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Background: Distant metastasis (DM) development in Oropharyngeal Squamous Cell Carcinoma (OPSCC) represents an important prognostic factor. The identification of a phenotype of metastatic patients may better define therapeutic and follow-up programs. Methods: We included 408 patients with OPSCC, non-metastatic at the time of diagnosis, and treated with curative intent. The Overall Survival (OS) analyses were performed and the impact of developing DM on survival was analyzed through Cox proportional-hazard regression model. Results: 57 (14%) patients develop DM. 302 (74%) were p16+ OPSCC and 35 of them experienced DM. Advanced clinical stage, smoking, p16-status, response to primary treatment, and loco-regional relapse influence the DM rate. Only in the p16+ group, DM onset results in a greater impact on OS (p < 0.0001). Lung metastases have a better OS compared to non-pulmonary ones (p = 0.049). Conclusion: This retrospective study shows a possible stratification of OPSCC patients based on the risk of the development of DMs.

To retrospectively evaluate oncological outcomes in two groups of patients with pT4aN0 glottic SCC treated with total laryngectomy (TL) and neck dissection (ND) who underwent postoperative radiotherapy or exclusive clinical and radiological follow-up.It includes patients with pT4N0 glottic SCC who underwent TL and unilateral or bilateral ND with or without PORT. Divided in two comparison groups: the first group underwent adjuvant RT (TL-PORT); the second group referred to clinical and radiological follow-up (TL).PORT was associated with a better OS while no differences were found in terms of DSS. A better local control is achieved when PORT is administered while no differences in terms of regional and distant control rates were found. Bilateral ND positively impacts on the regional control while the PNI negatively impact the regional control.A tailored PORT protocol might be considered for pT4N0 glottic SCC treated with TL and ND, both considering the ND's extent and presence of PNI.

Primary mucosal melanoma of the larynx (PLM) is a rare entity among head and neck cancers. Due to its rarity, clear protocols of management are not available. A deeper knowledge of the clinical and biological behaviour of PLM is strongly needed.According to PRISMA process, we searched through electronic databases case reports, case series and review articles providing relevant clinical data. The survival analysis was performed with Kaplan-Meier survival curves, using disease free survival (DFS) and overall survival (OS) as endpoints.1074 articles were initially screened, of which 37 studies describing 44 PLM cases were selected and included in the analysis. Mean age was 59.7 years with a mean follow-up time of 25.4 months. The most common symptom at presentation was hoarseness (52%), while the most involved laryngeal subsite was supraglottic region (62%). Most patients presented with an advanced stage. Tumour (T) and node (N) status at presentation did not influence OS nor DFS, whereas distant metastases (M) status resulted significantly associated with the reduction of OS and DFS time (Mantel-Cox: p 0.0001 and p = 0.001, respectively). The laryngeal subsite and the type of surgery performed did not significantly impact on OS and DFS.Treatment for PLM remains debated. Surgery with safe margins is recommended due to the high rates of local recurrence. Systemic therapy is advised for metastatic disease. However, the prognosis remains poor even after radical resection or targeted therapy.

Quality of Life (QoL) after extensive head and neck resections is of paramount importance, especially after pharyngolaryngectomy or pharyngolaryngoesophagectomy where complex digestive tract reconstruction is required (with gastric pull-up or colon transposition). Tracheodigestive puncture (TDP) is the only vocal restoration option in this group of patients. The aim of this study is to evaluate postoperative complications, vocal outcomes, voice-related and swallowing-related QoL after secondary TDP in this cohort of patients.A retrospective study was conducted in the tertiary referral center of Verona Hospital between June 2014 and June 2020. Patient demographics, clinical and surgical data were assessed. Speech objective and subjective evaluation was performed. QoL was assessed with Voice Handicap Index-10 (VHI-10) and M.D. Anderson Dysphagia Inventory (MDADI) questionnaires.Seven patients met the inclusion criteria, but two had died before questionnaires were administered. No intraoperative complications were noted after TDP surgery. There were delayed complications in four cases (57.1%) and all were treated with restoration. Intelligible voice was restored in all patients. Maximum phonation time and maximal voice intensity recorded were 5.42 ± 3.27 s and 65.20 ± 5.45 dB, respectively. Acceptable average VHI-10 and MDADI scores were obtained in all patients.Secondary TDP performed after gastric pull-up or colon transposition reconstructions are feasible and effective procedures. An intelligible voice was restored in all patients, with satisfactory patient-perceived voice-related and dysphagia-related quality-of-life outcomes.

