Marco de Vincentiis

CO2 laser cordectomy for early-stage Glottic carcinoma: A long-term follow-up of 156 cases

Objectives To define when laser resection of early‐stage glottic carcinoma is indicated and to compare the results obtained by laser surgery with other therapeutic options.

Churg–Strauss syndrome

Churg-Strauss syndrome (CSS), alternatively known as eosinophilic granulomatosis with polyangiitis (EGPA), was first described in 1951 by Churg and Strauss as a rare disease characterized by disseminated necrotizing vasculitis with extravascular granulomas occurring exclusively among patients with asthma and tissue eosinophilia. EGPA is classified as a small-vessel vasculitis associated with antineutrophil cytoplasmic antibodies (ANCAs) and the hypereosinophilic syndromes (HESs) in which vessel inflammation and eosinophilic proliferation are thought to contribute to organ damage. Although still considered an idiopathic condition, EGPA is classically considered a Th2-mediated disease. Emerging clinical observations provide compelling evidence that ANCAs are primarily and directly involved in the pathogenesis of AASVs, although recent evidence implicates B cells and the humoral response as further contributors to EGPA pathogenesis. EGPA has traditionally been described as evolving through a prodromic phase characterized by asthma and rhino-sinusitis, an eosinophilic phase marked by peripheral eosinophilia and organ involvement, and a vasculitic phase with clinical manifestations due to small-vessel vasculitis. The American College of Rheumatology defined the classification criteria to distinguish the different types of vasculitides and identified six criteria for EGPA. When four or more of these criteria are met, vasculitis can be classified as EGPA. The French Vasculitis Study Group has identified five prognostic factors that make up the so-called five-factor score (FFS). Patients without poor prognosis factors (FFS=0) have better survival rates than patients with poor prognosis factors (FFS≥1). The treatment of patients with CSS must be tailored to individual patients according to the presence of poor prognostic factors. A combination of high-dose corticosteroids and cyclophosphamide is still the gold standard for the treatment of severe cases, but the use of biological agents such as rituximab or mepolizumab seems to be a promising therapeutic alternative.

Endoscopic supraglottic laryngectomy: a proposal for a classification by the working committee on nomenclature, European Laryngological Society.

In July 1999, the European Laryngological Society (ELS) has accepted a proposal for the classification of different laryngeal endoscopic cordectomies. This is actually a common classification system used as a tool for surgical training, documentation and comparison of results. The same harmonization work is deemed necessary for the treatment of supraglottic lesions. The ELS is proposing a classification of the different laryngeal endoscopic supraglottic partial laryngectomies. This classification comprises four types of supraglottic laryngectomies: Type I, limited excision of small size superficial lesions of the free edge of the epiglottis, the ary-epiglottic fold, the arytenoid, or the ventricular fold or any other part of the supraglottis; Type II, medial supraglottic laryngectomy without resection of the pre-epiglottic space, suitable for T1 lesions of either the suprahyoid or the infrahyoid laryngeal surface of the epiglottis (Type IIa, superior hemi-epiglottectomy or Type IIb, total epiglottectomy, respectively); Type III, medial supraglottic laryngectomy with resection of the pre-epiglottic space, suitable for T1–T2 tumors of the infrahyoid endolaryngeal epiglottis without (Type IIIa) or with (Type IIIb) extension to the ventricular fold, necessitating its excision; finally, Type IV, lateral supraglottic laryngectomy, suitable for tumors of the threefolds’ region, which may include the ventricular fold (Type IVa) or the arytenoid (Type IVb), when involved. As in the cases of endoscopic cordectomies, these operations are similarly classified according to the surgical approach used and the degree of resection completed in order to facilitate their use in daily clinical practice.

