Critical Steps and Common Mistakes during Temporal Bone Dissection: A Survey among Residents and a Step-by-Step Guide Analysis

BACKGROUND

Given that the temporal bone is one of the most complex regions of the human body, cadaveric dissection of this anatomical area represents the first necessary step for the learning and training of the young oto-surgeon in order to perform middle ear surgery, which includes the management of inflammatory pathology, hearing rehabilitation, and also cognitive decline prevention surgery. The primary objective of this study was to identify common mistakes and critical passages during the initial steps of temporal bone dissection, specifically cortical mastoidectomy and posterior tympanotomy.

METHODS

A survey among 100 ENT residents was conducted, gathering insights into the most prevalent errors encountered during their training to uncover the most challenging aspects faced by novice surgeons during these procedures.

RESULTS

The most common mistakes included opening the dura of the middle cranial fossa (MCF), injury of the sigmoid sinus (SS), chorda tympani (CT), and facial nerve (FN) injury while performing the posterior tympanotomy. The most important critical steps to prevent mistakes are related to the absence of wide exposure during cortical mastoidectomy and the consequent impossibility of identifying the landmarks of the facial recess before performing posterior tympanotomy. Injury of these structures was more common in younger surgeons and in the ones who performed less than five temporal bone dissection courses.

CONCLUSIONS

Numerous temporal bone dissections on cadavers are mandatory for ENT residents looking forward to performing middle ear surgery.

Drug-induced inhibition of HMGA and EZH2 activity as a possible therapy for anaplastic thyroid carcinoma

Anaplastic thyroid carcinoma (ATC) is one of the most aggressive and lethal neoplasms in humans, and just limited progresses have been made to extend patient survival and decrease ATC-associated mortality. Thus, the identification of novel therapeutic strategies for treating ATC is needed. Recently, our group has identified two proteins with oncogenic activity, namely HMGA1 and EZH2, with pivotal roles in ATC cancer progression. Therefore, we tested the ability of trabectedin, a HMGA1-targeting drug, and GSK126, an inhibitor of EZH2 enzymatic activity, to impair cell viability of four ATC-derived cell lines. In the present study, we first confirmed the overexpression of HMGA1 and EZH2 in all ATC-derived cell lines and tissues compared to the normal primary thyroid cells and tissues. Then, treatment of the ATC cell lines with trabectedin and GSK126 resulted in a drastic induction of apoptotic cell death, which increased when the ATC cell lines were treated with a combination of both drugs. Conversely, normal primary human thyroid cells did not show any significant reduction in their viability when exposed to the same drugs. Noteworthy, both drugs induced the deregulation of EZH2- and HMGA1-controlled genes. Altogether, these findings propose the combination of trabectedin and GSK126 as possible novel strategy for ATC therapy.

Transoral Approach to Parapharyngeal Space Tumours: Preliminary Reports from a Single-Centre Retrospective Analysis

Purpose: The aim of this study is to identify certain parapharyngeal space tumours with specific characteristics that can be treated successfully through an endoscopically assisted transoral approach (EATA). Methods: Nine patients with PPS tumours underwent surgery through an EATA between 2003 and 2021. All patients underwent clinical examination and fibrolaryngoscopy. Preoperative CT and/or MRI was performed on all patients. Results: All the patients were successfully treated through an endoscopically assisted transoral approach. Histological examination revealed five pleomorphic adenomas, two schwannomas, one ectopic thyroid gland and one lipoma. The only long-term sequelae observed was Horner syndrome in the two schwannomas arising from the carotid space. The mean hospitalisation time was 2.6 days, while the mean follow-up time was of 9.7 years. Conclusions: An endoscopically assisted transoral approach (EATA) is a valid technique for treating benign capsulated tumours of the true PPS and some benign capsulated tumours of the superomedial aspect of the carotid space.

Long Process Incus necrosis in Revision Stapedotomy: Retrospective Clinical Study

OBJECTIVES

We describe our experience with long process incus (LPI) necrosis in revision stapedotomy and discuss the different management methods proposed in the literature to identify surgical techniques that can lead to satisfactory results over time.

METHODS

Twenty-two stapedotomy revisions, in 21 patients with the necrosis of the long process of the incus, are performed from 1997 to 2017. In cases of erosion or minimal necrosis of LPI, a new prosthesis of the same type or an angled prosthesis was applied higher on the residual incus stump. In cases of partial necrosis of LPI, a Donaldson type ventilation tube reshaped and placed on the residual incus stump to stabilize prosthesis, or glass ionomer bone cement was used. In cases of subtotal necrosis of LPI, a cup piston prosthesis in polycel was applied on incus residual stump. Pre- and postoperative (≥1 year) pure tone audiometry was performed for all cases. Air conduction threshold, bone conduction (BC) threshold, and air-bone gap (ABG) were documented according to the American Academy of Otolaryngology Head and Neck Surgery Committee of Hearing and Equilibrium guidelines.

RESULTS

At 1-year follow-up, postoperative ABG was reduced to ≤10 dB in 13 (59%) cases and ≤20 dB in 19 (86.4%) cases. The mean postoperative ABG significantly decreased in each group. There was no significant change in postoperative BC thresholds, and there were no cases with postoperative SNHL.

CONCLUSION

Excellent functional results can also be achieved in cases of long incus process necrosis. The choice of technique should be considered according to the degree of necrosis. Piston replacement with the same type or angled type prosthesis, in cases of erosion or minimal LPI necrosis, and modified Donaldson type ventilation tube, in cases of partial LPI necrosis, provided excellent hearing results.

