Management and Oncologic Outcomes of Close and Positive Margins after Transoral CO2 Laser Microsurgery for Early Glottic Carcinoma

Background: The present study analyzed the impact of margin status on local control and survival, and the management of close/positive margins after transoral CO2 laser microsurgery for early glottic carcinoma. Methods: 351 patients (328 males, 23 females, mean age 65.6 years) underwent surgery. We identified the following margin statuses: negative, close superficial (CS), close deep (CD), positive single superficial (SS), positive multiple superficial (MS), and positive deep (DEEP). Results: A total of 286 patients (81.5%) had negative margins, 23 (6.5%) had close margins (8 CS, 15 CD) and 42 (12%) had positive margins (16 SS, 9 MS, 17 DEEP). Among the 65 patients with close/positive margins, 44 patients underwent enlargement, 6 radiotherapy and 15 follow-up. Twenty-two patients (6.3%) recurred. Patients with DEEP or CD margins showed a higher risk of recurrence (hazard ratios of 2.863 and 2.537, respectively), compared to patients with negative margins. Local control with laser alone, overall laryngeal preservation and disease-specific survival decreased significantly in patients with DEEP margins (57.5%, 86.9% and 92.9%, p < 0.05). Conclusions: Patients with CS or SS margins could be safely submitted to follow-up. In the case of CD and MS margins, any additional treatment should be discussed with the patient. In the case of DEEP margin, additional treatment is always recommended

Bilateral selective laryngeal reinnervation in patients with bilateral vocal cord palsy

Objective: Bilateral selective reinnervation of the larynx aims to restore both vocal cord tone and abductor movements in patients with bilateral vocal cord palsy. Methods: Four females and one male treated by bilateral selective reinnervation of the larynx were included in the present study. In all cases, both posterior cricoarytenoid muscles were reinnervated using the C3 right phrenic nerve root through the great auricular nerve graft, while adductor muscle tone was bilaterally restored using the thyrohyoid branches of the hypoglossal nerve through transverse cervical nerve grafts. Results: After a minimum follow-up of 48 months, all patients were successfully tracheostomy free and had recovered normal swallowing. At laryngoscopy, the first patient recovered a left unilateral partial abductor movement, the second had complete bilateral abductor movements, the third did not show improvements of abductor movements, but symptomatology was improved, the fourth recovered partial bilateral abductor movements and the fifth case did not show improvements and needed posterior cordotomy. Conclusions: Bilateral selective laryngeal reinnervation, although a complex surgical procedure, offers a more physiologic recovery in the treatment of bilateral vocal fold paralysis. Selection criteria still needs to be precisely defined to avoid unexpected failures

Segmental Mandibulectomy and Mandibular Reconstruction with Fibula-Free Flap Using a 3D Template

Introduction: The present study evaluates the influence of virtual surgical planning with a preoperative 3D resin model on aesthetic and functional outcomes in patients treated by segmental mandibulectomy and reconstruction with fibula-free flap for oral cancer. Methods: All consecutive patients who underwent segmental mandibulectomy and mandibular reconstruction with a fibula-free flap using a 3D template at our department from January 2021 to January 2023 were included in the study. "Patients control" were patients treated by reconstruction with a fibula-free flap without using a 3D template. Three-dimensional modeling was performed by converting from preoperative computed tomography to a stereolithography format to obtain the resin 3D models. Qualitative analysis of anatomical and aesthetic results consisted of the evaluation of the patients' aesthetic and functional satisfaction and the symmetry of the mandibular contour observed at clinical examination. Quantitative analysis was based on the assessment of the accuracy and precision of the reconstruction by comparing preoperative and postoperative computed tomograms as objective indicators. Results: Seven patients (five males and two females, mean age of 65.1 years) were included in the study. All patients showed a symmetric mandibular contour based on the clinical examination. After recovery, six patients (85.7%) considered themselves aesthetically satisfied. The quantitative analysis (assessed in six/seven patients) showed that the mean difference between preoperative and postoperative intercondylar distance, intergonial angle distance, anteroposterior dimension, and gonial angle improved in the 3D template-assisted group. Conclusion: The 3D-printed template for mandibular reconstruction with microvascular fibula-free flap can improve aesthetic outcomes in comparison with standard approaches

Idiopathic sudden sensorineural hearing loss: effectiveness of salvage treatment with intratympanic dexamethasone or hyperbaric oxygen therapy in addition to systemic steroids

