Use of the pedicled nasoseptal flap in the endoscopic management of cholesterol granulomas of the petrous apex.

BACKGROUND: Nowadays the endoscopic approach represents a useful alternative to traditional surgical approaches in the treatment of cholesterol granulomas (CGs) of the petrous apex (PA). Recently the nasoseptal flap (NSF) has been employed to permit long-term patency of drainage site. The purpose of this study is to report our experience with the NSF in the endoscopic management of CG and to analyze the advantages, limitations, and outcomes of the technique. METHODS: A retrospective analysis was carried out on 10 patients affected by CG of the PA who had been treated endoscopically, using the NSF. RESULTS: An endoscopic transpterygoid approach was used for 6 patients and the remaining 4 were treated using the transclival approach. A NSF was used in all 10 cases. In 6 cases the flap was ipsilateral to the lesion whereas in 4 it was contralateral. In 90% of our patients no evidence of disease was observed after a mean follow-up period of 35.7 months, with resolution of their symptoms. One patient presented a recurrence because of a technical error (inadequate placement of the flap in the cavity), and has been retreated endoscopically. CONCLUSION: The pedicled NSF seems to be helpful in avoiding the concentric growth of the granulomatous cyst epithelium while assuring ventilation and drainage of the cyst. However, bigger studies with longer-term follow-up are needed to confirm these findings. Correct and meticulous placement of the flap inside the cystic cavity is the most critical issue for the success of the procedure.

HPV Type 6 and 18 Coinfection in a Case of Adult-Onset Laryngeal Papillomatosis: Immunization with Gardasil.

Laryngeal papillomatosis (LP) is a rare human papillomavirus (HPV) related disease that often requires multiple surgical interventions and residual impairment of voice is almost inevitable. We report the case of a patient with adult onset recurrent LP, showing moderate dysplasia and coinfection with HPV types 6 and 18. The tetravalent HPV vaccine Gardasil was prescribed off label, with the aim of triggering an immunogenic response and consequently reducing the probability of further recurrences. The patient was followed for 9 months with no sign of relapse of his LP. The postexposure use of the anti-HPV vaccine could represent a promising therapeutic agent in established LP. Unfortunately, the potential efficacy of this new therapeutic option in this situation has been suggested only by isolated case reports. Further controlled studies, with a longer follow-up and a larger sample size, are needed to assess efficacy of Gardasil in LP.

Comparison of three different polyvinyl alcohol packs following functional endoscopic Nasal surgery.

OBJECTIVES/HYPOTHESIS: To compare the extent of bleeding and patient discomfort during packing removal of three different polyvinyl alcohol (PVA) packs: 1) a standard PVA sponge (s-PVA) (Mondocel Standard 10 cm; Mondomed NV, Hamont-Achel, Belgium); 2) a PVA sponge with oxidized cellulose (oc-PVA) (Merocel Hemox 10 cm; Medtronic Xomed Surgical Products, Jacksonville, FL); and 3) a PVA sponge with polyethylene film (pf-PVA) (Merocel 2000 8 cm; Medtronic Xomed Surgical Products, Jacksonville, FL), after functional endoscopic sinus surgery and inferior turbinoplasty. STUDY DESIGN: A prospective, randomized, blinded, controlled trial. METHODS: Ninety consecutive patients were enrolled and randomized to receive in each side one pack in the middle meatus and another pack of the same material in the nasal fossa. The patients were equally divided in three groups of 30 patients each. Group A received the pf-PVA; group B received oc-PVA; and group C received s-PVA. Postoperatively, bleeding after removal of the entire nasal packing was evaluated by an observer, whereas the severity of pain was rated by patients with visual analog scales. RESULTS: Our study evaluated three nasal packing materials, demonstrating that the pf-PVA is less painful than the others but with intermediate bleeding ratio. However, the oc-PVA has an intermediate pain score but minimum bleeding. The s-PVA showed the worst pain and bleeding results. CONCLUSIONS: Considering that removal of the second pack (middle meatus) is more painful than the first (nasal fossa), our results suggest that a pf-PVA can be placed in the middle meatus and a oc-PVA in the nasal fossa in order to reduce patient's discomfort in terms of pain and bleeding. LEVEL OF EVIDENCE: 1b.

