Impact of SARS-CoV-2 infection in patients with hereditary hemorrhagic telangiectasia: epidemiological and clinical data from the comprehensive Italian retrospective multicenter study

Rare Disease patients manifested high concern regarding the possible increased risk of severe outcomes and worsening of disease-specific clinical manifestation due to the impact of COVID-19. Our aim was to assess the prevalence, outcomes, and impact of COVID-19 in patients with a rare disease such as Hereditary Hemorrhagic Telangiectasia (HHT) in Italian population. A nationwide, multicentric, cross-sectional observational study was conducted on patients with HHT from five Italian HHT centers by online survey. The association between COVID-19-related signs and symptoms and nosebleeds worsening, the impact of personal protective equipment on nosebleeds pattern, and the relationship between the presence of visceral AVMs and severe outcomes were analyzed. Out of 605 total survey responses and eligible for analysis, 107 cases of COVID-19 were reported. A mild-course COVID-19 disease, not requiring hospitalization, was observed in 90.7% of patients, while the remaining eight cases needed hospitalization, two of them requiring intensive-care access. No fatal outcome was recorded and 79.3% of patients reported a complete recovery. No difference in infection risk and outcome between HHT patients and general population was evidenced. No significative interference of COVID-19 on HHT-related bleeding was found. The majority of patients received COVID-19 vaccination, with relevant impact on symptoms and need for hospitalization in case of infection. COVID-19 in HHT patients had an infection profile similar to the general population. COVID-19 course and outcome were independent from any specific HHT-related clinical features. Moreover, COVID-19 and anti-SARS-CoV-2 measures did not seem to affect significantly HHT-related bleeding profile.

Silicone septal splint for recurrent epistaxis in HHT patients: experience of a national referral centre

Objective

To report our experience in the use of silicone septal splint for recurrent severe epistaxis in hereditary haemorrhagic telangiectasia patients (HHT).

Methods

This is a descriptive analysis carried out at the Otorhinolaryngology Department of Fondazione IRCCS Policlinico San Matteo in Pavia, a reference centre for the treatment and diagnosis of HHT. We retrospectively evaluated HHT patients who underwent silicone septal splint positioning after the endoscopic surgical treatment of epistaxis from 2000 to 2022.

Results

Of the 506 patients surgically treated in the period of analysis, 74 patients underwent silicone septal splint positioning and 37 were post-operatively interviewed. With a mean of 2.4 previous surgical treatments and a mean epistaxis severity of 7.38, the majority of patients presented with septal perforation (71.6%). On average, patients maintained the splint in place for 54.5 months, with a good tolerability and a significant reduction in epistaxis severity, need for blood transfusion and improvement of haemoglobin levels.

Conclusions

In HHT patients with recurrent severe epistaxis and with septal perforation, the placement of septal splints offers a useful additional strategy in the management of nosebleeds.

Hereditary hemorrhagic telangiectasia: First demonstration of a founder effect in Italy; the ACVRL1 c.289_294del variant originated in the country of Bergamo 200 years ago

Background

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular disorder, affecting 1:5000 individuals worldwide. All the genes associated to the disease (ENG, ACVRL1, SMAD4, GDF2) belong to the TGF‐β/BMPs signaling pathway.

We found 19 HHT unrelated families, coming from a Northern Italy region and sharing the ACVRL1 in‐frame deletion c.289_294del (p.H97_N98).

Methods

To test the hypothesis of a founder effect, we analyzed 88 subjects from 19 families (66 variant carriers, showing clinical signs of HHT, and 22 non‐carriers, unaffected) using eight microsatellite markers within 3.7 Mb around the ACVRL1 locus. After the haplotype reconstruction, age estimation of the variant was carried out.

Results

We observed a common disease haplotype in 16/19 families, while three families showed evidence of recombination around the ACVRL1 locus. The subsequent age estimation analyses suggested that the mutation occurred about 8 generations ago, corresponding to about 200 years ago. We also present novel in silico and modeling data supporting the variant pathogenicity: the deletion alters the protein stability and removes the unique extracellular glycosylation site.

Conclusion

We have demonstrated, for the first time, a “founder effect” for a HHT pathogenic variant in Italy.

Epidemiological, clinical and endoscopic features of epistaxis severity and quality of life in Hereditary haemorrhagic telangiectasia: a cross-sectional study

BACKGROUND

Epistaxis is the main complaint in patients with Hereditary haemorrhagic telangiectasia (HHT). Even though the role of epistaxis in affecting the quality of life (QoL) is well-known, little is known about epidemiological and clinical factors contributing to epistaxis severity and QoL.

METHODOLOGY

This is a cross-sectional study, including adult patients with HHT with epistaxis. All patients underwent an otolaryngological evaluation with nasal endoscopy. Epistaxis severity was graded using the FID score, and QoL was evaluated with the Short-Form Health Survey (SF-36). Descriptive statistics were produced for demographic characteristics; the Shapiro-Wilk test was used to test the normal distribution of quantitative variables. Correlation between the quantitative variables was evaluated with Pearson's correlation coefficient. Both univariate and multivariate linear regression models were fitted to find associations between demographic or clinical factors and the FID score or SF-36.

RESULTS

A total of 234 patients with HHT were included in the study. The univariate analysis highlighted the association between high blood pressure, septal perforation, nocturnal epistaxis, surgery, blood transfusion, hormonal therapy and both FID score and QoL. Sex, allergic rhinitis and nasal polyposis were neither related to epistaxis severity nor perceived health.

CONCLUSIONS

Epistaxis severity and QoL in patients with HHT are influenced by several clinical factors both dependent and independent from HHT. Some of the results are consistent with those already published, but for the first time, we extended the analysis to different clinical parameters, such as endoscopic findings, never assessed before.

Nasal Endoscopy in the Clinical Diagnosis of Hereditary Hemorrhagic Telangiectasia

OBJECTIVES

To evaluate the role of nasal endoscopy for early clinical diagnosis of hereditary hemorrhagic telangiectasia (HHT) in children and to investigate the characteristics of epistaxis and mucocutaneous telangiectases in our pediatric population.

