OBJECTIVES:The Apnea-Hypopnea Index (AHI) is considered the gold standard for diagnosis and severity classification of pediatric obstructive sleep apnea (OSA). This review critically analyzes the scientific foundations of this paradigm and its clinical implications. MATERIALS AND METHODS:A systematic literature review in the PubMed and Cochrane databases was conducted according to the SWiM methodology (Synthesis Without Meta-analysis) following EQUATOR network guidelines. Studies were grouped according to 5 themes: methodological foundations of the AHI, clinical correlations, alternative parameters (oximetry and respiratory effort), sleep study indications, natural history and therapeutic options. The narrative review focused on randomized studies (CHAT, PATS) and international guidelines. RESULTS:The definition of OSA in terms of an AHI threshold of 1 event/hour is based on old statistical data (Marcus et al., 1992) without clinical validation. The PATS study found no significant clinical difference between primary snorers (AHI<1) and mild OSA (AHI 1-5). The correlations between AHI and sleep questionnaires (Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder Scale [PSQ-SRBD], Obstructive Sleep Apnea-18 [OSA-18]) are very weak (r2≈2%). Oximetric parameters (oxygen desaturation index (ODI), pulse oximetry SpO2 nadir, hypoxic burden) correlate better with cardiovascular morbidity, although pediatric thresholds remain to be validated. Markers of respiratory effort (flow limitation, pulse transit time, mandibular movement) may identify airway resistance syndrome missed by AHI alone, but are without reference values. Sleep study, with AHI assessment, is not always contributive: in typical clinical presentations without comorbidity, adenotonsillectomy may be proposed upfront. CONCLUSION:AHI is useful but insufficient to guide therapeutic management. A personalized multiparametric approach integrating oximetric data, respiratory effort, symptoms and validated questionnaires seems more appropriate. Sleep study indications should be reserved for clinical discordance, comorbidity, young children and failure of adenotonsillectomy.
Acquired external auditory canal stenosis is rare, but leads to chronic otorrhea and conductive hearing loss that can become disabling. Surgery relies on canaloplasty associated to skin coverage to limit the high risk of recurrence. We describe a standardized retroauricular canaloplasty technique associated to retroauricular thin skin graft. The accompanying video (Supplementary Material) shows the key steps in fundus dissection, reaming, grafting and immobilization. This reproducible approach aims to optimize healing, limit the risk of anterior angle blunting and improve long-term functional results.
Objectives Pseudohypacusis (PHA), or non-organic hearing loss, is still poorly understood and often underdiagnosed. The primary objective of this study was to determine its audiometric characteristics and evolution. The secondary objective was to gather evidence for possible associated auditory processing disorders, learning difficulties or psychiatric conditions, with the aim of establishing a diagnostic and management algorithm. Materials and methods A single-center retrospective cohort study included all patients presenting PHA. Clinical, medical, psychological and speech therapy data were collected, along with subjective audiometric assessments (pure-tone and speech audiometry in quiet and in noise, central auditory processing assessment), objective audiometric tests, and radiological examinations. Results Thirty patients (57 ears) were included: 11 males and 19 females. Hearing loss was sensorineural in 61% of cases. Speech audiometry was consistent in 52% of cases. Speech therapy and/or psychological assessment was performed in 28 patients (93%). Audiometric follow-up showed normalization in 45% of cases, with a mean recovery time of 7.2months. Speech-in-noise audiometry alone was performed in 7 patients, and was impaired in 5 of these. Two patients underwent central auditory processing assessment, which revealed auditory processing disorders. Conclusion PHA is an auditory symptom that usually reflects an underlying disorder, which needs to be managed. It requires multidisciplinary evaluation and treatment.
INTRODUCTION:Congenital anosmia (CA) is a rare developmental condition that may occur in isolation or as part of a syndromic disorder. Gorlin-Goltz syndrome (GGS), an autosomal dominant condition most commonly caused by pathogenic variants in PTCH1, is classically characterized by cutaneous, odontogenic and skeletal abnormalities, while neurological manifestations remain incompletely defined. CASE SUMMARY:We report the case of a 10-year-old girl with genetically confirmed PTCH1-related GGS who presented with lifelong anosmia. Otolaryngological evaluation confirmed absent olfactory function by psychophysical testing and electrophysiological assessment. Neuroimaging revealed bilateral olfactory bulb hypoplasia. Endocrinological evaluation excluded hypogonadotropic hypogonadism, distinguishing this phenotype from classical Kallmann syndrome. DISCUSSION:This case adds to the limited, but growing evidence supporting an association between CA and PTCH1-related GGS, highlighting the role of disrupted Sonic Hedgehog signaling in olfactory system development. Recognition of olfactory dysfunction in these patients may contribute to a broader understanding of the neurodevelopmental spectrum associated with PTCH1 mutations.
