To detach or not to detach the umbo in type I tympanoplasty: functional results.

PURPOSE: To compare the audiological outcomes, tympanic membrane (TM) healing rates and complication rates in patients undergoing endoscopic underlay and over-under tympanoplasty type I (TTI). METHODS: The study includes 95 patients who underwent endoscopic TTI in the period between 2018 and 2023: 56% of the patients had the underlay technique and 41% had the over-under technique. Data regarding pre- and postoperative hearing, perforation characteristics, surgical procedures, graft types and complications were retrospectively analyzed. Audiometrical assessment included air conduction (AC) and bone conduction (BC) pure tone averages (PTA) and air-bone gap (ABG), pre- and postoperatively. RESULTS: Both underlay and over-under techniques significant improved AC PTA, with a mean ABG improvements of 5.9 dB and 7.2 dB, respectively. There was no significant difference in BC PTA between pre- and post-operative, indicating no inner ear damage in both techniques. The over-under technique showed a significantly higher TM closure rate (94.4%) compared to the underlay technique (80.6%). Complications were rare, with only one case of TM lateralization requiring revision surgery. CONCLUSIONS: Endoscopic TTI is an effective treatment in improving auditory function in chronic middle ear diseases. In our cohort, the detachment of the umbo does not negatively influence the postoperative hearing results and does not increase rate of complications. Moreover, the over-under technique demonstrates superior TM closure rates, making it a valuable option for specific cases. However, future prospective studies with larger sample sizes and longer term follow-up are needed to validate these findings and provide more comprehensive insights.

Limits in endoscopic ear surgery.

BACKGROUND: In recent decades, endoscopic ear surgery (EES) has been rapidly evolving, expanding its boundaries from the middle ear to the lateral skull base. Nonetheless, the advantages of the endoscopic technique are associated with a number of intrinsic limitations. METHODS AND OBJECTIVE: A narrative review was conducted to investigate the current limits of EES, analyzing the different otologic and skull base surgery procedures. RESULTS: Limitations of EES can be divided into general and procedure-related. General limitations have been extensively described in the literature and are related to the bidimensional image provided by the endoscope, as well as the one-handed surgical technique and its implications in the management of bleeding. Procedure-related limits are continuously evolving and are also discussed in the present review. CONCLUSION: Although endoscope use is intrinsically associated with general limitations, these have been systematically overcome by the refinement of the surgical technique as a consequence of the increasing surgical experience gained over the last 20 years. The main limits of EES are currently associated with specific procedure- and disease-related situations. This review describes the general limitations and their management, as well as the current limits in the endoscopic management of various otologic diseases, from the external ear to the lateral skull base.

Decision Making in Patients With Concomitant Otosclerosis and Superior Semicircular Canal Dehiscence: A Systematic Review of the Literature.

OBJECTIVE: Concomitant otosclerosis (OTS) and superior semicircular canal dehiscence (SSCD) is a rare, but difficult-to-identify and treat diagnosis. A systematic review of the literature was performed to analyze the diagnostic and therapeutic approaches of concurrent OTS and SSCD cases and to identify possible factors that may help in predicting the surgical outcome. DATA SOURCES: PubMed, Scopus, Medscape, Ovid databases. STUDY SELECTION: Studies showing diagnosis of OTS documented by audiometric test with or without associated radiological signs (computed tomography), and concomitant diagnosis of SSCD, documented at least by high-resolution computed tomography (and possibly supported by neurophysiological testing) were included. Both surgically treated and untreated patients were considered for data analysis. DATA EXTRACTION: The general characteristics of each study were recorded, when available. Clinical, audiological, vestibular testing, surgical, and radiological data were extracted from the published case reports and series, and recorded on a database. For each case, the diagnostic steps that confirmed OTS and concomitant SSCD in the same ear were extracted. DATA SYNTHESIS: Twelve studies were included in the review and 18 cases affected simultaneously by the 2 conditions were extracted and analyzed. Seven of 12 ears (58.3%) undergoing stapes surgery experienced a hearing improvement. In four (33.3%) cases, vestibular symptoms (with or without associated acoustic symptoms) of SSCD were unmasked or worsened by stapes surgery. CONCLUSIONS: A reliable preoperative diagnosis of the two concomitant conditions is possible with a proper interpretation of clinical signs, audiometric, and vestibular testing, in association with the radiologic assessment. Despite that the length and the location of the dehiscence may guide the surgical decision, definitive conclusions regarding the appropriate indications for surgical treatment cannot be drawn due to the limited number of cases with adequate data reported in the literature.

Quantification and Comparison of Droplet Formation During Endoscopic and Microscopic Ear Surgery: A Cadaveric Model.

OBJECTIVES: The COVID-19 pandemic and the disproportional spread of the disease among otorhinolaryngologists raised concerns regarding the safety of health care staff. Therefore, a quantitative risk assessment for otologic surgery would be desirable. This study aims to quantitatively compare the risk of perioperative droplet formation between microscopic and endoscopic approaches. STUDY DESIGN: Experimental research. SETTING: Temporal bone laboratory. METHODS: The middle ear of whole head specimens was injected with fluorescein (0.2 mg/10 mL) before endoscopic and microscopic epitympanectomy and mastoidectomy. Fluorescent droplet deposition on the surgical table was recorded under ultraviolet light, quantified, and compared among the interventions. Drilling time, droplet proportion, fluorescein intensity, and droplet size were assessed for every procedure. RESULTS: A total of 12 procedures were performed: 4 endoscopic epitympanectomies, 4 microscopic epitympanectomies, and 4 mastoidectomies. The mean (SD) proportion of fluorescein droplets was 0.14‰ (0.10‰) for endoscopic epitympanectomy and 0.64‰ (0.31‰) for microscopic epitympanectomy. During mastoidectomy, the deposition of droplets was 8.77‰ (6.71‰). Statistical comparison based on a mixed effects model revealed a significant increase (0.50‰) in droplet deposition during microscopic epitympanectomy as compared with endoscopic epitympanectomy (95% CI, 0.16‰ to 0.84‰). CONCLUSIONS: There is considerable droplet generation during otologic surgery, and this represents a risk for the spread of airborne infectious diseases. The endoscopic technique offers the lowest risk of droplet formation as compared with microscopic approaches, with a significant 4.5-fold reduction of droplets between endoscopic and microscopic epitympanectomy and a 62-fold reduction between endoscopic epitympanectomy and cortical mastoidectomy.

