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Background Patients with intestinal-type sinonasal adenocarcinoma (ITAC) have an unfavorable prognosis, and new diagnostic and therapeutic approaches are needed to improve clinical management. Methods Next-generation sequencing-based miRNome analysis was performed on 43 ITAC patients who underwent surgical resection, and microRNA (miRNA) data were obtained from 35 cases. Four miRNAs were identified, and their expression levels were detected by reverse-transcription quantitative polymerase chain reaction and related to the relevant patient outcome. Overall survival and disease-free survival rates were evaluated through the Kaplan-Meier method and log-rank test, and multivariate analysis was performed by means of Cox proportional hazard analysis. Results High levels of miR-205 and miR-34c/miR-449 cluster expression were associated with an increased recurrence risk and, therefore, a worse prognosis. Multivariate analysis confirmed that miR-205 and miR-449 were significant prognostic predictors. Conclusions A high expression of miR-205 and miR-449 is independent predictors of poor survival for ITAC patients.

OBJECTIVESurgical treatment of orbital lesions is challenging because complex approaches with a high risk of postoperative sequelae are required. Recently, minimally invasive endoscopic approaches through endonasal (EEA) and transpalpebral (ETP) routes have been proposed. The objective of this study was to assess outcomes of EEA and ETP in the authors’ series of patients with orbital lesions.METHODSData from all patients who underwent operations for an orbital tumor through an endoscopic approach at the authors’ institution from 2002 to 2018 were retrospectively collected. All patients underwent preoperative MRI and ophthalmological evaluation, which was repeated 3 months after surgery and then at regular follow-up intervals. A systematic review of the literature was also performed using Medline, Embase, and Web of Science databases.RESULTSThe series includes 23 patients (14 males); the mean patient age was 48 ± 23.9 years. Most of the lesions were intraconal (n = 19, 83%). The more frequent histotype was cavernous hemangioma (n = 5, 22%). Exophthalmos was the most common symptom (21 of 23 patients). EEA was performed in 16 cases (70%) and ETP in 7 (30%). The aim of the surgery was achieved in 94% of the cases after an EEA (successful biopsy in 5 of 6 cases and radical resection in all 10 remaining patients), and in 86% after an ETP (successful biopsy in 2 cases and radical tumor resection in 4 of 5 cases). Complications consisted of 3 cases (13%) of transitory diplopia. One recurrence (4%) was observed at follow-up (mean 59 ± 55 months).CONCLUSIONSThe EEA and ETP have demonstrated to be safe and effective for tumors located respectively in medial and lateral quadrants, permitting one to approach orbital lesions endoscopically at 360°. Innovative surgical tools, including intraoperative ultrasonography, may be useful to potentially reduce surgical morbidity. Larger series are needed to validate these preliminary suggestions.

Lo scopo di questa rassegna e fornire una visione generale dell’attuale stato della chirurgia ipofisaria e delle sue prospettive future, che possa essere utile ai differenti professionisti coinvolti nella gestione dei pazienti ipofisari per orientarsi nel rapido sviluppo di questo campo, anche per effetto dello sviluppo tecnologico. Oltre alla precisazione dei vantaggi, dei limiti, ma anche delle possibili evoluzioni, del rivoluzionario approccio endoscopico, verranno presentate anche le altre opzioni attualmente a disposizione della chirurgia. Saranno considerati quegli sviluppi tecnologici di imaging sia preoperatorio sia intraoperatorio che potranno caratterizzare il futuro prossimo della chirurgia ipofisaria, aumentandone ulteriormente le potenzialita, l’efficacia e la sicurezza, come la RM avanzata, i possibili sviluppi della radiomica, le applicazioni della realta aumentata e dell’Artificial Intelligence e il valore aggiunto di un nuovo modello organizzativo, rappresentato dalle Pituitary Units, comprendenti le differenti discipline coinvolte nella gestione delle patologie ipofisarie.

To evaluate frontal sinus complications developed after previous external craniotomies requiring frontal sinus reconstruction and their treatment with an endoscopic approach. We retrospectively evaluated 22 patients who referred to Sant’Orsola-Malpighi University Hospital and Bellaria Hospital (Bologna, Italy) between 2005 and 2017. All patients presented with frontal sinus disease after frontal craniotomy with sinus reconstruction performed to treat various pathological conditions. We reported our experience in the endoscopic management of such complications and we reviewed the current literature concerning the endoscopic treatment of these conditions. In total, 14 frontal mucoceles, 4 cases of chronic frontal sinusitis, 2 mucopyoceles and 2 fungus ball of the frontal sinus were identified. Endoscopic surgical treatment included 7 DRAF IIa, 1 DRAF IIb, 11 DRAF III and 3 DRAF IIc (modified DRAF III) approaches. The success rate of the surgical procedure was 86% (19/22 patients). Recurrence of the initial pathology occurred in three patients (14%) requiring a conversion of previous frontal sinusotomy into a DRAF III sinusotomy. Frontal sinusopathy can be a long-term complication following craniotomies and may lead to potentially severe pathological conditions, such as mucoceles and frontal sinus inflammation. Its management is still debated and requires recovery of the patency of nasal-frontal route. Our study confirms that the endoscopic endonasal approach may offer a valid solution with low morbidity avoiding re-opening of the craniotomic access. For selected cases, endoscopic approach could also be performed simultaneously to craniotomy as a combined surgery to reduce the risk of short- and long-term complications. Long-term follow-up is mandatory in patients with a history of opened and reconstructed frontal sinus and should include imaging and endoscopic outpatient evaluation.

