Intraoperative surgical navigation as a precision medicine tool in sinonasal and craniofacial oncologic surgery.

INTRODUCTION: Recent evidence supports the efficacy of surgical navigation (SN) in improving outcomes of sinonasal and craniofacial oncologic surgery. This study aims to demonstrate the utility of SN as a tool for integrating surgical, radiologic, and pathologic information. Additionally, a system for recording and mapping biopsy samples has been devised to facilitate sharing of spatial information. MATERIALS AND METHODS: SN was utilized for biopsy mapping in 10 sinonasal/craniofacial oncologic procedures. Twenty-five raters with experience in anterior skull base oncology were interviewed to identify 15 anatomical structures in preoperative imaging, relying on topographical descriptions and surgical video clips. The difference in the localization of anatomical structures by raters was analyzed, using the SN-mapped coordinates as a reference (this difference was defined as spatial error). RESULTS: The analysis revealed an average spatial error of 9.0 mm (95 % confidence interval: 8.3-9.6 mm), with significant differences between surgeons and radiation oncologists (7.9 mm vs 12.5 mm, respectively, p < 0.0001). The proposed model for transferring SN-mapped coordinates can serve as a tool for consultation in multidisciplinary discussions and radiotherapy planning. CONCLUSIONS: The current standard method to evaluate disease extension and margin status is associated with a spatial error approaching 1 cm, which could affect treatment precision and outcomes. The study emphasizes the potential of SN in increasing spatial precision and information sharing. Further research is needed to incorporate this method into a multidisciplinary workflow and measure its impact on outcomes.

Morbidity of multimodal treatments including endoscopic surgery for sinonasal malignancies: Results of an international collaborative study on 940 patients (MUSES).

INTRODUCTION: In the management of sinonasal malignancies treatment-induced morbidity and mortality is gaining relevance both for surgical approaches (endoscopic and open resection) and non-surgical therapies. The aim of this multicenter study is to assess complications associated with endoscopic surgery and non-surgical treatments (neoadjuvant and/or adjuvant) for malignant sinonasal tumors. METHODS: All patients with nasoethmoidal malignancies treated with curative intent with endoscopic or endoscopic-assisted surgery at three referral centers with uniform management policies were included. Neo- and/or adjuvant (chemo)radiotherapy was administered according to histology and pathological report. Demographics, treatment characteristics, and complications related both to the surgical and non-surgical approaches were retrieved. The data were analyzed with univariate and multivariate statistics to assess independent predictors of complications. RESULTS: Nine hundred and forty patients were included, 643 males (68%) and 297 females (32%). A total of 225 complications were identified in 187 patients (19.9%): cerebrospinal fluid (CSF) leak (3.5%), mucocele (2.3%), surgical site bleeding (2.0%), epiphora (2.0%), and radionecrosis (2.0%) were the most common. Treatment-related mortality was 0.4%. Variables independently associated with complications at multivariate analysis were principally dural resection (OR 1.92), cranioendoscopic or multiportal resection (OR 2.93), dural repair with multilayer technique with less than three layers (OR 2.17), and graft different from iliotibial tract (OR 3.29). CONCLUSION: Our study shows that modern endoscopic treatments and radiotherapy for sinonasal malignancies are associated with limited morbidity and treatment-related mortality. CSF leak and radionecrosis, although rare, remain the most frequent complications and should be further addressed by future research efforts.

Artificial intelligence for automatic detection and segmentation of nasal polyposis: a pilot study.

PURPOSE: Accurate diagnosis and quantification of polyps and symptoms are pivotal for planning the therapeutic strategy of Chronic rhinosinusitis with nasal polyposis (CRSwNP). This pilot study aimed to develop an artificial intelligence (AI)-based image analysis system capable of segmenting nasal polyps from nasal endoscopy videos. METHODS: Recorded nasal videoendoscopies from 52 patients diagnosed with CRSwNP between 2019 and 2022 were retrospectively analyzed. Images extracted were manually segmented on the web application Roboflow. A dataset of 342 images was generated and divided into training (80%), validation (10%), and testing (10%) sets. The Ultralytics YOLOv8.0.28 model was employed for automated segmentation. RESULTS: The YOLOv8s-seg model consisted of 195 layers and required 42.4 GFLOPs for operation. When tested against the validation set, the algorithm achieved a precision of 0.91, recall of 0.839, and mean average precision at 50% IoU (mAP50) of 0.949. For the segmentation task, similar metrics were observed, including a mAP ranging from 0.675 to 0.679 for IoUs between 50% and 95%. CONCLUSIONS: The study shows that a carefully trained AI algorithm can effectively identify and delineate nasal polyps in patients with CRSwNP. Despite certain limitations like the focus on CRSwNP-specific samples, the algorithm presents a promising complementary tool to existing diagnostic methods.

