Squamous Cell Carcinoma of the Nasal Vestibule: A Multi-Centric Observational Cohort Study.

OBJECTIVES: Squamous cell carcinoma of the nasal vestibule (NV-SCC) is a rare but challenging entity, due to the complex anatomy of the region. Consensus on the best treatment strategy is still lacking, as well as a dedicated staging system. Our aim was to analyze oncological outcomes of surgically treated patients and to investigate possible prognostic factors. METHODS: We performed a retrospective multi-centric observational study including six Academic Hospitals over a 10-year period, including only patients who underwent upfront surgery for primary NV-SCC. Patients were staged according to all currently available staging systems. The Kaplan-Meier method was used to compute overall, disease-free, and disease-specific survival. Logistic regression models were used to correlate between survival outcomes and clinical and pathological variables. RESULTS: Seventy-one patients with a median follow-up of 38 months were included in the study. Partial and total rhinectomy were the most commonly performed procedures, respectively, in 49.3% and 25.4% of cases. Neck dissection was performed on 31% of patients, and 45.1% of them underwent adjuvant radiotherapy. Three years overall, disease-specific and disease-free survival were, respectively, 86.5%, 90.3%, and 74.2%. None of the currently available staging systems were able to effectively stratify survival outcomes. Factors predicting lower overall survival on multivariate analysis were age (p = 0.021) and perineural invasion (p = 0.059), whereas disease-free survival was negatively affected by age (p = 0.033) and lymphovascular invasion (p = 0.019). CONCLUSION: Currently available staging systems cannot stratify prognosis for patients who underwent surgery for NV-SCC. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:2634-2645, 2024.

Atypical Tongue Abscesses Mimicking Submucosal Malignancies: A Review of the Literature Focusing on Diagnostic Challenges.

Tongue abscesses are rare conditions that usually follow mucosal disruption due to mechanical trauma or foreign body impaction. They typically manifest abruptly as a rapidly growing, hard mass or swelling in the context of tongue muscles; the patient frequently complains of pain, difficulties in swallowing or speaking, and fever. Nonetheless, the features of its presentation, together with accurate clinical evaluation, blood tests, and appropriate imaging tests, are usually sufficient to easily discern a tongue abscess from a malignancy. However, in rare cases, they may occur with slowly progressing and subtle symptoms, nuanced objective and laboratory findings, and inconclusive radiological evidence, leading to difficult differential diagnosis with submucosal malignancy. Herein, we review the literature, available on Pubmed, Embase, and Scopus, on publications reporting tongue abscesses, with atypical presentation suggesting an oral tumor. Our review confirms that tongue abscesses may manifest as a slowly growing and moderately painful swelling without purulent discharge and minimal mucosal inflammation; in this case, they may constitute an actual diagnostic challenge with potentially severe impact on correct management. Atypical tongue abscesses must therefore be considered in the differential diagnosis of tongue malignancy with submucosal extension, even when other diagnostic elements suggest a neoplasia; in this case, a deep biopsy under general anesthesia is essential for differential diagnosis, and simultaneous drainage of the necrotic and abscessual material may resolve the condition.

Current evidence on diagnosis and treatment of parotid gland lymphomas: a systematic review.

