Use of a navigation system in endonasal surgery: Impact on surgical strategy and surgeon satisfaction. A prospective multicenter study.

OBJECTIVES: Surgical navigation systems (SNS) are now widely used in endoscopic endonasal surgery. Benefit, however, has not been fully studied. The objective of this study was to evaluate the impact of an SNS in terms of performance of the surgical procedure and of surgeon satisfaction, in a prospective multicenter study. MATERIALS AND METHODS: A multicenter prospective study included patients undergoing endoscopic endonasal surgery using the electromagnetic DigiPointeur® (DGP) SNS in 16 French hospitals. An observation form, completed by the surgeon immediately at end of procedure, included type of procedure, and any changes in strategy or extent of surgery related to use of the SNS. Surgeon satisfaction was rated on an analog scale, with self-assessment of stress experienced during the procedure. RESULTS: The study included 311 patients operated on by 36 surgeons in 16 French hospitals. Ethmoidectomy was the most frequent procedure (90%); tumor resection was performed in 5.1% of cases. The SNS enabled more extensive surgery in 81% of cases, in particular by identifying and opening additional cells (57% of cases). Mean satisfaction was 8.6/10; surgeons reported decreased surgical stress thanks to the SNS in 95% of cases. CONCLUSION: In this observational study, the use of an SNS increased the extent of surgery in 81% of cases, and had a positive impact on the stress perceived by the surgeon in 95% of cases.

Guidelines of the French Society of Otorhinolaryngology (SFORL) (short version). Specific treatment of epistaxis in Rendu-Osler-Weber disease.

OBJECTIVES: The authors present the guidelines of the French Oto-Rhino-Laryngology - Head and Neck Surgery Society (Société Française d'Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou: SFORL) concerning specific treatment of epistaxis in Rendu-Osler-Weber disease. METHODS: A multidisciplinary work-group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group. The final version was established in a coordination meeting. The guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence. RESULTS: Rendu-Osler-Weber disease is diagnosed from the presence of at least three of Curaçao's four criteria. In acute epistaxis, bidigital compression is recommended. Embolization is reserved for resistant epistaxis. Non-resorbable nasal packing and cauterization are contraindicated. Patient education is essential. Telangiectasia of the nasal mucosa can be treated by various local means. In the event of insufficient control, systemic administration of tranexamic acid is recommended.

Guidelines of the French Society of Otorhinolaryngology (SFORL). Managing epistaxis under coagulation disorder due to antithrombotic therapy.

OBJECTIVE: The authors present the guidelines of the French Society of Otorhinolaryngology concerning the management of epistaxis during antithrombotic therapy. METHODS: A review of the literature was performed by a multidisciplinary work group. Guidelines were drafted, then re-edited by a reading group independent of the work group to produce the final text. The proposed recommendations were graded A, B, C or expert opinion, on decreasing levels of evidence. RESULTS: Before any decision to modify antithrombotic treatment, it is recommended to screen for overdose and assess the risk of thrombosis. In stented patients, dual antiplatelet therapy must be maintained during the month following stenting and, if possible, for 3 months. In epistaxis with antivitamin K (AVK) overdose controlled by packing, corrective measures are based on the International Normalized Ratio (INR). In uncontrolled epistaxis, it is recommended to stop AVK, administer antidotes and regularly monitor INR. In case of intravascular embolization, it is not recommended to alter anticoagulant treatment.

Guidelines of the French Society of Otorhinolaryngology (SFORL). Epistaxis and high blood pressure.

OBJECTIVES: The authors present the guidelines of the French Oto-Rhino-Laryngology - Head and Neck Surgery Society (Société Française d'Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou: SFORL) on epistaxis in high blood pressure. METHODS: A multidisciplinary work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group. The final version was established in a coordination meeting. The guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence. RESULTS: It is recommended to measure the blood pressure of patients in acute-phase epistaxis (Grade A); to control high blood pressure medically in the acute phase of bleeding, to reduce its duration; to monitor blood pressure at the waning of nosebleed; and to control high blood pressure medically in the waning phase to reduce the risk of recurrence. In case of persistent high blood pressure on waning of severe epistaxis, it is recommended to prescribe cardiovascular evaluation to screen for underlying hypertensive disease (Grade B).

Emergency Department care of childhood epistaxis.

