VITOM 3D System in Parotid Gland Surgery: Our Experience.

ABSTRACT: In this report, we present our experience with the VITOM 3D system for parotid gland surgery. A retrospective review of 9 consecutive VITOM 3D-assisted parotidectomies was carried out. All of the cases included had benign pathology. Eight of the tumors were in the superficial lobe whereas one case arose in the deep lobe. Superficial parotidectomy type II, according to the ESGS classification, was performed in 5 cases (55.6%): type I-II in 2 cases (22.2%), type I and III in 1 case respectively (11.1%). The postoperative period was uneventful for all of the patients, and no cases of postoperative temporary or definite facial nerve palsy or other complications were reported. The mean operating time was 145 minutes (range 135-165 minutes). Asthenopia never occurred, and there were no cases in which the first surgeon, the assistants, or the nurses needed to interrupt the 3D vision. VITOM 3D has been demonstrated to be safe and effective for parotid gland surgery. The main advantages of VITOM 3D are improved visualization, ergonomics, versatility, training, and education. The drawbacks are related to asthenopia and the learning curve, even though, in our experience, the impact of these factors is minimal.

Spontaneous CSF Leaks and IIH: A Flawless Connection? An Experience With 167 Patients.

OBJECTIVES: Spontaneous cerebrospinal fluid (CSF) leaks are a rare but insidious clinical entity. In the recent literature, their pathogenesis has been linked with idiopathic intracranial hypertension (IIH). Considering a worse surgical outcome compared to traumatic leaks, a medical treatment of the underlying IIH has been suggested in order to prevent relapses. Nevertheless, some aspects of this rare pathology remain unclear. We report our long experience in the management of spontaneous CSF leaks. METHODS: A retrospective evaluation of all patients with spontaneous CSF leaks treated from 1998 to 2018 in a tertiary referral center was carried out. All patients received surgery without any adjuvant routine medical treatment. Epidemiological and clinical data were reviewed. A telephone survey was conducted to investigate IIH-related symptoms in this population. RESULTS: One hundred sixty-seven patients and 195 procedures were included in the study. The total rate of failure after surgical treatment was 9%. Eight patients suffered a relapse in the same site (4%, 8 of 195), whereas seven patients experienced a relapse in a different site (4%, 7 of 167). Twenty-nine percent of the population interviewed referred at least one IIH-related symptom. CONCLUSION: Spontaneous CSF leaks represent a complex pathology that need a multidisciplinary evaluation. Surgical treatment seems to guarantee favorable results in most of the patients. Despite this, a not negligible percentage of patients experienced a relapse during a long-term follow-up. Further studies are needed to reach a deeper understanding of the presentation and course of this particular condition. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E401-E407, 2021.

Endoscopic endonasal resection of adenoid cystic carcinoma of the sinonasal tract and skull base.

OBJECTIVES: Adenoid cystic carcinoma (ACC) is a locally aggressive salivary gland malignancy prone to perineural invasion and local recurrences. In the literature, few data exist to guide treatment when this tumor involves the paranasal sinuses and skull base. We report our experience in the management of sinonasal adenoid cystic carcinoma through an endoscopic endonasal approach. METHODS: Retrospective analysis of patients affected by sinonasal ACC treated through an endoscopic endonasal approach from 1997 to 2015, managed at the Universities of Varese and Brescia, Italy. RESULTS: Thirty-four patients were included in the analysis. The ethmoid sinus (55.9%), nasal septum (17.7%), maxillary sinus (11.7%), and sphenoid sinus (5.9%) were the primary tumor sites encountered. Twenty patients (58.8%) presented with T3 or T4, without any systemic spreading. Twenty-nine patients underwent endoscopic transnasal resection, whereas the involvement of the anterior skull base in five cases required a transnasal endoscopic craniectomy. Overall, 20 of 34 (58.8%) patients received some form of adjuvant radiotherapy. The follow-up ranged from 12 to 202 months (mean of 73.2 months). The 5-year overall, disease-specific, and recurrence-free survival rates were 86.5% ± 7.39%, 86.5% ± 7.39%, and 71.8% ± 8.67%, respectively. CONCLUSIONS: The endoscopic approach is safe and effective for selected sinonasal ACC, reducing the comorbidities of the external approaches while producing similar oncological results. High T-stage, grade III histology, positive surgical margins, and perineural infiltration all have an important negative prognostic value. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1071-1077, 2019.

