Consensus criteria for chronic rhinosinusitis disease control: an international Delphi Study.

BACKGROUND: Chronic rhinosinusitis (CRS) disease control is a global metric of disease status for CRS. While there is broad acceptance that it is an important treatment goal, there has been inconsistency in the criteria used to define CRS control. The objective of this study was to identify and develop consensus around essential criteria for assessment of CRS disease control. METHODS: Modified Delphi methodology consisting of three rounds to review a list of 24 possible CRS control criteria developed by a 12-person steering committee. The core authorship of the multidisciplinary EPOS 2020 guidelines was invited to participate. RESULTS: Thirty-two individuals accepted the invitation to participate and there was no dropout of participants throughout the entire study (3 rounds). Consensus essential criteria for assessment of CRS control were: overall symptom severity, need for CRS-related systemic corticosteroids in the prior 6 months, severity of nasal obstruction, and patient-reported CRS control. Near-consensus items were: nasal endoscopy findings, severity of smell loss, overall quality of life, impairment of normal activities and severity of nasal discharge. Participants’ comments provided insights into caveats of, and disagreements related to, near-consensus items. CONCLUSIONS: Overall symptom severity, use of CRS-related systemic corticosteroids, severity of nasal obstruction, and patient-reported CRS control are widely agreed upon essential criteria for assessment of CRS disease control. Consideration of near-consensus items to assess CRS control should be implemented with their intrinsic caveats in mind. These identified consensus CRS control criteria, together with evidence-based support, will provide a foundation upon which CRS control criteria with wide-spread acceptance can be developed.

European Position Paper on Rhinosinusitis and Nasal Polyps 2020.

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

EPOS2020: development strategy and goals for the latest European Position Paper on Rhinosinusitis.

BACKGROUND: The European Position Papers on Rhinosinusitis from 2005, 2007 and 2012 have had a measurable impact on the way this common condition with high impact on quality of life is managed around the world. EPOS2020 will be the latest iteration of the guideline, addressing new stakeholders and target users, presenting a summary of the latest literature and evolving treatment modalities, and formulating clear recommendations based on all available evidence. METHODOLOGY: Based on the AGREE II framework, this article demonstrates how the EPOS2020 steering group will address six key areas to ensure consistency in quality and presentation of information in the latest rhinosinusitis clinical practice guideline: scope and purpose; stakeholder involvement; rigour of development; clarity of presentation; recommendations and applicability; editorial independence. RESULTS: By analysing the guidance from AGREE II, we formulated a detailed development strategy for EPOS2020. We identify new stakeholders and target users and ratify the importance of patient involvement in the latest EPOS guideline. New and expanded areas of research to be addressed are highlighted. We confirm our intention to use mixed methodologies, combining evidence-based medicine with real life studies; when no evidence can be found, use Delphi rounds to achieve clear, inclusive recommendations. We also introduce new concepts for dissemination of the guideline, using Internet and social media to improve accessibility. CONCLUSION: This article is an introduction to the EPOS2020 project, and presents the key goals, core stakeholders, planned methodology and dissemination strategies for the latest version of this influential guideline.

Design and assessment of an anatomical diagram for sinonasal malignant tumour resection.

BACKGROUND: The aim of our work was to design and assess the comprehensibility of an anatomical diagram for recording surgical and pathological results after the removal of sinonasal malignant tumours by endoscopic endonasal surgery. METHODOLOGY: To create the first version of the diagram, we determined the functional and technical specifications for its use. The anatomical structures that appear on it were selected from the pathological reports of previous interventions. The comprehensibility of the diagram was tested by two successive multicentre labelling tests. Successive modifications led to the creation of a definitive version of the diagram. RESULTS: A diagram of the sinonasal cavities in exploded view was created from 47 selected anatomical structures. Labelling tests led to modifying the diagram by the overall restructuring and removal of the least recognized structures. In the labelling test of version 2, the mean global identification rate was 97.1 plus/minus 4.9% for 36 participants and all tested structures achieved a specific identification rate equal to or greater than 75%. CONCLUSIONS: This diagram of the sinonasal cavities is a comprehensible validated tool that allows the resection and invasion of sinonasal malignant tumours to be recorded. This three-dimensional diagram facilitates the understanding of the size, location and extensions of tumours. It may improve case presentations and communication in multidisciplinary team meetings.

External versus endoscopic approach in the management of 131 sinonasal inverted papillomas.

