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.

Viruses and viral epidemics in the metabolic theory of evolution

Viruses, including the SARS-CoV-2 virus responsible for the current COVID-19 epidemic, are a key to the understanding of life and evolution. Cells may have arisen from aqueous sequestration inside a lipid envelope studded with chromophores capable of capturing solar photons. Nitrogen incorporation in the primordial cell chemistry allowed synthesis of amino acids and nucleic acids, a prelude to RNA and subsequently DNA. Metagenomics provides access to nucleoprotein sediments synthesised by a googol of metabolically differentiated cells that have marked the evolution of life. Replication of a virus, a nucleoprotein particle, occurs passively in competent cells. Viruses are only identified in the context of the epidemic that they induce as a result of transmission from one host to another. By breaking down the viral particle, the host cell appears to resurrect the metabolic function of the nucleic acid, which synthesises its components without any form of control. Viral products undergo self-assembly and are exported by either exocytosis or cytolysis. In the absence of cells, viruses appear to be inert. However, intracellular contamination of a virus does not always result in replication: the viral genome can disappear, remain latent, wake up, remain embedded in the cellular genome, become an oncogene or induce auto-immunity. The presence of endogenous retroviruses in eukaryotic cells raises the question of their possible role in evolution.

Septorhinoplasty by disarticulation

Septorhinoplasty by disarticulation is an esthetic and functional solution for naturally occuring nasal pyramid dysmorphia, releasing the anatomic traces of growth-related stresses. Disarticulating the septolateral cartilage from its bony framework via a closed approach to the septal pocket is associated to Rethi's external approach in order to disarticulate the fibrocartilaginous nasal dorsum, while conserving its integrity, under the bony dorsum. The bony pyramid is then disarticulated down to the nasion, after resecting any bone hump, by 2 paramedian and 2 low lateral osteotomies in the basal groove. The lateral sides of the bony pyramid are then fractured at their posterior edges by percutaneous pinching to close the open roof and realign them along the midline. The septolateral cartilage, reduced as necessary at the inferior and anterior edges, is thereafter repositioned on the premaxillary bone. Traction on its anterior edge restores rectilinear frontal and lateral tension in the fibrocartilaginous dorsum, fully conserved from its attachment to the nasion. This technique corrects any septal deformity and restores frontal and lateral dorsum straightness.

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.

Use of P-values and the terms "significant", "non-significant" and "suggestive" in Abstracts in the European Annals of Otorhinolaryngology, Head & Neck Diseases

OBJECTIVES

To evaluate the use of P-values and the terms "significant", "non-significant" and "suggestive" in Abstracts in the European Annals of Otorhinolaryngology, Head & Neck Diseases.

MATERIALS AND METHODS

Consecutive articles accepted for publication during the period January 2016 - February 2019 were systematically reviewed. Main goal: descriptive analysis of the citation of P-values and use of the terms "significant", "non-significant" and "suggestive" in Abstracts. Secondary goal: analytic study of: (i) correlations between citation of a P-value and the main characteristics of authors and topics; and (ii) misuse of the terms "significant", "non-significant" and "suggestive" with respect to cited P-values, and correlations with author and topic characteristics.

RESULTS

In all, 91 articles were included. P-values and the terms "significant", "non-significant" and "suggestive" were cited in 35.1%, 41.7%, 10.9% and 0% of Abstracts, respectively. Citing a P-value did not significantly correlate with author or topic characteristics. There were discrepancies between the terms "non-significant", "significant" and "suggestive" and P-values given in the body of the article in 57.1% of Abstracts, with 30.7% overestimation and 25.2% underestimation of results, without significant correlation with author or topic characteristics.

CONCLUSION

Authors, editors and reviewers must pay particular attention to the spin resulting from inappropriate use of the terms "significant", "non-significant" and "suggestive" in Abstracts of articles submitted to the European Annals of Otorhinolaryngology, Head & Neck Diseases, to improve the rigor, quality and value of the scientific message delivered to the reader.