Sinonasal Non-Intestinal-Type Adenocarcinoma: A Retrospective Review of 22 Patients.

OBJECTIVE: To analyze outcomes and prognostic factors of sinonasal nonsalivary non-intestinal-type adenocarcinoma (n-ITAC.) METHODS: A retrospective review of 22 consecutive patients with n-ITAC was performed. RESULTS: Average follow-up time was 77 months. The 5-year overall survival and disease-specific survival were 95.2%. The 5-year overall survival and disease-specific survival were 100% for pT1, pT2, and pT3 tumors and 83.3% for pT4a and pT4b tumors; 100% for G1 tumors and 87.5% for G3 tumors; and 100% for tumors with negative surgical margin and 50% for tumors with positive surgical margin. Stage, grade, and surgical margins were independent prognostic factors. Adjuvant radiotherapy was performed for high-grade and high-stage tumors. CONCLUSIONS: Surgery followed by radiotherapy has remained a mainstay for management of n-ITAC, and the endoscopic transnasal approach, when correctly planned and indicated, is the surgery of choice. Adjuvant radiotherapy is recommended in cases of high-stage (T3 and T4) and high-grade tumors. n-ITAC is associated with a favorable outcome. High grade, pT4 stage, and positive surgical margins are independent negative prognostic factors.

Endoscopic endonasal approach for sinonasal and anterior skull base malignancies in the elderly.

BACKGROUND: The purpose of this study was to report the outcomes of endoscopic transnasal resection for sinonasal and anterior skull-base cancers in elderly patients. METHODS: A retrospective review was performed. The patients were divided into 2 groups, <70 years old and ≥70 years old and compared by univariate analysis. Prognostic factors were evaluated with a multivariate analysis. Survival rates were also calculated. RESULTS: Two hundred three elderly patients and 397 younger patients were enrolled in this study. The elderly patients reported lower survival rates than the younger patients. When melanoma and esthesioneuroblastoma were censored, the disease-specific survival (DSS) and recurrence-free survival (RFS) were similar. Complication rates were 17.5% without any statistical significance between the groups. Multivariate analysis revealed that histology, stage, surgical margins, and surgical approaches were independent predictors of survival in elderly patients. CONCLUSION: The endoscopic transnasal approach reported low mortality and morbidity rates also in geriatric patients, and age itself is not to be considered as a contraindication.

Transnasal endoscopic partial maxillectomy: Operative nuances and proposal for a comprehensive classification system based on 1378 cases.

BACKGROUND: Despite the development of functional endoscopic endonasal surgery, there are still areas of the maxillary sinus that remain technically difficult to access using a standard middle meatal antrostomy as well as deep-seated skull base lesions requiring expanded transmaxillary approaches. METHODS: All patients who underwent transnasal endoscopic partial maxillectomy (TEPM) in a single institution from 2000 to 2014 were retrospectively reviewed. The TEPM was classified into 5 types according to the anatomic structures progressively removed and to the access provided. RESULTS: The TEPM was performed in 1378 patients for the management of: inflammatory diseases in 513 cases (37%), benign sinonasal tumors in 425 cases (31%), skull base malignancies in 285 cases (21%), and as a corridor to address deep-seated skull base lesions in 155 cases (11%). CONCLUSION: The TEPM is a stepwise approach offering increasing access that can be tailored to different maxillary, sinonasal, and skull base pathologies with minimal morbidity for patients. © 2016 Wiley Periodicals, Inc. Head Neck 39: 754-766, 2017.

