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.

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.

Chronic nasal dysfunction: A clinical case illustrating the concept in practice

INTRODUCTION

We illustrate the diagnostic method for chronic nasal dysfunction by an observation in which the clinical history was compared to preoperative responses on the DyNaChron self-administered questionnaire, with ENT interpretation of the sinonasal CT scan preceding and guiding nasal endoscopy.

CASE REPORT

The initial suspicion of rhinitis medicamentosa was transformed by the radiological and endoscopic findings of chronic respiratory rhinitis signs. Prick tests showing sensitivity to dust mites then suggested an allergic origin of the mucosal inflammation, which affected neither the olfactory nose nor the paranasal sinuses. A septal deviation hampering visualization of the right ethmoidal reliefs completed the clinical picture. Inferior turbinate hypertrophy secondary to allergic inflammation could have been aggravated by prolonged daily use of nasal vasoconstrictors. Failure of medical treatment combining nasal lavage, topical corticosteroids and an attempt at weaning led to effective medical and surgical management combining septoplasty, bilateral inferior turbinoplasty, continuation of topical corticosteroids and initiation of allergen immunotherapy. In addition to complete relief of nasal obstruction and abandonment of nasal vasoconstrictors, improved sense of smell completed the restoration of nasal comfort.

DISCUSSION

It is helpful to conceive the nose as being anatomically and pathophysiologically a triple organ and to evaluate therapy in terms of improvement in each symptom.

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).

Minimal clinically important differences on the DyNaChron questionnaire after surgery

OBJECTIVES

To determine minimal clinically important differences (MCIDs) for the DyNaChron chronic rhinosinusitis quality-of-life questionnaire.

INTRODUCTION

MCIDs are the smallest changes in a quality-of-life score that are of clinical relevance for the patient. They allow treatment benefit to be estimated. MCIDs have not previously been determined for DyNaChron.

MATERIAL AND METHODS

A single-center retrospective study analyzed DyNaChron questionnaires filled out between June 2016 and December 2021 by all patients consulting for chronic nasal dysfunction. Five hundred and thirteen of the 2390 patients were operated on for nasal polyposis (NP; n=282) or septo(rhino)plasty+inferior turbinoplasty (SPIT; n=231). Standard error of measurement was used to determine MCIDs.

RESULTS

MCID for DyNaChron global score was 60 in NP and 58 in SPIT. MCIDs per symptom domain in NP and SPIT respectively were: 15 and 13 for nasal obstruction, 21 and 21 for anterior rhinorrhea, 20 and 19 for posterior rhinorrhea, and 17 and 17 for olfaction. In agreement with global MCID, 257 NPs (91%) and 149 SPITs (65%) showed clinical improvement.

CONCLUSION

MCID helps assess response to treatment. In the DyNaChron questionnaire, MCIDs enable global and symptom-specific assessment of chronic nasal dysfunction and its impact on quality of life in a single patient or in groups.

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.

Dupilumab reduces systemic corticosteroid use and sinonasal surgery rate in CRSwNP

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a type 2 inflammatory disease with a high symptom burden and poor quality of life. Treatment options include recurrent surgeries and/or frequent systemic corticosteroids (SCS). Dupilumab, a fully human monoclonal antibody, blocks the shared receptor component for interleukin-4 and interleukin-13, key drivers of type 2-mediated inflammation. We report results of pooled analyses from 2 randomised, double-blind, placebo-controlled phase 3 studies (SINUS 24 [NCT02912468]; SINUS-52 [NCT02898454]) to evaluate dupilumab effect versus placebo in adults with CRSwNP with/without SCS use and sinonasal surgery.

METHODOLOGY

SINUS-24 patients were randomised 1:1 to subcutaneous dupilumab 300 mg (n=143) or placebo (n=133) every 2 weeks (q2w) for 24 weeks. SINUS-52 patients were randomised 1:1:1 to 52 weeks of subcutaneous dupilumab 300 mg q2w (n=150), 24 weeks q2w followed by 28 weeks of dupilumab 300 mg every 4 weeks (n=145) or 52 weeks of placebo q2w (n=153).

