Psychiatric Burden in Chronic Sinonasal Diseases: A Single-Center Cross-Sectional Observational Study

BACKGROUND AND OBJECTIVES

Chronic rhinosinusitis (CRS) and nasal septum deviation (SD) are two widely diffused clinical conditions in otorhinolaryngology clinical practice. Albeit nasal symptoms are the most commonly referred by patients affected by both conditions, recent evidence has explored the impairment of nasal function beyond its local implication. Indeed, the prevalence of psychiatric disorders, specifically anxiety and depression, was found higher in patients suffering from SD or CRS than in the general population. The aim of this study was to evaluate the psychiatric burden of these conditions in terms of anxiety and depression and to assess its relationship with clinical phenotype and age.

METHODS

Monocentric cross-sectional observational study. Consecutive patients affected by CRS with or without nasal polyps or by SD were considered eligible. At referral, each patient underwent nasal endoscopy for clinical diagnosis and had to fill in the Hospital Anxiety and Depression Scale (HADS), the Sinonasal Outcome Test-22 (SNOT-22), and the Visual Analogue Scale (VAS) for global nasal symptoms. The population was grouped according to disease and age.

RESULTS

One hundred fifty patients were enrolled. We observed a statistically significant difference in mean HADS score between patients affected by CRS with nasal polyps and those suffering from CRS without nasal polyps or SD both in the overall population and by age groups. Nevertheless, there was no significant difference in the HADS score between younger patients affected by CRS and SD. The mean HADS score was significantly higher in younger patients affected by SD compared to older. Furthermore, we observed an inverse correlation between age and HADS score in each disease group, statistically significant for SD. On the contrary, in the overall population, HADS score and patient-related outcomes (PROs) were directly correlated.  Conclusions: In the era of personalized medicine, our work remarks on the critical impact of anxiety and depression on the quality of life (QoL) of patients affected by sinonasal conditions. According to our results, age affects patient-reported outcomes (PROs) and should, therefore, be enhanced in the therapeutic decision process.

Outcomes of Endoscopic Endonasal Dacryocystorhinostomy in Glaucoma Patients

BACKGROUND

Anti-glaucoma eye drops have been investigated due to their production of fibrotic changes on the conjunctival surface, undermining the functioning of the upper lacrimal drainage system. We aimed to assess whether these effects may impair the effectiveness of endoscopic endonasal dacryocystorhinostomy (EE-DCR).

METHODS

This is a single-center observational retrospective study on EE-DCR via a posterior approach. Resolution of epiphora and dacryocystitis were analyzed after 1 (T1) and 6-months (T2) from surgery. Surgical success was defined as anatomical (patency at irrigation, no recurring dacryocystitis) or complete (zeroing of Munk score).

RESULTS

Twenty patients (32 sides) were enrolled. Preoperatively, 93.75% (n = 30/32) presented severe (Munk 3-4) epiphora and 68.75% (n = 22/32) recurrent dacryocystitis. At T1, 50.0% (n = 16/32) were referred with residual epiphora (Munk ≥ 1) and 18.75% (n = 6/32) dacryocystitis. At T2, 31.25% (n = 10/32) still complained of epiphora (Munk ≥ 1) and 6.25% (n = 2/32) dacryocystitis. Difference of outcomes at aggregate and paired timepoints (except for T1 versus T2) resulted in statistical significance (p < 0.05). At T2, 22 (68.75%) complete, 8 (25.0%) anatomical successes and 2 (6.25%) surgical failures were observed.

CONCLUSIONS

Despite the chronic uptake of anti-glaucoma eye drops, EE-DCR guaranteed high rates of clinical relief from epiphora and remarkable decreases in the rates of recurrent dacryocystitis.

The Use of Artificial Intelligence in Head and Neck Cancers: A Multidisciplinary Survey

Artificial intelligence (AI) approaches have been introduced in various disciplines but remain rather unused in head and neck (H&N) cancers. This survey aimed to infer the current applications of and attitudes toward AI in the multidisciplinary care of H&N cancers. From November 2020 to June 2022, a web-based questionnaire examining the relationship between AI usage and professionals' demographics and attitudes was delivered to different professionals involved in H&N cancers through social media and mailing lists. A total of 139 professionals completed the questionnaire. Only 49.7% of the respondents reported having experience with AI. The most frequent AI users were radiologists (66.2%). Significant predictors of AI use were primary specialty (V = 0.455; p < 0.001), academic qualification and age. AI's potential was seen in the improvement of diagnostic accuracy (72%), surgical planning (64.7%), treatment selection (57.6%), risk assessment (50.4%) and the prediction of complications (45.3%). Among participants, 42.7% had significant concerns over AI use, with the most frequent being the 'loss of control' (27.6%) and 'diagnostic errors' (57.0%). This survey reveals limited engagement with AI in multidisciplinary H&N cancer care, highlighting the need for broader implementation and further studies to explore its acceptance and benefits.

Airways Type-2 Related Disorders: Multiorgan, Systemic or Syndemic Disease?

Chronic rhinosinusitis (CRS) has recently undergone a significant paradigm shift, moving from a phenotypical classification towards an "endotype-based" definition that places more emphasis on clinical and therapeutic aspects. Similar to other airway diseases, like asthma, most cases of CRS in developed countries exhibit a dysregulated type-2 immune response and related cytokines. Consequently, the traditional distinction between upper and lower airways has been replaced by a "united airway" perspective. Additionally, type-2 related disorders extend beyond respiratory boundaries, encompassing conditions beyond the airways, such as atopic dermatitis. This necessitates a multidisciplinary approach. Moreover, consideration of possible systemic implications is crucial, particularly in relation to sleep-related breathing diseases like Obstructive Sleep Apnoea Syndrome (OSAS) and the alteration of systemic inflammatory mediators such as nitric oxide. The trends in epidemiological, economic, and social burden are progressively increasing worldwide, indicating syndemic characteristics. In light of these insights, this narrative review aims to present the latest evidence on respiratory type-2 related disorders, with a specific focus on CRS while promoting a comprehensive perspective on the "united airways". It also introduces a novel concept: viewing these conditions as a multiorgan, systemic, and syndemic disease.

A randomized prospective comparative study on sinonasal morbidity and quality of life of transsphenoidal endoscopic surgery for pituitary adenomas: endonasal versus trans-septal approach

PURPOSE

Endoscopic endonasal transsphenoidal approach (Endonasal approach) is commonly used to treat pituitary adenomas. The extent of dissection possibly changes the anatomy and the physiology of the nasal cavities and could give rise to post-operative morbidity and the quality of life (QoL). The purpose of this study was to investigate sinonasal morbidity and general QoL in patients who underwent surgery for treatment of pituitary adenoma, comparing Endonasal and endoscopic trans-septal transsphenoidal approach (Trans-septal approach).

METHODS

A prospective observational study, recruiting 40 patients undergoing surgery for pituitary adenoma, 20 via Endonasal approach and 20 via Trans-septal approach at our institution. Surveys with Sinonasal Outcome Test-22 (SNOT-22), Chronic Sinusitis Survey (CSS), and Short Form Health Survey 36 version 2 (SF-36v2) were obtained to collect QoL data pre- and postoperatively.

