Severe chronic rhinosinusitis treated with dupilumab, a real-life analysis of early effectiveness.

OBJECTIVE: The present study evaluated the safety and efficacy of dupilumab in severe uncontrolled type 2 chronic rhinosinusitis with nasal polyps (CRSwNP). PATIENTS AND METHODS: A retrospective analysis was conducted on a cohort of adult patients affected by severe CRSwNP treated with dupilumab. Maxillofacial computed tomography, evaluation of blood eosinophils and serum IgE levels, measurement of nasal polyp score (NPS), smell identification test (SSIT-16), sinonasal outcome test-22 (SNOT-22) and asthma control test (ACT) were performed. Follow-up was conducted at 2 weeks, and at 1, 3, and 6 months. Adverse events and the efficacy of treatment were monitored. RESULTS: 23 patients were enrolled. After 15 days, scores of the SNOT-22, NPS and SSIT-16 significantly improved. These outcomes were also maintained after 1, 3, and 6 months (p < 0.001). At this latter follow-up time, SNOT-22 showed a change of -33.10 (p < 0.001), NPS -3.36 (p < 0.001) and SSIT-16 +5.60 (p < 0.001). In all, 26.1% of patients experienced early minor complications. CONCLUSIONS: In the present study, dupilumab was effective in the treatment of severe uncontrolled CRSwNP, demonstrating a quick significant improvement in both questionnaires and endoscopic evaluation. Only minor complications were observed.

Clinical and radiological presentation of parasellar ectopic pituitary adenomas: case series and systematic review of the literature.

PURPOSE: Parasellar ectopic pituitary adenomas (pEPAs) are extremely rare tumors located out of the sella turcica. PEPAs are heterogeneous entities in terms of anatomical localization and secretion of anterior pituitary hormones. METHODS: Multicenter retrospective study. Clinical charts' consultation of patients diagnosed with parasellar lesions, to identify all subjects fulfilling the diagnostic criteria of parasellar EPAs. Systematic review of the literature focused on the medical management of prolactin-secreting pEPAs and on the prevalence of radiological bone invasion in pEPAs. RESULTS: We identified four cases of pEPAs: (1) 54-year-old female with a prolactin-secreting suprasellar EPA successfully treated with cabergoline; (2) 74-year-old male with a non-functioning EPA of the sphenoidal sinus treated with endoscopic transsphenoidal surgery; (3) 75-year-old female with a giant lesion of the skull base (maximum diameter 7.2 cm) diagnosed as a non-functioning EPA after biopsy; (4) 49-year-old male with a silent corticotroph EPA of the sphenoidal sinus and clivus. Three out of four cases had radiological evidence of invasion of the surrounding bone structures. A systematic review of the literature highlighted that medical therapy can be effective in prolactin-secreting pEPAs. Overall, we found mention of local invasiveness in 65/147 cases (44.2%), confirmed by radiological signs of bone invasion/erosion. CONCLUSION: Our experience confirms the heterogeneity of pEPAs in terms of clinical and radiological presentation, as well as hormone secretion. PEPAs show a high frequency of radiological bone invasion, though similar to that of sellar pituitary adenomas. Although extremely rare, pEPAs need to be considered in the differential diagnosis of parasellar lesions.

Clarithromycin in the Management of Chronic Rhinosinusitis: Preliminary Results of a Possible Its New Use.

The aim of this study is to evaluate the efficacy and safety of prolonged therapy with low-dose clarithromycin in patients with chronic rhinosinusitis with polyps (CRSwP) after endoscopic sinus surgery (ESS). A total of 10 patients with CRSwP were identified and subjected to bilateral ESS. In post-operative patients they were treated with nasal wash with saline solution and steroid sprays (beclomethasone). During follow-up, after 30-40 days after the operation (M = 35.4 SD = +4.33), patients reported a worsening of symptoms with onset of nasal obstruction; reduction/loss of smell; headache; onset of viscous secretions and therefore all patients continued therapy with saline nasal irrigation, topical steroid therapy and started macrolide (clarithromycin 500 mg/pill: 1 pill/day for 3 days a week for 1 month). 22-item SinoNasal Outcome Test (SNOT-22) and a score to the endoscopic evaluation (endoscopic appearance score, EAS) before and after treatment were performed to evaluate efficacy of treatment. The results of the SNOT-22 and EAS showed statistically significant improvements (p < 0.05) for some parameters such as: the need to blow nose, sneezing, hyposmia, viscous mucous secretions about the SNOT-22 and reduction of secretions and edema of the nasal mucosa about the EAS. The preliminary results of our study show that the low-dose clarithromycin for a period of 1 month can improve patient complaints with CRSwP not only through the antibacterial properties but also for the immunomodulatory characteristics.

