Endoscopic Endonasal Repair of Congenital Choanal Atresia: Predictive Factors of Surgical Stability and Healing Outcomes.

Background: To assess the long-term outcomes and independent predictors of surgical success of a one-stage minimally invasive surgical procedure for congenital choanal atresia (C.C.A.). Methods: a retrospective multicentric study was conducted between 2010 and 2022. An endonasal endoscopic approach was performed in 38 unilateral or bilateral C.C.A. children. All the patients were clinically and radiologically assessed and followed for at least 2 years. Seven outcome measures were applied. Consequently, surgical success was correlated with all the independent variables reported. Results: 18/38 (47.36%) patients presented normal postoperative healing, 8/38 (21.05) had moderate restenosis (<50%), while 12/38 (31.57%) cases were severe (>50%), requiring a surgical revision. No statistical significance was found for average hospital stay between stenosis >50% and <50% patients (p = 0.802) and postoperative pain (p = 0.075); instead, the severe restenosis group demonstrated a higher delay of breast suction (p < 0.001). Among the independent variables predictors of surgical success, the presence of Charge syndrome and rhinopharyngeal stenosis demonstrated higher risks for surgical revision (OR: 4.00, 95% CI: 0.57−28.01, and OR: 2.75, 95% CI: 0.55−13.69, respectively). On the contrary, the hypoplastic inferior turbinate and bilateral C.C.A. showed a lower risk for severe restenosis by a higher endoscopic surgical space and creating a single larger opening (OR: 0.88, 95% CI: 0.22−3.52, and OR: 0.45, 95% CI: 0.10−2.08). Conclusion: Several independent variables could influence the surgical success after C.C.A. endoscopic repair; however, more high-quality evidence is needed to generate an effective predictive model.

VITOM-3D assisted paramedian forehead flap for nasal reconstruction.

BACKGROUND: The study was designed with the purpose of showing the potential advantages of the VITOM-3D assisted paramedian forehead flap for nasal reconstruction. METHODS: A 72 years-old female patient presented to our department with a wide left nasal defect. On her clinical history she referred a basal cell carcinoma of the left nasal skin treated with multiple excision in another center without reconstruction. On clinical examination, we observed the absence of the left nasal tip, columella, upper lateral and lower lateral cartilage. In our experience the paramedian forehead flap based on supratrochlear artery is a feasible reconstruction (Shokri, T., et al). The first surgeon (Dr. Placentino) along with the head and neck team decided to reconstruct the nasal defect assisted by the 3D 4 K exoscope (VITOM®; Karl Storz, Tuttlingen, Germany). RESULTS: The goal of reconstruction is to carefully evaluate the nasal defects and rebuild the nose as close as possible to its original shape with the multilayer technique, creating the internal lining, the intermediate bony-cartilage structure and external skin. (Kim, I.A., et al). The exoscope allowed us to reconstruct the inner layer with the mucoperiostal septal flap, middle layer with auricular cartilage and the external skin through the elevation of the paramedian forehead flap. The flap is elevated from cranio-caudal direction including skin, subcutaneous tissue, frontalis muscle and associated fascia or periosteum. Donor site was primarily closed with the exception of a small defect. Post-operative period was uneventful, and after a period of 4 weeks when vascularization was complete, the patient underwent pedicle excision. At the recent 6 months follow-up, the flap had healed completely with the shape of nose restored with good symmetry. CONCLUSION: High-definition (4 K), three-dimensional (3D) exoscope are being used to perform a growing number of head and neck surgeries (Bartkowiak, E., et al). However, the use of the 3D exoscope in the nasal reconstruction has not been previously described. In our opinion the potential advantages of this technique are, firstly, to achieve a better magnification and to improve the vision of anatomical structure that leads to a better functional and aesthetic result, secondly, to reduce surgical times. High-definition allowed us to highlight the scar tissue and preserve as much healthy tissue as possible. In addition, we underline the use of the exoscope for a better remodeling of cartilage.

COVID-19 in the tonsillectomised population.

