Critical Steps and Common Mistakes during Temporal Bone Dissection: A Survey among Residents and a Step-by-Step Guide Analysis

BACKGROUND

Given that the temporal bone is one of the most complex regions of the human body, cadaveric dissection of this anatomical area represents the first necessary step for the learning and training of the young oto-surgeon in order to perform middle ear surgery, which includes the management of inflammatory pathology, hearing rehabilitation, and also cognitive decline prevention surgery. The primary objective of this study was to identify common mistakes and critical passages during the initial steps of temporal bone dissection, specifically cortical mastoidectomy and posterior tympanotomy.

METHODS

A survey among 100 ENT residents was conducted, gathering insights into the most prevalent errors encountered during their training to uncover the most challenging aspects faced by novice surgeons during these procedures.

RESULTS

The most common mistakes included opening the dura of the middle cranial fossa (MCF), injury of the sigmoid sinus (SS), chorda tympani (CT), and facial nerve (FN) injury while performing the posterior tympanotomy. The most important critical steps to prevent mistakes are related to the absence of wide exposure during cortical mastoidectomy and the consequent impossibility of identifying the landmarks of the facial recess before performing posterior tympanotomy. Injury of these structures was more common in younger surgeons and in the ones who performed less than five temporal bone dissection courses.

CONCLUSIONS

Numerous temporal bone dissections on cadavers are mandatory for ENT residents looking forward to performing middle ear surgery.

MiR-449a antagonizes EMT through IL-6-mediated trans-signaling in laryngeal squamous cancer

MicroRNAs (miRNAs) are involved in post-transcriptional gene expression regulation and in mechanisms of cancer growth and metastases. In this light, miRNAs could be promising therapeutic targets and biomarkers in clinical practice. Therefore, we investigated if specific miRNAs and their target genes contribute to laryngeal squamous cell carcinoma (LSCC) development. We found a significant decrease of miR-449a in LSCC patients with nodal metastases (63.3%) compared with patients without nodal involvement (44%). The AmpliSeq Transcriptome of HNO-210 miR-449a-transfected cell lines allowed the identification of IL6-R as a potential target. Moreover, the downregulation of IL6-R and the phosphorylation reduction of the downstream signaling effectors, suggested the inhibition of the IL-6 trans-signaling pathway. These biochemical effects were paralleled by a significant inhibition of invasion and migration in vitro and in vivo, supporting an involvement of epithelial-mesenchymal transition. These findings indicate that miR-449a contributes to suppress the metastasization of LSCC by the IL-6 trans-signaling block and affects sensitivity to external stimuli that mimic pro-inflammatory conditions.

Procalcitonin for Early Detection of Pharyngocutaneous Fistula after Total Laryngectomy: A Pilot Study

OBJECTIVES

The aim of this prospective study was to investigate the role of procalcitonin as an early diagnostic marker of pharyngocutaneous fistula (PCF) in a cohort of head and neck patients treated with total laryngectomy for squamous cell carcinoma.

METHODS

This prospective study was conducted on a sample of patients enrolled from January 2019 to March 2022. All patients were subjected to a "protocol" of blood chemistry investigations, scheduled as follows: complete blood count with formula, ESR dosage, CPR, and PCT. PCT was also dosed by salivary sampling and a pharyngo-cutaneous swab in patients who presented with PCF. The dosage scheme was systematically repeated: the day before the intervention (t0); the 5th day postoperative (t1); the 20th day postoperative (t2); and at time X, the day of the eventual appearance of the pharyngocutaneous fistula.

RESULTS

A total of 36 patients met the inclusion criteria. The patients enrolled in the study were subsequently divided into two groups: 27 patients underwent total laryngectomy (TL) for laryngeal cancer without postoperative complications, and 9 patients were undergoing TL with postoperative PCF. Using the Cochran's Q test, statistical significance was found for PCT among T0, T1, Tx, and T2 (p-value < 0.001) between the PCF and non-PCF groups. The Z test demonstrated that there is a difference in PCT levels at T1 and T2 and that this difference is statistically significant (p < 0.001).

CONCLUSIONS

PCT could be considered an early marker of complications in open laryngeal surgery. According to our results, it could be useful in the precocious detection of pharyngocutaneous fistulas and in the management of antibiotic therapy.

Subglottic Mass as Isolated Manifestation of Relapsing Polychondritis at Presentation

Relapsing polychondritis (RP) is a rare systemic disease that is characterized by recurrent episodic inflammation of the cartilaginous structures of the body, resulting in their progressive destruction and subsequent replacement with fibrotic scar. We present a case of RP that initially manifested with subglottic involvement and we propose an innovative strategy for the treatment for laryngeal RP in phase of active inflammation. A multidisciplinary approach (rheumatologist, otolaryngologist, immunologist, internist, cardiologist, etc) and adequate follow-up are essential. The timeliness of the diagnosis is fundamental to contain the destructive effects on the cartilages involved.

Effects of Adenotonsillectomy on Vocal Function

INTRODUCTION

Correct breathing is a fundamental condition for adequate vocal production. Respiratory dynamics are able to modify the growth of facial mass and lingual posture, i.e., of the skull, the mandibular one. For this reason, infant mouth breathing can cause hoarseness.

MATERIALS AND METHODS

We evaluated the actual changes in the characteristics of the voice and articulation of language in a group of subjects affected by adenotonsillar hypertrophy (grade 3-4), with frequent episodes of pharyngo-tonsillitis who underwent adenotonsillectomy. Our study included 20 children-10 boys and 10 girls-aged 4 to 11 years who had adenotonsillar hypertrophy and pharyngotonsillitis episodes exceeding 5-6 per year in the previous 2 years. The control group (Group B) included 20 children-10 boys and 10 girls-aged 4 to 11 years (average age of 6.4 years) who had not undergone surgery and shared the same degree of adenotonsillar hypertrophy as those in Group A but who did not experience recurrent pharyngotonsillitis episodes.

DISCUSSION

The hypertrophy of adenoids and tonsils significantly impacted breathing, vocal function, and speech articulation. All this is responsible for a state of tension in the neck muscles, which at the level of the vocal tract causes hoarseness. The changes objectively observed in our study in the pre- and post-operative phase demonstrate how adenotonsillar hypertrophy is responsible for an increase in resistance to the passage of air at the glottic level.

