Transoral laser microsurgery: feasibility of a new exoscopic HD-3D system coupled with free beam or fiber laser.

In the last decades, new technological devices and instruments have been developed to overcome the technical limits of transoral laser microsurgery. The recent introduction of 3D endoscopy seems to be a promising tool in the field of diagnostic and operative laryngology as an alternative to the traditional microlaryngoscopy. Our work aims to present a novel transoral microsurgical setting that expands the use of exoscopic systems (in this case the VITOM® 3D-HD) as an alternative to the standard operating microscope. A customized support arm and an adaptor to firmly connect the VITOM® 3D-HD camera to the laser micromanipulator were specially designed. This setup was used as an alternative to the standard operating microscope in a cohort of 17 patients affected by suspicious early to intermediate pharyngo-laryngeal neoplasms. A historical cohort of patients treated with the traditional setting and matching the same inclusion criteria was used as a reference for the duration of surgical procedures. The surgical procedures comprised 7 cordectomies, 2 endoscopic partial supraglottic laryngectomies, 4 tongue base resections, and 4 lateral oropharyngectomies or hypopharyngectomies. In 6 cases (35%), a simultaneous neck dissection was performed. The low rate of positive deep (6%) or superficial (12%) margins reinforced the safety of this platform, and the results obtained in terms of operating time were comparable to the control group (p > 0.05), which confirms the feasibility of the system. Our surgical setting setup is a convincing alternative to traditional transoral laser microsurgery for early to intermediate pharyngo-laryngeal neoplasms. The main advantages of this system are comfortable ergonomics for the first surgeon and a potential benefit in terms of teaching if applied in university hospitals, since the entire surgical team can view the same surgical 3D-HD view of the first operator. Further work is still needed to objectively compare the traditional and new technique, and to validate our preliminary clinical findings.

Intraoperative narrow band imaging better delineates superficial resection margins during transoral laser microsurgery for early glottic cancer.

OBJECTIVE: The high rate of positive margins after transoral laser microsurgery (TLM) remains a matter of debate. This study investigates the effect of intraoperative narrow band imaging (NBI) examination on the incidence of positive superficial surgical margins in early glottic cancer treated by TLM. METHODS: Between January 2012 and October 2013, 82 patients affected by Tis-T1a glottic cancer were treated with TLM by type I or II cordectomies. Intraoperative NBI evaluation was performed using 0-degree and 70-degree rigid telescopes. Surgical specimens were oriented by marking the superior edge with black ink and sent to a dedicated pathologist. Comparison between the rate of positive superficial margins in the present cohort and in a matched historical control group treated in the same way without intraoperative NBI was calculated by chi-square test. RESULTS: At histopathological examination, all surgical margins were negative in 70 patients, whereas 7 had positive deep margins, 2 close, and 3 positive superficial margins. The rate of positive superficial margins was thus 3.6% in the present group and 23.7% in the control cohort (P<.001). CONCLUSION: Routine use of intraoperative NBI increases the accuracy of neoplastic superficial spreading evaluation during TLM for early glottic cancer.

Transnasal approach to the orbital apex and cavernous sinus.

OBJECTIVES: The aim of this study was to provide the anatomic rationale for a transnasal approach to the orbital apex and cavernous sinus, and to evaluate its applicability and efficiency. METHODS: One hundred patients with lesions of the orbital apex, cavernous sinus, optic nerve, clivus, parapharyngeal space, infratemporal fossa, or pterygopalatine fossa were reviewed over a 10-year period. All patients underwent an endoscopic transnasal approach to the orbital apex and cavernous sinus. The surgical technique required a standard endoscopic sinus surgery set. The possible complications were recorded and classified as intraoperative or postoperative. RESULTS: There were complications in 8 cases: 4 intraoperative and 4 postoperative. The intraoperative complications included rupture of the internal carotid artery in 1 patient and cerebrospinal fluid leak in 3 patients. All intraoperative complications were resolved during surgery. The postoperative complications were transitory eyelid ptosis in 2 patients (resolved in 6 months) and transitory diplopia with immediate deficit of the medial rectus muscle in 2 patients (completely resolved in 1 month). CONCLUSIONS: With the use of this technique, the surgeon can precisely identify the position of the surgical instrument without losing his or her way, thereby significantly reducing the rate of complications.

