Multidisciplinary Decision-Making-ITAlian Consensus After Two Years of Real Practice on the Management of Severe Uncontrolled CRSwNP by Biologics (ITACA Study).

PURPOSE OF REVIEW: We aimed to reach an Italian multidisciplinary consensus on some crucial aspects of treatment decision making in CRSwNP, following 2 years of clinical experience in order to support specialists in the management of CRSwNP in clinical practice. We addressed issues relating to therapeutic decision-making and shared criteria for the treatment choice, as well as appropriate timing and criteria for evaluating treatment response, and highlighted the need for repeated multidisciplinary assessments. RECENT FINDINGS: A national survey has been conducted recently to understand how rhinology practice has changed in Italy with the advent of biologics and how this affects patients with uncontrolled, severe CRSwNP. Despite the many published consensus documents, practical recommendations, and protocols on the use of biologics in CRSwNP, heterogenous behaviors in practice are still observed mainly conditioned by the novelty of the topic. The consensus procedure followed a modified Delphi approach. The scientific board included 18 otorhinolaryngologists and 8 allergists, who selected the 4 main topics to be addressed and developed overall 20 statements. Consensus on these statements was sought by a larger group of 48 additional experts, through two rounds of voting, the first web-based, the second in presence with discussion and possible refinement of the statements. The statements reaching an average score ≥ 7 at the second voting round were approved. Five statements were proposed for each of the following topics: baseline evaluation of patients eligible for biologic therapy; choice between different therapeutic options; assessment of the response to biologic treatment; multidisciplinary management. At the first voting round, 19 out of the 20 statements reached a mean score ≥ 7. Following the discussion and a few consequent amendments, at the second round of voting all the 20 statements were approved.

Vestibular schwannoma removal through expanded transcanal transpromontorial approach: a multicentric experience.

PURPOSE: Expanded Transcanal Transpromontorial Approach (ExpTTA) is an endomicroscopic technique that allow surgical excision of small and symptomatic neuromas limited to the internal auditory canal (IAC) or minimally invasive the cerebellopontine angle (CPA). ExpTTA is a safer alternative to the exclusive endoscopic technique as it allows a wider surgical field and better management of the auditory porus and CPA. METHODS: We report a retrospective case series of 34 patients who underwent ExpTTA between 2017 and 2022 at the ENT Departments of the University Hospital of Modena, Bologna and Verona. Tumor size was defined according to the Koos staging and hearing function was classified according to the AAOHNS. A clinical evaluation of facial nerve (FN) function was performed using the House and Brackman scale (HBs). RESULTS: Our cohort consists of 34 patients. At time of surgery all patients had a normal preoperative facial function. Gross total resection was achieved in all patients, without intraoperative complications, and FN continuity was preserved in all cases. No major complications were observed. Regarding post-operative FN function, at hospital discharge ten patients had impairment equal or greater than IV grade according to H&Bs. At 6 months after surgery only two patients presented with moderate/severe facial paralysis (grade IV H&Bs) and finally at 12-month follow-up all patients had a satisfactory recovery of nervous function (grade < III H&Bs). CONCLUSIONS: ExpTTA is a safe and effectively technique for treatment of small VS (Koos I, II and selected cases of Koos III) with low postoperative morbidity.

Tumors of the Nose and Paranasal Sinuses: Promoting Factors and Molecular Mechanisms-A Systematic Review.

Sinonasal neoplasms are uncommon diseases, characterized by heterogeneous biological behavior, which frequently results in challenges in differential diagnosis and treatment choice. The aim of this review was to examine the pathogenesis and molecular mechanisms underlying the regulation of tumor initiation and growth, in order to better define diagnostic and therapeutic strategies as well as the prognostic impact of these rare neoplasms. A systematic review according to Preferred Reporting Items for Systematic Review and Meta-Analysis criteria was conducted between September and November 2022. The authors considered the three main histological patterns of sinonasal tumors, namely Squamous Cell Carcinoma, Intestinal-Type Adenocarcinoma, and Olfactory Neuroblastoma. In total, 246 articles were eventually included in the analysis. The genetic and epigenetic changes underlying the oncogenic process were discussed, through a qualitative synthesis of the included studies. The identification of a comprehensive model of carcinogenesis for each sinonasal cancer subtype is needed, in order to pave the way toward tailored treatment approaches and improve survival for this rare and challenging group of cancers.

