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The aim of the survey was to define the indications for preventive tracheostomy in transoral robotic surgery (TORS) for head and neck cancers.From October 2019 to January 2020, an online questionnaire was e-mailed to French surgical ENT teams with considerable experience of the TORS procedure (Gettec group). A descriptive analysis of the answers was performed.Eighteen French surgical teams answered the questionnaire. For 77.8% of the surgical teams, a past history of radiotherapy with residual edema was an indication for prophylactic tracheostomy, and for 88.9%, 75 mg of antiplatelet medication or anticoagulation treatment was an indication.Early preventive tracheostomy during TORS can protect airway from uncommon but potentially life-threatening complications, such as transoral hemorrhage or airway edema. We recommend it in high-risk situations, such as a past history of radiotherapy or antiplatelet therapy associated with large resections. Further studies are needed to establish evidence-based recommendations.

Transoral robotic surgery (TORS) as a first-line therapy has been well-documented but evidence is missing regarding salvage therapy. The aim of this study is to compare the oncological and functional outcomes of TORS as a primary and salvage therapy. This retrospective monocentric study included 74 patients operated by a single surgeon and sorted out into two groups: primary treatment (PT) or Salvage treatment (ST) in case of previous history of radiation therapy. Patients were further stratified by tumour location: larynx and pharynx (lST vs lPT and pST vs pPT). Forty-eight patients were included in PT group (64.9%) and 26 in ST group (35.1%). ST patients had more frequent cTis/T1 tumours (57.7% vs 29.2%, p = 0.0164) and no clinical lymph disease (3.8% vs 37.5%, p = 0.0016). Tracheostomy was more often performed in the ST group (57.7% vs 16.7%, p = 0.0003) and the lST subgroup (88.9% vs 9.1%, p

The aim of this study was to assess the performance of Narrow Band Imaging (NBI) added to White Light (WL) in the delineation of laryngopharyngeal superficial cancer spread during office-based transnasal flexible endoscopy. This bi-centric prospective study was conducted between October 2014 and December 2017. We included consecutive patients with laryngopharyngeal malignant tumors. Transnasal flexible endoscopy was performed by two endoscopists who were blinded to each other's assessments and who examined each patient independently. The first endoscopist only performed a WL examination, while the second endoscopist carried out both WL and NBI. The extent of tumor involvement was reported based on predefined anatomical sub-units. Biopsies in NBI + /WL− sub-units were subsequently performed during panendoscopy. Eighty-four patients were included in the study. A total of 72 NBI + /WL− sub-units were sampled in 38 patients, and 37 of the biopsies were positive (51.4%): 16 for invasive carcinoma, 17 for high-grade dysplasia/carcinoma in situ and 4 for low-grade dysplasia. Ultimately, 26.2% of patients had at least one positive biopsy in an NBI + /WL− sub-unit and, therefore, a better tumor delineation. The clinical T stage was upgraded in 4.8% of cases examined. Adding NBI to WL imaging during transnasal flexible endoscopy in patients presenting with laryngopharyngeal pre-malignant or malignant lesions improves the delineation of superficial cancer spread, thereby leading to better adapted treatments. Clinicaltrials.gov registration number: NCT02035735.

Purpose: To evaluate the risk factors of pharyngocutaneous fistula after total pharyngolaryngectomy (TPL) in order to reduce their incidence and propose a perioperative rehabilitation protocol. Materials and Methods: This was a multicenter retrospective study based on 456 patients operated for squamous cell carcinoma by total laryngectomy or TPL. Sociodemographic, medical, surgical, carcinologic, and biological risk factors were studied. Reactive C protein was evaluated on post-op day 5. Patients were divided into a learning population and a validation population with patients who underwent surgery between 2006 and 2013 and between 2014 and 2016, respectively. A risk score of occurrence of salivary fistula was developed from the learning population data and then applied on the validation population (temporal validation). Objective: To use a preoperative risk score in order to modify practices and reduce the incidence of pharyngocutaneous fistula. Results: Four hundred fifty-six patients were included, 328 in the learning population and 128 in the validation population. The combination of active smoking over 20 pack-years, a history of cervical radiotherapy, mucosal closure in separate stitches instead of running sutures, and the placement of a pedicle flap instead of a free flap led to a maximum risk of post-op pharyngocutaneous fistula after TPL. The risk score was discriminant with an area under the receiver operating characteristic curve of 0.66 (95% confidence interval [CI] = 0.59-0.73) and 0.70 (95% CI = 0.60-0.81) for the learning population and the validation population, respectively. Conclusion: A preoperative risk score could be used to reduce the rate of pharyngocutaneous fistula after TPL by removing 1 or more of the 4 identified risk factors.

