3D-4K exoscope-assisted temporal bone dissection: a new frontier in surgical training.

PURPOSE: To assess if 3D-4K exoscope is a valuable tool for temporal bone dissection and to evaluate its teaching potential. METHODS: Six consecutive 3D-4K-exoscope-assisted cortical mastoidectomies were performed by a novice, an intermediate and an expert surgeon (two dissections each). All dissections were entirely recorded and later evaluated independently by three other experienced surgeons. The dissection end-product was evaluated according to the Melbourne Mastoidectomy Scale (MMS). Paired t test was used to assess whether novice and intermediate surgeons have a score improvement in the second dissection compared to the first one. Surgeons' interactions, depth effect, and 3D impression were also assessed to perform a subjective analysis. RESULTS: Mean MMS scores for the novice, intermediate and expert surgeon were 11.3 ± 2.8, 13.8 ± 3.9 and 19 ± 1.3, respectively. Paired t test demonstrated a statically significant improvement between the first and the second dissection both for the novice and the intermediate surgeon (+ 4.7 and + 7 points; p = 0.0002). A high-quality magnification of the temporal bone was obtained, allowing the expert surgeon to identify all the anatomical structures without injuring them. The exoscope was capable of providing a high involvement in the dissections with very effective interactions between the expert surgeon and the trainees, that had access to the same surgical field view. CONCLUSION: 3D-4K-exoscope resulted adequate for a safe and effective mastoidectomy and showed a high potential for training and educational purposes. It can represent a valid option for surgical training of temporal bone dissection and a new interactive tool to understand the complex temporal bone anatomy.

Introducing the High-definition 3D exoscope in ear surgery: preliminary analysis of advantages and limits compared with operative microscope.

PURPOSE: The aim of this study was to evaluate the potential of 3D exoscope (EX) in selected ear procedures assessing if this new technology could be an improvement in the field of ear surgery. METHODS: A case series of consecutive patients surgically treated with a post-auricular approach using EX was retrospectively compared with a similar previous series treated with operating microscope (OM). Patient demographics, indications for surgery, procedure type, complications, operating room setting time (ORst), operative time, adequacy of visualization, image quality, ergonomics aspects, instrument usability, and technique as a teaching tool were investigated. Thirteen patients were included in each group. Surgical procedures in EX group were nine tympanoplasties with mastoidectomy, 1 mastoidectomy for acute complicated mastoiditis, 1 revision miringoplasty, and 2 cochlear implants. Same types of procedures were enrolled in OM group. RESULTS: No statistically significant difference was found between the two groups concerning ORst and operative time. In EX group, one complication occurred--a middle cranial fossa cerebrospinal fluid leak. Advantages of EX were lightness, maneuverability and compactness, less need of endoscopy during surgery, and teaching potential. Limits were a need of a large surgical corridor and the bright structures rendering in high magnification. CONCLUSION: EX resulted safe and efficient in treating diseases of the middle ear in post-auricular approaches. To date, EX advantages are not enough to abandon the OM, and it can be considered as an additional, innovative tool to be added to ear surgical equipment.

Microendoscopic Surgery of Middle Ear and Petrous Bone: Benefits Analysis.

OBJECTIVES: Endoscopy has become routinely used in middle ear surgery. The aim of this study is to analyze where this tool may complement the traditional microscopic approach. This is a retrospective study done in single tertiary hospital. METHODS: We reviewed 342 middle ear/petrous bone surgical procedures performed between 2005 and 2015. Only cases in which both microscopic and endoscope-assisted techniques were used have been included. Sixty-six patients received this double-technique surgery: 51 (77.2%) had middle ear/mastoid and petrous bone cholesteatomas (46 middle ear and mastoid and 5 acquired/congenital petrous bone cholesteatomas), 5 (7.5%) had glomus tympanicum tumors (GTT), 4 (6%) had an ossicular chain dislocation, 3 (4.5%) had purulent chronic otitis media, 2 (3%) had tympanosclerosis, and 1 (1.5%) had an ossicular chain malformation. RESULTS: The endoscope was helpful to remove disease remnants not accessible by microscope in 41 (62%) of the cases; 37 (90%) were cholesteatomas, 3 (7%) were GTT, and only 1 (3%) was an open tympanosclerosis. In the remaining 25 (37.8%) cases, the endoscope was useful only to visualize the cavity since the microscope had already been successful in removing the entire lesion. CONCLUSIONS: The endoscopy can add valuable information and support to the usual microscope approach alone. The consensus of a single best technique does not yet exist, but the physician should choose the best modality or combination of modalities in order to cure the patient and prevent any possible complications or recurrence of the pathology.