STUDY DESIGN

From May 2016 to December 2019, a cross-sectional observational study was conducted, recruiting children aged 2-18 years with a parent affected by HHT. To identify the Curaçao criteria, all children underwent collection of clinical history, mucocutaneous examination, and nasal endoscopy. The clinical data were then compared with the genetic data acquired subsequently.

RESULTS

Seventy children (median age, 10.8 years) were included. All underwent nasal endoscopy without complications. Forty-six children were positive by genetic testing; of these, 26 % had skin and oral telangiectases and 91 % had nasal telangiectases. The diagnostic sensitivity of the Curaçao criteria increased from 28 % (95 % CI, 16%-43 %) to 85 % (95 % CI, 71%-94 %; P < .0001) when the nasal telangiectases were included.

CONCLUSIONS

The magnified and complete endoscopic view of the nasal cavities proved useful in increasing the diagnostic sensitivity of the Curaçao criteria. Such an examination turned out to be feasible and safe. For this reason, we believe that nasal endoscopy should be included in the diagnostic assessment of pediatric patients with suspected HHT.

Characterization of epidemiological distribution and outcome of COVID-19 in patients with hereditary hemorrhagic telangiectasia: a nationwide retrospective multi-centre study during first wave in Italy

Background

Coronavirus Disease 2019 (COVID-19) continues to have a devastating impact across the world. A number of pre-existing common clinical conditions were reported to represent risk factors for more severe COVID-19 outcomes. Hereditary Hemorrhagic Telangiectasia (HHT) is a rare vascular heritable disorders, characterized by complications secondary to visceral Arterio-Venous Malformations. The impact of HHT, as well as for many Rare Diseases (RDs) on infection susceptibility profile and clinical adverse outcome risk is an unresolved issue.

Objectives

The main objectives were: to assess the clinical features and outcomes of HHT patients infected with COVID-19; to compare the relative infection risk in these patients with the Italian general population throughout the first pandemic wave; to investigate the factors potentially associated with severe COVID-19 outcome in HHT patients, and the possible impact of COVID-19 infection on HHT-related symptoms/complications. Finally, we aimed to estimate how the lockdown-associated wearing of personal protective equipment/individual protection devices could affect HHT-related telangiectasia bleeding frequency.

Methods

The study is a nation-wide questionnaire-based survey, with a multi-Center retrospective cross-sectional design, addressed to the whole Italian HHT population. COVID-19 cases, occurring throughout the first pandemic wave, were collected by a questionnaire-based semi-structured interview. Only the cases ascertained by laboratory confirmation (molecular/serological) were included for epidemiological estimates. Information concerning eventual SarS-Cov-2 infection, as well as regarding HHT-related manifestations and HHT-unrelated co-morbidities were collected by the questionnaire. Prevalence data were compared to Italian general population in the same period.

Results

The survey disclosed 9/296 (3.04%) COVID-19 cases, 8/9 of them being resident in Lombardy, the main epidemic epicenter. Pneumonia was reported by 4/9 patients, which prompted hospital admission and intensive care management in 2 cases. No fatal outcome was recorded. After careful refinement of epidemiological analysis, the survey evidenced overlapping infection risk in HHT compared to general population.

Conclusions

COVID-19 infection profile parallels geographical distribution of epidemic foci. COVID-19 in HHT patients can lead to highly variable clinical profile, likely overlapping with that of general population. The HHT disease does not seem to involve a different approach in terms of hospital admission and access to intensive care with respect to general population.

Clivus pathologies from diagnosis to surgical multidisciplinary treatment. Review of the literature

The Clivus is a bone that lies in a central position of the skull base, and it is a crucial point that splits and connects different anatomical compartments at the same time. There is significant variability of diseases involving the clivus, from neoplasms to non-neoplastic, inflammatory or traumatic lesions. Each of these is rare in frequency, and this heterogeneity contributes to yield the management even more challenging. Clival pathologies can be asymptomatic or have manifestations ranging from aspecific headache to cranial nerves palsies, till life-threatening complications as cerebrospinal fluid rhinorrhoea, meningitis or brain abscess. There isn’t an univocal endorsement among experts with regard to the best approaches to manage the clivus. The paths described are many, the main division is between the transclival and transcranial lateral approaches. We performed a review of the literature, thus highlighting how authors seem to suggest that the surgical approach shouldn’t be chosen aprioristically, but based on a patient centred analysis, considering the combination of multiple surgical corridors. From diagnosis to surgery and medical therapy, clival pathologies require a team of multidisciplinary experts to ensure the best standard of treatment and higher survival rate.

Endoscopic surgical treatment of epistaxis in hereditary haemorrhagic telangiectasia: our experience

Objectives

Hereditary haemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease characterised by epistaxis. Surgical procedures for epistaxis vary from diathermocoagulation to nasal closure. The aim of this paper is to report our experience in endoscopic surgical management of epistaxis in HHT patients.

Methods

This is a descriptive, longitudinal study carried out at the Otorhinolaryngology Department of IRCCS Policlinico San Matteo in Pavia, a reference centre for the treatment and diagnosis of HHT. We retrospectively evaluated HHT patients who underwent surgery for epistaxis from 1996 to 2015, including only those treated with endoscopic surgery.

Results

Among the 591 patients hospitalised and screened for HHT, 323 (54.7%) underwent endoscopic surgery for epistaxis, for a total of 679 procedures. General anaesthesia was used in 77.2% of procedures; argon plasma coagulation was the instrument of choice in the majority of patients, followed by lasers and quantum molecular resonance technology.

Conclusions

We report one of the largest cohorts undergoing endoscopic treatment of epistaxis in HHT patients. This mini-invasive surgical treatment allowed us to control epistaxis without major complications and nasal packaging and can be repeated over time. For these reasons, we recommend it as first choice in case of epistaxis in HHT patients.

An alternative way to perform diagnostic nasopharyngeal swab for SARS-CoV-2 infection

On March 11, 2020, WHO has defined the novel coronavirus disease SARS-CoV-2 (COVID-19) outbreak as a pandemic and still today continues to affect much of the world. Among the reasons for the rapid spread of SARS–CoV-2 infection, there is not only the high transmissibility of the virus, but also the role of asymptomatic or minimally symptomatic carriers. Therefore diagnostic testing is central to contain the global pandemic. Up to now real-time reverse transcriptase polymerase chain reaction (RT-PCR)–based molecular assays for detecting SARSCoV-2 in respiratory specimens is the current reference standard for COVID-19 diagnosis. Nasopharyngeal swab is the preferred choice for SARS–CoV-2 testing; however is not always a free of complications procedure. In patients with severe coagulopathies or diseases such as HHT, the risk of nosebleeding may be high. As in all those conditions like advanced stage sinonasal neoplasms or unfavorable anatomical characteristics, the nasopharyngeal swab may not be feasible.

