Alberto Maccari

The management of complications following displacement of oral implants in the paranasal sinuses: a multicenter clinical report and proposed treatment protocols

This study retrospectively analyses paranasal sinus complications following displacement of oral implants in the maxillary sinus treated according to clinical situation by functional endoscopic sinus surgery (FESS), an intraoral approach, or a combination of both procedures. Over 5 years, 27 patients (13 male; 14 female), aged 27-73 years (mean 53.9 years), underwent treatment for postoperative complications involving the paranasal sinuses following displacement of oral implants in the maxillary sinuses. According to the complication (implant displacement, implant displacement with or without reactive sinusitis and/or with or without associated oro-antral communication), patients were treated with FESS, intraoral approach to the sinus, or FESS associated with an intraoral approach. Follow up lasted for at least 1 year with clinical and radiographic controls. 26 patients recovered completely; one patient underwent re-intervention with FESS and an intraoral approach 2 years after implant removal, due to persistent signs and symptoms of maxillary sinusitis and oro-antral communication. Postoperative recovery after the second procedure was followed by complete recovery. The results demonstrate that a rational choice of surgical protocol for the treatment of complications involving the paranasal sinuses following displacement of implants in the maxillary sinuses may lead to reliable results.

Transnasal 3D endoscopic skull base surgery: questionnaire-based analysis of the learning curve in 52 procedures

In the past decade, surgical treatment of skull base pathologies has greatly advanced through the advent of the endoscope and later of the high definition endoscope. Recently a new type of three dimensional (3D) scope has been introduced to permit the surgeon a real stereoscopic vision of the operating field and to overcome the limitations of the 2D endoscopic set up. As with all new technologies a formalized adaptation period is essential for the surgeon to secure steady outcomes and low complications. To determine the subjective difficulties that one may encounter during this sensitive period we therefore devised and analyzed a questionnaire that evaluated the first ten procedures with the 3D device of junior and senior ENT and neurosurgeons. 52 consecutive patients were treated with purely 3D transnasal endoscopy for skull base pathologies. Sensation of strain or dizziness, difficulties in anatomical orientation and difficulties in performing the surgical gesture were assessed for each surgeon. The learning curve and difficulties of junior and senior surgeons are discussed and strategies to overcome the initial problems are devised. Our results confirm that after only few procedures, the advantages of the 3D endoscopic system including better visualization and depth perception are able to outweigh the inconveniences that go hand in hand with the learning of a new skill set.

Redefining boundaries in odontogenic sinusitis: a retrospective evaluation of extramaxillary involvement in 315 patients

Odontogenic sinusitis and “sinonasal complications of dental disease or dental treatment” (SCDDT) have been assumed to be limited to the maxillary sinus. Nevertheless, many patients also show more extensive sinonasal involvement and, occasionally, also have associated bilateral disease. We evaluated the incidence of extramaxillary extension over an 11‐year period in our clinic.

Endoscopic removal of alloplastic sinus graft material via a wide middle antrotomy

The purpose of this paper is to discuss the treatment required for a patient affected by chronic maxillary sinusitis following a sinus grafting procedure with an alloplastic material. Sinusitis was not the consequence of migration of alloplastic material into the maxillary sinus, but rather the consequence of overfilling the subantral space followed by obstruction of the ostium. The treatment involved removal of the alloplastic material and correction of the ostium obstruction via a nasal endoscopic approach.

Trismus, the first symptom in a challenging diagnosis of Tetanus

Tetanus is a severe, life-threatening infectious disease present worldwide. The incidence of this disease is very low in developed countries, and practitioners are unfamiliar with its symptoms and signs, resulting in late diagnosis and low recovery rate. Furthermore, main symptoms, such as trismus, are often associated with several confounding factors: these may lead the physician to send patients towards an incorrect diagnostic management and the calling on of wrong specialists. This case focuses on the importance of considering tetanus in the differential diagnosis of trismus associated with systemic symptoms, and discusses the clinical implications of an initial wrong diagnostic pathway.

Epidermoid cyst of the pituitary stalk: Case report and review of the literature

Objective and Importance:Epidermoid cysts are fairly uncommon lesions that have a maldevelopmental origin and are thought to arise from trapped surface ectodermal elements. These cysts are usually located in the subarachnoid spaces, typically in the cerebellopontine angle. Many unusual locations have been reported; however, to our knowledge this is the first described case of an epidermoid cyst arising in the pituitary stalk. Clinical Presentation:The patient is a 27-year-old woman with a 2-year history of amenorrhea, galactorrhea, and secondary polyuria and polydipsia. A preoperative magnetic resonance imaging study showed a lesion extending from the upper part of the sella to the suprasellar region (up to the chiasm) with inhomogenous signals in both T1 and T2 images. Intervention:The cyst was partially resected through an endonasal trans-sphenoidal extended endoscopic approach by a multidisciplinary team [neurosurgeons and ear nose throat (ENT) surgeons]. The postoperative course was uneventful. The histologic examination disclosed a squamous epithelium and the presence of dry keratinous debris, establishing the epidermoid nature of the lesion. Conclusions:Surgical removal is the treatment of choice of symptomatic epidermoid cysts. In this unusual presentation (intrasellar/suprasellar) the authors preferred an endonasal trans-sphenoidal extended endoscopic approach. However, as in almost every case of epidermoid cyst, the adherence between the capsule of the lesion and neurovascular structures made complete removal of the cyst walls impossible.