OBJECTIVE: The aim of this review is to determine an efficient and safe primary strategy care for paediatric epistaxis. DATA SOURCES: We searched PubMed and Cochrane databases for studies referenced with key words 'epistaxis AND childhood'. This search yielded 32 research articles about primary care in childhood epistaxis (from 1989 to 2015). Bibliographic references found in these articles were also examined to identify pertinent literature. We compared our results to the specific management of adult epistaxis classically described in the literature. RESULTS: Epistaxis is one of the most common reasons for referral of children to a hospital ENT outpatient department. The bleeding usually originates from the anterior septum, as opposed to adults. Crusting, digital trauma, foreign bodies and nasal colonisation with Staphylococcus aureus have been suggested as specific nosebleed factors in children. Rare aetiologies as juvenile nasopharyngeal angiofibroma appear later during adolescence. There are different modes of management of mild epistaxis, which begin with clearing out blood clots and bidigital compression. An intranasal topical local anaesthetic and decongestant can be used over 6 years of age. In case of active bleeding, chemical cauterisation is preferred to anterior packing and electric cauterisation but is only feasible if the bleeding site is clearly visible. In case of non-active bleeding in children, and in those with recurrent idiopathic epistaxis, antiseptic cream is easy to apply and can avoid 'acrobatic' cauterisation liable to cause further nasal cavity trauma. CONCLUSIONS: Aetiologies and treatment vary with patient age and the existence or not of active bleeding at the time of the examination. Local treatments are usually easy to perform, but physicians have to ponder their indications depending on the possible complications in order to inform parents and to know paediatric epistaxis specificities.

Guidelines of the French Society of Otorhinolaryngology (SFORL). Second-line treatment of epistaxis in adults.

OBJECTIVES: The authors present the guidelines of the French Oto-Rhino-Laryngology - Head and Neck Surgery Society (Société Française d'Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou: SFORL) on second-line treatment of epistaxis in adults, after failure of anterior and/or anterior-posterior nasal packing. METHODS: A multidisciplinary work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group. The final version was established in a coordination meeting. The guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence. RESULTS: Arterial embolization should be performed by an experienced interventional neuroradiologist with adequate technical facilities, to reduce the risk of complications. Cerebral and supra-aortic vessel CT angiography should be performed in case of post-traumatic epistaxis with suspected internal carotid injury. In case of persistent bleeding despite endoscopic hemostasis of the sphenopalatine artery, anterior ethmoidal artery hemostasis should be performed via a medial canthal incision, with endoscopic assistance as needed. In case of persistent epistaxis despite the usual surgical and neuroradiological procedures, surgical exploration of the sinonasal cavities should be performed, with elective coagulation in case of bleeding from secondary branches, and/or ethmoidectomy in case of diffuse bleeding. A decision-tree was drawn up for the management of second-line treatment of epistaxis.

Guidelines of the French Society of Otorhinolaryngology (SFORL). First-line treatment of epistaxis in adults.

OBJECTIVES: The authors present the guidelines of the French Otorhinolaryngology-Head and Neck Surgery Society (SFORL) on first-line treatment of epistaxis in adults. METHODS: A multidisciplinary work-group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work-group. The guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence. RESULTS: In first-line, clearing out blood-clots and bidigital compression are recommended. In case of persistent bleeding, local anesthesia with a vasoconstrictor is essential before nasal diagnostic and therapeutic procedures. When the origin of bleeding is not anterior, nasal endoscopy is an essential procedure, identifying the bleeding site in most cases. In case of active bleeding, cauterization is recommended but is only feasible if the bleeding site is clearly visible. When the bleeding site is not identifiable or the first measures failed, anterior packing may be performed by a non-specialist physician. Epistaxis requires subsequent nasal endoscopy performed by an ENT specialist. Patients should be informed of the measures to be taken in case of epistaxis at home, and the risks associated with the various treatments.

ORL residency in France: Satisfaction and training quality in 2013.

