Angelo Ghidini

Auto-crosslinked hyaluronan gel injections in phonosurgery

Objectives: To evaluate the clinical performance of an auto-crosslinked gel obtained from hyaluronic acid (ACP-based gel) as an anti-adhesive agent and/or augmentative agent in vocal cord surgery for the treatment of vocal fold (VF) atrophy, sulcus vocalis, and postsurgery scarring as well as its tolerability at short- and long-term follow-up. Study Design: This was a prospective multicenter trial conducted between 2007 and 2009. Setting: Academic center. Subjects and Methods: Inclusion criteria were patients with glottic gap due to previous endoscopic phonosurgery, VF scars, vocal cord atrophy, and sulcus vocalis. Forty patients who underwent endoscopic injection of hyaluronic acid under general anesthesia were enrolled. Two different injections sites were used: the thyroarytenoid muscle in cases of glottic gap for augmentative purposes, and the lamina propria for treatment of scars and sulcus vocalis. A voice-evaluation protocol was performed before surgery, at the first follow-up visit (3 mo), and at the final follow-up (12 mo). Results: Follow-up data at three months were available for 38 patients, while data at 12 months follow-up were available for 27 patients. No side effects, hematoma, or infection and allergic reactions were reported in either the perioperative or postoperative period. Patients had statistically significant improvement in voice parameters compared with the baseline data at the first follow-up visit and at the 12-month follow-up. Conclusion: ACP-based gel seems to be a new tool in the challenging treatment of VF scarring, functioning as both an anti-adhesive product and an augmentation agent. Improvements in all glottal parameters and in both objective and subjective evaluation of voice performance were observed.

Voice and swallowing after partial laryngectomy: Factors influencing outcome

The purpose of this study was to assess the factors influencing swallowing and phonatory results after partial laryngectomy.

Forestier disease: single-center surgical experience and brief literature review.

Objectives We describe the experience of our otolaryngology department in the treatment of Forestier disease, particularly regarding the diagnostic process, surgical treatment, and postoperative outcomes. Methods The charts of 12 patients who underwent surgical treatment of Forestier disease between January 1, 2003, and January 1, 2009, were analyzed. All patients were subjected to clinical, radiologic, and endoscopic evaluation that confirmed the presence of cervical osteophytes. All patients were treated by a right-sided prevascular transcervical approach to remove cervical osteophytes. A literature review on Forestier disease was also carried out. Results One case of immediate postoperative hemorrhage was reported. During the postoperative follow-up, ranging from 1 to 5 years, all patients underwent cervical radiography and fiberoptic laryngoscopy that confirmed no evidence of recurrence, and all patients remained asymptomatic. Conclusions A prevascular transcervical right-sided approach seems to be an effective treatment for surgical removal of hyperostosis in Forestier disease, with an acceptable rate of complications and recurrence.

Atypical neoglottis after supracricoid laryngectomy: a morphological and functional analysis

The objective of this study was to analyze atypical neoglottis after supracricoid subtotal laryngectomy (SSL) from a morphological and functional point-of-view using retrospective case series reviewin a Tertiary university referral center setting. From May 2003 until January 2010, 106 patients underwent SSL (CHEP, CHP, THEP, THP) for laryngeal cancer, in the Otolaryngology Department of the University Hospital of Modena. We performed a retrospective analysis of recorded videos in our database of patients who underwent SSL. Patients with atypical neoglottis were included in the study. Six patients with atypical neoglottis were identified and morphologically evaluated. The functional outcomes were collected and analyzed. Atypical neoglottis may form after SSL, in particular in the case of CHEP. In most cases, these atypical conformations are due to anomalous positioning of the epiglottis, or involvement of the lateral pharyngeal wall in the sphincteric and vibratory function of the neoglottis. Atypical neoglottis formation seems to guarantee adequate functional outcomes in terms of vocal and swallowing performance.

An unusual case of giant cell tumour involving the middle cranial fossa, originating from soft tissues of the temporomandibular joint

A rapid onset swelling in the left temporomandibular joint (TMJ) region occurred in a 70-year-old man. The remote clinical history was unremarkable; crepitus at the involved TMJ, omolateral tinnitus, hearing decrease and persistent headache in the sovraorbital area was reported. A firm mass was palpable intraand extra-orally. Laboratory investigations were within normal limits. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a 2.5-cm ovoidal mass in the infratemporal fossa (IF), which eroded the middle cranial fossa and emerged in an extradural location (Fig. 1a-c). A craniotomy was performed; the cut off of the zygomatic bone and the removal of the upper arm of the jaw allowed the exposure of the IF fully occupied by the neoplasm, which eroded the floor of the middle cranial fossa; the intact overlying dura was preserved. Tumour dissection was extended to the anterior cranial fossa and the ovale foramen, invaded by the tumour; the rotundum foramen was uninvolved. Histological examination showed (Fig. 1d-e) abundant giant cells with an osteoclast-like appearance, strong CD68 positivity, a large number of centrally located nuclei and abundant eosinophilic cytoplasm. Numerous ovoid to spindle-shaped stromal cells with a thin rime of eosinophilic cytoplasm were also present, as well as several foci of haemosiderin pigment deposition and no areas of necrosis. Mitotic figures were scarce and without atypia. The labelling index (Ki67) was <30% and predominant in the osteoclast-like cells. The diagnosis was: giant cell tumour (GCT). Chest radiograph excluded pulmonary metastases. At 3-years follow-up there was no evidence of recurrence.

