Adenoidectomy for middle ear disease in cleft palate children: a systematic review.

PURPOSE: Cleft palate children have a higher incidence of otitis media with effusion, more frequent recurrent acute otitis media episodes, and worse conductive hearing losses than non-cleft children. Nevertheless, data on adenoidectomy for middle ear disease in this patient group are scarce, since many feared worsening of velopharyngeal insufficiency after the procedure. This review aims at collecting the available evidence on this subject, to frame possible further areas of research and interventions. METHODS: A PRISMA-compliant systematic review was performed. Multiple databases were searched with criteria designed to include all studies focusing on the role of adenoidectomy in treating middle ear disease in cleft palate children. After duplicate removal, abstract and full-text selection, and quality assessment, we reviewed eligible articles for clinical indications and outcomes. RESULTS: Among 321 unique citations, 3 studies published between 1964 and 1972 (2 case series and a retrospective cohort study) were deemed eligible, with 136 treated patients. The outcomes were positive in all three articles in terms of conductive hearing loss improvement, recurrent otitis media episodes reduction, and effusive otitis media resolution. CONCLUSION: Despite promising results, research on adenoidectomy in treating middle ear disease in the cleft population has stopped in the mid-Seventies. No data are, therefore, available on the role of modern conservative adenoidectomy techniques (endoscopic and/or partial) in this context. Prospective studies are required to define the role of adenoidectomy in cleft children, most interestingly in specific subgroups such as patients requiring re-tympanostomy, given their known risk of otologic sequelae.

Isolated olfactory cleft involvement in SARS-CoV-2 infection: prevalence and clinical correlates.

PURPOSE: Smell alterations are a symptom of COVID-19 and have been associated with olfactory cleft mucosal thickening (OCMT). Although their pathogenesis is unclear, evidences link them to viral neuroinvasive potential. This study aims at estimating the prevalence of OCMT in CT scans of COVID-19 patients and investigating its clinical correlates. METHODS: In a single-institution retrospective cross-sectional study, we included all patients hospitalized for COVID-19 undergoing head CT scan for any reason. Exclusion criteria were history of recent head trauma or chronic rhinosinusitis; opacification > 2 mm in any sinonasal space other than the olfactory cleft; CT performed during/after invasive ventilation or feeding via nasogastric tube. We recorded the prevalence of OCMT and related it to age, sex, need for invasive ventilation during hospital stay, outcome, length of hospital stay, diffusion of lung SARS-CoV-19 lesions and outcome. RESULTS: 63 eligible patients were identified (39 male, 24 female; median age 77.82 ± 17.77 years). OCMT was identified in 16 patients (25.4%; 95% CI 15.3-37.9%). Patients with OCMT had longer hospital stays (median 16 ± 4 vs. 9 ± 14.5 days, p = .009, Mann-Whitney U test) and required invasive ventilation more frequently than patients without mucosal thickening (OR 4.89, 95% CI 0.96-24.89, p = .063, Fisher's test). No other difference was observed. CONCLUSION: OCMT affects nearly one in four patients hospitalized for COVID-19. It is associated with a worse disease course irrespective of age, sex and diffusion of lung lesions, although with no direct effect on survival.

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.

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.

Can preoperative 25-hydroxyvitamin D levels predict transient hypocalcemia after total thyroidectomy?

Transient postoperative hypocalcemia is a common complication after total thyroidectomy. Evidence on contributing metabolic factors is contradictory. Our work aims to define the role of preoperative 25-hydroxyvitaminD levels in developing transient postoperative hypocalcemia. 183 consecutive patients who underwent total thyroidectomy at our institution (May 2017-December 2019) were included in the retrospective study. We reported gender, age, estimated glomerular filtration rate, creatinine, preoperative 25-hydroxyvitaminD, serum pre- and postoperative calcium, pre- and postoperative PTH levels and transient postoperative hypocalcemia occurrences. We compared variables both among patients with and without transient postoperative hypocalcemia and between patients with different 25-hydroxyvitaminD levels (< 10 ng/ml deficitary; 11-30 ng/ml insufficient; > 30 ng/ml, normal). A binomial logistic regression model evaluating the risk for transient postoperative hypocalcemia was elaborated. Patients with transient postoperative hypocalcemia had lower levels of postoperative PTH (p < 0.001) and more frequently normal or deficitary 25-hydroxyvitaminD levels (p = 0.05). When comparing patients according to their 25-hydroxyvitaminD levels, insufficiency was associated with a lower rate of transient postoperative hypocalcemia (p = 0.05); deficiency was associated with higher preoperative PTH (p = 0.021), postoperative PTH (p = 0.043) and estimated glomerular filtration rate (p = 0.031) and lower serum creatinine (p = 0.014). In the regression model higher preoperative PTH (OR = 1.011, p = 0.041) and 25-hydroxyvitaminD deficiency (OR = 0.343, p = 0.011) significantly predicted transient postoperative hypocalcemia. Data analysis revealed a correlation between transient postoperative hypocalcemia and 25-hydroxyvitaminD levels: our work points towards the possibility to stratify the risk of transient postoperative hypocalcemia according to patients' preoperative 25-hydroxyvitaminD status.