International audience; The radial forearm flap is one of the most used micro‐anastomotic flaps in cervicofacial reconstruction in a carcinological context. This flap is an ideal in terms of reliability and fineness; it has, however, some disadvantages in terms of the functional and aesthetic complications of its donor site. In alternative to a radial forearm free flap, we report the use of the free super thin external pudendal artery flap (STEPA flap) for an oropharyngeal reconstruction. The aim was to decrease the donor site morbidity. A 71‐years‐old man with a T2N0M0 oropharyngeal squamous cell carcinoma has undergone surgical treatment. A left STEPA free flap was performed to reconstruct a defect about 8 × 6 cm2. This flap was designed as a half‐scrotal free flap sized 9 × 7 cm2 and was inset after tunneling of the pedicle at the floor of the mouth. A surgical revision was needed on the 15th day postoperative for disunion. There was no skin flap failure. After 12 month of follow‐up, no complication was observed at the donor site and no erectile dysfunction was recorded. Its characteristics in terms of fineness, flexibility, ease of conformation, and pedicle length are similar to those of the radial forearm flap with less aesthetic and functional sequelae of the donor site. The STEPA flap may be a promising free flap in oropharyngeal or oral cavity reconstruction.

BACKGROUND A forehead frontal flap is the treatment of choice for complex nasal defects. However, in patients with contra indications for such frontal flaps, few alternatives are available. METHODS We developed a three-stage, nasal reconstruction procedure using a bipedicled, propeller perforator flap based on the modiolus perforators. Here, we describe the flap, the harvesting thereof, and the 6-month outcomes after placement. RESULTS The flap did not exhibit any sign of necrosis or congestion. Six months after reconstruction, the patient had not suffered any esthetic or functional sequela. CONCLUSION Although the indications for our new flap are less numerous than those for a frontal flap, our flap is a useful alternative when frontal flap placement is not feasible (or the patient refuses such a flap) and when placement of a free flap is too risky.

Objectives Trans-nasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular arterial embolisation both provide excellent success rates for intractable epistaxis. Recent economic models suggest that TESPAL could be a cost-saving strategy. Our main aim was to perform cost-effectiveness analyses on TESPAL compared with embolisation to treat patients with epistaxis. Design We performed retrospective, monocentric, comparative analyses on patients referred to our centre and treated with embolisation or TESPAL. Setting This economic evaluation was carried out from a payer's perspective (ie French National Health Insurance) within a time horizon of 12 months. Participants Thirty-seven TESPAL procedures and thirty-nine embolisation procedures to treat intractable epistaxis were used in the analyses. Main outcome measures The primary outcome is presented as the cost per 1% of non-recurrence. Effectiveness was defined as avoiding recurrence of epistaxis during the 1-year follow-up. Cost estimates were performed from the payer's perspective. Results Hospitalisation costs were higher for embolisation compared with TESPAL (5972 vs 3769 euros). On average, hospitalisation costs decreased by 41% when a patient was treated by TESPAL compared with an embolisation strategy (P = 0.06). The presence of comorbidities increased hospitalisation costs by 79% (P = 0.04). TESPAL enabled 1867€ to be gained in intractable epistaxis. Conclusions The outcomes from our decision model confirm that TESPAL is more cost-effective for patients with intractable epistaxis.

Numerous techniques for closure of the anterior skull base in cancer patients have a high success rate but management of failure is poorly documented. To standardize the post-operative follow-up after reconstruction surgery of the anterior skull base after removal for sinonasal carcinoma. Retrospective review of failure of anterior skull base reconstruction between 2005 and 2018 in a multicenter setting. Twenty four patients were included. Reconstruction failure was detected by a cerebrospinal (CSF) leak in 79.2%, by an infectious complication without CSF leak (i.e. meningitis) in 12.5%, and in 8.3% by extensive pneumocephalus. Failure was observed during the first week after surgery in 75% of patients, in the second week in 21%, and in 4% after day 15. The delay in discovery of the failure was associated with multilayer reconstruction (p=.03). Failure was treated surgically in 54% of the patients and medically in 46%, with a similar success rate (85 vs. 100%). After carcinologic resection of the anterior skull base, monitoring should be systematic during the first postoperative week. Surgical management of failure is not always necessary.

Few studies have focused on assessing patient satisfaction after non-surgical rhinoplasty using hyaluronic acid (HA). The main objective of this study was to perform a systematic review assessing patient satisfaction after non-surgical rhinoplasty using HA. We conducted a systematic review using the PRISMA model. All articles assessing patient satisfaction using self-questionnaires or scales (visual analogic scales, Likert scale) after non-surgical rhinoplasty were included. We also analyzed injection protocols and complications. The criteria for considering studies for the review were based on the population, intervention, comparison, outcome, timing and setting (PICOTS) framework. A total of 674 patients were included in eight studies. Mean age was 29.5 years old (min = 19, max = 67, sex ratio = 0.20). Rates of “satisfied” or “very satisfied” patients were 100% immediately after injection (n = 404/404 patients), 98.2% in the weeks following injection (n = 628/639 patients), 84.7% 3 months after injection (n = 333/393 patients) and 96.4% one year after injection (n = 60/62 patients). Duration of HA effectiveness ranged between 8 and 14 months. One local infection (0.001%) but no skin necrosis and no blindness were reported. Most of authors used less than 1 mL of HA per procedure. Provided precautions for use and indications are observed, and presuming good anatomical knowledge, non-surgical rhinoplasty is an interesting procedure associated with high satisfaction rates. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background Because of the widespread and high reliability of free flaps in head and neck reconstruction, the challenge today is to reduce donor site morbidity. The external pudendal artery (EPA) free flap has been described in men and provides a minimal functional and cosmetic impact. This study aimed to assess the feasibility of the EPA free flap in women for buccopharyngeal reconstruction. Methods A dissection of the inguinal region was performed bilaterally on fresh female cadavers. The anatomy of the EPA and its angiosome were described, along with the design of the EPA free flap. A computed tomography angiographic study of the flap perfusion was performed. Results Fourteen cadavers were dissected. The EPA was constant. Its diameter ranged from 1.12 to 2.96 mm (median 2.0 mm). The mean area of its angiosome was 167.3 ± 38.5 cm2. An axial fasciocutaneous flap was designed with a horizontal skin paddle measuring on average 9.2 × 6 cm and a pedicle length of 8.4 ± 1.9 cm. The mean flap thickness was 11.7 ± 6.8 mm and depended on individual factors. A primary closure was achieved in all cases with a scar hidden in the underwear. Conclusions This anatomical study demonstrates that the EPA seems constant despite variations in its origin pattern. Its diameter and angiosome allow the design of an EPA free flap in women. A clinical study should confirm that this flap is suitable for the repair of buccopharyngeal defects and could be added to the armamentarium of the head and neck reconstructive surgeon.

