Myomucosal island flaps for oropharyngeal reconstruction.

The oropharynx represents one of the most challenging areas to reconstruct for the head and neck surgeon. The buccinator myomucosal island flaps pedicled on the facial artery [tunnelized facial artery myomucosal island flap (t-FAMMIF)] or the buccal artery [buccal artery myomucosal island flap (BAMMIF)] are an ideal reconstructive option for moderate size defects measuring up to 8-9cm. Two fresh specimens have been used to show the step-by-step surgical technique of both island flaps. Design and flap extension, dissection plane, identification of the vascular pedicle, flap rotation and insetting are described. Reconstructive indications and the pros and cons of each one are discussed in this article. Myomucosal island flaps represent a very useful and versatile option for the functional reconstruction of the oropharynx. A detailed knowledge of the vascular anatomy of the cheek is key to obtain a large flap while minimizing the risk of complications.

Right colonic interposition for severe pharyngoesophageal stricture in head and neck patients: A feasible rescue strategy after multiple failed reconstructive options.

Severe pharyngeal stricture is an uncommon complication that may occur afer laryngectomy especially in irradiated patients. Its management is a challenge and high risk of recurrence after reconstruction exists. We present two patients with severe end-stage pharyngoesophageal stricture after several failed attempts of reconstruction with regional and free flaps, in which a right colon transposition was performed. Twenty days after surgery both patients were able to tolerate an oral diet, and no minor or major complications were observed. Right colonic transposition may be a valid option for secondary pharyngeal reconstruction if other less invasive methods such as regional or free flaps have failed to restore the pharyngoesophageal continuity or if the inferior location of stricture makes a tension free anastomosis impossible.

Role of Intratympanic Dexamethasone for Intractable Posterior Canal Benign Paroxysmal Positional Vertigo.

BACKGROUND: Benign paroxysmal positional vertigo is a frequent diagnosed disorder, most of the patients are successfully treated with reposition maneuvers. In between 3-12.5% of these patients remain symptomatic. Recent studies support the use of intratympanic corticosteroid for intractable vertigo with promising results. MATERIAL AND METHODS: Patients diagnosed with benign paroxysmal positional vertigo between June 2017 and December 2019 in a tertiary university hospital and in two private hospitals were included in the study and analyzed prospectively. They were treated and followed with repositioning maneuvers and intratympanic dexamethasone injections if the criteria was met. RESULTS: 4 out 72 patients included in the study developed criteria for intractable vertigo after at least 6 repositioning maneuvers. The posterior semicircular canal was affected in all cases, 3 out of 4 patients experienced symptom resolution, after two, four and five intratympanic dexamethasone injections respectively. CONCLUSIONS: The use of intratympanic steroids to treat patients with refractory benign paroxysmal positional vertigo showed encouraging results. We believe a multicenter randomized clinical trial should be performed to assess the efficacy of intratympanic steroids in the treatment of this pathology.

Cervicofacial surgery and implantable hearing device extrusion: management of challenging cases.

OBJECTIVE: To describe our management of implantable hearing device extrusion in cases of previous cervicofacial surgery. METHODS: A review was conducted of a retrospectively acquired database of surgical procedures for implantable hearing devices performed at our department between January 2011 and December 2019. Cases of device extrusion and previous cervicofacial surgery are included. Medical and surgical management is discussed. RESULTS: Four cases of implant extrusion following cervicofacial surgery were identified: one involving a Bonebridge system and three involving cochlear implants. In all cases, antibiotic treatment was administered and surgical debridement performed. The same Bonebridge system was implanted in the middle fossa. The three cochlear implants were removed, and new devices were implanted in a more posterior region. CONCLUSION: Previous cervicofacial surgery is a risk factor for hearing implant extrusion. The middle fossa approach is the best option for the Bonebridge system. Regarding the cochlear implant, it is always suitable to place it in a more posterior area. An inferiorly based fascio-muscular flap may be a good option to reduce the risk of extrusion.

Early T1-T2 stage p16+ oropharyngeal tumours. Role of upfront transoral robotic surgery in de-escalation treatment strategies. A review of the current literature.

Human papillomavirus is responsible of approximately 70% oropharyngeal tumours and is related with more favourable outcomes. It has led to an increasing interest for de-escalation treatment strategies such as Trans Oral Robotic Surgery (TORS). A literature review was performed searching for the role of TORS as de-escalation modality of treatment in patients with p16 positive oropharyngeal squamous cell carcinoma (OPSCC). Special attention was paid to the potential advantage offered by TORS in reducing adjuvant radiation therapy. Six questions were formulated. 67 studies were selected. Several trials analysing the role of upfront TORS to treat early stage p16+ OPSCC and the possibility of reducing the adjuvant radiotherapy were founded. A lot of studies based on the experience of single centres show promising results. Nevertheless to date no definitive data can be extrapolated. The continued investigation of this line of de-escalation therapy with randomized prospective clinical trials is needed.