Endoscopic-assisted transorbital extended orbital exenteration: A multi-institutional preclinical study.

BACKGROUND: Sinonasal malignancies with orbital invasion have dismal prognosis even when treated with orbital exenteration (OE). Sugawara et al. developed a surgical strategy called "extended-OE (EOE)," showing encouraging outcomes. We hypothesized that a similar resection is achievable under endoscopic guidance through the exenterated orbit (endoscopic-EOE). METHODS: The study was conducted in three institutions: University of Vienna; Mayo Clinic; University of Insubria; 48 orbital dissections were performed. A questionnaire was developed to evaluate feasibility and safety of each step, scoring from 1 to 10, ("impossible" to "easy," and "high risk" to "low risk," respectively), most likely complication(s) were hypothesized. RESULTS: The step-by-step technique is thoroughly described. The questionnaire was answered by 25 anterior skull base surgeons from six countries. Mean, median, range, and interquartile range of both feasibility and safety scores are reported. CONCLUSIONS: Endoscopic-EOE is a challenging but feasible procedure. Clinical validation is required to assess real-life outcomes.

Intralesional cidofovir injections for the treatment of multifocal exophytic sinonasal papilloma.

KEY POINTS: Intralesional cidofovir injections in combination with surgery is an effective treatment for recurrent multifocal sinonasal exophytic papilloma. No malignant transformation has been observed in our experience. Anosmia is a potential side effect that patients should be aware of.

Dupilumab: a delayed response in asthmatic and atopic patients treated for chronic rhinosinusitis with nasal polyps.

PURPOSE: Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) is a common disease, which was previously approached with sinus surgery or systemic corticosteroids. The advent of biological therapies radically changed the approach to this disease. On the other hand, there is scarce scientific evidence of how specific subsets of patients respond to this treatment. METHODS: this is a monocentric, prospective study investigating the long-term efficacy on biweekly 300 mg dupilumab therapy in CRSwNP, prescribed to 61 patients. Patients were evaluated at baseline and every 2 months for the first 6 months, then at 9, 12, 16, 20 and 24 months. RESULTS: dupilumab proved to be an effective treatment, neatly improving both subjective and objective measurements in CRSwNP. The main finding of the study is the difference between specific subgroups of patients: while the overall response is similar, patients with Th2 comorbidities such as asthma and atopy tend to reach a stable response later, with the improvement ongoing even after 6 months of therapy, while non-asthmatic, non-atopic patients attain an earlier stability in response. CONCLUSIONS: dupilumab provides an excellent long-term control of CRSwNP, but the response in asthmatic and atopic patients appears to be different and delayed when compared to non asthmatic and non atopic ones.

Endovascular coils extrusion after internal carotid artery occlusion: From management to follow-up.

KEY POINTS: ICA coil extrusion (ICA-CE) occurs most frequently in the nasopharyngeal/sinonasal site. Evaluating the ICA coils stability, through an angiography, is of primary importance. ICA-CE management needs to be decided based on the patient's symptoms and general status.

Iatrogenic Cerebrospinal Fluid Leak in Endoscopic Sinus Surgery: Topographical Map and Influence of Skull Base Asymmetry.

BACKGROUND: Iatrogenic cerebrospinal fluid leak (iCSF-L) is a major complication of endonasal surgeries whose occurrence is always a potential adverse event due to anatomical variation/asymmetry of the skull base (SB). The aim of this manuscript is to provide a topographical map of iCSF-L and to investigate the role of SB asymmetry in iCSF-L occurrence. METHODS: In this retrospective study, the location of iCSF-L dural defect was studied and compared to patients affected by spontaneous and post-traumatic CSF-L. Considering only iCSF-L, after having collected the SB asymmetry data, the Keros, Gera, distance of the anterior ethmoidal artery from the SB, frontal sinus pneumatization, and Thailand-Malaysia-Singapore score classifications were compared to a control group of patients. RESULTS: A total of 153 CSF-Ls (103 spontaneous, 37 iatrogenic, and 13 traumatic) were included. A significant association was noted (p < 0.001) between the nature of the CSF-L and the areas involved. Considering iCSF-Ls, only the Gera classification was significantly different (p < 0.05) and the most reliable in predicting the risk of dural transgression (AUC = 0.719). CONCLUSIONS: ICSF-Ls present peculiar regional SB involvement with the cribriform plate, with the ethmoidal roof being the most involved. After having assessed the asymmetry of the SB, the Gera classification was the most reliable one.

Nasoseptal flap with extended pedicle dissection based on the maxillary artery: Clinical series of 55 cases.

KEY POINTS: Nasoseptal flap with extended pedicle dissection is a low morbidity and high success rate flap. It is a flap that can be applied to reconstruct a wide range of ipsilateral skull base defects.

