Otoendoscopy in the era of narrow-band imaging: a pictorial review.

PURPOSE: Otoendoscopy represents the initial non-invasive diagnostic cornerstone for external and middle ear disorders. Recently, new techniques of enhanced imaging such as narrow-band imaging (NBI) have been introduced but their role as a potential aid in otological practice remains unproven. In this pictorial review, we want to present the potential application of this endoscopic method, highlight its limitations, and give some hints regarding its future implementation. METHODS: Representative cases of external and/or middle ear pathologies were selected to illustrate the role of NBI in this regard. RESULTS: NBI may represent a useful aid in the otological work-up, in the differential diagnosis of ear tumor-like masses, and, possibly, in the prognosis of tympanic perforations. For other ear disorders, instead, this technique does not seem to add anything to the standard clinical practice. CONCLUSIONS: NBI might prove useful in the assessment of selected external and middle ear disorders but its role must be prospectively validated.

High proportion of inflammatory CD62Llow eosinophils in blood and nasal polyps of severe asthma patients.

BACKGROUND: In mice models, eosinophils have been divided into different subpopulations with distinct phenotypes and functions, based on CD62L and CD101 patterns of membrane expression. Limited data are available in humans. OBJECTIVE: To investigate eosinophils subpopulations in peripheral blood (PB) and nasal polyp tissue (NP) from severe eosinophilic asthma (SEA) patients plus concomitant chronic rhinosinusitis with nasal polyps (CRSwNP). METHODS: We recruited 23 SEA patients (14 with CRSwNP); as controls, we enrolled 15 non-severe asthma patients, 15 allergic rhinitis patients without asthma and 15 healthy donors. Eosinophils were isolated from PB and NP and analysed by FACS. Eotaxin-3 and eotaxin-1 mRNA expression in NP tissue was also evaluated. RESULTS: A significantly higher percentage of circulating CD62Llow cells was observed in SEA, as compared with controls, expressing higher levels of CCR3, CD69 and lower levels of CD125 (IL-5R), CRTH2, CD86 and CD28 in comparison with CD62Lbright cells. In NP, eosinophils showed a high proportion of CD62Llow phenotype, significantly greater than that observed in PB. Surface expression of IL-3R, IL-5R, CD69 and CD86 was significantly higher in CD62Llow eosinophils from NP than in those from blood. Moreover, eotaxin-3 mRNA expression positively correlated with the percentage of CD62Llow cells in NP. CONCLUSION: Two different eosinophil subphenotypes can be identified in blood and NP of SEA patients, with a preferential accumulation of CD62Llow inflammatory cells in NP.

Hearing outcomes and patient satisfaction after stapes surgery: local versus general anaesthesia.

Objective: Otosclerosis is a frequent ear disorder causing a stapedo-ovalar ankylosis and conductive hearing loss. Stapedoplasty, performed under both general (GA) and local anaesthesia (LA), is the most advisable surgical solution. Auditory recovery relies on the patient's conditions and on the intervention itself. The aim of our work was to compare hearing outcomes with stapedoplasty performed under GA or LA and to investigate patients' compliance to both methods. Methods: Fifty-five otosclerotic patients underwent stapedoplasty both under GA (32/55) and LA (23/55). Pre- and post-operative air and bone tone audiometry threshold values as well as the air-bone gap and its closure score, were analysed. All patients filled in a satisfaction questionnaire regarding their concern and level of appreciation of the type of anaesthesia. Results and conclusions: Our data show that the auditory results with stapedoplasty are good and do not differ between LA and GA. Even considering the advantages and limits of the two methods, one cannot favour one or the other type of anaesthesia. Finally, the patient's satisfaction cannot be considered a criterion of choice, since this was found to be high in both cases.

Polymer composition analysis of plastic debris ingested by loggerhead turtles (Caretta caretta) in Southern Tyrrhenian Sea through ATR-FTIR spectroscopy.

