Impact of the 2nd, 3rd and 4th waves of the COVID-19 pandemic on wait times in head and neck cancer: A retrospective study in a French expert center.

BACKGROUND: Treatment delay in head and neck cancer is a major problem, with impact on survival. The COVID-19 (coronavirus disease 2019) pandemic, evolving in waves around the world, caused diagnostic and therapeutic delays in certain cancers. The main objective of the present study was to analyze whether there was a change in wait times during three successive waves in our center. METHOD: This was a single-center retrospective study of patients with a first diagnosis of head and neck cancer. Three groups, corresponding to waves 2, 3 and 4, were compared to a control group corresponding to a pre-pandemic period. Study data comprised median times between first consultation and tumor board meeting (C1-TB) and between tumor board meeting and treatment (TB-T). The significance threshold was set at P<0.005. RESULTS: Ninety-six patients were included in the control group, and 154 in the "waves 2-3-4" group. There was no increase in C1-TB interval (respectively 35 and 26days, P=0.046) or TB-T interval (respectively 27 and 28days, P=0.723). CONCLUSION: Intervals between first consultation and tumor board meeting and between tumor board meeting and treatment did not increase during the 2nd, 3rd and 4th waves of COVID-19 in our center.

Surgery for chronic rhinosinusitis with nasal polyps: An update.

This update aimed to evaluate surgical indications in the management of chronic rhinosinusitis with nasal polyps (CRSwNP). It was conducted and reported according to the criteria stipulated by the Synthesis Without Meta-analysis (SwiM) guidelines. From the PubMed-National Library of Medicine database, 1098 articles were identified for the period 2006-2021 using the key words "nasal polyps" and "surgery". After screening and analysis, 39 publications were selected. The efficacy of surgery on functional improvement in CRSwNP, measured by the specific quality-of-life score SNOT-22, is established, and improvement in olfactory function is expected in 50% of patients. The rate of surgical revision is at least 10-15% at 4 years, but the disease can be controlled for several years, with the interval between primary surgery and symptomatic recurrence exceeding 10 years in some cases. The criteria for surgery are not clearly defined in the literature. However, several authors consider failure of ≥ 8 weeks' well-conducted local medical treatment and use of more than 2 courses of systemic corticosteroids as a reliable indication. No studies or meta-analyses are currently available to determine the superiority of one surgical technique over another.

The first wave of COVID-19 did not cause longer wait times in head and neck cancer. Experience of a French expert center.

BACKGROUND: Head and neck cancers (HNC) have poor survival prognosis, as tumors are often diagnosed at advanced stages in patients consulting late. The first lockdown linked to the 1st wave of COVID-19 (Coronavirus Disease 2019) disrupted consultation schedules in France. OBJECTIVE: The principal aim of the present study was to analyze consultation wait time in HNC during and after lockdown, in our university expert oncology reference center, to disclose any increase in treatment wait time. METHODS: A single-center retrospective study included patients with a first diagnosis of HNC. Three groups were distinguished: "lockdown", "post-lockdown", and a "control" group (corresponding to a reference period 1 year earlier). Intervals between first oncologic consultation and multidisciplinary tumor board (FC-MTB) and between MTB and first treatment (MTB-T) were assessed. RESULTS: One hundred and seven patients were included in the control group, 60 in the lockdown group and 74 in the post-lockdown group. There was no increase in median FC-MTB interval (respectively 35, 29 and 28 days) between the lockdown and post-lockdown groups compared to the control group (respectively P=0.2298 and P=0.0153). Likewise, there was no increase in MTB-T interval (27, 20 and 26 days respectively) (P=0.4203). CONCLUSION: No increase in wait times was observed during the lockdown and post-lockdown periods in our center.

Match between therapeutic proposal in multidisciplinary tumor board and actual treatment in head and neck cancer.