BACKGROUND: Incidence of inverted Papilloma (IP) is around 0.5% to 4% of all nasal tumours. It is characterised by its propensy for local invasiveness, recurrence and malignant transformation. The treatment of reference is surgery. The aim of our study was to compare our oncologic outcome and morbidity between the open and the endoscopic approach to remove inverted papillomas. MATERIAL AND METHOD: This retrospective study includes all primary and benign cases operated between 1985 and 2012. We assessed epidemiologic data, medical history, tumour location, morbidity of treatment, pathological outcomes, patient's follow-up and rate of recurrence. The mean time of surgery, of follow-up and recurrence delay were compared. RESULTS: 131 patients were included: 77 operated by lateral rhinotomy or mid-facial degloving and 54 by endoscopic approach (± associated with a limited Caldwell-Luc or a frontal incision). The mean time of surgery for the endoscopic approach was 76 ± 46 min (10-240 min) vs 163 ± 46 min (60-300 min) for the open approach (p< 10(-5)). The uncinate process was included in most of the IP (97/131; 74%), including its horizontal and/or vertical parts. The mean follow-up in endoscopic group was 43 ± 32 months (12-177 months) vs 73 ± 48 months (12-221 months) for the open approach group (p< 10(-4)). The recurrence rates are not significantly different for both groups: 9% (7/77) after open approach vs 7.4% (4/54) after endoscopic approach (p> 0.05). Also, the mean delay of recurrence was not different between both group (p> 0.05) and the propensy of recurrence didn't depend on the degree of dysplasia. There were fewer complications in the endoscopic group (13%) than in the open approach group (57%). CONCLUSION: According to several authors we found no statistical difference on the oncological outcome between surgery via open versus endoscopic approach to remove IP. Endoscopic surgery offers less complications and morbidity than external approach.

Respiratory epithelial adenomatoid hamartomas and olfactory function.

INTRODUCTION: Respiratory epithelial adenomatoid hamartoma can occur alone or associated with several diseases with very different pathological processes. Our hypothesis is that REAH is a non-specific reaction of the nose when olfaction is impaired. MATERIAL AND METHOD: This is a retrospective study including all patients with HERA operated in an academic ENT department. Data analysis focused on the pre and post-operative olfaction, corticosteroids consumption, histological results of the polyps, the evolution of the disease allowing a comparison of HERA with or without polyps and comparison of data literature. RESULTS: 28 patients suffered from REAH of which 18 are associated with polyps. Nineteen patients had inflammatory disease with a 9 year interval between initial diagnosis and surgery of REAH. Olfactory function was improved after surgery (p < 0.01). The cell content of the polyps showed eosinophilic infiltration in 8 patients which 6 were correlated with inflammatory disease. Lymphoplasmacytic infiltration was present in 10 patients which 8 were correlated with inflammatory disease. Nasal corticosteroid consumption decreased after surgery (p < 0.02). The mean follow-up after surgery was 34 ± 43 months. Polyp recurrence rate was 11% (3 patients), and 0% for REAH. CONCLUSION: In most cases, olfactory function, cellular infiltration and polyp recurrence rate are not correlated with the pathophysiological inflammatory processes that coincides with REAH. Therefore, the co-existence of nasal polyposis with REAH is probably overestimated.

Functional assessment of septo(rhino)plasty revision surgery.

INTRODUCTION: Functional septo(rhino)plasty incurs a 17-25% rate of revision for persistent symptoms. OBJECTIVES: The main study objective was to assess functional results before and after surgical revision. The secondary objective was to describe the shortcomings or excesses of the prior surgeries, with a-posteriori comparison of efficacy for the surgical techniques requiring revision. MATERIAL AND METHODS: A single-center retrospective study included functional salvage septo(rhino)plasties. Data comprised epidemiology, intraoperative anatomic abnormalities indicative of prior surgery, operative correction maneuvers, and pre- and post-intervention NOSE and RhinoQoL scores and satisfaction on VAS. RESULTS: Eighty-two patients were included. Anatomic abnormalities comprised deviated posterior septum (81.7%) and chondroethmoidal junction (58.5%), valve stenosis (54.9%), and obstructive boney spur or crest (46.3%). Prior surgeries comprised 33 submucosal resections, 29 septorhinoplasties, 14 Cottle septoplasties and 5 Killian procedures. Complete septoplasty was performed in 80% of cases, with associated maneuvers in 15%. All scores showed improvement taking the whole population together (P<10-5), but on subgroup analysis improvement concerned only revision of septorhinoplasty (P<10-4) and of submucosal resection (P<10-3), while 17% of patients showed no change in scores. CONCLUSION: Functional nasoseptal salvage surgery enables most patients to recover respiratory comfort, with the exception of a few cases despite a perfectly straight nasal septum.

