Persistent COVID-19 parosmia and olfactory loss post olfactory training: randomized clinical trial comparing central and peripheral-acting therapeutics.

PURPOSE: Although COVID-19 anosmia is often transient, patients with persistent olfactory dysfunction (pOD) can experience refractory parosmia and diminished smell. This study evaluated four putative therapies for parosmia in patients with chronic COVID-19 olfactory impairment. METHODS: After screening nasal endoscopy, 85 patients (49 female, 58%) with pOD and treatment-refractory parosmia were randomized to: (1) ultramicronized palmitoylethanolamide and luteolin + olfactory training (OT) (umPEALUT group, n = 17), (2) alpha-lipoic acid + OT (ALA group, n = 21), (3) umPEALUT + ALA + OT (combination group, n = 28), or 4) olfactory training (OT) alone (control group, n = 23). Olfactory function was assessed at baseline (T0) and 6 months (T1) using a parosmia questionnaire and Sniffin' Sticks test of odor threshold, detection, and identification (TDI). Analyses included one-way ANOVA for numeric data and Chi-Square analyses for nominal data on parosmia. RESULTS: The umPEALUT group had the largest improvement in TDI scores (21.8 ± 9.4 to 29.7 ± 7.5) followed by the combination group (19.6 ± 6.29 to 27.5 ± 2.7), both p < 0.01. The control and ALA groups had no significant change. Patients in the combination and umPEALUT groups had significantly improved TDI scores compared to ALA and control groups (p < 0.001). Rates of parosmia resolution after 6 months were reported at 96% for combination, 65% for control, 53% for umPEALUT and 29% for ALA (p < 0.001). All treatment regimens were well-tolerated. CONCLUSIONS: umPEALUT and OT, with or without ALA, was associated with improvement in TDI scores and parosmia, whereas OT alone or OT with ALA were associated with little benefit.

Modified Valente Technique for Cauliflower Ear: Outcomes in Children at Two-Year Follow-Up : New Surgical Technique for Cauliflower Ear.

BACKGROUND: Cauliflower ear deformity, a common sequela of auricular trauma, presents an esthetic and reconstructive challenge. Existing surgical techniques have limitations, including complexity, donor site morbidity, and variable long-term outcomes. MATERIALS AND METHODS: In this case series, we present a novel and minimally invasive surgical approach for the correction of cauliflower ear deformity that adapts the Valente otoplasty technique; it combines cartilage debulking with helical rim release and Mustardé mattress stitches to restore ear contour and reduce the risk of recurrence. The procedural steps include bielliptic post-auricular skin and soft tissue incision, release of the cartilaginous spring, removal of excess fibrocartilaginous tissue, cartilage reshaping with suture to restore contour, and tissue redistribution to promote adherence of skin to the cartilage framework. RESULTS: Outcomes were evaluated in 7 patients (9 ears) with cauliflower ear deformity, assessing surgical duration, complications, patient satisfaction, and esthetic outcomes at two years after surgery. The mean surgical duration per patient was 52 ± 17 minutes, including 2 bilateral procedures. Follow-up at 24 months showed favorable esthetic outcome in all patients with sustained improvements in auricular contour and symmetry with neither loss of the shape nor recurrence of deformity. Patients reported high satisfaction and improved quality of life, with mean Glasgow Children Benefit Questionnaire scores of 99.3 ± 6.3. CONCLUSIONS: This technique thus demonstrated lasting correction of cauliflower ear with favorable cosmetic outcomes, low risk of complications, and high patient satisfaction. Further investigations and longer-term follow-up are warranted to validate the technique's durability and expand its application to older and more diverse patient populations. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of contents or the online Instructions to Authors www.springer.com/00266 .

Use of Nutraceuticals in Elderly to Fight Inflammation and Immuno-Senescence: A Randomized Case-Control Study.