Objective Pituitary neuroendocrine tumours (PitNET)s can be aggressive, thus presenting local invasion, postsurgical recurrence and/or resistance to treatment, responsible for significant morbidity. The study aimed at identifying prognostic factors of postsurgical outcome using data-driven classification of patients.Design Retrospective observational study.Methods Clinicopathological and radiological data of patients with PitNET treated via endoscopic endonasal surgery were collected. Tumour recurrence/progression and progression-free survival were assessed by classification tree analysis (CTA) and Kaplan-Meier curves, respectively. Histological subtype, cavernous/sphenoid sinus invasion, mitosis, Ki-67, p53, Trouillas' grading, degree of tumour exeresis and postsurgery disease activity were also evaluated.Results A total of 1066 (466 gonadotroph, 287 somatotroph, 148 lactotroph, 157 corticotroph and 8 thyrotroph) tumours were included; 21.7% invaded the cavernous/sphenoid sinus. Based on Trouillas' classification, 64.3% were grade 1a, 14.2% 1b, 16.1% 2a, and 5.4% 2b; 18.3% had >2/10 HPF mitoses, 24.9% had Ki-67 >= 3%; 15.8% were positive for p53. Exeresis was radical in 81.2% of the cases. Median follow-up was 59.2 months. At last evaluation, 79.4% of the patients were cured; 20.6% had disease persistence, controlled by medical treatment in 18.3% of them. Disease recurrence/progression was recorded in 10.9% of the cases. CTA identified 5 distinct patient subgroups with different risk of disease recurrence/progression. Grade 2 of the Trouillas' grading, >2/10 HPF mitoses, Ki-67 >= 3%, p53 protein expression (P < .001), tumour invasion (P = .002) and ACTH-subtype (P = .003) were identified as risk factors of disease recurrence/progression.Conclusions The combined evaluation of Trouillas' grading, proliferation indexes and immunohistochemistry appears promising in the prediction of surgical outcome in PitNET.

Aims De-differentiated chordoma is an uncommon and incompletely characterised aggressive neoplasm. Only a few cases originating from the skull base have been reported. Methods and results All consecutive cases of skull-base de-differentiated chordomas treated surgically in a referral centre from January 1990 to June 2019 were retrospectively evaluated to assess peculiar pathological, radiological and clinical features. Patient data were retrieved from paper and electronic records. Six cases (two male, four female; mean age at surgery = 46 years, range = 35-64), treated surgically at our institution were identified. Transformation to de-differentiated chordomas occurred after radiation therapy in three cases (mean = 13.6 years after treatment, range = 5-25), two during tumour progression, while one was de-novo. Magnetic resonance imaging and surgical examination revealed the presence of two different tumour components, corresponding to the conventional and de-differentiated portion on histological examination. The de-novo case presented a PIK3CA mutation. DNA methylation analysis revealed consistent epigenetic changes in TERT, MAGEA11 and UXT. Prognosis was poor, as five of six patients died after surgery and radiation therapy, with a mean overall survival of 29 months (range = 11-52). Conclusions Skull-base de-differentiated chordomas are extremely rare and aggressive neoplasms with characteristic magnetic resonance imaging, surgical and histological features. Therefore, an early and accurate histological diagnosis is of paramount relevance. Molecular analysis appears promising to define mechanisms involved in tumour de-differentiation.

Recently, endoscopic approaches for orbital lesions have been proposed. Their results seem promising; however, orbital surgery remains challenging with possible significant morbidity, mostly because of orbital structures manipulation. Ultrasonography is an innovative intraoperative imaging technique that can assist the surgeon in these approaches.To assess the role of intraoperative ultrasound (IOUS) in endoscopic orbital surgery.All consecutive patients with orbital tumors operated in our institution through an endoscopic approach with IOUS have been prospectively collected from 2019 to May 2021.Fifteen patients were included. Based on tumor location, evaluated on preoperative MRI, the endoscopic endonasal approach was preferred in 7 tumors in medial quadrants while the endoscopic transpalpebral in 8 lateral ones. During surgery, IOUS allowed us to identify the tumors and the most relevant anatomic structures in all cases. Time spent for IOUS preparation before the first scan was 8 ± 6 minutes on average, and each intraoperative scan took approximately 30 to 120 seconds. Gross tumor removal was achieved in 8 patients, subtotal in 3, while in 4 patients, surgery was limited to a biopsy. No surgical complications were observed.IOUS has allowed us to localize the lesion and to identify the straighter surgical corridor and assess the tumor resection, effectively helping the surgeon and potentially reducing operative complications. This tool provides a real-time image, not affected by the orbital structures shift, which can be dynamically assessed multiple times during surgery. However, it is hampered by the need of specific training and possible artifacts.

Chronic rhinosinusitis (CRS) is one of the most frequent comorbidities associated with asthma and it contributes to an amplified global disease burden in asthmatics. CRS prevalence is much higher in asthmatic patients compared to the general population and it is more frequently related to severe asthma, especially in presence of nasal polyps (chronic rhinosinusitis with nasal polyps, CRSwNP). Moreover, asthma exacerbation has a higher occurrence in CRSwNP. From a pathologic point of view, CRS and asthma share similar and connected mechanisms (e.g., type-2 inflammation). A multidisciplinary approach represents a crucial aspect for the optimal management of patients with concomitant asthma and CRSwNP and improvement of patient quality of life. An Italian panel of clinicians with different clinical expertise (pulmonologists, ear, nose and throat specialists, immunologists and allergy physicians) identified three different profiles of patients with coexisting asthma and nasal symptoms and discussed the specific tracks to guide a comprehensive approach to their diagnostic and therapeutic management. Currently available biological agents for the treatment of severe asthma act either on eosinophil-centered signaling network or type-2 inflammation, resulting to be effective also in CRSwNP and representing a valid option for patients with concomitant conditions.