Intestinal and non-intestinal nasal cavity adenocarcinoma: Impact of wood dust exposure

The aim of the present study was to investigate the role of wood dust exposure in intestinal (ITAC) and non-intestinal type (non-ITAC) nasal adenocarcinoma, so as to improve understanding of the oncogenic mechanisms in the light of the recent literature and of evo-devo concepts.

MATERIALS AND METHODS

All consecutive patients operated in our institution for nasal adenocarcinoma diagnosed on anatomopathology between May 2004 and February 2014 were included. Surgical specimens were examined twice by independent pathologists, blind to wood dust exposure status. Clinical and demographic data, including wood dust exposure, were collected for the two groups (ITAC and non-IATC).

RESULTS

90 patients (84 ITAC, 6 non-ITAC) were included. No non-ITAC patients had history of wood dust exposure, versus 83/84 cases (99%) in ITAC (mean exposure duration: 30±16 years; range 2-65 years). Only 12 ITAC patients (18%) were still exposed at diagnosis. ITAC may develop long after the end of wood dust exposure (up to 60 years). Eight patients (12%) had exposure durations of less than 5 years. Latency between onset of exposure and onset of disease did not decrease with exposure duration.

CONCLUSION

Exposure to wood dust, even for short periods of time, incurs a risk of developing ITAC, usually after a long latency period. Any exposure requires lifetime follow-up, to ensure prompt treatment. Factors leading to the development of nasal ITAC and non-ITAC are probably different. The analogy with Barret's esophagus and esophageal adenocarcinoma may shed light on the oncogenesis of nasal ITAC.

Olfactory cleft dilatation

The surgical technique of olfactory cleft dilatation consists in transmucosal lateral fracture-dislocation of the lateral wall of each olfactory cleft (i.e., of the turbinate wall of the ethmoid, composed, from anterior to posterior, of the middle, superior and supreme turbinates), in order to get access to the recess hosting the human olfactory mucosa and to the roof of the olfactory cleft (i.e., cribriform plate), with minimal trauma to the mucosa. Olfactory cleft dilatation is indicated for dysosmia secondary to constitutional stenosis of the olfactory clefts due to abnormal development of the ethmoid. Constitutional stenosis of the olfactory clefts should be differentiated from inflammatory obstruction and other diseases of the olfactory clefts, and especially from respiratory epithelial adenomatoid hamartoma, which enlarges the olfactory clefts and must be treated by resection. The technique of olfactory cleft dilatation is illustrated by three surgical cases. There was clear improvement in dysosmia in all three cases, without any complications. The place of constitutional olfactory cleft stenosis needs still to be defined in both diagnosis and treatment of dysosmia.

Chronic respiratory rhinitis

The clinical distinction of chronic respiratory rhinitis appears to confirm the evo-devo theory of the three noses. The authors report two cases of advanced allergic rhinitis, in which chronic inflammation had induced a violaceous colour of the mucosa of the respiratory nose and a whitish polypoid appearance of the free edge of the middle turbinate. Nose and paranasal sinus CT scan revealed, beyond the virtual nasal cavities observed on nasal endoscopy and CT imaging, normal radiolucency or only minor opacities of the ethmoid (i.e. olfactory nose) and paranasal sinuses that could not explain the severity of the chronic nasal dysfunction. The hypothesis of non-allergic chronic respiratory rhinitis is developed according to these two observations. The differential diagnosis between chronic respiratory rhinitis and dysfunction of the cavernous plexuses of the respiratory nose is discussed. A precise diagnosis appears to be a prerequisite for appropriate and effective management. Surgery of the respiratory nose can associate septoplasty to inferior turbinoplasty, but must be preceded and combined with medical treatment adapted to the underlying inflammatory process.