OBJECTIVES: There are few published studies evaluating the quality and outcome of multidisciplinary tumor board (MDTB) decisions. The aim of the present study was to evaluate adherence to MDTB recommendations in head and neck cancer and to document reasons in case of discordance. MATERIAL AND METHODS: We included all patients with newly diagnosed head and neck cancer presented in our MDTB meetings between January 1st and December 31st, 2018, whatever the tumor site, histology type and TNM classification. MDTB recommendations were compared to actual treatment. Discordance was defined as treatment partially or entirely different from the treatment decision recorded in the MDTB minutes. RESULTS: Board decisions were made for 344 new patients. Complete treatment concordance rate was 91.6% (315/344 patients), with deviation in 29 patients. Reasons for deviation were complications of treatment in 10 cases, patient refusal in 8, and physician's decision in 4 cases. Five patients died before therapy initiation. Mean interval from board discussion to treatment was 21 days, and depended on type of treatment (range, 1 to 74 days). CONCLUSION: This study shows the importance of evaluating concordance between the protocol proposed in the MDTB and the treatment actually received, to identify factors for deviation and remedy them when possible.

T helper 2 inflammatory markers are associated with recurrence in chronic rhinosinusitis with nasal polyps after endoscopic sinus surgery.

BACKGROUND: Despite maximum medical treatment and endoscopic sinus surgery (ESS), chronic rhinosinusitis with nasal polyps (CRSwNP) can require revision surgery. With a growing literature on the diversity of cytokine inflammation patterns in CRSwNP, an endotype-driven approach could lead to the identification of cytokine profiles that predict recurrence. METHODS: A monocentric longitudinal study was carried out until June 2019 following CRSwNP patients who underwent surgery for the first time between December 2010 and January 2012. The biomarker profiles were established on blood and nasal secretions at the time of the first surgery (Interleukin (IL)-5, IgE, IgA, eosinophilic cationic protein (ECP) and eosinophilic- derived neurotoxin (EDN)). Profiles were compared between the patients still controlled by medical treatment and the patients requiring revision surgery during the course of the follow-up period. RESULTS: Among the 48 patients initially enrolled in our study, 8 required revision surgery (16,7%). Clinical features (asthma, allergy, aspirin intolerance, active smoking) and levels of blood markers measured at the time of the first surgery were comparable between the 2 groups of patients. Levels of IL-5, IgE and ECP in nasal secretions were significantly increased in the group of patients needing revision surgery. CONCLUSIONS: Based on simple approach of nasal secretions sampling, we showed that a predominant T helper 2 proteins expression profile can be associated with recurrent CRSwNP after ESS. Initial immunoprofiling in CRSwNP disease may contribute to better predict the therapeutic response to optimal medical and surgical treatment, and help define the role of innovative targeted treatment, beside corticosteroids and ESS.

Assessment and treatment of hypopharyngeal and cervical esophagus injury: Literature review.

Wounds and perforations of the upper gastrointestinal tract are serious and life-threatening. The hypopharynx and cervical esophagus, by their respective anatomical positions, are exposed to traumatic wounds, most often during diagnostic tests, but management such wounds remains a subject of discussion. The present article analyzes the current state of knowledge on epidemiology, etiologies, risk factors, diagnostic management, prognostic factors and available treatments.

Radiological assessment of mandibular invasion in squamous cell carcinoma of the oral cavity and oropharynx.

BACKGROUND: Preoperative assessment of mandibular bone invasion in squamous cell carcinoma of the oral cavity and oropharynx is crucial for optimizing bone resection. The principal aim of this study was to evaluate the diagnostic value of CT and MR imaging for the diagnosis of mandibular bone invasion compared to the histological reference. In addition, we assessed the survival impact of bone invasion. PATIENTS AND METHODS: A single-center retrospective study included all consecutive patients treated by mandibular bone interruption for squamous cell carcinoma of the oral cavity and/or oropharynx. RESULTS: Sixty-eight patients were included. Prevalence of bone invasion on histology was 43%. Sensitivity, specificity and positive and negative predictive value were respectively 70%, 71%, 66% and 76% for CT compared with histologic analysis, 83%, 50%, 59% and 78% for MRI, and 83%, 62% 62%, 83% for associated CT and MRI. The two tests showed good agreement, with kappa index 0.69 (95% CI, 0.49-0.89) (P<0.0001). There was no difference in overall survival (log-rank>0.70) between the groups with and without bone invasion. CONCLUSION: CT and MRI are complementary for preoperative assessment of mandibular bone invasion, be it cortical and/or medullary, and in some cases may allow mandibular bone-sparing.