Objective identification of the miRNA expression profile in sinonasal inverted papilloma (SNIP) as a tool to evaluate the risk of transformation into sinonasal squamous cell carcinoma (SNSCC). Materials and Methods paired tumour tissues and adjacent normal tissues were obtained from SNIP and SNSCC patients who had undergone surgical resection and used for next-generation sequencing (NGS)-based miRNome analysis. SNIP tissues with concomitant dysplasia (SNIP-DISP) were used as malignant transition samples. By comparing the deregulated miRNAs in SNIP and SNSCC, an miRNA cluster was identified and its physio- and clinical-pathological value was predicted. Results NGS identified 54 miRNAs significantly down- and upregulated in SNIP. Among them, the miR-449 cluster was upregulated in SNIP and could differentiate the benign tumour from normal tissue. Notably, the miR-449 cluster was found to be significantly underexpressed in SNSCC, and the cluster markedly changed in SNIP during the malignant transition into SNSCC. miRNA enrichment analysis and GO analysis revealed that miR-449 is involved in apoptotic and cell proliferation pathways. Conclusions Our findings suggest that miR-449 may be involved in the molecular pathogenesis of SNIP and its malignant transformation into SNSCC. miR-449 might therefore be a useful tumour biomarker in patients with SNIP and may also have the potential to be used as a tool for detecting and monitoring the course of the possible malignant transformation.

Quando è richiesto un approccio multidisciplinare nella gestione delle complicanze intracraniche delle patologie infiammatorie nasosinusali?Le complicanze intracraniche delle patologie infiammatorie nasosinusali sono relativamente rare, ma presentano un’elevata mortalità e morbidità. Si verificano in soggetti immunodepressi o con diverse comorbidità, ma anche in soggetti immunocompetenti senza particolari fattori di rischio. Le complicanze intracraniche derivanti da rinosinusite acuta sono rare, verosimilmente per la disponibilità di antibiotici per via orale, ma sono le più imprevedibili, poiché spesso si verificano in soggetti immunocompetenti e senza particolari comorbidità. Richiedono una gestione multidisciplinare che coinvolge diversi specialisti per pianificare l’iter terapeutico che deve essere personalizzato in base alla gravità e all’estensione della patologia. Le complicanze intracraniche derivanti da rinosinusiti croniche sono più prevedibili e si verificano in pazienti con particolari fattori di rischio. Per tale motivo è importante per gli altri specialisti riconoscere i primi sintomi per coinvolgere prontamente lo specialista ORL che ha un ruolo importante per la diagnosi e il trattamento chirurgico. Lo scopo di questo lavoro è quello di fornire una panoramica sulla diversa gestione multidisciplinare delle complicanze intracraniche delle patologie flogistiche nasosinusali in base all’eziologia e alla loro gravità.Intracranial complications of sinonasal inflammatory disorders are relatively unusual but can cause significant morbidity and mortality. They often occur in patients with comorbid disorders and immunocompromised but also people without risk factors can be affected. Intracranial complications of acute rhinosinusitis are rare, probably due to oral antibiotics availability, but are less predictable as they often occur in immunocompetent patients without comorbidity. Their management requires a multidisciplinary approach to plan and customize the therapeutic treatment. Intracranial complications of chronic rhinosinusitis are more predictable as they occur often in immunocompromised patient with particularly risk factors. For this reason, a multidisciplinary approach it’s important for treatment and mostly for prevention. The aim of this paper is to present an overview of different multidisciplinary management of intracranial complications of sinonasal inflammatory disorders according to their etiology and severity.

Endoscopic endonasal represents an expanding surgical approach for craniopharyngiomas, thanks to the recent technological innovation and advancement in the endoscopic technique. This approach has the advantages to permit to reach these complex tumors through a complete extra cranial route, avoiding brain retraction and vasculo-nervous structures manipulation, giving a wide and panoramic surgical view of the suprasellar region.

Introduction. Role of surgery for loco-regional recurrences of clivus chordomas (CCs) is still debated. It has been proposed in selected cases with a curative or with palliative intent, eventually followed by radiation or chemo/radiation treatments. Only limited data on the endoscopic endonasal approach (EEA) are available. Research question. To assess the role of EEA for loco-regional recurrent CCs. Materials and Methods. All consecutive loco-regional recurrent CCs operated by EEA at our Institution from 1998 to 2021 were identified. The extension of tumor resection, symptoms control, overall survival (OS), and progression free survival (PFS) were assessed. Results. Series includes 54 patients (53.7% females, mean age 55± 14 years). Surgery was planned with a resective aim in 35 (64.8%) patients, while it was palliative in 19 (35.2%). Gross tumor removal was achieved in 24 cases (44.4%). Main complications consisted of 2 (3.7%) CSF leaks. Further local relapses were observed in 30 (55.5%) patients after 25± 24 months; 29 (53.7%) patients deceased after 34 ± 31 months. OS and PFS were lower in these cases than primary surgeries (p

Head and neck squamous cell carcinomas evade immune response through multiple immunologic resistance mechanisms. Two of the most commonly involved checkpoint inhibitory mechanisms are CTLA-4 and PD-1/PD-L1, which act at earlier and later stages of immune response to tumors. Pembrolizumab and nivolumab are PD-1 antibodies that interrupt the immunosuppressive pathway of inhibitory checkpoints, which are used by tumor cells to prevent immune reaction. Both recently gained US FDA approval for the treatment of patients with recurrent or metastatic head and neck cancer with disease progression during or following platinum containing chemotherapy. No conclusions can be drawn on the role of PD-L1 in identifying patients responding to immunotherapy, given that similar studies lead to contrasting results. It will be crucial to identify predictive markers of immunotherapy response, and to evaluate them prospectively. A better understanding of the complex network between tumor, immune system and other oncologic treatments will help us to develop more efficient multimodality treatments.