OBJECTIVES: To assess the quality of ORL training in France and hierarchical relationships, working conditions and quality of life, based on a questionnaire answered by ORL residents and fellows. MATERIAL AND METHODS: The anonymous questionnaire covered the following topics (106 questions): structure of training, supervision by superiors, involvement in teaching medical students, work for publication, working conditions, quality of life and practical and surgical skills. RESULTS: One hundred and seventeen questionnaires were included, with 56% female respondents and 78% resident respondents. A total of 80% of respondents would choose the same training again, with overall satisfaction of 70%. In total, 71% felt appreciated, with responsibilities matching their level of training (85%). Supervisors were supportive (85%) and showed good teaching ability (92%). Residents were mainly guided by fellows (70%), or consultants (60%). Providing good training was an important aim for the training structures (78%). Respondents worked 11 hours per day, with a median of 4 duties per month; the post-duty rest-day was fully respected in the case of 38% of respondents. Surgical procedures were taught and delegated step by step, shared fairly between residents, in a large majority of cases. Training progression was in line with seniority. CONCLUSIONS: Overall satisfaction, quality and supervision of ORL training were good in France. There remain geographical differences in terms of theoretical and surgical training.

[Nasally delivered drugs (corticosteroids and vaccines), ultra long-acting bronchodilators and inhaled therapies in an animal model]. / Médicaments administrés par voie nasale (corticoïdes et vaccins), bronchodilatateurs de très longue durée d'action et aérosolthérapie dans un modèle animal.

Inhaled therapies are widely prescribed. Several aspects of these treatments were considered during the 4th meeting of the aerosol therapy workgroup (GAT) of the French-speaking respiratory society (Société de pneumologie de langue française [SPLF]). In this report, will be detailed the medications delivered by the nasal route, particularly corticosteroids and vaccines as well as the ultra long-acting beta2-agonists, and inhaled therapies for asthma due to allergy to cat dander.

Efficacy of tobramycin aerosol in nasal polyposis.

CONTEXT: Treatment of infected nasal polyposis. MATERIAL AND METHODS: Multicenter interventional prospective double-blind randomized study with matched groups: treatment with tobramycin aerosol versus isotonic saline aerosol. The study population included 55 patients: 23 receiving isotonic saline aerosol and 32 receiving tobramycin. A novel device (Easynose®) was used with an original principle limiting pulmonary deposition and ensuring homogeneous peripheral deposition in the nasal cavities. OBJECTIVES: The principal objective was to compare bacteriological eradication between tobramycin 150mg/3ml versus isotonic saline, both administered by nebulization via the Easynose® device. RESULTS AND CONCLUSION: Tobramycin aerosol administered via the Easynose® device showed significantly better bacteriological eradication than isotonic saline.

French Otorhinolaryngology Society guidelines for day-case nasal surgery.

OBJECTIVES: The French Otorhinolaryngology Society (SFORL) set up a work group to draw up a consensus document on day-case surgery in four rhinologic procedures: endoscopic middle meatal antrostomy (French National Health Insurance (CCAM) code GBPE001), septoplasty (GAMA007), and reduction of nasal bone fracture using a direct approach (LAEA007) and using a closed technique (LAEP002). MATERIALS AND METHODS: Methodology followed the French Health Authority (HAS) "Methodological Bases for Drawing Up Professional Guidelines by Formalized Consensus" published in January 2006; the method chosen was the short version of the RAND/UCLA Appropriateness Method (without editorial group), as the work group topic was highly specialized, with few experts available. RESULTS: Ahead of any day-case sinonasal surgery, it is recommended that patient eligibility criteria be respected and hemorrhagic risk assessed; preference should be given to short procedures involving little variation in surgery time and minimizing blood-loss, and associated procedures (e.g., septoplasty+turbinectomy) should be avoided. The patient and family should be informed of specific hemorrhagic, orbital and/or neuromeningeal risks, onset of which may preclude discharge home. Uni- or bilateral postoperative nasal packing is not a contraindication to day-case management. CONCLUSION: All four procedures may be performed on a day-case basis. Eligibility criteria should be systematically respected, but hemorrhagic risk, which is very specific to the sinonasal organ, is to be assessed on a case-by-case basis, as it is a major issue in this kind of management for a non-negligible number of patients.

Airway cell involvement in intermittent hypoxia-induced airway inflammation.