This work reports a safe and effective procedure of nasopharyngeal swab collection for COVID-19 testing, through the transoral way, in patients with contraindication to perform it transnasally.

The procedure proved feasible and well tolerated. The discomfort for the patient is comparable with the execution of an oropharyngeal swab without exposing him to additional complications.

In selected cases, the procedure described represents a valid alternative to nasopharyngeal swab performed transnasally. In particular, it allows reaching the area with the highest diagnostic sensitivity. Moreover it can be performed by Otolaryngology and, with adequate training, also by non-specialist staff.

Adenoidectomy: Anatomical variables as predictive factors of intraoperative adenoid residues

OBJECTIVES

Adenoid hypertrophy is a common cause of upper airway obstruction in children. However, after adenoidectomy, nasal obstructive symptoms may persist or recur, requiring surgical revision. The aim of this study is to evaluate if individual patient features can influence the efficacy of the traditional technique.

METHODS

A retrospective observational study was conducted by recruiting patients from candidates for adenoidectomy. All children underwent conventional transoral curettage adenoidectomy with endoscopic control at the end of procedure, and in presence of adenoid residues, a concomitant revision adenoidectomy was performed. For each patient, the following data were collected: age, sex, weight, height, length of the soft palate and surgical technique used.

RESULTS

In 18% of patients (113/612), the most critical areas of the nasopharynx were not reached by standard surgery, making a complete adenoidectomy difficult. In this group, the average length of the soft palate was 3.1 cm, 5 mm more than the average of the sample, and 6 mm more than the average length of patients undergoing standard surgery alone (p < 0.001).

CONCLUSION

Our study confirms the hypothesis that a greater length of the soft palate conditions the results of the intervention. The length of the soft palate can be considered an intraoperative criterion to select the cases in which perform endoscopic control after the standard procedure.

Diagnostic testing for SARS-CoV-2 infection in HHT patients: nasopharyngeal versus oropharyngeal swab

On March 11, 2020, WHO has defined the novel coronavirus disease SARS-CoV-2 (COVID-19) outbreak as a pandemic that still today continues to affect much of the world. Among the reasons for the rapid spread of SARS-CoV-2 infection, there is the role of asymptomatic or minimally symptomatic carriers. Therefore diagnostic testing is central to contain the global pandemic. Up to now real-time reverse transcriptase polymerase chain reaction-based molecular assays for detecting SARS-CoV-2 in respiratory specimens is the current reference standard for COVID-19 diagnosis. Based on current knowledge regarding the sensitivity of the molecular test, the highest positive detection rate is from lower respiratory tract specimens; alternatively it is possible to perform a nasopharyngeal or oropharyngeal swab. Nasopharyngeal swab is the preferred choice for SARS-CoV-2 testing since it seems to have a greater sensitivity; however the procedure is not always free of complications and an epistaxis can occur. Among patients with greatest risk of massive nosebleed there are HHT patients. Hereditary hemorrhagic telangiectasia is an autosomal dominant disease that leads to multiregional mucocutanous telangiectases and visceral arteriovenous malformations. Clinically, the presence of telangiectases in nasal mucosa is the cause of recurrent epistaxis. In HHT patients the execution of the nasopharyngeal swab can determine from little or no consequences to a massive epistaxis leading to the necessity of nasal packing generally followed by hospital admission. In HHT patients undergoing a diagnostic test to evaluate the SARS-CoV-2 infection status, especially in those patients with frequent epistaxis with a history of anemia and repeated hospitalizations, it is therefore advisable to perform an oropharyngeal swab. This, compared to the nasopharyngeal swab, exposes to a lower risk of severe nosebleeds related treatments, such as blood transfusions or invasive procedures. According to the risk-benefit assessment and based on our experience, we consider that, despite a lower diagnostic sensitivity, oropharyngeal swab is preferable to nasopharyngeal swab for the diagnosis of SARS CoV-2 infection in patients with HHT.

FID Score: an effective tool in Hereditary Haemorrhagic Telangiectasia - related epistaxis

BACKGROUND

Hereditary haemorrhagic telangiectasia (HHT) is a rare disease characterized by a multisystemic vascular dysplasia and epistaxis, that is the most common cause of disability and social impairment. Patient management strictly depends on the severity of this symptom; therefore, it is of paramount importance for the clinicians to effectively grade epistaxis severity. The aim of this report was to validate the Frequency, Intensity and Duration score (FID) for grading epistaxis severity in patients with HHT; we studied repeatability and external validity comparing FID score with Epistaxis Severity Score (ESS).

METHODS

This is a descriptive, observational study that included 264 adult HHT patients with epistaxis. Diagnosis of HHT was established with Curacao criteria or positivity at genetic testing. Nosebleed severity was evaluated according to the FID score and the ESS. The first 30 patients were included in the validation of the FID score, which was graded on days 0, 1, 3 and 7. In the remaining 234 patients, a comparison between the ESS and FID score was performed.

RESULTS

The statistical analysis performed in order to validate the FID score showed very good agreement between scores calculated on different days; analysis comparing the FID score with the ESS revealed a high correlation between the two grading systems.

CONCLUSIONS

The FID score is a quick, easy and precise tool for evaluating HHT-related epistaxis and could be a possible alternative to the ESS. The FID score meets the need for an intuitive and smart grading system that is easy to manage in clinicians’ hands.

Fluorescein-guided intraoperative endoscopy in patients with hereditary hemorrhagic telangiectasia: first impressions

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is a rare genetic disease that results in mucocutaneous telangiectasias and arteriovenous visceral malformations. Nasal telangiectasias lead to recurrent epistaxis, which affects up to 96% of patients. Different morphologic classifications and methods of visualization of nasal lesions have been described in the literature. We developed a new method of intraoperative endoscopy based on the intravenous administration of fluorescein. Preliminary data of this technique are reported.

