Intraoperative intraorbital bleeding: considerations from a collaborative and retrospective Italian study with a management algorithm proposal.

BACKGROUND: Intraoperative intraorbital bleeding is a rare but potentially catastrophic event that can lead even to blindness, if not treated promptly. The goal of surgery is to quickly reduce intraorbital pressure thus restoring normal visual function. Aim of our work is to propose a practical algorithm helping the surgeon in the setting of this critical event. METHODOLOGY: An Italian multi-institutional retrospective study was conducted. All the cases of intraoperative intra-orbital bleeding requiring at least some form of surgical management were analyzed. Cases simply managed conservatively were excluded from this analysis. RESULTS: Sixteen cases were collected. Of these, 12 were initially treated with a medial wall orbital decompression, while 4 were treated via a lateral canthotomy and inferior cantholysis (LCC). Ten patients recovered completely. Four patients presented post-op sequelae (diplopia, enophthalmous and/or eyelid malpositioning). Two major negative outcomes (blindness) were observed. CONCLUSIONS: Timely surgical intervention is critical. According to the setting in which the bleeding occurs, different options are available. LCC is probably the most rapid maneuver that can be done to reduce intraorbital pressure. Anyway, if the patient is still in the OR and a complete ethmoidectomy yet done we advise, as first step, to perform a medial orbital wall decompression.

Preliminary experience with 4K ultra-high definition endoscope: analysis of pros and cons in skull base surgery.

During the last two decades endoscopic skull base surgery observed a continuous technical and technological development 3D endoscopy and ultra High Definition (HD) endoscopy have provided great advances in terms of visualisation and spatial resolution. Ultra-high definition (UHD) 4K systems, recently introduced in the clinical practice, will shape next steps forward especially in skull base surgery field. Patients were operated on through transnasal transsphenoidal endoscopic approaches performed using Olympus NBI 4K UHD endoscope with a 4 mm 0° Ultra Telescope, 300 W xenon lamp (CLV-S400) predisposed for narrow band imaging (NBI) technology connected through a camera head to a high-quality control unit (OTV-S400 - VISERA 4K UHD) (Olympus Corporation, Tokyo, Japan). Two screens are used, one 31" Monitor - (LMD-X310S) and one main ultra-HD 55" screen optimised for UHD image reproduction (LMD-X550S). In selected cases, we used a navigation system (Stealthstation S7, Medtronic, Minneapolis, MN, US). We evaluated 22 pituitary adenomas (86.3% macroadenomas; 13.7% microadenomas). 50% were not functional (NF), 22.8% GH, 18.2% ACTH, 9% PRL-secreting. Three of 22 were recurrences. In 91% of cases we achieved total removal, while in 9% near total resection. A mean follow-up of 187 days and average length of hospitalisation was 3.09 ± 0.61 days. Surgical duration was 128.18± 30.74 minutes. We experienced only 1 case of intraoperative low flow fistula with no further complications. None of the cases required any post- or intraoperative blood transfusion. The visualisation and high resolution of the operative field provided a very detailed view of all anatomical structures and pathologies allowing an improvement in safety and efficacy of the surgical procedure. The operative time was similar to the standard 2D HD and 3D procedures and the physical strain was also comparable to others in terms of ergonomics and weight.

Tensor veli palatini electromyography for monitoring Eustachian tube rehabilitation in otitis media.

BACKGROUND: The pathogenesis of otitis media is related to Eustachian tube dysfunction. The tensor veli palatini muscle actively opens the Eustachian tube and promotes middle-ear ventilation. This study describes a technique for paratubal electromyography that uses a surface, non-invasive electrode able to record tensor veli palatini muscle activity during swallowing. METHODS: Twenty otitis media patients and 10 healthy patients underwent tensor veli palatini electromyography. Activity of this muscle before and after Eustachian tube rehabilitation was also assessed. RESULTS: In 78.5 per cent of patients, the electromyography duration phase and/or amplitude were reduced in the affected side. The muscle action potential was impaired in all patients who underwent Eustachian tube rehabilitation. CONCLUSION: This study confirmed that Eustachian tube muscle dysfunction has a role in otitis media pathogenesis and showed that muscle activity increases after Eustachian tube rehabilitation therapy.