The aim of this study was to determine the impact and cost-effectiveness of virtual surgical planning during fibula free flap mandibular reconstruction on peri- and postoperative data. We conducted a retrospective cohort study from January 2012 to December 2016 in four French university centres. Three hundred fibula free flaps for mandibular reconstruction were performed in 294 patients. Surgeries were planned in 29.7% of cases (n = 89). There was no significant difference in the rate of negative-margins excision, median length of hospital stay, operative time, and early complications between planned and non-planned surgeries. Morphological analysis revealed a higher rate of centred occlusion in planned patients (satisfactory alignment of interincisal points: Planned 65.5% vs Non-Planned 33.3%, p = 0.006). In mandibular reconstruction by fibula free flap, the additional cost generated by virtual surgical planning does not seem to be balanced by savings resulting from a shorter operative course, a reduced hospital stay, or a reduction in postoperative complications. However, virtual surgical planning may provide a higher rate of centred occlusion. Long-term benefits should be assessed by further studies.

Simultaneous lesions of both proper digital arteries of the thumb are common in hand trauma surgery. The purpose of this anatomical study was to determine if the dorsal arterial network could be sufficient to ensure the vascularization of the thumb skin sheath. We carried out a cadaveric study on 22 hands. The ulnar and radial proper digital arteries of the thumb were ligated at the base of the first phalanx. Red dye was injected into the radial artery and blue dye into the ulnar artery at the wrist level. Visual evaluation of skin staining and systematic photographs was done at 1, 3 and 10 min after injection of dyes. Staining of the thumb sheath was obtained in 100% of the dissections and complete in 91.91% of cases. Staining originated from mixed radial and ulnar artery origins in 81.82% of cases. It was incomplete in 9.09% of cases with a missing on the dorsoradial edge of the proximal phalanx. In one dissection, the whole hand skin was only stained red, and in another dissection only stained blue. The dorsal vascular network ensures the substitution of the skin vascularization in more than 90% of cases when ligating the proper digital arteries of the thumb. A clinical impression of good skin vascularization after injury of both proper digital arteries might lead the surgeon not to perform systematic revascularization, but the risk of variable damages of adjacent tissues due to an interruption of one major arterial system requires a palmar arterial anastomosis whenever possible.

Renal cell carcinoma (RCC) metastatic in the sinonasal cavity is rare. In many cases, it represents the initial presentation of RCC. We conducted a retrospective chart review to report the clinical presentation, imaging, and treatment of RCC metastases in the sinonasal cavity at two tertiary care referral centers. Our population was made up of 8 patients—6 men and 2 women, aged 55 to 86 years (mean: 66.9; median: 63.5)—who had been diagnosed with cancer in the sinonasal cavity. The most common complaints were epistaxis, nasal obstruction, and diplopia. Cancers were located in the ethmoid sinus (n = 3), nasal cavity (n = 2), sphenoid sinus (n = 2), and maxillary sinus (n = 1). Local treatment involved resection and adjuvant radiotherapy in 4 patients, surgery alone in 2 patients, and radiotherapy alone in the other 2. The lesion was embolized before surgery in 4 cases. We also performed a critical review of similar published cases. Our literature review covered 53 cases of RCC metastatic to the sinonasal cavity, including ours. Metastases were the first presentation of RCC in 24 of these cases (45.3%); in our series, the metastases led to the diagnosis of the primary RCC in 3 cases (37.5%). In the 53 reported cases, metastatic resection was performed on 35 patients (66.0%). Survival data were available for 22 of these operated patients, and 17 of them achieved a complete local response. Adjunctive radiotherapy was not associated with a better local response. Overall survival was significantly better in patients who had an isolated metastasis rather than multiple metastases (p = 0.013). There was no difference in overall survival between patients whose metastasis represented the initial presentation of RCC and those whose metastasis did not (p = 0.95). We recommend that sinonasal metastasis be suspected in the event of unilateral nasal bleeding or nasal obstruction in patients diagnosed with RCC. Embolization may prevent abundant bleeding during removal. Surgery may improve the quality of life of these patients while decreasing nasal obstruction and bleeding.

