The Impact of Piezoelectric Device in Cholesteatoma Endoscopic Surgery: Retrospective Evaluation of Safety and Functional Results.

OBJECTIVE: Atticotomy represents an essential surgical step within the management of attical cholesteatoma during endoscopic ear surgery. The aim of the present study was to evaluate the safety and functional results of an endoscopic atticotomy performed with piezosurgery, in terms of audiological outcomes and tissue's healing. METHODS: This is an observational retrospective study on patients with attical cholesteatoma who underwent endoscopic ear surgery with piezoelectric atticotomy and subsequent scutum reconstruction either with tragal cartilage or temporalis muscle fascia. Scutumplasty's status was evaluated via scheduled outpatient controls through an endoscopic check and classified as stable or unstable at least 10 months after surgery. A pre- and postoperative audiometric examination was performed in each patient. RESULTS: Eighty-four patients were enrolled. In 50 out of 84 patients (59.52%), an exclusive endoscopic procedure was performed, whereas in 34 patients (40.48%) a combined microscopic/endoscopicapproach was adopted. In 72 cases (85.71%), scutum's reconstruction appeared to be normally positioned, whereas 12 patients developed a retraction pocket, which was self-cleaning in 8 of them and non-self-cleaning in the remaining 4. In 17 patients, a slight sensorineural hearing loss (between 5 and 15 dBHL) was observed, and in 2 patients, the loss was greater than 15 dBHL. Overall, no significative differences between pre- and postoperative pure-tone average bone thresholds resulted (p = 0.4983), though a mild significant hearing deterioration was detected by the specific analysis at 4000 Hz (p = 0.0291). CONCLUSION: Piezosurgery represents an extremely useful tool in performing atticotomy during endoscopic tympanoplasties. Our data seem to support the safety of its usage in this specific step, as it did not lead to any significant sensorineural damage on overall pure-tone average. Moreover, satisfactory tissue healing in regard to scutum reconstruction was observed.

Radiological Classification and Management Algorithm of Petrous Apex Cholesterol Granuloma.

Background: Petrous apex cholesterol granulomas (PACGs) are benign inflammatory cystic lesions of the temporal bone. Usually, asymptomatic patients may develop symptoms as the lesions expand. The diagnosis is based on both CT and MRI scans and the management relies on "wait and scan" or surgery. This paper aims at evaluating surgical outcomes and proposing a CT-based classification and a management algorithm. Methods: Patients with PACGs who were surgically treated between 2014 and 2024 were included. Symptoms, imaging, approach type and complications were considered. CT scans were classified as Type A (preserved apex cellularity), Type B (erosion of the apex cellularity), and Type C (involvement of the noble structures bone boundaries). The possible connection of the lesion with the infracochlear, perilabyrinthine and sphenoidal cellularity was assessed. Results: Nineteen patients with symptoms like diplopia, headache and sensorineural hearing loss were included. According to our classification, 1/19 patients was Type A, 4/19 were Type B and 14/19 were Type C. Five patients underwent a total resection, seven a subtotal and seven a surgical drainage. Only two complications were recorded, and 17/19 patients showed symptom regression and stability during follow-up. Conclusions: While the management of PACGs is still controversial, according to our classification and surgical outcomes, Type A, being mostly asymptomatic, should be managed with "wait and scan", Type B should undergo surgery when symptoms are present, while Type C should always undergo surgery because of their invasiveness and potential complications. When possible, a drainage should be attempted; otherwise, a surgical resection is chosen, and its completeness depends on the preoperative general and hearing status.

Analysis and prediction of readmissions for heart failure in the first year after discharge with INCA score.

To determine the readmissions trends and the comorbidities of patients with heart failure that most influence hospital readmission rates. Heart failure (HF) is one of the most prevalent health problems as it causes loss of quality of life and increased health-care costs. Its prevalence increases with age and is a major cause of re-hospitalisation within 30 days after discharge. INCA study had observational and ambispective design, including 4,959 patients from 2000 to 2019, with main diagnosis of HF in Extremadura (Spain). The variables examined were collected from discharge reports. To develop the readmission index, capable of discriminating the population with higher probability of re-hospitalisation, a Competing-risk model was generated. Readmission rate have increased over the period under investigation. The main predictors of readmission were: age, diabetes mellitus, presence of neoplasia, HF without previous hospitalisation, atrial fibrillation, anaemia, previous myocardial infarction, obstructive pulmonary disease (COPD) and chronic kidney disease (CKD). These variables were assigned values with balanced weights, our INCA index showed that the population with values greater than 2 for men and women were more likely to be re-admitted. Previous HF without hospital admission, CKD, and COPD appear to have the greatest effect on readmission. Our index allowed us to identify patients with different risks of readmission.

