The role of the osteoplastic flap in the endoscopic era: a retrospective multicentre experience on revision surgery.

Objective: To retrospectively review the experience of five tertiary-care university hospitals on frontal sinus revision surgery with osteoplastic flap (OPF). Methods: Descriptive analysis of patients who underwent frontal sinus surgery with OPF after one or more endoscopic procedures for benign and inflammatory pathologies from 2000 to 2022. Clinical charts were reviewed for demographics, indications, clinical presentation, previous frontal procedures, OPF technique and outcomes. Results: Of the 124 patients who underwent an OPF procedure, 33 met inclusion criteria. With a mean of 2.1 previous endoscopic surgeries, Draf III was the most common former procedure. In 30 (91%) cases OPF was part of a combined procedure. The most common indications were inverted papilloma (61%), mucocele (9%) and chronic rhinosinusitis (6%). Frontal outflow stenosis (36%) and mucocele (9%) were the most frequent complications observed. Improvement of overall symptoms and patient satisfaction after the OPF procedure were recorded. Conclusions: Even in the endoscopic era, OPF still represents a paramount procedure that should be included in the rhino-surgeon's armamentarium, in particular in patients with challenging pathologies and anatomy when previous endoscopic endonasal attempts have failed.

Endoscopic Endonasal Removal of Orbital Schwannoma: Focus on Surgical Technique.

Orbital schwannomas are a rare disease, representing about 1% of orbital tumors, potentially involving any subsite within the orbit. They usually present with painless, nonpulsatile proptosis, while diplopia and vision impairment due to extrinsic ocular muscles or optic nerve involvement are rarely observed.1 A wait-and-see policy is advocated in case of small asymptomatic lesions. However, if progressive dimensional increase or symptoms are observed, surgical resection represents the treatment of choice.2 Different surgical approaches have been proposed, mainly depending on tumor dimension and location inside the orbit, as well as surgical expertise. With advances in technology,3 knowledge,4 and surgical techniques,5 transnasal endoscopic approaches have emerged as a valid option in the management of lesions located medially to the optic nerve, with the advantage of improved visualization and overall decreased morbidity as compared with external approaches.6 We present the case of a 19-year-old woman, affected by an intraextraconal orbital schwannoma located in the left orbit's inferomedial aspect, with a 1-year history of left proptosis associated with retrobulbar pain exacerbated by the upward gaze. The lesion was completely removed with an endoscopic transnasal approach (Video 1), without evidence of postoperative sequelae or visual impairment. Magnetic resonance imaging performed 3 months after surgery showed good surgical results without evidence of persistence of disease. A multidisciplinary approach, involving different specialists familiar with orbital anatomy and physiology, is required for a proper management of patients affected by orbital pathologies.

Combined Endonasal-Transorbital Approach to Manage the Far Lateral Frontal Sinus: Surgical Technique.

In recent decades, the ever-expanding use of endoscopes and development of dedicated instrumentation have reshaped the panorama of surgical approaches to the frontal sinus.1 Nonetheless, the far lateral portion of the sinus might still represent a concern, especially in cases with unfavorable or distorted anatomy.2,3 We report the case of a 52-year-old man, referred to our department for recurrent episodes of left orbital swelling and supraorbital headache, 3 months after Draf III frontal sinusotomy for marsupialization of multiple frontal mucoceles. Computed tomography and magnetic resonance imaging scans were consistent with persistent inflammatory tissue in the far lateral left frontal sinus. Revision surgery was performed, adopting a combined endonasal orbital transposition3 and superior eyelid transorbital approach.4,5 The postoperative course was uneventful, and the microbiologic and histologic examinations demonstrated noninvasive Aspergillus fumigatus infection. The radiologic control showed patency of the frontal recess and complete clearance of the sinus. The patient is asymptomatic after 16 months (Video 1). The transorbital approach is effective in managing orbital and frontal sinus diseases,6 and the combination with the endonasal route grants complete access to the frontal sinus, even in cases of high pneumatization and lateral extension.4,7 Multiportal transorbital approaches represent additional techniques in the rhinologist's surgical armamentarium, which can overcome the limits of a single port approach.8,9 Reports on their use providing technical hints and critical considerations are to be encouraged to ease and stimulate the surgical training in this field.

Changing paradigms in sinus and skull base surgery as the COVID-19 pandemic evolves: Preliminary experience from a single Italian tertiary care center.

BACKGROUND: Italy was the first European country suffering from COVID-19. Health care resources were redirected to manage the pandemic. We present our initial experience with the management of urgent and nondeferrable surgeries for sinus and skull base diseases during the COVID-19 pandemic. METHODS: A retrospective review of patients treated in a single referral center during the first 2 months of the pandemic was performed. A comparison between the last 2-month period and the same period of the previous year was carried out. RESULTS: Twenty-four patients fulfilled the inclusion criteria. A reduction of surgical activity was observed (-60.7%). A statistically significant difference in pathologies treated was found (P = .016), with malignancies being the most frequent indication for surgery (45.8%). CONCLUSIONS: Although we feel optimistic for the future, we do not feel it is already time to restart elective surgeries. Our experience may serve for other centers who are facing the same challenges.

Elective Tracheostomy During Mechanical Ventilation in Patients Affected by COVID-19: Preliminary Case Series From Lombardy, Italy.

The COVID-19 outbreak poses continued struggles due to the unprecedented number of patients admitted to intensive care units and the overwhelming need for mechanical ventilation. We report a preliminary case series of 32 patients with COVID-19 who underwent elective tracheostomies after a mean intubation period of 15 days (range, 9-21 days). The procedure was performed with percutaneous (10 cases) and open (22 cases) surgical techniques. Neither procedure-related complications nor viral transmission to health care workers was observed. Our preliminary experience supports the safety of tracheostomy, provided that appropriate protocols are strictly followed. The postoperative care is still debated, and, prudentially, our protocol includes tracheal tube change not before 2 weeks after tracheostomy, with cuff deflation and decannulation deferred until confirmation of negative SARS-CoV-2 test results. This is the first case series to report on such a rapidly evolving issue and might represent a source of information for clinicians worldwide who will soon be facing the same challenges.