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Currò N, Guastella C, Pirola G, Calonghi B, Bottari de Castello A, Fazio M, di Benedetto S, Minorini V, Daga M, Contarino A, Muller I, Arosio M, Viola F, Pignataro L, Salvi M. CLINICAL AND VISUAL OUTCOMES OF DYSTHYROID OPTIC NEUROPATHY AFTER SURGICAL ORBITAL DECOMPRESSION. Thyroid 2023. [PMID: 37140534 DOI: 10.1089/thy.2022.0564] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Current guidelines suggest high dose steroids as first line treatment for dysthyroid optic neuropathy (DON). When steroids fail, decompressive surgery is mandatory. METHODS We conducted a single-centre, retrospective cohort study in a tertiary care combined Thyroid-Eye clinic in Milan, Italy. We studied 88 orbits of 56 patients which were submitted to surgical orbital decompression to treat DON from 2005 to 2020. Of these, 33 orbits (37.5%) underwent surgery as first line treatment for DON while the other 55 (62.5%) were decompressed after being unresponsive to very high dose steroids. Previous orbital surgery, concurrent neurological or ophthalmologic diseases or incomplete follow-up were considered as exclusion criteria from this study. Surgery was considered successful if no further decompression was needed to preserve vision. Pinhole best corrected visual acuity (p-BCVA), color sensitivity, automated visual field, pupil reflexes, optic disc and fundus appearance, exophtalmometry and ocular motility were studied before and after surgery (1 week, 1, 3, 6 and 12 months). Activity of Graves' Orbitopathy (GO) was graded using a clinical activity score (CAS). RESULTS Surgery was successful in 77 orbits (87.5%). The remaining 11 orbits (13%) needed further surgery to treat DON definitively. All parameters of visual function improved significantly at follow up and GO inactivated (CAS<3) within one month. At three months, all 77 responding orbits had p-BCVA > 0.63 while all of the 11 non-responding orbits had p-BCVA ≤ 0.63. Visual field parameters and color sensitivity were not associated with response to surgery. High dose steroid treatment before surgery was associated to a better response rate (96% vs. 73%; P=0.004). Balanced decompression was associated with a higher response rate compared to medial wall decompression (96% vs. 80%; P=0.04). A significant inverse correlation was observed between final p-BCVA and patient's age (r = -0.42; P=0.0003). CONCLUSIONS Surgical decompression was found to be a very effective treatment for DON. In this study, all clinical parameters improved after surgery and further intervention was rarely needed.
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Affiliation(s)
- Nicola Currò
- Policlinico di Milano, 9339, Ophthalmology Unit, Departement of Surgery, Milan, Lombardia, Italy;
| | | | - Giacinta Pirola
- Policlinico di Milano, 9339, Ophthalmology Unit, department of Surgery, Milan, Lombardia, Italy;
| | - Barbara Calonghi
- Policlinico di Milano, 9339, Ophthalmology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | | | - Mariachiara Fazio
- Policlinico di Milano, 9339, Ophthalmology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | - Sabina di Benedetto
- Policlinico di Milano, 9339, Ophthalmology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | - Valeria Minorini
- Policlinico di Milano, 9339, Ophthalmology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | - Marco Daga
- Policlinico of Milan, 9339, Otolaringology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | - Andrea Contarino
- Policlinico di Milano, 9339, Endocrinology Unit, department of Clinical Sciences and Community Health, Milan, Lombardia, Italy;
| | - Ilaria Muller
- Policlinico di Milano, 9339, Endocrinology Unit, department of Clinical Sciences and Community Health, Milan, Lombardia, Italy;
| | - Maura Arosio
- Policlinico di Milano, 9339, Endocrinology Unit, department of Clinical Sciences and Community Health, Milan, Lombardia, Italy;
| | - Francesco Viola
- Policlinico di Milano, 9339, Ophthalmology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | - Lorenzo Pignataro
- Policlinico di Milano, 9339, Otolaringology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | - Mario Salvi
- Policlinico di Milano, 9339, Endocrinology Unit, department of Clinical Sciences and Community Health, Milan, Lombardia, Italy;
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Guastella C, di Furia D, Torretta S, Ibba TM, Pignataro L, Accorona R. Upper Eyelid Retraction in Graves' Ophthalmopathy: Our Surgical Experience on 153 Cases of Full-Thickness Anterior Blepharotomy with Mullerectomy. Aesthetic Plast Surg 2022; 46:1713-1721. [PMID: 35129648 DOI: 10.1007/s00266-022-02770-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/03/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND We present our experience on 153 cases of full-thickness anterior blepharotomy with mullerectomy (FTABM) in the treatment of upper eyelid retraction (UER) related to Graves' ophthalmopathy (GO). METHODS We included all the patients who underwent a graded FTABM between 1st January 2015 and 30th June 2020 for UER GO-related. The analysis included: pre-/post-operative conjunctival symptoms, epiphora, GO-Quality of Life Questionnaire (QoL), lagophthalmos, marginal reflex distance (MRD-1) index, eyelid symmetry within 1mm. The statistical analysis was designed to detect postoperative improvement in objective and subjective clinical features. Outcomes were analysed through Chi-squared test for dichotomous variables and through Wilcoxon-Mann-Whitney test for continuous variables. RESULTS Of the 111 patients, 42 underwent a bilateral procedure, while 69 a monolateral. Conjunctival symptoms were reported in 32% of cases before surgery and in 12.4% after FTABM (p < 0.001). Epiphora was complained by 29.6% of patients preoperatively and in 12.4% postoperatively (p < 0.001). Preoperative lagophthalmos was found in 12.4% (mean value of 0.34 ± 0.76 mm) of eyelids, and in 2.6% (mean value 0.05 ± 0.19 mm) eyelids (p = not significant) postoperatively. Pre-operative GO-QoL was 24.9 ± 4.4 mm; while post-operative GO-QoL was 35.3 ± 5.5 mm (p < 0.001). The MRD-1 varied from 10.12 ± 2.1 mm preoperatively, to 4.3 ± 0.6 mm (p < 0.001) after surgery. Asymmetric palpebral fissure was noted in 94 (84.7%) patients before surgery and in 7 (6.3%) after the procedure (p < 0.001). CONCLUSION FTABM is an effective procedure to treat UER GO-related. The technique manages to prevent complications of UER and determine good aesthetics. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . Level IV, therapeutic study.
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Affiliation(s)
- Claudio Guastella
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
- Referral Centre for Graves' Ophthalmopathy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Domenico di Furia
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milano, Italy
| | - Sara Torretta
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milano, Italy
| | - Tullio Mattia Ibba
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
| | - Lorenzo Pignataro
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
- Referral Centre for Graves' Ophthalmopathy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milano, Italy
| | - Remo Accorona
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy.
- Referral Centre for Graves' Ophthalmopathy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
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Torretta S, Ibba T, Guastella C, Gaini L, Di Cicco M, Folino F, Marchisio P, Bosis S, Pinzani R, D'Amico M, Pignataro L. Management of upper retropharyngeal abscesses in children: Two case reports of a troublesome situation. Clin Case Rep 2021; 9:e04598. [PMID: 34631059 PMCID: PMC8489505 DOI: 10.1002/ccr3.4598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/13/2021] [Accepted: 06/24/2021] [Indexed: 11/24/2022] Open
Abstract
Management of upper retropharyngeal abscesses in children is challenging. In surgical cases, ultrasound-assisted intra-operative procedures may be helpful to reach peculiar locations, thus reducing surgical morbidity and complications rate.
