Diagnostic therapeutic assistance pathway (PDTA) of type 2 chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a complex and heterogeneous disorder whose etiopathogenetic picture is not yet completely known and is classically divided into CRS with (CRSwNP) and without nasal polyps (CRSsNP). But today the distinction is made with type 2 and nontype 2 variants. A rational and defined pathway for the diagnosis of chronic rhinosinusitis is an indispensable means to be able to arrive at a correct identification of the patient. This typing is essential to be able to arrive at the correct course of treatment, which turns out to be different for different types of patients. For this reason, the realization of a diagnostic therapeutic pathway represents a fundamental way for the otolaryngologist specialist but not only, since today diagnostics has a multidisciplinary framework. In the present work, precise indications have been developed to arrive at a correct diagnosis. The various diagnostic pathways and processes to arrive at a correct therapeutic framing have been highlighted. Therapy ranging from medical therapy to surgical therapy without neglecting the new biological therapies. It does not represent a guideline but a diagnostic method that can be adapted to all the various territorial realities

Sense of smell in chronic rhinosinusitis: A multicentric study on 811 patients

Introduction: The impairment of the sense of smell is often related to chronic rhinosinusitis (CRS) with or without nasal polyps (CRSwNP, CRSsNP). CRSwNP is a frequent condition that drastically worsens the quality of life of those affected; it has a higher prevalence than CRSsNP. CRSwNP patients experience severe loss of smell with earlier presentation and are more likely to experience recurrence of their symptoms, often requiring revision surgery. Methods: The present study performed a multicentric data collection, enrolling 811 patients with CRS divided according to the inflammatory endotype (Type 2 and non-Type 2). All patients were referred for nasal endoscopy for the assessment of nasal polyposis using nasal polyp score (NPS); Sniffin' Sticks olfactory test were performed to measure olfactory function, and SNOT-22 (22-item sinonasal outcome test) questionnaire was used to assess patients' quality of life; allergic status was evaluated with skin prick test and nasal cytology completed the evaluation when available. Results: Data showed that Type 2 inflammation is more common than non-type 2 (656 patients versus 155) and patients suffer from worse quality of life and nasal polyp score. Moreover, 86.1% of patients with Type 2 CRSwNP were affected by a dysfunction of the sense of smell while it involved a lesser percentage of non-Type 2 patients. Indeed, these data give us new information about type-2 inflammation patients' characteristics. Discussion: The present study confirms that olfactory function weights on patients' QoL and it represents an important therapeutic goal that can also improve patients' compliance when achieved. In a future - and present - perspective of rhinological precision medicine, an impairment of the sense of smell could help the clinician to characterize patients better and to choose the best treatment available

Dupilumab in the treatment of severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP): A multicentric observational Phase IV real-life study (DUPIREAL)

Background Chronic rhinosinusitis with nasal polyps (CRSwNP) is associated with significant morbidity and reduced health-related quality of life. Findings from clinical trials have demonstrated the effectiveness of dupilumab in CRSwNP, although real-world evidence is still limited. Methods This Phase IV real-life, observational, multicenter study assessed the effectiveness and safety of dupilumab in patients with severe uncontrolled CRSwNP (n = 648) over the first year of treatment. We collected data at baseline and after 1, 3, 6, 9, and 12 months of follow-up. We focused on nasal polyps score (NPS), symptoms, and olfactory function. We stratified outcomes by comorbidities, previous surgery, and adherence to intranasal corticosteroids, and examined the success rates based on current guidelines, as well as potential predictors of response at each timepoint. Results We observed a significant decrease in NPS from a median value of 6 (IQR 5–6) at baseline to 1.0 (IQR 0.0–2.0) at 12 months (p < .001), and a significant decrease in Sino-Nasal Outcomes Test-22 (SNOT-22) from a median score of 58 (IQR 49–70) at baseline to 11 (IQR 6–21; p < .001) at 12 months. Sniffin' Sticks scores showed a significant increase over 12 months (p < .001) compared to baseline. The results were unaffected by concomitant diseases, number of previous surgeries, and adherence to topical steroids, except for minor differences in rapidity of action. An excellent-moderate response was observed in 96.9% of patients at 12 months based on EPOS 2020 criteria. Conclusions Our findings from this large-scale real-life study support the effectiveness of dupilumab as an add-on therapy in patients with severe uncontrolled CRSwNP in reducing polyp size and improving the quality of life, severity of symptoms, nasal congestion, and smell

