Daniele Marchioni

Endoscopic management of acquired cholesteatoma: our experience.

OBJECTIVES 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. MATERIAL AND METHODS Thirty-two ears with acquired cholesteatoma (primary) were resected. Twenty cases were resected using a canal wall up (CWU) technique and six cases using a canal wall down (CWD) technique, and in six cases, a transcanal tympanotomy-atticotomy was performed. All of the patients in our study group underwent explorative and operative endoscopic ear surgery complementary to use of 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 residual disease, followed by the anterior epitympanic recess and protympanum. Of the 20 CWU cases, 12 second-look endoscopies were performed. Two residuals were identified, both in the sinus tympani. No significant complications were associated with the 32 endoscopic procedures. CONCLUSION 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 the operating microscope.

Selective epitympanic dysventilation syndrome

Although middle ear aeration is certainly related to eustachian tube (ET) function, other anatomic factors may play an important role in ventilation of these spaces, particularly the epitympanum.

Endoscopic approach to tensor fold in patients with attic cholesteatoma.

Conclusion. The endoscopic approach to attic cholesteatoma allows clear observation of the tensor fold area and consequently, excision of the tensor fold, modifying the epitympanic diaphragm. This permits good removal of cholesteatoma and direct ventilation of the upper unit, preventing the development of a retraction pocket or attic cholesteatoma recurrence, with good functional results. Objectives. An isthmus block associated with a complete tensor fold is a necessary condition for creation and development of an attic cholesteatoma. During surgical treatment of attic cholesteatoma, tensor fold removal is required to restore ventilation of the attic region. Use of a microscope does not allow exposure of the tensor fold area and so removal of the tensor fold can be very difficult. In contrast, the endoscope permits better visualization of the tensor fold area, and this aids understanding of the anatomy of the tensor fold and its removal, restoring attic ventilation. Patients and methods. In all, 21 patients with limited attic cholesteatoma underwent an endoscopic approach with complete removal of the disease. Patients with a wide external ear canal were operated through an exclusively endoscopic transcanal approach; patients with a narrow external ear canal or who were affected by external canal exostosis were operated through a traditional retroauricular incision and meatoplasty followed by the endoscopic transcanal approach. Results. In 18/21 patients, the endoscope permitted the discovery of different anatomical morphologies of the tensor fold. Sixteen patients presented a complete tensor fold (one with an anomalous transversal orientation), one patient presented an incomplete tensor fold and one patient presented a bony ridge in the cochleariform region. In all 16 cases of complete tensor tympani fold, the fold was removed and anterior epitympanic ventilation was restored. The ridge bone over the cochleariform process was also removed with a microdrill.

Transcanal endoscopic approach to the sinus tympani: a clinical report.

Objectives: To investigate the anatomic limitations of the endoscopic transcanal approach to sinus tympani (ST), in particular, how this approach might allow a complete visualization of the ST recesses and to propose a morphologic classification of the ST using computed tomography and to examine if this could be useful for the surgeon in preoperative planning to decide the type of approach to the ST. Study Design: Case series. Patients and Methods: Forty patients affected by middle ear disease with ST involvement were included in our study. All patients underwent a preoperative computed tomographic scan of the temporal bone. All patients underwent tympanomastoid surgery with intraoperative use of the endoscope. We assessed the variation in depth of the ST area, analyzing the posterior and medial extension of the medial boundary of the ST, and performing a radiomorphologic classification of the ST. Results: Of the 40 patients, it has been possible to describe the detailed morphology of the shape of the ST in 38. We classified the depth of the ST into 3 types based on radiologic findings: Type A (a limited ST), Type B (a deep ST), and Type C (a deep ST with a posterior extension). Of 35 ST of Types A and B, there was good exposure of the medial boundary of the sinus using a transcanal endoscopic approach in 33 (94.2%), whereas in 3 (60%) of 5 patients of Type C, it was not possible to explore the complete depth of the sinus, especially the ST portion under and posterior to the facial nerve. Conclusion: The transcanal endoscopic approach to the ST is indicated in ST of Types A and B. In ST of Type C, it is not always possible to have good control of the ST; in these cases, a posterior retrofacial approach is suggested.

Inferior retrotympanum revisited: An endoscopic anatomic study

To describe the inferior retrotympanic anatomy from an endoscopic perspective.

Endoscopic tympanoplasty in patients with attic retraction pockets

Patients undergoing endoscopic middle ear surgery require reconstruction procedures that are able to give adequate functional results, with particular attention to ventilation of middle ear routes and mastoid tissue preservation.