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Affiliation(s)
- Sara Torretta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
- Department of Clinical Sciences and Community Health Università degli Studi di Milano Milan Italy
| | - Tullio Ibba
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
| | - Claudio Guastella
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
| | - Lorenzo Gaini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
| | - Maurizio Di Cicco
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
| | - Francesco Folino
- Department of Pathophysiology and Transplantation Università degli Studi di Milano Milan Italy
| | - Paola Marchisio
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
- Department of Pathophysiology and Transplantation Università degli Studi di Milano Milan Italy
| | - Samantha Bosis
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
| | - Raffaella Pinzani
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
| | - Mario D'Amico
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
| | - Lorenzo Pignataro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
- Department of Clinical Sciences and Community Health Università degli Studi di Milano Milan Italy
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Affiliation(s)
- R Accorona
- Department of Otorhinolaryngology, Head and Neck Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
| | - C Guastella
- Department of Otorhinolaryngology, Head and Neck Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - L Pignataro
- Department of Otorhinolaryngology, Head and Neck Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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Fiore G, Bertani GA, Carrabba GG, Guastella C, Marfia G, Tariciotti L, Gribaudi GL, Mantovani G, Di Cristofori A, Locatelli M. The "Parachute" Technique for the Endoscopic Repair of High-Flow Anterior Skull-Base CSF Leaks. World Neurosurg 2021; 151:e880-e887. [PMID: 33974988 DOI: 10.1016/j.wneu.2021.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This study aims to assess the feasibility and reliability of our endoscopic trans-nasal technique for the repair of cribriform and sellar high-flow cerebrospinal fluid (CSF) leaks. METHODS A comparison between patients suffering from high-flow rhinorrhea and treated through a free grafting endoscopic technique or the "parachute" technique, our nasal packing proposal, was performed. RESULTS Thirty-three patients were included. The mean age was 52 years (range: 36-68 years). The etiology of the CSF leaks was iatrogenic in 16 cases (48.5%), traumatic in 5 cases (15.2%), spontaneous in 11 cases (33.3%), and related to anterior skull base tumors in 1 case (3%). The bone defect affected the sphenoidal sinus in 20 cases (60.6%), the cribriform plate of the ethmoid in 10 cases (30.3%), and both the sphenoid and ethmoid in 3 cases (9.1%). The mean size of bone defects was 8.5 ± 3.9 mm. The median follow-up was 28 (64) months. A CSF leak recurrence occurred in no cases treated with the parachute technique and in 3 cases that underwent conventional endoscopic treatments. The CSF leak recurrences were associated with 2 iatrogenic and 1 post-traumatic fistula. All the CSF leak recurrences underwent the parachute technique, not showing second recurrences. CONCLUSIONS Our results suggest that the parachute technique is simple, safe, and effective. We recommend it as an alternative treatment to vascular flaps for the treatment of high-flow and recurrent fistulas.
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Affiliation(s)
- Giorgio Fiore
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Medical-Surgical Physiopathology and Transplantation, University of Milan, Milan, Italy.
| | - Giulio Andrea Bertani
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Claudio Guastella
- Department of Otorhinolaryngology, Head and Neck Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Giovanni Marfia
- Laboratory of Experimental Neurosurgery and Cell Therapy, Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; "Aldo Ravelli" Research Center, Milan, Italy; Clinical Pathology Unit, Istituto di Medicina Aerospaziale "A. Mosso", Aeronautica Militare, Milan, Italy
| | - Leonardo Tariciotti
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Medical-Surgical Physiopathology and Transplantation, University of Milan, Milan, Italy
| | - Giulia Letizia Gribaudi
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Andrea Di Cristofori
- Division of Neurosurgery, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza (MB), Italy
| | - Marco Locatelli
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; "Aldo Ravelli" Research Center, Milan, Italy; Department of Medical-Surgical Physiopathology and Transplantation, University of Milan, Milan, Italy
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Vannucchi G, Campi I, Covelli D, Currò N, Lazzaroni E, Palomba A, Soranna D, Zambon A, Fugazzola L, Muller I, Guastella C, Salvi M. Efficacy Profile and Safety of Very Low-Dose Rituximab in Patients with Graves' Orbitopathy. Thyroid 2021; 31:821-828. [PMID: 33234032 DOI: 10.1089/thy.2020.0269] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Rituximab (RTX), a chimeric human-murine anti-CD20 monoclonal antibody, has been used for treatment of active moderate-severe Graves' orbitopathy (GO) since 2004 as second-line therapy in patients unresponsive to intravenous steroids. We conducted an open-label prospective study (EUDRACT 2012-001980-53) in which patients were treated with a single infusion of only 100 mg RTX to analyze the efficacy and safety of this low dose. Methods: Seventeen patients, of whom nine had disease that was unresponsive to intravenous methylprednisolone and eight with newly diagnosed GO, were enrolled. Disease activity was assessed with the clinical activity score (CAS) and severity with a composite ophthalmic score. Long-term surgical treatment and quality of life were also assessed, as well as treatment-related adverse events. Results: Mean baseline CAS was 4.56 ± 0.96 and decreased to 1.25 ± 1.14 at 24 weeks (p = 0.001). Disease inactivation occurred within 24 weeks in >90% of patients and was unrelated to disease duration. Severity improved in about 60% of patients, with no relapses. All patients showed peripheral depletion of CD20+ and CD19+ cells at the end of RTX infusion (60 minutes). Two patients required surgical orbital decompression because of optic neuropathy (ON). Among adverse events observed, there was one patient who developed a cytokine release syndrome. Conclusions: A dose of 100 mg RTX is effective in patients with active moderate-severe GO. Low doses are better tolerated, expose patients to immune suppression for a shorter period of time, and are extremely cost effective, compared with higher doses. This dose, consistently with all other immunosuppressants, does not prevent the progression of GO to dysthyroid ON.
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Affiliation(s)
- Guia Vannucchi
- Endocrine and Metabolic Department, Istituto Auxologico Italiano IRCCS, Milano, Italy
| | - Irene Campi
- Endocrine and Metabolic Department, Istituto Auxologico Italiano IRCCS, Milano, Italy
| | - Danila Covelli
- Department of Clinical Sciences and Community Health, Graves' Orbitopathy Center, Endocrinology, Milan, Italy
| | - Nicola Currò
- Department of Ophthalmology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Elisa Lazzaroni
- Department of Clinical Sciences and Community Health, Graves' Orbitopathy Center, Endocrinology, Milan, Italy
| | - Andrea Palomba
- Division of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | | | - Antonella Zambon
- Division of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Laura Fugazzola
- Endocrine and Metabolic Department, Istituto Auxologico Italiano IRCCS, Milano, Italy
| | - Ilaria Muller
- Department of Clinical Sciences and Community Health, Graves' Orbitopathy Center, Endocrinology, Milan, Italy
| | - Claudio Guastella
- Department of Otolaryngology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Mario Salvi
- Department of Clinical Sciences and Community Health, Graves' Orbitopathy Center, Endocrinology, Milan, Italy
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Campi I, Currò N, Vannucchi G, Covelli D, Simonetta S, Fugazzola L, Dazzi D, Pignataro L, Guastella C, Lazzaroni E, Pirola G, Salvi M. Quantification of Global Ocular Motility Impairment in Graves' Orbitopathy by Measuring Eye Muscle Ductions. Thyroid 2021; 31:280-287. [PMID: 32940167 DOI: 10.1089/thy.2020.0165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: The overall changes of ocular motility in Graves' orbitopathy (GO) are not easily quantifiable with the methods currently available, especially in clinical studies. The aim of the present study was to calculate parameters that quantify the changes of ocular motility in GO in relation to the Gorman score for diplopia. Methods: We studied 100 GO patients (Group 1) and 100 controls (Group 2). We also included 30 patients treated with intravenous methylprednisolone (iv-MP), assessed at baseline and after 12 and 24 weeks (Group 3), and 66 patients submitted to squint surgery, assessed at baseline and after 12 weeks (Group 4). Ocular ductions were measured in four gaze directions by a perimeter arc and were used to calculate a total motility score (TMS) as the sum of ductions in each direction; a biocular TMS (b-TMS) as the sum of the TMS of two eyes; and an asymmetry ratio (AR) as the sum of the differences of the corresponding ductions between the two fellow eyes divided by the mean difference found in controls. Quality of life was accessed by a specific questionnaire (Graves' orbitopathy quality of life [GO-QoL] questionnaire). Results: TMS and b-TMS were lower, while AR was higher, in Group 1 compared with controls (p < 0.001). In Group 1, TMS and b-TMS were inversely correlated with the Gorman score (p < 0.001) and AR was higher in patients with constant diplopia compared with the others (p < 0.001). In Group 3, TMS and b-TMS increased after treatment in responders to iv-MP (p < 0.001). In Group 4, TMS and b-TMS improved in all patients after surgery (p < 0.01), while AR and GO-QoL score improved only in those without residual constant diplopia (p < 0.001). Conclusion: We describe a quantitative method to assess eye motility dysfunction in any stage of GO to be used as an outcome measure in clinical studies.
