Influence of Prior Endoscopic Sinus Surgery Extent on Dupilumab Effectiveness in CRSwNP Patients

BACKGROUND

Guidelines recommend that the vast majority of patients with severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) should have at least one endoscopic sinus surgery (ESS) prior to starting biologics. Because ESS can be performed with a variable extension, the aim of this study would be to evaluate the association between surgical extensiveness, as measured by ACCESS score, and outcomes collected in patients treated with Dupilumab.

MATERIALS AND METHODS

This is a multicentric retrospective study; patients affected by CRSwNP who were subjected to Dupilumab therapy and who underwent at least one ESS prior to Dupilumab initiation were included. ACCESS score was assigned to each patient's pre-Dupilumab CT scan. Subjective and objective parameters (SNOT-22, NPS, VAS scores, Sniffin' Sticks) were collected before and during the administration of therapy. Statistical correlations between ACCESS scores and clinical outcomes were investigated.

RESULTS

A total of 145 patients were included; mean time from last previous ESS was 68.6 months, and on average, patients were subjected to 2.2 surgeries. Many correlations with ACCESS scores were demonstrated: better NPS at all timepoints and subjective scores (30-days SNOT-22, VAS nasal obstruction, and rhinorrhea) were achieved in patients with low ACCESS score (more extensive ESS). On the other hand, significantly worse VAS loss of smell values were demonstrated in patients with lower ACCESS scores.

CONCLUSION

Dupilumab patients subjected to a prior extensive ESS may have reduced size of polyps and improved subjective indicators, together with a decreased chance to recover smell, when compared with patients who underwent a minimal excision.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1556-1563, 2024.

Surgical anatomy of posterior tympanotomy: influence of the retrotympanum on round window exposure

OBJECTIVES

To describe how the retrotympanic structures could influence the visibility of the round window niche and the round window membrane during cochlear implant surgery, and to investigate if a round window approach is possible even in cases with unfavourable anatomy.

METHODS

Video recordings from 37 patients who underwent cochlear implantation were reviewed. The visibility of the round window niche and round window membrane at different timepoints was assessed according to a modified version of the Saint Thomas Hospital classification. The structures that concealed the round window niche and round window membrane were evaluated.

RESULTS

After posterior tympanotomy, 54 per cent of cases had limited exposure (classes IIa, IIb and III) of the round window niche. After remodelling the retrotympanum, round window niche visibility significantly increased, with 100 per cent class I and IIa cases. Following remodelling of the round window niche, visibility of more than 50 per cent of the round window membrane surface was achieved in 100 per cent of cases.

CONCLUSION

Remodelling the retrotympanum and the round window niche significantly increased exposure of the round window niche and round window membrane respectively, allowing round window insertion in all cases.

Multilayer Anterior Skull Base Reconstruction with Cortical Rib Bone Graft: Preliminary Experience

OBJECTIVE

During the past decades, different methods have been described for anterior skull base reconstruction. Regarding larger skull base defects, few investigators have described the use of bone grafts to foster support and prevent frontal lobe sagging, herniation, or falling. The aim of this study is to describe the use of a rib bone graft, which could be an option in these cases due to its rigidity and dimensions.

METHODS

We retrospectively collected preoperative, intraoperative, and postoperative data at the last follow-up of 10 patients who underwent multilayer anterior skull base reconstruction, including rib bone graft, for large anterior cranial base defects at 2 tertiary care academic hospitals.

RESULTS

Eight patients underwent endoscopic craniectomy for sinonasal malignancies, and the other two underwent transnasal endoscopic surgery for congenital meningoencephalocele. Anterior skull base defects measured on average 3.8 cm ± 0.9 SD antero-posteriorly (range 2.5-5 cm) and 2.3 ± 0.9 SD latero-laterally (range 0.9-4 cm). Multilayer reconstruction was performed in all cases, including a rib bone graft positioned as intracranial extradural layer. No patient experienced thoracic complications during the postoperative period. No side effects related to the bone graft or meningoencephalocele occurrence were reported after a mean follow-up of 8.0 ± 6.3 months.

CONCLUSIONS

The use of a cortical rib bone graft could be a safe and effective option in skull base reconstruction when managing large defects after cancer removal.

Pericranial Flap-Based Multilayer Reconstruction of Endoscopic Transcribriform Craniectomy for Sinonasal Malignancies

OBJECTIVE

Diffusion of endoscopic techniques for the resection of ethmoid bone malignancies through a transcribriform approach (TA) has raised new challenges regarding reconstruction options to reduce post-operative complications. Although there is consensus on the advantages of vascularized flaps over free grafts for large defects, no standard protocol exists on reconstruction procedures. In addition, although the pedicled nasoseptal flap has been extensively discussed, few studies have been published on extranasal pedicled flaps. The aim of this manuscript is to provide a detailed description of a reconstruction technique for large anterior skull base defects with the pericranial flap as part of a multilayered reconstruction. Moreover, patients treated with this approach were retrospectively assessed for post-operative complications.

METHODS

A detailed description of the reconstruction procedure as performed in our departments is provided. Pictures depicting the main surgical steps are also included. In addition, preliminary functional results from a retrospective series of patients who underwent a TA and subsequent pericranial flap-based multilayer reconstruction for ethmoid roof malignancies between 2016 and 2022 at two institutional centers are reported.

RESULTS

16 patients were included in the study. Nine patients (56.3%) underwent adjuvant radiotherapy. Two patients had a biochemically-confirmed postoperative CSF leak. Only one of the two patients required surgical revision. During follow-up (mean 13 months), no other early nor delayed complications were observed.

CONCLUSION

A standardized surgical technique with pericranial flap as part of a multilayered reconstruction for large anterior skull base defects following resection of sinonasal malignancies is proposed, which appears to be a safe choice when endonasal flaps are not available.

LEVEL OF EVIDENCE

Level 4 Laryngoscope, 133:2942-2947, 2023.

Acquired bilateral facial palsy: a systematic review on aetiologies and management

OBJECTIVE

To systematically review the published cases of bilateral facial palsy (BFP) to gather evidence on the clinical assessment and management of this pathology.

METHODS

Following PRISMA statement recommendations, 338 abstracts were screened independently by two authors. Inclusion criteria were research articles of human patients affected by BFP, either central or peripheral; English, Italian, French or Spanish language; availability of the abstract, while exclusion criteria were topics unrelated to FP, and mention of unilateral or congenital FP. Only full-text articles reporting the diagnostic work-up, the management, and the prognosis of the BFP considered for further specific data analysis.

RESULTS

A total of 143 articles were included, resulting a total of 326 patients with a mean age of 36 years. The most common type of the paralysis was peripheral (91.7%), and the autoimmune disease was the most frequent aetiology (31.3%). The mean time of onset after first symptoms was 12 days and most patients presented with a grade higher than III. Associated symptoms in idiopathic BFP were mostly non-specific. The most frequently positive laboratory exams were cerebrospinal fluid analysis, autoimmune screening and peripheral blood smear, and the most performed imaging was MRI. Most patients (74%) underwent exclusive medical treatment, while a minority were selected for a surgical or combined approach. Finally, in more than half of cases a complete bilateral recovery (60.3%) was achieved.

CONCLUSIONS

BFP is a disabling condition. If a correct diagnosis is formulated, possibilities to recover are elevated and directly correlated to the administration of an adequate treatment.

