Surgical repair of persisting CSF leaks following standard or extended endoscopic transsphenoidal surgery for pituitary tumor.

INTRODUCTION: In this article, the aim of the authors is to discuss their experience with skull base reconstruction in endoscopic transsphenoidal and extended transsphenoidal surgery for pituitary tumor resection. METHODS: Between January 1997 and January 2008, 665 patients underwent either transnasal transsphenoidal endoscopic or extended transsphenoidal surgery for pituitary tumors. In patients without intraoperative CSF leak, we prefer to pack the surgical cavity with absorbable material, such as collagen sponge (Gelfoam), or, in the case of thin diaphragma sellae and postoperative risk of rupture with abdominal fat. In patients with minimal CSF oozing, but without any visible diaphragma sellae defect or only a small dural defect with leak, we pack the surgical cavity with abdominal fat. In case of a leak from an anterior face of the diaphragma sellae defect we prefer to reconstruct the defect by means of mucoperiosteum taken from the resected middle turbinate. Patients with larger sellar or supradiaphragmatic defects were treated with a multilayer reconstruction. RESULTS: 529 patients (79.5%) did not require any repair besides a packing of the surgical cavity with absorbable material such as collagen sponge, while 128 patients (19.2%) required an endoscopic skull base repair at the end of the procedure for an overt CSF leak. 8 patients (1.2%) required repair because of overt thin diaphragma sellae without a visible CSF leak but with a postoperative risk of rupture. Out of the latter two groups (n = 136) only 11 patients (8 %) developed persistent postoperative CSF leaks requiring revision multilayer reconstruction. CONCLUSIONS: More complex defects after pituitary surgery should be repaired with a multilayer technique, using autologous materials such as fat, fascia lata, bone and mucoperiosteum taken from the middle turbinate. This type of autologous material is generally reliable in more complex defects, and it appears to be easy to harvest and handle for repair.

Antenatal syphilis serology in pregnant women and follow-up of their infants in northern Italy.

Positive syphilis serology was noted in 119 (0.49%) of the 24 053 pregnant women delivering at St Orsola Hospital in Bologna, Italy, from November 2000 through July 2007. Six presumptive cases of congenital syphilis with IgM western blot positive results were found. Two infants had a positive cerebrospinal fluid (CSF) Venereal Disease Research Laboratory test result (one also had a positive CSF PCR result), another presented long-bone lesions, and the remaining three were preterm. These observations confirmed that antenatal syphilis screening facilitates treatment during pregnancy and offsets vertical transmission; moreover, the use of IgM western blot and careful CSF examination allowed the identification and treatment of high-risk newborns.

Unilateral laryngeal and hypoglossal paralysis (Tapia's syndrome) following rhinoplasty in general anaesthesia: case report and review of the literature.

Extracranial involvement of the recurrent laryngeal nerve and the hypoglossal nerve is known as Tapia's syndrome. Ipsilateral paralysis of the vocal cord and tongue is present. Lesion of these nerves may be a rare complication of airway management. Herein, a case of Tapia's Syndrome complicating transoral intubation during general anaesthesia in a rhinoplasty operation, together with a review of pertinent literature to evaluate the incidence and the possible pathogenic mechanism of the lesion. There are recent reports in the literature on mono or bilateral paralysis of the XII or laryngeal recurrent nerve after use of laryngeal mask with a pathogenic mechanism of compression. Furthermore, there are reports, following oro-tracheal intubation, of recurrent laryngeal paralysis, likely legacies to the compression of the anterior branch of inferior laryngeal nerve by the cuff of the oro-tracheal tube against the postero-medial part of the thyroid cartilage. Hypoglossal nerve damage could be caused by a stretching of the nerve against the greater horn of the hyoid bone by a laryngeal mask or oro-tracheal tube or compression of the posterior part of the laryngoscope or oro-tracheal tube. In our case, the lesion probably occurred as the result of a two-fold compressive mechanism: on one hand, compression by the cuff of the endo-tracheal tube due to excessive throat pack in the oro-pharynx; on the other hand a prolonged stretching mechanism of these nerves may have occurred due to excessive anterior and lateral flexion of the head. From the data reported in the literature, as in our case, complete recovery of function is generally achieved within the first six months. This progressive recovery of function suggests nerve damage of a neuro-praxic type, which is typical of compression injury. In conclusion, the response of this rare complication confirms the importance not only of the position of the head and patient on the operating table but also the meticulous and correct performance of the routine manoeuvres of airway management.

Endoscopic treatment of encephaloceles of the lateral wall of the sphenoid sinus.

OBJECTIVE: The suitability of the endoscopic approach for the treatment of an encephalocele of the lateral wall of the sphenoid is discussed. This is a retrospective review of 4 cases diagnosed with temporosphenoidal encephalocele and having a history of CSF leak who were surgically treated using an endoscopic endonasal approach between January 2001 and June 2002 at the Department of Otolaryngology of Sant'Orsola-Malpighi University Hospital and the Department of Neurosurgery at Bellaria Hospital in Bologna. METHODS: Three patients were female between 48 and 73 years of age (mean: 61 years). All patients had suffered from a CSF leak for 5 months to 18 years. None of the patients had a past medical history of head trauma. A fourth patient had undergone a previous microscopic approach for a previously misdiagnosed CSF leak wrongly ascribed to an empty sella. Three patients underwent an ethmoid-pterygo-sphenoidal endoscopic approach (EPSEA), while the patient who had undergone previous microscopic surgery, was treated using a transnasal transsphenoidal endoscopic approach. RESULTS: The follow-up of the patients ranged from 10 to 26 months (mean: 18 months) and no case of a recurrent CSF leak was observed postoperatively. CONCLUSIONS: In our report, the endoscopic approach was a useful tool for the treatment of encephaloceles of the lateral wall of the sphenoid sinus. In skilled hands, this technique permits both the resection of the encephalocele and the subsequent reconstruction of the defect also with a low rate of morbidity.

