Basic and advanced endoscopic sinus surgery course: open and endoscopic cadaver dissection techniques and live surgery.

This course originates from the close collaboration experienced and established over many years between the three professionals most involved in the surgical treatment of lesions of the anterior skull base. We believe, and the results have proved us right, that the achievement of the best treatment in such complex anatomical regions can be born only from an accurate preoperative study, the realization of several surgical procedures and the care of every detail during the post-operative period carried out in a close collaboration among Otolaryngologists, Maxilo-Facial surgeons and Neurosurgeons. The relatively recent introduction of endoscopic surgery and the huge expansion of the latter has further expanded the possibilities of collaboration. On the other hand those who want to approach to this type of pathologies necessarily have to know not only the techniques and possibilities of endoscopy but also the open techniques which are essential to face certain situations or clinical manifestations. The experience of many years of shared work between two surgical university schools with great traditions such as Modena and Verona besides a personal friendship established over time has enabled us both to joint the three specialties and to create a group that is inspired by the same principles

Rediscovering tuberculosis of the middle ear

Tuberculous otitis media (TOM) has no specific clinical presentation. Early diagnosis is necessary in order to avoid serious complications. The aim of this paper is rediscovering this rare forgotten disease that can re-emerge in a globalized society.A case of a 37 year-old woman with persistent unilateral otitis media with ear discharge and deafness since two years is presented. Systemic and topic antibiotic therapy was not effective. She underwent surgery twice with no improvement. As clinical conditions worsened, she was hospitalized. Histological examination and culture for mycobacteria detection revealed Mycobacterium tuberculosis complex infection.The patient was treated with anti-tuberculosis medical therapy for 9 months with clinical improvement.TOM is a diagnostic challenge and is often treated late because not suspected. Chronic otitis media not responding to common antibiotics should be investigated for tuberculous infection. Keywords: Tuberculosis, Otitis media, Atypical tuberculosi

Role of osteocyte apoptosis in peculiar ossicles of the hearing sense organ: preliminary observations on hearing loss and osteoporosis

Starting point of the present study is the osteocyte role in bone remodelling that allows bone adaptation to mechanical load [1-3]. Bone remodelling has been investigated in relation to the occurrence of apoptosis [4] to understand if and how the process of programmed cell death interferes with bone turnover. In 1998, in a study on human middle ear, Marotti et al. [5] demonstrated that: 1) over 40% of osteo-cytes are dead within the 2nd year of age (but the authors were not able to demonstrate if osteocyte death occurred by degeneration or apoptosis); 2) bone remodelling occurs only occasionally. Recently [6], we showed that: 1) osteocytes of human auditory ossicles die by apoptosis; 2) also osteocytes located inside scleral ossicles of lower vertebrate eye (reptiles and birds) phylogenetically so far from human auditory ossicles are widely affected by apoptosis (about 60%); 3) in scleral ossicles bone turnover never occur. It is to be noted that both auditory ossicles of human ear and scleral ossicles of vertebrate eye are peculiar bony segments continuously submitted to stereotyped stresses and strains, with specialized func-tions: the first are involved in sound wave transmission and the latter protect the eyeball against deformation during the movement and have a role in visual accomodation, providing attachment for the ciliary muscles. In both cases, bone remodelling might severely impair, by resorption, the mechanical resistance of these extremely small specialized bony segments. Thus, we suggested that in auditory and scleral ossicles, submitted to stereotyped loading for all life, bone mechanical adaptation is not needed and osteocyte programmed death could represent the mechanism to avoid bone remodelling and to make stable, when necessary, bone structure and mechanical resistance. More recently, to confirm this hypothesis, clinical data were collected from a cohort of patients aged 55-85 years affected by hearing loss. The main target of the present study is to exclude any correlation between hearing loss and osteoporosis. During osteoporosis, unbalanced bone turnover causes the bone depletion in skeletal segments; such condition, in the peculiar ossicles of human middle ear, should imply hearing impairment. Our preliminary observations indicate, instead, that osteoporotic patients do not show higher percentage of hearing loss with respect to non osteoporotic ones. This evidence is ascribable to osteocyte apoptosis of auditory ossicles that avoid bone remodelling, thus assuring the integrity of such bony segments also in osteoporotic conditions. References [1] Turner (1991) Omeostatic control of bone structure: an application of feed-bach theory. Bone 12: 203-217. [2] Turner and Forwood (1995) What role does the osteocyte network play in bone adaptation? Bone 16: 283-285. [3] Marotti (1996) The structure of bone tissue and the cellular control oftheir deposition. IJAE 101(4): 26-79. [4] Noble et al. (1997) Identification of apoptotic changes in osteocytes in normal and pathological human bone. Bone 20: 273-282. [5] Marotti et al. (1998) Morphometric investigation on osteocytes in human auditory ossicles. Ann Anat 180: 449-453. [6] Palumbo et al. (2012) Osteocyte apoptosis in human auditory ossicles and scleral ossicles of lower ver-tebrates: a mere coincidence or linked processes? Calcif. Tissue Int. 90: 211-218

Digital image enhancement may improve sensitivity of cholesteatoma detection during endoscopic ear surgery.