Nasal packing in sphenopalatine artery bleeding: therapeutic or harmful?

The aim of this study is to present our management protocol of sphenopalatine artery bleeding, demonstrating that nasoendoscopic cautery (NC) was a more effective method than the nasal packing, in terms of shorter inpatient stay and reduced complications rate. We present ten posterior epistaxis not resolved by nasal packing. Tabotamp® was placed in the area of sphenopalatine foramen and/or in those parts of the posterior nasal cavity, where it was suspected that bleeding origins. In two cases, the bleeding was resolved in this way, instead eight cases needed of subperiosteal cauterization of sphenopalatine artery by Dessi bipolar forceps (MicroFrance®). 4 of these 8 patients evidenced a remarkable bleeding removing nasal packing (Hb before-nasal packing = 15 ± 0.69 versus Hb after-nasal packing = 13.3 ± 0.81; t student = 2.94; p value = 0.025). These four patients showed a deviation of the nasal septum ipsilateral to epistaxis, and according our experience, a traumatism of sphenopalatine area can be caused by Merocel® nasal packing in this condition. During follow-up, no recurrences of nasal bleeding have been observed in such patients. Nasal packing must be considered if posterior epistaxis is severe, but always taking into account the specific anatomy of patient and in particular septal spurs that can further compromise sphenopalatine artery. In our experience, the endoscopic endonasal cauterization of the sphenopalatine branches represented a safe and effective procedure.

Endoscopic endonasal management of non-functioning pituitary adenomas with cavernous sinus invasion: a 10- year experience.

BACKGROUND: The management of Non-Functioning Pituitary Adenoma (NFPA) invading the cavernous sinus (CS) is currently a balancing act between the surgical decompression of neural structures, radiotherapy and a wait-and-see policy. METHODS: We undertook a retrospective review of 56 cases of NFPA with CS invasion treated through an endoscopic endonasal approach (EEA) between 2000 and 2010. The Knosp classification was adopted to describe CS involvement using information from preoperative MRI and intraoperative findings. Extent of resection and surgical outcomes were evaluated on the basis of postoperative contrast-enhanced MRI. Endocrinological improvement and visual outcomes were assessed according to the most recent consensus criteria. RESULTS: EEA was performed using direct para-septal, trans-ethmoidal-sphenoidal or trans-ethmoidal-pterygoidal-sphenoidal approach. Visual outcomes improved in 30 (81%) patients. Normalization or at least improvement of previous hypopituitarism was obtained in 55% of cases. A gross total resection was achieved in 30.3% of cases. The recurrence-free survival was 87.5%, with a mean follow-up of 61 months (range, 36-166 months). No major intraoperative or postoperative complications occurred. DISCUSSION: EEA is a minimally-invasive, safe and effective procedure for the management of NFPA invading the CS. The extent of CS involvement was the main factor limiting the degree of tumor resection. The EEA was able to resolve the mass effect, preserving or restoring visual function, and obtaining adequate long-term tumor control.

Endoscopic treatment of maxillary inverted papilloma.

OBJECTIVES: Evaluate the efficacy of endoscopic treatment in maxillary inverted papilloma (IP). METHODOLOGY: Between July 2002 - April 2008, 20 patients affected by maxillary localization of IP were treated in our Clinic. All patients underwent endoscopic treatment consisting of an endoscopic medial maxillectomy (simple or extended), or attachment-site endoscopic tumour surgery. RESULTS: The cohort was composed of 20 patients (male: 15, female: 5), mean age 58 years, and included 21 endoscopic resections of maxillary IP. Minimum follow-up: 24 months, mean follow-up: 50 months. We registered only 1 case of tumour persistence/recurrence after 15 months, which underwent a second endoscopic treatment. No association with malignant lesions was noted. The efficacy of the endoscopic treatment was 95% (19/20 cases) after primary surgery, and 100% after endoscopic revision. CONCLUSIONS: Our experience demonstrates the efficacy of endoscopic treatment in maxillary IP. Based On its reduced morbidity in comparison to external approaches and its good control of the disease, we consider it our standard treatment for maxillary-originated inverted papilloma.

Endonasal approaches to the sellar and parasellar regions: closure techniques using biomaterials.