Chronic Rhinosinusitis with Nasal Polyps: A Survey on Routine Management and Evaluation of Disease Control in Practice

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a disease with a significant impact on quality of life. The overall goal of CRSwNP management, as with other chronic conditions, is to achieve "disease control", and for that reason, a definition of control of disease is pivotal in deciding the best treatment strategy. Although many staging systems have already been developed to evaluate the disease, disease control is not yet to be standardized, and a specific tool that is consistently applied and accepted by all practitioners is still missing in daily clinical practice. To gain an overview of the implementation and limitations of existing guidelines and to shed light on real-life definitions of control and disease severity, we conducted a nationwide survey of otorhinolaryngologists routinely treating CRSwNP to identify unmet clinical needs in Italy. The results showed homogeneous responses regarding the knowledge contained in international guidelines while highlighting the difficulty of their implementation in day-to-day practice. Respondents called attention to the importance of clinical symptoms, giving more weight to the patient's perspective. Among the symptoms to be considered, respondents emphasized nasal obstruction, followed by loss of sense of smell and rhinorrhea. Others also believe that the physician's perspective should be considered, and the inclusion of endoscopy as a measure of control was warranted by many. The need for a specific tool that is able to unequivocally ascertain disease control is increasingly pivotal in this new era of biologics for treating CRSwNP.

Effects of Total Intravenous Versus Inhalational Anesthesia on Bleeding During Endoscopic Ear Surgery: Preliminary Results From a Case-Control Study

OBJECTIVE

To assess the impact of the type of maintenance anesthesia on the bleeding conditions of the surgical field and hemodynamic parameters during endoscopic ear surgery (EES), comparing totally intravenous inhalational anesthesia (TIVA) with inhalational anesthesia (IA).

STUDY DESIGN

Retrospective case-control study.

SETTING

Tertiary referral center.

PATIENTS

Fifteen consecutive EES cases performed with TIVA between 2019 and 2020 at our Institution were matched to a control group of patients who underwent EES with IA in the same period. Patients with American Society of Anesthesiologists IV grade, acute otitis before surgery, congenital or acquired coagulopathies, use of anti-inflammatory drugs, or antiaggregant or anticoagulant therapy in the 5 days before the intervention were excluded.

INTERVENTIONS

Both primary and revision tympanoplasty and stapes surgery were considered.

MAIN OUTCOME MEASURES

Surgical videos were reviewed to quantify the entity of bleeding according to the Modena Bleeding Score. Hemodynamic parameters during surgery were retrospectively collected. A comparison between the two groups was performed.

RESULTS

No statistically significant differences between the two groups in terms of bleeding were found at any of time point evaluated. The tympanomeatal flap elevation resulted in the bloodiest step in both groups. Hemodynamic parameters were similar in both groups ( p > 0.05).

CONCLUSIONS

These preliminary data do not support a significant difference in bleeding conditions and hemodynamic parameters between EES patients receiving TIVA and those receiving IA. Further studies involving a higher number of patients will improve our understanding on how maintenance anesthesia with TIVA may be beneficial in terms of bleeding control as compared with IA for patients undergoing EES.

Cadaver Homologous Banked Fascia Lata in Skull Base Reconstruction: Preliminary Multidisciplinary Experiences

Skull base reconstruction has been a widely debated issue. Both autologous and heterologous materials have been proposed, however the formers are usually preferred due to their optimal healing outcomes and integration. Nevertheless they are still associated with donor-site functional and aesthetic morbidity. The aim of this study is to report a preliminary experience of different sites defects skull base repair with Cadaver homologous banked fascia lata graft. Patients who underwent reconstruction of skull base defects with Cadaver homologous banked fascia lata between January 2020 until July 2021 were included in the study. Three patients were finally identified for the study. Patient 1 underwent combined craniotomic-endoscopic surgical access for extended anterior skull base neoplasm with subsequent repair with homologous cadaver fascia lata. Patient 2 underwent endoscopic transphenoidal surgery for sellar-parasellar neoplasm. After tumor debulking the surgical cavity was obliterated with homologous cadaver fascia lata. Patient 3 finally had politrauma with otic capsule-violating fracture with profused CSF leak. An endoscopic obliteration of external and middle ear was performed using homologous cadaver fascia lata with blind sac closure of external auditory canal. No graft displacement or reabsorption was observed in these patients at the last follow-up. Cadaver homologous banked fascia lata has proved safety, efficacy and ductility in reconstruction of different skull base defects. Level of Evidence: Level IV-retrospective cohort study.

Prognostic role of EAONO/JOS, STAMCO, and ChOLE Staging for Exclusive Endoscopic and Endoscopic-Microscopic Tympanoplasty

OBJECTIVE

The aim of the study is to evaluate cholesteatoma's surgical outcomes in patients treated with endoscopic ear surgery (EES) or a combined endoscopic-microscopic approach (cEMA) according to STAM, STAMCO, ChOLE, and EAONO/JOS system (EJS) classifications and staging.

STUDY DESIGN

Retrospective study.

SETTING

Monocentric study in a tertiary referral center.

METHODS

One-hundred sixty-eight patients who underwent EES or cEMA for cholesteatoma between 2010 and 2018 were classified according to the abovementioned classification and staging. Data on cholesteatoma's recurrence and residual rates were collected. Inferential statistical analysis was performed to evaluate surgical outcomes and the prognostic value of classifications and staging.

RESULTS

The recurrence rate was significantly lower in cholesteatomas classified in EJS stage 1 (2.6%) and STAM stage 1 (0%). A comparison of the different stages of the disease showed a significantly lower recurrence only for stage 1 versus the superior stages of both classifications. Involvement of mastoid bone was associated with a higher risk of recurrence (odds ratio [OR]: 4.12; p = .031). Attical involvement was associated with a higher risk of residual cholesteatoma (OR: 1.165; p = .046).

CONCLUSION

EES or cEMA represents an effective treatment for middle ear cholesteatoma. The STAM classification and the EJS have shown a prognostic value, with STAM 1 and EAONO-JOS 1 stages associated with a better prognosis. Mastoid involvement represents a risk factor for recurrence. Attic localization is associated with residual disease. Localization at difficult access sites did not implicate a higher risk for recurrence or residual. ChOLE classification, Ossicular chain status, and complication status did not provide prognostic information regarding recurrence or residual cholesteatoma.

Endoscopic "retrograde" dacryocystorhinostomy: A fast route to the lacrimal sac

Endoscopic Dacryocystorhinostomy (DCR) is an established surgical technique for the management of peripheral nasolacrimal duct (NLD) obstruction. Its main points are the correct identification of the lacrimal sac and the execution of surgical procedures that allow a rapid and accurate healing of the surgical field. The main endoscopic landmarks used for the identification of the lacrimal sac are the middle turbinate and the maxillary line. However, in some cases, this procedure can be difficult due to several factors (e.g. anatomical variations, former surgery). In the present study, a variation of "classic" endoscopic DCR, named "retrograde" endoscopic endonasal DCR (rDCR), is described. rDCR is performed through the quick identification of the NLD at the level of the most anterior insertion of the inferior turbinate in the lateral nasal wall. In most cases, at this level only a very thin shell of bone is present (crack point), easily fractured by using blunt angled dissector. The duct is then followed upward along its course by removing the overlying bone in order to correctly identify the lacrimal sac and unequivocally drill along the lacrimal pathway. This technique proved to be a safe, quick and effective procedure, even in patients with difficult anatomy.