CONCLUSIONS

For this reason, adenotonsillectomy has an impact on recurrent infections and can also lead to an improvement in speech, breathing, and posture.

Diffuse Idiopathic Skeletal Hyperostosis (DISH): Role of Logopedic Rehabilitation in Dysphagia

Forestier's disease is a systemic, degenerative metabolic condition, which is still insufficiently investigated and understood, characterized by the progressive ossification of the ligaments and entheses. This case describes a 63-year-old man admitted to our department after several years of failed attempts to obtain a definitive diagnosis presenting with a painless mass in the pre-auricular region, gradually worsening dysphonia, severe dysphagia relating to solids, stiffness, and mild pain at the back of the neck. After performing further diagnostic tests, in addition to a pleomorphic adenoma, the simultaneous presence of diffuse spondylarthrosis on the cervical spine was highlighted, with beak-like osteophytes at C2-C5 resulting in esophageal compression. Given the absence of upper digestive endoscopy abnormalities, we initiated an intense logopedic and postural rehabilitative treatment, which led to a significant improvement in the patient's dysphagia symptoms. In addition, we limited the use of medical therapy to solely indomethacin in order to control the osteophytic process.

Sport in the Laryngectomized Patient: A Literature Review and Single Case Presentation

BACKGROUND

Total laryngectomy is an operation that involves numerous problems for the patient, especially in daily life: loss of the fact, loss of voice, evident scars and persistence of the tracheostoma. Much is known about rehabilitation programs involving the voice, swallowing, shoulder girdle rehabilitation; less explored is the field of sport and sports rehabilitation in the laryngectomized patient.

METHODS

We conduced systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement in order to evaluate the possibilities of practicing sports for the patient after total laryngectomy.

RESULTS

From an initial search of 4191 papers, we have come to include six papers for this literature review. We have also reported one of our clinical cases referring to a laryngectomized patient who swims competitively at an amateur level even after surgery with a particular device. The purpose of this work is to understand the role and importance of sport in rehabilitation and the possibilities that a frail patient like the laryngectomized patient has in practicing sport. Surely the best results are obtained in subjects who practiced sports before surgery.

CONCLUSION

It is evident that sport is important in the psychological and motor recovery of the laryngectomized patient. There is still a lack of clear rehabilitation protocols, especially for water sports, which allow all laryngectomized patients to return to sports. We believe that early resumption of physical activity makes the experience of the disease less dramatic.

Extracapsular Tonsillectomy versus Intracapsular Tonsillotomy in Paediatric Patients with OSAS

OBJECTIVE

The objective of our study was to compare our experience of intracapsular tonsillotomy performed with the help of a microdebrider usually used for adenoidectomy with results obtained from extracapsular surgery through dissection and from adenoidectomy in cases of people affected with OSAS, linked to adeno-tonsil hypertrophy, observed and treated in the last 5 years.

METHODS

3127 children with adenotonsillar hyperplasia and OSAS-related clinical symptoms (aged between 3 and 12 years) underwent tonsillectomy and/or adenoidectomy. A total of 1069 patients (Group A) underwent intracapsular tonsillotomy, while 2058 patients (Group B) underwent extracapsular tonsillectomy, from January 2014 to June 2018. The parameters considered in order to evaluate the effectiveness of the two different surgery techniques taken into consideration were as follows: the presence of possible postoperative complications, represented mainly by pain and perioperative bleeding; the level of postoperative respiratory obstruction compared with the original obstruction through night pulse oximetry, performed 6 months before and after the surgery; tonsillar hypertrophy relapse in Group A and/or the presence of residues in Group B with clinical evaluation performed 1 month, 6 months, and 1 year after the surgery; and postoperative life quality, evaluated through submitting to parents the same survey proposed before the surgery 1 month, 6 months, and 1 year after the surgery.

RESULTS

Regardless of the technique used (extracapsular tonsillectomy or intracapsular tonsillotomy), there was a clear improvement in both the obstructive respiratory symptomatology and quality of life in both patient groups, as highlighted by the pulse oximetry and the OSA-18 survey submitted later.

CONCLUSIONS

Intracapsular tonsillotomy surgery has improved in terms of a reduction in postoperative bleeding cases and pain reduction, with an earlier return to patients' usual lifestyle. Lastly, using a microdebrider with the intracapsular technique seems to be particularly effective in removing most of the tonsillar lymphatic tissue, leaving only a thin border of pericapsular lymphoid tissue and preventing lymphoid tissue regrowth during one year of follow-up.

Subjective Perception and Psychoacoustic Aspects of the Laryngectomee Voice: The Impact on Quality of Life

Purpose: A retrospective study is presented to correlate the inter-judge consistency for the different psycho-perceptual parameters of the recently proposed Impression Noise Fluency Voicing (INFVo) perceptual rating scale for substitution voices, and the vocal function as perceived by the patient. Methods: The scale Voice-Related Quality of Life (V-RQoL) and the Self Evaluation of Communication Experiences After Laryngectomy scale (SECEL)—a self-evaluation questionnaire of communicative experience after laryngectomy surgery—were administered to 89 total laryngectomees, subdivided in four groups depending on their type of alaryngeal voice (i.e., tracheoesophageal and esophageal speakers, electro larynx users, voiceless patients), in order to evaluate the impact of the impairment of the phonatory function on the quality of life. Results: No significant differences exist among the various groups on their perception of QoL using subjective questionnaires, whereas the INFVo scale has proven to be a useful tool for the description and analysis of the psychoacoustic characteristics of the vocal signal and a reliable instrument to correctly classify the patients. It is also notable that the judgement of the patients on their own voice and those of the referees are highly significant. Conclusion: Although speech rehabilitation for the acquisition of a substitution voice offers a new way of communication for the laryngectomized patients, nonetheless, their QoL is not significantly related to the type of substitution voice. Therefore, improving the patient’s adaptation to the new phonatory condition is mandatory.