Transoral robotic surgery and intensity-modulated radiotherapy in the treatment of the oropharyngeal carcinoma: a systematic review and meta-analysis.

PURPOSE: To perform a meta-analysis evaluating trans-oral robotic surgery (TORS), and intensity-modulated radiation therapy (IMRT) in the treatment of oropharyngeal squamous cell carcinoma (OPSCC). METHODS: This study adhered to the PRISMA guidelines. RESULTS: A total of 5624 patients (IMRT, n = 4322; TORS, n = 1302) were included in this meta-analysis. The majority of patients in the IMRT cohort were treated with concurrent CT (n = 3433, 81.3%). On the other hand, the majority of patients in the TORS cohort was treated with an adjuvant treatment (n = 826, 67.8%). IMRT subgroup showed a cumulative survival rate of 83.6% (99% CI 76.9-89.3%), while it was 91.3% (99% CI 81.2-97.8%) in the TORS subgroup. Disease-free survival was significantly different between IMRT (79.6%, 99% CI 70.6-87.3%), and TORS (89.4%, 99% CI 82.7-94.5%). IMRT subgroup showed a feeding tube dependence rate of 4.0% (99% CI 1.1-8.4%), but it was not significantly different from the TORS subgroup (1.3%, 99% CI 0-4.9%). Tracheostomy dependence rates were similar among the two subgroups (IMRT, 0.7%, 99% CI 0-1.1%; TORS, 0.2%, 99% CI 0-1.1%). CONCLUSIONS: TORS appears to be a consolidated effective surgical approach in the management of OPSCC, according to both oncologic and functional outcomes. Further RCTs comparing TORS and IMRT with homogeneous cohorts in terms of tumor staging and HPV status are advisable.

Prevalence of Taste and Smell Dysfunction in Coronavirus Disease 2019.

Importance: Early diagnosis of coronavirus disease 2019 (COVID-19) may help control the diffusion of the disease into the population. Objective: To investigate the presence of sinonasal manifestations at the onset of COVID-19 to achieve an earlier diagnosis. Design, Setting, and Participants: This retrospective telephone survey study investigated patients diagnosed with COVID-19 from March 5 to March 23, 2020, who were hospitalized or discharged from a single referral center. Patients who were unable to answer (intubated, receiving noninvasive ventilation, or deceased) or unreachable by telephone were excluded. Of 359 consecutive patients, 204 fulfilled the inclusion criteria; 76 were unable to answer, 76 were unreachable by telephone, and 3 refused. Exposures: Sinonasal manifestations reported before COVID-19 diagnosis were studied with a validated questionnaire: Italian Sino-Nasal Outcome Test 22 (I-SNOT-22). If reduction of taste and/or smell was documented by item 5 of the I-SNOT-22, further inquiries were made to score them separately on a scale from 0 to 5, with 0 indicating no problem and 5 indicating problem as bad as it can be. Main Outcomes and Measures: The prevalence of sinonasal manifestations preceding COVID-19 diagnosis. Results: Among the 204 patients enrolled (110 [53.9%] male; mean [SD] age, 52.6 [14.4] years), the median I-SNOT-22 total score was 21 (range, 0-73). I-SNOT-22 identified 116 patients (56.9%) with reduction of taste and/or smell, 113 (55.4%) with taste reduction (median score, 5; range, 2-5), and 85 (41.7%) with smell reduction (median score, 5; range, 1-5). Eighty-two patients (40.2%) reported both. Severe reduction of taste was present in 81 patients (39.7%), and severe reduction of smell was present in 72 patients (35.3%). Only 12 patients (14.8%) with severe taste reduction and 12 patients (16.7%) with severe smell reduction reported severe nasal obstruction. Severe reduction of taste and smell was more prevalent in female vs male patients (odds ratios, 3.16 [95% CI, 1.76-5.67] vs 2.58 [95% CI, 1.43-4.65]) and middle-aged vs younger patients (effect sizes, 0.50 [95% CI, 0.21-0.78] vs 0.85 [95% CI, 0.55-1.15]). No significant association was observed between smoking habits and severe reduction of taste (odds ratio, 0.95; 95% CI, 0.53-1.71) and/or smell (odds ratio, 0.65; 95% CI, 0.35-1.21). Conclusions and Relevance: The findings of this telephone survey study suggest that reduction of taste and/or smell may be a frequent and early symptom of COVID-19. Nasal obstruction was not commonly present at the onset of the disease in this study. The general practitioner may play a pivotal role in identifying potential COVID-19 in patients at an early stage if taste and/or smell alterations manifest and in suggesting quarantine before confirmation or exclusion of the diagnosis.