Nasal Microbiome in COVID-19: A Potential Role of Corynebacterium in Anosmia

The evolution and the development of the symptoms of Coronavirus disease 19 (COVID-19) are due to different factors, where the microbiome plays a relevant role. The possible relationships between the gut, lung, nasopharyngeal, and oral microbiome with COVID-19 have been investigated. We analyzed the nasal microbiome of both positive and negative SARS-CoV-2 individuals, showing differences in terms of bacterial composition in this niche of respiratory tract. The microbiota solution A (Arrow Diagnostics) was used to cover the hypervariable V1-V3 regions of the bacterial 16S rRNA gene. MicrobAT Suite and MicrobiomeAnalyst program were used to identify the operational taxonomic units (OTUs) and to perform the statistical analysis, respectively. The main taxa identified in nasal microbiome of COVID-19 patients and in Healthy Control subjects belonged to three distinct phyla: Proteobacteria (HC = 14%, Cov19 = 35.8%), Firmicutes (HC = 28.8%, Cov19 = 30.6%), and Actinobacteria (HC = 56.7%, Cov19 = 14.4%) with a relative abundance > 1% in all groups. A significant reduction of Actinobacteria in Cov19 group compared to controls (P < 0.001, FDR = 0.01) was found. The significant reduction of Actinobacteria was identified in all taxonomic levels down to the genus (P < 0.01) using the ANOVA test. Indeed, a significantly reduced relative abundance of Corynebacterium was found in the patients compared to healthy controls (P = 0.001). Reduced abundance of Corynebacterium has been widely associated with anosmia, a common symptom of COVID-19 as suffered from our patients. Contrastingly, the Corynebacterium genus was highly represented in the nasal mucosa of healthy subjects. Further investigations on larger cohorts are necessary to establish functional relationships between nasal microbiota content and clinical features of COVID-19.

Minimal Margin Surgery and Intraoperative Neuromonitoring in Benign Parotid Gland Tumors: Retrospective Clinical Study

Extracapsular dissection (ECD) was introduced for the removal of superficial and small benign parotid tumors. According to a recent proposal, ECD is reserved for tumors that are 3 cm or less, mobile, and close to the parotid borders in cases of pleomorphic adenoma. The aim of the study is to evaluate the effectiveness of ECD for treatment of benign parotid tumors also in cases of tumors that were larger than 3 cm and deeper. All ECD for benign parotid neoplasms conducted between 2007 and 2017 were reviewed. The lesions included were limited to primary parotid tumors and categorized by Quer proposal. Facial nerve monitoring was used in all cases. Facial nerve palsy and local recurrences were assessed. The 88 ECD performed met inclusion criteria. The mean lesion size was 4.26 cm. Of the tumors, 68 were less than 3 cm in diameter and 20 were larger, 64 were superficial, and 24 were deep. The most common lesion types were pleomorphic adenoma (88.6%). There was no significant difference in complication rates between the size of tumor (p = 0.9) and location (p = 0.91). Our results suggest that extracapsular dissection could be considered an option for first-time diagnosed benign parotid tumors, even in cases of large dimensions and deep lobe involvement.

Intravascular Papillary Endothelial Hyperplasia (Masson’s Tumor) of the Supraclavicular Region: Management of a Rare Case

Patient: Female, 24-year-old

Final Diagnosis: Hemangioendothelioma

Symptoms: Swelling

Medication: —

Clinical Procedure: —

Specialty: Otolaryngology • Surgery

Expression of Matrix Metalloproteinases and Their Tissue Inhibitors in Chronic Rhinosinusitis With Nasal Polyps: Etiopathogenesis and Recurrence

Chronic rhinosinusitis with nasal polyps is a multifactorial disease of the nasal and paranasal sinus mucosa and it includes, as comorbidities, anatomic and morphologic alterations, allergic rhinitis, and immunologic diseases. We investigated matrix metalloproteinases (MMP-2, MMP-7, and MMP-9) and their tissue inhibitors (TIMP-1 and TIMP-2) concentration in different etiopathogenetical groups of patients with nasal polyposis (NP) in relation to recurrence after sinonasal surgery. The study group consisted of 45 patients with NP (those with allergic rhinitis, nonallergic rhinitis and asthma or nonallergic rhinitis, and obstruction of osteomeatal complex [OMC]) who underwent endonasal sinus surgery. We also collected 10 patients who underwent septoplasty as control. Immunohistochemistry of nasal mucosa fragments, Western blotting, and polymerase chain reaction analysis showed increased MMPs levels (MMP-9 more than MMP-2 and MMP-7) and decreased tissue inhibitors of MMPs levels (TIMP-1 less than TIMP-2), in patients with chronic rhinosinusitis with nasal polyps compared with control group, in particular in patients with nonallergic rhinitis and asthma compared to those with allergic rhinitis and nonallergic rhinitis and obstruction of OMC. We observed a higher risk of recurrence in patients with nonallergic rhinitis and asthma than in those with allergic rhinitis and nonallergic rhinitis and obstruction of OMC after 36 months from surgery. In this research, we evaluated pathogenesis of NP related to MMPs and their inhibitors concentrations in polypoid tissue.

