Cranial Nerve Injuries Post Carotid Endarterectomy: A 15-Year Prospective Study with Routine Otolaryngologist and Neurological Evaluation.

OBJECTIVE: The aim of this prospective monocentric cohort study was to analyse the risk of otolaryngologist-assessed cranial nerve injuries (CNIs) following carotid endarterectomy (CEA) in our academic centre during a 15-year period, and to identify possible risk factors for CNI development. METHODS: From January 2007 to December 2022, 3749 consecutive CEAs were performed and their data prospectively recorded in a dedicated database. Cranial nerve injuries were assessed and defined according to a standardized protocol. Instrumental ear, nose and throat (ENT) evaluations were conducted within 30 days before intervention and before discharge. Preoperative neurological assessments were carried out in all patients with symptomatic carotid stenosis, while postoperative neurological evaluations were performed in all patients. Patients with newly onset cranial nerve injuries underwent follow-up assessments at 30 days and, if necessary, at 6, 12 and 24 months. Perioperative results, including mortality, major central neurological events, and postoperative CNIs, were analyzed. Regression or persistence of lesions during follow-up visits was assessed, and multivariate analysis (binary logistic regression) was conducted to evaluate clinical, anatomical, and surgical technique factors influencing the occurrence of CNIs. RESULTS: CEAs were performed more frequently in male patients (2453 interventions, 65.5%) than in females (1296 interventions, 34.5%). The interventions were performed in asymptomatic patients in 3078 cases (82%). In 66 cases the interventions followed a previous ipsilateral CEA. At preoperative ENT evaluation, no cases of ipsilateral pre-existent CNI were recorded. The 30-day stroke and death rate was 1%. In 113 patients (3%) a postoperative neck bleeding requiring surgical revision and drainage was noted. Pre-discharge ENT evaluations identified 259 motor cranial nerve injuries, accounting for 6.9% of the entire study group. Eighteen patients had lesions in more than one cranial nerve. ENT and neurological evaluations at 30 days showed the complete resolution of 161 lesions, whereas in 98 (2.6%) cases the CNI persisted. At one year, the rate of persistent CNI was 0.4% (10 patients), whereas at two years it was 0.25% (six cases), in all but one asymptomatic. At multivariate analysis, urgent intervention in unstable patients, secondary intervention, a clamping time >40 min., a hematoma requiring revision and a postoperative stroke were independent predictors of CNI. CONCLUSIONS: Data from this prospective monocentric cohort study showed that the occurrence of CNI following CEA was low, even when an independent multi-specialist evaluation was performed. The percentage of persistent lesions at two years was negligible and in most cases asymptomatic.

The surgical treatment of unilateral vocal cord paralysis (UVCP): qualitative review analysis and meta-analysis study.

PURPOSE: The objectives of this meta-analysis were to summarize the key surgical procedures for UVCP and to evaluate which of these is associated with better results in terms of vocal improvement. METHODS: A systematic review of the literature was conducted in search of articles focused on the comparison of voice outcome between different techniques for the UVCP treatment. Then, a quantitative analysis was carried out for papers published from 2013 onwards, reporting only adult patients with unilateral paralysis for each study, and each surgical technique was evaluated for its capability of achieving good functional outcomes in terms of GRBAS-I scale and maximum phonation time in seconds (MPT). RESULTS: The search identified 1853 publications. A total of 159 articles were stratified and included according to our selection criteria. 21 out of 159 articles were selected for quantitative synthesis. For trans-oral techniques: the mean GRBAS-I scale were 2.33 before injection and 0.41 after injection. The mean MPT before injection were 4.78 and 12.50 after injection. For open techniques the mean GRBAS-I scale were 2.43 before surgery and 0.68 after surgery. For open technique, the mean MPT were 3.50 before surgery and 12.40 after surgery. CONCLUSIONS: The two types of techniques lead to an improvement in terms of vocal outcomes emphasizing that from the examined literature an indication emerges to perform an early injection because this could reduce the possible need for a more invasive intervention of permanent medialization in the future.

Endoscopic evaluation of neurological dysphagic patients.

