Michele Gaffuri

Narrow-band imaging in the diagnosis of vascular nasal lesions

The management of unilateral nasal lesions can sometimes be a challenge and an ordinary bioptic assessment should be avoided in order to prevent complications due to their possible vascular or meningoencephalic origin. Narrow-band imaging (NBI) endoscopy could improve the diagnosis of vascular nasal formations by enhancing the visualisation of the mucosal microvascular supply. We describe the case of a 68-year-old male patient who was brought to our attention because of a left nasopharyngeal mass that had elsewhere been unsuccessfully biopsied (with conspicuous bleeding) and assessed by means of traditional endoscopic and radiological techniques. NBI endoscopy revealed increased vasculature covering most of the mucosal surface without any features suggestive for malignancy. Subsequent angiography showed that the feeding vessel was the left sphenopalatine artery, which was embolised using 150-250 μm Contour embospheres. The mass was then completely removed surgically using an NBI-assisted endoscopic technique, and a histopathological examination revealed it was a hemangiopericytoma-like (HPCL) tumor. This case suggests the usefulness of NBI endoscopy in diagnosing unilateral vascularised nasal lesions and guiding the therapeutic approach before and during major surgery.

Step-by-step iconographic description of a prolonged but still favourable course of orbital cellulitis in a child with acute rhinosinusitis: an iconographic case study

Orbital cellulitis is an infrequent complication of acute ethmoiditis possibly leading to life- or visual-threatening complications. Despite its natural history is well known, its clinical evolution may widely vary among patients, and even in the most favourable cases long-term sequelae may persist. We here provide a step-by-step iconographic description of a periorbital and orbital cellulitis occurring in a child with ipsilateral acute rhinosinusitis. Our report shows that an unusual long-term evolution of periorbital and orbital cellulitis is possible also in apparently favourable cases.

Pharyngolaryngeal location of Kaposi's sarcoma with airway obstruction in an HIV-negative patient.

Kaposis sarcoma (KS) is a human herpes virus-8 (HHV-8)-associated angioproliferative disorder, and its occurrence may be favored by human immunodeficiency virus (HIV) infection and iatrogenic immunosuppression. It has also been postulated that a chronic inflammatory disease of the skin can pave the way to its development. KS generally involves mucosal and cutaneous sites, including the head and neck. An oropharyngeal location is quite common, but laryngeal involvement with possible upper airway obstruction and respiratory distress requiring tracheotomy is rare, and no hypopharyngeal locations have yet been reported. We describe the case of a 68-year-old male patient who developed KS after immunosuppressive treatment for pemphigus vulgaris, an autoimmune bullous disease presenting with blisters and erosions on the skin and the oral mucosa. KS was initially localized to the oral cavity and oropharynx, but subsequent involvement of the laryngeal and hypopharyngeal tract led to acute airway obstruction and the need for tracheotomy. This unique case of pharyngolaryngeal KS suggests that clinicians faced with purple nodular lesions should consider a differential diagnosis of KS in immunocompromised patients, even if they are HIV negative, and should carefully manage the patency of the upper airways.

Why, when and how to investigate primary ciliary dyskinesia in adult patients with bronchiectasis

Bronchiectasis represents the final pathway of several infectious, genetic, immunologic or allergic disorders. Accurate and prompt identification of the underlying cause is a key recommendation of several international guidelines, in order to tailor treatment appropriately. Primary ciliary dyskinesia (PCD) is a genetic cause of bronchiectasis in which failure of motile cilia leads to poor mucociliary clearance. Due to poor ciliary function in other organs, individuals can suffer from chronic rhinosinusitis, otitis media and infertility.This paper explores the current literature describing why, when and how to investigate PCD in adult patients with bronchiectasis. We describe the main PCD diagnostic tests and compare the two international PCD diagnostic guidelines. The expensive multi-test diagnostic approach requiring a high level of expertise and specialist equipment, make the multifaceted PCD diagnostic pathway complex. Therefore, the risk of late or missed diagnosis is high and has clinical and research implications.Defining the number of patients with bronchiectasis due to PCD is complex. To date, few studies outlining the aetiology of adult patients with bronchiectasis conduct screening tests for PCD, but they do differ in their diagnostic approach. Comparison of these studies reveals an estimated PCD prevalence of 1–13% in adults with bronchiectasis and describe patients as younger than their counterparts with moderate impairment of lung function and higher rates of chronic infection with Pseudomonas aeruginosa.Diagnosing PCD has clinical, socioeconomic and psychological implications, which affect patients’ life, including the possibility to have a specific and multidisciplinary team approach in a PCD referral centre, as well as a genetic and fertility counselling and special legal aspects in some countries.To date no specific treatments for PCD have been approved, standardized diagnostic protocols for PCD and recent diagnostic guidelines will be helpful to accurately define a population on which planning RCT studies to evaluate efficacy, safety and accuracy of PCD specific treatments.

