the upper pharynx? MATERIAL & METHODS: We conducted a retrospective single-center study in patients with obstructive sleep apnea syndrome (OSAS) treated by single-level surgery of the upper pharynx (tonsillectomy with or without pharyngoplasty). Preoperative assessment included polysomnography (PSG) and DISE. Surgical efficacy was assessed on postoperative PSG. Treatment response was defined by postoperative apnea-hypopnea index (AHI) <20 events/h with 50% reduction, and cure by AHI <10 (patients with preoperative AHI ≤10 being excluded). Efficacy was compared between groups without (group A) and with basilingual or laryngeal collapsus on DISE (group B). RESULTS: We analyzed 63 patients, with mean preoperative AHI 33.8±17.9 events/h. The two groups (A, n=36; B, n=27) were clinically comparable. Postoperative PSG took place at a mean 8.5 ± 11.5 months. The success rate was 66.7% in group A (mean reduction in AHI, 57.3±36.2%) and 59.3% in group B (mean reduction, 53.9±39.2%). Cure rates were respectively 48.5% and 48.1%. There was no statistically significant difference between the two groups (P>0.1). CONCLUSIONS: Oropharyngeal surgery can alleviate associated obstructive sites found on DISE in the lower pharynx, and step-by-step treatment shows efficacy equal to that of single-step multilevel surgery.

Does advanced age affect treatment of early glottic carcinoma?

AIMS: Early glottic carcinoma is currently managed by radiation therapy or endoscopic surgery. Both are effective in elderly patients, but their respective indications are poorly determined. The present study assessed our management of very elderly patients with early glottic carcinoma. MATERIAL AND METHODS: A retrospective single-center study included all patients aged 75 years and older at diagnosis, treated by radiation therapy or endoscopic surgery with curative intent for T1 or T2 glottic carcinoma between 2004 and 2018. RESULTS: Records of 33 patients (27 men and 6 women; mean age, 82.2 years (range, 76.1-93.1 years)) were reviewed. 24 patients received radiation therapy and 9 endoscopic resection. The only factor for choice of treatment was anterior commissure involvement. Overall survival was 87% at 2 years and 62% at 5 years. 19% of patients relapsed within 5 years and had to undergo further treatment. There were no treatment-related deaths. Radiation therapy was associated with more acute local complications, with two temporary treatment interruptions and one uncompleted treatment. Surgical treatment was more likely to result in dysphonia, found in 80% of cases. CONCLUSION: Treatment of early glottic cancer in elderly subjects can consist in either radiotherapy or endoscopic surgery. Age should not affect management. Surgical treatment is shorter and better tolerated, although with poorer vocal outcome, and may be preferred in the most comorbid patients.

[Subperiostal orbital hemorrhage induced by effort for vomiting]. / Hémorragie sous-périostée orbitaire après un effort de vomissement.

UNLABELLED: Subperiostal orbital hemorrhage is a rare condition. It usually occurs as a result of trauma or because of a vascular disorder. We present a case of subperiostal orbital hemorrhage induced by effort for vomiting. CASE: A 41-year-old pregnant patient (30 weeks of amenorrhea), with no prior history, was referred to the ENT emergency by her gynecologist for unilateral ptosis and proptosis secondary to efforts for vomiting. Clinical examination and CT scanner showed a subperiostal hematoma of the orbital roof. The hematoma resolved in ten days without sequels, under simple surveillance. DISCUSSION: Non-traumatic subperiostal orbital hemorrhage remains rare. Clinical examination and orbital CT scan allow making the diagnosis. If the optic nerve is not compressed, clinical surveillance during hematoma resorption is sufficient.

Effect of sleeping alone on sleep quality in female bed partners of snorers.

