Cross-over septal flap technique for choanal atresia surgery in two centres: how I do it.

BACKGROUND: Choanal atresia is a congenital obstruction of the posterior nasal aperture. Endoscopic endonasal surgery has led to successful choanal atresia repair. This paper describes our surgical technique using septal mucosal flaps without the need for stenting. METHODS: This study comprised a multicentre retrospective review of patient notes. A cross-over septal technique is described, whereby bilateral vertical mucosal incisions are made at the posterior third of the septum, and the atretic plate and posterior vomer are removed. One flap is pedicled superiorly and rotated over the bare skull base and sphenoid bone; the contralateral flap is pedicled inferiorly to cover the exposed vomer remnant and hard palate. RESULTS: There were 12 patients from 2013 to 2020, aged 0.07-50 years, with a male to female ratio of 1:5. Ten patients had unilateral and two had bilateral choanal atresia. Nine patients had bony choanal atresia, with the remainder mixed. CONCLUSION: The cross-over technique for choanal atresia has low morbidity and 100 per cent success in our series. The use of mucoperiosteal flaps to cover exposed bone and minimal instrumentation to the lateral nasal wall reduce post-operative stenosis.

First record of Dosima fascicularis (Ellis amp; Solander, 1786) (Crustacea, Cirripedia) in the Strait of Messina (Central Mediterranean Sea).

Four specimens of Dosima fascicularis were collected from the Strait of Messina (Central Mediterranean Basin), representing the first record of the species from this locality, the second from Italian waters, and the most eastern indication of the species in the Mediterranean Sea.

Nasoseptal flap for palatal reconstruction after hemi-maxillectomy: case report.

OBJECTIVE: Palatal reconstruction following maxillectomy is a surgical challenge, and a nasoseptal flap is a feasible approach. This paper reports the first known successful clinical case of a nasoseptal pedicle flap applied for the reconstruction of maxillary bone following hemi-maxillectomy. CASE REPORT: This report describes hemi-maxillectomy in a 60-year-old Italian male diagnosed with stage IV squamous cell carcinoma of the left maxilla. Endoscopic transnasal extended medial maxillectomy was performed, followed by a transoral modified midfacial degloving technique for removal of the maxillary bone. The contralateral nasoseptal pedicle flap was used to reconstruct the defect. The case was followed up prospectively for the assessment of flap reception and healing. CONCLUSION: The locally accessible nasoseptal flap is a viable alternative for palatal reconstruction; therefore, a second surgical procedure with its associated donor site morbidity can be avoided. Large-scale studies may help in establishing the cosmetic and functional outcomes.

Anisakis spp. larvae in three mesopelagic and bathypelagic fish species of the central Mediterranean Sea.

In this work 437 fish samples of species belonging to the families Myctophidae (Electrona risso and Diaphus metopoclampus) and Phosichthyidae (Vinciguerria attenuata) were examined for the presence of Anisakidae larvae. The study was performed with fishes in the central Mediterranean Sea, particularly in the Strait of Sicily and in the Strait of Messina. The visual inspection and chloro-peptic analysis revealed the presence of nematode parasites with prevalence values between 2.9% in Electrona risso samples and 5.4% in Vinciguerria attenuata samples. A positive correlation was found between standard length (SL) and prevalence of infestation in D. metopoclampus samples (p<0.05). The larvae examined were morphologically ascribed, at genus level, to Anisakis morphotypes I and II and molecularly identified as Anisakis pegreffii, Anisakis ziphidarum and Anisakis physeteris, in 67%, 9% and 24% of the fish samples examined. Overall, A. pegreffii and A. ziphidarum larvae were isolated in 14 and 2 specimens of D. metopoclampus respectively, A. physeteris larvae were found in 3 E. risso and 2 V. attenuata. A positive correlation was found between standard length and prevalence of infestation in D. metopoclampus samples (p<0.05). First information is provided on the presence of Anisakis spp. larvae of the myctophid fish species E. risso, D. metopoclampus and V. attenuata from the Central Mediterranean. It is also confirmed the role of lanternfishes (Myctophidae) as paratenic hosts for Anisakis spp.