Management of parapharyngeal space tumors with transparotid-transcervical approach: analysis of prognostic factors related with disease-control and functional outcomes.

PURPOSE: Different therapeutic strategies have been developed to improve surgical and functional outcome of parapharyngeal space (PPS) neoplasms. The transparotid-transcervical approach (TTa) is a valid surgical option to manage most PPS tumors. Its short- and long-term disease control and cranial nerve (c.n.) function outcomes have not been discussed extensively. METHODS: All patients who underwent TTa over a 10-year period at a tertiary academic center were retrospectively reviewed. Data about preoperative imaging, clinical presentation, tumor's size, location and histology, and postoperative oncological and functional results were registered and analyzed. RESULTS: Sixty patients matched the inclusion criteria. Most of the lesions were benign (71.7%), involved the prestyloid PPS (63.3%) and measured more than 30 mm (75%). Fifty-two (86.7%) lesions were resected en-bloc. Clear margins were achieved in 91.7% of the cases, with positive margins solely associated with malignancy (p = 0.008). Post-operative c.n. function was satisfactory, with X c.n. function significantly associated with the retrostyloid location (p = .00) and neurogenic tumors (p = 0.02). Local disease-control was achieved in 96% of the cases after a median follow-up of 46 (± 19.7-82.0 IQR) months. CONCLUSIONS: The TTa was safe and effective, achieving a satisfactory local control rate. Nevertheless, malignancies maintain a higher rate of positive margin due to their infiltrative nature and the complex anatomy of the PPS. In such cases, multiportal approaches might be more effective. However, post-operative c.n. function remained satisfactory, irrespective of lesions' size and histopathologic behavior. A higher X c.n. deficit rate was observed in retrostyloid and neurogenic lesions.

Taste impairment after endoscopic stapes surgery: Do anatomic variability of chorda tympani and surgical technique matter? : Post-operative dysgeusia after EStS.

PURPOSE: To investigate how the anatomical configuration of the oval window region (OWR) influences the management of the chorda tympani (ChT) and the curetting of adjacent bony structures, in a setting of patients undergoing endoscopic stapes surgery (EStS); to assess the incidence of early and late post-operative dysgeusia and to identify anatomical and surgical factors influencing taste function after EStS. METHODS: Surgical video recordings of 48 patients undergoing EStS for otosclerosis between January 2019 and July 2020 were retrospectively revised, to classify the anatomical variability of selected middle ear structures and the management strategies for the ChT. Clinical records of included patients were reviewed for subjective early and late post-operative taste impairment using a 5-point Likert-scale. RESULTS: The most common configuration of the OWR was type III. The extension of the bony curettage resulted inversely proportional to the exposure of the OWR. The long-term rate of preserved post-operative taste function was 85%. Displacement of the ChT was necessary in 43/48 cases (90%), mostly medially (36/48, 75%). CONCLUSION: Bone curetting during EStS does not correlate with post-operative taste impairment. Despite 100% ChT preservation rate, dysgeusia may occur in a minority of patients, with no apparent relationship to anatomical variability or intraoperative management of the ChT. The use of CO2 laser could have a role in increasing the risk of post-operative dysgeusia after EStS.

Disease-specific quality of life and psychological distress after endoscopic tympanoplasty.