Endoscopic Treatment of Ewing Sarcoma of the Sinonasal Tract.

The extra-skeletal form is an unusual type of Ewing sarcoma (ES) arising from soft tissue and in the literature there are reports of less than 50 patients describing the tumor in the paranasal sinuses and skull base. The histological diagnosis is crucial to plan the correct treatment and the molecular confirmation is mandatory in equivocal patients. A multimodality treatment with chemotherapy, surgery and radiotherapy improved the outcomes of these diseases during the last decades and a free-margin resection with the endoscopic transnasal technique is one of the most recent ways to manage these pathologies in selected patients, reducing the morbidities of the external approaches and preserving the quality of life of the patient.Here, the authors present the first patient of primary sinonasal ES free from disease after 5 years of follow-up and treated with an endoscopic endonasal approach and a second patient of sinonasal metastases of ES treated with and endoscopic transnasal approach.

Survival outcomes after endoscopic resection for sinonasal squamous cell carcinoma arising on inverted papilloma.

BACKGROUND: Sinonasal inverted papillomas (IPs) can be associated synchronously or metachronously to invasive squamous cell carcinoma (SCC) in 5% to 10% of cases. The purposes of the present study were to analyze the outcomes of patients with sinonasal SCC arising from inverted papilloma (IP-SCC) treated through an endoscopic approach and review the pertinent literature. METHODS: The medical records of all patients treated for IP-SCC between 1997 and 2014 at 2 referral centers following a uniform policy were retrospectively analyzed. RESULTS: Thirty-four patients fulfilled the inclusion criteria. The 5-year overall survival (OS), disease-specific survival (DFS), and recurrence-free survival (RFS) rates were 66.8 ± 0.99%, 71.2 ± 0.96%, and 73.1 ± 0.82%, respectively. Multivariate analysis revealed that the advanced pT classification (pT3 or greater), the high-grade of tumoral differentiation, the cranioendoscopic approach, and the recurrence of disease impacted negatively on survival rates. CONCLUSION: The endoscopic approach provides encouraging oncologic outcomes for sinonasal IP-SCC, comparable to those observed with traditional external approaches while minimizing morbidity for patients. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Endoscopic transnasal approaches to pterygopalatine fossa tumors.

BACKGROUND: The pterygopalatine fossa (PPF) is a difficult area to access, as it has been traditionally treated by external approaches. The development of endoscopic transnasal approaches enables surgeons to reach this region through a minimally invasive route, reducing the associated morbidity. METHODS: We conducted a retrospective review of patients with benign and malignant tumors arising in or extending to the PPF, treated from 2000 to 2013 at a single institute, using endoscopic transnasal transmaxillary approaches. RESULTS: Thirty-seven consecutive patients with benign (27 cases) and malignant (10 cases) tumors were treated with curative intent. Radical resection was achieved in 36 of 37 patients. No major complications were observed. No local recurrences were observed, with a median follow-up of 38.5 months for malignancies and 60 months for benign tumors. CONCLUSION: The endoscopic transnasal approaches are safe and feasible techniques for the radical resection of selected tumors involving the PPF and should be tailored according to the biology and extension of the lesion. © 2015 Wiley Periodicals, Inc. Head Neck 38: E214-E220, 2016.

Transorbital endoscopic assisted resection of a superior orbital fissure cavernous haemangioma: a technical case report.