RESULTS

All the 40 patients completed the questionnaires. At 6 months postoperatively, the SNOT-22 and CSS score shows significant improvements both in Endonasal approach (p = 0.01) and in Trans-septal approach (p = 0.02). No significant difference in sinonasal morbidity is observed between the two groups for SNOT-22 (p = 0.13) and CSS scores, except for sinus headache (p = 0.49), with a better score in Endonasal approach. The mean SF-36v2 scores remain the same in pre- and post-operative periods, but an improvement in time is seen in general health (p = 0.027), and general health compared to one year ago (p < 0.001).

CONCLUSIONS

Endoscopic transsphenoidal surgery has negligible morbidity and does not negatively affect the nasal function in the long term. Endonasal approach and Trans-septal approach are comparable in terms of morbidity outcomes and general QoL, leaving the choice of the approach to the surgeon preference.

Squamous Cell Carcinoma of the Nasal Vestibule: A Multi-Centric Observational Cohort Study

OBJECTIVES

Squamous cell carcinoma of the nasal vestibule (NV-SCC) is a rare but challenging entity, due to the complex anatomy of the region. Consensus on the best treatment strategy is still lacking, as well as a dedicated staging system. Our aim was to analyze oncological outcomes of surgically treated patients and to investigate possible prognostic factors.

METHODS

We performed a retrospective multi-centric observational study including six Academic Hospitals over a 10-year period, including only patients who underwent upfront surgery for primary NV-SCC. Patients were staged according to all currently available staging systems. The Kaplan-Meier method was used to compute overall, disease-free, and disease-specific survival. Logistic regression models were used to correlate between survival outcomes and clinical and pathological variables.

RESULTS

Seventy-one patients with a median follow-up of 38 months were included in the study. Partial and total rhinectomy were the most commonly performed procedures, respectively, in 49.3% and 25.4% of cases. Neck dissection was performed on 31% of patients, and 45.1% of them underwent adjuvant radiotherapy. Three years overall, disease-specific and disease-free survival were, respectively, 86.5%, 90.3%, and 74.2%. None of the currently available staging systems were able to effectively stratify survival outcomes. Factors predicting lower overall survival on multivariate analysis were age (p = 0.021) and perineural invasion (p = 0.059), whereas disease-free survival was negatively affected by age (p = 0.033) and lymphovascular invasion (p = 0.019).

CONCLUSION

Currently available staging systems cannot stratify prognosis for patients who underwent surgery for NV-SCC.

LEVEL OF EVIDENCE

4 Laryngoscope, 2023.

Radiological Versus Clinical 1-Year Outcomes of Dupilumab in Refractory CRSwNP: A Real-Life Study

OBJECTIVE

To provide real-life evidence on long-term radiological changes in patients with severe chronic rhinosinusitis with nasal polyps (CRSwNP) treated with dupilumab, and to assess possible differences between radiological and clinical results in terms of endoscopic findings and Patient-Reported-Outcomes (PROs).

METHODS

Consecutive patients treated with dupilumab for recalcitrant CRSwNP were required to undergo CT scan at baseline (T0) and after 12 (T1) since first administration. A group of patients also performed CT scan at 52 weeks (T2) to assess long-term outcomes. At each timepoint, patients underwent nasal endoscopy, assessment of Nasal-Polyp-Score (NPS), Lund-Kennedy-Score (LKS), and had to fill in the 22-item Sinonasal-Outcome-Test (SNOT-22) and Visual-Analogue-Scales (VAS) for sinonasal symptoms.

RESULTS

In fifty-three included patients, from T0 to T1 we detected a significant reduction in mean Lund-Mackay score (LM), PROs (SNOT-22, VAS) and endoscopic (NPS, LKS) scores (p < 0.05). In the subset of patients that reached T2 (n = 30), compared to T1, we observed a further significant decrease in mean LM, SNOT-22, VAS, and NPS scores, but not in LKS (p = 0.420). At T1, the highest improvement was observed in PROs (SNOT-22: 56.26%), and polyp size (NPS: 49.83%). Conversely, between T1 and T2, sinus opacification was shown to be the most improved outcome (LM: 36.86%).

CONCLUSIONS

Our experience showed that poorly controlled CRSwNP patients treated with dupilumab experienced significant improvement in radiologic, endoscopic and clinical disease severity. While in the initial 3 months, PROs garnered attention for showing earlier effectiveness, radiological outcomes revealed sustained and gradual efficacy in a longer term.

LEVEL OF EVIDENCE

Level 4. According to the Oxford Center for Evidence-Based Medicine 2011 level of evidence guidelines, this non-randomized retrospective cohort study is classified as level 4 evidence Laryngoscope, 2023.

Very Rapid Improvement in Extended Nitric Oxide Parameters Is Associated With Clinical and Functional Improvement in Patients With Chronic Rhinosinusitis With Nasal Polyps Treated With Dupilumab

BACKGROUND AND OBJECTIVE

Dupilumab, an anti-IL-4 receptor a monoclonal antibody, was recently approved for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) and moderate-to-severe asthma. Onset of its clinical effects is rapid. CRSwNP is characterized by extended type 2 inflammatory involvement that can be assessed using extended nitric oxide analysis. We investigated whether dupilumab was associated with a rapid improvement in extended nitric oxide parameters, lung function, and clinical outcomes in patients with CRSwNP.

METHODS

Consecutive patients with CRSwNP and an indication for dupilumab were evaluated for extended nitric oxide analysis (exhaled, FeNO; bronchial, JawNO; alveolar, CalvNO; nasal, nNO) and lung function 15 and 30 days after initiation of treatment and for clinical outcomes (nasal polyps score [NPS], quality of life questionnaires, visual analog scale [VAS] for the main symptoms, and the Asthma Control Test [ACT]) 30 days after initiation of treatment.

RESULTS

We enrolled 33 patients. All extended nitric oxide and lung function parameters improved significantly after 15 days of treatment, remaining stable at 30 days. Scores on the NPS, VAS for the main RSwNP symptoms, quality of life questionnaires, and the ACT improved significantly 30 days after initiation of treatment.

CONCLUSION

Dupilumab is associated with very rapid improvement in type 2 inflammation in all airway areas. This is associated with improved lung function and clinical parameters in patients with CRSwNP.

Preoperative systemic inflammatory markers as prognostic factors in differentiated thyroid cancer: a systematic review and meta-analysis

BACKGROUND

Inflammation has been associated with tumor development and circulating inflammatory biomarkers have been proposed as possible predictors of recurrence of several solid tumors. However, the role of inflammation markers in differentiated thyroid carcinoma (DTC) is still uncertain.

OBJECTIVE

This meta-analysis aimed to assess the prognostic value of neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) in patients with DTC.

METHODS

Studies investigating the association between survival and preoperative circulating inflammatory markers in DTC patients were included. The primary outcome was disease-free survival (DFS). Cumulative logarithms of the hazard ratio (log-HRs) with 95% CI were calculated through the inverse variance method using a random-effects model.

RESULTS

A total of 7599 patients with a mean age of 48.89 (95% CI 44.16-53.63) were included. The estimated pooled log-HRs for DFS were 0.07 for NLR (95% CI -0.12-0.26; p = 0.43), -0.58 for LMR (95% CI -1.21-0.05; p = 0.06), and 0.01 (95% CI 0-0.01; p = 0.21) for PLR.

CONCLUSIONS

Our meta-analysis showed no association between NLR, PLR, LMR and DFS in DTC; however, more prospective data are needed to better define the association between inflammatory status and prognosis of DTC.