Electric Bioimpedance Sensing for the Detection of Head and Neck Squamous Cell Carcinoma.

The early detection of head and neck squamous cell carcinoma (HNSCC) is essential to improve patient prognosis and enable organ and function preservation treatments. The objective of this study is to assess the feasibility of using electrical bioimpedance (EBI) sensing technology to detect HNSCC tissue. A prospective study was carried out analyzing tissue from 46 patients undergoing surgery for HNSCC. The goal was the correct identification of pathologic tissue using a novel needle-based EBI sensing device and AI-based classifiers. Considering the data from the overall patient cohort, the system achieved accuracies between 0.67 and 0.93 when tested on tissues from the mucosa, skin, muscle, lymph node, and cartilage. Furthermore, when considering a patient-specific setting, the accuracy range increased to values between 0.82 and 0.95. This indicates that more reliable results may be achieved when considering a tissue-specific and patient-specific tissue assessment approach. Overall, this study shows that EBI sensing may be a reliable technology to distinguish pathologic from healthy tissue in the head and neck region. This observation supports the continuation of this research on the clinical use of EBI-based devices for early detection and margin assessment of HNSCC.

The prometastatic relevance of tumor-infiltrating B lymphocytes in laryngeal squamous cell carcinoma.

Objectives: Laryngeal squamous cell carcinomas (LSCCs) typically have an excellent prognosis for stage I tumors but a significant risk of locoregional and distant recurrence for intermediate to advanced disease. This study will investigate the clinical relevance of the tumor microenvironment in a large cohort of treatment-naïve patients affected by stage II-IV LSCC. Methods: Whole slide-based digital pathology analysis was applied to measure six immune cell populations identified by immunohistochemistry (IHC) staining for CD3, CD8, CD20, CD66b, CD163 and CD38. Survival analysis was performed by Cox proportional hazards models and unsupervised hierarchical clustering using the k-means method. Double IHC staining and in-situ hybridisation by RNAscope allowed further analysis of a protumoral B cell population. Results: A cohort of 98 patients was enrolled and analysed. The cluster of immune-infiltrated LSCCs demonstrated a significantly worse disease-specific survival rate. We also discovered a new association between high CD20+ B cells and a greater risk of distant recurrence. The phenotypic analysis of infiltrating CD20+ B cells showed a naïve (BCL6-CD27-Mum1-) regulatory phenotype, producing TGFß but not IL10, according to an active TGFß pathway, as proved by positive pSMAD2 staining. Conclusion: The identification of regulatory B cells in the context of LSCC, along with the activation of the TGFß pathway, could provide the basis for new trials investigating the efficacy of already available molecules targeting the TGFß pathway in the treatment of LSCC.

Long-Term Efficacy of Mepolizumab at 3 Years in Patients with Severe Asthma: Comparison with Clinical Trials and Super Responders.

The efficacy mepolizumab in severe asthmatic patients is proven in the literature. Primarily to study the effect of mepolizumab on exacerbations, steroid dependence, and the continuation of efficacy in the long term. Secondarily to evaluate the effect of the drug on nasal polyps. Analyzing data from SANI (Severe Asthma Network Italy) clinics, we observed severe asthmatic patients treated with mepolizumab 100 mg/4 weeks, for a period of 3 years. 157 patients were observed. Exacerbations were reduced from the first year (-84.6%) and progressively to 90 and 95% in the second and third ones. Steroid-dependent patients decreased from 54% to 21% and subsequently to 11% in the second year and 6% in the third year. Patients with concomitant nasal polyps, assessed by SNOT-22, showed a 49% reduction in value from baseline to the third year. The study demonstrated the long-term efficacy of mepolizumab in a real-life setting.

