Intraoperative Neuromonitoring Does Not Reduce the Risk of Temporary and Definitive Recurrent Laryngeal Nerve Damage during Thyroid Surgery: A Systematic Review and Meta-Analysis of Endoscopic Findings from 73,325 Nerves at Risk.

BACKGROUND: While intraoperative neuromonitoring (IONM) helps the early identification of recurrent laryngeal nerve (RLN) damage, IONM's role in RLN damage prevention is not defined, given the lack of large studies on the subject. METHODS: In a PRISMA-compliant framework, all original thyroid surgery prospective studies providing early postoperative endoscopic data for all patients were pooled in a random-effects meta-analysis. We compared the temporary (and definitive where available) RLN damage rates according to IONM use and IONM type (intermittent, I-IONM, or continuous, C-IONM). RESULTS: We identified 2358 temporary and 257 definitive RLN injuries in, respectively, 73,325 and 66,476 nerves at risk. The pooled temporary and definitive RLN injury rates were, respectively, 3.15% and 0.422% considering all procedures, 3.29% and 0.409% in cases using IONM, and 3.16% and 0.463 in cases not using IONM. I-IONM and C-IONM, respectively, showed a pooled temporary RLN injury rate of 2.48% and 2.913% and a pooled definitive injury rate of 0.395% and 0.4%. All pooled rates had largely overlapping 95% confidence intervals. CONCLUSIONS: Our data suggest that IONM does not affect the temporary or definitive RLN injury rate following thyroidectomy, though its use can be advised in selected cases and for bilateral palsy prevention.

Mini-Invasive Endoscopic Approaches to the Maxillary Sinus Floor: A Comparative Anatomical Study.

BACKGROUND: While middle antrostomy (MA) is the most common approach to the maxillary sinus (MS), it is known for not allowing to fully inspect the whole MS, especially in its inferior and anterior portions. To overcome this limitation, alternative approaches have been proposed, such as inferior antrotomy (IA) and canine fossa accesses (CFA). OBJECTIVE: Given the lack of studies on the MS floor visualization with different accesses, our study aims, in a cadaver lab setting, to systematically compare three different approaches (MA, IA and CFA) in these regards. METHODS: Eight cadaver heads, previously submitted to CTscan, were prepared inserting fixtures corresponding to teeth 2, 4, 6, 11, 13 and 15 and into the canine fossae. Three approaches were prepared: a wide MA, an IM and a CFA. We endoscopically evaluated, for each specimen, side, access type and scope angle (0°, 30°, 45°, and 70°), which fixtures were visible on the maxillary sinus floor and whether the canine fossa fixture was visible (MA and IA only). RESULTS: IA allowed to visualize all fixtures in nearly all cases (14/16 with 70° endoscope), while MA showed poor visualization results (3/16 with 70° endoscope); CFA failed to gain full visualization in most specimens (7/16 with 70°endoscope). Such difference was statistically significant. MA proved unable to visualize the canine fossa fixture in most cases while IA showed excellent possibilities. All differences were statistically significant (p < .001, Mcnemar's test). CONCLUSIONS: Our data show that the IA grants a statistically significant superior surgical field vision when compared to MA and CFA, though in vivo validation of these results is still required.

Odontogenic rhinosinusitis and sinonasal complications of dental disease or treatment: prospective validation of a classification and treatment protocol.

PURPOSE: Odontogenic sinusitis and sinonasal complications of dental disease or treatment (SCDDT) represent a heterogeneous group of conditions that often require multidisciplinary care. The present study aims to prospectively validate a classification and treatment protocol for SCDDT patients. METHODS: One hundred twenty-eight consecutive patients (73 females and 45 males, mean age 52.4 years) affected by SCDDT not responding to dental and medical therapy were classified and surgically treated according to the proposed protocol. The protocol classified patients into three aetiology-based groups (preimplantologic, implantologic, and related to traditional dental diseases and procedures, respectively). The groups were further divided into classes according to the presence of oro-antral communications and/or dislocated dental hardware. Each condition was treated according to the class-related, protocol-defined treatment, by either a transnasal or combined transnasal/transoral approach. All patients were successfully classified according to our protocol. None of the proposed classes were redundant, and no condition fell outside the definitions. RESULTS: The surgical treatment protocol proved to be adequate and effective, in that 125 of the 128 patients completely recovered after surgical treatment. CONCLUSIONS: The term SCDDT and the consequent classification proposed by the authors appear, therefore, to be nosologically correct. Furthermore, the protocol-related proposed treatment appears to be clinically sound, with a success rate nearing 98%.

One-Step Maxillary Sinus Augmentation in Association With Endoscopic Sinus Surgery: Case Series and Review of the Literature.

