Paediatric endoscopic endonasal middle skull base reconstruction: retrospective analysis of 78 patients treated in a single tertiary care paediatric center.

INTRODUCTION: Skull base pathologies in the paediatric population are rare and require treatment by multiple qualified specialists. The endoscopic endonasal approach has revolutionized surgical treatment because it is less invasive than existing treatments.The goal of this study was to retrospectively review our experience with the reconstruction of paediatric skull middle base defects and associated complications. MATERIALS AND METHODS: We analysed medical records from patients aged ≤ 18 years who were treated at our centre between 2013 and 2021. Patients treated with an endoscopic skull base approach and reconstruction, and who had complete clinical and radiological documentation and a minimum follow-up of 12 months, were included in the analysis. Personal data, reconstructive techniques, and complications were analysed. RESULTS: A total of 78 patients met the inclusion criteria and were enrolled in the study. Of these patients, 32 were male and 46 were female, and the mean age was 11.5 years. The main signs and symptoms were as follows: bitemporal hemianopsia in 53 cases, visual impairment in 23 cases, and headache in 30 cases. The most frequent aetiologies were craniopharyngioma (38 cases), pituitary adenoma (23 cases), and clivus chordoma (4 cases). All patients were treated via a pure endoscopic approach. For reconstruction, a multilayer technique was used in 18 cases, naso-septal flap in 43 cases, Gasket-Seal technique in 12 cases, and heterologous reconstruction in 5 cases. Only six patients presented a major complication: two had a postoperative cerebral spinal fluid leak, one developed a brain abscess, and three had diabetes insipidus.The mean follow-up period was 23.4 months.There were no statistically significant differences in postoperative CSF leak in relation to different reconstructive techniques. CONCLUSION: Endoscopic endonasal skull base surgery is a safe and effective treatment for paediatric middle skull base pathologies. Reconstruction techniques have a high success rate of 96.5-100%, and the rate of associated complications is < 3%.

Secondary Rhinoplasty in Binder Syndrome: Considerations and Management of Complex Problem With Heterologous Bone Graft.

ABSTRACT: Binder Syndrome occurs in less than 1 per 10,000 live births. Mean features of the syndrome include arhinoid face, abnormal position of the nasal bones, intermaxillary hypoplasia with associated malocclusion, reduced or absent anterior nasal spine, atrophy of the nasal mucosa and absence of the frontal sinus. Treatment of these facial deformities is obviously surgical. In the present work, the authors describe, step by step, their technique in secondary rhinoplasty in a 36-years-old patient affected by Binder Syndrome. In this case, the authors used autologous cartilage graft and heterologous bone graft.Satisfying results are achieved in 12 months of follow-up: graft resorption is acceptable, position of the graft is stable, the authors have no signs of infection and the patient is satisfied with the aesthetical and functional results. The authors believe that the first option, in complex nose's reconstruction, is the use of autologous grafts but, the use of cartilage heterologous bone graft should be taken in account, in the future, as a secondary option in Binder Syndrome and in malformed patients.

Endoscopic Forehead Approach for Minimally Invasive Frontal Osteoma Excision.

Benign osseous tumors of the frontal bone can be treated with endoscopic surgery, minimizing postoperative complications associated with the coronal approach and guaranteeing more functional and aesthetic results. The authors describe a case of a patient who had endoscopic removal of osteoma of the forehead using two 1 cm incisions behind the hairline. No complications such as hematoma and edema were detected. Endoscopic technique offered both good illumination and excellent magnification; it permitted safe anatomic dissection, minimum bleeding, avoiding visible scars. The outcome achieved with endoscopic technique could be the first-line surgical treatment of benign bone tumors of the frontal area, offering more advantages and better results than the conventional surgical approaches.

Endoscopy-Assisted Intraoral Removal of Elongated Styloid Process: Mini-Invasive Surgical Treatment of Eagle Syndrome.

The aim of this work is to illustrate a transoral mini-invasive approach to safely remove elongated styloid process in Eagle syndrome. A 34-year-old Asian male came to our center referring pharyngeal and cervical pain on the right side on swallowing and opening the mouth. Computed tomography showed elongation of the right styloid process. Surgical removal was performed through endoscopy-assisted intraoral approach using a pituitary curette to perform dissection and piezosurgery for the osteotomy. Surgical intervention was completed in 25 minutes. Postoperative period was uneventful except for transient (12 hours) right facial palsy that resolved spontaneously. Two months after surgery, patient referred resolution of symptoms. This technique is easy to perform and permits to obtain good result with reduction of surgical time and with low risk of complication.