BACKGROUND AND PURPOSE: Parotid gland lymphoma (PGL) is a rare and challenging diagnosis. Different lymphomas can develop in the parotid gland, with the most common being the mucosa-associated lymphoid tissue (MALT) lymphoma, which originates directly from the glandular parenchyma. Other histologic subtypes arise from both intraglandular and extraglandular parotid lymph nodes. A consensus on diagnosis and treatment of PGL is still lacking, and published data is scarce and heterogeneous. METHODS: We performed a systematic review of the literature, including studies published after 2001, when the WHO classification of lymphoid tumours was introduced. RESULTS: Twenty retrospective studies were included in the analyses, eight of which focused exclusively on MALT lymphomas. Final analysis included 612 cases of PGL, with a 1.68:1 F/M ratio. MALT lymphoma was the most common histology, followed by follicular and diffuse large B-cell lymphoma. Most cases were low stages (IE/IIE acc. Ann Arbour, 76.5%) and only 10% of patients presented with symptoms, most commonly pain (4.8%) and B symptoms (2.2%). A high prevalence of associated autoimmune diseases was found, particularly Sjögren's syndrome, that affected up to 70% of patients with MALT lymphoma. In most cases diagnosis was achieved through parotidectomy (57.5%), or open biopsy (31.2%). Treatment strategies were either surgical, non-surgical or a combination of modalities. Surgery as a single-modality treatment was reported in about 20% of patients, supposing it might be a valuable option for selected patients. CONCLUSIONS: Our review showed that the diagnosis and treatment of PGLs is far from being standardized and needs further, more homogeneous reports to reach consensus.

Skeletal Muscle Depletion and Major Postoperative Complications in Locally-Advanced Head and Neck Cancer: A Comparison between Ultrasound of Rectus Femoris Muscle and Neck Cross-Sectional Imaging.

Skeletal muscle mass (SMM) depletion has been validated in many surgical fields as independent predictor of complications through cross-sectional imaging. We evaluated SMM depletion in a stage III-IV head and neck cancer cohort, comparing the accuracy of CT/MRI at C3 level with ultrasound (US) of rectus femoris muscle (RF) in terms of prediction of major complications. Patients submitted to surgery were recruited from 2016 to 2021. SMM was estimated on CT/MRI by calculating the sum of the cross-sectional area (CSA) of the sternocleidomastoid and paravertebral muscles at C3 level and its height-indexed value (cervical skeletal muscle index, CSMI) and on US by computing the CSA of RF. Specific thresholds were defined for both US and CT/MRI according to ROC curve in terms of best prediction of 30-day major complications to detect sarcopenic subjects (40-53%). Sixty-five patients completed the study. At univariate analysis, major complications were associated to lower RF CSA, lower CSA at C3 level and lower CSMI, together with previous radiotherapy, higher ASA score and higher modified frailty index (mFI). At multivariate analysis RF CSA (OR 7.07, p = 0.004), CSA at C3 level (OR 6.74, p = 0.005) and CSMI (OR 4.02, p = 0.025) were confirmed as independent predictors in three different models including radiotherapy, ASA score and mFI. This analysis proved the value of SMM depletion as predictor of major complications in a head and neck cancer cohort, either defined on cross-sectional imaging at C3 or on US of RF.

Spontaneous extracapsular parathyroid adenoma hemorrhage: when surgery is required?

PURPOSE: Spontaneous bleeding is a rare but serious complication of parathyroid adenomas and few cases were reported in the literature. Clinical manifestations and treatment may vary but sometimes an immediate surgery is required. In other cases a conservative approach can be preferred based on clinical stability and patients' conditions. The purpose of this work is to describe our case and to carry out a review of the current literature on this topic. METHODS: We reported a case of a parathyroid adenoma hemorrhage in an elderly patient describing its management. Moreover, a literature review of 57 cases was carried out, with the aim of collecting data about the most involved parathyroid gland and identifying the most correct management based on clinical manifestations and chosen treatments. RESULTS: The patients had an age between 29 and 81 years (mean 56.9 ± 16.4 years). Forty-four patients were females (77.2%), whereas 12 were males (21.8%). Based on clinical severity, age, comorbidities and calcemic status, three possible scenarios were identified, each with a recommended management. CONCLUSIONS: In parathyroid adenoma hemorrhages a careful clinical assessment is crucial to identify emergency conditions requiring immediate intubation, tracheostomy or neck exploration. Elderlies and comorbid patients have a higher risk of perioperative complications and indication for surgery should be evaluated case by case: whenever feasible, a conservative approach should be preferred in these subjects, especially in those with a stable course and without hypercalcemia-related symptoms.

Applications of Co2 laser in endoscopic surgery for sinonasal neoplasms.