Efficacy and safety of ribosome-component immune modulator for preventing recurrent respiratory infections in socialized children.

Attending day care is associated with recurrent respiratory infections (RRIs) and asthma. Ribosomal immunotherapy may confer protection against RRIs in children. This study was designed to assess the efficacy of a ribosome-component immune modulator (RCIM) as preventive treatment of respiratory infections in socialized children aged ≤5 years, with or without a history of frequent RRI. In a multicenter, Italian, randomized, double-blind, placebo-controlled, parallel-group study, 164 socialized day care center children (mean age, 3.8 ± 1.1 years) were treated with RCIM or placebo for 6 months and followed-up for additional 6 months. Outcomes are presented for the intent-to-treat population. In socialized children with five or less RRIs (n = 95; 49 RCIM and 46 placebo, group A) the duration of the infectious episodes was significantly shorter with RCIM than with placebo (6 months, 3.7 ± 2.1 versus 4.5 ± 1.9 days, p = 0.040; 12 months, 3.6 ± 2.0 versus 4.7 ± 2.5 days, p = 0.015). The proportion of patients reporting no respiratory infectious episodes with RCIM at 6 and 12 months was also significantly larger in group A (20.4% versus 4.4% placebo; p = 0.028). No such differences were found in children with more than five RRIs in the preceding year (n = 63; 32 RCIM and 31 placebo, group B). In all children, general well-being improved significantly more under RCIM than under placebo (11.6 ± 1.8% versus 10.2 ± 1.8%; p = 0.002). No statistically significant between-treatment differences were observed for other end points. Both treatments were similarly well tolerated. Six-month treatment with RCIM effectively prevented the 12-month risk of RRIs in children <5 years old and with five or less RRIs in the preceding year.

Audiometric characteristics in patients with noise-induced hearing loss after sodium enoxaparin treatment.

OBJECTIVES: The aim of this study was to evaluate the effect of sodium enoxaparin treatment on patients with noise-induced hearing loss. METHODS: Sixty patients with noise-induced hearing loss were included and randomly divided into two numerically equal groups. Group A underwent therapy with sodium enoxaparin for 10 days, followed by an additional 10 days of treatment after 10 days of no treatment. Group B received placebo as a control. Before treatment, at the end of treatment, and 2 months after the end of treatment, all patients underwent evaluation by laboratory tests, pure tone audiometry, transient evoked otoacoustic emissions (TEOAEs) testing, distortion product otoacoustic emissions (DPOAEs) testing, and auditory brain stem response testing. RESULTS: In contrast to group B, at the end of the treatment in group A pure tone audiometry showed a significant (p < 0.05) improvement of the audiometric thresholds at 0.5, 1, 2, 4, and 8 kHz. Depending on the air and bone conduction thresholds, TEOAEs and DPOAEs, which had previously been absent, were evoked at the frequencies examined. These improvements were confirmed at last follow-up. We found no significant differences in auditory brain stem responses or laboratory results. CONCLUSIONS: These preliminary data encourage further studies to collect additional evidence on the effect of sodium enoxaparin in preventing the development of noise-induced hearing loss.

Efficacy of a topical suspension of bacterial antigens for the management of chronic suppurative otitis media.

The aim of this study was to compare the efficacy and safety of a topical suspension of bacterial antigens for the management of chronic suppurative otitis media (CSOM). Two-hundred ten patients with CSOM were enrolled in this study. The patients were divided into two numerically equal groups and randomized to receive a topical suspension of bacterial antigens, Lantigen B (group A), or placebo (group B), according to the following protocol: 5 drops thrice a day for 12 consecutive weeks in the external acoustic duct. The topical suspension of bacterial antigens and placebo were administered by identical, anonymous dispensers in order to maintain double-blind conditions. Before, at the end and 3 months, and after the end of the treatment, all patients who entered in the study underwent pure tone audiometry, microscopic examination of ears, microbiological examination of the ear swab, aural suctioning and subjective assessment of symptoms by visual analog scale. In group A, we saw a statistically significant improvement in the different items measured. A topical suspension of bacterial antigens was significantly more effective than placebo in the treatment of CSOM.

