Alessandro Pusateri

Adenoids in children: Advances in immunology, diagnosis, and surgery.

Adenoids are strategically located for mediating local and regional immune functions as they are exposed to antigens from both the outside air and the alimentary tract. Recurrent or chronic respiratory infections can induce histomorphological and functional changes in the adenoidal immunological barrier, sometimes making surgical treatment necessary. Our aim in this review is to summarize the crucial points about not only the immunological histopathology of adenoidal tissue, especially in patients with adenoid hypertrophy, but also the most common and useful diagnostic techniques and surgical options. Clin. Anat. 27:346–352, 2014.

Sphenoid sinus fungus ball: our experience

Background Fungal rhinosinusitis is a common disease of the paranasal sinuses. The fungus ball (FB) is defined as an extramucosal mycotic proliferation that fills one or more paranasal sinuses. Sphenoid sinus is an uncommon localization of this disease, as reported in the literature. This study describes our experience in the diagnosis and treatment of sphenoid sinus FB (SSFB), with a particular focus on the surgical approach to the sphenoid sinus. Methods We retrospectively analyzed the clinical records of patients affected by FB of the sphenoid sinus, who underwent endoscopic sinus surgery (ESS) in our institutions between 1995 and 2009. We described the surgical technique, the methods of mycological and histopathological evaluation, as well as the perioperative and postoperative management. Results From 1995 to 2009, 226 patients affected by sinonasal FB underwent ESS in our institutions. A sphenoid localization was found in 56 patients (24.78%; mean age, 62 years). Cephalea was the most common symptom, and 14.3% of patients complained of ocular symptoms. We performed a direct paraseptal sphenoidotomy in 31 patients (55.4%) and a transethmoidal sphenoidotomy in 25 patients (44.6%). Histology unveiled fungal hyphae with absent mucosal invasion in all cases. Cultural results revealed positivity for mycotic colonization in 26 cases (46.4%, most commonly Aspergillus fumigatus). Follow-up ranged from 12 to 181 months with a mean of 70.7 months. Conclusion The description of our experience in the diagnosis and treatment of SSFB underlines the importance of a precise diagnostic pathway in case of sphenoidal disease. Nowadays, in our opinion, the paraseptal direct sphenoidotomy represents the less invasive, fastest and most anatomically conservative approach to the sphenoid sinus in case of SSFB.

Evolution in the treatment of sinonasal inverted papilloma: pedicle-oriented endoscopic surgery.

Background In the literature, the global endoscopic sinus surgery (ESS) success in the treatment of sinonasal inverted papilloma (IP) is 95%. This study was designed to describe a conservative endoscopic approach, based on research of the tumors pedicle and treatment concentrated on its site of attachment, and to compare the results of this technique with the outcome of standard endoscopic treatment. Methods Retrospective analysis of the patients treated in our institution for paranasal inverted papilloma (IP), between 2002 and 2011 with a minimum of 18 months follow-up was performed. Group A received a standard ESS including whole sinus demucosization (maxillary, ethmoid, frontal, or sphenoid sinus) and bony wall drilling. Group B patients instead underwent pedicle-oriented endoscopic surgery (POES); in this group, bony demucosization and drilling were selectively conducted around the site of pedicle attachment of the tumor. Results The cohort included 73 patients (median age, 60.5 years; median follow-up, 58 months). Group A/group B consisted of 37/36 patients. IP persistence—recurrence for group A/group B was 0/1 cases. Oncological success for global endoscopic/group A/group B was 98.6% (72/73)/100% (37/37)/97.2% (35/36). We noticed a significant difference in surgical operative time and postoperative complication rate among the groups, in favor of POES technique. Conclusion Our data confirm the efficacy of the endonasal endoscopic treatment for sinonasal IP. Moreover, the even more conservative endoscopic treatment proposed (POES) seems to offer good control of the disease, shorter operating times, avoidance of unnecessary surgery with respect to uninvolved structures, and permits a follow-up aimed at the site of the pedicle attachment.

Transnasal endoscopic approach to symptomatic sinonasal osteomas.

