Luca Guastini

Intraoperative Narrow Band Imaging Better Delineates Superficial Resection Margins During Transoral Laser Microsurgery for Early Glottic Cancer

Objective: The high rate of positive margins after transoral laser microsurgery (TLM) remains a matter of debate. This study investigates the effect of intraoperative narrow band imaging (NBI) examination on the incidence of positive superficial surgical margins in early glottic cancer treated by TLM. Methods: Between January 2012 and October 2013, 82 patients affected by Tis-T1a glottic cancer were treated with TLM by type I or II cordectomies. Intraoperative NBI evaluation was performed using 0-degree and 70-degree rigid telescopes. Surgical specimens were oriented by marking the superior edge with black ink and sent to a dedicated pathologist. Comparison between the rate of positive superficial margins in the present cohort and in a matched historical control group treated in the same way without intraoperative NBI was calculated by chi-square test. Results: At histopathological examination, all surgical margins were negative in 70 patients, whereas 7 had positive deep margins, 2 close, and 3 positive superficial margins. The rate of positive superficial margins was thus 3.6% in the present group and 23.7% in the control cohort (P < .001). Conclusion: Routine use of intraoperative NBI increases the accuracy of neoplastic superficial spreading evaluation during TLM for early glottic cancer.

A novel computerized surgeon-machine interface for robot-assisted laser phonomicrosurgery.

To introduce a novel computerized surgical system for improved usability, intuitiveness, accuracy, and controllability in robot‐assisted laser phonomicrosurgery.

Sulphurous water inhalations in the prophylaxis of recurrent upper respiratory tract infections

OBJECTIVE The aim of this study was to evaluate the efficacy and the effect of sulphurous thermal water inhalations in the treatment of the recurrent upper respiratory tract (RURT) infections in children. METHODS A total of 100 children with RURT infections were included. All children underwent a 12-day course warm vapour inhalations. For the inhalations, we used sulphurous thermal water in the group A, while physiological solution in the group B. At the beginning, at the end and 3 months after start, all children underwent medical history, ENT examination, plasma levels of immunoglobulins class E, G, A, M (IgE, IgG, IgA, IgM), subjective assessment of symptoms (VAS), nasal mucociliar transport time (NMTT) determination, and evaluation of frequency, duration, severity and social impact of RURT episodes. RESULTS Compared with group B, after the treatment and at the end of the study, in children treated with sulphurous thermal water, the serum concentration of IgE was significantly (p<0.05) lower (75.13+/-27.1mg/dl vs 96.87+/-41.3mg/dl; 74.23+/-26.2mg/dl vs 98.24+/-42.7 mg/dl), IgA titers were higher (238.14+/-122.1mg/dl vs 218.62+/-115.8 mg/dl; 239.72+/-119.7 mg/dl vs 210.46+/-107.3mg/dl), serum concentrations of IgG and IgM unchanged, VAS scores presented a significant (p<0.05) improvement (1.8+/-0.19 vs 6.8+/-0.54; 1.9+/-0.21 vs 6.9+/-0.61), NMTT was normal (11.15+/-1.59 min vs 17.63+/-2.17; 11.25+/-2.10 min vs 17.77+/-2.19 min) and frequency, duration, severity and social impact of RURT episodes were significantly (p<0.05) lower. CONCLUSIONS Our findings indicate that, in addition to their known effects, the sulphurous water also have an immunomodulant activity that contributes to their therapeutic effects.

A prognostic multigene classifier for squamous cell carcinomas of the larynx.

Survival after diagnosis of laryngeal cancer has not improved over the last 20 years. Selection of patients for radio- and chemotherapy or surgery or follow-up strategies based on a prognostic classifier could improve survival without unduly extending radical surgery. We performed microarray gene expression analysis and developed a four-gene classifier for laryngeal cancer using Prediction Analysis of Microarray and leave-one-out cross validation. A four-gene classifier containing the non-coding gene H19, the histone HIST1H3F and the two small nucleolar RNAs, SNORA16A and SNORD14C was developed that assigns cases to low and high risk classes. The high risk class has a relative risk of 6.5 (CI=1.817-23.258, Fisher exact test p<0.0001). The maternally imprinted gene H19 is the top classifier gene.

Evaluation of an automated auditory brainstem response in a multi-stage infant hearing screening

An automated auditory brainstem response (AABR) method, the Maico MB-11 with BERAphone®, has been developed for hearing screening in newborns. The aim of this study was to test the validity of this automated ABR screening method in a multistage newborn hearing screening (NHS). We applied a “five level” protocol using transient evoked otoacoustic emission (TEOAE), AABR-MB-11 with BERAphone® and conventional auditory brainstem response (ABR). TEOAE, AABR, and conventional ABR testing were performed by ENT specialists experienced in neonatal screening techniques. Among the 8,671 newborns tested (males 3,889; females 4,782), only 42 newborns were lost to follow-up and the final false-positive rate was of 0.03%. Our experience highlights that for the neonatal period, conventional auditory brainstem response is the most reliable method for assessing the hearing level and minimizing the false-positive rate. Although AABR (performed by ENT specialists experienced in neonatal screening techniques) is easy to use, fast and with a good compliance, the device is unable to provide accurate and certain diagnosis on the degree of hearing loss to allow a proper treatment.