INTRODUCTION:The COVID-19 pandemic and the associated public health measures (shielding) altered the circulation of respiratory infections. However, their impact on pharyngeal abscess remains poorly documented. OBJECTIVE:The primary objective was to assess the progression in the number of pharyngeal abscess cases between March 2018 and February 2024. MATERIALS AND METHODS:A retrospective single-center study compared the periods before, during and after the implementation of shielding measures. Demographic, clinical, therapeutic, and bacteriological data were analyzed. RESULTS:Two hundred twenty patients with pharyngeal abscess were included. A significant increase in cases was observed after the lifting of shielding. We also identified a higher rate of surgical management and a predominance of Streptococcus pyogenes after the measures were lifted. CONCLUSION:Shielding measures implemented during the COVID-19 pandemic affected not only the number of pharyngeal abscess cases but also their management and bacteriological profile.
INTRODUCTION:Local complications secondary to intravascular cocaine injection are various, with cellulitis, abscess and tissue necrosis. Cervical involvement after direct injection incurs a risk of major hemorrhage, due to the proximity of vascular structures. CASE REPORT:A female patient presented necrosing cervical fasciitis secondary to cocaine injection in the external jugular vein. She consulted 3 weeks later with a large ulcer at the base of the sternocleidomastoid muscle. Biological and radiological assessment confirmed the absence of any deep vascular complications but revealed necrosis associated with deep cervical abscesses. She underwent emergency surgery to resect the necrotic tissue, drain the collections and ligate the vein. Viable muscle above the vascular fascia made flap coverage unnecessary. Directed healing provided favorable progression. Postoperative course was straightforward, and addictologic follow-up was initiated. CONCLUSION:Intravascular cocaine injection can lead to deep cervical necrosis, which could be serious due to the vascular risk. Urgent specialized treatment is essential to prevent complications.
INTRODUCTION:Neuroborreliosis (NB) is a neurologic complication of Lyme disease that can cause sudden hearing loss, which can in some cases be bilateral. CASE REPORT:A 61-year-old woman consulted for bilateral sudden hearing loss with headache and earache, following an episode of fever. Interview found a skin lesion suggestive of migratory erythema, which had developed 3months previously after a walk in a German forest and had not initially been treated. Examination revealed severe sensorineural hearing loss and lymphocytic meningitis. Blood tests found long-standing IgM and IgG positive Borrelia burgdorferi infection with intrathecal synthesis of IgM and IgG antibodies. Corticosteroid treatment and ceftriaxone was initiated, and normalized hearing within 3weeks. DISCUSSION:Hearing impairment in NB may involve inflammatory, immunologic or cytotoxic mechanisms affecting hair cells. Early treatment with corticosteroids and targeted antibiotics should be prescribed when NB is suspected, to optimize the chances of recovery. In endemic geographic areas, signs of Lyme disease should be screened for in case of sudden hearing loss.
OBJECTIVES:To evaluate the criteria used by surgeons to select tracheoesophageal voice (TEV) rehabilitation by voice prosthesis (VP) after total laryngectomy (TL) or pharyngolaryngectomy (TPL). MATERIAL AND METHODS:This was a retrospective study conducted in a tertiary referral center between January 2014 and December 2023. The primary objective was to assess the selection criteria for TEV rehabilitation with VP after TL or TPL. Secondary objectives were to analyze VP longevity, related complications, and factors influencing their occurrence. The STROBE reporting guidelines were followed, and the significance threshold was set at P<0.005. RESULTS:A total of 114 patients who underwent TL, TPL or circular TPL were included, 53 of whom received a VP. On binomial logistic regression, patients who underwent TEV rehabilitation with VP were younger (P=0.020), had better general health status (ASA>2, P<0.001), and underwent surgery with direct closure (P=0.026). Median VP lifespan was 188days [IQR: 124-305]. Periprosthetic leakage was the most frequent complication (75% of all complications). CONCLUSION:TEV rehabilitation tended to be proposed to younger patients in good general health and in cases other than salvage surgery. Patients should be assessed preoperatively before determining the method of voice rehabilitation.