INTRODUCTION: Sinonasal anatomical anomalies and inflammatory conditions may reduce success rates of maxillary sinus elevation (MSE) procedures used to allow implant placement in the atrophic posterior maxilla. Approaches combining endoscopic sinus surgery (ESS) and MSE were firstly proposed by our group and have already been described in the literature. This article aims to re-evaluate the procedure in a larger sample of patients comparing results and indications with the pertaining literature. MATERIALS AND METHODS: Thirty-three patients (19 men and 14 women, mean age 52.79 ± 11.95 years) underwent combined ESS/MSE with 48 MSE procedures performed. RESULTS: No intraoperative complications were reported. An uneventful and complete graft integration was obtained after 6 months in all but one patient. All patients completed prosthetic rehabilitation within 9 to 12 months. CONCLUSION: Combined ESS and MSE has proven to be a safe and reliable procedure, which can be proposed to selected patients presenting with reversible sinonasal contraindications to MSE and should be no more considered an experimental procedure.

Redefining boundaries in odontogenic sinusitis: a retrospective evaluation of extramaxillary involvement in 315 patients.

BACKGROUND: Odontogenic sinusitis and "sinonasal complications of dental disease or dental treatment" (SCDDT) have been assumed to be limited to the maxillary sinus. Nevertheless, many patients also show more extensive sinonasal involvement and, occasionally, also have associated bilateral disease. We evaluated the incidence of extramaxillary extension over an 11-year period in our clinic. METHODS: We retrospectively evaluated 315 surgically treated SCDDT patients. Sinonasal involvement was assessed with presurgical imaging and confirmed with intraoperative findings. Patients were subsequently categorized into 3 groups, based on the sinonasal extension. RESULTS: In 40.3% of patients the sinonasal condition was limited to the maxillary sinus. Forty-one percent of patients had unilateral extramaxillary involvement, and in 18.7% of patients, we found bilateral involvement. CONCLUSION: Complete presurgery evaluation with endoscopy and a computed tomography (CT) scan in SCDDT patients is essential. SCDDT patients not responding to medical and dental treatment should be addressed with a planned approach targeting the extramaxillary extension, which may necessitate a combined oral and endonasal approach. It is unclear whether disease in the maxillary sinus contralateral to the primary maxillary sinus demonstrating odontogenic-induced disease is incidental, associated, or represents a subclinical odontogenic infection.

Therapeutic efficacy of bromelain in impacted third molar surgery: a randomized controlled clinical study.

OBJECTIVE: Bromelain is the name given to a family of proteolytic enzymes obtained from Ananas comosus, the pineapple plant. It is considered a potent anti-inflammatory and antiedematous substance. Surgery of impacted third molars in the outpatient setting is one of the procedures most often associated with postoperative pain and swelling. The aim of this study was to evaluate the efficacy of bromelain in reducing postoperative pain and swelling. METHOD AND MATERIALS: 80 patients were recruited to the study from patients attending the Maxillofacial Surgery Unit of the Istituto Stomatologico Italiano, Milan, Italy, for impacted third molar surgery. At time 0 when surgery was performed, patients started simultaneous antibiotic and analgesic therapy. On the following day, patients were divided into two groups. Patients in group 1 were prescribed bromelain. Patients in group 2 were prescribed only the analgesic if required. Three parameters were evaluated: pain, edema, and erythema. The first evaluation visit was performed 3 hours after surgery, the second 48 hours after surgery, and the final evaluation 7 days after surgery. RESULTS: Postoperative pain, edema, and erythema were significantly lower in the study group than in the control group. Analgesic consumption, both in terms of days of treatment and number of tablets taken, was slightly lower in the study group. Only one adverse event was recorded, which occurred in a patient in the control group. CONCLUSION: The present study demonstrates an important anti-inflammatory and anti-edematous effect of bromelain. Statistical analysis shows that in the group treated with bromelain the inflammatory response was significantly less than in the control group.

Sinonasal complications resulting from dental treatment: outcome-oriented proposal of classification and surgical protocol.

BACKGROUND: Odontogenic sinusitis is a relevant infectious condition of the paranasal sinuses. The widespread use of dental implants and reconstructive procedures for dental implant placement has led to new types of complication. To the authors' knowledge, no publication has extensively examined sinonasal complications resulting from dental treatment, and no classification system allowing standardization and comparison of results is currently available. This study was designed to (a) analyze the results obtained from surgical treatment of complications resulting from dental procedures combining functional endoscopic sinus surgery (FESS) and an intraoral approach and (b) propose a new classification system and standardized treatment protocols for sinonasal complications resulting from dental procedures. METHODS: A total of 257 patients consecutively treated with FESS (136 in conjunction with oral surgery) were included in the study. Different clinical situations were integrated into a new classification system based on the pathogenesis and clinical aspects of each case, with the aim of identifying homogenous treatment groups. Results were evaluated for each class. RESULTS: Of the 257 patients, 254 were successfully treated with surgery performed according to the proposed protocols. Three of 257 patients required a second surgery, after which they completely recovered. Complications of implant and preimplant surgery (maxillary sinus floor elevation) showed longer recovery times. CONCLUSION: The results obtained are very encouraging. The majority of patients (254/257; 98.8%) were successfully treated with the proposed protocols. These results seem to indicate that the rationalization of surgical treatment protocols according to the initial clinical situation may significantly improve the clinical outcome.

Rock, paper, endoscopy: a baffling case of rhinolith.