Endoscopic transcanal surgery of pars tensa cholesteatoma: Preliminary results.

INTRODUCTION AND OBJECTIVES: The aim of the present study is the assessment of exclusive endoscopic ear surgery for the management of primarily acquired pars tensa cholesteatoma, which is commonly linked to the failure of the Eustachian tube leading to the formation of retraction pockets. MATERIALS AND METHODS: Patients suffering from primarily acquired pars tensa cholesteatoma, who underwent primary surgery in our clinic, between 2014 and 2018 were included in this retrospective study. The disease was classified according to the EAONO/JOS system. Exclusive endoscopic ear surgery was performed for patients without mastoid involvement, while a microscopic-endoscopic tympanoplasty was carried out in case of mastoid extension. We assessed the recidivism rate during the follow-up. RESULTS: Cholesteatomas belonged to stage I in 28% of cases, to stage II in 68% and only one patient was stage III. Only a portion of the pars tensa was involved in 13 instances, the whole pars tensa in 3 and both the tensa and the flaccida in 9. 17 out of 25 patients underwent exclusive endoscopic ear surgery and 8 needed a combined approach. We discovered 1 recurrence and 6 residual diseases. CONCLUSIONS: With only one case of recurrence in our series, we showed how pars tensa cholesteatoma cannot be exclusively explained through Eustachian tube dysfunction, but also through a ventilation blockage between the Eustachian tube and other mesotympanic areas due to the formation of intratympanic folds. Endoscopic ear surgery proved highly effective in the control of recurrences and it should be considered the treatment of choice.

Endoscopic transcanal surgery of pars tensa cholesteatoma: Preliminary results / Cirugía endoscópica transcanal del colesteatoma de la pars tensa: resultados preliminares

Introduction and objectives: The aim of the present study is the assessment of exclusive endoscopic ear surgery for the management of primarily acquired pars tensa cholesteatoma, which is commonly linked to the failure of the Eustachian tube leading to the formation of retraction pockets.Materials and methodsPatients suffering from primarily acquired pars tensa cholesteatoma, who underwent primary surgery in our clinic, between 2014 and 2018 were included in this retrospective study. The disease was classified according to the EAONO/JOS system. Exclusive endoscopic ear surgery was performed for patients without mastoid involvement, while a microscopic–endoscopic tympanoplasty was carried out in case of mastoid extension. We assessed the recidivism rate during the follow-up.ResultsCholesteatomas belonged to stage I in 28% of cases, to stage II in 68% and only one patient was stage III. Only a portion of the pars tensa was involved in 13 instances, the whole pars tensa in 3 and both the tensa and the flaccida in 9. 17 out of 25 patients underwent exclusive endoscopic ear surgery and 8 needed a combined approach. We discovered 1 recurrence and 6 residual diseases.ConclusionsWith only one case of recurrence in our series, we showed how pars tensa cholesteatoma cannot be exclusively explained through Eustachian tube dysfunction, but also through a ventilation blockage between the Eustachian tube and other mesotympanic areas due to the formation of intratympanic folds. Endoscopic ear surgery proved highly effective in the control of recurrences and it should be considered the treatment of choice. (AU)

