Impact of COVID-19 on otolaryngology in Italy: a commentary from the COVID-19 task force of the Young Otolaryngologists of the Italian Society of Otolaryngology.

OBJECTIVE: The ongoing pandemic of coronavirus disease 2019 is having a dramatic effect on most medical disciplines. Otolaryngology Head and Neck Surgery is one of the most engaged disciplines, and otolaryngology specialists are facing a radical change of their role and daily activities that will have severe impact on the return to the ordinary. In this paper, the COVID-19 Task Force of the Young Otolaryngologists of the Italian Society of Otolaryngology comment on the changes that occurred for otolaryngology in Italy during the pandemic. Changes include organizational rearrangement of Otolaryngology Units, with merges and closures that affected a significant portion of them; reallocation of otolaryngology personnel, mainly to COVID-19 wards; reduction of elective clinical and surgical activity, that was mainly limited to oncology and emergency procedures; and execution of screening procedures for SARS-CoV-2 among healthcare providers and patients in otolaryngology units in Italy.

Rhinology Future Debates 2018, a EUFOREA Report.

The third Rhinology Future Debates was organized by the European Forum for Research and Education in Allergy and Airways diseases (EUFOREA) in 2018 in Brussels. Experts from different specialties and countries, alongside patients, health policy makers and industry representatives discussed relevant topics in Rhinology, in an attempt to improve current clinical practices, through implementation of precision medicine, by empowering patients' participation and the use of eHealth tools. The debates which are available on-line (www.rhinology-future.com) dealt with 5 topics in Rhinology: the adoption of allergen-specific immunotherapy (AIT) by implementing change management strategies, the needs and obstacles in care delivery in respiratory diseases, 3D technology in nose and sinus surgery, ambulatory nasal surgery, and clinical evidence for efficacy of biologicals in CRSwNP and asthma. This report summarizes the outcomes of the brainstorming sessions highlighting novel approaches and unmet needs in the field of respiratory diseases by focusing on integrated care pathways.

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.

Microvascular reconstruction two years after subtotal glossectomy: Is it worth it?

We ought to report an unusual case of a 49-year-old patient who underwent delayed reconstruction of the oral cavity defect, with an anterolateral thigh flap, two years after surgical demolition and adjuvant chemo-radiotherapy. At the end of oncologic treatment, he could not eat through oral route and presented evident speech articulation difficulties. After surgical reconstruction, swallowing assessment showed an improvement of swallowing with no gross signs of airways inhalation. His understandability of speech improved as well. Delayed reconstruction by a microvascular free flap with exclusive functional rehabilitation intent is feasible and may have satisfactory functional outcomes.

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.

Unravelling the risk factors that underlie oral and oropharyngeal surgery in elderly.

Oral squamous cell carcinoma (OSCC) diagnoses in elderly patients are expected to double in the next 20 years. Current guidelines suggest surgery as a preferred approach, but elderly patients are hardly considered suitable to challenging surgical treatments. Using a multi-centric retrospective analysis, we evaluated the outcomes of 99 patients affected by OSCC and aged at least 70, who underwent to either transoral procedures (TP), open neck resection without (OR) or with reconstruction (ORR). In our cohort, overall survival was significantly hampered by concomitant diseases and postsurgical complications, whose development is driven by the former. Thus, our findings support the growing acceptance that chronological age alone should not be a sufficient contraindication for aggressive surgery in the treatment of OSCC. However, elderly patients affected by OSCC are undoubtedly delicate surgical candidates and accurate selection prior to surgery with curative intent is mandatory.

Unravelling the risk factors that underlie laryngeal surgery in elderly.

Older patients are not considered good candidates to undergo more challenging therapeutic treatments, e.g. highly invasive surgery and complex chemotherapy. However, their exclusion from standard therapeutic options is not justifiable. Herein, we reviewed 212 patients aged ≥ 70, affected with laryngeal squamous cell carcinoma, and treated with transoral laser microsurgery or open neck (partial / total) laryngectomy with radical intent. The main aim was to compare patient outcomes to identify predictive factors that can be used by surgeons to choose the most appropriate treatment option. In our cohort, patients affected with more advanced tumour and hence treated by invasive open neck surgeries (above all TL) are more prone to develop complications and undergo fatal outcome than those with early disease treated by laser microsurgery, independently of age at surgery. In conclusion, elderly patients affected by laryngeal cancer can be treated similarly to younger patients, keeping in mind that more invasive surgeries are associated with a higher risk of developing complications. The advantages of mini-invasive surgery make it a possible first choice treatment in very old and frail patients suffering from laryngeal cancer, especially considering the recent success in treatment of some advanced stage tumours. Furthermore, comorbidities, by themselves, should not be used as exclusion criteria for subjecting an elderly patient to a different treatment that is from standard therapy.