Objective Silent sinus syndrome (SSS) and chronic maxillary atelectasis (CMA) are unusual conditions having subtle symptoms with a possible progressive evolution. They are particularly infrequent in the pediatric population. Our objective was to review our experience with pediatric patients having SSS or CMA, and to review all cases involving patients under 14 years of age reported in the literature. Methods A retrospective review of 6 patients diagnosed with SSS or CMA surgically treated from 2001 to 2014 was carried out. All cases reported in literature were reviewed. Results All patients underwent functional endoscopic sinus surgery with an improvement in symptoms after surgery. Diplopia disappeared in two patients who presented with it and enophthalmos improved in all five patients presenting with it. Only one patient out of four presenting with headache had a persistence of the symptoms which were, however, milder than they had been preoperatively. Endoscopic examination demonstrated a reventilated maxillary sinus in all cases. A radiological examination at follow-up was performed in 5 cases and demonstrated a reexpansion of the maxillary sinus as compared to the contralateral side in all patients except one. None of the patients required an orbital floor reconstruction. Eleven similar cases reported in the literature were analyzed and compared. Conclusion Endoscopic uncinectomy and middle meatal antrostomy should be the treatment of choice for these conditions in patients presenting with enophthalmos and/or hypoglobus and symptoms related to it. Orbital floor reconstruction should be performed as a delayed procedure only in selected cases. Chronic maxillary atelectasis or SSS should be considered as a possible cause of persistent headache of unknown origin in pediatric patients.

To assess outcomes and predictors of early and long-term remission in patients with Cushing’s disease (CD) due to ACTH-secreting adenomas treated via endoscopic endonasal approach (EEA). This is a retrospective study. Consecutive patients operated for CD from 1998 to 2017 in an Italian referral Pituitary Center were enrolled. Clinical, radiological, and histological data at enrollment and follow-up were collected. 151 patients (107 F) were included; 88.7% were naive for treatment, 11.3% had been treated surgically and 11.2% medically. At pre-operative magnetic resonance imaging (MRI), 35 had a macroadenoma and 80 a microadenoma, while tumor was undetectable in 36 patients. Mean age at surgery was 41.1 ± 16.6 years. Diagnosis was confirmed histologically in 82.4% of the cases. Patients with disease persistence underwent second surgery and/or medical and/or radiation therapy. Mean follow-up was 92.3 ± 12.0 (range 12–237.4) and median 88.2 months. Remission rate was 88.1% after the first surgery and 90.7% at last follow-up. One patient died of pituitary carcinoma. Post-surgical cortisol drop (p = 0.004), tumor detection at MRI (p = 0.03) and size

Trattamento chirurgico dei polipi antrocoanali: due tecniche endoscopiche a confronto.Il polipo antrocoanale (ACP) è una lesione benigna che origina dalla mucosa del seno mascellare. Al fine di evitare la recidiva chirurgica della patologia è importante scegliere il miglior approccio chirurgico per la rimozione del ACP a seconda del suo sito di attacco all’interno del seno mascellare. Uno studio retrospettivo è stato condotto analizzando il database di 82 pazienti operati per ACP presso le cliniche Otorinolaringoiatriche dell’Ospedale Sant’Orsola-Malpighi e dell’Ospedale Bellaria di Bologna, da gennaio 2001 a novembre 2017 al fine di confrontare il tasso di recidiva dopo la rimozione chirurgica utilizzando due differenti tipi di approccio. Il primo tipo prevede una polipectomia endoscopica attraverso un’antrostomia media mentre il secondo approccio è stato eseguito attraverso una rimozione endoscopica combinata con meatotomia media e un accesso di minima attraverso il meato inferiore. Quarantanove pazienti sono stati operati con il primo tipo di approccio con un tasso di recidiva del 18,4% mentre i rimanenti 33 sono stati sottoposti a un approccio combinato con un tasso di recidiva del 3%. La differenza fra i due gruppi è risultata essere statisticamente significativa (p = 0,0441). La strategia di combinare un accesso tradizionale con un accesso di minima attraverso il meato inferiore ha mostrato un minor tasso di recidiva senza un incremento della morbilità post-operatoria a breve e a lungo termine.An antrochoanal polyp (ACP) is a benign sinonasal lesion that originates from the mucosa of the maxillary sinus. In order to avoid any recurrence of disease, it is important to choose the best surgical approach for removal of ACP with respect to the site of attachment within the maxillary sinus walls. A retrospective cohort study was carried out by analysing a database of 82 patients who were operated on for ACPs in the Ear, Nose and Throat (ENT) clinics of both Sant’Orsola-Malpighi Polyclinic Hospital and Bellaria Hospital in Bologna, Italy from January 2001 to November 2017 to compare the rate of recurrence of ACPs after surgical removal using two different approaches. The first technique was endoscopic antrochoanal polypectomy with middle meatal antrostomy and the second was endoscopic antrochoanal polypectomy combined with both middle meatal antrostomy and a minimal access through the inferior meatus. A total of 49 patients were operated on with an endoscopic polypectomy with middle meatal antrostomy and 18.4% experienced a recurrence. The remaining 33 patients underwent endoscopic polypectomy with combined middle meatal antrostomy and access through the inferior meatus with a recurrence rate of 3%. The difference between the two groups was statistically significant (p = 0.0441). The strategy of the authors, namely combining medial antrostomy with a small inferior meatus access, was associated with a lower rate of recurrence and no increased morbidity in the short- or long-term.

Background: The endoscopic endonasal opening of the optic canal has been recently proposed for tumors with medial invasion of this canal, such as tuberculum sellae meningiomas. Injury of the ophthalmic artery represents a dramatic risk during this maneuver. Therefore, the aim of this study was to analyze the endoscopic endonasal anatomy of the precanalicular and canalicular portion of this vessel, discussing its clinical implication. Methods: The course of the ophthalmic artery was analyzed through five endoscopic endonasal dissections, and 40 nonpathological consecutive MRAs were reviewed. Results: The ophthalmic artery arises from the intradural portion of the supraclinoid internal carotid artery, in 93 % of cases about 1.9 mm (range: 1–3) posterior to the falciform ligament. At the entrance into the optic canal, the ophthalmic artery is located infero-medially to the optic nerve in 13 % of cases. In 50 % of these cases the artery moves infero-laterally along its course, remaining in a medial position in the others. In cases with an non medial entrance of the ophthalmic artery, it runs infero-lateral to the optic nerve for its entire canalicular portion, with just one exception. Conclusion: The endoscopic endonasal approach gives a direct, extensive and panoramic view of the course of the precanalicular and canalicular portion of the ophthalmic artery. Dedicated high-field neuroimaging studies are of paramount importance in preoperative planning to evaluate the anatomy of the ophthalmic artery, reducing the risk of jeopardizing the vessel, particularly for those uncommon cases with an infero-medial course of the artery.

