Transcanal transpromontorial approach for vestibular schwannoma: experience of a single center.

BACKGROUND: The expanded transpromontorial transcanal approach (ExpTTA) represents a recent addition to the surgical approaches available for the treatment of vestibular schwannoma. An initial purely endoscopic version has been complemented by the use of the microscope and it is now one of the possible surgical options for small to medium-sized vestibular schwannomas with a predominantly intracanalar development. METHODS: This is a series of 54 patients who underwent microsurgical resection of sporadic, unilateral vestibular schwannoma, mainly Koos I-II with non-serviceable hearing, between January 2016 and January 2023 using the expanded transcanal transpromontorial approach. We describe the surgical technique, focusing on anatomical landmarks, and analyzing its advantages and shortcomings. Retrospective analysis of clinical outcomes is presented, including early and late complications. The mean follow-up was 46.7 months. RESULTS: We achieved gross total resection of the lesion in all cases, confirmed on the first follow-up MRI at least 6 months after each procedure. We did not record any intraoperative complication nor disease recurrence. We recorded two postoperative severe facial nerve palsies, one of which was permanent. No cases of disabling vertigo or imbalance were reported, and all patients reported full recovery of autonomy in daily activities. Three cases of otoliquorrhea were managed conservatively successfully. CONCLUSIONS: The transcanal transpromontorial approach combines the advantages of endoscopy with the possibilities provided by microsurgery. Our experience confirms its safety in terms of surgical complications and facial nerve outcome. This approach is amongst the treatment options for small-medium schwannomas in patients with impaired hearing, especially in young patients, ensuring radical resection, disease control, and minimal morbidity.

A comparison between endoscopic and microscopic approaches for stapes surgery: experience of a tertiary referral center.

PURPOSE: Otosclerosis is a common ear disease causing ankylosis of the stapedio-vestibular joint and conductive hearing loss. Stapedoplasty is the most advisable surgical solution. The restoration of hearing depends on the condition of the patient and the surgery itself. The aim of our work was to compare the surgical and audiological results of stapedoplasty performed with endoscopic versus microscopic technique. METHODS: This is a retrospective study of 254 patients treated with stapedoplasty with a microscopic approach (91/254) or with an endoscopic approach (163/254) between 2014 and 2021 at our tertiary referral center. Statistical significance of differences between the two methods was determined using the Mann-Whitney test for quantitative variables and the Wilcoxon matched-pairs signed-rank test for repeated measures. Categorical variables were assessed with Fisher's exact test. RESULTS: Both techniques improved the hearing status of patients, with no statistically significant difference between them. There was also no statistically significant difference in reported complications between the two techniques. There is a statistical difference (p < 0.001) in operating time between the two techniques: the endoscopic technique had a mean operating time of 39 min versus 45 min for the microscopic technique. CONCLUSIONS: The two techniques are comparable in terms of results and the choice depends on the surgeon's preferences and experience.

Is the intra-operative morphology of the cochlear nerve a good predictor of the results of simultaneous ipsilateral cochlear implantation in vestibular schwannoma surgery?

OBJECTIVE: There are currently no guidelines for simultaneous vestibular schwannoma surgery and cochlear implantation. This paper therefore provides our experience and our results regarding predictive parameters of good hearing. METHODS: Morphological appearance of the cochlear nerve after tumour resection was used as the main criterion for implantation in the case series. Patients were then divided into responders and non-responders to cochlear implantation, and potential outcome predicting factors were evaluated in the two groups. RESULTS: Nine of the 16 patients showed a response to cochlear implantation. Pre-surgery serviceable hearing was significantly more common in the responder group, while no difference was found in the two groups for other variables. CONCLUSION: This study highlights how the morphological appearance of the cochlear nerve can be useful to predict the hearing outcome and indicates that satisfactory hearing results are closely related to pre-surgery serviceable hearing.

Quality of life in vestibular schwannoma: a comparison of three surgical techniques.

OBJECTIVE: Through years, interest in quality of life (QoL) among patients affected by vestibular schwannoma (VS) has increased. The expansion of the indications for endoscopic ear surgery allowed the development of the transcanal transpromontorial surgery (TTS) for VS removal. The objective of the present study was to assess QoL in a cohort of VS patients operated on by translabyrinthine (TL), retrosigmoid (RS) and TTS approach. METHODS: The study was conducted on 111 patients who underwent surgery for VS between January 2017 and January 2020 at two different institutions. Patients fulfilled three questionnaires during follow-up: Glasgow Benefit Inventory, Depression Anxiety Stress Scales-21 and Penn Acoustic Neuroma Quality-Of-Life. The association between sex, age, date of surgery, tumor size, post-operative facial nerve (FN) function and QoL outcomes was assessed. RESULTS: An overall subjective impairment was demonstrated in all groups. Age, Koos staging and FN functions were associated to distinct QoL outcomes. CONCLUSIONS: QoL decreases in patients surgically treated for VS. The TTS may allow improved scores in many domains, confirming to be a subjectively well-tolerated technique.