OBJECTIVES This study investigates the possible benefits and limitations of the digital image enhancement systems provided by Storz Professional Image Enhancement System (SPIES) during endoscopic ear surgery (EES) for cholesteatoma. An increased detection of cholesteatoma residuals during the final steps of endoscopic surgery using DIE technology was hypothesized. DESIGN Cross-sectional study. SETTING Tertiary referral hospital. METHODS A total of 10 questionnaires of 18 intraoperative pictures with equal numbers of cholesteatoma and non-cholesteatoma images, each presented in three different image-enhancing modalities (Clara, Spectra A, Spectra B), were generated. Fifty-one experienced ear surgeons participated to the survey and were randomly assigned to a questionnaire and completed it at two time points. The experts were asked to rate for each picture whether cholesteatoma was present or not. The answers were compared with the histopathological reports. RESULTS Clara showed the highest accuracy in cholesteatoma detection, followed by Spectra A and lastly Spectra B. In contrast, Spectra B showed the highest sensitivity and Clara the highest specificity, while Spectra A was placed in the middle for both values. Using the Spectra B modality, most responses agreed across the two time points. Ear surgeons assessed the usefulness, as well as preference among image modalities for cholesteatoma surgery, in the following order: Clara, Spectra B, Spectra A. CONCLUSION Digital enhancement technologies are applicable to EES. After complete cholesteatoma removal, Spectra B showed the highest sensitivity in the detection of cholesteatoma residuals as compared with Clara and Spectra A. Thus, Spectra B may be recommended to avoid missing any cholesteatoma residuals during EES

Effect of a fixed combination of nimodipine and betahistine versus betahistine as monotherapy in the long-term treatment of M\ue9ni\ue8re's disease: a 10-year experience

Despite an abundance of long-term pharmacological treatments for recurrent vertigo attacks due to M\ue9ni\ue8re's disease, there is no general agreement on the their efficacy. We present the results of a retrospective study based on a 10-year experience with two long-term medical protocols prescribed to patients affected by M\ue9ni\ue8re's disease (diagnosed according to the American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium guidelines) who completed treatments in the period 1999-2009. A total of 113 medical records were analysed; 53 patients received betahistine-dihydrochloride at on-label dosage (32 mg die) for six months, and 60 patients were treated with the same regimen and nimodipine (40 mg die) as an add-therapy during the same period. Nimodipine, a 1,4-dihydropyridine that selectively blocks L-type voltage-sensitive calcium channels, has previously been tested as a monotherapy for recurrent vertigo of labyrinthine origin in a multinational, double-blind study with positive results. A moderate reduction of the impact of vertigo on quality of life (as assessed by the Dizziness Handicap Inventory) was obtained in patients after therapy with betahistine (p 0.05), whereas the fixed combination of betahistine and nimodipine was associated with a significant reduction of tinnitus annoyance and improvement of hearing loss (p < 0.005). It was concluded that nimodipine represents not only a valid add-therapy for M\ue9ni\ue8re's disease, and that it may also exert a specific effect on inner ear disorders. Further studies to investigate this possibility are needed