Background Sinonasal undifferentiated carcinoma (SNUC) is a very rare entity with a poor prognosis. Due to the lack of studies on the subject, evidence is lacking concerning its management. Methods A multicenter collaborative study was conducted to assess treatment strategy, oncological outcome, and prognostic factors. Results Definitive analyses focused on 54 patients with a majority of advanced stage; the 3-year overall survival (OS) and 3-year recurrence-free survival (RFS) rates were, respectively, 62.4% and 47.8%. During the follow-up, 18 patients (33.3%) died, 10 (18.5%) developed metastases, 7 had lymph-node involvement (13%), and 12 (22.2%) showed recurrence or local progression. In univariate analyses, treatment modalities associated with improved RFS were induction chemotherapy (p = 0.02) and intensity-modulated radiotherapy (p = 0.007). In the multivariate analyses, only induction chemotherapy (p = 0.047, hazard ratio [HR] = 0.39) was significantly associated with improved RFS. Conclusion Multimodal therapies including induction chemotherapy and intensity-modulated radiotherapy may improve the prognosis of SNUC; surgery might improve local control. Further multicenter studies are required.

Introduction Depuis la generalisation et la grande fiabilite des lambeaux libres en reconstruction cervico-faciale, l’enjeu est aujourd’hui de diminuer la morbidite du site donneur [1] , [2] . Le lambeau pudendal externe libre chez l’homme permet de reduire cette morbidite avec une cicatrice dissimulee, sans complication fonctionnelle [3] , [4] . Objectif Etude anatomique de faisabilite du prelevement d’un lambeau libre pudendal externe chez la femme pour reconstruction de la cavite buccale ou de l’oropharynx. Materiels et methode Une dissection du trigone femoral a ete realisee de facon bilaterale sur cadavres frais feminins. L’origine de l’artere pudendale externe, son diametre a l’origine ainsi que la distance de son origine par rapport au bord superieur du ligament inguinal ont ete decrits. Puis une injection de l’artere pudendale par du bleu patente a ete realisee de facon bilaterale afin de decrire l’angiosome de l’artere pudendale externe. Resultats Cinq cadavres ont ete disseques et injectes de facon bilaterale (10 cas). L’artere pudendale externe a ete systematiquement retrouvee et son origine etait situee au niveau de l’artere femorale superficielle sur les 5 cadavres (100 %). Elle etait unique dans 6 cas, avec un tronc commun dans 2 cas, dupliquee dans 1 cas et triple dans 1 cas. Le diametre de l’artere pudendale externe allait de 1,12 mm a 2,28 mm. Le diametre du tronc commun etait compris entre 2,72 mm et 2,96 mm. Sa distance au bord superieur du ligament inguinal allait de 4,4 cm a 8,7 cm. La taille de l’angiosome allait de 101 cm2 a 216,9 cm2. Conclusion Les resultats preliminaires montrent une technique de prelevement reproductible. Une description du lambeau par injection de latex colore, ainsi qu’une etude statique angio-tomographique de sa vascularisation sont en cours de realisation.

Objectif La connaissance precise de la vascularisation arterielle des fosses nasales est un prerequis indispensable a l’utilisation de lambeaux locaux en chirurgie rhinosinusienne et basicrânienne ainsi qu’a la gestion des epistaxis severes notamment par embolisation arterielle. L’objectif de notre etude etait de preciser la participation de l’artere faciale et de proposer une classification de la variabilite de celle-ci. Materiel et methode Nous avons injecte 10 mL de latex colore dans les deux arteres faciales apres reperage et catheterisme en regard du bord basilaire de la mandibule, de 15 cadavres frais. Une endoscopie des fosses nasales etait alors realisee. Pour chaque sujet injecte nous avons repertorie les territoires muqueux vascularises par une branche terminale de l’artere faciale. Resultats Un total de 24 arteres faciales a ete injecte. Dans 8 cas (33 %) aucune vascularisation ou une simple coloration du vestibule narinaire etait notee. Dans 5 cas (20 %) il existait une participation classique, limitee au vestibule narinaire homolateral, a la partie anterieure du septum jusqu’a la tâche vasculaire, a la tete du cornet inferieure et a la cloison inter-sinusonasale. On retrouvait une coloration atteignant la choane dans 10 cas (41 %), associee a une coloration complete du plancher des fosses nasales pour 8 d’entre elles. Conclusion La vascularisation des fosses nasales par l’artere faciale peut se reveler bien plus importante que celle couramment decrite dans la litterature. La grande variabilite de sa participation doit etre prise en compte avant la realisation de lambeau de couverture de base du crâne, ou dans le traitement des epistaxis severes.