OBJECTIVE: Interactions between SARS-CoV-2 and pharyngeal associated lymphoid tissue are thought to influence the manifestations of COVID-19. We aimed to determine whether a previous history of tonsillectomy, as a surrogate indicator of a dysfunctional pharyngeal associated lymphoid tissue, could predict the presentation and course of COVID-19. METHODS: Multicentric cross-sectional observational study involving seven hospitals in Northern and Central Italy. Data on the clinical course and signs and symptoms of the infection were collected from 779 adults who tested positive for SARS-CoV-2, and analysed in relation to previous tonsillectomy, together with demographic and anamnestic data. RESULTS: Patients with previous tonsillectomy showed a greater risk of fever, temperature higher than 39°C, chills and malaise. No significant differences in hospital admissions were found. CONCLUSIONS: A previous history of tonsillectomy, as a surrogate indicator of immunological dysfunction of the pharyngeal associated lymphoid tissue, could predict a more intense systemic manifestation of COVID-19. These results could provide a simple clinical marker to discriminate suspected carriers and to delineate more precise prognostic models.

3D endoscopic endonasal craniectomy for intestinal type adeno-carcinoma (ITAC) of the nasal cavity.

BACKGROUND: The aim of this study was to describe the potential advantages of the 3D endoscope-assisted craniectomy for tumor of the nasal cavity. METHODS: A 77-year-old man with a 6 month history of persistent progressive right nasal obstruction and iposmia is reported. Physical examination, including nasal endoscopy, revealed a large mass within the right nasal cavity. He had no associated symptoms such as visual complaints, paresthesia, and facial pain. He worked as a carpenter. Further imaging by CT and MRI revealed a large, expansive nasal-ethmoid lesion that almost completely occupies the right nasal cavity with partial extension posterior to the choana, extensive erosion of the ethmoid. Medially marks the nasal septum with deviation to the left. Laterally it marks the medial wall of the maxillary sinus and at the top it is in contact with the cribriform plate which seems to be interrupted in the right parasagittal seat at the 3rd anterior of the olfactory cleft. Histopathological analysis of the specimen was consistent with sinonasal adenocarcinoma, intestinal type (ITAC) cT4aN0 ([1]). RESULTS: Patient was taken up for surgery by transnasal 3D endoscopic approach for excision of tumor with repair of the skull base defect, using Karl Storz IMAGE1 S D3-Link™ and 4-mm TIPCAM®. The mass could be dissected free of the dura and the entire specimen was removed completely and sent for histopthological examination. We followed our 8 main surgical steps: 1) Tumor disassembling; 2) Nasal septum removal; 3) Centripetal bilateral ethmoidectomy and sphenoidotomy; 4) Draf III frontal sinusotomy 5) Anterior and posterior ethmoidal artery closure 6) Skull base removal; 7) Intracranial work; 8) Reconstruction time. A 4 × 2.3 cm skull base defect was repaired using triple layer of fascia lata (Intracranial intradural, intracranial extradural and extracranial) and was sealed using tissue glue (TisselR). Post-operative recovery was uneventful, pack were removed on 3rd postoperative day and patient was discharged on the 7th post-operative day. After 2 years of follow up, the patient is free of disease. CONCLUSION: We describe 3D endoscopic transnasal craniectomy for Intestinal Type Adeno-Carcinoma (ITAC) of the nasal cavity as a feasible technique for the surgical management of sino-nasal tumors ([2].) Our experience with this approach has been outstanding. We firmly believe that in the first three steps of the procedure the 3D endoscope is not necessary because it extends the surgical time and induce eyestrain of the main surgeon. Nevertheless, 3D endoscope gives the major advantage during the skull base removal and the intracranial work. It offers an optimal vision and better perception of depth with safe manipulation of the instruments avoiding injuries to healthy tissue ([3]). Furthermore, 3D images offer better understanding of the relationship between anatomical landmarks, helping the didactic learning curve of our residents.

Otolaryngology activity in two hospitals in northern and central Italy differently affected by COVID-19 pandemic.

The Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) pandemic had a significant impact on the Italian healthcare system, although geographical differences were present; regions in northern Italy have been the most severely affected while regions in the south of the country were relatively spared. Otolaryngologists were actively involved in the management of the pandemic. In this work, we analyzed and compared the otolaryngology surgical activity performed during the pandemic in two large public hospitals located in different Italian regions. In northern Italy, otolaryngologists were mainly involved in performing surgical tracheotomies in COVID-19 positive patients and contributed to the management of these patients in intensive care units. In central Italy, where the burden of the infection was significantly lower, otolaryngologists focused on diagnosis and treatment of emergency and oncology patients. This analysis confirms the important role of the otolaryngology specialists during the pandemic, but also highlights specific differences between two large hospitals in different Italian regions.

Eagle Syndrome: 3D endoscope-assisted anterior tonsillar fossa approach to styloid process.

BACKGROUND: The aim of this study was to describe the potential advantages of the 3D endoscope-assisted anterior tonsillar fossa approach to elongated styloid process. METHODS: A 58 years-old woman was reported to our Department with one-year history of odynophagia, latero-cervical pain on the left side, and ipsilateral foreign body sensation. Pain was dull and intermittent in nature. The patient had visited different clinics, she had a physiatric and maxillo-facial evaluation with two dental extraction without any relief of the symptoms. On physical examination a hard-bony consistency area was palpated over left-sided tonsillar fossa, evocating severe pain. Three-dimensional computed tomography (CT) confirmed an anomalous length of the left styloid process and a diagnosis of Eagle's syndrome (ES) was made. After careful surgical and anesthesiology evaluation, we decided to proceed with the partial excision of the styloid process with a 3d endoscope-assisted transoral anterior tonsillar fossa approach (Reddy et al., 2020). RESULTS: The patient was relieved of her symptoms after the surgery and was discharged after 1 day. Postsurgical healing was uneventful, pharyngodynia was observed for the first 48 h and treated with anti-inflammatory medication. No early or late postoperative complications, including massive bleeding, neurovascular injury or infection, were encountered. At 1 year follow up visit the patient was still asymptomatic and the CT scan did not show any abnormalities. The 3D endoscope provided a high-quality magnification of the tonsillar fossa, which allow us to correctly identify the site of incision. Styloid process was identified through digital palpation. After sufficient dissection of the tip, the distal part of the elongated styloid process was osteotomised and retrieved with a curved instrument. Local hemostasis was achieved and wound was closed in layers. CONCLUSION: Some authors suggested novel surgical approach for ES like transoral robotic surgery (Rizzo-Riera et al., 2020 [2]). We present the 3D endoscope-assisted anterior tonsillar fossa approach as a feasible alternative for the surgical management of ES. Our experience with this approach has been outstanding, guaranteeing an optimal vision and depth of the surgical field with safe manipulation of the instruments which avoided injuries to healthy tissue. Furthermore, 3d endoscope was a great didactic tool. In our opinion is not necessary to remove all the styloid process, as other authors suggest (Lisan et al., 2019 [3]), but is sufficient a partial styloidectomy after cutting the stylohyoid ligament.

Endoscopic Resection of Sinonasal Inverted Papilloma: A Multivariate Retrospective Analysis of Factors Affecting Recurrence and Persistence.

Sinonasal inverted papilloma (IP) is the most common benign epithelial tumor in the nasal cavity and paranasal sinuses, with a worldwide incidence between 0.6 and 1.5/100 000 persons per year. However, only a few studies have investigated patient-dependent factors related to IP recurrence and persistence. According to available evidence, these factors are still debated, and results are contradictory. In this multicenter retrospective study, we analyzed the clinical records of 130 patients who were surgically treated for sinonasal IP to evaluate the factors affecting recurrence and persistence of IP and compared the curative rates of different surgical approaches. Our analysis showed that IP recurrence is strongly related to specific risk factors including incomplete surgical removal, stage of disease, site of the lesion, surgical technique, and malignancy rate. In conclusion, the recurrence of IP may be affected by several risk factors; these factors must be carefully considered during clinical evaluation and especially during the follow-up of patients with IP.