Does pregnancy have an influence on otosclerosis?

OBJECTIVE: Otosclerosis affects women twice as often as men, especially during fertile age. A role of female hormones has been claimed, but controversy still exists regarding the influence of pregnancy. The purpose of this research was to analyse the role of pregnancy on the course of otosclerosis. METHOD: PubMed was searched in May 2019 using the terms 'otosclerosis AND pregnancy', 'otosclerosis AND pregnant', 'otosclerosis AND parous', 'otosclerosis AND parity', and 'otosclerosis AND puerperium'. Age at diagnosis, number of pregnancies and the temporal relationship of the disease with childbearing were considered. RESULTS: From 65 articles, 11 were chosen for review. They described 2323 women affected by otosclerosis: 1805 had at least 1 pregnancy, while 518 did not. During childbearing, otosclerosis began in 1 per cent of pregnant women, worsened in 21 per cent and worsened during puerperium in 4 per cent. Often, the authors reported hearing change with pregnancy without details, so a further group has been considered composed of women belonging to any of the groups just mentioned or to another group of women not further characterised. Overall, hearing change occurred during pregnancy in 44 per cent. A statistically significant correlation emerged between hearing change and number of pregnancies (p = 0.003). CONCLUSION: Because of wide data heterogeneity and the difficulty in analysing a single factor, absolute statements could not be formulated. According to this review, pregnancy seems to have a worsening effect on the course of otosclerosis.

Non-traumatic pneumocephalus caused by increased depth of olfactory fossa.

We report a case of unilateral Keros type III variant of the cribriform plate (olfactory fossa >7 mm deep) that caused non-traumatic pneumocephalus. A 61-year-old male patient presented to the emergency room complaining of acute-onset headache after blowing his nose. Computed tomographic (CT) examination showed a massive pneumocephalus; a CT scan from three months before showed a Keros type III variant. The defect was repaired endoscopically with mucoperichondrial and mucoperiostal grafts. Pneumocephalus that has developed in a Keros type III variant has been theorised about, but never reported to our knowledge. Radiologists should be familiar with the Keros classification so that they can identify patients who are at increased risk of fractures of the cribriform plate.

Oncological outcomes of parotid gland malignancies: a retrospective analysis of 74 patients.

INTRODUCTION: Salivary gland malignancies are rare neoplasms whose management has been evolving over the last two decades. Nevertheless, patient outcomes have not improved accordingly. OBJECTIVE: In the present paper, factors and variables that could influence Overall, Disease-Specific and Disease-Free Survival, and Loco-Regional Control were analyzed. METHODS: Chart data from 74 patients who underwent parotid gland surgery were retrospectively analyzed and stratified for tumor histology, grading, size, pT stage, pN stage, extracapsular spread, involved salivary gland lobe, and age at diagnosis. Major outcomes were estimated at 5 years by Kaplan-Meier curves. RESULTS: Advanced stage, high grade, and lymph nodes involvement greatly impaired patient outcomes. Furthermore, in our cohort, the age at diagnosis ≥ 55 was a cause of poorer disease survival likely due to a different distribution in tumor histotypes between older and younger patients. Despite the two groups were homogeneous for the numerosity of squamous cell carcinomas, older patients were more rarely affected by mucoepidermoid and acinic cell carcinomas, which have generally better prognosis. Finally, patients aged ≥ 55 had a more frequent pathological involvement of the deep lobe of the parotid gland if compared to the younger counterpart. CONCLUSION: The rarity of some salivary gland tumor histotypes requires further high-number series to fully understand the prognostic factors for both patient survival and recurrence development. In our cohort, the age at diagnosis ≥ 55 raises concerns that play crucial roles in disease survival shortening.

Trans-nasal endoscopic and intra-oral combined approach for odontogenic cysts.

Maxillary cysts are a common finding in maxillofacial surgery, dentistry and otolaryngology. Treatment is surgical; a traditional approach includes Caldwell-Luc and other intra-oral approaches. In this article, we analyse the outcomes of 9 patients operated on using a combined intra-oral and trans-nasal approach to the aforementioned disease. Although the number of patients is small, the good results of this study suggest that the combined approach might be a reliable treatment option.

Acquisition of surgical skills for endoscopic ear and lateral skull base surgery: a staged training programme.

