Prospective comparison of acute severe toxicities between smokers and non-smokers during radiotherapy for head and neck cancers

BACKGROUND AND PURPOSE

The association between smoking and acute radiation toxicities of head and neck cancer (HNC) is currently unproven. The aim of the study was to compare the occurrence of acute severe toxicity between active and non-active smokers treated for HNC by radiotherapy.

MATERIALS AND METHODS

A prospective monocentric cohort study included patients treated by (chemo)radiotherapy for HNC from January 2021 to January 2023. Smoking status was recorded. Patients underwent a medical exam weekly during the radiotherapy to report acute toxicities according to the Common Terminology Criteria for Adverse Effects system version 5.0. Primary endpoint was the occurrence of at least one grade ≥ 3 acute toxicity among mucositis, dysphagia and dermatitis.

RESULTS

Among the 102 patients included, 27.4 % were active smokers, 58.8 % were former smokers and 13.7 % had never smoked. Regarding toxicity, 23.5 % (n = 24) patients experienced severe mucositis, 37.2 % (n = 38) severe dysphagia, 13.7 % (n = 14) severe dermatitis and 54.9 % (n = 56) experienced at least one of them. Occurrence of severe acute toxicity was not statistically associated with smoking during radiotherapy (64.3 % among active smokers versus 51.3 % among non-active smokers; p = 0.24). On multivariate analysis, concurrent chemotherapy (87.5 % vs 65.2 %; OR = 5.04 [1.64-15.52]; p = 0.004) and 2.12 Gy versus 2 Gy fractionation schedule (64.3 % vs 41.3 %; OR = 2.53 [1.09-5.90]; p = 0.03) were significantly associated with severe acute toxicity.

CONCLUSION

This study did not find an association between smoking during radiotherapy for HNC and occurrence of severe acute toxicities.

Epidemiology and risk factors for extension of necrotizing otitis externa

PURPOSE

Necrotizing otitis externa (OEN) is an aggressive and morbid infection of the external acoustic meatus. What are the risk factors for OEN extension?

METHODS

French monocentric retrospective study (2004-2021), including patients with OEN defined by the association of an inflamed EAM, a positive nuclear imaging, the presence of a bacteriological sample and the failure of a well-followed local and/or general antibiotic treatment. OEN was extensive if it was associated with vascular or neurological deficits, if nuclear imaging fixation and/or bone lysis extended beyond the tympanic bone.

RESULTS

Our population (n = 39) was male (74%), type 2 diabetic (72%), aged 75.2 years and pseudomonas aeruginosa was found in 88% of cases. Complications for 43% of patients were extensive fixation on nuclear imaging, for 21% of them the presence of extensive bone lysis, for 13% the appearance of facial palsy, for 5.3% the presence hypoglossal nerve palsy and for 2.5% the presence of thrombophlebitis or other nerves palsies. 59% of our population had extensive OEN. The diagnosis of the extensive OEN was made 22 days later (p = 0.04). The clinical presentation was falsely reassuring due to easier identification of the tympanic membrane (70% vs 46%, p = 0.17) but associated with periauricular oedema (42% vs 0%), bone exposure (16% vs 0%) and a temporomandibular joint pain (41% vs 12%).

CONCLUSION

Delayed treatment of OEN, identification of clinical bone lysis, especially when the tympanic membrane is easily visualized, and the presence of unbalanced diabetes are potential risk factors for extension of OEN.

Carcinomas of the external auditory canal: Management and results: A multicenter REFCOR propensity score matching study

OBJECTIVES

To analyse prognostic factors and survival outcomes of malignant tumors of the external auditory canal, to investigate the role of regional surgery, and adjuvant radiotherapy in early stages and to investigate the role of surgery in operable T4 stage.

SETTING

A retrospective analysis was conducted on all patients prospectively included in the national database of the French Expertize Network for Rare ENT Cancers (REFCOR) from January 2000 to December 2016.

PARTICIPANTS

103 patients from 19 reference centers were included. A propensity score matching analysis was applied to enable comparisons between treatments.

MAIN OUTCOMES AND MEASURES

Event-free survival, overall survival and factors of poor prognosis of the cohort were described. The interest of local and regional surgery and postoperative radiotherapy were evaluated.

RESULTS

The factors of poor prognosis on event-free survival were immunosuppression (p = 0.002), Karnofsky status less than 90% (p = 0.02), body mass index less than 19 Kg / m2 (p = 0.0009), peripheric facial palsy (p = 0.0016), and positive margin (p = 0.0006). In early stages, locoregional surgery was associated with an increase in event-free survival (p = 0.003, HR = 0.21) versus local surgery alone, while postoperative radiotherapy was not associated with an increase in event-free survival (p = 0.86, HR = 0.91) or overall (p = 0.86, HR = 0.91). In locally advanced stages, locoregional surgery followed by radiotherapy was associated with an increase in event-free survival (p = 0.03, HR = 0.39) and overall (p = 0.02, HR = 0.34) versus chemoradiotherapy alone.

CONCLUSION AND RELEVANCE

Regional surgery is recommended for early stages of cancers of the external auditory canal. In operable cases, locoregional surgery followed by radiotherapy is recommended.