Septal flip flap for anterior skull base reconstruction after endoscopic resection of sinonasal cancers: preliminary outcomes.

Over the past decade surgery for sinonasal malignancies encroaching into the anterior skull base (ASB) has evolved from open craniofacial resection to the use of minimally invasive transnasal endoscopic approaches. Using these techniques, ASB reconstruction is most often performed in a multilayer fashion with autologous free grafts (fascia lata or iliotibial tract) which leads to the production of abundant nasal crusting in the postoperative months and discomfort for patients. In carefully selected cases, we propose harvesting a flap from the contralateral nasal septum based on the septal branches of the anterior and posterior ethmoidal arteries (Septal Flip Flap, SFF), which can be rotated to resurface the ASB defect. The exclusion criteria for using the SFF were as follows: cases where the tumour extended to both ethmoid complexes; cases where there was nasal septum or planum spheno-ethmoidalis involvement by the disease; cases of sinonasal malignant tumour with multifocal histology. In our tertiary care referral centre, skull base reconstruction using the SFF was performed in four patients; one was affected by ethmoidal teratocarcinosarcoma, one by persistence of sinonasal undifferentiated carcinoma after radio-chemotherapy, another by olfactory cleft esthesioneuroblastoma and the fourth by ethmoidal squamous cell carcinoma. Successful skull base reconstruction was obtained in all four cases without any intra- or post-operative complications. Post-operatively, nasal crusting was significantly reduced with faster healing of the surgical cavity. No recurrences of disease have been observed after a mean follow-up of 15 months. The SFF can be considered as a safe and effective technique for ASB reconstruction with high success rates similar to those obtained with other pedicled flaps. This flap also ensured a faster healing process with reduction of nasal crusting and improvement in the quality of life of patients in the postoperative period. This technique appears to be a safe and effective option for ASB reconstruction after endonasal resection of sinonasal malignancies in selected cases. Larger case series with a longer follow-up are needed to validate the preliminary results obtained with such an innovative and promising surgical technique.

Transorbital endoscopic assisted management of intraorbital lesions: lessons learned from our first 9 cases.

BACKGROUND: The management of intraorbital lesions is challenging and it is strongly dependent to their nature, position and biological behaviour. Traditionally, the superior and lateral compartments of the orbit are addressed via lateral orbitotomy or transcranial approaches. Herein we present our preliminary experience in the management of selected supero-lateral intraorbital lesion through an endoscopic-assisted superior-eyelid approach. METHODOLOGY: All cases of intraorbital lesion treated in two Italian tertiary care referral centres using a superior eyelid endoscopic-assisted transorbital approach were retrospectively reviewed. RESULTS: Nine patients have been analysed. The aim of surgery was diagnostic in 5 cases and curative in the remaining 4 patients. Significant tissue biopsy was obtained in all the five diagnostic procedures. Complete resection was obtained in 3/4 lesions. No major intra- or postoperative complications have been observed. Mean surgical time was 68 minutes. Mean hospitalization time was 4.4 days. All patients were satisfied about the surgical procedure, as emerged by the post-operative counselling. At present, the mean follow-up time is 18 months, ranging from 11 to 25 months. CONCLUSIONS: Our preliminary results are promising with successful functional and cosmetic outcomes and reduced morbidity for the patient. This approach should be considered as an option for selected intraorbital lesions.

Relationships between otolith size and fish length in some mesopelagic teleosts (Myctophidae, Paralepididae, Phosichthyidae and Stomiidae).

Length-mass relationships and linear regressions are given for otolith size (length and height) and standard length (LS ) of certain mesopelagic fishes (Myctophidae, Paralepididae, Phosichthyidae and Stomiidae) living in the central Mediterranean Sea. The length-mass relationship showed isometric growth in six species, whereas linear regressions of LS and otolith size fit the data well for all species. These equations represent a useful tool for dietary studies on Mediterranean marine predators.

Endoscopic endonasal management of non-functioning pituitary adenomas with cavernous sinus invasion: a 10- year experience.