Treatment of COVID-19 olfactory dysfunction with olfactory training, palmitoylethanolamide with luteolin, or combined therapy: a blinded controlled multicenter randomized trial

PURPOSE

Few evidence-based therapies are available for chronic olfactory dysfunction after COVID-19. This study investigated the relative efficacy of olfactory training alone, co-ultramicronized palmitoylethanolamide with luteolin (um-PEA-LUT, an anti-neuroinflammatory supplement) alone, or combined therapy for treating chronic olfactory dysfunction from COVID-19.

METHODS

This double-blinded controlled, placebo-controlled multicenter randomized clinical trial was conducted in 202 patients with persistent COVID-19 olfactory dysfunction of > 6 month duration. After a screening nasal endoscopy, patients were randomized to: (1) olfactory training and placebo; (2) once daily um-PEA-LUT alone; (3) twice daily um-PEA-LUT alone; or (4) combination of once daily um-PEA-LUT with olfactory training. Olfactory testing (Sniffin' Sticks odor identification test) was performed at baseline and at 1, 2, and 3 months. The primary outcome was recovery of over three points on olfactory testing, with outcomes compared at T0, T1, T2 and T3 across groups. Statistical analyses included one-way ANOVA for numeric data and chi-square for nominal data.

RESULTS

All patients completed the study, and there were no adverse events. At 90 days, odor identification scores improved by > 3 points in 89.2% of patients receiving combined therapy vs. 36.8% receiving olfactory training with placebo, 40% receiving twice daily um-PEA-LUT alone, and 41.6% receiving once daily um-PEA-LUT alone (p < 0.00001). Patients receiving treatment with um-PEA-LUT alone demonstrated subclinical improvement (< 3 point odor identification improvement) more often than patients receiving olfactory training with placebo (p < 0.0001.) CONCLUSIONS: Olfactory training plus once daily um-PEA-LUT resulted in greater olfactory recovery than either therapy alone in patients with long-term olfactory function due to COVID-19.

TRIAL REGISTRATION

20112020PGFN on clinicaltrials.gov.

LEVEL OF EVIDENCE

1b (Individual Randomized Clinical Trial).

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Image-Guided Intraoperative Assessment of Surgical Margins in Oral Cavity Squamous Cell Cancer: A Diagnostic Test Accuracy Review

(1) Background: The assessment of resection margins during surgery of oral cavity squamous cell cancer (OCSCC) dramatically impacts the prognosis of the patient as well as the need for adjuvant treatment in the future. Currently there is an unmet need to improve OCSCC surgical margins which appear to be involved in around 45% cases. Intraoperative imaging techniques, magnetic resonance imaging (MRI) and intraoral ultrasound (ioUS), have emerged as promising tools in guiding surgical resection, although the number of studies available on this subject is still low. The aim of this diagnostic test accuracy (DTA) review is to investigate the accuracy of intraoperative imaging in the assessment of OCSCC margins. (2) Methods: By using the Cochrane-supported platform Review Manager version 5.4, a systematic search was performed on the online databases MEDLINE-EMBASE-CENTRAL using the keywords "oral cavity cancer, squamous cell carcinoma, tongue cancer, surgical margins, magnetic resonance imaging, intraoperative, intra-oral ultrasound". (3) Results: Ten papers were identified for full-text analysis. The negative predictive value (cutoff < 5 mm) for ioUS ranged from 0.55 to 0.91, that of MRI ranged from 0.5 to 0.91; accuracy analysis performed on four selected studies showed a sensitivity ranging from 0.07 to 0.75 and specificity ranging from 0.81 to 1. Image guidance allowed for a mean improvement in free margin resection of 35%. (4) Conclusions: IoUS shows comparable accuracy to that of ex vivo MRI for the assessment of close and involved surgical margins, and should be preferred as the more affordable and reproducible technique. Both techniques showed higher diagnostic yield if applied to early OCSCC (T1-T2 stages), and when histology is favorable.

Care for Patients with Type-2 Chronic Rhinosinusitis

In the last 20 years, growing interest in chronic rhinosinusitis (CRS) has become evident in medical literature; nevertheless, it is still difficult to identify the real prevalence of the disease. Epidemiological studies are few and focused on heterogeneous populations and diagnostic methods. Recent research has contributed to identifying CRS as a disease characterized by heterogeneous clinical scenarios, high impact on quality of life, and elevated social costs. Patient stratification with phenotypes and identification of the pathobiological mechanism at the origin of the disease (endotype) and its comorbidities are pivotal in the diagnostic process, and they should be addressed in order to properly tailor treatment. A multidisciplinary approach, shared diagnostic and therapeutic data, and follow-up processes are therefore necessary. Oncological multidisciplinary boards offer models to imitate in accordance with the principles of precision medicine: tracing a diagnostic pathway with the purpose of identifying the patient’s immunological profile, monitoring therapeutical processes, abstaining from having only a single specialist involved in treatment, and placing the patient at the center of the therapeutic plan. Awareness and participation from the patient’s perspective are fundamental steps to optimize the clinical course, improve quality of life, and reduce the socioeconomic burden.

Radiomics-based machine learning for the diagnosis of lymph node metastases in patients with head and neck cancer: Systematic review

Machine learning (ML) is increasingly used to detect lymph node (LN) metastases in head and neck (H&N) carcinoma. We systematically reviewed the literature on radiomic-based ML for the detection of pathological LNs in H&N cancer. A systematic review was conducted in PubMed, EMBASE, and the Cochrane Library. Baseline study characteristics and methodological quality items (modeling, performance evaluation, clinical utility, and transparency items) were extracted and evaluated. The qualitative synthesis is presented using descriptive statistics. Seven studies were included in this study. Overall, the methodological quality items were generally favorable for modeling (57% of studies). The studies were mostly unsuccessful in terms of transparency (85.7%), evaluation of clinical utility (71.3%), and assessment of generalizability employing independent or external validation (72.5%). ML may be able to predict LN metastases in H&N cancer. Further studies are warranted to improve the generalizability assessment, clinical utility evaluation, and transparency items.

Cross-Cultural Validation of the Short Version of the Questionnaire of Olfactory Disorders-Negative Statements into Italian: Towards Personalized Patient Care

Given the high burden of olfactory dysfunction worldwide, recently increased due to the COVID-19 pandemic, it is mandatory to adopt a specific questionnaire to assess the impact of olfactory impairment on quality of life, to be used in clinical practice. The aim of this study is to adapt and validate the short version of the Questionnaire of Olfactory Disorders-Negative Statements (svQOD-NS) for Italian. In the pilot phase, the Italian version of the questionnaire (ITA-svQOD-NS) was produced following recommended guidelines. It was then given to 50 healthy subjects and 50 patients (affected by either nasal polyposis or septal deviation), and results were compared to those of other widely used questionnaires. Test-retest reliability was assessed on a sample of 25 patients. All 50 patients repeated the questionnaires at one and nine months after surgery. The internal consistency of ITA-svQOD-NS measured with Cronbach α was excellent (α = 0.92). The intraclass correlation coefficient for test-retest reliability was also optimal (0.93; 95%CI: 0.90-0.96). Concurrent validity tested with the Pearson coefficient was significant with all other tests administered; also, concerning responsiveness, statistically significant differences were obtained between pre- and post-operative conditions. ITA-svQOD-NS showed high internal consistency, test-retest reliability, and significant correlation with all most-used clinical questionnaires; thus, it can be efficiently applied to assess olfaction-related QoL in the Italian population.

Surgical prevention of pharyngocutaneous fistula in salvage total laryngectomy: a systematic review and network meta-analysis

PURPOSE

To compare the efficacy of different reconstructive techniques in preventing pharyngocutaneous fistula (PCF) after salvage total laryngectomy (STL).