Venous insufficiency is the main cause of failure and surgical revision in free flap surgery. Achieving a double venous anastomosis is frequently proposed to improve flap drainage. However, this procedure remains controversial. The authors evaluated, through a meta-analysis, the benefit of double venous anastomoses in the venous thrombosis, surgical revision, and failure rates of free flaps in head and neck oncologic reconstruction.A systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria in the MEDLINE, PubMed Central, Cochrane Library, and EMBASE databases. Statistical heterogeneity evaluation and then fixed effects and random effects models were used.Sixteen articles were included involving 3684 flaps. The overall success rate was 96.15 percent. The authors reported a failure rate of 1.51 percent in the group with two anastomoses versus 5.03 percent in the group with single anastomoses (OR, 0.64; 95 percent CI, 0.277 to 1.522; p = 0.320). The authors found a venous thrombosis rate of 2.74 percent in the group with two anastomoses versus 4.54 percent in the group with single anastomoses (OR, 0.535; 95 percent CI, 0.334 to 0.858; p = 0.009). There were also more surgical revisions in the single venous anastomoses group, 11.87 percent versus 6.04 percent (OR, 0.474; 95 percent CI, 0.349 to 0.643; p0.001).This meta-analysis supports that performing a double venous anastomosis confers protective effects in venous thrombosis and surgical revision, thus reducing free flap failure. The authors recommend the achievement of double venous anastomosis whenever it is feasible in head and neck oncologic reconstruction.Therapeutic, IV.

OBJECTIVES/HYPOTHESIS: Adipose derived stromal cells (ASCs) are abundant and easy to prepare. Such cells may be useful for treating severe vocal disturbance caused by acute vocal fold scars. STUDY DESIGN: Prospective animal experiments with controls. METHODS: Twenty New-Zealand white rabbits were used in the present study. We evaluated vocal fold healing, with or without injection of autologous ASCs, after acute scarring. A defined lesion was created and the ASCs were immediately injected. Vocal fold regeneration was evaluated histomorphometrically and via viscoelastic analysis using an electrodynamic shaker. RESULTS: Six weeks after ASC injection, vocal folds exhibited significantly less inflammation than control folds (P < 0.005). In addition, hypertrophy of the lamina propria and fibrosis were significantly reduced upon ASC injection (P < 0.02). The decrease in viscoelastic parameters was less important in the ASC injected group compared to the noninjected group (P = 0.08). CONCLUSION: Injection of autologous ASCs improved vocal fold healing in our preclinical model. Further studies are needed, but this method may be useful in humans. LEVEL OF EVIDENCE: NA. Laryngoscope, 126:E278-E285, 2016.

Purposes: The purpose of this study was to compare the efficacy of a mineral-rich solution vs normal saline solution (0.9% NaCl) following endoscopic complete bilateral ethmoidectomy. Methods: This was a prospective, multicenter, randomized, controlled, open-label trial in subjects suffering from steroid-resistant sinonasal polyposis. Adults performed 4 nasal irrigations of mineral or saline solutions daily for 28 days. Evaluations included subject-reported RHINO quality of life (QoL) and NOSE scores, tolerability, and satisfaction, the Lund-Kennedy endoscopic score and assessments of crusting, secretions and mucociliary clearance (rhinoscintigraphy). Results: A total of 189 subjects were randomized. Clinically relevant improvements (> 20 points) in RhinoQOL and NOSE scores were measured in both groups without any significant inter-group difference. Among the subjects with impaired RhinoQOL at pre-inclusion, the change in Impact-RhinoQOL score was significantly superior in mineral-rich vs saline solution at day 21 (p = 0.028) and day 28 (p = 0.027). The Lund-Kennedy score continuously improved in both groups earlier with the mineral-rich solution. Crusts were significantly fewer in number and less severe/obstructive in patients receiving mineral-rich vs saline solution at day 7 (p = 0.026) and day 14 (p = 0.016). Furthermore, secretions disappeared significantly more quickly and were less thick/purulent with mineral-rich solution at day 14 (p = 0.002) and day 21 (p = 0.043). Less epistaxis was reported in the mineral vs saline solution (p = 0.008 at day 21). Conclusions: Our findings indicate that the composition of a nasal irrigation solution influences endoscopic scores and QoL after sinus surgery for patients over 60, those with an initially poor QoL and higher symptom score, and smokers.

Background: The management of malignant wounds remains particularly difficult. They are often malodorous, highly exuding, and painful. In this context, the use of negative pressure wound therapy is usually not recommended. It is, however, an effective procedure for maintaining a good quality of life in certain palliative situations. Case presentation: Five patients underwent negative pressure wound therapy for a malignant wound in our unit. Three had sarcomas, one patient had a parietal recurrence of breast carcinoma, and one patient had melanoma. They were in a metastatic palliative situation and were no longer receiving specific treatment. Case management and outcomes: The patients reported a decrease in odor and exudates with negative pressure wound therapy, compared with conventional dressings. No patients complained of pain associated with the suction system itself. Fewer dressing changes reduced the pain and encouraged the resumption of social interactions. The average duration of negative pressure wound therapy before the death of the patients was 49 days. No complications or bleeding were observed. The duration of the patients’ stay was shortened by implementing negative pressure wound therapy at home. Conclusion: We report on our experiences with five patients for whom manufacturers and health authorities contraindicated the use of negative pressure wound therapy because of its potential to encourage tumor growth, although it was considered to be beneficial for all of these patients. This procedure may offer an alternative to conventional wound dressings at the end of life and improve the quality of life of patients by controlling the three most disabling elements: the odor, exudate, and pain associated with changing the dressings. Miniaturization and lower costs could promote the systematic use of negative pressure wound therapy.