Expanded transcanal transpromontorial approach for acoustic neuroma removal

Axial sections from preoperative magnetic resonance imaging without contrast, showing a cone-shaped lesion of the internal auditory canal, extending toward the most lateral part of the cerebello-pontine angle. (A) T1-weighted high-resolution isotropic volume excitation (THRIVE) sequence; (B) T1-weighted sequence; (C) Fluid attenuated inversion recovery (FLAIR) sequence. Laryngoscope, 133:282-286, 2023.

The role of adjuvant therapy in pT4N0 laryngectomized patients: Multicentric observational study

BACKGROUND

To retrospectively evaluate oncological outcomes in two groups of patients with pT4aN0 glottic SCC treated with total laryngectomy (TL) and neck dissection (ND) who underwent postoperative radiotherapy or exclusive clinical and radiological follow-up.

METHODS

It includes patients with pT4N0 glottic SCC who underwent TL and unilateral or bilateral ND with or without PORT. Divided in two comparison groups: the first group underwent adjuvant RT (TL-PORT); the second group referred to clinical and radiological follow-up (TL).

RESULTS

PORT was associated with a better OS while no differences were found in terms of DSS. A better local control is achieved when PORT is administered while no differences in terms of regional and distant control rates were found. Bilateral ND positively impacts on the regional control while the PNI negatively impact the regional control.

CONCLUSIONS

A tailored PORT protocol might be considered for pT4N0 glottic SCC treated with TL and ND, both considering the ND's extent and presence of PNI.

Vestibular schwannoma removal through expanded transcanal transpromontorial approach: a multicentric experience

PURPOSE

Expanded Transcanal Transpromontorial Approach (ExpTTA) is an endomicroscopic technique that allow surgical excision of small and symptomatic neuromas limited to the internal auditory canal (IAC) or minimally invasive the cerebellopontine angle (CPA). ExpTTA is a safer alternative to the exclusive endoscopic technique as it allows a wider surgical field and better management of the auditory porus and CPA.

METHODS

We report a retrospective case series of 34 patients who underwent ExpTTA between 2017 and 2022 at the ENT Departments of the University Hospital of Modena, Bologna and Verona. Tumor size was defined according to the Koos staging and hearing function was classified according to the AAOHNS. A clinical evaluation of facial nerve (FN) function was performed using the House and Brackman scale (HBs).

RESULTS

Our cohort consists of 34 patients. At time of surgery all patients had a normal preoperative facial function. Gross total resection was achieved in all patients, without intraoperative complications, and FN continuity was preserved in all cases. No major complications were observed. Regarding post-operative FN function, at hospital discharge ten patients had impairment equal or greater than IV grade according to H&Bs. At 6 months after surgery only two patients presented with moderate/severe facial paralysis (grade IV H&Bs) and finally at 12-month follow-up all patients had a satisfactory recovery of nervous function (grade < III H&Bs).

CONCLUSIONS

ExpTTA is a safe and effectively technique for treatment of small VS (Koos I, II and selected cases of Koos III) with low postoperative morbidity.

Occlusal splint therapy in patients with Ménière's disease and temporomandibular joint disorder

Objective

This retrospective study aimed to verify the outcomes of stabilising occlusal splint therapy prescribed to 22 patients with unilateral definite Ménière’s disease and comorbid temporomandibular joint disorder.

Methods

The results of a battery of audiometric and vestibular tests were recorded before and after 6 months of treatment, as well as the scores of disease-specific questionnaires.

Results

The average hearing threshold in the affected ear and the acoustic immittance were unchanged. No spontaneous and positional nystagmus were recorded. Caloric hypo-responsiveness and vestibular myogenic evoked responses did not vary. No changes of stabilometric body sway parameters in eyes opened condition and with optokinetic stimulation delivered to the unaffected labyrinth were observed. A significant reduction was recorded in eyes closed condition and with the optokinetic stimulation toward the affected ear. The Tinnitus Handicap Inventory, the Situational Vertigo Questionnaire and the Numeric Pain Rating Scale scores improved. The number of vertigo attacks was reduced.

Conclusions

Occlusal splint therapy is a favourable option to reduce aural symptoms of Ménière’s disease and comorbid temporomandibular joint disorder, even if its pathophysiological mechanism remains elusive.

Head and Neck Cancer During Covid-19 Pandemic: Was there a Diagnostic Delay?

The aim of the present study is to investigate a possible delay in diagnosis and therapy administration for Head and Neck oncological patients, during the Sars-Cov2 pandemic and to compare the median tumor stage (MTS) at presentation. This is a retrospective review on patients who presented at the University Hospital of Modena with a newly diagnosis of Head and Neck cancer (HNC), comparing the first pandemic period (from March 1st, to October 15th 2020) to the same period of 2019. The time in days from the diagnostic suspicion to the beginning of the treatment, hereafter referred to as delay in treatment initiation (DTI), and the tumor stage were calculated for all the enrolled patients. Mean percentage of reduction of the clinical and surgical activities was − 25.8% (range: − 66–1.5%), with higher percentages in phase 1 for all the analyzed activities. 125 HNC patients were enrolled in the analysis as the study group, compared with a cohort of 140 patients from the previous year. The MTS was III for both groups, however a significant statistical difference was determined in the stage comparison, p = 0.023. When DTI was analyzed no statistically significant differences were appreciated. A more advanced stage at presentation was demonstrated at our institution for HNC patients during the first phase of the Covid-19 pandemic in 2020. However, a statistically significant delay in time between diagnosis and therapy administration was not assessed, thus confirming the maintenance of a high level of care even in the COVID-19 era.

Technique for foreign-body removal with the use of transnasal endoscopic prelacrimal approach - A case report

The Rationale:

Foreign body (FB) in the nasal cavities is a frequent cause of otolaryngology emergency consultation that sometimes requires surgical treatment. When there is involvement of the posterolateral wall of the maxillary sinus (MS) and of the pterygopalatine fossa (PPF), conventional techniques such as antrostomy and medial endoscopic maxillectomy may not allow sufficient domination of the surgical field.

Patient Concerns:

We report the case of a woman who suffered from intranasal trauma with epistaxis and pain.

Diagnosis:

A computed tomography scan revealed a metallic FB at the level of the right posterolateral wall of the MS, PPF, and greater wing of the sphenoid bone.

Treatment and Outcome:

A minimally invasive transnasal endoscopic prelacrimal approach was chosen for its removal.

Take-away Lessons:

The postoperative recovery was rapid and without complication.

An Integrated (Microscopic/Endoscopic) Dissection Ear Surgery Course

Traditionally, otologic surgical training consisted of microscopic cadaveric dissections. However, during the last decades the endoscope has significantly changed the surgical perspective in the otologic field. Thus, the modern ear and lateral skull base surgeon should master the entire spectrum of endoscopic and microscopic approaches, with the aim of tailoring the procedure and guaranteeing the best possible functional outcome. This work proposes a step-by-step guided and illustrated dissection course, including indications for the setup of the cadaver lab and the integration of the microscope and endoscope to enhance the use of both instruments. The alternation of the endoscope and microscope allows the novice to train the correct handling of the instruments in the surgical field under both optical views. This aspect is of utmost importance since it is not advisable to start off a technique without practicing the other one, as both are important and complementary in the modern otologic surgery setting.

Use of Foley catheter in control of internal carotid hemorrhage during endoscopic endonasal surgery

Internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) are rare life-threatening events. We describe a technique to manage ICA injuries based on the use of Foley catheters.A 26-year-old female underwent endoscopic transnasal trans-sphenoidal removal of pituitary adenoma. Cerebrospinal fluid leak occurred 4 days postoperatively. During repair procedure, accidental injury of ICA occurred. Emergency nasal packing through positioning of four Foley urologic catheters was successfully performed to stop bleeding. The patient did not report neurologic deficits.In author&rsquo;s opinion, Foley catheters are suitable to obtain immediate bleeding control since they are rapidly available and easily usable.