PURPOSE: To assess the postoperative quality of life (QoL) of patients operated on for chronic otitis media (COM) and cholesteatoma by endoscopic approach, with respect to disease-specific complaints and psychological distress, using two validated questionnaires: Chronic Ear Survey (CES) and Depression Anxiety Stress Scale-21 (DASS-21). METHODS: Eighty-five consecutive patients operated on for cholesteatoma and COM by endoscopic tympanoplasty from March 2018 to February 2020 filled in CES and DASS-21, within one month prior to surgery. A second administration of each questionnaire was performed at the yearly postoperative evaluation. A multivariate analysis using a linear regression model was performed to evaluate the role of the different variables associated with the questionnaires' subscales and overall scores. RESULTS: A significant improvement was achieved in all CES and DASS-21 subscales after endoscopic tympanoplasty. No patient showed a DASS-21 score compatible with a psychological distress both at the pre- and postoperative assessments. At multivariate analysis, the only significant factors associated with postoperative improvement in CES scores were preoperative DASS-21 "depression" score and months of follow-up. CONCLUSION: Endoscopic tympanoplasty shows significantly improved QoL as assessed by disease-specific and psycho-emotional questionnaires. A subjective favourable effect of fully endoscopic ear surgery was demonstrated.

Endoscopic tympanoplasty type I for tympanic perforations: analysis of prognostic factors.

PURPOSE: To assess the anatomical and functional outcomes of endoscopic transcanal tympanoplasty type I for tympanic membrane perforations. METHODS: Eight hundred thirty-five patients who underwent tympanoplasty between January 2011 and January 2019 were selected. Patients with tympanic membrane perforation treated with a transcanal endoscopic tympanoplasty type 1 and a follow-up period longer than 6 months have been retrospectively reviewed. The presence of cholesteatoma or ossicular chain dysfunctions were considered exclusion criteria. Eighty-one patients were included in the present study population. The main outcome was the rate of overall graft success. Secondary outcomes included hearing results. Prognostic factors related to both the abovementioned outcomes were assessed. RESULTS: Overall, 66 patients (81.5%) had a successful graft at the last follow-up evaluation. Mean follow-up was 22.1 (range 6-104) months. The anterior quadrants were entailed by the perforation in 62 (76.5%) cases. The overall success rate with cartilage (or cartilage and perichondrium) was 91.2% (p < 0.01). The median preoperative and postoperative ABG were 18.7 (13.4-25.6) and 7.5 (2.5-12.5), respectively, revealing a significant median improvement of 11.2 (p < 0.001). The type of graft and the postoperative tympanic membrane status were significantly associated with the audiologic outcome with p = 0.01 and p = 0.02, respectively. CONCLUSIONS: Endoscopic tympanoplasty type I is a reliable technique with reasonable anatomic and audiologic results. Tympanic membrane grafting with cartilage (or cartilage and perichondrium) guarantees a higher rate of perforation closure and satisfactory hearing results. Anterior eardrum perforations can be successfully and safely managed with transcanal endoscopic approach avoiding postauricular approach and canalplasty.

Use of IMAGE1 S technology for detection of cholesteatoma in endoscopic ear surgery: a retrospective case series on 45 patients.

PURPOSE: To evaluate the role of selected modalities of Storz Professional Image Enhancement System (IMAGE1 S) in differentiating cholesteatoma during endoscopic ear surgery (EES); to assess the potential usefulness of IMAGE1 S in recognition of cholesteatoma residuals at the end of EES. METHODS: A retrospective study on 45 consecutive patients who underwent EES for cholesteatoma between March 2019 and November 2019 at a tertiary referral center was performed. For each case, Spectra A and Spectra B filters were applied intra-operatively. When examining the surgical field, a switch from white light (WL) to IMAGE1 S was performed to detect cholesteatoma and differentiate it from non-cholesteatomatous tissue. When the IMAGE1 S pattern was suspicious for the presence of cholesteatoma, images of the field under both enhancement modalities were taken and the targeted lesions were sent for histologic analysis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of IMAGE1 S were calculated. A final recognition of the surgical field using the selected filters was performed to detect any possible cholesteatomatous residuals. RESULTS: Detection of cholesteatoma by IMAGE1 S selected filters revealed the following data: sensitivity 97%, specificity 95%, PPV 95%, NPV 97%. On three occasions, there was no correspondence between enhanced endoscopy and histology. In 5 out of 45 cases (11%), cholesteatoma residuals, which had not been identified at WL inspection at the end of the procedure, were detected by IMAGE1 S. CONCLUSION: Our results suggest a potential role for IMAGE1 S Spectra A and B filters in EES for cholesteatoma surgery. We propose the integration of IMAGE1 S as a final overview of the surgical cavity for recognition of cholesteatomatous residuals.

