Domenico Villari

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.

Therapy of unilateral vocal fold paralysis with polydimethylsiloxane injection laryngoplasty: our experience.

The objective of this study was to document functional results and to compare objective and subjective voice measures after endoscopic laryngoplasty with injection of polydimethylsiloxane (PDMS) for the treatment of unilateral vocal fold paralysis, and to verify PDMS biocompatibility in vocal fold. The design used was a longitudinal prospective study. Fifteen patients with unilateral vocal fold paralysis underwent endoscopic injection of PDMS in general anesthesia. Accurate voice evaluation protocol (acoustic and aerodynamics analyses, GIRBAS [Grade, Instability, Roughness, Breathiness, Asthenia, and Strain] scale, videostrobolaryngoscopy, and Voice Handicap Index test) before, after surgery, and at follow-up time was performed. The median follow-up was 21.7 months (range, 6-35). Data obtained were statistically significant. All acoustic, aerodynamics, perceptive, and subjective evaluations showed a significant improvement. No complications due to PDMS were reported. Functional results were found comparable to framework surgery. Endoscopic injection laryngoplasty with PDMS is a safe and long-term option for treatment of unilateral vocal fold paralysis.

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.

Endoscopic exclusive transcanal approach to the tympanic cavity cholesteatoma in pediatric patients: Our experience

OBJECTIVES The aim of the present study is to describe our experience in the management of tympanic cavity cholesteatoma in pediatric patients, treated with endoscopic exclusive transcanal approach. METHODS A chart review of clinical data and videos from the operations of 54 pediatric patients, undergoing surgery between January 2007 and December 2013, was made. Patients presenting with cholesteatoma involving the tympanic cavity (mesotympanum, epitympanum, protympanum and/or hypotympanum), with no mastoid involvement, were included in the first group and underwent an exclusive transcanalar endoscopic approach (TEA). In case of mastoid extension of the pathology, patients were included in the control group and underwent a canal wall up microscopic technique (CWU). RESULTS In this study, 34 males and 20 females, including 5 bilateral cases, giving a total of 59 ears, were reviewed. Median age was 9.6 years (range 4-16 years). 31 cholesteatomas underwent a TEA approach, while 28 underwent a CWU approach, based on inclusion criteria. No differences from congenital vs acquired form was made, due to the difficult to correctly distinguish always the two forms. The ossicular chain was preserved in 26.6% of patients (16 ears): 42% of patients (13 ears) undergoing a transcanal endoscopic approach and 10% of patients undergoing a canal wall up microscopic approach (3 ears) (P=0.006). Second look surgery was executed in 41.6% of patients (25 ears). In partial ossicular prosthesis reconstructions, the mean preoperative pure-tone average was 29.4dB, while the mean postoperative pure-tone average was 27.1dB, with a mean increase of 2.3dB. In total ossicular prosthesis reconstructions, the mean preoperative pure-tone average was 47.8dB, while the mean postoperative pure-tone average was 26.5dB, with a mean increase of 21.3dB. Recurrence rate was 12.9% (4 ears) for the transcanal endoscopic approach group and 17.2% (5 ears) for the canal wall up microscopic approach. Residual disease was present in 26.6%: 19.3% (6 ears) for the transcanal endoscopic approach group and 34.4% (10 ears) for the canal wall up microscopic approach. The mean follow up was 36 months (range 8-88). Kaplan-Meier analysis at 36 months showed a lower recurrence risk for the transcanal endoscopic approach compared with the canal wall up microscopic approach, but this data was not statistically significant (P=0.58). CONCLUSION The transcanal endoscopic approach represents a feasible, minimally invasive and conservative technique for the management of pediatric middle ear cholesteatoma.

Wnt pathway, angiogenetic and hormonal markers in sporadic and familial adenomatous polyposis-associated juvenile nasopharyngeal angiofibromas (JNA)

Juvenile nasopharyngeal angiofibroma (JNA) is a rare, invasive, and locally destructive tumor of the nasopharynx. The Wnt pathway, angiogenetic and hormonal factors are involved in the pathophysiology of JNA; it can result in an extracolonic manifestation of familial adenomatous polyposis (FAP) or in a sporadic tumor. All patients who underwent resection of JNA between 1991 and 2006 at the University of Modena and Reggio Emilia were studied to identify immunohistochemical markers of associated FAP syndrome. Paraffin-embedded JNA samples were analyzed immunohistochemically for the expression of adenomatous polyposis coli (APC), β-catenin, E-cadherin, androgen receptor, and vascular endothelial growth factors receptor (VEGFR2). In one out of the 4 (25%) young patients affected by JNA the diagnosis of FAP syndrome linked to APC mutation was made. All of the sporadic and familial JNA tumors showed nuclear staining of β-catenin, whereas altered APC expression was seen only in FAP-associated JNA. All cases were stained with VEGFR2. A combined clinical, immunohistochemical, and biomolecular screening may be useful for the identification of FAP among patients with a diagnosis of JNA. The Wnt pathway can be involved in the JNA pathogenesis either by somatic mutations of β-catenin or by germline APC mutations. As the VEGFR has an important impact on the pathogenesis of JNA, we suggest that a targeted therapy with monoclonal antibodies against VEGFR might lead to a specific chemoprevention and treatment of these tumors and their recurrences.