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Affiliation(s)
- Irene Campi
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Nicola Currò
- Ophthalmology Unit, Department of Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Guia Vannucchi
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Danila Covelli
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Simona Simonetta
- Ophthalmology Unit, Department of Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Fugazzola
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Davide Dazzi
- Division of Internal Medicine, Ospedale Vaio, Fidenza, Italy
| | - Lorenzo Pignataro
- ENT Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Claudio Guastella
- ENT Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Elisa Lazzaroni
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacinta Pirola
- Ophthalmology Unit, Department of Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Salvi
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
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Campi I, Vannucchi G, Muller I, Lazzaroni E, Currò N, Dainese M, Montacchini B, Covelli D, Guastella C, Pignataro L, Fugazzola L, Arosio M, Salvi M. Therapy With Different Dose Regimens of Rituximab in Patients With Active Moderate-To-Severe Graves' Orbitopathy. Front Endocrinol (Lausanne) 2021; 12:790246. [PMID: 35145479 PMCID: PMC8822584 DOI: 10.3389/fendo.2021.790246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/22/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Immunosuppressive therapy of Graves' orbitopathy (GO) is indicated during the active phase of disease. Intravenous steroids (IVGC) are effective in about 70% of patients, although unresponsiveness or relapse are observed. In previous studies, rituximab (RTX) has been shown to be effective in inactivating moderate-to-severe GO when used early in the disease, but its optimal dosage has never been studied in randomized clinical trials. Aim of this study was to compare the efficacy and safety of different doses of RTX, based on a post-hoc analysis of two open label studies and one prospective trial randomized to IVGC. METHODS of 40 patients (35 women, 5 men), with active moderate-to-severe GO treated with RTX, 14 received a single dose of 100 mg (Group 1), 15 a single dose of 500 mg (Group 2) and 11 two 1000 mg doses, administered one week apart (Group 3). Thyroid function, TSH-receptor antibodies (TRAb) and peripheral CD19+ cells were measured. Primary endpoint was disease inactivation, measured as a decrease of the Clinical Activity Score (CAS) of at least two points. Secondary endpoints were improvement of proptosis, diplopia, quality of life and safety. RESULTS Baseline CAS decreased significantly in all groups (P<0.0001), independently of GO duration or whether patients had newly occurring or relapsing GO after IVGC. Proptosis did not significantly change. There was an inverse correlation between the Gorman score for diplopia and RTX dose (P<0.01). The appearance score of the GO-QoL improved in Group 1 (P=0.015), and the visual function score, in Group 2 (P=0.04). A reduction of serum TRAb was observed in Group 1 (P=0.002) and Group 2 (P<0.0002), but not in Group 3. CD19+ cell decreased in all groups (P<0.01), independently of the dose. CONCLUSIONS We studied the optimal dosage of RTX in the treatment of active moderate-to-severe GO. In this analysis, we considered the efficacy of RTX in inactivating GO, in changing its natural course, its effect on disease severity and on the patients' quality of life. Based on our clinical findings, and balancing the cost of therapy, a single 500 mg dose regimen is suggested in the majority of patients.
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Affiliation(s)
- Irene Campi
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Guia Vannucchi
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Ilaria Muller
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Elisa Lazzaroni
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Nicola Currò
- Ophthalmology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Martina Dainese
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Benedetta Montacchini
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Danila Covelli
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Claudio Guastella
- Otolaryngology, University of Milan and Fondazione IRCCS Cà Granda, Milan, Italy
| | - Lorenzo Pignataro
- Otolaryngology, University of Milan and Fondazione IRCCS Cà Granda, Milan, Italy
| | - Laura Fugazzola
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Maura Arosio
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Mario Salvi
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
- *Correspondence: Mario Salvi,
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Solimeno L, Torretta S, Marchisio P, Iofrida E, Bosis S, Tagliabue C, Di Pietro GM, Pignataro L, Guastella C. Abscess of the clivus in an adolescent with complicated acute rhinosinusitis: a case report. Ital J Pediatr 2020; 46:97. [PMID: 32665003 PMCID: PMC7362412 DOI: 10.1186/s13052-020-00863-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/06/2020] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Complications of acute sinusitis affecting multiple sites are very uncommon, and generally develop for a delayed diagnosis of the primary infection, with possible severe and life-threatening evolution. Patients can have variable presentations according to the site and extent of the infection. Multiple forms generally include the coexistence of orbital manifestations and intracranial infections. We here present a case with unusual multiple sites locations (i.e.: intraorbital intraconic abscess, sigmoid sinus thrombosis, preclival abscess, multiple splanchnocranium osteomyelitic processes).
Case presentation
A 13-year-old male presented at our hospital with right progressive orbital oedema with eyesight worsening and signs of meningitis. Computed tomography and magnetic resonance (MRI) demonstrated right intraorbital intraconic abscess, left sphenoidal sinusitis, transverse and sigmoid sinus thrombosis. Ophthalmologic evaluation documented a right optic nerve sufferance. Endoscopic and superior right trans-palpebral surgical decompression was performed, and the abscess was drained. Microbiological analysis revealed the presence of multi-sensitive Streptococcus Intermedius. Subsequent prolonged antibiotic and anti-thrombotic treatments were started. In the following two-weeks the sinusal and ophthalmologic clinical conditions improved, whereas the patients complained of mild to moderate cervical pain and suffered from intermittent pyrexia. Control MRI documented clival abscess extending up to preclival soft tissues posterior to the nasopharynx, associated with mandible osteomyelitis, occipital condyles and anterior part of the temporal bone hyper intensity. Endoscopic trans-nasal surgical approach to the clival compartment with neurosurgery navigation-guided achieved preclival abscess drainage. Complete clinical and radiological recovery was achieved after 45 days of medical treatment.
Conclusions
Multiple sites complicated rhinosinusitis is uncommon, and its management is challenging. A proper history and thorough clinical examination along with a radiological evaluation are key factors in the final diagnosis of patients with complicated multiple sites acute rhinosinusitis. A quick multidisciplinary approach is always necessary to avoid unwanted life-threatening complications.
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10
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Bonomo G, Bertani GA, Carrabba GG, Ferrante E, Pluderi M, Guastella C, Pignataro L, Rampini P, Mantovani G, Locatelli M. The suprasellar volume of nonfunctioning pituitary adenomas: a useful tool for predicting visual field deficits. Pituitary 2020; 23:552-557. [PMID: 32562134 DOI: 10.1007/s11102-020-01060-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of the present study is to assess the predictive value of the suprasellar volume (SSV) of nonfunctioning pituitary adenomas (NFPAs) for visual field (VF) impairment in order to guide clinical decision-making and improve neurosurgical management. METHODS Two independent samples of patients with NFPAs (exploratory population N = 50, testing population N = 98) were included in the present study. In the first phase, we determined the optimal cut-off value of the SSV correlating with VF deficits in the exploratory population. In the second phase, we then studied the accuracy of identified cut-off in predicting a VF deficit in the testing population. RESULTS In the exploratory population, the optimal cut-off value of the SSV to determine the presence of a VF deficit was 1.5 mL. Sensitivity and specificity of the cut-off were 81.3 and 100%, respectively. The positive predictive value (PPV) and the negative predictive value (NPV) were 100 and 75%, respectively. When we checked the identified cut-off score on the testing population, we found a sensitivity of 71% and a specificity of 100%. The PPV and NPV were 100 and 59.2%, respectively. In six cases with VF defects and SSV inferior to 1.5 mL, the displacement of optic chiasm was in superior position. CONCLUSION The SSV may represent an accurate method in routinely clinical practice for predicting VF deficit in patients affected by NFPA.