Background One of the most challenging benign tumors for the ear, nose, and throat (ENT) surgeon is represented by sinonasal osteomas. Surgical treatment should regard just symptomatic osteomas, because these tumors can provoke rhinosinusitis and mucoceles. Recently, new instruments have been applied in endoscopic sinus surgery (ESS). This study was designed to present our experience in the endoscopic management of osteomas of the paranasal sinuses. Clinical findings, preoperative imaging strategy, and surgical techniques are discussed. Methods We retrospectively reviewed clinical records of patients who underwent ESS for sinonasal osteomas between 2003 and 2010 in our institutions. Results We have treated with a transnasal endoscopic approach 29 patients affected by paranasal osteomas (13 men and 16 women; age range, 20–78 years; mean, 49.5 years). We found frontoethmoidal junction localization in 14 patients, frontal sinus in 6 patients, ethmoid in 6 patients, sphenoid in 1 patient, maxillary in 1 patient, and multiple osteomas in 1 patient. Initially, patients were treated by the cavitation technique with standard ESS instruments, whereas in more recent cases surgery was assisted by the use of ENT navigation system, curved drills, and ultrasound bone emulsifier. No major complications occurred. No radiological or endoscopic signs of recurrence (mean follow-up, 52 months; range, 6–89 months) have been observed. Conclusion Endoscopic removal of osteomas of the sinonasal region is feasible, taking into account the location and size of the lesion. Particular importance should be given to new instruments that have been applied in the last years in ESS.

Transoral power-assisted marsupialization of vallecular cysts under local anesthesia.

INTRODUCTION Vallecular cysts (VCs), also known as epiglottic mucous retentions or base of the tongue cysts, are ductal cysts resulting from obstruction and retention of mucus in the collecting ducts of the submucosal glands located at the base of the tongue. VCs are covered with ductal cells rather than with acinar cells, and this supports the hypothesis that they are dilated ducts and not distended glands. VCs are usually considered self-limiting lesions of the larynx, but in early infancy, this entity may be associated with severe airway obstruction and feeding difficulties. In adults, VCs are most frequently asymptomatic, and apart from causing nonspecific throat discomfort, are usually discovered during routine laryngeal examinations. Large VCs can become symptomatic, usually causing various degrees of dysphagia. Less frequently, VCs are discovered during the induction of general orotracheal anesthesia when they cause difficulty in endotracheal intubation. Moreover, infection of a VC can initiate acute epiglottitis with or without abscess formation, and thus may be associated with life-threatening acute airway obstruction also in adults. VCs are quite rare entities, and most publications in the literature are case reports that describe neonatal airway obstruction or difficult intubation in adults. Recently, Berger et al. performed a retrospective analysis of 38 adult patients, in which they identified two types of adult VCs: the first by acute onset of infection that extends to the epiglottis with abscess formation and possible airway obstruction, and the second by a less ominous disease with prolonged mild symptoms that result from pressure effects on neighboring tissues. Conservative management (wait and see) is usually performed in asymptomatic VCs. Moreover, in symptomatic cases, treatment options include cyst aspiration, marsupialization, surgical debulking, and laser excision. In this article we propose an innovative and effective surgical technique, consisting of transoral power-assisted marsupialization of VCs under local anesthesia using a curved microdebrider.

Argon plasma coagulation is an effective treatment for hereditary hemorrhagic telangiectasia patients with severe nosebleeds

Abstract Conclusions: In contrast to the current trend according to which the treatment of hereditary hemorrhagic telangiectasia (HHT) epistaxis depends on clinical severity, argon plasma coagulation (APC) has also proven to be effective as a first-line procedure in patients with severe nosebleeds. Furthermore, with this approach patients are free from requirements for blood transfusions for a long time in the vast majority of cases. Objective: The aim of this study was to test the efficacy of APC treatment as a first-line procedure in HHT patients affected by severe epistaxis. Methods: From 1996 until 2011, 252 HHT patients were treated with APC in our clinic. We selected 26 patients with severe epistaxis for whom the need for blood transfusion had been recorded. This group of patients was asked to answer a questionnaire that aimed to evaluate the severity of epistaxis (defined by its intensity, frequency, and duration), to assess the duration of the benefit of treatment and to evaluate the number of blood transfusions required before and after treatment. Results: After APC treatment, a statistically significant decrease in all epistaxis parameters was recorded and most patients did not need blood transfusions for several years after the procedure.

Adenoid assessment in paediatric patients: the role of flexible nasal endoscopy.

Adenoid hypertrophy is the most common cause of nasal obstruction in paediatric patients. Over the years, various methods to assess the adenoid size were proposed such as the posterior rhinoscopy and the radiological examination of the nasopharynx. Nasal endoscopy was introduced for children in the 80s, and nowadays this is a known and diffuse method in routine practice. The purpose of this article is to describe the personal experience in the assessment of the adenoid size in children, with a particular regard to the flexible nasal endoscopy, and to analyse the literature reports. The personal technique is described in performing nasal endoscopy in paediatric patients, reporting advantages and possible disadvantages of the procedure. A retrospective analysis was conducted on 6036 children since 1999 to 2010. In most cases children fully collaborated to complete the exam. No major or minor complications (such as nose bleedings or other traumatic injuries) were observed. No topical intranasal decongestant, local or general anaesthesia were used in our series. In our opinion, nasal endoscopy in children is a reliable, safe, accurate, easily tolerated and dynamic diagnostic method to assess the adenoid size.