Management of parapharyngeal space tumors with transparotid-transcervical approach: analysis of prognostic factors related with disease-control and functional outcomes

PURPOSE

Different therapeutic strategies have been developed to improve surgical and functional outcome of parapharyngeal space (PPS) neoplasms. The transparotid-transcervical approach (TTa) is a valid surgical option to manage most PPS tumors. Its short- and long-term disease control and cranial nerve (c.n.) function outcomes have not been discussed extensively.

METHODS

All patients who underwent TTa over a 10-year period at a tertiary academic center were retrospectively reviewed. Data about preoperative imaging, clinical presentation, tumor's size, location and histology, and postoperative oncological and functional results were registered and analyzed.

RESULTS

Sixty patients matched the inclusion criteria. Most of the lesions were benign (71.7%), involved the prestyloid PPS (63.3%) and measured more than 30 mm (75%). Fifty-two (86.7%) lesions were resected en-bloc. Clear margins were achieved in 91.7% of the cases, with positive margins solely associated with malignancy (p = 0.008). Post-operative c.n. function was satisfactory, with X c.n. function significantly associated with the retrostyloid location (p = .00) and neurogenic tumors (p = 0.02). Local disease-control was achieved in 96% of the cases after a median follow-up of 46 (± 19.7-82.0 IQR) months.

CONCLUSIONS

The TTa was safe and effective, achieving a satisfactory local control rate. Nevertheless, malignancies maintain a higher rate of positive margin due to their infiltrative nature and the complex anatomy of the PPS. In such cases, multiportal approaches might be more effective. However, post-operative c.n. function remained satisfactory, irrespective of lesions' size and histopathologic behavior. A higher X c.n. deficit rate was observed in retrostyloid and neurogenic lesions.

Surgical multidisciplinary approach of orbital complications of sinonasal inflammatory disorders

Orbital infection complicating sinonasal inflammatory disorders may lead to serious sequelae, including blindness and death, if untreated. Communication between the otorhinolaryngologist, neuroradiologist, ophtalmologist, neurosurgeon and maxillo-facial surgeon is critical and time-sensitive for a successful treatment. The large majority of pre-septal cellulitis cases resolves after broad-spectrum antibiotic therapy. Also orbital cellulitis has been found responsive to pharmacological approach in most cases. The management of the subperiosteal abscess (SPA) is more controversial. An aggressive surgical approach is always recommended also in case of cavernous sinus thrombosis. In cases of surgical indication, debate is still open on the timing and the approach (endoscopic or external). The surgeon should be prepared to convert an endoscopic approach to an external one if needed and this should be included in the informed consent. Decompression of one or more orbital walls may be necessary if orbital pressure remains elevated. Immediate surgery is indicated in children with large SPA or orbital abscesses (OA), or in immune-compromised patients. Moreover, any worsening in the ophthalmological function must be carefully considered as a landmark in candidacy to surgery.

Endoscopic Anatomy of the Chorda Tympani: Systematic Dissection, Novel Anatomic Classification, and Surgical Implications

HYPOTHESIS

A transcanal endoscopic approach enables visualization of the variable course of the chorda tympani inside the middle ear.

BACKGROUND

The chorda tympani is the longest intrapetrous branch of the facial nerve. Despite having been investigated in several studies, a description of its tympanic tract from an endoscopic point of view is lacking in the literature.

METHODS

We performed transcanal endoscopic dissections of 44 human cadaveric head and ear specimens. The entry point of the chorda tympani into the middle ear was classified into four categories according to its location, and as covered or dehiscent according to its appearance. The chordal eminence (CE) was defined as absent, shallow, intermediate, prominent, or fused, based on its shape and extension. The relationship of the chorda tympani to adjacent bony and ligamental structures was assessed.

RESULTS

The tympanic tract of the chorda tympani was divided into three portions. The periannular segment was dehiscent in 54.5% of specimens, with type II being the most frequent entry point configuration (52.3%). In the interossicular segment, the nerve consistently passed lateral to the incus and medial to the malleus. The course of the intrapetrous segment was independent from the conformation of the tensor fold and supratubal recess.

CONCLUSION

The transcanal endoscopic approach allows a detailed description of tympanic segment of the chorda tympani. Novel anatomic classifications of the chorda tympani and CE are proposed herein to highlight their possible surgical implications during otologic procedures.

The Tensor Tympani Tendon: A Hypothetical Site of Origin of Congenital Cholesteatoma

Multiple theories have been discussed about the etiopathogenesis of congenital middle ear cholesteatoma (CMEC) and its specific site of origin. The intraoperative identification of the precise location of the keratinous mass is important to guarantee its complete removal, in order to reduce the risk of recurrence. This study proposes the tensor tympani tendon (TTT) as a possible site of origin of CMEC. All CMECs treated between 2013 and 2019 were reviewed. Only Potsic stage I lesions were included. Preoperative radiologic images were compared to intraoperative findings. Three removed TTT were sent for histologic evaluation. Seven patients were included (M:F = 3:4). Preoperative CT images were classified as type A in 2 cases (28.6%) and type B in 5 cases (71.4%). At intraoperative evaluation all CMEC sacs were found pedunculated on the TTT. The histologic examinations confirmed the connection between the cholesteatomatous sac and the TTT. According to the correlation of imaging, intraoperative findings and histology, we proposed that the TTT could be the primary site from which CMEC originates.

Quality of life in vestibular schwannoma: a comparison of three surgical techniques

OBJECTIVE

Through years, interest in quality of life (QoL) among patients affected by vestibular schwannoma (VS) has increased. The expansion of the indications for endoscopic ear surgery allowed the development of the transcanal transpromontorial surgery (TTS) for VS removal. The objective of the present study was to assess QoL in a cohort of VS patients operated on by translabyrinthine (TL), retrosigmoid (RS) and TTS approach.

METHODS

The study was conducted on 111 patients who underwent surgery for VS between January 2017 and January 2020 at two different institutions. Patients fulfilled three questionnaires during follow-up: Glasgow Benefit Inventory, Depression Anxiety Stress Scales-21 and Penn Acoustic Neuroma Quality-Of-Life. The association between sex, age, date of surgery, tumor size, post-operative facial nerve (FN) function and QoL outcomes was assessed.

RESULTS

An overall subjective impairment was demonstrated in all groups. Age, Koos staging and FN functions were associated to distinct QoL outcomes.

CONCLUSIONS

QoL decreases in patients surgically treated for VS. The TTS may allow improved scores in many domains, confirming to be a subjectively well-tolerated technique.

Prelaminated flaps in head and neck cancer reconstructive surgery: A systematic review

Background

Prelamination is a reconstructive technique providing fasciomucosal or composite flaps with low donor‐site morbidity. We conducted a systematic review of retrospective studies to assess the application of prelaminated flaps in reconstructive surgery of head and neck cancer patients, and to evaluate the advantages and disadvantages of this technique.

Methods

This systematic review adhered to the recommendations of the PRISMA (Preferred Reporting Items of Systematic Reviews and Meta‐analysis) 2009 guidelines. A computerized MEDLINE search was performed using the PubMed service of the U.S. National Library of Medicine (www.pubmed.org) and Scopus database (www.scopus.com), running the following search string: “prelamination OR prelaminated AND flap.” Two authors screened the articles, then selected and extracted data on malignancies characteristics, reconstructive techniques, outcomes and complications.