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Affiliation(s)
- Giulio Bonomo
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via Francesco Sforza, 20122, Milan, Italy.
| | - Giulio A Bertani
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via Francesco Sforza, 20122, Milan, Italy
| | - Giorgio G Carrabba
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via Francesco Sforza, 20122, Milan, Italy
| | - Emanuele Ferrante
- Department of Endocrinology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Mauro Pluderi
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via Francesco Sforza, 20122, Milan, Italy
| | - Claudio Guastella
- Department of Otolaryngology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Lorenzo Pignataro
- Department of Otolaryngology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
- Departments of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Paolo Rampini
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via Francesco Sforza, 20122, Milan, Italy
| | - Giovanna Mantovani
- Department of Endocrinology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
- Departments of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marco Locatelli
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via Francesco Sforza, 20122, Milan, Italy
- Dino Ferrari Center, Neuroscience Section, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Aldo Ravelli Center for Neurotechnology and Experimental Brain Therapeutics, Milan, Italy
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11
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Vannucchi G, Covelli D, Campi I, Currò N, Dazzi D, Rodari M, Pepe G, Chiti A, Guastella C, Lazzaroni E, Salvi M. Prevention of Orbitopathy by Oral or Intravenous Steroid Prophylaxis in Short Duration Graves' Disease Patients Undergoing Radioiodine Ablation: A Prospective Randomized Control Trial Study. Thyroid 2019; 29:1828-1833. [PMID: 31860407 DOI: 10.1089/thy.2019.0150] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Radioiodine (RAI) is a known risk factor for activation or de novo occurrence of Graves' orbitopathy (GO). Several studies demonstrated that GO can be prevented by glucocorticoids (GCs) in patients with pre-existing GO. We have previously shown that Graves' disease duration (GDd) <5 years is a risk factor for RAI-induced GO. We studied the effect of prophylaxis with either oral GCs (OGCs) or intravenous GCs (IVGCs) on GO activation in patients with GDd. Methods: In total, 99 hyperthyroid patients without GO or with pre-existing inactive GO with GDd <5 years were randomized to receive IVGCs (N = 49) or OGCs (N = 50) before RAI; 22 patients with GDd >5 did not receive steroids and were studied as controls. All patients underwent ophthalmological assessment before and 45, 90, 180 days and for a 5-year follow-up after RAI. Serum thyrotropin (TSH) receptor antibodies (TRAbs), thyroid hormones, and thyroid volume (TV) were also measured in response to RAI therapy and steroid prophylaxis. Results: No patient on prophylaxis developed GO after RAI. One woman of the control group, without steroid prophylaxis, and who had a marked elevation of her TSH, showed transient reactivation of GO, which spontaneously improved after restoring euthyroidism. On follow-up at 12 and 20 months after RAI, two patients developed overt optic neuropathy. A smaller TV was associated with a higher prevalence of RAI-induced hypothyroidism. Serum TRAbs increased significantly after RAI (p < 0.0001) but less in patients receiving steroids than in those without prophylaxis at 45 days (p < 0.01). Conclusions: The risk of RAI-induced GO can be prevented in all patients with GDd <5 years by steroids. Such treatment may not be necessary in patients with GDd >5 years. The blunting of TRAb elevation after RAI may be related to the prophylactic effect of steroids.
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Affiliation(s)
- Guia Vannucchi
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Danila Covelli
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Campi
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Nicola Currò
- Ophthalmology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Dazzi
- Division of Internal Medicine, Ospedale Vaio, Fidenza, Italy
| | - Marcello Rodari
- Department of Nuclear Medicine, Istituto Clinico Humanitas, Milan, Italy
| | - Giovanna Pepe
- Department of Nuclear Medicine, Istituto Clinico Humanitas, Milan, Italy
| | - Arturo Chiti
- Department of Nuclear Medicine, Istituto Clinico Humanitas, Milan, Italy
| | - Claudio Guastella
- Department of Otolaryngology, University of Milan and Fondazione IRCCS Cà Granda, Milan, Italy
| | - Elisa Lazzaroni
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Salvi
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
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12
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Torretta S, Guastella C, Ibba T, Gaffuri M, Pignataro L. Surgical Treatment of Paediatric Chronic Rhinosinusitis. J Clin Med 2019; 8:jcm8050684. [PMID: 31096610 PMCID: PMC6571701 DOI: 10.3390/jcm8050684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/26/2019] [Accepted: 05/13/2019] [Indexed: 11/16/2022] Open
Abstract
Rhinosinusitis (RS) is a common disease in children, significantly affecting their quality of life. Chronic rhinosinusitis (CRS) is frequently linked to other respiratory diseases, including asthma. Children affected by CRS may be candidates for surgery in the case of failure of maximal medical therapy comprising three to six weeks of broad-spectrum systemic antibiotics with adjunctive therapies. Although endoscopic sinus surgery (ESS) is the surgical treatment of choice in adult patients with CRS, different surgical procedures are scheduled for refractory paediatric CRS and include adenoidectomy, paediatric ESS (PESS), and balloon catheter sinuplasty (BCS). The present paper discusses the indications and limitations of each treatment option in children with CRS. Given the amount of current evidence, it is reasonable to suggest that, in young and otherwise healthy children with refractory CRS, an adenoidectomy (eventually combined with BCS) should be offered as the first-line surgical treatment. Nevertheless, this approach may be considered ineffective in some patients who should be candidates for traditional ESS. In older children, those with asthma, or in the case of peculiar conditions, traditional ESS should be considered as the primary treatment.
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Affiliation(s)
- Sara Torretta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
| | - Claudio Guastella
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Tullio Ibba
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Michele Gaffuri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Lorenzo Pignataro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
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13
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Torretta S, Brevi A, Guastella C, Rampini P, Locatelli M, Pignataro L. An Unusual Hypopharyngeal Foreign Body Causing Dyspnea After Vertebroplasty. Ear Nose Throat J 2019; 98:321-323. [PMID: 30922109 DOI: 10.1177/0145561319837457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sara Torretta
- 1 Department of Otorhinolaryngology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,2 Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Alessandra Brevi
- 1 Department of Otorhinolaryngology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,2 Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Claudio Guastella
- 1 Department of Otorhinolaryngology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,2 Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Paolo Rampini
- 3 Neurosurgery Clinic, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Locatelli
- 3 Neurosurgery Clinic, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Pignataro
- 1 Department of Otorhinolaryngology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,2 Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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14
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Torretta S, Guastella C, Marchisio P, Marom T, Bosis S, Ibba T, Drago L, Pignataro L. Sinonasal-Related Orbital Infections in Children: A Clinical and Therapeutic Overview. J Clin Med 2019; 8:jcm8010101. [PMID: 30654566 PMCID: PMC6351922 DOI: 10.3390/jcm8010101] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/09/2019] [Accepted: 01/14/2019] [Indexed: 12/21/2022] Open
Abstract
Sinonasal-related orbital infections (SROIs) are typically pediatric diseases that occur in 3⁻4% of children with acute rhinosinusitis. They are characterised by various clinical manifestations, such as peri-orbital and orbital cellulitis or orbital and sub-periosteal abscesses that may develop anteriorly or posteriorly to the orbital septum. Posterior septal complications are particularly dangerous, as they may lead to visual loss and life-threatening events, such as an intracranial abscess and cavernous sinus thrombosis. Given the possible risk of permanent visual loss due to optic neuritis or orbital nerve ischemia, SROIs are considered ophthalmic emergencies that need to be promptly recognised and treated in an urgent-care setting. The key to obtaining better clinical outcomes in children with SROIs is a multi-disciplinary assessment by pediatricians, otolaryngologists, ophthalmologists, radiologists, and in selected cases, neurosurgeons, neurologists, and infectious disease specialists. The aim of this paper is to provide an overview of the pathogenesis, clinical manifestations, diagnosis, and treatment of pediatric SROIs, and to make some practical recommendations for attending clinicians.
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Affiliation(s)
- Sara Torretta
- Otolaryngological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
| | - Claudio Guastella
- Otolaryngological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Paola Marchisio
- Otolaryngological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
- Department of Physiopathology and Transplantation, University of Milan, 20122 Milan, Italy.
| | - Tal Marom
- Department of Otolaryngology-Head and Neck Surgery, Samson Assuta Ashdod University Hospital, Faculty of Health Sciences, Ben Gurion University, 7747629 Ashdod, Israel.
| | - Samantha Bosis
- Otolaryngological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Tullio Ibba
- Otolaryngological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Lorenzo Drago
- Department of Clinical Microbiology, University of Milan, 20122 Milan, Italy.
| | - Lorenzo Pignataro
- Otolaryngological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
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15
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Torretta S, Pasquale DD, Carioli D, Guastella C, Ibba T, Marchision P, Pignataro L. Aneurysmal bone cyst in the inferior nasal turbinate in a pediatric patient: A case report. Turk J Pediatr 2018; 60:747-750. [PMID: 31365215 DOI: 10.24953/turkjped.2018.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Torretta S, Di Pasquale D, Carioli D, Guastella C, Ibba T, Marchision P, Pignataro L. Aneurysmal bone cyst in the inferior nasal turbinate in a pediatric patient: A case report. Turk J Pediatr 2018; 60: 747-750. Aneurysmal bone cysts (ABCs) are non-neoplastic, highly vascularised bone lesions that rarely involve the craniofacial complex. We describe the first case of an ABC involving the inferior turbinate in a 17-month-old boy who attended our Pediatric Emergency Department because of recurrent epistaxis, and discuss the diagnostic and therapeutic work-up in children with nasal masses.