Nimodipine in otolaryngology: from past evidence to clinical perspectives

As L-type voltage-gated calcium channels (VGCCs) control Ca(2+) influx and depolarisation of cardiac and vascular smooth muscle, they represent a specific therapeutic target for calcium channel blockers (CCBs), which are approved and widely used to treat hypertension, myocardial ischaemia and arrhythmias. L-type currents also play a role in calcium entry in the sensory cells of the inner ear. In hair cells of both cochlea and labyrinth, calcium cytoplasmic influx is the first physiological process that activates complex intracellular enzymatic reactions resulting in neurotransmitter release. Excessive calcium ion entry into sensory cells, as a consequence of L-VGCCs malfunction is responsible for over-activation of phospholipase A2 and C, protein kinase II and C, nitric oxide synthase and both endonucleases and depolymerases, which can cause membrane damage and cellular death if the cytoplasmic buffering capacity is overcome. Nimodipine, a highly lipophilic 1-4 dihydropyridine that easily crosses the brain-blood barrier, is generally used to reduce the severity of neurological deficits resulting from vasospasm in patients with subarachnoid haemorrhage. Moreover, due to its selective blocking activity on L-channel calcium currents, nimodipine is also suggested to be an effective countermeasure for cochlear and vestibular dysfunctions known as channelopathies. Indeed, experimental data in amphibians and mammalians indicate that nimodipine has a stronger efficacy than other CCBs (aminopyridine, nifedipine) on voltage-dependent whole-cell currents within hair cells at rest and it is the only agent that is also effective during their mechanically induced depolarisation. In humans, the efficacy of nimodipine is documented in the medical management of peripheral vestibular vertigo, sensorineural hearing loss and tinnitus, even in a pathology as complex as Ménière's disease. Nimodipine is also considered useful in the prophylaxis of damage to the facial and cochlear nerves caused by ablative surgery of cerebellopontine tumours; it has been recently hypothesised to accelerate functional recovery of recurrent nerve lesions during thyroid cancer surgery. Further trials with adequate study design are needed to test the efficacy of nimodipine in the treatment of vertigo due to cerebrovascular disease and vestibular migraine.As L-type voltage-gated calcium channels (VGCCs) control Ca(2+) influx and depolarisation of cardiac and vascular smooth muscle, they represent a specific therapeutic target for calcium channel blockers (CCBs), which are approved and widely used to treat hypertension, myocardial ischaemia and arrhythmias. L-type currents also play a role in calcium entry in the sensory cells of the inner ear. In hair cells of both cochlea and labyrinth, calcium cytoplasmic influx is the first physiological process that activates complex intracellular enzymatic reactions resulting in neurotransmitter release. Excessive calcium ion entry into sensory cells, as a consequence of L-VGCCs malfunction is responsible for over-activation of phospholipase A2 and C, protein kinase II and C, nitric oxide synthase and both endonucleases and depolymerases, which can cause membrane damage and cellular death if the cytoplasmic buffering capacity is overcome. Nimodipine, a highly lipophilic 1-4 dihydropyridine that easily crosses the brain-blood barrier, is generally used to reduce the severity of neurological deficits resulting from vasospasm in patients with subarachnoid haemorrhage. Moreover, due to its selective blocking activity on L-channel calcium currents, nimodipine is also suggested to be an effective countermeasure for cochlear and vestibular dysfunctions known as channelopathies. Indeed, experimental data in amphibians and mammalians indicate that nimodipine has a stronger efficacy than other CCBs (aminopyridine, nifedipine) on voltage-dependent wholecell currents within hair cells at rest and it is the only agent that is also effective during their mechanically induced depolarisation. In humans, the efficacy of nimodipine is documented in the medical management of peripheral vestibular vertigo, sensorineural hearing loss and tinnitus, even in a pathology as complex as Ménière's disease. Nimodipine is also considered useful in the prophylaxis of damage to the facial and cochlear nerves caused by ablative surgery of cerebellopontine tumours; it has been recently hypothesised to accelerate functional recovery of recurrent nerve lesions during thyroid cancer surgery. Further trials with adequate study design are needed to test the efficacy of nimodipine in the treatment of vertigo due to cerebrovascular disease and vestibular migraine

Assessment of a novel patient-specific 3D printed multi-material simulator for endoscopic sinus surgery

Background: Three-dimensional (3D) printing is an emerging tool in the creation of anatomical models for surgical training. Its use in endoscopic sinus surgery (ESS) has been limited because of the difficulty in replicating the anatomical details. Aim: To describe the development of a patient-specific 3D printed multi-material simulator for use in ESS, and to validate it as a training tool among a group of residents and experts in ear-nose-throat (ENT) surgery. Methods: Advanced material jetting 3D printing technology was used to produce both soft tissues and bony structures of the simulator to increase anatomical realism and tactile feedback of the model. A total of 3 ENT residents and 9 ENT specialists were recruited to perform both non-destructive tasks and ESS steps on the model. The anatomical fidelity and the usefulness of the simulator in ESS training were evaluated through specific questionnaires. Results: The tasks were accomplished by 100% of participants and the survey showed overall high scores both for anatomy fidelity and usefulness in training. Dacryocystorhinostomy, medial antrostomy, and turbinectomy were rated as accurately replicable on the simulator by 75% of participants. Positive scores were obtained also for ethmoidectomy and DRAF procedures, while the replication of sphenoidotomy received neutral ratings by half of the participants. Conclusion: This study demonstrates that a 3D printed multi-material model of the sino-nasal anatomy can be generated with a high level of anatomical accuracy and haptic response. This technology has the potential to be useful in surgical training as an alternative or complementary tool to cadaveric dissection

Oncological and Functional Outcomes for Horizontal Glottectomy: A Systematic Review