A systematic review of different treatment strategies for the squamous cell carcinoma of the posterior pharyngeal wall.

OBJECTIVE: To perform a systematic review of the literature available about the posterior pharyngeal wall squamous cell carcinomas, with a special focus on oncologic outcomes. METHODS: A comprehensive research was performed on PubMed/MEDLINE, Google Scholar, and Cochrane Library datasets for published studies meeting the established criteria. The last search was conducted on December 8, 2019. RESULTS: Eleven studies were included in the review, for a total of 534 patients (median age 60.4; male: n = 359, 67.2%). Six of the studies evaluated the oncologic outcomes of primary surgery, while three studies focused on results achieved through primary radiotherapy. Two studies evaluated both surgery and radiotherapy outcomes for the treatment of early or advanced posterior pharyngeal wall carcinoma. CONCLUSIONS: Primary surgery associated with adjuvant radiotherapy would seem to ensure better oncologic outcomes, especially for locally advanced tumors. Moreover, this systematic review showed that oro- and hypo-pharyngeal wall tumors are similar in terms of clinical and biological behavior.

High definition three-dimensional exoscope (VITOM 3D) for microsurgery training: a preliminary experience.

PURPOSE: To assess the feasibility of a high definition 3D exoscope (VITOM®) for microsurgery training in a cohort of naïve medical students. METHODS: Twenty-two consecutive medical students performed a battery of four exercises assessing basic microsurgical skills. The students were randomized in two different groups based on two different VITOM® holding systems (VERSACRANE™ and ARTip™ cruise). Participants self-reported the VITOM® system quality on a 4-point Likert scale (VITOM Quality Assessment Tool). The time needed to complete the exercises was analyzed. RESULTS: All students successfully completed the training, and no technical issues were raised during the simulation. The majority of the individual items were judged "good" or "very good" (n = 187; 94.4%), regardless of the two groups. "Image quality" (n = 21; 95%), "magnification rate" (n = 20; 91%), "stereoscopic effect" (n = 19; 86%), and "focusing" (n = 18; 82%) represented the best-rated items. No statistically significant difference between the two groups was measured in almost all items of the VITOM Quality Assessment Tool (p > 0.05). The time needed to perform each exercise showed a statistically significant difference between groups in two tests (p < 0.05). CONCLUSION: This study demonstrated the feasibility of a VITOM-based microsurgery training. The students' subjective assessment of the VITOM® 3D system was promising in terms of technological quality and technical feasibility. Further studies are recommended to define which VITOM® holding system could be more appropriate for microsurgery training.

"L" shape technique for endoscopic sinus surgery: An alternative method.

