International expert consensus statement: surgical failure in obstructive sleep apnea.

PURPOSE: Upper airway (UA) surgery is commonly employed in the treatment of patients with obstructive sleep apnea (OSA). The intricate pathophysiology of OSA, variability in sites and patterns of UA collapse, and the interaction between anatomical and non-anatomical factors in individual patients may contribute to possible surgical failures. This clinical consensus statement aims to identify areas of agreement among a development group comprising international experts in OSA surgery, regarding the appropriate definition, predictive factors in patients, and management of surgical failure in OSA treatment. METHODS: A clinical consensus statement (CCS) was developed using the Delphi method by a panel of 35 contributors from various countries. A systematic literature review adhering to PRISMA guidelines was conducted. A survey consisting of 60 statements was then formulated and presented to the experts. RESULTS: Following two rounds of the Delphi process, consensus or strong consensus was achieved on 36 items, while 24 items remained without consensus. Specifically, 5 out of 10 statements reached consensus regarding on the 'Definition of Surgical Success/Failure after OSA Surgery'. Regarding the 'Predictive Factors of Surgical Failure in OSA Surgery', consensus was reached on 10 out of 13 statements. In the context of the 'Diagnostic Workup in OSA Surgery', consensus was achieved on 9 out of 13 statements. Lastly, in 'Treatment in Surgical Failure Cases', consensus was reached on 12 out of 24 statements. CONCLUSION: The management of OSA after surgical failure presents a significant clinical challenge for sleep specialists. This CCS provides valuable guidance for defining, preventing, and addressing surgical failures in the treatment of OSA syndrome.

The effect of drug-induced sleep endoscopy on surgical outcomes for obstructive sleep apnea: a systematic review.

PURPOSE: Drug-induced sleep endoscopy (DISE) is the most widespread diagnostic tool for upper-airway endoscopic evaluation of snoring and obstructive sleep apnea (OSA). However, a consensus on the effectiveness of DISE on surgical outcomes is still lacking. This study aimed to quantify the effect of DISE on surgical outcomes and to compare DISE with awake examination using the Müller Maneuver (MM). METHODS: This systematic review was performed according to the PRISMA guidelines. Published studies from the last 30 years were retrieved from the Cochrane Library, MEDLINE, SCOPUS, and PubMed databases. Studies comparing DISE with awake examination, or MM were included. Surgical success rate was defined according to Sher's criteria, achieving a postoperative apnoea-hypopnea index (AHI) value < 20 events per hour and a 50% improvement from preoperative AHI. Outcomes are presented in terms of surgical success, pre- and postoperative AHI, Epworth sleepiness score (ESS), oxygen desaturation index (ODI) and lowest oxygen saturation (LOS). RESULTS: This review included 8 studies comprising 880 patients. DISE group showed a higher LOS increase, ODI decrease, ESS decrease than non-DISE group (6.83 ± 3.7 versus 3.68 ± 2.9, p<0.001; 19.6 ± 11.2 versus 12.6 ± 10.4, p<0.001; 6.72 ± 4.1 versus 3.69 ± 3.1, p<0.001). Differences in surgical success rate were significant only between DISE and MM (64.04% versus 52.48%, p = 0.016). AHI decrease resulted higher in non-DISE than in DISE group (39.92 ± 24.7 versus 30.53 ± 21.7, p<0.001). CONCLUSION: Results of this systematic review suggest that the evidence is mixed regarding a positive effect of DISE on surgical outcomes.

3D 4K exoscope in snore surgery simulation: pre-clinical experience.

PURPOSE: The application of 3D exoscopic technology is spreading worldwide, in several surgical scenarios. In this study, we present the first-time use of the exoscopic system (VITOM® and Versacrane™) in a cadaver simulation of transoral Snore Surgery. METHODS: All participants (n = 14) were asked to perform 2 exercises that simulate tasks required in Snore Surgery, they were then administered a questionnaire assessing their evaluation of the applied exoscopic technology. Participants were divided into groups according to age and experience. RESULTS: Mean zooming and focusing time was higher in young surgeons than in seniors, and similar results were obtained for mean procedural times. The responses to the questionnaire showed that in the vast majority (86%), the exoscopic technology was well rated. CONCLUSION: The exoscope can be considered a useful tool, thanks to its magnifying power and high-definition images, as well as for its indirect ability to enhance staff involvement in the procedure and for educational purposes.

Barbed pharyngoplasty for the treatment of obstructive sleep apnea: the surgical learning curve.