Supratracheal laryngectomy: current indications and contraindications.

Cancer of the larynx in the intermediate/advanced stage still presents a major challenge in terms of controlling the disease and preserving the organ. Supratracheal partial laryngectomy (STPL) has been described as a function-sparing surgical procedure for laryngeal cancer with sub-glottic extension. The aim of the present multi-institutional study was to focus on the indications and contraindications, both local and general, for this type of surgery based on the long-term oncological and functional results. We analysed the clinical outcomes of 142 patients with laryngeal cancer staged pT2-pT4a who underwent STPL. Five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and loco-regional control (LRC) rates were: glottic pT2 [71.4%, 95.2%, 76.0%, 76.0%], glottic-transglottic pT3 [85.3%, 91.1%, 86.4%, 88.7%], and pT4a [73.2%, 88.1%, 52.7%, 60.7%], respectively. DFS and LRC prevalences at 5 years were greatly affected by pT4a staging. Five-year laryngeal function preservation (LFP) and laryngectomy free survival (LFS) were: glottic pT2 [90.9%, 95.2%], glottic-transglottic pT3 [84.4%, 93.1%], and pT4a [63.7%, 75.5%], respectively, being affected by pT staging and age 65 ≥ years (LFP 54.1%). As a result of Type III open horizontal partial laryngectomies (OPHLs) (supratracheal laryngectomies), the typical subsites of local failure inside the larynx were the mucosa at the passage between the remnant larynx and trachea, the mucosa at the level of the posterior commissure and the contralateral cricoarytenoid unit as well as outside the larynx at the level of the outer surface of the remnant larynx. For patients with glottic or transglottic tumours and with sub-glottic extension, the choice of STPL can be considered to be effective, not only in prognostic terms, but also in terms of functional results.

Analysis of risk factors for pharyngocutaneous fistula after total laryngectomy with particular focus on nutritional status.

Pharyngocutaneous fistula (PCF) is the most common complication following total laryngectomy and the most difficult to manage. It often causes increased morbidity, delays starting adjuvant therapy, prolongs hospitalisation, increases treatment costs and reduces the quality of life (QoL). The objective of this study is to analyse the predisposing factors and the most important nutritional parameters related to the development of PCF in patients undergoing total laryngectomy and to suggest medical alternatives that might improve results. We performed a retrospective study of 69 patients who underwent either primary or salvage total laryngectomy in our department between January 2008 and January 2012. Risk factors for fistula formation were analysed including tumour characteristics (histology, grading, AJCC stage), treatment (primary or salvage surgery, extent of resection, flap reconstruction, preoperative radiotherapy), comorbidity and nutritional status (preoperative haemoglobin, albumin and prealbumin levels and their changes during hospitalisation). Twenty-four patients developed a PCF (overall incidence 34.8%). Fistula formation was significantly higher in patients with diabetes, preoperative malnutrition (identified from low preoperative albumin and prealbumin levels). After specific nutritional evaluation and support, no patient developed a PCF. Risk factors for PCF formation are extensively treated in the literature but identification of high-risk patients is still controversial. Our study demonstrates that nutritional status of the patient, assessed by preoperative albumin, is also an important risk factor for PCF formation in addition to classical factors. Maintenance of a normal perioperative nutritional status can be helpful to avoid this complication.

Aesthetic comparison between synthetic glue and subcuticular sutures in thyroid and parathyroid surgery: a single-blinded randomised clinical trial.