BackgroundThe development of standardized treatments for idiopathic sudden sensorineural hearing loss (ISSNHL) is hampered by uncertainty over the etiology of this disorder. Systemic steroids are historically the primary therapy, with variable hearing outcomes. Over the last two decades, intratympanic steroids (ITS) and hyperbaric oxygen therapy (HBOT) have been proposed as salvage treatments in case of failure of systemic steroids. The present study aims to evaluate the effectiveness of these salvage treatments in addition to systemic steroids.MethodsWe performed a retrospective study on 75 consecutive patients with a diagnosis of ISSNHL who were admitted to the Department of Otorhinolaryngology of our hospital between December 2018 and December 2022. All patients received primary treatment with systemic steroids. In case of slight or no hearing recovery within the 5th day from the beginning of the therapy (T1), a salvage treatment with ITS or HBOT was proposed. Patients were divided into three groups according to the therapy received: systemic steroids (group A), systemic steroids + HBOT (group B), and systemic steroids + ITS (group C). Pure-tone average at 500, 1000, 2000, and 3000 Hz and the mean gain were evaluated at T1 and 3 months after the beginning of the salvage treatment (T2). The hearing recovery was assessed according to the Siegel's criteria.ResultsSixty-two patients (31 men and 31 women, mean age 56 years) with failure of the primary treatment were definitively enrolled in the study: 34 (54.8%) in group A, 16 (25.8%) in group B, and 12 (19.4%) in group C. The ratio of patients responding to therapy was higher in group A (29.4%) than in groups B (18.75%) and C (16.7%). We did not find any statistically significant difference between groups in terms of mean hearing gain at T2 (17.4 ± 15.4 dB in group A vs. 18.6 ± 21.1 dB in group B and 15.7 ± 14.2 dB in group C, p = 0.9).ConclusionIn our experience, ITS or HBOT associated with systemic steroids, as salvage treatment, did not show significant improvement in hearing outcomes. The evolution of ISSNHL, regardless of the treatment, remains unpredictable

Survival in Patients with Primary Parotid Gland Carcinoma after Surgery—Results of a Single-Centre Study

This study aims to analyse a single-centre cohort series of patients who underwent parotidectomy for primary malignant parotid tumours. A retrospective chart review of 64 consecutive patients treated from November 2010 to March 2022 was performed. Outcomes were analysed by Kaplan-Meier curves. Sixty-four patients with a primary parotid malignancy were included in the study, with one bilateral case in this cohort. Patients were classified as stage I–II in 39 cases and stage III–IV in 26 cases. The five-year overall survival (OS), disease-specific survival (DSS), local relapse-free survival (LRFS), and distant metastasis-free survival (DMFS) rates were 78.4%, 89%, 92.5%, and 87.1%, respectively. Univariate analysis showed that high-risk histology, stage IV disease, lymphovascular invasion, perineural invasion, node metastasis, skin involvement, facial nerve involvement, and positive or close margins were risk factors associated with poorer outcomes. At present, the best evidence suggests that radical surgery should be the standard approach, and adjuvant therapy, in terms of radiotherapy/chemoradiotherapy, is recommended in patients with risk factors

How future surgery will benefit from SARS-COV-2-related measures: a SPIGC survey conveying the perspective of Italian surgeons

COVID-19 negatively affected surgical activity, but the potential benefits resulting from adopted measures remain unclear. The aim of this study was to evaluate the change in surgical activity and potential benefit from COVID-19 measures in perspective of Italian surgeons on behalf of SPIGC. A nationwide online survey on surgical practice before, during, and after COVID-19 pandemic was conducted in March-April 2022 (NCT:05323851). Effects of COVID-19 hospital-related measures on surgical patients' management and personal professional development across surgical specialties were explored. Data on demographics, pre-operative/peri-operative/post-operative management, and professional development were collected. Outcomes were matched with the corresponding volume. Four hundred and seventy-three respondents were included in final analysis across 14 surgical specialties. Since SARS-CoV-2 pandemic, application of telematic consultations (4.1% vs. 21.6%; p < 0.0001) and diagnostic evaluations (16.4% vs. 42.2%; p < 0.0001) increased. Elective surgical activities significantly reduced and surgeons opted more frequently for conservative management with a possible indication for elective (26.3% vs. 35.7%; p < 0.0001) or urgent (20.4% vs. 38.5%; p < 0.0001) surgery. All new COVID-related measures are perceived to be maintained in the future. Surgeons' personal education online increased from 12.6% (pre-COVID) to 86.6% (post-COVID; p < 0.0001). Online educational activities are considered a beneficial effect from COVID pandemic (56.4%). COVID-19 had a great impact on surgical specialties, with significant reduction of operation volume. However, some forced changes turned out to be benefits. Isolation measures pushed the use of telemedicine and telemetric devices for outpatient practice and favored communication for educational purposes and surgeon-patient/family communication. From the Italian surgeons' perspective, COVID-related measures will continue to influence future surgical clinical practice