The role of the ear, nose and throat specialist in diagnosing headaches

The revised International Headache Society classification (2004) represents a very good reference also for ear, nose and throat (ENT) specialists and can be largely shared. The authors follow the classification outline and comment on the chapters of ENT interest. The classification leaves unsolved problems and most of them are of ENT competence, such as mucosal contact point headache. It will be a task for ENT specialists to clarify the real role of very hypothetical primary forms frequently assigned to diagnosis without a correct rationale.

Endoscopic approaches to the craniovertebral junction.

Dear Editor, We read with great interest the article by Visocchi et al. [7] published online in October 2013 in Acta Neurochirurgica regarding an “Anterior video-assisted approach to the craniovertebral junction: transnasal or transoral? A cadaver study”. The authors performed a valuable anatomical and radiological study of two different endoscopic approaches to the craniovertebral junction (CVJ) that were compared by means of X-ray. The two approaches were compared in this study by inserting thin probes into the two natural corridors and surgical exposition distances and angles, in both sagittal and axial planes, were evaluated by the aid of X-ray. They finally found that the endoscopic transoral approach (ETA) “provides a better CVJ exposure in sagittal and axial planes, providing a larger working channel and an easier maneuverability” than endonasal approach. When evaluating the merits of the endonasal approach, it is important to consider an extended endonasal approach, which augments the surgical exposure and provides wider working angles that are comparable to the ETA, as already outlined by Baird et al. [2], rather than working through the simple nasal natural corridor. Furthermore, we would like to point out that our group examined the actual lower limit of the endoscopic endonasal approach (EEA) through cadaveric dissection and found it to be no lower than the middle third of C2. Also, we found that the nasopalatine line routinely overestimated the lower limit of the EEA (average 84 mm below the actual lower limit). We devised a novel line the naso-axial line (NAxL), which more accurately predicts the inferior limit of the EEA to the CVJ (Fig. 1) [1]. It is defined as the line in the midsagittal plane that starts from the midpoint of the distance from rhinion to the anterior nasal spine of maxillary bone and ends on C2 vertebra, tangential to the posterior nasal spine of palatine bone. It can be used easily in preoperative images and help the surgeon in the planning and choice of the right surgical approach. In order to evaluate the rostro-caudal extent of the lesion at the CVJ, we would like to suggest the use of the hard palate as a reference to, rather than the base of C2 as described by El Sayed et al. [3, 4]. The palate serves as the floor or roof to the endonasal or transoral corridors to the CVJ, it can help in the E. La Corte Cerebrovascular and Skull Base Unit, Department of Neurosurgery, Neurological Institute “Carlo Besta”, San Paolo Medical School University of Milan, Milan, Italy

Snorting the clivus away: an extreme case of cocaine-induced midline destructive lesion

Cocaine is a drug with relevant socioeconomic and clinical implications, which is usually recreationally used for its stimulant effects. It is widely known that the habit of snorting cocaine is associated with a peculiar type of drug-induced chronic rhinitis, which leads to inflammation of the sinonasal mucosa, slowly progressing to a destruction of nasal, palatal and pharyngeal tissues. These characteristic lesions due to cocaine abuse are commonly called cocaine-induced midline destructive lesions (CIMDL). Diagnosis is not always straightforward, since various conditions, mainly vasculitis, might mimic this acquired condition. The extent of pharyngeal involvement varies, although often a prolonged abuse can trigger a progressive destruction of oral and nasal tissues, with development of infections and recurrent inflammation. Our article focuses on cocaine as a world health problem with important ear, nose and throat implications and discusses the difficulties in diagnosing and treating CIMDL, through a case report.

Unusual case of bilateral maxillary fungus ball

An otherwise healthy 34-year-old man was referred to our ear, nose and throat (ENT) clinic for a bilateral maxillary radiologic opacity. This condition was accidentally discovered with a panoramic radiography performed during a follow-up visit after a bilateral endodontic treatment. The patient did not report any specific sinonasal symptom such as purulent nasal discharge, loss of smell and cough, apart from an unspecific sinus pressure. The CT scans showed a bilateral inflammatory process into the maxillary-ethmoidal sinuses and an iron-like density within the maxillary sinuses, while nasal endoscopy showed purulent discharge in the ostiomeatal complex. The patient underwent functional endoscopic sinus surgery under general anaesthesia and the inflammatory material collected was histologically diagnosed as a rare case of bilateral fungus ball. The patient was dismissed the following day with no complications; there were not any sign of recurrence or symptoms during a 4 month follow-up.