RESULTS

Dupilumab reduced the number of patients undergoing sinonasal surgery (82.6%), the need for in-study SCS use (73.9%), and SCS courses (75.3%). Significant improvements were observed with dupilumab vs placebo regardless of prior sinonasal surgery or SCS use in nasal polyp, nasal congestion, Lund-MacKay, and Sinonasal Outcome Test (22-items) scores, and the University of Pennsylvania Smell Identification Test.

CONCLUSIONS

Dupilumab demonstrated significant improvements in disease signs and symptoms and reduced the need for sino-nasal surgery and SCS use versus placebo in patients with severe CRSwNP, regardless of SCS use in the previous 2 years, or prior sinonasal surgery.

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.

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.

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.

Optimizing DyNaChron instrument for assessing chronic nasal dysfunction symptoms by Rasch analysis

BACKGROUND

The DyNaChron (Dysfonctionnement Nasal Chronique) questionnaire is a self-reporting 78-item instrument assessing six symptoms and their consequences of chronic nasal dysfunction. Patients complete items of a symptom domain only when it is present but in case the patient presents several or all symptoms, its length can limit its use. Here, we aimed to optimize, or shorten, the DyNaChron for clinical use.

METHODS

A total of 640 patients in 14 rhinology outpatient clinics all over France completed the original DyNaChron questionnaire before the first rhinologic clinic and 15 days later. The optimization process involved Rasch analysis and then qualitative content analyses. Rasch analysis flagged items with a floor/ceiling effect or with important differential item functioning and an expert committee decided whether to retain the flagged items on the basis of clinical importance and statistical characteristics. The psychometric properties of the optimized version were studied according to classical test theory and Rasch analysis.

RESULTS

Rasch analysis revealed 4 items with underfit, 6 with an extreme score, 2 that were highly locally dependent and 16 with differential item functioning which 5 of these 16 items were retained after content analysis. In total, 19 flagged items were removed. Factorial analysis confirmed the preservation of the initial instrument structure in the optimized scale; psychometrics properties and scale calibration were the same as or better than the original version.

CONCLUSION

The shortened DyNaChron optimizes the quality of assessment by deleting redundant items and reduces the burden on respondents; the structure is preserved and the psychometrics properties are improved.

Virus et épidémies virales dans la théorie métabolique de l’évolution

Les virus, dont l’épidémie de SARS-CoV-2 actuelle, représentent une clé dans la compréhension de la vie et de l’évolution. La cellule a pu naître d’un enfermement aqueux dans une enveloppe lipidique incrustée de chromophores capturant les photons solaires. L’incorporation d’azote dans la chimie cellulaire primordiale autorisait la synthèse des acides aminés et nucléiques, prélude de l’ARN qui aurait précédé l’ADN. La métagénomique permet d’accéder aux sédiments nucléoprotéiques synthétisés par le gogol de cellules métaboliquement différenciées qui ont jalonné l’évolution du vivant. La réplication d’un virus, particule nucléoprotéique, se déroule passivement dans une cellule compétente. Un virus ne semble connu que par l’épidémie qu’il déclenche en étant transporté d’un hôte à l’autre. En décomposant la particule virale, la cellule hôte paraît ressusciter la fonction métabolique de l’acide nucléique qui synthétise sans contrôle ses composants. Ceux-ci s’auto-assemblent et sont exportés par exocytose ou cytolyse. Sans cellule, les virus ne paraissent que matière inerte. La contamination intracellulaire d’un virus ne parvient cependant pas toujours à la réplication : le génome viral peut disparaître, rester latent, se réveiller, rester inséré dans le génome cellulaire, devenir un oncogène ou induire l’auto-immunité. Les rétrovirus endogènes des cellules eucaryotes soulèvent la question de leur rôle dans l’évolution.