Results

A total of 19 articles were selected and reviewed from 128 identified. Seven of 19 articles were case reports, 12 articles were case series. One‐hundred‐two patients underwent reconstructive treatment by prelamination technique using a wide variety of flaps (92 free, 10 pedicled). The sites of reconstruction were oral cavity (66 floor of the mouth, 3 retromolar trigone, 6 hard palate, 4 cheek, 4 tongue), 8 facial skin (5 of them sited on the nose), 4 oropharyngeal defects, 1 laryngotracheal region. No case of total flap loss was reported. Partial flap loss or shrinkage requiring minor surgical revisions was observed in 18 patients (17.6%). Primary closure of the donor site was achieved in 97 cases (97%) and 3 (3%) required revision surgery of the donor site.

Conclusion

Prelamination is an effective and versatile technique, with low donor‐site morbidity. Further studies would be needed to investigate the impact on the patient's oncologic outcome. More comparative studies with standard reconstructive techniques are essential to understand when it is worth performing this sophisticated procedure.

Anatomic and radiologic relationships of neck structures to cervical spine: implications for anterior surgical approaches

The position of the pharyngolaryngeal framework is very important in choosing the best surgical approach for cervical spine disease. The aim of the present paper is to investigate the position of the hyoid bone and cricoid cartilage in relation to the cervical spine. Moreover, the surgical implications for anterior transcervical approaches to the upper spine and the prevertebral space are discussed. To minimise complication rates and increase surgical effectiveness, the location and extent of the cervical spine disease should be evaluated in the context of the patient’s specific anatomy. A retrospective analysis of 100 cervical spine MRIs was conducted. Patients with diseases that could alter anatomic relationships of cervical structures were excluded. The mid-sagittal view of the hyoid and the inferior margin of the cricoid cartilage were projected perpendicularly to the anterior surface of the cervical vertebrae. The distance between these two landmarks was measured on the same view. The distribution of hyoid projections ranged between C2-C3 and C4-C5 intervertebral space, while the cricoid cartilage ranged between C4-C5 and C7-T1 intervertebral spaces. The mean distance between these two landmarks was 49.1 ± 7.7 mm, with statistically significant differences between males and females. The position of the cricoid cartilage significantly influenced the length of the pharyngolaryngeal framework, while the position of hyoid did not. A wide range of variability in the position of the hyoid bone and the cricoid cartilage in relation to cervical levels exists. This implies that an a priori association of a cervical level to neck structures at risk might be inaccurate. The use of these easily identifiable landmarks on pre-operative imaging may help to guide the choice among different anterior surgical approaches to cervical spine and reduce the risk of surgical complications.

Validation of the Modena bleeding score in endoscopic sinus surgery

Introduction

The Modena bleeding score is a categorical rating scale that allows the assessment of the surgical field in relation to bleeding during endoscopic surgery. It has recently been presented and validated in the field of endoscopic ear surgery by the present authors. The Modena bleeding score provides five grades for rating the surgical field during endoscopic procedures (from grade 1 − no bleeding to grade 5 − bleeding that prevents every surgical procedure except those dedicated to bleeding control).

Objective

The aim of this study was to validate the Modena bleeding score in the setting of endoscopic sinus surgery.

Methods

Fifteen three-minute videos of endoscopic sinus surgery procedures (each containing three bleeding situations) were evaluated by 15 specialists, using the Modena bleeding score. Intra and inter-rater reliability were assessed, and the clinical validity of the Modena bleeding score was calculated using a referent standard.

Results

The data analysis showed an intra-rater reliability ranging from 0.6336 to 0.861. The inter-rater reliability ranged from 0.676 to 0.844. The clinical validity was α = 0.70; confidence limits: 0.64 − 0.75, corresponding to substantial agreement.

Conclusion

The Modena bleeding score is an effective method to score bleeding during endoscopic sinus surgery. Its application in future research could facilitate the performance and efficacy assessment of surgical techniques, materials or devices aimed to bleeding control during endoscopic sinus surgery.

Functional Results and Learning Curve of Endoscopic Stapes Surgery: A 10-Year Experience

OBJECTIVES/HYPOTHESIS

To assess hearing outcomes and complications of endoscopic stapes surgery by a single surgeon in a 10-year period, to compare these data with conventional microscopic procedures by the same operator, and to describe the learning curve of endoscopic stapedotomy.

STUDY DESIGN

Retrospective study.

METHODS

This is a retrospective study on patients who underwent endoscopic stapes surgery performed by the same senior surgeon, experienced both in microscopic and endoscopic techniques, between January 2009 and December 2018. Audiological data were compared, and intraoperative and postoperative complications were collected. The surgeon's last 30 cases of microscopic stapedotomy were enrolled as the control group. The results of the first 100 endoscopic stapes surgeries were analyzed separately to create a cumulative sum (CUSUM) control chart for learning curve assessment.

RESULTS

One hundred seventy-eight endoscopic and 30 microscopic stapes surgeries were included. In the endoscopic group, the mean postoperative air-bone gap was 8.2 dB. No significant differences between the endoscopic and microscopic preoperative and postoperative values were reported. A total of eight complications (4.5%) were observed in the endoscopic cohort, although in the control group, no complication occurred. The mean surgical time was 51.9 minutes in the endoscopic group versus 48.2 minutes in the microscopic group (P > .05). No association between stapedotomy success and the increasing number of procedures was found.

CONCLUSIONS

Our article demonstrates that functional results from endoscopic stapes surgery are similar to those from microscopic stapes surgery in terms of both safety and efficacy. After gaining endoscopic experience, the surgical duration of stapes surgery will be adequate starting from the first cases.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:885-891, 2021.

Treatment of Recurrent Tracheocutaneous Fistulas in the Irradiated Neck with a Two Layers-Two Flaps Combined Technique

The development of a tracheocutaneous fistula (TCF) is a well-documented complication after tracheostomy, especially in chronic morbid patients, in whom tubes or cannulas are left in place over time, or in irradiated patients.

Surgical treatments are therefore needed which range from simple curettage and dressings to local skin flaps, muscle flaps and, in the more complex cases, microsurgical free tissue transfers.

We present a novel combined technique used to successfully treat recurrent TCFs in irradiated patients, involving a superiorly based turnover fistula flap and a sternocleidomastoid transposition flap.

Does microscopic experience influence learning curve in endoscopic ear surgery? A multicentric study

OBJECTIVE

The aim of the present study was to illustrate the learning curve of endoscopic type-1 tympanoplasty comparing experts in microscopic otology versus neophyte surgeons.

METHODS

Eight ear surgeons, from tertiary referral centers, who had performed at least 30 endoscopic type 1 tympanoplasties were included in the study. Demographic data and medical records regarding the first 30 endoscopic type-1 tympanoplasties were retrospectively collected by each surgeon. A 14-questions survey focused on subjective aspects of the learning curve was administered. Surgeons were divided in two groups: one with previous experience in microscopic ear surgery (group 1) and one with no previous experience in ear surgery (group 2). The learning curve of endoscopic type 1 tympanoplasty was compared between the groups.

RESULTS

Mean surgical time was 89.2 min in group 1 vs. 79.5 min in group 2 (p < 0.01). When divided in 5 surgeries-steps, the only significant difference was appreciated in the first 5 surgeries with a longer mean time in group 1 vs. group 2 (+28.4 min; p < 0.05).