Introducción y objetivos: El objetivo del presente estudio es la evaluación de la cirugía endoscópica exclusiva del oído para el manejo del colesteatoma de la pars tensa adquirido primario, que comúnmente está relacionado con la falla de la trompa de Eustaquio que conduce a la formación de bolsas de retracción.Materiales y métodosEn este estudio retrospectivo se incluyeron pacientes con colesteatoma de la pars tensa adquirido primario, que se sometieron a cirugía primaria en nuestra clínica, entre 2014 y 2018. La enfermedad se clasificó según el sistema EAONO/JOS. En pacientes sin afectación mastoidea se realizó únicamente cirugía endoscópica de oído, mientras que, en caso de extensión mastoidea, se realizó timpanoplastia microscópica-endoscópica. Se evaluó la tasa de recidiva durante el seguimiento.ResultadosEl 28% de los colesteatomas pertenecían al grado I, el 68% al grado II y solo un paciente estaba en el grado III. Solo una porción de la pars tensa estuvo afectada en 13 casos, toda la pars tensa en tres y tanto la tensa como la fláccida en nueve. Se sometieron a cirugía endoscópica exclusiva del oído 17 de 25 pacientes y ocho necesitaron un abordaje combinado. Descubrimos una recurrencia y seis enfermedades residuales.ConclusionesCon un solo caso de recurrencia en nuestra serie, mostramos cómo el colesteatoma de la pars tensa no puede explicarse exclusivamente por una disfunción de la trompa de Eustaquio, sino también por un bloqueo de la ventilación entre la trompa de Eustaquio y otras áreas mesotimpánicas debido a la formación de pliegues intratimpánicos. La cirugía endoscópica de oído demostró ser altamente eficaz en el control de las recurrencias y debe considerarse el tratamiento de elección. (AU)

Evolución del perfil clínico y pronóstico de pacientes con alta hospitalaria por insuficiencia cardíaca en las dos primeras décadas del sigloxxi. El Registro INCA-Ex / Clinical and prognostic profile evolution of patients discharged from hospital due to heart failure in the first two decades of the 21st century. The INCA-Ex Registry

Objetivo: Estudiar la evolución del perfil clínico de una población dada de alta con diagnóstico principal de insuficiencia cardíaca (IC) en las dos primeras décadas del siglo y las variables predictoras de mortalidad y reingreso en el primer año de alta. Diseño: Estudio observacional, retrospectivo, longitudinal. Emplazamiento: Área de salud Don Benito-Villanueva de la Serena, Badajoz, España. Participantes: Todos los pacientes dados de alta con diagnóstico principal de IC entre 2000 y 2019 en un complejo hospitalario general.Mediciones principalesSe recogieron variables sociodemográficas y clínicas, y se realizó un seguimiento de un año; la variable resultado fue un compuesto de mortalidad y/o reingreso. Resultados: Se incluyeron 4.107 altas, edad media 77,1 (DE 10,5) años, 53,1% de mujeres. El número de ingresos, la edad, los antecedentes de neoplasias, los ictus, la insuficiencia renal y la anemia fueron en aumento, así como los reingresos (p de tendencias <0,001), mientras permaneció constante la mortalidad. Fueron variables predictoras de reingreso y/o muerte HR (IC95%): edad (por año) 1,04 (1,03-1,04), diabetes: 1,11 (1,01-1,24), IC previa 1,41 (1,28-1,57), variable compuesta infarto, ictus y/o arteriopatía periférica 1,24 (1,11-1,38), enfermedad pulmonar obstructiva crónica (EPOC) 1,29 (1,15-1,44), neoplasia 1,33 (1,16-1,53), anemia 1,63 (1,41-1,86), insuficiencia renal 1,42 (1,26-1,60). Conclusiones: En los últimos 20años se han incrementado los ingresos de pacientes por IC, su edad y la comorbilidad. Fueron variables predictoras de mortalidad y/o reingreso la edad, la diabetes, la enfermedad cardiovascular previa, las neoplasias, la EPOC, la insuficiencia renal y la anemia; sin embargo, la mortalidad al año se mantuvo constante.(AU)