Prelaminated flaps in head and neck cancer reconstructive surgery: A systematic review.

BACKGROUND: Prelamination is a reconstructive technique providing fasciomucosal or composite flaps with low donor-site morbidity. We conducted a systematic review of retrospective studies to assess the application of prelaminated flaps in reconstructive surgery of head and neck cancer patients, and to evaluate the advantages and disadvantages of this technique. METHODS: This systematic review adhered to the recommendations of the PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-analysis) 2009 guidelines. A computerized MEDLINE search was performed using the PubMed service of the U.S. National Library of Medicine (www.pubmed.org) and Scopus database (www.scopus.com), running the following search string: "prelamination OR prelaminated AND flap." Two authors screened the articles, then selected and extracted data on malignancies characteristics, reconstructive techniques, outcomes and complications. RESULTS: A total of 19 articles were selected and reviewed from 128 identified. Seven of 19 articles were case reports, 12 articles were case series. One-hundred-two patients underwent reconstructive treatment by prelamination technique using a wide variety of flaps (92 free, 10 pedicled). The sites of reconstruction were oral cavity (66 floor of the mouth, 3 retromolar trigone, 6 hard palate, 4 cheek, 4 tongue), 8 facial skin (5 of them sited on the nose), 4 oropharyngeal defects, 1 laryngotracheal region. No case of total flap loss was reported. Partial flap loss or shrinkage requiring minor surgical revisions was observed in 18 patients (17.6%). Primary closure of the donor site was achieved in 97 cases (97%) and 3 (3%) required revision surgery of the donor site. CONCLUSION: Prelamination is an effective and versatile technique, with low donor-site morbidity. Further studies would be needed to investigate the impact on the patient's oncologic outcome. More comparative studies with standard reconstructive techniques are essential to understand when it is worth performing this sophisticated procedure.

A case-control study of visually evoked postural responses in childhood with primary headaches.

BACKGROUND: Disorientation, nausea, confusion, dizziness, and displacement are frequently complained by headache-suffering children. Anyhow, the cause of these symptoms is still unclear, and a dysfunction of vestibular pathways or their alteration due to central pain pathways hyper-activation, has been proposed. The aim of this study is to use posturography to explore the balance function of headache-suffering children during pain-free periods. METHODS: Posturography was performed on 19 migraineurs, 11 tension-type headache sufferers, and 20 healthy controls. Posturographic measures were performed during headache-free periods under different conditions: with eyes opened, eyes closed, and during right and left optokinetic stimulation. The last 2 conditions were used to mimic unreliable visual signals that can confound vestibular system. RESULTS: During eyes-closed conditions, headache-suffering children displayed higher displacements than healthy controls, since statokinesiogram surface was higher in tension-type headache sufferers and migraineurs compared with controls (P value = 0.0095). Romberg's index, indicating the overall stability of the subject, was lower in healthy controls than in headache sufferers (P = 0.0139), thus suggesting a vestibular impairment in the seconds. Moreover, both during right and left optokinetic stimulation, the statokinesiogram length was higher in headache-suffering children (P < 0.0001). Thereafter, statokinesiogram surface was higher in migraineurs during right optokinetic stimulation (P = 0.0388) than in tension-type headache sufferers when stimulation was directed on the opposite side (P = 0.0249). CONCLUSIONS: These results suggest a central alteration of vestibular pathways in headache-suffering children, that makes balance function more dependent from visual inputs than healthy subjects, even in inter-ictal phases.

Endoscopic facial nerve decompression in post-traumatic facial palsies: pilot clinical experience.

