Exclusive surgical treatment for vestibular schwannoma regrowth or recurrence: A meta-analysis of the literature

Vestibular schwannomas can be treated in different ways, but for symptomatic or growing tumors, the gold standard is surgical removal of the lesion. In order to preserve neurovascular structures, partial removal is often performed, leaving a residual that may grow in subsequent years. To date, there is no consensus with regard to surgical treatment of vestibular schwannoma residuals, and so this review focuses on this topic. A structured search was performed on PubMed searching for all articles discussing vestibular schwannoma residuals and recurrences. Only articles discussing surgical treatment were included, focusing on studies which also examined facial nerve outcomes. A total of 51 articles were eligible for review and these included 375 patients. Statistical analysis was performed by correlating the following parameters: patients' gender and age at first surgery, surgical approach adopted at first and subsequent surgeries, tumor and residual size, and extent of resection (gross total, near total, subtotal or others) at first and subsequent surgical procedures. Facial nerve function was also analyzed focusing on its performance when correlated with the different surgical approaches. The data were analyzed by linear regression but there were no correlations between any of the parameters chosen. There was a statistically significant difference between the first approach used (mainly the retrosigmoid route) compared with subsequent approaches (mainly the translabyrinthine route). In total, 8.5 % of patients needed further treatment due to residual regrowth. Facial nerve outcome was independent of the parameters chosen. Exclusive surgical treatment for vestibular schwannoma residuals had a very low failure rate in terms of requiring further treatment. The approach usually chosen for second surgery was the translabyrinthine technique, and this may be explained by the location of the residual, rather than its size. The choice of a particular surgical approach rather than another had no influence on facial nerve function. Complications rates are comparable to Gamma Knife Radiosurgery's as reported in the literature

Role of endoscopy in lateral skull base approaches to the petrous apex

Objective: The aim of this article is to study the role and advantages of combined microscopic/endoscopic procedures or exclusive endoscopic approaches in the treatment of petrous apex pathologies. Methods: The study was designed as a retrospective case series analysis. We included patients affected by pathologies of the petrous apex, who underwent microscopic/endoscopic-assisted or exclusive endoscopic procedures. Patient and pathology characteristics and surgical data (focusing on the involvement of the internal carotid artery (ICA) and facial nerve by the disease) were collected. Residual disease, detected through the endoscopic check, and the feasibility of endoscopic residual tumor removal were also evaluated. Finally, facial nerve and hearing functions were assessed pre- and postoperatively. Results: The records of 75 patients undergoing lateral skull base surgery for petrous apex lesions, from May 2009 to March 2019, were collected. In 17 out of 75 patients, an exclusive endoscopic procedure was possible. The remaining 58 patients underwent a combined microscopic/endoscopic approach. In 15 cases, residual disease was found and removed endoscopically at the end of the microscopic procedure; in eight cases, the residual disease was medial and/or inferior to the horizontal segment of the ICA, while in two cases, it was located in the fundus of the internal auditory canal. In five cases, it involved the labyrinthine segment of the facial nerve. Conclusion: Petrous apex surgery remains a traditional microscopic-based surgery, but the recent advent of endoscopic surgery has permitted an improvement in radicality minimizing the manipulation of neurovascular structures

Is endoscopic inspection necessary to detect residual disease in acoustic neuroma surgery?

