"Pharyngolab": a new surgical simulator for pharyngoplasties.

Pharyngoplasty represents one of the most widely performed surgical procedures for the treatment of obstructive sleep apnea (OSA) in the presence of palate-oropharyngeal collapse. The learning curve for pharyngoplasties is steep and success is conditional on the correct use of the sutures and the careful application of the surgical steps in a narrow surgical field. The use of synthetic models may be conveniently and safely employed for hands-on surgical practice in pharyngoplasties, especially when fresh frozen cadaveric specimens are not available. We present the "Pharyngolab", a new simulator for pharyngoplasties.

No-cutting remodelling intra-pharyngeal surgery can avoid CPAP in selected OSA patients: myth or reality?

INTRODUCTION: Oropharyngeal surgery for Obstructive Sleep Apnea (OSA) has evolved from a radical excision of "redundant" soft tissue for the enlargment of the airway to a minimally invasive reconstruction to fulfill both preservation of pharyngeal function and improvement of sleep apnea. Recently, Alianza surgical technique has been successfully introduced as a new, non-resective procedure aimed to treat concentric pharyngeal collapse at the velum using Barbed Sutures. The aim of this study was to show the effectiveness and safety of Alianza technique as standalone surgical treatment in selected patients with moderate-severe OSA and concentric pharyngeal collapse that refused or did not tolerate Continuous Positive Airway Pressure therapy. MATERIALS AND METHODS: Effectiveness of the surgical procedure was assessed by means of the Epworth Sleepiness Scale (ESS), Home Sleep Test, and a 0-10 snoring VAS. RESULTS: At the end of our selection process, 26 patients were enrolled, with a mean age of 52.7 ± 9.2 years, that undergone Alianza tecnique. There was a statistically significant reduction in mean post-operative apnea-hypopnea indexes (34.1 ± 11.5-16.3 ± 10.3; p <0.01), mean oxygen desaturation index (29.0 ± 14.5-13.1 ± 9.2; p < 0.01), and mean ESS scores (12.1 ± 5.8 and 5.8 ± 4.4; p < 0.01).There was also a significant decrease in mean post-operative snoring VAS scores (7.85 ± 1.23 vs 3.2 ± 1.7, p < 0.01). There were no major complications. CONCLUSIONS: Our preliminary results suggest that Alianza technique is a safe and repeatable surgery. Further studies on a larger scale are needed to confirm these encouraging data supporting the role of Alianza alone or in OSA multilevel surgery in selected OSA patients.

Could nasal irrigation and oral rinse reduce the risk for COVID-19 infection?

Public health measures are essential to protect against COronaVIrus Disease 2019 (COVID-19). The nose and the mouth represent entry portals for the COVID 19. Saline Nasal Irrigations (SNIs) can reduce the viral load in the nasal cavities. Oral rinse with antimicrobial agents is efficacious in reducing the viral load in oral fluids. We advocate the inclusion of SNIs and ethanol oral rinses as additional measures to the current public health measures, to prevent and control the transmission of any respiratory infectious disease, including COVID-19.

Different barbed pharyngoplasty techniques for retropalatal collapse in obstructive sleep apnea patients: a systematic review.

BACKGROUND: The use of barbed sutures (BS) for the treatment of retropalatal collapse and vibration in patients suffering from snoring and obstructive sleep apnea (OSA) has significantly increased in the last few years. Many surgeons have discovered the advantages and unique properties of the BS and allowed the popular surgical pharyngoplasty techniques to be updated and improved. METHODS: A systematic review was performed to identify all the clinical studies concerning the different barbed pharyngoplasty (BP) techniques used for the treatment of palatal collapse in snoring and OSA patients. A qualitative analysis of data extracted was conducted. RESULTS: We included 12 studies of which 10 are prospective and 2 retrospective: 9 single-arm studies on the efficacy of a specific BP technique, 1 randomized clinical trial on the comparison between BP and control groups, and 2 studies on the correlation between two different BP techniques. To date, in the literature, 5 different types of BP techniques have been described: barbed snore surgery, barbed reposition pharyngoplasty, barbed expansion sphincter pharyngoplasty, barbed suture suspension, and barbed soft palate posterior webbing flap pharyngoplasty. All the studies showed an overall improvement in the primary efficacy parameters investigated (apnea-hypopnea index, oxygen desaturation index, and Epworth sleepiness scale) in each of the surgical techniques performed without any major complications. CONCLUSIONS: Given the extreme heterogeneity of the studies analyzed, it is necessary to perform more randomized and control studies on large samples aimed to define the best BP technique based on its effectiveness, surgical success rate, patient's compliance, and complications.

Management of Parapharyngeal Space Tumor Using Transoral Robotic Surgery: The Tonsillar Fossa Battlefield.