Costs analysis of cochlear implantation in children

OBJECTIVES

The study assessed the direct medical costs of the cochlear implantation pathway from the healthcare payer's perspective, in children with bilateral severe to profound hearing loss, from diagnosis to 3 years' follow-up after first implantation. We also compared costs between two populations: congenital and progressive deafness.

MATERIAL AND METHODS

A retrospective costs analysis was performed for 56 children who received a cochlear implant in one French pediatric ENT center. The children had severe to profound hearing loss, and were implanted before the age of 10 years. We calculated direct medical costs in 3 phases: diagnosis to pre-implantation assessment, surgical and hospital management of implantation, and 3 years' follow-up.

RESULTS

Mean costs were €64,675 (range, €38,709-113,954) per child from diagnosis to 3 years after first implantation. Mean costs in congenital deafness detected on neonatal screening and on progressive deafness were respectively €65,420 and €63,930 (P=0.7).

CONCLUSION

The global cost was €64,675 per child from diagnosis to 3 years after first implantation. There was no difference in cost according to congenital versus progressive hearing loss.

Functional or radical surgical treatment of laryngeal chondrosarcoma, analysis of survival and prognostic factors: A REFCOR and NetSarc-ResOs multicenter study of 74 cases

INTRODUCTION

Laryngeal chondrosarcoma (LCS) is a rare tumor of slow evolution whose treatment is poorly codified. For a long time, a radical treatment by total laryngectomy (TL) was proposed. More recent studies tend to propose a conservative surgical approach of the larynx. The objective of this study was to compare the overall survival (OS) of total laryngectomized patients (TL+) versus non-laryngectomized patients (TL-). The secondary objectives were to analyse the reoperation free survival (RFS), the total laryngectomy free survival (TLFS) and to identify the preoperative factors leading surgeons to propose TL.

MATERIALS AND METHODS

A retrospective analysis of prospectively collected incident cases from the REFCOR and NetSarc-ResOs multicenter databases between March 1997 and June 2021 was conducted. A propensity score matching analysis was performed to compare the OS of TL+ and TL-patients.

RESULTS

74 patients were included. After propensity score, the 5-year OS of TL+ and TL-patients was comparable (100 %, p = 1). The 5-year RFS rate was 69.2 % (95 % CI [57.5-83.4]) and the 5-year TLFS was 61.7 % (95 % CI [50.4-75.5]). Cricoid involvement greater than 50 % (HR 3.58; IC 95 % [1.61-7.92] p < 0.001), an ASA score of 3 or 4 (HR 5.07; IC 95 % [1.64-15.67] p = 0.009) and involvement of several cartilages (HR 5.26; IC 95 % [1.17-23.6] p = 0.04) are prognostic factors for TL. Dyspnea caused by the tumour is a prognostic factor for reoperation (HR 2.59; IC 95 % [1.04-6.45] p = 0.03).

CONCLUSION

These results demonstrate that conservative treatment should be considered as first-line treatment for laryngeal chondrosarcoma.

Intra-parotid facial nerve path by MRI tractography: radio-clinical comparison in parotid tumors

PURPOSE

The objective of our study was to evaluate the ability of preoperative MRI tractography to visualize and predict the path of the facial nerve with respect to an intra-parotid mass.

METHODS

We performed an observational bicentric study from June 2019 to August 2020. All patients older than 18 years old, treated for a parotid mass with surgical indication, without MRI contraindication and who agreed to participate in the study were enrolled prospectively. All patients underwent a cervico-facial MRI with tractographic analysis. Postprocessed tractography images of the intra-parotid facial nerve were analyzed by two expert radiologists in head and neck imaging. The intraoperative anatomical description of the facial nerve path and its relationship to the mass was performed by the surgeon during the operation, with no visibility on MRI examination results. A statistical study allowed for the description of the data collected as well as the measurement of inter-observer agreement and agreement between tractography and surgery using kappa coefficients.

RESULTS

Fifty-two patients were included. The facial nerve trunk and its first two divisional branches were visualized via tractography in 93.5% of cases (n = 43). The upper distal branches were visualized in 51.1% of cases (n = 23), and the lower branches were visualized in 73.3% of cases (n = 33). Agreement with the location described per-operatively was on average 82.9% for the trunk, 74.15% for the temporal branch, and 75.21% for the cervico-facial branch.

CONCLUSION

Fiber tractography analysis by MRI of the intra-parotid facial nerve appears to be a good test for predicting the path of the nerve over the parotid mass and could be an additional tool to guide the surgeon in the operative procedure.

Assessing the time-to-removal of totally implantable venous access devices comparing valved-versus open-ended catheters in patients treated with chemotherapy

BACKGROUND

Totally IntraVenous Acess Devices (TIVAD) are used to have long-term bloodstream access. The catheter connected to the subcutaneous chamber may be valved (TIVAD-V) or open-ended (TIVAD-O). Infectious and occlusion complications require the removal of the TIVAD. We compared the two types of catheters (TIVAD-V and TIVAD-O) in terms of time-to-removal and complication rates.

METHODS

A retrospective study of 636 patients treated for any malignancy using a TIVAD were included. TIVAD complication was defined as the occurrence of infection or occlusion requiring TIVAD removal. Risk factors of complications and time-to-removal of TIVAD were assessed by a Cox proportional hazard analysis.