BACKGROUND: Barbed snore surgery (BSS) was recently introduced for the management of obstructive sleep apnea (OSA) with optimistic clinical outcomes associated with a low complication rate. The purpose of the present study was to describe the surgical learning curve of the BSS to determine the effect of surgeon experience on surgical procedure time and complication rates. METHODS: Patients who underwent tonsillectomy with barbed lateral pharyngoplasty were divided in two different groups based on surgeon experience. Operative time, intraoperative blood loss, intra- and post-operative complications, and hospitalization time were compared. RESULTS: A total of 144 consecutive patients (F: 27; mean age: 47.5 years, SD 9.7) were included. All procedures were successfully completed in 37.0 min (IQR 29.0-47.0). Senior surgeons completed the procedure in 33.0 min (IQR 27.0-41.0), while junior surgeons needed 52.0 min (IQR 36.5-64.5) (p < .05). No intra-operative complications were observed, and intra-operative blood loss was minimal in both groups. No difference was measured in terms of hospitalization time. Only one post-operative bleeding resolved with conservative treatment was detected in both groups. Junior surgeons showed a positive trend in the reduction of operative time (r = - 2.32, 95% CI: - 2.74 to - 1.90; p < .05). CONCLUSIONS: The findings suggest that BSS may be safely performed by inexperienced surgeons with no increased risk of intra- and post-operative complications. The surgical LC is short and the junior surgeon can reach the ability of senior surgeons after a few number of procedures with a progressive reduction of the operative time.

Efficacy of fluralaner spot-on solution for the treatment of Ctenocephalides felis and Otodectes cynotis mixed infestation in naturally infested cats.

BACKGROUND: Cats can be infested with several ectoparasite species, especially Ctenocephalides felis and Otodectes cynotis. The aim of this study was to evaluate the efficacy of a single topical application of fluralaner against C. felis and O. cynotis natural infestation in stray (study 1) and owned (study 2) cats in central and southern Italy. RESULTS: The number of live fleas found on each cat on Day 0 ranged from 1 to more than 30 (arithmetic mean live flea count = 11.9 in study 1; 14.6 in study 2) while no live fleas were found on days 7 and 84 post topical application of fluralaner. The number of live mites found on each cat on Day 0 ranged from 1 to 42 (arithmetic mean live mite count = 6.4 in study 1; 8.9 in study 2) while no live mites were found on days 7 and 84 post topical application of fluralaner. CONCLUSIONS: Topical fluralaner completely eliminated fleas and ear mites from infested cats and was 100% effective against both parasites up to 84 days after treatment.

A case report of Dermanyssus gallinae infestation in three cats.

BACKGROUND: Dermanyssus gallinae is a major threat for the poultry industry; these mites also feed on the blood of many other birds, small mammals and potentially humans. HYPOTHESIS/OBJECTIVES: Three cats with dermatitis attributed to D. gallinae infestation. ANIMALS: Two 40-day-old kittens, living in a rural area, and one 7-year-old female indoor cat, were presented with a pruritic skin condition. METHODS: Mite specimens were collected from the cats and examined by light and scanning electron microscopy. Cytological and histological examinations of the skin lesions were performed. RESULTS: A diagnosis of D. gallinae infestation was made after identification of the mites. Histological findings were compatible with eosinophilic dermatitis. Clinical improvement was noted two weeks after treatment. CONCLUSIONS AND CLINICAL IMPORTANCE: The two kittens showed chronic blood loss which reflects the ability of D. gallinae mites to switch host. For the indoor cat, mites were presumed to be carried by birds regularly present on the balcony of the apartment. This demonstrates that mite infestation is possible even in urban areas, through contact with birds or their abandoned nests. When birds are not present, cats or other small mammals as well as humans, can be infested.

Pustular dermatitis in dogs affected by leishmaniosis: 22 cases.

BACKGROUND: Skin lesions in canine leishmaniosis (CanL) are diverse, including exfoliative, ulcerative, nodular and papular dermatitides. An uncommon pustular form has also been reported. HYPOTHESES/OBJECTIVES: We hypothesized that CanL infection can produce a pustular reaction pattern in the skin of dogs. The aim of this retrospective study was to describe the clinicopathological features of dogs with CanL infection and pustular dermatitis, and correlate them with response to therapy. ANIMALS: Twenty two affected dogs. METHODS: Retrospective review of medical records and examination of archived biopsy materials or previously processed glass slides was performed. Cytological examinations had been recorded for all cases. Specimens were available for histopathological examination in 17 of 22 cases and for immunohistochemical detection of Leishmania amastigotes in 13 of 22 cases. RESULTS: All dogs presented with multifocal to diffuse pustular dermatitis. CanL was diagnosed by IFAT serology (20 cases), bone marrow cytology (one case) or bone marrow PCR (one case). Cytological and/or histopathological examinations revealed acantholytic keratinocytes within pustules in 18 of 22 cases. Bacterial and fungal cultures were not performed. Leishmania amastigotes were identified by histopathology within the dermis in three cases; immunohistochemistry was positive in four cases. All dogs underwent concurrent anti-leishmanial and immunosuppressive therapy to control the pustular dermatitis, with favourable outcome in 11 of 22 cases. CONCLUSIONS AND CLINICAL IMPORTANCE: Due to the retrospective nature of this study it is not possible to either accept or reject the hypothesis that CanL is the direct cause of pustular dermatitis.