SUMMARY: Endoscopic ear surgery is radically changing the treatment of several middle and inner ear pathology, but its learning presents well-known manual and technical difficulties. The aim of this paper is be to present a training programme based on a modular model of increased difficulties. The experience from 2007 to 2016 at the University Hospital of Modena and University Hospital of Verona was reviewed and analysed for further considerations and to establish stages of training. The increasing experience of expert surgeons who deal with this kind of surgery represented the main guide to establish the steps and progression of training. In addition, the potential risk of damage of vascular structures or nerves represents fundamental criteria for progression toward higher levels. Some not-mandatory skills were also suggested for stage of difficulty. Five stages of training were deemed appropriate for progressive learning of endoscopic ear and lateral skull base surgery, ranging from simple middle and external ear procedures to surgery of inner ear and internal auditory canal. Mastering of each level is suggested before attempting procedures at a higher level, in particular for procedures involving lateral skull base. Standardisation and adoption of modular incremental training are expected to facilitate improvement of otolaryngologists and neurosurgeons starting with endoscopic middle ear and lateral skull base surgery. Adherence to such a programme during the growth phase may potentially decrease the rate of complications, making the training programme safer.

The protympanum, protiniculum and subtensor recess: an endoscopic morphological anatomy study.

OBJECTIVES: An anatomical study was performed to describe the endoscopic anatomy and variations of the protympanum, including classification of the protiniculum and subtensor recess. METHODS: A retrospective review was conducted of video recordings of cadaveric dissections and surgical procedures, which included visualisation of the protympanum, across 4 tertiary university referral centres over a 16-month period. A total of 97 ears were used in the analysis. RESULTS: A quadrangular conformation of the protympanum was seen in 60 per cent of ears and a triangular conformation in 40 per cent. The protiniculum was type A (ridge) in 58 per cent, type B (bridge) in 23 per cent and type C (absent) in 19 per cent. The subtensor recess was type A (absent) in 30 per cent, type B (shallow) in 48 per cent and type C (deep) in 22 per cent. CONCLUSION: The protympanum is an area that has been ignored for many years because of difficulties in visualising it with an operating microscope. However, modern endoscopic equipment has changed this, providing detailed anatomical knowledge fundamental to ensuring the safety of endoscopic surgical procedures in the region.

Iatrogenic traumatic optic neuropathy: report of an injury occurring during a choanal atresia correction surgery treatment.

We report the case of a 36-year-old adult male patient who came to our attention for the evaluation of a possible iatrogenic injury suffered during the surgical correction of congenital choanal atresia. This case report retraces the patient's medical history and the events lapsed in the peri-operative time analyzing if any malpractice has occurred in causing the amaurosis.

Using the method of triads in the validation of a food frequency questionnaire to assess the consumption of fatty acids in adults.

BACKGROUND: It is of great value to develop valid instruments to estimate food consumption; for this purpose, the triads method has been applied in validation studies of dietary intake to evaluate the correlation between three measurements [food frequency questionnaire (FFQ), reference method and biomarker]. The main aim of the present study was to validate a FFQ for Brazilian adults by means of the method of triads by estimating the ingestion of total fatty acids based on the level of saturation. METHODS: The present study enrolled 152 Brazilian adults of both sexes, who were residents in the city of Viçosa, Brazil. The ingestion of total saturated, monounsaturated, polyunsaturated, trans, linoleic and linolenic fatty acids was assessed by means of a FFQ, two food records, and biomarkers, which were detected by gas chromatography. The validation coefficients were calculated using the method of triads and concordance was determined by Kappa statistics. RESULTS: The FFQ was considered an adequate dietary method, because, based on the validation coefficients, it estimates the intake of total fat (0.84), as well as linolenic (0.90) and linoleic acids (0.31). A high concordance rate was confirmed for all nutrients assessed by the FFQ and food records. Regarding the biomarkers, linolenic acid and linoleic acid presented greater concordance. CONCLUSIONS: According to the validation coefficients, the FFQ precisely estimated total fat, linolenic acid and linoleic acid contents.

Expanded transcanal transpromontorial approach to the internal auditory canal and cerebellopontine angle: a cadaveric study.