CONCLUSIONS

Surgeon's previous experience may influence the EES learning curve. Our results show that the first 5 surgical procedures are more challenging for surgeons experienced in microscopic surgery, subsequently the curve progression improves sharply and appears reversing the initial trend by the end of the 30 surgeries.

Use of IMAGE1 S technology for detection of cholesteatoma in endoscopic ear surgery: a retrospective case series on 45 patients

PURPOSE

To evaluate the role of selected modalities of Storz Professional Image Enhancement System (IMAGE1 S) in differentiating cholesteatoma during endoscopic ear surgery (EES); to assess the potential usefulness of IMAGE1 S in recognition of cholesteatoma residuals at the end of EES.

METHODS

A retrospective study on 45 consecutive patients who underwent EES for cholesteatoma between March 2019 and November 2019 at a tertiary referral center was performed. For each case, Spectra A and Spectra B filters were applied intra-operatively. When examining the surgical field, a switch from white light (WL) to IMAGE1 S was performed to detect cholesteatoma and differentiate it from non-cholesteatomatous tissue. When the IMAGE1 S pattern was suspicious for the presence of cholesteatoma, images of the field under both enhancement modalities were taken and the targeted lesions were sent for histologic analysis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of IMAGE1 S were calculated. A final recognition of the surgical field using the selected filters was performed to detect any possible cholesteatomatous residuals.

RESULTS

Detection of cholesteatoma by IMAGE1 S selected filters revealed the following data: sensitivity 97%, specificity 95%, PPV 95%, NPV 97%. On three occasions, there was no correspondence between enhanced endoscopy and histology. In 5 out of 45 cases (11%), cholesteatoma residuals, which had not been identified at WL inspection at the end of the procedure, were detected by IMAGE1 S.

CONCLUSION

Our results suggest a potential role for IMAGE1 S Spectra A and B filters in EES for cholesteatoma surgery. We propose the integration of IMAGE1 S as a final overview of the surgical cavity for recognition of cholesteatomatous residuals.

Evaluation of Performance and Tolerability of Nebulized Hyaluronic Acid Nasal Hypertonic Solution in the Treatment of Chronic Rhinosinusitis

BACKGROUND

Nasal solutions are part of the recommended therapy of chronic rhinosinusitis (CRS). Formulations containing hyaluronic acid (HA) may represent a promising topical treatment in CRS patients in light of the anti-inflammatory and protective effect of HA on the sinonasal mucosa.

OBJECTIVE

Primary aim was to evaluate the performance of a new nebulized HA nasal hypertonic solution in the relief of symptoms of CRS. Secondarily, evaluation of symptoms improvement, endoscopic nasal findings, and safety profile were assessed.

METHODS

A monocenter, single arm, not controlled, premarket clinical trial on a new nasal solution containing HA was performed. All the included patients had a history of previously diagnosed or recurrent CRS or they had received a clinical diagnosis of CRS defined, according to the European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Each patient was evaluated on 3 visits. Endoscopic nasal examination and Nasal Obstruction Symptom Evaluation Instrument questionnaire filling were performed during each visit. Patients' adherence to treatment and overall satisfaction, patients' and investigator's global evaluation of performance, and safety parameters were also assessed.

RESULTS

Eighty patients were enrolled. The use of the investigated HA nasal solution revealed to be significantly effective in the relief of symptoms of CRS. According to daily patients' diaries, several signs and symptoms significantly improved after therapy. The comparison between endoscopic assessments before and after treatment confirmed improvement of the condition in at least 75% of patients. Seventy-four percent of the patients were quite or very satisfied with the treatment and 80% reported an improvement. The investigator's global assessment of performance was in agreement with this view, as more than 80% of the patients were considered clinically improved.

CONCLUSIONS

The use of the investigated new nebulized HA nasal hypertonic solution is an effective and safe the treatment of CRS.

Endoscopic facial nerve decompression in post-traumatic facial palsies: pilot clinical experience

PURPOSE

Post-traumatic facial nerve (FN) paralysis might need surgical decompression in selected patients. Different microscope-based surgical techniques are described in the literature such as the transmastoid, the middle cranial fossa and the translabyrinthine approach. The effectiveness of the transcanal endoscopic approach (TEA) in managing such condition has never been described and its possible indications has to be defined.

METHODS

Retrospective multi-centric case series of patients with post-traumatic FN paralysis surgically treated with TEA. From July 2013 to July 2017, 6 patients underwent TEA for post-traumatic FN paralysis with involvement of the second genu and/or the tympanic segment of the nerve. The surgical technique is described step by step, with focus on anatomic landmarks. Post-operative outcomes are specified in terms of FN postoperative function and audiologic results.

RESULTS

The TEA showed to recover a House-Brackmann grade I-II FN function in 83.2% of the patient. Post-operative air-bone gap significantly improved; whereas, the pure-tone average bone conduction did not differ significantly.

CONCLUSIONS

TEA represents a viable option for the treatment of post-traumatic facial palsy in patients with radiologic evidence of tympanic segment and/or perigeniculate region involvement with no involvement of the mastoid segment of the FN. Transcanal endoscopic facial nerve decompression is a safe and effective approach in highly selected cases.

LEVEL OF EVIDENCE

4.

Pharyngo-Esophageal Perforations After Anterior Cervical Spine Surgery: Management and Outcomes

OBJECTIVE

To report about the diagnosis, surgical treatment, and postoperative management of pharyngo-esophageal perforations (PEPs) after anterior cervical spine (ACS) surgery in 17 patients.

METHODS

A retrospective multicenter case series of patients surgically treated for PEP after ACS surgery was performed. Data regarding cervical spine pathology and surgery, comorbidities, diagnosis and surgical management of PEP, airway management, antibiotic therapy, postoperative course, and feeding route after repair surgery at discharge and last follow-up were collected.

RESULTS

Seventeen patients were included in the study, for a total of 22 surgical procedures for PEP repair. Seven PEPs (41%) had early onset, whereas 10 (59%) were delayed. All patients underwent PEP surgical repair through an anterior prevascular retrovisceral cervicotomic approach, consisting of multiple layer sutures of the perforation, with flap interposition. Despite the challenging management of these patients, 16 of 17 patients from our series restored oral feeding.

CONCLUSIONS

PEPs are among the most appalling complications of cervical spine surgery. Because of their rarity and heterogeneous presentation, a standardized management is difficult to define. From our experience with the largest case series in the literature, a multidisciplinary approach is advisable to deal with these patients.

The endoscopic anatomy of the cochlear hook region and fustis: surgical implications

The cochlear hook region can be considered as the interface between the middle and inner ear. The identification of surgically-relevant endoscopic landmarks of this anatomical entity and assessment of their clinical value is still lacking in the literature. Procedures like cholesteatoma surgery and minimal invasive endoscopic approaches to the lateral skull base may particularly benefit from these considerations. We hypothesize that the spatial orientation of anatomical landmarks in the cochlear hook can be expressed in angles and are reproducibly identifiable by transcanal otoendoscopy. Therefore, endoscopic dissection of the cochlear hook region was performed in 32 temporal bone specimens. Topographic anatomy was documented and analysed. We performed computed tomography of 28 specimens to assess the region in three-dimensional reconstructions. The mean angle between the round window and the basal scala tympani was assessed 25.9° in endoscopic and 28.2° in three-dimensionally reconstructed models. The fustis was recognised as a reliable landmark for the basal turn. A mean angle of 155.4° to the basal scala tympani was assessed. A slight bulging without obstruction of the basal turn was observed in 5 cases. The utility of the revealed anatomical details was assessed in minimal invasive endoscopic lateral skull base approaches. In conclusion, we described the angles between anatomical landmarks of the cochlear hook region. Moreover, the angle as recorded through an endoscope was found to be reliable compared to three-dimensional reconstructions from computed tomography.

