Paolo Farneti

Endoscopic transnasal intraorbital surgery: our experience with 16 cases.

The objective of the study is to present our multicentric experience on intraorbital lesions managed by means of an endonasal endoscopic approach. The study design used was multi-institutional retrospective review. We collected data on 16 intraorbital medially-located lesions, all managed by means of an endonasal route, treated in four different skull base centers. We retrospectively reviewed the technical details, complications, histology, and general outcome. The endoscopic endonasal approach was effective in removing completely intraorbital extra-intraconal tumors in 8 cases, in performing biopsies for histological diagnosis in 6 intraorbital intraconal tumors, and in draining 1 extraconal abscess. No major complications were observed; in particular, there was no optic nerve damage. Minor, temporary complications (diplopia) were seen in 3 cases; only 2 patients experienced a permanent diplopia related to medial rectus muscle impairment, in 1 case associated with enophthalmos. Our preliminary multi-centric clinical experience suggests that medially located intraorbital lesions, and in particular the infero-medial ones, can be successfully and safely managed by such an approach. The well-known advantages of the endoscopic techniques, namely the lack of external scars, less bleeding, shorter hospital stay, and fewer complications, are confirmed.

Metastasizing "benign" pleomorphic salivary adenoma: a dramatic case-report and literature review.

Pleomorphic salivary adenomas are the most common benign neoplasms affecting the salivary glands. Very occasionally however, metastatic lesions are identified in patients with a history of PSA, which, on detailed pathological evaluation, are found to exhibit all the histological hallmarks of the preceding benign lesions. Diagnosis of benign metastasizing pleomorphic adenoma of the salivary gland is extremely rare and still under debate. We present the first case-report in literature of multiple metachronous nasal cavity, scalp and encephalic metastases of a pleomorphic adenoma of the parotid gland in a young girl.

Meningocele and Meningoencephalocele of the Lateral Wall of Sphenoidal Sinus: The Role of the Endoscopic Endonasal Surgery.

BACKGROUND Meningocele and meningoencephalocele of the lateral wall of the sphenoidal sinus (LWSS) are rare lesions, crossing the borders of multiple disciplines such as ear-nose-throat, maxillofacial, and neurologic surgery. We reviewed our surgical experience to analyze the role of the endoscopic endonasal approach and consider these pathologies from different perspectives. METHODS All consecutive cases of meningocele and meningoencephalocele of LWSS operated through an endoscopic endonasal approach from 1998 to 2015 in our institutions were collected. Medical history, focusing on previous episodes of cerebrospinal fluid leak, meningitis or seizures, was considered. The outcome was assessed considering the medical condition and the postoperative neuroimaging. RESULTS The series includes 23 patients (7 male, 16 female). Mean age was 52 years (26-73 years). Eleven cases were meningoencephaloceles and 12 meningoceles. A clear cerebrospinal fluid leak occurred on in 19 patients and was associated with meningitis in 3. Two were presenting a history of epilepsy. No complications were observed, but 1 case presented seizures on waking. At follow-up (mean 84 months, 4-167) each patient is in good clinical condition with no further episodes of leaking or seizures. CONCLUSIONS Endoscopic endonasal surgery is a safe and effective approach for meningocele and meningoencephalocele of LWSS; it allows resection of herniated tissue and repair of the osteodural defect. The favorable clinical outcome and the possible effectiveness on seizures lead us to support this approach as first minimally invasive treatment also in presence of epilepsy, as a first low risk epilepsy surgical procedure.

Risultati della scialoendoscopia interventistica nelle patologie ostruttive delle ghiandole salivari: Uno studio multicentrico Italiano

SUMMARY Interventional sialendoscopy has become the predominant therapeutic procedure for the management of obstructive salivary disorders, but only a few multicentre studies of large series of patients with a long-term follow-up have been published. This Italian multicentre study involved 1152 patients (553 females; mean age 50 years) who, after at least a clinical and ultrasonographic evaluation, underwent a total of 1342 diagnostic and interventional sialendoscopies, 44.6% of which involved the parotid gland. 12% (n = 138) of patients underwent multiple treatments. The procedure was successful in 1309 cases. In 33 cases (2.4%) the procedure could not be concluded mainly because of complete duct stenosis (21 cases). Salivary stones were the main cause of obstruction (55%), followed by ductal stenosis and anomalies (16%), mucous plugs (14.5%) and sialodochitis (4.7%). Complete therapeutic success was obtained in 92.5% of patients after one or more procedures, and was ineffective in < 8%. Untoward effects (peri and postoperative complications) were observed in 5.4% of cases. Sialendoscopy proved to be an effective, valid and safe procedure in the diagnostic and therapeutic management of non-neoplastic obstructive salivary gland diseases.Interventional sialendoscopy has become the predominant therapeutic procedure for the management of obstructive salivary disorders, but only a few multicentre studies of large series of patients with a long-term follow-up have been published. This Italian multicentre study involved 1152 patients (553 females; mean age 50 years) who, after at least a clinical and ultrasonographic evaluation, underwent a total of 1342 diagnostic and interventional sialendoscopies, 44.6% of which involved the parotid gland. 12% (n = 138) of patients underwent multiple treatments. The procedure was successful in 1309 cases. In 33 cases (2.4%) the procedure could not be concluded mainly because of complete duct stenosis (21 cases). Salivary stones were the main cause of obstruction (55%), followed by ductal stenosis and anomalies (16%), mucous plugs (14.5%) and sialodochitis (4.7%). Complete therapeutic success was obtained in 92.5% of patients after one or more procedures, and was ineffective in < 8%. Untoward effects (peri and postoperative complications) were observed in 5.4% of cases. Sialendoscopy proved to be an effective, valid and safe procedure in the diagnostic and therapeutic management of non-neoplastic obstructive salivary gland diseases.