The aim of the present study was to objectively measure the effect of sleeping alone for one night on sleep quality in female bed partners of male snorers. Females complaining of poor sleep due to snoring by their bed partner and having no known hearing loss or snoring were included in a prospective multicentre cross-sectional study. 23 females underwent one polysomnography recording while sleeping with their bed partner and another while sleeping alone. Their sleep parameters were compared between the two nights. We excluded seven couples because the female partner snored for >10% of the sleep time (n = 6) or had obstructive sleep apnoea syndrome (n = 1). In the remaining 16 females, sleep time, sleep efficiency, arousal index and percentages of deep sleep (stages 3-4) and rapid eye movement (REM) sleep were not significantly different between the two nights. Percentages of light sleep (non-REM stage 2) and awakening index were lower when sleeping alone (p = 0.023 and p = 0.046, respectively). Sleep quality was decreased and sleep fragmentation increased in females sleeping with male snorers. Some females had unrecognised snoring. However, our data do not suggest that objective sleep quality improves substantially in the female nonsnoring partner when she sleeps alone for one night.

Surgical ablation of lingual tonsils in the treatment of obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: The retrolingual space is one of the potential sites of obstruction identified in patients with obstructive sleep apnea syndrome (OSAS). Hypertrophied lingual tonsils (LT) can obstruct the airway at this level. The goal of this study was to measure the tolerance and efficacy of lingual tonsillectomy in patients with OSAS. STUDY DESIGN: A retrospective chart review was conducted recruiting all patients with OSAS confirmed on sleep recording, who either had failed or refused medical treatment and who underwent lingual tonsillectomy. MATERIALS AND METHODS: Diagnosis of LT hypertrophy was made by full ENT clinical examination using a flexible endoscopy, completed by MRI and followed by drug-induced sleep endoscopy. The surgical intervention was carried out endoscopically by diode laser or coblation. The primary endpoint to measure efficacy was drop in apnea-hypopnea index (AHI) on sleep recording at 6 months. Secondary endpoints comprised reduced snoring and Epworth Sleepiness Scale (ESS) and postoperative symptom tolerance. RESULTS: Eleven patients aged 44.3±12.6 years were included. AHI dropped from 29.5±21.7/h to 11.6±9.6/h: i.e., by 60% (P=0.005). Five patients had AHI<10/h: i.e., cure rate of 45%. ESS dropped from 13±3.4 to 8.1±4.9 (P=0.012). No complications were observed. CONCLUSIONS: LT ablation seemed effective in OSAS with retrolingual obstruction in failure of medical treatment. LEVEL OF EVIDENCE: 4.

Prefabricated fibula free flap with dental implants for mandibular reconstruction.

Free fibula transplant is routinely used for mandibular reconstruction in head and neck cancer. Dental rehabilitation, the objective of mandibular reconstruction, requires the use of dental implants as supports for fixed or removable dentures. Positioning of fibular bone grafts and implants determines implant osseointegration and the possibilities of dental rehabilitation. Prefabrication of a fibula free flap with dental implants prior to harvesting as a free flap can promote implant osseointegration. The position of the implants must then be precisely planned. Virtual surgery and computer-assisted design and prefabrication techniques are used to plan the reconstruction and then reproduce this planning by means of tailored fibula and mandible cutting guides, thereby ensuring correct positioning of fibular bone fragments and implants. The prefabricated fibula free flap technique requires two surgical procedures (prefabrication and flap transfer) and precise preoperative planning. Prefabricated fibula free flap with dental implants, by improving the quality of osseointegration of the implants before flap transfer, extends the possibilities of prosthetic rehabilitation in complex secondary mandibular reconstructions.

International consensus (ICON) on the ENT role in diagnosis of obstructive sleep apnea syndrome.

During the 2017 IFOS ENT World Congress, an international expert panel was asked to clarify the role of ENT in the diagnosis process of the obstructive sleep apnea syndrome (OSA) in adults around the world. OSA is a major public health issue throughout the world. OSA is a highly prevalent disease with heavy clinical, social and economical outcomes. This high prevalence raises serious difficulties of diagnosis accessibility if only somnologists are able to confirm OSA diagnosis. First of all, the panellists reviewed the impact of OSA. Secondly, they defined the ENT role stressing ENT legitimacy, professional expertise and academic and institutional tasks. They also defined when somnologists were necessary. For the international panel, the ENT is a major player in the OSA diagnosis process.