Background Meningocele and meningoencephalocele of the lateral wall of the sphenoidal sinus (LWSS) are rare lesions, crossing the borders of multiple disciplines such as ear-nose-throat, maxillofacial, and neurologic surgery. We reviewed our surgical experience to analyze the role of the endoscopic endonasal approach and consider these pathologies from different perspectives. Methods All consecutive cases of meningocele and meningoencephalocele of LWSS operated through an endoscopic endonasal approach from 1998 to 2015 in our institutions were collected. Medical history, focusing on previous episodes of cerebrospinal fluid leak, meningitis or seizures, was considered. The outcome was assessed considering the medical condition and the postoperative neuroimaging. Results The series includes 23 patients (7 male, 16 female). Mean age was 52 years (26–73 years). Eleven cases were meningoencephaloceles and 12 meningoceles. A clear cerebrospinal fluid leak occurred on in 19 patients and was associated with meningitis in 3. Two were presenting a history of epilepsy. No complications were observed, but 1 case presented seizures on waking. At follow-up (mean 84 months, 4–167) each patient is in good clinical condition with no further episodes of leaking or seizures. Conclusions Endoscopic endonasal surgery is a safe and effective approach for meningocele and meningoencephalocele of LWSS; it allows resection of herniated tissue and repair of the osteodural defect. The favorable clinical outcome and the possible effectiveness on seizures lead us to support this approach as first minimally invasive treatment also in presence of epilepsy, as a first low risk epilepsy surgical procedure.

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.

Recently, an alternative endoscopic endonasal approach to Meckel’s cave (MC) tumors has been proposed. To date, few studies have evaluated the results of this route. The aim of our study was to evaluate long-term surgical and clinical outcome associated with this technique in a cohort of patients with intrinsic MC tumors. All patients with MC tumors treated at out institution by endoscopic endonasal approach (EEA) between 2002 and 2016 were included. Patients underwent brain MRI, CT angiography, and neurological evaluation before surgery. Complications were considered based on the surgical records. All examinations were repeated after 3 and 12 months, then annually. The median follow-up was of 44.1 months (range 16–210). The series included 8 patients (4 F): 5 neuromas, 1 meningioma, 1 chondrosarcoma, and 1 epidermoid cyst. The median age at treatment was 54.5 years (range 21–70). Three tumors presented with a posterior fossa extension. Radical removal of the MC portion of the tumor was achieved in 7 out of 8 cases. Two patients developed a permanent and transitory deficit of the sixth cranial nerve, respectively. No tumor recurrence was observed at follow-up. In this preliminary series, the EEA appeared an effective and safe approach to MC tumors. The technique could be advantageous to treat tumors located in the antero-medial aspects of MC displacing the trigeminal structures posteriorly and laterally. A favorable index of an adequate working space for this approach is represented by the ICA medialization, while tumor extension to the posterior fossa represents the main limitation to radical removal of this route.

Background The endoscopic endonasal approach has been recently proposed for cranio-vertebral junction lesions. The more common indication for this sagittal extension of the endonasal route is represented by odontoidectomy for irreducible ventral brainstem compression due to congenital or degenerative conditions. However, in an increasing number of studies its adoption for tumors involving the cranio-cervical junction has been reported. The aim of this study is to consider retrospectively our surgical series, focusing on the advantages and limits of this approach. Methods Each consecutive case of tumor involving the cranio-vertebral junction since 2007 to 2017 treated through an endoscopic endonasal approach has been included. All patients undergone preoperative neurological examination and neuroimaging (magnetic resonance imaging [MRI] and computed tomography angiography). These examinations were repeated after 3 months and then annually. Complementary treatments, recurrence rate and clinical status at mean follow-up of 18±7.3 months were considered. Results Seven patients have been included in this study, mean age was of 47±17 years; male-to-female ratio was of 3:4. Series is composed by 6 chordomas and one foramen magnum meningioma. One patient had been already posteriorly stabilized for cranio-vertebral instability. Gross tumor removal was achieved in two cases, in the others a subtotal removal was demonstrated at postoperative MRI. One patient presented a transitory worsening of CN XII palsy, resolved within 3 months. For preoperative dysphagia and inhalation pneumonia, one case undergone tracheostomy and was fed with oro-gastric tube for 10 days. Three patients died for chordoma progression and at follow-up one presented a local recurrence. Conclusions Despite our experience is preliminary, the endoscopic endonasal approach has resulted safe for cranio-cervical junction tumor with a reduced number of complications. It can give a straight and direct trajectory to this deep region. We suggest that lateral extension of the tumor beyond the plane of cranial nerves is a limit for this approach, as well as an inferior expansion caudal to C1. Larger series and longer follow-up are required to assess the proper indications of this approach.