Elderly people are at high risk of suffering from infection and being affected by severe forms of disease because their immunosystem suffers from aging. The alteration of normal immune functions causes the increase of pro-inflammatory cytokines which can expose these people to increased risk of developing pathologies as cancer, diabetes, and/or arthritis. Some supplements could be helpful for restoring normal immune functions. We conducted a case-control study to evaluate the efficacy of a supplement containing Sambucus nigra, zinc, tyndallized Lactobacillus acidophilus (HA122), arabinogalactans, vitamin D, vitamin E, and vitamin C to improve the inflammatory levels (IL-6 and CRP) and to modulate the lymphocytes growth. Additionally, we analyzed wellness by self-questionnaire. This study had two control group: a young group and an elderly one. Our study showed that treating elderly patients with the supplement for 30 days improved IL-6, CRP, and lymphocytes levels; the result was independent from the dosage of the supplements used. Elderly patients, despite the improvement, were not able to reach the same conditions of young patients; however, most of the patients (>70%) claimed to "feel better" after the use of the supplement. The use of this supplement should be considered at a low dosage for a prolonged period to reduce inflammation and modulate immune senescence in patients over 60 years old.

Longitudinal randomized study to evaluate the long-term outcome of endoscopic primary dacryocystorhinostomy with or without silicone tube.

OBJECTIVE: Dacryocystorhinostomy (DCR) is indicated for the treatment of nasolacrimal obstruction with some authors suggesting the use of a silicone tube (stent) to maintain rhinostomy patency a long time. This study aims at comparing the results of endoscopic-DCR (En-DCR) with and without silicone stenting. METHODS: A randomized prospective study was conducted from January 2013 to January 2018, following patients for up to 72 months. Sixty outbound patients suffering from chronic epiphora for primary acquired nasolacrimal duct obstruction were simply randomized and assigned to En-DCR with "silicone stent tube" (SST) or "no silicone stent tube" (NSST) group. Data about the results of the two procedures were collected using Munk' and Ali' assessments. The results were statistically compared to evaluate the differences. RESULTS: 30 patients were in the SST group and 30 in NSST. In the SST group, the tube remained in place for 3-6 months (4.1 ± 1.2 months). The follow-up period was 12-72 months (48.3 ± 6.2 months). Success rates (Junk and Javed Ali assessments) were, respectively, 97% in SST and 90% NSST group, with no statistical difference (Student's test). On a long-term follow-up, SST patients had an increased risk of re-stenosis by 14 months. CONCLUSIONS: Our results showed there were not benefit in using tube, in the opposite it increased risk of re-stenosis. Despite preliminary results, our data confirmed comparing the two methods that silicone tube should not be used.

Covid-19 negatively impacted on small oncology surgery but none on major procedures: Regional experience.

AIM: To understand the impact of COVID pandemic on the activity and patients' care of the Head and Neck regional Unit, temporary moved in a COVID-free hospital. METHODS: We retrospectively analyzed the yearly activity of the "Head & Neck Cancer Unit" at the Azienda Ospedali Riuniti Marche Nord (Italy) during 2020 (COVID-19 pandemic) and we compared it with the one performed in 2019. Statistical analyses were performed using Chi-square. RESULTS: No significant differences were observed comparing the total number of patients treated for H&N squamous cell carcinoma (SCC) in 2019 with the ones in 2020. Moreover, no differences were identified in term of cancer stage at the moment of the surgery between 2019 and 2020. On the contrary, a significant reduction in the number of surgical procedures carried out for thyroid (p < 0.05) and skin (p < 0.001) malignancies was identified. CONCLUSIONS: Despite Covid-19 limitations, our institution was able to preserve the number of major oncologic procedures without negative impact on patients' care. We believe that the creation of specific COVID-free hospital can be the key preserve quality of care in epidemic emergency.

Misinterpretation of head and neck masses can delay the correct diagnosis. A two-step demolitive-reconstruction surgery for saving patient's life.