Endoscopic endonasal resection of respiratory epithelial adenomatoid hamartomas of the sinonasal tract.

BACKGROUND: Respiratory epithelial adenomatoid hamartomas (REAHs) are rare benign tumors and may manifest as either isolated lesions or in association with sinonasal polyposis. The aim of this study is to report our experience in the management of patients with REAH and to analyze the long-term results of the endoscopic endonasal approach. METHODS: A retrospective analysis of a database dedicated to patients with REAH treated between May 2003 and December 2012 was performed. Clinical presentation, demographic, histologic and radiographic features, operative findings, and follow-up data were examined. RESULTS: Twenty-seven patients with REAH, 14 males and 13 females, with a mean age of 51 years, underwent endoscopic sinus surgery (ESS). The most frequent reported symptoms were nasal obstruction (80%), headache (12%), mucous rhinorrhea (20%), and hyposmia (40%). Seventeen cases (first group) were present as isolated masses, 10 cases (second group) were associated with nasal polyposis. The first group with a preoperative diagnosis of REAH was submitted to a more aggressive resection with subperiosteal dissection and drilling of the underlying bone. The patients in the second group, because of the unrevealed diagnosis of REAH and due to the presence of nasal polyposis, underwent standard ESS. No evidence of recurrence in either of the subgroups after a mean follow-up of 61.2 months. CONCLUSION: REAH is a benign well-defined pathological entity but is still unfamiliar. REAH should be kept in mind as a differential diagnosis from more aggressive lesions to avoid unnecessary surgical procedure. A complete but conservative endoscopic resection appears to be curative.

Palatovaginal (pharyngeal) artery: clinical implication and surgical experience.

The palatovaginal or pharyngeal artery is a small branch of the internal maxillary artery supplying the nasopharynx. Bleeding from this artery is exceptional and only one case of traumatic epistaxis from this artery has been reported previously. We report a case of a 66-year-old male presenting with right recurrent posterior epistaxis. Endoscopic dissection of the pterygopalatine fossa and direct visualization of the palatosphenoidal canal permitted to identify the origin of bleeding, and coagulation of the pharyngeal artery solved the epistaxis. Although rare, intractable posterior epistaxis may arise from the pharyngeal artery. The anatomical knowledge of this artery and of the palatosphenoidal canal is of outmost importance in endoscopic transpterygoid and nasopharyngeal procedures, to identify the vidian canal, evaluate nasopharyngeal cancer spread in the pterygopalatine fossa, reduce bleeding during surgery of the nasopharynx, and harvest adequately the pedicle of the nasoseptal flap.

Oncocytic Schneiderian papillomas: Clinical behavior and outcomes of the endoscopic endonasal approach in 33 cases.

BACKGROUND: The purpose of this study was to evaluate the clinical behavior of oncocytic Schneiderian papillomas in relation to the rate of malignant transformation and recurrences and to report the long-term results of the endoscopic endonasal treatment. METHODS: A retrospective analysis was carried out on patients with oncocytic papilloma, endoscopically managed over the past 20 years, at 2 university centers following a uniform policy. RESULTS: Thirty-three patients were treated between November 1991 and December 2010. The mean follow-up period was 62 months. We observed 2 cases of persistence (6%) at the maxillary sinus level. Both of these patients underwent endoscopic surgical revision. Squamous cell carcinoma (SCC) was observed in 1 patient (3%). CONCLUSION: The endonasal endoscopic technique proved to be a safe and effective approach for the treatment of oncocytic papillomas. An oncocytic papilloma is not to be considered a negative prognostic factor in terms of malignant transformation or recurrence.

Mediastinal abscess and esophageal stricture following voice prosthesis insertion.

The use of a tracheo-esophageal voice prosthesis is a well-established procedure to restore the voice in total laryngectomees. The insertion of the prosthesis is not a risk-free procedure, various complications having been reported especially in irradiated patients. Here described is a case of an esophageal rupture after secondary tracheo-esophageal puncture with mediastinal abscess in a patient previously treated with pharyngo-laryngectomy and subsequent radiotherapy for a left pyriform sinus carcinoma, which required immediate surgical drainage through a left cervical approach. Few weeks after surgical drainage an esophageal stricture at the site of the rupture developed, which was only temporarily resolved after the insertion of biodegradable esophageal stents, followed by re-stenosis once the reabsorption of the stent took place.