RESULTS

A total of 55 TIVADs (8.7%) were removed including 47 for infection and eight for occlusion in 54 months. There was no significant difference in the frequency of complications between TIVAD-V and TIVAD-O. There was no significant difference in time-to-removal between TIVAD-V and TIVAD-O (17.0 months, IQR [10.5-25.0] and 18.4 months, IQR [11.5-22.9], p = 0.345, respectively).

CONCLUSION

There was no difference between TIVAD with valved and open catheter in terms of complications and time-to-removal in patients treated by chemotherapy.

Management of 80 sinonasal undifferentiated carcinomas. Retrospective multicentre study of the French Network of Rare Head and Neck Cancers (REFCOR)

OBJECTIVES

Sinonasal undifferentiated carcinoma (SNUC) is a rare and aggressive disease requiring multimodal treatment, and multiple new entities once included in the spectrum of SNUC, such as SWI/SNF-deficient carcinomas, are emerging. We aimed to provide new data regarding the role of chemotherapy and surgery and the prognostic factors of disease-free survival.

METHODS

This study was based on data from the REFCOR database and included patients with SNUC treated with curative intent from 2007 to 2021 across 22 centres in France.

RESULTS

A total of 80 patients were included in the analysis. Among the entire cohort, the 5-year disease-free survival (DFS) and overall survival (OS) rates were 58% and 63%, respectively. Of 100% of the patients treated with irradiation, 29% underwent surgery, 56% neoadjuvant chemotherapy (82% had either a partial or a complete response) and 76% chemoradiotherapy. No treatment modality was associated with a better OS or DFS, including surgery (p = 0.34). There was a trend for a better DFS for the patients treated with chemotherapy (neoadjuvant or concomitant, p = 0.062). Overall survival at 3 years was 58% for SWI/SNF deficient group and 86% for non deficient group (p = 0.14). The locoregional relapse rate without distant metastases was 21% in the exclusive radiotherapy group and 26% in the surgery group. Grade 3 or higher toxicities concerned 9%, 32% and 29% of patients for surgery, radiotherapy and chemotherapy respectively.

CONCLUSION

In the management of localised SNUC among all patients treated with irradiation, surgery yielded no benefit, whereas the addition of chemotherapy tended to improve disease-free survival.

The study of predictive factors for the evolution of vestibular schwannomas

PURPOSE

The primary objective was to determine whether the analysis of textural heterogeneity of vestibular schwannomas on MRI at diagnosis was predictive of their radiological evolutivity. The secondary objective was to determine whether some clinical or radiological factors could also be predictive of growth.

METHODS

We conducted a pilot, observational and retrospective study of patients with a vestibular schwannoma, initially monitored, between April 2001 and November 2019 within the Oto-Neurosurgical Institute of Champagne Ardenne, Texture analysis was performed on gadolinium injected T1 and CISS T2 MRI sequences and six parameters were extracted: mean greyscale intensity, standard deviation of the greyscale histogram distribution, entropy, mean positive pixels, skewness and kurtosis, which were analysed by the Lasso method, using statistically penalised Cox models. Extrameatal location, tumour necrosis, perceived hearing loss < 2 years with objectified tone audiometry asymmetry, tinnitus at diagnosis, were investigated by the Log-Rank test to obtain univariate survival analyses.

RESULTS

78 patients were included and divided into 2 groups: group A comprising 39 "stable patients", and B comprising the remaining 39 "progressive patients". Independent analysis of the texture factors did not predict the growth potential of vestibular schwannomas. Among the clinical or radiological signs of interest, hearing loss < 2 years was identified as a prognostic factor for tumour progression with a significant trend (p = 0.05).

CONCLUSIONS

This study did not identify an association between texture analysis and vestibular schwannomas growth. Decreased hearing in the 2 years prior to diagnosis appears to predict potential radiological progression.

[Postoperative radiotherapy with cetuximab for head and neck squamous cell carcinoma patients at high risk of recurrence not eligible for cisplatin: A single-center experience and literature review]

PURPOSE

The use of concurrent cetuximab with postoperative radiotherapy for patients with head and neck cancer has been scarcely discussed in the literature. The main aim of this study was to report clinical outcomes of high-risk head and neck cancer patients treated by postoperative radiotherapy with cetuximab.

PATIENTS AND METHODS

Between January 2013 and December 2016, all medical records of patients operated for head and neck cancer who underwent postoperative radiochemotherapy were retrospectively analyzed. Patients who received cisplatin were excluded; only patients who received cetuximab were included in the analysis.

RESULTS

Among 52 patients with head and neck cancer treated with postoperative radiochemotherapy, 18 patients received cetuximab potentiation due to ineligibility for cisplatin. Median overall survival (OS) and progression-free survival (PFS) were 23 and 19,5 months and 3-year OS and PFS were 30,5% and 25,9%, respectively. There was a 22% treatment discontinuation rate.

CONCLUSION

In our single-center retrospective analysis, postoperative radiotherapy with cetuximab for patients with high-risk head and neck cancer ineligible for cisplatin showed similar outcomes to the literature data for exclusive postoperative radiotherapy, with a high discontinuation rate. These low-power data support the lack of indication for cetuximab in combination with postoperative radiotherapy.