The Normal-Weight Snorer: Polysomnographic Study and Correlation with Upper Airway Morphological Alterations

Obesity is recognized as playing an important role in causing snoring and in turning simple snoring into obstructive sleep apnea syndrome (OSAS). From our series of patients with sleep disturbances, we studied a group of 43 normal-weight snorers in whom we detected a significant number of OSAS episodes. An articulated diagnostic protocol was adopted, and Müllers maneuver was extensively applied. The resulting data were compared to data from a group of 43 obese patients from the same series. The major risk factor for developing OSAS in normal-weight snorers appears to be anatomic abnormalities, in particular, septal deviation and base of tongue hypertrophy. Soft palate hypertrophy alone is not enough, although in obese snorers it can produce a sleep disorder. The normal-weight snorer needs to be thoroughly investigated because of the significant risk of developing OSAS and for the detection of multiple concomitant sites of obstruction.

Quality of life in patients treated with PDMS injection for swallowing disorders

Objective: To document the efficacy of polydimethylsiloxane (PDMS) injections in patients with swallowing disorders after partial supracricoid laryngectomy; to assess the importance of quality-of-life (QOL) outcome in oncologic patients. Subjects and Methods: The study included 11 patients with swallowing disorders after partial laryngectomy and appropriate rehabilitation. They were treated with endoscopic injection of PDMS; QOL was investigated with four questionnaires (M.D. Anderson Dysphagia Inventory, Performance Status Scale for Head and Neck Cancer, Performance Karnofsky Scale, and Voice Handicap Index-10) before and after surgical treatment and further rehabilitation. Results: A significant improvement in QOL of all 11 patients was seen after endoscopic injection. The impact of this treatment on the social life of patients was considerable. Conclusion: Swallowing disorders and speech problems are quite common complications of partial laryngectomy. QOL in oncologic patients is a mandatory outcome measure. PDMS injection showed an improvement in the everyday life of selected patients.

MR evaluation of PDMS injections in head and neck tissues: A pilot study

OBJECTIVES To describe the magnetic resonance (MR) appearance of polydimethylsiloxane (PDMS) injections in the head and neck region. STUDY DESIGN Retrospective review of MR images from a case series. METHODS MR images of 10 patients, who underwent PDMS injections at our department, were reviewed. Data from imaging were collected and analyzed. RESULTS After injection, PDMS can be identified in MR images, particularly in T2-weighted images in the early stages. Its MR characteristics are similar to silicone in other regions, but with time, its appearance can change. CONCLUSIONS The integration of PDMS with tissues may also be reflected in changes in MR appearance, as a result of an increased amount of fibrous tissue in the region injected. Radiologists and ENT specialists may benefit from knowledge of the MR characteristics and variability in appearance of PDMS in human tissues for improving image interpretation.

Vox-Implants Injection after Partial Laryngectomy

Objective To illustrate a surgical technique for swallowing rehabilitation of patients after partial laryngectomy and to evaluate quality of life after treatment. Methods A longitudinal prospective study. 11 patients with persistent swallowing impairment after partial laryngectomy were included in the study. Swallowing disorders were diagnosed with videofluoroscopy and FEES (fiberoptic endoscopic evaluation of swallowing), and were quantified by 2 scales (a dysphagia score and a modified Penetration-Aspiration scale). A self-evaluation questionnaire about quality of life after polydimethylsiloxane (PDMS) injection was submitted to each patient (EORTC-QLQ 30). After identification of site of inhalation of bolus, PDMS was injected into the neoglottis to fill the neoglottic gap in order to obtain a better continence of the neolarynx. Aerodynamics and acoustic analysis were assessed before and after treatment. Results Average follow-up was 25 months (range 5–39). All patients showed an improvement both in the dysphagia score and in the modified Penetration-Aspiration scale. Average improvement was 2.6 points in the dysphagia score (p=0.0042) and 2.1 in the modified Penetration-Aspiration scale (p=0.0043). MPT showed an average improvement of 5 sec (p=0,037). The quality of life assessment showed a subjective improvement in each patient. Conclusions PDMS injection can be a useful technique in surgical rehabilitation of swallowing in patients who underwent partial laryngectomy. FEES is a very important tool in identifying anatomical alterations that can cause incorrect passage of bolus in the airways during deglutition. Filling these regions with PDMS can avoid passage of food into the airways, thus improving deglutition and voice and by consequence, patients’ quality of life.

Endoscopic Management of Acquired Cholesteatoma

Objective The purpose of this study was to examine the utility of using an endoscope in cholesteatoma surgery and to demonstrate how it allows a reduction in the incidence of residual disease. Methods A prospective study. A total of 53 ears with acquired cholesteatoma (primary) were resected. 20 cases were resected using a canal wall up (CWU) technique, 6 cases using a canal wall down (CWD) technique, and in 27 cases a transcanal tympanotomyatticotomy was performed. All of the patients in our study group underwent an explorative and operative endoscopic ear surgery complementary to the operating microscope to uncover and remove residual cholesteatoma. Results In the primary surgery after completion of microscopic cleaning, the overall incidence of intraoperative residual disease detected with the endoscope was 37.5%. The sinus tympani was the most common site of intraoperative residuals, followed by the anterior epitympanic recess and protympanum. Out of the 20 CWU cases, 12 second-look endoscopies were performed. Two recurrences were identified, both in the sinus tympani. There were no significant complications associated with the 53 endoscopic procedures. Conclusions The endoscope allowed a better understanding of cholesteatoma and improved eradication of residual disease from hidden areas such as the anterior epitympanic recess, retrotympanum and hypotympanum not yet controllable by operating microscope.