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model according to the PRISMA-NMA guidelines.

RESULTS

A total of 1694 patients with a median age of 64 years (n = 1569, 95% CI: 62-66 years) were included. If compared to primary pharyngeal closure alone, only a pedicled flap onlay (PFO) showed a statistically significant reduction in PCF rate (OR: 0.35, CI: 0.20-0.61). PFO seemed to perform better than other treatments according to the rank probabilities test (39.9% chance of ranking first).

CONCLUSIONS

A pedicled flap placed with an overlay technique might be preferred over a patch reconstruction to prevent PCF after STL.

Radiological Findings in Laryngeal Anterior Commissure Invasion: CT Scan Highlights

OBJECTIVES

Preoperative anterior commissure (AC) evaluation in glottic cancer is crucial for therapeutic decisions. Endoscopy is often inadequate to precisely detect the presence of cancer in the AC; thus, computed tomography (CT) scan could help. We investigated the relation between AC thickness on CT scan (in mm), AC involvement by cancer at histology, and radiologic signs of anterior paraglottic space (PGS) infiltration.

STUDY DESIGN

Retrospective observational study.

METHODS

An experienced radiologist retrospectively measured AC thickness and identified signs of anterior PGS infiltration on pretreatment contrast-enhanced CT scans of 80 patients with primary glottic cancer. The gold standard to define the presence of cancer in the AC was histology. The receiver operating characteristic (ROC) curves were used to determine the potential cut-off values of AC thickness (Youden index method) able to maximize both sensitivity and specificity in identifying the presence of cancer in the AC at histology and PGS infiltration on CT scan.

RESULTS

AC was significantly thicker in patients with cancer in the AC at histology (P < .001) and in patients with PGS infiltration on CT scan (P < .001). The cut-off values to discriminate the presence of cancer at histology and PGS infiltration on CT scan were 3.62 and 2.6 mm, respectively. We found a substantial agreement between anterior PGS infiltration on CT scan and the presence of cancer in the AC at histology (Cohen Kappa: P = .70).

CONCLUSION

AC thickness and radiologic signs of PGS infiltration on pretreatment CT scan could represent a method to predict the presence of cancer in the AC at histology.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:2427-2433, 2022.

Outcomes of Non-Mucosa Sparing Endoscopic Sinus Surgery (Partial Reboot) in Refractory Chronic Rhinosinusitis with Nasal Polyposis: An Academic Hospital Experience

OBJECTIVE

The reboot approach could be an effective treatment option to lower recurrence rates (RRs) in recalcitrant Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). The purpose of this study was to investigate RR, recurrence-free survival (RFS), quality of life (QoL) improvement, and oral corticosteroid (OCS) intake in pluri-operated CRSwNP patients treated with partial reboot surgery.

METHODS

A consecutive sample of patients with recalcitrant CRSwNP, ineligible for monoclonal antibodies, underwent partial reboot surgery. The 22-item SinoNasal Outcome Test (SNOT-22), Visual Analogue Scales (VAS) scores, OCS intake, and endoscopic Nasal Polyp Score (NPS) were collected pre and postoperatively. The main outcomes were RR and RFS, and comparison of disease-free time with previous endoscopic surgeries.

RESULTS

Thirty pluri-operated patients were enrolled. Before the reboot, all had experienced disease recurrence at a mean recurrence time of 8.08 ± 2.83 months after surgery. After reboot, 7 (23.3%) had recurrence at a mean time of 16.67 ± 3.07 months (p = 0.02); none needed additional revision surgery till time of data collection. RR at 12, 18, and 24 months follow-up resulted significantly lower for reboot than other previous surgeries (p = 0.010, p = 0.002, p = 0.016, respectively); RFS difference resulted significant (log-rank test = 4.16; p = 0.04). Differences between pre-and post-operative total and single-items scores of SNOT-22 were significant (p = 0.001), as well as VAS scores (p = 0.001). Before the reboot, 21 patients (70%) took ≥2 OCS courses per year; at the latest follow-up visit, none had taken any course of OCS after reboot.

CONCLUSIONS

The reboot approach showed lower RR, longer RFS, improved QoL, and zeroing of OCS uptake. Larger samples and longer follow-up studies are needed to assess long-term efficacy and safety of this procedure.

LEVEL OF EVIDENCE

Level 4. According to the Oxford Center for Evidence-Based Medicine 2011 level of evidence guidelines, this non-randomized retrospective cohort study is classified as level 4 evidence Laryngoscope, 2022. Laryngoscope, 2022.

Different surgical approaches in retropharyngeal lymph nodes dissection in head and neck cancer: A systematic review

OBJECTIVE

To perform a systematic review of studies analyzing different surgical approaches in the treatment of retropharyngeal lymph node (RPLN) metastases.

METHODS

The study was performed according to the PRISMA guidelines.

RESULTS

Twenty-one studies were included in the review, for a total of 481 patients (median age: 55.8 years; male: n = 279/393, 70.1%). The success rate by type of approach was 100% (n = 233/233), 93.5% (n = 29/31), 95.7% (n = 67/70), 100% (n = 14/14), 100% (n = 82/82), and 100% (n = 51/51) in the transcervical, endoscopic-assisted transcervical, TORS, transoral, maxillary swing and transmandibular cohorts, respectively. The complication rate by type of approach was 11.2% (n = 26/233), 48.4% (n = 15/31), 48.6% (n = 34/70), 14.3% (n = 2/14), 6.1% (n = 5/82) in the transcervical, endoscopic-assisted transcervical, TORS, transoral and maxillary swing cohorts, respectively. Oncological outcomes were reported by 17 studies (n = 404/481; 84%). Overall, after a median follow-up of 28 months (n = 339/481; IQR 23-40.5), no evidence of disease (NED) was found in 238 patients (58.9%), recurrence at the RPLNs in 14 (3.5%), local recurrence in 22 (5.4%), regional recurrence in 23 (5.7%), locoregional recurrence in 16 (4%), distant metastases in 42 (10.4%), death from disease in 36 (8.9%), death from other cause in 23 (5.7%), and death from unspecified cause in 26 (6.4%).

CONCLUSIONS

Further prospective randomized controlled trials are needed to provide direct comparison between different approaches for RPLNs dissection.

Ultramicronized Palmitoylethanolamide and Luteolin Supplement Combined with Olfactory Training to Treat Post-COVID-19 Olfactory Impairment: A Multi-Center Double-Blinded Randomized Placebo- Controlled Clinical Trial

BACKGROUND

Olfactory training is the only evidence-based treatment for post-viral olfactory dysfunction. Smell disorders after SARS-CoV-2 infection have been attributed to neuroinflammatory events within the olfactory bulb and the central nervous system. Therefore, targeting neuroinflammation is one potential strategy for promoting recovery from post-COVID-19 chronic olfactory dysfunction. Palmitoylethanolamide and luteolin (PEA-LUT) are candidate antiinflammatory/ neuroprotective agents.

OBJECTIVE

To investigate recovery of olfactory function in patients treated with PEA-LUT oral supplements plus olfactory training versus olfactory training plus placebo.

METHODS

Multicenter double-blinded randomized placebo-controlled clinical trial was held. Eligible subjects had prior COVID-19 and persistent olfactory impairment >6 months after follow-up SARS-CoV-2 negative testing, without prior history of olfactory dysfunction or other sinonasal disorders. Participants were randomized to daily oral supplementation with ultramicronized PEA-LUT 770 mg plus olfactory training (intervention group) or olfactory training with placebo (control). Sniffin' Sticks assessments were used to test the patients at baseline and 90 days.

