P. Gallet

Transfacial versus endoscopic approach in the treatment of woodworker's nasal adenocarcinomas

The purpose of this study was to present a monocentric retrospective study designed to compare oncologic results and morbidity between transfacial surgery and endoscopic endonasal surgery for nasal adenocarcinomas.

Respiratory epithelial adenomatoid hamartoma: a poorly recognized entity with mast cell recruitment and frequently associated with nasal polyposis.

Abstract:Respiratory epithelial adenomatoid hamartoma (REAH) is regarded as a rare tumor of the nasal cavity. The mechanisms driving the development of REAH are unknown, and its nature as a benign tumor, hamartoma, or reactive inflammatory process is still open to discussion. A total of 150 consecutive patients operated on for nasal polyposis (NP) were extensively checked for the diagnosis of REAH. The profile of REAH occurring in association with NP was compared with solitary REAH in a series of 19 cases. The possible role of tryptase-producing mast cells (MC) and of metalloproteinases MMP2 and MMP9 in REAH development was investigated by immunohistochemistry. REAH lesions were identified in 35% of patients who had surgery for NP (53/150). The distribution of the lesions suggested that REAH originated in the olfactory cleft. Solitary REAH occurred about 20 times less frequently than those observed in an NP context but shared the same microscopic characteristics. Tryptase-producing MCs were recruited at high density in REAH (135/10 hpf), compared with inflammatory polyps (45/10 hpf; P<0.00005) and hypertrophied turbinates (51/10 hpf; P<0.0005). REAH also showed constant MMP9 expression and to a lesser degree MMP2 expression in epithelial cells. If solitary REAH is a relatively rare lesion, we demonstrated that an exhaustive sampling allows the detection of a high proportion of NP-associated REAH, sharing the same clinical and histologic characteristics with solitary REAH. Tryptase-producing MCs, possibly in association with MMP expression, may play a central role in REAH formation.

Olfactory neuroblastoma behavior inside and outside the olfactory cleft.

PurposeOlfactory neuroblastoma (ONB) is a rare malignant tumor of the nose. The currently available evidence links this disease with cells of the olfactory epithelium. The detailed description of tumor site and its extension is the key of treatment. The aim of the present study was to describe the way ONB develops inside and outside the olfactory cleft.MethodsThirteen consecutive patients treated between 2004 and 2014 for ONB with unequivocal pathologic diagnosis, complete diagnostic imaging and endonasal endoscopy surgery were enrolled in this retrospective study. The site of origin and local extension of each tumor were studied in detail based on computed tomography/magnetic resonance imaging, surgical report, registered videotape of the surgery, and pathological reports.ResultsThis series shows the behavior of a tumor arising either in the olfactory clefts (11 cases) or in the ethmoidal labyrinth (2 cases). When the setting begins with a tumor located in the olfactory cleft (below or in contact with the cribriform plate), the further step can be the extension to the ethmoidal labyrinth before intracranial or intraorbital extension. When tumors originate inside the ethmoidal labyrinths, the extension can first be into frontal sinus or orbital cavity.ConclusionsThis fine anatomic and radiologic description shows the natural behavior of ONB inside and outside the olfactory cleft. As a consequence, the staging system developed by Kadish seems inadequate and Dulguerov’s staging system could be improved. However, the preliminary proposed modification has to be evaluated in a prospective and large, multicenter cohort of patients.

Otitis media with effusion as a marker of the inflammatory process associated to nasal polyposis

Despite the close location of polyps with the Eustachian tube, association between nasal polyposis (NP) and otitis media with effusion (OME) has not been described in the literature. Our retrospective case-control study aimed at assessing the relative risk to develop OME when NP is associated to factors such as asthma, aspirin intolerance (AI), atopy, eosinophil infiltration of polyp tissue, and history of surgical treatment (HST). We compared the charts of 25 NP patients presenting symptomatic OME with 50 NP patients without OME. All the charts contained validated data about OME, asthma, AI, atopy, eosinophil count in polyp tissue, and HST. Our study showed that the risk to develop OME in NP patients is five times higher in patients presenting aspirin triad (NP + asthma + AI) (OR = 5.6, p = 0.009) and three times higher in HST patients (OR = 3.5, p = 0.03), than in isolated NP patients. A linear trend exists between the different degrees of respiratory disease and the risk of OME (p = 0.01). Our data suggest that the development of OME could be considered as another marker of severity of the inflammatory disease leading to NP, asthma and AI. Better characterisation of NP patients with OME could allow is to define more accurately the nature, type and severity of the underlying inflammatory process.

Olfactory exploration: State of the art.

Olfactory disorders are fairly common in the general population. Exploration, on the other hand, is seldom performed by ENT specialists, even in reference centers. There may be three reasons for this: this particular sensory modality may seem unimportant to patients and/or physicians; available treatments may be underestimated, although admittedly much yet remains to be done; and olfactory exploration is not covered by the national health insurance scheme in France. Advances in research in recent decades have shed light on olfactory system functioning. At the same time, several techniques have been developed to allow maximally objective olfactory assessment, as olfactory disorder is sometimes the first sign of neurodegenerative pathology. Moreover, objective olfactory assessment may be needed in a medico-legal context. The present paper updates the techniques currently available for olfactory exploration.

