Efficacy of autofluoroscence videoendoscopy in the diagnosis of laryngeal lesions.

Aim of this prospective preliminary study was to assess effectiveness and reliability of autofluorescence endoscopy in the diagnosis of laryngeal lesions, in particular, evaluating whether it could represent an improvement in comparison to standard endoscopy alone. A total of 81 laryngeal biopsy specimens, taken from 46 consecutive patients who underwent intra-operative endoscopic assessment in a period of 2 years, were examined. Thirteen patients underwent the procedure for presumed benign lesions; the other 33 cases for pre-operative endoscopic suspicion of pre-cancerous or cancerous lesions. In our experience, autofluorescence evaluation seemed to accurately delineate the limits of the tumour and the possible presence of second primary, proving a useful guide in the choice of sites to make a biopsy. In particular, this endoscopic method has proved to be characterized by higher sensitivity and specificity not inferior to standard endoscopy, both in the discrimination between benign and preneoplastic/neoplastic lesions and between pre-neoplastic and neoplastic. Correct choice of the application field is mandatory in order to obtain the maximum effectiveness of this method. Autofluorescence endoscopy, in fact, was found to be very useful in the evaluation of untreated tissues with suspected pre-cancerous or cancerous lesions. On the contrary, in the study of "frankly benign" laryngeal lesions, this exam does not improve upon the results obtained by standard endoscopy but increases the risk of false positives. The best results can be obtained only by integration of data provided by both white-light and accurate auto-fluorescence endoscopic assessment.

Fibrous dysplasia of middle turbinate associated with Widal syndrome: endoscopic treatment of a rare case.

Fibrous dysplasia, a rare bony disease, is characterised by substitution of normal bone with immature tissue embedded in a fibrous stroma. It can be either monostotic or involve several bones. Fibrous dysplasia is usually asymptomatic but, in the advanced stage, pain due to neural compression or pathological fractures may occur. In the case of cranio-facial involvement, ocular, masticatory, respiratory or auditory functional alterations are possible. A case of fibrous dysplasia, limited to the middle turbinate and associated with Widal triad (sinus-nasal polyposis, asthma, acetyl salicylic acid intolerance), is described. Craniofacial computed tomography revealed enlargement of left middle turbinate with characteristic "ground-glass" appearance. The patient underwent anterior bilateral functional endoscopic sinus surgery with near-total resection of left middle turbinate. Histopathological examination confirmed the diagnosis of fibrous dysplasia. After 2 years the patient is still asymptomatic. Videorhinoscopy shows good sinus-nasal patency without disease recurrence. Even though exceptional, localization of fibrous dysplasia at middle turbinate has been described, therefore, it must be considered in the differential diagnosis of the craniofacial ossifying disorder. For localized and symptomatic lesions, endoscopic surgery is an effective option. Scrupulous life-long follow-up is necessary due to the high percentage of recurrence and possible malignant degeneration.

Contact laser surgery in treatment of vocal fold paralysis.

Vocal fold paralysis is a pathological condition characterised by varying degrees of respiratory distress in relation to the degree of glottic stenosis. Dyspnoea may be present even when resting and may even require emergency tracheotomy. Frequently, the patient arrives for attention after the onset of exertional dyspnoea associated with a certain degree of dysphonia. The causes may be central or peripheral, more commonly iatrogenic following thyroid or tracheal surgery or secondary to injury. The aim of all surgical techniques used in the treatment of vocal fold paralysis is to restore a lumen sufficient to guarantee adequate breathing through the natural airway, without the patient having to permanently maintain the tracheotomy tube, while preserving acceptable phonatory quality. Between 1990 and 2001, at the Padua Hospital Unit of Endoscopic Airway Surgery, 48 patients (27 female, 21 male) were treated for respiratory distress secondary to vocal fold paralysis. At the beginning of this experience, 7 patients underwent arytenoidectomy with the Ossoff technique. In 34 cases, a modified Dennis-Kashima posterior cordectomy was performed. In 7 patients, since widening of the airway was necessary, cordectomy was extended to the false homolateral chord in 5 cases and to the arytenoid vocal process in another 2. In 9 patients, the operation was carried out with a Nd Yag (1064 nm) contact laser; the remaining 39 were treated with a GaArAl (810 nm) diode laser in use since 1995. Satisfactory results were obtained in all patients first treated by us and not already tracheotomised (35). In 23 cases (66%), results were considered "good" since no exertional dyspnoea occurred. In 12 patients (34%), the result was considered "sufficient" since there was no resting dyspnoea and normal everyday activity could be undertaken. Of the 13 patients already tracheotomised on arrival, 11 (85%) were decanulated on average 2 months after surgery. In conclusion, the present results show that endoscopic posterior cordectomy, performed by contact diode laser, gives reliable results, is rapid and simpler to perform than arytenoidectomy and guarantees a sufficient airway without impairing swallowing, while maintaining entirely acceptable voice quality.