Aim: To study the evolution of the clinical profile of a population discharged with a main diagnosis of heart failure (HF) in the first two decades of the century and the predictive variables of mortality and readmission in the first year of discharge. Design: Observational, retrospective, longitudinal study. Site: Don Benito Villanueva de la Serena Badajoz health area. Participants: All patients discharged with a main diagnosis of HF between 2000 and 2019 in a general hospital complex were included. Main measurements: Sociodemographic and clinical variables were collected, and a one-year follow-up; the result variable was a composite of mortality and/or readmission. Results: A total of 4107 discharges were included, mean age 77.1 (SD±10.5) years, 53.1% women. The number of admissions, age, history of neoplasms, stroke, kidney failure, and anemia increased, as did readmissions (P for trends <.001), while mortality remained constant. Predictive variables for readmission and/or death were HR (95%CI): age (per year) 1.04 (1.03-1.04), diabetes: 1.11 (1.01-1.24), previous HF 1.41 (1.28-1.57), composite variable myocardial infarction, stroke and/or peripheral artery disease 1.24 (1.11-1.38), chronic obstructive pulmonary disease (COPD) 1.29 (1.15-1.44), neoplasia 1.33 (1.16-1.53), anemia 1.63 (1.41-1.86), chronic kidney failure 1.42 (1.26-1.60). Conclusions: In the last 20 years, admissions for heart failure, patient age, and comorbidity have increased. Predictive variables for mortality and/or readmission were age, diabetes, previous cardiovascular disease, neoplasms, COPD, kidney failure, and anemia; however, mortality at one year remained constant.(AU)

[Clinical and prognostic profile evolution of patients discharged from hospital due to heart failure in the first two decades of the 21st century. The INCA-Ex Registry]. / Evolución del perfil clínico y pronóstico de pacientes con alta hospitalaria por insuficiencia cardíaca en las dos primeras décadas del sigloxxi. El Registro INCA-Ex.

AIM: To study the evolution of the clinical profile of a population discharged with a main diagnosis of heart failure (HF) in the first two decades of the century and the predictive variables of mortality and readmission in the first year of discharge. DESIGN: Observational, retrospective, longitudinal study. SITE: Don Benito Villanueva de la Serena Badajoz health area. PARTICIPANTS: All patients discharged with a main diagnosis of HF between 2000 and 2019 in a general hospital complex were included. MAIN MEASUREMENTS: Sociodemographic and clinical variables were collected, and a one-year follow-up; the result variable was a composite of mortality and/or readmission. RESULTS: A total of 4107 discharges were included, mean age 77.1 (SD±10.5) years, 53.1% women. The number of admissions, age, history of neoplasms, stroke, kidney failure, and anemia increased, as did readmissions (P for trends <.001), while mortality remained constant. Predictive variables for readmission and/or death were HR (95%CI): age (per year) 1.04 (1.03-1.04), diabetes: 1.11 (1.01-1.24), previous HF 1.41 (1.28-1.57), composite variable myocardial infarction, stroke and/or peripheral artery disease 1.24 (1.11-1.38), chronic obstructive pulmonary disease (COPD) 1.29 (1.15-1.44), neoplasia 1.33 (1.16-1.53), anemia 1.63 (1.41-1.86), chronic kidney failure 1.42 (1.26-1.60). CONCLUSIONS: In the last 20 years, admissions for heart failure, patient age, and comorbidity have increased. Predictive variables for mortality and/or readmission were age, diabetes, previous cardiovascular disease, neoplasms, COPD, kidney failure, and anemia; however, mortality at one year remained constant.

Assessment of the Cost of the Mediterranean Diet in a Low-Income Region: Adherence and Relationship with Available Incomes.

BACKGROUND: The Mediterranean Diet (MD) is recognized as heart-healthy, but the economic cost associated with this type of diet has scarcely been studied. The objective of the present study is to explore the cost and adherence of a low-income region population to the MD and its relationship with income. METHODS: A population-based study was carried out on 2,833 subjects between 25 and 79 years of age, 54% women, selected at random from the municipalities of Vegas Altas, La Siberia and La Serena in the province of Badajoz, Extremadura (Spain). Average monthly cost of each product included in the MD was computed and related to adherence to the MD using the Panagiotakos Index and average disposable income. RESULTS: The monthly median cost was 203.6€ (IQR: 154.04-265.37). Food-related expenditure was higher for men (p<0.001), age cohort between 45 and 54 years (p<0.013) and those living in urban areas (p<0.001). A positive correlation between food-related expenditure and the MD adherence was found. Monthly median cost represents 15% of average disposable income, ranging between 11% for the group with low MD adherence and 17% for the group with high MD adherence. CONCLUSIONS: The monthly cost of the MD was positively correlated with the degree of adherence to this dietary pattern. Given that the estimated monthly cost is similar to that of other Spanish regions with a higher income level, the economic effort required to be able to afford the Mediterranean diet is higher. This may represent a barrier to access, which should be analyzed in detail by public decision-makers.