Main goals: To analyze how and when the endoscope is used in vestibular schwannoma surgery and identify the benefits of using endoscopy in this type of surgery. Background: It is currently unclear if there is any benefit from using an endoscope in vestibular schwannoma surgery so this retrospective analysis set out to study this. Methods: All the patients who underwent vestibular schwannoma surgery at our clinic were included for all the vestibular schwannoma approaches taken. We studied when endoscopy was used during surgery and the goal of using endoscopy. Several pre- and postoperative factors were assessed such as complications, facial function, and hearing function in the case of techniques that allow hearing preservation. Results: From January 2015 to September 2018, 280 patients underwent lateral skull base surgery. Of these, 112 were included in this study. The endoscope was used in all 112 patients, and in eight cases it was possible to identify residual disease using the endoscope to check the surgical field, and then to remove the disease under endoscopic view. Moreover, in two other cases, the endoscope was used to resolve a vasculoneural conflict between the anterior inferior cerebellar artery (AICA) loop and facial nerve in one case, and for deafferentation of the superior and inferior vestibular nerves in the second case. No major intraoperative complications occurred in our series. There was no statistically significant difference in postoperative facial nerve function between patients in whom the endoscope was used as a diagnostic tool and patients in whom it was used as an operative tool (p = 0.3152). Conclusions: The endoscope may be useful, especially in surgical techniques where there is poor control of the internal auditory canal (IAC). An endoscopic support technique is strongly recommended to avoid residual disease, particularly in retrosigmoid and retrolabyrinthine approaches. Moreover, the recent introduction of the transcanal transpromontorial approach allows the endoscope to be used during all the procedures in patients affected by a vestibular schwannoma limited to the IAC or to support surgical procedures during an enlarged microscopic approach

Endoscopic stapedotomy: safety and audiological results in 150 patients

Objective: The most widely accepted treatment for otosclerosis is currently microscopic stapes surgery under either local or general anesthesia. The aim of the study is to describe the surgical steps in endoscopic stapes surgery and to evaluate the audiologic and surgical outcomes. Materials and methods: All patients who underwent exclusive endoscopic stapes surgery or revision surgery for previous stapedotomy between November 2014 and September 2018 were enrolled in this study. Demographic data, surgical information, preoperative and postoperative pure tone averages and air bone gaps, intraoperative and postoperative complications and follow-up data were summarized and gathered in a database for further consideration and analysis. Results: In the period examined, 181 stapes surgical procedures were performed and out of these 150 met the inclusion criteria. There were no cases of major intraoperative complications. Sensorineural hearing loss was observed in one case. In one patient a gusher effect occurred during surgery. The postoperative air-bone gap improved significantly compared to the preoperative gap (8 vs 29 dB HL, respectively), and the mean air-bone gap closure was 20 dB HL. In 78.7% of cases, the observed postoperative air-bone gap was less than 10 dB HL and in 14% it was between 11 dB HL and 20 dB HL. An ABG closure lower than 20 dB HL was achieved in a total of 92.7% of patients. Conclusions: Endoscopic stapes surgery is a safe procedure with a low risk of peri- or postoperative complications and is a possible alternative to the traditional microscopic surgical procedure in the treatment of otosclerosis

Complications in endoscopic ear surgery

Objective: The aim of this study was to examine the premise that endoscopic ear surgery (EES) is associated with a low rate of complications (intraoperative and postoperative). Study design: Retrospective review at two institutions. Setting: Tertiary referral center. Patients: The study included 825 patients who underwent exclusive EES between 2008 and 2016 at the Otorhinolaryngology-Head and Neck Surgery Department of Modena University Hospital, and between 2014 and 2016 at the Otorhinolaryngology-Head and Neck Surgery Department of Verona University Hospital. Interventions: Exclusive endoscopic ear surgery between 2008 and 2016 (tympanoplasties, second look or revision tympanoplasties, myringoplasties, stapedoplasties, canalplasties, ossiculoplasties, and exploratory tympanotomies). All surgical procedures were performed by two experienced surgeons. Main outcome measure: For each procedure, intraoperative, and early and delayed postoperative complications were evaluated. Results: The most common ear pathologies for which patients were sent for EES were cholesteatoma (33.6%), chronic otitis media (36.3%) and otosclerosis (26.8%). There was no case of major intraoperative complications such as injury to the dura or vascular structures. We observed minor intraoperative complications in 4.1% of the cases. Only 1.3% of patients experienced early postoperative complications. Delayed complications affected less than 1% of the cohort. Conclusions: Data from this study confirm the safety of the endoscopic technique, with very low complication rates, indicating that EES is a reliable therapeutic option, in particular, for tympanoplasties, myringoplasties, and stapedoplasties, as well as second look procedures. We have reported our experience with EES morbidity so that it can be compared with data from other centers using the same surgical technique