Septal Nasopharyngeal "Kite Flap" for Long-Term Patency of Petrous Apex Cholesterol Granuloma.

Medial petrous apex cholesterol granuloma is a benign lesion which treatment is generally based on a trans-nasal marsupialization. When the artificial ostium is created, it is usually kept open with local flaps, like the septal nasopharyngeal "kite flap", a reliable local vascularized flap. Laryngoscope, 134:2111-2114, 2024.

Extended sphenoidotomy combined with transpterygoid approach for sphenoidal sinus inverted papilloma.

PURPOSE: Inverted papilloma of the sphenoid sinus (IPSS) is a rare tumor with debated surgical management due to its proximity to vital structures. The aim of this manuscript is to highlight the role of a transpterygoid approach (TPA) and pedicle-orientated strategy in case of involvement of critical structures in IPSS and compare it with data from the literature. METHODS: Patients with primary IPSS between January 2000 and June 2021 were included. Pre-operative CT/MRI were analyzed to classify the pneumatization of the SS and predict the insertion point of the inverted papilloma. All patients were treated with a trans-sphenoidal approach which was combined with a TPA in case of lateral insertion point. A systematic search was also performed to summarize the available literature. RESULTS: Twenty-two patients were treated for IPSS. By CT, the SS was categorized with type III pneumatization in 72.8% of cases. Eleven patients (50%) were treated with a TPA with a statistical association with the insertion point on the SS lateral wall (p = 0.01), rather than a SS pneumatization (p = 0.63). The overall success was 95.5% after a mean follow-up of 35.9 months. For the literature, 26 publications were included on 97 patients and described a trans-sphenoidal approach with a success rate of 84.6% after a mean follow-up of 24.5 months. CONCLUSION: IPSS is generally treated with a sphenoidotomy approach, although in selected cases, a TPA should be preferred to expose the whole SS lateral wall though allowing a complete pedicled oriented resection of the tumor.

Early increase in eosinophil count may predict long-term hypereosinophilia during dupilumab treatment: a 2-year observational study.

KEY POINTS: In a limited subset of patients, dupilumab-induced hypereosinophilia is persistent. Two-month follow-up eosinophil count may predict long-lasting hypereosinophilia.

Use of a Fiberoptic-Laser Approach During Endoscopic Sinus Surgery: A Cadaver Feasibility Study.

Aims: The aim of the present study is to evaluate the clinical applicability of laser energy during an oro-nasal endoscopic approach (ONEA) in the management of the anterior maxillary sinus wall. Methods: An experiment on three adult human cadavers was performed to study the nasal cavities with angled rigid scopes and using the ONEA technique. In order to evaluate the effectiveness of laser energy on the bone, the drilling effect was compared to laser energy (1470 nm diode laser, continuous wave, power 8, 9 and 10 W). Results: Compared to a rigid angled scope, the ONEA technique allowed complete visualization of the anterior wall of the maxillary sinus. Microscopic analysis of frontal bone revealed similar bone Exeresis with high-speed drilling (270.28 µm) and laser approaches (285.73-456.6 µm). Conclusions: The laser ONEA technique is an innovative, mini-invasive, and safe approach to the anterior wall of the maxillary sinus. Additional study is warranted to further develop this technique.

Expression, Prognostic Value and Correlation with HPV Status of Hypoxia-Induced Markers in Sinonasal Squamous Cell Carcinoma.

(1) Background: In head and neck squamous cell carcinoma, tumor hypoxia has been associated with radio/chemoresistance and poor prognosis, whereas human papillomavirus (HPV)-positive status has a positive impact on treatment response and survival outcomes. The aim of this study was to evaluate the expression and the potential prognostic value of hypoxia-induced endogenous markers in patients treated for squamous cell carcinoma of the nasal cavity and paranasal sinuses (SNSCC), and their correlation with HPV status. (2) Methods: In this monocentric study, patients treated in a curative intent for a SNSCC were screened retrospectively. Protein expression of CA-IX, GLUT-1, VEGF, VEGF-R1, and HIF-1α was determined by immunohistochemical staining, scored, and then correlated with overall survival (OS) and locoregional recurrence free survival (LRRFS). HPV status was assessed and correlated with hypoxic markers. (3) Results: 40 patients were included. A strong expression of CA-IX, GLUT-1, VEGF, and VEGF-R1 was detected in 30%, 32.5%, 50%, and 37.5% of cases, respectively. HIF-1α was detected in 27.5% of cases. High CA-IX expression was associated in univariate analysis with poor OS (p = 0.035), but there was no significant association between GLUT-1, VEGF, VEGF-R1, and HIF-1α expression, and OS/LRRFS. There was no correlation found between HPV status and hypoxia-induced endogenous markers (all p > 0.05). (4) Conclusions: This study provides data on the expression of hypoxia-induced endogenous markers in patients treated for SNSCC and underlines the potential role of CA-IX as a prognostic biomarker for SNSCC.