Small-Cell Carcinoma of Nasopharynx: A Case Report of Unusual Localization

Neuroendocrine tumors are a spectrum of rare and highly heterogeneous neoplasms with distinct functional and biological behavior in relation to location, tumor size, and histological differentiation. Neuroendocrine tumors arise from the neuroendocrine cells of the diffuse neuroendocrine system located in almost every organ. Neuroendocrine tumors in the head and neck district are usually reported in sinonasal cavities and larynx. We present the case of a nasopharyngeal small-cell neuroendocrine carcinoma, which, as far as we know, is the 16th case reported in literature.

New Therapeutic Strategies in the Treatment of Stomal Recurrence After Total Laryngectomy: Role of Immunotherapy

OBJECTIVE

The aim of this study was to investigate the incidence of stoma recurrence and the therapeutic strategy outcomes in relation to survival that have been adopted over the past few decades using a monoclonal antibody, specifically nivolumab.

METHODS

This study included a total of 487 patients diagnosed with laryngeal carcinoma undergoing either a laryngectomy or salvage surgery after conservative interventions at the ENT Unit of Federico II University in Naples, Italy, between 2011 and 2021. Following a minimum 2.5-year follow-up and a maximum 21-year follow-up, the results revealed that only 38 patients suffered a stomal recurrence.

RESULTS

Despite various adopted treatment strategies, the literature reports lower patient survival rates. Following a total laryngectomy, stomal recurrence represents a therapeutic management challenge due to a poor prognosis for nearly every treated case. According to the literature, in fact, despite a low incidence (ie, 0.8-31.3%), the overall mortality rate increases from 77% to 100% after three years. Nevertheless, introducing immunotherapy into cancer treatment has resulted in an observable revolution in the treatment of different types of cancers over the years.

CONCLUSION

In light of recorded data on survival following the use of the nivolumab, the case presented in this study allows a new perspective of successfully treating recurrences of squamous carcinoma of the head and neck.

Isolated neurofibromas of the great auricular nerve: A rare localization in a pediatric patient with neurofibromatosis type-1

Peripheral nerve sheath tumors encompass a spectrum of well-defined clinicopathologic entities, ranging from benign tumors, such as neurofibromas, to high grade malignant neoplasms termed malignant peripheral nerve sheath tumors. Morphologic variability of these tumors is wide, and they engender some of the most controversial, difficult differential diagnoses. Localized neurofibromas often involve a major nerve and result typically in fusiform expansion of the nerve trunk (intraneural subtype). We report a case of circumscribed solitary neurofibromas in a 14-year-old boy with NF1 who presented to our department with a left neck swelling. The neurofibromas lesion involved the anterior branch of the great auricular nerve. The sensory symptoms initially reported by the patient (paresthesia and hyperesthesia) in the lower preauricular region. Surgical treatment represents the therapeutic method of choice in the approach to neurofibromas, considering functional disorders and possible aesthetic deformities. The case described presented difficulties in surgical excision, based on risk of functional and aesthetic results.

Obstructive sleep apnoea/hypopnoea syndrome: relationship with obesity and management in obese patients

Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a disease characterised by upper airway obstruction during sleep, quite frequent in the general population, even if underestimated. Snoring, sleep apnoea and diurnal hypersomnia are common in these patients. Central obesity plays a key role: it reduces the size and changes the conformation of the upper airways, besides preventing lung expansion, with consequent reduction of lung volumes. Furthermore, obese people are also resistant to leptin, which physiologically stimulates ventilation; as a result, this causes scarce awakening during apnoea. OSAHS diagnosis is based on the combination of clinical parameters, such as apnoea/hypopnoea index (AHI), medical history, physical examination and Mallampati score. The first objective reference method to identify OSAHS is polysomnography followed by sleep endoscopy. Therapy provides in the first instance reduction of body weight, followed by continuous positive airway pressure (CPAP), which still remains the treatment of choice in most patients, mandibular advancement devices (MAD) and finally otolaryngology or maxillofacial surgery. Among surgical techniques, central is barbed reposition pharyngoplasty (BRP), used in the field of multilevel surgery.

Supracricoid Partial Laryngectomy: Oncological and Functional Outcomes

Introduction In the present study, we have reviewed the outcomes of patients with supracricoid partial laryngectomy (SCPL) in our institution. Our results show that SCPL is a well-tolerated procedure with generally good functional outcomes for patients with advanced laryngeal cancer.

Objective We analyzed the oncological and functional results of a cohort of 35 patients who had undergone SCPL, and we highlighted the complications, identified the overall and disease-free survivals, demonstrating that the reconstructive laryngectomy guarantees the oncological safety and reproducibility of the oncological results, preserving the laryngeal functions and promoting an improvement in the patient's quality of life, favoring communication and interpersonal relationships.

Methods Between 2010 and 2018, 35 patients underwent SCPL for primary and recurrent laryngeal squamous cell carcinomas, and they were divided into two subgroups: in 16 cases, the cricohyoidoepiglottopexy according to the Mayer-Piquet technique was performed, while the remaining 19 cases were submitted to the cricohyoidopexy according to the Labayle technique. In addition to evaluating the oncological results of patients undergoing reconstructive laryngectomy, the present study also aimed to evaluate the functionality of the residual larynx and the quality of life.

Results The overall and disease-free survivals were of 83% and 76.3% respectively. All patients were able to swallow. The nasogastric tube was removed after a mean period of 21.8 days (range: 14 to 28 days). The mean decannulation time was of 23.4 days after surgery (range: 15 to 36 days).

Conclusion The curves for the overall and disease-free survivals show that SCPL can guarantee oncological safety comparable to that of total laryngectomies in diseases in the intermediate stage and in carefully-selected advanced stages.