Respiratory epithelial adenomatoid hamartoma (REAH) is a relatively recent diagnosis that is gaining more interest in sinus surgery. REAH of the olfactory cleft was often misdiagnosed, and interpreted as nasal polyposis (NP). We present a retrospective case series of 27 patients who were diagnosed and treated for REAH of the olfactory cleft, in the past 7 years, in our department. The aim of this study is to present the diagnostic modalities and the results and follow-up after surgery. The male to female ratio was 2.9:1, with a mean age of 56 years. Almost half of these patients were operated at least once before on their sinuses. The most common presenting symptoms of isolated REAH are olfactory disorders. All cases were treated surgically with endoscopic sinus surgery, without recurrences in the follow-up period. Knowledge and identification of REAH of the olfactory cleft are fundamental. Knowledge, identification, and adequate treatment of these lesions are fundamental, as they limit the number of recurrences.

Endoscopic techniques seem to be safe approaches for the treatment of esthesioneuroblastomas (ENBs). However, they are intended for selected patients and require extensive experience in base of the skull surgery.ENB is a rare tumor of the nasal cavity. The craniofacial approaches remain the gold standard of treatment in multiple centers. Endoscopic endonasal approaches were progressively developed. The main objective of this work was to study the overall survival and recurrence-free period for patients with ENB who underwent endoscopic resection.We performed a retrospective study from 1996 to 2014, reviewing the patients treated by endonasal endoscopic surgery for ENB.Eight patients benefited from endoscopic surgical resection. According to the Kadish classification, one patient was stage A, three patients were stage B, and four patients were stage C. According to the Dulguerov classification, one patient was stage T1, five patients were stage T2, and two were stage T4. Reconstruction of the base of the skull was performed in three patients. No postoperative complications were noted. The mean follow-up period was 95 months. The 5-year overall survival was 87.5% and the 5-year recurrence-free survival was 75%. To date, there have been no local recurrences but two patients had lymph node recurrences. Seven patients are disease-free and one is deceased.

Surgical resection followed by radiotherapy can be considered like the optimal treatment modality for limited esthesioneuroblastoma. However, therapeutic management of locally advanced tumors remains a challenge. The aim of our study was to access and compare the oncologic results of the different treatment modalities in advanced esthesioneuroblastoma. We performed a systematic review using the Medline, and Cochrane database in accordance with PRISMA criteria and included all the cases of advanced esthesioneuroblastoma published between 2000 and 2013. We also retrospectively included 15 patients with an advanced esthesioneuroblastoma managed at our tertiary care medical center. Long-term survival rates defined as the time from diagnosis or randomization to the date of death or last follow-up were evaluated for each treatment with Kaplan-Meier survival curve analyses. 283 patients have been included. The mean follow-up was 78 months. Five-year highest survival rates were obtained in patients treated by surgery associated with radiotherapy. Ten-year highest survival rates were obtained in patients treated by the association of surgery, radiotherapy and chemotherapy (p = 0.0008). Within the surgical group, 5-year highest survival rates were obtained in patients treated by endoscopic resection (p = 0.003). Surgical resection combined with radiotherapy offers the gold standard of care. Adjuvant chemotherapy seems to improve the long-term survival in patients with locally advanced esthesioneuroblastoma. Endoscopic resection in advanced tumors should be discussed on a case-by-case basis.

International audience

Epistaxis constitutes a significant proportion of the Otolaryngologist’s emergency workload. Optimal management differs in relation to the anatomic origin of the bleeding. The outcome of our study was to determine which artery(ies) could be considered as the cause of severe bleeding in the context of severe epistaxis. Fifty-five procedures of embolization preceded by angiography were reviewed. Medical records of interventionally treated patients were analysed for demographics, medical history, risk factors and clinical data. Angiographic findings were also assessed for active contrast extravasation (blush), vascular abnormality and embolised artery. Previous angiography showed an active contrast extravasation in only 20 procedures. The most common bleeding source was the sphenopalatine artery (SPA) followed by anterior ethmoidal artery (AEA) and facial artery. Majority of multiple or bilateral extravasations occured in patients with systemic factors. A better understanding of the potential bleeding source might help and limit the risk of treatment failures. Our study confirms that the SPA is the most common cause of severe bleeding. We also emphasise the role of the AEA not only in traumatic context. Others arteries are rarely involved except in patients with comorbidities or frequent recurrences.

