Elective tracheostomy during COVID-19 outbreak: to whom, when, how? Early experience from Venice, Italy.

PURPOSE: The need for prolonged invasive mechanical ventilation in COVID-19 patients is placing the otorhinolaryngologist in front of an increasing request for tracheostomy. Nowadays, there is uncertainty regarding the timing of tracheostomy, the prognosis of these patients and the safety of healthcare workers. The aim of this study is to evaluate the efficacy and safety of tracheostomy placement in patients with COVID-19. METHODS: A retrospective cohort study on 23 COVID 19 patients, to analyse the timing of tracheostomy, the risk factors associated with in-hospital death and the infection of the involved health care workers. Early tracheostomy was defined as ≤ 10 days and late ones > 10 days. RESULTS: The mortality rate of COVID-19 patients admitted to ICU that underwent tracheostomy was 18%. The overall mortality of patients admitted to ICU was 53%. The univariate analysis revealed that early tracheostomy, SOFA score > 6, and D-dimer level > 4 were significantly associated with a greater risk of death. At the multivariate analysis SOFA score > 6 and D-dimer level > 4 resulted as significant factors for a higher risk of death. No health care workers associated with tracheostomy are confirmed to be infected by SARS-CoV2. CONCLUSION: We suggest to wait at least 14 days to perform tracheostomy. In patients with SOFA score > 6 and D dimer > 4, tracheostomy should not be performed or should be postponed. Optimized procedures and enhanced personal protective equipment can make the tracheostomy safe and beneficial in COVID-19 patients.

New trends in rehabilitation of children with ENT disorders.

In the last 20 years, neonatal survival has progressively increased due to the constant amelioration of neonatal medical treatment and surgical techniques. Thus, the number of children with congenital malformations and severe chronic pathologies who need rehabilitative care has progressively increased. Rehabilitation programs for paediatric patients with disorders of voice, speech and language, communication and hearing, deglutition and breathing are not widely available in hospital settings or in long-term care facilities. In most countries, the number of physicians and technicians is still inadequate; moreover, multidisciplinary teams dedicated to paediatric patients are quite rare. The aim of the present study is to present some new trends in ENT paediatric rehabilitation.

Transnasal endoscopic management of anterior cerebrospinal fluid (CSF) leak: experience from a large case series.

Transnasal endoscopic management of anterior cerebrospinal fluid (CSF) leak: experience from a large case series. OBJECTIVES: Anterior cerebrospinal fluid (CSF) leak is a consequence described after head trauma, skull base surgery or inflammatory diseases, but may also occur spontaneously. Prompt recognition and management is crucial in order to avoid complications and to achieve successful surgical repair. The purpose of this study is to present the clinical features of a large group of patients with anterior CSF leak and the results of their surgical management. METHODOLOGY: The study approach was a retrospective review of 110 consecutive patients treated by the same surgeon for CSF leak of the anterior skull base via a transnasal endoscopic approach between 2003 and 2013. Patients with anterior skull base surgery due to cancer or pituitary adenoma were excluded from this study. The diagnostic workup included nasal endoscopy, beta2-transferrin and -trace protein assay in the rhinoliquorrhoea and radiological imaging. The intrathecal fluorescein test was performed in selected cases. The surgical techniques used to repair dural defects were primarily middle turbinate placement and fascia lata grafting. RESULTS: Primary endoscopic repair of the CSF fistula was successful in 106/110 (96.4%) patients. Four patients (3.6%) required a revision procedure due to early failure of the repair. After a minimum follow-up of 24 months, no recurrent CSF leaks were observed in the study group. None of the patients developed meningitis as a surgical complication. CONCLUSIONS: The endoscopic transnasal approach is a reliable technique for treating CSF leaks. The intrathecal fluorescein test is safe and helpful in locating the defect. The fascia lata proved the best graft available in our experience.

Nasopharyngeal thyroid-like low-grade papillary adenocarcinoma.