A 60-year-old woman presented with a bulky nasal mass. The mass was accidentally discovered during examination following a head injury. The patient, suffering from severe mental retardation, did not complain of any nasal symptoms, though her relatives, upon direct questioning, reported a two year history of fetid rhinorrhoea and occasional epistaxis. The CT scan showed a large inhomogeneous calcified mass in left nasal cavity, impacted on the choanal border. The patient underwent endoscopic nasal surgery under general anaesthesia in order to remove the mass. A transnasal approach granted a successful and complete removal. The patient was discharged the following day without any complication and no sign of recurrence or symptoms relapse was reported during a two year follow-up.

How the simplest dental implant procedure can trigger an extremely serious complication.

A 62-year-old man came to our attention after an operation in a small dental outpatient clinic where only a single dentist was working. The man was showing complications after insertion of a dental implant in the anterior segments of the mandible. Bleeding led to a slow swelling of the neck with airway obstruction. Only an immediate intervention by a mobile emergency unit and prompt tracheal intubation avoided death by asphyxia. The patient was then transferred to our hospital. We inspected the patient and we performed a CT scan that showed complete airway obstruction. First, we performed a tracheotomy in order to ensure the airway patency and then we identified the source of bleeding: the mylohyoid artery placed anomalously close to the mandible. After clamping and tying the artery, the bleeding resolved. One day after the procedure, the tracheotomy was closed; the patient was discharged after 3 days.

Osteonecrosis of the jaws caused by bisphosphonates: evaluation of a new therapeutic approach using the Er:YAG laser.

A series of 49 patients diagnosed with osteonecrosis and all treated with latest-generation bisphosphonates was reviewed retrospectively to evaluate the use of erbium-doped: yttrium, aluminum, and garnet laser (Er:YAG) in terms of clinical outcome, and examine current trends from the clinical-therapeutic standpoint. Pathology reports on specimens submitted over the previous 7 years from either the mandible or the maxilla were reviewed; 49 patients were identified as having osteonecrosis of the jaws. For each of these cases, the medical history and profile were evaluated; 19 were treated with conservative therapy, 20 with radical surgery, and 10 with Er:YAG laser (2,940 nm). Of the 20 patients treated surgically (bone baquette, curettage, sequestrectomy of the necrotic bone), some required re-treatment, which resulted in bone fracturing. None of the patients were treated successfully. The 19 cases treated conservatively produced an improvement in symptoms, but not remission of the lesions. Of the ten patients treated with Er:YAG laser, six achieved total remission of signs and symptoms, four an improvement, and re-treatment was required in one case. Our present approach is to recommend intensive prophylactic care before the administration of bisphosphonates, and great caution is advised even in simple maneuvers like curettage, because this may exacerbate the avascular process. The use of Er:YAG laser appears to be promising (within the limits of our experience). It can be concluded that at 1 year of laser surgery, the treatment led to significant improvements in clinical parameters, and may represent a valid alternative, although studies on a larger scale are needed.

Ameloblastic carcinoma of the maxillary sinus.

Ameloblastic carcinoma is a very rare malignant odontogenic neoplasm of the mandible and maxilla, accounting for some 66 reported cases. The case of a 68-year-old man who presented a fistula with orosinus communication of 14-year duration that, after anti-aggregant therapy, began bleeding is reported. The initial microscopic evaluation of the biopsy and radiographic findings were consistent with benign peripheral ameloblastoma without cellular atypia and extensive fields of acantomatous pattern, but immunohistochemical investigation found strong positivity for Bcl-2, cytokeratins CAM 5 and 6, and for Ki-67/MIB-1, changing our diagnosis. The treatment consisted of left maxillary resection followed by reconstruction. Cellular features of malignancy in the surgical specimen confirmed the diagnosis of ameloblastic carcinoma. This case of an aggressive ameloblastic carcinoma of the maxillary gingiva that presented with an unusual histological pattern illustrates that these tumors can create a diagnostic challenge that may require extensive surgical sampling and/or removal to establish the diagnosis. Immunohistochemically analyzed expression of bcl-2 protein, cytokeratins CAM 5 and 6, and Ki-67/MIB-1 antigen serve to characterize the cyto-differentiation and cellular activity of ameloblastic carcinoma.

Endoscopic removal of an unusual foreign body in the sphenoid sinus: an oral implant.

AIM: Migration of oral implants displaced in the maxillary sinus toward the sphenoid sinus is an extremely rare event. This case report is focused on the possibility of treating such a rare complication by means of endoscopic treatment through the nasal cavity. MATERIAL AND METHODS: A 45-year-old female patient received one oral implant for the substitution of the left first upper molar, but during the surgical procedure the implant was displaced in the maxillary sinus. Owing to a delay in treatment, a spontaneous migration of the implant in the sphenoid sinus occurred. RESULTS: The implant was removed endoscopically through the nasal cavity: postoperative recovery was uneventful. CONCLUSION: To the authors' knowledge, this case represents the first report concerning migration of an oral implant into the sphenoid sinus and demonstrates the reliability and safety of an endoscopically driven surgical removal of the foreign body, thus preventing potential complications with extremely low postoperative morbidity.