Neuroendocrine carcinoma of the larynx with Lambert-Eaton myasthenic syndrome: a rare case report and literature review

This current report describes a rare clinical case of neuroendocrine carcinoma (NEC) of the larynx with associated Lambert-Eaton myasthenic paraneoplastic syndrome (LEMS). A 68-year-old male patient presented with severe dysphonia and dysphagia. He underwent a total laryngectomy and the excised lesion was extremely large. A pathological examination demonstrated ‘morphological findings of a poorly differentiated carcinoma (G3) with aspects of neuroendocrine differentiation’ (i.e. a poorly differentiated neuroendocrine carcinomas [PD-NEC]). Based on the patient’s medical history and the immunohistochemical findings, he was treated with three cycles of neoadjuvant chemotherapy (cisplatin–etoposide) and then radiotherapy with a total dose of 70 Gy. Of the 10 cases of paraneoplastic syndrome (PNS) related to laryngeal NEC reported in the literature, nine of these syndromes were of an endocrine type. Only one case of PNS associated with laryngeal cancer had a neurological manifestation, which was LEMS. To the best of our knowledge, this current case has only one similar precedent in the literature and it is the second report of an association between a PD-NEC and LEMS. Laryngeal NECs are rare lesions with different prognostic characteristics. The diagnosis should be made using an endocrinological, neurological, radiological and histological multidisciplinary approach. A radical surgical approach is recommended.

Computed-Tomography-Structured Reporting in Middle Ear Opacification: Surgical Results and Clinical Considerations From a Large Retrospective Analysis

Purpose: The aim of the study is to compare the accuracy of unstructured preoperative Computed Tomography (CT) reports from non-tertiary diagnostic centers with intraoperative findings in a large cohort of patients with Chronic Otitis Media (COM) undergone surgery.

Methods: From 2012 to 2019, a total number of 301 patients were considered for our purposes. All patients with clinical evidence of COM had preoperative non-contrast high resolution CT scan of the temporal bone in non-tertiary diagnostic centers, performed within 3 months before surgery.

Results: The accuracy of CT reports was analyzed in terms of nature, anatomical site, disease extension, bony erosion, vascular structures abnormalities relevant to surgical planning, and Eustachian tube patency. Compared to post-surgical findings, CT reporting critical analysis revealed a tendency to overestimation of bony erosion, coupled to underestimated description of facial canal/lateral semi-circular canal, vascular structures, and Eustachian tube.

Conclusion: Discrepancies between CT reports and surgical findings in middle ear opacification can be at least in part due to limited expertise of general radiologists in ENT neuroimaging. To limit this lack of information and the limited accuracy of middle ear structures depiction, here we propose a structured checklist to adopt in the case of a temporal bone CT scan for COM, in order to optimize the communication with surgeons and provide all the crucial information for an accurate surgical planning.

Is Timing of Tracheotomy a Factor Influencing the Clinical Course in COVID-19 Patients?

The timing of tracheotomy is a complex decision that requires understanding of the relative risks and benefits as compared with prolonging intubation. The role of tracheotomy during the COVID-19 pandemic remains to be determined. There is no evidence that early tracheostomy improves patient's clinical course and it is not impact on the natural history of these patients. In our opinion, the tracheotomy should be proposed in stable COVID-19 patients after 18th days after orotracheal intubation when the viral load is finished. Only in the case of patients with difficult of intubation do we perform earlier tracheotomies.

Strategies and Controversies in the Treatment With Carbon Dioxide Laser of Laryngeal Hemangioma: A Case Series and Review of the Literature

INTRODUCTION

The hemangioma is the most common vascular tumor, involving the head and neck in 60% of cases. It is rare in the larynx. In children, hemangiomas are more frequent on the subglottis, whereas in adults the most common site is the supraglottis. Laryngeal hemangioma with cavernous features isolated to the free edge of the vocal fold is a very rare clinical finding. We present 2 cases of glottic hemangioma. Both patients reported severe hoarseness.

CASES

In the first patient, an extensive blue-purple mass was seen on the right vocal cord. The patient was posted for microlaryngeal surgery with carbon dioxide (CO₂) laser. Second patient had a large, smooth, flesh-colored polypoid mass emanating from the left vocal cord. The patient was posted for microlaryngeal surgery. After 2 months, both patients showed a considerable voice improvement.

DISCUSSION

Vocal cord hemangiomas are very rare, and they usually cause problem in the voice of the patient. A vascular lesion that may mimic a hemangioma may sometimes result from an organizing hematoma following a hemorrhage on the vocal cords due to voice abuse. Laryngeal hemangiomas also need to be distinguished pathologically from polypoidal vascular granulation tissue that may be produced by laryngeal biopsy, intubation, or trauma. Indirect endoscopy is enough to diagnosis. No active treatment is advised for adult laryngeal hemangiomas unless the lesions are symptomatic or show a tendency to involve other parts. There is no uniformly accepted treatment of head and neck hemangiomas. Surgical excision with laser CO₂ microlaryngoscopic techniques gives satisfactory results.

Definition of miRNA Signatures of Nodal Metastasis in LCa: miR-449a Targets Notch Genes and Suppresses Cell Migration and Invasion

Laryngeal cancer (LCa), a neoplasm of the head and neck region, is a leading cause of death worldwide. Surgical intervention remains the mainstay of LCa treatment, but a crucial point is represented by the possible nodal involvement. Therefore, it is urgently needed to develop biomarkers and therapeutic tools able to drive treatment approaches for LCa. In this study, we investigated deregulated microRNAs (miRNAs) in tissues from LCa patients with either lymph node metastases (N+) or not (N−). miRNA expression profiling was performed by a comprehensive PCR array and subsequent validation by RT-qPCR. Results showed a significant decrease of miR-449a expression in N+ compared to N− patients, and miR-133b down-modulation in LCa tissues compared to paired normal ones. Receiver operating characteristic (ROC) curve analysis revealed the potential diagnostic power of miR-133b for LCa detection. According to the validation results, we selected miR-449a for further in vitro studies. Ectopic miR-449a expression in the LCa cell line Hep-2 inhibited invasion and motility in vitro, slowed cell proliferation, and induced the downregulation of Notch1 and Notch2 as direct targets of miR-449a. Collectively, this study provides new promising biomarkers for LCa diagnosis and a new opportunity to use miR-449a for the treatment of nodal metastases in LCa patients.

Focus on localized laryngeal amyloidosis: management of five cases

Amyloidosis is a group of idiopathic clinical syndromes caused by the deposition of insoluble fibrillar proteins (amyloid) in the extracellular matrix of organs and tissues. These deposits disrupt the function of the target organ. Amyloidosis can manifest as a systemic disease or a single-organ involvement (local form). Its etiology still remains unclear. Deposits of amyloid in the larynx are rare, accounting for between 0.2 and 1.2% of benign tumors of the larynx. In this retrospective study, we report the clinical aspects, diagnosis, treatment and follow-up of five female patients with localized laryngeal amyloidosis without systemic involvement. The patients were all treated successfully using microlaryngoscopy with CO₂ laser or cold instruments. Prognosis is excellent; however, appropriate follow-up is an important part of the long-term management of this disease in order to prevent and control the possibility of local recurrence.