Nasal polyposis (or chronic olfactory rhinitis)

The concept of chronic rhinosinusitis with or without polyps is founded on the structural and functional unicity of the pituitary mucosa and its united response to environmental aggression by allergens, viruses, bacteria, pollution, etc. The present review sets this concept against the evo-devo three-nose theory, in which nasal polyposis is distinguished as specific to the olfactory nose and in particular to the non-olfactory mucosa of the ethmoid, which is considered to be not a sinus but rather the skull-base bone harboring the olfactory mucosa. The evo-devo approach enables simple and precise positive diagnosis of nasal polyposis and its various clinical forms, improves differential diagnosis by distinguishing chronic diseases of the respiratory nose and those of the paranasal sinuses, hypothesizes an autoimmune origin specifically aimed at olfactory system auto-antigens, and supports the surgical concept of nasalization against that of functional sinus and ostiomeatal-complex surgery. The ventilation function of the sinuses seems minor compared to their production, storage and active release of nitric oxide (NO) serving to oxygenate arterial blood in the pulmonary alveoli. This respiratory function of the paranasal sinuses may indeed be their most important. NO trapped in the ethmoidal spaces also accounts for certain radiographic aspects associated with nasal polyposis.

Chronic nasal dysfunction

Chronic nasal dysfunction is a clinical concept in the diagnostic and therapeutic management of sinonasal diseases, based on the evo-devo theory of formation of the nose according to which the nose is not a single organ but rather an association of three organs: olfactory nose, respiratory nose and paranasal sinuses. In chronic nasal dysfunction theory, etiological diagnosis takes account of the possible pathophysiological independence of nasal symptoms, in accordance with the different origins and physiology of the three organs constituting the nose. The diagnostic approach of the chronic nasal dysfunction concept breaks down the pathology so as to propose treatment(s) adapted to the diseased organ(s) and to the capacity for physiological resolution of dysfunction induced in one organ by pathology in a neighboring nasal organ. The ethmoid is not a sinus according to evo-devo, and therefore functional endoscopic endonasal surgery (FEES) cannot be restricted to functional endoscopic sinus surgery (FESS). Evo-devo theory and the chronic nasal dysfunction concept offer an alternative to the concept of chronic rhinosinusitis with or without polyps for the management of sinonasal diseases.

Endoscopic surgery of the olfactory cleft

The olfactory cleft is the specific site of development of many tumours (respiratory epithelial adenomatoid hamartoma, intestinal-type adenocarcinoma, neuroblastoma, inverted papilloma, glomangiopericytoma, etc.) and is also the site of CSF rhinorrhoea via the cribriform plate (cribri-rhinorrhoea). Olfactory cleft surgery must therefore be considered to be a specific type of surgery, complementary to ethmoidal labyrinth surgery and anterior skull base surgery. Olfactory cleft tumours can be resected according to five different surgical procedures: olfactory cleft mucosal resection, partial resection of the olfactory cleft, total resection of the olfactory cleft, unilateral endoscopic anterior skull base resection, and bilateral endoscopic anterior skull base resection. The diagnosis and closure of cribri-rhinorrhoea (i.e. documented CSF rhinorrhoea, demonstrated to arise from the cribriform plate during endoscopic examination of the olfactory cleft under general anaesthesia in a patient with no localizing signs on imaging) completes this range of treatment options.

Sinonasal symptom-related sleep disorders before and after surgery for nasal polyposis

BACKGROUND

Patients with nasal polyposis (NP) complain of several sinonasal symptoms that impact their sleep and quality of life. However, data on sleep disorders related to NP symptoms, before and after surgery, is poor. The aim of the present study was to analyze sleep complaints related to each NP symptom, before and after surgery, using the Dynachron questionnaire.

METHODOLOGY

63 patients operated for NP were included in this prospective study. They filled the DyNaChron questionnaire one day before surgery (V0), 6 weeks (V1) and 7 months (V2) after surgery. The self-ratings (0-10 point visual analog scale) of nasal obstruction, anterior rhinorrhea, postnasal discharge, cough and 5 items related to sleep disturbances, due to each symptom of chronic nasal dysfunction, were extracted from the questionnaire and analyzed.