INTRODUCTION:Post-extubation dysphagia (PED) is a frequent and underestimated complication in intensive care, with increased risk of morbidity and mortality. The role of the otorhinolaryngologist in management is not well defined. METHODS:A systematic literature review was conducted following the 2020 PRISMA guidelines. It focused on studies of adult patients assessed in intensive care for swallowing disorder after extubation. Study data comprised population, means and timing of assessment and criteria for ENT involvement. Risk of bias was assessed qualitatively using the STROBE, MINORS and AMSTAR guidelines. RESULTS:Forty-one studies published between 2001 and 2024 were selected. Prevalence of PED ranged from 7% to 80%, exceeding 30% in two-thirds of the studies. Risk factors comprised advanced age, >5-7days' intubation, high severity score, endotracheal tube≥8mm, nasogastric catheter, laryngeal lesion, acquired muscle weakness, and no oral intake at 72hours. Methods varied: 34% of studies used instrumental assessment (FEES, VFSS) and the others used clinical tests (FOIS, FILS). ENT involvement was reported in only 27% of studies, on the following criteria: persistent voice abnormality, ineffective coughing, no oral feeding by day 3, failure on clinical tests, and radiologic suspicion of inhalation. CONCLUSION:PED has significant prognostic impact, but is variably assessed. The ENT physician can play a key role, but intervention needs to be targeted. Based on the present findings, we propose a decision support algorithm combining simple clinical criteria and tests. Multicenter prospective studies are needed to validate the algorithm and assess its clinical and organizational contribution.
INTRODUCTION:Olfactory neuroblastoma (ONB) is a rare malignant tumor of the sinonasal tract. The objective of this study is to present an evidence-based synthesis of the recommendations of the French Expert Network of Rare ENT Cancers (REFCOR), published in 2022, concerning the diagnostic and therapeutic management of ONB. METHOD:These recommendations result from a multidisciplinary consensus based on a critical analysis of the literature and feedback from expert centers within a structured process. RESULTS:ONB accounts for 6% of sinonasal cancers, with no identified risk factors. Diagnosis is based on CT and MRI of the paranasal sinuses and skull base, together with systemic disease staging. Histopathological analysis requires specialized expertise, with Hyams histological grade as the main prognostic factor. The standard of care consists in surgical resection followed by adjuvant radiotherapy. Chemotherapy may be considered in high-grade or unresectable forms. Because of the risk of late recurrence, at least 20years' follow-up is recommended. CONCLUSION:The REFCOR guidelines aim to standardize diagnosis and treatment for ONB, but require completion by discussion in a specialized multidisciplinary tumor board.
INTRODUCTION:Progression of advanced-stage head-and-neck cancer (HNC) can lead to respiratory distress requiring emergency tracheotomy. In the context of palliative care, this raises major prognostic and ethical issues. The present study sought to assess survival and morbidity after emergency tracheotomy in HNC patients under palliative care. MATERIAL AND METHODS:A 2-center retrospective study included all HNC patients in palliative care who underwent emergency tracheotomy between 2000 and 2023 in our institution. Demographic, clinical/pathologic and survival data were analyzed. RESULTS:Thirty-eight of the 1243 tracheotomies performed during the study period were for patients in palliative care. Mean age was 64.5±11.9years. Ninety-five percent of cancers were stage IV and 40% were metastatic. Forty-two percent of patients experienced postoperative complications. No deaths directly implicated surgery. Median overall post-tracheotomy survival was 2months (IQR: 1-4months), for a mean 4.3±6.6months. Discharge home was the only significant protective factor (HR: 0.27; P=0.006). CONCLUSION:Emergency tracheotomy is rare in the context of palliative care, with fewer than 2 cases per year in our center. It prolongs survival by a few weeks, but at the cost of elevated morbidity. Indications should be anticipated and discussed in a tumor board including palliative care professionals.