Laryngeal Candidiasis Mimicking Supraglottic Carcinoma by Prolonged Inhaled Steroid Therapy: A Case Report and Review of the Literature

Candidiasis is a rare entity reported as an isolated and primary laryngeal disease. In this condition, inhaled steroids were the single most common predisposing factor. Also mycotic infections of larynx are frequently seen in patients with immune insufficiency, although they have also been reported in individual with normal immune status. We report a case of isolated laryngeal Candidiasis in an immunocompetent individual, with an unusual presentation with exophytic lesion, edema, ulceration, white plaque, and pseudomembranous formation mimicking supraglottic carcinoma, to highlight the clinical of this condition and provide a review of the literature.

The CO2-laser in the treatment of laryngeal and tracheal stenosis Our personal experiences

AIM

In the last twenty years, the statement of the CO2 laser in laryngeal microsurgery has proved particularly useful in the surgical treatment of laryngotracheal stenosis. The Authors report their surgical experiences and discuss them considering the location, size and pathologic features of the disease. The aim of this study was to evaluate the results that may be obtained in the treatment of laryngotracheal stenosis by endoscopy using the CO2 laser, and analyze the advantages and limitations of surgical methods implemented.

MATERIAL OF STUDY

It includes 128 patients treated from 1981 to 2016 by endoscopy using the CO2 laser.

RESULTS

The healing occurred in 121 of the 128 patients (94.5%); in the remaining 7 cases (5.5%) - 4 subjects (3.1%) with supraglottic cicatricial stenosis and 3 patients (2.3%) with widespread laryngotracheal stenosis - it had to integrate the technique of endoscopic surgery with a traditional surgery of recovery. In particular, it has observed as follows: In supraglottic stenosis: - oedematous forms healed without difficulty, a limited number of controls (1-2) was necessary to practice and any type of stent has not been used; - cicatricial forms required a greater number of controls (3-6) and the execution in 2 cases (1.6%) of an arytenoidectomy, we had 4 failures (3.1%) for which it had to implement a recovery surgery of traditional type; In glottic/ipoglottic stenosis: - all oedematous forms healed with a number of checks less than 3, without use of stents; - scarring forms resolved after a higher number of controls (3-6), in 4 of them (3.1%) it was necessary to practice an arytenoidectomy (associated to exeresis of 1/3 posterior ipsilateral true vocal cord) and in 4 (3.1%) had to applied an endolaryngeal guardian (in one case a Traissac stent and in 3 ones a Montgomery T-tube); In tracheal stenosis has occurred healing in all cases, more specifically: - in limited forms to the third anterior of the trachea were enough 1-2 checks and it was not necessary using stent; - in extended forms (involvement of the 2/3 anterior and/or of the whole tracheal circumference) a higher number of controls (3-6) was necessary; - in concentric forms, with total obstruction of the lumen, the application of endoluminal stent (3 Montgomery T-tubes and 2 tracheal cannulas of Silastic) was always necessary in addition to a number of controls superior to 7. - In laryngotracheal spread forms, 3 failures (2.3%) recorded, in all cases, however, many controls (greater than 7) was necessary and a Montgomery T-tube was placed.

CONCLUSIONS

The introduction of the CO2 laser in the surgical treatment of laryngotracheal stenosis has undoubtedly improved the chances of endoscopic surgery; it is currently able to offer significant advantages compared to traditional techniques (cures faster, less traumatic interventions, post-operative elapsed better tolerated by patients, etc.) but it is also indisputable that to ensure the success of these operations is essential a correct understanding of the size and pathologic features of the same stenosis: the data, in fact, affect the choice of surgical addresses to adopt in individual cases and the prognostic judgment.

KEY WORDS

Airway management, Airway problems, CO2 laser, Direct laryngoscopy, Endoscopy, External surgical approach, Laryngotracheal stenosis, Minimally invasive surgery, Montgomery Safe T-tube, Tracheal stenosis, Tracheostomy.

Adenoid cystic carcinoma of the larynx in a 70-year-old patient: A case report

Adenoid cystic carcinoma (ACC) is a relatively rare tumor that accounts for <1% of all head and neck malignancies. Laryngeal localization of ACC, which is most commonly hypoglottic, is relatively rare, occurring in 0.07-0.25% of all laryngeal tumors. ACC is characterized as a slow-growing tumor with a high recurrence rate, which often causes dyspnea and hoarseness. ACC exhibits a propensity for perineural invasion and thus, patients may experience pain as a late symptom of the disease. Distant metastasis occurs in 35-50% of cases and the lungs are the most common site of metastasis. Tumors are usually diagnosed by physical examination with fiberoscopy and computed tomography of the neck and chest, due to the high rate of lung metastases. The standard therapy for ACC is surgery followed by radiotherapy. In this study, a 70-year-old patient presented with laryngeal ACC, who underwent total laryngectomy with bilateral neck dissection and adjuvant radiotherapy, is presented. Follow-up examination performed 2 years after surgery revealed no evidence of locoregional recurrence or distant metastases. Previously published literature regarding ACC of the larynx was also reviewed.

Overexpression of chromatin assembly factor-1/p60 predicts biological behaviour of laryngeal carcinomas

This study analysed the immunohistochemical expression of the CAF-1/p60 protein in laryngeal cancers. CAF-1/p60 assumes an independent discriminative and prognostic value in laryngeal neoplasms; the presence of this protein in carcinoma in situ compared with laryngeal precancerous and larynx infiltrating tumours. We assessed the immunohistochemical expression of CAF-1/p60 in 30 cases of moderate and/or severe dysplasia, 30 cases of carcinoma in situ and 30 cases of laryngeal squamous cell carcinoma (LSCCs). CAF-1/p60 expression increased significantly according to the high index of neoplastic cellular replication; therefore, CAF-1/p60 was overexpressed in neoplastic cells and its moderate-severe expression is correlated with poorer prognosis compared to less expression. In conclusion, overexpression of the CAF-1/p60 protein is related to a risk of higher morbidity and mortality and is a reliable independent prognostic index of laryngeal carcinoma. CAF1-p60 protein overexpression can be used in cancer management as an indicator of malignant evolution, especially in carcinoma in situ.