METHODS

After the intravenous administration of sodium fluorescein, an intraoperative fluorescein-guided endoscopy was carried out using photographic customized yellow filters on top of a 0-degree, 4-mm endoscope.

RESULTS

In 2015, 65 HHT patients underwent surgery for their epistaxis in our institution, and in 7 patients (3 males, 4 females; mean age, 54 years) an intraoperative fluorescein-guided intraoperative nasal endoscopy was performed. No adverse events or complications were observed.

CONCLUSION

First impressions regarding the usage of this technique in HHT patients seem to be promising and positive in terms of efficacy and safety. However, further studies with larger cohorts of patients should be performed in order to better investigate the use of this method for diagnostic and surgical purposes in HHT.

A novel device for intraoperative cauterization of bleeding points in endoscopic sinus surgery

Hemostasis is a critical point in endoscopic sinus and skull base surgery. A variety of techniques are presently available for reducing intraoperative bleeding; however, several limitations of the classical instruments should be stated. For example, reaching bleeding points in an anatomically angled site with straightforward bipolar devices could be quite difficult. With the aim of solving this problem, we developed a simple system using a standard curved suction tube, a rubber catheter and a monopolar system. This device provides an integrated suction function and is able to reach all paranasal and skull base areas, making it extremely useful in gaining precise access to the site of bleeding while providing excellent endoscopic vision. The described monopolar suction tube has proven to be a valid instrument for intraoperative hemostasis in endoscopic procedures; moreover, it does not add any further cost, making it applicable in particular healthcare settings, such as those in developing countries.

Invasive fungal rhinosinusitis in adult patients: Our experience in diagnosis and management

BACKGROUND

This paper describes our experience in the management of acute and chronic invasive fungal rhinosinusitis (IFRS) in adults.

METHODS

Medical files of all patients aged >18 years treated in our institutions for IFRS from 2002 to 2013 were retrospectively reviewed.

RESULTS

A total of 18 cases (10 acute and 8 chronic) were recorded. In acute form, haematological malignancies represented the principal comorbidity (100%), while in chronic form this was diabetes mellitus (87.5%). All patients received systemic antifungal agents. Endoscopic sinus surgery was performed in 16/18 patients (88.9%). Among patients with an acute IFRS, 4/10 died of fungal infection (40%), on the other side 2/8 patients with chronic IFRS died of the evolution of the mycosis (25%).

CONCLUSIONS

Acute and chronic IFRS are different entities: in acute form, prognosis is poor, so therapy should be promptly performed, although host immune status and evolution of the haematological disease are key factors for the outcome. In chronic form, a wide surgical excision of the disease is recommended in order to obtain a complete removal of fungal infection. In both forms, early clinical findings are non-specific and ambiguous, so diagnosis depends on a high index of suspicion, taking into account predisposing factors.

Endoscopic Management of Spontaneous Clival Cerebrospinal Fluid Leaks: Case Series and Literature Review

OBJECTIVE

Spontaneous cerebrospinal fluid leaks are most commonly located along the anterior skull base. Sphenoidal localization is less common, and clival localization is even rarer. We analyzed a group of patients with spontaneous leaks and selected patients with clival localization. This article discusses surgical management of these entities and provides a brief literature review regarding spontaneous clival leaks.

METHODS

Of a cohort of 67 patients who presented to our departments with a spontaneous leak during the period 2005-2014, a retrospective data analysis was performed on 6 patients with clival localization of the defect. A skull base repair with a multilayered reconstruction was performed in 3 patients, and a single-layered reconstruction using a pedicled nasoseptal flap was performed in 3 patients.

RESULTS

The patients included 6 women with a mean age of 60 years (range, 36-91 years). The mean length of the follow-up period was 69.5 months (range, 22-114 months). The overall success rate of the primary endoscopic repair was 83.3% (5 of 6 patients); this increased to 100% after revision surgery.

CONCLUSIONS

This series, although numerically limited, suggests that a minimally invasive endoscopic repair of idiopathic clival leaks may be accomplished with an acceptable rate of morbidity and excellent outcomes. Moreover, the pedicled nasoseptal flap has been confirmed to be the "workhorse" for the reconstruction of clival defects.

Efficacy and safety of thalidomide for the treatment of severe recurrent epistaxis in hereditary haemorrhagic telangiectasia: results of a non-randomised, single-centre, phase 2 study

BACKGROUND

Hereditary haemorrhagic telangiectasia is a genetic disease that leads to multiregional angiodysplasia. Severe recurrent epistaxis is the most common presentation, frequently leading to severe anaemia. Several therapeutic approaches have been investigated, but they are mostly palliative and have had variable results. We aimed to assess the efficacy of thalidomide for the reduction of epistaxis in patients with hereditary haemorrhagic telangiectasia that is refractory to standard therapy.

METHODS

We recruited patients aged 17 years or older with hereditary haemorrhagic telangiectasia who had severe recurrent epistaxis refractory to minimally invasive surgical procedures into an open-label, phase 2, non-randomised, single-centre study at IRCCS Policlinico San Matteo Foundation (Pavia, Italy). We gave patients thalidomide at a starting dose of 50 mg/day orally. If they had no response, we increased the thalidomide dose by 50 mg/day increments every 4 weeks, until a response was seen, up to a maximum dose of 200 mg/day. After patients had achieved a response, they continued treatment for 8-16 additional weeks. The primary endpoint was the efficacy of thalidomide measured as the percentage of patients who had reductions of at least one grade in the frequency, intensity, or duration of epistaxis. We followed up patients each month to assess epistaxis severity score and transfusion need, and any adverse events were reported. We included all patients who received any study drug and who participated in at least one post-baseline assessment in the primary efficacy population. The safety population consisted of all patients who received any dose of study treatment. This trial is registered with ClinicalTrials.gov, number NCT01485224.

FINDINGS

Between Dec 1, 2011, and May 12, 2014, we enrolled 31 patients. Median follow-up was 15·9 months (IQR 10·1-22·3). Three (10%, 95% CI 2-26) patients had a complete response, with bleeding stopped, 28 (90%, 95% CI 74-98) patients had partial responses. Overall, all 31 (100%, 89-100) patients responded to therapy with a significant decrease in all epistaxis parameters (p<0·0001 for frequency, intensity, and duration). A response was achieved by 25 (81%) patients at 50 mg/day of thalidomide, five (16%) patients at 100 mg/day, and one (3%) patient at 150 mg/day. Patients had only non-serious, grade 1 adverse effects, the most common of which were constipation (21 patients), drowsiness (six patients), and peripheral oedema (eight patients). One patient died a month after the end of treatment, but this was not deemed to be related to treatment.