Spontaneous Nasal Cerebrospinal Fluid Leak Repaired With Single-Layer Mucoperichondrial Graft: Long-term Results

Background

Spontaneous cerebrospinal fluid leak (sCSFL) has been historically related to obesity and elevated intracranial pressure (ICP), with a lower rate of success of endoscopic repair reported in the literature. Moreover, defects related to this condition have been largely repaired with multilayer reconstructions and pedicled flaps. Long-term postoperative results have not been appropriately discussed yet.

Objective

The aim of this study is to investigate the outcome of a cohort of patients treated with single-layer mucoperichondrial graft.

Methods

A retrospective review of clinical records of a consecutive series of patients who underwent endonasal endoscopic surgery for sCSFL was carried out at a tertiary care referral center for skull base pathologies. All patients underwent reconstruction with single-layer mucoperichondrial free graft. Local flap failures and postoperative outcomes, in terms of recurrence of sCSFL or brain herniation, were registered.

Results

Neither intraoperative nor perioperative complications were reported. Definitive closure was achieved in 27 of 29 (93%) patients after the first attempt, while in 2 cases, a revision surgery was required. In both of these, an inadequate position of the graft was detected and was repaired likewise with the same mucoperichondrial graft. None of the patients required postoperative lumbar drain placement. After a median follow-up period of 57 months, only 1 patient developed a meningocele without CSFL about 2 years after surgery at the contralateral lateral recess of the sphenoid sinus. None of the patients reported symptoms referable to elevated ICP nor underwent ventricular derivation.

Conclusions

Single-layered mucoperichondrial free graft was safe and effective in the majority of the examined patients. In 7% of the study population, a surgical revision was necessary due to local failure of the graft. However, during long-term follow-up, only 1 case of recurrent meningocele without CSFL was reported in a patient who presented borderline ICP.

Transcanal Transpromontorial Approach to Lateral Skull Base: Maximal Area of Exposure and Surgical Extensions

OBJECTIVE

To determine the possible surgical extensions and maximal area of exposure (AOE) achievable through the transcanal transpromontorial approach (TTA) to the internal auditory canal (IAC) and cerebellopontine angle. We hypothesize a possible extension of indication for this minimally invasive approach to the lateral skull base.

METHODS

In this experimental anatomic study, the expanded TTA was first carried out in 4 temporal bones to define the anatomic boundaries of the maximal exposure, from 2 perspectives, the middle ear and the porus of the IAC. Consecutively, these identified boundaries were translated on segmented 3-dimensional (3D) surface models of 32 temporal bone high-resolution computed tomography scans.

RESULTS

The dissections performed were the basis followed during the determination of the AOE on the 3D surface models. The measurements revealed that the AOE at the middle ear was 152.9 ± 33.6 mm², whereas it was 151.9 ± 24.8 mm² at the porus of the IAC. The mean superoinferior and anteroposterior extensions at the middle ear were 14.7 ± 2.5 mm and 16.9 ± 2.5 mm, respectively. On the other hand, the mean superoinferior and anteroposterior extensions at the IAC porus were 10.3 ± 1.3 mm and 18.5 ± 1.9 mm, respectively.

CONCLUSIONS

Consistent with the minimally invasive approaches, the AOE is limited; however, if compared with traditional approaches, it appears of considerable size. Our results may assist the surgeon in the selection process of the appropriate candidates for the TTA and to tailor the approach to the disease.

Management of Jugular Bulb Injuries during Endoscopic Ear Surgery: Our Experience

Objectives  The main objective of this article is to describe endoscopic management of intraoperative massive bleeding from jugular bulb injury during exclusively transcanal endoscopic procedures for middle ear pathologies. Design  Case series with chart review. Setting  Tertiary referral center. Participants  We retrospectively reviewed two patients who experienced jugular bulb injury during endoscopic transcanal approach for glomus tympanicum and chronic otitis media. The surgical videos and charts were carefully investigated and analyzed. Main Outcome Measures  Feasibility and suitability of exclusive endoscopic management of jugular bulb bleeding and description of surgical maneuvers that should be performed to obtain safe and effective hemostasis. Results  In both patients, jugular bulb bleeding was progressively controlled by means of exclusive endoscopic approach with no need to convert to microscopic approach. None of the cases required a second surgeon helping in keeping the endoscope during hemostatic maneuvers. Both patients had a normal postoperative period with no recurrence of hemorrhage. Conclusions  Endoscopic management of jugular bulb bleeding is feasible by using the technique described with reasonable efficacy and with no additional risk or morbidity to the procedure. Knowledge of anatomy and its variants, preoperative evaluation of imaging, and the ability of the surgeon to adapt the surgical technique to the specific case are recommended to prevent vascular complications during endoscopic ear surgery.

Low-dose intratympanic gentamicin administration for unilateral Meniere's disease using a method based on clinical symptomatology: Preliminary results

PURPOSE

There are many therapeutic options for Meniere's disease (MD); intratympanic (IT) gentamicin has been proposed for intractable cases although controversy about dosage and method exists. The purpose of this study was to assess the efficacy and safety of low-dose IT gentamicin on vertigo attacks in MD using a clinical symptomatology-based method in which administration was repeated only if vertigo attacks recurred, with a 2-week interval between injections.

MATERIALS AND METHODS

Forty-eight patients with unilateral intractable MD were included in the study. All patients received one to five IT injections with 0.5 ml of 10 mg of gentamicin (80 mg/2 ml) with an interval of 2 weeks between injections. Vertigo attacks were evaluated before and after therapy and categorized into classes A-F according to the 2015 Equilibrium Committee criteria. Audiovestibular assessment with pure tone audiometry, vestibular bed-side examination and video head impulse test was performed.

RESULTS

Before treatment patients had an average of 4.4 vertigo attacks/month; after treatment the average number decreased to 0.52. The majority of patients (77%) reached Class A vertigo control with 5 or less gentamicin injections. VOR gain was unaffected in the healthy side and significantly reduced in the affected side. No hearing deterioration was found in all treated patients.

CONCLUSIONS

Low-dose IT gentamicin administration based on clinical symptomatology can produce a satisfactory control of vertigo attacks after treatment; such protocol had an effect mainly on the vestibular function as demonstrated by the significant reduction in VOR gain in the affected side avoiding a cochlear damage.

Food-induced stimulation of the antisecretory factor to improve symptoms in Meniere's disease: our results

PURPOSE

Specially processed cereals (SPC) that increase endogenous antisecretory factor (AF) synthesis have been proposed to improve symptoms of Meniere's disease (MD) with controversial results. The aim of this study was to evaluate the effects of SPC in patients with definite unilateral MD and compare the results to a treatment protocol with intravenous glycerol and dexamethasone.

METHODS

Thirteen patients with unilateral MD were treated with SPC and 13 patients were treated with intravenous glycerol and dexamethasone for 12 months. Audio-vestibular evaluation was performed before (T0) and at the end of the treatments (T12). The number of vertigo spells were evaluated before and after therapy and the Efficacy Index (EI) was calculated. Questionnaires for hearing loss (HHIA), tinnitus (THI) and quality of life (TFL) were administered.