Middle turbinate preservation versus middle turbinate resection in endoscopic surgical treatment of nasal polyposis

Conclusion. Relapse in patients affected by nasal polyposis and subjected to endoscopic surgery appears to be a relevant feature. Surgical treatment shows a significant increase in quality of life in all the patients aside from surgical technique used. Our results show a better control of relapse of nasal pathology in patients subjected to more radical surgery (group B) vs patients subjected to conservative surgery on middle turbinate (group A). Allergic patients in group B had a smaller number of relapses during the follow-up period compared with allergic patients in group A and this was statistically significant. Objectives. Different endoscopic surgical techniques have been applied for the treatment of nasal polyposis. During ethmoidectomy, some authors prefer to remove the middle turbinate while others preserve this structure. To date, there have been no studies comparing the results, in a homogeneous case series of patients operated exclusively for nasal polyposis, between those whose middle turbinate was resected and those whose middle turbinate was preserved. The aim of our study was to compare results in these two groups of patients. Patients and methods. A prospective study was performed. Nasal polyposis was studied on the basis of endoscopic examination and all the patients were classified on the basis of CT of paranasal sinuses using the Kennedy CT staging system. In the study group, only subjects affected by nasal polyposis with stage II–III at endoscopic evaluation and a Kennedy score of III–IV, affected by nasal polyposis, and not responsive to medical treatment were recruited. The presence of allergy was evaluated by skin prick test results and that of asthma by spirometric examination. Recurrence rates and quality of life were evaluated in a 3-year follow-up. Results. In total, 56 patients were selected and all were observed over a 3-year follow-up period. We identified two groups: group A, 34 patients (60.71%) affected by nasal polyposis who underwent endoscopic surgery with the conservation of middle turbinate; group B, 22 patients (39.29%) affected by nasal polyposis who underwent more radical endoscopic sinus surgery. Analyzing the entire study group, during the 3-year follow-up, 20 (35.71%) of the 56 patients had a relapse of nasal polyposis. Analyzing time to relapse curves in the allergic and non-allergic patients, we obtained a p value of 0.0589, i.e. at the limit of statistical significance. The comparison between preoperative and postoperative Cologne test in the whole study group was statistically significant for a symptomatic improvement (p<0.001). Trends within the two groups were also evaluated: there was a statistically significant difference in behavior upon time to relapse of the patients in group B vs group A (p=0.0102). The patients in group A developed nasal recurrence more frequently during the follow-up periods. In patients affected by allergy vs patients not affected by allergy in group A, a statistically significant difference was noted (p=0.0074); the allergic patients developed nasal recurrence more frequently during the follow-up period. We could not find a statistically significant difference between those patients affected by allergy and those not affected by allergy, as regards the number of relapses in patients in group B.

Endoscopic transcanal corridors to the lateral skull base: Initial experiences

Surgical approaches to the lateral skull base, internal auditory canal (IAC), and petrous bone are widely known and have been extensively recorded. Despite the benign nature and limited dimensions of lesions located in this anatomical region, extirpative surgical approaches are often required to reach and remove the disease. The aim of present report was to describe our initial experiences with minimally invasive endoscopic approaches to the lateral skull base.

Transcanal Endoscopic Management of Cholesteatoma

A detailed and comprehensive discussion of transcanal endoscopic management of cholesteatoma is presented. After a presentation of the anatomy of the area, the rationale, advantages and limitations, technique, and long-term results of each technique are presented. A case presentation follows each technique. Techniques presented are: endoscopic transcanal management of limited cholesteatoma, endoscopic open cavity management of cholesteatoma, and expanded transcanal access to middle ear and petrous apex.

Nasal septal perforations: Our surgical technique

Objective The aim of this paper was to describe our surgical technique for the treatment of nasal septal perforations. Study and Design We studied 31 patients with nasal septal perforation treated with an endoscope-assisted technique, based on a bilateral dissection of monopedicled mucosal flaps from the nasal fossa floor, sutured at the edge of the perforation previously unstuck, without any graft interposed between the two mucosal layers. Results In our experience with 31 patients, the use of this technique led to the persistent closing (with follow-up for at least one year) of 96.3% of the perforations smaller than 3 cm. Conclusions Our technique has the advantage of an endonasal approach, without any external incision, and the use of monopedicled flaps from the nasal fossa floor without any graft interposition, avoiding any other surgical procedure and morbidity in the donor site of the graft. The use of nasal endoscopy permits superior precision in all surgical steps. Significance The high success rate in perforations smaller than 3 cm seems to confirm the effectiveness of this technique.