INTERPRETATION

Low-dose thalidomide seems to be safe and effective for the reduction of epistaxis in patients with hereditary haemorrhagic telangiectasia. Our findings should be validated by further studies with larger patient populations, longer follow-up, and that also assess the benefit for quality of life.

FUNDING

Telethon Foundation.

Evolution in the treatment of sinonasal inverted papilloma: pedicle-oriented endoscopic surgery

BACKGROUND

In the literature, the global endoscopic sinus surgery (ESS) success in the treatment of sinonasal inverted papilloma (IP) is 95%. This study was designed to describe a conservative endoscopic approach, based on research of the tumor's pedicle and treatment concentrated on its site of attachment, and to compare the results of this technique with the outcome of standard endoscopic treatment.

METHODS

Retrospective analysis of the patients treated in our institution for paranasal inverted papilloma (IP), between 2002 and 2011 with a minimum of 18 months follow-up was performed. Group A received a standard ESS including whole sinus demucosization (maxillary, ethmoid, frontal, or sphenoid sinus) and bony wall drilling. Group B patients instead underwent pedicle-oriented endoscopic surgery (POES); in this group, bony demucosization and drilling were selectively conducted around the site of pedicle attachment of the tumor.

RESULTS

The cohort included 73 patients (median age, 60.5 years; median follow-up, 58 months). Group A/group B consisted of 37/36 patients. IP persistence-recurrence for group A/group B was 0/1 cases. Oncological success for global endoscopic/group A/group B was 98.6% (72/73)/100% (37/37)/97.2% (35/36). We noticed a significant difference in surgical operative time and postoperative complication rate among the groups, in favor of POES technique.

CONCLUSION

Our data confirm the efficacy of the endonasal endoscopic treatment for sinonasal IP. Moreover, the even more conservative endoscopic treatment proposed (POES) seems to offer good control of the disease, shorter operating times, avoidance of unnecessary surgery with respect to uninvolved structures, and permits a follow-up aimed at the site of the pedicle attachment.

Transnasal endoscopic removal of dental implants from the maxillary sinus

PURPOSE

The penetration of dental implants into the maxillary sinus is becoming more common as a result of the use of new techniques to rehabilitate edentulous jaws. This complication requires the removal of the foreign body, even in asymptomatic patients, to prevent inflammatory disease. This article reports the authors' experience with the surgical removal of dental implants from the maxillary sinus with an endoscopic approach via middle meatotomy.

MATERIALS AND METHODS

A 10-year (2001 to 2011) retrospective analysis was performed in the authors' departments to identify all patients who underwent endoscopic removal of a dental implant from the maxillary sinus.

RESULTS

Sixteen patients (seven women and nine men, mean age 50.7 years) underwent endoscopic removal of the implant from the maxillary sinus via a middle meatotomy. Seven patients (43.8%) received general anesthesia for the surgery, and nine (56.2%) were treated with local anesthesia. No intraoperative or postoperative complications were observed. The mean follow-up period was 62 months.

CONCLUSION

In the authors' experience, endoscopic transnasal removal of dental implants from the maxillary sinus via a middle meatotomy is a successful, rapid, safe, and minimally invasive procedure.

Argon plasma coagulation is an effective treatment for hereditary hemorrhagic telangiectasia patients with severe nosebleeds

CONCLUSIONS

In contrast to the current trend according to which the treatment of hereditary hemorrhagic telangiectasia (HHT) epistaxis depends on clinical severity, argon plasma coagulation (APC) has also proven to be effective as a first-line procedure in patients with severe nosebleeds. Furthermore, with this approach patients are free from requirements for blood transfusions for a long time in the vast majority of cases.

OBJECTIVE

The aim of this study was to test the efficacy of APC treatment as a first-line procedure in HHT patients affected by severe epistaxis.

METHODS

From 1996 until 2011, 252 HHT patients were treated with APC in our clinic. We selected 26 patients with severe epistaxis for whom the need for blood transfusion had been recorded. This group of patients was asked to answer a questionnaire that aimed to evaluate the severity of epistaxis (defined by its intensity, frequency, and duration), to assess the duration of the benefit of treatment and to evaluate the number of blood transfusions required before and after treatment.

RESULTS

After APC treatment, a statistically significant decrease in all epistaxis parameters was recorded and most patients did not need blood transfusions for several years after the procedure.

Transnasal endoscopic approach to symptomatic sinonasal osteomas

BACKGROUND

One of the most challenging benign tumors for the ear, nose, and throat (ENT) surgeon is represented by sinonasal osteomas. Surgical treatment should regard just symptomatic osteomas, because these tumors can provoke rhinosinusitis and mucoceles. Recently, new instruments have been applied in endoscopic sinus surgery (ESS). This study was designed to present our experience in the endoscopic management of osteomas of the paranasal sinuses. Clinical findings, preoperative imaging strategy, and surgical techniques are discussed.

METHODS

We retrospectively reviewed clinical records of patients who underwent ESS for sinonasal osteomas between 2003 and 2010 in our institutions.

RESULTS

We have treated with a transnasal endoscopic approach 29 patients affected by paranasal osteomas (13 men and 16 women; age range, 20-78 years; mean, 49.5 years). We found frontoethmoidal junction localization in 14 patients, frontal sinus in 6 patients, ethmoid in 6 patients, sphenoid in 1 patient, maxillary in 1 patient, and multiple osteomas in 1 patient. Initially, patients were treated by the cavitation technique with standard ESS instruments, whereas in more recent cases surgery was assisted by the use of ENT navigation system, curved drills, and ultrasound bone emulsifier. No major complications occurred. No radiological or endoscopic signs of recurrence (mean follow-up, 52 months; range, 6-89 months) have been observed.

CONCLUSION

Endoscopic removal of osteomas of the sinonasal region is feasible, taking into account the location and size of the lesion. Particular importance should be given to new instruments that have been applied in the last years in ESS.