RESULTS

EI decreased in the SPC group in the second semester compared to the first although not significantly (p = 0.6323). There was a significant reduction for THI score in the SPC group at T12 (p = 0.0325). No significant differences were found between the two groups at T0 (p = 0.4723), while a significant difference was found at T12 (p = 0.0041). Quality of life showed an improvement in daily activities in the SPC group compared to infusion therapy group.

CONCLUSION

Our study shows a reduced number of vertigo attacks and a positive effect on the discomfort generated by tinnitus and quality of life in patients with unilateral MD treated with SPC and when compared to patients treated with intravenous glycerol and dexamethasone. No effects on hearing thresholds were noted in both groups.

Neuroendoscopic Aspiration of Blood Clots in the Cerebral Aqueduct and Third Ventricle During Posterior Fossa Surgery in the Prone Position

BACKGROUND

During surgery in the posterior fossa in the prone position, blood can sometimes fill the surgical field, due both to the less efficient venous drainage compared to the sitting position and the horizontally positioned surgical field itself. In some cases, blood clots can wedge into the cerebral aqueduct and the third ventricle, and potentially cause acute hydrocephalus during the postoperative course.

OBJECTIVE

To illustrate a technique that can be used in these cases: the use of a flexible scope introduced through the opened roof of the fourth ventricle with a freehand technique allows the navigation of the fourth ventricle, the cerebral aqueduct, and the third ventricle in order to explore the cerebrospinal fluid pathways and eventually aspirate blood clots and surgical debris.

METHODS

We report on one patient affected by an ependymoma of the fourth ventricle, for whom we used a flexible neuroendoscope to explore and clear blood clots from the cerebral aqueduct and the third ventricle after the resection of the tumor in the prone position. Blood is aspirated with a syringe using the working channel of the scope as a sucker.

RESULTS

A large blood clot that was lying on the roof of the third ventricle was aspirated, setting the ventricle completely free. Other clots were aspirated from the right foramen of Monro and from the optic recess.

CONCLUSION

We describe this novel technique, which represents a safe and efficient way to clear the surgical field at the end of posterior fossa surgery in the prone position. The unusual endoscopic visual perspective and instrument maneuvers are easily handled with proper neuroendoscopic training.

Gusher in stapes surgery: a systematic review

OBJECTIVE

The aim of this study is to perform a systematic literature review on the occurrence of gusher during stapes surgery, to understand its surgical management and outcomes.

METHODS

The PRISMA standard was applied to identify English, Italian or French-language studies, related to stapes surgery and mentioning gusher or perilymphatic leak. Full-texts lacking information on the management of gusher and/or the post-operative hearing outcome were excluded.

RESULTS

Twenty-four articles were eventually included. Seventy-six patients were involved in the qualitative synthesis. The management of gusher mostly consisted in covering the oval window and/or filling the tympanic cavity, with absorbable and autologous graft materials. Packing of the external auditory canal was reported in 51 patients (67%). Gusher was related to complete/profound loss of hearing in 25% of the cases and to a worsening of hearing function in 31% of patients. In 19% of patients an improvement in hearing tests was reported; in 28% the hearing function was unchanged. Post-operative vestibular symptoms were reported in 7 patients, and were mainly mild and transient. The absence of vestibular symptoms was underlined in 9 cases, while in 79% of the patients the authors did not provide information.

CONCLUSION

The unexpected occurrence of gusher during stapes surgery represents a relevant issue for the otologic surgeon. Its management most commonly consists in plugging the oval window and the tympanic cavity. In most of the cases, a stapes prosthesis could be positioned. The results on hearing and vestibular functions are widely variable.

Surgical outcomes in the treatment of temporal bone cerebrospinal fluid leak: A systematic review

Objective

Temporal bone CSF leak represents a rare condition that may be associated to some particular symptoms as hearing loss, otorrhea and tinnitus. In the opinion of many authors a surgical treatment is mandatory to avoid serious consequences as meningitis. Middle cranial fossa (MCF), transmastoid (TM) and combined approaches are all described to manage this condition. The objective of this paper was firstly to analyze the overall outcomes of this surgery. Our second aim was to make a comparison between different surgical modalities on the basis of their rate of success and complications.

Methods

A search thorough Ovid MEDLINE was organized in January 2017 to enroll all eligible articles. A statistical analysis of the obtained data was performed.

Results

Thirtythree studies comprising a total of 873 procedures were included. The overall rate of success resulted 95.6% (94.1–96.8). The rate of major complications analyzed for 818 procedures was 3.4% (2.3–4.8). Subgroups analysis showed a success rate of 97.1% (90.7–99.5) for TM approach. A success rate of 94.1% (89.1–97.3) was calculated for MCF approach. Combined procedure (TM + MCF) showed a success rate of 97.9% (92.9–99.7).

Conclusion

The results of our review showed as the surgical treatment for CSF leak of temporal bone origin represents a safe option with high rate of success. Moreover our statistical data suggested that no significant differences are present in terms of outcomes between the analyzed surgical approaches.

Novel Surgical and Radiologic Classification of the Subtympanic Sinus: Implications for Endoscopic Ear Surgery

Objective

The aim of this study is to describe the endoscopic anatomy of the subtympanic sinus (STS), establish a classification according to its extension regarding the level of the facial nerve (FN), and assess the feasibility of the transcanal endoscopic approach to the STS.

Study Design

Experimental anatomic research.

Setting

Temporal bone laboratory.

Methods

We performed endoscopic dissection of 34 human whole head and ear block specimens. Of those, 29 underwent high-resolution computed tomography. The STS was classified according to its extension regarding the level of the FN: type A, no extension medial to the FN; type B, extension to the medial limit of the FN; type C, extension of the sinus medially and posteriorly from the FN into the mastoid cavity.

Results

The majority of cases (n = 21, 72%) showed a shallow type A STS. We observed a deep type B configuration in 6 cases (21%) and a type C in 2 cases (7%). The STS was completely exposable with a 0° endoscope in 44% of the specimens. Using a 45° endoscope, we gained complete insight in 79%. However, in 21% of the cases, the posteromedial extension of the STS was too deep to be completely explored by an endoscopic transcanal approach.

Conclusion

The majority of the STS is shallow and does not extend medially from the FN. This morphologic variant allows complete transcanal endoscopic visualization. In more excavated STS, a complete endoscopic exploration is not achievable, and a retrofacial approach may be adopted to completely access the STS.

Expanded transcanal transpromontorial approach to the internal auditory canal and cerebellopontine angle: a cadaveric study

The aim of this paper is to describe and evaluate the feasibility of an expanded endoscopic transcanal transpromotorial approach (ExpTTA) to the internal auditory canal and the cerebellopontine angle. To this end, we performed a cadaveric dissection study in September 2015. In total, 2 heads (4 sides) were dissected focusing on anatomical landmarks and surgical feasibility. Data from dissections were reviewed and analysed for further consideration. In all 4 sides of the cadavers the procedure was feasible. In all cadavers, it was necessary to extensively drill the temporo-mandibular joint and to calibrate the external ear canal to allow adequate room to manoeuver the instruments and optics and to comfortably access the cerebellopontine angle. In addition, thorough skeletonisation of the carotid artery and the jugular bulb were necessary for the same purpose. In conclusion, ExpTTA appeared to be successful to access the internal auditory canal and cerebellopontine angle region. Potential extensive and routine application of this type of approach in lateral skull base surgery will depend on the development of technology and surgical refinements and on the diffusion of skull base endoscopic skills among otolaryngologists and neurosurgical community.