The aim of the study was to evaluate the effectiveness of the endoscopic approach for the management of inverted papilloma (IP) of the nose and paranasal sinuses and the possible factors associated with its recurrence. One hundred and forty-one patients affected by an IP originating at the level of the sinonasal tract were treated surgically using an endoscopic technique alone or a combined external–endoscopic approach at the ENT Department of the University of Bologna between January 1994 and December 2012. Of these patients, 110 were selected for the recurrence analysis. Univariate and multivariate analyses were performed to detect risk factors for IP recurrence. The patients had a mean follow-up of 56.7 months (24–167 months). Seven cases (6.3 %) of recurrence were observed in patients treated with the endoscopic approach for the primary or recurrent tumor. Previous surgery (p = 0.005) and number of previous surgical procedures (p = 0.003) were associated with higher recurrence rate. The number of previous operations was associated to recurrence-free survival at Cox regression analysis. In our study, the endoscopic approach showed itself to be a useful tool for the radical resection of an IP. The endoscopic approach should be tailored for the different extensions of IP. Recurrent cases showed an increased risk of further recurrence. Therefore, these should be treated paying particular attention to the boundaries of the primary tumor.

La scialoendoscopia è un nuovo strumento diagnostico e chirurgico che offre l’opportunità di trattare alcune patologie delle ghiandole salivari con procedure non invasive e con risultati potenzialmente superiori alle precedenti tecniche. Come per tutte le nuove tecniche, per raggiungere rapidamente risultati paragonabili a quelli riportati in letteratura, è indispensabile un corretto programma di formazione che segua una graduale curva di apprendimento. Questo include un appropriato programma diagnostico, una corretta selezione dei pazienti e la conoscenza delle possibili insidie operatorie. Abbiamo eseguito uno studio retrospettivo confrontando le prime 141 procedure (74 parotidee e 67 sottomandibolari) eseguite con questa tecnica nel nostro Dipartimento dal 2009 al 2013 con analoghe esperienze riportate in letteratura. I pazienti sono stati divisi in 3 gruppi: Gruppo A (le prime 49 procedure effettuate), gruppo B (le successive 50), Gruppo C (le ultime 42 procedure effettuate). Fra i tre gruppi non sono state evidenziate differenze statisticamente significative nei tempi medi di durata delle procedure, nella percentuale di ricorrenza della sintomatologia dopo il trattamento, nel numero di pazienti che hanno necessitato di più trattamenti e nell’incidenza di complicanze minori. Non sono state riportate complicanze maggiori. Con l’acquisizione di una maggiore esperienza da parte dei chirurghi si è evidenziato un progressivo calo del numero di interventi eseguiti in anestesia generale rispetto a quelli in anestesia locale (51% vs 18% vs 14%). Solo in tre casi su 130 ghiandole trattate (2.3%) è stato necessario eseguire un’asportazione ghiandolare. Per i calcoli salivari è stato valutato il tipo di tecnica utilizzato per l’estrazione e la percentuale d’insuccesso che era analoga nei tre gruppi (13.6% vs 15% vs 15%). I nostri risultati non differiscono sostanzialmente da quelli riportati in letteratura. Abbiamo risolto la difficoltà iniziale nella cateterizzazione del dotto con esercizi chirurgici su cadavere o su teste di maiale. La mancanza di precisione degli strumenti diagnostici radiologici può essere migliorata autonomizzando il chirurgo nell’esecuzione delle ecografie pre e post-operatorie. Viene infine sottolineata l’opportunità di creare dei centri di scialoendoscopia con un bacino di utenza di circa 1 o 2 milioni di abitanti in modo da concentrare le patologie, far fronte agli elevati costi della strumentazione necessaria e poter guadagnare la necessaria esperienza nelle gestione delle varie tecniche chirurgiche.

Odontoidectomy is the treatment of choice for irreducible ventral cervical-medullary compression. The endonasal endoscopic approach is an innovative approach for odontoidectomy. The aim of this article is to identify in which conditions this approach is indicated, discussing variants of the technique for selected cases of craniovertebral malformation with platybasia. We believe that the technical difficulties of this approach are balanced by the advantages for patients. Some conditions related to the patient and to the anatomy of the craniovertebral junction may favor adoption of the endoscopic endonasal approach, which should be considered complementary and not alternative to standard approaches.

Background Orbital cavernous hemangiomas are the most common primary benign orbital tumors in adults. Although a rudimentary lesion may be present at birth, cavernous hemangiomas do not usually become symptomatic until the third to fifth decade of life and lesions occurring in pediatric age are quite rare. Surgical treatment is indicated in symptomatic cases, and surgical approach is planned according to the localization of the tumor in the orbit. Methods and Results We described the first case of pediatric intraorbital extraconal cavernous hemangioma, treated successfully by a pure endoscopic endonasal approach, and demonstrated the minimal invasiveness of this approach, without skin incision and neurovascular retraction. Review of the literature, surgical technique, pitfalls, and differences from previous reports are discussed. Conclusion Endoscopic transnasal approaches can now be considered as an alternative option to traditional external approaches in the management of medial and inferior orbital lesions in childhood. © 2014 Wiley Periodicals, Inc. Head Neck, 2014

A high risk of neoplastic transformation of nasal and paranasal sinuses mucosa is related to the occupational exposure to wood dust. However, the role of occupational exposures in the aetiology of the airway cancers remains largely unknown. Here, an in vitro model was performed to investigate the carcinogenic effect of wood dusts. Human bronchial epithelial cells were incubated with hard and soft wood dusts and the DNA damage and response to DNA damage evaluated. Wood dust exposure induced accumulation of oxidised DNA bases, which was associated with a delay in DNA repair activity. By exposing cells to wood dust at a prolonged time, wood dust-initiated cells were obtained. Initiated-cells were able to form colonies in soft agar, and to induce blood vessel formation. These cells showed extensive autophagy, reduced DNA repair, which was associated with reduced OGG1 expression and oxidised DNA base accumulation. These events were found related to the activation of EGFR/AKT/mTOR pathway, through phosphorylation and subsequent inactivation of tuberin. The persistence in the tissue of wood dusts, their repetitious binding with EGFR may continually trigger the activation switch, leading to chronic down-regulation of genes involved in DNA repair, leading to cell transformation and proliferation.

