Cross-over septal flap technique for choanal atresia surgery in two centres: how I do it.

BACKGROUND: Choanal atresia is a congenital obstruction of the posterior nasal aperture. Endoscopic endonasal surgery has led to successful choanal atresia repair. This paper describes our surgical technique using septal mucosal flaps without the need for stenting. METHODS: This study comprised a multicentre retrospective review of patient notes. A cross-over septal technique is described, whereby bilateral vertical mucosal incisions are made at the posterior third of the septum, and the atretic plate and posterior vomer are removed. One flap is pedicled superiorly and rotated over the bare skull base and sphenoid bone; the contralateral flap is pedicled inferiorly to cover the exposed vomer remnant and hard palate. RESULTS: There were 12 patients from 2013 to 2020, aged 0.07-50 years, with a male to female ratio of 1:5. Ten patients had unilateral and two had bilateral choanal atresia. Nine patients had bony choanal atresia, with the remainder mixed. CONCLUSION: The cross-over technique for choanal atresia has low morbidity and 100 per cent success in our series. The use of mucoperiosteal flaps to cover exposed bone and minimal instrumentation to the lateral nasal wall reduce post-operative stenosis.

Effect of surgery, delivery device and head position on sinus irrigant penetration in a cadaver model.

OBJECTIVE: The extent of surgery, the type of device used and head position may influence nasal irrigation. The aim of this study was to determine the effectiveness of topical irrigant delivery to the paranasal sinuses according to these factors. METHOD: Four cadaveric heads underwent four stepwise endoscopic dissections. Irrigations were evaluated after every stage using different delivery devices (squeeze-bottle, gravity-dependent device and syringe) in two head positions (nose-to-sink and vertex down). Irrigant penetration into each sinus was estimated using a four-point scale. RESULTS: A significant positive effect of surgery was demonstrated for each sinus as well as for the delivery device. High-volume irrigant devices are more effective, and the head position plays a significant role in irrigant distribution to the frontal sinus. CONCLUSION: This study further confirms the efficacy of high-volume irrigant devices. A vertex down position during the irrigation could improve delivery to the frontal sinus, and the widening of the ostia increases irrigant access to the sinuses.

Frontal sinus ablation (Riedel-Mosher’s procedure): indications and role in the endonasal endoscopic era.

BACKGROUND: The aim of this article is to describe the Riedel-Mosher’s surgical technique and identify its current role in the endoscopic endonasal era based on the experience of a tertiary care medical centre. It also provides a brief excursus on materials available for frontal reconstruction. METHODS: A retrospective review of patients submitted to Riedel-Mosher’s procedure from 2005 to 2018 at a single tertiary care centre was carried out. Details of the surgical technique along with data on frontal reconstruction timing and materials used were collected. RESULTS: A total of 21 patients (16 males and 5 females) underwent the Riedel-Mosher’s procedure. The age of the patients ranged from 15 to 84 years. The underlying pathology was represented mainly by chronic osteitis of the frontal bone (17 cases), followed by benign tumours (3 cases) and malignancy (1 case). Perioperative complications occurred in 3 patients. Cranioplasty was carried out only on 16 cases and delayed by an average time of 10 months. Materials for reconstruction included titanium, ceramic, plastic and free flap . CONCLUSIONS: Nowadays, Riedel-Mosher’s procedure is still indicated in selected cases of benign and malignant pathologies of the frontal sinus and/or frontal bone. Surgical expertise is key to approach the frontal sinus safely. Its reconstruction requires proper planning and a wide variety of materials to perform it is now available.

Implementing strategies for data collection in chronic rhinosinusitis.

SUMMARY: Chronic rhinosinusitis (CRS) is a debated topic in the international rhinologic literature because of its high prevalence, heterogeneity of clinical manifestations and unpredictability of disease course. Recently, the focus in CRS research has moved to identify biological subtypes that might explain its aetiology and clinical variability. However, these analyses are still expensive and limited to scientific purposes, so that they cannot be used on a large scale in daily practice. For this reason, we wondered if it was possible to define a risk stratification for CRS patients based only on first level investigations. The heterogeneity of the disease has given us a large amount of data compelling to find an additional storage system. Herein, we present the results of our work, the RhinoBank, as we believe that it is an easy-to-use tool for those professionals dealing with CRS and an effective system to exploit in clinical research.