The ingestion of anthropogenic plastic debris by marine wildlife is widespread in the Mediterranean Sea. The endangered status (in the IUCN Red List) of Loggerhead turtle (Caretta caretta, Linnaeus, 1758) is a consequence of its vulnerability. In this study, macro-/meso-plastics (5-170 mm) collected from faeces of twelve loggerhead turtles rescued (live) in the Aeolian Archipelago (Southern Tyrrhenian Sea, Italy) were analyzed by size, weight, shape, color and polymer type through Attenuated Total Reflectance Fourier-Transform Infrared Spectroscopy (ATR-FTIR). The defecation rate during hospitalization (7-14 days) varied among turtles (from 0.08 to 0.58). The mean number of plastic expulsions (2.7 ± 1.8 items for turtle) was higher during the 5th day of hospitalization (Kruskal-Wallis test, P = 0.01). However, the mean number of plastic-like items defecated during the common days of hospitalization did not vary among turtles (Kruskal-Wallis test, P > 0.05). All turtles were found to have ingested plastic. A total of 114 debris items were recovered from their faeces, 113 of which were identified as plastic. Their color was mostly white-transparent (64.9%) and light (19.3%). Shape was mainly fragments (52.6%), sheets (38.6%), followed by nylon, net-fragments, elastic plastic, foamed plastic and industrial granules (8.8%). Meso-plastics (5-25 mm) represented 72% of the total number of debris and were found more frequently in turtle with Curved Carapace Length (CCL) ≤ 60 cm (CCL = 30-60 cm, n = 5) than those with CCL >60 cm (CCL = 60-71 cm, n = 7). Plastic items were composed mainly of polyethylene (48.2%) and polypropylene (34.2%). Polypropylene (R2 = 0.95, P < 0.001) and polyisoprene (R2 = 0.45, P = 0.017) were more common in meso-plastics while polyethylene (R2 = 0.44, P < 0.01) in macro-plastics. Finally, high-density polyethylene, polyvinyl chloride, polyamide and polyurethane were also found in some turtles. This study reveals high spreads of plastic contamination in faeces of both turtles with CCL ≤60 cm and CCL >60 cm, particularly vulnerable to the increasing quantity of floating plastic into their foraging sites highlighting the need of further research to associate debris ingestion with turtle diet and their size.

Current outcomes of myringoplasty in a European referral children's hospital.

OBJECTIVES: Myringoplasty is a frequently performed procedure in children, with a heterogeneous failure rate. Our study aimed to evaluate the outcome of myringoplasty in a pediatric hospital and to identify which are risk factors for reperforation or poor hearing improvement after surgery. METHODS: Preoperative and intraoperative variables between pediatric patients who had undergone myringoplasty with an intact tympanic membrane at follow-up and the cases with reperforation were compared. The same factors were investigated as potential predictors of audiological success. Pre and postoperative PTA and ABG were compared in the whole population, in structural success and failure groups and closure of ABG was calculated and used to compare the audiological outcomes between the two groups. RESULTS: Parameters that affected the postoperative integrity of TM were age, the time between diagnosis and surgery, the intraoperative status of the middle ear, and secondhand smoke exposure. Early perforations occurred mostly after surgeries performed by trainees, while late perforations were more frequently in autumn. Myringoplasty, regardless of the structural outcome, can improve the ABG and PTA. No preoperative and intraoperative parameters affected the audiological outcome. CONCLUSION: Pediatric myringoplasty is a safe and successful procedure that can improve hearing, regardless of the structural outcome. In light of our results, parameters to consider before surgery are age, the time between diagnosis and surgery, the intraoperative status of the middle ear, and secondhand smoke exposure.

Recurrence of ischemic stroke on direct oral anticoagulant therapy in a patient with marantic endocarditis related to lung cancer.

Venous thromboembolism (VTE) and arterial thromboembolism (ATE) are frequent complications in cancer patients. For curative treatment of VTE in a neoplastic context, recent randomized controlled trials and meta-analyses suggest that direct oral anticoagulants (DOACs) can be an alternative to conventional treatment by low molecular weight heparins (LMWHs). On the other hand, the role of DOACs in the treatment of cancer-related ATE remains unclear. Here, we report a case of stroke recurrence in a patient initially treated with DOACs that were started for cancer-related VTE. The failure of the DOACs, compared to LMWHs, to prevent the stroke recurrence led us to the infrequent final diagnosis of nonbacterial thrombotic endocarditis (formerly known as marantic endocarditis). This case illustrates the association between ATE and VTE in a patient with marantic endocarditis related to lung cancer and recurrence of ischemic stroke on direct oral anticoagulant therapy. .