PURPOSE: Post-traumatic facial nerve (FN) paralysis might need surgical decompression in selected patients. Different microscope-based surgical techniques are described in the literature such as the transmastoid, the middle cranial fossa and the translabyrinthine approach. The effectiveness of the transcanal endoscopic approach (TEA) in managing such condition has never been described and its possible indications has to be defined. METHODS: Retrospective multi-centric case series of patients with post-traumatic FN paralysis surgically treated with TEA. From July 2013 to July 2017, 6 patients underwent TEA for post-traumatic FN paralysis with involvement of the second genu and/or the tympanic segment of the nerve. The surgical technique is described step by step, with focus on anatomic landmarks. Post-operative outcomes are specified in terms of FN postoperative function and audiologic results. RESULTS: The TEA showed to recover a House-Brackmann grade I-II FN function in 83.2% of the patient. Post-operative air-bone gap significantly improved; whereas, the pure-tone average bone conduction did not differ significantly. CONCLUSIONS: TEA represents a viable option for the treatment of post-traumatic facial palsy in patients with radiologic evidence of tympanic segment and/or perigeniculate region involvement with no involvement of the mastoid segment of the FN. Transcanal endoscopic facial nerve decompression is a safe and effective approach in highly selected cases. LEVEL OF EVIDENCE: 4.

Food-induced stimulation of the antisecretory factor to improve symptoms in Meniere's disease: our results.

PURPOSE: Specially processed cereals (SPC) that increase endogenous antisecretory factor (AF) synthesis have been proposed to improve symptoms of Meniere's disease (MD) with controversial results. The aim of this study was to evaluate the effects of SPC in patients with definite unilateral MD and compare the results to a treatment protocol with intravenous glycerol and dexamethasone. METHODS: Thirteen patients with unilateral MD were treated with SPC and 13 patients were treated with intravenous glycerol and dexamethasone for 12 months. Audio-vestibular evaluation was performed before (T0) and at the end of the treatments (T12). The number of vertigo spells were evaluated before and after therapy and the Efficacy Index (EI) was calculated. Questionnaires for hearing loss (HHIA), tinnitus (THI) and quality of life (TFL) were administered. RESULTS: EI decreased in the SPC group in the second semester compared to the first although not significantly (p = 0.6323). There was a significant reduction for THI score in the SPC group at T12 (p = 0.0325). No significant differences were found between the two groups at T0 (p = 0.4723), while a significant difference was found at T12 (p = 0.0041). Quality of life showed an improvement in daily activities in the SPC group compared to infusion therapy group. CONCLUSION: Our study shows a reduced number of vertigo attacks and a positive effect on the discomfort generated by tinnitus and quality of life in patients with unilateral MD treated with SPC and when compared to patients treated with intravenous glycerol and dexamethasone. No effects on hearing thresholds were noted in both groups.

Epinephrine Use in Endoscopic Ear Surgery: Quantitative Safety Assessment.

INTRODUCTION: The management of bleeding in exclusive endoscopic ear surgery (EES) is largely dependent on epinephrine use. However, to date its suitability and safety have not been assessed. The aim of the present study would be to assess the safety profile of topical application and/or local infiltrationof diluted epinephrine during EES regarding the intra- and postoperative periods. We hypothesize that epinephrine may be safely used during EES. METHODS: Retrospective analysis of 90 EES cases performed at the University Hospital of Modena, Italy. Patient's charts and video recordings of the operations were assessed. RESULTS: Epinephrine was used in all cases for hemostatic purposes as following: (1) diluted epinephrine (1:200,000) injection: mean 1.2 mL (range: 0-3.5) corresponding to 0.006 mg (range 0-0.018), and (2) topical application (1:1,000) directly in the surgical field: mean 7 cottonoids (range: 0-18) corresponding to mean 0.56 mg (range: 0-1.44). No major cardiovascular adverse effects were assessed. Only 2 intraoperative hypertensive events were recorded. One sensorineural hearing loss was observed in a case of cholesteatoma involving the stapes; no facial palsy occurred during the study period. CONCLUSION: The combined use of local injection and topical epinephrine is a safe and effective strategy to control bleeding in exclusive EES, when used within the dilutions and quantities reported in this study.

Low-dose intratympanic gentamicin administration for unilateral Meniere's disease using a method based on clinical symptomatology: Preliminary results.