OBJECTIVE: To investigate the influence of the COVID-19 pandemic on operative practices of otology and neurotology providers internationally. STUDY DESIGN: Cross-sectional survey. METHODS: A 78-question survey was distributed to otologists and neurotologists between May 12, 2020 and June 8, 2020 to assess the impact of the pandemic on surgical practices. Sections within the survey delineated time periods: prior to the crisis, onset of the crisis, during the crisis, postcrisis transition. RESULTS: Of 396 survey respondents, 284 participants from 38 countries met inclusion criteria.Respondents were 16.9% female and 82.4% male, with a most common age range of 40 to 49 years (36.3%). 69.8% of participants had been in practice for over 10 years and most respondents worked in an academic medical center (79.2%). The average operative weekly caseload was 5.3 (SD 3.9) per surgeon prior to the crisis, 0.7 (SD 1.2) during the COVID-19 crisis, and 3.5 (SD 3.3) for those who had begun a postcrisis transition at the time of survey administration (p 

Ossiculoplasty is aimed at improving or maintaining the conductive portion of hearing in patients subjected to otologic surgery. However, satisfying hearing is frequently observed after tympanoplasty even in the absence of ossicular chain reconstruction. Aims of this article would be to evaluate hearing outcomes, in terms of pure tone average air-bone gap (PTA-ABG), in patients subjected to tympanoplasty for middle ear disease whose ossicular chain has not been reconstructed, and then to investigate factors influencing those outcomes.Retrospective chart review of patients who underwent ear surgery from year 2003 to 2021 at the Otolaryngology-Head and Neck surgery department of the University Hospital of Modena was performed. Audiometric test results from patients who did not receive any ossicular chain reconstruction were collected and analyzed.Tertiary University referral center.The mean patients' follow-up was 34.1 months. Overall, mean PTA-ABG in the study population was 23.5 dB. Integrity of stapes superstructure, malleus handle and malleus head, together with the use of tragal cartilage graft over autologous temporalis fascia to reconstruct the tympanic membrane were found to be significantly associated with better hearing outcomes, as demonstrated by lower PTA-ABG values. Stapes superstructure was found to be associated with more favorable outcomes in multivariate analysis, net of confounding factors.Good hearing performance can be obtained in patients subjected to middle ear surgery, even if the ossicular chain is not reconstructed. Presence of ossicular chain remnants and the use of a rigid material for tympanic membrane reconstruction are the factors that seem to most favorably influence hearing outcomes after surgery for middle ear disease.

Objective: Recently, a novel host‐related index, the Host‐index (H‐index), including both inflammatory and nutritional markers, has been described and observed to stratify prognosis in patients with squamous cell carcinoma (SCC) of the oral cavity more accurately than other host‐related indexes This study aimed to investigate the prognostic performance of the H‐index using pretreatment blood tests in patients receiving up‐front surgery for SCC of the larynx. Methods: This retrospective observational study included a multicenter series of consecutive patients with SCC of the larynx diagnosed between 1 January 2009 and 31 July 2018, whose pretreatment blood tests were available and included the parameters necessary for the calculation of neutrophil to lymphocyte ratio (NLR) and the H‐index. Their association with disease‐free survival (DFS) and overall survival (OS) was measured. Results: A total of 231 patients were eligible for the present analysis (median [range] age, 68 [37‐96] years; 191 [82.7%] men). The median follow‐up was 73 months. In multivariable Cox proportional hazards regression models, increasing age (adjusted hazard ratio [aHR], 1.07 per year; 95% CI, 1.04‐1.09), advanced pT stage (aHR = 1.71 95% CI: 1.07‐2.71), and having close or positive surgical margins (aHR = 2.01; 95% CI: 1.21‐3.33) were significantly associated with poor OS. Among blood parameters, a higher neutrophil count was a strong predictor of both worse DFS (aHR for recurrence/death = 2.34; 95% CI: 1.24‐4.40) and OS (aHR for death = 2.67; 95% CI: 1.51‐4.71). Among inflammatory blood indexes, while NLR was not significantly associated with DFS or OS, patients with H‐index ≥8.37 showed a higher aHR for both recurrence/death (2.82; 95% CI: 1.65‐4.79) and death (2.22; 95% CI: 1.26‐3.89). Conclusion: In conclusion, the present study confirms the prognostic value of pretreatment H‐index, an easily measurable inflammatory and nutritional index, in patients with SCC of the larynx. Level of Evidence: III