[Feasibility study of septoplasties and septorhinoplasties in ambulatory surgery]. / Etude de faisabilité des septoplasties et septorhinoplasties en chirurgie ambulatoire.

OBJECTIVES: Feasibility assessment of septoplasty and septorhinoplasty as ambulatory procedures, from analysis of the activity of a university ENT department. METHODS: This is a retrospective analysis over 2 years. The demographic data, the distance between the patient's home and the ENT department, the cause of the septal deviation, the exact kind of surgery, the time of the beginning of the anaesthesia, the duration of the surgery, the postoperative data, the complications and the duration of hospitalization were collected. The operating durations were compared according to the sex, to the cause of the septal deviation, to previous surgery or not and to the kind of surgery performed, using Mann-Whitney's test. The correlations between the age, the operating duration and the time of the beginning of the anaesthesia were estimated using Spearman's test. Then, all the criteria of eligibility for an ambulatory surgical procedure were applied to this population, taking into account or not the distance between the patient's home and the ENT department. A financial analysis was realized on the eligible population, comparing the earnings for a traditional hospitalization with an ambulatory one. RESULTS: 424 patients were included, with an average age of 38 years old. 47 patients had an anaesthetic contraindication for the ambulatory surgery. 226 nasoseptal deviations were congenital (53.3%) and 198 post-traumatic (46.7%). 353 patients had never had a nasoseptal surgery (83.25%). The average time of the beginning of the anaesthesia was 10:55 am. The average durations were 75.8 +/- 32 min for septoplasty versus 127.5 +/- 44 min for the other acts (p < 10-5). There was a strong statistical difference of operating durations between a first surgery and a secondary surgical revision; as well as between a congenital cause and post-traumatic one (p < 10-5). There was an inverse correlation between the age and the operating duration (p < 10-4) and a correlation between the age and the time of the beginning of the anaesthesia (p < 10-5). 23 patients (5.42%) suffered from pains, nausea/vomitings and epistaxis within the 6 postoperative hours, that would have prevented them from going back home. 23 patients (5.42%) presented hematoma, infections, scar disunity, pains and faintness between day 4 and day 8 after surgery. In all, considering a distance shorter then an 1 hour drive from the ENT department, 69 patients (16.3%) were eligible retrospectively for an ambulatory surgery; they would have been 154 (40.8%) in the absence of this criteria. The medico-economic earnings would have been about 39,900 euros for 69 patients, for 2 years. CONCLUSION: 17 to 40% of the patients were potentially eligible for an ambulatory procedure, without endangering them.

Osteoblastoma of the ethmoid sinus.

Osteoblastoma is a rare benign bone tumor that occurs unusually in the nasal sinuses. We report one case of sinonasal osteoblastoma in a 12-year-old girl who presented with nasal obstruction and telecanthus on the right side. Computed tomography revealed a lesion of the right ethmoid sinus with heterogenous bony density, which was displacing the orbital contents and the skull base. Biopsy caused significant bleeding. Magnetic resonance imaging showed intense homogeneous enhancement with typical flow-void areas due to large pathological vessels. This MRI feature must alert the clinician on the diagnosis before biopsy and surgical resection after embolization is performed. This case report describes the diagnostic and therapeutic difficulties of this rare tumor.

A short history of nasal polyposis.

Nasal polyposis was initially considered a tumor, but came to be seen as a chronic inflammatory mucosal disease during the second half of the 20th century. Although pathogenesis remains unclear, this has not prevented progress in diagnosis and treatment, both surgical and medical, based on the hypotheses of chronic rhinosinusitis with type-2 inflammation and autoimmune inflammation maintained by the vestigial olfactory mucosa of the ethmoid.

[Guidelines for the management of chronic cough in adults]. / Recommandations de prise en charge de la toux chronique de l'adulte.

Patients with chronic cough experience major alteration in their quality of life. Given its numerous etiologies and treatments, this disease is a complex entity. To help clinicians involved in patient management of patients, guidelines have been issued by a group of French experts. They address definitions of chronic cough and initial management of patients with this pathology. We present herein the second-line tests that might be considered in patients whose coughing has persisted, notwithstanding initial management. The experts have also put forward a definition of unexplained or refractory chronic cough (URCC), the objective being to more precisely identify those patients whose cough persists despite optimal management. Lastly, these guidelines indicate the pharmacological and non-pharmacological interventions of use in URCC. Amitriptyline, pregabalin, gabapentin or morphine combined with speech and/or physical therapy are mainstays in treatment strategies. Other treatment options, such as P2X3 antagonists, are being developed and have generated high hopes among physicians and patients alike.