OBJECTIVE: To present a rare case of sebaceous cyst masking skin squamous carcinoma. The delayed diagnosis made necessary a two-step (demolition and reconstruction) surgery to save patient's life. MATERIAL AND METHODS: A 77-year-old male, suffering from persistent right hemicrania and eye pain referred to different specialists, who misinterpreted his symptoms. The man presented on the right zygomatic area a big sebaceous cyst which masked a squamous cells carcinoma (SCC) infiltrating the surrounding structures including the orbito zygomatic complex and the orbital content that was the cause of the symptoms. Patient underwent biopsy, CT thorax and MRI of the head and neck as pre-operative examinations. A two-step surgery was performed to remove the tumor. RESULTS: The skin biopsy showed the presence of sun damaged skin contains moderately differentiated invasive SCC within the context of sebaceous cyst. While the CT chest was negative, the head and neck MRI showed a huge tumor invading the orbit and periorbital tissue, the zygomatic bone and the soft tissues up to the posterior orbital area, without presence of neck lymph nodes. Le lesion has been classified as cT4 N0 M0 (TNM 8) and a two-step surgery approach (demolition and reconstruction) was performed with successful results at 1 year-follow up. CONCLUSIONS: The delayed diagnosis of SCC was due to the misdiagnosis of the signs of the tumor invasion. Demolitive and reconstructive surgeries allowed to preserve patient's life. The careful attention to patient's skin characteristic, the analysis of general and local clinical signs (irradiated pain, cyst and skin type) and the evaluation of the complex differential diagnosis could be the key to avoid delayed treatment in head and neck cancer.

Quick septoplasty in children: Long-term effects on nasal breathing and dentofacial morphology. A prospective cephalometric study.

OBJECTIVE: Many authors have investigated the most appropriate surgical approach to the deviated septum in childhood, considering the obligate mouth-breathing habit a possible cause of malocclusion and disharmonious development of the facial skeleton in growing kids. Nevertheless, controversies still remain about the long-term functional/esthetic results of such procedures, mainly due to the duration of the follow-up and possible confounding factors. METHODS: 111 Caucasian children (age range: 6-13 years) were submitted to a personal "Quick" septoplasty surgical technique between 2005 and 2010. Preoperative otorhinolaryngological examination using flexible nasal endoscopy, anterior active rhinomanometry (AAR), Nasal Obstruction Septoplasty Effectiveness (NOSE) questionnaire, and dentofacial evaluation (including cephalometry) were performed. Postoperative AAR, NOSE questionnaire and cephalometric assessment were carried out in all patients at the age of 18 years. Informed consent was obtained from children's parents as appropriate. RESULTS: No surgical complication was recorded. Among our patients, a significant (p <0.001) improvement of nasal breathing resistances at AAR and NOSE questionnaire scores was found after surgery. A significant improvement in cephalometric/dental parameters (gonial angle values, anterior facial height, prevalence of class I occlusion, maxillary intermolar width, and cross-bite frequency) was noticed after the follow-up with respect to preoperative conditions. CONCLUSION: The "Quick" septoplasty technique described is a practical and conservative procedure with a low complication rate that offers long-term favourable results for the correction of nasal septum deviations in children. Nasal-breathing restoration may favor a physiological and harmonious development of craniofacial and dental structures in offspring.

Metastatic signet ring cell gastric carcinoma bypassing Virchow's node: An unexpected etiology of a painful neck mass.

Metastatic lymph nodes of the head and neck are often associated with locoregional spread of mucosal squamous carcinoma, but in rare instances visceral malignancies may bypass Virchow's node. The possibility of distant metastasis should be considered.

Endoscopic "Quick" Septoplasty in Preservation Rhinoplasty.