Decompression of the geniculate ganglion and labyrinthine segments of the facial nerve through a middle cranial fossa approach using an ultrasonic surgical system: an anatomic study.

PURPOSE: The aim of this study is to evaluate the feasibility and the safety of a novel, alternative method for bone tissue management in facial nerve decompression by a middle cranial fossa approach. Several applications of Piezosurgery technology have been described, and the technique has recently been extended to otologic surgery. The piezoelectric device is a bone dissector which, using micro-vibration, preserves the anatomic integrity of soft tissue thanks to a selective action on mineralized tissue. METHODS: An anatomic dissection study was conducted on fresh-frozen adult cadaveric heads. Facial nerve decompression was performed by a middle cranial fossa approach in all specimens using the piezoelectric device under a surgical 3D exoscope visualization. After the procedures, the temporal bones were examined for evidence of any injury to the facial nerve or the cochleovestibular organs. RESULTS: In all cases, it was possible to perform a safe dissection of the greater petrosal superficial nerve, the geniculate ganglion, and the labyrinthine tract of the facial nerve. No cases of semicircular canal, cochlea, or nerve damage were observed. All of the dissections were carried out with the ultrasonic device without the necessity to replace it with an otological drill. CONCLUSION: From this preliminary study, surgical decompression of the facial nerve via the middle cranial fossa approach using Piezosurgery seems to be a safe and feasible procedure. Further cadaveric training is recommended before intraoperative use, and a wider case series is required to make a comparison with conventional devices.

Subcochlear canaliculus patterns in the pediatric and adult population: radiological findings and surgical implications.

INTRODUCTION: The pneumatization of the different regions of the temporal bone is strictly related to the age and the degree of development of the mastoid and the middle ear. Petrous apex pneumatization is the last step of the development of the petrous bone system. The subcochlear canaliculus is an anatomical cavity, originating in the space between the fustis and the finiculus, and connecting the round window area to the petrous apex. The aim of the present article is analyzing the trend of development of the subcochlear canaliculus pneumatization, classified through CT scan examination, in different age subgroups. MATERIALS AND METHODS: We conducted a retrospective review of patients who underwent temporal bone CT scans between 2014 and 2019. Pediatric and adult patients were included and divided into different age subgroups. The subcochlear canaliculus was examined through coronal view scans at the level of the round window niche and classified into 3 different groups (A, B and C) according to the degree of pneumatization. RESULTS: A total of 270 Petrous bone CT scans was analyzed. The percentage of type A subcochlear canaliculus was significantly higher in the pediatric population if compared to the adult population (p = 0.001326). As far as type B subcochlear canaliculus is concerned, the difference between children and adults was not statistically significant (p = 0.2378). On the other hand, type C subcochlear canaliculus was predominant in the adult population (p = 0.000256). CONCLUSIONS: There is a constant increase in pneumatization of the subcochlear canaliculus from 0 to 19 years and then a progressive decrease. This discovery has relevant surgical implications and has to be borne in mind in particular for cholesteatoma surgery and cochlear implantation surgery in the age groups in which the subcochlear canaliculus is highly pneumatized.

Endoscopic Ear Surgery: Redefining Middle Ear Anatomy and Physiology.

Middle ear anatomy and physiology is highly complex, yet familiarity is important to perform middle ear surgery and understand surgically relevant ventilation pathways of the ear compartments. The middle ear is divided into five subspaces: the mesotympanum, the retrotympanum posteriorly, the epitympanum superiorly, the protympanum anteriorly, and the hypotympanum inferiorly. The Eustachian tube plays a crucial role in maintaining middle ear aeration and atmospheric pressure. There are two independent aeration routes of the epitympanum. Thanks to the advent of the endoscope, this anatomic and physiologic knowledge has allowed one to understand the pathophysiology of ear diseases, improving surgical concepts.

Covid-19 and ENT practice: Our experience: ENT outpatient department, ward and operating room management during the SARS-CoV-2 pandemic.