Aggressiveness pattern and second primary tumor risk associated with basaloid squamous cell carcinoma of the larynx

Basaloid squamous cell carcinoma (BSCC) is a rare, aggressive and distinct variant of squamous cell carcinoma (SCC) of the upper respiratory and digestive tract. We have evaluated disease specific survival (DSS) and overall survival (OS) through Kaplan-Meier method and mortality risk through univariate statistical analysis of Cox in 42 cases of BSCC and other 42 of laryngeal SCC (LSCC) matched for both age and sex. We demonstrated that laryngeal BSCC is a more aggressive tumor than LSCC as is associated to higher nodal recurrence of pathology (5 vs 2 patients, overall risk, OR 2.7), a reduced survival (median survival 34 vs 40 months, OR 3.2 for mortality); in addition, basaloid patients have a higher risk to be affected by second primary tumors (13 vs 3 patients, OR 5.8) and a higher probability to die for this second tumor (Hazard Risk, HR 4.4). The analysis of survival shows an increased mortality risk concurrent with the parameters assessed by univariate analyses that assume a predictive and statistical significance in second tumor and grading in basaloid LSSC.

Chemoprevention using folic acid for dysplastic lesions of the larynx

Folate deficiency may be directly associated with carcinogenesis. Folate supplementation may reduce the risk of progression in a mucosa that is already genetically altered. The aim of the present study was to determine the role of folic acid in the treatment of mild and moderate laryngeal dysplasia recurring after surgery. The data obtained by laryngoscopy, measurement of serum folate levels and functional vocal assessment with the GIRBAS scale and VHI questionnaire were compared in patients who had received folic acid with a homogeneous group of patients with dysplasia who had not undergone any therapy. A total of 24 patients suffering from recurrence of mild or moderate laryngeal dysplasia (n=12, group A) were treated with 400 mg folic acid per os, once daily for 6 months. The patients in group B (n=12) received no treatment and were used as the control group. In group A, 7 (58%) patients exhibited a complete response, with clinically evident regression of leukoplakia, 3 (25%) displayed a partial decrease in the lesions with reduced volume of the area involved, whereas 2 patients exhibited no change. As regards patients in control group B, 8 (67%) exhibited no change, in 1 case there was a spontaneous regression, and in 3 (25%) there was disease progression with suspected malignant transformation, leading to repeat surgery. Therefore, folate deficiency may be considered to be a factor predisposing to precancerous lesions, and dietary folate supplementation may prevent and reduce the emergence of cancer.

Coexistent Squamous Cell Carcinoma and Granular Cell Tumor of Head and Neck Region: Report of Two Very Rare Cases and Review of the Literature

Granular cell tumor (GCT), a relatively rare neuroectodermal tumor occurring most often in the head and neck region, is not uncommonly associated with pseudoepitheliomatous hyperplasia of the overlying surface epithelium, which may be at times nonreadily distinguishable from well-differentiated squamous cell carcinoma (SCC). To the best of our knowledge, only a handful of coexisting SCC and GCT, mostly described in the esophagus, have been reported in (the current) literature so far. We herein report 2 new cases of coexisting GCT and SCC of the head and neck region, located, respectively, in larynx and tongue; comment on their clinical, imaging, and pathologic features; and discuss their management. In the present work, we also review the literature concerning this association to contribute to the head and neck pathologists' and surgeons' awareness regarding the possibility of this association for an adequate surgical excision and a better management of these patients.

Our experience in the treatment of Malignant Fibrous Hystiocytoma of the larynx: clinical diagnosis, therapeutic approach and review of literature

Hereditary spherocytosis (HS) and Chronic myelocytic leukemia (CML) are both life threatening hemotologic diseases. They are rarely seen to occur simultaneously in one individual patient. Here we demonstrate a case of HS associated with CML in this study. The patient is a young female, diagnosed with HS in 2005, and was given partial embolization of the splenic artery. She got significant remission after the procedure. In 2008, she was found abnormal in blood routine test, after bone marrow routine, chromosome and fusion gene tests, she was diagnosed with CML (chronic phase). She did not receive regular treatment until 3 months prior, and is currently being treated with Dasatimib. She achieved hematological remission, but had no significant improvement in chromosome and fusion gene figures. Due to her severe condition of hemolysis, a splenectomy or an allogeneic hematopoietic stem cell transplantation is considered.

Delayed recurrent nerve paralysis following post-traumatic aortic pseudoaneurysm

Blunt trauma to the neck or to the chest are increasingly observed in the emergency clinical practice. They usually follow motor vehicle accidents or may be work or sports related. A wide pattern of clinical presentation can be potentially encountered. We report the uncommon case of a patient who was referred to our observation presenting with hoarseness and disphagia. Twenty days before he had sustained a car accident with trauma to the chest, neck and the mandible. Laryngoscopy showed a left recurrent laryngeal nerve palsy. Further otolaryngo-logical examination showed no other abnormality. At CT and MR imaging a post-traumatic aortic pseudoaneurysm was revealed. The aortic pseudoaneurysm was consequently repaired by implantation of an endovascular stent graft under local anesthesia. The patient was discharged 10 days later. At 30-days follow-up laryngoscopy the left vocal cord palsy was completely resolved. Hoarseness associated with a dilated left atrium in a patient with mitral valve stenosis was initially described by Ortner more than a century ago. Since then several non malignant, cardiovascular, intrathoracic disease that results in embarrassment from recurrent laryngeal nerve palsy usually by stretching, pulling or compression; thus, the correlations of these pathologies was termed as cardiovocal syndrome or Ortner's syndrome. The reported case illustrates that life-threatening cardiovascular comorbidities can cause hoarseness and that an impaired recurrent laryngeal nerve might be correctable.