PURPOSE: Respiratory inflammation has been described in patients with obstructive sleep apnea syndrome, but it is unknown whether the increased neutrophil and interleukin (IL)-8 levels observed in induced sputum reflect systemic or local airway inflammation. We assessed the potential role of resident cells in intermittent hypoxia-induced airway inflammation. METHODS: Airway epithelial cells (AEC) and bronchial smooth muscle cells (BSMC) were exposed to intermittent hypoxia (IH) in vitro. Cell supernatants were assessed for matrix metalloproteinase, growth factor, and cytokine expression. The role of IH on neutrophil and BSMC migration capacities was evaluated, and the effect of supernatants from IH-exposed or control AEC was tested. RESULTS: Compared to normoxic conditions, 24 h of exposure to IH induced a significant increase of MMP-9 and MMP-2 expression and pro-MMP-9 activation (p < 0.05), and IL-8 (p < 0.05), platelet-derived growth factor (PDGF)-AA (p < 0.05), and vascular endothelial growth factor (VEGF) (p < 0.05) expression by AEC and VEGF expression (p = 0.04) by BSMC. Neutrophil chemotaxis and BSMC migration were enhanced by IH and supernatants of IH-exposed AEC (112.00 ± 4.80 versus 0.69 ± 0.43 %, p = 0.0053 and 247 ± 76 versus 21 ± 23, p = 0.009 respectively). This enhanced BSMC migration was totally abolished in the presence of an antibody blocking PDGF-AA. CONCLUSIONS: These data suggest a specific inflammatory response of airway cells to IH, independently of systemic events.

[Inhalation therapy: provocation tests, infectious risks, acute bronchiolitis and ENT diseases. GAT aerosolstorming, Paris 2011]. / Aérosolthérapie: tests de provocation, risques infectieux, bronchiolites et pathologie ORL. Aérosolstorming du GAT, Paris 2011.

Communications from the 2011 meeting of the GAT are reported in this second article on the practical management of bronchial provocation tests and infectious risks associated with the use of nebulization. Recent advances on the role of nebulized hypertonic saline in the treatment of acute bronchiolitis in infants and of the nebulization in sinusal diseases are also reported.

Sinus fungal balls: characteristics and management in patients with host factors for invasive infection.

BACKGROUND: The characteristics of sinus fungal ball (SFB), classically considered being a non-invasive form of fungal infection, in patients with host factors for invasive fungal infection (IFI) are unknown. OBJECTIVE: To characterize SFB and their management in patients with host factors for IFI. METHODOLOGY: Retrospective single-centre study of the clinical, radiology, histology and mycology records of patients treated for SFB between 1997 and 2007. Patients with and without host factors for IFI were compared. RESULTS: One hundred eighty one patients were classified into two groups: 19 (group 1) with and 162 (group 2) without host fac- tors for IFI. In group 1, SFB were asymptomatic in 26.3% of the cases, ethmoido-sphenoidal sinuses were more frequently involved than in group 2 and fungal culture was positive in 37.5% of the cases. The main species was Aspergillus sp. in both groups. Four cases of complicated SFB were observed, only in patients of group 1. Cure without recurrence was obtained in both groups by endonasal surgery, combined with triazole therapy in complicated forms with osteolysis. CONCLUSION: In patients with host factors for IFI, SFB more frequently involves deep sinuses and can be complicated by clinical signs suggestive of invasion and radiological signs of osteolysis, with no histological evidence of fungal invasion.

Oxidative stress induces unfolding protein response and inflammation in nasal polyposis.

BACKGROUND: Nasal polyposis, a chronic inflammatory disease affecting the upper airways, is a valuable and accessible model to investigate the mechanisms underlying chronic inflammation. The main objective of this study was to investigate a potential involvement of the unfolded protein response (UPR) in the context of oxidative stress and inflammation in nasal epithelial cells from nasal polyps (NP). METHODS: Epithelial cells from NP (n = 20) and normal mucosa (Controls, n = 15) in primary culture were analyzed by global proteomic approach and cell biology techniques for the glucose-regulated protein 78 (GRP78), the spliced X-box-binding protein 1 (sXBP-1), the glucose-regulated protein 94 (GRP94), and the calreticulin (immunoblot, mass spectrometry, immunocytochemistry). RESULTS: Proteomics analysis of human nasal epithelial cells in culture revealed the activation of the unfolded protein response in NP. Systematic cell biology and biochemical analysis of two markers (GRP78, sXBP-1) in the presence and absence of oxidative stress in NP showed a susceptibility of the unfolded protein response to oxidative stress compared to controls at least partially linked to an abnormal redox state of the protein disulfide-isomerase 4. This unfolded protein response was correlated with mitochondrial depolarization and secretion of interleukin 8 (IL-8) and leukotriene B4 (LTB4) and was prevented by mitochondrial antioxidant. CONCLUSIONS: We show the existence of UPR in nasal epithelial cells that is linked to oxidative stress leading to IL-8 and LTB4 secretions. These mechanisms may participate in chronic inflammation in nasal polyposis.