New olfactometric findings in Parkinson's disease.

OBJECTIVES: To investigate in Parkinson's disease-affected patients a correlation between hyposmia and gastrointestinal dysfunction and their possible identical etiopathogenesis. DESIGN: Retrospective cohort study. SETTING: ENT and neurology departments (Gemelli Hospital, Rome, Italy). PARTICIPANTS: A total of 78 patients with diagnosis of PD according to the UK Brain Bank criteria. INCLUSION CRITERIA: informed consent and olfactory testing executed; exclusion criteria: signs of dementia according to the DSM-IV criteria; Mini Mental State Examination score ≤26; head trauma; central neurological disorders, nasal or systemic diseases potentially affecting olfactory function. Motor condition was assessed by means of Hoehn and Yahr staging and by section III of the Unified PD Rating Scale, performed off and on medications. MAIN OUTCOME MEASURES: The patients underwent olfactory evaluation (TDI score), after rhinomanometry with nasal decongestion. A total of 25 non-motor symptoms were evaluated through an interview. RESULTS: Olfactory dysfunction was objectively found in 91.0% of patients, a percentage higher than the subjective hyposmia reported (55.1%) P = 0.0001. Seven patients (9.0%) were normosmic, 49 (62.8%) hyposmic and 22 (28.2%) anosmic. Subjective hyposmia, constipation, bloating and dyspepsia differed across groups, being higher in anosmic and hyposmic ones than in the normosmic group. P value was ≤0.05 for each symptom. Despite the original results, this study has the limitation of being based on subjective ratings by a relatively limited group of patients. CONCLUSIONS: Hyposmia and gastrointestinal symptoms are correlated, and this would support a possible common origin; the CNS could be reached through two different pathways, both starting in the peripheral nervous system.

Outcomes of interventional sialendoscopy for obstructive salivary gland disorders: an Italian multicentre study.

Interventional sialendoscopy has become the predominant therapeutic procedure for the management of obstructive salivary disorders, but only a few multicentre studies of large series of patients with a long-term follow-up have been published. This Italian multicentre study involved 1152 patients (553 females; mean age 50 years) who, after at least a clinical and ultrasonographic evaluation, underwent a total of 1342 diagnostic and interventional sialendoscopies, 44.6% of which involved the parotid gland. 12% (n = 138) of patients underwent multiple treatments. The procedure was successful in 1309 cases. In 33 cases (2.4%) the procedure could not be concluded mainly because of complete duct stenosis (21 cases). Salivary stones were the main cause of obstruction (55%), followed by ductal stenosis and anomalies (16%), mucous plugs (14.5%) and sialodochitis (4.7%). Complete therapeutic success was obtained in 92.5% of patients after one or more procedures, and was ineffective in < 8%. Untoward effects (peri and postoperative complications) were observed in 5.4% of cases. Sialendoscopy proved to be an effective, valid and safe procedure in the diagnostic and therapeutic management of non-neoplastic obstructive salivary gland diseases.

Sensory dysfunction and quality of life after great auricular nerve sacrifice during parotidectomy: our experience.

OBJECTIVE: This study aimed to investigate the impact on patients' quality of life of great auricular nerve sacrifice during parotidectomy. METHODS: A retrospective review was conducted of 191 consecutive patients who underwent parotidectomy with great auricular nerve sacrifice between 2006 and 2011. Residual sensory dysfunction and its impact on quality of life was analysed using an eight-item quality of life survey. RESULTS: In all, 139 out of 191 patients (72.8 per cent) experienced one or more abnormal sensations in the ear or neck region after surgery. There was a moderate inverse correlation between the number of abnormal sensations and time elapsed since surgery. Moreover, the degree of discomfort correlated significantly with the frequency of symptom occurrence (p < 0.001), duration of the abnormal sensation (p < 0.001) and size of the affected area (p < 0.001). CONCLUSION: Sacrifice of the great auricular nerve has only a small impact on patient quality of life; their daily activities are not significantly affected.

Intracapsular microenucleation technique in a case of intraparotid facial nerve schwannoma. Technical notes for a conservative approach.