Expanded Transcanal Transpromontorial Approach (ExpTTA) is an endomicroscopic technique that allow surgical excision of small and symptomatic neuromas limited to the internal auditory canal (IAC) or minimally invasive the cerebellopontine angle (CPA). ExpTTA is a safer alternative to the exclusive endoscopic technique as it allows a wider surgical field and better management of the auditory porus and CPA.We report a retrospective case series of 34 patients who underwent ExpTTA between 2017 and 2022 at the ENT Departments of the University Hospital of Modena, Bologna and Verona. Tumor size was defined according to the Koos staging and hearing function was classified according to the AAOHNS. A clinical evaluation of facial nerve (FN) function was performed using the House and Brackman scale (HBs).Our cohort consists of 34 patients. At time of surgery all patients had a normal preoperative facial function. Gross total resection was achieved in all patients, without intraoperative complications, and FN continuity was preserved in all cases. No major complications were observed. Regarding post-operative FN function, at hospital discharge ten patients had impairment equal or greater than IV grade according to HBs. At 6 months after surgery only two patients presented with moderate/severe facial paralysis (grade IV HBs) and finally at 12-month follow-up all patients had a satisfactory recovery of nervous function (grade III HBs).ExpTTA is a safe and effectively technique for treatment of small VS (Koos I, II and selected cases of Koos III) with low postoperative morbidity.

Middle ear anatomy and physiology is highly complex, yet familiarity is important to perform middle ear surgery and understand surgically relevant ventilation pathways of the ear compartments. The middle ear is divided into five subspaces: the mesotympanum, the retrotympanum posteriorly, the epitympanum superiorly, the protympanum anteriorly, and the hypotympanum inferiorly. The Eustachian tube plays a crucial role in maintaining middle ear aeration and atmospheric pressure. There are two independent aeration routes of the epitympanum. Thanks to the advent of the endoscope, this anatomic and physiologic knowledge has allowed one to understand the pathophysiology of ear diseases, improving surgical concepts.

This combined American Neurotology Society, American Otological Society, and American Academy of Otolaryngology - Head and Neck Surgery Foundation document aims to provide guidance during the coronavirus disease of 2019 (COVID-19) on 1) "priority" of care for otologic and neurotologic patients in the office and operating room, and 2) optimal utilization of personal protective equipment. Given the paucity of evidence to inform otologic and neurotologic best practices during COVID-19, the recommendations herein are based on relevant peer-reviewed articles, the Centers for Disease Control and Prevention COVID-19 guidelines, United States and international hospital policies, and expert opinion. The suggestions presented here are not meant to be definitive, and best practices will undoubtedly change with increasing knowledge and high-quality data related to COVID-19. Interpretation of this guidance document is dependent on local factors including prevalence of COVID-19 in the surgeons' local community. This is not intended to set a standard of care, and should not supersede the clinician's best judgement when managing specific clinical concerns and/or regional conditions.Access to otologic and neurotologic care during and after the COVID-19 pandemic is dependent upon adequate protection of physicians, audiologists, and ancillary support staff. Otolaryngologists and associated staff are at high risk for COVID-19 disease transmission based on close contact with mucosal surfaces of the upper aerodigestive tract during diagnostic evaluation and therapeutic procedures. While many otologic and neurotologic conditions are not imminently life threatening, they have a major impact on communication, daily functioning, and quality of life. In addition, progression of disease and delay in treatment can result in cranial nerve deficits, intracranial and life-threatening complications, and/or irreversible consequences. In this regard, many otologic and neurotologic conditions should rightfully be considered "urgent," and almost all require timely attention to permit optimal outcomes. It is reasonable to proceed with otologic and neurotologic clinic visits and operative cases based on input from expert opinion of otologic care providers, clinic/hospital administration, infection prevention and control specialists, and local and state public health leaders. Significant regional variations in COVID-19 prevalence exist; therefore, physicians working with local municipalities are best suited to make determinations on the appropriateness and timing of otologic and neurotologic care.

Background Studies concerning programmed death-ligand 1 (PD-L1) expression in precancerous lesions of head and neck (HN) region have shown variable results. Methods We systematically reviewed the published evidence on PD-L1 expression in HN precancerous lesions. Results Of 1058 original articles, 14 were included in systematic review and 9 in meta-analysis. The pooled estimate of PD-L1 expression was 48.25% (confidence interval [CI] 21.07-75.98, I2 98%, tau2 0.18). PD-L1 expression appeared to be more frequent in precancerous lesions than in normal mucosa (risk ratio [RR] 1.65, CI 0.65-4.03, I2 91%, tau2 0.82) and less frequent than in invasive squamous cell carcinoma (RR 0.68, CI 0.43-1.08, I2 91%, tau2 0.22). Conclusions PD-L1 expression could reflect a point of balance between host immune response and cancer escape ability. High heterogeneity and moderate quality suggest that further studies with larger sample size and more rigorous case selection will allow more precise assessment of PD-L1 expression in HN precancerous lesions.