Presence in head and neck cancer multidisciplinary team meeting: The patient's experience and satisfaction.

BACKGROUND: In oncology, multi-disciplinary team meetings improve overall survival and reduce time to treatment in head and neck cancer. Interestingly, no study has examined the experience of patients attending an MTM. The present study addressed two questions: Does the MTM cause anxiety/depression for patients who are present? Are patients satisfied at the end of the meeting? PATIENTS AND METHODS: The study included all patients attending an MTM, who agreed to participate in the study and who fully completed two questionnaires. The Hospital Anxiety and Depression Scale (HADS) and a satisfaction questionnaire were filled out at three time-points: T0 before MTM, T1 at end of MTM, and T2 1 month after MTM for the HADS; and T1 and T2 for the satisfaction questionnaire. RESULTS: There were no significant differences in the number of patients experiencing anxiety between T0 and T1 (P=0.6085), T0 and T2 (P=1) or T1 and T2 (P=1). Likewise, there were no significant differences in the number of patients in depression between T0 and T1 (P=0.9397), T0 and T2 (P=1) or T1 and T2 (P=1). Mean satisfaction was good (question 14 on the satisfaction questionnaire: 8.7/10 at T1 and 7.7/10 at T2), but with a significant decrease between T1 and T2 (P=0.0009: i.e.,<0.05). Percentage information remembered (question 12) significantly decreased between T1 (mean 86%, standard deviation 0.2, median 94%) and T2 (78%±0.2, median 81%) (P=0.03). Presence in the MTM did not appear to induce or increase anxiety or pre-existing depressive syndrome.

Cost-effectiveness assessment in outpatient sinonasal surgery.

AIMS: To assess the cost-effectiveness of outpatient sinonasal surgery in terms of clinical efficacy and control of expenses. METHODS: A retrospective study was conducted from January 2014 to January 2016. Patients scheduled for outpatient sinonasal surgery were systematically included. Clinical data were extracted from surgical and anesthesiology computer files. The cost accounting methods applied in our institution were used to evaluate logistic and technical costs. The standardized hospital fees rating system based on hospital stay and severity in diagnosis-related groups (Groupes homogènes de séjours: GHS) was used to estimate institutional revenue. RESULTS: Over 2years, 927 outpatient surgical procedures were performed. The crossover rate to conventional hospital admission was 2.9%. In a day-1 telephone interview, 85% of patients were very satisfied with the procedure. All outpatient cases showed significantly lower costs than estimated for conventional management with overnight admission, while hospital revenue did not differ between the two. CONCLUSION: This study confirmed the efficacy of outpatient surgery in this indication. Lower costs could allow savings for the health system by readjusting the rating for the procedure. More precise assessment of cost-effectiveness will require more fine-grained studies based on micro costing at hospital level and assessment of impact on conventional surgical activity and post-discharge community care.

Impact of allergy on phenotypic and endotypic profiles of nasal polyposis.

OBJECTIVES: To assess the impact of allergy on clinical presentations (phenotypes) and inflammatory patterns (endotypes) of chronic rhinosinusitis with nasal polyps (CRSwNP). METHODS: A single-center prospective study was conducted over an 18-month period. Fifty-seven patients with refractory CRSwNP were included. The diagnosis of allergy was based on concordant skin prick tests and symptoms. Phenotypes were determined on symptom severity score, polyp size classification and Lund-Mackay CT staging. Inflammatory endotypes were determined on biomarker analysis (IgE, IgA, IL-5, IL-9, ECP, EDN) in blood and nasal secretions. Eosinophil counts were obtained in blood, nasal secretions and polyps. RESULTS: Phenotype and endotype profiles were comparable in patients with (n=15) or without (n=42) allergy. Only asthma with high total IgE blood concentration showed association with allergy. CONCLUSIONS: The present results suggest that allergy is not directly involved in the clinical expression and specific inflammatory pathways of CRSwNP. New therapies target inflammation signaling pathways, and identifying accurate blood and tissue biomarkers will be the line of research most likely to improve treatment of CRSwNP.