Transoral endonasal-controlled combined adenoidectomy (TECCA)†

INTRODUCTION Adenoidectomy with or without tonsillectomy is one of the most commonly performed surgical procedures in the pediatric population. The standard surgical technique with adenoid curette or LaForce adenotome has evolved in the lasts years with the introduction of the endoscopic sinus surgery instrumentary, with an improved patients’ outcome, and a better satisfaction for the surgeon itself. However, in up to one-third of children with clinically significant adenoid hypertrophy a classical surgical technique canot completely remove the obstructive adenoid tissue, especially in the upper portion of the nasopharynx, the peritubaric region, and in the case of an intranasal extension. With the introduction of microdebriders in the otolaryngologist’s armamentarium, adenoidectomy (partial or total) has been one of the most interesting applications of this instrument, but for most surgeons the approach still remained transoral with a laryngeal mirror control. The advent of endoscopic sinus surgery in the 1990s popularized the use of intranasal scopes, and so the endoscopic adenoidectomy became the natural evolution of the conventional one. The endoscopic control permitted a complete removal of the adenoid tissue also in areas such as the eustachian tube, the upper part of nasopharynx, and the choanae. Parson, in 1996, and Yanagisawa and Weaver, in 1997, introduced for the first time the use of a transnasal microdebrider under endoscopic transnasal control to perform an adenoidectomy. In a recent publication, similar to that published by Havas and Lowinger in 2002, we described the surgical procedure used in our institution: a combined method of traditional curette and power-assisted transnasal adenoidectomy under endoscopic transnasal control. The purpose of this article is to report our experience in the evolution of such surgical approach: a combined use of a traditional curette adenoidectomy, completed, when necessary, by a transoral curved microdebrider revision under endoscopic transnasal control (TECCA).

Invasive fungal rhinosinusitis in adult patients: Our experience in diagnosis and management

BACKGROUND This paper describes our experience in the management of acute and chronic invasive fungal rhinosinusitis (IFRS) in adults. METHODS Medical files of all patients aged >18 years treated in our institutions for IFRS from 2002 to 2013 were retrospectively reviewed. RESULTS A total of 18 cases (10 acute and 8 chronic) were recorded. In acute form, haematological malignancies represented the principal comorbidity (100%), while in chronic form this was diabetes mellitus (87.5%). All patients received systemic antifungal agents. Endoscopic sinus surgery was performed in 16/18 patients (88.9%). Among patients with an acute IFRS, 4/10 died of fungal infection (40%), on the other side 2/8 patients with chronic IFRS died of the evolution of the mycosis (25%). CONCLUSIONS Acute and chronic IFRS are different entities: in acute form, prognosis is poor, so therapy should be promptly performed, although host immune status and evolution of the haematological disease are key factors for the outcome. In chronic form, a wide surgical excision of the disease is recommended in order to obtain a complete removal of fungal infection. In both forms, early clinical findings are non-specific and ambiguous, so diagnosis depends on a high index of suspicion, taking into account predisposing factors.

Adenoids and clinical symptoms: Epidemiology of a cohort of 795 pediatric patients

OBJECTIVE Adenoid hypertrophy (AH) is very common in children and can cause airway obstruction. The aim of this retrospective study was to investigate the relationship between AH and other factors, including age, possible related symptoms, and allergies. METHODS Seven hundred and ninety-five patients (460 males, 335 females; mean age=5.9 years; range age: 1-14 years) were seen in an ENT clinic for nasal symptoms. Nasal endoscopy was performed with a pediatric flexible endoscope. One hundred and sixty-nine patients had documented allergy sensitization. Patients were divided into two groups according to their age: group 1 included children aged 1-7 years, and group 2 included subjects aged 8-14 years. RESULTS Adenoid size was related to age (p<0.0001). A logistic regression model - performed to evaluate adenoid grade considering, as dependent variables, age, sex, and the presence or absence of symptoms - was statistically significant (p<0.001). Moreover, AH was more common (p=0.0104) in patients with allergy sensitization, in particular in patients aged 8-14 years (p=0.0043). Nasal obstruction (OR=3.27) significantly predicted AH, whereas major age was not associated with pathological AH (OR=0.81). CONCLUSIONS The present retrospective study described the relationship between AH and other demographic and clinical factors. In conclusion, our findings demonstrated a significant association among pathological AH, age, and nasal obstruction.