INTRODUCTION: The management of parapharyngeal space (PPS) tumors is surgical, but the approach remains a challenge. Attention should be paid to avoid intra-operative bleeding, cranial nerves damage, and external scars. PRESENTATION OF CASE: The authors report a case of a 23-year-old female, with complaint of progressive, painless swelling just below the right angle of the mandible of 6-month's duration. Magnetic resonance imaging images reported the presence of an oval-shaped expansive lesion (maximum diameter 3 cm), from the lower polar region of the parotid gland while fine needle aspiration cytology (FNAC) was not diagnostic. We performed a Trans Oral Robotic surgical excision of the tumors with Da Vinci Robot. DISCUSSION: Thanks to a detailed magnification, the authors were able to reach the PPS region through the tonsillar fossa saving the palatine tonsil without any significant bleeding or nerve lesions. The histological examination confirmed the diagnosis of pleomorphic adenoma of parotid gland. The decision on which surgical approach to be used is determined by site, size vascularity, histology of the tumor, and knowledge of radiological images. CONCLUSION: There is not only 1 surgical approach for PPS tumors but the surgeon must know all the different options and possible outcomes. Transoral Robotic Surgery approach with Da Vinci could represent a valid option with a good knowledge of Robot surgical instruments and a detailed preoperative plan.

Hypoglossal Nerve Stimulation in the Treatment of Obstructive Sleep Apnea: Patient Selection and New Perspectives.

Hypoglossal nerve stimulation (HNS) is an increasingly widespread OSA treatment. It is a non-anatomical modifying surgery able to achieve an adequate objective and subjective result with a reasonable complication rate. HNS exploits the neurostimulation to reduce upper airway collapsibility providing a multilevel upper airway improvement within a single procedure. Proper patient selection has a fundamental role in determining an adequate long-term clinical outcome. All patient candidates for HNS undergo a standard comprehensive sleep medicine assessment and upper airway surgical examination. Several features should be assessed preoperatively in order to predict patients' response to HNS treatment. In particular, the assessment of OSA severity, BMI > 32 Kg/m2, collapse pattern during drug-induced sleep endoscopy (DISE), and many other parameters, is central for a good patient selection and customization of OSA treatment. HNS is indeed one of the most promising tools in the widespread context of personalized sleep medicine. HNS is an adjustable medical device that could be titrated in order to improve HNS effectiveness, maintaining patient comfort. Moreover, HNS provides the opportunity for patients to play an active role in their own care, with a potential improvement in therapy adherence and efficacy. This review summarizes the current evidence in patient selection for HNS, highlighting the reasons behind the optimistic future of this OSA treatment in the context of personalized medicine.

Hypoglossal nerve stimulation long-term clinical outcomes: a systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review and meta-analysis for studies evaluating hypoglossal nerve stimulation (HNS) clinical outcomes in the treatment of moderate to severe obstructive sleep apnea (OSA). METHODS: Two authors conducted a literature search to identify prospective studies in PubMed/MEDLINE, Google Scholar, and Cochrane Library databases. The last search was performed on November 17, 2018. RESULTS: A total of 350 patients (median age 54.3 (IQR 53-56.25) years, BMI 29.8 (IQR 28.8-31.6) kg/m2) from 12 studies were included. The procedure has obtained a surgical success rate of 72.4% (Inspire), 76.9% (ImThera), 55% (Apnex) at 12 months, and 75% (Inspire) at 60-month follow-up. At 12 months, the apnea-hypopnea index (AHI) mean differences was - 17.50 (Inspire; 95% CI: - 20.01 to - 14.98, P < 0.001), - 24.20 (ImThera; 95% CI: - 37.39 to 11.01, P < 0.001), and - 20.10 (Apnex; 95% CI: - 29.62 to - 10.58, P < 0.001). The AHI mean reduction after 5 years was - 18.00 (Inspire, - 22.38 to - 13.62, P < 0.001). The Epworth sleepiness scale (ESS) mean reduction was - 5.27 (Inspire), - 2.90 (ImThera), and - 4.20 (Apnex) at 12 months and - 4.40 (Inspire) at 60 months, respectively. Only 6% of patients reported serious device-related adverse events after 1- and 5-year follow-up. CONCLUSION: HNS has obtained a high surgical success rate with reasonable long-term complication rate related to the device implanted. The procedure represents an effective and safe surgical treatment for moderate-severe OSA in selected adult patients who had difficulty accepting or adhering to CPAP treatment.

Postoperative Pain and Wound Healing After Coblation-Assisted Barbed Anterior Pharyngoplasty (CABAPh): An Observational Study.