OBJECTIVES: The current study aims at assessing the effectiveness of the guidelines set up by our clinic for the protection of patients and staff which enabled us to proceed with urgent and oncological surgery after the outbreak of the Covid-19 pandemic. MATERIAL AND METHODS: Our ENT department devised specific equipment to be worn by the staff for personal protection when dealing with Covid-19 patients both in aerosol generating and non-generating procedures. Moreover, restrictive measures were enforced both for the outpatient department and for the ward where only urgent practices were carried out and visitors were not allowed, while non-urgent elective surgery was postponed. A codified scheme was followed to perform tracheostomy procedure in Covid-19 positive testing patients on the part of 3 specific teams of 2 surgeons each, while the resident educational program was reorganized to limit the spread of the infection. RESULTS: In about a couple of months (from March 8th to May 3rd) a relevant amount of medical tests and surgical procedures were carried out on non COVID-19 patients and a certain number of tracheostomies were performed on COVID-19 patients. Consequently, all the ENT personnel were checked and found negative. Also, all the patients in the ward were swab tested and chest X-rayed, only one had a positive outcome and was adequately handled and treated. CONCLUSION: Our ENT guidelines regarding personal protection equipment and multiple simultaneous diagnostic procedures have proved to be an essential instrument for the management of patients with both known and unknown COVID-19 status.

Transcanal infrapromontorial approach for internal auditory canal surgery and cochlear implantation.

OBJECTIVE: To demonstrate the feasibility of a transcanal infrapromontorial approach for vestibular schwannoma surgery through an anatomical dissection study and the description of a clinical case. METHODS: A microscopic and endoscopic dissection of cadaveric heads was undertaken through a transcanal infrapromontorial approach to the internal auditory canal (IAC), preserving the cochlea and the cochlear nerve. Description of the anatomy and surgical steps is reported as well as presentation of a clinical case in which a transcanal infrapromontorial approach was performed. RESULTS: In all of the cadaveric dissections, a transcanal infrapromontorial route with near total cochlea preservation was performed, removing only the most posterior portion of the basal turn of the cochlea. The IAC was opened through removal of "cochlear-vestibular bone". At the end of the dissection a cochlear implant array was placed. A transcanal infrapromontorial approach was also performed in a patient to allow a concurrent cochlear implant placement, with good postoperative results. CONCLUSION: The transcanal infrapromontorial approach permits the preservation of the cochlea and the cochlear nerve. This approach may be considered as an option in case of a small intracanalicular schwannoma removal (< 0.5 cm cerebellopontine angle spread), when concurrent cochlear implantation is indicated.

The Endoscopic Relationship of the Stapedius Muscle to the Facial Nerve: Implications for Retrotympanic Surgery.

OBJECTIVES: The stapedius muscle, tendon, and pyramidal eminence are structures within the retrotympanum. In cholesteatoma surgery, the retrotympanum is a common site of residual disease. The removal of the pyramidal eminence during surgery is sometimes necessary to obtain better visualization of the superior retrotympanum during surgery. Understanding the relational anatomy of structures in the region to the facial nerve allows the surgeon to safely access regional disease. This study aims to better understand the anatomical relationship between the mastoid portion of the facial nerve, the pyramidal eminence, and the stapedius muscle. A secondary aim is to demonstrate that removal of the stapedius muscle in the cadaver model, can increase exposure to the retrotympanic space. STUDY DESIGN: Anatomical cadaveric observation study. METHODS: Endoscopic dissection of cadaveric heads was undertaken. Classification of the superior and inferior retrotympanic area was performed. The anatomy of the stapedius muscle was described including relationships, depth, course, and angle with respect to the facial nerve. The pyramidal eminence and stapedius muscle were removed in all specimens and the exposure of the retrotympanum re-evaluated to determine if exposure of the region was increased. RESULTS: In all cases (11 ears), the stapedius muscle was located medial and anterior to the mastoid portion of the facial nerve, with the second genu superior. The mean antero-posterior distance from the apex of the pyramidal eminence, which the stapedius tendon enters, to the stapes itself was 4.10 mm (range, 2.92-5.73 mm; standard deviation [SD] 0.90 mm). In all cases, irrespective of sinus tympani conformation, removal of the pyramidal eminence and stapedial bony crest in proximity to the facial nerve allowed exposure of the whole retrotympanic region, using a 0-degree endoscope. CONCLUSIONS: The pyramidal eminence and stapedius muscle have a relatively constant relationship to the facial nerve. Removal of the stapedius muscle in the human cadaver model increases the exposure of the sinus tympani and subpyramidal space. Increased visualization in this region, may reduce risk of residual cholesteatoma in patients.