PURPOSE: There are many therapeutic options for Meniere's disease (MD); intratympanic (IT) gentamicin has been proposed for intractable cases although controversy about dosage and method exists. The purpose of this study was to assess the efficacy and safety of low-dose IT gentamicin on vertigo attacks in MD using a clinical symptomatology-based method in which administration was repeated only if vertigo attacks recurred, with a 2-week interval between injections. MATERIALS AND METHODS: Forty-eight patients with unilateral intractable MD were included in the study. All patients received one to five IT injections with 0.5 ml of 10 mg of gentamicin (80 mg/2 ml) with an interval of 2 weeks between injections. Vertigo attacks were evaluated before and after therapy and categorized into classes A-F according to the 2015 Equilibrium Committee criteria. Audiovestibular assessment with pure tone audiometry, vestibular bed-side examination and video head impulse test was performed. RESULTS: Before treatment patients had an average of 4.4 vertigo attacks/month; after treatment the average number decreased to 0.52. The majority of patients (77%) reached Class A vertigo control with 5 or less gentamicin injections. VOR gain was unaffected in the healthy side and significantly reduced in the affected side. No hearing deterioration was found in all treated patients. CONCLUSIONS: Low-dose IT gentamicin administration based on clinical symptomatology can produce a satisfactory control of vertigo attacks after treatment; such protocol had an effect mainly on the vestibular function as demonstrated by the significant reduction in VOR gain in the affected side avoiding a cochlear damage.

Gusher in stapes surgery: a systematic review.

OBJECTIVE: The aim of this study is to perform a systematic literature review on the occurrence of gusher during stapes surgery, to understand its surgical management and outcomes. METHODS: The PRISMA standard was applied to identify English, Italian or French-language studies, related to stapes surgery and mentioning gusher or perilymphatic leak. Full-texts lacking information on the management of gusher and/or the post-operative hearing outcome were excluded. RESULTS: Twenty-four articles were eventually included. Seventy-six patients were involved in the qualitative synthesis. The management of gusher mostly consisted in covering the oval window and/or filling the tympanic cavity, with absorbable and autologous graft materials. Packing of the external auditory canal was reported in 51 patients (67%). Gusher was related to complete/profound loss of hearing in 25% of the cases and to a worsening of hearing function in 31% of patients. In 19% of patients an improvement in hearing tests was reported; in 28% the hearing function was unchanged. Post-operative vestibular symptoms were reported in 7 patients, and were mainly mild and transient. The absence of vestibular symptoms was underlined in 9 cases, while in 79% of the patients the authors did not provide information. CONCLUSION: The unexpected occurrence of gusher during stapes surgery represents a relevant issue for the otologic surgeon. Its management most commonly consists in plugging the oval window and the tympanic cavity. In most of the cases, a stapes prosthesis could be positioned. The results on hearing and vestibular functions are widely variable.

Correlation between pre-operative CT findings and intra-operative features in pediatric cholesteatoma: a retrospective study on 26 patients.

OBJECTIVE: To assess the predictive value of pre-operative CT imaging in pediatric patients affected by cholesteatoma of the middle ear, comparing pre-operative CT findings to intra-operative features. METHODS: A retrospective study was performed on a population of 26 pediatric patients who underwent tympanoplasty for middle ear cholesteatoma at the Otorhinolaryngology Departments of Verona and Modena University Hospitals between December 2011 and June 2018. Comparison between pre-operative CT images and intra-operative findings (assessed from video recording) was made focusing on the involvement of specific structures: ossicular chain, tegmen tympani, labyrinthine fistula, facial nerve, and temporal bone involvement. CT sensitivity, specificity, positive and negative predictive values were calculated. RESULTS: Overall, 28 surgical procedures were evaluated. No statistically significant differences were encountered between CT images and intra-operatory findings regarding the selected parameters. CONCLUSIONS: Based on our study, pre-operative temporal bone CT scan is a valuable tool for the assessment of pediatric patient candidates for cholesteatoma surgery given the absence of statistically significant differences between radiologic and intra-operative findings. The present findings might support the indication to routinely perform temporal bone CT scan in children with cholesteatoma as part of pre-surgical plan. LEVEL OF EVIDENCE: III.