Through years, interest in quality of life (QoL) among patients affected by vestibular schwannoma (VS) has increased. The expansion of the indications for endoscopic ear surgery allowed the development of the transcanal transpromontorial surgery (TTS) for VS removal. The objective of the present study was to assess QoL in a cohort of VS patients operated on by translabyrinthine (TL), retrosigmoid (RS) and TTS approach. The study was conducted on 111 patients who underwent surgery for VS between January 2017 and January 2020 at two different institutions. Patients fulfilled three questionnaires during follow-up: Glasgow Benefit Inventory, Depression Anxiety Stress Scales-21 and Penn Acoustic Neuroma Quality-Of-Life. The association between sex, age, date of surgery, tumor size, post-operative facial nerve (FN) function and QoL outcomes was assessed. An overall subjective impairment was demonstrated in all groups. Age, Koos staging and FN functions were associated to distinct QoL outcomes. QoL decreases in patients surgically treated for VS. The TTS may allow improved scores in many domains, confirming to be a subjectively well-tolerated technique.

ObjectiveOtosclerosis affects women twice as often as men, especially during fertile age. A role of female hormones has been claimed, but controversy still exists regarding the influence of pregnancy. The purpose of this research was to analyse the role of pregnancy on the course of otosclerosis.MethodPubMed was searched in May 2019 using the terms ‘otosclerosis AND pregnancy’, ‘otosclerosis AND pregnant’, ‘otosclerosis AND parous’, ‘otosclerosis AND parity’, and ‘otosclerosis AND puerperium’. Age at diagnosis, number of pregnancies and the temporal relationship of the disease with childbearing were considered.ResultsFrom 65 articles, 11 were chosen for review. They described 2323 women affected by otosclerosis: 1805 had at least 1 pregnancy, while 518 did not. During childbearing, otosclerosis began in 1 per cent of pregnant women, worsened in 21 per cent and worsened during puerperium in 4 per cent. Often, the authors reported hearing change with pregnancy without details, so a further group has been considered composed of women belonging to any of the groups just mentioned or to another group of women not further characterised. Overall, hearing change occurred during pregnancy in 44 per cent. A statistically significant correlation emerged between hearing change and number of pregnancies (p = 0.003).ConclusionBecause of wide data heterogeneity and the difficulty in analysing a single factor, absolute statements could not be formulated. According to this review, pregnancy seems to have a worsening effect on the course of otosclerosis.

Ménière's disease is an idiopathic inner ear disorder characterized by recurrent vertigo, fluctuating sensorineural hearing loss, and persistent tinnitus. In 10% to 30% of cases, conservative therapy fails, and Ménière's disease is defined as intractable. In these patients, ablative techniques with unilateral vestibular deafferentation are mandatory. Several approaches for vestibular neurectomy, which preserve hearing capability, are described. In patients presenting severe dizziness associated with high-grade sensorineural hearing loss, surgical labyrinthectomy, or selected vestibular neurectomy through a translabyrinthine approach are the treatments commonly considered. This study reports the first application of transcanal transvestibular endoscopic neurectomy in two patients with frequent disabling vertigo and high-grade sensorineural hypoacusia.This was a retrospective chart review including patients with intractable Ménière's disease who underwent vestibular neurectomy, performed in our ENT department between January 2017 and January 2020, selecting patients with disabling vertigo and high-grade sensorineural hypoacusia. We describe step-by-step the surgical technique of transcanal transvestibular endoscopic neurectomy.Overall, two patients underwent transcanal transvestibular endoscopic neurectomy. We performed transcanal transvestibular neurectomy in all cases. No intraoperative complications were observed. On the 2nd postoperative day, one patient presented CSF leak, leading to surgical revision. A complete resolution of vertigo attacks was observed 6 months after surgery.Even though this study presents a limited number of cases, transcanal transvestibular neurectomy is a promising, safe, and effective procedure in selected cases.

Recurrent salivary gland carcinomas (RSCs) are poorly characterized and their clinical features and treatment options have not yet been fully described. The goal of this study was to analyze the therapeutic strategies and oncological outcomes of RSC patients through a literature review analysis. This systematic review was performed according to the PRISMA statements. Inclusion criteria for the systematic review were based on the population, intervention, comparison, and outcomes according to (PICO) framework. Two thousand seven hundred and four records were selected and 1817 recurrences were studied. Three hundred and sixty-five patients underwent salvage surgery (20.1%) and their 5-year mortality rate, overall survival and disease-free survival were 35%, 70%, and 42%, respectively. RSCs are aggressive neoplasms with a high rate of distant metastases (28.9%). Salvage surgery can be considered in patients with limited local and/or regional recurrences, even in case of single distant relapse, appearing within the first 3 years of follow-up.

