Diego Cazzador

Intracranial venous sinus thrombosis as a complication of otitis media in children: Critical review of diagnosis and management

OBJECTIVES Otogenic lateral sinus thrombosis (LST) is a rare intracranial complication of acute otitis media (AOM), which can lead to severe neurological sequelae and death. The aim of this study was to analyze the clinical presentation, management and outcome of LST in children, investigating a possible correlation between clinical aspects, radiological findings and anatomical variations. METHODS At a tertiary Italian hospital, a retrospective review was conducted on the medical records of eight patients diagnosed with otogenic LST over a 3-year period. Four children were males and mean age was 4.7 years. RESULTS All patients had a history of otitis media at diagnosis and 4/8 presented also with more than one neurological sign or symptom. Mastoiditis signs were detected in 5/8 patients. Thrombosis was diagnosed by computed tomography, enhanced magnetic resonance and magnetic resonance venography. Treatment was medical, alone or combined with surgery. Medical treatment consisted in anticoagulants eventually combined with anti-edema medication on clinical basis. Mastoidectomy and/or myringotomy±trans-tympanic drainage placement were performed in 7/8 patients. Complete vessel recanalization was obtained in 6/8 children after a median follow-up time of 4.8 months. No complications, neither clinical sequelae occurred. In our series, neurological signs and symptoms were significantly associated with the presence of hypoplasia of the contralateral venous sinus (p=0.029). CONCLUSION LST is a severe condition occurring even in absence of otological signs, and despite adequate antibiotic therapy for AOM, which should be ruled out and promptly treated. A dominant neurological presentation is associated in our series with anatomical variations of cerebral sinus venous drainage patterns. This should be carefully evaluated and considered in diagnosis, treatment planning and prognosis.

The endoscopic endonasal approach for cerebrospinal fluid leak repair in the elderly

INTRODUCTION Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant morbidity and mortality, especially in the elderly. Endoscopic endonasal surgery is a validated technique in the repair of anterior skull base CSF leaks. The aim of this study is to assess diagnostic management, surgical technique and clinical outcome in a consecutive series of elderly patients. METHODS Patients older than 65 years treated for anterior skull base CSF leaks through endoscopic endonasal surgery between 2003 and 2014 were retrospectively reviewed. All patients underwent preoperative nasal endoscopy, laboratory and radiological assessment. In doubtful cases endoscopic exploration was performed after intrathecal fluorescein (IF) injection. Patients were discharged between 3 and 4 days after surgery, and the endoscopic follow-up ranged from 3 to 24 months. RESULTS 20 patients (age range 65-92) presented with 10 spontaneous and 10 traumatic/iatrogenic CSF leaks. In 40% of patients formal rhinoscopy and radiological assessment did not localize the CSF leak and IF injection was performed. IF enabled the identification of the skull base defect in all cases, with no adverse effects. In 11 cases the dura was repaired with fascia lata graft. All patients had successful endoscopic repair of the CSF fistula with no complications nor recurrences during follow-up. CONCLUSION Endoscopic endonasal surgery is a minimally invasive procedure for CSF leak treatment. In our experience, IF injection proved safe and efficient in detecting skull base defects not identified by preoperative imaging. Endoscopic endonasal surgery proved effective and reliable also in elderly patients, with short hospitalization times and no morbidity.

Combined Surgical Approach to Giant Cholesteatoma: A Case Report and Literature Review.

Objectives: Cholesteatomas can grow to a remarkable size before clinically making their presence felt. Managing giant cholesteatomas and their complications can become a challenge for the otological surgeon. Methods: We describe a case of a giant congenital cholesteatoma of the mastoid in an adult. The lesion extended to the sigmoid sinus, jugular bulb, carotid canal, occipital condyle, and the lateral portion of the first cervical vertebra. Surgical excision was performed using a combined microscopic and endoscopic surgical approach. Results: Our combined surgical technique enabled a more accurate removal of the cholesteatoma than a microscopic approach alone, with no surgical complications or damage to the structures affected by the disease. Conclusions: Using endoscopic instruments to manage giant cholesteatomas can help to avoid complications and improve surgical radicality.