Short-term versus long-term antimicrobial prophylaxis in oncologic head and neck surgery.

BACKGROUND: Although antimicrobial prophylaxis is mandatory in major clean-contaminated oncologic surgery of the head and neck, both the choice of specific antimicrobial compounds and the treatment duration are still discussed. METHODS: A prospective, randomized trial was carried out to compare efficacy and tolerability of clindamycin-cefonicid administered for 1 day versus 3 days in reducing the rate of wound and systemic infections. The following potential risk factors for surgical wound infection were evaluated: type of surgery, stage of disease, preoperative tracheostomy, preoperative radiotherapy, and diabetes mellitus. RESULTS: One-hundred sixty-two patients were evaluable; 81 received 1-day chemoprophylaxis, while the remaining 81 were treated according to the 3-day schedule. During the first 20 days after surgery, wound infections occurred in 2 (2.5%) and 3(3.7%) patients, respectively, in the 1-day and 3-day treatment groups, so that no significant difference was found among the two evaluated chemoprophylaxis schedules. CONCLUSION: A 3-day schedule did not prove useful in preventing wound and systemic infections. All presumed risk factors were not associated with an increased rate of wound infections, although preoperative radiotherapy was associated with a greater severity of infections and a higher risk of late wound complications.

Detection of deglutition disorders after reconstructive laryngectomy. Clinical and radiological evaluations.

Subtotal reconstructive laryngectomy is an appropriate surgical procedure for intralaryngeal squamous cell carcinoma. After this surgery the functions of the larynx are greatly modified. These functions may be retained if at least one cricoaryténoid is preserved with good function. The aim of our study was to determine the recovery of swallowing in the late postoperative period and to establish the possible causes of dysphagia. 34 patients previously submitted to reconstructive laryngectomy were studied by clinical and endoscopical evaluation as well as videofluoroscopic examination. The results of our study confirm what has been reported by other authors, that is that the sphincter function greatly altered in the early postoperative period, is progressively restored, especially when both arytenoids are preserved. Videofluoroscopic examination frequently showed the asymptomatic false passage of liquid boluses.

Clindamycin/cefonicid in head and neck oncologic surgery: one-day prophylaxis is as effective as a three-day schedule.

The aim of our study was to evaluate the optimal duration of antibiotic prophylaxis in major oncologic surgery of the head and neck using a novel broad spectrum drug combination: clindamycin and cefonicid. A prospective randomized study was carried out on 126 evaluable patients undergoing clean-contaminated (skin to mucosa) surgery for cancer of larynx, pharynx or oral cavity. Cases at high surgical risk (because of need of pedicled or microvascular free flaps reconstruction), were excluded from the study. Within 20 days after surgery, only one case of wound infection was recorded among the 62 patients treated with the one-day schedule, versus three cases registered among the 64 subjects receiving three-day chemoprophylaxis. Episodes of systemic infections and eventual wound complications occurring in the first 20 days after surgery have also been recorded. The role of potential risk factors for postoperative complications has been evaluated. According to our findings, a three-day antibiotic regimen is not more effective than a short-term (one-day) schedule in preventing wound or systemic infection in clean-contaminated head and neck cancer surgery without flap reconstruction.

A case of Merkel-cell carcinoma metastatic to the tonsil.

Metastatic tumours are rare in the tonsil. We describe a 69-year-old male patient who had previously undergone a resection of a Merkel-cell tumour of the left forearm and subsequently presented with a left tonsillar tumour. Biopsy revealed a metastatic Merkel-cell carcinoma. Our patient is the first described case of Merkel-cell carcinoma metastasizing to the tonsil. The clinical and histopathological picture of this rare tumour is presented, along with a review of literature.

[Ultrasound staging research of progressive pathology of the base of the tongue]. / L'indagine ecografica nello studio della patologia espansiva della base linguale.

Diagnosis of tongue tumours is often retarded mainly because tumours grow prevalently in deep muscular layers. A correct exploration of the region might be difficult solely employing clinical examination. Therefore, it would be useful to confirm the suspect of a neoplastic lesion at the base of the tongue with a promptly available imaging method. These considerations led us to evaluate ultrasonography (US) as a diagnostic tool for neoplastic lesions of this region. Initially 10 normal patients were studied in order to become familiar with US anatomy of the area. In a second phase our study involved 24 patients with diagnosed carcinoma of the tongue base and 26 patients with clinical suspect of neoplasm in the region. US examination was carried out with real-time equipment provided by a 5 Mhz convex transducer. Patients were examined in supine position with the neck hyperextended. Longitudinal, oblique and transverse scan of the submental region were obtained. The study showed that US gives detailed images of the floor of the mouth and the tongue. Neoplastic infiltration of the base of the tongue is clearly recognizable as a hypoechoic area. It was possible to detect masses ranging from 1.4 to 3.8 cm. In cases of larger lesions, US was useful in evaluating deep infiltration, whereas in other cases the method allowed the diagnosis of small lesions with submucosal growth. US did not proved to be highly reliable in the diagnosis of lesions confined to superficial planes (false negative results).(ABSTRACT TRUNCATED AT 250 WORDS)

Laryngeal metastasis from colonic adenocarcinoma.

Metastases to the larynx from distant primaries are very rare. Usually the secondary lesion comes from an hypernephroma or malignant melanoma. A case of metastatic laryngeal tumour from a colonic adenocarcinoma, occurring in a 59-year-old woman, is presented and the routes for laryngeal spread are discussed. The poor survival-rate of these patients justified only conservative surgery.