The Role of Elective Neck Treatment in the Management of Sinonasal Carcinomas: A Systematic Review of the Literature and a Meta-Analysis.

The impact of elective neck treatment (ENT), whether by irradiation or dissection, on the prognosis of patients with cN0 sinonasal carcinomas (SNCs) remains an understudied issue. METHODS: A systematic review and meta-analysis of the literature were performed according to PRISMA guidelines in order to assess regional nodal relapse rate after ENT compared to observation in cN0 SNCs patients. Twenty-six articles for a total of 1178 clinically N0 patients were analyzed. Globally, the 5-year overall survival was 52%; 34.6% of patients underwent ENT and 140 regional recurrences were registered (5.9% in the ENT cohort and 15% in the observation group). ENT appears to confer a lower risk of regional recurrence compared to observation alone, with a cumulative OR of 0.38 (95% CI 0.25-0.58). Our meta-analysis supports the efficacy of ENT for reducing the risk of regional recurrence, but its overall impact on survival remains uncertain.

The impact of the COVID-19 pandemic on the quality of life of head and neck cancer survivors.

BACKGROUND: Head and neck cancer (HNC) survivors are particularly vulnerable to the deleterious consequences of lockdown and social distancing. The psychosocial effects of the COVID-19 pandemic on this group are still unknown, and we want to explore how their quality of life (QoL) has changed in this unique situation. MATERIALS AND METHODS: An online survey, composed of pandemic-specific items, plus the EORTC QLQ-C30, was administered to a cohort of HNC survivors. Using previously published reference values as a control group, we have evaluated the impact of the pandemic on their QoL. We have also explored the differences between those who had received a total laryngectomy (LP, laryngectomized population) vs other HNC patients, in order to assess the role of tracheostomy in this regard. RESULTS: One hundred and twenty-one HNC patients completed the survey. The scores of the physical (80.5 vs 85, p = 0.028), role (78 vs 84, p = 0.030), and emotional functioning (76 vs 81, p = 0.041) were significantly different in the two groups, with worse functioning in our patients. Comparing LP with the other HNC patients, social (76.6 vs 88.9, p = 0.008) and physical functioning (75.5 vs 86.1, p = 0.006) were significantly worse in the former group. LP also reported a greater perception that others are afraid to be close to them (1.67 vs 1.32, p = 0.020). No differences were found between LP with and without voice prosthesis. CONCLUSIONS: Our results show how HNC patients are at high risk for a worsening in QoL because of the ongoing COVID-19 global pandemic.

Early glottic cancer recurrence: A critical review on its current management.

INTRODUCTION: Recurrent early glottic cancer (rEGC) poses several issues in terms of timely diagnosis, correct re-staging, and treatment. We want to critically review the latest evidence about rEGC considering its epidemiology, biology, diagnostic challenges, and treatment strategies. METHODS: A systematic search of the literature using PubMed from 1990 to October 31, 2020 was performed. RESULTS: There are many different treatment options available (open surgery, transoral mini-invasive surgery, radiotherapy), and many factors related to the patient's status and previous treatments must be considered when planning the best management strategy for rEGC. While its overall prognosis remains satisfactory, it is of the utmost importance to appreciate all the clinical implications derived from the choice of the initial therapeutic modality, and from a correct primary and recurrent staging. CONCLUSION: The balance between oncological and voice and swallowing functions represents the fundamental principle underlying rEGC management. Future studies should focus on molecular profiling of rEGC, and on the results of the emerging radiation delivery techniques and mini-invasive procedures.

The Risks of Complications During Endoscopic Sinus Surgery in Cystic Fibrosis Patients: An Anatomical and Endoscopic Study.

