Paediatric endoscopic endonasal middle skull base reconstruction: retrospective analysis of 78 patients treated in a single tertiary care paediatric center.

INTRODUCTION: Skull base pathologies in the paediatric population are rare and require treatment by multiple qualified specialists. The endoscopic endonasal approach has revolutionized surgical treatment because it is less invasive than existing treatments.The goal of this study was to retrospectively review our experience with the reconstruction of paediatric skull middle base defects and associated complications. MATERIALS AND METHODS: We analysed medical records from patients aged ≤ 18 years who were treated at our centre between 2013 and 2021. Patients treated with an endoscopic skull base approach and reconstruction, and who had complete clinical and radiological documentation and a minimum follow-up of 12 months, were included in the analysis. Personal data, reconstructive techniques, and complications were analysed. RESULTS: A total of 78 patients met the inclusion criteria and were enrolled in the study. Of these patients, 32 were male and 46 were female, and the mean age was 11.5 years. The main signs and symptoms were as follows: bitemporal hemianopsia in 53 cases, visual impairment in 23 cases, and headache in 30 cases. The most frequent aetiologies were craniopharyngioma (38 cases), pituitary adenoma (23 cases), and clivus chordoma (4 cases). All patients were treated via a pure endoscopic approach. For reconstruction, a multilayer technique was used in 18 cases, naso-septal flap in 43 cases, Gasket-Seal technique in 12 cases, and heterologous reconstruction in 5 cases. Only six patients presented a major complication: two had a postoperative cerebral spinal fluid leak, one developed a brain abscess, and three had diabetes insipidus.The mean follow-up period was 23.4 months.There were no statistically significant differences in postoperative CSF leak in relation to different reconstructive techniques. CONCLUSION: Endoscopic endonasal skull base surgery is a safe and effective treatment for paediatric middle skull base pathologies. Reconstruction techniques have a high success rate of 96.5-100%, and the rate of associated complications is < 3%.

Extranodal follicular dendritic cell sarcoma of the tonsil: An extremely rare clinical entity.

Follicular dentritic cell sarcomatous neoplasms originate from dendritic cells contained within the lymph nodes. In extranodal location, these neoplasms, are rare clinical entities, and even more so, their location in the head-neck region is extremely rare. Only 17 cases of primary dendritic cell sarcoma of the tonsil are reported in the literature at present. Being such a rare entity, histopathological diagnosis can be complex and requires great expertise and proper immunohistochemical analysis [1]. We present a case of a 48-year-old young man diagnosed with follicular dendritic cell sarcoma of the tonsil who underwent, probably for the first time in the literature, transoral robotic surgical resection.

Analysis of Surgical Complications in Mandibular Fractures in the Center of Italy: A Retrospective Study.

Mandibular fractures are the second most common maxillofacial fractures. The prevalent treatment for this kind of fractures is either a surgical procedure such as maxillomandibular fixation or open reduction and internal fixation or a combination of both. Sometimes the patients might develop locoregional postoperative complications. The most frequently reported complications are trigeminal V3 injury and surgical site infection. A 4-year retrospective study was performed at the Department of Oral and Maxillofacial Surgery, Policlinico Umberto I of Rome, Italy, and the postoperative complications after mandibular fracture surgical treatment were collected. The authors studied the characteristics of each complication and the correlation with the type of mandibular fracture and the surgical treatment chosen.

Long-Term Aesthetic Cicatrization Analysis of Lower Eyelid Incision for Orbital Floor Fracture Approach.