Introduction Le sphincter superieur de l’œsophage est defini comme une zone de « haute pression » situee au niveau de l’extremite superieure de l’œsophage. Il est responsable de diverses pathologies notamment d’episodes de dysphagie en cas d’hypertonie. D’un point de vue anatomique, sa definition reste abstraite et il est souvent confondu avec le faisceau cricopharyngien du muscle constricteur du pharynx. L’objectif de notre etude etait de realiser une cartographie micro-architecturale des elements musculaires de la jonction pharyngo-œsophagienne. Methode Cinq pharyngo-œsophagectomies ont ete realisees sur cadavres frais. Le bord superieur du cartilage cricoide (CC) etait systematiquement repere. Nous avons realise sur chaque piece trois coupes longitudinales : posterieure, laterale gauche et laterale droite. La zone d’interet s’etendait de 1 cm au-dessus du bord superieur du cartilage cricoide a 2 cm en dessous. L’orientation des fibres musculaires, le type de fibre musculaire ainsi que l’epaisseur musculaire etaient mesures tous les 500 microns. Resultats Les resultats confirment l’existence d’un epaississement musculaire predominant au niveau des coupes laterales. Cet epaississement est maximal 5 mm au-dessus du CC (moy : 2200, min. : 1800, max. : 2544) sur les coupes laterales droites. Il apparait maximal en regard du CC (moy : 2496, min. : 2120, max. : 2832) sur les coupes laterales gauches. Sur la ligne mediane, nous ne notons aucun epaississement particulier, mais plutot une tendance a une rarefaction des cellules musculaires 5 mm sous le bord superieur du cartilage cricoide. La grande majorite des cellules musculaires observees etaient striees. Conclusion Il existe bel et bien un epaississement musculaire lateral en regard du bord superieur cartilage cricoide. Celui-ci semble correspondre macroscopiquement au faisceau cricopharyngien du constricteur inferieur. Les caracteristiques morphologiques des cellules musculaires a ce niveau ne semblent pas differees des autres localisations pharyngo-œsophagiennes.

Wounds with exposed vessels, especially in artery bypass procedures, can pose a barrier to adequate skin healing. Skin grafts or flaps are sometimes difficult to perform in the face of the ischaemia that is often present in such cases. We report a case of a 73-year-old man who presented with grade IV peripheral arterial disease necessitating salvage of the lower limb using artery bypass surgery. Immediate exposure of femorotibial artery secondary to skin necrosis following the bypass led us to propose an innovative means of wound coverage using Integra(®) , a well-known dermal regeneration template. The wound healed uneventfully with an appearance similar to that of the adjacent skin. Integra(®) seems to be less demanding in terms of the vascular wound bed and the degree of oxygenation than a conventional skin graft. This finding could support further indications for this dermal regeneration template.

International audience

Introduction/Objectifs La neurostimulation du nerf hypoglosse (XII) est actuellement une alternative therapeutique prometteuse dans le traitement du syndrome d’apnees-hypopnees obstructives du sommeil. Une stimulation supra-selective des branches terminales du XII, dont la branche a destinee de la portion horizontale du muscle genioglosse (GGh), permettrait son optimisation. Nous avons defini a partir des donnees recentes de la litterature [1] , [2] un protocole de reperage percutane standardise permettant la localisation des branches destinees a GGh. Materiels/patients et methodes Dix sujets cadaveriques frais ont ete disseques apres injection percutanee bilaterale d’un colorant. Le protocole d’injection etait standardise et avait pour objectif de verifier la presence de la branche GGh dans le volume colore. Les coordonnees du point moteur, retenu comme la penetration de la branche GGh dans le muscle genioglosse, et son ecart par rapport au centre de la zone coloree etaient mesures dans un repere tridimensionnel dont l’origine etait situee a la moitie de la distance genio-hyoidienne (GH). Resultats La ou les branches GGh etaient incluses dans le volume colore dans 50 % des cas, 65 % chez les femmes contre 22 % chez les hommes (p = 0,046). Seulement 27 % des branches etaient incluses chez les patients ayant une distance GH≥50 mm contre 67 % chez ceux ayant une distance GH Conclusions Le point moteur GGh a ete colore dans au moins 50 % des cas dans notre etude et cela avec precision selon l’axe GH. Cependant, des ajustements sont necessaires en fonction de l’indice de masse corporelle, de la distance GH ou encore du perimetre cervical.

Objectif Evaluer la devascularisation pelvienne et perineale chez la femme apres cystectomie totale pour cause neuro-urologique et ses consequences fonctionnelles. Materiel et methode Il s’agit d’une etude anatomique, clinique et radiologique prospective. Nous avons realise 25 dissections de pelvis de cadavres frais de femmes adultes de facon bilaterale afin d’identifier les branches de division de l’artere ombilicale et ainsi montrer que l’artere ombilicale conserve chez certaines patientes son statut embryonnaire qui est d’etre a l’origine de la vascularisation pelvienne [1] , [2] . Nous avons compare les examens d’imagerie realises en pre- et postoperatoire (angio IRM) de 11 patientes devant beneficier d’une cystectomie. Nous avons ainsi quantifie l’amputation de la vascularisation pelvienne sur l’imagerie postoperatoire. Egalement le questionnaire Female Sexual Function Index (FSFI) a ete analyse dans le but de mettre en evidence un eventuel retentissement fonctionnel sexuel. Resultats L’etude anatomique met en evidence une grande variabilite de la distribution des branches de division de l’artere iliaque interne dont certaines naissent de l’artere ombilicale : l’artere uterine dans la majorite des cas, et l’artere pudendale interne (qui vascularise le clitoris et les petites levres). L’etude radiologique montre une devascularisation pelvienne et perineale consequente dependante de la topographie de la ligature chirurgicale (lors de la ligature de l’artere ombilicale a son origine). Les resultats preliminaires de l’analyse comparative du questionnaire FSFI en pre- et postoperatoire ne semblent pas mettre en evidence de majoration des troubles sexuels. Conclusion La ligature non selective prive le perinee d’une partie de sa vascularisation. Il est donc licite au vu des possibles consequences fonctionnelles engendrees, notamment sexuelles, de discuter le benefice d’une ligature chirurgicale plus selective. L’etude preliminaire des consequences fonctionnelles chez ces patientes traitees pour cause neuro-urologique pourrait etre biaisee par l’atteinte perineale neurologique associee.