BACKGROUND: Several techniques for performing ethmoidectomy have been reported. We describe a safe, effective and efficient technique during functional endoscopic sinus surgery (FESS). We present text, images and videos to illustrate our preferred technique during an antero-posterior ethmoidectomy and to provide a multimedia tool for educational purpose. METHODS: A description of the technique without prospective or retrospective data is reported. A complete ethmoidectomy with an L-shape approach is described step-by-step, using the backbiting circular and miniature cutting forceps, with safe exposure of the lamina papyracea (LP) and skull base. RESULTS: In our hands, the L-shape approach for chronic rhinosinusitis with or without polyposis, performed with punch circular cutting and miniature cutting forceps, allowed for a reliably safe and efficient ethmoidectomy. CONCLUSION: The technique described can be added to the armamentarium of the endoscopic sinus surgeon.

NKp46-expressing human gut-resident intraepithelial Vδ1 T cell subpopulation exhibits high antitumor activity against colorectal cancer.

γδ T cells account for a large fraction of human intestinal intraepithelial lymphocytes (IELs) endowed with potent antitumor activities. However, little is known about their origin, phenotype, and clinical relevance in colorectal cancer (CRC). To determine γδ IEL gut specificity, homing, and functions, γδ T cells were purified from human healthy blood, lymph nodes, liver, skin, and intestine, either disease-free, affected by CRC, or generated from thymic precursors. The constitutive expression of NKp46 specifically identifies a subset of cytotoxic Vδ1 T cells representing the largest fraction of gut-resident IELs. The ontogeny and gut-tropism of NKp46+/Vδ1 IELs depends both on distinctive features of Vδ1 thymic precursors and gut-environmental factors. Either the constitutive presence of NKp46 on tissue-resident Vδ1 intestinal IELs or its induced expression on IL-2/IL-15-activated Vδ1 thymocytes are associated with antitumor functions. Higher frequencies of NKp46+/Vδ1 IELs in tumor-free specimens from CRC patients correlate with a lower risk of developing metastatic III/IV disease stages. Additionally, our in vitro settings reproducing CRC tumor microenvironment inhibited the expansion of NKp46+/Vδ1 cells from activated thymic precursors. These results parallel the very low frequencies of NKp46+/Vδ1 IELs able to infiltrate CRC, thus providing insights to either follow-up cancer progression or to develop adoptive cellular therapies.

The Emerging Role of Robotic Surgery among Minimally Invasive Surgical Approaches in the Treatment of Hypopharyngeal Carcinoma: Systematic Review and Meta-Analysis.

The aim of this systematic review with meta-analysis was to investigate the available literature on transoral approaches in the treatment of hypopharyngeal squamous cell carcinoma, with a special focus on transoral robotic surgery (TORS). A systematic review was conducted according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) check-list, and 15 studies were included. Five of the included studies evaluated TORS, while ten studies focused on transoral laser microsurgery (TLM) for the treatment of early or advanced stage hypopharyngeal cancer. Overall, survival rates of TLM and TORS studies, analyzed together in the cumulative meta-analysis, were 66.4% (95% confidence interval (CI) 54.3%⁻76.7%) at 36+ months of follow up. The TORS subgroup showed a higher cumulative survival rate (85.5%, 95% CI 55.8%⁻96.5%) compared to TLM (58.5%, 95% CI 46.6%⁻69.6%). Cumulative data showed that 29.3% (95% CI 24.0%⁻35.3%) of deaths were attributable to cancer. The results were similar between TLM and TORS studies. The larynx function preservation cumulative rate was 94.3% (95% CI 91.8%⁻96.1%). The results were similar among the two subgroups. The present review supports the use of transoral approaches in the treatment of hypopharyngeal cancer. TORS is oncologically sound and provides excellent functional results with low complication rates.

The multiplanar analysis of the retromandibular vein in surgical planning for parotid gland tumors.