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.

Local extension staging of sinonasal tumours: retrospective comparison between CT/MRI assessment and pathological findings.

OBJECTIVES: To assess the reliability of clinical staging with CT and MRI in sinonasal cancers. METHODS: We conducted a retrospective review of patients who underwent surgery for a sinonasal cancer. The 7th edition of the TNM classification was used to establish tumour staging. Standardised preoperative CT/MRI staging was compared with the pathological staging based on specimens obtained during surgery from each subsite within and around the tumour. RESULTS: We analysed data from 68 patients between January 2010 and December 2014. A comparison of cT and pT stages was established for 49 naso-ethmoidal and 16 maxillary tumours. Clinical staging for naso-ethmoidal cT1 and maxillary cT2 was consistent with pathological results. Clinical staging for naso-ethmoidal cT2, cT3 and cT4b was overstated in comparison with pT findings. The positive predictive value of imaging was <65% for the lamina papyracea, the cribriform plate, the dura, and the frontal and sphenoid sinuses. Sensitivity was over 75% for each anatomical site except for the cribriform plate (73.3%) and the sphenoid sinus (57.2%). CONCLUSION: Systematic pathologic analysis of the anatomical areas around the sinonasal cancer has to be applied in further studies to improve our therapeutic management. CT/MRI mapping cannot replace accurate assessment of tumour extension during surgery.

Desmoid tumours of the head and neck in children: Review of management.

OBJECTIVE: Desmoid tumours of the head and neck in children are rare, local invasive and potentially fatal tumours. The purpose of this review is to discuss the management of these tumours in the light of a case series and a review of the literature. MATERIAL AND METHODS: This retrospective study summarised the medical data of children treated for desmoid tumours of the head and neck between 1976 and 2014. RESULTS: Five of the 6 children were treated by radical surgical resection, with positive surgical margins (R1) in 2 cases, followed by recurrence requiring further resection. One child with a very advanced lesion was treated by weekly methotrexate and vinorelbine chemotherapy for 18months, allowing 93% reduction of tumour volume without recurrence. CONCLUSIONS: Desmoid tumours of the head and neck in children are more aggressive than their adult counterparts and are associated with high morbidity and mortality and a high recurrence rate. CT and MRI imaging assessment should preferably be performed before biopsy. External beam radiotherapy must be avoided in children as it is less effective than in adults, and is responsible for long-term cosmetic and functional sequelae and even a risk of second tumours. Treatment is surgical whenever radical resection is possible. In patients presenting an excessive risk of morbidity and mortality, chemotherapy devoid of long-term adverse effects (such as methotrexate in combination with a Vinca alkaloid) can be proposed. Long-term follow-up must be ensured due to the risk of recurrence.

Predictors of unanticipated admission within 30 days of outpatient sinonasal surgery.

OBJECTIVES: To identify predictive factors of readmission after day-case rhinologic surgery. METHODS: A 2-year retrospective chart review of patients scheduled for ambulatory sinonasal surgery in a tertiary medical center was conducted. The operating room and the anesthetic files were screened to identify demographic data, types of procedure, comorbidities and post-operative complications. RESULTS: From January 2014 to January 2016, 924 outpatient sinonasal procedures were identified. The overall readmission rate within the 30-postoperative days was 5.1% (2.9% for overnight hospital stay, 2.2% for unplanned post procedure visit to the hospital via the emergency room, or directly to the surgical unit within 30 days of discharge). Age at least 50 years, surgical duration at least 80 min, endoscopic sinus surgery procedures and postoperative nasal packing were identified as negative predictive factors of readmission. CONCLUSION: Careful scheduling of those higher-risk patients undergoing sinonasal surgery and appropriate postoperative observation should be implemented to improve healthcare quality in an outpatient setting.