BACKGROUND: Preservation rhinoplasty (PR) is revolutionizing rhinoplasty surgery, based on new anatomical studies, advanced tip suture techniques, and refinement of surgical techniques. Septal surgery is a fundamental preparatory stage during PR, especially for the dorsal preservation let/push-down procedure. To increase the predictability of the septoplasty aesthetic effects on the nasal dorsum and further extend the principles of PR to septal surgery, we applied the endoscopic technology to the "quick" septoplasty technique we had already developed in the past decades. METHODS: One hundred sixty-six patients (41 males, 125 females; mean age, 39.7 years; age range, 18-61 years) were submitted to endoscopic "quick" septoplasty for septal deviation during PR procedure. Preoperative evaluation of the nasal dorsum included external examinations of the size, shape, and orientation of the dorsum. Anterior active rhinomanometry was performed in all patients to determine nasal flow resistance preoperatively and 6 months after surgery. Preoperative and postoperative patients' scores on the Nasal Obstruction Septoplasty Effectiveness questionnaire were compared to assess the improvement of nasal symptoms after surgery. The duration of the septoplasty procedure was measured for all the patients. Standard nasal photographic assessment was performed before and 6 months after surgery. RESULTS: Postoperatively, 98.8% of our patients displayed an improvement of their nasal breathing function. No complication in terms of septal perforation, nasal infection, or bleeding was noticed. No case of turbinoseptal synechiae or cerebrospinal fluid leak was recorded. The dorsum preservation rhinoplasty procedure was successfully completed in all patients. The mean septoplasty operative time, excluding local anesthesia injection and other surgical procedures associated with septal surgery such as turbinoplasty and rhinoplasty, was 11.41 ± 6.23 minutes (range, 9-31 minutes). CONCLUSIONS: Our results show that a short surgical time is needed to perform the proposed endoscopic septoplasty procedure. Such a short operative time allows the physician to both correct septal deviations quickly and correct/reduce the cartilaginous hump, thus representing a fundamental element of PR. In addition, the minimal tissue dissection reduces intraoperative nasal edema, favoring intraoperative aesthetic evaluation.

Olfactory Dysfunction in COVID-19 Patients: Prevalence and Prognosis for Recovering Sense of Smell.

While olfactory dysfunction associated with coronavirus disease 2019 (COVID-19) has attracted considerable interest, few studies have tracked outcomes at serial time points or beyond 2 weeks. Furthermore, data are conflicting regarding whether COVID-19 severity correlates with degree of olfactory dysfunction. This prospective case-control study analyzed prevalence and severity of subjective loss of smell in outpatients (n = 23) and inpatients (n = 20) with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection vs healthy controls (n = 25). Olfactory dysfunction was reported more commonly in COVID-19 patients than in healthy controls (P < .001), and outpatients paradoxically reported loss of smell more commonly than inpatients (P = .02). Headaches were present in 52% of patients with olfactory dysfunction. Anosmia or hyposmia persisted beyond 5 days but most of the patients recovered by 30 days, suggesting favorable prognosis for olfaction. Differences between inpatients and outpatients are potentially reflective of timeline of olfactory symptoms and contextual factors, underscoring the importance of corroborative objective testing, coupled with careful tracking of temporal relationships.

Airway obstruction from tracheostomy balloon cuff herniation during oral cancer removal. Emergency successfully managed and lessons learnt from device malfunction.

OBJECTIVE: Tracheostomy tube cuff balloon herniation is a rare event and can determine airway obstruction. Sometimes the obstruction is not very evident but, if it is not correctly solved, can determine a severe hypoxia with patient's death. MATERIAL AND METHODS: We present a 49-year-old male patient, with cT4aN0M0 squamous cell carcinoma of the oral cavity, who was admitted to the hospital for definitive surgical resection. Due to mass an endo-oral intubation was not possible, so a surgical tracheotomy was performed. General anaesthesia was induced with Propofol (2 mg/kg) and Fentanil (1 mcg/kg) without gas. Surgery commenced via a trans-oral and trans-cervical approach, but it was halted after approximately 2 min as oximetry demonstrated a progressive fall from 98% to 78%. After confirmation of correct function of anaesthetic devices, the endotracheal cannula was tested; although surgeon deflated the tube cuff, repositioned the tube, and re-inflated the cuff, oxygen saturation did not change. So, the cannula was changed and patient's saturation increased up to normal value. RESULTS: The balloon cuff of the cannula showed a herniation, responsible of insufficient ventilation. CONCLUSIONS: Cuff herniation should be considered in case of unexpected airway obstruction, and a systematic, rapid approach to investigation and management should ensure timely identification and correction.