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

Objective: To assess the predictive value of pre-operative CT imaging in pediatric patients affected by cholesteatoma of the middle ear, comparing pre-operative CT findings to intra-operative features. Methods: A retrospective study was performed on a population of 26 pediatric patients who underwent tympanoplasty for middle ear cholesteatoma at the Otorhinolaryngology Departments of Verona and Modena University Hospitals between December 2011 and June 2018. Comparison between pre-operative CT images and intra-operative findings (assessed from video recording) was made focusing on the involvement of specific structures: ossicular chain, tegmen tympani, labyrinthine fistula, facial nerve, and temporal bone involvement. CT sensitivity, specificity, positive and negative predictive values were calculated. Results: Overall, 28 surgical procedures were evaluated. No statistically significant differences were encountered between CT images and intra-operatory findings regarding the selected parameters. Conclusions: Based on our study, pre-operative temporal bone CT scan is a valuable tool for the assessment of pediatric patient candidates for cholesteatoma surgery given the absence of statistically significant differences between radiologic and intra-operative findings. The present findings might support the indication to routinely perform temporal bone CT scan in children with cholesteatoma as part of pre-surgical plan. Level of evidence: III.

The aim of this study is to evaluate the feasibility and the safety of a novel, alternative method for bone tissue management in facial nerve decompression by a middle cranial fossa approach. Several applications of Piezosurgery technology have been described, and the technique has recently been extended to otologic surgery. The piezoelectric device is a bone dissector which, using micro-vibration, preserves the anatomic integrity of soft tissue thanks to a selective action on mineralized tissue. An anatomic dissection study was conducted on fresh-frozen adult cadaveric heads. Facial nerve decompression was performed by a middle cranial fossa approach in all specimens using the piezoelectric device under a surgical 3D exoscope visualization. After the procedures, the temporal bones were examined for evidence of any injury to the facial nerve or the cochleovestibular organs. In all cases, it was possible to perform a safe dissection of the greater petrosal superficial nerve, the geniculate ganglion, and the labyrinthine tract of the facial nerve. No cases of semicircular canal, cochlea, or nerve damage were observed. All of the dissections were carried out with the ultrasonic device without the necessity to replace it with an otological drill. From this preliminary study, surgical decompression of the facial nerve via the middle cranial fossa approach using Piezosurgery seems to be a safe and feasible procedure. Further cadaveric training is recommended before intraoperative use, and a wider case series is required to make a comparison with conventional devices.

Objective To describe the outcome and feasibility of an exclusive endoscopic transcanal transpromontorial approach (ETTA) for decompression of the labyrinthine segment of the facial nerve (LSFN). Patient A 60-year-old man with a left-sided transverse fracture of temporal bone involving the LSFN, resulting in a grade VI House-Brackmann (HB) facial palsy, associated with ipsilateral total sensorineural hearing loss. Intervention Surgical decompression of the LSFN by ETTA. Main outcome measure The patient underwent ETTA which allowed complete exposure and decompression of the LSFN. Results One year postoperatively, the patient had recovered with House-Brackmann grade II facial function. Conclusion ETTA can be considered a valuable and appropriate technique for posttraumatic decompression of LSFN, associated with unilateral total sensorineural hearing loss. The procedure resulted in significant facial nerve function improvement. ETTA should be considered both a scarless, mastoid conserving and less invasive surgical technique for posttraumatic LSFN decompression associated with pre-existing cochlear impairment.

Approccio transmeatale microchirurgico nei neurinomi intralabirintici e intrameatali: revisione della letteratura.

BackgroundThe excellent surgical results obtained with transnasal endoscopic approach to the anterior skull base (ASB) are universally recognized; less is known about the quality of life of patients after surgery.ObjectiveThe aim of this study is to analyze the quality of life of patients after endoscopic transnasal surgery for the treatment of neoplasms of the ASB.MethodsWe conducted a retrospective review of patients who underwent transnasal endoscopic surgery for treatment of ASB tumors at the Tertiary Referral Center University Hospital of Verona. All patients were asked to complete the Anterior Skull Base Questionnaire (ASBQ), the Skull Base Inventory (SBI), and the Sino-nasal Outcome Test – 22 Items (SNOT-22) after surgical treatment. The study population was divided into subgroups; a statistical analysis of the overall results and of the different questionnaire domains was performed.Results51 patients were enrolled in this study. The average score was 3.04 for ASBQ, 4.05 for SBI and 28.88 for SNOT-22. Analysis of the overall results for the ASBQ showed a lower quality of life in patients after recurrent surgery and in female patients. The SBI showed similar results in relation to recurrent surgery and radiotherapy. Similarly, the results for SNOT-22 highlighted the negative impact of recurrent surgery and radiotherapy.ConclusionOur results confirmed that the endoscopic transnasal approach shows excellent results not only in terms of surgical outcome, but also for the possibility of ensuring a good QoL after treatment. Recurrent surgery and radiation treatments were the most important negative prognostic factors.