Orbital fractures are among the most frequent facial injuries. Of the 3 most widely described approaches in the literature, the lower eyelid approach is the authors' preference. This study retrospectively analyzed the patients treated at the Trauma Center of the Umberto I Hospital, Sapienza University of Rome from January 2010 to December 2020. Inclusion criteria were as follows: diagnosis of pure/impure orbital bone fracture, complete clinical and radiological documentation, and a minimum of 12 months follow-up. Sex, age, etiology, treatment, and associated complications were analyzed using IBM SPSS Statistics. Two internationally validated scales were used for the functional and esthetic long-term evaluation: the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver one. The scales were compiled by the patient himself and by 3 independent expert observers. Of the 543 patients who underwent surgery in the specified period, 208 fully met the inclusion criteria. One hundred forty-two (68.2%) were males and 66 (31.8%) were females, with a mean age of 40.68 years. The main cause was represented by assaults (33.1%). One hundred seventy-nine patients had a pure orbital fracture (83.8%) and 29 an impure one (16.2%). The most frequent symptoms at the time of diagnosis were diplopia (31.2%), followed by anesthesia of the second trigeminal branch (24.3%). Open reduction with internal fixation was the preferred treatment and proved to be effective in reducing the main signs and symptoms of the fracture in a statistically significant way ( P < 0.05). Long-term esthetic results of the lower eyelid, using the Vancouver and POSASs, were respectively as follows: Vancouver Scar Scale mean total score was 2.41 (range: 0-8), observer POSAS mean total score was 1.83 (range: 1.2-3.9), observer general opinion mean score was 1.66, patient POSAS mean total score was 2.23 (range: 1.33-3.7), and patient general opinion mean score was 2.87. The lower eyelid approach has proven to be reproducible, with a fast-learning curve and a low complication rate. The analysis conducted highlighted an excellent long-term esthetic-functional result. Further studies will be needed to statistically compare the results obtained with other orbital floor surgical approaches.

The 'Maxillary Pull-through' Technique: A Minimally Invasive Endoscopic-Assisted Approach to Nasal Septum Neoformations with Maxillary Bone Infiltration.

Study Design: Description and validation of a surgical technique. Objective: En-bloc maxillectomy with removal of the nasal septum is a rare procedure; preservation of the nasal bones and integrity of the alveolar ridge is even rarer. These procedures traditionally required a combined transfacial-transoral approach based on lateral rhinotomy. We describe a combined endoscopic transnasal-transoral approach for treatment of nasal septal malignancies that involve the hard palate. Methods: Excision of malignant tumours arising from the nasal septum was achieved in 4 patients using a transnasal-transoral endoscopic approach. Using 4-mm optics angled at 0° and 30°, the septum was freed from the ethmoid and removed en-bloc with the hard palate, by pulling the septum down through the hard palate. Results: Of the 4 patients, 2 underwent complete removal of septal chondrosarcomas, one removal of a sinonasal undifferentiated carcinoma and one removal of a mucoepidermoid carcinoma. In two cases, the palatal mucosa was spared and repositioned to restore separation between the nose and oral cavity. The remaining two cases underwent complete resection of the hard palate; one palate was reconstructed using a pedicled temporalis muscle flap and the other by employing an obturator. No infection was encountered. Partial ethmoidectomy was performed in all four cases. The mean hospital stay was 5 days. All patients are free of disease after a mean follow-up of 4 years (range: 2-7 years). Conclusions: Our new approach allows for minimally invasive resection of nasal septal malignancies that extend to the palate. Our maxillary pull-through technique is a valuable new surgical procedure for malignant pathologies of the nasal septum; the only drawback is that endoscopic surgery has a steep learning curve.

Orbital bone fractures: 10 years' experience at the Rome trauma centre: retrospective analysis of 543 patients.