We report a rare case of a large intraparotid facial nerve schwannoma (IFNS) in a 51-year-old female who presented with a painless, slow growing left parotid mass without peripheral facial nerve palsy, with non-specific findings at preoperative diagnostic work-up, that was treated with conservative surgery. Management of IFNS is very challenging because the diagnosis is often made intra-operatively, and in most cases resection may lead to severe facial nerve paralysis, with important aesthetic sequelae. Our experience suggests a new surgical option, namely intra-capsular enucleation using a microscope, currently used for schwannomas arising from a major peripheral nerve, which should be a safe and reliable treatment for IFNS. This surgical technique is the first experience of intracapsular microenucleation of facial nerve schwannoma described in the literature and allows preservation of the nerve without resection and reconstruction.

Impact of microvascular free flap reconstruction in oral cavity cancer: our experience in 130 cases.

The aim of this study was to investigate the oncological outcomes in patients affected by oral carcinoma treated with radical compartmental surgery followed by microvascular flap reconstruction. We conducted a retrospective analysis on a cohort of 130 patients. All patients underwent ablative tumour resection (compartmental surgery) followed by immediate reconstruction with free flaps and adjuvant chemoradiotherapy, when necessary according to our tumour board and international guidelines. Disease-specific survival (DSS) curves were obtained using the Kaplan-Meier method. Log-rank test and generalised Wilcoxon test were used to investigate the most important prognostic factors on 5-year DSS. A Cox proportional hazards model was constructed to provide hazard ratios or relative risks for individual variables. 88.5% of patients were affected by SCC. There were 46 (35.4%) women and 84 (64.6%) men in the sample with a mean age of 58.5 years. At the end of the follow-up period, 36 (27.7%) patients died, only 3 of which for other causes. The 5-year DSS rate was 67.8% (S.E. 4.9%). In univariate Kaplan-Meier analysis and in multivariate Cox regression model, seven variables were found to have a significant relationship with DSS: T (p = 0.026) and N (p = 0.0001) status, clinical stage (according to the UICC TNM Sixth Edition) (p = 0.007), margins of resection (p = 0.001), extracapsular spread (p = 0.005), recurrence of disease (p = 0.00002) and treatment modality (evaluated as surgery alone or surgery + RT/CHT) (p = 0.004). Our results confirmed findings already reported in the literature, and allowed us to conclude that compartmental surgery combined with free flap reconstruction can increase survival in oral cancer patients.

Synovial sarcoma of the parotid gland: a case report and review of the literature.

Parotid gland tumours are very heterogeneous, being benign in 80% of cases, and generally arising from epithelial cells. Nevertheless, a small group of non-epithelial tumours representing just 5% of all salivary gland neoplasms has also been reported, the most common of these being haemangioma, especially in children. However, lymphomas, neuromas, neurofibromas, lipomas and sarcomas can also be found. Synovial cell sarcoma is a high grade histological variety of sarcoma and is generally located near large joints and bursae of the lower extremities, such as knee, tendon sheaths and bursal structures. It is rarely found in the head and neck region due to its lack of synovioblastic tissue. Herewith, the case of a young female, affected by a synovial sarcoma of the left parotid gland, is presented and a review is made of the literature on this rare specific localization focusing on management and outcome.

Oral cavity defect reconstruction using anterolateral thigh free flaps.

BACKGROUND: It is estimated that about 92,000 new cases of oral cavity and pharyngeal cancer occurred in Europe in 2008. During the past 30 years in the USA and Western Europe, the prognosis for oral cancer has clearly improved thanks to the possibility of reconstruction with microvascular free flaps, resulting in broader and safer resections. The anterolateral thigh flap is now being increasingly employed for this goal. The aim of the present work is to evaluate the anterolateral thigh free flap in the reconstruction of oral cavity defects. MATERIALS AND METHODS: Between July 2004 and February 2009, we harvested 73 free flaps for the reconstruction of soft tissue defects in the oral cavity of 70 patients at our institution. The oncological and functional results in these 70 patients were evaluated, particularly in those patients reconstructed with anterolateral thigh (ALT) free flap. We also evaluated the quality of life using the FACT-H&N questionnaire. RESULTS: We observed no significant differences in functional and oncological results between patients reconstructed by ALT and patients reconstructed with other flaps. Swallowing may be more difficult in patients who undergo adjuvant irradiation. CONCLUSIONS: In our opinion, the very low morbidity at the donor site, great versatility, and very long pedicle make the ALT free flap the first choice for reconstructing soft tissue defects in the oral cavity (particularly mobile tongue).