BACKGROUND: The management of Non-Functioning Pituitary Adenoma (NFPA) invading the cavernous sinus (CS) is currently a balancing act between the surgical decompression of neural structures, radiotherapy and a wait-and-see policy. METHODS: We undertook a retrospective review of 56 cases of NFPA with CS invasion treated through an endoscopic endonasal approach (EEA) between 2000 and 2010. The Knosp classification was adopted to describe CS involvement using information from preoperative MRI and intraoperative findings. Extent of resection and surgical outcomes were evaluated on the basis of postoperative contrast-enhanced MRI. Endocrinological improvement and visual outcomes were assessed according to the most recent consensus criteria. RESULTS: EEA was performed using direct para-septal, trans-ethmoidal-sphenoidal or trans-ethmoidal-pterygoidal-sphenoidal approach. Visual outcomes improved in 30 (81%) patients. Normalization or at least improvement of previous hypopituitarism was obtained in 55% of cases. A gross total resection was achieved in 30.3% of cases. The recurrence-free survival was 87.5%, with a mean follow-up of 61 months (range, 36-166 months). No major intraoperative or postoperative complications occurred. DISCUSSION: EEA is a minimally-invasive, safe and effective procedure for the management of NFPA invading the CS. The extent of CS involvement was the main factor limiting the degree of tumor resection. The EEA was able to resolve the mass effect, preserving or restoring visual function, and obtaining adequate long-term tumor control.

Prevalence of occupational hazards in patients with different types of epithelial sinonasal cancers.

BACKGROUND: Occupational exposure to carcinogens contributes greatly to the etiology of sinonasal cancer (SNC), but the role of different risk factors in determining different histological subtypes is disputed. METHODOLOGY: All consecutive surgical epithelial SNC cases (case-series study) underwent a systematic occupational medicine examination to determine previous exposure to a wide range of work-related chemical hazards. RESULTS: We investigated 65 SNC cases including intestinal-type adenocarcinoma [ITAC] squamous-cell carcinoma [SCC], and others. Occupational exposure was recognized for 39 cases. Occupational exposures were sensibly more frequent among ITAC than among SCC or other histotypes. Occupational exposure in ITAC cases was to leather or wood dust only, while among non-ITAC cases, we recognised exposure to formaldehyde, solvents and metal fumes. A high proportion of SNC with occupational exposure originated in the ethmoidal epithelium. CONCLUSION: In our case-series of SNC, a very high frequency of previous occupational exposure to carcinogens was detected, suggesting that occupational hazards may be associated to the aetiopathogenesis, primarily for ITAC, but also for other histotypes. Besides leather or wood, other chemical agents must be recognized as occupational risk factors.

Endoscopic transnasal resection of anterior skull base malignancy with a novel 3D endoscope and neuronavigation.

The surgical treatment of sinonasal malignancies is in continuous evolution. In selected patients, endoscopic resection has become a sound alternative to traditional external approaches. Further improvements are necessary to enhance the possibilities of endoscopic transnasal resection of sinonasal malignancies. We present a case of intestinal-type adenocarcinoma of the left nasal fossa eroding the skull base that affected a 56-year-old male. The patient was surgically-treated by means of a four-hand binarial endoscopic transnasal resection using a 3D endoscopic system and neuronavigation. Surgery was completed in 5 hours without significant complications. Surgeons were able to recognize and manage anatomical structures, and to control bleeding easily thanks to the bimanual technique and 3D visualization. The new 3D scopes and the bimanual technique under the guidance of a navigation system represent an interesting solution that can overcome the traditional limits of the traditional set up currently used.

Combined transnasal transcervical robotic dissection of posterior skull base: feasibility in a cadaveric model.

The current surgical trend is to expand the variety of minimally invasive approaches and, in particular, the possible application of robotic surgery in head and neck surgery. For this purpose, we explored the feasibility of a combined transcervical-transnasal approach to the posterior skull base, using the da Vinci Surgical System in 3 cadaver heads. Superb visualization of the sellar, suprasellar and clival regions was possible in all three specimens. The trocars` placement through a transcervical port made a more cephalad visualization possible, eliminating the need to split the palate. The advantages of robotic surgery applied to the posterior cranial fossa are similar to the ones already clinically experienced in other districts (oropharynx, tongue base), in terms of tremor-free, bimanual, precise dissection. The implementation of instruments for bony work will definitely increase the applicability of such a system in the forthcoming years.