Orbital fractures are among the most frequent facial traumas. This study retrospectively analysed patients treated in Umberto I Hospital Trauma-Centre, Sapienza University of Rome from 1 January 2010 to 31 December 2020. The inclusion criteria were as follows: diagnosis of pure/impure orbital bone fracture, complete clinical and radiological records, and a minimum 12-month follow up. Gender, age, aetiology, fracture type, treatment, and associated complications were analysed using IBM SPSS Statistics, and p values of <0.05 were considered significant. In total, 1393 patients presented with orbital trauma, 543 of whom met the inclusion criteria and underwent surgery (394 males (72.6%) and 149 females (27.4%); mean (range) age 39.2 (7-90) years). Assault (n = 165, 30.4%) was the most common cause of trauma, followed by road traffic accidents and sports-related incidents. Diplopia was the major symptom at diagnosis (n = 183, 33.6%). Open reduction and internal fixation via a sub-eyelid approach was the preferred treatment, achieving a significant reduction in the functional changes induced by fracture (p < 0.05). Our data will aid future studies of maxillofacial traumatology and suggest that education and prevention measures could reduce the incidence of this type of trauma.

Three-Dimensional Comparison of the Maxillary Surfaces through ICP-Type Algorithm: Accuracy Evaluation of CAD/CAM Technologies in Orthognathic Surgery.

PURPOSE: This retrospective study aims to compare the accuracy of two different CAD/CAM systems in orthognathic surgery. The novelty of this work lies in the method of evaluating the accuracy, i.e., using an Iterative Closest Point (ICP) algorithm, which matches a pair of 2D or 3D point clouds with unknown dependencies of the transition from scan s(k) to scan s(k+1). METHODS: The study population was composed of ten patients who presented to the Maxillofacial Surgery Department of the University "Sapienza" of Rome for the evaluation and management of skeletal malocclusions. The patients were divided into two groups, depending on the technique used: group 1: splintless group (custom-made cutting guide and plates); group 2: splint group (using a 3D-printed splint). STL files were imported into Geomagic® Control X™ software, which allows for comparison and analysis using an ICP algorithm. The RMSE parameter (3D error) was used to calculate the accuracy. In addition, data were compared in two different patient subgroups. The first subgroup only underwent a monobloc Le Fort I osteotomy (p-value = 0.02), and the second subgroup underwent a Le Fort I osteotomy associated with a segmental osteotomy of the maxilla (p-value = 0.23). RESULTS: Group 1 showed a 3D error of 1.22 mm ± SD 0.456, while group 2 showed a 3D error of 1.63 mm ± SD 0.303. These results have allowed us to compare the accuracy of the two CAD/CAM systems (p-value = 0.09). CONCLUSIONS: The ICP algorithm provided a reproducible method of comparison. The splintless method would seem more accurate (p-value = 0.02) in transferring the surgical programming into the operating room when only a Le Fort I osteotomy is to be performed.

Endoscopic Endonasal Treatment of Intra-Axial Ventral Brainstem Cavernomas: Case Experience and Literature Review.

INTRODUCTION: Cavernous malformations of the ventral brainstem are a challenging disease to treat. From an anatomical perspective, the best surgical options are endoscopic endonasal approaches. The first reports of their usage for this purpose date back to 2012. In this study, we gathered data on the subject, share our experience, and outline technical notes and tips for this surgery. CASE PRESENTATION: We report a 14-year-old female with a ventral pons cavernoma, treated using an endoscopic endonasal transclival approach and followed-up for 5.9 years. This is the longest reported follow-up for this condition to date. Written informed consent was obtained from the patient for publication of this case report and the accompanying images. DISCUSSION: An endoscopic endonasal transclival approach was used. The skull base was reconstructed using the multilayer grafting technique and a nasoseptal flap. There was no postoperative cerebrospinal fluid leakage. In a literature review, we identified 8 patients who were treated endoscopically: 1 transplanum-transtuberculum, 1 transtuberculum-transclival, and 6 transclival approaches were employed. Skull base closure was achieved using multilayer grafting and a nasoseptal flap in 4 cases, a gasket seal technique combined with nasoseptal flap in 3 cases and a periumbilical fat graft, fibrin sealant patch, and fibrin glue in 1 case. There were 2 cases of leakage, which resolved completely with revision surgery. CONCLUSION: Endoscopic surgery is a reliable alternative to traditional open surgery. It may be the preferred choice for intra-axial ventral brain cavernomas.