Narrow band imaging in head and neck unknown primary carcinoma: A systematic review and meta-analysis.

OBJECTIVE: To estimate the diagnostic performance of Narrow Band Imaging (NBI) in patients with cervical metastasis from head and neck squamous cell carcinoma of unknown primary (SCCUP) origin. METHODS: PubMed, Embase, and Scopus databases were systematically scrutinized up to July 1, 2019, looking for studies that encompassed the NBI in the SCCUP diagnostic work up. The main inclusion criteria for eligible articles for the meta-analysis were non-evidence of primary tumor after physical examination and conventional cross-section imaging before NBI assessment and the availability of complete data on the diagnostic accuracy of NBI. A set of random-effects model meta-analyses was then performed following the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. RESULTS: Five studies, conducted between January 2003 and September 2016, comprising 169 patients imaged with NBI, were included in the meta-analysis. The pooled sensitivity and specificity of NBI in patients with head and neck SCCUP was 0.83 (99% CI, 0.54-0.95) and 0.88 (99% CI, 0.55-0.97), respectively. The positive and negative likelihood ratios were 6.38 (99% CI, 1.6-25.44) and 0.06 (99% CI, 0.005-0.86). The pooled diagnostic odds ratio (DOR) was 82.15 (99% CI, 7.06-955). The overall detection rate of NBI was 0.35 (99% CI, 0.18-0.53), which allowed localization the primary tumor in 61 out of 169 patients, otherwise not detected by the usual diagnostic work-up. CONCLUSIONS: Current available evidence suggests that NBI has a considerable diagnostic accuracy in patients affected by head and neck SCCUP. Laryngoscope, 130:1692-1700, 2020.

Endoscope-assisted retrosigmoid approach in hemifacial spasm: our experience / Abordagem retrosigmóidea assistida por endoscopia em espasmo hemifacial: nossa experiência

Abstract Introduction: The use of surgical decompression of facial hemispasm due to the loop in the internal auditory canal is not always accepted due to the risk related to the surgical procedure. Currently a new surgical technique allows surgeons to work in safer conditions. Objective: To report the results with endoscope-assisted retrosigmoid approach for facial nerve microvascular decompression in hemifacial spasm due to neurovascular conflict. The surgical technique is described. Methods: We carried out a prospective study in a tertiary referral center observing 12 (5 male, 7 female) patients, mean age 57.5 years (range 49-71) affected by hemifacial spasm, that underwent to an endoscope assisted retrosigmoid approach for microvascular decompression. We evaluated intra-operative findings, postoperative HFS resolution and complication rates. Results: Hemifacial spasm resolution was noticed in 9/12 (75%) cases within 24 h after surgery and in 12/12 (100%) subjects within 45 days. A significant (p < 0.001) correlation between preoperative historical duration of hemifacial spasm and postoperative recovery timing was recorded. Only 1 patient had a complication (meningitis), which resolved after intravenous antibiotics with no sequelae. No cases of cerebrospinal fluid leak, facial palsy or hearing impairment were recorded. Hemifacial spasm recurrence was noticed in the only subject where the neurovascular conflict was due to a vein within the internal auditory canal. Conclusions: The endoscope assisted retrosigmoid approach technique offers an optimal visualization of the neurovascular conflict thorough a minimally invasive approach, thus allowing an accurate decompression of the facial nerve with low complication rates. Due to the less invasive nature, the procedure should be considered in functional surgery of the cerebellar pontine angle as hemifacial spasm treatment, specially when the procedure is performed by an otolaryngologist.