Clinical Application of Pediatric Sleep Endoscopy: An International Survey.

OBJECTIVES: To investigate through an international survey the actual clinical application of drug-induced sleep endoscopy (DISE) in pediatric patients with obstructive sleep apnea (OSA) and to clarify the use, application, clinical indications, and protocol of pediatric DISE. METHODS: A specific survey about pediatric DISE was initially developed by five international otolaryngologists with expertise in pediatric sleep apnea and drug-induced sleep endoscopy and was later spread to experts in the field of sleep apnea, members of different OSA-related associations. RESULTS: A total of 101 participants who answered all the survey questions were considered in the study. Sixty-four sleep apnea experts, equivalent to 63.4% of interviewed experts, declared they would perform DISE in pediatric OSA patients. A total of 81.9% of responders agreed to consider the DISE as the first diagnostic step in children with persistent OSA after adenotonsillectomy surgery, whereas 55.4% disagreed with performing DISE at the same time of scheduled adenotonsillectomy surgery to identify other possible sites of collapse. In the case of young patients with residual OSA and only pharyngeal collapse during DISE, 51.8% of experts agreed with performing a velopharyngeal surgery. In this case, 27.7% disagreed and 21.4% were neutral. CONCLUSION: Pediatric DISE is internationally considered to be a safe and effective procedure for identifying sites of obstruction and collapse after adenotonsillectomy in children with residual OSA. This is also useful in cases of patients with craniofacial malformations, small tonsils, laryngomalacia or Down syndrome to identify the actual site(s) of collapse. Despite this evidence, our survey highlighted that pediatric DISE is not used in different sleep centers.

Feline trombiculosis: a retrospective study in 72 cats.

BACKGROUND: Trombiculosis is the infestation of a host by the larval form of mites belonging to the Trombiculidae family. Few data are available regarding this infestation in cats. HYPOTHESIS/OBJECTIVES: The aim of this retrospective study was to report data, clinical signs, diagnostic and therapeutic features of feline trombiculosis. METHODS: Clinical records of cats presented for dermatological examination or annual vaccination in Italy, from 2002 to 2012, were retrospectively searched using the key words trombiculosis, cat and Neotrombicula. RESULTS: Seventy-two indoor/outdoor domestic short-hair cats with infestation by Neotrombicula autumnalis were enrolled. Pruritus was reported by the owners in 43% of cases, while 57% of cats were asymptomatic. The most common clinical signs included sudden onset of pruritus and the appearance of orange-coloured granules on the skin. Mites were found incidentally in 12 cats. The larvae were localized in multiple sites in 68% of cases. The most frequently affected area was the ear (80.5% of cases). Mites were more often identified in autumn (41 cases). Eleven cats were diagnosed during winter, 13 in spring and seven in summer. CONCLUSIONS AND CLINICAL IMPORTANCE: This retrospective study suggests that feline trombiculosis is probably underestimated as a cause of pruritus and dermatological lesions. Epidemiological data regarding this infestation in cats are still lacking, and it will be interesting to perform a multicentre study to increase knowledge of this disease.

Nodular lesions due to infestation by Dirofilaria repens in dogs from Italy.

