Salvage surgery of vestibular schwannoma after failed radiotherapy: the Gruppo Otologico experience and review of the literature.

OBJECTIVES: The use of radiation therapy has largely widespread and becomes in many centers the preference modality of treatment for symptomatic patients who are old, medically unfit for surgical therapy, those who refuse surgery and in some recurrent or residual growing tumors. The risk of radiotherapy failure in the treatment of vestibular schwannoma might be underestimated in the literature. The purpose of this study is to show the Gruppo Otologico experience with salvage surgery to better understand the surgical outcomes and difficulties in treating vestibular schwannoma after failed radiotherapy. STUDY DESIGN: Retrospective chart review of patients who required salvage surgery of vestibular schwannoma after failed radiotherapy. SETTINGS: Quaternary referral otology and skull base center. RESULTS: Between 1987 and 2010, 2500 cases of VS underwent surgical treatment at the Gruppo Otologico. Nineteen patients had received stereotactic radiation therapy before the surgical treatment. The interval time between radiotherapy and surgical salvage ranged from 1 to 10 years. In all the cases decision of surgery was taken following an increase in tumor size with or without new onset of symptoms. Complete tumor removal was achieved in 86.6% of the cases through a transotic, transcochlear or enlarged translabyrinthine approach with trans-apical extension. Difficult dissection of the tumor was encountered in 93.3% the cases. The facial nerve was anatomically preserved in 93.3% but its function was worsened in 73.3% of patients after at least 6 months of follow up. Malignant transformation of the vestibular schwannoma was encountered in one patient. CONCLUSION: Complete surgical resection of VS is more difficult after radiotherapy with relatively poor facial nerve outcomes and nearly impossible hearing preservation. Patients who receive radiation therapy for the treatment of vestibular schwannoma should be made aware of its potential complications and risk of failure, especially in young patients and NF2 cases.

Deep Neck Infections: Decisional Algorithm for Patients with Multiple Spaces Involvement.

BACKGROUND: Deep Neck Infections (DNIs) spread along fascial planes and involve neck spaces. Recently, their incidence has decreased due to the introduction of antibiotics; nevertheless, complications related to DNIs are often life-threatening. OBJECTIVE: The purpose of this article is focused on the identification of predisposing factors of these complications, as well as on the development of a reliable therapeutic algorithm. METHODS: Sixty patients with DNIs were enrolled from 2006 to 2019 for a retrospective study. The exclusion criteria for the present study were cellulitis, small abscesses responding to empiric or specific antibiotic therapy, or involvement of only one deep neck space. During the analysis, the following parameters of interest have been evaluated: gender, age, site of origin, pathways of spread, comorbidities, clinical features, bacteriology data, type of surgical approach required, complications, duration of hospitalization and mortality rate. On admission, microbial swab analysis was performed. RESULTS: Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), iron deficiency anemia and the involvement of multiple spaces have been associated with a significantly higher risk of developing complications. Most of our patients had polymicrobial infections. All patients underwent surgical drainage. The complication rate had occurred in 56.6% of patients, while death in 18.3%. CONCLUSION: DNIs represent a medical and surgical emergency with potentially serious complications; thus, avoidance of diagnostic delay is mandatory. Our preliminary data suggest the importance of evaluating the extent of infections because the involvement of multiple spaces requires timely surgery due to the higher risk of complications and mortality.

Comparison between overlay and underlay primary myringoplasty: retrospective analysis on anatomical and functional results in 497 adult patients

PURPOSE: Retro-auricular approach using an autologous graft is the main surgical method for myringoplasty (MPL). Endaural and transcanal or endoscopic approaches are also used. There is no definitive consensus on the best MPL surgical technique. The aim of this study is to compare the two most used technique, over and underlay MPL, to evaluate the difference in anatomical and functional outcomes. MATERIALS AND METHODS: We made a retrospective analysis of 497 adult patients who underwent underlay or overlay primary MPL, between 2010 and 2018, and evaluated the difference in anatomical and functional outcomes. RESULTS: Successful functional results, evaluated 18 months after surgery, were obtained in 380 patients (76,4%); the underlay MPL obtained a successful result in 85% of patients, while the overlay technique in the 68%. We observed anatomical failure in 13.4% patients, in detail 9,8% of underlay MPL and 17,2% of overlay MPL had an anatomical failure. CONCLUSION: Our results show less complications related to the underlay technique. We believe that this remains the technique to prefer, except in subtotal or wide anterior perforations that could be better managed using the overlay technique.

Anomaly of digastric muscle: an alarm bell for head and neck surgeon.