Pleomorphic salivary adenomas are the most common benign neoplasms affecting the salivary glands. Very occasionally however, metastatic lesions are identified in patients with a history of PSA, which, on detailed pathological evaluation, are found to exhibit all the histological hallmarks of the preceding benign lesions. Diagnosis of benign metastasizing pleomorphic adenoma of the salivary gland is extremely rare and still under debate. We present the first case-report in literature of multiple metachronous nasal cavity, scalp and encephalic metastases of a pleomorphic adenoma of the parotid gland in a young girl. Pleomorphic salivary adenomas are the most common benign neoplasms affecting the salivary glands. Very occasionally however, metastatic lesions are identified in patients with a history of PSA, which, on detailed pathological evaluation, are found to exhibit all the histological hallmarks of the preceding benign lesions. Diagnosis of benign metastasizing pleomorphic adenoma of the salivary gland is extremely rare and still under debate. We present the first case-report in literature of multiple metachronous nasal cavity, scalp and encephalic metastases of a pleomorphic adenoma of the parotid gland in a young girl.

Background The optimal management of pituitary apoplexy (PA) remains debated. The aim of this study was to assess the outcome of the transsphenoidal approach for PA in a large surgical experience. Materials Each consecutive case of PA consecutively operated by endoscopic endonasal approach from our tertiary care center, from 1998 to 2015, was included in this series. Results Seventy-five patients (47 male; mean age 52.4 ± 16.2 years) were included. Mean follow-up was 69.3 ± 46.7 months. On admission, all patients presented with abrupt severe headache (100%), associated with anterior hypopituitarism in 51 patients (68%), visual disturbances in 55 (73.4%), ophthalmoplegia in 38 (50.7%), and a remarkable reduction of consciousness in 2 (2.6%). Apoplexy proved to be ischemic in 35 patients (46.7%) and hemorrhagic in 40 (53.3%). Patients with hemorrhagic necrosis presented more often with major suprasellar expansion (P = 0.012) Radical removal was achieved in 60 cases (80%). Surgical morbidity consisted in one case of postoperative cerebrospinal fluid leak (1.3%). Anterior hypopituitarism worsened in 15 cases (20%), and diabetes insipidus occurred in 4 cases (5.3%). Ophthalmoplegia improved/normalized in 71% and visual symptoms in 85.5% of the patients, with better results achieved in ischemic forms (P = 0.043). The 2 comatose patients regained normal consciousness. Conclusions The endoscopic endonasal approach represents a valid, effective, and safe technique in the management of PA. Favorable outcomes can be achieved by referring patients to dedicated pituitary centers with a multidisciplinary team. Further studies are still needed to define criteria for surgical indication and to identify outcome predictors.

We present the case of a 47-year-old man with left exophthalmus. MRI showed a left intraorbital intraconal cavernous malformation, located in the superoesternal quadrant and medially displacing the optic nerve. An endoscopic transpalpebral approach was performed and total removal was achieved after dissection of the lesion from the optic nerve and other orbital structures. Pathology confirmed the diagnosis of cavernous malformation. The patient was discharged neurologically intact on the second postoperative day free of complications. Follow-up MRI demonstrated radical resection of the cavernoma and resolution of the exophthalmus with an excellent esthetic result.The video can be found here: https://youtu.be/o1a1tneZ6qk.

The aim of this study was to perform a systematic literature review of risks and medico-legal aspects of endoscopic sinus surgery. The development of sophisticated technologies and instruments for endoscopic sinus surgery (ESS) has caused a dramatic increase in the number of otolaryngologists performing sinus surgery and the number of cases performed. This expansion was accompanied by an increase in malpractice lawsuits. Over the past 20 years, rhinology claims represented 70 % of the total indemnity compensation for otolaryngology claims and ESS was the surgical procedure most often involved. Only then will a careful analysis and assessment of the possible and potential risk factors of ESS, which may mislead the surgeon, allow a correct clinical risk management, with activities and procedures aimed at reducing the possibility of complications that may expose the physician to a malpractice suit.

Salivary gland tumours represent 1-4% of all human neoplasms and less than 5% occur in children and adolescents. Malignant salivary gland tumours only represent 0.08% of all childhood tumours and mucoepidermoid carcinoma (MEC) is the most common histological type. The majority of MECs in the paediatric group are histologically classified as low or intermediate grade of malignancy, favouring a good prognosis. Complete excision of the lesion with free surgical margins is the treatment of choice and the one that offers the best local control of the disease. Experience with minor salivary gland carcinoma arising specifically within the nasopharynx is limited because nasopharyngeal MEC is an extremely rare malignancy and there is controversy regarding its optimal treatment. We hereby report a case of mucoepidermoid carcinoma arising from the nasopharynx in a 7-year-old girl, which was managed via an endonasal endoscopic procedure. To our knowledge the case we describe is the second case of nasopharyngeal MEC in paediatric age reported in literature and is the only one occurred in the first decade of life.