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Affiliation(s)
| | - Daniele Di Pasquale
- Fondazione IRCSS Ca' Granda Ospedale Maggiore Policlinica, University of Milan, Milan, Italy
| | - Daniela Carioli
- Fondazione IRCSS Ca' Granda Ospedale Maggiore Policlinica, University of Milan, Milan, Italy
| | - Claudio Guastella
- Fondazione IRCSS Ca' Granda Ospedale Maggiore Policlinica, University of Milan, Milan, Italy
| | - Tullio Ibba
- Fondazione IRCSS Ca' Granda Ospedale Maggiore Policlinica, University of Milan, Milan, Italy
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16
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Locatelli M, Di Cristofori A, Draghi R, Bertani G, Guastella C, Pignataro L, Mantovani G, Rampini P, Carrabba G. Is Complex Sphenoidal Sinus Anatomy a Contraindication to a Transsphenoidal Approach for Resection of Sellar Lesions? Case Series and Review of the Literature. World Neurosurg 2017; 100:173-179. [PMID: 28065874 DOI: 10.1016/j.wneu.2016.12.123] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 12/24/2016] [Accepted: 12/27/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The transsphenoidal approach is considered the gold standard for resection of pituitary adenomas and other sellar region lesions. This approach is guided by a few fundamental anatomic landmarks that conduct the surgeon toward the sellar floor. Some anatomic structures may vary a lot (e.g., intrasphenoidal septa, intercarotid distance) and may be difficult to identify. Pneumatization and conformation of the sphenoidal sinus (SS) plays a key role in accessing the floor of the sella and other skull base structures. A poorly pneumatized SS may be a relative contraindication to the transsphenoidal approach. We analyzed outcome and complications in transsphenoidal surgery for sellar lesions with a difficult SS. METHODS We analyzed 243 consecutive patients who underwent a transsphenoidal approach for sellar lesions. Patients with poor pneumatization of the SS were included. Neurosurgical and endocrinologic outcomes were reported. RESULTS Successful treatment using a transsphenoidal approach with neuronavigation and Doppler ultrasound was achieved in 15 patients with a low degree of pneumatization of the SS. A pituitary adenoma was present in 13 of 15 patients. Endocrinologic and neurosurgical outcomes were similar to patients with normal pneumatization of the SS, showing a cure of disease in 6 of 9 patients with functioning adenomas and an improvement of symptoms in cases of nonfunctioning adenomas. CONCLUSIONS Patients with a poorly pneumatized SS can be treated safely with a transsphenoidal approach using image guidance techniques to avoid major neurovascular complications.
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Affiliation(s)
- Marco Locatelli
- Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Di Cristofori
- Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Organ Transplantation, University of Milan, Milan, Italy.
| | - Riccardo Draghi
- Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Organ Transplantation, University of Milan, Milan, Italy
| | - Giulio Bertani
- Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudio Guastella
- Unit of Otolaryngology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Pignataro
- Unit of Otolaryngology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Giovanna Mantovani
- Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Endocrinology and Diabetology Unit, University of Milan, Milan, Italy
| | - Paolo Rampini
- Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Carrabba
- Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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17
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Guastella C, Rinaldi V, Di Pasquale D, Coviello DA, Pignataro L. Oral pyogenic granuloma gravidarum: A case report describing a large bleeding lingual lesion. J OBSTET GYNAECOL 2016; 37:537-538. [PMID: 28019137 DOI: 10.1080/01443615.2016.1256957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Claudio Guastella
- a Department of Otolaryngology, Department of Clinical Sciences and Community Health , Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, University of Milan , Milan , Italy
| | - Vittorio Rinaldi
- a Department of Otolaryngology, Department of Clinical Sciences and Community Health , Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, University of Milan , Milan , Italy
| | - Daniele Di Pasquale
- a Department of Otolaryngology, Department of Clinical Sciences and Community Health , Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, University of Milan , Milan , Italy
| | - Dario Augusto Coviello
- b Department of Obstetrics and Gynaecology, Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico , University of Milan , Milan , Italy
| | - Lorenzo Pignataro
- a Department of Otolaryngology, Department of Clinical Sciences and Community Health , Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, University of Milan , Milan , Italy
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18
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Giammattei L, Mantovani G, Carrabba G, Ferrero S, Di Cristofori A, Verrua E, Guastella C, Pignataro L, Rampini P, Minichiello M, Locatelli M. Pituitary apoplexy: considerations on a single center experience and review of the literature. J Endocrinol Invest 2016; 39:739-46. [PMID: 26733212 DOI: 10.1007/s40618-015-0424-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 12/11/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE To present a single-center experience on pituitary tumor apoplexy and a review of literature focusing on predisposing and precipitating factors. METHODS Clinical presentation of our series of cases. Contemporary published literature is also reviewed. RESULTS The definition of this syndrome has not been consistent although now the majority of authors agree to definite it as an acute condition caused by hemorrhage or infarction of a pre-existing pituitary adenoma. Different predisposing and precipitating factors have been described in literature; among these antithrombotic and anticoagulant drugs, seem to play relevant roles. The clinical cases observed in our clinic confirm these data and suggest a probable association between elderly patients taking anticoagulant therapy and pituitary apoplexy adenoma. CONCLUSION Pituitary tumor apoplexy remains a challenging disease in relation to difficulties in correct diagnosis and thus in appropriate treatment. Antithrombotic/anticoagulant therapy may have an important role as precipitating factor. When a pituitary disorder is known, great care should be taken in the prescription of anticoagulant therapy.
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Affiliation(s)
- L Giammattei
- Unit of Neurosurgery - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Organ Transplantation, University of Milan, Milan, Italy
| | - G Mantovani
- Unit of Endocrinology - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - G Carrabba
- Unit of Neurosurgery - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - S Ferrero
- Unit of Pathology - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - A Di Cristofori
- Unit of Neurosurgery - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Organ Transplantation, University of Milan, Milan, Italy
| | - E Verrua
- Unit of Endocrinology - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Guastella
- Unit of Otolaringology - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - L Pignataro
- Unit of Otolaringology - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - P Rampini
- Unit of Neurosurgery - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Minichiello
- Unit of Neurosurgery - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Organ Transplantation, University of Milan, Milan, Italy.