RESULTS

A total of 185 patients, including intervention (130) and control (55) were enrolled. The intervention group showed significantly greater improvement in olfactory threshold, discrimination, and identification scores compared to controls (p=0.0001). Overall, 92% of patients in the intervention group improved versus 42% of controls. Magnitude of recovery was significantly greater in the intervention group versus control (12.8 + 8.2 versus mean 3.2 + 3), with >10-fold higher prevalence of anosmia in control versus intervention groups at the 90-day endpoint.

CONCLUSION

Among individuals with olfactory dysfunction post-COVID-19, combining PEA-LUT with olfactory training resulted in greater recovery of smell than olfactory training alone.

Salivary bypass tube in total laryngectomy: Systematic review and meta-analysis

The aim of this study is to determine whether the preventive positioning of a salivary bypass tube (SBT) after total laryngectomy (TL) reduces the incidence of postoperative pharyngocutaneous fistula (PCF) and pharyngeal stenosis (PS). This study was conducted in conformity with the PRISMA statement. 1960 patients with a median age of 62.0 years were included. A SBT was placed in 980 (50%) patients (SBT group). The cumulative PCF incidence in the SBT group was 15.8% (95% CI: 9.3-23.6). The measured pooled OR comparing PCF incidence in patients with SBT compared to those without was 0.40 (95% CI: 0.24-0.65). The pooled PS incidence in the SBT group was 12.3% (95% CI: 5.4-21.6). The measured pooled OR comparing PS incidence in patients with SBT compared to those without was 0.43 (95% CI: 0.24-0.65). PCF and PS could be prevented by the intra-operative placement of a SBT.

Long-standing gustatory and olfactory dysfunction in COVID-19 patients: a prospective study

Purpose

Our study aimed to describe recovery of gustatory dysfunction (GD) and olfactory dysfunction (OD) in COVID-19 patients, and to analyze variables associated with early or late recovery.

Methods

Telephone surveys were administered during an 18-month follow-up after COVID-19 diagnosis. One hundred and thirty-two included patients rated olfactory and gustatory function at each follow-up.

Results

One hundred and twenty-nine patients reported GD, of whom 91 (70.5%) reported severe GD, and 99 patients reported OD, of whom 84 (84.9%) reported severe OD. Seventy-two/129 (55.8%) and 52/99 (52.5%) patients reported an improvement in GD and in OD during the first 7 days from the onset, respectively. At 3-month follow-up, 110/120 patients (85.3%) recovered from GD, while 80/99 patients (80.8%) recovered from OD. At 18-month follow-up, a total of 120/129 patients (93.0%) recovered from GD and 86/99 patients (86.9%) recovered from OD; while 10 patients (7.0%) still reported GD and 13 patients (13.1%) still reported OD. Severe GD/OD at presentation were associated with late complete recovery of taste/smell (p = 0.019 and p = 0.034, respectively). Improvement over the first 7 days from onset was significantly associated with faster recovery (p < 0.001).

Conclusions

More than 80% of patients reported complete recovery of olfactory/gustatory function in the first 3 months after symptom onset. At 18-month follow-up, patients reporting complete recovery of gustatory and olfactory function were 93% and 87%, respectively. Severity of chemosensory dysfunction at the onset was negatively correlated to recovery, and improvement of taste and/or smell function within the first 7 days from symptom onset was significantly associated with early resolution.

High-Definition 3D Exoscope in Thyroid Surgery

BACKGROUND

The high-definition 3D exoscope is an innovative and promising tool that was recently introduced in the clinical practice. It may be used during open surgical procedures to enhance the ability to perform precise dissection of fine structures. We describe our preliminary experience with the 3D exoscope in thyroid surgery, discussing potential advantages of this system.

METHODS

A high-definition 3D exoscope (3D VITOM^®) mounted on the VERSACRANE^TM holding system (Karl Storz, Tuttlingen, Germany) was used to perform open thyroid surgery.

RESULTS

The 3D exoscope was used in three patients without significant intra-operative delay or complications. Both thyroidectomy and central compartment dissection were performed. The 3D exoscope allows to perform precise dissection in the identification and preservation of the recurrent laryngeal nerve and the parathyroid glands.

CONCLUSIONS

3D exoscope-assisted thyroid surgery seems to be feasible and safe. Further studies should be encouraged to analyze potential clinical benefit in the post-operative period.

Applications of Co2 laser in endoscopic surgery for sinonasal neoplasms

OBJECTIVE

The aim of the study is to assess safety, effectiveness, and potential advantages of CO₂ fiber laser during endoscopic endonasal surgery for the resection of sinonasal neoplasms. We present text, images, and videos to show our experience with this new device recently introduced in endoscopic endonasal surgery and as a potential tool for educational purpose.

METHODS

Six patients affected by benign or malignant sinonasal tumors who underwent endoscopic resection between January and May 2021 were enrolled in the study. Surgical approach was conducted via standardized centripetal endonasal technique. During the surgery we evaluated instrument ergonomics, quality in section on both healthy tissue and tumor, coagulation, and bleeding control from major vessels.

RESULTS

In our experience, CO₂ fiber laser has proved to have good ergonomics, as well as to be a safe and effective tool for the resection of both neoplastic and healthy tissues. Cauterization was efficient only in vessels with average diameter lower than 1 cm. Prolonged procedural time, costs, and necessity of learning-curve and expertise are possible drawbacks.

CONCLUSION

Co2-fiber laser is an effective tool which can aid the surgeon during endoscopic endonasal approach to sinonasal neoplasms.

Circumferential pharyngeal reconstruction after total laryngopharyngectomy: A systematic review and network meta-analysis

OBJECTIVE

To compare the functional outcomes of different reconstructive techniques for circumferential pharyngeal reconstruction.

METHODS

A comprehensive electronic search was performed on PubMed/MEDLINE, Cochrane Library, and Google Scholar databases. Retrospective and prospective studies were included. Two independent reviewers extracted thirty-four studies after applying the eligibility criteria. An arm-based network analysis was conducted using a Bayesian hierarchical model. The main outcomes were pharyngo-cutaneous fistula (PCF) incidence, stenosis incidence and feeding tube dependence (FTD) incidence. Network estimates from outcome variables were presented as absolute risks, odds ratio [OR] with 95% credible intervals (CIs), and ranking probability.

RESULTS

A total of 1357 patients were included for 5 different interventions (tubed pectoralis muscle myocutaneous flap, t-PMMCF; tubed anterolateral tight flap, t-ALTF; tubed radial forearm free flap, t-RFFF; free jejunal flap, FJF; U-shaped pectoralis muscle myocutaneous flap, u-PMMCF). FJF showed a 92.8% chance of ranking first in terms of pharyngo-cutaneous fistula prevention (absolute risk: 10%), while the highest PCF incidence (42%) was measured for t-PMMCF. u-PMMCF showed the lowest absolute risk (11%) of stenosis incidence (62.2% chance of ranking first). t-PMMCF (5%), FJF (8%), and u-PMMCF (8%) showed similar results in terms of feeding tube dependence, with a 53.2%, 23.1% and 18.9% chance of ranking first, respectively.