Primary orbital eosinophilic angiocentric fibrosis with intranasal extension.

BACKGROUND: Eosinophilic angiocentric fibrosis is a chronic, idiopathic disorder that usually involves the upper respiratory tract and features progressive submucosal perivascular fibrosis of unknown etiology. To our knowledge, only 5 cases of eosinophilic angiocentric fibrosis with primary orbital involvement have been reported. METHODS AND RESULTS: We report the case of a 46-year-old man with right proptosis and lateral globe displacement caused by a primary eosinophilic angiocentric fibrosis extending from the orbit into the anterior ethmoid. The nasal extension of the lesion helped in establishing the correct diagnosis. CONCLUSION: Physicians involved in the treatment of orbital pathologies should be familiar with this entity, because it may manifest as an intraorbital mass growing primarily or secondly into the orbit. The clinical manifestations of eosinophilic angiocentric fibrosis with orbital involvement often mimic other more common ophthalmological diseases. Biopsies are necessary for diagnosis and treatment planning, although cures are usually of palliative effect.

Pediatric follicular dendritic cell sarcoma of the head and neck: a case report and review of the literature.

OBJECTIVE: Follicular dendritic cell sarcoma is a rare disease with a non-specific and insidious presentation that is further complicated by difficult diagnostic and therapeutic assessment. METHODS: The database PubMed was searched for reports of follicular dendritic cell sarcoma between 1986 (first case published) and 2012. All of the articles presenting informations regarding one or more cases of follicular dendritic cell sarcoma of the head and neck region, in patients less than 18 years of age, were included. The reference lists for pertinent reports were also scanned to ensure that all relevant literature was included. RESULTS: We present a case of a 14 year-old girl, with a 2-month history of a right-sided level II neck mass. After a carefull radiologic evaluation the mass was resected combined with a right selective neck dissection. Histology with immunohistochemical staining was positive for follicular dendritic cell sarcoma. No recurrence was seen after 31 months follow-up. The literature search identified six more cases of pediatric follicular dendritic cell sarcoma of the head and neck. This is the first female patient with follicular dendritic cell sarcoma in the pediatric population. CONCLUSIONS: Current treatment of head and neck follicular dendritic cell sarcoma consists of wide radical resection, with associated radiotherapy or chemotherapy only for cases with aggressive disease such as extracapsular invasion, tumor size ≥6 cm or after failure of the first-line surgical treatment.

A rare localization of actinomycosis mimicking ulcerative malignancy.

Actinomycosis is a chronic, suppurative, and granulomatous process caused by Actinomycetes, saprophytic bacteria normally residing in the oral cavity. It can involve any organ, but the cervicofacial disease is the most frequent. Pharyngolayngeal involvement is rare and usually occurs secondary to the oral or cervical disease. There are few cases of primary pharyngolaringeal actinomycosis described in the literature. A rare case of pharyngeal actinomycosis mimicking an ulcerative malignancy in a 63-year-old man is reported. The patient was treated successfully with long-term antibiotic therapy. The clinical and pathological features and the aspects of diagnosis and treatment of cervicofacial actinomycosis are discussed.

A novel technique for tailoring frontal osteoplastic flaps using the ENT magnetic navigation system.

CONCLUSION: The ENT magnetic navigation system is potentially useful and offers the most accurate technique for harvesting frontal osteoplastic flaps. It represents a valid tool in the wide range of instruments available to rhinologists. OBJECTIVE: Precise delineation of the boundaries of the frontal sinus is a crucial step when harvesting a frontal osteoplastic flap. We present a novel technique using the ENT magnetic navigation system. METHODS: Nineteen patients affected by different pathologies involving the frontal sinus underwent an osteoplastic flap procedure using the ENT magnetic navigation system between January 2009 and April 2011. RESULTS: The ENT magnetic navigation system was found to be a safe and accurate tool for delineating the frontal sinus boundaries. No intraoperative complications occurred during the osteoplastic procedures.

Cardiocutaneous fistula in a delayed iathrogenic ventricular perforation of the heart: computed tomographic and magnetic resonance imaging findings.