| | - M Locatelli
- Unit of Neurosurgery - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Levi V, Bertani G, Guastella C, Pignataro L, Zavanone M, Rampini P, Caroli M, Sala E, Malchiodi E, Mantovani G, Carrabba G, Locatelli M. Microscopicversusendoscopic transsphenoidal surgery for pituitary adenoma: analysis of surgical safety in 221 consecutive patients. Clin Otolaryngol 2016; 42:466-469. [DOI: 10.1111/coa.12631] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2016] [Indexed: 11/28/2022]
Affiliation(s)
- V. Levi
- Neurosurgery Unit; Department of Surgery; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - G.A. Bertani
- Neurosurgery Unit; Department of Surgery; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - C. Guastella
- Otorhinolaryngology Unit; Department of Surgery; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - L. Pignataro
- Otorhinolaryngology Unit; Department of Surgery; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - M.L.P.F. Zavanone
- Neurosurgery Unit; Department of Surgery; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - P.M. Rampini
- Neurosurgery Unit; Department of Surgery; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - M.A.R. Caroli
- Neurosurgery Unit; Department of Surgery; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - E. Sala
- Endocrinology and Diabetology Unit; Department of Clinical Sciences and Community Health; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - E. Malchiodi
- Endocrinology and Diabetology Unit; Department of Clinical Sciences and Community Health; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - G. Mantovani
- Endocrinology and Diabetology Unit; Department of Clinical Sciences and Community Health; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - G.G. Carrabba
- Neurosurgery Unit; Department of Surgery; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - M. Locatelli
- Neurosurgery Unit; Department of Surgery; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
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Salvi M, Vannucchi G, Currò N, Campi I, Covelli D, Dazzi D, Simonetta S, Guastella C, Pignataro L, Avignone S, Beck-Peccoz P. Efficacy of B-cell targeted therapy with rituximab in patients with active moderate to severe Graves' orbitopathy: a randomized controlled study. J Clin Endocrinol Metab 2015; 100:422-31. [PMID: 25494967 PMCID: PMC4318899 DOI: 10.1210/jc.2014-3014] [Citation(s) in RCA: 231] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Preliminary studies have shown that rituximab (RTX) is effective in the treatment of active Graves' orbitopathy (GO). METHODS We conducted a double-blind, randomized trial (European Clinical Trials Database [EudraCT] 2007-003910-33) to compare RTX with iv methylprednisolone (ivMP) in patients with active moderate to severe GO. Thirty-two patients were randomized to receive either ivMP (7.5 g) or RTX (2000 or 500 mg). The primary end point was the decrease of the clinical activity score of 2 points or to less than 3 at week 24. Changes of proptosis, lid fissure, diplopia and eye muscle motility, and quality of life score were secondary end points. The number of therapeutic responses, disease reactivation, and surgical procedures required during follow-up and the patients' quality of life were also assessed. RESULTS The clinical activity score decreased with both treatments but more after RTX at 16, 20, and 24 weeks (P < .04, P < .02, P < .006, respectively), whether 1000 mg RTX twice or 500 mg RTX once was used (P = NS). At 24 weeks 100% of RTX patients improved compared with 69% after ivMP (P < .001). Disease reactivation was never observed in RTX patients but was observed in five after ivMP. Patients treated with RTX scored better motility at 52 weeks in both the right (P = .014) and the left eye (P = .026). Overall rehabilitative surgical procedures carried out during follow-up (at 76 wk) were 12 in 16 ivMP patients and 5 in 15 RTX patients (P = .049). CONCLUSIONS The results of this trial confirm preliminary reports on a better therapeutic outcome of RTX in active moderate to severe GO, when compared with ivMP, even after a lower RTX dose. The better eye motility outcome, visual functioning of the quality of life assessment, and the reduced number of surgical procedures in patients after RTX seem to suggest a disease-modifying effect of the drug.
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Affiliation(s)
- Mario Salvi
- Graves' Orbitopathy Center, Endocrinology Unit, Departments of Clinical Sciences and Community Health (M.S., G.V., I.C., D.C., P.B.-P.), Ophthalmology (N.C., S.S.), Otolaryngology (C.G., L.P.), and Neuroradiology (S.A.), Fondazione Cà Granda Istituto di Ricovero e Cura a Carattere Scientifico and University of Milan, I-20122 Milan, Italy; and Division of Internal Medicine (D.D.), Ospedale di Fidenza, I-43036 Fidenza, Italy
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Currò N, Covelli D, Vannucchi G, Campi I, Pirola G, Simonetta S, Dazzi D, Guastella C, Pignataro L, Beck-Peccoz P, Ratiglia R, Salvi M. Therapeutic outcomes of high-dose intravenous steroids in the treatment of dysthyroid optic neuropathy. Thyroid 2014; 24:897-905. [PMID: 24417307 DOI: 10.1089/thy.2013.0445] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND While pulsed intravenous methylprednisolone (iv-MP) has been shown to be effective and well tolerated in moderate to severe Graves' orbitopathy (GO), limited data are available on dysthyroid optic neuropathy (DON). The objective of this retrospective study was to investigate the efficacy of iv-MP in the treatment of DON and to seek parameters predictive of response. METHODS Twenty-four DON patients (40 eyes) treated with iv-MP from 2007 to 2012 were included in the study. Concurrent neurological or ophthalmologic diseases or signs of corneal exposure were considered as exclusion criteria. Iv-MP was administered daily for three consecutive days and repeated the following week. At six months, eyes not requiring surgery to preserve visual function were considered as responsive to treatment. Visual acuity, color sensitivity, visual field, and optic discs were analyzed at two and four weeks, and at 3, 6, and 12 months after treatment. Activity of GO was graded using a clinical activity score (CAS). Visual and clinical characteristics of the eyes responsive to iv-MP were studied by comparison to those of nonresponsive eyes. RESULTS At six months, 17 of 40 (42.5%) eyes had complete visual recovery and were spared from surgical decompression. At two weeks, visual acuity, color sensitivity, and visual field improved significantly in almost all eyes, but GO inactivated (CAS<4) only in the eyes that permanently responded to iv-MP (p<0.01). The CAS at two weeks was a good predictor of response (cutoff ≥4; 66.7% sensitivity, 76.9% specificity). Optic disc swelling at diagnosis was highly predictive for unresponsiveness to iv-MP (34% sensitivity, 100% specificity). At baseline, high CAS (cutoff >5; 40.2% sensitivity, 94.1% specificity) and severely altered visual field mean defect (cutoff ≤6.31 dB; 73.9% sensitivity, 58.8% specificity) were associated with unresponsiveness to steroids. No major side effects were observed. CONCLUSIONS High-dose iv-MP was effective in permanently restoring visual function in about 40% of the eyes treated. When successful, it generally induced inactivation of the orbital disease within two weeks and normalization of visual function within one month. The presence of optic disc swelling at diagnosis and persistent active disease at two weeks were good predictors of unresponsiveness to steroids.
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Affiliation(s)
- Nicola Currò
- 1 Unit of Ophthalmology, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda , Ospedale Maggiore Policlinico, Milan, Italy
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Campi I, Vannucchi GM, Minetti AM, Dazzi D, Avignone S, Covelli D, Currò N, Ratiglia R, Guastella C, Pignataro L, Beck-Peccoz P, Salvi M. A quantitative method for assessing the degree of axial proptosis in relation to orbital tissue involvement in Graves' orbitopathy. Ophthalmology 2013; 120:1092-8. [PMID: 23399378 DOI: 10.1016/j.ophtha.2012.10.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 10/26/2012] [Accepted: 10/26/2012] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To define a method of quantifying axial proptosis in patients with Graves' orbitopathy (GO) and to validate a score that correlates with the orbital involvement and helps determine the degree of proptosis correction for elective orbital decompression. DESIGN Retrospective, case series. PARTICIPANTS The study included 50 patients (group A) and 29 control subjects who underwent orbital computed tomography (CT). The method was then validated in another group of 21 patients with GO (group B). METHODS The orbital area (OA) was measured manually on the central axial section of the CT scan at a level where the lens is visualized. The OA intersects the projection of the globe and delimitates the chord of an arch (globe chord [OC]). The area of the circular sector under the chord (CA) represents the portion of the globe within the orbit. MAIN OUTCOME MEASURES A CA-to-OA ratio was calculated to reduce the error due to variability of the measurements and to perform correlations with some of the clinical parameters of GO. RESULTS Measurement error was low (<2%). We did not observe significant differences in the mean OA of patients with GO (783.6 ± 12.1 mm(2)) and controls (758.5 ± 20.4 mm(2); P = not significant). The OC value in patients with GO was 130.2 ± 11.5 mm(2), significantly lower than in controls (281.8 ± 9.7 mm(2); P<0.0001). The CA-to-OA ratio also was lower in patients with GO than in controls (0.16 ± 0.01 vs. 0.38 ± 0.01; P<0.0001). A significant correlation was found in patients with GO between the CA-to-OA ratio and proptosis (P<0.001), lid fissure (P = 0.004), and intraocular pressure (P<0.001). In group B, the CA-to-OA ratio was 0.18 ± 0.02, significantly different from that of controls (P<0.0001) and inversely correlated with proptosis (P<0.0001) and lid fissure (P<0.045). CONCLUSIONS By measuring the CA-to-OA ratio, we were able to quantify the degree of axial proptosis in patients with GO. The significant correlation of CA/OA with some orbital parameters confirms that this parameter also may be used as a measure of orbital involvement in GO. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Irene Campi