Reporting Criteria for Clinical Trials on Medication-Related Osteonecrosis of the Jaw (MRONJ): A Review and Recommendations

Medication-related osteonecrosis of the jaw (MRONJ) is a complication caused by anti-resorptive agents and anti-angiogenesis drugs. Since we wanted to write a protocol for a randomized clinical trial (RCT), we reviewed the literature for the essential information needed to estimate the size of the active patient population and measure the effects of therapeutics. At the same time, we designed a questionnaire intended for clinicians to collect detailed information about their practices. Twelve essential criteria and seven additional items were identified and compiled from 43 selected articles. Some of these criteria were incorporated in the questionnaire coupled with data on clinical practices. Our review found extensive missing data and a lack of consensus. For example, the success rate often combined MRONJ stages, diseases, and drug treatments. The occurrence date and evaluation methods were not harmonized or quantitative enough. The primary and secondary endpoints, failure definition, and date coupled to bone measurements were not well established. This information is critical for writing a RCT protocol. With this review article, we aim to encourage authors to contribute all their findings in the field to bridge the current knowledge gap and provide a stronger database for the coming years.

Airway replacement using stented aortic matrices: Long-term follow-up and results of the TRITON-01 study in 35 adult patients

Over the past 25 years, we have demonstrated the feasibility of airway bioengineering using stented aortic matrices experimentally then in a first-in-human trial (n = 13). The present TRITON-01 study analyzed all the patients who had airway replacement at our center to confirm that this innovative approach can be now used as usual care. For each patient, the following data were prospectively collected: postoperative mortality and morbidity, late airway complications, stent removal and status at last follow-up on November 2, 2021. From October 2009 to October 2021, 35 patients had airway replacement for malignant (n = 29) or benign (n = 6) lesions. The 30-day postoperative mortality and morbidity rates were 2.9% (n = 1/35) and 22.9% (n = 8/35) respectively. At a median follow-up of 29.5 months (range 1-133 months), 27 patients were alive. There have been no deaths directly related to the implanted bioprosthesis. Eighteen patients (52.9%) had stent-related granulomas requiring a bronchoscopic treatment. Ten among 35 patients (28.6%) achieved a stent free survival. The actuarial 2- and 5-year survival rates (Kaplan-Meier estimates) were respectively 88% and 75%. The TRITON-01 study confirmed that airway replacement using stented aortic matrices can be proposed as usual care at our center. Clinicaltrials.gov Identifier: NCT04263129.

Tips and Tricks and Clinical Outcome of Cryopreserved Human Amniotic Membrane Application for the Management of Medication-Related Osteonecrosis of the Jaw (MRONJ): A Pilot Study

Medication-related osteonecrosis of the jaw (MRONJ) is a complication of certain pharmacological treatments such as bisphosphonates, denosumab, and angiogenesis inhibitors. There are currently no guidelines on its management, particularly in advanced stages. The human amniotic membrane (hAM) has low immunogenicity and exerts anti-inflammatory, antifibrotic, antimicrobial, antiviral, and analgesic effects. It is a source of stem cells and growth factors promoting tissue regeneration. hAM acts as an anatomical barrier with suitable mechanical properties (permeability, stability, elasticity, flexibility, and resorbability) to prevent the proliferation of fibrous tissue and promote early neovascularization at the surgical site. In oral surgery, hAM stimulates healing and facilitates the proliferation and differentiation of epithelial cells in the oral mucosa and therefore its regeneration. We proposed using cryopreserved hAM to eight patients suffering from cancer (11 lesions) with stage 2–3 MRONJ on a compassionate use basis. A collagen sponge was added in some cases to facilitate hAM grafting. One or three hAMs were applied and one patient had a reapplication. Three patients had complete closure of the surgical site with proper epithelialization at 2 weeks, and two of them maintained it until the last follow-up. At 1 week after surgery, three patients had partial wound dehiscence with partial healing 3 months later and two patients had complete wound dehiscence. hAM reapplication led to complete healing. All patients remained asymptomatic with excellent immediate significant pain relief, no infections, and a truly positive impact on the patients’ quality of life. No adverse events occurred. At 6 months of follow-up, 80% of lesions had complete or partial wound healing (30 and 50%, respectively), while 62.5% of patients were in stage 3. Radiological evaluations found that 85.7% of patients had stable bone lesions (n = 5) or new bone formation (n = 1). One patient had a worsening MRONJ but remained asymptomatic. One patient did not attend his follow-up radiological examination. For the first time, this prospective pilot study extensively illustrates both the handling and surgical application of hAM in MRONJ, its possible association with a collagen sponge scaffold, its outcome at the site, the application of multiple hAM patches at the same time, and its reapplication.

Efficacy and complications of microvascular decompression in patients over 70 years with trigeminal neuralgia

OBJECTIVE

Treatment of choice for trigeminal neuralgia (TN) by neurovascular conflict in case of failure of medical treatment is microvascular decompression (MVD). It is a safe and effective technique in the short and long term. But what about older patients who are considered more fragile anesthetically and surgically? Our Objective is to demonstrate the efficacy and complication rate of microvascular decompression (MVD) for older and younger patients with trigeminal neuralgia (TN) due to neurovascular conflict.

