The transcervical-transparotid corridor for management of parapharyngeal space neoplasms: strengths and limits in a bi-institutional retrospective series.

BACKGROUND AND PURPOSE: Parapharyngeal space (PPS) neoplasms represent 1% of all head and neck tumors and are mostly benign. Surgery is the mainstay of treatment and the transcervical-transparotid (TC-TP) corridor still represents the workhorse for adequate PPS exposure. Our series investigates strengths and limits of this approach on a multi-institutional basis. METHODS: We reviewed consecutive patients submitted to PPS surgery via TC-TP route between 2010 and 2020. Hospital stay, early and long-term complications, and disease status were assessed. RESULTS: One hundred and twenty nine patients were enrolled. Most tumors were benign (79.8%) and involved the prestyloid space (83.7%); the median largest diameter was 4.0 cm. The TC-TP corridor was used in 70.5% of patients, while a pure TC route in about a quarter of cases. Early postoperative VII CN palsy was evident in 32.3% of patients, while X CN deficit in 9.4%. The long-term morbidity rate was 34.1%, with persistent CN impairment detectable in 26.4% of patients: carotid space location, lesion diameter and malignant histology were the main independent predictors of morbidity. A recurrence occurred in 12 patients (9.4%). CONCLUSIONS: The TC-TP corridor represents the benchmark for surgical management of most of PPS neoplasms, though substantial morbidity can still be expected.

SCIP flap in head and neck reconstruction after oncologic ablative surgery: a systematic review.

BACKGROUND: In the surgical treatment of head and neck locally advanced malignancies, microvascular free flaps represent the most valuable solution to reconstruct the tissue defect after resection of the primary neoplasm. In particular, microvascular free flaps allow to restore the functional and aesthetical features of the head and neck compartments. The superficial circumflex iliac perforator (SCIP) flap represents, as an evolution of the groin flap, a valid alternative to the radial fasciocutaneous free (RFFF) flap or the anterolateral thigh (ALT) flap. METHODS: This systematic review adhered to the recommendations of the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) 2009 guidelines. A computerized MEDLINE search was performed using the PubMed service of the U.S. National Library of Medicine ( www.pubmed.org ) and Scopus database ( www.scopus.com ). Two authors screened the articles, then selected and extracted data on malignancies characteristics, reconstructive techniques, outcomes, and complications. RESULTS: A total of 25 articles were selected and reviewed among the 39 identified through the search string. Six out of the selected 25 articles were case reports, while the remaining 19 articles were retrospective case series. The whole study population was represented by 174 oncologic patients undergoing ablation of a head and neck tumor and reconstruction with a SCIP flap. The site of reconstruction was the oral cavity in 125 (71.0%) patients, being the tongue the most common subsite in 73 (41.5%) patients, the pharynx in 10 (5.7%) cases, the larynx in 3 (1.7%) and head and neck skin in 36 (20.4%) patients. Only two cases of total flap loss were reported. Partial flap loss or shrinkage requiring minor surgical revisions was observed in 11 patients (6.32%). Primary closure of the donor site was achieved in the whole study population, according to the available data. CONCLUSIONS: In head and neck postoncological reconstruction, despite the caliber and the length of the pedicle, SCIP flap offers a pliable and thin skin paddle, allowing single-stage resurfacing, medium to large skin paddle, possibility of composite-fashion harvest and a well-concealed donor site.

Global frequency and distribution of head and neck sarcomas in adulthood: a systematic review.

PURPOSE: Head and neck sarcomas (HNS) constitute a rare and heterogeneous cancer entity. Management remains a challenge due their rarity and different biological behaviour among tens of subtypes. This systematic review aimed to describe HNS global frequency and distribution in adulthood. METHODS: A systematic review was performed using PICOTS search strategies for qualitative question and it was written in accordance with PRISMA 2020 Statement. 70,653 publications were identified, and 15 variables were evaluated for a total of 2428 patients. RESULTS: We identified 47 studies from 21 different countries from 5 different continents. Most of studies (83.3%) were performed in single institutions and America and Asia overruled for number of papers included (21 and 10, respectivelly). Osteosarcoma was more frequent, followed by chondrosarcoma, angiosarcoma and malignant fibrous histiocytoma. Early stage accounted for almost 80% of cases; advanced stage prevailed in developing countries. 1783 patients (90.1%) underwent surgery and 780 (39.4%) had adjuvant therapy. 50.8% of patients experienced tumour recurrence and the lowest mortality rate was reported in Europe (29.9%). CONCLUSIONS: HNS holds a relative poor prognosis possibly explained by the heterogeneity of the disease. Treatment of HNS has shown to be highly diverse among different countries, underlining the importance of uniformed treatment guidelines to achieve better patient management and to improve survival outcomes.