- Endocrinology, Department of Clinical Sciences and Community Health, Graves' Orbitopathy Center, Università degli Studi di Milano, Fondazione Cà Granda, IRCCS Milan, Italy
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Vannucchi G, Covelli D, Currò N, Dazzi D, Maffini A, Campi I, Bonara P, Guastella C, Pignataro L, Ratiglia R, Beck-Peccoz P, Salvi M. Serum BAFF concentrations in patients with Graves' disease and orbitopathy before and after immunosuppressive therapy. J Clin Endocrinol Metab 2012; 97:E755-9. [PMID: 22399512 DOI: 10.1210/jc.2011-2614] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION B cells are known to play a key role in the pathogenesis of autoimmune disease. B lymphocyte activating factor (BAFF), a member of TNF family, promotes autoantibody production by increasing B cell survival and proliferation. Serum BAFF concentrations have been found to be increased in systemic lupus erythematosus, rheumatoid arthritis, and Sjogren's syndrome. OBJECTIVE We have measured serum BAFF concentrations in patients with Graves' disease (GD) with or without Graves' orbitopathy (GO) and in active GO in relation to immunosuppressive treatment. METHODS Forty-two patients and nine normal controls were studied. Thirty-four patients had GO, which was active in 23. Of these, nine were treated with rituximab (RTX) and 14 with i.v. methylprednisolone (MP). Serum BAFF concentrations were measured at baseline in all patients, at peripheral B cell depletion and repopulation after RTX, and after therapy with MP. RESULTS Serum basal BAFF concentrations in GD patients were significantly higher when compared with normal controls (P = 0.0001), and no difference was observed in those with active or inactive GO. Serum BAFF concentrations were also significantly correlated with serum antithyroglobulin antibodies (P = 0.04) but not with sex, age, smoking habits, therapy for thyroid disease, and serum antithyroperoxidase antibodies and TSH receptor antibodies. After RTX, there was an increase of serum BAFF concentrations at the time of B cell depletion (P = 0.02) but also at B cell repopulation (P = 0.04). In patients treated with MP, serum BAFF concentrations decreased significantly after therapy (P < 0.01). CONCLUSIONS We report that serum BAFF concentrations are elevated in patients with GD, in whom hyperthyroidism is known to be based on a B-cell-driven pathophysiological mechanism. In active GO, BAFF further increases after therapy with RTX as a consequence of the B cell depletion per se. The decrease of serum BAFF after iv steroids suggests that MP may exert an immunosuppressive effect by modifying B-cell-derived immune reactions.
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Affiliation(s)
- Guia Vannucchi
- Endocrine Unit, Department of Medical Sciences, University of Milan and Fondazione Cà Granda Istituto di Ricovero e Cura a Carattere Scientifico, 20122 Milan, Italy
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Salvi M, Vannucchi G, Currò N, Introna M, Rossi S, Bonara P, Covelli D, Dazzi D, Guastella C, Pignataro L, Ratiglia R, Golay J, Beck-Peccoz P. Small dose of rituximab for graves orbitopathy: new insights into the mechanism of action. ACTA ACUST UNITED AC 2012; 130:122-4. [PMID: 22232486 DOI: 10.1001/archopthalmol.2011.1215] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mario Salvi
- Endocrine Unit, Department of Medical Sciences, University of Milan, Italy.
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Locatelli M, Carrabba G, Guastella C, Gaini SM, Spagnoli D. Endoscopic endonasal removal of a cavernous hemangioma of the orbital apex. Surg Neurol Int 2011; 2:58. [PMID: 21697974 PMCID: PMC3114373 DOI: 10.4103/2152-7806.80123] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 04/18/2011] [Indexed: 11/24/2022] Open
Abstract
Background: Cavernous hemangioma are the most common benign lesions of the orbit. Their surgical resection is still challenging and several surgical approaches have been proposed. Case Description: We present the case of a 59-year-old woman with a cavernous hemangioma of the orbital apex, which was diagnosed incidentally. The hemangioma was extraconal and involved mainly the medial orbital apex; it also extended to the pterygoid fossa, to the middle fossa, to the maxillary and sphenoid sinuses. The surgical resection was performed by a pure endoscopic transphenoidal, transmaxillary, transethmoidal approach, achieving a total removal. The patient had a transient and incomplete paresis of the VI cranial nerve on the left side and did not experience other postoperative complications. Conclusion: The endoscopic endonasal approach proved successful in the management of this case and it should be considered in the surgical management of extraconal orbital apex lesions with medial or inferior extension.
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Affiliation(s)
- Marco Locatelli
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milano, Via Francesco Sforza 35, Milano 20122, Italy
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Vannucchi G, Campi I, Bonomi M, Covelli D, Dazzi D, Currò N, Simonetta S, Bonara P, Persani L, Guastella C, Wall J, Beck-Peccoz P, Salvi M. Rituximab treatment in patients with active Graves' orbitopathy: effects on proinflammatory and humoral immune reactions. Clin Exp Immunol 2011; 161:436-43. [PMID: 20529087 DOI: 10.1111/j.1365-2249.2010.04191.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
In active Graves' orbitopathy (GO), proinflammatory cytokines predominate. Circulating thyroid stimulating hormone (TSH)-receptor antibodies (TRAb) have been correlated with GO clinical activity and severity. In preliminary studies rituximab (RTX), an anti-CD 20 monoclonal antibody, has induced clinical improvement of active GO without a change in serum anti-thyroid antibodies. We have studied whether RTX in GO acts by affecting proinflammatory cytokines and thyroid and orbital-directed antibodies. Ten patients with GO were treated with RTX, administered twice intravenously (i.v.) (1000 mg) at days 1 and 15, and 20 with methylprednisolone, administered weekly i.v. (500 mg), for 16 weeks. Patients were studied before treatment, at B cell depletion and at 4, 8, 16, 20, 30 and 50 weeks. Peripheral lymphocytes, serum interleukin (sIL)-6, sIL-6r, chemokine (C-X-C motif) ligand 10 (CXCL10), TRAb and stimulating antibodies (TSAb) and autoantibodies against orbital calsequestrin, collagen XIII and flavoprotein subunit of succinate dehydrogenase (FP-SDH) were measured at baseline and after treatment. Serum IL-6 and sIL-6R concentrations did not change after RTX [P = not significant (n.s.)]. Serum CXCL10 increased after RTX at B cell depletion and at 30 weeks (P < 0·003). Serum TSAb did not change in relation to TRAb, nor did antibodies against orbital antigens (P = n.s.). In conclusion, this study shows that RTX in GO does not affect humoral reactions. The observed increase of serum CXCL10 concentrations at B cell depletion may result from cell lysis. We suggest that RTX may exert its effect in GO by inhibiting B cell antigen presentation.
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Affiliation(s)
- G Vannucchi
- Department of Medical Sciences, University of Milan, Milan, Italy
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Vener C, Carrabba M, Fracchiolla NS, Costa A, Fabio G, Hu C, Sina C, Guastella C, Pignataro L, Deliliers GL. Invasive fungal sinusitis: An effective combined treatment in five haematological patients. Leuk Lymphoma 2009; 48:1577-86. [PMID: 17701590 DOI: 10.1080/10428190701457923] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Invasive fungal rhinosinusitis (IFR) is a life-threatening infection. Its onset is subtle and a late diagnosis leads to severe complications. Death may occur within a few weeks notwithstanding treatment. We describe a comprehensive pre- and post-operative approach to care for haematological patients with IFR. Five haematological patients with IFR were treated with systemic antifungal therapy and endoscopic surgical debridement of infected tissues, followed by amphotericin-B directly instilled in the sinuses by a new type of ethmoidal drainage. The IFR remitted in all cases; after 32 months of follow-up, three patients are still alive, and two have died of other causes. Two of the patients who experienced IFR progression to the brain at the IFR onset are still alive. The pharmacological and surgical approach with the post-operative local therapy by a new ethmoidal drainage system could support radical antifungal sinus treatment, thus improving the overall survival.