Mindfulness in the Maintenance of Cognitive Capacities in Alzheimer's Disease: A Randomized Clinical Trial.

BACKGROUND: The Canary Islands longitudinal study on non-pharmacological treatments showed the overall effectiveness of mindfulness in Alzheimer's disease (AD). However, no specific data on the maintenance of cognitive capacities were presented. OBJECTIVE: To determine whether the practice of mindfulness modifies the course of cognitive impairment in AD. DESIGN: Longitudinal, non-inferiority and equivalence, randomized clinical trial, repeated-measures design, with three experimental groups and one control group. PARTICIPANTS: Patients with AD who voluntarily attended the Lidia García Foundation (n = 502). Only those who were treated with donepezil and MMSE ≥18 were included (n = 120). INTERVENTION: Over a two-year period, each group carried out three weekly sessions of stimulation based on mindfulness, cognitive stimulation therapy, and progressive muscle relaxation. MEASURES: Cognitive assessment CAMDEX-R (MMSE and CAMCOG). STATISTICAL ANALYSIS: Repeated-measures ANOVA (p <  0.05) and the effect size Cohen's d were performed. RESULTS: The mindfulness group showed significant scores compared with the control and muscle relaxation groups (p <  0.05), while mindfulness and cognitive stimulation therapy were equivalent (p≥0.05). Group cognitive stimulation evolved better than the control (p <  0.05) group but not better than the muscle relaxation group (p≥0.05). The effect size compared over two years was large for the mindfulness group (p≥0.80), moderate for the relaxation group (p≥0.50), and low for the cognitive stimulation group (p≥0.20). CONCLUSION: The practice of mindfulness maintained cognitive function over a period of two years. This longitudinal study suggests that mindfulness can be used as a non-pharmacological treatment to slow cognitive impairment in AD.

Clinical significance of BRAF mutation in thyroid papillary cancer.

OBJECTIVE: To correlate the presence of BRAF V600E mutation with clinicopathological parameters. STUDY DESIGN: Case-control study. SETTING: BRAF mutation represents the most common oncogenic event in sporadic papillary thyroid cancer (PTC). There are, however, significant discrepancies regarding the overall frequency and its relationship with clinicopathological parameters of poor outcome. We analyzed BRAF mutation in a cohort of patients affected by PTCs to identify its association with clinical variables. SUBJECTS AND METHODS: We analyzed retrospectively a series of 304 patients, treated for PTC from 1999 to 2011 at Bologna University Hospital. We searched BRAF mutation by reverse transcription polymerase chain reaction (PCR) followed by PCR and direct sequencing. RESULTS: BRAF mutation was found in 77.4% of classical PTCs, 31.9% of the follicular variant, and 72.2% of high tall cell PTCs, being significantly associated, at univariate analysis, with recurrence, stage, multicentricity, histologic subtype, extrathyroidal extension, nodule dimension, body mass index, and American Thyroid Association (ATA) risk stratification. Furthermore, higher T, but not N or M, stage was associated with BRAF mutation. In the multivariate analysis, the BRAF mutation was significantly associated only with the ATA risk stratification, in turn showing a significant negative association with recurrence-free survival time with Cox multivariate analysis. CONCLUSION: Our results indicate that BRAF mutation identifies a subset of PTC with increased risk of recurrence. The presence of BRAF mutation might be a valuable diagnostic and prognostic marker of the disease. To confirm the diagnostic usefulness of this marker, further studies should be carried out.

Sinonasal risk factors for the development of invasive fungal sinusitis in hematological patients: Are they important?

Invasive fungal sinusitis (IFS) is a highly aggressive infection that can affect hematologic patients. The classically described general risk factors, however, do not fully explain the development of IFS in a small percentage of cases. This study examined the impact of anatomic sinonasal factors and environmental factors on the development of IFS in high-risk patients. Medical records and computed tomography (CT) scans of patients admitted to our institution who were at high risk of developing IFS were retrospectively reviewed. Twenty-seven patients of 797 fulfilled the inclusion criteria. Patients affected by IFS were compared with patients not affected to identify possible sinonasal and environmental risk factors of IFS. Seven patients were excluded because of the lack of adequate radiological images. Six of the 20 eligible patients were assigned to the study group of patients affected by IFS and the remaining 14 patients were assigned to the control group. All but one case developed the infection during the summer with a significantly higher mean environmental temperature (p = 0.002). Anatomic nasal alterations were found in all patients affected by IFS and were significantly more frequent than in the control group (p = 0.014). It would be advisable to have patients with hematologic risk factors of IFS, especially during the summer period, undergo endoscopic nasal assessment. Furthermore, a CT finding of anatomic nasal alterations, such as anterior nasal septum deviation causing nasal obstruction, should increase the suspicion of IFS in case of the occurrence of nasal symptoms.