Comparison of Local Sclerotherapy With Lauromacrogol Versus Nasal Packing in the Treatment of Anterior Epistaxis

Objectives Epistaxis is one of the most common otorhinolaryngologic emergencies representing more than 12% of conditions managed at the Ear, Nose and Throat (ENT) Emergency Consulting Room of our Otorhinolaryngologic Unit each year. The elevated frequency of this pathology makes it necessary to adopt the most effective and least expensive therapeutic strategy available. The aim of this study was to compare the efficacy, costs and morbidity of nasal packing (NP), which is the mainstay of treatment for anterior epistaxis in our ENT Emergency Consulting Room versus submucosal infiltrations of lauromacrogol (LA). Methods A retrospective study was designed from August 2012 to April 2013 involving 53 patients suffering from anterior epistaxis. Anterior NP was used in 27 patients versus 26 patients undergoing 27 procedures performed with submucosal infiltrations of LA (or polidocanol). Outcomes for each treatment were evaluated. Patients in group 1 were treated with LA 400 injection next to the bleeding point: 0.5- to 1-mL single or multiple infiltrations with a 27-gauge needle. The whitening of the nasal mucosa around the bleeding point during infiltration was considered a marker of correct procedure in order to achieve the best results. Bilateral treatment was also performed at the same time. Patients in group 2 were treated with standard NP. Results Bleeding recurrence was higher in the NP group even if it was not statistically significant (P=0.2935). However, the LA infiltrations were better tolerated with lower morbidity and costs as compared to NP. No complications were observed in either group. Conclusion LA infiltrations were shown to be a viable alternative in anterior epistaxis treatment. They are safe, easy to use with good efficacy and have a low cost.

Learning curve in diagnostic and interventional sialendoscopy for obstructive salivary diseases

SUMMARY Sialendoscopy is a new diagnostic and surgical tool for management of salivary gland diseases that offers the opportunity to treat selected pathologies less invasively and with better results compared to previous techniques. As with any new technique, an adequate training programme involving a gradual learning curve is mandatory to quickly obtain results similar to those reported in the literature. This includes an appropriate diagnostic programme, correct patient selection and knowledge of possible pitfalls. In this retrospective study, the outcomes of the first 141 procedures (74 on the parotid gland and 67 on the submandibular gland) performed with this technique in our Department from 2009 to 2013 were compared with those reported in the literature. Patients were divided into three groups: Group A (the first 49 procedures performed), Group B (the next 50 procedures), and Group C (the last 42 procedures). There were no statistically significant differences relative to mean procedure times, recurrence of symptomatology after treatment, need for further treatments and rates of minor complications between groups. No major complications were seen. The increase in experience resulted in an increased number of interventional sialendoscopies performed under local anaesthesia instead of general anaesthesia (51% vs 18% vs 14%). In only three of 130 glands treated (2.3%) was gland resection required. We also evaluated which technique had been used for stone removal and rate of failure, which was similar in all groups (13.6% vs 15% vs 15%). Our results do not substantially differ from those reported in the literature. Initial difficulties in catheterising the papilla could be overcome with practise on fresh human specimens or fresh pig heads. Lack of precision regarding diagnostic imaging techniques was remedied by improving the competence of the surgeon in performing pre- and postoperative ultrasound. The creation of specialised centres capable of treating up to 1 to 2 million people would be desirable in order to better stratify pathologies, validate the investment in equipment and gain the necessary experience in the various surgical techniques.