Drug-induced sleep endoscopy: A new gold standard for evaluating OSAS? Part I: Technique.

Surgical results in obstructive sleep apnea syndrome (OSAS) vary greatly, whatever the surgical technique or site treated. Most authors agree that rigorous patient selection is logical and mandatory. Drug-induced sleep endoscopy (DISE) was introduced in 1991 and has been rediscovered and used extensively since the 2000s. It mimics sleep in order to observe the upper airway on flexible endoscopy. A review of the DISE literature was performed, and is reported in two parts. The present first part describes the technique: drugs, practical anesthesiologic and ENT modalities, reproducibility, and limitations.

Drug-induced sleep endoscopy: A new gold standard for evaluating OSAS? Part II: Results.

Surgical results in obstructive sleep apnea syndrome (OSAS) vary greatly, whatever the surgical technique or site. Most authors agree that rigorous patient selection is logical and mandatory. Drug-induced sleep endoscopy (DISE) was introduced in 1991 and has been rediscovered and used extensively since the 2000s. It attempts to mimic natural sleep in order to observe the upper airway on flexible endoscopy in a situation in which obstruction may occur. A review of the DISE literature was performed, and is reported in two parts. The present second part reports DISE results concerning obstruction sites, impact on treatment efficacy and the consequent indications for this exploration.

Supraclavicular artery island flap in head and neck reconstruction.

Due to the complex anatomy of the head and neck, a wide range of pedicled or free flaps must be available to ensure optimal reconstruction of the various defects resulting from cancer surgery. The supraclavicular artery island flap is a fasciocutaneous flap harvested from the supraclavicular and deltoid regions. The blood supply of this flap is derived from the supraclavicular artery, a direct cutaneous branch of the transverse cervical artery in 93% of cases or the supraclavicular artery in 7% of cases. The supraclavicular artery is located in a triangle delineated by the posterior border of the sternocleidomastoid muscle medially, the external jugular vein posteriorly, and the median portion of the clavicle anteriorly. This pedicled flap is thin, malleable, and is easily and rapidly harvested with a reliable pedicle and minimal donor site morbidity. It can be used for one-step innervated reconstruction of many types of head and neck defects. It constitutes an alternative to local flaps, while providing equivalent functional results and must be an integral part of the cancer surgeon's therapeutic armamentarium.

Extranodal lymphoma of the head and neck: a 67-case series.

UNLABELLED: The present study sought to describe clinical presentation in extranodal lymphoma of the head and neck (ELHN), with the aim of improving diagnostic management. MATERIAL AND METHODS: A single-center retrospective observational study was conducted over the period 2001-13. Age, gender, histologic type, location, type of clinical presentation, time interval between symptom onset and histologic diagnosis and presence of specific symptoms were recorded, as were the specialty of the physician initially consulted and of the physician taking the diagnostic sample. RESULTS: Sixty-seven cases of ELHN were diagnosed: 39 male and 28 female patients, with a median age of 68 years. B-cell lymphoma (84%) was more frequent than plasmacytoma (7%) or T-cell lymphoma (6%). Location was mainly palatine tonsil (28%), nasal fossa and sinus (19%), nasopharynx (14%) or parotid (13%). Revelation often involved a mass (33%), and only rarely any specific symptoms (9%). Time interval from symptom onset to diagnosis was short in aggressive lymphoma and longer in low-grade lymphoma (mean 4 and 10 months respectively). The physician initially consulted was an ENT specialist in 67% of cases, and an ENT specialist performed diagnostic sampling in 97% of cases. CONCLUSION: ELHN is a rare pathology (5 cases per year in our department) of highly variable clinical presentation depending on location and histologic type. The ENT physician should be prepared for diagnosis regardless of anatomic location, so as to optimize diagnostic management.