Impact of COVID-19 pandemic on Italian Otolaryngology Units: a nationwide study.

OBJECTIVE: The aim of this study was to provide an accurate picture of the changes which have occurred during the COVID-19 pandemic, and the contributions given by Italian Otolaryngology Units. METHODS: A 29-item questionnaire was completed and returned by 154 Otorhinolaryngology Units across Italy that investigated geographic distribution, the main changes which occurred in workload management and in clinical and surgical activities and screening procedures for COVID-19 in healthcare personnel and patients. RESULTS: Nearly half of the Otolaryngology Units that responded to the questionnaire were merged with other units, while 22% were converted into COVID-19 units or temporarily closed. A reduction of 8.55% in the number of team members was reported, and about 50% of the units applied uniform work shifts for all staff. Elective activities were uniformly stopped or delayed, passing from 30,295 (pre-COVID data) to 5,684 (COVID data) weekly procedures, with a mean decrease of 81.24% (p < 0.001). CONCLUSIONS: Most of the elective otolaryngology activities were suspended during the pandemic; the only procedures were for oncology and emergency patients. Italian Otolaryngologists have demonstrated a high availability to collaborate with non-surgical colleagues.

Electrochemotherapy as a new therapeutic strategy in advanced Merkel cell carcinoma of head and neck region.

BACKGROUND: Merkel Cell Carcinoma (MCC) is a rare and aggressive tumour, arising from a cutaneous mechanoceptor cell located in the basal layer of epidermis, with poor prognosis. The treatment of choice for the initial stage of the disease is surgery and/or radiotherapy. The treatment of recurrent or advanced disease is still controversial. CASE REPORT: We report a case of 84 years old woman with a recurrent MCC of the chin treated with electrochemotherapy (ECT). During the period of 20 months, four sessions of ECT were employed, which resulted in an objective response of the tumour and good quality of residual life. CONCLUSIONS: Our case shows the effectiveness of ECT in the treatment of locally advanced MCC of the head and neck region in a patient not suitable for standard therapeutic options.

Oral HPV infection and persistence in patients with head and neck cancer.

OBJECTIVE: To investigate the presence and persistence of human papillomavirus (HPV) infection in the oral mucosa of patients with head and neck squamous cell carcinoma (HNSCC), and its correlation with prognosis. STUDY DESIGN: HPV infection was characterized in tumors and pre and posttreatment oral scrapings in 51 patients with HNSCC and matched controls using the SPF10 LiPA Extra assay. p16INK4A immunostain and in situ hybridization for high-risk HPV genotypes recognized transcriptionally active infection in tumor samples. The risk of infection was compared in patients and controls. The association of pretreatment HPV status with recurrence and survival and with posttreatment HPV persistence was assessed. RESULTS: Oral HPV infection risk was significantly higher in patients with HNSCC than in controls (P < .001). Oral HPV infection was associated with infection in the first posttreatment scrapings (P = .015), but did not affect recurrence or prognosis. CONCLUSION: Oral HPV infection is frequent in patients with HNSCC and has no prognostic implications, suggesting that posttreatment polymerase chain reaction monitoring on oral cells is not effective to monitor patient recurrence risk.

Unusual esophageal foreign body: a table fork.

The presence of an esophageal foreign body (EFB) is a medical emergency requiring urgent evaluation and treatment. Swallowing of foreign bodies is most common in children aged between 6 months and 6 years, in whom it usually occurs during games. In adults, foreign bodies tend to be ingested accidentally together with food. The authors report an unusual case of EFB (a table fork) in an adult and briefly report the clinical presentation and the therapeutic procedures adopted in this case and similar cases.

Multiple symmetric lipomatosis: a review of 3 cases.