[The treatment of choanal atresia]. / Trattamento dell'atresia coanale.

Choanal atresia occurs in approximately 1 out of every 8000 live births. In about 60% of these cases it is unilateral and is often associated with other major craniofacial anomalies or visceral malformations such as the so-called CHARGE syndrome (i.e. Choloboma, Heart defects, choanal Atresia, Retarded growth and development, Genital anomaly, and Ear defect with deafness) first described by Pagon in 1981. In newborns the clinical manifestations of choanal atresia consist of respiratory distress strictly related to the entity of nasal obstruction. Total bilateral congenial choanal atresia must, therefore, be considered a surgical emergency since nasal obstruction impedes the suction mechanism and hence normal feeding in the newborn. For this reason, prompt surgery is mandatory. The surgical approach employed in choanal atresia consists of both the trans-nasal and trans-palatal approaches. Between 1985 and 1997 31 patients with choanal atresia were treated in our department (16 males, 15 females; age range 2 days-5.5 years; mean 11.4 months). In 25 cases (80.6%) the malformation was bilateral. Associated anomalies were seen in 8 patients (25.8% of cases). All of these patients were treated using the trans-nasal approach, under general anesthesia, and endoscopic control. In 27 cases a trocar was employed to perforate the bony atresia and a stent was then positioned. Three patients underwent contact-laser resection of the stenosis without requiring any further stent and without any complications. None of these patients developed total recurrences, although after varying amounts of time, in 8 of the 27 patients operated using the trocar (29.6% of cases) a partial reduction of the airway occurred, the substenosis requiring dilatation with progressive Hegar dilators. In the remaining cases contact-laser therapy was associated with dilation. Three of the patients were treated by laser-therapy alone and none developed a recurrence. One patient dropped out of the follow-up for other serious malformations.

[Endoscopic treatment of iatrogenic rhino-csf fistulas: notes of surgical techniques]. / Il trattamento endoscopico della fistola rinoliquorale iatrogenica: note di tecnica operatoria.

The Authors describe an endoscopic technique which may be employed in closing an iatrogenic rhino-CSF fistula, today one of the most frequent complication of endonasal surgery performed in the treatment of polyposis. The technique is relatively simple for surgeons with a certain amount in expertise in endoscopic surgery of the nose. Offering the possibility of being repeated without creating great problems, the procedure also allows the surgeon to avoid much more destruction techniques carried out externally.

[Current treatment of epistaxis]. / Il trattamento attuale dell'epistassi: considerazioni personali.

In the field of minor ENT pathology, epistaxis can be a dramatic emergency. Appearing occasionally in 10-12% and repeatedly in 4% of the population, it is the most common emergency requiring hospitalization. Epistaxis is somewhat unpleasant for the patient and relatives: distress (pain, fever, hypoxia) can be brought about by treatment such as nasal packing; complication and sequelae. If one takes into consideration the cost of medical and paramedical services, drugs, hospital, stay etc., it is clear that expenditure of time and money are not negligible. In this study the Authors present the results of about 2290 patients, treated during the last seven years for epistaxis of various types and severity.

[Synovial sarcoma of the head and neck: a case report of parapharyngeal region and review of the literature]. / Il sarcoma sinoviale della testa e del collo: presentazione di un caso a localizzazione parafaringea e revisione della letteratura.