Videomics of the Upper Aero-Digestive Tract Cancer: Deep Learning Applied to White Light and Narrow Band Imaging for Automatic Segmentation of Endoscopic Images.

Introduction: Narrow Band Imaging (NBI) is an endoscopic visualization technique useful for upper aero-digestive tract (UADT) cancer detection and margins evaluation. However, NBI analysis is strongly operator-dependent and requires high expertise, thus limiting its wider implementation. Recently, artificial intelligence (AI) has demonstrated potential for applications in UADT videoendoscopy. Among AI methods, deep learning algorithms, and especially convolutional neural networks (CNNs), are particularly suitable for delineating cancers on videoendoscopy. This study is aimed to develop a CNN for automatic semantic segmentation of UADT cancer on endoscopic images. Materials and Methods: A dataset of white light and NBI videoframes of laryngeal squamous cell carcinoma (LSCC) was collected and manually annotated. A novel DL segmentation model (SegMENT) was designed. SegMENT relies on DeepLabV3+ CNN architecture, modified using Xception as a backbone and incorporating ensemble features from other CNNs. The performance of SegMENT was compared to state-of-the-art CNNs (UNet, ResUNet, and DeepLabv3). SegMENT was then validated on two external datasets of NBI images of oropharyngeal (OPSCC) and oral cavity SCC (OSCC) obtained from a previously published study. The impact of in-domain transfer learning through an ensemble technique was evaluated on the external datasets. Results: 219 LSCC patients were retrospectively included in the study. A total of 683 videoframes composed the LSCC dataset, while the external validation cohorts of OPSCC and OCSCC contained 116 and 102 images. On the LSCC dataset, SegMENT outperformed the other DL models, obtaining the following median values: 0.68 intersection over union (IoU), 0.81 dice similarity coefficient (DSC), 0.95 recall, 0.78 precision, 0.97 accuracy. For the OCSCC and OPSCC datasets, results were superior compared to previously published data: the median performance metrics were, respectively, improved as follows: DSC=10.3% and 11.9%, recall=15.0% and 5.1%, precision=17.0% and 14.7%, accuracy=4.1% and 10.3%. Conclusion: SegMENT achieved promising performances, showing that automatic tumor segmentation in endoscopic images is feasible even within the highly heterogeneous and complex UADT environment. SegMENT outperformed the previously published results on the external validation cohorts. The model demonstrated potential for improved detection of early tumors, more precise biopsies, and better selection of resection margins.

Deep Learning Applied to White Light and Narrow Band Imaging Videolaryngoscopy: Toward Real-Time Laryngeal Cancer Detection.