Management of benign parotid tumors. What can we learn from our experience?

AIM: Parotid gland is the most common location for salivary gland tumors, more commonly pleomorphic adenoma and Warthin's tumor. Types of parotid surgery include superficial parotidectomy (SP), partial superficial parotidectomy (PSP), total conservative parotidectomy (TCP), enucleation (E), extracapsular dissection (ECD), and are related to different incidence of complications. The choice depends on tumors localization, dimension and histology. The aim was to compare complications rate such as facial and great auricular nerve impairment and Frey syndrome according to type of surgery performed. MATERIALS AND METHODS: We retrospectively review the management of 116 benign tumors of the parotid gland treated between January 2004 and January 2020 at our Department. RESULTS: Most frequent complication observed was a GAN deficiency (22.41%), permanent in 13% of cases. Post-operative facial nerve impairment was observed in 19 patients (persistent only in 1 case). Only Frey syndrome (4,31% of cases) seemed to be related to type of surgery (p<0.05) resulting more frequent in the group of patients that underwent "classical" parotidectomy, while facial nerve impairment, even if more frequent in this cases, did not statistically correlated with operative technique (p=0.054). CONCLUSIONS: Once experience is gained, in order to reduce post-operative morbidity extracapsular dissection is a reliable technique in the management of these neoplasms, even if attention has to be paid particularly in the removal of superficial masses "emerging" from the parenchyma. PSP is an alternative to SP, while CTP has to be reserved to selected cases ot tumors arising in the deep lobe. KEY WORDS: Benign tumor, Extracapsular dissection, Enucleation, Facial nerve Parotid gland, Parotidectomy, Superficial parotidectomy.

The Use of Scapular Bone Flaps During Head-and-Neck Reconstruction: Functional, Orthopedic, and Quality of Life Analyses of Flap-Harvest-Related Deficits.

ABSTRACT: The authors sought correlations between harvesting of the scapular bone tip free flap used for head-and-neck reconstruction and any shoulder function deficit, particularly at the level of the rotator cuff. The flap permits reconstruction of large and diverse regions of the head and neck, but long-term harvest morbidity has not been investigated extensively. The authors analyzed the clinical records of all patients who underwent head-and-neck reconstructions using free scapular tip flaps in our department over the past 5 years. The inclusion criteria were complete clinical and radiological documentation and follow-up for at least 12 months. Two populations, a surgical and control population, were analyzed. All patients in both populations underwent the simple shoulder test, an internationally validated self-administered test that highlights functional shoulder deficits, and 3 additional tests at orthopedic visits: the external rotation test, Patte test, and external rotation lag sign test. A head-and-neck cancer-specific questionnaire (University of Washington Quality of Life, version 4) was completed by the surgical patients. All statistical analyses were performed using Software IBM SPSS Statistics (IBM Corp., Armonk, NY).A total of 19 patients met the inclusion criteria: 11 males (57.8%) and 8 females (42.2%) of mean age 60.9 years (range 23-75 years). In addition, 20 age-and sex-matched volunteers with no history of shoulder pathology were evaluated in terms of shoulder functionality. The average score on the simple shoulder test was 10.55 in the healthy population versus 8.31 in the study population ( P < 0.001); in particular, shoulder strength differed between the groups. Similarly, the orthopedic examinations revealed clinically significant differences between the controls and patients on the Patte test and external rotation lag sign test (both P < 0.001), but not the external rotation test ( P > 0.001). The mean University of Washington Quality of Life was 73.39; most patients reported good quality of life (52.6%), followed by very good (15.7%).The free scapular bone tip flap is valuable for reconstruction of head-and-neck defects; the long and reliable vascularpedicle allows rapid patient mobilization. Morbidity was confined to small reductions in shoulder strength and external rotation, which do not affect quality of life.

Reconstruction of the mandibular symphysis: pilot study compares three different flaps.