BACKGROUND: Canine subcutaneous dirofilariosis caused by Dirofilaria repens is an important cause of human dirofilariosis in the Old World. OBJECTIVES: To describe the clinical and pathological features of infestation by D. repens in dogs with cutaneous nodules and to discuss key diagnostic procedures. ANIMALS: Sixteen privately owned dogs of different breeds, ages and genders with subcutaneous nodules were positive for D. repens on at least one diagnostic test. METHODS: Diagnostic tests included cytological examination of fine-needle aspiration biopsies, detection of circulating larvae by Knott's test, morphological and molecular identification of adult parasites and microfilariae, and histopathological examination of excised nodules. RESULTS: Twelve animals were positive for D. repens microfilariae, using cytology and at least one other diagnostic test. Four of twelve dogs screened by Knott's test had circulating D. repens microfilariae, and three of them were co-infected with Dirofilaria immitis. In eight dogs, adult nematodes were morphologically identified as D. repens. Nodular panniculitis was observed in all cases, with nodules containing either one or several cross-sections of nematodes and microfilariae. The nematodes extracted were identified as D. repens by an RT-PCR on the second internal transcribed spacer (ITS-2). CONCLUSIONS AND CLINICAL IMPORTANCE: Adults and larvae of D. repens can induce skin nodules in dogs, and these lesions should be carefully evaluated in endemic areas. Clinicians should be aware that correct tissue sampling (including the storage of part of a sample in ethanol instead of formalin) is pivotal to achievement of a specific diagnosis. Cytology of fine-needle tissue aspirates was shown to be useful.

The T-shaped FST pharyngoplasty step-by-step closure technique.

Pharyngocutaneous fistula is one of the most common and serious complications associated with total laryngectomy. Numerous studies tried to evaluate causative and predisposing factors associated with this complication, but data are considerably variable and there is still no international consensus. Incidence rate varies considerably between studies, with reported rates from 3% to 65%. This 4K video presents our T-shaped four-step technique (FST) for closing the pharyngeal mucosa after total laryngectomy in a step-by-step manner. All sutures were performed by braided absorbable 3/0 26 mm 1/2c (Vicryl plus 3.0; Ethicon, Somerville, NJ, USA). Recordings were performed using a Karl Storz 4K 3D VITOM® exoscope (Karl Storz SE & Co. KG, Tuttlingen, Germany). We have been described this technique through a high-definition video, showing each step, and tips from the authors. Our T-shaped pharyngoplasty closure technique can be divided into four steps: 1. "Key Stitches"; 2. "Area Refinement Stitches"; 3. "Modified Connell Suture"; 4. "Modified Purse String Suture." Our T-shaped FST closure technique proved to be an effective and reproducible method, which we feel could be the preferred choice for primary pharyngoplasty closure.

Methylation Drivers and Prognostic Implications in Sinonasal Poorly Differentiated Carcinomas.

BACKGROUND: Poorly differentiated sinonasal carcinomas (PDSNCs) are rare and aggressive malignancies, which include squamous cell carcinoma (SCC), sinonasal undifferentiated carcinoma (SNUC), and neuroendocrine carcinomas (NEC). Several epigenetic markers have been suggested to support the histopathological classification, predict prognosis, and guide therapeutic decision. Indeed, molecularly distinct subtypes of sinonasal carcinomas, including SMARCB1-INI1 or SMARCA4 deficient sinonasal carcinoma, isocitrate dehydrogenase (IDH)-mutant SNUC, ARID1A mutant PDSNCs, and NUT carcinomas, have recently been proposed as separate entities. Identification of aberrant DNA methylation levels associated with these specific epigenetic driver genes could be useful for prognostic and therapeutic purpose. METHODS: Histopathological review and immunohistochemical study was performed on 53 PDSNCs. Molecular analysis included mutational profile by NGS, Sanger sequencing, and MLPA analyses, and global DNA methylation profile using LINE-1 bisulfite-PCR and pyrosequencing analysis. RESULTS: Nine SWI/SNF complex defective cases and five IDH2 p.Arg172x cases were identified. A significant correlation between INI-1 or IDH2 defects and LINE-1 hypermethylation was observed (p = 0.002 and p = 0.032, respectively), which were associated with a worse prognosis (p = 0.007). CONCLUSIONS: Genetic and epigenetic characterization of PDSNCs should be performed to identify distinct prognostic entities, which deserved a tailored clinical treatment.

Obstructive sleep apnoea after radiotherapy for head and neck cancer.

OBJECTIVE: The aim of this study is to focus attention on obstructive sleep apnoea hypopnoea syndrome (OSHAS) as a sequela of non-surgical treatments of selected head and neck cancer (HNca), sharing our experience in drug-induced sleep endoscopy (DISE). To the best of our knowledge, this is the first study that documents dynamic anatomical and functional alterations during sleep in irradiated OSAHS patients by DISE. METHODS: A retrospective study of patients affected by OSAHS referring to our department from January 2018 to December 2019 was carried out. Inclusion criteria were: patients who underwent radiation or chemo-radiation for HNca affecting upper airways that presented sleep-related breathing disorders after treatment. RESULTS: 6 patients with moderate to severe OSAHS and a clinical story of previous non-surgical treatment for an HNca were enrolled. DISE showed in all patients typical anatomical alterations observed in irradiated individuals. Four patients were treated with continuous positive airway pressure, while 2 subjects were treated with tailored minimal invasive surgery without post-operative complications. CONCLUSIONS: Our results suggest that minimal invasive surgical treatments can be a good therapeutic option in very selected patients with post-irradiation iatrogenic OSAHS.