Role of early voice therapy in patients affected by unilateral vocal fold paralysis.

OBJECTIVE: To evaluate the functional results obtained after voice therapy in patients with unilateral vocal fold paralysis caused by different aetiologies. DESIGN: Prospective analysis of the outcome of unilateral vocal fold paralysis cases treated at our speech and language rehabilitation service from November 2003 to January 2006. Thirty cases underwent behavioural treatment, between two and six weeks after unilateral vocal fold paralysis onset. A multi-dimensional assessment was carried out before, immediately after and six months after treatment. RESULTS: After behavioural therapy, the prevalence of complete glottal closure increased significantly (p < 0.05). Subjects' pre-therapy mean values for jitter, shimmer and noise-to-harmonic ratio were statistically significantly different from those taken both immediately and six months after treatment (p < 0.05). The mean values for voice turbulence index significantly improved only six months after therapy (0.08 vs 0.04). At both post-treatment assessments, voice range profile analysis showed a significant decrease of lowest voice frequency and a significant increase of the number of semitones (p < 0.05). Mean values for grade, instability, breathiness, asthenia and voice handicap index scores were significantly decreased both immediately and six months after treatment, compared with pre-treatment values (p < 0.05). CONCLUSIONS: Early voice therapy may enable significant improvement in vocal function, allowing the patient to avoid surgery.

Role of ossiculoplasty in canal wall down tympanoplasty for middle-ear cholesteatoma: hearing results.

The aim of this study was to evaluate the hearing results of ossiculoplasty in canal wall down tympanoplasty in one stage middle-ear cholesteatoma surgery. We carried out a retrospective review of a consecutive series of 142 cases which had undergone type two or three canal wall down tympanoplasty with ossicular reconstruction, between January 1995 and December 2002, due to chronic otitis media with cholesteatoma.Pre-operative audiometric testing revealed a mean air conduction pure tone average (PTA) of 50.97 dB and a mean bone conduction PTA of 22.14 dB. The mean post-operative result for air conduction PTA was 37.62 and for bone conduction PTA was 23.37 dB. The mean pre- and post-operative air-bone gaps (ABGs) were 28.83 and 13.94 dB, respectively, with a gain of 14.89 dB. Almost 62.67 per cent of patients closed their ABGs to within 20 dB. Our functional results are comparable with those of other authors. In the present study, we show that hearing improvement is possible following cholesteatoma surgery with canal wall down tympanoplasty and ossicular chain reconstruction.

High resolution magnifying endoscopy: a new diagnostic tool also for laryngeal examination?

Aim of this report is to introduce the use of a new high resolution magnifying endoscope in the endoscopic examination of the upper aerodigestive tract and discuss the usefulness of this tool in the diagnosis of laryngeal lesions. A total of 26 patients presenting various laryngeal disorders were examined by means of an electronic videoendoscope and a high resolution magnifying endoscope. The images obtained were examined and compared. High resolution high magnification endoscopic examination allowed a better description of the laryngeal lesions (colour, extension and thickness of the lesion, irregularities in surface and borders) with easy characterisation of aspect of neighbouring laryngeal mucosa especially in pre-malignant lesions. Furthermore, the optical magnifying zoom does not require a close approach to the laryngeal mucosa, therefore, local anaesthesia is not required. In conclusion, the high resolution magnified images obtained with this new tool provide important information on the characteristics of the laryngeal structures. This new endoscopic technology, as already occurred in gastric, oesophageal and colorectal disorders, could also be improved by using chromo-endoscopy and other vital stain techniques in order to provide useful information concerning pre-neoplastic lesions of the larynx.

Accuracy of laryngeal examination during upper gastrointestinal endoscopy for premalignancy screening: prospective study in patients with and without reflux symptoms.