Despite the numerous progresses in the palatal surgery, one of the critical aspect of snoring and OSA surgery is the postoperative pain. Over the last decades several surgical palatal procedures have been proposed. Our aim was to evaluate the tolerability of the coblation-assisted barbed anterior pharyngoplasty (CABAPh) in terms of postoperative pain and wound healing, compared with bipolar assisted barbed anterior pharyngoplasty (BAPh). An observational study on 20 patients with simple snoring was conducted. The outcomes measured to assessing pain were a 10 cm visual analog scale (VAS) and the dose of paracetamol + codeine administrated postoperatively. The wound healing was evaluated using a 3-point scale. The other parameters indicative of both pain and surgical repair were food intake and weight loss postoperatively. The mean overall pain (VAS scale) was significantly less in the CABAPh group (M 3.7; CI 3.34-4.06) compared with the BAPh (M 4.73; CI 4.28-5.19) with a P = 0.003. The mean wound healing after 4 weeks was significantly less in CABAPh group (M 2.7; CI 3.12-2.28) compared with the BAPh (M 2.1; CI 2.45-1.75) with a P = 0.02. There were no statistically significant difference with regard to food intake (P = 0.09) and weight loss (P = 0.94). The CABAPh was able to achieve a greater pain reduction and a faster wound healing compared with bipolar forceps.

Ex-vivo surgical model for "Barbed Snore Surgery": a feasibility study.

INTRODUCTION: The "Barbed Snore Surgery" is one of the last technical innovations in palatal surgery for Obstructive Sleep Apnea. The availability of a low-cost surgical model able to replicate tissue consistency and main anatomical structures could be fundamental for the spreading of this surgery. The aim of this study was to assess the feasibility of an ex-vivo ovine model in the surgical training of BSS. METHODS: After adequate preparation of adult lamb heads, a post-graduate student with no surgical expertise was guided by a skilled surgeon in the execution of two BSS procedures: "Barbed Roman Blinds Technique" and "Barbed Anterior Pharyngoplasty". Anatomical limitations and similarity with the human tissue were assessed and recorded during the simulation. RESULTS: All the procedures were successfully completed. Despite proportional differences, the palatal tissue was assessed as similar in consistency and thickness to the human tissue. The simulation was considered satisfactory and suitable for surgical training. CONCLUSION: This ex-vivo ovine surgical model could represent the right tool for BSS training thanks to readily available and inexpensive specimens. Moreover, it appears to present the realistic anatomy and tissue consistence essential for an adequate surgical simulation.

Topical Ectoine: A Promising Molecule in the Upper Airways Inflammation-A Systematic Review.

To date, topical therapies guarantee a better delivery of high concentrations of pharmacologic agents to the mucosa of the upper airways (UA). Recently, topical administration of ectoine has just been recognized as adjuvant treatment in the Allergic Rhinitis (AR) and Rhinosinusitis (ARS). The aim of this work is to review the published literature regarding all the potential therapeutic effects of ectoine in the acute and chronic inflammatory diseases of UA. Pertinent studies published without temporal limitation were selected searching on MEDLINE the following terms: "ectoine" and "nasal spray," "oral spray," "upper respiratory tract infections," "rhinosinusitis," "rhinitis," "rhinoconjunctivitis," "pharyngitis," and "laryngitis." At the end of our selection process, six relevant publications were included: two studies about the effect of ectoine on AR, one study about ARS, one study about rhinitis sicca anterior, and two studies about acute pharyngitis and/or laryngitis. Due to its moisturizing and anti-inflammatory properties, topical administration of ectoine could play a potential additional role in treatment of acute and chronic inflammatory diseases of UA, in particular in the management of sinonasal conditions improving symptoms and endoscopic findings. However, these results should be viewed cautiously as they are based on a limited number of studies; some of them were probably underpowered because of their small patient samples.

Image-guided endoscopic marsupialization technique for frontal sinus mucocele with orbital extension: A case report.

INTRODUCTION: Frontal sinus mucocele with intra-orbital extension represents a rare benign cyst-like lesion. Surgical management could be summarized in an open approach, an endoscopic marsupialization or a combined procedure. The present study reports a case of frontal mucocele with wide intra-orbital invasion treated with endoscopic marsupialization assisted by an image-guided navigation system. PRESENTATION OF CASE: A 34-year-old African male was referred to the otolaryngology clinic for unilateral supraorbital swelling and post-nasal drip. A clinical ophthalmic assessment showed normal ocular movement, the absence of diplopia and normal visual acuity. CT scan showed a large soft tissue density lesion originating from the right frontal sinus with a supero-medial orbital erosion. The mass invaded the orbital cavity compressing and dislocating the eyeball forward and laterally. An image-guided ESS was performed according to Draft type IIa. Frontal mucocele's inferior wall was open in order to drain muco-purulent content. No complications were detected and the patient was completely recovered with open frontal sinus drainage at 4 months follow-up visit. DISCUSSION: We have successfully treated a wide intra-orbital frontal mucocele with an endoscopic marsupialization thanks to image-guided navigation system support. This technology prevented an external approach with associated morbidity and longer hospitalization. CONCLUSION: Navigated assisted endoscopic approach with marsupialization can be considered a safe treatment for FM with orbital extension. In particular, the image-guided system could be useful if bony landmarks are missing, if orbital erosion is present, and to completely drain lateral and multi-cystic lesions.