Objective To report on the application of the 3D exoscopic system to microsurgery in a cohort of head and neck cancer patients; to analyse the performance of microvascular anastomoses, flap harvesting and insetting under exoscopic view and to evaluate the surgeon's feedback after procedures. Methods An observational study was performed on 10 consecutive patients undergoing exoscopic microsurgical free flap reconstruction. The VITOMⓇ 3D system was applied to all procedures for microsurgical anastomoses, flap harvesting and insetting. Data about the type of resection and reconstruction, intraoperative and post-operative complications were recorded. Surgeon's feedback on exoscopic experience was collected through a questionnaire. Results Reconstruction after oncologic demolition was performed by radial forearm flap in 3 cases (30%), antero-lateral thigh flap in 4 cases (40%), composite fibula flap in 2 cases (20%) and chimeric scapula flap in 1 case (10%). The mean surgical time for the microsurgical anastomoses (1 vein and 1 artery) was 34 min (range: 32–38). No intraoperative complications occurred and only two patients experienced pharyngo-cutaneous fistula in the post-operative time. There were neither cases of loss of flap, nor need of surgical revision. None of the cases had to be converted to OM technique. The surgeon never experienced back/neck pain, headache and nausea/vertigo. Occasionally, he felt tired and stressed and he reported eyestrain after one procedure only. Conclusions VITOMⓇ 3D is easy to apply in the field of head and neck microsurgery and provides optimal stereoscopic view and anatomical details. Further studies are needed to validate indications and advantages of 3D exoscope as compared to OM.

The procedure for salvage total laryngectomy (STL) is burdened by a high rate of postoperative complications as a result of delayed wound healing in previously irradiated tissue. Several observational studies have investigated the role of prophylactic vascularized flaps to aid pharyngeal closure after STL and prevent the development of PCF. The use of a temporoparietal fascia free flap (TFFF) as an overlay flap for STL has been described previously in two published studies and both sets of authors agreed that the most obvious benefit of the TFFF in STL is a reduced PCF rate with low site morbidity and good functional outcomes. The aim of this video is to illustrate the use of the temporoparietal fascia flap to provide an adjunctive reinforcement layer in the reconstruction of the pharynx.

Pathology of the lateral skull base poses a unique challenge for the surgeon. An intimate knowledge of the anatomy and the various approaches used for accessing pathology of the lateral skull base is critical. Three novel, minimally invasive, transcanal approaches for the management of lateral skull base pathology are described herein along with their respective indications, advantages, and disadvantages.

Open partial laryngectomies still play an important role in contemporary conservative management of laryngeal cancer. A comprehensive and systematic classification of open partial horizontal laryngectomies (OPHLs) was presented by the European Laryngological Society working committee in 2014. The aim of this video is to show the main surgical steps in OPHL using a cadaveric dissection and to explain the modular approach for removal of laryngeal tumors.

The purpose of this study is to present the chimeric scapula tip-free flap as a reconstructive choice in composite head and neck defects and to highlight the experiences of the authors in this field.A retrospective study and a literature review were conducted. Data about preoperative condition, intraoperative images, and radiological and clinical documentation were collected.Excision of head and neck advanced cancers may result in large composite defects containing different types of soft tissue and bone. This topic is particularly challenging in salvage surgery after radiation therapy. In this setting, reconstructive techniques are very complex and traditionally require the use of multiple microvascular flaps. Chimeric free flaps, based on the subscapular system, allow complex reconstructions, providing both soft tissue and bone on a single vascular peduncle.The regional anatomy of the subscapular system and the possible chimeric flaps that can be harvested will be discussed, together with the reconstructive surgical technique used and the positioning of the patient. Two representative clinical cases of complex head and neck reconstruction after radiotherapy are presented.Different types of chimeric flap can be harvested from the subscapular system. These flaps can include different tissues: skin, bone, muscle on a single vascular peduncle. This characteristic is particularly useful in complex defects with different tissue types involved, following large en-bloc excision of advanced head and neck tumors.Free flaps based on the subscapular system can be an excellent reconstructive choice in complex head and neck defects.