Spectrophotometric characterization of human impacted surface waters in the Moselle watershed.

In order to characterize the pollution discharged into the Moselle River and some of its tributaries, spectroscopic techniques, namely UV-vis spectroscopy and synchronous fluorescence spectroscopy, have been combined. UV-visible spectra were analysed using the maximum of the second derivative at 225 nm (related to nitrates), the SUVA254 and E2/E3 indices (related to the nature of organic matter). Synchronous fluorescence spectra (delta lambda = 50 nm) presented different shapes depending upon the type of pollution. The pollution results from anthropogenic activities: untreated domestic sewage due to misconnections in a periurban river, effluent from urban WWTPS, agricultural runoff (nitrates) in several streams, discharge from a paper mill (humic-like substances due to wood processing) and from steel mills (PAHs).

Subdural haematoma after endoscopic skull base surgery: case report and lesson learned.

We report a case of a left fronto-temporo-parietal subdural haematoma that emerged as a complication of an endonasal endoscopic resection of a sinonasal adenocarcinoma of the left ethmoidal region. During the first surgical intervention, following oncological principles, the dura mater above the ethmoidal plate was removed and a skull base plasty was performed. In the post-operative phase a massive cerebrospinal fluid leak was observed and a revision duraplasty was performed the following day. Subsequently the patient was discharged on day 8 with no signs of CSF leakage. At the three month follow-up MR examination a subdural haematoma was observed and then treated by the neurosurgeon in a standard fashion. The collection was quite asymptomatic and discovered accidentally. We strongly advise the role of early post-op neuroimaging in every patient undergoing skull base procedures. We maintain that a massive CSF leak, that causes a significant reduction of intracranial pressure, should be managed as a surgical emergency, in order to reduce the risk of subdural haematoma.

Transnasal approach to the medial intraconal space: anatomic study and clinical considerations.

BACKGROUND: The aim of this study was to illustrate the anatomy of the medial compartment of the orbit by comparing the endoscopic transnasal perspective with the external ones. METHODS: 8 orbits from 5 double-injected heads were carefully dissected. An endoscopic anterior transconjunctival dissection was performed in one orbit while an endoscopic transnasal intraconal dissection was conducted in 3 orbits. External dissections (from medial, superior and anterior perspective) were also performed. RESULTS: The role of the medial rectus muscle is emphasised. It represents the first important landmark encountered, covering all the other structures during transnasal approaches. By displacing it, the medial intraconal space with its contents becomes visible: the ophthalmic artery and related branches, the superior ophthalmic vein, the nasociliary nerve and, in the deepest part of the medial compartment, the optic nerve. CONCLUSION: The medial compartment of the orbit can be addressed transnasally. By displacing the medial rectus muscle, it is possible to gain adequate space for the instruments and to control all of the medial compartment, including the medial aspect of the optic nerve.

Nasopharyngeal endoscopic resection in the management of selected malignancies: ten-year experience.

OBJECTIVE: To evaluate the feasibility of endoscopic surgery in the management of selected nasopharyngeal cancers. Three different types of nasopharyngeal endoscopic resections (NER) are described. METHOD OF STUDY: From January 1997 to October 2008, 17 consecutive patients (mean age: 50 years) with previously untreated (5) or recurrent nasopharyngeal tumours (12) were treated with curative intent by pure endoscopic resection. The extent of surgical resection was classified as follows: type I NER: resection limited to the postero-superior nasopharyngeal wall; type 2 NER: resection superiorly extended to the sphenoid sinus; type 3 NER: resection with lateral extension including the cartilaginous portion of the Eustachian tube and parapharyngeal space. RESULTS: Type 1 NER was performed in 4 cases, type 2 in 6, and type 3 in 7. No intra- or post-operative complications were observed. Mean hospitalization time was 4 days (range: 1-7). Follow-up ranged from 10 to 138 months (mean: 41.2±38). At the time of writing, 12 (71/%) patients were free of disease, 3 (17%) alive with disease, and 2 (12%) dead of disease. CONCLUSIONS: NER is a feasible surgical technique that can be tailored in relation to tumour extension. Larger series and longer follow-up are needed to further validate the long-term results.

