Management of parapharyngeal space tumors with transparotid-transcervical approach: analysis of prognostic factors related with disease-control and functional outcomes.

PURPOSE: Different therapeutic strategies have been developed to improve surgical and functional outcome of parapharyngeal space (PPS) neoplasms. The transparotid-transcervical approach (TTa) is a valid surgical option to manage most PPS tumors. Its short- and long-term disease control and cranial nerve (c.n.) function outcomes have not been discussed extensively. METHODS: All patients who underwent TTa over a 10-year period at a tertiary academic center were retrospectively reviewed. Data about preoperative imaging, clinical presentation, tumor's size, location and histology, and postoperative oncological and functional results were registered and analyzed. RESULTS: Sixty patients matched the inclusion criteria. Most of the lesions were benign (71.7%), involved the prestyloid PPS (63.3%) and measured more than 30 mm (75%). Fifty-two (86.7%) lesions were resected en-bloc. Clear margins were achieved in 91.7% of the cases, with positive margins solely associated with malignancy (p = 0.008). Post-operative c.n. function was satisfactory, with X c.n. function significantly associated with the retrostyloid location (p = .00) and neurogenic tumors (p = 0.02). Local disease-control was achieved in 96% of the cases after a median follow-up of 46 (± 19.7-82.0 IQR) months. CONCLUSIONS: The TTa was safe and effective, achieving a satisfactory local control rate. Nevertheless, malignancies maintain a higher rate of positive margin due to their infiltrative nature and the complex anatomy of the PPS. In such cases, multiportal approaches might be more effective. However, post-operative c.n. function remained satisfactory, irrespective of lesions' size and histopathologic behavior. A higher X c.n. deficit rate was observed in retrostyloid and neurogenic lesions.

Surgical management of benign cervical tracheoesophageal fistulas: A single-tertiary academic institution experience.

PURPOSE: Despite improvements of diagnosis and management, acquired benign tracheoesophageal fistulas (AB-TEFs) remain a challenging clinical problem and a life-threating condition. In the present study, we reviewed the early results and the long-term outcomes after surgical treatment of cervical AB-TEFs treated in our institution during the last 9 years. METHODS: This retrospective study included patients who underwent transcervical repair of benign cervical AB-TEFs. Patients were identified from a prospectively filled electronic database which included patients' demographics, medical history, disease presentation, prior treatments, operative report, morbidity and mortality, hospital stay, postoperative results and follow-up information. RESULTS: A total of 13 patients affected by cervical AB-TEF were treated. Most of the patients (91%) in our series were treated with a lateral cervicotomic approach with interposition of either sternocleidomastoid muscle flap (72.7%) or pectoralis major myocutaneous flap (9.1%) or infrahyoid muscle flap (9.1%). The univariate analysis of showed that the etiology and surgical technique were significantly associated with immediate postoperative outcome. Esophageal diversion was removed in all patients but 3 due to their neurological status, which was the only significant factor related to post-operative oral-intake (p =0.016). We experienced 2 (18.2%) failures of the reconstruction, which occurred in patients previously treated with chemoradiation for head and neck malignancies. None of the remaining patients (72.8%) relapsed after a long-term follow-up restoring a normal oral diet was restored. CONCLUSION: The lateral cervicotomic approach with sternocleidomastoid flap interposition showed its effectiveness and safety in the treatment of AB-TEFs in our single-institution experience.

Transcanal Endoscopic Management of Glomus Tympanicum: Multicentric Case Series.

OBJECTIVE: The aim of this study was to report a multicentric surgical experience in the exclusive endoscopic management of glomus tympanicum (GT). STUDY DESIGN: Retrospective case series review at two institutions. SETTING: Tertiary referral centers. PATIENTS: The study included 30 patients who underwent exclusive transcanal excision of GT between 2010 and 2017 at the two referral centers. INTERVENTIONS: Exclusive endoscopic transcanal excision of GT type A1, A2, and B1 (modified Fisch-Mattox classification). All surgical procedures were performed by two senior surgeons (L.P.; M.B.). MAIN OUTCOME MEASURES: For each procedure, intraoperative features of the disease, postoperative complications, and functional outcomes were evaluated. Recurrent or residual diseases were clinically and radiologically assessed during the follow-up period. RESULTS: None of the patients treated with transcanal endoscopic approach (TEA) experienced intraoperative complications, nor required conversion to microscopic approach. Gross total resection (GTR) was obtained in 90% of the cases, while a near total resection was advocated when the residual pathology had a close relationship with the internal carotid artery. Mean hospitalization time was 1.6 (±0.8 SD) days and no postoperative complications were reported. No recurrences were reported in the GTR group after a mean follow-up period of 38.1 (±28.7 SD) months. CONCLUSIONS: Middle ear paragangliomas with no mastoid involvement (Class A1, A2, and B1) can be safely managed by means of a transcanal endoscopic approach. Low rate of postoperative complications, short hospitalization, and high rate of gross total resection demonstrate that TEA is a safe and effective procedure.

Ex Vivo Porcine Larynx Model for Microlaryngoscopy Laryngeal Surgery: Proposal for a Structured Surgical Training.