RESULTS

There was significant improvement of symptoms and symptom-related sleep disturbance scores at V1 and V2 compared to baseline scores. Before surgery, moderate/severe sleep disorders that patients attributed to nasal obstruction (the patient thinks it is due to nasal obstruction rather than a clinical test to show nasal obstruction) or anterior rhinorrhea were reported in two thirds of patients, postnasal discharge in one half, and chronic cough in one third. After surgery, less than 10% of patients reported moderate/severe sleep disorders at V1. There was a mild increase of patients who rated moderate/severe sleep disorders at V2 in comparison to V1. The correlation between scores of nasal obstruction and its impacts on sleep quality was weak before surgery and strong afterwards.

CONCLUSION

Nasalization improved sleep quality significantly at 6 weeks and at 7 months after surgery. However, there was a mild increase of complaints related to postnasal discharge and cough at 7 months after surgery.

Specific immunotherapy in allergic rhinitis

Allergic rhinitis is a common condition, with significant impact on quality of life depending on severity and quality of control. Allergen-specific immunotherapy (allergen-SIT) is the only known treatment able to alter the natural course of allergic rhinitis. Although well known to allergologists, it has yet to be fully adopted by the ENT community. This review, based on the most recent meta-analyses and clinical studies, shows that SIT significantly reduces symptoms and medication requirements (nasal corticosteroids, H1-antihistamines) in allergic rhinitis. It can reduce the risk of progression to asthma and, if initiated early enough, of developing new sensitizations. Immunobiological analysis shows an altered inflammatory profile following SIT, with immune tolerance involving T-regulatory lymphocyte induction and IgG production. Sublingual SIT with drops is as effective as subcutaneous SIT and is simpler to use, with less anaphylactic risk. Standardization of trial protocols in terms of treatment response assessment and side effect grading is recommended to improve comparative studies. Sublingual SIT with tablets has recently been introduced, providing a good opportunity for ENT practitioners to adopt the SIT approach in rhinitis triggered by allergy to pollens and, in the near future, to house dust mites.

Awareness of obstructive sleep apnea-hypopnea syndrome among the general population of the Lorraine Region of France

OBJECTIVE

Obstructive sleep apnea-hypopnea syndrome (OSAHS) seems to be underdiagnosed. The aim of this study was to assess awareness of OSAHS among the general population of the Lorraine Region of France.

METHODS

A descriptive epidemiological study was carried out from July to November 2015 in the Lorraine Region, using an anonymous questionnaire that assessed knowledge of OSAHS-related symptoms and complications. The survey was also circulated on the Internet via social media. Exclusion criteria comprised age under 18 years, refusal to fill out the questionnaire and linguistic barrier.

RESULTS

1307 subjects filled out the survey: 1020 on paper format and 287 via the Internet. About two-thirds of the population recognized a majority of symptoms. However, there was a significant lack of knowledge of complications, especially cardiological and neurological. Suffering from OSAHS, having had higher education, and being under 40 years of age, were factors linked to better awareness of the syndrome. Internet respondents also showed better awareness.

CONCLUSION

Despite encouraging results regarding OSAHS symptoms, the general population showed limited awareness of its complications. Innovative educational campaigns must be organized to inform practitioners and the general public about the disease and raise awareness of its complications.

Assessment of facial pain and headache before and after nasal polyposis surgery with the DyNaChron questionnaire

OBJECTIVES

Facial pain/headache is reported in 16-67% of nasal polyposis (NP) patients. This wide range may be due to differences in assessment methods. The present prospective study assessed facial pain/headache and quality-of-life (QoL) impact before and after NP surgery.

METHODS

Pain was assessed on the DyNaChron self-administered questionnaire in patients undergoing NP surgery, the day before the procedure (V0) and 6 weeks (V1) and 7 months (V2) after. All patients underwent the same nasalization procedure, sparing the middle turbinates when possible. The questionnaire extract comprised 1 item assessing pain, 13 assessing physical impact and 4 assessing psychosocial impact, with responses on visual analog scales (VAS) graded 0 (no discomfort) to 10 (unbearable discomfort).