The olfactory fascia: an evo–devo concept of the fibrocartilaginous nose

PurposeEvo–devo is the science that studies the link between evolution of species and embryological development. This concept helps to understand the complex anatomy of the human nose. The evo–devo theory suggests the persistence in the adult of an anatomical entity, the olfactory fascia, that unites the cartilages of the nose to the olfactory mucosa.MethodsWe dissected two fresh specimens. After resecting the superficial tissues of the nose, dissection was focused on the disarticulation of the fibrocartilaginous noses from the facial and skull base skeleton.ResultsDissection shows two fibrocartilaginous sacs that were invaginated side-by-side in the midface and attached to the anterior skull base. These membranous sacs were separated in the midline by the perpendicular plate of the ethmoid. Their walls contained the alar cartilages and the lateral expansions of the septolateral cartilage, which we had to separate from the septal cartilage. The olfactory mucosa was located inside their cranial ends.ConclusionThe olfactory fascia is a continuous membrane uniting the nasal cartilages to the olfactory mucosa. Its origin can be found in the invagination and differentiation processes of the olfactory placodes. The fibrous portions of the olfactory fascia may be described as ligaments that unit the different components of the olfactory fascia one to the other and the fibrocartilaginous nose to the facial and skull base skeleton. The basicranial ligaments, fixing the fibrocartilaginous nose to the skull base, represent key elements in the concept of septorhinoplasty by disarticulation.

Nasal polyposis (or chronic olfactory rhinitis)

The concept of chronic rhinosinusitis with or without polyps is founded on the structural and functional unicity of the pituitary mucosa and its united response to environmental aggression by allergens, viruses, bacteria, pollution, etc. The present review sets this concept against the evo-devo three-nose theory, in which nasal polyposis is distinguished as specific to the olfactory nose and in particular to the non-olfactory mucosa of the ethmoid, which is considered to be not a sinus but rather the skull-base bone harboring the olfactory mucosa. The evo-devo approach enables simple and precise positive diagnosis of nasal polyposis and its various clinical forms, improves differential diagnosis by distinguishing chronic diseases of the respiratory nose and those of the paranasal sinuses, hypothesizes an autoimmune origin specifically aimed at olfactory system auto-antigens, and supports the surgical concept of nasalization against that of functional sinus and ostiomeatal-complex surgery. The ventilation function of the sinuses seems minor compared to their production, storage and active release of nitric oxide (NO) serving to oxygenate arterial blood in the pulmonary alveoli. This respiratory function of the paranasal sinuses may indeed be their most important. NO trapped in the ethmoidal spaces also accounts for certain radiographic aspects associated with nasal polyposis.

Chronic respiratory rhinitis

The clinical distinction of chronic respiratory rhinitis appears to confirm the evo-devo theory of the three noses. The authors report two cases of advanced allergic rhinitis, in which chronic inflammation had induced a violaceous colour of the mucosa of the respiratory nose and a whitish polypoid appearance of the free edge of the middle turbinate. Nose and paranasal sinus CT scan revealed, beyond the virtual nasal cavities observed on nasal endoscopy and CT imaging, normal radiolucency or only minor opacities of the ethmoid (i.e. olfactory nose) and paranasal sinuses that could not explain the severity of the chronic nasal dysfunction. The hypothesis of non-allergic chronic respiratory rhinitis is developed according to these two observations. The differential diagnosis between chronic respiratory rhinitis and dysfunction of the cavernous plexuses of the respiratory nose is discussed. A precise diagnosis appears to be a prerequisite for appropriate and effective management. Surgery of the respiratory nose can associate septoplasty to inferior turbinoplasty, but must be preceded and combined with medical treatment adapted to the underlying inflammatory process.

Successful management of rhinosinusal zygomycosis in a renal transplant recipient

Patrice Gallet, Anne Debourgogne, Alexandre Rivier, Nathalie Marcon, Thomas Georgel, Marc Ladrière, Jean-Michel Vignaud, Roger Jankowski and Marie Machouart Service d Oto-Rhino-Laryngologie et de Chirurgie Cervico-Faciale, CHU de Nancy, Hôpital Central, Nancy Cedex, France, Service de Parasitologie-Mycologie, CHU de Nancy, Hôpital Brabois, Vandoeuvre-les-Nancy, France, Service d Anatomie et Cytologie Pathologiques, Hôpital Central, CHU de Nancy, Nancy Cedex, France and Service de Néphrologie-Hémodialyse, CHU de Nancy, Hôpital Brabois, Vandoeuvre-lès-Nancy, France

Endoscopic surgery of the olfactory cleft

The olfactory cleft is the specific site of development of many tumours (respiratory epithelial adenomatoid hamartoma, intestinal-type adenocarcinoma, neuroblastoma, inverted papilloma, glomangiopericytoma, etc.) and is also the site of CSF rhinorrhoea via the cribriform plate (cribri-rhinorrhoea). Olfactory cleft surgery must therefore be considered to be a specific type of surgery, complementary to ethmoidal labyrinth surgery and anterior skull base surgery. Olfactory cleft tumours can be resected according to five different surgical procedures: olfactory cleft mucosal resection, partial resection of the olfactory cleft, total resection of the olfactory cleft, unilateral endoscopic anterior skull base resection, and bilateral endoscopic anterior skull base resection. The diagnosis and closure of cribri-rhinorrhoea (i.e. documented CSF rhinorrhoea, demonstrated to arise from the cribriform plate during endoscopic examination of the olfactory cleft under general anaesthesia in a patient with no localizing signs on imaging) completes this range of treatment options.