OBJECTIVE: The aim of the study is to assess safety, effectiveness, and potential advantages of CO2 fiber laser during endoscopic endonasal surgery for the resection of sinonasal neoplasms. We present text, images, and videos to show our experience with this new device recently introduced in endoscopic endonasal surgery and as a potential tool for educational purpose. METHODS: Six patients affected by benign or malignant sinonasal tumors who underwent endoscopic resection between January and May 2021 were enrolled in the study. Surgical approach was conducted via standardized centripetal endonasal technique. During the surgery we evaluated instrument ergonomics, quality in section on both healthy tissue and tumor, coagulation, and bleeding control from major vessels. RESULTS: In our experience, CO2 fiber laser has proved to have good ergonomics, as well as to be a safe and effective tool for the resection of both neoplastic and healthy tissues. Cauterization was efficient only in vessels with average diameter lower than 1 cm. Prolonged procedural time, costs, and necessity of learning-curve and expertise are possible drawbacks. CONCLUSION: Co2-fiber laser is an effective tool which can aid the surgeon during endoscopic endonasal approach to sinonasal neoplasms.

Supraclavicular artery fascial flap (SAFF): a valuable tool in salvage total laryngectomy and hemipharyngolaryngectomy.

OBJECTIVE: To describe the surgical technique of the supraclavicular artery fascial flap (SAFF) and outcomes in neopharyngeal covering with overlay technique during salvage total laryngectomy for residual or recurrent carcinoma after chemo/radiation treatment. METHODS: Chart review of patients treated between October 2018 and February 2019 at two tertiary care hospitals. Variables extracted from patient records were age, gender, history of chemo/radiation therapy, neck dissection, surgical and postoperative complications. Outcomes measured were surgical time, postoperative complications and flap failure, oral intake start and patient discharge. RESULTS: Ten male patients were included. Median age was 64 years. All patients underwent salvage total laryngectomy and neopharyngeal covering with SAFF. Mean flap harvest time was 25 minutes. No surgical complications or flap failure were recorded. Oral intake was started on a median of post-operative day 10. No cases of pharyngocutaneous fistula were encountered. CONCLUSIONS: SAFF is a reliable, easy and quick to harvest flap, which provides a good alternative to other pedicled and free flaps for hypopharyngeal coverage in laryngeal salvage surgery. Donor site morbidity is almost null and postoperative complications are very rare.

The importance of the patient's perspective in function-sparing parotid surgery for benign neoplasms: clinical reappraisal.

OBJECTIVE: Function-sparing surgery is the cornerstone for the treatment of benign parotid neoplasms. We assessed the incidences and determinants of the main postoperative complications, reappraising their influence on the patient's quality of life (QoL). METHODS: Patients who underwent parotid surgery for benign neoplasms were reviewed (2016-2019). Parotidectomy Outcome Inventory-8 (POI-8) and condition-specific questionnaires were used to investigate the patient's perspective. RESULTS: We enrolled 211 patients. Preservation of the posterior branch of the great auricular nerve (GAN) seemed to reduce early dysfunction (87% vs 96%, p = 0.053), but not the late one. Deep lobe dissection and resection of more than one parotid segment favoured first bite syndrome (FBS) and Frey's syndrome (FS), respectively (16% vs 3%, p = 0.003; 37% vs 15%, p = 0.003). Neither GAN impairment, FBS, nor FS influenced patient QoL. Facial weakness affected 19 patients (9%), being more likely after total parotidectomy (23% vs 7%, p = 0.034). According to POI-8, QoL was mainly jeopardised by fear of revision surgery, especially in females (p = 0.005) and those experiencing early complications (p = 0.004). CONCLUSIONS: Reappraisal of the patient's perspective after functional parotid surgery is fundamental to tailor preoperative counselling.

High-risk early-stage oral tongue squamous cell carcinoma, when free margins are not enough: Critical review.