PURPOSE: Microlaryngoscopy laryngeal surgery (MLS) is a highly specialized and delicate surgical procedure performed by a single operator. The aim of this study is to report the initial development of a validated and codified training program on ex vivo porcine larynx, allowing residents to obtain the basic skills of the MLS. METHODS: Two residents without previous MLS experience were tested with four different exercises on 10 larynxes, one side at a time. The time needed for each exercise was noted. A skilled surgeon performed the same procedure, and this was considered to be the gold standard. Videos of the training exercise were evaluated by the two expert surgeons in a random, blinded sequence, using a modified global rating scale (GRS) to evaluate specific surgical skills. RESULTS: The median execution times and GRS scores were calculated for both residents. Execution times and surgical skill scores were subsequently analyzed. For each exercise, a Spearman test between observations and time was performed to evaluate a significative increasing or decreasing trend in time execution. Execution times and surgical skills were also compared between the two subjects. Wilcoxon rank-sum test was used to evaluate any significant differences between them. A P value ≤0.05 was considered statistically significant. The results showed a significant improvement of the execution times for each resident (P value < 0.01). While the GRS scores for the exercises have remained between 3.0 and 5.0 from the first to the last procedure. CONCLUSION: MLS training on a porcine ex vivo model is useful, repeatable, and low cost. The work showed that, after only 10 training sessions, two residents without experience in MLS could quickly improve their execution times without statistically significant decrease of the visual analysis of surgical skills.

Management of Jugular Bulb Injuries during Endoscopic Ear Surgery: Our Experience.

Objectives The main objective of this article is to describe endoscopic management of intraoperative massive bleeding from jugular bulb injury during exclusively transcanal endoscopic procedures for middle ear pathologies. Design Case series with chart review. Setting Tertiary referral center. Participants We retrospectively reviewed two patients who experienced jugular bulb injury during endoscopic transcanal approach for glomus tympanicum and chronic otitis media. The surgical videos and charts were carefully investigated and analyzed. Main Outcome Measures Feasibility and suitability of exclusive endoscopic management of jugular bulb bleeding and description of surgical maneuvers that should be performed to obtain safe and effective hemostasis. Results In both patients, jugular bulb bleeding was progressively controlled by means of exclusive endoscopic approach with no need to convert to microscopic approach. None of the cases required a second surgeon helping in keeping the endoscope during hemostatic maneuvers. Both patients had a normal postoperative period with no recurrence of hemorrhage. Conclusions Endoscopic management of jugular bulb bleeding is feasible by using the technique described with reasonable efficacy and with no additional risk or morbidity to the procedure. Knowledge of anatomy and its variants, preoperative evaluation of imaging, and the ability of the surgeon to adapt the surgical technique to the specific case are recommended to prevent vascular complications during endoscopic ear surgery.

Endoscopic Transcanal Approach to Geniculate Ganglion Hemangioma and Simultaneous Facial Nerve Reinnervation: A Case Report.

Hemangioma of the facial nerve (FN) is a very rare benign tumor whose origin is the vascular plexi that surround the nerve. The transpetrous, retrosigmoid, and middle cranial fossa (MCF) routes are the traditional and most widely used approaches to reach these lateral skull base neoformations. However, this very complex region can be reached through an exclusive transcanal endoscopic procedure in selected cases. One of these was a 42-year-old patient who had been presenting a worsening left FN paralysis (grade VI according to the House-Brackmann scale at the time of visit) for 22 months without a history of trauma or infection. Radiological studies showed a lesion in the region of the geniculate ganglion. A suprageniculate endoscopic approach was performed to remove the lesion, with the sacrifice of the FN and a simultaneous hypoglossal-facial anastomosis. The aim of this minimally invasive surgery is the complete excision of the disease, maintaining the hearing function intact and restoration of facial function, whenever possible, avoiding more invasive approaches.

Central compartment revision surgery for persistent or recurrent thyroid carcinoma: analysis of survival and complication rate.

PURPOSE: Locoregional recurrence of thyroid carcinoma is relatively common and reported rate are between 5 and 20%. Cervical nodes are usually involved, especially at the central compartment. The management of recurrent thyroid carcinoma at central compartment still remains challenging because of higher incidence of complication rate. The aim of the study is to evaluate the survival and complications rate after revision surgery. METHODS: Retrospective cohort study on a group of patients that underwent revision surgery for persistent or recurrent thyroid carcinoma from January 1, 2003 to December 31, 2017. Survival outcomes were calculated using Kaplan-Meier method. Significant variables on univariate analysis were subjected to a Cox proportional hazards regression multivariate model. RESULTS: Fifty-two patients involved, 22 male (40%) and 30 female (60%). Mean age was 54 years old (range 24-85). Mean follow-up was 79 months, median follow-up was 85 months, with a range between 8 and 153 months. The 5-year overall survival was 90.8% while at 10 years it was 69.8%. The 5-year disease-specific survival was 93.5%, while at 10 years it dropped to 77.9%. The rate of recurrent laryngeal nerve paralysis and persistent hypocalcemia in our series were 1.3% and 5.9%, respectively. No evidence of thoracic duct, esophageal or laryngeal and tracheal injury was found in this case series. Regarding prognostic factors, univariate and multivariate analysis highlighted as statistically significant: the aggressive histological variants, the presence extranodal extension or soft-tissue metastasis. CONCLUSION: The surgical option remains the gold standard in locoregional recurrences of thyroid carcinoma and should be performed by experienced surgeons to reduce postoperative complications.