When and how ruling out cystic fibrosis in adult patients with bronchiectasis

BackgroundBronchiectasis is the final result of different processes and most of the guidelines advocate for a careful evaluation of those etiologies which might be treated or might change patients’ management, including cystic fibrosis (CF).Main bodyCFTR mutations have been reported with higher frequency in bronchiectasis population. Although ruling out CF is considered as a main step for etiological screening in bronchiectasis, CF testing lacks of a standardized approach both from a research and clinical point of view. In this review a list of most widely used tests in CF is provided.ConclusionsExclusion of CF is imperative for patients with bronchiectasis and CFTR testing should be implemented in usual screening for investigating bronchiectasis etiology. Physicians taking care of bronchiectasis patients should be aware of CFTR testing and its limitations in the adult population. Further studies on CFTR expression in human lung and translational research might elucidate the possible role of CFTR in the pathogenesis of bronchiectasis.

Sialendoscopy-assisted transfacial surgery for the removal of an iatrogenic foreign body in Stensen's duct: a stone and broken wire basket

BACKGROUNDnA foreign body is a rare cause of parotid gland obstructive sialadenitis; intra-oral penetration via Stensens duct is unusual. The relatively recent introduction of interventional sialendoscopy to treat obstructive sialadenitis has allowed surgeons to adopt a gland-sparing approach by means of miniaturised endoscopes and instruments. However, unusual anatomy or pathological conditions can give rise to a risk of intraductal rupture that may lead to a subsequent iatrogenic foreign body.nnnCASE REPORTnThis paper describes the case of a patient with a 4 mm stone engaged by a broken wire basket stuck in a secondary branch of Stensens duct.nnnRESULTSnThe iatrogenic foreign body was successfully retrieved by means of sialendoscopy-assisted transfacial surgery.nnnCONCLUSIONnThis is the first reported case of an intraductal rupture of a miniaturised device during interventional sialendoscopy successfully resolved by means of combined endoscopy and external surgery. This proved to be an effective method of rescuing a foreign body stuck in Stensens duct.

Recurrent parotid swelling secondary to masseter muscle hypertrophy: a multidisciplinary diagnostic and therapeutic approach

Purpose: To present a patient with an atypical recurrent parotid swelling due to masseter muscle hypertrophy and the diagnostic/therapeutic assessment to treat this condition. Case Report: A patient referring recurrent right facial swelling underwent a complete multidisciplinary assessment of the parotid region that revealed masseter muscle hypertrophy, confirmed by means of clinical (otolaryngological and gnathological evaluation), radiological (utrasonography, dynamic magnetic resonance imaging, and cone beam computed tomography), instrumental (electromyography to evaluate the right masseter muscle function and kinesiography to evaluate maximum right deflection – MaxRDefl and maximum opening – MaxMO) and sialendoscopy assessment where T0 indicates the pre-treatment values. All electromyographic and kinesiographic parameters were evaluated six months after the orthodontic application of a neuromuscular orthosis at T1. At T1, the effectiveness of the orthodontic therapy was demonstrated by the complete resolution of symptoms, and instrumental results documented more efficient muscle activity at rest and during clenching and a better mandibular position. At EMG T1, the resting and post-TENS values were, respectively, 1.2 and 1.8 microV. At kinesiography, MaxRDefl increased from 10.2 (T0) to 10.5 mm (T1); maxMO increased from 41.2 (T0) to 48 mm (T1). Conclusion: The proposed multidisciplinary assessment based on otolaryngological, gnathological, and radiological evaluation may be useful in the case of recurrent parotid swelling secondary to masseter muscle hypertrophy to plan an appropriate management with a removable neuromuscular orthosis.