Endoscopic treatment of esthesioneuroblastoma: A minimally invasive approach combined with radiation therapy

OBJECTIVE: In a retrospective analysis we discuss our experience in the treatment of olfactory neuroblastoma (ON), a rare tumor of the sinonasal tract. STUDY DESIGN AND SETTING: Nine patients with olfactory neuroblastoma were treated at the Bolognini Hospital of Seriate and at the Department of Otolaryngology of “La Sapienza” University of Rome combining endoscopic surgery and postoperative radiation therapy. All patients were staged according to Kadish criteria. No chemotherapy was administered in any cases. Local radiation therapy was started postoperatively in all the cases. RESULTS: All patients, over an average follow-up which ranged from 26 through 60 months, are actually alive with non evidence of disease (NED). CONCLUSIONS: Despite the short follow-up in this small series of patients, we suggest endoscopic surgery combined with postoperative radiation therapy as an alternative to the conventional modalities of treatment for esthesioneuroblastoma in selected cases.

Supracricoid Laryngectomy With Cricohyoidopexy (CHP) in the Treatment of Laryngeal Cancer: A Functional and Oncologic Experience

Subtotal laryngectomy with cricohyoidopexy (CHP) results in a satisfactory cure rate in selected T1b, T2, and T3 supraglottic and glottic cancers. The clinical, oncologic, and functional results of this type of surgery have led to an ever‐increasing number of patients undergoing this procedure. This study involved 70 patients operated on from 1984 to 1993 using this surgical procedure. This report also discusses the clinical (cTNM) and pathologic (pTNM) classifications of CHP cases. Fifty‐two of these patients were evaluated after a follow‐up of more than 3 years. Lymph node treatment protocol comprised 51 functional ipsilateral neck dissections (FNDs), 9 bilateral FNDs, 1 radical ipsilateral dissection, and 1 radical ipsilateral and contralateral FND. There were 6 recurrences (5 local, 1 neck); after CHP physiologic deglutition was recovered in most of the patients (95.5%), and all but 6 (92%) were decannulated. Results were excellent after phoniatric rehabilitation. This surgical procedure may be indicated for selected laryngeal cancers and allows for the preservation of laryngeal functions even when the neoplastic lesions are advanced. However, care must be taken when evaluating the infiltration of the paraglottic space, as that infiltration represents the main cause of failure in this type of surgery.

Evolution of precancerous laryngeal lesions: A clinicopathologic study with long-term follow-up on 259 patients

A wide spectrum of lesions ranging from dysplasia to in situ carcinoma have to be considered when dealing with laryngeal precancerous conditions. Recently the concept of laryngeal intraepithelial neoplasia (LIN) was introduced.

Parkinson's disease: Autoimmunity and neuroinflammation

Parkinsons disease is a neurodegenerative disease that causes the death of dopaminergic neurons in the substantia nigra. The resulting dopamine deficiency in the basal ganglia leads to a movement disorder that is characterized by classical parkinsonian motor symptoms. Parkinsons disease is recognized as the most common neurodegenerative disorder after Alzheimers disease. PD ethiopathogenesis remains to be elucidated and has been connected to genetic, environmental and immunologic conditions. The past decade has provided evidence for a significant role of the immune system in PD pathogenesis, either through inflammation or an autoimmune response. Several autoantibodies directed at antigens associated with PD pathogenesis have been identified in PD patients. This immune activation may be the cause of, rather than a response to, the observed neuronal loss. Parkinsonian motor symptoms include bradykinesia, muscular rigidity and resting tremor. The non-motor features include olfactory dysfunction, cognitive impairment, psychiatric symptoms and autonomic dysfunction. Microscopically, the specific degeneration of dopaminergic neurons in the substantia nigra and the presence of Lewy bodies, which are brain deposits containing a substantial amount of α-synuclein, have been recognized. The progression of Parkinsons disease is characterized by a worsening of motor features; however, as the disease progresses, there is an emergence of complications related to long-term symptomatic treatment. The available therapies for Parkinsons disease only treat the symptoms of the disease. A major goal of Parkinsons disease research is the development of disease-modifying drugs that slow or stop the neurodegenerative process. Drugs that enhance the intracerebral dopamine concentrations or stimulate dopamine receptors remain the mainstay treatment for motor symptoms. Immunomodulatory therapeutic strategies aiming to attenuate PD neurodegeneration have become an attractive option and warrant further investigation.