Oral tongue squamous cell carcinoma (OTSCC) is a quite peculiar disease from an anatomical and biological standpoint. An increasing amount of literature highlights the existence of a small subset of T1-T2N0 OTSCC, properly resected on a margin-dependent basis, which conversely proved higher than expected rates of loco-regional/distant failure and disease-specific mortality. These specific high-risk tumors might not have a margin-dependent disease and could possibly benefit from a more aggressive upfront loco-regional treatment, especially addressing the so-called T-N tract. Widespread adoption of a histopathological risk model would allow early recognition of these high-risk diseases and, consequently, intensification of the traditional treatment strategies in that specific niche. We reviewed the available knowledge trying to shed light on the potential determinants of the dismal prognosis of these high-risk OTSCC, with special reference to the role of overlooked T-N tract involvement and possible alternatives in terms of elective neck management and risk stratification.

Uncommon Site of Metastasis and Prolonged Survival in Patients with Anaplastic Thyroid Carcinoma: A Systematic Review of the Literature.

Anaplastic thyroid carcinoma (ATC) is a very rare, highly aggressive malignant thyroid tumor with an overall survival from 3 to 5 months in most of the cases. Even the modern and intensive treatments seem not to be enough to provide a cure, also for the resectable ones, and the role of chemotherapy is still unclear but does not seem to prolong survival. Nevertheless, some patients survive longer and have a better outcome, even in the presence of metastasis, than what the literature reports. We present the case of a 64-year-old female affected by ATC, treated on February 2018 with surgery followed by chemoradiation. One year after surgery, the patient developed a subcutaneous recurrence that was radically resected and is still alive 29 months after the diagnosis. We propose a systematic review of the literature to deepen the knowledge of the prognostic factors of ATC with the aim to recognize and select the patients with a better outcome, even if metastatic, and to describe a very uncommon site of metastatization.

Fine needle aspiration cytology for parotid neoplasms: risk of malignancy through inconclusive results and lower grade tumors.

PURPOSE: Fine needle aspiration cytology (FNAC) is a commonly performed procedure for parotid masses, although its accuracy in detecting malignancies widely varies through different series. We evaluated our single-center cohort of parotidectomies to highlight possible limitations of preoperative FNAC. METHODS: Seven hundred and eighteen consecutive patients submitted to parotid surgery at San Raffaele Scientific Institute (Milan) were retrospectively evaluated (2002-2018). Five hundred and fifty four FNAC were analyzed. FNAC accuracy was assessed with and without inclusion of "inconclusive" results. The peculiar role of lower grade primary parotid cancers was investigated. RESULTS: FNAC reports were "diagnostic" in 502 cases (90.4%) and "inconclusive" in 52 (9.6%). Histopathology revealed 488 benign lesions (88.1%) and 66 malignancies (11.9%). FNAC sensitivity, specificity, PPV, NPV and accuracy in detecting malignancies were 59%, 99%, 89%, 95%, and 95%, respectively. Sensitivity fell to 48%, when "inconclusive" FNAC was computed. Within 66 parotid cancers, FNAC could discriminate malignancy in 32 cases (48.5%), provide proper grading in 21 (31.8%), and precise histopathological diagnosis in 15 (22.7%). Malignancy was more likely in patients with "inconclusive" FNAC than in those with "diagnostic" cytologies (23.1% vs 10.8%, p = 0.003). Low-intermediate-grade primary parotid cancers were associated to a higher rate of FNAC failure in comparison with high-grade ones (86.4% vs 19.0%; p < 0.001). CONCLUSION: FNAC is an important tool for preoperative assessment of parotid masses, though its sensitivity in detecting malignancy remains poor. "Inconclusive" FNAC results could further jeopardize FNAC accuracy and should elicit resorting to additional tests, especially when a lower grade parotid cancer is suspected.

Pre-operative transnasal endoscopy as a predictor of difficult airway: A prospective cohort study.