Prevalence of Maxillary Sinus Hypoplasia and Silent Sinus Syndrome: A Radiological Cross-Sectional Retrospective Cohort Study.

BACKGROUND: Maxillary sinus hypoplasia (MSH), associated with enophthalmos and hypoglobus in the silent sinus syndrome (SSS), is a poorly studied condition. The real incidence of MSH and SSS in the adult population is not known. Our study aims at estimating the radiological prevalence of MSH and identifying undiagnosed cases of SSS in a retrospective cohort. METHODS: A cross-sectional retrospective cohort study was performed in adults, without a history of maxillofacial surgery or trauma, undergoing head CT scans. A radiological database of 1012 consecutive scans was reviewed independently by two authors to identify patients with signs of MSH and SSS and associated findings (septal deviation, uncinate deviation, concha bullosa, sinus opacification, bony rarefaction, and pterygopalatine fossa enlargement). The findings of MSH and SSS were compared with radiological reports. RESULTS: 891 eligible CT scans were analyzed. MSH and SSS prevalences were 6.17% (n = 55) and 0,56% (n = 5), respectively. The maxillary sinus was normally or partially ventilated in 96.36% of MSH patients. Lateralization of the uncinate process was detected in about 50% of MSH patients, while a septal deviation towards the affected sinus was detected in 21.82%. In 20% of MSH scans, a concha bullosa was identified. Radiological reports identified a single MSH case. CONCLUSIONS: Our study confirmed the literature data on MSH prevalence, while it determined a precedently unknown prevalence for SSS, underestimated in the radiology reports. This prevalence needs further confirmation but suggests a routine accurate comparison of both maxillary sinuses in CT scans.

Conversion rates in robotic thyroid surgery: A systematic review and meta-analysis.

OBJECTIVE: To define the conversion risk to open procedure during robot-assisted thyroid surgery (RATS) identifying potential specific subclasses of procedures or accesses at higher conversion risk. METHODS: In a PRISMA-compliant framework, all original prospective studies providing RATS conversion rates from multiple databases were pooled in a random-effects meta-analysis. Conversion rates were compared between different typologies of thyroid surgery and robotic access. RESULTS: 13 studies were deemed eligible. Four conversions from two studies were reported out of 398 procedures. No significant heterogeneity was observed (Cochran's Q p = 0.932; I2 = 0%). The pooled conversion rate was 1% (95% confidence interval, 0.1%-2%). The ANOVA-Q test failed to show significant differences when comparing type of thyroid surgery or robotic access (respectively p = 0.766 and p = 0.457). CONCLUSION: While the conversion rate appears consistently low across studies, prospective data collection and systematic reporting of procedural complications are required for framing high-risk procedures and accesses.

Advanced Differentiated Thyroid Cancer: A Complex Condition Needing a Tailored Approach.

Differentiated thyroid cancers (DTCs) are slow-growing malignant tumours, including papillary and follicular carcinomas. Overall, prognosis is good, although it tends to worsen when local invasion occurs with bulky cervical nodes, or in the case of distant metastases. Surgery represents the main treatment for DTCs. However, radical excision is challenging and significant morbidity and functional loss can follow the treatment of the more advanced forms. Literature on advanced thyroid tumours, both differentiated and undifferentiated, does not provide clear and specific guidelines. This emerges the need for a tailored and multidisciplinary approach. In the present study, we report our single-centre experience of 111 advanced (local, regional, and distant) DTCs, investigating the rate of radical excision, peri-procedural and post-procedural complications, quality of life, persistence, recurrence rates, and survival rates. Results are critically appraised and compared to the existing published evidence review.