PSEUDOANEURYSM OF SUPERIOR THYROID ARTERY FOLLOWING A TRANSESOPHAGEAL ECHOCARDIOGRAPHY: A CASE PRESENTATION

The pseudo-aneurysm is an encapsulated hematoma of post-traumatic origin which is in communication with the lumen of the artery of relevance. We present a rare case of pseudo-aneurysm occurring after superior thyroid trans-esophageal echocardiography (TEE) and external cardioversion. Singular occurrence in otolaryngology, if not recognized early a pseudo-aneurysm can result in dramatic events such cataclysmic bleeding or acute occlusion of the upper airway

Endoscopic Preoperative Assessment, Classification of Stenosis, Decision-Making

Pediatric Laryngo-Tracheal Stenosis (LTS) comprises different conditions that require precise preoperative assessment and classification. According to the guidelines, the optimal diagnostic work-up of LTS patients relies both on a comprehensive anamnesis and on endoscopic and radiological assessments. All the causes of LTS result in an impairment in airflow, mucociliary clearance, phonation, and sometimes in swallowing disorders. The main goals of treatment are to maintain an adequate respiratory space and restore the Upper Aero-Digestive Tract (UADT) physiology. The first step when dealing with LTS patients is to properly assess their medical history. The main causes of pediatric LTS can be divided into two groups, i.e., congenital and acquired. The most common causes of congenital LTS are: laryngomalacia (60%), vocal fold paralysis (15-20%), subglottic stenosis (SGS) (10-15%), laryngeal webs and atresia (5%), subglottic hemangioma (1.5-3%), and others. On the other hand, 90% of acquired pediatric LTS cases are subsequent to post-intubation injuries. Other less frequent causes are: iatrogenic complications from endoscopic laryngeal interventions, benign tumors, caustic or thermal injuries, external blunt force injury or trauma, chronic inflammatory disorders, or idiopathic causes. Diagnostic work-up consists in a step-by-step investigation: awake and asleep transnasal fiberoptic laryngoscopy (TNFL), direct laryngoscopy with 0° and angled telescopes to investigate the type of stenosis (arytenoid mobility, craniocaudal extension, involved anatomical sites, and active or mature scar tissue), and broncho-esophagoscopy to rule out associated mediastinal malformations. To date there are several available classifications for each of the involved sites: Cohen's classification for anterior glottic stenosis, Bogdasarian's for posterior glottic stenosis (PGS) and Myer-Cotton's for subglottic stenosis, even though others are used in daily practice (Lano-Netterville, FLECS, etc.). The European Laryngological Society recently proposed a new classification which is applicable in all LTS cases. In this chapter we deal with preoperative assessment and staging, reviewing the most relevant classifications applicable in patients affected by LTS, conditio sine qua non in order to tailor the best treatment modality to each subject. We'll also detail the comprehensive radiological, endoscopic and functional assessment for the correct use of each staging classification

The new indications for biologicals in type 2 diseases: perspectives

Purpose of review: To provide a literature review of what is on the market and under study for some diseases treated with drugs targeting type 2 (T2) inflammation. Recent findings: Literature data have shown that drugs targeting type 2 inflammation are effective in asthma and nasal polyposis, conditions for which they are on the market, and have promising expectations in the case of eosinophilic esophagitis, especially using anti-IL-5/IL-5 receptor and IL-4 receptor antibodies, while concerning eosinophilic granulomatosis with polyangitis (EGPA), mepolizumab (MEP) was approved by FDA and EMA as a drug for the treatment of this condition because of the promising results obtained in trials and in real life. Summary: The use of these drugs is certainly an important achievement in the treatment of complex diseases such as those mentioned above, which are too often orphaned from innovative treatments and limited to the use of immunosuppressants and systemic corticosteroid for their control

The endoscopic transnasal paraseptal approach to a sphenoid sinus osteoma: case report and literature review

Osteomas are the most common benign tumors of the nose and paranasal sinuses. Their symptoms, which are nonspecific, occur as the result of a blocked nasal airflow or, in some rare cases, the involvement of nearby structures. Isolated sphenoid sinus osteomas are very rare, as only 20 cases have been previously reported in the literature. Most authors advise surgical treatment for symptomatic lesions. Surgical access to the sphenoid sinus has traditionally been a challenge for surgeons. We describe an endoscopic transnasal paraseptal resection of a sphenoid osteoma in a 35-year-old man. We also discuss surgical access and review the evolution of the surgical approaches to the sphenoid sinus

Trans-Oral Robotic Surgery for a Ewing's sarcoma of tongue in a pediatric patient: A case report