BACKGROUND: Consequences of failed endotracheal intubation can be catastrophic and predicting difficulty is therefore a critical issue. There is no consensus on the best way to predict difficulty. OBJECTIVE: To evaluate the role of transnasal flexible endoscopic laryngoscopy (TFEL), a minimally invasive procedure, in the prediction of difficult intubation. DESIGN: Prospective cohort study. SETTING: San Raffaele Hospital, Milan, a tertiary university hospital. PATIENTS: One hundred and sixty nine adults scheduled for elective ear, nose and throat surgery under general anaesthesia with pre-operative TFEL. INTERVENTION: In addition to routine pre-operative evaluation by an anaesthesiologist, glottis exposure during TFEL was assessed with a scoring system similar to the modified Cormack-Lehane (MCL). MAIN OUTCOME MEASURES: The extent to which TFEL improves the prediction of difficult direct laryngoscopy, measured with the MCL score, and of difficult intubation, measured with the intubation difficulty scale score. RESULTS: When added to bedside evaluation, TFEL performed during tongue protrusion significantly (P = 0.005) improved the prediction of MCL. The area under the receiver operating characteristics curve was 0.75 [95% confidence interval (CI) 0.67 to 0.83] vs. 0.65 (95% CI 0.58 to 0.74). For the intubation difficulty scale (P = 0.049), the area under the receiver operating characteristics curve was 0.70 (95% CI 0.61 to 0.80) vs. 0.66 (95% CI 0.58 to 0.74). CONCLUSION: TFEL is a useful tool in predicting difficult intubation, improving predictability of routine bedside evaluation. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02671877.

Long-term Swallowing Function, Pulmonary Complications, and Quality of Life after Supracricoid Laryngectomy.

OBJECTIVES: Long-term effects of supracricoid laryngectomies are nowadays under discussion. The purpose of this study was to detect the prevalence of chronic aspiration and incidence of pulmonary complications, to investigate possible influencing factors, and to analyze dysphagia-related quality of life in a cohort of patients who recovered swallowing function after undergoing supracricoid laryngectomies. STUDY DESIGN: Retrospective observational study. SETTING: San Raffaele Hospital, Vita-Salute University, Milan, Italy. METHODS: A cohort of 39 patients who recovered swallowing function free of disease after a minimum 3-year follow-up period was retrospectively investigated between October and December 2017-clinically with the Pearson's Scale and M. D. Anderson Dysphagia Inventory and instrumentally with fiberoptic endoscopic evaluation of swallowing. RESULTS: Chronic aspiration was demonstrated in a significant portion of patients (clinically in 33.3% and instrumentally in 35.9%). Aspiration was influenced by advanced age at surgery (P = .020). Type of surgical procedure, resection of 1 arytenoid cartilage, postoperative rehabilitation with a speech-language therapist, radiotherapy, age at consultation, and length of follow-up did not influence the prevalence of aspiration. Pulmonary complications affected 5 patients; incidence of pulmonary complications was related to aspiration and was favored by poor laryngeal sensation/cough reflex. Aspiration significantly affected quality of life. CONCLUSIONS: Chronic aspiration is frequent and affects patients' quality of life. However, incidence of pulmonary complications is low; therefore, oral feeding should not be contraindicated for aspirating patients. Preservation of laryngeal sensation and cough reflex is mandatory to prevent pulmonary complications.

Diagnosis and Treatment of Laryngeal Schwannoma: A Systematic Review.