OBJECTIVE: To analyze the effectiveness of the multiplanar analysis of the retromandibular vein in establishing the position of the parotid gland tumor and its relationship with the facial nerve, together with the most common radiological criteria (facial nerve line, Utrecht line, retromandibular vein and parapharyngeal space variations) using the magnetic resonance imaging. STUDY DESIGN: Retrospective study SETTING: Tertiary Academic Hospital SUBJECTS AND METHODS: 128 preoperative magnetic resonances were analyzed to study preoperative tumor location (medial or lateral to the expected course of the facial nerve) based on comparison between the radiological criteria and the surgical findings. RESULTS: FN line had the lowest accuracy at 77%, whereas the retromandibular vein achieved 85% accuracy and the UT line achieved accuracy of 93%. The retromandibular vein could not be identified in 11 cases (9%). The multiplanar evaluation of the retromandibular vein allowed us to identify it on almost all MR images (99% of cases) and reach 87% of accuracy. The parapharyngeal space evaluation achieved 92% of accuracy. In the subgroup of 66 cases where the neoplasms were strictly related to the main trunk, where the surgery entailed manipulation if situated laterally to the tumor, the multiplanar evaluation of the retromandibular vein reached 98% of accuracy and UT line achieved 94%. CONCLUSIONS: The multiplanar modality, combined with the evaluation of the parapharyngeal space, is effective in helping the surgeon to achieve accurate planning: it enables the tumor to be located and the facial nerve course predicted with a good precision.

Surgical management of parapharyngeal space tumors: The role of cervical and lateral skull base approaches.

We conducted a retrospective study to analyze the role of the cervical and lateral skull base approaches in the surgical excision of parapharyngeal space (PPS) tumors. Our study population was made up of 34 patients-15 males and 19 females, aged 13 to 73 years (mean: 50.6)-who had presented to us with a PPS tumor during a 9-year period. The 34 cases included 23 benign tumors and 11 malignancies. The 23 benign tumors consisted of 11 pleomorphic adenomas, 5 schwannomas, 2 paragangliomas, 2 Warthin tumors, 1 oncocytoma, 1 hamartoma, and 1 osteochondroma. The 11 malignancies included 3 cases of recurrent nasopharyngeal carcinoma, 2 cases of mucoepidermoid carcinomas, and 1 case each of carcinoma ex pleomorphic adenoma, liposarcoma, lymph node metastasis from nasopharyngeal carcinoma, lymph node metastasis from follicular thyroid carcinoma, rhabdomyosarcoma, and cranial nerve (CN) X neurofibrosarcoma. Among the benign tumors, 14 were removed via the transparotid approach, 3 via the transcervical approach, 3 via the transcervical-transparotid approach, 2 via the petro-occipital-trans-sigmoid approach, and 1 via the Fisch type A infratemporal fossa approach. During postoperative follow-up, 5 of the 23 patients with a benign tumor exhibited facial nerve paresis, 2 developed CN IX to XII palsy, and 1 each developed Frey syndrome and CN X palsy. In the malignant tumor group, 4 of the 11 patients were treated via the transcervical-transparotid approach, 3 via the Fisch type C infratemporal fossa approach, 3 via the transcervical-transmandibular approach, and 1 via the transcervical-lateral petrosectomy approach. The neural deficits observed during the postoperative period were more extensive among the patients with a malignant tumor. We conclude that the transparotid and transcervical approaches were adequate for excising most benign tumors. For malignant tumors, large tumors, and tumors with skull base involvement and transcranial extension, the transparotid-transcervical, transcervical-transmandibular, infratemporal fossa, and petro-occipital-trans-sigmoid approaches were necessary.

Treatment of endolymphatic sac tumour (Papillary adenocarcinoma) of the temporal bone.

AIM: To define a better treatment of sporadic endolymphatic sac tumours (ELST) analysing our experience and literature available data. BACKGROUND: ELST can arise as sporadic case (rare) or as a part of von Hippel-Lindau (VHL) disease. It is a low grade malignancy with local spread by continuity. MATERIALS AND METHODS: we described our experience with 7 cases with up to date follow up. RESULTS: Five cases were free of disease after first surgical procedure. One case had recurrence in the temporal lobe after 12 years. One case had two surgical procedures followed by irradiation and died five years after radiotherapy with a slow disease progression. CONCLUSION: With increasing expertise in the skull base surgery, complete tumour excisions are achieved in majority of the more recent cases and appear to be the treatment of choice. External irradiation is also used as palliative measures with doubtful effectiveness. Some recent reports showed encouraging results with gamma knife radiosurgery.