3D exoscopic surgery of lateral skull base.

PURPOSE: The aim of the study is to assess whether the 3D exoscopic surgery technique could be used in lateral skull base surgery and if it could ultimately replace the microscope in the future. METHODS: This is a retrospective study in which were included 24 patients affected by lateral skull base pathologies, who underwent surgery using the 3D exoscope or the operative microscope at the Department of Otolaryngology-Head and Neck Surgery at the University Hospital of Verona. The exoscope and microscope groups each included 12 cases. The feasibility of all the surgical steps solely using the 3D exoscope was evaluated. The exoscope group and microscope group were compared taking into account the following factors: time of the surgery, facial and hearing functions outcomes, as well as the intraoperative and postoperative complications. RESULTS: No intraoperative complication occurred during all the procedures. Postoperatively, only one minor complication emerged. The average operative time was 289 in the exoscope group and 313 min in the microscope one. No significant statistical differences were identified between the two groups (p > 0.05). The facial and hearing function outcomes were fully comparable. CONCLUSION: Our experience demonstrated that the exclusive use of the 3D exoscope, as that of the traditional microscope during lateral skull base surgery, is feasible for all open approaches. The use of the 3D exoscopic technique is very promising for future lateral skull base surgeries.

Role of endoscopy in lateral skull base approaches to the petrous apex.

OBJECTIVE: The aim of this article is to study the role and advantages of combined microscopic/endoscopic procedures or exclusive endoscopic approaches in the treatment of petrous apex pathologies. METHODS: The study was designed as a retrospective case series analysis. We included patients affected by pathologies of the petrous apex, who underwent microscopic/endoscopic-assisted or exclusive endoscopic procedures. Patient and pathology characteristics and surgical data (focusing on the involvement of the internal carotid artery (ICA) and facial nerve by the disease) were collected. Residual disease, detected through the endoscopic check, and the feasibility of endoscopic residual tumor removal were also evaluated. Finally, facial nerve and hearing functions were assessed pre- and postoperatively. RESULTS: The records of 75 patients undergoing lateral skull base surgery for petrous apex lesions, from May 2009 to March 2019, were collected. In 17 out of 75 patients, an exclusive endoscopic procedure was possible. The remaining 58 patients underwent a combined microscopic/endoscopic approach. In 15 cases, residual disease was found and removed endoscopically at the end of the microscopic procedure; in eight cases, the residual disease was medial and/or inferior to the horizontal segment of the ICA, while in two cases, it was located in the fundus of the internal auditory canal. In five cases, it involved the labyrinthine segment of the facial nerve. CONCLUSION: Petrous apex surgery remains a traditional microscopic-based surgery, but the recent advent of endoscopic surgery has permitted an improvement in radicality minimizing the manipulation of neurovascular structures.

Is endoscopic inspection necessary to detect residual disease in acoustic neuroma surgery?

MAIN GOALS: To analyze how and when the endoscope is used in vestibular schwannoma surgery and identify the benefits of using endoscopy in this type of surgery. BACKGROUND: It is currently unclear if there is any benefit from using an endoscope in vestibular schwannoma surgery so this retrospective analysis set out to study this. METHODS: All the patients who underwent vestibular schwannoma surgery at our clinic were included for all the vestibular schwannoma approaches taken. We studied when endoscopy was used during surgery and the goal of using endoscopy. Several pre- and postoperative factors were assessed such as complications, facial function, and hearing function in the case of techniques that allow hearing preservation. RESULTS: From January 2015 to September 2018, 280 patients underwent lateral skull base surgery. Of these, 112 were included in this study. The endoscope was used in all 112 patients, and in eight cases it was possible to identify residual disease using the endoscope to check the surgical field, and then to remove the disease under endoscopic view. Moreover, in two other cases, the endoscope was used to resolve a vasculoneural conflict between the anterior inferior cerebellar artery (AICA) loop and facial nerve in one case, and for deafferentation of the superior and inferior vestibular nerves in the second case. No major intraoperative complications occurred in our series. There was no statistically significant difference in postoperative facial nerve function between patients in whom the endoscope was used as a diagnostic tool and patients in whom it was used as an operative tool (p = 0.3152). CONCLUSIONS: The endoscope may be useful, especially in surgical techniques where there is poor control of the internal auditory canal (IAC). An endoscopic support technique is strongly recommended to avoid residual disease, particularly in retrosigmoid and retrolabyrinthine approaches. Moreover, the recent introduction of the transcanal transpromontorial approach allows the endoscope to be used during all the procedures in patients affected by a vestibular schwannoma limited to the IAC or to support surgical procedures during an enlarged microscopic approach.

