Utility of flexible interventional endoscopy in endoscopic sinus surgery: a case series.

PURPOSE: During endoscopic sinus surgery (ESS), difficult-to-reach pathologies need an extended endoscopic approach or an external approach. We started to use a flexible interventional endoscope (FIE) to evaluate the necessity of those approaches. The study's objective is to describe our experience and define patients who could benefit from this technique. METHODS: We reviewed every patient who benefited from FIE associated with ESS at our tertiary University Hospital between January 2021 and February 2022. RESULTS: During this period, we did 107 ESS, and 14 patients benefited from the FIE, representing 13% of our ESS. The median duration of the flexible endoscopy time was 14 min (4-38 min). We identified three groups of patients who can benefit from the FIE. The first one is for patients with a fungal infection, to control and to clean lateral recesses in a noninvasive manner. The second one is for patients with a pathology of the lateral frontal sinus, to remove the frontoethmoidal cells or mucocele with the biopsy forceps through the working channel. The third group is for patients with inverted papillomas, to precisely identify the insertion and to decide on the most appropriate surgical approach. CONCLUSIONS: In selected cases, using flexible endoscopy during ESS helps decide the optimal surgical approach and sometimes treat the pathology through a limited approach. Prospective studies for each group of patients are needed to confirm the benefit of this new combined procedure.

[Tonsillar asymmetry in adults: review of the literature and management algorithm]. / Asymétrie amygdalienne chez l'adulte: revue de littérature et proposition de prise en charge.

Tonsillar asymmetry is both a common clinical finding and a potential sign of cancer. The diagnosis of the latter requires tonsillectomy, which is associated with two weeks off work and post-operative risk of bleeding, which ranges between 1.5 and 15% of the cases. Thus, it is crucial to determine which patients can be followed clinically and which ones will need a diagnostic tonsillectomy. This article provides a review of the literature on tonsillar asymmetry in the adult population and an algorithm for its management.

L'asymétrie amygdalienne est à la fois une découverte clinique fréquente et un potentiel signe de cancer. Le diagnostic de ce dernier se pose par une amygdalectomie. Celle-ci est associée à un arrêt de travail d'environ deux semaines, ainsi qu'à des risques postopératoires de saignement qui varient de 1,5 à 15% des cas. Il est donc crucial de déterminer quels patients peuvent être suivis cliniquement et quels sont ceux qui doivent bénéficier d'une amygdalectomie diagnostique. Cet article propose une revue de la littérature sur l'asymétrie amygdalienne dans la population adulte ainsi qu'un algorithme de prise en charge.

Minimally Invasive Endoscopic Sinus Surgery for Frontal Sinus Pathologies Using Interventional Flexible Bronchoscopy: Case Reports.

Background: Lateral pathologies of the frontal sinus are difficult to visualize and treat with classical endoscopic sinus surgery (ESS) using rigid endoscopes and instruments. Hence, they often require extended endoscopic or external approaches. Methods and Results: We describe the advantages of using interventional flexible bronchoscopy in frontal ESS without extended approaches in 2 illustrated cases: (1) A fungus ball in the frontal sinus with a frontoethmoidal cell. The flexible bronchoscope allowed treatment of all recesses of the frontal sinuses and the opening of a frontoethmoidal cell through a Draf IIa. (2) A revision surgery with a frontoethmoidal cell obstructing drainage pathway was successfully treated with this same technique. Patients did not experience complications or recurrent symptomatology after, respectively, 4 and 15 months of follow-up. Conclusion: Flexible bronchoscopy allows a good visualization and treatment of lateral frontal sinus pathologies through limited endoscopic approaches. Through-the-scope instruments permit the resection of frontoethmoidal cells.

[ENT management of head and neck cutaneous melanoma]. / Prise en charge par l'ORL des mélanomes cutanés cervico-faciaux.

A quarter of cutaneous melanomas occur on the head and neck. Despite close collaboration between the dermatology, oncology, pathology, nuclear medicine and otorhinolaryngology departments, the survival of patients presenting with this type of melanomas remains inferior to that of other parts of the body. The morbidity of head and neck surgery significantly alters the quality of life. Therefore, specific multidisciplinary expertise is required. We present here the specificities of ENT management.

Un quart des mélanomes cutanés se présentent au niveau de la tête et du cou. Malgré une étroite collaboration entre les services de dermatologie, oncologie, pathologie, médecine nucléaire et oto-rhino-laryngologie (ORL), la survie des patients qui présentent ce type de mélanomes reste inférieure à celle des patients ayant un mélanome d'une autre partie du corps. La morbidité d'une chirurgie cervico-faciale modifie significativement la qualité de vie. Ainsi, une expertise spécifique multidisciplinaire est nécessaire. Nous présentons ici les spécificités de la prise en charge ORL des mélanomes cervico-faciaux.

[New therapy for sleep apnea at CHUV: hypoglossal nerve stimulation]. / Nouvelle thérapie de l'apnée du sommeil au CHUV: le neurostimulateur du nerf hypoglosse.