BACKGROUND: Restoration of mandibular continuity, functionality and attempting to return to the patient's premorbid state is the ultimate goal of reconstruction. Some studies compare different flaps, but the reconstructed portions vary and there is little consensus on the best option for a particular defect. METHODS: This pilot study compares three different reconstructive options with free flaps. We will analyze the accuracy of the reconstruction, the postoperative complications related to the reconstruction, the morbidity of the donor site. This pilot study compares three different reconstructive options with free flap in the reconstruction of the mandibular symphysis: iliac crest, scapula and fibula. RESULTS: In our sample the morbidity of the donor site was overlapping, as for all three choices free from complications. In post resection edentulous patients, the fibula seems to guarantee better positioning, while in patients with residual occlusion the iliac crest seems to allow a more congruous repositioning. The fibula seems to have a superiority over the other flaps in terms of accuracy in all types of patients. CONCLUSIONS: Contrary to the most recent work on the accuracy of CAD/CAM, we have analyzed the error in the reconstruction of a specific segment and in the repositioning of the residual mandibular component without the use of guided computer programming.

Management of orbital and brain complications of sinusitis: A practical algorithm.

The aim of this work was to present a practical management algorithm for orbital and brain complications of sinusitis. According to the inclusion criteria, a sample of 68 patients was collected between 2008 and 2018 (39 males and 29 females). Among them, 44 were adults, with a mean age of 50.46 years, and 24 were pediatric patients, with a mean age of 10.33 years. Oral or intravenous antibiotic therapy was administered to all patients. Pharmacological resolution was observed in 14 cases. Early surgical treatment within 48 hours was necessary in 10 cases. Surgery consisted of abscess drainage, associated or not with functional endoscopic sinus surgery. Delayed surgery within 15-30 days was performed in 44 patients. The core procedure was functional endoscopic sinus surgery. Subsidiary procedures were abscess drainage, tooth extraction or cranial base repair. The combination of two or more of these procedures was case selected. Median follow-up was of 46.36 months. Sinusitis complications necessitate rapid diagnosis and prompt treatment. Antibiotic therapy alone is enough for mistreated rhinosinusitis with no anatomical predisposing factor. Surgery is mandatory for altered nasal and paranasal sinus anatomy or odontogenic infections.

Prediction of Recurrence by Machine Learning in Salivary Gland Cancer Patients After Adjuvant (Chemo)Radiotherapy.

BACKGROUND/AIM: To investigate survival outcomes and recurrence patterns using machine learning in patients with salivary gland malignant tumor (SGMT) undergoing adjuvant chemoradiotherapy (CRT). PATIENTS AND METHODS: Consecutive SGMT patients were identified, and a data set included nine predictor variables and a dependent variable [disease-free survival (DFS) event] was standardized. The open-source R software was used. Survival outcomes were estimated by the Kaplan-Meier method. The random forest approach was used to select the important explanatory variables. A classification tree that optimally partitioned SGMT patients with different DFS rates was built. RESULTS: In total, 54 SGMT patients were included in the final analysis. Five-year DFS was 62.1%. The top two important variables identified were pathologic node (pN) and pathologic tumor (pT). Based on these explanatory variables, patients were partitioned in three groups, including pN0, pT1-2 pN+ and pT3-4 pN+ with 26%, 38% and 75% probability of recurrence, respectively. Accordingly, 5-year DFS rates were 73.7%, 57.1% and 34.3%, respectively. CONCLUSION: The proposed decision tree algorithm is an appropriate tool to partition SGMT patients. It can guide decision-making and future research in the SGMT field.

Secondary Rhinoplasty in Binder Syndrome: Considerations and Management of Complex Problem With Heterologous Bone Graft.