Complications in Endoscopic Ear Surgery.

OBJECTIVE: The aim of this study was to examine the premise that endoscopic ear surgery (EES) is associated with a low rate of complications (intraoperative and postoperative). STUDY DESIGN: Retrospective review at two institutions. SETTING: Tertiary referral center. PATIENTS: The study included 825 patients who underwent exclusive EES between 2008 and 2016 at the Otorhinolaryngology-Head and Neck Surgery Department of Modena University Hospital, and between 2014 and 2016 at the Otorhinolaryngology-Head and Neck Surgery Department of Verona University Hospital. INTERVENTIONS: Exclusive endoscopic ear surgery between 2008 and 2016 (tympanoplasties, second look or revision tympanoplasties, myringoplasties, stapedoplasties, canalplasties, ossiculoplasties, and exploratory tympanotomies). All surgical procedures were performed by two experienced surgeons. MAIN OUTCOME MEASURE: For each procedure, intraoperative, and early and delayed postoperative complications were evaluated. RESULTS: The most common ear pathologies for which patients were sent for EES were cholesteatoma (33.6%), chronic otitis media (36.3%) and otosclerosis (26.8%). There was no case of major intraoperative complications such as injury to the dura or vascular structures. We observed minor intraoperative complications in 4.1% of the cases. Only 1.3% of patients experienced early postoperative complications. Delayed complications affected less than 1% of the cohort. CONCLUSIONS: Data from this study confirm the safety of the endoscopic technique, with very low complication rates, indicating that EES is a reliable therapeutic option, in particular, for tympanoplasties, myringoplasties, and stapedoplasties, as well as second look procedures. We have reported our experience with EES morbidity so that it can be compared with data from other centers using the same surgical technique.

Intralabyrinthine schwannomas: a new surgical treatment.

OBJECTIVE: To define a new surgical option, with lower morbidity, for the treatment of intralabyrinthine schwannomas. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral centers. PATIENTS: Eight patients affected by an intralabyrinthine schwannoma, with or without extension to the internal auditory canal, that underwent surgery with a transcanal transpromontorial approach, were included in the study. The average age at presentation was 47 years. Patients' characteristics, symptoms, tumor features, and surgical results were analyzed. INTERVENTIONS: All patients were diagnosed and evaluated pre-operatively with high-resolution, gadolinium-enhanced MRI and CT scan of the temporal bone, and underwent surgery via either transcanal transpromontorial endoscopic approach (TTEA) or enlarged transcanal transpromontorial endoscopic approach (ETTA). MAIN OUTCOME MEASURES: Hearing function was evaluated with the Hearing Classification System according to the Committee on Hearing and Equilibrium Guidelines. Facial nerve function was evaluated using the House-Brackmann grading system (HB). RESULTS: In six patients out of eight, a TTEA was performed, whereas, due to the extension of the pathology to the cerebellopontine angle, two patients underwent an ETTA. The mean follow-up period was 15.5 months (range 1-69). No intra-operative and post-operative major complications were observed. Post-operative facial nerve function was normal in seven out of eight patients (grade I HB). One patient presented a grade II HB. CONCLUSION: The endoscopic approach to cochlear schwannoma represents a good treatment option for patients and should be preferred to other more invasive surgical techniques when indicated, to reduce complications, hospitalization, and offer to patients the chance to eradicate the disease, thus avoiding the stress of a long-life radiological follow-up. LEVEL OF EVIDENCE: 4.