Head and neck cancer: the role of anti-EGFR agents in the era of immunotherapy

Head and neck cancers (HNC) represent the seventh most frequent cancer worldwide, with squamous cell carcinomas as the most frequent histologic subtype. Standard treatment for early stage diseases is represented by single modality surgery or radiotherapy, whereas in the locally advanced and recurrent or metastatic settings a more aggressive multi-modal approach is needed with locoregional intervention and/or systemic therapies. Epidermal Growth Factor Receptor (EGFR) plays an important role in HNC biology and has been studied extensively in preclinical and clinical settings. In this scenario, anti-EGFR targeted agent cetuximab, introduced in clinical practice a decade ago, represents the only approved targeted therapy to date, while the development of immune-checkpoint inhibitors has recently changed the available treatment options. In this review, we focus on the current role of anti-EGFR therapies in HNCs, underlying available clinical data and mechanisms of resistance, and highlight future perspectives regarding their role in the era of immunotherapy.

Anthropometric Parameters for Nose Evaluation and Nasal Surgery Planning

BACKGROUND

The esthetic characteristics of face and nose are commonly evaluated before rhinoplasty using a completely subjective method, due to the lack of validated and reliable methods for quantifying facial esthetics and for accurate nose treatment planning. The aim of the study was to review the literature to determine and evaluate the points, distances, and angles commonly used in the treatment planning for rhinoplasty.

METHODS

Research based on anthropometric studies of the face and nose, published from 1987 to 2018 was included. Finally, 138 papers were selected after a statistical analysis through a simple random and non-random sample selection, and all papers were evaluated in their entirety.

RESULTS

According to the frequency of citation, 198 points, 336 distances, and 199 angles were listed. The first quartile of each distribution was eliminated, and frequency of more than 25% was selected. A group of 49 points, 77 distances, and 11 angles, were classified according to their anatomical region, that is, bone and soft tissues, was obtained.

CONCLUSIONS

An enormous inhomogeneity and lack of standardized anthropometric measurement system, specifically of the nose, was evident, as the studies were conducted by authors of different origins. According to universally accepted parameters, the importance of a reliable method for nose surgery planning is highlighted.

Manufacturing, installation, commissioning, and first results with the 3D low-temperature co-fired ceramic high-frequency magnetic sensors on the Tokamak à Configuration Variable

Innovative high-frequency magnetic sensors have been designed and manufactured in-house for installation on the Tokamak à Configuration Variable (TCV), which are now routinely operational during the TCV experimental campaigns. These sensors combine the Low Temperature Co-fired Ceramic (LTCC) and the classical thick-film technologies and are in various aspects similar to the majority of the in-vessel inductive magnetic sensors foreseen for ITER (around 450 out of the 505 currently being procured are of the LTCC-1D type). The TCV LTCC-3D magnetic sensors provide measurements in the frequency range up to 1 MHz of the perturbations to the wall-aligned toroidal (δB_TOR), vertical (δB_VER), and radial (δB_RAD) magnetic field components. Knowledge of the equilibrium at the last closed flux-surface allows us to then obtain the field-aligned parallel (δB_PAR ∼ δB_TOR), poloidal (δB_POL), and normal (δB_NOR) components, the latter being in most cases rather different from the vertical and radial components, respectively. The main design principles were aimed at increasing the effective area and reducing the self-inductance of the sensor in each of the three measurement axes, which are centered at the same position on each sensor, while reducing the mutual and parasitic coupling between them by optimizing the on-board wiring. The physics requirements are set by the installation of two high-power/high-energy neutral beam injection systems on TCV, i.e., studying fast ions physics, coherent instabilities, and turbulence in the (super-)Alfvénic frequency range. In this paper, we report the manufacturing, installation, and commissioning work for these high-frequency LTCC-3D magnetic sensors and conclude with an overview of illustrative experimental results obtained with this system. The LTCC-3D data provide new insights into the δB_POL coherent (eigenmodes, up to ∼400 kHz) and in-coherent background turbulent fluctuations in the higher frequency range up to ∼1 MHz, which were not previously available with the TCV Mirnov sensors. Furthermore, the LTCC-3D δB_POL measurements allow us to cross-check the data obtained with the standard Mirnov coils and have led to the identification of largeelectromagnetic (EM) noise pick-up for the Mirnov data acquisition (DAQ). When the sources of EM noise pick-up on the Mirnov DAQ are removed, the LTCC-3D data for δB_POL are in good overall agreement, i.e., within the expected measurement uncertainties, with those obtained with the standard Mirnov sensors located at the same poloidal position in the frequency range where the respective data acquisition overlap, routinely up to 125 kHz and up to 250 kHz in some discharges. The LTCC-3D δB_PAR measurements (not previously available in TCV or elsewhere) provide evidence that certain instabilities have a finite parallel δB at the wall, hence at the LCFS, consistent with the recent theoretical results for pressure-driven modes. The LTCC-3D δB_NOR measurements improve significantly on the corresponding measurements with the saddle loops, which are mounted onto the wall and have a bandwidth of ∼3 kHz (due to the wall penetration time). A detailed end-to-end system modeling tool has been developed and applied to test on the simulated data the actual measurement capabilities of this new diagnostic system and obtain the ensuing estimates of the intrinsic measurement uncertainties. A detailed error analysis is then performed so that, finally, fully calibrated, absolute measurements of the frequency-dependent amplitude and spectral breaks of coherent eigenmodes and in-coherent broadband magnetic fluctuations are provided for the first time in physical units with quantitative uncertainties.

Intrinsic Laryngeal Lipoma Treated with Transoral CO₂ Laser Microsurgery: An Unusual Case Report

Patient: Female, 28-year-old

Final Diagnosis: Intrinsic laryngeal lipoma

Symptoms: Dyspnoea

Medication: —

Clinical Procedure: —

Specialty: Otolaryngology

AB0367 USING UNSUPERVISED CLUSTERING ANALYSIS OF REAL LIFE DATA FROM AN ONLINE COMMUNITY TO IDENTIFY LUPUS PATIENTS’ PROFILES REGARDS TO THEIR TREATMENT PREFERENCES

Background:

Lupus is a prototype of a chronic complex autoimmune disease. Non-adherence rate to treatment is surprisingly high and impairs its management. Adherence to drug treatment is a complicated and multifactorial phenomenon, including characteristics of treatment.