OBJECTIVES: To assess a new application of artificial intelligence for real-time detection of laryngeal squamous cell carcinoma (LSCC) in both white light (WL) and narrow-band imaging (NBI) videolaryngoscopies based on the You-Only-Look-Once (YOLO) deep learning convolutional neural network (CNN). STUDY DESIGN: Experimental study with retrospective data. METHODS: Recorded videos of LSCC were retrospectively collected from in-office transnasal videoendoscopies and intraoperative rigid endoscopies. LSCC videoframes were extracted for training, validation, and testing of various YOLO models. Different techniques were used to enhance the image analysis: contrast limited adaptive histogram equalization, data augmentation techniques, and test time augmentation (TTA). The best-performing model was used to assess the automatic detection of LSCC in six videolaryngoscopies. RESULTS: Two hundred and nineteen patients were retrospectively enrolled. A total of 624 LSCC videoframes were extracted. The YOLO models were trained after random distribution of images into a training set (82.6%), validation set (8.2%), and testing set (9.2%). Among the various models, the ensemble algorithm (YOLOv5s with YOLOv5m-TTA) achieved the best LSCC detection results, with performance metrics in par with the results reported by other state-of-the-art detection models: 0.66 Precision (positive predicted value), 0.62 Recall (sensitivity), and 0.63 mean Average Precision at 0.5 intersection over union. Tests on the six videolaryngoscopies demonstrated an average computation time per videoframe of 0.026 seconds. Three demonstration videos are provided. CONCLUSION: This study identified a suitable CNN model for LSCC detection in WL and NBI videolaryngoscopies. Detection performances are highly promising. The limited complexity and quick computational times for LSCC detection make this model ideal for real-time processing. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1798-1806, 2022.

Cerebrospinal Fluid Leak Repair: Usefulness of Intrathecal Fluorescein for Correct Topographic Identification of the Skull Base Defects.

BACKGROUND: In the management of cerebrospinal fluid (CSF) leak, the identification of the exact discharge spot is paramount. This process can represent a challenge for the radiologist and the surgeon. In the present study, we analyzed a series of patients affected by endonasal CSF leak who underwent endoscopic surgical reconstruction aided by the use of ITF. The purpose of this work is to assess the efficacy of intraoperative ITF in addition to computed tomography (CT) and magnetic resonance imaging for correct topographic localization of the CSF leak. METHODS: Eighty-three patients were enrolled in the study. The main outcome was the concordance between the supposed radiologic defect site and the actual one seen intraoperatively. Recurrence-free survival was evaluated as secondary outcome. RESULTS: ITF better defined the defect site, allowing a change in the treatment in 21 patients (25.3%), in whom nonconcordance was observed between the suspected radiologic site and the actual surgical site. Good agreement was found between the specific topographic localization (κ = 0.737; P < 0.0001), whereas fair agreement was observed considering the side of the defect (κ = 0.362; P = 0.0009) and correct identification of multiple sites (κ = 0.044; P = 0.666). The 10-year 96% estimate of recurrence-free survival confirmed the correct repair of the fistula site in most cases. CONCLUSIONS: Our data show the usefulness and safety of intraoperative ITF for management of patients affected by endonasal CSF leak. ITF improved the topographic diagnosis of the leak site, ensuring the best target reconstruction and very low recurrence rate.

Potential nerve damage following contact with a piezoelectric device.

OBJECTIVES: The aim of the study was to assess the extent of the potential nerve damage following prolonged contact with a piezoelectric device. METHODS: The study was conducted with 30 patients; all of the patients had cervical metastatic lymph nodes at levels II, III, and IV (N2b) and a negative evaluation for metastatic disease (MO). The patients underwent radical neck dissection. After its skeletonization, the spinal nerve was exposed directly to ultrasonic activation with a piezoelectric device for various times (5, 10, and 20 seconds) and with different inserts (OP3 insert and OT7 insert). The axonal damage was graded from 0 to 3 as follows: 0, no damage; 1, minor axonal damage; 2, severe axonal damage but not covering the entirety of the nerve fascicles; 3, severe axonal damage covering the entirety of the nerve fascicles. RESULTS: Histologic examination showed no evidence of damage to the perineurium and axons after 5 and 10 seconds of exposure to ultrasonic activation with each insert. CONCLUSIONS: Our histologic data highlight the selective action of the piezoelectric device, which reduces the risk of accidental nerve damage in otolaryngological bone surgery.

The role of three-dimensional CT in the evaluation of nasal structures and anomalies.