RESULTS

Sixty-three patients (mean age: 50.6±12.8 years; 32 male [50.8%], 31 female [49.2%]) were included. Thirty-seven patients (58.7%) had history of NP surgery. Fifty-two percent reported moderate to severe pain before surgery, 17.5% at 6 weeks, and 22.2% at 7 months. One-third reported no pain preoperatively, versus a half at 6 weeks and 7 months. Scores for the physical and psychosocial impact of pain were improved after surgery.

CONCLUSION

Headache/facial pain is frequent in patients for whom NP surgery is indicated. Endoscopic surgery relieves the symptom and its physical and psychosocial impacts. However, one-fifth of patients reported residual postoperative pain.

Structure of the lateral mass of the ethmoid by curved stacking of endoturbinal elements

CONTEXT

According to evo-devo theory, the embryonic development of the nasal organ mimics its phylontogenic formation: the lateral masses of the human ethmoid bone develop by curved "onion" stacking of the endoturbinals (the horizontal bone septa of the mammalian olfactory chamber) under the impact of facial and skull-base remodeling, rather than by pneumatization of cavities communicating via ostia.

OBJECTIVES

To assess the frequency of the onion structure on coronal CT.

MATERIAL AND METHODS

Three independent examiners performed a retrospective descriptive study of coronal CT scans taken ahead of septorhinoplasty between June 2010 and December 2012 in adult patients without history of sinonasal surgery.

RESULTS

Fifty patients were included. In the anterior right and left and posterior right ethmoid, an onion arrangement of the endoturbinals was systematically found on at least 1 view, and on 60% of views taking all ethmoid compartments together. Two endoturbinals were generally involved, but a rolling-up of 3 endoturbinals was also observed, significantly more frequently in the posterior compartments (P=0.004 on the right side, P=0.012 on the left).

CONCLUSION

The onion structure of the lateral masses of the ethmoid can be observed on coronal CT scans. This structure confirms evo-devo theory. The ethmoid thus appears fundamentally different from the paranasal sinuses, suggesting that the pathogenesis of nasal polyposis and ethmoidectomy techniques need to be reconsidered.

Nasal or canthal-alar parentheses: A study of the facial base of the nose

OBJECTIVES

The facial implantation of the osseous nasal pyramid corresponds to the piriform aperture, the shape of which is projected on the facial skin in the form of bracket-shaped parentheses. The objective of this study was to compare inter-parenthesis width with subjective visibility on frontal photographs.

MATERIAL AND METHODS

The "patient" group came from a retrospective cohort of photographs taken ahead of septorhinoplasty. The "model" group photographs were collected from the Web or magazines. Nasal parentheses were first judged subjectively as frank or faint. Then, independently, parenthesis width was measured by computer in pixels and converted into millimeters by iris-dependent calibration. Inter-parenthesis width was compared statistically with the frank/faint assessment, according to gender and group.

RESULTS

A total of 113 photographs were included: 46 patients (19 women, 27 men) and 67 models (43 women, 24 men). Sixty-seven of the 113 nasal parentheses appeared frank (59.3%), more frequently in men than women (70.6% vs 50.0%, P=0.02) and in patients than models (69.6% vs 52.2%, P=0.06). Inter-parenthesis width was significantly greater in frank than faint presentations (34.9±3.5mm vs 30.7±3.4mm, P<0.0001), in men than women (35.2±4.1mm vs 31.5±3.1mm, P<0.0001), and in patients than models (34.9±4.0mm vs 32.0±3.6mm, P<0.0001).

CONCLUSION

Frank nasal parentheses correspond to wider facial implantation of the nose.