Objectives: Here follows the discussion of a case of hypoplasia of both bellies of digastric muscle and the difficult during neck dissection, because of his surgical importance like a pivotal landmark. METHODS: We reported a case report concerning digastric muscle abnormalities, accidentally discovered during neck dissection due to surgical excision of a glottic squamous cell carcinoma staged as cT3N0. A brief literature review was done to compare and research similar cases. RESULTS: Literature counts several reports of digastric muscle abnormalities, namely involving the anterior belly. Little has been written about hypoplasia of digastric muscle. CONCLUSION: Digastric muscle abnormalities are rare, which can be absent or, more frequently, duplicated. Albeit its anomalies are anecdotal, it is advisable to give due consideration to the hypoplasia of both bellies of the digastric muscle during the analysis of radiological imaging, in order to prevent the risk of operative complications. According to our knowledge, this is the first and singular case of digastric muscle's hypoplasia.

Aggressiveness pattern and second primary tumor risk associated with basaloid squamous cell carcinoma of the larynx.

Basaloid squamous cell carcinoma (BSCC) is a rare, aggressive and distinct variant of squamous cell carcinoma (SCC) of the upper respiratory and digestive tract. We have evaluated disease specific survival (DSS) and overall survival (OS) through Kaplan-Meier method and mortality risk through univariate statistical analysis of Cox in 42 cases of BSCC and other 42 of laryngeal SCC (LSCC) matched for both age and sex. We demonstrated that laryngeal BSCC is a more aggressive tumor than LSCC as is associated to higher nodal recurrence of pathology (5 vs 2 patients, overall risk, OR 2.7), a reduced survival (median survival 34 vs 40 months, OR 3.2 for mortality); in addition, basaloid patients have a higher risk to be affected by second primary tumors (13 vs 3 patients, OR 5.8) and a higher probability to die for this second tumor (Hazard Risk, HR 4.4). The analysis of survival shows an increased mortality risk concurrent with the parameters assessed by univariate analyses that assume a predictive and statistical significance in second tumor and grading in basaloid LSSC.

Hyaluronan in the Treatment of Chronic Rhinosinusitis with Nasal Polyposis.

Chronic rhinosinusitis (CRS) is a common condition and affects the quality of life of approximately 16 % of adults in US and 10.9 % in Europe. Hyaluronan (HA) is a nonsulphate glycosaminoglycan found in the extracellular matrix of connective tissues, and plays an important role in the healing process and repair of mucosal surfaces. We aim to evaluate the effect of HA on nasal symptoms and endoscopic appearance in patients with CRS and nasal polyps (NP) who have not undergone sinus surgery. Eighty patients older than 18 years old were randomized to receive either open-label nebulized saline solution (NS) or intranasal corticosteroid spray (ICS) 200 µg bid or nebulized sodium hyaluronate (NHA, YABRO(®)) or both ICS and NHA. Results were collected at 1 month, 3 months and 3 months after treatment. Significant improvements in nasal symptoms scores, endoscopic appearance scores, radiologic scores, rhinomanometry and saccharine clearance test were observed in the NHA, ICS and ICS + NHA groups after 1 month and 3 months of treatment compared with baseline (all p ≤ 0.005). The use of oral steroids was significantly reduced after 3 months of therapy in the same groups versus baseline (all p < 0.05). The incidence of adverse events at 3 months was similar between the 4 groups (all p > 0.05). Throat irritation, nasal burning and drug-related epistaxis were not reported in the group NHA. HA, as a nebulized nasal douche preparation, improved nasal symptoms and endoscopic appearances in patients with CRS and NP who have not undergone sinus surgery.

Less than 1% cerebrospinal fluid leakage in 1,803 translabyrinthine vestibular schwannoma surgery cases.

OBJECTIVE: To determine the incidence rate of cerebrospinal fluid (CSF) leak after translabyrinthine vestibular schwannoma surgery since the alteration of the surgical procedure. To compare with previous series and other series in literature. STUDY DESIGN: Database analysis. SETTING: Tertiary referral neurotologic private practice. PATIENTS: A series of 1,803 patients who underwent translabyrinthine vestibular schwannoma surgery between 1993 and 2009. The result of this group was compared with corresponding series. INTERVENTION: Translabyrinthine and extended translabyrinthine vestibular schwannoma surgery. Literature review and comparison. MAIN OUTCOME MEASURES: Rates of CSF leak in this series and historical perspective of the outcome. RESULTS: Fifteen patients (0.8%) of 1,803 cases had CSF leaks. The method used since 1993 has shown a significant improvement compared with major case series of the last 10 years. CONCLUSION: The methods used in translabyrinthine vestibular schwannoma surgery in our center can reduce CSF leakage to an absolute minimum. Compared with all large series, this could be a new era of translabyrinthine vestibular schwannoma surgery.