OBJECTIVE:Prognostic influence of invasion pattern and circumferential spread of internal carotid artery (ICA) on survival in patients with nasopharyngeal cancer (NPC) was not well established. Thus, we conducted a retrospective study to investigate the association with survival. MATERIAL AND METHODS:This was a retrospective study and included pathologically proved NPC patients from November 2015 to Dec 2022 at our Hospital. The invasion pattern and circumferential spread of ICA were carefully reviewed from computed tomogram or magnetic resonance image. Survival were estimated by the Kaplan-Meier method with five-year overall survival (OS) rate and five-year disease specific survival (DSS) rate. RESULTS:A total of 200 NPC patients were included in this study for outcome analysis. Of the included patients, ICAI by NPC was observed in 55 (27.5%) patients. After stratifying by ICA invasion (ICAI) or not, the OS and DSS were 41% and 44% in patients with ICAI, while 81% and 85% in those without ICA invasion, respectively (P<0.001 in both OS and DSS). Subgroup analysis found that patients with C4 segment invasion had worst outcomes. The OS and DSS were 14% and 14% in patients with C4 segment invasion of ICA, while 72% and 77% in those without C4 segment invasion of ICA, respectively. As for extent of circumferential spread, the 5-year survival rate and 5-year disease specific survival rate were 80% versus 40% and 85% versus 45% for patients with spread less than 180 degree and more than 180 degree, respectively. CONCLUSIONS:Locally advanced NPC patients with ICAI has miserable outcomes, especially those with ICAI more than 180 degree and C4 segment involvement. More aggressive interventions were needed to extend their survival.
AIMS:Parotidectomy is a common surgery to treat parotid neoplasms. While much discussion has been invested in complications such as facial nerve injury and Frey syndrome, outcomes arising from great auricular nerve (GAN) sacrifice are not well studied. The present study aims to investigate quality of life outcomes post-parotidectomy according to GAN preservation status. MATERIALS AND METHODS:A cross-sectional study of parotidectomy patients between 2011-2020 for benign tumours was performed. Data on quality of life (QoL) was collected through a composite questionnaire (Douleur Neuropathique 4 [DN4] and Leeds Assessment of Neuropathic Symptoms and Signs [LANSS]). OBJECTIVES:To assess patient quality of life post-parotidectomy according to GAN preservation status. RESULTS:Among the contacted patients, 76/205 (37.1%) responded. Of these, 38/76 were categorised as GAN-preserved, 34/76 as GAN-sacrificed and 4/76 were excluded as GAN status could not be ascertained. All patients were >6months post-operation. On a scale of 0-10, for pain, the mean values were 2.21/10 (GAN-sacrificed) and 1.32/10 (GAN-preserved) (P=0.645), and for numbness 4.47/10 (GAN-sacrificed), and 4.34/10 (GAN-preserved) (P=0.645). The angle of mandible was the most reported area for neuropathic sensations (42.1% (16/38) of GAN-preserved; 50.0% (17/34) of GAN-sacrificed). Tingling sensation was the most frequent sensation described. On a scale of 0-10 for effect on general QoL, the mean was 1.08/10 for GAN-preserved, and 1.62/10 GAN-sacrificed cohort (P=0.29). No statistical differences for specific QoL measures were found. CONCLUSION:Our results suggest that GAN sacrifice is not associated with increased sensory defects and does not negatively impact on quality of life. LEVEL OF EVIDENCE:III.
INTRODUCTION:Thermal injury of the upper aerodigestive tract related to inhalational drug abuse is uncommon but increasingly recognized. While airway injury associated with crack cocaine inhalation has been reported, the otolaryngologic manifestations of inhaled heroin vapor ("chasing the dragon") remain poorly described. CASE SUMMARY:We report the case of a 39-year-old woman presenting with progressive dysphonia and dyspnea. She had a history of polysubstance smoking including tobacco, cannabis, crack cocaine, and heroin vapor inhalation. Flexible fiber-optic nasopharyngolaryngoscopy demonstrated extensive bilateral necrosis of the vocal fold mucosa with preserved vocal fold mobility and abundant carbonaceous debris within the laryngeal lumen. Histopathological analysis of expectorated fragments confirmed ischemic necrosis of squamous mucosa. The patient was managed conservatively with corticosteroids, antibiotics, and close outpatient follow-up, with partial clinical improvement. DISCUSSION:Thermal injury from crack cocaine inhalation has been associated with supraglottic and laryngeal mucosal damage. In contrast, the effects of inhaled heroin vapor on the upper airway remain poorly documented. Combined inhalation of multiple substances may result in additive thermal and chemical mucosal injury, potentially explaining the extensive laryngeal necrosis observed in this case. This report highlights the need to consider polysubstance inhalational abuse in patients presenting with unexplained necrotizing laryngeal lesions.