Review of Systemic Antibiotic Treatments in Children with Rhinosinusitis.

Antibiotic treatment in paediatric rhinosinusitis is still a matter of debate, as the current guidelines have been drafted mainly based on clinical studies published before 2013. Recent modifications in the epidemiological basis of the disease might mean that current treatments are not completely adequate considering the evolving microbiological profile of the disease. The present paper reviews the role of systemic antibiotics in children with acute (ARS), chronic (CRS), recurrent (RARS), and complicated acute (CoARS) rhinosinusitis. A total of 14 studies (including 3 prospective non-randomised studies, 8 retrospective studies, and 3 prospective randomised studies) of the 115 initially identified papers were included in this review, corresponding to 13,425 patients. Five papers dealt with ARS, four papers with RARS or CRS, and five papers with CoARS; the remaining papers included patients with either ARS or CRS. Data about the effectiveness of antibiotic treatment in children with ARC, CRS, and CoARS is scarce, as only three randomised controlled trials have been published in the last decade, with contrasting results. There is an urgent need for dedicated controlled trials not only to test the actual clinical benefits deriving from the routine use of systemic antibiotics in different categories of patients but also to compare the effectiveness of various therapeutic protocols in terms of the type of antibacterial molecules and the duration of treatment.

New low-cost magnifying device for temporal bone laboratory.

Temporal bone dissection has important role in educating and training oto and skull base surgeons. Mounting of a temporal bone laboratory is expensive. A dedicated magnifying system, such as a surgical microscope or an endoscopic equipment, represents one of the most significant costs. The aim of this study is to test and demonstrate the utility of a commercial USB as a low-cost solution to equip the laboratory with a good magnifying system and illumination.

"Barbed snore surgery" simulator: a low-cost surgical model.

BACKGROUND: "Barbed snore surgery" (BSS) represents one of the last innovation for obstructive sleep apnea syndrome (OSAS) surgical management. Although this technique represents an effective and minimally invasive surgery, it is not still widespread in many ENT centers. The aim of our study was to develop an inexpensive surgical simulator useful to expedite the surgical learning curve for BSS in untrained ENT surgeons. MODEL ASSEMBLY: The simulator is a simple model composed of a manually shaped silicone palate (3 × 4 × 1 cm) fixed on a resin skeleton (21 × 16 × 12 cm) using a transparent silicon rubber. The mandible is fixed bilaterally with the aid of two screws allowing for modular inter-incisive distance. SIMULATION: Barbed anterior pharyngoplasty (BAPh) was readily performed on the simulator to show the feasibility of this BSS model. All surgical steps were carried out determining a lift and a shortening of the palate as in real surgery. CONCLUSIONS: This is the first surgical model that provides a realistic, easily repeatable training in the performance of BSS. Our BSS surgical model is very inexpensive with a cost of approximately 19.25$ dollars and it is manufactured to facilitate a worldwide diffusion of this promising palatal surgery for OSAS.

Nasal Delivery Devices: A Comparative Study on Cadaver Model.

Nasal nebulization is a more effective method of delivering topical medication than nasal spray. The purpose of this study was to assess the deposition patterns of nebulization in delivering topical agents to the nasal cavities in the human cadaveric model using a color-based method. We have compared these following nasal devices: single-dose vial irrigation, syringe-irrigation, common nasal spray, Spray-sol, MAD nasal, and Rinowash nasal douche. Endoscopic images were recorded at six anatomical regions prior to and following each nasal device application and four reviewers evaluated the amount of surface area staining. At the nasal vestibule, the blue dye distribution achieved with Spray-sol was more extensive than nasal sprays. At inferior turbinate and nasal cavity floor, single dose vial, syringe, MAD nasal, Spray-sol, and Rinowash demonstrated a greater extent of dye distribution than nasal spray. At the middle turbinate, the average score of both Spray-sol and MAD nasal was significantly higher than other nasal investigated devices. At the nasopharynx, Spray-sol nebulization covers a surface significantly greater than other devices. Compared to traditional sprays, Spray-sol and MAD nasal provided a more effective method of delivering topical agents to the deeper and higher portions of the nasal cavities.