Co-benefits of changing diet. A modelling assessment at the regional scale integrating social acceptability, environmental and health impacts.

Several commentaries have suggested that the overconsumption of animal foods exerts several detrimental effects on human and environmental health. However, no studies have accurately estimated the impact of a reduction in animal food consumption on mortality due to the direct effects on metabolic health (i.e. animal protein and saturated fat intake as modulators of pathways leading to cardiovascular disease, cancer and accelerated ageing), and indirect effects on health due to excessive exposure to pollutants (i.e. PM10 concentrations originated by livestock ammonia emissions). The proposed modelling approach is innovative since it integrates social acceptability, environmental and health impacts. It is adopted to investigate different scenarios at a regional scale presenting the Lombardy region case study. The work focuses on the impact on the human and environmental health of diets characterized by three different animal protein intake levels. Our integrated assessment modelling approach faces the issue from two points of view. On one side, it estimates the mortality due to the population exposure to PM10 concentrations including the inorganic fraction originated by livestock ammonia emissions, on the other, it evaluates the mortality (i.e. total, cardiovascular and cancer) due to high dietary animal protein and/or saturated fat intake. The impacts of the mentioned animal protein intake levels of diets are also estimated through the people willingness to change their eating behaviour. The importance of putting in place end-of-pipe and energy measures in order to reduce ammonia and methane emissions from the breeding activities, going further the current EU legislation on air quality and climate, is emphasized.

Pseudo mastoid obliteration with conchal cartilage may be a safe alternative technique for cochlear implantation in canal wall down mastoidectomy with large meatoplasty.

OBJECTIVE: Safe cochlear implantation is challenging in patients with canal wall down mastoid cavities, and the presence of large meatoplasties increases the risk of external canal overclosure. This paper describes our results of obliteration of the mastoid cavity with conchal cartilage as an alternative procedure in cases of canal wall down mastoidectomy with very large meatoplasty. METHODS: The cases of seven patients with a canal wall down mastoidectomy cavity who underwent cochlear implantation were retrospectively reviewed. Post-operative complications were analysed. The mean follow-up duration was 4.5 years. RESULTS: There was no hint of cholesteatoma recurrence and all patients have been free of symptoms during follow up. Only one patient showed cable extrusion six months after surgery, and implantation of the contralateral ear was needed. CONCLUSION: Pseudo-obliteration of the mastoid cavity with a cartilage multi-layered palisade reconstruction covering the electrode may be a safe alternative in selected patients with a large meatoplasty.

A clinical, histopathological and laboratory study of 19 consecutive Italian paediatric patients with chilblain-like lesions: lights and shadows on the relationship with COVID-19 infection.

BACKGROUND: Acral chilblain-like lesions are being increasingly reported during COVID-19 pandemic. However, only few patients proved positivity for SARS-CoV-2 infection. The relationship between this skin manifestation and COVID-19 infection has not been clarified yet. OBJECTIVE: To thoroughly characterize a prospective group of patients with chilblain-like lesions and to investigate the possible relationship with SARS-CoV-2 infection. METHODS: Following informed consent, patients underwent (i) clinical evaluation, (ii) RT-PCR and serology testing for SARS-CoV-2, (iii) digital videocapillaroscopy of finger and toe nailfolds, (iv) blood testing to screen for autoimmune diseases and coagulation anomalies, and (v) skin biopsy for histopathology, direct immunofluorescence and, in selected cases, electron microscopy. RESULTS: Nineteen patients, all adolescents (mean age: 14 years), were recruited. 11/19 (58%) of them and/or their cohabitants reported flu-like symptoms one to two months prior to skin manifestation onset. Lesions were localized to toes and also heels and soles. Videocapillaroscopy showed pericapillary oedema, dilated and abnormal capillaries, and microhaemorrhages both in finger and toe in the majority of patients. Major pathological findings included epidermal basal layer vacuolation, papillary dermis oedema and erythrocyte extravasation, perivascular and perieccrine dermal lymphocytic infiltrate, and mucin deposition in the dermis and hypodermis; dermal vessel thrombi were observed in two cases. Blood examinations were normal. Nasopharyngeal swab for SARS-CoV-2 and IgG serology for SARS-CoV-2 nucleocapsid protein were negative. Importantly, IgA serology for S1 domain of SARS-CoV-2 spike protein was positive in 6 patients and borderline in 3. CONCLUSIONS: Chilblain-like lesions during COVID-19 pandemic have specific epidemiologic, clinical, capillaroscopic and histopathological characteristics, which distinguish them from idiopathic perniosis. Though we could not formally prove SARS-CoV-2 infection in our patients, history data and the detection of anti-SARS-COV-2 IgA strongly suggest a relationship between skin lesions and COVID-19. Further investigations on the mechanisms of SARS-CoV-2 infection in children and pathogenesis of chilblain-like lesions are warranted.