CONCLUSIONS

FJF seems to be the best reconstructive choice after total laryngo-pharyngectomy in terms of PCF, stenosis and FTD incidence. If this reconstructive method is not feasible, a u-PMMCF should be favored over tubed free and pedicled flaps. Further comparative studies are needed to confirm these results.

Clinical outcome and quality of life of lacrimal sac mucocele treated via endoscopic posterior approach

OBJECTIVE

Dacryocystorhinostomy (DCR) is the surgical treatment for lacrimal sac mucoceles (LSM), yet variants of the procedure are several. Since LSM causes bone remodeling and thinning, especially of the lacrimal bone, osteotomy at that site is reasonably the easiest. The aim of the study is to support treatment of LSM via a posterior DCR approach, in a large cohort of cases, and report patients' quality of life after the procedure with validated questionnaires.

METHODS

Single-center observational retrospective study on a specific methodology (endoscopic-DCR via posterior approach). Consecutive patients with LSM were enrolled in 2008-2020; CT scans were reviewed, bone thickness was measured bilaterally and compared. Resolution of mucocele, epiphora and infection were analyzed after 6-months. Patients were administered the Munk Score and Lacrimal Symptom Questionnaire (Lac-Q). Statistical analysis was done to compare bone thickness between the two sides; descriptive analysis of the questionnaires results was presented.

RESULTS

Forty-four patients with LSM were enrolled. The LSM side showed frontal process thickness of 4.00 ± 1.06 mm (vs 3.90 ± 1.03 on the unaffected side; p = 0.23) and a lacrimal bone of 0.32 ± 0.12 mm (vs 0.41 ± 0.12; p < 0.001). Resolution of infection was achieved in 97.4% cases, anatomical patency in 87.2%. After 5 years, 84.6% of patients reported no relevant epiphora (Munk score 0-1). Social impact (Lac-Q) due to lacrimal malfunctioning was still noted in 30.8% patients.

CONCLUSIONS

Adult LSM is a rare condition and DCR remains the mainstay of treatment. LSM physiopathology may support a preferred surgical choice via a posterior approach. Despite objective patency, some lacrimal way malfunctioning may be experienced in a minority of cases.

High-Definition 3-D Exoscope for Micro-Laryngeal Surgery: A Preliminary Clinical Experience in 41 Patients

OBJECTIVE

The aim of this prospective clinical study is to evaluate the feasibility of the micro-laryngeal surgery (MLS) using a 3D operating exoscope (OE) in substitution to a conventional operating microscope (OM).

METHODS

A total of 41 consecutive patients were included (male: 26; median age: 55.0 years; IQR: 46.0-68.0). After each procedure, the surgeon and the scrub nurse were asked to fill out a tailored questionnaire on a 3-point Likert scale (1-not acceptable, 2-acceptable, 3-good) including 12 items.

RESULTS

The majority of the procedures were therapeutic (n = 31, 75.6%), while the remaining were diagnostic (n = 10, 24.4%). All surgeries were successfully completed without the support of the OM, and no complications or unwanted delays were detected. The majority of the individual items were judged "good" either by surgeons (n = 399, 81.1%) and scrub nurses (n = 287, 87.5%). The natural posture during the procedure, and the ease of use the joystick and focusing were the best-rated items by the surgeons.

CONCLUSIONS

This study demonstrates the feasibility of MLS using the OE. Further comparative clinical studies are needed to clarify its real value in substitution to a conventional operating microscope and to better define advantages and disadvantages.

Frozen Section Analysis and Real-Time Magnetic Resonance Imaging of Surgical Specimen Oriented on 3D Printed Tongue Model to Assess Surgical Margins in Oral Tongue Carcinoma: Preliminary Results

Background

A surgical margin is the apparently healthy tissue around a tumor which has been removed. In oral cavity carcinoma, a negative margin is considered ≥ 5 mm, a close margin between 1 and 5 mm, and a positive margin ≤ 1 mm. Currently, the intraoperative surgical margin status is based on the visual inspection and tissue palpation by the surgeon and intraoperative histopathological assessment of the resection margins by frozen section analysis (FSA). FSA technique is limited and susceptible to sampling errors. Definitive information on the deep resection margins requires postoperative histopathological analysis.

Methods

We described a novel approach for the assessment of intraoperative surgical margins by examining a surgical specimen oriented through a 3D-printed specific patient tongue with real-time Magnetic Resonance Imaging (MRI). We reported the preliminary results of a case series of 10 patients, prospectively enrolled, with oral tongue carcinoma who underwent surgery between February 2020 and April 2021. Two radiologists with 5 and 10 years of experience, respectively, in Head and Neck radiology in consensus evaluated specimen MRI and measured the distance between the tumor and the specimen surface. We performed intraoperative bedside FSA. To compare the performance of bedside FSA and MRI in predicting definitive margin status we computed the weighted sensitivity (SE), specificity (SP), accuracy (ACC), area under the ROC curve (AUC), F1-score, Positive Predictive Value (PPV), and Negative Predictive Value (NPV). To express the concordance between FSA and ex-vivo MRI we reported the jaccard index.

Results

Intraoperative bedside FSA showed SE of 90%, SP of 100%, F1 of 95%, ACC of 0.9%, PPV of 100%, NPV (not a number), and jaccard of 90%, and ex-vivo MRI showed SE of 100%, SP of 100%, F1 of 100%, ACC of 100%, PPV of 100%, NPV of 100%, and jaccard of 100%. These results needed to be validated in a larger sample size of 21- 44 patients.

Conclusion

The presented method allows a more accurate evaluation of surgical margin status, and the first clinical experiences underline the high potential of integrating FSA with ex-vivo MRI of the fresh surgical specimen.

3D-4K exoscope-assisted temporal bone dissection: a new frontier in surgical training

PURPOSE

To assess if 3D-4K exoscope is a valuable tool for temporal bone dissection and to evaluate its teaching potential.

METHODS

Six consecutive 3D-4K-exoscope-assisted cortical mastoidectomies were performed by a novice, an intermediate and an expert surgeon (two dissections each). All dissections were entirely recorded and later evaluated independently by three other experienced surgeons. The dissection end-product was evaluated according to the Melbourne Mastoidectomy Scale (MMS). Paired t test was used to assess whether novice and intermediate surgeons have a score improvement in the second dissection compared to the first one. Surgeons' interactions, depth effect, and 3D impression were also assessed to perform a subjective analysis.

RESULTS

Mean MMS scores for the novice, intermediate and expert surgeon were 11.3 ± 2.8, 13.8 ± 3.9 and 19 ± 1.3, respectively. Paired t test demonstrated a statically significant improvement between the first and the second dissection both for the novice and the intermediate surgeon (+ 4.7 and + 7 points; p = 0.0002). A high-quality magnification of the temporal bone was obtained, allowing the expert surgeon to identify all the anatomical structures without injuring them. The exoscope was capable of providing a high involvement in the dissections with very effective interactions between the expert surgeon and the trainees, that had access to the same surgical field view.

CONCLUSION

3D-4K-exoscope resulted adequate for a safe and effective mastoidectomy and showed a high potential for training and educational purposes. It can represent a valid option for surgical training of temporal bone dissection and a new interactive tool to understand the complex temporal bone anatomy.