Objectives:

This study used unsupervised clustering analysis to identify profiles among lupus patients with regards to their treatment preferences (apart from efficiency).

Methods:

An online survey among adult lupus patients from Carenity was conducted between August 2018 and April 2019. Multiple Correspondence Analysis (MCA) of a French lupus patient dataset was used with 3 unsupervised clustering methods (hierarchical, kmeans and partitioning around medoids).

Results:

The 268 participating lupus patients were mostly female (96%), with a mean age of 44.3 years, and 83% fulfilled the ACR SLE diagnostic criteria. Overall, the preferred galenic form was oral (62%), and the most important characteristic was fewer side effects (32%).

A MCA was performed using 8 profile variables and the best unsupervised clustering method for this dataset (hierarchical clustering) identified 3 clusters (Table 1). Cluster 1, main one (59%), comprised patients with few comorbidities, less capacity to identify coming flares, and that wanted mostly (84%) oral treatments with limited side effects, most of them (83%) already on oral treatments. Cluster 2, the smallest one (13%), comprised younger patients, having already participated in clinical trials, favoring implants and the compatibility of treatments with pregnancy. Cluster 3 comprised patients (28%) that had longer lupus duration but less controlled disease with more comorbidities. A third had injectable treatments, wanting mainly implants and injections and with the main goal of reducing corticosteroids. The robustness of these results was confirmed by external validation and sensitivity analyses.

Table 1.Overalln=268Cluster 1 n=158Cluster 2n=36Cluster 3n=74p-valueMost represented age group (%)41-50 (32%)41-50 (41%)31-40 (42%)51-60 (39%)< 0.001Comorbidities 0 / ≥ 420% / 37%30% / 4%14% / 8%3% / 36%< 0.001Ability to identify coming flare82%73%97%93%< 0.001Current lupus control (no or poor)26%20%25%38%< 0.05Current galenic (inj. / oral)12% / 76%2% / 83%8% / 78%35% / 61%< 0.001Trial participation7%0%50%1%< 0.001Ideal galenic oral62%84%50%20%< 0.001 implant19%9%33%32% home / auto-inj.14% / 9%6% / 2%11% / 11%32% / 22% hospital inj.6%1%5%15%Top ranked drug characteristics$(%)Side effects(32%)Side effects(41%)Pregnancy(55%)Cortisone sparing (24%)< 0.001

$among the 10 following items: less side effects, compatibility with pregnancy, better long term tolerance, less costly for collectivity, more convenient place for administration, easier administration, less medical follow-up needed, less risk of infection, cortisone sparing effect, shorter time of administration. P-values obtained after χ2 tests. Inj.: injection.

Conclusion:

Most lupus patients preferred a drug galenic favoring the conservation of their autonomy. The identified clusters could help physicians to tailor their therapeutic proposition taking into account patients’ preferences and to maximize therapeutic adherence. Our study also highlights the potential of using unsupervised machine learning techniques in combination with direct-access patient community data to provide new a priori knowledge in the field of rare and complex chronic diseases.

References:

[1]Meunier B, et al., Lupus. 2016 Apr;25(4):370-5.

[2]Qu H, et al., Arthritis Care Res (Hoboken). 2016 Dec;68(12):1787-1794.

[3]Fraenkel L, et al., Med Care. 2001 Nov;39(11):1203-16.

Disclosure of Interests:

None declared

Evaluation of neurocognitive abilities in children affected by obstructive sleep apnea syndrome before and after adenotonsillectomy

Obstructive sleep apnoea syndrome (OSAS) is the most severe form of sleep-related disordered breathing (SRDB) and is characterised by snoring, apnoeas, and/or hypopnoeas associated to hypoxia, hypercarbia, or repeated arousals from sleep. OSAS has three major categories of morbidities: neurobehavioural, cardiovascular and somatic growth failure. The gold standard for objective diagnosis of obstructive-SRDB severity is polysomnography (PSG). The indication for surgical treatment in children is moderate-severe OSAS (AHI, apnoea hypopnoea index > 5/h) and in mild OSAS (AHI 2-5/h) with complications or morbidity. The entire spectrum of PSG-defined SRDB (ranging from Primary Snoring to severe OSAS) may correlate with behavioural, attentional and executive function deficits relating to hypoxia and sleep disruption: in some cases, these alterations may mimic attention deficit hyperactivity disorder (ADHD). The aim of this research was to evaluate visuoperceptual and constructional abilities, paediatric sleep questionnaire and polysomnographic scores before and 6 months after adenotonsillectomy with objective and subjective information. We included 59 children who underwent neuropsychiatric and otolaryngologist clinical evaluation and the Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI); children parents were asked to fill in the Paediatric Sleep Questionnaire (PSQ); each child underwent PSG. At 6 months after adenotonsillectomy, all patients were evaluated again. There is a significant difference in PSQ parameters, VMI standard, visual tests scores and PSG parameters before and after adenotonsillectomy in children affected by OSAS. These results showed the achievement of therapeutic benefits with improvement of the quality of life for both children and their parents.