Sinusology

This paper presents a brief history of the successive anatomical, physiological and pathophysiological concepts about the paranasal sinuses. Sinusology, the science of the paranasal sinuses, is founded on scientific work on the production of nitric oxide (NO) by the sinuses and on the evo-devo theory of their formation. The paranasal sinuses seem to develop after regression of the erythropoietic marrow in the maxillary, frontal and sphenoid bones and its replacement by cavities filled with gas, which escapes into the nasal fossae through the ostium. The sinus epithelium synthesizes NO continuously. The paranasal sinus cavities form a compartmentalized reservoir of NO, which is released discontinuously in boli after an opening of the ostium. Ostium opening can be induced by sound vibration, either internal (humming) or external (an acoustic vibration added to the in-breath). NO plays the role of an "aerocrine" messenger between the upper and lower respiratory tracts, reducing pulmonary vascular resistance and facilitating alveolar oxygen transfer into the bloodstream. Its physiological role in arterial blood oxygenation could be involved in speech and singing or be activated by physiological snoring during sleep. Rhinology, the science of the nose, in which the evo-devo concept distinguishes the respiratory and the olfactory nose, is now backed up by sinusology.

Analysis of case reports submitted to the European Annals of Otorhinolaryngology Head & Neck Diseases

OBJECTIVES

To assess flaws, rejection rate and reasons for rejection of case reports submitted for publication in the European Annals of Otorhinolaryngology Head & Neck Diseases.

MATERIALS AND METHODS

A prospective analysis of flaws noted in reviewing 118 case reports from 29 countries consecutively submitted to the European Annals of Otorhinolaryngology Head & Neck Diseases during the period Sept. 1, 2014 to Sept. 30, 2015.

RESULTS

The most frequent flaws, noted in 74.5% of cases, were: lack of originality (more than 15 such cases previously reported in the medical literature) and lack of new data contributing to the medical literature. Overall, 5% of the cases were accepted for publication, 7% were not resubmitted by the authors, and 88% were rejected. On univariate analysis, none of the variables under analysis correlated with acceptance or rejection of the submitted case. Editorial decision time varied from 1 to 7months (median, 1 month). In 16.3% of the 104 cases of rejection (17/104), the editors suggested resubmission in the section "Letter to the Editor" or "What is your diagnosis?"; 15 of the 17 reports were resubmitted, and 10 (66.6%) were ultimately accepted for publication.

CONCLUSION

The editorial committee of the European Annals of Otorhinolaryngology Head & Neck Diseases hope that the present data and review of the literature will provide authors with a framework to avoid major errors leading to rejection and will speed publication of the case reports they submit to our columns in the near future.

Characteristics and analysis of scientific articles submitted to the European Annals of Otorhinolaryngology, Head and Neck Diseases

OBJECTIVES

To evaluate characteristics, suggested modifications and reasons for rejection in scientific articles submitted for publication in the European Annals of Otorhinolaryngology, Head and Neck Diseases.

MATERIALS AND METHODS

A prospective study analyzed the flaws noted by reviewers in 52 scientific articles submitted to the European Annals of Otorhinolaryngology, Head and Neck Diseases between August 31, 2014 and February 28, 2015.

RESULTS

Fifteen flaws concerning content and 7 concerning form were identified. In more than 25% of submissions, major flaws were noted: purely descriptive paper; lack of contribution to existing state of knowledge; failure to define a clear study objective and/or analyze the impact of major variables; poorly structured Materials and methods section, lacking description of study population, objective and/or variables; lack of or inappropriate statistical analysis; Introduction verbose and/or misrepresenting the literature; excessively heterogeneous and/or poorly described study population; imprecise discussion, straying from the point, overstating the significance of results and/or introducing new results not mentioned in the Results section; description of the study population placed in the Results section instead of under Materials and methods; serious mistakes of syntax, spelling and/or tense; and failure to follow the Instructions to Authors. After review, 21.1% of articles were published, 65.3% rejected and 13.4% non-resubmitted within 3 months of review. On univariate analysis, the only variable increasing the percentage of articles accepted was the topic not being devoted to head and neck surgery (P=0.03).

CONCLUSION

These results document the excessive flaw rate still to be found in manuscripts and demonstrate the continuing need for authors to master and implement the rules of scientific medical writing.