BACKGROUND AND STUDY AIMS: Gastroesophageal reflux disease may be associated with laryngeal damage caused by reflux material. The aim of this study was to investigate the accuracy of laryngeal examinations during routine upper gastrointestinal endoscopy as a method of screening for major laryngeal injury in a series of patients with reflux symptoms. PATIENTS AND METHODS: A total of 100 consecutive patients with reflux symptoms and 100 control individuals underwent upper gastrointestinal endoscopy with standard or high-resolution magnifying video endoscopes. Any laryngeal abnormalities were initially identified by the gastroenterologist before the scope was inserted into the esophagus. All of the examinations were recorded on video and subsequently reevaluated by an otorhinolaryngologist. All of the patients underwent standard laryngoscopy as a reference procedure. RESULTS: All of the patients completed the study. The sensitivity, specificity, negative predictive value, and positive predictive value of the preliminary laryngeal exploration for detecting laryngeal abnormalities (such as laryngitis and vocal leukoplakia) were 90%, 90%, 92%, and 89%, respectively. High-resolution magnifying endoscopy had a higher sensitivity and specificity than standard endoscopy for detecting laryngeal pathology. Two patients were found to have laryngeal leukoplakia. CONCLUSIONS: This study shows that preliminary diagnosis of laryngeal disorders can be accurately carried out by the gastroenterologist when patients are undergoing upper endoscopy for reflux symptoms. This approach could also be helpful for the timely diagnosis of major reflux-related laryngeal disease.

Tensor veli palatini electromyography with surface electrode applied transnasally.

A new technique is proposed for paratubal electromyography, using a surface, non-invasive, electrode applied transnasally under nasopharyngoscope guidance. This electrode records activity of the tensor veli palatini muscle during swallowing. This technique is of interest for two reasons: endoscopic guidance offers the possibility to check correct positioning of the electrode recording at tensor veli palatini muscle level. Introduction of the non-invasive surface electrode is simple and not painful.

New techniques and technology to repair cerebrospinal fluid rhinorrhea.

Cerebrospinal fluid rhinorrhea occurs as a result of abnormal communication between the subarachnoid space and the pneumatized portion of the skull base, the paranasal sinuses and the middle ear. Conservative measures may be sufficient in the management of cerebrospinal fluid rhinorrhea, but, in some cases, surgical treatment may be required. Transnasal endoscopic techniques are constantly being used in preference to the intra- and extracranial approaches. Recently, image guidance systems have been adopted in neurosurgery, skull base and paranasal sinus surgery. The present report refers to 4 cases of nasal cerebrospinal fluid rhinorrhea leak successfully treated with a transnasal endoscopic approach using various techniques and materials to close the bone defect, in 2 of which, the navigation system (Stealth Station Treon ENT Image Guidance System with Landmark X, Software, Medtronic, XOMED, Jacksonville, FL, USA) was also used. In all cases, correct localization and repair of the leak was achieved and no major complications occurred. Following a review of the literature, the Authors conclude that, at present, transnasal endoscopic repair of cerebrospinal fluid rhinorrhea is the surgical treatment of choice when the techniques and materials are correctly used. Furthermore, preliminary findings indicate that it is possible to make routine use of the navigation systems and that this technology may be usefully employed, above all, in the management of cerebrospinal fluid leaks.

Midfacial fractures: our experience.

Authors report their experience in the treatment of midfacial fractures in 201 patients, 177 of whom underwent surgery for reduction and fixation of the fracture. Since no functional or aesthetic deficits were present, surgery was not performed in the remaining 24 cases. Of the 177 patients, the maxillary complex was involved in 70 (classified as central and centro-lateral fractures), the zygomatic-maxillary-orbital complex in another 70, isolated fractures of the orbital floor blow-out in 18, and, isolated fractures of the zygomatic arch in 19. The results obtained and the degree of satisfaction were evaluated in 90 patients with clinical visits, as well as by telephone interview. A total of 88 patients expressed complete satisfaction with the results of the surgical outcome, while the remaining 2 patients were not satisfied with the aesthetic outcome. All patients were operated within 24-48 hours post-trauma in the case of incarceration of extrinsic ocular muscles, and within 10 days in other types of trauma, even in those patients in intensive care. The importance of clinical and radiological pre-operative diagnosis is stressed as well as the choice of the most suitable therapeutic approach for the different types of fractures, considering recent tendencies towards minimally invasive procedures to achieve better cosmetic results. The latest developments in fixation techniques with reference to titanium mini- and/or micro-plates that may eventually be substituted with absorbable materials are discussed.