Nasal polyposis in children

Nasal polyposis is a chronic inflammatory disease affecting the nasal cavity and the paranasal sinuses. It is a relatively common disease, occurring in 1-4 % of the general population, but it is rarely described in the pediatric population. Most of the published series include children presenting with other underlying systemic diseases, mainly cystic fibrosis. The aim of the present study was to describe the characteristics of the patients suffering from nasal polyposis, evaluated at the Pediatric Clinic of the University of Pavia (Italy) over the last 17 years. 56 consecutive pediatric patients referring to our Pediatric Department had a diagnosis of nasal poyposis over the last 17 years. All children underwent allergy evaluation, nasal endoscopy, CT scan of the paranasal sinus, and Functional Endoscopic Sinus Surgery. The mean age of the present cohort was of 11.8 years and most of the patients were male. 50% of the patients presented with unilateral, polyposis, mostly with a diagnosis of antrochoanal polyp. 4 patients presenting with bilateral polyposis suffered from cystic fibrosis. Main symptoms at diagnosis included nasal obstruction, snoring and rhinorrhea 32% of the patients presented at least a positivity to skin prick test, for major inhalant and food allergens. Nasal polyposis in children could represent an alert sign for other underlying systemic diseases. Nasal endoscopy should therefore be prescribed when a diagnosis is suspected. To properly treat a patient presenting with nasal polyposis, it is necessary to integrate medical and surgical skills through a multidisciplinary approach.

Adenoid hypetrophy: definition of some risk factors

Adenoids removed for airway obstruction and-or recurrent infections have been studied to identify a possible mechanism to explain chronicity. In this regard, macrophages may play a relevant pathogenic role as well as neutrophils during bacterial infections and eosinophils in allergic inflammation. Therefore, this study aimed at investigating some mediators as surrogate markers of inflammation in children who had to undergo to adenoidectomy. Globally, 67 children (25 females, 42 males, mean age 4.9 years), affected by persistent obstruction caused by adenoid hypertrophy were consecutively enrolled into the study. Blood samples were collected from patients and controls to determine serum CD163, Myeloperoxidase (MPO) and ECP. There were significant differences between patients and controls for serum CD163 (p less than 0.0001); MPO (p less than 0.0001); serum ECP (p less than 0.0001). This study demonstrated some risk factors for severe AH: apnoea, recurrent respiratory infections, and high serum CD163 levels.

Adenoid assessment in paediatric patients: the role of flexible nasal endoscopy

Adenoid hypertrophy is the most common cause of nasal obstruction in paediatric patients. Over the years, various methods to assess the adenoid size were proposed such as the posterior rhinoscopy and the radiological examination of the nasopharynx. Nasal endoscopy was introduced for children in the 80&#x0027;s, and nowadays this is a known and diffuse method in routine practice. The purpose of this article is to describe the personal experience in the assessment of the adenoid size in children, with a particular regard to the flexible nasal endoscopy, and to analyse the literature reports. The personal technique is described in performing nasal endoscopy in paediatric patients, reporting advantages and possible disadvantages of the procedure. A retrospective analysis was conducted on 6036 children since 1999 to 2010. In most cases children fully collaborated to complete the exam. No major or minor complications (such as nose bleedings or other traumatic injuries) were observed. No topical intranasal decongestant, local or general anaesthesia were used in our series. In our opinion, nasal endoscopy in children is a reliable, safe, accurate, easily tolerated and dynamic diagnostic method to assess the adenoid size.

The evolution of the adenoidectomy: analysis of different power-assisted techniques

Techniques and instruments for adenoidectomy have considerably changed over the years. With the introduction in Otolaryngology of power-assisted instruments for endoscopic sinus surgery, the classic adenoidectomy performed with curette or adenotome has evolved, with an improved patients&#x0027; outcome and a better satisfaction of the surgeon. The purpose of this article is to describe and critically analyze the literature reports about different methods of power-assisted adenoidectomy. We performed a literature search (Medline) to identify all available reports. We discussed the surgical techniques and reviewed advantages and disadvantages of each method. The techniques can be schematically divided in non-endoscopic, usually performed with a laryngeal mirror, and endoscopic-assisted. The endoscopic control can be obtained either trans-nasally or trans-orally, as well as the microdebrider can be inserted in the nasal cavity or maneuvered through the oral cavity. Some authors reported the usage of the power-assisted instruments in performing the entire adenoidectomy; while, according with other authors, the microdebrider can be used as a step of the surgical procedure, for a combined adenoidectomy. In conclusion, all the methods seem to be safe and effective, and the personal experience of the surgeon should guide the choice of the instruments. However, we personally consider the endoscopic techniques as the most suitable, and among these the Transoral Endonasal-Controlled Combined Adenoidectomy (TECCA) should be considered as the most ergonomic technique to perform a power-assisted adenoidectomy.

Endoscopic treatment of maxillary inverted papilloma

OBJECTIVES

Evaluate the efficacy of endoscopic treatment in maxillary inverted papilloma (IP).

METHODOLOGY

Between July 2002 - April 2008, 20 patients affected by maxillary localization of IP were treated in our Clinic. All patients underwent endoscopic treatment consisting of an endoscopic medial maxillectomy (simple or extended), or attachment-site endoscopic tumour surgery.

RESULTS

The cohort was composed of 20 patients (male: 15, female: 5), mean age 58 years, and included 21 endoscopic resections of maxillary IP. Minimum follow-up: 24 months, mean follow-up: 50 months. We registered only 1 case of tumour persistence/recurrence after 15 months, which underwent a second endoscopic treatment. No association with malignant lesions was noted. The efficacy of the endoscopic treatment was 95% (19/20 cases) after primary surgery, and 100% after endoscopic revision.

CONCLUSIONS

Our experience demonstrates the efficacy of endoscopic treatment in maxillary IP. Based On its reduced morbidity in comparison to external approaches and its good control of the disease, we consider it our standard treatment for maxillary-originated inverted papilloma.