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.

Radiotherapy of sinonasal cancers.

We present the update of the recommendations of the French society of radiotherapy and oncology on the indications and the technical methods of carrying out radiotherapy of sinonasal cancers. Sinonasal cancers (nasal fossae and sinus) account for 3 to 5% of all cancers of the head and neck. They include carcinomas, mucosal melanomas, sarcomas and lymphomas. The management of sinonasal cancers is multidisciplinary but less standardized than that of squamous cell carcinomas of the upper aerodigestive tract. As such, patients with sinonasal tumors can benefit from the expertise of the French expertise network for rare ENT cancers (Refcor). Knowledge of sinonasal tumour characteristics (histology, grade, risk of lymph node involvement, molecular characterization, type of surgery) is critical to the determination of target volumes. An update of multidisciplinary indications and recommendations for radiotherapy in terms of techniques, target volumes and radiotherapy fractionation of the French society of radiotherapy and oncology (SFRO) was reported in this manuscript.

Carbon nanotubes have a deleterious effect on the nose: the first in vitro data.

BACKGROUND: The information currently available concerning carbon nanotubes toxicity is disturbing and conflicting. Moreover, little is known about their effect on the nasal cavities, which are the first target for nanoparticles. MATERIAL AND METHOD: We investigated the cytotoxicity (50 to 0.5 microg/mL) of double-walled carbon nanotube with two independent tests (MTT, Wst-1) on normal human nasal epithelial cells after 12-day exposure (control untreated nasal cells and A549). Nasal cell differentiation function, oxidative stress, the morphological features of cells in contact with DWCNTs and the localizations of the latter were also investigated. RESULTS: Exposure revealed a dose-dependent decrease in cell metabolic activity and cell growth. In nearly all conditions, normal human nasal epithelial cells were more sensitive than malignant ones. Even with both tests, the cytotoxic threshold dose could not be accurately determined because of dye adsorption by DWCNTs. Nasal cells showed stronger cytokeratin 7 and persistent UEA-I immunostaining. Cytokeratin 19 production was increased at 25 microg/mL and mucus production was stimulated from 0.5 microg/mL. A significant increase in Reactive Oxygen Species was observed from 25 microg/mL. The cell plasma membrane showed several holes and DWCNTs were present in the cytoplasm. CONCLUSION: DWCNTs seem to have a deleterious effect on nasal cells after 12-day exposure.

Paediatric nasal irrigation: The "fencing" method.

Nasal irrigation is a grade A recommendation treatment, which is essential in many pathological conditions. Very heterogeneous practices are observed in paediatrics as a result of poor instruction in this technique. We propose to describe the nasal irrigation technique developed by a team of respiratory physiotherapists in Lille for the management of cystic fibrosis and bronchiolitis. This technique is intended for children over the age of 6 months, as it requires an oral breathing reflex and cough reflex that are not systematically acquired before this age. Nasal irrigation is performed on a 30° upward inclined plane on a calm and cooperative child, away from meals. The child is maintained gently, without pressure, in the fencing position with the head turned away from the practitioner. Using a continuous flow spray, the practitioner grasps the top of the upper nostril and irrigates the nostril for an average of 3 s (6mL per nostril). These steps are then repeated until satisfactory patency is achieved in both nostrils. This technique constitutes a practical tool to help healthcare professionals and parents perform nasal irrigation in young children over the age of 6 months.

Assessment of quality and safety in rhinologic day surgery.

OBJECTIVES: To assess and compare the safety and quality of the management of sinonasal surgery (all procedures) between day-case and traditional admission. MATERIAL AND METHODS: A 2-year retrospective study included all patients undergoing functional septonasal surgery, ethmoidectomy, middle antrostomy, frontal sinusotomy or endoscopic sphenoidotomy, as day-surgery on inpatient admission. Demographic, operative, pre- and post-operative anesthetic data, complications, and rates of emergency consultation and readmission within 30 days were collected and compared between out- and in-patients. RESULTS: Nine hundred and nine patients were included: 569 functional septonasal surgeries, 180 ethmoidectomies, 101 middle meatotomies, 40 Draf procedures and 19 sphenoidotomies; respectively 60%, 21%, 54%, 20% and 37% were performed in the day-surgery unit. There were no significant differences in number of emergency consultations or readmissions between the out- and in-patient groups. There were more complications in in-patients (P<0.0001) (4.9% anticoagulant and 12% antiplatelet treatments, 18% obstructive sleep apnea-hypopnea syndromes). The conversion rate to conventional admission was 4.6%. Antiplatelet treatment or postoperative nasal packing were not significant risk factors for complications or readmission. CONCLUSION: Outpatient sinonasal surgery does not seem to incur extra risk for the patient or surgeon when eligibility criteria are met.