Definition of miRNA Signatures of Nodal Metastasis in LCa: miR-449a Targets Notch Genes and Suppresses Cell Migration and Invasion

Laryngeal cancer (LCa), a neoplasm of the head and neck region, is a leading cause of death worldwide. Surgical intervention remains the mainstay of LCa treatment, but a crucial point is represented by the possible nodal involvement. Therefore, it is urgently needed to develop biomarkers and therapeutic tools able to drive treatment approaches for LCa. In this study, we investigated deregulated microRNAs (miRNAs) in tissues from LCa patients with either lymph node metastases (N+) or not (N−). miRNA expression profiling was performed by a comprehensive PCR array and subsequent validation by RT-qPCR. Results showed a significant decrease of miR-449a expression in N+ compared to N− patients, and miR-133b down-modulation in LCa tissues compared to paired normal ones. Receiver operating characteristic (ROC) curve analysis revealed the potential diagnostic power of miR-133b for LCa detection. According to the validation results, we selected miR-449a for further in vitro studies. Ectopic miR-449a expression in the LCa cell line Hep-2 inhibited invasion and motility in vitro, slowed cell proliferation, and induced the downregulation of Notch1 and Notch2 as direct targets of miR-449a. Collectively, this study provides new promising biomarkers for LCa diagnosis and a new opportunity to use miR-449a for the treatment of nodal metastases in LCa patients.

Choanal Polyp with Osseous Metaplasia: Radiological and Therapeutic Management of a Rare Case and a Review of Bone Metaplastic Lesions of Sinonasal Tract

Patient: Female, 51-years-old

Final Diagnosis: Choanal polyp with osseous metaplasia

Symptoms: Nasal obstruction

Medication:—

Clinical Procedure: Combined surgical approach, endoscopic and trans-oral

Specialty: Otolaryngology

The use of 3D printing model as tool for planning endoscopic treatment of benign airway stenosis

Benign tracheal stenosis is a life-threatening condition that needs a prompt treatment when the tracheal lumen is less than 5 mm. In patients unfit for surgery, endoscopic dilation with stent insertion (if indicated) remains the main alternative to restore airway patency and assure ventilation. Endoscopic management of tracheal stenosis may be a cumbersome procedure, that sometimes takes a long time, and may be complicated by stent dislocation especially in cases of complex stenosis, near to vocal folds. In recent years, the 3D printing industry has undergone rapid development, and 3D printing model has been increasingly applied to different medical fields where therapeutic interventions rely on defining complex anatomic structural relationships. Thus, in this review we aimed to evaluate whether the use of 3D printing model as tool for preoperative planning could facilitate the endoscopic treatment of tracheal stenosis and improve outcome. Three papers evaluated this issue: one paper reported a consecutive series of patients while the remaining single case report. All authors concluded that the 3D model aided the understanding of patient’s anatomy and the stenosis’s characteristic. The possibility of recreating the endoscopic procedure in the 3D model facilitated and shorted the procedural time in live patient. Furthermore, the 3D model was additionally useful to choose the length, diameter and shape of stent and to define the exact distance of the proximal end of stent from the vocal folds after its insertion. Finally, it represented an educational tool for patients and his/her family to understand the procedure, and for residents and fellows to improve endoscopic skills.

Allergic rhinitis and asthma assessment of risk factors in pediatric patients: A systematic review

Allergic rhinitis (AR) is the most prevalent allergic disease in children and can be associated with asthma (A); this association can have significant effect on child's quality of life. The objective of this work was to systematically review existing literature on the risk factors of AR and A in children to better understand the link between these two diseases. We performed a literature search over the last 25 years in PubMed and Medline. Inclusion criteria comprised English language papers containing original human data with greater than 30 subjects and papers that statistically analyze the relationship between AR and A and the risk factor(s), in children population. A statistically significant correlation was found between children with AR and A and ambient Polycyclic Aromatic Hydrocarbons exposure, live in an industrialized city with elevated traffic, dampness and moulds exposure, electric cooking, male gender, single nucleotide polymorphisms in PTNP22 gene and CTLA-4 gene, fast food and margarine products consumption, use of paracetamol in last year, history of tuberculosis, parental atopy, high total serum IgE, antibiotics in uterus and infections in uterus exposure, history of formula feeding and caesarian section. A strong and complex link between AR and A was accounted: A represents a major risk factor for the onset of AR, that correlates with more severe asthmatic symptoms. Even the onset of A in a child with AR worsen it. The interaction of genetic and environmental risk factors and the consequent epigenetic, microbiota and immunological changes, were found to led to the development of AR and A in children, with both atopic and non-atopic pathways. Close monitoring of evidenced risk factors may help with an early recognize and treat A in patients with AR.

The Long Non-Coding RNA Prader Willi/Angelman Region RNA5 (PAR5) Is Downregulated in Anaplastic Thyroid Carcinomas Where It Acts as a Tumor Suppressor by Reducing EZH2 Activity

Anaplastic thyroid carcinoma (ATC) represents one the most aggressive neoplasias in humans, and, nowadays, limited advances have been made to extend the survival and reduce the mortality of ATC. Thus, the identification of molecular mechanism underlying its progression is needed. Here, we evaluated the long non-coding RNA (lncRNA) expression profile of nine ATC in comparison with five normal thyroid tissues by a lncRNA microarray. By this analysis, we identified 19 upregulated and 28 downregulated lncRNAs with a fold change >1.1 or <−1.1 and p-value < 0.05, in ATC samples. Some of them were subsequently validated by qRT-PCR. Then, we investigated the role of the lncRNA Prader Willi/Angelman region RNA5 (PAR5), drastically and specifically downregulated in ATC. The restoration of PAR5 reduces proliferation and migration rates of ATC-derived cell lines indicating that its downregulation contributes to thyroid cancer progression. Our results suggest that PAR5 exerts its anti-oncogenic role by impairing Enhancer of Zeste Homolog 2 (EZH2) oncogenic activity since we demonstrated that PAR5 interacts with it in thyroid cancer cell lines, reducing EZH2 protein levels and its binding on the E-cadherin promoter, relieving E-cadherin from the negative regulation by EZH2. Consistently, EZH2 is overexpressed in ATC, but not in differentiated thyroid carcinomas. The results reported here define a tumor suppressor role for PAR5 in undifferentiated thyroid neoplasias, further highlighting the pivotal role of lncRNAs in thyroid carcinogenesis.