METHODS

102 patients with TN due to neurovascular conflict were included (June 2005-December 2016) in a single Regional hospital. 25 were included in the group composed of ≥ 70-year-old patients (G1), while 77 were included in the < 70-year-old group (G2). The patients were operated on by the same surgical team using a retro-sigmoid approach to access the neurovascular conflict. The epidemiologic, clinical, anesthetic, and surgical data were extracted.

RESULTS

The immediate efficacy of surgical treatment (BNI pain intensity = I) was 96% in G1 and 96.10% in the G2 group (p = 0.71). At 3-year follow-up, the efficacy rate was 89% and 86%, respectively (p = 0.93). At 5 years, it was 92% and 92% (p = 0.98). Complication rates were comparable between the two groups (20% versus 27%; p = 0.47) and no deaths occurred despite the fact that G1 group had worst preoperative anesthetic score (ASA-NYHA).

CONCLUSION

MVD is a durable procedure in patients over 70 years of age diagnosed with essential TN. The complication rate and immediate-, medium-, and long-term efficacy were similar to those of younger patients.

Whole-Body Cryotherapy as an Innovative Treatment for COVID 19-Induced Anosmia-Hyposmia: A Feasibility Study

The article entitled, "Whole-Body Cryotherapy as an Innovative Treatment for COVID 19-Induced Anosmia-Hyposmia: A Feasibility Study," by Legrand FD, Polidori G, Beaumont F, Bouchet B, Morin A, Derruau S, and Brenet E (Epub ahead of print Jan 13, 2022; DOI: 10.1089/jicm.2021.0254) is officially retracted at the request of the authors. This request came after the paper had undergone full peer review, three rounds of revisions, acceptance, page proofs, and ultimately, online publication. The Methods section of the published paper states that the study had "secured University ethics clearance…"¹ but the authors explained that, "after re-discussion and internal reassessment, it appears clearly that this study required, according to French law, the approval of a specific committee known as the '[C]ommittee for the [P]rotection of [P]ersons (CPP)' and not a simple ethical agreement. For this reason, [we] request, in good faith, that the article be retracted. We apologize for this delay in taking a position, but this study gave rise to a re-discussion with our peers of the methodology which led us to realize our error 'a posteriori.'" The authors' respective institutions have been notified by the publisher. Journal of Integrative and Complementary Medicine is committed to upholding the rigors of scientific publishing and the veracity of the literature. Reference 1. Legrand FD, Polidori G, Beaumont F, et al. Whole-body cryotherapy as an innovative treatment for COVID 19-induced anosmia-hyposmia: a feasibility study. Epub ahead of print Jan 13, 2022; DOI: 10.1089/jicm.2021.0254.

Long-term efficacy of vestibular neurotomy in disabling Ménière's disease and Tumarkin drop attacks

OBJECTIVE

When Ménière's disease (MD) becomes disabling due to the frequency of attacks or the appearance of drop attacks (i.e., Tumarkin otolithic crisis) despite "conservative" medical and surgical treatments, a radical treatment like vestibular neurotomy (VN) is possible. An ideal MD treatment would relieve symptoms immediately and persist after the therapy. The aim of this study was to identify if VN was effective after 10 years of follow-up regarding vertigo and drop attacks, and to collect the immediate complications.

METHODS

The authors report a retrospective, single-center (i.e., in a single tertiary referral center with otoneurological surgery activity) cohort study conducted from January 2003 to April 2020. All patients with unilateral disabling MD who had received a VN with at least 10 years of follow-up were included. The therapeutic efficacy was defined by complete disappearance of vertigo and drop attacks. The postoperative complications (CSF leak, total deafness, meningitis, death) were determined immediately after the surgery, and the hearing thresholds were determined during the patient follow-up with the pure tone average (PTA).

RESULTS

A total of 74 patients (of 85 who were eligible), average age 51.9 ± 11.1 years, including 38 men (51.4%), with disabling MD and/or Tumarkin drop attacks (24.3%) received VN, with at least 10 years of follow-up after surgery. After an average follow-up of 12.4 ± 1.7 years (range 10.0-16.3 years), 67 patients (90.5%) no longer presented any vertiginous attacks, and no patient experienced drop attack. The mean variation in early pre- and postoperative PTA was not statistically significant (n = 64, 2.2 ± 10.3 decibels hearing level [range -18 to 29], 95% CI [-0.4 to 4.37]; p = 0.096), and 84.4% of the patients evaluated had unchanged or improved postoperative PTA. Three significant complications were noted, including two surgical revisions for CSF leak. There was no permanent facial paralysis, meningitis, or death.

CONCLUSIONS

In case of disabling MD (disabling vertigo refractory to conservative vestibular treatments-Tumarkin drop attacks), VN via the retrosigmoid approach must be the prioritized proposal in comparison to intratympanic gentamicin injections, because of the extremely low complication rate and the immediate and long-lasting effect of this treatment on vertigo and falls.

Is Revision Surgery Necessary for Patients With High Risk of Recurrence After Parotidectomy? A Multicenter Retrospective Study

OBJECTIVES

Close margin is a frequent situation after parotidectomy. The need for systematic prophylactic revision surgery is a question that arises regularly for malignant tumors, as it exposes to a high risk of facial palsy, while oncological benefits are unclear.

STUDY DESIGN

retrospective study.

SETTING

Multicentric.