Purpose: Post-traumatic facial nerve (FN) paralysis might need surgical decompression in selected patients. Different microscope-based surgical techniques are described in the literature such as the transmastoid, the middle cranial fossa and the translabyrinthine approach. The effectiveness of the transcanal endoscopic approach (TEA) in managing such condition has never been described and its possible indications has to be defined. Methods: Retrospective multi-centric case series of patients with post-traumatic FN paralysis surgically treated with TEA. From July 2013 to July 2017, 6 patients underwent TEA for post-traumatic FN paralysis with involvement of the second genu and/or the tympanic segment of the nerve. The surgical technique is described step by step, with focus on anatomic landmarks. Post-operative outcomes are specified in terms of FN postoperative function and audiologic results. Results: The TEA showed to recover a House–Brackmann grade I–II FN function in 83.2% of the patient. Post-operative air–bone gap significantly improved; whereas, the pure-tone average bone conduction did not differ significantly. Conclusions: TEA represents a viable option for the treatment of post-traumatic facial palsy in patients with radiologic evidence of tympanic segment and/or perigeniculate region involvement with no involvement of the mastoid segment of the FN. Transcanal endoscopic facial nerve decompression is a safe and effective approach in highly selected cases. Level of evidence: 4

Objective The objective of this study is to describe what we consider to be the state-of-the-art procedure for the treatment of tympanic membrane perforations, and to present the results attained in our institution. Study design A retrospective cohort study, using data of Verona University Hospital, Italy. This medical record includes the data of 98 patients who underwent 100 transcanal endoscopic type I tympanoplasties from November 2014 to October 2017. Setting Tertiary referral center University Hospital of Verona, Italy. Patients Were enrolled 109 patients, that underwent endoscopic type I tympanoplasty in the period considered. Out of the selected patients, 11 (10.1%) were lost to long-term follow-up, and were therefore excluded from our study. Other exclusion criteria were surgical approaches that included other procedures. Patients whose follow-up was shorter than 6 months were excluded from this study. Intervention The technique is based on an endoscopic placement of underlay graft of temporal fascia or tragal cartilage. We consider the data of four surgeons from Verona University ENT department. Main outcome measure In the study we considered the reduction of the Air Bone Gap as functional outcome and the integrity of the reconstruction as anatomical outcome of success. Results No major intraoperative complications were observed. The closure rate was 86%. The mean surgery time was 48.6 minutes. The air bone gap was improved within 20 DB HL in 89% of patient. Only 8% of patients needed revision surgery, and none needed a third surgical evaluation. Conclusion Endoscopic ear surgery is by now a reality that has replaced in many cases exclusive microscopic ear surgery. Transcanal endoscopic type I tympanoplasty can be considered nowadays as an alternative technique for tympanic membrane perforations.

To demonstrate the feasibility of a transcanal infrapromontorial approach for vestibular schwannoma surgery through an anatomical dissection study and the description of a clinical case. A microscopic and endoscopic dissection of cadaveric heads was undertaken through a transcanal infrapromontorial approach to the internal auditory canal (IAC), preserving the cochlea and the cochlear nerve. Description of the anatomy and surgical steps is reported as well as presentation of a clinical case in which a transcanal infrapromontorial approach was performed. In all of the cadaveric dissections, a transcanal infrapromontorial route with near total cochlea preservation was performed, removing only the most posterior portion of the basal turn of the cochlea. The IAC was opened through removal of “cochlear-vestibular bone”. At the end of the dissection a cochlear implant array was placed. A transcanal infrapromontorial approach was also performed in a patient to allow a concurrent cochlear implant placement, with good postoperative results. The transcanal infrapromontorial approach permits the preservation of the cochlea and the cochlear nerve. This approach may be considered as an option in case of a small intracanalicular schwannoma removal (

Spontaneous skull base cerebrospinal fluid leaks occurring without any apparent cause are rare. But those patients that present such leaks simultaneously, or successively, in multiple locations are even rarer. Given the rarity of this condition, we collected data from other groups in a multicentre study to reach an adequate number of patients and draw some preliminary considerations.We carried out a multicentre retrospective study on a cohort of patients treated at third level hospitals in Italy, Spain, United Kingdom and Greece for multiple spontaneous-CSF leaks and we compared them with a control group of patients treated for recurrent spontaneous-CSF leaks. Data regarding clinical aspects, radiological findings, surgical techniques and outcome were collected and preliminary considerations on the results were discussed.A total of 25 patients presented multiple simultaneous spontaneous CSF leaks while 18 patients fit with the criteria of recurrent spontaneous CSF leaks. Data analysis was conducted separately.Our understanding of the pathogenesis of this condition is currently very limited. A causative role of IIH may be present but the differences that emerged from the comparison with patients with recurrent fistulas seem to promote the possible role of other cofactors. A longer follow-up period is needed, and, in our opinion, prospective and multicentre studies are the only solution to seriously deal with such a complex topic.