Image-guided sinus surgery.

Image-guided surgery (IGS) is extremely useful for anatomic location in at-risk sinus surgery: extensive inflammatory disease, sinus cavity revision, and frontal sinus, posterior ethmoid, sphenoid or nasosinal tumor surgery. There are two systems on the market, based on electromagnetic and infrared detection, respectively; optimal functioning depends on calibration. IGS is only a location aid, complementary to and not a substitute for endoscopy. It enables the experienced endonasal surgeon to check the endoscopic location at any time, and provides appreciable "psychological" comfort in what are difficult and sometimes stressful operations, the limits of which are being forever pushed back.

Muco-ciliary differentiation of nasal epithelial cells is decreased after wound healing in vitro.

BACKGROUND: Epithelial damage and modifications of cell differentiation are frequent in airway diseases with chronic inflammation, in which transforming growth factor-beta1 (TGF-beta1) plays an important role. The aim of this study was to evaluate the differentiation of human nasal epithelial cells (HNEC) after wound healing and the potential effects of TGF-beta1. METHODS: Basal, mucus, and ciliated cells were characterized by cytokeratin-14, MUC5AC, and betaIV tubulin immunodetection, respectively. Their expression was evaluated in situ in nasal polyps and in an in vitro model of wound healing in primary cultures of HNEC after wound closure, under basal conditions and after TGF-beta1 supplementation. Using RT-PCR, the effects of TGF-beta1 on MUC5AC and DNAI1 genes, specifically transcribed in mucus and ciliated cells, were evaluated. RESULTS: In situ, high TGF-beta1 expression was associated with low MUC5AC and betaIV tubulin expression. In vitro, under basal conditions, MUC5AC expression remained stable, cytokeratin-14 expression was strong and decreased with time, while betaIV tubulin expression increased. Transforming growth factor-beta1 supplementation downregulated MUC5AC and betaIV tubulin expression as well as MUC5AC and DNAI1 transcripts. CONCLUSION: After a wound, differentiation into mucus and ciliated cells was possible and partially inhibited in vitro by TGF-beta1, a cytokine that may be involved in epithelial remodeling observed in chronic airway diseases.

Rhinitis and epistaxis in patients treated by anti-angiogenic therapy.

Anti-angiogenic therapies have a particular drug-related toxicity profile including hypertension, thrombosis, haemorrhages, and proteinuria. Moreover, patients treated by angiogenesis inhibitors present nasal symptoms including symptomatic rhinitis and epistaxis. For the first time, a new entity of "atrophic rhinitis" induced by angiogenesis inhibitors is described and revealed that angiogenesis inhibitors alter the differentiation of nasal epithelium. VEGF may act on epithelial cell proliferation and differentiation in nasal epithelium.

Transforming growth factor-beta1 increases airway wound repair via MMP-2 upregulation: a new pathway for epithelial wound repair?

In vivo, transforming growth factor (TGF)-beta1 and matrix metalloproteinases (MMPs) present at the site of airway injury are thought to contribute to epithelial wound repair. As TGF-beta1 can modulate MMP expression and MMPs play an important role in wound repair, we hypothesized that TGF-beta1 may enhance airway epithelial repair via MMPs secreted by epithelial cells. We evaluated the in vitro influence of TGF-beta1 on wound repair in human airway epithelial cells cultured under conditions allowing differentiation. The results showed that TGF-beta1 accelerated in vitro airway wound repair, whereas MMP inhibitors prevented this acceleration. In parallel, we examined the effect of TGF-beta1 on the expression of MMP-2 and MMP-9. TGF-beta1 induced a dramatic increase of MMP-2 expression with an increased steady-state level of MMP-2 mRNA, contrasting with a slight increase in MMP-9 expression. To confirm the role of MMP-2, we subsequently evaluated the effect of MMP-2 on in vitro airway wound repair and demonstrated that the addition of MMP-2 reproduced the acceleration of wound repair induced by TGF-beta1. These results strongly suggest that TGF-beta1 increases in vitro airway wound repair via MMP-2 upregulation. It also raises the issue of a different in vivo biological role of MMP-2 and MMP-9 depending on the cytokine microenvironment.