Reasonable limits for transoral laser microsurgery in laryngeal cancer

Purpose of reviewTransoral laser microsurgery (TLM) is widely acknowledged to offer several advantages in the treatment of early and selected intermediate-advanced laryngeal cancers. Nevertheless, a number of issues are still under debate. The purpose of this review is to discuss the reasonable limits for TLM in laryngeal cancer to highlight its most appropriate and reproducible indications, putting this therapeutic tool in the right perspective within a comprehensive frame of alternative treatment strategies such as open partial laryngectomies and nonsurgical organ preservation protocols. Recent findingsInadequate laryngeal exposure, anterior commissure involvement in the cranio-caudal plane (T2), invasion of the posterior paraglottic space with arytenoid fixation, massive infiltration of the preepiglottic space, and even minor thyroid cartilage erosion (T3) represent the most controversial applications of TLM in management of glottic and supraglottic cancer. SummaryPublished oncological results appear to be satisfactory when TLM is applied to T1-T2 and accurately selected T3 glottic and supraglottic cancers with favourable exposure. Caution should be used for more advanced tumours.

Learning Curve for Piezosurgery in Well-Trained Otological Surgeons

OBJECTIVE: Piezosurgery is an ultrasound instrument (24.7–29.5 kHz) capable of cutting bone without necrosis and nonmineralized tissue damage. The aim of this work has been to determine the time required for a well-trained surgeon to perform otological surgery with the piezoelectric device. STUDY DESIGN: Case series with planned data collection. Sixty-three patients affected by otosclerosis and 63 by chronic otitis media were enrolled. For each disease, patients were divided into three numerically equal groups, with each group assigned to a well-trained otological surgeon. Patients underwent stapedotomy (n = 63) and intact canal wall tympanoplasty (n = 63) with the piezoelectric device. SETTING: ENT Department, University of Genoa (Italy). SUBJECTS AND METHODS: We recorded “skin-to-skin” operation time, surgical success, surgical complication, and hospital stay duration. Before and one year after surgery, all patients underwent pure-tone audiometry, tympanometry, recording of transient-evoked otoacoustic emission, recording of distortion product otoacoustic emission, auditory brainstem response, and electronystamographic recording. RESULTS: In each surgical technique, the piezoelectric device provided excellent control without side effects on the adjacent structures of the middle and inner ear. CONCLUSION: The piezoelectric device is a new bony scalpel that uses microvibrations at ultrasonic frequency so that soft tissue (nerve, vessel, dura mater, etc) will not be damaged even on accidental contact with the cutting tip. A feature of the piezoelectric device is its good manageability, which makes it easy for a well-trained otological surgeon to create a straight osteotomy line without any learning period: this renders the piezoelectric device suitable for bone surgery.

Sulphurous thermal water inhalations in the treatment of chronic rhinosinusitis.

INTRODUCTION The aim of this study was to evaluate the efficiency of sulphurous thermal water in the treatment of chronic rhinosinusitis (CRS). METHODS Eighty patients with CRS were included and randomly assigned into two groups. Patients underwent a 12-day course of warm vapour inhalations and nasal irrigations with sulphurous thermal water in group A, and a physiological solution in group B. RESULTS Compared with group B, in group A the results were as follows: serum concentration of IgE was significantly lower (p<0.05) 12 days (76.27+26.3 mg/dl vs. 97.44±45.4) and 3 months after the beginning of the treatment (75.48+26.1 mg/dl vs. 98.37±41.4); IgA titers were not significantly higher 12 days (231.09±120.3 mg/dl vs. 220.44+114.4 mg/dl) and 3 months after the beginning of the treatment (235.44±118.5 mg/dl vs. 214.51±111.8 mg/dl); VAS scores were significantly (p<0.05) improved at 12 days (1.7+0.18 vs. 6.9±0.51) and 3 months after the start (1.8+0.22 vs. 7.1±0.59); NMIT was normal at 12 days (11.54±1.59 min vs. 17.38+1.83 min) and 3 months after the beginning of the treatment (11.46+2.07 min vs. 17.43±2.01 min); total nasal resistances were significantly (p<0.05) decreased at 12 days and 3 months. CONCLUSION Our results indicate the efficiency and applicability of sulphurous thermal water in the treatment of CRS.

Transoral laser microsurgery as primary treatment for selected T3 glottic and supraglottic cancers

T3 laryngeal cancer encompasses heterogeneous lesions whose treatment is still debated. The purpose of this study was to evaluate transoral laser microsurgery (TLM) in management of selected T3 glottic and supraglottic cancers.

Transnasal approach to the orbital apex and cavernous sinus.

Objectives: The aim of this study was to provide the anatomic rationale for a transnasal approach to the orbital apex and cavernous sinus, and to evaluate its applicability and efficiency. Methods: One hundred patients with lesions of the orbital apex, cavernous sinus, optic nerve, clivus, parapharyngeal space, infratemporal fossa, or pterygopalatine fossa were reviewed over a 10-year period. All patients underwent an endoscopic transnasal approach to the orbital apex and cavernous sinus. The surgical technique required a standard endoscopic sinus surgery set. The possible complications were recorded and classified as intraoperative or postoperative. Results: There were complications in 8 cases: 4 intraoperative and 4 postoperative. The intraoperative complications included rupture of the internal carotid artery in 1 patient and cerebrospinal fluid leak in 3 patients. All intraoperative complications were resolved during surgery. The postoperative complications were transitory eyelid ptosis in 2 patients (resolved in 6 months) and transitory diplopia with immediate deficit of the medial rectus muscle in 2 patients (completely resolved in 1 month). Conclusions: With the use of this technique, the surgeon can precisely identify the position of the surgical instrument without losing his or her way, thereby significantly reducing the rate of complications.