The pathology of the facial nerve is extremely varied and extensive knowledge of the surgical anatomy in different approaches is required to manage it. During the last 15 years, the development of endoscopic ear surgery has significantly changed anatomical concepts, introducing new surgical approaches. The aim of this review is to illustrate five different surgical approaches to the facial nerve: the endoscopic approach, the middle cranial fossa approach, two translabyrinthine approaches (one simple and one endoscopic-assisted) with decompression of the whole petrous portion of the facial nerve, and a transotic approach with temporal craniotomy. Representative cases of middle and/or inner ear pathologies, surgically treated at our ENT Department, were selected to illustrate each of the five different approaches involving the facial nerve throughout its course. In all cases, the pathology was removed with effective decompression of the facial nerve. The surgical anatomy in each surgical approach is described and illustrated. Facial nerve surgery is challenging for ENT specialists. An excellent knowledge of facial nerve anatomy is needed to eradicate pathology, avoiding nerve injuries and providing a good outcome after surgery.

The aim of the study is to assess whether the 3D exoscopic surgery technique could be used in lateral skull base surgery and if it could ultimately replace the microscope in the future. This is a retrospective study in which were included 24 patients affected by lateral skull base pathologies, who underwent surgery using the 3D exoscope or the operative microscope at the Department of Otolaryngology—Head and Neck Surgery at the University Hospital of Verona. The exoscope and microscope groups each included 12 cases. The feasibility of all the surgical steps solely using the 3D exoscope was evaluated. The exoscope group and microscope group were compared taking into account the following factors: time of the surgery, facial and hearing functions outcomes, as well as the intraoperative and postoperative complications. No intraoperative complication occurred during all the procedures. Postoperatively, only one minor complication emerged. The average operative time was 289 in the exoscope group and 313 min in the microscope one. No significant statistical differences were identified between the two groups (p > 0.05). The facial and hearing function outcomes were fully comparable. Our experience demonstrated that the exclusive use of the 3D exoscope, as that of the traditional microscope during lateral skull base surgery, is feasible for all open approaches. The use of the 3D exoscopic technique is very promising for future lateral skull base surgeries.

OBJECTIVES To describe facial sinus anatomy from an endoscopic perspective and present a radiologic classification. METHODS Facial sinus was studied by endoscopy and high-resolution computed tomography (HRCT) scan in 39 temporal bones that underwent exclusive transcanal endoscopic approach. A radiomorphologic classification based on the relationship between the facial sinus and the mastoid portion of the facial nerve is created as follows. In type A facial sinus, the pneumatization of the facial sinus did not extend medially or posteriorly to the mastoid portion of the facial nerve. In type B facial sinus, the pneumatization extended posteriorly to the mastoid portion of the facial nerve. In type C facial sinus, the pneumatization extended posteriorly and medially to the mastoid portion of the facial nerve. RESULTS In all the specimens that underwent HRCT (n = 31), facial sinus could be identified, and its depth classified, in relation to the facial nerve. In this group, 58% type A, 29% type B, and 13% type C facial sinuses were identified. In all the specimens (n = 39), the facial sinus could be assessed by means of an exclusive endoscopic transcanal approach, and anatomical variants of the chordiculus, previously known as chordal ridge, could be described: ridge (39%), bridge (18%), incomplete (15%), and absent (28%). CONCLUSION Endoscopic exploration of the retrotympanum guarantees a very good exposure of the facial sinus, allowing detailed anatomic descriptions of its conformation and relationships with other structures. Improvement in our knowledge of its anatomy might decrease the possibility of residual disease during cholesteatoma surgery. Angled endoscopes (e.g. 45 °, 70 °) can guarantee a better view of the facial sinus. LEVEL OF EVIDENCE NA. Laryngoscope, 128:2397-2402, 2018.

Objective: Vestibular schwannoma (VS) is a benign tumor of the lateral skull base. Different microscopic surgical techniques are described in literature: the retrosigmoid and translabyrinthine approaches are used to treat big tumors located in the cerebellopontine angle, and the middle cranial fossa approach is utilized for small tumors with good hearing preservation. The expanded transcanal transpromontorial (ExpTT) approach is a combined microscopic-endoscopic technique previously indicated for Koos stage I and II VS and now proposed for larger VS, up to 3 cm in diameter, with linear progression into the cerebellopontine angle and touching the brainstem. Study Design: The study was a retrospective case series of patients who underwent ExpTT surgery for VS in our ear, nose, and throat department. Setting: We reviewed the surgical videos and electrophysiologic data recorded during the surgical operations. Subjects and Methods: From January 2015 to January 2017, 20 patients affected by Koos stage II and III VS underwent surgery in our department with the ExpTT approach. This novel technique is described step by step, with a focus on the surgical procedure and anatomic landmarks; outcomes are detailed in terms of early and late complications. The mean follow-up was 15 months. Results: The ExpTT approach permitted, in all patients, gross total resection of the tumor without any complication and with preservation of facial nerve function. All patients had a good postoperative recovery. Conclusion: The ExpTT technique is a new approach that combines the advantages of a microscopic technique with the ones offered by the endoscope in removal of VS.