OBJECTIVE/HYPOTHESIS: An increasing proportion of adult cystic fibrosis (CF) patients is being referred to endoscopic sinus surgery (ESS) in order to relieve the symptoms of chronic rhinosinusitis (CRS). Given that CFTR mutations profoundly alter sinonasal development, we want to explore the relationship between their peculiar surgical anatomy and the risk of postoperative complications. STUDY DESIGN: Retrospective case-control study. METHODS: Paranasal sinuses CT scans of 103 CF adult patients with CRS were compared to those belonging to a cohort of 100 non-CF adult patients to explore their anatomical differences. Secondly, CF and non-CF patients who received primary/revision ESS were analyzed in order to assess their preoperative CT scan in terms of surgically relevant variants, and according to the CLOSE checklist. Surgical outcomes were statistically compared in order to explore the differences between groups. RESULTS: CF group presented more frequently with smaller and less pneumatized paranasal sinuses and a higher Lund-Mckay score compared with controls. No anatomical differences emerged in terms of genotype stratification. Non-CF CRS patients undergoing ESS showed a significantly deeper olfactory fossa and a more frequent supraorbital pneumatization compared to CF patients (P < .001 and P = .031, respectively). Whereas this latter group underwent more often aggressive surgical procedures (P = .001), no difference in terms of postoperative adverse events was found (P = .620). CONCLUSIONS: Despite receiving more often aggressive ESS procedures, adult CF patients do not show an increased risk of postoperative complication and this may be linked to a different proportion of anatomical and surgically-relevant variants. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2481-E2489, 2021.

The Umbrella Technique for the Closure of Cerebrospinal Fluid Fistula.

ABSTRACT: The diagnosis and management of cerebrospinal fluid (CSF) rhinorrhea remains an important challenge in the field of rhinology. In this study, the authors want to propose a technique for transnasal endoscopic closure of CSF fistulas, tested for the first time on 2 adult fresh cadaveric specimens. The authors think that the use of a device similar to the umbrella device, used to close cardiac atrial defects, may also be valid for the closure of defects at the level of the anterior skull base.

A New Solution for Routine Endoscopic Aerosol-Generating Procedures (AGPs) in the COVID-19 Pandemic.

INTRODUCTION: There is urgent need to find a swift and cheap way to safely perform routine endoscopic procedures during the otolaryngological and anesthesiological practice. We want to share our experience of a novel device, inspired by the pediatric head box experience. MATERIALS AND METHODS: Five otolaryngologists and four anesthesiologists were asked to visualize the glottic plane by using the device. A total of 15 attempts was allowed to reach the vocal folds within 60 seconds after entering the box. Student's t-test for unpaired samples was used to compare groups. RESULTS: Transnasal laryngoscopy through our endobox could be successfully performed by all the physicians involved and the mean number of attempts before visualizing and passing the glottis for the first time was 2.8 (range 1-5) in the otolaryngologists' group versus 3.2 (range 1-6) in the anesthesiologists' group (P=0.583). Out of the 15 attempts, the group of otolaryngologists reached the glottis 10.2 times, on average, against 9.7 in the other group (P=0.692). CONCLUSIONS: Our endobox seems a practical and feasible strategy to control droplets diffusion during standard ear, nose, and throat and anesthesiological practice.

An Integrated Care Strategy for the Follow-up of Patients With COVID-19-Associated Chemosensory Dysfunction.

The proportion of patients with residual olfactory and gustatory dysfunction after COVID-19 is increasing, and practical health care strategies need to be developed to manage this novel situation in otolaryngology services worldwide. Starting from our experience in a large Italian hospital, we estimated that >1500 people will complain of some form of olfactory and gustatory dysfunction in the future months in our region. We want to share our logistical and clinical integrated pathway that is aimed to screen and refer each patient to the most appropriate level of care in order to optimize resources and avoid overwhelming the available clinics.

The clinical consequences of the COVID-19 lockdown: A report from an Italian referral ENT department.

Objectives: To evaluate the clinical effects of health care reorganization because of COVID-19, in a non-red zone Italian referral department of Otorhinolaryngology. Materials and Methods: We retrospectively reviewed the statistics of admissions to the Emergency Department (ED) of the Careggi University Hospital, Florence, from January 1, 2020, to May 17, 2020. Data regarding elective and urgent head and neck disorders were reviewed and the most challenging cases were discussed. Results: During the lockdown period, outpatient otolaryngological consultations and elective procedures decreased by 78% and 75% respectively, while emergency/urgency surgery increased by 128%. The five most emblematic clinical cases were thoroughly analyzed. Conclusion: Our analysis shows how the profound rearrangement of clinical and surgical activities, along with the citizens' fear to seek medical care has probably exacerbated the management of many routine head and neck conditions. Level of Evidence: 4.