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.

Suprameatal-transzygomatic root endoscopic approach to the geniculate ganglion: an anatomical and radiological study.

PURPOSE: To describe the suprameatal-transzygomatic root endoscopic approach (STEA) to the geniculate ganglion (GG), the labyrinthine facial nerve (FN) and epitympanum. METHODS: The feasibility and limits of the STEA, maintaining the integrity of the ossicular chain, were analysed. Ten human cadaveric ears were dissected. Step-by-step description of the technique and relevant measurements were taken during the approach. The visualization and surgical working field on the anterior and posterior medial epitympanum, GG, greater superficial petrosal nerve, the labyrinthine FN and suprageniculate area were evaluated. The range of motion through the approach and the rate of the decompression of the GG and the labyrinthine portion of the FN were assessed as well. CT-scan measurements were compared with those obtained during the dissection. RESULTS: A complete exploration of the epitympanum was possible in every specimen. Decompression of the GG and first portion of the FN was achieved without any trauma to the ossicular chain in nine ears. The endoscope movements were mainly limited by the distance between bony buttress-short process of the incus-tegmen. The working space, during GG and labyrinthine FN decompression, was limited by the distance between malleus head-medial epitympanic wall and malleus head-GG. Radiologic measurements were consistent with those obtained during the dissections. CONCLUSION: The STEA is a promising minimally invasive approach for decompression of the GG and FN's labyrinthine portion. The applications of this corridor include the exploration and surgery of the medial epitympanum, preserving the ossicular chain.

Revision canal-wall down surgery: comparison of surgical outcomes with three different techniques.

OBJECTIVE: This study aimed to analyze the role of the endoscope in revision canal-wall down (CWD) tympanomastoid surgery and compare its use to the more traditional microscopic approach. Moreover, we aim to investigate functional outcomes of revision surgeries in a cohort of two tertiary reference centers. METHODS: A total of 103 patients undergoing revision surgery after previous CWD tympanomastoidectomy were included in the present study and divided in three groups according to the surgical technique used: endoscope exclusive (n = 22), combined (n = 35) and microscope exclusive (n = 46). Data regarding surgical indications, pre-operative clinical and audiological assessments, intraoperative findings and surgical considerations were extracted. During follow-up, data regarding anatomic and audiologic outcomes were collected and persistence or recurrence of the disease assessed. RESULTS: The most frequent sites of cholesteatoma recurrence or persistence was the anterior epitympanum. There was a statistically significant ABG improvement of - 6.02 dB HL (95% CI - 8.87 to - 3.16, p < 0.001) between pre-operative and postoperative ABG, without significant effect of surgical technique. During follow-up, no significant differences regarding disease or otorrhea control were observed. Duration of surgery and hospitalization was shorter in the endoscopic cohort without statistical significance. Intra- and postoperative complications were lower in the endoscopic group. CONCLUSION: Revision CWD surgery can take advantage of the endoscope as a minimally invasive exclusive or adjunct tool to traditional microscopic procedures. Outcome measures of endoscopic revision CWD surgery showed anatomic and functional results comparable to those of the microscopic group. The complication rate, the duration of surgery and hospitalization were favorable in the endoscopic group.

Disease-specific quality of life and psychological distress after endoscopic tympanoplasty.

PURPOSE: To assess the postoperative quality of life (QoL) of patients operated on for chronic otitis media (COM) and cholesteatoma by endoscopic approach, with respect to disease-specific complaints and psychological distress, using two validated questionnaires: Chronic Ear Survey (CES) and Depression Anxiety Stress Scale-21 (DASS-21). METHODS: Eighty-five consecutive patients operated on for cholesteatoma and COM by endoscopic tympanoplasty from March 2018 to February 2020 filled in CES and DASS-21, within one month prior to surgery. A second administration of each questionnaire was performed at the yearly postoperative evaluation. A multivariate analysis using a linear regression model was performed to evaluate the role of the different variables associated with the questionnaires' subscales and overall scores. RESULTS: A significant improvement was achieved in all CES and DASS-21 subscales after endoscopic tympanoplasty. No patient showed a DASS-21 score compatible with a psychological distress both at the pre- and postoperative assessments. At multivariate analysis, the only significant factors associated with postoperative improvement in CES scores were preoperative DASS-21 "depression" score and months of follow-up. CONCLUSION: Endoscopic tympanoplasty shows significantly improved QoL as assessed by disease-specific and psycho-emotional questionnaires. A subjective favourable effect of fully endoscopic ear surgery was demonstrated.