“TuNa-saving” endoscopic medial maxillectomy: a surgical technique for maxillary inverted papilloma

The maxillary sinus is the most common site of sinonasal inverted papilloma. Endoscopic sinus surgery, in particular endoscopic medial maxillectomy, is currently the gold standard for treatment of maxillary sinus papilloma. Although a common technique, complications such as stenosis of the lacrimal pathway and consequent development of epiphora are still possible. To avoid these problems, we propose a modification of this surgical technique that preserves the head of the inferior turbinate and the nasolacrimal duct. A retrospective analysis was performed on patients treated for maxillary inverted papilloma in three tertiary medical centres between 2006 and 2014. Pedicle-oriented endoscopic surgery principles were applied and, in select cases where the tumour pedicle was located on the anterior wall, a modified endoscopic medial maxillectomy was carried out as described in this paper. From 2006 to 2014 a total of 84 patients were treated. A standard endoscopic medial maxillectomy was performed in 55 patients (65.4%), while the remaining 29 (34.6%) had a modified technique performed. Three recurrences (3/84; 3.6%) were observed after a minimum follow-up of 24 months. A new surgical approach for select cases of maxillary sinus inverted papilloma is proposed in this paper. In this technique, the endoscopic medial maxillectomy was performed while preserving the head of the inferior turbinate and the nasolacrimal duct (“TuNa-saving”). This technique allowed for good visualization of the maxillary sinus, good oncological control and a reduction in the rate of complications.

Endoscopic surgery for recurrent undifferentiated nasopharyngeal carcinoma.

AbstractOne of the biggest challenges for otolaryngologists is represented by the locally recurrent undifferentiated nasopharyngeal carcinoma (uNPC). Despite improvements in its treatment options, such as modern radiotherapy, chemotherapy, or external surgical approaches, the risk for severe complications, functional disabilities, and even death remains considerable. Over the years, advances in endoscopic surgery have led to a new alternative in the salvage surgery for recurrent uNPC: the nasopharyngeal endoscopic resection (NER). We retrospectively reviewed clinical records of 8 patients (6 men and 2 women), who underwent NER for recurrent T1 (rT1) locally recurrent uNPC between 2008 and 2011. Together with resections for subsequent recurrences, a total of 9 NERs were performed by a single surgeon with curative intent. Negative margins were obtained for the whole group of patients. After a mean follow-up period of 27 months (range, 16–54 mo), all the patients had no evidence of the disease. We had only 1 recurrence after 7 months. Two-year overall survival and disease-free survival rates were 100% and 88.9%, respectively. Only 1 patient presented with a complication, osteitis. Nasopharyngeal endoscopic resection can be considered a valid and promising treatment option for rT1 locally recurrent uNPC, showing encouraging short-term outcomes and complication rate. Long-term follow-up is needed to state the efficacy of NER, together with a larger number of patients.

Endoscopic Transsphenoidal Salvage Surgery for Symptomatic Residual Cystic Craniopharyngioma after Radiotherapy

Objectives Ideal treatment of craniopharyngiomas is still controversial. Radiotherapy (RT) is considered effective for recurrences or after subtotal tumor removal (STR). About 40 to 50% of patients may experience tumor cyst expansion soon after RT; in these cases, the role of salvage surgery is debated. Design Operative video. Setting Tertiary care center. Participants An 11‐year‐old boy diagnosed with persistent craniopharyngioma. In 2015, the patient underwent right frontotemporal craniotomy for STR at another center, complicated by panhypopituitarism. Two years later, fractionated 54‐Gy RT was performed on growing residual tumor. After 3 months, he was admitted to our hospital due to persistent malaise, vomiting, pulsating headache, and epistaxis. Ophthalmologic evaluation evidenced left homonymous hemianopsia. Results A contrast‐enhanced magnetic resonance imaging (MRI) showed a 27‐mm cystic component enlarging from the cranial end of the persistent craniopharyngioma lesion, extending into the third ventricle. Biventricular hydrocephalus and brain midline shift to the right were present. Compared with the early post‐RT MRI, the cystic component of the tumor demonstrated growth. The patient underwent external ventricular drainage placement for emergent treatment of hydrocephalus and endoscopic transsphenoidal surgery. After cystic content drainage, the lesion was completely removed with its capsule. A “gasket seal” technique was performed for skull base reconstruction, with autologous fascia lata, septal bone, and mucoperiosteum from inferior turbinate. Histologic examination confirmed the craniopharyngioma diagnosis. Postoperative MRI showed resolution of the hydrocephalus and complete tumor removal. Conclusion Although shrinkage of cystic components of craniopharyngioma residuals may occur within 5 to 6 months after RT, salvage surgery is indicated in symptomatic patients. The link to the video can be found at https://youtu.be/4x6Qe76bf60.

Clinical features and management of antrochoanal polyps in children: Cues from a clinical series of 58 patients

OBJECTIVE To review the clinical features of pediatric patients affected by antrochoanal polyps (ACPs) and surgically treated at three University settings. METHODS Retrospective study. The present research includes the clinical data of subjects affected by ACPs, aged <18 years and referred to three ENT Departments, between January 1st 2003 and September 30th 2016. All patients underwent nasal endoscopy and sinonasal imaging; all subjects have been treated surgically. RESULTS Fifty-eight patients underwent functional endoscopic sinus surgery (FESS) for ACPs removal, under general anesthesia. There were no major intraoperative complications. Recurrence occurred in 12 cases (20.5%). CONCLUSIONS FESS was the first-choice treatment for APCs in the present series; our recurrence rate was similar to that of other reports available in literature. Recurrences of ACPs in children still represent a clinical challenge; it is likely that an improved comprehension of ACPs biology could help in better understanding the pathophysiology of this disease.