Leiomyosarcoma of the Larynx: A Complex Diagnosis

An 84-year-old man was referred to our institution for dysphonia present for 2 months. Fiberoptic laryngoscopy demonstrated a polypoid lesion of the right true vocal fold with normal motility. Excisional biopsy of a submucosal thickening of the right vocal fold with vocal ligament calcification was performed. Histology revealed squamous cell epithelium without malignancy. Postoperative endoscopic follow-up was regular. Six months after surgery, dysphonia and dyspnea occurred. Flexible laryngoscopy demonstrated right hemilaryngeal paralysis, edema, and partial airway obstruction. Necrotic tissue and purulent secretions were visible at the anterior commissure, right vocal fold, and ipsilateral vestibule. A second microlaryngoscopic surgery included multiple biopsies and debridement of the necrotic tissue. Histological report was negative for malignancy, and purulent chondritis was diagnosed. Intravenous antibiotic therapy was administered with improvement of infection, inflammation, dysphonia, and dyspnea. The patient was discharged

Studi confraternali: orientamenti, problemi, testimonianze

Il volume raccoglie interventi di studiosi italiani e stranieri miranti a offrire una panoramica di percorsi storiografici e di problematiche relativi alla storia del movimento confraternale, così come sono emersi nell'ambito di discipline storiche, sociali, giuridiche, letterarie e artistiche sviluppatesi nel corso del Novecento. I contributi si riferiscono al contesto storico dell'Europa occidentale, con più specifico riguardo per l'Italia, nel periodo compreso fra medioevo e prima età moderna. La raccolta si articola in quattro sezioni: Individui e gruppi, che sonda l'emergere di un interesse verso le comunità confraternali all'interno di ambiti di studio come la storia dei gruppi sociali, del mondo rurale, delle donne, dei giovani; L'inquadramento giuridico e istituzionale, che affronta problemi di legittimità e di assetto istituzionale; L'economia della carità, che analizza il rapporto delle confraternite con gli enti ospedalieri, le modalità amministrative dei patrimoni confraternali, le culture di governo che sottostanno a politiche assistenziali di cui le confraternite sono tramite principale; Testimonianze teatrali, musicali, artistiche, documentarie dedicata alle fonti che le confraternite hanno saputo trasmettere

The Future of International Investment Regulation: Towards a World Investment Organisation?

With growth in foreign investment and in the number of companies investing in foreign countries, the application of general principles of public international law has not been deemed adequate to regulate foreign investment and there is, as yet, no comprehensive international treaty on the regulation of foreign investment. Consequently, states have resorted to bilateral investment treaties (BITs), regional trade and international investment agreements (IIAs) and free trade agreements (FTAs) to supplement and complement the regime of protection for foreign investors. In the absence of an international investment court, states hosting foreign investment or investor states have opted for investor-state dispute settlement mechanism (ISDS). This mechanism has brought about its own challenges to the international law of foreign investment due to inconsistency in the application and interpretation of the key principles of international investment law by such arbitration tribunals, and further, there is no appellate mechanism to bring about some cohesion and consistency in jurisprudence. Therefore, there are various proposals mooted by scholars to address these challenges and they range from tweaks to BITs and IIAs, the creation of an appellate mechanism and the negotiation of a multilateral treaty to proposals for reform of ISDS only. After assessing the merits and demerits of such proposals, this study goes further, arguing for the creation of a World Investment Organisation (WIO) with a standing mechanism for settlement of investment disputes in order to ensure legal certainty, predictability and the promotion of the flow of foreign investment in a sustainable and responsible manner