Minimally-Invasive Endoscopic-Assisted Sinus Augmentation.

OBJECTIVES: The purpose of this article is to evaluate endoscopic-assisted technique by lateral approach for sinus floor augmentation, to reduce the incidence of Schneiderian membrane perforation, and to guarantee a sufficient apposition of new bone even in the posterior maxillary sinus. METHODS: From January 2017 to December 2017, 10 patients affected by severe maxillary atrophy underwent endoscopic-assisted sinus augmentation using a lateral approach. RESULTS: In only 1 patient, a little perforation of sinus membrane was observed intraoperatively and it was repaired. No abnormal postoperative bleeding was observed. None of the patients experienced oro-antral fistula, infection, or V2 dysesthesia. The authors did not find radiologic evidences of biomaterial displaced on the maxillary sinus or postoperative sinusitis. CONCLUSIONS: The authors evaluated endoscopic-assisted maxillary sinus augmentation technique using a lateral approach that allows a direct and clear view of the surgical field. This technique, as the preliminary results demonstrate, is safe and helpful, especially in avoiding membrane perforation and in xenograft optimal distribution. It could be very useful in retreatment patients.

Maxillo-Mandibular Reconstruction in Pediatric Patients: How To Do It?

Maxillo-mandibular reconstruction in pediatric patients involves particular functional and cosmetic implications. Attention is required for the craniofacial growth over time, involvement of the permanent dentition, facial symmetry, and donor site morbidity. Our aim is to identify the best reconstructive options for maxilla-mandibular defects in children (<18 years) based on our experience with 25 pediatric patients. We believe that reconstruction has to be performed at the same time as resection in pediatric patients. Local flaps should be reserved for cases of maxillary defects because of malignant neoplasms, which ultimately have poor prognosis. In cases of large mandibular defects, radiotherapy is eventually required. When the condition of the soft tissues is poor (because of previous surgery, etc), free flaps potentially represent the best options. Nevertheless, in patients younger than 5 years old (with no damaged tissues), reconstruction with rib grafts should be performed, and the use of titanium plates should be reserved for very select cases (such as temporary reconstruction in toddlers).

Endoscopic sinus surgery in sinus-oral pathology.

OBJECTIVE: Oral surgery is compounded by safe and well-known techniques and presents a low rate of complications. When the superior alveolar ridge is approached, surgery may result in oroantral fistula or tooth or implant dislocation in maxillary sinus. Those conditions lead to development of the maxillary sinusitis that, if underestimated, may evolve in orbital cellulitis and cerebritis or cerebral abscess. Our work aimed to compare the surgical techniques suitable for treatment of those complications and define the better surgical strategy. METHODS: Between 2005 and 2010, 55 patients, presenting with displaced or migrated oral implants in the paranasal sinuses, with oroantral communication or with paranasal sinusitis of odontoiatrogenic origin, were visited and referred for treatment in the Maxillofacial Surgery Department of the University of Rome "La Sapienza." Surgical treatment consists of one of the following procedures: functional endoscopic sinus surgery (FESS); intraoral approach to the sinus with Caldwell-Luc technique; and oroantral fistula closure with a local flap, alone or combined with FESS. RESULTS: The study group consisted of 55 patients: 28 female and 27 male patients aged 43 to 78 years (mean, 60 years). All had undergone oral surgery before our first visit: 17 patients had a prosthetic implant surgery (3 lateral-approach sinus augmentation and 15 implant placement). Seventeen patients had tooth extractions, 7 did root canal treatments, and 14 had sinus maxillary augmentation. CONCLUSIONS: Functional endoscopic sinus surgery has slowly taken the place of the Caldwell-Luc technique in treating odontogenic maxillary sinusitis. Advantages of FESS are the less invasivity, the preservation of sinus anatomy and physiology, the reduction of recovery time, and oral rehabilitation without loosening efficacy compared with the previous transoral approach.

The 'Maxillary Pull-through' Technique: A Minimally Invasive Endoscopic-Assisted Approach to Nasal Septum Neoformations with Maxillary Bone Infiltration.