Neurostimulation of the hypoglossal nerve is a new alternative treatment to CPAP (Continuous Positive Airway Pressure) for patients with moderate-to-severe OSAS (Obstructive Sleep Apnea Syndrome) with anteroposterior pharyngeal obstruction visualized during a Drug Induced Sleep Endoscopy (DISE). Implantation and follow-up are performed at the CHUV with the collaboration between the SAOS-ronchopathie unit, the maxillofacial and dental surgery division and the center for investigation and research on sleep (CIRS). In this article, we present the technique, its indication and the outcomes through a recent review of the literature. This new device has been used for five years, mainly in the United States and Europe.

La neurostimulation du nerf hypoglosse est un nouveau traitement alternatif à la CPAP (Continuous Positive Airway Pressure: ventilation en pression positive continue) pour les patients présentant un SAOS (syndrome d'apnées obstructives du sommeil) de stade modéré à sévère avec une obstruction pharyngée antéro-postérieure, objectivée lors d'un examen endoscopique en sommeil induit (DISE). L'implantation du dispositif et le suivi sont réalisés au CHUV grâce à une étroite collaboration entre l'Unité SAOS-ronchopathie, la division de chirurgie maxillo-faciale et dentaire et le Centre d'investigation et de recherche sur le sommeil (CIRS). Dans cet article, nous présentons la technique, ses indications ainsi que les résultats à travers une revue de la littérature récente sur cette technologie qui est pratiquée depuis maintenant cinq ans, principalement aux Etats-Unis et en Europe.

Factors Influencing the Incidence of Severe Complications in Head and Neck Free Flap Reconstructions.

BACKGROUND: Complications after head and neck free-flap reconstructions are detrimental and prolong hospital stay. In an effort to identify related variables in a tertiary regional head and neck unit, the microvascular reconstruction activity over the last 5 years was captured in a database along with patient-, provider-, and volume-outcome-related parameters. METHODS: Retrospective cohort study (level of evidence 3), a modified Clavien-Dindo classification, was used to assess severe complications. RESULTS: A database of 217 patients was created with consecutively reconstructed patients from 2009 to 2014. In the univariate analysis of severe complications, we found significant associations (P < 0.05) between type of flap used, American Society of Anesthesiologists classification, T-stage, microscope use, surgeon, flap frequency, and surgeon volume. Within a binomial logistic regression model, less frequently versus frequently performed flap (odds ratio [OR] = 3.2; confidence interval [CI] = 2.9-3.5; P = 0.000), high-volume versus low-volume surgeon (OR = 0.52; CI = -0.22 to 0.82; P = 0.007), and ASA classification (OR = 2.9; CI = 2.4-3.4; P = 0.033) were retained as independent predictors of severe complications. In a Cox-regression model, surgeon (P = 0.011), site of reconstruction (P = 0.000), T-stage (P = 0.001), and presence of severe complications (P = 0.015) correlated with a prolonged hospitalization. CONCLUSIONS: In this study, we identified a correlation of patient-related factors with severe complications (ASA score) and prolonged hospital stay (T-stage, site). More importantly, we identified several provider- (surgeon) and volume-related (frequency with which a flap was performed and high-volume surgeon) factors as predictors of severe complications. Our data indicate that provider- and volume-related parameters play an important role in the outcome of microvascular free-flap procedures in the head and neck region.

Impact of induction therapy on airway complications after sleeve lobectomy for lung cancer.

BACKGROUND: Sleeve lobectomy is a valid alternative to pneumonectomy for the treatment of centrally located operable non-small cell lung cancer (NSCLC), but concern has been evoked regarding a potentially increased risk of bronchial anastomosis complications after induction therapy. This study examined the impact of induction therapy on airway healing after sleeve lobectomy for NSCLC. METHODS: Bronchial anastomosis complications were recorded with respect to the induction regimen applied (neoadjuvant chemotherapy vs chemoradiotherapy) in a consecutive series of patients with sleeve lobectomy for NSCLC. RESULTS: Ninety-nine patients underwent sleeve resection, 28 of them after induction therapy. Twelve patients received chemotherapy alone, and 16 patients had radiochemotherapy. There were no significant differences in postoperative 90-day mortality (3.6% vs 2.8%) and morbidity (54% vs 49%) for patients with and without induction therapy. Bronchial anastomosis complications occurred in 3 patients (10.8%) with neoadjuvant therapy and in 2 (2.8%) without (p = 0.3). In the induction therapy group, two bronchial stenoses occurred after radiochemotherapy and one bronchopleural fistula after chemotherapy alone. In patients without induction therapy, one bronchial stenosis and one bronchopleural fistula were observed. All bronchial stenoses were successfully treated by dilatation, and both bronchopleural fistulas occurring after right lower lobectomy were successfully treated by reoperation and completion sleeve bilobectomy with preservation of the upper lobe. CONCLUSIONS: Sleeve lobectomy for NSCLC can be safely performed after induction chemotherapy and radiochemotherapy with mortality and incidence of airway complications similar to that observed in nonpretreated patients. The treatment of airway complications does not differ for patients with and without induction therapy.