Objective This review summarizes the clinical features, diagnostic workup, and surgical treatment of laryngeal schwannoma with the aim of providing guidance for the management of this rare disease. The collated data allowed the statistical testing of several hypotheses, including the efficacy of endoscopic vs open surgical intervention and the usefulness of preoperative biopsy. Data Sources PubMed, Google Scholar, Cochrane, and SCOPUS. Review Methods Basic epidemiological and clinical presentation data were collated together with details of diagnostic image modality, lesion attributes, and the use of preoperative biopsy. Surgical approach to intervention and outcome was also collated and simple statistical analyses applied. Results The 60 original articles selected provided a combined cohort of 74 patients for review. The combined data revealed that schwannoma with pedunculated morphology were always safely removed by endoscopic resection regardless of size and should be treated as a separate entity. Of the nonpedunculated schwannoma, larger tumors were more likely to undergo an open approach, which in turn was associated with higher rates of tracheotomy and postoperative vocal fold paralysis. The small cohort did not reveal a significant association between surgery type and persistent disease. Interestingly, the data revealed a significant association between the use of incisional biopsy and persistent disease. Cases exhibiting extralaryngeal extension of the lesion were shown to exclusively belong to patients with neurofibromatosis/schwannomatosis syndromes. Conclusions Taken together, these findings suggest that incisional biopsy should be avoided, and given the benign nature of the pathology, the least invasive radical approach should be employed.

Columella reconstruction with an inferiorly-based philtral advancement flap in a cocaine abuser.

Nasal columella defects can significantly impair aesthetic appearance. Columella reconstruction can be very challenging for surgeons, especially if due to cocaine abuse. The case of a 32-year-old male patient with subtotal columellar necrosis secondary to cocaine abuse is presented. An inferiorly based philtral advancement flap was performed to cover the defect. Aesthetic outcome was the primary goal of surgery. Reconstruction led to good aesthetic and functional results.

Rupture of the extracranial carotid artery caused by misdiagnosed infected pseudoaneurysm during deep cervical abscess drainage: A case report.

Infected aneurysms or pseudoaneurysms of the extracranial carotid artery are extremely rare, but they can lead to lethal complications. In some cases, infected pseudoaneurysms can be masked by the excessive inflammation of surrounding tissues. Here we describe the case of a 69-year-old woman with several comorbidities, who presented with a rapidly enlarging left neck bulge. CT was suggestive of an abscess involving the left common carotid artery. Colour Doppler ultrasound did not document intralesional flow. Abscess drainage under ultrasonographic assistance was attempted unsuccessfully, with collection of creamy, purple material. Surgical drainage of the abscess was, therefore, decided. As soon as necrotic tissue debridement was started, a massive haemorrhage originating from the common carotid artery invaded the surgical field. The carotid artery was then repaired with a bovine pericardial patch and covered with a pectoralis major muscle flap. The patient recovered without any neurological consequences. Revision of CT imaging revealed a very small misdiagnosed infected pseudoaneurysm. With better preoperative surgical planning and a good suspicion index, such a life-threatening emergency could have been avoided.

Supraclavicular artery island flap (SCAIF): a rising opportunity for head and neck reconstruction.

Over the last 20 years, free flaps have represented the gold standard for moderate to large head and neck reconstruction. However, regional flaps continue to evolve and still play an important role in a reconstructive surgeon's armamentarium, especially for the more delicate patients who would certainly benefit from simpler surgical procedures. The supraclavicular artery island flap (SCAIF) is a pedicled flap that has recently gained great popularity for reconstruction of most head and neck sites, because of its unusual versatility and wide arc of rotation. SCAIF is a fasciocutaneous flap that is very reliable and both easy and quick to harvest. It is pedicled on the supraclavicular artery, which is a branch of the transverse cervical artery. Between October 2012 and July 2015, at Ospedale San Raffaele (Milan, Italy) and Policlinico San Matteo (Pavia, Italy), we used the SCAIF procedure on 14 patients with cervical and facial skin, oral cavity, oropharyngeal, and hypopharyngeal defects after oncologic surgery or as revision surgery after free-flap failure. The presence of the supraclavicular artery was demonstrated preoperatively by computed tomography angiography. Harvesting time never exceeded 50 min. Functional outcomes were excellent, and the donor site was always closed. We reported only one case of tip desquamation, which was treated conservatively, and two cases of partial flap necrosis, which required revision surgery. In our opinion, SCAIF should be considered to be a valid alternative to free-flap reconstruction, especially for facial and cervical skin, floor-of-mouth, and hypopharyngeal defects; oropharyngeal defects may be harder to reconstruct.