The Ewing's sarcoma Family of Tumors (EFT) includes classic Ewing's Sarcoma (ES) of bone, Extraskeletal Ewing's Sarcoma (EES) and malignant peripheral primitive Neuroectodermal Tumor (pNET) of bone and soft tissue. ES is an aggressive tumor with a high incidence of local recurrence and distant metastasis, which is more common in males respect to females, particularly in the first 2–3 decades of life.1 The skeletal form is more common and typically occurs in the long bones of the extremities. The extra skeletal form occurs in the soft tissues of the lower extremities, paravertebral tissues, chest wall, retroperitoneum and rarely in the head and neck region in about 1–4% of cases.2 Involvement of the head and neck is usually identified in the nasal or oral cavities, sinuses or soft tissues of the neck.3 Primary Ewing's sarcoma of the base of tongue is exceedingly rare and we present the first case in literature in a 16 year-old male treated by Trans-Oral Robotic Surgery (TORS) and postoperative chemotherapy

Direct fascia lata reconstruction to reduce donor site morbidity in endoscopic endonasal extended surgery: a pilot study

Objective: Fascia lata is a validated source of autologous grafts, adopted by many surgical figures throughout different types of reconstructive procedures. Postoperative pain and muscle prolapse are frequent complications after harvesting fascia lata; donor site morbidity causes delayed mobilization and increased lenght of hospital stay. In our department fascia lata is used as autologous graft in reconstruction of skull base after extended endoscopic transsphenoidal surgery (EETS) and the thigh defect is usually repaired with allograft to restore tissue continuity and avoid muscle prolapse. Our aim was to evaluate the post-operative pain and muscle prolapse in a group of patients who underwent EETS with fascia lata reconstruction with allograft. Methods: We retrospectively analyzed clinical data of 11 patients who underwent harvesting and reconstruction of fascia lata during EETS, collected in our department of Neurosurgery between January 2012 and September 2015. "Pain on rest" and "pain on walking" data were collected daily according to the Numerical Rating Scale (NRS) system, during hospital stay until sutures removal and 1 month after surgery. Furthermore, the degree of muscle prolapse was analyzed at the time of sutures removal and 1 month following surgery. Results: 11 patients were studied between January 2012 and September 2015: 4 men and 7 women (1:1.75). Mean age 53.6±11.1years. During the post-operative stay, "pain on rest" and "pain on walking" values of all patients did not exceed grade 4 of NRS. While removing sutures, "pain on rest" resulted grade 1 of NRS in 27.3% (3/11) patients, while "pain on walking" was grade 1 of NRS in 18.2% (2/11) and grade 2 in 9.1% (1/11). After a month of surgery "pain on rest" reduced to NRS grade 1 in 9.1% (1/11), while patients NRS results for "pain on walking" were the same as the previous evaluation. Mean duration of hospital stay was 5.7±2.28 days. 10 patients were discharged home, only 1 patient was transferred to a rehabilitation ward. No visible nor palpable muscle prolapse was found in our group of patients during the entire assessment. Conclusion: Findings show how fascia lata reconstruction with allograft reduced post-operative discomfort and muscle prolapse in our serie; it also permitted their early mobilization and discharge. These are promising results. However further studies are needed to see this technique approved

Endoscopic Endonasal Approaches for Treatment of Craniovertebral Junction Tumours

Tumours involving the craniovertebral junction (CVJ) are challenging because of their local invasiveness and high recurrence rates, as well as their proximity to critical neurovascular structures and the difficulty of reconstructing the resulting skull base defect at this site. Several surgical techniques are currently available to access these lesions, including the far lateral, extreme lateral, direct lateral, transcervical, transoral and transnasal approaches. In this paper, application of the endoscopic endonasal approach (EEA) in the treatment of CVJ tumours is analysed. The indications, contraindications, preoperative workup, step-by-step surgical technique, skull base reconstruction options and postoperative management are described. The advantages and limitations of the EEA are also discussed. Finally, a systematic review of the literature is provided to elucidate the levels of evidence supporting the use of the EEA in this field. Employment of this approach to the CVJ has contributed to high success rates in achieving gross total resection of tumours and improvement in neurological symptoms. Intraoperative and postoperative complication rates are acceptable, with cerebrospinal fluid leakage being the major concern (with a 17-25% incidence). Moreover, in comparison with traditional approaches to the CVJ, the EEA provides lower rates of postoperative dysphagia and respiratory complications. Use of the EEA for treatment of CVJ tumours appears to be a rational alternative to the conventional transoral, transcranial and transcervical approaches in selected cases. Multidisciplinary teamwork including different specialists-such as medical and radiation oncologists, radiologists, otorhinolaryngologists and neurosurgeons-is strongly recommended for the purpose of offering the best treatment strategy for the patient