SUBJECTS AND METHODS

We included all patients operated for systematic revision surgery in case of close margins after parotidectomy for a malignant tumor and analyzed the rate of tumor residue and its risk factors.

RESULTS

A tumor residue was identified in 43.5% of 23 cases, but none in case of initial complete excision with supra-millimetric margins. Invaded lymph nodes were identified in 6 cases, but none in case of low-grade tumors.

CONCLUSIONS

Systematic revision seems mandatory in case of infra-millimetric margins and high-grade tumors or positive lymph node; further studies are needed to confirm whether it can be spared for T1-T2/N0 low-grade tumors, with close margins but complete initial excision.

Assessment of peak inspiratory flow in the management of acute inspiratory dyspnoea

PURPOSE

Assessment of inspiratory dyspnoea associated with upper airway obstruction is based on subjective clinical and nasal fibreoptic laryngoscopy (NFL) signs. The aim of this study was to determine whether peak inspiratory flow (PIF) measurement could indicate the need for upper airway release surgery in patients with acute inspiratory dyspnoea during emergency.

METHODS

A retrospective single-institution study (February 2018-March 2020) of 48 patients with acute inspiratory dyspnoea and PIF measurement (Peak Flow In-Check Dial G16^®-Harlow-England) was conducted. The surgical decision was based on the clinical evaluation of the patient's respiratory tolerance and NFL.

RESULTS

Forty-eight patients were included in this study. Thirty-five patients underwent surgery (PIF: 36 L/min), and 13 patients did not (PIF: 58 L/min) (p = 0.0009). Three of these 13 patients underwent an operation later (PIF value: 42 L/min versus 63 L/min for the 10 others [p = 0.25]).

CONCLUSION

PIF measurement is a quantitative, objective, inexpensive, non-invasive, and quick test that is potentially useful for general practitioners, mobile medical teams, or for ear-nose-and-throat specialists. A threshold of 42 L/min can help doctors in emergency decision making to refer patients to an ear-nose-and-throat specialist to release the upper airway and perform surgery or to choose medical monitoring for patients with emergency inspiratory dyspnoea.

Influence of postoperative radiotherapy target volumes in unilateral head and neck carcinoma of unknown primary: A multicentric study using propensity score

OBJECTIVE

To compare the impact of two radiation modalities on loco-regional control, survival and tumour emergence, after node dissection for an unilateral head and neck carcinoma of unknown primary (HNCUP).

MATERIALS AND METHODS

This is a multicentric retrospective study of 138 patients with unilateral HNCUP treated between 2002 and 2017. The absence of primary tumour was assessed by a systematic panendoscopy and positron emission tomography. Neck dissection was initially performed for all patients. Radiation Therapy was delivered on ipsilateral lymph node areas in 62 cases (44%: UL-RT group) and on bilateral lymph node areas and the entire pharyngeal mucosa in 77 cases (56%: COMP-RT group). Impact of radiation modalities on locoregional control and overall survival was assessed using propensity score matching method in order to balance baseline characteristics between the two groups.

RESULTS

The population included 80.4% men, 80.4% smokers, 32.6% P16 positive tumours and 71.0% extracapsular extension. After a median follow-up of 5 years, the locoregional control rate was 80.3% in the UL-RT group and 75.3% in the COMP-RT group (p = 0.688). The corresponding rate of contralateral lymph node recurrence was 0% versus 2.6% (p = 0.503) and the rate of tumour emergence was 11.5% versus 9.1% (p = 0.778). No significant difference was observed between the UL-RT and the COMP-RT groups for overall survival (p = 0.9516), specific survival (p = 0.4837) or tumour emergence (p = 0.9034).

CONCLUSION

UL-RT seems to provide similar outcomes as COMP-RT in unilateral HNCUP post-operative management.

Efficacy and Complications of Microsurgical Neurovascular Decompression in 55 Patients With Hemifacial Spasm

OBJECTIVE

To analyze the efficacy and complications of microvascular decompression for hemifacial spasm.

STUDY DESIGN

Retrospective study.

SETTING

Regional hospital.

METHODS

Fifty-five patients with hemifacial spasm were treated by microvascular decompression. All patients with hemifacial spasm who underwent retrosigmoid microvascular decompression from May 2004 to January 2017 were included. Patients with no conflict on preoperative magnetic resonance imaging or with an alternate diagnosis were excluded.

RESULTS

The overall cure rate was 83.64%, with an average follow-up of 7.4 years. A left-sided hemifacial spasm was a healing-promoting factor (P = .01). The median healing was 0.03 months, and the mean was 6 months. The efficacy remained high in the medium term (88% at 3 years), long term (90.24% at 5 years), and very long term (90.48% at 8 years). The recurrence rate was 9.8%. Favorable criteria included a right-sided spasm (P = .01) and an average age of 62 years (P = .03). The specific complications were permanent facial palsy (3.63%), unilateral deafness (5.45%), and hearing loss (3.63%). No death was reported. Regarding the quality of life of the patients, 94.7% had a modified HFS-8 postoperative score of 0 (Hemifacial Spasm 8 Quality of Life Scale).

CONCLUSION

Microvascular decompression for hemifacial spasm is an effective and lasting technique. Its low rate of complications and the considerable quality-of-life improvement should lead surgeons to propose it to patients as soon as botulinum toxin injections become ineffective or poorly tolerated.