Endoscopic Management of Attic Cholesteatoma: A Single-Institution Experience

At present, the main application of endoscopic surgery is in the surgical treatment of middle ear cholesteatoma; however, for definitive validation and acceptance by scientific community, results are needed regarding recurrent and residual rates of the condition. This article analyzes the single-institution experience from results of surgical treatment of attic cholesteatoma.

From external to internal auditory canal: surgical anatomy by an exclusive endoscopic approach

Surgical approaches to the inner ear and internal auditory canal (IAC) are well known and well documented. The objective of this study is to analyze the morphology, and surgical and anatomic findings of an exclusive endoscopic transcanal approach (EETA) to the IAC. Cadaveric dissections were performed on 11 temporal bones, approaching the internal auditory meatus directly through the external ear canal and avoiding mastoidectomy. In all cases, it was possible to dissect the internal carotid artery and jugular bulb with a 0° endoscope, and with good control of these two structures. The medial wall of the bony labyrinth guaranteed good landmarks for IAC dissection, such as the spherical recess, and the labyrinthine tract of the facial nerve. The IAC can be thoroughly visualized in the cadaver using EETA, avoiding mastoidectomy, extensive temporal bone tissue removal and external incisions. Clinically based reports will be required in future to strengthen our preliminary results.

Ossicular Chain Preservation After Exclusive Endoscopic Transcanal Tympanoplasty: Preliminary Experience

Objectives: The aim of the present study is to document and analyze the ossicular chain preservation rate in patients affected by acquired primary cholesteatoma with epitympanic involvement and with preoperative intact ossicular chain. Study Design: A retrospective case series in a tertiary university referral center. Methods: From January 2006 to February 2010, at the Otolaryngology Department of the University Hospital of Modena, 68 patients affected by acquired primary cholesteatoma with attic involvement underwent exclusive endoscopic transcanal tympanoplasty. In April 2010, we performed a retrospective chart and video review of these patients. Patients in whom the ossicular chain was found to be intact and not involved by the pathology at the beginning of the operation were included in the study. A cholesteatoma staging was introduced based on tympanic subsite involvement by pathology. Results: Out of 68 patients affected by acquired primary cholesteatoma and who underwent exclusive endoscopic transcanal tympanoplasty, 23 had intraoperative integrity of the ossicular chain (17 male and 6 female subjects; mean age, 40 yr) and were included in the study. An inverse correlation was found between number of subsites involved and chain preservation (Spearman rank correlation coefficient, r = -1; p = 0.017). Medial attic involvement was the factor that most negatively influenced the likelihood of chain preservation. Conclusion: Middle ear endoscopic techniques may increase the likelihood of ossicular chain preservation during cholesteatoma surgery. Medial attic involvement and a high number of subsites involved represent the most significant negative factors for chain preservation. The rate of residual disease requires more thorough evaluation in the future to validate the results.

Petrous apex cholesterol granuloma: transsphenoid endoscopic approach.

The transsphenoid approach to the petrous apex, a surgical procedure described for the first time by Montgomery in 1977, is a rarely performed approach for the drainage and ventilation of cholesterol granuloma. We consider this approach to be the technique of choice when the cholesterol granuloma is located in the medial section of the petrous apex abutting and/or prolapsing into the posterior wall of the sphenoid sinus. The transsphenoid approach, unlike other lateral approaches to the petrous apex, is highly conservative and spares cochlear and vestibular function; moreover, it allows simple and adequate post-operative endoscopic follow up as an out-patient, with easier treatment in the case of recurrence.

Management of Bleeding in Exclusive Endoscopic Ear Surgery: Pilot Clinical Experience.

Objective Transcanal exclusive endoscopic ear surgery requires the management of the endoscope and the surgical instruments in the external auditory canal. Bleeding in this narrow space is one of the most challenging issues, especially for novice endoscopic ear surgeons. We aim to assess the severity and occurrence of bleeding and describe strategies to control the bleeding during endoscopic ear surgery. We hypothesize that bleeding is reasonably controllable in endoscopic ear surgery. Study Design Case series with chart review. Setting Tertiary referral center. Subjects and Methods We retrospectively assessed 104 consecutive cases of exclusive endoscopic ear surgery at the University Hospital of Modena, Italy. The surgical videos and the patient charts were carefully investigated and analyzed. Results Hemostatic agents included injection of diluted epinephrine (1:200,000, 2% mepivacaine), cottonoids soaked with epinephrine (1:1000), mono- or bipolar cautery, washing with hydrogen peroxide, and self-suctioning instruments. The localization of bleeding in the external auditory canal was most frequently the posterior superior part, and inside of the middle ear, it was the pathology itself. Statistical analysis revealed significant differences comparing the mean arterial pressure and the type of intervention among bleeding scores. Conclusion The management of bleeding in endoscopic ear surgery is feasible through widely available hemostatic agents in reasonable frequency. This study gives an instructive overview on how to manage the bleeding in the exclusive endoscopic technique. Even the highest bleeding scores could be managed in an exclusively endoscopic technique.