Study Design: Description and validation of a surgical technique. Objective: En-bloc maxillectomy with removal of the nasal septum is a rare procedure; preservation of the nasal bones and integrity of the alveolar ridge is even rarer. These procedures traditionally required a combined transfacial-transoral approach based on lateral rhinotomy. We describe a combined endoscopic transnasal-transoral approach for treatment of nasal septal malignancies that involve the hard palate. Methods: Excision of malignant tumours arising from the nasal septum was achieved in 4 patients using a transnasal-transoral endoscopic approach. Using 4-mm optics angled at 0° and 30°, the septum was freed from the ethmoid and removed en-bloc with the hard palate, by pulling the septum down through the hard palate. Results: Of the 4 patients, 2 underwent complete removal of septal chondrosarcomas, one removal of a sinonasal undifferentiated carcinoma and one removal of a mucoepidermoid carcinoma. In two cases, the palatal mucosa was spared and repositioned to restore separation between the nose and oral cavity. The remaining two cases underwent complete resection of the hard palate; one palate was reconstructed using a pedicled temporalis muscle flap and the other by employing an obturator. No infection was encountered. Partial ethmoidectomy was performed in all four cases. The mean hospital stay was 5 days. All patients are free of disease after a mean follow-up of 4 years (range: 2-7 years). Conclusions: Our new approach allows for minimally invasive resection of nasal septal malignancies that extend to the palate. Our maxillary pull-through technique is a valuable new surgical procedure for malignant pathologies of the nasal septum; the only drawback is that endoscopic surgery has a steep learning curve.

Role of functional and anatomic study in sleep endoscopy for treatment of OSA.

Objective: To describe a clear and intuitive way to analyse the anatomical meaning of images observed in Drug-induced Sleep Endoscopy (DISE) to fully understand the obstructive dynamics and therefore opt for a tailor-made pharyngeal surgical technique. Methods: From January 2016 to December 2020, 298 patients who underwent DISE were selected according to inclusion criteria. Results: The case series consisted of 204 males and 94 females with a mean age of 56 years. Body mass index ranged from 19 kg/m2 to 34 kg/m2 with a median of 26.5 kg/m2. Median Apnoea-Hypopnea Index (AHI) was 27 (range 5-62.3). The authors also observed four palate pharyngeal phenotypic patterns of collapse and clarify the morphology and role of the main muscles involved in upper airway collapse. Conclusions: DISE is fundamental to determine the collapse site in patients affected by obstructive sleep apnoea syndrome. The velopharyngeal region is the most common site of obstruction and lateral pharyngeal wall collapse is the major determining factor. DISE can lead to a deeper understanding of the obstructive dynamic patterns and a more precise identification of the muscle bundles responsible for upper airway collapse.

Orbital lesions, an interdisciplinary pathology. The experience of the maxillo-facial surgeons.

AIM: The main focus of this paper was to describe our experience in the management of primary lesions involving the orbit, analyzing signs and symptoms and illustrating surgical management. MATERIAL OF STUDY: We describe our experience managing 62 consecutive patients diagnosed with orbital tumors confined to the orbital content (not involving skin or bone, with no intracranial invasion) and treated between January 2013 and December 2016. Demographic characteristics, symptoms, clinical findings, histological types and approaches have been recorded. RESULTS: We found that the most common clinical manifestations were exophthalmos/proptosis and ocular movement impairment; the most common histological types were vascular malformation and ocular adnexal lymphomas. DISCUSSION: Primary neoplasms involving orbital contents include a broad spectrum of pathologies difficult to manage without a firm diagnosis, usually histological. Different surgical accesses are described in order to perform incisional biopsy or resection of the mass. CONSCLUSION: In every case, accurate surgical planning is mandatory, in order to prevent functional and/or aesthetic complications. KEY WORDS: Blepharoplasty incision, Intraorbital neoplasia, Lateral orbital tumor, Orbitotomy, Surgical treatment, Transconjunctival approach.

Management of orbital and brain complications of sinusitis: A practical algorithm.