Endoscopic, endonasal management of sinonasal haemangiopericytoma: 12-year experience.

AIM: To report our experience with endoscopic, endonasal management of sinonasal haemangiopericytoma. MATERIALS AND METHODS: Retrospective review of the medical records of 10 patients undergoing endoscopic, endonasal surgery for sinonasal haemangiopericytoma of the nose and paranasal sinuses, between 1997 and 2008. RESULTS: Five men and five women were included. Their mean age at surgery was 59 years. All patients underwent endoscopic, endonasal resection of their tumour. Major post-operative complications were encountered in only one patient (stroke). Local recurrence was diagnosed in only one patient (10 per cent), who subsequently underwent a combined resection (endoscopic and external) with orbital exenteration. CONCLUSIONS: Sinonasal haemangiopericytomas are rare tumours that are usually benign. The mainstay of treatment is wide surgical excision with free resection margins. Nowadays, the great majority of patients can be treated using a purely endoscopic, endonasal approach.

Endoscopic transnasal anatomy of the infratemporal fossa and upper parapharyngeal regions: correlations with traditional perspectives and surgical implications.

BACKGROUND: The aim of this study was to illustrate the endoscopic surgical anatomy of the infratemporal fossa (ITF) and upper parapharyngeal space and to provide useful landmarks by comparing transnasal perspectives with external ones. MATERIALS AND METHODS: 6 fresh double injected heads were dissected. External lateral dissection was performed through a pre-auricular skin incision while external anterior dissection started with a modified Weber-Ferguson incision. External medial to lateral dissection was performed starting from the rhinopharyngeal and pterygoid regions, after cutting the specimen in 2 halves passing through the nose. Endoscopic dissection was performed through an endonasal approach (0° and 45° scopes). RESULTS: Among all the structures identified during the dissection, the most useful landmark when dissecting the ITF in a lateral to medial direction is the lateral pterygoid muscle. In anterior approaches (mostly endoscopic) the role of the lateral pterygoid muscle is less important and the Eustachian tube (ET) represents the most important landmark to point out the upper portion of the parapharyngeal internal carotid artery (ICA). The role of the ET, in lateral dissection is, on the contrary, by far less important given the fact that it is very deep in the surgical field and that the ICA is encountered earlier during surgical approaches. Another crucial landmark during anterior endoscopic surgery is the vidian nerve because it points to the anterior genu of the internal carotid artery. CONCLUSION: The complex 3-dimensionality of the ITF and the upper parapharyngeal space needs a sound knowledge of the surgical anatomy. The role of the same landmarks changed in different approaches. The ability to orientate oneself in this complex area is related to an accurate knowledge of its anatomy through comparison of endoscopic and external perspectives.

Endoscopic endonasal management of petroclival cerebrospinal fluid leaks: anatomical study and preliminary clinical experience.

BACKGROUND: Endonasal management of most anterior cranial fossa cerebrospinal fluid leaks is a well established procedure, and even some middle cranial fossa cerebrospinal fluid leaks can be managed safely endonasally. Endonasal endoscopic management of leakages of the posterior cranial fossa represents an unique challenge. OBJECTIVE: The aim of this study was to assess the feasibility of an endoscopic endonasal approach for treating well-selected cerebrospinal fluid leaks of the petroclival region. METHODS: Clinical charts of patients with leakages of the petroclival region treated at our institution were retrospectively reviewed. Careful dissection of the petroclival region was performed, both endonasally and externally, in three fresh injected heads. RESULTS: Two patients presented a leakage of the petroclival region. Both the patients presented multiple skull base defects. The two patients underwent a supratubaric trans-spheno-petroclival approach; in one of these, it was performed in combination with a middle cranial fossa approach. Multilayer reconstruction was performed in both patients. No cerebrospinal fluid leak recurrences were observed during follow-up (17 and 19 months, respectively). CONCLUSIONS: Endonasal endoscopic management of well-selected petroclival cerebrospinal fluid leaks is feasible.