Role of perineural invasion as a prognostic factor in laryngeal cancer

The diffusion of laryngeal cancer cells in the perineural space is a parameter associated with a negative prognosis, high loco-regional recurrence and low disease-free survival rates. The spread of tumor cells on the perineural sheath highlights the histopathological and clinically aggressive behavior of this type of tumor, which may extend proximally or distally in the nerve for >10 cm. Therefore, the surgical resection margin is generally insufficient to treat patients with laryngeal cancer presenting with perineural invasion (PNI) with surgery alone. In PNI, the minor laryngeal nerves are frequently involved, rather than the superior and inferior laryngeal nerves. The aim of the present study was: i) To evaluate the prognostic importance of PNI; ii) to correlate the rate of infiltration with factors associated with the tumor, including histotype, site and tumor-node-metastasis stage, and with the type of surgery (total or partial laryngectomy); and iii) to evaluate the rate of disease-free survival according to the outcome of combined surgery and radiotherapy (RT) treatment, by means of retrospective analysis. The results of the present study highlighted the importance of performing a closer clinical and instrumental follow-up in patients with laryngeal cancer whose histopathological examination is positive for PNI. In such cases, it is important to complement the surgical therapeutic treatment with adjuvant RT.

Cavernous hemangioma of rhinopharynx: our experience and review of literature

Hemangiomas are benign tumors originating in the vascular tissues of skin, mucosa, muscles, glands, and bones. Although these tumors are common lesions of the head and neck, they rarely occur in the nasal cavity and paranasal sinuses. Cavernous haemangioma of the lateral wall of the nasopharynx has not previously been reported. We examined the clinical, radiological and therapeutic management of cavernous haemangioma of nasopharynx starting from a clinical case of a 26-year-old woman with a history of recurrent and conspicuous epistaxis and left-sided nasal associated severe obstruction. Nasopharynx examination, by flexible endoscopy, showed a cystic mass borne by the left side wall of the nasopharynx, in contact with the soft palate, covered by intact and regular mucosa. Contrast-enhanced computed tomography (CT) scan, confirmed these findings and showed contextual lamellar calcifications and inhomogeneous enhancement. The nasal endoscopic approach (FESS), under general anesthesia, allowed removal of the mass, without complications, after careful hemostasis of arterial branches. It was possible to establish the precise site of origin of the tumor only during the surgical procedure. Histopathological study showed mucosa with extensive vascular proliferation, with framework of lacunar/cavernous haemangioma, also present at lamellar bone tissue level. An unusual site and an unspecific clinical appearance can make diagnosis and treatment of a cavernous hemangioma of the nasopharynx difficult. The nasal endoscopic technique proved to be reliable in terms of adequate exposure and visualization of the lesion, control of bleeding, and complete removal of the mass.

Simultaneous PET/MR head-neck cancer imaging: Preliminary clinical experience and multiparametric evaluation

PURPOSE

To evaluate the role of simultaneous hybrid PET/MR imaging and to correlate metabolic PET data with morpho-functional parameters derived by MRI in patients with head-neck cancer.

METHODS

Forty-four patients, with histologically confirmed head and neck malignancy (22 primary tumors and 22 follow-up) were studied. Patients initially received a clinical exam and endoscopy with direct biopsy. Next patients underwent whole body PET/CT followed by PET/MR of the head/neck region. PET and MRI studies were separately evaluated by two blinded groups (both included one radiologist and one nuclear physician) in order to define the presence or absence of lesions/recurrences. Regions of interest (ROIs) analysis was conducted on the primary lesion at the level of maximum size on metabolic (SUV and MTV), diffusion (ADC) and perfusion (K(trans), Ve, kep and iAUC) parameters.

RESULTS

PET/MR examinations were successfully performed on all 44 patients. Agreement between the two blinded groups was found in anatomic allocation of lesions by PET/MR (Primary tumors: Cohen's kappa 0.93;

FOLLOW-UP

Cohen's kappa 0.89). There was a significant correlation between CT-SUV measures and MR (e.g., CT-SUV VOI vs.

MR-SUV VOI

ρ=0.97, p<0.001 for the entire sample). There was also significant positive correlations between the ROI area, SUV measures, and the metabolic parameters (SUV and MTV) obtained during both PET/CT and PET/MR. A significant negative correlation was observed between ADC and K(trans) values in the primary tumors. In addition, a significant negative correlation existed between MR SUV and ADC in recurrent tumors.

CONCLUSION

Our study demonstrates the feasibility of PET/MR imaging for primary tumors and recurrent tumors evaluations of head/neck malignant lesions. When assessing HNC, PET/MR allows simultaneous collection of multiparametric metabolic and functional data. This technique therefore allows for a more complete characterization of malignant lesions.

Keratin 5 expression in squamocellular carcinoma of the head and neck

Keratin 5 (K5) is present in the basal layer of a stratified squamous keratinized and non-keratinized epithelium. K5 and K14 have been demonstrated in the mucosa and tumors of the oral cavity, oropharynx, hypopharynx and larynx, and in the mitotic active basal cells of a stratified squamous epithelium. The aim of the present study was to assess K5 expression in squamocellular carcinoma with various localizations in the head and neck. A total of 13 biopsy fragments were included from patients diagnosed with squamocellular carcinoma of the larynx area (n=2), pharynx (n=2), hard palate (n=1), tongue (n=2), submandibular (n=1), lip (n=1), gingival sulcus (n=1), nasal pyramid (n=1), maxilla (n=1) and zygomatic (n=1). The immunohistochemical staining for K5 was evaluated according to the following score criteria: 0 (0% positive cells); 1 (<10% positive cells); 2 (10-30% positive cells); and 3 (>30% positive cells). K5 expression was observed in all squamocellular carcinomas included in the present study with scores between 1 and 3. For well- and moderately-differentiated histopathological types, a maximum score of 3 was recorded for all of the cases, not including the laryngeal area, which presented a score of 2. The following scores were identified in the regions of the poorly differentiated carcinomas: Jaw, 3; gingival sulcus, 2; and tongue and submandibular area, 1. These observations may aid with an improved stratification of head and neck squamocellular carcinoma, thus improving the diagnosis and treatment strategies for this type of cancer.