Comparison of radial forearm flap and thoracodorsal artery perforator flap donor site morbidity for reconstruction of oral and oropharyngeal defects in head and neck cancer.

INTRODUCTION: Reconstruction of the oral cavity and oropharynx after tumour resection often involves the use of free flaps, but donor site morbidity must be taken into account. The radial forearm flap, the flap most commonly used in this setting, leaves a readily visible scar on an exposed region of the body. The thoracodorsal artery perforator flap (TDAP), which possesses the same plastic qualities as the radial forearm flap, leaves a scar that is hidden in the axilla. The purpose of this study was to evaluate the cosmetic results of radial forearm and thoracodorsal artery perforator free flap donor sites. MATERIAL AND METHODS: The medical charts of all patients undergoing reconstruction by a radial forearm or thoracodorsal artery perforator free flap between January 2011 and December 2011 were retrospectively reviewed. The Patient and Observer Scar Assessment Scales and the Vancouver Scar Scale were used to evaluate the quality of the scars. RESULTS: Reconstruction was performed by radial forearm flap in 4 cases and TDAP flap in 7 cases. The PSAS score was significantly lower in the TDAP group than in the radial forearm group (P=0.03), and the OSAS score was higher in the radial forearm group (21.5 versus 14). The Vancouver Scar Scale was significantly higher for radial forearm flap scars than for TDAP scars (8 versus 2.7, P=0.005). CONCLUSION: This is the first study to compare radial forearm and thoracodorsal artery perforator free flap donor site scars. It demonstrates the minimal TDAP donor site morbidity and the high level of patient satisfaction.

Tongue base reduction with hyoepiglottoplasty: a treatment for severe obstructive sleep apnea.

OBJECTIVE: To describe a surgical procedure for the treatment of severe obstructive sleep apnea syndrome (OSAS), the procedure's indications, and its results. STUDY DESIGN: A retrospective study of 10 male patients with OSAS treated by tongue base reduction with hyoepiglottoplasty (TBRHE) at the Foch Hospital (Suresnes, France) between 1994 and 1997. Patients had a mean body mass index (BMI) of 32 kg/m2, a mean respiratory disturbance index (RDI) of 70 events/h, and a mean minimal oxygen saturation of 78%. They had refused positive airway pressure therapy or wished to discontinue it. METHODS: Subtotal tongue base reduction preceded by lingual neurovascular bundle identification and derouting, epiglottal verticalization, mouth floor horizontalization, and hyoid bone repositioning was performed, associated in some cases to uvulopalatopharyngoplasty (UPPP). Indications were based on a site-related obstruction, on the absence of craniofacial deficiencies, and on the presence of hyolingual abnormalities determined by cephalometry and magnetic resonance imaging. RESULTS: TBRHE associated to UPPP in most cases had an 80% success rate, based on a postoperative RDI below 20 events/h and a reduction of the preoperative RDI of more than 50%. Snoring and excessive daytime sleepiness decreased or disappeared, respectively, in 100% and 90% of the cases. No neurovascular complications occurred. CONCLUSION: TBRHE is a safe procedure for the neurovascular bundle. Associated to a pharyngotomy, it is an effective treatment for severe OSAS attributable to tongue base obstruction. These results require confirmation in a larger series of patients.

[Efficacy of uvulopalatopharyngoplasty (UPPP) and modifications in sleep structure in the sleep apnea syndrome (SAS)]. / Efficacité de l'uvulopalatopharyngoplastie (UPPP) et modifications de la structure du sommeil dans le syndrome d'apnée du sommeil (SAS).