Update on Vertigo in Autoimmune Disorders, from Diagnosis to Treatment

The prevalence of autoimmune diseases has been increasing over the last 20 years. The clinical presentation of this large and heterogeneous group of disorders depends on whether the involvement is organ-specific or non-organ-specific. Dizziness, vertigo, and disequilibrium are common symptoms reported by patients with vestibulocochlear involvement. The association of vertigo and autoimmune diseases has been largely documented, suggesting that autoimmune disorders could be overrepresented in patients with vertigo in comparison to the general population. The aim of this review is to present the recent literature findings in the field of autoimmune-mediated diseases with cochleovestibular involvement, focusing on the clinical presentation, diagnosis, and treatment of immune-mediated inner ear diseases including autoimmune inner ear disease (AIED), Menieres disease, and bilateral vestibulopathy, as well as of systemic autoimmune diseases with audiovestibular disorders, namely, Behçets disease, Cogans syndrome, sarcoidosis, autoimmune thyroid disease, Vogt-Koyanagi-Harada syndrome, relapsing polychondritis, systemic lupus erythematosus, antiphospholipid syndrome, IgG4-related disease, and ANCA-associated vasculitides.

Carcinoma nasosinusale in esposizione a cromo in un settore industriale inconsueto

BACKGROUND Occupational exposure to chromium is carcinogenic for human respiratory system. Due to the low incidence of sinonasal malignancies, there is still a paucity of evidence to confirm that chromium(VI) exposure is a cause of nasal cancer. OBJECTIVES To report on a sinonasal cancer (SNC) of rare occupational origin, increasing the awareness on epidemiological knowledge of occupational exposures to chromium compounds. METHODS We describe a case of a 64-year-old chrome plater who worked in the galvanic industry in the early 1970s. After a latency period of 39 years, he was diagnosed with sinonasal undifferentiated carcinoma (SNUC). A brief review of the literature was conducted. RESULTS A thorough occupational history revealed a 4-year-long occupational exposure to chromium(VI) during a magnesium cylinder plating process involved in computer production. The patient underwent endoscopic endonasal removal of the SNUC. He is alive with no evidence of disease at 40-month follow-up. Our literature review identified 8 papers concerning 40 cases of chrome-induced sinonasal tumors. The maximum relative risk of SNC developing in chromium-exposed workers was 15.4. CONCLUSIONS When dealing with patients diagnosed with SNC, the possibility of an underlying occupational risk is worth further investigation. Because chromium exposure is rare, and the incidence of SNUC is low, any information emerging on clinical and exposure-related aspects of SNCs in chrome plating workers can contribute to adding evidence on the possible causal relationship between chromium and sinonasal malignancies.

Hearing preservation and growth of small vestibular schwannomas: preliminary outcomes from patients under observation

Abstract Objective: Conservative management in sporadic vestibular schwannomas (VS) represents a valid treatment option, however, tumour growth and hearing decay during observation are still a matter of controversy and shift to alternative therapies. The present study aims at evaluating patients diagnosed with VS submitted to a wait and scan protocol of treatment. Study design: Case series review from a tertiary referral centre. Data collected from an in-house prospectively-maintained database of 108 patients with sporadic small VS, managed with primary observation, were evaluated. Inclusion criteria were tumour diameter less than 10 mm in the cerebello-pontine angle. At serial follow-up evaluations, objective measures of hearing status and tumour growth through magnetic resonance imaging were conducted. Hearing status was stratified according to the Tokyo Consensus Meeting Guidelines. Tumour growth and hearing function represented the main endpoints and were analysed according to tumour site at diagnosis. Results: Eighty-one patients were included in the study. During observation with a mean follow-up time of 27 months, 29.6% of the patients demonstrated tumour growth, with extrameatal lesions growing faster than intrameatal tumours (p = .049). Decay of good hearing was observed in 32.5% of patients, with a higher frequency of hearing instability revealed in the intrameatal group of VS (p = .004). Conservative treatment was maintained in 75.3% of cases. In 18% of cases, patients underwent surgical VS removal, while only 6.2% of patients favoured radiotherapy. Conclusions: Conservative treatment led to low rates of tumour growth after a mean 27 months observation. The cases with good hearing at diagnosis evidenced hearing deterioration in 33.3% of patients. Wait and scan outcomes need to be evaluated in comparison with other active treatments in terms of hearing and growth and further studies are required in this sense.