Antibiotic Prophylaxis in Endoscopic Endonasal Pituitary and Skull Base Surgery

OBJECTIVE Postoperative infection is a potentially dramatic consequence in endoscopic endonasal surgery. The aim of this study was to assess the efficacy of our intraoperative antibiotic prophylaxis by analyzing the risk factors of postoperative meningitis in our series. METHODS Each endoscopic endonasal procedure performed since 1998 in patients with no preoperative infections and a follow-up longer than 30 days were included and retrospectively reviewed. Antibiotic protocol consisted in single antibiotic administration of ampicillin/sulbactam 3 g or cefazolin 2 g on induction; no postoperative administrations were performed after 2005. All cases of cerebrospinal fluid (CSF) leak, meningitis, and systemic infection were recorded. RESULTS Two thousand thirty-two procedures matched the inclusion criteria (median age 50 years; range: 1-89 years, male/female ratio: 1:1.12). Intraoperative CSF leak occurred in 32.8% of the cases and postoperative CSF leak in 3.4%. The rate of meningitis was 0.69%; other systemic infections were observed in 0.44% of cases. Meningitis was statistically associated with intra- and postoperative CSF leak (P < 0.001). Other risk factors were the intradural extension of the tumors and their malignant histology. Extended approaches producing wide osteodural defects were correlated with a greater risk of meningitis (P < 0.001). CONCLUSIONS All surgical maneuvers to prevent, detect, and quickly repair intra- and postoperative CSF leak are crucial to avoid postoperative meningitis. The proposed prophylaxis protocol is comparable in safety to those recommended in literature as assessed by the low rate of meningitis.

Silent sinus syndrome and maxillary sinus atelectasis in children

OBJECTIVE Silent sinus syndrome (SSS) and chronic maxillary atelectasis (CMA) are unusual conditions having subtle symptoms with a possible progressive evolution. They are particularly infrequent in the pediatric population. Our objective was to review our experience with pediatric patients having SSS or CMA, and to review all cases involving patients under 14 years of age reported in the literature. METHODS A retrospective review of 6 patients diagnosed with SSS or CMA surgically treated from 2001 to 2014 was carried out. All cases reported in literature were reviewed. RESULTS All patients underwent functional endoscopic sinus surgery with an improvement in symptoms after surgery. Diplopia disappeared in two patients who presented with it and enophthalmos improved in all five patients presenting with it. Only one patient out of four presenting with headache had a persistence of the symptoms which were, however, milder than they had been preoperatively. Endoscopic examination demonstrated a reventilated maxillary sinus in all cases. A radiological examination at follow-up was performed in 5 cases and demonstrated a reexpansion of the maxillary sinus as compared to the contralateral side in all patients except one. None of the patients required an orbital floor reconstruction. Eleven similar cases reported in the literature were analyzed and compared. CONCLUSION Endoscopic uncinectomy and middle meatal antrostomy should be the treatment of choice for these conditions in patients presenting with enophthalmos and/or hypoglobus and symptoms related to it. Orbital floor reconstruction should be performed as a delayed procedure only in selected cases. Chronic maxillary atelectasis or SSS should be considered as a possible cause of persistent headache of unknown origin in pediatric patients.

Comparison of two different epidemiological profiles of otorhinolaryngology emergencies

Andrade et al. published on the May/June 2013 issue of this journal an interesting article on otorhinolaryngology (ENT) emergencies (‘‘Profile of otorhinolaryngology emergency unit care in a high complexity public hospital’’). The aim of this letter is to compare and comment what has been published to our data. We retrospectively reviewed all patients sent for urgent/emergent consultation to our ENT emergency room (ER) from the general emergency department (ED) between two periods of time: from June 1 to July 31, 2012, and from November 1 to December 31, 2012. In our hospital, the protocol for referrals states that patients do not have direct access to the ENT ER and they need to be triaged by the ED consultant who establishes the level of urgency/emergency and the need for ENT evaluation. We considered all patients referred for evaluation through this way, thus excluding patients triaged in general practice (GP) and referred to us as planned consultation within 24 h. We collected 2021 ENT emergency cases: among these, 18 cases were excluded for lack of data. The remaining 2003 cases were included in the review. The mean age at presentation was 46 ± 25 years old, with a median of 45 years. The demographic results and the ten most common diagnoses for referral are shown in Table 1. When classified for subspecialties, we found a lower rate of otological complaints (986 cases -49.23% vs. 65.41% reported by Andrade et al. and 62.27% reported by Furtado et al.) and a higher rate of head and neck complaints (204

Acute Invasive Fungal Rhinosinusitis in Immunocompromised Patients: Role of an Early Diagnosis:

Objective The aims of the present study were to evaluate the clinical significance of the delay for surgical treatment and the prognostic value of other clinical, pathologic, and microbiological variables among hematologic patients affected by acute invasive fungal rhinosinusitis (AIFRS). Furthermore, we propose our early diagnosis and treatment protocol, reporting its 10-year results. Study Design Monocentric retrospective analysis. Setting The study was conducted from 2001 to 2017 at the University Hospital of Bologna, Italy. Subjects and Methods The impact of time to treatment and clinical, pathologic, and microbiological variables were analyzed among patients with histologically and microbiologically proven AIFRS. The outcomes of patients treated before the introduction of the early diagnosis protocol were compared with those treated afterward. Results Nineteen patients affected by AIFRS were eligible for the study. Treatment delay >4 days (P = .002), infection caused by Mucorales (P = .015), and extension of the disease were negative prognostic variables (P = .017). The application of our protocol significantly reduced the delay for diagnosis and appropriate treatment by an average of 7.3 days (P = .02). Conclusion The promptness of the diagnosis and surgical treatment may play a significant role in the management of AIFRS, as it appears to be significantly associated with the disease outcome. Our protocol may help to reduce the time required for diagnosis of high-risk hematologic patients.