The CO2-laser in the treatment of laryngeal and tracheal stenosis Our personal experiences

AIM

In the last twenty years, the statement of the CO2 laser in laryngeal microsurgery has proved particularly useful in the surgical treatment of laryngotracheal stenosis. The Authors report their surgical experiences and discuss them considering the location, size and pathologic features of the disease. The aim of this study was to evaluate the results that may be obtained in the treatment of laryngotracheal stenosis by endoscopy using the CO2 laser, and analyze the advantages and limitations of surgical methods implemented.

MATERIAL OF STUDY

It includes 128 patients treated from 1981 to 2016 by endoscopy using the CO2 laser.

RESULTS

The healing occurred in 121 of the 128 patients (94.5%); in the remaining 7 cases (5.5%) - 4 subjects (3.1%) with supraglottic cicatricial stenosis and 3 patients (2.3%) with widespread laryngotracheal stenosis - it had to integrate the technique of endoscopic surgery with a traditional surgery of recovery. In particular, it has observed as follows: In supraglottic stenosis: - oedematous forms healed without difficulty, a limited number of controls (1-2) was necessary to practice and any type of stent has not been used; - cicatricial forms required a greater number of controls (3-6) and the execution in 2 cases (1.6%) of an arytenoidectomy, we had 4 failures (3.1%) for which it had to implement a recovery surgery of traditional type; In glottic/ipoglottic stenosis: - all oedematous forms healed with a number of checks less than 3, without use of stents; - scarring forms resolved after a higher number of controls (3-6), in 4 of them (3.1%) it was necessary to practice an arytenoidectomy (associated to exeresis of 1/3 posterior ipsilateral true vocal cord) and in 4 (3.1%) had to applied an endolaryngeal guardian (in one case a Traissac stent and in 3 ones a Montgomery T-tube); In tracheal stenosis has occurred healing in all cases, more specifically: - in limited forms to the third anterior of the trachea were enough 1-2 checks and it was not necessary using stent; - in extended forms (involvement of the 2/3 anterior and/or of the whole tracheal circumference) a higher number of controls (3-6) was necessary; - in concentric forms, with total obstruction of the lumen, the application of endoluminal stent (3 Montgomery T-tubes and 2 tracheal cannulas of Silastic) was always necessary in addition to a number of controls superior to 7. - In laryngotracheal spread forms, 3 failures (2.3%) recorded, in all cases, however, many controls (greater than 7) was necessary and a Montgomery T-tube was placed.

CONCLUSIONS

The introduction of the CO2 laser in the surgical treatment of laryngotracheal stenosis has undoubtedly improved the chances of endoscopic surgery; it is currently able to offer significant advantages compared to traditional techniques (cures faster, less traumatic interventions, post-operative elapsed better tolerated by patients, etc.) but it is also indisputable that to ensure the success of these operations is essential a correct understanding of the size and pathologic features of the same stenosis: the data, in fact, affect the choice of surgical addresses to adopt in individual cases and the prognostic judgment.

KEY WORDS

Airway management, Airway problems, CO2 laser, Direct laryngoscopy, Endoscopy, External surgical approach, Laryngotracheal stenosis, Minimally invasive surgery, Montgomery Safe T-tube, Tracheal stenosis, Tracheostomy.

Role of α-Tocopherol Acetate on Nasal Respiratory Functions: Mucociliary Clearance and Rhinomanometric Evaluations in Primary Atrophic Rhinitis

Primary atrophic rhinitis is a disease of the nose and of paranasalsinuses characterized by a progressive loss of function of nasal and paranasal mucosa caused by a gradual destruction of ciliary mucosalepithelium with atrophy of serous-mucous glands and loss of bonestructures.The aim of this study was to evaluate the therapeutic effects of topic α-tochopherol acetate (vitamin E) in patients with primary atrophicrhinitis based on subjective and objective data.We analyzed 44 patients with dry nose sensation and endoscopic evidence of atrophic nasal mucosa. We analyzed endoscopic mucosascore, anterior rhinomanometry, and nasal mucociliary clearance before and after 6 months of topic treatment with α-tochopherol acetate. For statistical analysis, we used paired samples t test (95% confidence interval [CI], P < .05) for rhinomanometric and muciliary transit time evaluations and analysis of variance 1-way test (95% CI, P < .05) for endoscopic evaluation. All patients showed an improvement in "dry nose" sensation and inperception of nasal airflow. Rhinomanometric examination showed increase of nasal airflow at follow-up (P < .05); nasal mucociliaryclearance showed a reduction in mean transit time (P < .05); and endoscopic evaluation showed significative improvement of hydration of nasalmucosa and significative decreasing nasal crusts and mucusaccumulation (P < .05). Medical treatment for primary atrophic rhinitis is not clearly documented in the literature; in this research, it was demonstrated that α-ochopherol acetate could be a possible treatment for atrophic rhinitis.