Hypoxic acclimation negatively impacts the contractility of steelhead trout (Oncorhynchus mykiss) spongy myocardium.

Cardiac stroke volume (SV) is compromised in Atlantic cod and rainbow trout following acclimation to hypoxia (i.e., 40% air saturation; ~8 kPa O2) at 10-12°C, and this is not due to changes in heart morphometrics or maximum achievable in vitro end-diastolic volume. To examine if this diminished SV may be related to compromised myocardial contractility, we used the work-loop method to measure work and power in spongy myocardial strips from normoxic- and hypoxic-acclimated steelhead trout when exposed to decreasing Po2 levels (21 to 1.5 kPa) at several frequencies (30-90 contractions/min) at 14°C (their acclimation temperature). Work required to lengthen the muscle, as during filling of the heart, was strongly frequency dependent (i.e., increased with contraction rate) but was not affected by hypoxic acclimation or test Po2. In contrast, although shortening work was less frequency dependent, this parameter and network (and power) 1) were consistently lower (by ~30-50 and ~15%, respectively) in strips from hypoxic-acclimated fish and 2) fell by ~40-50% in both groups from 20 to 1.5 kPa Po2, despite the already-reduced myocardial performance in the hypoxic-acclimated group. In addition, strips from hypoxic-acclimated trout showed a poorer recovery of net power (by ~15%) when returned to normoxia. These results strongly suggest that hypoxic acclimation reduces myocardial contractility, and in turn, may limit SV (possibly by increasing end-systolic volume), but that this diminished performance does not improve the capacity to maintain myocardial performance under oxygen limiting conditions.

Endoscopic reconstruction of large anterior skull base defects with opening of the sellar diaphragm. Experience at a tertiary level university hospital.

BACKGROUND: The indications for expanded endoscopic transnasal approaches continue to increase, with more complex skull base defects needing to be repaired. This study reviews the management of large anterior skull base defects with opening of the sellar diaphragm. METHOD: A prospective analysis of endonasal endoscopic surgery carried out at Son Espases University Hospital between January 2013 and December 2018 was performed. The analysis included only the cases with a significative intra-operative cerebrospinal fluid leak. In all cases, reconstruction was performed by combining the gasket seal technique with a pedicled mucosal endonasal flap. RESULTS: Twenty-eight patients were included. The mucoperiosteal nasoseptal flap, the lateral wall flap and the middle turbinate flap were used in 13, 8 and 7 patients, respectively, combined with the gasket seal technique. One case of post-operative cerebrospinal fluid leak was observed (3.57 per cent). CONCLUSION: The combination of a gasket seal with an endonasal mucosal flap is an excellent technique for repairing large anterior skull base defects.

The Bonebridge active bone conduction system: a fast and safe technique for a middle fossa approach.

BACKGROUND: The transmastoid pre-sigmoid approach is always the preferred choice for implantation of the Bonebridge active bone conduction system in patients with a normal anatomy. When an anatomical variant exists or a previous surgery has been performed, a retrosigmoid approach or middle fossa approach can be performed. METHODS: The preferred surgical technique for a middle fossa approach is described. A 14 mm drill head (Neuro Drill) was used to create the bed at the squamous portion of the temporal bone. Surgical time and complication rate were analysed. RESULTS: The surgical time was shorter than 30 minutes in all cases, and only 14 seconds were needed to create a 14 mm bone bed. No complications were observed during the follow-up period (6-45 months). CONCLUSION: Use of the Neuro Drill for the middle fossa approach is an easy technique. It significantly decreases the surgical time, without increasing the complication rate.

Impact of reduced mass of light commercial vehicles on fuel consumption, CO2 emissions, air quality, and socio-economic costs.

This study presents a modelling system to evaluate the impact of weight reduction in light commercial vehicles with diesel engines on air quality and greenhouse gas emissions. The PROPS model assesses the emissions of one vehicle in the aforementioned category and its corresponding reduced-weight version. The results serve as an input to the RIAT+ tool, an air quality integrated assessment modelling system. This paper applies the tools in a case study in the Lombardy region (Italy) and discusses the input data pre-processing, the PROPS-RIAT+ modelling system runs, and the results.