Prevalence of occult level 2b nodal metastases in cN0 squamous cell carcinoma of the oral cavity: A systematic review and meta-analysis

Elective neck dissection of levels I, II and III is being increasingly used for detecting occult node metastases in patients with oral squamous cell carcinoma (OSCC) and clinically negative neck (cN0). The most frequent potential long-term complication of this procedure is shoulder dysfunction, because of micro- or macroscopic damage to the spinal accessory nerve (SAN). In particular, many studies have reported an association between SAN damage and dissection of level 2b. Furthermore, level 2b dissection is a technically demanding and time-consuming procedure. Our study aims to clarify whether level 2b sparing in cN0 patients with OSCC can be oncologically justifiable. The PubMed, Cochrane and Scopus databases were searched by three different authors for articles on this topic. The primary endpoint of the meta-analysis was the overall prevalence of occult metastases in cervical level 2b nodes in patients with OSCC and clinically negative neck. The meta-analysis was performed using R version 4.0.1. A total of 13 studies and 937 patients were included. The cumulative rate of occult nodal metastases in level 2b was 0.8% (n = 937, 95% CI: 0.1% - 2.2%, τ² = 0.004). No isolated level 2b metastases was found among the patients with positive level 2b, and in the six studies that reported this association, all patients with nodal disease in level 2b had a positive level 2a. This meta-analysis highlights how level 2b can be safely spared in supraomohyoid neck dissection (SOHND) of patients with OSCC and clinically negative neck, reducing the risk of postoperative shoulder dysfunction.

Preoperative predictors of difficult oropharyngeal exposure for transoral robotic surgery: The Pharyngoscore

BACKGROUND

Insufficient exposure may require termination of procedure in transoral robotic surgery (TORS). The aim of study was to develop a "Pharyngoscore" to quantify the risk of difficult oropharyngeal exposure (DOE) before TORS.

METHODS

Three-hundred six patients undergoing any surgical procedure at one Academic Hospital were prospectively enrolled. Oropharynx was exposed with Feyh-Kastenbauer retractor. Exposure was evaluated by direct and endoscopic visualization of the four oropharyngeal subsites. Preoperative clinical/anthropometric parameters were studied in good oropharyngeal exposure and DOE groups. Logistic regression was performed to explore association between clinical/anthropometric parameters and DOE. Statistically significant parameters at multivariate analysis were incorporated into a nomogram.

RESULTS

Sixty-five (21.2%) subjects were characterized by DOE. Variables associated with DOE at univariate analysis were male (p = 0.031), modified Mallampati Class (MMC) ≥ III (p < 0.001), smaller interincisor gap (p < 0.001), and larger neck circumference (p = 0.006). MMC, interincisor gap, and neck circumference were significant at multivariate analysis and were presented with a nomogram for creating the Pharyngoscore.

CONCLUSIONS

The Pharyngoscore is a promising tool for calculating DOE probability before TORS.

Prevalence of Taste and Smell Dysfunction in Coronavirus Disease 2019

Importance

Early diagnosis of coronavirus disease 2019 (COVID-19) may help control the diffusion of the disease into the population.

Objective

To investigate the presence of sinonasal manifestations at the onset of COVID-19 to achieve an earlier diagnosis.

Design, Setting, and Participants

This retrospective telephone survey study investigated patients diagnosed with COVID-19 from March 5 to March 23, 2020, who were hospitalized or discharged from a single referral center. Patients who were unable to answer (intubated, receiving noninvasive ventilation, or deceased) or unreachable by telephone were excluded. Of 359 consecutive patients, 204 fulfilled the inclusion criteria; 76 were unable to answer, 76 were unreachable by telephone, and 3 refused.

Exposures

Sinonasal manifestations reported before COVID-19 diagnosis were studied with a validated questionnaire: Italian Sino-Nasal Outcome Test 22 (I-SNOT-22). If reduction of taste and/or smell was documented by item 5 of the I-SNOT-22, further inquiries were made to score them separately on a scale from 0 to 5, with 0 indicating no problem and 5 indicating problem as bad as it can be.

Main Outcomes and Measures

The prevalence of sinonasal manifestations preceding COVID-19 diagnosis.

Results

Among the 204 patients enrolled (110 [53.9%] male; mean [SD] age, 52.6 [14.4] years), the median I-SNOT-22 total score was 21 (range, 0-73). I-SNOT-22 identified 116 patients (56.9%) with reduction of taste and/or smell, 113 (55.4%) with taste reduction (median score, 5; range, 2-5), and 85 (41.7%) with smell reduction (median score, 5; range, 1-5). Eighty-two patients (40.2%) reported both. Severe reduction of taste was present in 81 patients (39.7%), and severe reduction of smell was present in 72 patients (35.3%). Only 12 patients (14.8%) with severe taste reduction and 12 patients (16.7%) with severe smell reduction reported severe nasal obstruction. Severe reduction of taste and smell was more prevalent in female vs male patients (odds ratios, 3.16 [95% CI, 1.76-5.67] vs 2.58 [95% CI, 1.43-4.65]) and middle-aged vs younger patients (effect sizes, 0.50 [95% CI, 0.21-0.78] vs 0.85 [95% CI, 0.55-1.15]). No significant association was observed between smoking habits and severe reduction of taste (odds ratio, 0.95; 95% CI, 0.53-1.71) and/or smell (odds ratio, 0.65; 95% CI, 0.35-1.21).

Conclusions and Relevance

The findings of this telephone survey study suggest that reduction of taste and/or smell may be a frequent and early symptom of COVID-19. Nasal obstruction was not commonly present at the onset of the disease in this study. The general practitioner may play a pivotal role in identifying potential COVID-19 in patients at an early stage if taste and/or smell alterations manifest and in suggesting quarantine before confirmation or exclusion of the diagnosis.

Applying the Exoscope to Lacrimal Surgery: Preliminary Experience

PURPOSE

The aim of the study was to investigate the role of the exoscope as an assisting tool in endoscopic dacryocystorhinostomy (e-DCR).

MATERIALS AND METHODS

In this observational retrospective study, the application of the VITOM® exoscope was studied in a group of 21 patients undergoing mono- or bilateral DCR. The primary endpoint was to evaluate resolution of symptoms (epiphora/dacryocystitis) at the 6-month follow-up and time for surgery. Qualitative features of the exoscope (intraoperative view of the surgical field) and comparison with the typical setting for DCR were analyzed as secondary endpoints. A questionnaire was administered to surgical team members (ENT surgeon, ophthalmologist, and scrub nurse) to evaluate the perceived quality of this new technology (12 items valued as "good" = 2, "acceptable" = 1, and "not acceptable" = 0). A questionnaire score of 24 out of 24 was valued as "completely approved," score 20-23 as "moderately approved," and score ≤19 as "weakly approved." Patients were divided into 3 consecutive groups, and questionnaire scores by each team member were analyzed for tendencies. Statistical analysis was performed to test significance at p < 0.05. Local Ethical Committee approval was obtained.

RESULTS

No significant differences were found between exoscope-set DCR and classic setting for concerned patient outcomes (failure rate: 3.2 vs. 3.8%, respectively, p = 0.896) and mean time for surgery (20' vs. 23', respectively, p = 0.091). The exoscope was valued by surgical team members as "completely approved" in 55.5% of cases, "moderately approved" in 39.7%, and "weakly approved" in 4.8%. Questionnaire scores by the ENT, ophthalmologist, and scrub nurse showed an average increase in the 3 consecutive groups (p = 0.119, p = 0.024, and p < 0.001, respectively).

CONCLUSIONS

The exoscope is a new tool that may support e-DCR. It has no effects on symptom outcomes (epiphora/dacryocystitis) and time for surgery compared to classic DCR. Based on self-perception, this new technology was accepted by all team members.