The aim of this work was to present a practical management algorithm for orbital and brain complications of sinusitis. According to the inclusion criteria, a sample of 68 patients was collected between 2008 and 2018 (39 males and 29 females). Among them, 44 were adults, with a mean age of 50.46 years, and 24 were pediatric patients, with a mean age of 10.33 years. Oral or intravenous antibiotic therapy was administered to all patients. Pharmacological resolution was observed in 14 cases. Early surgical treatment within 48 hours was necessary in 10 cases. Surgery consisted of abscess drainage, associated or not with functional endoscopic sinus surgery. Delayed surgery within 15-30 days was performed in 44 patients. The core procedure was functional endoscopic sinus surgery. Subsidiary procedures were abscess drainage, tooth extraction or cranial base repair. The combination of two or more of these procedures was case selected. Median follow-up was of 46.36 months. Sinusitis complications necessitate rapid diagnosis and prompt treatment. Antibiotic therapy alone is enough for mistreated rhinosinusitis with no anatomical predisposing factor. Surgery is mandatory for altered nasal and paranasal sinus anatomy or odontogenic infections.

Masseter-facial neurorrhaphy for facial palsy reanimation: What happens after masseter denervation? Histomorphometric and stomatognathic functional analysis.

The aim of the present study was to analyse the consequences of masseter muscle denervation. In facial palsy surgical treatment, the masseteric nerve constitutes an important nerve source for facial reanimation due to its anatomical position and large amount of available axons. Computed tomography and/or magnetic resonance imaging were performed in 30 control subjects, and three radiologists separately measured the longitudinal diameter (LD), anteroposterior diameter (APD), transverse diameter (TD), and skeletal muscle area (SMA) of the masseter muscles as reference values. Regarding the facial palsy group, from 2009 to 2018, 11 patients (4 men and 7 women) were selected on the following inclusion criteria: diagnosis of unilateral facial paralysis, minimum follow-up of 14 months, absence of temporomandibular dysfunction, presence of complete dentition (to minimise bias of stomatognathic evaluation), complete clinical and radiological records. The mean LD, APD, TD, and SMA values of the healthy and denervated masseter muscles were obtained and compared. Stomatognathic function was clinically examined through mean mouth opening (MMO) and Maximum Bite Force (MBF). Furthermore, facial symmetry analysis (FSA) was carried out using EMOTRICS Software. Reference values obtained were as follows: mean LD = 69 ± 5.9 mm (range: 59-85 mm); mean APD = 40.2 ± 3.3 mm (range: 34-48 mm); mean TD = 15.5 ± 3.1 mm (range: 11-26 mm); and mean SMA = 43.8 ± 13.5 mm3 (range: 26-85.8 mm3). No statistically significant difference was observed between the healthy facial palsy groups's masseter muscles and reference values. As the latter, in denervated masseter muscles, no statistically significant difference was observed for APD value in contrast to LD, TD and SMA that showed statistically significant difference in comparison with control population (p < 0.05, CI 95%). Moreover fibro-adipose degeneration was consistently observed, with its degree being directly proportional to the denervation time. MMO and MBF mean values were, respectively, 54.75 mm in men, 44.4 mm in women and 705N. None of the latter showed a statistically significant difference with respect to the control population and the parameters present in the literature, indicating that masseter-facial neurorrhaphy is a safe and effective procedure for facial reanimation with good functional and aesthetic outcomes.

Head and Neck Cancer Treatment during COVID-19 Pandemic: A Central Experience in Rome. Emergency Management, Infection Prevention and Control.

The COVID-19 pandemic has significantly affected the surgical units, especially those operating on the airways. This study evaluates the series of patients with tumors of the head and neck treated by our unit during Phase-1 of the pandemic and the efficacy of the preventive measures implemented for protecting both the patients and staff. A screening program was administered to all the patients who had to undergo surgery. None of the patients tested and operated during Phase 1, between 10 March and 18 May 2020, were positive for COVID-19. A significant portion of the patients was suffering from tumors in advanced stages (T3 and T4). Two patients developed respiratory symptoms during their stay at the unit, so they were put in precautionary isolation and tested, but resulted negative for COVID-19. All the surgical department staff followed the Italian Ministry of Health's prevention protocol and underwent serological testing. IgG and IgM were negative in everyone, thus confirming that nobody had been exposed to the virus. This study highlights the commitment to efficiently treating patients suffering from tumors of the head and neck region and confirms the effectiveness of the safety measures used to protect our patients and staff's health.

Sinonasal Undifferentiated Carcinoma in a Patient Previously Treated for an Intestinal-Type Adenocarcinoma: Metachronous Neoplasms or Recurrence of a Different Tumor Type?