Adipose derived stromal cells (ASCs) are abundant and easy to prepare. Such cells may be useful for treating severe vocal disturbance caused by acute vocal fold scars.Prospective animal experiments with controls.Twenty New-Zealand white rabbits were used in the present study. We evaluated vocal fold healing, with or without injection of autologous ASCs, after acute scarring. A defined lesion was created and the ASCs were immediately injected. Vocal fold regeneration was evaluated histomorphometrically and via viscoelastic analysis using an electrodynamic shaker.Six weeks after ASC injection, vocal folds exhibited significantly less inflammation than control folds (P0.005). In addition, hypertrophy of the lamina propria and fibrosis were significantly reduced upon ASC injection (P0.02). The decrease in viscoelastic parameters was less important in the ASC injected group compared to the noninjected group (P = 0.08).Injection of autologous ASCs improved vocal fold healing in our preclinical model. Further studies are needed, but this method may be useful in humans.NA. Laryngoscope, 126:E278-E285, 2016.

Objectif Evaluer la devascularisation pelvienne et perineale chez la femme apres cystectomie totale. Materiel et methode Il s’agit d’une etude anatomique et radiologique. Nous avons realise 15 dissections de pelvis de cadavres frais de femmes adultes de facon bilaterale afin d’identifier et de quantifier les branches de division de l’artere ombilicale et ainsi montrer que l’artere ombilicale conserve chez certaines patientes son statut embryonnaire qui est notamment d’etre a l’origine de la vascularisation pelvienne [1] , [2] , [3] . Parallelement nous avons analyse et compare les examens d’imagerie realises en pre- et postoperatoire des patientes devant beneficier d’une cystectomie radicale. Nous avons ainsi evalue l’amputation de la vascularisation pelvienne sur l’imagerie postoperatoire. En effet, lorsque le chirurgien realise une cystectomie, la technique chirurgicale consiste a lier l’artere ombilicale a son origine [4] . Resultats Nos resultats preliminaires sont concordants avec ceux de la litterature. Nous avons constate une variabilite non negligeable concernant la naissance des branches viscerales de division de l’artere iliaque interne. En effet, certaines naissent de l’artere ombilicale : l’artere uterine dans la majorite des cas, mais egalement l’artere pudendale interne assurant la vascularisation du clitoris et des petites levres. Parallelement, l’etude des premiers examens realises en postoperatoire met en evidence une devascularisation pelvienne et perineale consequente. Conclusion Cette ligature non selective est donc susceptible de lier des arteres a destinee pelvienne, privant ainsi le perinee d’une partie de sa vascularisation. Il est donc licite au vu des possibles consequences fonctionnelles engendrees de discuter du benefice d’une ligature chirurgicale plus selective.

Objectif Realiser une etude anatomique du drainage lymphatique de l’ovaire. Materiel et methode En se basant sur les travaux de Hidden, nous avons realise 8 dissections de pelvis de cadavres frais de femmes adultes indemnes de cicatrice abdominale. Apres realisation d’une laparotomie mediane xypho-pubienne, une injection de colorant chimique de couleur bleue avec ajout de catalyseur, a ete effectuee au niveau du cortex ovarien par un point de ponction unique de facon bilaterale. L’injection a ete debutee sous pression afin de voir apparaitre les vaisseaux collecteurs. La pression etait poursuivie a pression moderee afin d’eviter la rupture des vaisseaux lymphatiques. Une fois l’injection achevee, le temps de diffusion etait compris entre trente minutes et quelques heures. L’evaluation du marquage etait dans un premier temps observationnelle par la recherche de coloration visible avant toute dissection. Puis une incision du peritoine a ete realisee suivant les axes ilio-obturateurs et lombo-aortique. Les lymphatiques et ganglions colores ont ete preleves et notes sur un schema. L’ouverture et la dissection du peritoine ont ete poursuivies selon la coloration observee. Resultats Nos resultats sont concordants avec ceux de la litterature dans le cancer de l’ovaire [1] . Nous avons mis en evidence une voie de drainage majeure et immediate au niveau du peritoine du cul de sac de douglas de facon constante. Nous avons observe des voies de drainage preferentielles : la principale etant le drainage le long des veines ovariennes en para-aortique et para-cave jusqu’aux hiles renaux ; la seconde au niveau des chaines ilio-obturatrices selon la classification de Rouviere [2] , et la troisieme le long des ligaments ronds au niveau inguinal. Notre etude a egalement mis en evidence un drainage supra-cœliaque. Conclusion Cette etude experimentale et de faisabilite montre une bonne concordance avec la litterature du cancer de l’ovaire.