Current therapeutic prospectives in the functional rehabilitation of vocal fold paralysis after thyroidectomy: CO2 laser aritenoidectomy

A frequent complication of thyroid surgery is laryngeal nerve palsy with transitory or permanent deficiency of cordal motility. Peripheral mono-or bilateral palsy in these cases may either occur, in adduction or abduction, and be complete or not complete. Bilateral vocal cords paralysis cause a persistent dyspnoic symptomatology with worsening during physical exercise or flogistic episodes of the upper airway: true vocal cords adduction, in median or paramedian position reduce the glottic space and increases respiratory resistances. Several surgical procedures have been proposed for the treatment of respiratory distress secondary to bilateral cord palsy. The aim of this study is to value the role of CO2 laser aritenoidectomy in 93 patients affected by bilateral paralysis in adduction of true vocal cords. Pre and postoperative evaluations included clinical results, spirometry, aerodynamics studies and evaluation of foniatric performance (MPT, H/N Ratio, Jitter and Shimmer) with a mean follow-up of 12 years. CO2 laser aritenoidectomy induces a complete resolution of respiratory failure, maintaining a good vocal quality, minimum surgical stress with low percentage of complications and a short hospitalization.

Morphological, diagnostic and surgical features of ectopic thyroid gland: a review of literature

Ectopic thyroid tissue remains a rare developmental abnormality involving defective or aberrant embryogenesis of the thyroid gland during its passage from the floor of the primitive foregut to its usual final position in pre-tracheal region of the neck. Its specific prevalence accounts about 1 case per 100.000-300.000 persons and one in 4.000-8.000 patients with thyroid disease show this condition. The cause of this defect is not fully known. Despite genetic factors have been associated with thyroid gland morphogenesis and differentiation, just recently some mutation has been associated with human thyroid ectopy. Lingual region in the most common site of thyroid ectopy but ectopic thyroid tissue were found in other head and neck locations. Nevertheless, aberrant ectopic thyroid tissue has been found in other places distant from the neck region. Ectopic tissue is affected by different pathological changes that occur in the normal eutopic thyroid. Patients may present insidiously or as an emergency. Diagnostic management of thyroid ectopy is performed by radionuclide thyroid imaging, ultrasonography, CT scan, MRI, biopsy and thyroid function tests. Asymptomatic euthyroid patients with ectopic thyroid do not usually require therapy but are kept under observation. For those with symptoms, treatment depends on size of the gland, nature of symptoms, thyroid function status and histological findings. Surgical excision is often required as treatment for this condition.

Treatment of c-kit positive adenoid cystic carcinoma of the tongue: A case report

Adenoid cystic carcinoma (ACC) or ‘cylindroma’ is a malignant tumor that often occurs in the areas of the head and neck, affecting the secretory glands and the major and minor salivary glands. The present study describes a case of a patient who presented with a posterior tongue lesion. The case is of a 71-year-old female with an asymptomatic volume growth of the posterior left tongue perceived 8 months prior, and neoplastic cells positive for c-kit. A computed tomography of the head and neck showed asymmetry of the base of the tongue, which was enlarged in the left portion. A physical examination revealed a nodule on the posterior left tongue of ~3 cm in diameter, while the cervical lymph node chain had a normal size and consistency. Surgical exeresis of the tongue lesion and cervical lymph node dissection were performed. Subsequent to surgical removal of the cancer cells and adjuvant radiotherapy, the patient showed excellent health, although the follow-up remains in progress. ACC, one of the most biologically destructive tumors of the head and neck, is locally aggressive and gives rise to distant metastases. The tongue is the place of origin in 3.4–17.1% of cases. The treatment for ACC consists of primary surgical resection with adjuvant radiotherapy. To prevent the risk for distant metastasis, it is necessary to remove the first echelon nodes and monitor the patient with a long-term follow-up.

Notes on the microbiology of cholesteatoma: clinical findings and treatment

Anomalous proliferation of the cholesteatoma epithelium is caused by extrinsic factors such as toxins or bacterial antigens combined with lytic enzymes, lymphokines and cytokines released from the inflammatory infiltrate. This could explain the close relationship between the aggressiveness of cholesteatoma and repeated bacterial superinfection, therefore it is very important to know the bacteria involved in order to control the regrowth of skin following surgery, reduce the aggressive potential of the cholesteatoma and limit the incidence of complications. This study focused on 70 females and 80 males aged between 15 and 65 years, affected by cholesteatomatous otitis media; all underwent bacteriological examination of the auricular secretion. The floral bacteria which proved to play the most important role (60.3%) were the aerobic type and the highest levels were those of Pseudomonas aeruginosa (31.1%) followed by Staphylococcus aureus (19.1%), Proteus mirabilis (7.7%), Escherichia coli (1.4%) and Klebsiella pneumoniae (1%). Anaerobic floral bacteria were found in a fairly high percentage of cases (38.2%); in particular, anaerobic gram-positive cocci (Peptococcus 12.4% and Peptostreptococcus in 4.8% of cases), Bacteroides (12.4%), Clostridium (3.8%), Fusobacterium (2.9%) and Propionobacterium (1.9%) were isolated. In 3 cases of mycetes (1.4%) only Aspergillus, in association with Pseudomonas and Staphylococcus, was identified. The study showed, then, how effective second generation fluoroquinolones and third generation cephalosporins are (the latter being used in pre-adolescent children), the reason being that these antibiotics work not only on Pseudomonas and Staphylococcus, but also on the anaerobic bacteria.

Isolated laryngeal leishmaniasis in an immunocompetent patient: a case report

Visceral leishmaniasis, a protozoan disease caused by Leishmania infantum, is endemic in the Mediterranean basin, especially southern and Tyrrhenian Italy. Its aetiological agent can also sporadically cause isolated laryngeal localization in at-risk patients (i.e., heavy smokers, immunocompromised patients). This rare localization is often pauci-symptomatic and thus can easily escape diagnosis. A case of isolated leishmaniasis limited to the left vocal cord in an immunocompetent Italian male without significant risk factors, randomly discovered upon histological examination, is described herein. We inquire how many patients affected by non-specific symptoms such as dysphonia and live in countries where Leishmania infantum infection is reported, could be truly affected by Leishmania spp infection.