Traditionally, computed tomography (CT) is the primary radiographic method to analyze the morphology of the craniofacial bones: Because of the many overlapping anatomical structures, it is difficult and sometimes impossible to evaluate craniofacial bones three-dimensionally (3D) with these images. For this reason, the aim of this paper has been to evaluate and demonstrate the importance of CT scans integrated by three-dimensional reconstructions (3D-CT) volume rendering imaging for the accurate understanding of the nasal pyramid morphology in the evaluation of patients submitted to secondary rhinoseptoplasty. Twenty patients enrolled for a secondary rhinoseptoplasty, underwent a preoperative evaluation through 3D-CT volume rendering imaging. This technique allowed a prefect reconstruction of the nasal structures at the level of the valve, as well as the medial and lateral walls of the nasal fossa in all of its components (bone and cartilage). In our experience, the 3D-CT volume rendering imaging studies improve the preoperative evaluation of structures and anomalies which are hard to evaluate by the anterior rhinoscopy and/or nasal endoscopy: alar and lateral cartilages, interdomal distance, tip morphology, valvular configuration, loss of bone-cartilaginous substance, etc. All of these points are important during the preoperative planning of secondary rhinoseptoplasty.

Comparison of postoperative pain: piezoelectric device versus microdrill.

Piezosurgery® is a recently developed system for cutting bone with microvibrations. The objective of this study was to compare the severity of pain over the first 10 postoperative days in a group of 70 patients who underwent intact canal wall mastoidectomy, with the piezoelectric device, and to compare the results with traditional method by means of microdrill (70 patients). The subjective perception of pain was evaluated on a scale from 0 to 10, such that 0 represented no pain and 10 represented maximum pain; the severity was recorded as null when the score was 0; slight, when it was 1-4; moderate, when it was 5-7; or severe, when it was 8-10. Compared with microdrill, the patients that underwent surgery with the piezoelectric device showed a significant (P < 0.05) lower postoperative pain on day 1 (52 vs. 26 patients presented a slight pain, 12 vs. 37 presented a moderate pain, and 6 vs. 7 presented a severe pain) and day 3 (68 vs. 44 patients presented a slight pain, 2 vs. 23 presented a moderate pain, and 0 vs. 3 presented a severe pain). These results highlight as the piezoelectric device is a safe and minimally invasive tool.

Vestibular evoked myogenic potential in vestibular neuritis.

This study wants to show the diagnostic value of vestibular evoked myogenic potential (VEMP) in the diagnosis of vestibular neuritis (VN), independently of the caloric test results. Twenty patients were enrolled with acute vertigo caused by VN. VEMP was tested with the binaural simultaneous stimulation method. Surface electromyographic activity was recorded in the supine patients from symmetrical sites over the upper half of each sternocleidomastoid muscle, with a reference electrode on the lateral end of the upper sternum. During the acute attack, 8 days, 1 month and 3 months after the beginning of the acute attack, all the patients underwent the following examinations: Dix-Hallpike manoeuvre, Pagnini-McClure manoeuvre, head shaking test, pure-tone audiometry, tympanometry, caloric labyrinth stimulation according to the Fitzgerald-Hallpike method and VEMP. At the last visit, the 11 patients diagnosed with superior branch vestibular neuritis did not show any improvement at the caloric labyrinth stimulation and presented VEMP on both sides with normal amplitude and latency; in the 9 cases diagnosed with inferior branch vestibular neuritis, there was an improvement of the VEMP reflex and normal caloric test. Our experience highlights that VEMP recording is applicable for patients with VN as a screening test.

Office-based procedures in laryngology.