A critical evaluation of computed tomography-derived depth of invasion in the preoperative assessment of oral cancer staging.

BACKGROUND: Depth of invasion (DOI) has been introduced into the latest TNM classification of oral squamous cell carcinoma (OSCC). Despite its primarily pathological definition (pDOI), a preoperative evaluation of a radiological DOI (rDOI) would be useful but a standard and practical definition is lacking. The primary aim of this study is to measure the rDOI by computed tomography (CT) and compare it to the pDOI in a cohort of OSCC patients. Then, we analyze the utility and reliability of rDOI in the preoperative setting. METHODS: 58 cases of OSCC operated at our Institution from 2016 to 2019 were included. After accounting for plane-specific shrinkage factors and for different oral subsites, we have compared pDOI and rDOI for each spatial plane by paired difference test and correlation coefficient. Radiological accuracy and survival analysis were also determined to identify rDOI's clinical value. RESULTS: For lateral tongue, pDOI was more strongly related with axial rDOI (P < 0.01); for hard palate, the best plane was the sagittal one (P < 0.01); in floor of mouth (FOM) lesions, the strongest correlation was with coronal rDOI (P < 0.01), as well as for cheek buccal mucosa; sagittal scans seem to be the best to evaluate dorsum of the tongue and retromolar trigone; gingiva (P < 0.01) was most correctly evaluated in the coronal plane. Overall accuracy of rDOI restaging was 75.41%. Disease-free survival seems to be worse as rDOI increases. CONCLUSIONS: We suggest that with a standardized imaging protocol patients could be better classified according to CT-derived DOI.

Survival Outcomes and Prognostic Factors of Open Partial Laryngeal Surgery: A Thirty Years' Experience.

BACKGROUND: Open partial laryngeal surgery (OPLS) represents a wide array of procedures that can be fitted to treat different types of laryngeal cancer (LC). We would like to present our 30-years' institutional experience, to analyze survival outcomes and to critically discuss prognostic factors. METHODS: We reviewed all cases of OPLS performed at our Institution from 1982 to 2016 for LC. Survival analysis by Kaplan-Meier estimate was performed and prognostic variables by multivariate analysis were identified. RESULTS: Mean follow-up time was 68.3 months, 30-day mortality 0.2%, subsequent functional total laryngectomy (TL) was 1.01%. Over 80% of cases were stage I to II. We had 25 local, 62 regional and eight distant recurrences. Local control was 94.9%, overall survival (OS) was 83.4% and disease-specific survival (DSS) was 87.7%. The two major risk factors significantly associated with the risk of death were cT and cN stage. CONCLUSIONS: We have confirmed that OPLS represents an oncologically sound option in the treatment of LC despite the emergence of non-surgical strategies and new transoral mininvasive techniques. Our results highlight that accurate staging, correct selection of the patient and a strong surgical expertise are of paramount importance in this type of surgery.

A nomogram to estimate the risk of developing distant metastases in parotid cancer.

BACKGROUND: Parotid cancer (PC) is a heterogeneous group of malignant tumors whose management mainly focuses on locoregional control. However, distant metastases (DM) can represent the most common cause of treatment failure. We have defined the predictors and developed a model that can predict a single patient's risk to develop DM. METHODS: We have analyzed our institutional database of 259 patients with PC and use it to develop a nomogram. C-index and calibration curves were used to assess performance of our model. RESULTS: DM appeared in 18.9% of patients. Age, cT, pN, perineural invasion, and adenoid cystic carcinoma were significantly associated with distant failure. CONCLUSIONS: We here present the first model to identify patients with PC at high risk of DM. Such tool can be of great value in managing these rare cancers in terms of a more precise prognosis and follow-up while waiting for better systemic therapies to come in the future.