Salvage open partial horizontal laryngectomy after failed radiotherapy: A multicentric study.

OBJECTIVES: The primary aim of the present study was to report our multi-institutional experience in surgical salvage with open partial horizontal laryngectomies (OPHL) after failed radiotherapy (RT) for laryngeal squamous cell carcinoma (LSCC). Secondary aims were to analyze the prognostic meaning of the main clinical and pathological parameters in relation to the oncologic outcome and to compare our results with the available literature. STUDY DESIGN: A retrospective multicenter analysis of surgical oncological outcomes. METHODS: We retrospectively review the clinical charts of 70 recurrent LSCC patients after primary RT failure undergone salvage OPHL. RESULTS: At last follow-up, 46 patients (65%) were disease-free; six (9%) were alive with disease; nine (12%) died because of the disease; and nine (12%) died without evidence of disease. The final local control, overall survival, disease-specific survival, and laryngectomy-free survival were 87%, 75%, 87%, and 91%, respectively. Twelve patients (17%) experienced postoperative complications, whereas 18 patients (25%) experienced late sequelae. In five patients (7%), decannulation was not possible because of postoperative laryngeal stenosis. CONCLUSION: In selected patients, when proper selection criteria for conservation laryngeal surgery are adopted, OPHL can be considered for salvage after RT failure. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:431-436, 2020.

Septal Flip Flap for Anterior Skull Base Reconstruction After Endoscopic Transnasal Craniectomy: Long-Term Outcomes.

BACKGROUND: Endoscopic endonasal anterior skull base malignant sinonasal tumor resection and reconstruction remains a challenge. We describe our septal flip flap (SFF) reconstruction, a new surgical technique for repairing anterior skull base defects and report our outcomes. METHODS: We retrospectively reviewed the clinical data of 24 patients who underwent skull base reconstruction using a SFF following endoscopic resection with transnasal craniectomy. We raise the SFF from the contralateral nasal septum based on the septal branches of the anterior and posterior ethmoidal arteries; the SFF is then rotated laterally for anterior skull base reconstruction after transnasal resection with craniectomy. RESULTS: The SFF was used for multiple tumor types including, most commonly, intestinal-type adenocarcinoma, followed by olfactory neuroblastoma, squamous cell carcinoma, sinonasal undifferentiated carcinoma, and other types. All of the cases had either preoperative or postoperative radiation therapy. All flaps remained viable postoperatively. Postoperatively, nasal crusting was significantly reduced with faster healing of the surgical cavity. CONCLUSIONS: The SFF adds to the clinical armamentarium the opportunity to provide vascularized mucosal coverage extending from the frontal recess back to the planum sphenoidalis. The use of SFF requires careful consideration when dealing with paranasal sinus cancers so as not to infringe oncologic principles.

Endoscopic endonasal approach for sinonasal and anterior skull base malignancies in the elderly.

BACKGROUND: The purpose of this study was to report the outcomes of endoscopic transnasal resection for sinonasal and anterior skull-base cancers in elderly patients. METHODS: A retrospective review was performed. The patients were divided into 2 groups, <70 years old and ≥70 years old and compared by univariate analysis. Prognostic factors were evaluated with a multivariate analysis. Survival rates were also calculated. RESULTS: Two hundred three elderly patients and 397 younger patients were enrolled in this study. The elderly patients reported lower survival rates than the younger patients. When melanoma and esthesioneuroblastoma were censored, the disease-specific survival (DSS) and recurrence-free survival (RFS) were similar. Complication rates were 17.5% without any statistical significance between the groups. Multivariate analysis revealed that histology, stage, surgical margins, and surgical approaches were independent predictors of survival in elderly patients. CONCLUSION: The endoscopic transnasal approach reported low mortality and morbidity rates also in geriatric patients, and age itself is not to be considered as a contraindication.

Canine notoedric mange: a case report.

Notoedric mange is a cutaneous ectoparasitic disease of cats caused by Notoedres cati, a mite belonging to the Sarcoptidae family. The disease occurs in felids, occasionally in other mammals and in humans. The canine form, even if cited by some authors, has never been documented. This report describes for the first time a case of notoedric mange in a dog.