Surgical treatment of non-tuberculous mycobacterial lymphadenitis in children: Our experience and a narrative review

Non-tuberculous mycobacterial lymphadenitis (NTML) accounts for about 95% of the cases of head-and-neck mycobacterial lymphadenitis, and its prevalence has been increasing in the Western world. The diagnostic work-up can be challenging, and differential diagnoses such as tuberculous and suppurative lymphadenitis need to be considered. It may, therefore, not be diagnosed until the disease is in a late stage, by which time it becomes locally destructive and is characterized by a chronically discharging sinus. The treatment options include a medical approach, a wait-and-see policy, and surgery, with the last being considered the treatment of choice despite the high risk of iatrogenic nerve lesions. The aim of this article is to provide an overview of pediatric, head-and-neck NTML based on the literature and our own experience, with particular emphasis on the impact and limitations of surgery.

Utility of PET scan in diagnosis and monitoring descending necrotizing mediastinitis complicating Lemierre’s syndrome

A 76-year-old woman was admitted at our department because of a 3-day history of fever up to 39 C, sore throat, and neck pain, associated with a left erythematosus supraclavicular swelling (Fig. 1; panel a). She reported no other significant comorbidities except the surgical excision of a breast lobular carcinoma 7 years prior with a subsequent negative follow-up. At admission, the patient appeared seriously ill, and rapidly developed dysphagia, dyspnoea, and confusion. Laboratory findings showed an elevated C-reactive protein and neutrophil leucocytosis, whereas repeated blood culture resulted negative. Neck ultrasonography revealed a segmental thrombosis of the left internal jugular vein with inflammatory tissue in the adjacent soft tissues, leading to the diagnosis of Lemierre’s syndrome (LS). Exudate in the supraclavicular and lateral cervical tissues with extension to the upper mediastinum above the tracheal carina was confirmed by neck and chest computed tomography (CT) scan (Fig. 1; panel b). Piperacillin–tazobactam and anticoagulation were started, with initial partial clinical benefit. Nevertheless, 2 days after treatment initiation, the patient experienced a clinical deterioration with sepsis and dyspnoea, but the extension of the infection appeared unmodified on the repeated CT scan. Given her previous oncologic medical history, we performed on the same day a total body positron emission tomography (PET) scan that revealed a massive metabolic active lesion, beginning from the left oro-hypopharynx and involving the supraclavicular and lateral cervical regions, with extension below the tracheal carina to both the anterior and lower posterior mediastinum (Fig. 1; panel c). These findings were compatible with an extended form of descending necrotizing mediastinitis (DNM). Antibiotic therapy was modified with imipenem and metronidazole with progressive clinical benefit, fever remission, and normalization of laboratory findings. An ultrasound-guided tru-cut biopsy performed after the resolution of the septic state showed a inflammatory xanthogranulomatosis with no evidence of any underlying neoplastic lesion. The patient was discharged after 30 days of intravenous antibiotic treatment in good clinical condition, and was followed with PET scans. The 3-month PET scan outlined a complete resolution of the infection and no evidence of residual increased metabolic tissue activity (Fig. 1; panel d). LS is a neck infection associated with thrombophlebitis of the internal jugular vein or one of its tributaries, generally due to anaerobic pathogens, most commonly Fusobacterium species. Symptoms include sepsis often evolving after a sore throat or tonsillitis, pain, and swelling in the throat or neck, as well as respiratory symptoms [1, 2]. Diagnosis of LS is clinical, and requires the radiological finding of venous thrombosis [1]. LS can be treated with antibiotics alone, preferentially with b-lactamase-resistant b-lactams, such as piperacillin-tazobactam. Some patients are additionally treated with anticoagulants, & Tiziana Carandini tizianacarandini@gmail.com

Etiology-Related Results of Vocal Fold Lipoinjection

Etiology-Related Results of Vocal Fold Lipoinjection Giovanna Cantarella;Giovanna Baracca;Stella Forti;Michele Gaffuri;Riccardo Mazzola; Otolaryngology - Head & Neck Surgery