Synovial sarcoma is a clinically and morphologically well defined entity that has been described extensively in Literature. It occurs primarily in the para-articular regions, usually in close association with tendon sheaths, bursae and joint capsules. On rare occasions it is also encountered in areas without any apparent relationship to synovial structures, as in the parapharyngeal region or the abdominal wall. It is considered the fourth most common type of sarcoma (7-10%) after malignant fibrous histiocytoma, liposarcoma and rhabdomyosarcoma. There are three histological variants: the classical biphasic, the monophasic fibrous type and the monophasic epithelial type (the biphasic and monophasic fibrous type are equally common). Clinical sign complaints are subtle and at times noted 20 years before diagnosis. The course of the disease is slow and insidious. The most typical presentation is that of a palpable deep-seated swelling or mass associated with pain or tenderness. Patients with synovial sarcoma in the head and neck (10%) tend to have difficulties in swallowing and breathing and not infrequently have alteration or loss of voice. Head and neck synovial sarcoma seem to originate from the paravertebral connective tissue spaces and manifest themselves as solitary retropharyngeal or parapharyngeal masses near the forking of the carotid. Additional cases in this general area have been reported in the soft palate, tongue, maxillofacial region, mandible corner, sternoclavicular region, scapular region and the cervical oesophagus. As in other types of sarcoma, the principal sites of metastases are the lung, but many make their appearance many years after the initial diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Our experience in microsurgery of rhino-sinus phlogosis]. / La nostra esperienza nella microchirurgia nelle flogosi rinosinusali.

Rhino-microscopy has made great progress in the diagnosis and surgical treatment of rhino-sinus phlogosis. In fact, a larger portion of the endonasal pathologies, which would not otherwise have been detected, can now be diagnosed through rhino-microscopic exploration. From the surgical point of view microscopy offers a clear, enlarged operating field. Moreover, with the aid of an autostatic speculum, it frees the surgeon to use both hands. These features make intricate, precise surgery possible thus enabling preservation of those structures which are not involved in the disease. At the same time it allows for re-establishment of the physiological functionality of the rhino-sinus cavity. Between 1980 and 1989 the microsurgery technique was employed in 950 cases of rhino-sinus cavity surgery. The results achieved using this technique were quite good and the number of complications was quite limited although the number of patients to be followed up over the years was not sufficient to draw any statistical conclusions. For several years now optic-fibre endoscopy has also been employed. This, too, is a functional technique although the method and instruments are totally different. It is not the intention of the authors here to assert that microsurgery is superior to endoscopy even though some technical details (i.e. the ability to operate with both hands) has made it easier to use, particularly for those accustomed to using a microscope. It is, however, felt that for rhino-surgery it is advisable to be familiar with both techniques so that they can be used alternately depending on the type of pathology and patient.

[Carcinoma of the hypopharynx: reconstruction of the alimentary canal using the residual larynx]. / Carcinoma dell'ipofaringe. Ricostruzione del canale alimentare mediante la laringe residua.

Treatment of hypopharyngeal carcinoma is difficult and frustrating due to notable problems in reconstruction and because of the low rate of healing. A review of the reconstruction techniques proposed over the last fifty years is given, particularly in regard to those using the residual larynx in reconstructing the alimentary canal. Wookey-type surgery provides for multiple stages and requires long hospital stays; even the reconstruction proposed by Bakamjian requires two operations and is often hampered by a distal necrosis of the deltopectoral flap. The one-stage reconstructions use the abdominal intestine, myocutaneous tubulized flaps and local mucosa flaps made of the tongue, epiglottis and residual larynx stripped of its cartilage. Those techniques using the abdominal intestine have an elevated rate of complications and per-operative mortality, while those using tubulized pectoral myocutaneous flaps at times compress the vascular peduncle due to their thickness, thus leading to post-operative stenosis. In the present work description is given of the hypopharyngeal reconstruction technique using the residual larynx stripped of its cartilage. In cases of cancer of the pyriform sinus the contralateral hemilarynx has been used while, in posterior tumors, the anterior larynx has been used, sutured to the residual posterior mucosa or to a myocutaneous flap. Nine patients underwent surgery using this technique; of these, seven had a tumor of the pyriform sinus, one a retrocricoid tumor and one carcinoma of the posterior wall of the hypopharynx. The oncological results do not appear much different than those obtained with the more well-known techniques, although follow-up is still too short.(ABSTRACT TRUNCATED AT 250 WORDS)