Atypical Lemierre syndrome.

INTRODUCTION: Lemierre syndrome is a complication of oropharyngeal infection and consists of a combination of internal jugular vein septic thrombophlebitis with septicaemia and distant septic emboli (mainly in the lungs). We describe an atypical case with facial vein and anterior jugular vein thrombophlebitis. CASE SUMMARY: A 34-year-old woman attended the emergency room with tonsillitis, left head and neck cellulitis, left facial vein thrombosis and lung abscesses. A diagnosis of atypical Lemierre syndrome was proposed and the patient was treated surgically (neck incision and tonsillectomy) and medically (antibiotics, hyperbaric oxygen therapy and anticoagulation) allowing cure without sequelae. DISCUSSION: Lemierre syndrome, a rare but serious complication requiring immediate treatment, should be investigated (by blood cultures and chest CT scan) in the presence of neck vein thrombosis complicating oropharyngeal infection.

Histopathological classification of refractory chronic rhinosinusitis with nasal polyps.

OBJECTIVE: To delineate the histopathological characteristics of nasal mucosa in refractory chronic rhinosinusitis with nasal polyps (CRSwNP) in order to demonstrate subtypes of nasal polyps and their potential relation with lower airway comorbidity. STUDY DESIGN: Clinical- and pathological-based cross-sectional study Methods: Nasal polyp specimens were prospectively collected from patients with refractory CRSwNP referred to our institution for endoscopic sinus surgery. Oral and topical steroids were stopped 1 month before surgery. The pathological analysis was conducted by 2 independent reviewers with light microscopy on Hematoxylin-Eosin-Saffron stained slides. Each observer fulfilled a standardized protocol with cell count and stromal characterization on the most representative field. Mean grading scores were established. Morphological aspects were compared with the cell distribution and the clinical conditions. RESULTS: Among 36 patients, three subtypes of nasal polyps were depicted: eosinophilic edematous (64%), fibrous (9%) and intermediate with mixed edematous and collagen stromal structure (27%). Basement membrane thickening and seromucous gland hyperplasia were observed in the fibrosis sub-type (p<0.03). Eosinophilic mucosal infiltrate was significantly increased (p=0.026) in patients with concomitant pulmonary disease (n=21). Nasal polyp distribution was not influenced by asthma, allergy, previous surgery and smoking. CONCLUSION: Our 3-subtype classification of refractory CRSwNP in Caucasian population shows a predominant edematous structure whatever the clinical conditions may have been. Eosinophilia as a major factor of adaptive immune response in nasal inflammation is a feature of concomitant pulmonary disease. Further studies concerning mucosal remodelling and outcome assessment after sinus surgery are required to evaluate the impact of our classification on a daily basis.

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.

Olfactory cleft opacity and CT score are predictive factors of smell recovery after surgery in nasal polyposis.

OBJECTIVES: To assess subjective improvement of olfactory function following endoscopic sinus surgery (ESS) in chronic rhinosinusitis associated with nasal polyps (CRSwNP) and to analyse factors of recovery with the European Test of Olfactory Capabilities (ETOC). METHODS: We carried out a prospective study of 30 patients with CRSwNP from November 2011 to April 2013. The ETOC was filled the day before surgery and in the short term follow-up. Sixteen suprathreshold odorants with a detection task and a forced choice verbal identification task were tested. RESULTS: The mean composite score (MCS) improved at 3 and 6 months. The preoperative MCS was correlated to the Lund-Mackay score and to the olfactory cleft opacification on preoperative computed tomography (CT) scan. Multivariate linear regression modelling of patients with preoperative anosmia showed that the olfactory recovery at 3 months was predicted by the preoperative Lund-Mackay score and the age, and at 6 months by the preoperative Lund-Mackay score. CONCLUSION: With a convenient psychophysical test, we showed that olfactory cleft opacification and CT scan score could be predictive factors of olfaction disorder severity and improvement after ESS in CRSwNP. These results need to be strengthened in the long term with a larger panel of patients.