Shrinkage of specimens after CO2 laser cordectomy: an objective intraoperative evaluation

The margin status after CO2 laser cordectomy for glottic carcinoma may influence prognosis. There are no studies assessing the possible bias due to anatomic changes of the specimens for shrinkage. The authors evaluated the intraoperative shrinkage of specimens immediately after transoral CO2 laser microsurgery (CO2 TOLMS) to improve the understanding and the interpretation of surgical margins

Intraoperative recurrent laryngeal nerve monitoring in unconventional thyroid surgery

Abstract The most common surgical risk after total thyroidectomy remains the recurrent laryngeal nerve (RLN) injury. Nowadays, the use of intraoperative nerve monitoring systems (IONM) such as the endotracheal tube‐based is recommended to prevent RLN palsy. The use of the nerve monitoring is standardized by dedicated guidelines on the basis of a normal laryngeal anatomy, but previous head and neck surgical procedures may complicate its application. The authors herewith present a case of a non‐conventional use of endotracheal tube‐based IONM in a 72‐year‐old patient who underwent to a second‐stage total thyroidectomy for metastatic papillary cancer incidentally detected after an open partial horizontal laryngectomy (OPHL) extended to one arytenoid (Type IIa + ary left) for squamous cell carcinoma. The use of the endotracheal tube‐based IONM in such particular case where the function of the only remaining arytenoid had to be absolutely preserved was effective in avoiding the RLN accidental injury. The authors reviewed the non‐traditional use of IONM and described the procedure in case of thyroidectomy in patients previously treated by OPHL

Concomitant bilateral vocal cord cysts in a 12-year-old patient treated by one-stage mini-microflap CO2 laser microsurgery: case report and review of the literature

Introduction: Dysphonia in the pediatric population has effects on school, family and social activity. Among the benign pathologies causing dysphonia in children, concomitant bilateral vocal cord cysts are quite uncommon. Vocal cord cysts can be congenital or acquired. The diagnosis is not always straight, but when defned the only treatment is surgery. Objective: The authors reported a pediatric case of chronic dysphonia due to bilateral vocal cord retention cysts and discuss the etiopathogenetic hypothesis and surgical treatment with the CO2 laser mini-microfap technique. A review of the literature was also performed. Case report: A 12-year-old patient was admitted at the Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Italy for chronic dysphonia lasting from one year: Grade Roughness Breathiness Asthenia Strain scale was 3 in every specifc area, and Pediatric Voice Handicap Index score was 48. Laryngoscopy showed a bilateral vocal cord swelling at the middle third of both vocal cords suspect for cystic lesions. The patient underwent microlaryngoscopy under general anesthetic and CO2 laser microsurgical excision with the mini-microfap technique. The procedure was performed with the aid of an UltraPulse® Duo (Lumenis®, Tel Aviv, Israel) CO2 laser (10 W, CW, UP, AB 2 mm and 1 mm) with an AcuBlade™ focusing system by Lumenis® (Tel Aviv, Israel). Histology confrmed the diagnosis of bilateral vocal fold epidermoid cyst. One month after surgery, indirect laryngoscopy showed complete healing of both vocal cords with an adequate vibratory pattern. Dysphonia recovered completely. Conclusion: CO2 laser microsurgery can be safely and effectively performed even in the pediatric population

Perforator-based chimeric anterolateral thigh flap U-shaped insetting for total pharyngoesophageal reconstruction: Surgical technique and functional outcomes

Pharyngoesophageal reconstruction with the tubed anterolateral thigh (ALT) flap is burdened by possible strictures and pharyngocutaneous fistulae (PCF). We present our experience with the U-shaped insetting of perforator-based chimeric ALT flap focusing on surgical technique, complications and functional outcomes