Rating surgical field quality in endoscopic ear surgery: proposal and validation of the "Modena Bleeding Score".

PURPOSE: To develop and validate a bleeding score that could be applied in endoscopic ear surgery (EEarS). METHODS: A prospective validation study was performed. A new bleeding score, called "Modena Bleeding Score" (MBS), was created by the authors. It provides five grades for rating the surgical field during EEarS procedures (from grade 1-no bleeding to grade 5-bleeding that prevents every surgical procedure except those dedicated to bleeding control). A preliminary "face validity" was performed by 18 ENT specialists to assess possible misunderstandings in interpreting the scale. Then, 15 videos of endoscopic ear surgery procedures, each divided into three parts (t0, t1, and t2), were subsequently evaluated by 15 specialists, using MBS. The videos were randomly selected and assigned. Intra-rater reliability and inter-rater reliability were calculated. The clinical validity of the instrument was calculated using a referent standard (i.e., four ENT experts whose ratings were compared to those obtained by the former sample). RESULTS: The face validity showed a good consensus about the clarity and comprehension of the scale; both intra and inter-rater reliability demonstrated good performance (intra-rater reliability ranged from 0.741 to 0.991 and inter-rater reliability was 0.790); clinical validity also showed positive values, ranging from 0.75 to 0.93. CONCLUSIONS: MBS has proved to be an effective method to rate surgical field during EEarS, with good-to-excellent performances. Its use would possibly help comparisons of groups in clinical trials or comparisons between studies.

Middle ear microvascularization: an "in vivo" endoscopic anatomical study.

PURPOSE: To describe the in vivo vascularization of middle ear by an endoscopic point of view, particularly focusing on the medial wall of tympanic cavity and incudostapedial region (ISR). STUDY DESIGN: Case series with surgical videos review and anatomical description. METHODS: 48 videos from exclusive endoscopic middle ear surgery performed at the University Hospital of Modena from November 2015 to July 2017 were reviewed. Data about anatomy of vessels, and blood flow direction (BFD) were collected in an appropriate database for further analyses. RESULTS: 48 cases were included in the present study. In 18/48 patients (37,5%), a clearly identifiable inferior tympanic artery (ITA) was present, running just anteriorly to the round window (RW), with a superior BFD (65% of cases) from the hypotympanic region toward the epitympanum. Some promontorial variants were described in 67% of cases and the most common finding was a mucosal vascular network with a multidirectional BFD. On the ISR, an incudostapedial artery (ISA) was detected in 65% of cases with BFD going from the long process of the incus (LPI) toward the pyramidal eminence in the majority of cases. CONCLUSION: The vascular anatomy and BFD of the medial wall of the tympanic cavity can be easily studied in transcanal endoscopy. ITA (with a superior BFD in most cases) and ISA (with a main BFD from the incus to the stapes) are the most constant identifiable vessels.

Transcanal surgery for vestibular schwannomas: a pictorial review of radiological findings, surgical anatomy and comparison to the traditional translabyrinthine approach.

The most popular approaches for vestibular schwannoma (VS) removal are retrosigmoid, middle cranial fossa and translabyrinthine (TL). All require a certain degree of invasivity, bone removal, or brain manipulation. Recently, the authors described the transcanal transpromontorial approaches (TTA), which allow the inner ear to be accessed directly through the external auditory canal (EAC), either with a microscopic (Expanded TTA, or ExpTTA) or even an exclusive endoscopic technique (Endoscopic TTA, or EndoTTA). The advantages compared to traditional approaches are a direct view of the internal auditory canal (IAC) from lateral to medial, very little or no superficial tissue dissection and very little petrous bone drilling. In summary, from an anatomical point of view, they could be considered to be minimally invasive approaches. The radiologic outcome and the anatomical correspondence of these new approaches are described so as to share with the readers the possible radiologic findings and to compare and differentiate them from classic transpetrous approaches such as the TL approach. LEVEL OF EVIDENCE: 4.