Acinic cell carcinoma of the parotid gland: Timeo Danaos et dona ferentes? A multicenter retrospective analysis focusing on survival outcome.

OBJECTIVES: To analyze the demographic data, surgical and adjuvant treatment data and the survival outcomes in adult patients affected by acinic cell carcinoma of the parotid gland (AciCC). METHODS: A retrospective multicenter analysis of patients treated for AciCC of the parotid gland from 2000 to 2021 was performed. Exclusion criteria were pediatric (0-18 years) patients, the absence of follow-up and patients with secondary metastatic disease to the parotid gland. Multivariable logistic regression was used to determine factors associated with survival. RESULTS: The study included 81 adult patients with AciCC of the parotid gland. The median age was 46.3 years (SD 15.81, range 19-84 years), with a gender female prevalence (F = 48, M = 33). The mean follow-up was 77.7 months (min 4-max 361, SD 72.46). The 5 years overall survival (OS) was 97.5%. The 5 years disease-free survival (DFS) was 60%. No statistical differences have been found in prognosis for age (< 65 or ≥ 65 years), sex, surgery type (superficial vs profound parotid surgery), radicality (R0 vs R1 + Rclose), neck dissection, early pathologic T and N stages and adjuvant therapy (p > 0.05). CONCLUSION: This study did not find prognostic factor for poorest outcome. In contrast with the existing literature, our results showed how also high-grade tumours cannot be considered predictive of recurrence or aggressive behaviour.

Molecular Mechanisms and Physiological Changes behind Benign Tracheal and Subglottic Stenosis in Adults.

Laryngotracheal stenosis (LTS) is a complex and heterogeneous disease whose pathogenesis remains unclear. LTS is considered to be the result of aberrant wound-healing process that leads to fibrotic scarring, originating from different aetiology. Although iatrogenic aetiology is the main cause of subglottic or tracheal stenosis, also autoimmune and infectious diseases may be involved in causing LTS. Furthermore, fibrotic obstruction in the anatomic region under the glottis can also be diagnosed without apparent aetiology after a comprehensive workup; in this case, the pathological process is called idiopathic subglottic stenosis (iSGS). So far, the laryngotracheal scar resulting from airway injury due to different diseases was considered as inert tissue requiring surgical removal to restore airway patency. However, this assumption has recently been revised by regarding the tracheal scarring process as a fibroinflammatory event due to immunological alteration, similar to other fibrotic diseases. Recent acquisitions suggest that different factors, such as growth factors, cytokines, altered fibroblast function and genetic susceptibility, can all interact in a complex way leading to aberrant and fibrotic wound healing after an insult that acts as a trigger. However, also physiological derangement due to LTS could play a role in promoting dysregulated response to laryngo-tracheal mucosal injury, through biomechanical stress and mechanotransduction activation. The aim of this narrative review is to present the state-of-the-art knowledge regarding molecular mechanisms, as well as mechanical and physio-pathological features behind LTS.

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.

Endoscopic tympanoplasty type I for tympanic perforations: analysis of prognostic factors.

PURPOSE: To assess the anatomical and functional outcomes of endoscopic transcanal tympanoplasty type I for tympanic membrane perforations. METHODS: Eight hundred thirty-five patients who underwent tympanoplasty between January 2011 and January 2019 were selected. Patients with tympanic membrane perforation treated with a transcanal endoscopic tympanoplasty type 1 and a follow-up period longer than 6 months have been retrospectively reviewed. The presence of cholesteatoma or ossicular chain dysfunctions were considered exclusion criteria. Eighty-one patients were included in the present study population. The main outcome was the rate of overall graft success. Secondary outcomes included hearing results. Prognostic factors related to both the abovementioned outcomes were assessed. RESULTS: Overall, 66 patients (81.5%) had a successful graft at the last follow-up evaluation. Mean follow-up was 22.1 (range 6-104) months. The anterior quadrants were entailed by the perforation in 62 (76.5%) cases. The overall success rate with cartilage (or cartilage and perichondrium) was 91.2% (p < 0.01). The median preoperative and postoperative ABG were 18.7 (13.4-25.6) and 7.5 (2.5-12.5), respectively, revealing a significant median improvement of 11.2 (p < 0.001). The type of graft and the postoperative tympanic membrane status were significantly associated with the audiologic outcome with p = 0.01 and p = 0.02, respectively. CONCLUSIONS: Endoscopic tympanoplasty type I is a reliable technique with reasonable anatomic and audiologic results. Tympanic membrane grafting with cartilage (or cartilage and perichondrium) guarantees a higher rate of perforation closure and satisfactory hearing results. Anterior eardrum perforations can be successfully and safely managed with transcanal endoscopic approach avoiding postauricular approach and canalplasty.