Adenoids during Childhood: The Facts

Adenoids are constantly exposed to viral and bacterial agents as well as to allergens. They play a major role in the upper airways immunity, being effector organs in both mucosal-type and systemic-type adaptive immunity. Because of both their immunological function and their specific location, adenoids are considered to be as reservoirs of viruses and bacteria. Reiterative infections may therefore contribute both to Eustachian tube dysfunction and to tissue hypertrophy. Nasal endoscopy is a key diagnostic tool to detect both adenoid hypertrophy and adenoiditis. Moreover, such a procedure may be very helpful in detecting bacterial biofilms that could justify the concomitant presence of recurrent episodes of otitis media, chronic and occult sinusitis in children. Even though the connection between allergies and adenoidal diseases is not completely clear, allergic diseases cause an inflammatory state that influences adenoidal tissue as well, configuring the picture of allergic adenoiditis, a condition in which adenoid tissue exhibit numerous IgE positive mast cells. Several studies are still needed to better understand the relationship between allergies and infections and the influence they play on adenoids during childhood.

Sphenoid Sinus Fungus Ball: Our Experience

Background

Fungal rhinosinusitis is a common disease of the paranasal sinuses. The fungus ball (FB) is defined as an extramucosal mycotic proliferation that fills one or more paranasal sinuses. Sphenoid sinus is an uncommon localization of this disease, as reported in the literature. This study describes our experience in the diagnosis and treatment of sphenoid sinus FB (SSFB), with a particular focus on the surgical approach to the sphenoid sinus.

Methods

We retrospectively analyzed the clinical records of patients affected by FB of the sphenoid sinus, who underwent endoscopic sinus surgery (ESS) in our institutions between 1995 and 2009. We described the surgical technique, the methods of mycological and histopathological evaluation, as well as the perioperative and postoperative management.

Results

From 1995 to 2009, 226 patients affected by sinonasal FB underwent ESS in our institutions. A sphenoid localization was found in 56 patients (24.78%; mean age, 62 years). Cephalea was the most common symptom, and 14.3% of patients complained of ocular symptoms. We performed a direct paraseptal sphenoidotomy in 31 patients (55.4%) and a transethmoidal sphenoidotomy in 25 patients (44.6%). Histology unveiled fungal hyphae with absent mucosal invasion in all cases. Cultural results revealed positivity for mycotic colonization in 26 cases (46.4%, most commonly Aspergillus fumigatus). Follow-up ranged from 12 to 181 months with a mean of 70.7 months.

Conclusion

The description of our experience in the diagnosis and treatment of SSFB underlines the importance of a precise diagnostic pathway in case of sphenoidal disease. Nowadays, in our opinion, the paraseptal direct sphenoidotomy represents the less invasive, fastest and most anatomically conservative approach to the sphenoid sinus in case of SSFB.

A unique case of multiple sites of pneumatization of the sinonasal bony framework in a pediatric patient

Anatomic variations of the sinonasal bony framework in the pediatric population are quite common. In children with such variations, however, bony pneumatization is uncommon. Moreover, pneumatization of the inferior turbinate in children is extremely rare; to the best of our knowledge, only 3 cases have been previously reported in the literature-none of which involved additional pneumatization variations of the sinonasal skeleton. Herein we present a new pediatric case that was unique in that an inferior concha bullosa coexisted with rarely seen pneumatized anatomic structures.

Is canine fossa access necessary for successful maxillary fungus ball treatment?

BACKGROUND

Sinus fungus ball (FB) is a non-invasive mycosis that affects immunocompetent hosts, most frequently localized in the maxillary sinus. The current golden standard treatment is surgical removal.

OBJECTIVE

To evaluate the effectiveness of an endonasal endoscopically assisted approach to remove a maxillary FB combined or not with a transoral approach (sinusoscopy via canine fossa).

METHODS

A retrospective evaluation of paranasal FB treated by functional endoscopic sinus surgery (FESS) + transoral approach, compared to those treated by a sole FESS procedure.

RESULTS

In total, 65 out of 90 patients presented with a maxillary localization and were treated by FESS. Thirthy-three patients received a combined FESS + transoral approach and 32 received solely a FESS procedure. Antimycotic medical therapy was not used in any case. With a mean follow-up of 93 months, the treatment was successful in 62 patients (95,4%) without significant differences between the two groups.

CONCLUSIONS

Our data confirm the efficacy of FESS in the treatment of maxillary FB. A similarity in long-term results in both groups demonstrated that transoral sinusoscopy can be avoided. With the assistance of lateral-view and flexible endoscopes, angled surgical equipment and maxillary saline solution irrigations, complete removal of the diseased material and sinus clearance can be achieved by a sole middle meatotomy, reducing both morbidity and operating time.

Immunohistochemical analysis of a merkeloma observed in a patient affected by hereditary haemorrhagic telangiectasia

Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterised by epistaxis, telangiectases, and multiorgan vascular dysplasia. Mutations of the ENG and ACVRL1 genes cause at least 80% of cases. We report the first case of merkeloma found in a patient with HHT carrying an ENG mutation. We analysed the tumour with immunohistochemical methods using primary antibodies against CD105 (endoglin), TGF-β, Smad4, CD31 and CD34. Tumour cells were positive for Smad4, weakly positive for TGF-β, and negative for CD105. Vasal endothelial cells were highly positive for CD105, CD31 and CD34. No remarkable differences between cancer and normal cells in our patient or between the patient's merkeloma and two control merkelomas were observed. The presence of a merkeloma in an HHT patient could be an occasional association, but to certainly assume it further investigations are needed.

Rhinosinusitis and otitis media: the link with adenoids

Rhinosinusitis and otitis media are very common diseases observed in pediatric patients. A clear association has been reported in literature between these two conditions. Even concordance in the microbiologic findings has been reported. These findings lead to a discussion in regard to a possible relationship between the two diseases and an eventual interference of another concomitant condition promoting this association. A key role in the linkage between rhinosinusitis and otitis media has been attributed to hypertrophic adenoidal tissue because of its mechanical obstruction of both choanae and Eustachian tube orifices. Recently some works in literature evidenced the presence of bacterial biofilms on adenoids and suggested a responsibility of bacterial biofilms in both chronic rhinosinusitis and otitis media. The debate is still active and more investigations are needed to clarify these topics.