OBJECTIVES: Superior orbital fissure and orbital apex lesions are challenging to manage, regardless of the approach chosen, due to the potential morbidity. The objectives of this study are to describe an innovative, minimally invasive surgical approach addressing this critical area and to discuss its indications and outcomes. SUBJECT: A young patient presented with visual disturbances (reduction of color discrimination, central scotoma) and mild exophthalmos owing to the presence of a right orbital apex cavernous haemangioma with superior orbital fissure invasion. METHODS: The lesion was removed via a minimally invasive, neuronavigated, transorbital superior eyelid endoscopic-assisted approach. MAIN OUTCOME MEASURES: Technical feasibility and safety, early and late complications, length of hospitalization time and follow-up data were collected and analyzed. RESULTS: The lesion was radically resected minimizing the surgical morbidity and hospitalization time for the patient and with encouraging functional and cosmetic outcomes. No recurrences were observed 1 year after surgery. CONCLUSIONS: The endoscopic-assisted transorbital approach should be considered a safe and effective option that can be applied in the treatment of lesions affecting such complex anatomical regions, as it offers excellent visualization of the surgical field, acceptable sequelae and reduced morbidity in relation to the traditional transcranial/transfacial approaches. Further studies and larger case series are needed in order to validate the reproducibility and range of applications of this surgical technique.

Endoscopic transnasal resection of Eustachian-tube dermoid in a new-born infant.

INTRODUCTION: Dermoids of the Eustachian tube are rare benign developmental tumours that typically occur in female children. General consensus of classification and nomenclature has still not been reached. The treatment of choice consists of a radical surgical excision. Several approaches have been described and few cases are reported in literature. A gross total resection is now safely achievable through an endoscopic mini-invasive approach. MATERIALS AND METHODS: We have reported a case of dermoid pedicled in the left Eustachian tube and resected with a pure endoscopic transnasal approach. A review of the literature was performed. CASE STUDY: The aim of this paper is to present the first case of pure endoscopic transnasal resection in a 4-day-old infant as emergency treatment of Eustachian tube dermoid presenting an acute respiratory failure at birth. CONCLUSION: The endoscopic transnasal resection is a safe and feasible technique in selected dermoids of the Eustachian tube, when the middle ear is not involved. This approach could be used also in new-born children, decreasing the morbidity of the classic surgical treatment and avoiding the risk of craniofacial alterations.

Quality of life following endoscopic endonasal resection of anterior skull base cancers.

OBJECT: For several decades, the exclusive purpose in the management of anterior skull base malignancies has been to increase survival rates. Recently, given the improved prognosis achieved, more attention has been focused on quality of life (QOL) as well. Producing data on QOL in anterior skull base cancers is hampered by the rarity of the neoplasm and the lack of specific questionnaires. The purpose of this study was to assess health-related QOL in a large and homogeneous cohort of patients affected by anterior skull base cancers who had undergone endoscopic endonasal resection. METHODS: The authors conducted a retrospective review of patients treated for sinonasal and skull base cancers via an endoscopic endonasal approach at two Italian tertiary care referral centers. All patients were asked to complete the Anterior Skull Base Surgery Questionnaire to evaluate their QOL before and 1 month and 1 year after surgical treatment. To assess which parameters affect QOL, the study population was divided into subgroups according to age, sex, stage of disease, surgical approach, and adjuvant therapy. RESULTS: One hundred fifty-three patients were enrolled in this study according to the adopted inclusion criteria. Overall QOL started at a score of 4.68 for the preoperative period, sharply decreased as far as a score of 4.03 during the 1st postoperative month, and rose again to a score of 4.59 over the course of 1 year after treatment, with a significant difference among the 3 values (p < 0.05). The specific symptoms and physical status domains registered poorer results at the 1-year assessment (4.00 and 4.71, respectively) than at the preoperative assessment (both domains 4.86), with a statistically significant reduction in scores (p < 0.05). Worse outcomes were associated with several variables: age > 60 years (difference of 0.21 points between the preoperative and 1-year period, p < 0.05), expanded surgical approaches with transnasal craniectomy (decrease of 0.20 points between the preoperative and 1-year period, p < 0.05), and postoperative radiotherapy (score of 4.53 at the 1-year period vs. 4.70 in patients without any adjuvant treatment, p < 0.05). No statistically significant differences were found when analyzing the study population according to sex (p > 0.1) and T classification of disease at presentation (p > 0.05). CONCLUSIONS: Radical endoscopic endonasal resection led to either complete or at least partial recovery of patient QOL within the 1st postoperative year.