Relationship between sleep quality and rhinitis in children: role of medical treatment with isotonic and hypertonic saline

BACKGROUND

The nose represents the port of entry, the first part of the upper airway and accounts for 50% of its total resistance. Many authors identified rhinitis as relevant factor affecting quality of life, and sleep habits of sufferers and their caregiver's, particularly between 4-17 years old children. Both allergic rhinitis and non-allergic rhinitis may represent an important risk for obstructive sleep apnea syndrome in children. We evaluated the quality of sleep and the role of nasal irrigations with saline solutions in children with sign and symptoms of rhinitis.

METHODS

An observational retrospective study was conducted on 58 children aged 3-6 years old receiving diagnosis of rhinitis according to clinical and amnestic evaluation. All recruited children were screened before medical topic treatment with the Pediatric Sleep Questionnaire test in order to evaluate the sleep habits and after isotonic and hypertonic saline nasal irrigation for six months. One-Way ANOVA was used for statistical analysis of the results.

RESULTS

Forty-nine of 58 recruited children reached the follow-up control after six months of medical treatment. Mean score at Pediatric Sleep Questionnaire before and after medical treatments was respectively 0.39 and 0.28. One-Way ANOVA test showed a significant statistical difference (P<0.05).

CONCLUSIONS

Nasal topic decongestant may be used only for short-term treatments, and they do not seem to have long-term results. Topic corticosteroids may be used for long term treatment and their correlations with OSA seem to have different results. This study aims to attracting the attention of pediatricians on the importance of nasal topic saline solutions irrigations in children with rhinitis in improving HRQoL decreasing snoring and apneas and so daytime symptoms.

Relationship between sleep quality and rhinitis in children: role of medical treatment with isotonic and hypertonic salines

BACKGROUND

The nose represents the port of entry, the first part of the upper airway and accounts for 50% of its total resistance. Many authors identified rhinitis as relevant factor affecting quality of life, and sleep habits of sufferers and their caregiver's, particularly between 4-17 years old children. Both allergic rhinitis and non-allergic rhinitis may represent an important risk for obstructive sleep apnea syndrome in children. We evaluated the quality of sleep and the role of nasal irrigations with saline solutions in children with sign and symptoms of rhinitis.

METHODS

An observational retrospective study was conducted on 58 children aged 3-6 years old receiving diagnosis of rhinitis according to clinical and amnestic evaluation. All recruited children were screened before medical topic treatment with the Pediatric Sleep Questionnaire test in order to evaluate the sleep habits and after isotonic and hypertonic saline nasal irrigation for six months. One-Way Anova was used for statistical analysis of the results.

RESULTS

49 of 58 recruited children reached the follow-up control after six months of medical treatment. Mean score at Pediatric Sleep Questionnaire before and after medical treatments was respectively 0,39 and 0,28. One-Way Anova test showed a significant statistical difference (p<0,05).

CONCLUSIONS

Nasal topic decongestant may be used only for short term treatments and they do not seem to have long-term results. Topic corticosteroids may be used for long term treatment and their correlations with OSA seem to have different results. This study aims to attracting the attention of pediatricians on the importance of nasal topic saline solutions irrigations in children with rhinitis in improving HRQoL decreasing snoring and apneas and so daytime symptoms.

CO₂ Laser for the Treatment of Auricle Schwannoma: A Case Report and Review of the Literature

Patient: Male, 23

Final Diagnosis: Auricular schwannoma (root of the helix)

Symptoms: Erythematous neoplasm

Medication: —

Clinical Procedure: Surgery

Specialty: Otolaryngology

Maxillary sinus mucocele with orbital complications

INTRODUCTION

Maxillary sinus mucocele is an unusual clinic entity (incidence of 3-10%), represented by mucous secretion lined by respiratory stratified pavemented epithelium and its origin is mainly secondary to infections, inflammations, surgery, trauma or neoplasia.

CASE REPORT

We present a case of maxillary sinus mucocele. Subject of the study is a 74 aged patient referring positive anamnesis for nasal cavity surgery. His symptoms appeared six months ago and he complainted vertical ocular diplopia and ocular tension sensation, without rhinologic complaints. Oculistic examination confirmed an isolated left inferior rectus palsy, and CT showed mucous secretion occupying left maxillary sinus, with bone erosion to the orbital floor until orbital muscles. MRI is the gold standard for differential diagnosis with neoplastic lesions but the patient refused to perform this radio-diagnostic exam. He underwent to Endoscopic sinus surgery, consisting in middle meatal antrostomy and removal of the mucocele. Four months later the endoscopic follow-up showed regular maxillary cavity and regular ocular motility.

CONCLUSION

In our opinion the rebuilding of the eroded bone is not mandatory if the integrity of the maxillary upper wall mucosa is respected, and antrostomy with drainage allows to recover ocular and paranasal sinus function. KEY WORDS:, Diplopia, Endoscopic sinus surgery.

Unintentional recurrent laryngeal nerve injuries following thyroidectomy: Is it the surgeon who pays the bill?

BACKGROUND

Thyroidectomy is one of the most common intervention in general surgery and, after the turn of the century, its rate has sharply increased, along with a worldwide increased incidence of differentiated thyroid cancers. Therefore, injuries of the recurrent laryngeal nerve have become one of the most frequent cause of surgical malpractice claims, mostly following surgery for benign pathology.