OBJECTIVE: Epistaxis is extremely common in children. Although rare, the presence of an intranasal mass as a cause of bleeding should be ruled out in patients with recurrent or massive epistaxis. We present a patient whose recurrent nose-bleeding had been due to a nasopharyngeal mass. METHODS: Case report with relevant literature review. RESULTS: A 15-year-old girl with a history of sudden posterior nasal bleeding was diagnosed with thyroid-like low-grade nasopharyngeal papillary adenocarcinoma of the nasopharynx. A type II nasopharyngeal endoscopic resection was performed with an excellent outcome at 30-months follow-up. The literature review on the topic disclosed only five other paediatric cases, none of which presented with epistaxis. CONCLUSIONS: Recurrent epistaxis may infer the presence of nasopharyngeal malignant neoplasms, even in children. To our knowledge, this represents the sixth case in the literature of a paediatric low-grade nasopharyngeal adenocarcinoma and the first presenting with massive epistaxis. The possibility of such a finding should be kept in mind when evaluating children with massive epistaxis.

Post-traumatic optic neuropathy: our surgical and medical protocol.

Post-traumatic optic neuropathy (TON) is a rare, but very much feared event. It is a traumatic injury of the optic nerve at any level along its course (often inside the optic canal), with partial or total loss of visual acuity, temporarily or permanently. Until now, an univocal treatment strategy does not exist. The clinical records of 26 patients, treated from 2002 to 2013, were reviewed. The most frequent cause of injury was road traffic accident (63%), followed by iatrogenic damage, work injuries, sport or home accidents. All patients underwent pre-operative ophthalmological evaluation, neuro-imaging (angio-CT or angio-MRI scans) and systemic corticosteroid therapy. All patients required a surgical treatment, due to poor response to medical therapy; it consisted of an endonasal endoscopic decompression of the intracanalicular segment of the optic nerve, performed by removing the bony wall of the optical canal and releasing the perineural sheath. Improvement of visual acuity was reached in 65% of cases. No minor or major complication occurred intra- or post-operative, with a maximum follow-up time of 41 months. An improvement in visual acuity was achieved, although very limited in some cases, when surgery was performed as close as possible to the traumatic event. In the literature, there is no evidence-based data evaluating both of the two main treatment options (medical therapy versus surgical decompression), to state which is the gold standard in the treatment for TON. We discuss the pro and cons of our protocol: medical endovenous steroid treatment, within 8 h of injury, and endoscopic surgical decompression within 12-24 since the beginning of medical therapy, represent the best solution in terms of risk-benefit ratio for the patients.

Hair phenotype in non-syndromic deafness.

The GJB2 gene is located on chromosome 13q12 and it encodes the connexin 26, a transmembrane protein involved in cell-cell attachment of almost all tissues. GJB2 mutations cause autosomal recessive (DFNB1) and sometimes dominant (DFNA3) non-syndromic sensorineural hearing loss. Moreover, it has been demonstrated that connexins are involved in regulation of growth and differentiation of epidermal tissues. Hence, mutations in GJB2 gene, which is responsible for non-syndromic deafness, may be associated with an abnormal skin and hair phenotype. We analyzed hair samples from 96 subjects: a study group of 42 patients with hearing impairments of genetic origin (38 with a non-syndromic form, 4 with a syndromic form), and a control group including 54 people, i.e. 43 patients with other, non-genetic hearing impairments and 11 healthy volunteers aged up to 10 years old. The surface structure of 49 hair samples was normal, whereas in 45 cases it was altered, with a damaged appearance. Two hair samples were considered unclassifiable: one from the patient heterozygotic for the pendrin mutation (Fig. 2C), the other from a patient from Ghana with a R134W mutation (Fig. 2D). Among the 43 altered hair samples, 31 belonged to patients with connexin mutations and the other 12 came from patients without connexin mutations.

Carotidynia: new aspects of a controversial entity.

Idiopathic carotidynia or Fay syndrome is a little known pathology, which in the past was the subject of much controversy. Even though carotydinia was removed as a pathological entity from the second International Headache Society classification in 2004, recent reports seem to confirm that the disease demonstrates unusual radiological findings. The presence of a typical amorphous enhancing soft tissue surrounding the carotid artery by MRI, CT and ultrasonography in patients with carotidynia has reopened discussion on the hypothesis that carotidynia may represent a distinctive inflammatory process. The aetiology of carotidynia is unknown. We report a case of carotidynia that developed after an upper airway infection, wherein MR studies demonstrated typical enhanced tissue surrounding the common carotid artery in contiguity with pathological enhancement in laryngeal tissue.