Functional evaluation of mandibular reconstruction with bone free flap. A GETTEC study

OBJECTIVES

To assess the functional results of oromandibular reconstruction by free bone flap, in terms of swallowing, speech and esthetics.

MATERIALS AND METHODS

A transverse multicenter study included 134 patients reconstructed by free bone flap between 1998 and 2016, with more than 6 months' follow-up, in 9 centers. A standardized questionnaire collected data on patients and treatment. Study endpoints comprised: weight loss, mouth opening, gastrostomy dependence, type of feeding, and DHI score. The impact of patient baseline characteristics on these functional criteria was explored by uni/multivariate analysis.

RESULTS

Ninety of the 134 patients had cancer. Fibula flap was mainly used (80%). 94% of reconstructions were primary successes. 71% of patients had pre- or post-operative radiation therapy. 88% had less than 50% lingual resection. 97% recovered oral feeding. 89% had intelligible speech. 86% judged their esthetic appearance as good/average. 9% had dental prosthetic rehabilitation. Radiation therapy and extensive lingual resection significantly impacted swallowing function (P=0.04 and P=0.03, respectively). Radiation therapy and oropharyngeal extension significantly increased gastrostomy dependence (P=0.04 and P=0.02, respectively).

CONCLUSION

Oromandibular reconstruction by free bone flap enabled return to oral feeding in most cases. More than 80% of patients were satisfied with their result in terms of speech and esthetics. However, the rate of dental rehabilitation was low and the rate of complications was high.

Zenker diverticulum treatment: retrospective comparison of flexible endoscopic window technique and surgical approaches

INTRODUCTION

Different treatments exist for Zenker diverticulum. We compared flexible endoscopic myotomy of the cricopharyngeal muscle, using a technique called the "window technique" in order to improve the field of view, to surgical approaches.

MATERIALS AND METHODS

Patients were retrospectively included and divided into a gastrointestinal group, with flexible endoscopic myotomy, and an ear-nose-throat treatments group with either rigid endoscopic treatment, either cervicotomy. We evaluated effectiveness in terms of quality of life (on a scale on 0 to 10) safety and technical aspects of each procedure.

RESULTS

A total 106 patients who underwent 128 interventions were included. Rigid endoscopic procedures were the shortest (p < 0.001), with no difference for adverse event. Endoscopic approaches, flexible and rigid ones, were associated with shorter time to intake resumption (1 and 3 days, respectively, vs 6 after cervicotomy) and shorter length of hospital stay (3 and 4 days, respectively, vs 7 after cervicotomy) (p = 0.001). Post-operative QoL was better after flexible endoscopy (9/10) and open cervicotomy (9/10) than after rigid endoscopy (7/10) (p = 0.004). Patients declared fewer residual symptoms after open cervicotomy (77% of low symptomatic patients) and flexible endoscopy (80%) than after rigid endoscopy (43%) (p = 0.003). Conversion to open surgery was more frequent during rigid than flexible endoscopies (18% vs 0%, p = 0.0008).

CONCLUSION

Flexible endoscopic approach of Zenker diverticulum treatment seems to be safe and effective and may be an alternative to surgical approaches. Myotomy can be eventually helped by the window technique.

Predictive Value of Early Post-Treatment Diffusion-Weighted MRI for Recurrence or Tumor Progression of Head and Neck Squamous Cell Carcinoma Treated with Chemo-Radiotherapy

Aims: To investigate the predictive capacity of early post-treatment diffusion-weighted magnetic resonance imaging (MRI) for recurrence or tumor progression in patients with no tumor residue after chemo-radiotherapy (CRT) for head and neck squamous cell carcinoma, and, to assess the predictive capacity of pre-treatment diffusion-weighted MRI for persistent tumor residue post-CRT. Materials and Method: A single center cohort study was performed in one French hospital. All patients with squamous cell carcinoma receiving CRT (no surgical indication) were included. Two diffusion-weighted MRI were performed: one within 8 days before CRT and one 3 months after completing CRT with determination of median tumor apparent diffusion coefficient (ADC). Main outcome: The primary endpoint was progression-free survival. Results: 59 patients were included prior to CRT and 46 (78.0%) completed CRT. A post-CRT tumor residue was found in 19/46 (41.3%) patients. In univariate analysis, initial ADC was significantly lower in patients with residue post CRT (0.56 ± 0.11 versus 0.79 ± 0.13; p < 0.001). When initial ADC was dichotomized at the median, initial ADC lower than 0.7 was significantly more frequent in patients with residue post CRT (73.7% versus 11.1%, p < 0.0001). In multivariate analysis, only initial ADC lower than 0.7 was significantly associated with tumor residue (OR = 22.6; IC [4.9–103.6], p < 0.0001). Among 26 patients without tumor residue after CRT and followed up until 12 months, 6 (23.1%) presented recurrence or progression. Only univariate analysis was performed due to a small number of events. The only factor significantly associated with disease progression or early recurrence was the delta ADC (p = 0.0009). When ADC variation was dichotomized at the median, patients with ADC variation greater than 0.7 had time of disease-free survival significantly longer than patients with ADC variation lower than 0.7 (377.5 [286–402] days versus 253 [198–370], p < 0.0001). Conclusion and relevance: Diffusion-weighted MRI could be a technique that enables differentiation of patients with high potential for early recurrence for whom intensive post-CRT monitoring is mandatory. Prospective studies with more inclusions would be necessary to validate our results.