PURPOSE: We reviewed the clinical outcomes resulting from various closure techniques used following endoscopic endonasal surgery for lesions in the sellar and parasellar regions. We compared our current closure technique, which uses a biological matrix of native equine collagen (TissuDura) fixed with fibrin sealant (Tisseel), with the technique we employed previously, using autologous materials, in order to assess the comparative efficacy and tolerability of both methods over the medium- to long-term. METHODS: A review was conducted of all cases of endonasal endoscopic intervention carried out in our institution between 1997 and 2007. Operations performed between January 1st 1997 and December 31st 2003 involved a sellar closure technique using autologous materials, either alone or supported by fibrin sealant. From January 1st 2004, sellar reconstruction techniques involving resorbable heterologous materials were used in the closure phases. Post-operatively, clinico-endoscopic assessments took place at 15 days, 1, 3, and 6 months and yearly thereafter, supplemented by magnetic resonance imaging (MRI) scanning at 3 months and annually. RESULTS: Between January 1st 1997 and December 31st 2003, 79 operations were performed in which the sellar closure technique involved the use of autologous materials. Between January 1st 2004 and January 1st 2008, 125 operations were performed in which biomaterials were used for sellar closure. The incidence of complications (fluid fistula) was 2.5% in the autologous materials closure group and 1.6% in the biomaterials closure group. The most marked difference between the two approaches was seen at 1-month follow-up, when restoration of mucociliary transport in the sphenoidal sinus and physiological functionality of the nasal mucosa and paranasal sinuses were observed to be superior in the biomaterials patient cohort. CONCLUSIONS: The development of biomaterials for closure of the sellar floor offers a viable alternative to traditional techniques using autologous materials.

Silent familial isolated pituitary adenomas: histopathological and clinical case report.

Familial isolated pituitary adenoma (FIPA) is a rare condition independent of Carney Complex or MEN1. An international multicenter study recently described 28 nonfunctioning pituitary adenomas in 26 families with only two homogeneous nonsecreting phenotype families consistent of silent GH and silent gonadotroph adenomas, respectively. We present the clinical, genetic, and morphological analysis of two silent pituitary adenomas occurring in a man and his daughter, and discuss the differential diagnosis associated with their histological, immunohistochemical, and ultrastructural features. The patients developed invasive nonsecreting macroadenomas manifesting only with compressive symptoms. Genetic analysis in the father showed no MEN-1 germ-line mutation. Tissue samples obtained after paraseptal trans-sphenoidal surgery were studied by immunohistochemistry for adenohypophyseal hormones, low molecular weight cytokeratins (CAM 5.2), proliferation markers, and anterior pituitary transcription factors (Pit-1 and SF-1) and by electron microscopy for secretory granules. The clinical, histological, and immunohistochemical features of the lesions posed a differential diagnosis between a null cell adenoma and a silent corticotroph adenoma (Type II); on the basis of immunohistochemical stains for cytokeratin and adenohypophysis cell lineage markers, tumor behavior and ultrastructural studies we concluded for the second. The reported cases represent an as yet undescribed example of homogeneous family with silent corticotroph adenomas (Type II). Our observations support the trend for more aggressive behavior in nonsecreting FIPAs as compared with sporadic adenomas.

[Paranasal sinus mycoses]. / Le micosi rinosinusali.

In recent years there has been a marked increase in mycosis infections of the paranasal sinuses, attributed both to an increase in the survival of subjects at risk and improved diagnostic techniques (endoscopy, CT, MR) able to identify cases which had previously gone unrecognized and treated as aspecific chronic sinusitis. The present study involves 45 cases (4.3%) out of a total of 1050 patients who had undergone endoscopic surgery for sinusopathy between April 1994 and December 1998. Following the Katzenstein classification, the cases were broken down into non-invasive chronic mycoses or fungus ball (34 cases), allergic mycoses (7), chronic indolent invasive mycoses (3) and fulminating invasive mycosis (1 case). The mycetes most often involved was Aspergillus Fumigatus (76.9%). The recurrent symptom was facial algia, followed by nasal obstruction. Paranasal sinuses endoscopy did not modify the specific picture. CT presented such indicative signs as focal areas with non-homogeneous intensity, images of metal-like foreign bodies and endosinus calcifications in 84.4% of the cases. MR--performed in only 6 cases--always presented T2 images showing the typical signal void area corresponding to pathological lesions. All patients underwent endoscopic surgery of the paranasal sinus. The effectiveness of this treatment differed according to the clinical form. In the fungus balls surgery always resolved the pathology without requiring subsequent pharmacological treatment. In allergic mycosis, surgery improved the symptom of nasal respiratory obstruction but local drug treatment was required. With the aid of drug treatment, surgery resolved chronic indolent invasive mycoses and prevented the endocranial progression of complications. In the cases of fulminating invasive mycosis, timely surgery prevented the onset of endocranial complications and made it possible to perform antimycotic polychemotherapy to control the disease. This experience shows how important a protocol involving several different tests is in diagnosing the many clinical forms of paranasal sinus mycoses and distinguishing them from sinusopathies. Endoscopic surgery is indicated for all forms of paranasal sinus mycoses although the realistic objectives differ according to type.