The aim of this paper is to describe and evaluate the feasibility of an expanded endoscopic transcanal transpromotorial approach (ExpTTA) to the internal auditory canal and the cerebellopontine angle. To this end, we performed a cadaveric dissection study in September 2015. In total, 2 heads (4 sides) were dissected focusing on anatomical landmarks and surgical feasibility. Data from dissections were reviewed and analysed for further consideration. In all 4 sides of the cadavers the procedure was feasible. In all cadavers, it was necessary to extensively drill the temporo-mandibular joint and to calibrate the external ear canal to allow adequate room to manoeuver the instruments and optics and to comfortably access the cerebellopontine angle. In addition, thorough skeletonisation of the carotid artery and the jugular bulb were necessary for the same purpose. In conclusion, ExpTTA appeared to be successful to access the internal auditory canal and cerebellopontine angle region. Potential extensive and routine application of this type of approach in lateral skull base surgery will depend on the development of technology and surgical refinements and on the diffusion of skull base endoscopic skills among otolaryngologists and neurosurgical community.

An overview of folate status in a population-based study from São Paulo, Brazil and the potential impact of 10 years of national folic acid fortification policy.

BACKGROUND/OBJECTIVES: Food fortification is an important strategy in public health policy for controlling micronutrient malnutrition and a major contributing factor in the eradication of micronutrients' deficiencies. Approximately 50 countries worldwide have adopted food fortification with folic acid (FA). FA fortification of wheat and maize flours has been mandatory in Brazil since 2004. To assess the effect of 10 years of FA food fortification policy on folate status of residents of São Palo, Brazil using a population-based survey. SUBJECTS/METHODS: Data were from 750 individuals aged ⩾12 years who participated in a cross-sectional population-based survey in São Paulo city, Brazil. Fasting blood samples were collected, and folate was assayed by affinity-high performance liquid chromatografy method with electrochemical detection. The participants provided information about food intake based on two 24 h dietary recall. RESULTS: Only 1.76% of population had folate deficiency (<6.8 nmol/l). The mean folate concentration was 29.5 (95% confidence interval: 27.3-31.7) nmol/l for all sex-age groups. The mean folate intake for the population was 375.8 (s.e.m.=6.4) µg/day of dietary folate equivalents (DFEs). When comparing folate intake in DFE from food folate and FA from fortified foods, FA contributed 50% or more of the DFE in almost all sex-age groups. The major contributors of folate intake are processed foods made from wheat flour fortified with FA, especially among subjects younger than 20 years old. CONCLUSIONS: The deficiency of folate is very low, and food fortification contributed to folate intake and had a notable influence on rankings of food contributors of folate.

Agreement between Dietary Intake of Older Adults and Proxy Respondents Assessed by a Food Frequency Questionnaire.

OBJECTIVE: To evaluate the degree of agreement of dietary intake reported by the patient subject with the dietary intake reported by a respondent (a next-of-kin or a caregiver), collected by a validated Food Frequency Questionnaire (FFQ). METHODOLOGY: 126 adults, both sexes, the average age was 65.9 years for patients and 54.4 years for respondents. They were recruited from the General Practice Clinic at the Clinical Hospital of São Paulo (AGD-FMUSP). The agreement between the responses given by patients and respondents was assessed using Spearman, weighted Kappa and Bland Altman tests. RESULTS: The analysis for accuracy between responses (Spearman test) showed a moderate degree of agreement (0.31-0.39) for Energy, Total fat, Total Saturated Fatty Acids (SFA), Total Monounsaturated Fatty Acids (MUFA). Regarding food groups a moderate agreement was found for the majority of the foods (fruits (0.30), dairy products (0.50), natural juices (0.45), beans (0.48), butter/margarine (0.55), coffee (0.41) and soda (0.45), with the exception of vegetables (0.12) and rice (0.63). The ingestion differences did not exceeded the limit of the two standard deviations for the majority of the pairs (Bland Altman). A respondent subsample composed only of husband/wives (N = 36) revealed a moderate agreement concordance for most macronutrients studied (0.30 - 0.58), except polyunsaturated fats (0.25). CONCLUSION: The results of this study show that, the FFQ may be used in cases where is impossible to get the answers directly from the patients.

Comparisons of physical activity, adipokines, vitamin D status and dietary vitamin D intake among adolescents.