The aim of our study was to compare, in terms of aesthetic results, the use of synthetic glue to intradermal absorbable sutures in postthyroidectomy and parathyroidectomy wound closure in a single blinded, randomised, per protocol equivalence study. From September 2008 to May 2010, patients undergoing thyroid or parathyroid surgery (with an external approach) at the Otolaryngology Department of the University Hospital of Modena were assessed for eligibility. In total, 42 patients who had had synthetic glue application on surgical incisions (A) and 47 patients who had subcuticular sutures on their surgical incisions (B) were enrolled. The mean of the endpoint (based on the Wound Registry Scale) of group A at 10 days was 1.4, while that in group B (based on the Stony Brook Scar Evaluation Scale) was 2.9. Statistically significant (p = 0.002) and clinically significant (difference of the means = 1.5) differences in the aesthetic results were found between groups A and B at 10 days, with better results in group B. On the other hand, at 3 months, the mean of the endpoint in group A was 3.1 while that in group B was 2.8; no statistically significant (p = 0.62) or clinically significant (difference in means = 0.3) differences were found between groups A and B. In conclusion, synthetic glue differs from subcuticular suture in post-thyroidectomy or post-parathyroidectomy incision for early aesthetic results, with better outcomes for subcuticular sutures. At 3 months, there were no differences in aesthetic outcomes between groups. Moreover, sex, incision length, age, cold/hot blade and correspondence of the incision with a wrinkle in the skin did not seem to influence aesthetic outcomes with this type of incision.

Therapy of unilateral vocal fold paralysis with polydimethylsiloxane injection laryngoplasty: our experience.

The objective of this study was to document functional results and to compare objective and subjective voice measures after endoscopic laryngoplasty with injection of polydimethylsiloxane (PDMS) for the treatment of unilateral vocal fold paralysis, and to verify PDMS biocompatibility in vocal fold. The design used was a longitudinal prospective study. Fifteen patients with unilateral vocal fold paralysis underwent endoscopic injection of PDMS in general anesthesia. Accurate voice evaluation protocol (acoustic and aerodynamics analyses, GIRBAS [Grade, Instability, Roughness, Breathiness, Asthenia, and Strain] scale, videostrobolaryngoscopy, and Voice Handicap Index test) before, after surgery, and at follow-up time was performed. The median follow-up was 21.7 months (range, 6-35). Data obtained were statistically significant. All acoustic, aerodynamics, perceptive, and subjective evaluations showed a significant improvement. No complications due to PDMS were reported. Functional results were found comparable to framework surgery. Endoscopic injection laryngoplasty with PDMS is a safe and long-term option for treatment of unilateral vocal fold paralysis.

"Collision" metastasis from unknown primary squamous cell carcinoma and papillary microcarcinoma of thyroid presenting as lateral cervical cystic mass.

We report an unusual case of "collision metastasis". In a single lymph node, we found a metastatic mass composed of two immunohistochemically distinct components originating from two primary tumors: a papillary microfollicular thyroid cancer and an unknown primary squamous cell carcinoma. The clinical features and immunohistochemical profile are reported. Collision phenomena in oncology are extremely rare and pose diagnostic and management challenges which are discussed.

Outcome in right living related liver transplantation with branch-patch arterial reconstruction.

cRight lobe living liver transplantation is being performed worldwide with increased frequency. Difficult arterial reconstructions are often encountered because of small diameter or discrepancy between arterial stumps. The risk of arterial thrombosis is reported as high as 26%: microsurgical techniques have reduced this rate below 2%, increasing warm ischemia time. We have developed a new branch patch technique in living related liver transplantation using the donor cystic artery to create an enlarged patch anastomosis that enables increase in the vessel's diameter and therefore greater inflow to the liver. We have followed 8 patients treated with this technique. After more than 1 year (mean follow-up: 636 days) we did not observe any arterial thrombosis by Doppler ultrasound performed every 3 months. The mean resistance index was 0.68 (0.57-0.83-). Three patients died with functional graft without signs of thrombosis. We believe that the cystic artery branch patch technique is feasible in all cases. It is fast (mean time: 6.2 min), it allows a shorter warm ischemia time, and there is no increased risk of thrombosis.

[Outcome of isolated small bowel transplantation in adults: experience from a single Italian center]. / Risultati del trapianto di intestino isolato nell'adulto: esperienza di un singolo centro italiano.