Resumo Introdução: O uso de descompressão cirúrgica do espasmo hemifacial devido ao loop no canal auditivo interno nem sempre é aceito devido ao risco relacionado ao procedimento cirúrgico. Atualmente, uma nova técnica cirúrgica permite trabalhar em condições seguras. Objetivo: Relatar os resultados que obtivemos com a abordagem retrosigmóidea assistida por endoscopia para a descompressão microvascular do nervo facial em casos de espasmo hemifacial devido a conflito neurovascular. A técnica cirúrgica é descrita. Método: Realizamos um estudo prospectivo em um centro de referência terciária observando 12 pacientes (5M, 7F), com média de idade de 57,5 (intervalo 49-71) anos com espasmo hemifacial submetidos a uma abordagem retrosigmóide assistida por endoscopia para descompressão microvascular. Foram avaliados os achados intraoperatórios, a resolução pós-operatória do espasmo hemifacial e as taxas de complicações. Resultados: A resolução do espasmo hemifacial foi observada em 9/12 (75%) dos casos nas 24 horas após a cirurgia e em 12/12 (100%) dos indivíduos até 45 dias. Uma correlação significativa (p < 0,001) entre a duração do histórico pré-operatório de espasmo hemifacial e o tempo de recuperação pós-operatório foi registrado. Apenas um paciente apresentou uma complicação (meningite), que foi resolvida após administração de antibióticos por via intravenosa sem sequelas. Nenhum caso fístula liquórica, paralisia facial ou deficiência auditiva foi registrado. A recorrência do espasmo hemifacial foi observada em único indivíduo em quem o conflito neurovascular foi causado por um vaso no interior do canal auditivo interno. Conclusões: A técnica da abordagem retrosigmóidea assistida por endoscopia oferece uma ótima visualização do conflito neurovascular através de uma abordagem minimamente invasiva, permite assim uma descompressão precisa do nervo facial com baixas taxas de complicações. Por ser menos invasivo, o procedimento deve ser considerado na cirurgia funcional do ângulo pontocerebelar como tratamento de espasmo hemifacial, especialmente quando o procedimento é feito por um otorrinolaringologista.

Endoscope-assisted retrosigmoid approach in hemifacial spasm: our experience.

INTRODUCTION: The use of surgical decompression of facial hemispasm due to the loop in the internal auditory canal is not always accepted due to the risk related to the surgical procedure. Currently a new surgical technique allows surgeons to work in safer conditions. OBJECTIVE: To report the results with endoscope-assisted retrosigmoid approach for facial nerve microvascular decompression in hemifacial spasm due to neurovascular conflict. The surgical technique is described. METHODS: We carried out a prospective study in a tertiary referral center observing 12 (5 male, 7 female) patients, mean age 57.5 years (range 49-71) affected by hemifacial spasm, that underwent to an endoscope assisted retrosigmoid approach for microvascular decompression. We evaluated intra-operative findings, postoperative HFS resolution and complication rates. RESULTS: Hemifacial spasm resolution was noticed in 9/12 (75%) cases within 24h after surgery and in 12/12 (100%) subjects within 45 days. A significant (p<0.001) correlation between preoperative historical duration of hemifacial spasm and postoperative recovery timing was recorded. Only 1 patient had a complication (meningitis), which resolved after intravenous antibiotics with no sequelae. No cases of cerebrospinal fluid leak, facial palsy or hearing impairment were recorded. Hemifacial spasm recurrence was noticed in the only subject where the neurovascular conflict was due to a vein within the internal auditory canal. CONCLUSIONS: The endoscope assisted retrosigmoid approach technique offers an optimal visualization of the neurovascular conflict thorough a minimally invasive approach, thus allowing an accurate decompression of the facial nerve with low complication rates. Due to the less invasive nature, the procedure should be considered in functional surgery of the cerebellar pontine angle as hemifacial spasm treatment, specially when the procedure is performed by an otolaryngologist.