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Affiliation(s)
- Claudia Vener
- U.O. Ematologia I, Centro Trapianti di Midollo, Università degli Studi di Milano & Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico, Mnagiagalli e Regina Elena, Milano, Italy
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Mourits MP, Bijl H, Altea MA, Baldeschi L, Boboridis K, Curro N, Dickinson AJ, Eckstein A, Freidel M, Guastella C, Kahaly GJ, Kalmann R, Krassas GE, Lane CM, Lareida J, Marcocci C, Marino M, Nardi M, Mohr C, Neoh C, Pinchera A, Orgiazzi J, Pitz S, Saeed P, Salvi M, Sellari-Franceschini S, Stahl M, von Arx G, Wiersinga WM. Outcome of orbital decompression for disfiguring proptosis in patients with Graves' orbitopathy using various surgical procedures. Br J Ophthalmol 2008; 93:1518-23. [DOI: 10.1136/bjo.2008.149302] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Bonara P, Vannucchi G, Campi I, Rossi S, Cantoni F, Frugoni C, Sbrozzi F, Guastella C, Avignone S, Beck-Peccoz P, Salvi M. Rituximab Induces Distinct Intraorbital and Intrathyroidal Effects in One Patient Satisfactorily Treated for Graves’ Ophthalmopathy. Clin Rev Allergy Immunol 2007; 34:118-23. [DOI: 10.1007/s12016-007-8024-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Salvi M, Vannucchi G, Campi I, Currò N, Dazzi D, Simonetta S, Bonara P, Rossi S, Sina C, Guastella C, Ratiglia R, Beck-Peccoz P. Treatment of Graves' disease and associated ophthalmopathy with the anti-CD20 monoclonal antibody rituximab: an open study. Eur J Endocrinol 2007; 156:33-40. [PMID: 17218723 DOI: 10.1530/eje.1.02325] [Citation(s) in RCA: 182] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Hyperthyroid Graves' disease (GD) is a B-cell-mediated condition caused by TSH receptor antibodies (TRAb), which decline when GD remits. Anti-CD20 monoclonal antibody rituximab (RTX) induces transient B-cell depletion that may potentially modify the active inflammatory phase of thyroid-associated ophthalmopathy (TAO). METHODS Nine patients with GD, (seven with active TAO, two with mild lid signs) were studied. The trial was only approved as an open pilot study; thus we compared the effect of RTX therapy to that of i.v. glucocorticoids (IVGC) in 20 consecutive patients. Patients were treated with RTX (1000 mg i.v. twice at 2-week interval) or with IVGC (500 mg i.v. for 16 weeks). TAO was assessed by the clinical activity score (CAS) and severity was classified using NOSPECS (No signs or symptoms; Only signs (lid); Soft tissue involvement; Proptosis, Extraocular muscle involvement; Corneal involvement; Sight loss). Thyroid function and lymphocyte count were measured by standardized methods. RESULTS All patients attained peripheral B-cell depletion with the first RTX infusion. Minor side effects were reported in three patients. Thyroid function was not affected by RTX therapy and hyperthyroid patients required therapy with methimazole. After RTX, the changes in the levels of thyroglobulin antibodies, thyroperoxidase antibodies and TRAb were neither significant nor correlated with CD20+ depletion (P = NS). CAS values before RTX were 4.7 +/- 0.5 and decreased to 1.8 +/- 0.8 at the end of follow-up (P < 0.0001) and more significantly compared with IVGC (P < 0.05). Proptosis decreased significantly after RTX both in patients with active TAO (ANOVA; P < 0.0001) and those with lid signs (ANOVA; P < 0.003). The degree of inflammation (class 2) decreased significantly in response to RTX (ANOVA; P < 0.001). Relapse of active TAO was not observed in patients treated with RTX, but occurred in 10% of those treated with IVGC, who also experienced adverse effects more frequently (45 vs 33% of patients). CONCLUSIONS RTX positively affects the clinical course of TAO, independently of either thyroid function or circulating antithyroid antibodies, including TRAb. If our findings are confirmed in large controlled studies, RTX may represent a useful therapeutic tool in patients with active TAO.
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Affiliation(s)
- Mario Salvi
- Department of Medical Sciences, University of Milan, Fondazione Ospedale Maggiore IRCCS, Milan, Italy
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Salvi M, Vannucchi G, Campi I, Rossi S, Bonara P, Sbrozzi F, Guastella C, Avignone S, Pirola G, Ratiglia R, Beck-Peccoz P. Efficacy of rituximab treatment for thyroid-associated ophthalmopathy as a result of intraorbital B-cell depletion in one patient unresponsive to steroid immunosuppression. Eur J Endocrinol 2006; 154:511-7. [PMID: 16556712 DOI: 10.1530/eje.1.02119] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
One patient with Graves' hyperthyroidism and ophthalmopathy in its active phase and unresponsive to steroid, was treated with the anti-CD20 monoclonal antibody, rituximab (RTX), as part of an open study. The effect of RTX in the thyroid and the orbital tissues was studied. The ophthalmopathy responded to RTX therapy by ameliorating the eye signs with a decrease in the clinical activity score from 5 to 2 in 3 months, while the patient had peripheral B-cell depletion. Hyperthyroidism did not improve during the 6 months of B-cell depletion and serum TSH-receptor antibodies (TRAb) levels did not significantly change after RTX therapy. Therefore, the patient underwent total thyroidectomy and few B-cells were found in the thyroid tissue specimens. While the patient eye disease remained stable (clinical activity score = 2), we performed corrective orbital decompression and we found absence of lymphocytes in the orbital tissue specimens. We believe that RTX treatment in Graves' disease may cause amelioration of ophthalmopathy by depleting total lymphocytes population in the orbit. The persistence of Graves' hyperthyroidism suggests that a single cycle of RTX does not result in complete lymphocyte depletion in thyroid tissue and thus no decline in serum TRAb was observed.
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Affiliation(s)
- Mario Salvi
- Institutes of Endocrine Sciences, University of Milan, Fondazione Ospedale Policlinico IRCCS, Italy
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Guastella C, Borsi C, Gibelli S, Della Berta LG. Madelung's lipomatosis associated with head and neck malignant neoplasia: a study of 2 cases. Otolaryngol Head Neck Surg 2002; 126:191-2. [PMID: 11870352 DOI: 10.1067/mhn.2002.122004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Claudio Guastella
- Department of Scienze Otorinolaringologiche IRCCS Ospedale Maggiore Policlinico, Milano, Italy.
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Abstract
A new internal nasal device, the Guastella-Mantovani septal-valve splint, ensures the correct healing of the crucial area of the internal valve, simultaneously "centering" the septum orthopedically after nasal surgery.
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Affiliation(s)
- M Mantovani
- Department of Otorhinolaryngology, Ospedale Maggiore IRCCS, University of Milan, Italy
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Ey M, Guastella C. [The so-called plastic tracheotomy]. Dtsch Krankenpflegez 1990; 43:492-6. [PMID: 2116297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Guastella C. Cost savings realized from interchanging ceftizoxime for cefoxitin. Am J Hosp Pharm 1988; 45:2376-7. [PMID: 3228095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- C Guastella
- Department of Pharmacy Services, Humana Hospital-Sun Bay, St. Petersburg, FL 33705
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Ey M, Guastella C. [Hemangiopericytoma of the larynx]. Laryngol Rhinol Otol (Stuttg) 1988; 67:255-8. [PMID: 3405024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Only 9 cases of haemangiopericytoma of the larynx have been described so far in international literature. In the present paper the tenth case is reported. This report concerns a woman patient of 79 years of age suffering from haemangiopericytoma localised on the left aryepiglottidian fold and in the laryngeal wall of the left piriform sinus. Generally, the histopathological diagnosis of this type of tumour presents problems, in particular the differential diagnosis to glomus tumours and haemangioendotheliomas. Haemangiopericytoma is considered to be a malignant tumour, and hence the tumour must be extirpated as radically as possible while protecting the organ system. It is recommended to provide for regular clinical control of these patients. In our case we could extirpate the complete tumour radically via lateral pharyngotomy, protecting the larynx and its function. In addition, we performed cricopharyngeal myotomy to prevent postoperative deglutition disorders. 6 months postoperatively the patient is symptom-free and up to now there is no local recurrence of the tumour.
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Affiliation(s)
- M Ey
- Hals-Nasen-Ohren-Klinik der Städtischen Kliniken Darmstadt-Eberstadt
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