AIM: Isolated small bowel transplantation is becoming the treatment of choice for adult patients with serious parenteral nutrition (PN) related complications: we report our three-year experience (December 2000-December 2003) from a single Italian center (Modena-Italy), with one of the larger European series. METHODS: We transplanted 14 patients, with a previous mean PN course of 27 months and a mean 21-month post-transplantation follow-up (range 3-36 months), obtaining a one-year actuarial survival rate of 92.3% with no intraoperative deaths. RESULTS: We lost 1 patient (7.2%), died for post-transplantation overwhelming sepsis following Cytomegalovirus (CMV) enteritis. Thirteen patients are alive, with one-year actuarial graft survival rate of 85.1%: 1 patient underwent graft removal (7.2%) for intractable severe acute rejection. Our immunosuppressive regimen was based on tacrolimus and 3 induction protocols: daclizumab (8 patients) with steroids, alemtuzumab (4 patients) and thymoglobulin (2 patients) without steroids. In 9 cases, we added sirolimus. Nine recipients experienced 22 episodes of acute cellular rejection (ACR), treated successfully in all cases but one. One patient (7.2%) was treated successfully for Post Transplant Lymphoproliferative Disease (PTLD) and is disease-free after 8 months. CONCLUSIONS: Small bowel transplantation can achieve optimal results depending on appropriate immunosuppressive management and candidate selection, added to shorter ischemia time and careful donor and graft selection.

Voluminous frontoethmoidal mucocele with epidural involvement. Surgical treatment by coronal approach.

The case is described of mucocele of the right frontoethmoidal sinus with bilateral maxillary sinusitis and a large polyp in the right nasal cavity. The mucocele had determined erosion of the anterior and posterior walls of the frontal sinus and superomedial wall of the orbit. The patient was operated upon by a surgical team comprising ENT and maxillofacial specialists. Right maxillary sinusotomy (Caldwell-Luc procedure) was performed, and an osteoplastic flap was prepared, repositioned in the canine fossa and fixed with a titanium plate. Debris was removed from the left osteomeatal complex during endoscopy. To reach the mucocele, an external surgical approach was used, through a bitemporal coronal cutaneous incision, according to Unterberger. This approach was used in order to gain better access to the area of the lesion and in order to make reconstruction easier, with a view to achieving good functional results without untoward scarring. The scalp was detached down to the root of the nose to allow optimal visualisation of the anterior area of erosion determined by the mucocele, and, after excision and removal of the latter from the bony walls, of the posterior bony breach and underlying dura mater. Another bony breach involved the medial and superior walls of the orbit. The nasofrontal canal was obliterated with bone fragments and Tissucol; the posterior breach, with Surgical and Tissucol. The orbit wall was repaired with high-density porous polyethylene sheeting; the frontal sinus was filled with fat. The anterior wall of the frontal sinus was repaired with two split of calvarial bone grafts harvested from the parietal bone and fixed with a titanium microplate. The morphological outcome of reconstruction was satisfactory, with no recurrences, as confirmed at post-operative follow-up, including computed tomography scan, at 5 months. Ocular motility and patency of the tear drainage system were also normal. No diplopia, or inflammation occurred.

[Musculoskeletal conditions of the upper and lower limbs as an occupational disease: what kind and under what conditions. Consensus document of a national working-group. ISPESL]. / Le affezioni muscolo-scheletriche degli arti superiori e inferiori come patologie professionali: quali e a quali condizioni. Documento di Consenso di un gruppo di lavoro nazionale. ISPESL.

BACKGROUND AND OBJECTIVES: In via of the progressive emergence in Italy of work-related musculoskeletal disorders, the EPM Research Unit decided to set up a national working group with the aim of producing a Consensus Document including methods and criteria as an initial attempt towards managing such diseases as true "listed" work-related diseases as is already done in the other European Union countries. The working group includes experts from INAIL, ISPESL, welfare assistance institutions, local prevention and health protection services: The group's research activity was included in ISPESL's funded research plan. CONTENTS: The Consensus Document includes a review of epidemiologic issues reported in the international literature, comments on the application of current legislation, observations on the guilt profiles of employers and occupational physicians, as well as medical-legal issues. The document proposes an analytical list of musculoskeletal disorders of upper (and lower) limbs and the operational criteria for identification of working activities involving a risk from upper limb biomechanical overload. In this case, more than on other occasions, it was realized how difficult it is to adopt consolidated task/risk/damage matrices since the same task may or may not be at risk depending both on the way the task is done and on the technical aspects (lines, work parts, procedures, tools) and organization (rate, rotas, breaks). CONCLUSIONS: For the specific aims of the present document, it is possible to identify, though not exhaustively and with some limitations, a series of jobs and working conditions where the risk may be reasonably presumed and for which it is possible to adopt a list system (at least as regards "significant exposure"). The document also includes a chapter on health surveillance recommendations for the occupational physician.