Horizontal lateral lamella as a risk factor for iatrogenic cerebrospinal fluid leak. Clinical retrospective evaluation of 24 cases.

BACKGROUND: Several authors highlighted the limitations of the Keros classification system in predicting intracranial entry risk. Recently, our group proposed a new classification system based on the angle formed between the lateral lamella of the cribriform plate (LLCP) and the continuation of an horizontal plane passing through the cribriform plate (Gera classification). The aim of this study was to analyze whether the risk of iatrogenic cerebrospinal fluid leak (CSF-L) was better predicted by Keros or Gera classification. METHODOLOGY: The pre-operative CT scans of 24 patients (CSF-L group) who suffered from iatrogenic CSF-L during endoscopic sinus surgery (ESS) were compared to those obtained from a group of 100 patients who underwent uneventful ESS (control group). The skull base measurements as well as the distribution of Keros and Gera classes in the 2 groups were analyzed. RESULTS: No difference in the distribution of Keros classes or in the depth of the cribriform plate between CSF-L and control group were demonstrated. On the contrary, significant differences in the distribution of Gera classes and in the degree of the angle formed by the LLCP and the continuation of the horizontal plane passing through the cribriform plate were found. In particular, according to Gera classification system, 19 out of 24 patients in the CSF-L group were considered at risk for iatrogenic CSF-L. CONCLUSIONS: Gera classification system might be more sensitive to anatomical variations associated with CSF-L than the Keros one, further suggesting the application of the former during the preoperative CT scan evaluation.

Lateral lamella of the cribriform plate, a keystone landmark: proposal for a novel classification system.

BACKGROUND: The aim of this study is to propose a classification of the angle formed by the lateral lamella of the cribriform plate (LLCP) and the horizontal plane passing through the cribriform plate. In particular, the angle was classified into class I (over 80 degrees), class II (45 to 80 degrees, and class III (under 45 degrees) METHODOLOGY: A total of 190 computed tomography scans were retrospectively reviewed in order to obtain four sets of measurements. 1) depth of the cribriform, 2) angle, 3) length of the LLCP, 4) width of the fovea ethmoidalis. The relationship among these measurements were analyzed. RESULTS: The angle was significantly correlated with the depth of the cribriform and the length of the fovea, while it was negatively correlated with the length of the LLCP. Significant negative correlation was also found between the length of the LLCP and the width of the fovea. CONCLUSIONS: This angle classification is based on the theoretical risk of iatrogenic injuries, but it could be helpful also in clinical practice by providing indirect information on the thickness of the anterior skull base. As the angle decreases, in fact, the portion of the anterior skull base composed by the LLCP, increases.

Cross-cultural adaptation and validation of the SNOT-22 into Italian.

The aim of this study is to evaluate the reliability and validity of the Italian SNOT-22 (I-SNOT-22). The study consisted of five phases: item generation, reliability analysis, normative data generation, validity analysis and responsiveness analysis. The item generation phase followed the five-step, cross-cultural, adaptation process of translation and back-translation. A group of 222 patients with chronic rhinosinusitis (CRS) were enrolled for the internal consistency analysis. Sixty patients completed the I-SNOT-22 twice, 2 weeks apart, for test-retest reliability analysis. A group of 119 asymptomatic subjects completed the I-SNOT-22 for normative data generation. I-SNOT-22 scores obtained by CRS patients and asymptomatic subjects were compared for validity analysis. I-SNOT-22 scores were correlated with Lund-Mackay and visual analogue scale (VAS) scores in 50 CRS patients for criterion validity analysis. Finally, I-SNOT-22 scores obtained in a group of 59 CRS patients before and after surgical treatment for CRS were compared for responsiveness analysis. All the enrolled subjects managed to complete the I-SNOT-22 without needing any assistance. Internal consistency was satisfactory (α = 0.86). Test-retest reliability was also satisfactory (ICC = 0.85). A significant difference in the I-SNOT-22 scores between the CRS patients and the asymptomatic subjects was found (p < 0.008). Positive significant correlations were found between I-SNOT-22 and VAS scores, while no significant correlations were found between I-SNOT-22 scores and Lund-Mackay scores. I-SNOT-22 scores obtained in the pre-treatment condition were significantly higher than those obtained after surgery. I-SNOT-22 is reliable, valid, responsive to changes in QOL, and recommended for clinical practice and outcome research.