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Orbital approaches provide significant trajectory to the skull base and are used with differently designed pathways. The aim of this study is to investigate the feasibility of a combined transorbital and transnasal approach to the anterior and middle cranial fossa. Cadaveric dissection of five silicon-injected heads was used. A total of 10 bilateral transorbital approaches and 5 extended endonasal approaches were performed. Identification of surgical landmarks, main anatomical structures, feasibility of a combined approach and reconstruction of the superior orbital defect were examined. Rod lens endoscope (with 0° and 45° lenses) and endoscopic instruments were used to complete the dissection. The transorbital approach showed good versatility and provides the surgeon with a direct route to the anterior and middle cranial fossa. The transorbital avascular plane showed no conflict with major nerves or vessels. Large exposure area from crista galli to the third ventricle was demonstrated with significant control of different neurovascular structures. A combined transorbital transnasal approach provides considerable value in terms of extent of exposure and free hand movement of the two surgeons, and allows better visualisation and control of the ventral skull base, thus overcoming the current surgical limits of a single approach. Combination of these two minimally invasive approaches should reduce overall morbidity. Clinical trials are needed to evaluate the virtual applications of this approach.Gli approcci transorbitari permettono di ottenere un'ampia via d'accesso al basicranio e sono utilizzati in diverse procedure chirurgiche. Lo scopo di questo studio è valutare la fattibilità di un approccio endoscopico combinato transobitario e transnasale alla fossa cranica anteriore e media. Su cinque teste iniettate con silicone, sono stati eseguiti un totale di 10 approcci endoscopici transorbitari e 5 "extended endonasal approach" (EEA). Durante le procedure sono stati identificati i punti di repere chirurgici e le strutture anatomiche principali, valutando la fattibilità dell'approccio combinato e della successiva ricostruzione del tetto orbitario. Per eseguire la dissezione sono stati utilizzati endoscopi rigidi con sistema a lente cilindrica 0° e 45° e una strumentazione endoscopica dedicata. L'approccio transorbitario ha mostrato grande versatilità ed ha permesso al chirurgo di ottenere un corridoio diretto alla fossa cranica anteriore e media. Il piano transorbitario avascolare non era in conflitto con vasi o nervi maggiori. La dissezione ha mostrato una vasta esposizione del basicranio, dalla crista galli fino al terzo ventricolo, assicurando un controllo efficace sulle strutture neurovascolari circostanti. L'approccio combinato transorbitario e transnasale ha portato dei vantaggi significativi sia nell'ampiezza dell'esposizione che nella manovrabilità della strumentazione chirurgica. L'approccio endoscopico combinato transnasale e transorbitario ha dimostrato una migliore visualizzazione del basicranio ventrale e di poter superare alcune attuali limitazioni dei due singoli approcci. Inoltre la combinazione di due approcci mini-invasivi dovrebbe contribuire a ridurre la morbilità chirurgica. Sono tuttavia necessari studi clinici per validare questo approccio..

Necrotising fascitiis is a rapidly progressive bacterial infection of the soft tissues and generally attacks the walls of the abdomen, the perineum, the limbs or, to a lesser degree, the cranio-cervical area. In the latter region, the infection involves the soft tissues of the neck, in a more or less extensive manner, and causes diffuse necrosis. Crepitation, areas with linear infiltration and others with fluctuation are detected on manual examination. Systemic symptoms such as fever, tachycardia, tachypnoea and signs of septic shock are always present, at least during the more advanced stages of the disease. Computed tomography may prove fundamental since it reveals an increase in the thickness and degree of impregnation of the cervical soft tissues, as well as the presence of liquid or gaseous infiltration in the thoracic areas, especially in cases of mediastinitis. Personal experience in a case is described which led to a review of the literature. The best approach in the management of this devastating condition is early diagnosis, adequate antibiotic treatment and radical surgical procedures, which may often need to be repeated several times.

Metabolic, hormonal and vascular disorders are considered to cause hearing dysfunction such as progressive sensorineural hearing loss (PSNHL). The diseases most commonly associated with PSNHL are diabetes mellitus, congenital and acquired hypothyroidism, chronic renal failure, chronic labyrinthine ischemia determined by non-hematologic factors (tissue perfusion pressure, blood vessel diameter) or by hematologic factors (blood viscosity and/or rigidity of the red blood cells). In this study a review of data on the relationship between these clinical disorders and the presence and deterioration of the hearing function was carried out. PSNHL seems to be significantly associated with diabetes mellitus, in particular the mitochondrial type: a progressive deterioration of the hearing function is reported in 60% of the patients suffering from this type of disease with mitochondrial mutations. Regarding hypothyroid disorders, the data do not support a pathogenetic link between PSNHL and acquired hypothyroidism, whereas in subjects with congenital hypothyroidism both clinical and experimental results indicate a progressive damage of hearing function if the thyroid disorder is not treated early in life. Also, in patients with chronic renal failure the hearing thresholds seem to be significantly worse than in control subjects, particularly in patients undergoing dialysis, whereas the effect of kidney transplantation on auditory function is still not understood. Finally a relationship between PSNHL and chronic labyrinthine ischemia due to alterations of hematologic factors (increase of blood viscosity and/or increase of rigidity of the red blood cells) has been reported by several authors. However, data on high blood pressure and hyperlipoproteinemia as causes of deterioration of hearing acuity are controversial, and it is often difficult to understand whether the progressive hearing deficit is due only to these factors or also to the elderly age of patients.

Hibernoma is a rare, benign, soft-tissue tumour composed of cells similar to those of brown adipose tissue. Only seven cases in the cervical area have been reported and none in the larynx. A case of hibernoma of the pre-epiglottic area is presented and the histological, histogenetical and clinical features are discussed.