Training model for salvage procedures in endoscopic stapes surgery.

PURPOSE: The learning curve in endoscopic stapes surgery, is flat and long. There is limited space during training for advanced and salvage procedures, which could be necessary in unexpected intraoperative scenarios. The aim of the present study is to develop an ex-vivo animal model for training in salvage and advanced procedures in endoscopic stapes surgery METHODS: After defining the difficult intraoperative scenarios requiring a salvage procedure during stapes surgery, we used the ovine model to create those intraoperative situations. After assessing the suitability of the model for that purpose, it was validated by subjective feedback rating (scale from 1 to 10) and by comparing the relevant anatomical structures for stapes surgery with the human. Finally, an optimal sequence of surgical steps was defined. RESULTS: 8 Fresh frozen lamb heads (16 ears) were studied. The selected intraoperative scenarios were: floating footplate, footplate fracture, luxation of the incus or necrosis of the long process, overhanging facial nerve, obliterative otosclerosis. The simulation resulted feasible and close to real. The mean overall rating for surgical scenarios ranged from 7.5 to 8.8 for residents and was consistent with the rating of senior surgeons, ranging from 7.67 and 9.0. Anatomical measures of the oval window area resulted similar between the ovine and the human. CONCLUSION: The ex-vivo ovine model is a suitable model for training in salvage and advanced procedures in exclusively endoscopic stapes surgery. The model can be used both for the training and maintenance of the acquired advanced skills in endoscopic stapes surgery.

Prelaminated flaps in head and neck cancer reconstructive surgery: A systematic review.

BACKGROUND: Prelamination is a reconstructive technique providing fasciomucosal or composite flaps with low donor-site morbidity. We conducted a systematic review of retrospective studies to assess the application of prelaminated flaps in reconstructive surgery of head and neck cancer patients, and to evaluate the advantages and disadvantages of this technique. METHODS: This systematic review adhered to the recommendations of the PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-analysis) 2009 guidelines. A computerized MEDLINE search was performed using the PubMed service of the U.S. National Library of Medicine (www.pubmed.org) and Scopus database (www.scopus.com), running the following search string: "prelamination OR prelaminated AND flap." Two authors screened the articles, then selected and extracted data on malignancies characteristics, reconstructive techniques, outcomes and complications. RESULTS: A total of 19 articles were selected and reviewed from 128 identified. Seven of 19 articles were case reports, 12 articles were case series. One-hundred-two patients underwent reconstructive treatment by prelamination technique using a wide variety of flaps (92 free, 10 pedicled). The sites of reconstruction were oral cavity (66 floor of the mouth, 3 retromolar trigone, 6 hard palate, 4 cheek, 4 tongue), 8 facial skin (5 of them sited on the nose), 4 oropharyngeal defects, 1 laryngotracheal region. No case of total flap loss was reported. Partial flap loss or shrinkage requiring minor surgical revisions was observed in 18 patients (17.6%). Primary closure of the donor site was achieved in 97 cases (97%) and 3 (3%) required revision surgery of the donor site. CONCLUSION: Prelamination is an effective and versatile technique, with low donor-site morbidity. Further studies would be needed to investigate the impact on the patient's oncologic outcome. More comparative studies with standard reconstructive techniques are essential to understand when it is worth performing this sophisticated procedure.

Cochlear function after type-1 tympanoplasty: endoscopic versus microscopic approach, a comparative study.