Thirty-four patients (32 male, 2 female; mean age 53 +/- 7 years) with confirmed sleep apnea syndrome (SAS) were studied before and after uvulopalatopharyngoplasty (UPPP). Clinical symptoms were tiredness, excessive daytime sleepiness and snoring. All patients were overweight. Patients underwent a thorough physical and oropharyngeal examination and polysomnography before and 3 months after surgery. On the basis of post-operative results, patients are divided into 3 groups: --group 1: 16 cured patients: apnea index (A.I./h) 38 +/- 17 before and 4.4 +/- 4 apneas/h sleep after surgery. Improved nocturnal hypoxemia: mean minimum oxyhemoglobin saturation (SAO2) before and after UPPP in NREM sleep 83 +/- 4% v. 90 +/- 4% in REM sleep 76 +/- 11% v. 85 +/- 7%. Uninterrupted sleep is restored; --group 2: 8 improved patients: A.I./h of 64 +/- 11 before and 20 +/- 6 after UPPP: improved nocturnal hypoxemia: mean minimum SAO2 in NREM sleep 74 +/- 10% before and 86 +/- 6% after UPPP: in REM sleep 59 +/- 9% before and 79 +/- 6% after UPPP, lower amount and percentage of fragmented sleep; --group 3: 10 non-improved patients: A.I./h unchanged 55 +/- 22% before and 50 +/- 20% after UPPP. Persistent nocturnal hypoxemia: mean minimum SAO2 in NREM sleep 76 +/- 13 before and 81 +/- 12% after UPPP: in REM sleep 63 +/- 16% before and 65 +/- 24% after UPPP. Sleep remains fragmented. In this last group patients are more overweight and all suffer from severe SAS with greater nocturnal oxyhemoglobin desaturation. Surgical treatment by UPPP is shown to be effective for 70% of our patients. Better results are obtained when SAS is less severe and overweight less important.

The Chorimac 12. A multichannel intracochlear implant for total deafness.

In all of our cases, phonetic discrimination has been obtained without the help of lip-reading. Speech intelligibility is generally better in postlingual deafness that in prelingual deafness. We believe this method, despite the size of the external transmitter, is best for rehabilitation of totally deaf patients.

The velo-impedancemetry. A new technique for dynamic study of soft palate.

Using a slightly modified electro-glottograph, we designed a device for the registration of soft palate movements. Correlating such curves with corresponding phonogram and physio-pathological data, we have been able to define an iconographic semiology, which may be useful in the functional pathology of the soft palate and indications of uvulo-pharyngoplasty for snoring.

Efficacy of fusafungine in acute rhinopharyngitis: a pooled analysis.

Upper respiratory tract infections are generally mild but they are associated with an enormous loss in productivity. Treatment consists of reduction of local symptoms e.g. local inflammation and prevention of potential superinfections. Besides its bacteriostatic activity against most micro-organisms involved in respiratory tract infections fusafungine displays original anti-inflammatory properties. To optimise nasal and throat deposition, a new fusafungine oro-nasal spray using HFA 134a was developed and its efficacy was evaluated in patients with acute rhinopharyngitis based on improvement of significant nasal symptoms. Three randomised double-blind placebo-controlled parallel-group studies with identical objectives design and dosage were performed and results were pooled for a better evaluation of treatment effect (532 patients). The percentage of responders (patients with nasal symptom score improvement from Day 0 to Day 4) was 61.5 +/- 2.9% with fusafungine vs 46.8 +/- 3.1% with placebo (p=0.009) with an odds ratio of 1.8 (p=0.01) in favour of fusafungine. The nasal symptom score distribution at Day 4 showed an odds ratio of 1.56 (p=0.011) also in favour of fusafungine. For patients treated early (onset of symptoms 1 pounds day) the percentage of responders was 65.9 +/- 4.1% with fusafungine vs 38.3 +/- 4.0% with placebo (p=0.022) with an odds ratio of 3.08 (p=0.033) in favour of fusafungine. Therefore fusafungine through its dual bacteriostatic and original anti-inflammatory properties is an effective treatment of acute rhinopharyngitis especially when administered early.