Spontaneous healing in maxillary fungus ball: Beware of asymptomatic patients.

Incidentally diagnosed, asymptomatic, paranasal fungus ball might occasionally undergo spontaneous healing. Accurate preoperative workup may avoid unnecessary surgical or anesthesiological procedures.

Sphenopalatine endoscopic ganglion block in cluster headache: a reevaluation of the procedure after 5 years.

Cluster headache (CH) is considered the most painful form of primary headaches. It is characterized by severe unilateral pain, typically associated with autonomic manifestations and may be divided into an episodic and a chronic form. The latter is often resistant to a multitude of medication and is, therefore, very hard to treat. In 2002, our group developed a technique for the endoscopic sphenopalatine ganglion block that was able to ameliorate the symptoms in 55% of drug-resistant chronic CH patients. This paper is intended as an update on the technique as well as a comparison in effectiveness to our prior approach.

Endoscopic endonasal repair with polyethylene implants in medial orbital wall fractures: A prospective study on 25 cases.

The aim of the study was to assess the mid-term effectiveness and safety of an original technique consisting of reconstructing fractures of the medial wall of the orbit with porous polyethylene implants with an exclusive transnasal approach. Twenty-five patients were treated. Each patient underwent a pre-operative ophthalmologic evaluation and a CT scan. The surgery started with an anteroposterior ethmoidectomy of the fractured side; all the fractured bone fragments were removed and all usual landmarks of healthy bony margins were identified. A Medpor sheet was placed endoscopically to reconstruct the fractured wall. Each patient received an immediate postoperative CT scan, and was evaluated at day 1, 7, 30 and 6 months after surgery clinically and with an endoscopic examination. In all patients, preoperative enophthalmos and/or diplopia were corrected. The CT scans showed excellent reconstruction of the fractured bony walls. The immediate postoperative period was characterized by a very high degree of subjective comfort. No perioperative complications were detected. At the 6 months follow up, all meshes appeared covered by epithelialized mucosa at the endoscopic inspection, and clinical results were stable. Scars or lid complications are always prevented. The technique described has become the standard to treat medial wall fractures in our department.

Sphenopalatine endoscopic ganglion block: a revision of a traditional technique for cluster headache.

The diagnosis of chronic cluster headache (CH), the most painful form of headache, is based on typical clinical features characterized by strictly unilateral pain with no side shift and ipsilateral oculofacial autonomic phenomena. The attacks occur several times a day for periods of 1 to 2 months in the episodic form of the disease or less frequently on a daily basis in the chronic form. The pathogenesis of CH involves the activation of parasympathetic nerve structures located within the sphenopalatine ganglion (SPG), which explains many of the associated symptoms, whereas the activation of the ipsilateral hypothalamic gray matter may explain its typical circadian and circannual periodicity. A number of surgical approaches have been tried in cases of chronic CH resistant to pharmacologic therapy, of which SPG blockade has been shown to have certain efficacy. We have adopted a new technique based on endoscopic ganglion blockade that approaches the pterigo-palatine fossa by way of the lateral nasal wall and consists of the injection of a mixture of local anesthetics and corticosteroids, which was performed in 20 selected patients with chronic CH, according to the International Headache Society criteria (18 male, 2 female; mean age 40 yr), who were selected for SPG blockade because they were totally drug resistant. The symptoms improved significantly, but always only temporarily, in 11 cases. These results should be considered rather good because, unlike other frequently used techniques, SPG blockade is not invasive and should therefore always be attempted before submitting patients to more invasive surgical approaches.

Unusual case of bilateral maxillary fungus ball.

An otherwise healthy 34-year-old man was referred to our ear, nose and throat (ENT) clinic for a bilateral maxillary radiologic opacity. This condition was accidentally discovered with a panoramic radiography performed during a follow-up visit after a bilateral endodontic treatment. The patient did not report any specific sinonasal symptom such as purulent nasal discharge, loss of smell and cough, apart from an unspecific sinus pressure. The CT scans showed a bilateral inflammatory process into the maxillary-ethmoidal sinuses and an iron-like density within the maxillary sinuses, while nasal endoscopy showed purulent discharge in the ostiomeatal complex. The patient underwent functional endoscopic sinus surgery under general anaesthesia and the inflammatory material collected was histologically diagnosed as a rare case of bilateral fungus ball. The patient was dismissed the following day with no complications; there were not any sign of recurrence or symptoms during a 4 month follow-up.

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.

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.

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.