PURPOSE: To investigate and compare the effect of endoscopic and microscopic type 1 tympanoplasty on the cochlear function, to determine if they have a different impact on the inner ear function. METHODS: 72 ears treated by transcanal endoscopic type 1 tympanoplasty and 84 ears treated by microscopic type 1 tympanoplasty in 3 tertiary referral centers were enrolled in the study. Microscopic type 1 tympanoplasty were performed by transcanal or retroauricular approach. Only patients with mobile and intact ossicular chain were involved in the study. A retrospective chart review was performed. Main outcome measures were: (1) change in bone conduction thresholds at 250, 500, 1000, 2000, 4000 Hz; (2) change in bone conduction Pure Tone Audiometry; (3) correlation of audiometric outcomes with surgical technique, graft type and graft position. RESULTS: A mild postoperative bone conduction threshold shift was observed at 2000 Hz and 4000 Hz in both groups, without significant differences between the two groups. No statistically significant modifications in bone conduction were observed at any frequencies in patients operated by transcanal endoscopic approach compared with those who underwent transcanal or retroauricular microscopic type 1 tympanoplasty. Moreover, neither the placement nor the type of the graft seemed to influence the cochlear function preservation. CONCLUSIONS: The endoscopic and the microscopic approaches have a similar impact on the bone conduction threshold during type 1 tympanoplasty. In particular, the one-handed manipulation of the ossicular chain during the endoscopic technique did not show an increased risk of inner ear damage.

Endoscopic facial nerve decompression in post-traumatic facial palsies: pilot clinical experience.

PURPOSE: Post-traumatic facial nerve (FN) paralysis might need surgical decompression in selected patients. Different microscope-based surgical techniques are described in the literature such as the transmastoid, the middle cranial fossa and the translabyrinthine approach. The effectiveness of the transcanal endoscopic approach (TEA) in managing such condition has never been described and its possible indications has to be defined. METHODS: Retrospective multi-centric case series of patients with post-traumatic FN paralysis surgically treated with TEA. From July 2013 to July 2017, 6 patients underwent TEA for post-traumatic FN paralysis with involvement of the second genu and/or the tympanic segment of the nerve. The surgical technique is described step by step, with focus on anatomic landmarks. Post-operative outcomes are specified in terms of FN postoperative function and audiologic results. RESULTS: The TEA showed to recover a House-Brackmann grade I-II FN function in 83.2% of the patient. Post-operative air-bone gap significantly improved; whereas, the pure-tone average bone conduction did not differ significantly. CONCLUSIONS: TEA represents a viable option for the treatment of post-traumatic facial palsy in patients with radiologic evidence of tympanic segment and/or perigeniculate region involvement with no involvement of the mastoid segment of the FN. Transcanal endoscopic facial nerve decompression is a safe and effective approach in highly selected cases. LEVEL OF EVIDENCE: 4.

Tracheostomy in the COVID-19 pandemic.

PURPOSE: The role of tracheostomy in COVID-19-related ARDS is unknown. Nowadays, there is no clear indication regarding the timing of tracheostomy in these patients. METHODS: We describe our synergic experience between ENT and ICU Departments at University Hospital of Modena underlining some controversial aspects that would be worth discussing tracheostomies in these patients. During the last 2 weeks, we performed 28 tracheostomies on patients with ARDS due to COVID-19 infection who were treated with IMV. RESULTS: No differences between percutaneous and surgical tracheostomy in terms of timing and no case of team virus infection. CONCLUSION: In our experience, tracheostomy should be performed only in selected patients within 7- and 14-day orotracheal intubation.

The role of endoscopic stapes surgery in difficult oval window niche anatomy.

PURPOSE: The surgical treatment of otosclerosis can be challenging in case of anatomical abnormalities or variations of the oval window niche (OWN) area, as in very narrow OWN or in an overhanging facial nerve. The aim of the present study was to explore the role of endoscopic stapes surgery in cases with difficult OWN anatomy. METHODS: Patients undergoing endoscopic stapes surgery from 2008 to 2017, which fulfilled the CT scan criteria for a "difficult" anatomical condition, according to the measurements and cut-off values defined in the literature, were retrospectively selected. The intraoperative endoscopic view of the anatomical details and surgical difficulties were analysed through the review of the operative videos. Finally, a statistical analysis of the relationship between endoscopic visualization of anatomical details and radiological measurements was carried out. RESULTS: Eighteen out of 205 patients (8.7%) were included in the study. The 94.4% of patients obtained an optimal endoscopic exposure and visualization of all the anatomical details considered in the study, during each step of stapes surgery. The OWN measurements (width, depth and facial-promontory angle) did not affect significantly the endoscopic surgical exposure of the footplate or any of the other anatomical details. CONCLUSIONS: The anatomic features of the oval window area which reduce the visualization in microscopic surgery, did not affect the surgical exposure in endoscopic stapes surgery. Patients having a difficult anatomy of the OWN can be treated safely with the endoscopic approach. In the case of a predicted "difficult anatomy", the endoscopic approach can be considered a viable option.

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.