An Asymptomatic Schwannoma of the Nasal Septum: Report of a Unique Case

Schwannomas of the nasal septum are extremely rare, and therefore their diagnosis and treatment can pose certain challenges. We describe the case of an incidentally discovered schwannoma of the nasal septum that was unique in that the lesion was completely asymptomatic. In view of our finding, we believe that routine examinations of both nasal fossae should be considered during routine diagnostic laryngeal flexible endoscopy.

An asymptomatic schwannoma of the nasal septum: report of a unique case

Schwannomas of the nasal septum are extremely rare, and therefore their diagnosis and treatment can pose certain challenges. We describe the case of an incidentally discovered schwannoma of the nasal septum that was unique in that the lesion was completely asymptomatic. In view of our finding, we believe that routine examinations of both nasal fossae should be considered during routine diagnostic laryngeal flexible endoscopy.

Correlation of severity of epistaxis with nasal telangiectasias in hereditary hemorrhagic telangiectasia (HHT) patients

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is an autosomal dominant disease that leads to multiregional angiodysplasia. The presence of telangiectasias in nasal mucosa leads to recurrent epistaxis that affects up to 96% of patients but with unpredictable severity. Some authors have previously explained that endonasal morphology and distribution of telangiectasias can be variable too. The purpose of this study was to evaluate any possible relationship between the severity of epistaxis and the different morphology and distribution of nasal telangiectasias in HHT patients.

METHODS

A review was performed of nasal endoscopy records of 76 consecutive HHT patients treated for epistaxis between 2003 and 2007 at our institution. An evaluation was performed of severity of epistaxis in the same patient group using a questionnaire and considering frequency, intensity, duration of nosebleeds, and need for blood transfusions. Comparison of data collected on morphology and distribution of nasal telangiectasias with data collected on severity of epistaxis was performed.

RESULTS

Morphology and distribution of nasal telangiectasias showed a statistically significant correlation with frequency and intensity of epistaxis. Presence of telangiectasias endoscopically appearing as large and prominent correlates with higher frequency of epistaxis. An increase in number of nasal subsites involved correlates with higher intensity of nosebleeds.

CONCLUSION

Our data suggest that to reduce frequency and intensity of epistaxis in HHT patients, treatments should be directed also at lesions located in the posterior part of nasal fossae and especially on telangiectasias endoscopically appearing as large and prominent.

How we do it: a combined method of traditional curette and power-assisted endoscopic adenoidectomy

CONCLUSION

After conventional curette adenoidectomy, a significant mass of residual adenoid tissue is observed in about 50% of the cases. The combined approach of conventional curette and endoscopic adenoidectomy with microdebrider assures a complete and accurate removal of the mass. It is an effective and safe method without significantly prolonging the operative time.

OBJECTIVES

To describe the surgical technique of conventional curette adenoidectomy completed with the microdebrider under endoscopic vision in case of residual adenoid tissue.

PATIENTS AND METHODS

This was a retrospective review of 143 consecutive patients (age range 2-16 years, mean 6.2) who underwent endoscopic adenoidectomy for adenoid hypertrophy at an academic hospital-based institution. A classic transoral curette adenoidectomy was performed initially. Then a rigid fibre-optic endoscope was used transnasally to assess the completeness of surgery. Residual adenoid tissue was removed using a microdebrider under endoscopic vision.

RESULTS

After conventional curette adenoidectomy 70 children (48.9%) underwent residual adenoid tissue transnasal removal. Mean curette adenoidectomy time with endoscopic visualization of the nasopharynx was 9.1 min and, in the case of completion with the microdebrider, 14.6 min. No significant intraoperative bleeding, postoperative haemorrhage or other complications have occurred. After a mean follow-up of 24.4 months, no patients have been readmitted for symptoms of adenoid regrowth.

Hyoidthyroidpexia as a treatment in multilevel surgery for obstructive sleep apnea

CONCLUSION

This type of surgery is effective in patients with obstructive sleep apnea syndrome (OSAS), but may not be effective in obese patients or those with a preoperative apnea hypopnea index (AHI)>35. For these reasons, the careful study and selection of patients is fundamental in the surgical treatment of OSAS.

OBJECTIVES

Evaluation of the efficacy of hyoid surgery combined with oropharynx and nose surgery in the treatment of OSAS.

SUBJECTS AND METHODS

A total of 109 OSAS patients underwent hyoidthyroidpexia as a treatment in multilevel surgery. Before surgery all patients were treated with continuous positive airway pressure (CPAP) therapy for at least 6 months and underwent preoperative and postoperative polysomnography. The preoperative examination was composed of upper airways endoscopy, lateral cephalometric radiograph, calculation of body mass index (BMI), and subjective analysis of daytime sleepiness.

RESULTS

In all, 67/109 patients (61.5%) with postoperative AHI<20 were defined as 'responders', while the other 42 patients (38.5%) were defined as 'non-responders'. The correlation between preoperative BMI and postoperative AHI revealed that non-responders had a much higher average BMI compared with responders. Moreover, when analyzing median preoperative and postoperative AHI, it emerged that non-responders had a much higher preoperative AHI compared with responders.

Acoustic changes in voice after surgery for snoring: preliminary results

All surgical procedures for treatment of snoring and obstructive sleep apnoea modify the anatomical structure of the upper airways and the resonance characteristics of the vocal tract; this can lead to a modification in voice quality. Purpose of this study was to evaluate the possible modifications of the fundamental frequency (F0) and of the frequency and amplitude of the first (F1) and second (F2) formants of the 5 Italian vowels after different surgical procedures for snoring, to verify if and how these operations can influence voice quality. A total of 40 snoring or obstructive sleep apnoea syndrome patients, not affected by laryngeal, pulmonary or neurologic disorders likely to alter voice production, were selected for the study. All were submitted to acoustic voice analysis prior to surgery and again 1 month after discharge. F0 was unchanged. The frequency of F1 of the vowel /a/ audio of F2 of the vowel /e/ were significantly higher, while F1 of /i/ and F2 of /o/ and /u/ were significantly lower compared to pre-operative values. The modifications in the anatomical structure and volume of the vocal tract, induced by the surgical procedures used for the treatment of snoring, can modify the values of the formants and, as a consequence, quality of the voice. This change can be detected not only by means of the acoustic analysis but also by the patient itself. For this reason, singers and all professional voice users about to undergo surgical treatment for snoring should be informed of this potential modification of the voice not only for clinical reasons but also for legal purposes.