OBJECTIVE: Development of transnasal fiberoptic laryngoscopy, integration of an operative channel (OC), the advent of high-definition television imaging, with improvements in laser technology, cleared the way for office-based laryngology. Three treatment categories can be identified: bioendoscopy-guided biopsy; laryngeal injection; laser-assisted surgery. METHODS: 26 patients underwent OBPs at the Otolaryngology Clinic of IRCCS Policlinico San Martino, Genoa, Italy. Sixty-eight procedures were performed: 60 for recurrent respiratory papillomatosis (RRP), 5 for unilateral vocal fold paralysis (UVFP) and 3 for glottic leukoplakias. Neoblucaine 5% was administrated through the operative channel, for local anaesthesia. All procedures were carried out with the physician standing behind the patient. Narrow band imaging (NBI - Olympus Medical) or i-scan (Pentax Medical) were used to enhance the accuracy of the biopsy thanks to identification of atypical vascular patterns. Laryngeal injections were made using a 25G flexible needle. Opera Evo (Quanta system IEC/EN 60825-1:2007) is a hybrid fibre laser that is used for "blanching" and vaporisation of RRP lesions and to treat selected leukoplakias that were previously biopsied. CONCLUSIONS: No major complications occurred during the procedures.

µRALP and Beyond: Micro-Technologies and Systems for Robot-Assisted Endoscopic Laser Microsurgery.

Laser microsurgery is the current gold standard surgical technique for the treatment of selected diseases in delicate organs such as the larynx. However, the operations require large surgical expertise and dexterity, and face significant limitations imposed by available technology, such as the requirement for direct line of sight to the surgical field, restricted access, and direct manual control of the surgical instruments. To change this status quo, the European project µRALP pioneered research towards a complete redesign of current laser microsurgery systems, focusing on the development of robotic micro-technologies to enable endoscopic operations. This has fostered awareness and interest in this field, which presents a unique set of needs, requirements and constraints, leading to research and technological developments beyond µRALP and its research consortium. This paper reviews the achievements and key contributions of such research, providing an overview of the current state of the art in robot-assisted endoscopic laser microsurgery. The primary target application considered is phonomicrosurgery, which is a representative use case involving highly challenging microsurgical techniques for the treatment of glottic diseases. The paper starts by presenting the motivations and rationale for endoscopic laser microsurgery, which leads to the introduction of robotics as an enabling technology for improved surgical field accessibility, visualization and management. Then, research goals, achievements, and current state of different technologies that can build-up to an effective robotic system for endoscopic laser microsurgery are presented. This includes research in micro-robotic laser steering, flexible robotic endoscopes, augmented imaging, assistive surgeon-robot interfaces, and cognitive surgical systems. Innovations in each of these areas are shown to provide sizable progress towards more precise, safer and higher quality endoscopic laser microsurgeries. Yet, major impact is really expected from the full integration of such individual contributions into a complete clinical surgical robotic system, as illustrated in the end of this paper with a description of preliminary cadaver trials conducted with the integrated µRALP system. Overall, the contribution of this paper lays in outlining the current state of the art and open challenges in the area of robot-assisted endoscopic laser microsurgery, which has important clinical applications even beyond laryngology.

Harmonic Scalpel vs "cold knife" dissection in uvulopalatopharyngoplasty.

PURPOSE: The aim of this study has been to compare the Harmonic Scalpel (HS) and the "cold knife" dissection in the treatment of snoring by uvulopalatopharyngoplasty (UPPP). MATERIALS AND METHODS: The investigation included 40 adult males with snoring. Patients were assigned to two homogeneous groups (A and B) and UPPP was performed using HS or "cold knife" dissection in groups A and B, respectively. Before and 6 months after surgery, each patient was studied using the apnea-hypopnea index and a visual analogue scale of snore levels. Postoperative assessment of pain was evaluated on postoperative days 1 and 10. All the patients underwent to a perioperative evaluation concerning the duration of surgical dissection, the amount of intraoperative blood loss and days of hospitalization. RESULTS: In group A, the HS provided excellent control without side effects on the adjacent structures and postoperative complications. Harmonic Scalpel's group experienced shorter operation time, lesser blood loss, fewer days of hospitalization and lower postoperative pain. CONCLUSIONS: The use of the HS in UPPP is safe and confers some advantages over conventional methods of UPPP: its use led to diminished bleeding, shorter operation time, lesser pain, and better wound healing in the postoperative period.