Multiple symmetrical lipomatosis, or Madelung's disease, is a rare disease of unknown etiology. It is characterized by the presence of loose adipose tissue deposits localized in the cervical region and in the upper body. The neoformations grow slowly and their initial consequence is purely esthetic. They can, however, lead to compression of the laryngotacheal area and of the esophagus. This disease usually affects middle-aged males from the Mediterranean area with a history of alcohol abuse. Although most cases have been sporadic, a few authors have indicated that the disorder may be hereditary. It is thought that this pathology originates from an alteration in lipid metabolism. Since the patients were asymptomatic temperance and diet was proposed, surgical removal of the lipomatose mass is the treatment of choice in case of complications due to fat mass compression on upper aerodigestive tract. The authors present three cases of Madelung's disease with different and particular manifestations.

Exfoliated cells of the oral mucosa for HPV typing by SPF10 in head and neck cancer.

HPV infection in the superficial cells of the oral mucosa could reflect the presence of HPV in head and neck cancer cells. Due mostly to the use of heterogeneous analytical methods, discordant data exist in the literature regarding the agreement between the presence of HPV in non-neoplastic oral mucosa and in tumour tissue from the same patient. The presence of HPV DNA and viral types were compared in paired cytological and biopsy samples from 56 patients with head and neck neoplastic and preneoplastic lesions using the highly sensitive SPF10 LiPA Extra assay, which has been validated recently for formalin-fixed paraffin-embedded tissue using paired cervical cytology and biopsy samples. Kappa statistics were used to measure the inter-rater agreement. The overall agreement with respect to HPV infection was 96.43% (kappa=0.8367). For 76.79% of subjects (kappa=0.6937), the same number of HPV types was detected in cytological and biopsy specimens. The overall positive typing agreement was 90.90%, comprising 130 out of 143 individual HPV type analyses. The agreement shown was good for HPV 18, 44, 45, 54 and 66 (kappa=0.6585-0. 7321), excellent for HPV 6, 16, 40, and 54 (kappa=0.8108-0.8679), and absolute for HPV 11, 31, 33, 35, 39, 51, 52, 53, 59, 74, and 69-71 (kappa=1.0000). The high sensitivity of the SPF10 LiPA and its excellent performance both for recognising HPV infection and for identifying the viral types present in tumour tissue and in oral exfoliated cells make it a useful method for the assessment of HPV infection in patients with head and neck cancer. The excellent agreement for HPV infection and genotyping in paired samples suggests that oral exfoliated cells can be used for HPV detection in the head and neck region.

Electrochemotherapy for the treatment of recurrent head and neck cancers: preliminary results.

AIMS AND BACKGROUND: Electrochemotherapy is a tumor ablation modality providing delivery into the cell interior of impermeant or poorly permeant chemotherapeutic drugs such as cisplatin and bleomycin. A locally applied electrical field enhances the membrane permeability allowing intracellular accumulation of the chemotherapeutic agent. The aim of the study was to evaluate the effectiveness of ECT for the treatment of a group of patients affected by recurrent of extended primary head and neck cancer and not suitable for standard therapeutic options. METHODS AND STUDY DESIGN: From April 2009 to January 2011, we treated with electrochemotherapy a total of 15 patients with head and neck cancers, 13 with squamous cell carcinoma, 1 with basaloid carcinoma and 1 with Merkel cell carcinoma. Electrical pulses were delivered to 33 lesions (3 primaries, 30 recurrences) after an intravenous bolus injection of a dose of 15,000 IU/m2 of bleomycin. In 3 cases, the lesion treated was a pathologic lymph node. RESULTS: Of the 31 lesions assessable for the study, 19 (61.5%) showed a complete response, 10 (32.5%) a partial response, 1 (3%) stable disease and 1 (3%) progression of the disease. The objective response 2 months after the procedure was 94%. All the lesions that underwent complete regression were less than 3 cm in their maximum diameter. The 2 assessable cases of pathologic lymph nodes showed a partial or no response. After a follow-up of 2 to 20 months, 29% of the patients were alive and free of disease, 50% were alive with disease, 14% died for disease and 7% died for other causes. CONCLUSIONS: Our study confirms the effectiveness of electrochemotherapy in the treatment or local control of recurrent or extended primary head and neck cancer in patients not suitable for standard therapeutic options.