Guillaume de Bonnecaze

Endoscopic vs Transfacial Resection of Sinonasal Adenocarcinomas

Objectives. Compare the survival and the complication rates of 2 comparable groups of patients who underwent either endoscopic or transfacial resection of a sinonasal adenocarcinoma. Study Design. Historical cohort study. Setting. Tertiary referral center. Subjects and Methods. Twenty-four patients with sinonasal adenocarcinomas who recently underwent an endoscopy (the ENDO group, 1999-2009) were compared with 24 patients who underwent a lateral rhinotomy procedure (the LR group, 1993-2007). The present retrospective study included patients who would have had an endoscopic resection in 2011. Results. The groups were comparable in terms of age and sex (P = .49), as well as tumor stages; 43 of the 48 patients had undergone postoperative radiotherapy. There were 13 T1-T2 and 11 T3-T4 tumors in the ENDO group compared with 12 T1-T2 and 12 T3-T4 tumors in the LR group (P = .77). The mean length of follow-up was 38 months for the ENDO group and 89 for the LR group. The overall survival and recurrence-free rates were not significantly different (P = .3 and P = .87, respectively). The median duration of hospitalization was significantly shorter in the ENDO group than in the LR group (4 vs 8 days, P < .0001). The rate of early complications was identical in both groups (12.5%). Conclusion. The endoscopic approach is a safe and effective treatment in selected sinonasal adenocarcinoma cases. The early oncological outcome and morbidity associated with the endoscopic approach were comparable with a transfacial approach. Hospitalization was significantly reduced by the endoscopic approach. Although the endoscopic approach is less invasive, it requires an optimal preoperative imaging protocol and an experienced surgical team.

Is the use of negative pressure wound therapy for a malignant wound legitimate in a palliative context? “The concept of NPWT ad vitam”: A case series

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.

Long-term oncological outcome after endoscopic surgery for olfactory esthesioneuroblastoma

Abstract Conclusions: 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. Objectives: 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. Methods: We performed a retrospective study from 1996 to 2014, reviewing the patients treated by endonasal endoscopic surgery for ENB. Results: 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.

Adipose stromal cells improve healing of vocal fold scar: Morphological and functional evidences

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.

Intractable epistaxis: which arteries are responsible? An angiographic study

PurposeEpistaxis 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.MethodsFifty-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.ResultsPrevious angiography showed an active contrast extravasation in only 20 procedures. The most common bleeding source was the sphenopalatine artery (SPA) followed by anterior ethmoïdal artery (AEA) and facial artery. Majority of multiple or bilateral extravasations occured in patients with systemic factors.ConclusionsA 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.

Chronic ischaemia does not appear to hinder healing with Integra(®) : implementation at a tibial artery bypass site.

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.

Modified keystone island flap design for lateral nasal defect: aesthetic subunit consideration.

1 Benoit Chaput, MD Department of Plastic and Reconstructive Surgery Faculty of Medicine University of Toulouse CHU Rangueil Toulouse, France Guillaume de Bonnecaze, MD Department of Oto-rhino-laryngology Head and Neck Surgery University of Toulouse CHU Rangueil-Larrey Toulouse, France Raphael Lopez, MD, PhD Department of Maxillofacial Surgery University of Toulouse CHU Purpan Toulouse, France Vairel Benjamin, MD Department of Oto-rhino-laryngology Head and Neck Surgery University of Toulouse CHU Rangueil-Larrey Toulouse, France Ignacio Garrido, MD, PhD Jean Louis Grolleau, MD, PhD Department of Plastic and Reconstructive Surgery Faculty of Medicine University of Toulouse CHU Rangueil Toulouse, France Sir: D in 2003 by Behan,1 the interest for keystone island flap continues to grow and gain followers, mainly in dermatological oncology. Its 2-fold vascularization (perforating skin vessels and lateral by preservation of subcutaneous vessels on the edges) makes it a very reliable flap, and its innovative design is an excellent alternative to many local flaps. This flap allows one sometimes to get out of difficult situations, which previously would have required one to perform free flaps.2 The authors report their initial experience with the use of a modified keystone island flap procedure for lateral nasal defect on 5 patients (3 men and 2 women) aged between 70 and 84 years (mean, 74 years). In this indication, our preferred technique was originally the Rybka’s flap.3 All the defects resulted from prior basal cell carcinoma excision. The average defect size after debridement was 1.9 cm of diameter (range of 1.7–2.1 cm). It was type I keystone flap (KF), and the average time of flap harvesting was 12 minutes (range of 10–14 minutes) under local anesthesia. No temporary venous insufficiency was observed, nor suffering of the flaps or scar dehiscence. All flaps healed successfully, and the patients were satisfied with the aesthetic results. All patients underwent a 1-stage procedure. Typically, we strictly avoid rotation or transposition flap in 1-stage for skin tumors. Instead, advancement flap as the KF will not modify the initial location of the tumor. Thus, in case of insufficient resection margins, or in case of recurrence, there is no risk of having modified the tumor location. The KF is based on the random perforating vessels and does not require prior identification by an acoustic Doppler.4 This makes it accessible to all practitioners quite easily. For the defects located on the lateral nasal sidewall, the KF will perfectly respect the aesthetic subunit as described by Burget and Menick.5 The 2 V-Y advancement at each end reduce the longitudinal tension, creating skin laxity and allowing a direct closure. In some situations, this flap can avoid performing a forehead flap that is sometimes refused by patients. We report the case of a 76-year-old man presented to clinic with a basal cell carcinoma involving the lateral nasal sidewall (Fig. 1). We performed excision margin of 4–5 mm. The defect was reconstructed using a modified keystone island flap, designed to respect nasal subunit principle. The KF offers the alternative to replace like with like and respect the aesthetic unit. Aesthetically, the scar is almost inapparent at 6 months follow-up due to placement between aesthetic subunits with a harmonious contour of the alar rim (Fig. 2). We believe that this flap is difficult to adapt to defect larger than 2.2 to 2.5 cm, but we are convinced that in this very specific indication it has a place. Finally, the KF could be considered as a first-line option when direct closure is unfeasible.

Clinical characteristics and prognostic factors of sinonasal undifferentiated carcinoma: a multicenter study: Management of SNUC: the REFCOR experience

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.