Long-term single-center results of management of ethmoid adenocarcinoma: 95 patients over 28 years.

OBJECTIVES: To assess management options for ethmoid adenocarcinoma. STUDY DESIGN: Retrospective review over 28 years. PATIENTS AND METHODS: Ninety-five patients were included. Statistical analysis using the Kaplan-Meier method was performed to establish survival rates, and univariate analysis to determine prognostic factors. Independent chi(2) test was used to compare survival rates between T3 and T4a stages operated by transfacial and craniofacial approaches, respectively. RESULTS: Mean age was 64 years, and 76% patients were stage T3 or T4. Three patients had node metastasis, none of whom had distant metastases at time of diagnosis. Eighty-three percent of patients received surgery and adjuvant radiotherapy on tumor bed. Mean follow-up was 5 years. The recurrence and metastasis rate were 31 and 9% at median time of 3 years, respectively. The disease-specific 5- and 10-year survival rates were 78 and 64%, respectively. The disease-free survival rate was 61 and 44%, respectively, at the same time points. Meningo-encephalic (P = 10(-8)), orbit or infratemporal fossae (P = 0.046), and frontal sinus extension (P = 0.02) negatively impacted survival. There was no statistically significant difference in survival rate between T3 and T4a. CONCLUSIONS: Our data suggest that less surgical treatment may be needed than is usually advocated for T1-T4a tumors and that surgery alone may be appropriate for T1-T3 tumors that have been resected with adequate margins in those patients for whom excellent follow-up is anticipated. No neck irradiation is indicated for N0 disease.

[Resorption of cartilage grafts in rhinoplasty: fundamental basis]. / La résorption des greffons cartilagineux en rhinoplastie: bases fondamentales.

Resorption of the autologous cartilage graft of the nasal dorsum is a problem which concerns all rhinoplasticians. Their rate of resorption is estimated between 20 to 30% of the graft volume and can occur with no means of prevention from the side of the surgeon. The goal of this article is to highlight, through a short review of the literature, the current data regarding the composition of the septal cartilage, its healing process and the progress made in cartilaginous tissue engineering to adapt our surgical technique. Cartilaginous tissue engineering does not yet have the abilities to provide a replacement septal cartilage with the same molecular composition, the same mechanical properties and devoid of volume loss after implantation and in spite of a certain progress, autologous cartilage grafts are still making the headlines. However to avoid the resorption of the latter and to preserve their volume, it seems necessary to avoid crushing them so as not to compromise chondrocyte viability and proliferation. Cutting-out millimeter-length dices seems more adapted to preserve cellular viability but remains insufficient because of the low healing capacities of the cartilage. Diced-cartilage wrapped with connective tissue seems an elegant and efficient solution over the long run to safeguard their volume and to harmonize contours and irregularities of the dorsum.

The influenza virus, SARS-CoV-2, and the airways: Clarification for the otorhinolaryngologist.

The influenza virus and SARS-CoV-2 cause trivial upper and severe lower respiratory infections (Influenza virus 290,000 to 650,000 deaths/year). These viruses come into contact with the airways either by direct projection, by secondary inhalation of airborne droplets, or by handling (fomites). The objective of this article is to clarify the mechanisms of production and penetration of droplets of secretions emitted during all expiratory phenomena likely to transport these viruses and come into contact with the respiratory mucosa. The droplets>5µm follow the laws of ballistics, those<5µm follow Brownian motion and remain suspended in the air. The aerosols of droplets are very heterogeneous whether the subject is healthy or sick. During an infectious period, not all droplets contain viral RNA. If these RNAs are detectable around patients, on surfaces, and in the ambient air at variable distances according to the studies (from 0.5m to beyond the patient's room), this is without prejudice to the infectious nature (viability) of the virus and the minimum infectious dose. There is a time lag between the patient's infectious period and that of RNA detection for both viruses. Subsequently, the inhaled particles must meet the laws of fluid dynamics (filtration) to settle in the respiratory tree. All of this partly explains the contagiousness and the clinical expression of these two viruses from the olfactory cleft to the alveoli.

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.