ABSTRACT: Binder Syndrome occurs in less than 1 per 10,000 live births. Mean features of the syndrome include arhinoid face, abnormal position of the nasal bones, intermaxillary hypoplasia with associated malocclusion, reduced or absent anterior nasal spine, atrophy of the nasal mucosa and absence of the frontal sinus. Treatment of these facial deformities is obviously surgical. In the present work, the authors describe, step by step, their technique in secondary rhinoplasty in a 36-years-old patient affected by Binder Syndrome. In this case, the authors used autologous cartilage graft and heterologous bone graft.Satisfying results are achieved in 12 months of follow-up: graft resorption is acceptable, position of the graft is stable, the authors have no signs of infection and the patient is satisfied with the aesthetical and functional results. The authors believe that the first option, in complex nose's reconstruction, is the use of autologous grafts but, the use of cartilage heterologous bone graft should be taken in account, in the future, as a secondary option in Binder Syndrome and in malformed patients.

Mandibular Fractures Epidemiology and Treatment Plans in the Center of Italy: A Retrospective Study.

ABSTRACT: The epidemiology of maxillofacial fractures is variable in different geographic regions. Economic and social conditions, laws and types of behavior can be considered the most important factors influencing these differences.Mandibular fractures were first cited in 1650 BC in an Egyptian papyrus. Today, these fractures are one of the most prevalent facial skeletal injuries.A 4-year retrospective study was performed and the trauma - related data were collected from medical and radiological archives. The analysis comprised patients admitted for mandibular fracture at Sapienza University of Rome - Policlinico Umberto I between January 1, 2016 and December 31, 2019. The data include age, sex, etiology, anatomical sites of the fractures, eventual maxillofacial associated fractures and treatment.We collected 172 patients, 138 males (80.2%) and 34 females (19.8%) with 270 mandibular fractures. The average age was 35.4 years. The youngest and oldest patients were aged 6 and 90 years, respectively. The age group 20 to 29 years was the most represented with 52 patients (30.2% of the total sample). Assaults were the most common etiology (n = 53, 30.8%), followed by falls (n = 45, 26.2%). The condyle was the most involved region (n = 86, 32%), followed by parasymphysis region (n = 72, 26.6%) and angle (n = 62, 23%).154 patients (89.5%) reported only mandibular fractures. Eighteen patients (10.5%) had other associated maxillofacial fractures; the most frequently encountered maxillofacial fractures associated with mandibular fractures were the zygomatic complex fractures (n = 9, 5.2%). Open reduction and internal fixation was the most preferred surgical treatment (n = 115, 66.9%).This study showed that mandibular fractures predominate in 20 to 29 years group and in the male sex. Assaults are the most frequent cause. The prevalent fracturing site is condylar process. Orbital - maxillary - zygomatic complex fractures were the most common associated maxillofacial fractures and open reduction and internal fixation was the preferred surgical strategy.The results of this analysis agree to other studies and provide important clinical information that will help in study of these injuries.

Head and Neck Cancer Treatment during COVID-19 Pandemic: A Central Experience in Rome. Emergency Management, Infection Prevention and Control.

The COVID-19 pandemic has significantly affected the surgical units, especially those operating on the airways. This study evaluates the series of patients with tumors of the head and neck treated by our unit during Phase-1 of the pandemic and the efficacy of the preventive measures implemented for protecting both the patients and staff. A screening program was administered to all the patients who had to undergo surgery. None of the patients tested and operated during Phase 1, between 10 March and 18 May 2020, were positive for COVID-19. A significant portion of the patients was suffering from tumors in advanced stages (T3 and T4). Two patients developed respiratory symptoms during their stay at the unit, so they were put in precautionary isolation and tested, but resulted negative for COVID-19. All the surgical department staff followed the Italian Ministry of Health's prevention protocol and underwent serological testing. IgG and IgM were negative in everyone, thus confirming that nobody had been exposed to the virus. This study highlights the commitment to efficiently treating patients suffering from tumors of the head and neck region and confirms the effectiveness of the safety measures used to protect our patients and staff's health.