3D 4K VITOM-assisted transoral removal of distal stone in the Wharton's duct

BACKGROUND

The aim of this study was to describe the potential advantages of the transoral 3D 4K exoscope-assisted removal of calculus of the Wharton's duct.

METHODS

A 24-year-old female with swelling in the left oral pelvis was diagnosed of sialolithiasis of distal Wharton's duct. A CT scan confirmed the lithiasic formation and a transoral removal in local anesthesia was planned through the 3D 4K exoscope (VITOM 3D, Karl Storz).

RESULTS

A high-quality magnification of the oral pelvis was obtained, with an easy identification of the entrance of the left submandibular gland's duct and the calculus. After blunt dissection the Wharton's duct was incised and the calculus removed. An angiocatheter (20G) was carefully inserted in the duct and removed after 3 days. No postoperative complications occurred. At 7 days post-operative follow-up the patient had developed a neo-ostium 5 mm from the papilla. The exoscope provided a better involvement in the surgery and more interactions of all operating room personnel, residents and students, that had access to the same field of view of the first surgeon with the perception of the depth of the surgical field with 3D technology.

CONCLUSIONS

The exoscope could represent a valid option for transoral removal of calculi, allowing for precise surgical dissection of the oral floor, thus reducing the risks for iatrogenic lesion of the lingual nerve. It showed also a high potential for training and educational purposes.

High-definition three-dimensional exoscope for head and neck reconstruction: Prospective analysis of 27 consecutive patients

PURPOSE

To analyze the advantages and disadvantages of a three-dimensional (3D) operating exoscope (OE) in head and neck free flap reconstruction.

METHODS

Twenty-seven consecutive patients (females: 8; mean age: 57.0) were included. After each procedure, both surgeon and nurse were asked to fill out a tailored questionnaire on a three-point Likert scale including 12 items.

RESULTS

All microvascular anastomoses were successfully completed, and no related complications were detected with a final free flap survival rate of 100% (mean follow-up of 5.6 months, SD: 3.1 months). The ergonomics, the ease of use, and the possibility to share the view among all the OR members were the best-rated items by the surgeons, while the luminance of the surgical field and the eye strain determined by the 3D glasses can still be improved.

CONCLUSION

Further comparative clinical studies are needed to clarify its real value in substitution to a conventional operating microscope.

Different Surgical Strategies in the Prevention of Frey Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE/HYPOTHESIS

To define the best surgical technique able to reduce Frey syndrome (FS) incidence after parotidectomy.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model. The primary and secondary outcomes were the incidence of subjective (clinical) and objective (positive starch-iodine test result) FS, respectively.

RESULTS

A total of 3830 patients with a median age of 50.35 years (n = 2323; IQR 44.25-54.18) were included for six interventions [temporoparietal fascia (TPFF), free fat graft (FFG), acellular dermal matrix (ADM), sternocleidomastoid muscle (SCM) flap, and superficial musculoaponeurotic system (SMAS) flap]. If compared to no treatment, the greatest reduction of subjective (clinical) FS incidence was measured for the TPFF (OR: 0.07, CI: 0.004-0.57), the ADM (OR: 0.09, CI: 0.02-0.35), and the FFG (OR: 0.11, CI: 0.03-0.42) techniques. However, a significant difference was measured also for the SCM flap (OR: 0.38, CI: 0.18-0.73) and for the SMAS flap (OR: 0.42, CI: 0.19-0.97). All treatments showed a significant reduction of the objective FS incidence if compared to no treatment (FFG, OR: 0.06, CI: 0.002-0.62; TPFF, OR: 0.07, CI: 0.01-0.33; ADM, OR: 0.11, CI: 0.03-0.44; SMAS, OR: 0.36, CI: 0.17-0.71; SCM, OR: 0.40, CI: 0.19-0.74).

CONCLUSIONS

TPFF, ADM, and FFG seem to be the best treatment strategies to prevent FS after parotidectomy. Further randomized controlled trials comparing these techniques should be conducted to define specific indications. Laryngoscope, 131:1761-1768, 2021.

Introducing the High-definition 3D exoscope in ear surgery: preliminary analysis of advantages and limits compared with operative microscope

PURPOSE

The aim of this study was to evaluate the potential of 3D exoscope (EX) in selected ear procedures assessing if this new technology could be an improvement in the field of ear surgery.

METHODS

A case series of consecutive patients surgically treated with a post-auricular approach using EX was retrospectively compared with a similar previous series treated with operating microscope (OM). Patient demographics, indications for surgery, procedure type, complications, operating room setting time (ORst), operative time, adequacy of visualization, image quality, ergonomics aspects, instrument usability, and technique as a teaching tool were investigated. Thirteen patients were included in each group. Surgical procedures in EX group were nine tympanoplasties with mastoidectomy, 1 mastoidectomy for acute complicated mastoiditis, 1 revision miringoplasty, and 2 cochlear implants. Same types of procedures were enrolled in OM group.

RESULTS

No statistically significant difference was found between the two groups concerning ORst and operative time. In EX group, one complication occurred--a middle cranial fossa cerebrospinal fluid leak. Advantages of EX were lightness, maneuverability and compactness, less need of endoscopy during surgery, and teaching potential. Limits were a need of a large surgical corridor and the bright structures rendering in high magnification.

CONCLUSION

EX resulted safe and efficient in treating diseases of the middle ear in post-auricular approaches. To date, EX advantages are not enough to abandon the OM, and it can be considered as an additional, innovative tool to be added to ear surgical equipment.

Accuracy of fine-needle aspiration cytology in detecting cervical node metastasis after radiotherapy: Systematic review and meta-analysis

PURPOSE

To define the accuracy of fine-needle aspiration cytology (FNAC) in diagnosing persistent or recurrent neck metastases in previously irradiated patients.

METHODS

The study was performed according to the PRISMA-DTA guidelines.

RESULTS

A total of 382 FNACs were used for calculation of diagnostic accuracy parameters. The overall pooled sensitivity and specificity in detecting malignant nodes were 69.1% (95% CI: 56.3%-80.7%; I² = 79.5%) and 84.2% (95% CI: 71.8%-93.5%; I² = 87.0%), respectively. Cumulative diagnostic odds ratio (DOR) was 16.54 (95% CI: 4.89-38.99; I² = 65.8%), while cumulative positive and negative likelihood ratio (PLR and NLR) were 5.4 (95% CI: 2.3-11.2) and 0.37 (95% CI: 0.22-0.54), respectively.

CONCLUSIONS

FNAC alone could not guide the decision to perform a salvage neck dissection in previously irradiated patients, but its results should be assessed in relation to the specific clinical context.

"L" shape technique for endoscopic sinus surgery: An alternative method

BACKGROUND

Several techniques for performing ethmoidectomy have been reported. We describe a safe, effective and efficient technique during functional endoscopic sinus surgery (FESS). We present text, images and videos to illustrate our preferred technique during an antero-posterior ethmoidectomy and to provide a multimedia tool for educational purpose.

METHODS

A description of the technique without prospective or retrospective data is reported. A complete ethmoidectomy with an L-shape approach is described step-by-step, using the backbiting circular and miniature cutting forceps, with safe exposure of the lamina papyracea (LP) and skull base.

RESULTS

In our hands, the L-shape approach for chronic rhinosinusitis with or without polyposis, performed with punch circular cutting and miniature cutting forceps, allowed for a reliably safe and efficient ethmoidectomy.

CONCLUSION

The technique described can be added to the armamentarium of the endoscopic sinus surgeon.