A prospective multicentre REFCOR study of 470 cases of head and neck Adenoid cystic carcinoma: epidemiology and prognostic factors

BACKGROUND

Adenoid cystic carcinoma (ACC) accounts for 1% of malignant head and neck tumours [1] and 10% of salivary glands malignant tumours. The main objective of our study is to investigate the prognostic factors influencing the event-free survival (EFS) of patients with ACC.

PATIENTS AND METHODS

A multicentre prospective study was conducted from 2009 to 2018. All 470 patients with ACC whose survival data appear in the REFCOR database were included in the study. The main judgement criterion was EFS. Both a bivariate survival analysis using log-rank test and a multivariate using Cox model were performed using the R software.

RESULTS

Average age was 55 years. Females accounted for 59.4% of the cohort. The body mass index (BMI) was normal in 86% of cases. Tumours were located in minor salivary glands in 60% of cases. T3/T4 stages represented 58%; 89% of patients were cN0. histological grade III was observed on 21% of patients. The EFS and overall 5-year survival rates were 50% and 85%, respectively. After adjustment, the most significant pejorative prognostic factors were age ≥65 years (hazard ratio [HR] = 1.67), BMI<16.5 (HR = 2.62), and lymph node invasion cN (HR = 2.08).

CONCLUSION

Age, BMI and N stage are the three main clinical prognostic factors determining EFS identified in this prospective series of patients with ACC. Such findings open new research perspectives on the influence of these components on initial patient care.

Long-term quality of life and psycho-social outcomes after oropharyngeal cancer surgery and radial forearm free-flap reconstruction: A GETTEC prospective multicentric study

OBJECTIVE

To assess long-term quality of life (QoL) and psycho-social outcomes, and to determine their predictive factors after oropharyngeal cancer (OPC) surgery and radial forearm free-flap (RFFF) reconstruction.

METHODS

Patients who had undergone OPC surgery and RFFF reconstruction who were still alive and disease-free at least 1 year after surgery were enrolled in this prospective multicentric study. Patients completed the European Organization for Research and Treatment of Cancer (EORTC) Core (QLQ-C30) and Head and Neck Cancer (QLQ-H&N35) QoL questionnaires, the Voice Handicap Index (VHI-10) questionnaire and the Hospital Anxiety and Depression Scale (HADS). The level of dysphagia was evaluated using the Dysphagia Handicap Index (DHI) and the Dysphagia Outcomes and Severity Scale (DOSS). Predictive factors of these clinical outcomes were determined in univariate and multivariate analysis.

RESULTS

A total of 58 patients were included in this study. Long-term QoL and functioning scales scores were well-preserved (all superior to 70%). Main persistent symptoms were fatigue, reduced sexuality and oral function-related disorders (swallowing, teeth, salivary and mouth-opening problems). HADS anxiety and depression scores were 7.2 and 5.4, respectively. Twenty-one (36%) patients presented an anxiodepressive disorder (HADS global score ≥ 15). Among the 21 patients who were still working before surgery, 11 (52%) had returned to work at the time of our study. The HADS global score (p < 0.001) was the main predictor of QoL, VHI-10 and DOSS scores.

CONCLUSIONS

Psychological distress is the main determinant of long-term QoL and is therefore of critical importance in the multidisciplinary management of OPC patients.

[The tumors of the ear]

Any cutaneous lesion of the outer ear must be managed jointly by a dermatologist and an ENT, regardless of the age of the patient. The presence of a malignant cutaneous carcinoma (Squamous cell carcinoma or melanoma) of the pavilion requires a minimum extension assessment by a cervical ultrasound, CT-scan and MRI will be prescribed according to the degree of infiltration and the presence of clinics signs (lymphadenopathy, facial paralysis, cognitive impairment). A polyp of the external auditory meatus must be systematically biopsied in consultation and, if necessary, in the operating room with fresh anatomopathological analysis. Any "otitis externa", which does not progress favorably under local treatment, must lead to eliminate a tumoral pathology of the external acoustic meatus or of the middle ear. Any suspicion of cholesteatoma should lead to an ENT consultation to confirm the diagnosis and consider its treatment to limit the auditory dysfunction. Any unilateral neurosensorial hearing loss or unilateral vestibular involvement with normal otoscopy should lead to eliminate a inner ear tumor by an MRI of the inner ear and the ponto-cerebellar angle in millimeter sections.

Assessment and management of cervico-mediastinal goiter

Cervico-mediastinal goiter is a particular entity from the point of view of thyroid surgery. Its volume, hardness and intrathoracic extension require the surgeon to adapt technique and perform a painstaking preoperative work-up, so as to draw up fully-fledged plan. CT is now indispensable, to anticipate risks and determine whether sternotomy is needed. Surgery seems to induce more postoperative complications than in conventional surgery, although they can be reduced by retrograde dissection of the inferior laryngeal nerve and downward dissection of the posterior side of the lobe to optimize control of adjacent structures. This surgery requires optimal teamwork between all of the specialties involved in patient management: medical, radiological, anesthesiological and surgical.