Cardiac iathrogenic lesions can occur during diagnostic or therapeutic procedures. Resistance of the heart to an injury may cause a delay from the traumatic event to onset of the symptomatology or to heart rupture. We describe a rare case cardiac perforation with delayed rupture of the heart in a patient previously submitted to radiation therapy for breast cancer. Cardiocutaneous fistula at the cross-sectional computed tomographic and magnetic resonance imaging findings has not been previously reported, to our knowledge.

Laryngeal true malignant mixed tumor.

BACKGROUND: True malignant mixed tumor, also known as carcinosarcoma, is a salivary gland type malignant neoplasm, which is extremely rare, and only a few cases arising in the larynx have been previously reported. METHODS AND RESULTS: We report a case of true malignant mixed tumor arising in the larynx of a 65-year-old woman successfully treated with surgery. Histologically, the neoplasm was composed of variably mixed, neoplastic glandular, spindle, and chondroid tissues. Immunohistochemical analyses showed a peculiar expression of myoepithelial markers such as p63 and calponin in the glandular epithelial component, whereas malignant spindle cell proliferation was immunoreactive for calponin and actin. CONCLUSION: These results strengthen the hypothesis that these neoplasms may develop from a divergent differentiation of a totipotent, myoepithelial precursor cell. Despite the unfavorable prognosis that has always been described for these neoplasms, the patient is alive with no evidence of recurrences 5 years after surgery.

Omental Well-Differentiated Liposarcoma: US, CT and MR Findings.

Liposarcomas are the most common of sarcoma tumours, they are usually located in the lower limbs, retroperitoneum, or abdominal cavity; up to date, only a few cases of omental liposarcoma with different histotype have been described. We present a case of omental well-differentiated liposarcoma and discuss imaging findings on ultrasound, computed tomography, and magnetic resonance to differentiate omental liposarcomas from other abdominal tumour entities.

Effective management of intrathoracic anastomotic leak with covered self-expandable metal stents. Report on three cases.

Intrathoracic anastomotic leakage is one of the major complications of esophageal surgery that can lead to high mortality rate. Depending on the clinical presentation, therapeutic options include surgical reintervention and conservative management with or without external drainage or stenting. In this paper, we report a series of three patients, two men and one woman, mean age of 55.6 years (range 34-68 years), having intrathoracic anastomotic leak after esophagogastrectomy treated by insertion of four covered self-expandable metal stents performed exclusively under fluoroscopic view. Complete resolution of the leakage was obtained in all patients. Despite the limited number of patients, conservative management of intrathoracic anastomotic leaks with covered self-expandable metal stents performed under fluoroscopic guidance has proved to be rapid, safe, and effective in all cases of this series.

Distortion-product otoacoustic emission: early detection in deferoxamine induced ototoxicity.

OBJECTIVE: Deferoxamine therapy in lifelong transfusion-dependent anaemias, as beta-thalassemia major, is associated with an increased risk of ototoxic changes. With increasing survival rates, prevention and/or early detection of ototoxicity are important for providing management options. The predictive value of pure-tone audiometry in early detection of ototoxicity has been questioned, particularly in the higher frequencies. Otoacoustic emissions appear to be more sensitive to cochlear insult than the conventional pure-tone audiometry. The aim of our study was to compare the efficacy of otoacoustic emissions (distortion-product otoacoustic emissions) with that of pure-tone audiometry as method of audiological monitoring. METHODS: Baseline audiometric (0.25-8kHz) and otoacoustic emission testing (distortion-product otoacoustic emissions) was conducted in a group of patients with beta-thalassemia major, 60 of whom met the criteria for inclusion in the study. Comparisons were performed between baseline measurements and those recorded after 20 months. Distortion-product otoacoustic emissions were obtained as DP-grams. The DP-gram amplitude was determined for each child. RESULTS: Threshold changes from baseline were found to be statistically significant from 4 to 8kHz in 68.4% of the subjects (P<0.01). Distortion-product otoacoustic emissions demonstrated a significant threshold shift and a decreased amplitude in the frequencies >3kHz (P<0.05). Furthermore, DP-gram amplitude also reduced significantly at 3kHz (P<0.05) without any similar change in pure-tone audiometry. CONCLUSIONS: As ototoxicity screening tool DP-gram was extremely sensitive and superior to pure-tone audiometry. Their use is recommended for regular monitoring of cochlear function, aiming in prevention of permanent damage.