MAIN BODY

Even if the incidence of definitive paralysis is generally lower than 3%, during the last 20 years in Italy, the number of claims for damages has sharply raised. As a consequence, a lot of defensive medicine has been caused by this issue, and a witch-hunt has been accordingly triggered, so determining mostly a painful and lasting frustration for the surgeons, who sometimes are compelled to pay a lot of money for increasing insurance premiums and lawyers fees. Recurrent laryngeal nerve injury should be considered as a potentially catastrophic predictable but not preventable event, rather than the result of a surgical mistake.

CONCLUSION

Purposes of the Authors are analyzing incidence, conditions of risk, and mechanisms of recurrent laryngeal nerve injuries, underlining notes of surgical technique and defining medical practice recommendations useful to reduce the risk of malpractice lawsuits and judgments against surgeons.

Chemoprevention using folic acid for dysplastic lesions of the larynx

Folate deficiency may be directly associated with carcinogenesis. Folate supplementation may reduce the risk of progression in a mucosa that is already genetically altered. The aim of the present study was to determine the role of folic acid in the treatment of mild and moderate laryngeal dysplasia recurring after surgery. The data obtained by laryngoscopy, measurement of serum folate levels and functional vocal assessment with the GIRBAS scale and VHI questionnaire were compared in patients who had received folic acid with a homogeneous group of patients with dysplasia who had not undergone any therapy. A total of 24 patients suffering from recurrence of mild or moderate laryngeal dysplasia (n=12, group A) were treated with 400 mg folic acid per os, once daily for 6 months. The patients in group B (n=12) received no treatment and were used as the control group. In group A, 7 (58%) patients exhibited a complete response, with clinically evident regression of leukoplakia, 3 (25%) displayed a partial decrease in the lesions with reduced volume of the area involved, whereas 2 patients exhibited no change. As regards patients in control group B, 8 (67%) exhibited no change, in 1 case there was a spontaneous regression, and in 3 (25%) there was disease progression with suspected malignant transformation, leading to repeat surgery. Therefore, folate deficiency may be considered to be a factor predisposing to precancerous lesions, and dietary folate supplementation may prevent and reduce the emergence of cancer.

Descending necrotizing mediastinitis in the elderly patients

Descending Necrotizing Mediastinitis (DNM) is a polymicrobic, dangerous and often fatal process, arising from head or neck infections and spreading along the deep fascial cervical planes, descending into the mediastinum. It can rapidly progress to sepsis and can frequently lead to death. It has a high mortality rate, up to 40% in the different series, as described in the literature. Surgical and therapeutic management has been discussed for long time especially in an elderly patient population. The literature has been reviewed in order to evaluate different pathogenesis and evolution and to recognise a correct therapeutic management.

Clinical significance of prophylactic central compartment neck dissection in the treatment of clinically node-negative papillary thyroid cancer patients

Background

Lymph nodal involvement is very common in differentiated thyroid cancer, and in addition, cervical lymph node micrometastases are observed in up to 80 % of papillary thyroid cancers. During the last decades, the role of routine central lymph node dissection (RCLD) in the treatment of papillary thyroid cancer (PTC) has been an object of research, and it is now still controversial. Nevertheless, many scientific societies and referral authors have definitely stated that even if in expert hands, RCLD is not associated to higher morbidity; it should be indicated only in selected cases.

Main body

In order to better analyze the current role of prophylactic neck dissection in the surgical treatment of papillary thyroid cancers, an analysis of the most recent literature data was performed. Prophylactic or therapeutic lymph node dissection, selective, lateral or central lymph node dissection, modified radical neck dissection, and papillary thyroid cancer were used by the authors as keywords performing a PubMed database research. Literature reviews, PTCs large clinical series and the most recent guidelines of different referral endocrine societies, inhering neck dissection for papillary thyroid cancers, were also specifically evaluated. A higher PTC incidence was nowadays reported in differentiated thyroid cancer (DTC) clinical series. In addition, ultrasound guided fine-needle aspiration citology allowed a more precocious diagnosis in the early phases of disease. The role of prophylactic neck dissection in papillary thyroid cancer management remains controversial especially regarding indications, approach, and surgical extension. Even if morbidity rates seem to be similar to those reported after total thyroidectomy alone, RCLD impact on local recurrence and long-term survival is still a matter of research. Nevertheless, only a selective use in high-risk cases is supported by more and more scientific data.

Conclusions

In the last years, higher papillary thyroid cancer incidence and more precocious diagnoses were worldwide reported. Among endocrine and neck surgeons, there is agreement about indications to prophylactic treatment of node-negative “high-risk” patients. A recent trend toward RCLD avoiding radioactive treatment is still debated, but nevertheless, prophylactic dissections in low-risk cases should be avoided. Prospective randomized trials are needed to evaluate the benefits of different approaches and allow to drawn definitive conclusions.

Our experience in the treatment of Malignant Fibrous Hystiocytoma of the larynx: clinical diagnosis, therapeutic approach and review of literature

Hereditary spherocytosis (HS) and Chronic myelocytic leukemia (CML) are both life threatening hemotologic diseases. They are rarely seen to occur simultaneously in one individual patient. Here we demonstrate a case of HS associated with CML in this study. The patient is a young female, diagnosed with HS in 2005, and was given partial embolization of the splenic artery. She got significant remission after the procedure. In 2008, she was found abnormal in blood routine test, after bone marrow routine, chromosome and fusion gene tests, she was diagnosed with CML (chronic phase). She did not receive regular treatment until 3 months prior, and is currently being treated with Dasatimib. She achieved hematological remission, but had no significant improvement in chromosome and fusion gene figures. Due to her severe condition of hemolysis, a splenectomy or an allogeneic hematopoietic stem cell transplantation is considered.