Goodpasture's syndrome: A clinical update

Goodpastures syndrome (GS) is a rare and organ-specific autoimmune disease that is mediated by anti-glomerular basement membrane (anti-GBM) antibodies and has pathology characterized by crescentic glomerulonephritis with linear immunofluorescent staining for IgG on the GBM. It typically presents as acute renal failure caused by a rapidly progressive glomerulonephritis, accompanied by pulmonary hemorrhage that may be life-threatening. It was first described as a distinctive syndrome by Pasture in 1919. Autoimmune Inner Ear Disease (AIED) may be associated. The etiology of GS is unknown. Researchers hypothesized a genetic predisposition HLA-associated. Complex immunological mechanisms are in the pathogenesis. The disease is caused by autoantibodies against the NC1 domain of the alpha 3 chain of type IV collagen. The limited presence of this molecule in the body explains the interest confined to specific target organs, such as the lung and kidney. It occurs when the immune system attacks the walls of the lungs and the tiny filtering units in the kidneys. Without prompt diagnosis and treatment, the disease can lead to bleeding in the lungs, kidney failure, and even death.

Kawasaki disease: An evolving paradigm

Kawasaki disease (KD) is a self-limited childhood systemic vasculitis that exhibits a specific predilection for the coronary arteries. KD predominantly affects young children between the ages of 6months and 4years. Incidence rates in Asians are up to 20 times higher than Caucasians. The aetiology of KD is not known. One reasonable open hypothesis is that KD is caused by an infectious agent that produces an autoimmune disease only in genetically predisposed individuals. The typical presentation of KD is a young child who has exhibited a high swinging fever for five or more days that persists despite antibiotic and/or antipyretic treatment. The lips are dry and cracked. There is a characteristic strawberry tongue, and a diffuse erythema of oropharyngeal mucosal surfaces. Lymphadenopathy is usually unilateral and confined to the anterior cervical triangle. Coronary aneurysms generally appear during the convalescence phase (beginning during the second week). The absence of any laboratory tests for KD means that the diagnosis is made by the presence of a constellation of clinical features. The aim of echocardiography is to assess the presence of coronary artery dilatation or aneurysm formation. Effective therapies exist for most patients with acute KD, but the exact mechanisms of action are not clear. Treatment with aspirin and intravenous immunoglobulins (IVIG) are first-line therapies. However, options are plentiful for the children who fail this treatment, but these treatments are not as beneficial. Some centres attempt to salvage resistant patients using intravenous pulsed doses of methylprednisolone. Other centres use infliximab or combinations of these approaches.

Swallowing ability and chronic aspiration after supracricoid partial laryngectomy

Objective: Sporadic episodes of aspiration may occur after supracricoid partial laryngectomy. To prevent risks of pulmonary consequences, a limitation of oral intake of food or a “nothing by mouth” regimen has been suggested. The objective of this study was to evaluate the long-term swallowing and pulmonary status of patients after supracricoid partial laryngectomy. Study Design: Case series with chart review. Setting: Tertiary University Hospital Policlinico “Umberto I” and Santa Lucia Foundation, Rome, Italy. Subjects and Methods: The swallowing status of a selected group of 116 patients who recovered functional deglutition after supracricoid partial laryngectomy was analyzed during follow-up consultation. Swallowing evaluation included clinical observation, fiberoptic endoscopic evaluation of swallowing, and a videofluoroscopy. When aspiration was confirmed by videofluoroscopy, a high-resolution computed tomography (CT) of the chest was performed in order to assess the radiological manifestations of aspiration. A group of 45 patients with chronic obstructive pulmonary disease and normal deglutition was used as a control. Results: Seventy-nine patients out of 116 showed a fiberoptic endoscopic evaluation of swallowing suggestive for aspiration; only 45 patients had aspiration confirmed by videofluoroscopy. No significant differences in radiological findings were noted in the patients affected by postoperative chronic aspiration compared to the control group. Conclusion: Patients with functional deglutition after supracricoid partial laryngectomy show a mild and well-tolerated degree of chronic aspiration and do not require a limitation of oral intake of food.