: Horizontal glottectomy (HG) is a particular type of partial laryngectomy indicated for exclusive glottic tumor with anterior commissure involvement. The purpose of this study is to systematically review the literature about functional and oncological outcome of HG. This systematic review adhered to the recommendations of the PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-analysis) 2009 guidelines. Articles mentioning patients undergoing HG for laryngeal squamous cell carcinoma were included. A total of 14 articles were selected and reviewed from 19 identified. The whole study population consisted of 420 patients who underwent HG. Three hundred and thirty-nine patients out of 359 were staged as T1. The range of post-operative follow-up was 5 months to 10 years. Fifty-five recurrences were experienced, being local, regional and distant in 35, 12 and 8 patients, respectively. Laryngeal preservation rate was 93.6%. Nasogastrict tube was removed on average after 10.1 days. The tracheostomy was maintained for 11.3 days. Mean hospitalization lasted for 11.7 days. According to the results of this systematic review, HG is an oncologically safe surgical option for T1a-T1b glottic tumors with oncological outcomes comparable to other treatment. HG could be a good therapeutical choice whenever poor laryngeal exposure and/or patient's refusal of radiotherapy are encountered, or when patient's medical history represents a contraindication for radiation therapy

Topographic Anatomy of the Medial Labyrinthine Wall: Implications for the Transcanal Endoscopic Approach to the Internal Auditory Canal.

Hypothesis To characterize transcanal endoscopic landmarks of the medial labyrinthine wall and correlate these with anatomical features of the fundus of the internal auditory canal (IAC). Background The transcanal transpromontorial approach (TTA) enables minimally invasive access to the IAC. The establishment of a landmark-based dissection technique for the approach is crucial to avoid injury to the facial nerve. Methods Twenty temporal bones were dissected endoscopically through the TTA. Furthermore, high-resolution computed tomography (CT) scans from ten adult normal temporal bones were analyzed and three-dimensionally reconstructed. Results A stepwise dissection technique for the TTA was demonstrated depending on a newly described landmark used in the identification of the facial nerve. The proposed landmark, which was named the intervestibulocochlear crest (IVCC), is an integrated part of the otic capsule. It can be differentiated after the excision of the lateral labyrinthine wall as a laterally based bony pyramid between the cochlea and the vestibule. Its medially directed apex blends with the central part of the falcifrom crest and points to the distal part of the meatal facial nerve. The IVCC is best detected on axial CT images at the level of the tympanic facial nerve. The union between the IVCC and the falciform crest appears radiologically as a short stem or mini-martini glass. Conclusion The proposed IVCC is a novel landmark with a consistent relationship to the IAC fundus and the facial nerve. It may be utilized in conjunction with the falciform crest to identify the facial nerve during minimally invasive transcanal surgeries. METHODS Twenty temporal bones were dissected endoscopically through the TTA. Furthermore, high-resolution computed tomography (CT) scans from ten adult normal temporal bones were analyzed and three-dimensionally reconstructed. RESULTS A stepwise dissection technique for the TTA was demonstrated depending on a newly described landmark used in the identification of the facial nerve. The proposed landmark, which was named the intervestibulocochlear crest (IVCC), is an integrated part of the otic capsule. It can be differentiated after the excision of the lateral labyrinthine wall as a laterally based bony pyramid between the cochlea and the vestibule. Its medially directed apex blends with the central part of the falcifrom crest and points to the distal part of the meatal facial nerve. The IVCC is best detected on axial CT images at the level of the tympanic facial nerve. The union between the IVCC and the falciform crest appears radiologically as a short stem or mini-martini glass. CONCLUSION The proposed IVCC is a novel landmark with a consistent relationship to the IAC fundus and the facial nerve. It may be utilized in conjunction with the falciform crest to identify the facial nerve during minimally invasive transcanal surgeries

A Case Report of a Solitary Fibrous Tumor of the Maxillary Sinus

A solitary fibrous tumor (SFT) is a benign neoplasm, firstly described as a mesenchymal tumor of the pleura. Its incidence range in the head and neck region is about 5\u201327%, but only rarely does it affect paranasal sinuses. The differential diagnosis is challenging, owing to its erosive growth pattern and immuno-histochemical features. SFTs have an aggressive behavior and an important recurrence potential. Therefore, a radical surgical excision is the gold standard therapeutic procedure. A rare SFT originating from the right maxillary sinus is reported here. The 37-year-old patient presented to the outpatient clinic with a painful expansive lesion in the whole right maxillary region. The overlying skin was inflamed and the patient had no epistaxis episodes. The 1.5 dentary element tested negative for vitality; however, a puncture of the lesion led to a hematic spill and no purulent discharge. An endoscopic-guided biopsy was suggestive either of SFT or hemangioperictoma, excluding a malignant neoplasm. A multi-equipe surgical team was activated. The lesion was embolized in order to achieve a good hemostatic control and, after 48 h, the neoplasm was radically excised with a combined open and endoscopic approach. The patient was disease-free at 12-month radiological and clinical follow-up. Given the rarity of this lesion and the delicacy required in addressing head and neck neoplasms, we believe that the present case report might be of help in further understanding how to approach cranio-facial SFTs