BACKGROUND: Considering that lifestyle and diet are key factors responsible for the increases in adiposity in youth, it is important to understand how vitamin D, adipokines and markers of glucose metabolism are related to physical activity level (PAL) during growth. The present study aimed to investigate associations between physical activity level, adiponectin/leptin ratio, vitamin D status and dietary vitamin D intake among adolescents. METHODS: A cross-sectional study was conducted with adolescents aged 14-18 years old who were living in São Paulo, Brazil. Serum 25 hydroxyvitamin D [25(OH)D], adiponectin (A), leptin (L), glucose and insulin were obtained after 12 h of fasting. Dietary calcium and vitamin D intake were measured by 24-h food record, as repeated in 62.6% of the sample. PAL was measured by the International Physical Activity Questionnaire (IPAQ). Pearson's chi-square test, Pearson correlation and linear regression analysis were performed. RESULTS: A total of 198 subjects, mean (SD) age 16.3 (1.4) years, 51% male, were enrolled in the study. Some 9% of participants were sedentary, 22% were insufficiently active (IA), 51% were active and 18% were very active (VA). The A/L ratio was lower among sedentary/IA subjects [2.2 (4.0) versus 5.6 (12.3); P = 0.01] compared to active/VA subjects. PAL was not associated with vitamin D status or markers of glucose metabolism. Serum 25(OH)D positively associated with vitamin D intake, after adjusting for sex, sun exposure and season of the year in regression analysis (partial r2 =0.026, P = 0.02). CONCLUSIONS: Low PAL was associated with a lower A/L ratio. Vitamin D status was not associated with sun exposure habits, although it was positively correlated with vitamin D intake.

Evaluation of the psychometric properties of the main meal quality index when applied in the UK population.

BACKGROUND/OBJECTIVES: The aim of this study was to evaluate the validity and reliability of the Main Meal Quality Index when applied on the UK population. SUBJECTS/METHODS: The indicator was developed to assess meal quality in different populations, and is composed of 10 components: fruit, vegetables (excluding potatoes), ratio of animal protein to total protein, fiber, carbohydrate, total fat, saturated fat, processed meat, sugary beverages and desserts, and energy density, resulting in a score range of 0-100 points. The performance of the indicator was measured using strategies for assessing content validity, construct validity, discriminant validity and reliability, including principal component analysis, linear regression models and Cronbach's alpha. RESULTS: The indicator presented good reliability. CONCLUSIONS: The Main Meal Quality Index has been shown to be valid for use as an instrument to evaluate, monitor and compare the quality of meals consumed by adults in the United Kingdom.

Indices for the assessment of nutritional quality of meals: a systematic review.

This systematic review aimed to synthesise information on indices developed to evaluate nutritional quality of meals. A strategy for systematic search of the literature was developed using keywords related to assessment of meal quality. Databases searched included ScienceDirect, PubMed, Lilacs, SciELO, Scopus, Cochrane, Embase and Google Scholar. The literature search resulted in seven different meal quality indices. Each article was analysed in order to identify the following items: authors, country, year, study design, population characteristics, type of meal evaluated, dietary assessment method, characteristics evaluated (nutrients or food items), score range, index components, nutritional references, correlations performed, validation and relationship with an outcome (if existing). Two studies developed instruments to assess the quality of breakfast, three analysed lunch, one evaluated dinner and one was applied to all types of meals and snacks. All meal quality indices reviewed were based on the evaluation of presence or absence of food groups and relative contributions of nutrients, according to food-based guidelines or nutrient references, adapting the daily dietary recommendations to one specific meal. Most of the indices included three items as components for meal quality assessment: (I) total fat or some specific type of fat, (II) fruits and vegetables and (III) cereals or whole grains. This systematic review indicates aspects that need further research, particularly the numerous approaches to assessing meals considering different foods and nutrients, and the need for validation studies of meal indices.

Dietary intake and food contributors of polyphenols in adults and elderly adults of Sao Paulo: a population-based study.

A comprehensive estimation of polyphenol intake is needed to gain a better understanding of the association between polyphenol-rich food intake and the potential effects of this intake on chronic diseases. The aim of this study was to estimate the intake of polyphenols and the major dietary contributors in the population of Sao Paulo. Data were obtained from the Health Survey-São Paulo (ISA-Capital 2008) and were reported for 1103 adults and elderly adults. Food intake was estimated by one 24-h dietary recall (24HR). Polyphenol intake was calculated by matching food consumption data from the 24HR with the polyphenol content in foods listed in the Phenol-Explorer database. The mean total intake of polyphenols was 377·5 (se 15·3) mg/d. The main polyphenol classes were phenolic acids (284·8 (se 15·9) mg/d) and flavonoids (54·6 (se 3·5) mg/d). Intakes were higher in the elderly adults than in other adults (P<0·001) and higher in individuals with lower educational level (P=0·01) and current smokers (P=0·02). The main dietary contributors for total polyphenols were coffee (70·5 %), citrus fruits (4·6 %) and tropical fruits (3·4 %). Coffee was the major source of polyphenols, providing 266·2 (se 16·5) mg/d, and contributed 92·3 % of the phenolic acids and 93·1 % of the alkylmethoxyphenols. These findings will be useful for assessing the potential role on health of polyphenols and specific polyphenol-rich foods, such as coffee, and enable a comparison with people from other countries.