A case of a sinonasal undifferentiated carcinoma occurring 2 years after a successfully surgically treated intestinal-type adenocarcinoma has never been reported. Treatment modality of paranasal sinus cancer strictly depends on histology so it is important to recognize a different tumor type in the follow-up of these patients.

Metastasis from pancreatic adenocarcinoma to the cheekbone.

Skeletal metastasis by pancreatic adenocarcinoma are infrequent, and those located in the craniofacial region are very rare. We report the case of a 63-year-old Caucasian woman with a metastatic adenocarcinoma of the pancreatic head previously treated with surgery and chemotherapy presenting a skeletal metastasis in the left cheekbone 5 years after primary treatment. No other similar cases have been previously described. The therapeutic decision was not simple because of the uncommon site of pancreatic metastasis. Surgical resection was the only possibility after the radiotherapy failure. KEY WORDS: Cheekbone mass, Cheekbone metastasis, Pancreatic adenocarcinoma, Pancreatic adenocarcinoma metastasis.

Adalimumab: Another Medication Related to Osteonecrosis of the Jaws?

Objective. The acronym MRONJ has been created in order to identify "Medication-Related Osteonecrosis of the Jaw," observed after the use of Bisphosphonates, RANK ligand inhibitor, and antiangiogenic medications. Only a case of osteonecrosis of the jaw in a Chron's disease patient following a course of Bisphosphonate and Adalimumab therapy has been recently described, so that it has been supposed that also this medication could promote manifestation of osteonecrosis. Clinical Case. On August, 2014, a 63-year-old female with a history of idiopathic arthritis treated with medical treatment with Adalimumab from 2010 to 2013 presented referring pain in the right mandible. Results. This patient presented with nonexposed osteonecrosis of the jaw after placement, on September, 2010, of four titanium fixtures in the mandible. Conclusions. The authors suggest that the biologic therapy with an anti-TNF-α antibody might promote the manifestation of osteonecrosis and compromise oral healing capacity of the bone.

Treatment timing and multidisciplinary approach in Apert syndrome.

Apert syndrome is a rare congenital disorder characterized by craniosynostosis, midface hypoplasia and symmetric syndactyly of hands and feet. Abnormalities associated with Apert syndrome include premature fusion of coronal sutures system (coronal sutures and less frequently lambdoid suture) resulting in brachiturricephalic dismorphism and impaired skull base growth. After this brief explanation it is clear that these anatomical abnormalities may have a negative impact on the ability to perform essential functions. Due to the complexity of the syndrome a multidisciplinary (respiratory, cerebral, maxillo-mandibular, dental, ophthalmic and orthopaedic) approach is necessary in treating the psychological, aesthetic and functional issues. The aim of this paper is to analyse the different functional issues and surgical methods trying to enhance results through a treatment plan which includes different specialities involved in Apert syndrome treatment. Reduced intellectual capacity is associated to the high number of general anaesthesia the small patients are subject to. Therefore the diagnostic and therapeutic treatment plan in these patients has established integrated and tailored surgical procedures based on the patients' age in order to reduce the number of general anaesthesia, thus simplifying therapy for both Apert patients and their family members.

Mini invasive transoral approach to the glenoid fossa: Benign lesion removal using endoscopy.

OBJECTIVE: We describe an endoscopic transoral approach for treating benign lesions of the glenoid fossa with or without infratemporal fossa involvement. STUDY DESIGN: Description and validation of surgical technique on living humans. METHODS: Excision of benign lesions arising from the glenoid fossa was achieved in five patients through a transoral endoscopic approach. Using 0- and 45-degree angled 4-mm optics, the entire middle skull base and infratemporal fossa were explored without damaging the nearby neurovascular structures. RESULTS: Three of the five patients had complete removal of osteochondroma. In the remaining two patients, the lesion removed was diagnosed as osteoma. In one patient, postoperative numbness of the alveolar nerve was observed. No infections were reported. The surgical approach utilized was determined to be valid not only for glenoid fossa exposure but also for management of the middle skull base and infratemporal fossa. CONCLUSION: The described approach to the glenoid fossa offers direct and minimally invasive access to benign lesions within this region. Further use of this approach will allow us to determine its potential in treating malignancies. LEVEL OF EVIDENCE: 4.