Dysphagia is a frequent finding in neurological patients and is a symptom related to the severity of the clinical picture. The swallowing impairments, in these patients, increase the risk of aspiration pneumonia, that leads to death, in at least 6% of patients, within the first year. Therefore, evaluation of the swallowing status is essential in patients with dysphagia and videofluoroscopic study of swallowing (VFSS) is the method of choice. It cannot be performed in all patients on account of the complexity of the procedure and since they must be brought to the Radiology Unit. In the 1980, a new bedside method was introduced, namely: fiber-optic endoscopic study of swallow (FESS) which is easy, low-cost, well-tolerated and repeatable. We use this bedside technique to assess swallowing function in patients with dysphagia admitted to acute care units, neurological and internal medicine units. The evaluation aims to indicate the safer nutritional method (oral intake, feeding tube or percutaneous gastrostomy) and, consequently, reducing the risk of aspiration pneumonia during hospitalization. We found that more than 50% of the dysphagic patients present cerebrovascular injuries and in 2% of the population, the first diagnostic hypothesis of Myasthenia Gravis can be made with the FESS technique. In 60%, we indicate a change in nutritional method: in 20% we indicate percutaneous endoscopic gastrostomy (PEG). With these indications, none of those patients had aspiration pneumonia. Our protocol for the bedside fiberoptic study of neurological patients with dysphagia has demonstrated its efectiveness by eliminating the incidence of aspiration pneumonia.

Rehabilitation protocol of dysphagia after subtotal reconstructive laryngectomy.

Dysphagia is a constant complication of subtotal reconstructive laryngectomy, due to modifications in the anatomy and in sensitivity of the larynx and pharynx. The reduced sphincteric activity of the larynx can enhance aspiration with a higher risk of pneumonia. In our opinion, the presence of the tracheotomy tube in the first weeks after surgery interferes with proper mobility of the laryngo-tracheal axis during swallowing, as it anchors the trachea to the skin. We have conducted swallowing rehabilitation, without the tracheotomy tube, ready to aspirate eventual saliva or food debris dropping into the trachea. This protocol has been applied in 33 patients undergoing subtotal reconstructive laryngectomy and better patient compliance and swallowing performance were observed. The period to recover complete autonomous oral intake is less than one month and none of these patients showed signs or symptoms of aspiration pneumonia during hospitalisation or follow-up. This rehabilitation protocol is, therefore, a valid and effective alternative to other well-known procedures.

Multiple neurinomas of the parapharyngeal space.

The authors describe a rare case of three neurinomas arising in the parapharyngeal space. In spite of the large extension of the neoplasms, the only symptom reported by the patient was some dysphagia. Magnetic resonance imaging allowed us to identify the three masses and suppose their diagnosis. The therapeutic approach used is also reported.

A comparison of nimesulide and ketoprofen in the prevention and treatment of painful postoperative inflammatory complications of ear, nose and throat surgery.

In a randomised double-blind clinical study, 76 patients undergoing major ear, nose or throat (ENT) surgery (including 45 for cancer) were treated with nimesulide (200mg twice daily) or ketoprofen (100mg twice daily) administered rectally for 5 days. Pain intensity was significantly and similarly reduced in both treatment groups compared with baseline (p = 0.0001). A significant reduction in oedema and hyperaemia was observed on the second day for nimesulide-treated patients and on the third day for those treated with ketoprofen, with complete relief being noted for almost all patients by the fifth day. Fever was resolved in all patients. Adverse events attributable to treatment were observed for 1 patient in each group. These results suggest that nimesulide provides a worthwhile alternative to other NSAIDs in the treatment of postoperative pain and inflammation associated with ENT surgery.

Fibre size in the left and right recurrent laryngeal nerves (RLNs) in the man.

Some morphological data of the right and left human RLNs were evaluated with the aim of verifying possible differences in the fibre composition of the two nerves. The following parameters were evaluated in the right and left RLNs of five human cases: 1) the maximum diameter of the fibres; 2) the axon diameter and area; 3) the myelin sheath area obtained substracting the axon area from the total area of each fibre. The obtained data were plotted on histograms for each case: moreover, histograms of all fibres of both left and right nerves of all five cases were made. The results show that the values of the maximum diameter of the fibres and of the myelin sheath area are always greater in a statistically significant way in the left RLNs than in the right RLNs. On the other hand the axon diameter is nearly the same in the nerves of both sides. These data suggest that the greater calibre of the myelin sheath in the fibres of the left inferior laryngeal nerve can be responsible of the faster conduction speed in this nerve. This fact might explain the simultaneous arrival of the impulses to the laryngeal muscles of the two sides in spite to the different length of the two nerves.