Extended Endoscopic Pre-Lacrimal Medial Maxillectomy To the Anterior Maxillary Sinus Wall.

Endoscopic pre-lacrimal medial maxillectomy involving the resection of the antero-medial maxillary sinus wall is a novel expanded procedure that allows the management of far lateral or antero-medial benign pathologies of the maxillary sinus, without increasing peri-operative morbidity. Laryngoscope, 133:2874-2877, 2023.

Endonasal Lacrimal Transposition to Expand Pre-Lacrimal Medial Maxillectomy Approach.

EPLA lacrimal transposition facilitates management of maxillary sinus/pterygopalatine fossa lesions and overcomes limitations such as the Simmen type I recess or IPMS pedicled on the medial wall, without increasing peri-operative morbidity. Laryngoscope, 133:2090-2094, 2023.

The use of near-infrared autofluorescence during total laryngectomy with hemi- or total thyroidectomy.

PURPOSE: The aim of this study is to describe the use of near-infrared autofluorescence (NIR-AF) to identify and preserve parathyroid glands (PGs) in a group of patients with advanced hypopharyngeal/laryngeal cancer undergone total (pharyngo)laryngectomy with hemi- or total thyroidectomy. METHODS: At San Raffaele Hospital, Milan (Italy), from January 2021 to May 2021, 7 patients affected by cT4a laryngeal squamous cell carcinoma (SCC) underwent surgery using an autofluorescence detection system (Fluobeam-Fluoptics®). For proper surgical planning, the demolition phase envisaged extension of the intervention to 4 hemithyroidectomies and 3 total thyroidectomies associated, respectively, with homolateral or bilateral CCND. Serum calcium, ionized calcium, and parathyroid hormone (PTH) levels at post-operative day (POD) 1 and 2 and at 2 weeks after surgery were monitored. Finally, we compared the data obtained with a cohort of patients who underwent surgery without the adoption of NIR-AF. RESULTS: With the use of NIR-AF, 18/20 PGs were identified, of which 7/18 were preserved exclusively thanks to the use of autoflorescence. The technique also made it possible to identify and isolate three PGs from the surgical specimen, which were subsequently transplanted only after intraoperative histological confirmation. On POD-1, 3/7 patients (42.8%) were hypocalcemic; on POD-2 and after 2 weeks only 1/7 patient (14.2%) was hypocalcemic. Comparing the two groups, we highlighted that the utilization of NIR-AF was related to a significant decrease of median serum (p = 0.026) and ionized calcium levels (p = 0.017) 2 weeks after surgery. Using this new technology, in no case did definitive histological examination reveal the presence of PGs in the surgical specimen, reaching an accuracy of 100%. CONCLUSIONS: In our cohort of patients who underwent total (pharyngo)laryngectomy with hemi- or total thyroidectomy, the use of near-infrared autofluorescence improved medium term postoperative hypocalcemia rates. This new technology helps to achieve a better calcemic outcome compared to the standard naked eye approach, since it helps the surgeon to identify and preserve parathyroid glandular tissue with a lower incidence of post-operative hypocalcemia.

The impact of near-infrared autofluorescence on postoperative hypoparathyroidism during total thyroidectomy: a case-control study.

PURPOSE: Near-infrared autofluorescence is a new technology in thyroid surgery to better localize and preserve parathyroid glands. The purpose of this study is to assess if the adoption of NIR-AF can improve in short-, medium-, and long-term post-operative calcium and PTH levels compared to conventional "naked eye" surgery in patients undergoing TT for benign or malignant conditions. METHODS: 134 patients undergone total thyroidectomy between January 2020 and June 2022; 67 were treated with conventional thyroidectomy, the other 67 underwent surgery adopting an autofluorescence detecting device. RESULTS: Significant differences were found between the two groups in percentage of patients with short-term hypocalcemia (p = 0.04) and short-term hypoparathyroidism (p = 0.011). Median short-term (p = 0.01) and medium-term (p = 0.03) PTH levels were significantly higher in autofluorescence group, while, short- (p = 0.001), medium- (p < 0.001) and long-term (p = 0.019) percentage variation of PTH levels from baseline were significantly higher in the standard-care group. Finally, the prescription of oral calcium (p < 0.01) after surgery were significantly lower in the autofluorescence group. CONCLUSION: The adoption of near-infrared autofluorescence during total thyroidectomy is related to lower short-term hypocalcemia and hypoparathyroidism rates, decreased variation of post-operative PTH levels in short- and medium- and long-term, reducing the necessity of supplementation therapy with oral calcium compared to conventional surgery.