Obstructive sialadenitis is the most common non-neoplastic disease of the salivary glands, and sialendoscopy is increasingly used in both diagnosis and treatment, associated in selected cases with endoscopic laser lithotripsy. Sialendoscopy is also used for combined minimally invasive external and endoscopic approaches in patients with larger and proximal stones that would require excessively long laser procedures. The present paper reports on the technical experience from the Ear, Nose and Throat Unit of the Sant'Orsola-Malpighi Hospital of Bologna, and from the Department of Otorhinolaryngology of the University Hospital of Cagliari, Italy, including the retrospective analysis of the endoscopic and endoscopic assisted procedures performed on 48 patients (26 females and 22 males; median age 45.3; range 8-83 years) treated for chronic obstructive sialadenitis at the University Hospital of Cagliari from November 2010 to April 2016. The results from the Sant'Orsola-Malpighi Hospital of Bologna have been previously published. The technical aspects of sialendoscopy are carefully described. The retrospective analysis of the University Hospital of Cagliari shows that the disease was unilateral in 40 patients and bilateral in 8; a total of 56 major salivary glands were treated (22 submandibular glands and 34 parotids). Five patients underwent bilateral sialendoscopy for juvenile recurrent parotitis. 10 patients were treated for non-lithiasic obstructive disease. In 33 patients (68.75%) the obstruction was caused by salivary stones (bilateral parotid lithiasis in 1 case). Only 8 patients needed a sialectomy (5 submandibular glands and 3 parotids). The conservative approach to obstructive sialadenitis is feasible and can be performed either purely endoscopically or in a combined modality, with a high percentage of success. The procedure must be performed with dedicated instrumentation by a skilled surgeon after proper training since minor to major complications can be encountered. Sialectomy should be the "extrema ratio" after failure of a conservative approach.La scialoadenite cronica ostruttiva rappresenta una delle più frequenti patologie non-neoplastiche delle ghiandole salivari e la scialoendoscopia è sempre più utilizzata nella sua diagnosi e nel suo trattamento, associata o meno con la litotripsia laser. La scialoendoscopia può essere inoltre associata ad approcci esterni mini-invasivi nelle litiasi troppo voluminose per essere rimosse con un approccio unicamente endoscopico. Il presente articolo riporta l’esperienza delle Cliniche Otorinolaringoiatriche dell’Ospedale Sant’Orsola-Malpighi di Bologna e dell’Azienda Ospedaliero Universitaria di Cagliari, Italia. È stata eseguita un’analisi retrospettiva su 48 pazienti (26 femmine, 22 maschi; età media di 45,3 anni; range 8-83 anni) trattati per patologia cronica ostruttiva delle ghiandole salivari maggiori mediante procedure chirurgiche endoscopiche o combinate da novembre 2010 ad aprile 2016 presso l’Azienda-Ospedaliero-Universitaria di Cagliari. I risultati dell’Ospedale Sant’Orsola-Malpighi di Bologna erano stati precedentemente pubblicati. Gli aspetti tecnici della scialoendoscopia sono stati accuratamente descritti. I pazienti trattati presso l’Azienda Ospedaliero Universitaria di Cagliari presentavano una patologia unilaterale in 40 casi e bilaterale in 8 casi; sono state trattate 56 ghiandole salivari maggiori (22 sottomandibolari e 34 parotidi). 5 pazienti sono stati sottoposti a scialoendoscopia bilaterale per parotite ricorrente giovanile, 10 per patologia ostruttiva non litiasica e 33 (68,75%) presentavano calcoli salivari (1 paziente presentava una litiasi parotidea bilaterale). Solo 8 pazienti sono stati sottoposti a scialectomia radicale per via esterna (5 scialectomie sottomandibolare e 3 parotidectomie). La chirurgia conservativa nei pazienti con scialoadenite cronica ostruttiva appare efficace e può essere realizzata mediante un approccio puramente endoscopico o combinato, con un’alta percentuale di successo. La procedura richiede una strumentazione adeguata e deve essere eseguita da un chirurgo esperto, che abbia svolto un training specifico scialoendoscopico, in modo da evitare le possibili complicanze maggiori e minori. La scialectomia tradizionale rappresenta la “extrema ratio”, limitata nei casi in cui un approccio conservativo sia risultato inefficace o controindicato.

In the last decades, endoscopic endonasal approach has gained a relevant role among the surgical approaches for cavernous sinus tumors. Indeed, this route allows the surgeon to follow the extension of the tumor into the cavernous sinus though a direct, straightforward, and completely extracranial route. Thus, it allowed to combine the high versatility of the endoscopic technique to the greater tolerability given by the endonasal transsphenoidal route. Along these years of adoption, this surgery has demonstrated its safety and effectiveness, with a low risk of permanent neurological sequelae and a good outcome for well-selected tumors. Indeed, the endoscopic endonasal approach should not be considered as a “magic bullet” for all cavernous sinus tumors. Its indications should be well considered, and even if it can be the first choice for many cases, mainly pituitary adenomas and chordomas or chondrosarcomas, in the hands of a properly trained endoscopic endonasal surgeon in a well-equipped surgical center, it is just only one of the weapons that a skull base surgeon should have in his arsenal to face these demanding diseases.

Il riscontro incidentale di un processo espansivo a livello della sella turcica durante indagini neuroradiologiche (risonanza magnetica o tomografia computerizzata) richieste per motivi non correlati al sospetto di malattie ipotalamo-ipofisarie (traumi, vertigine, epilessia, ecc.) e evenienza alquanto frequente nella pratica clinica quotidiana, potendosi verificare in circa il 10% della popolazione. Non v’e dubbio che gli adenomi ipofisari clinicamente non-funzionanti ne siano la causa piu frequente; tuttavia, occorre ricordare che anche lesioni sellari piu rare (cisti della tasca di Rathke, craniofaringioma, metastasi, ecc.) possono talora mostrarsi con le modalita dell’incidentaloma ipofisario. Nel caso in cui il processo espansivo ha dimensioni inferiori al centimetro, esso e indicato con il termine di “microincidentaloma”; viceversa, nel caso di lesioni superiori al centimetro si utilizza il termine di “macroincidentaloma”. La storia naturale dell’incidentaloma ipofisario e poco nota e cid condiziona le reali difficolta nel delineare principi generali d’inquadramento iniziale e di successivo follow-up. In questo scenario, le recenti linee guida proposte dall’Endocrine Society costituiscono indubbiamente un aiuto rilevante nella gestione clinica dei pazienti che giungono all’attenzione dei clinici per il riscontro incidentale di una massa sellare, pur persistendo aree d’incertezza che solamente studi prospettici su ampie coorti potranno chiarire.

The objective of the study is to present our multicentric experience on intraorbital lesions managed by means of an endonasal endoscopic approach. The study design used was multi-institutional retrospective review. We collected data on 16 intraorbital medially-located lesions, all managed by means of an endonasal route, treated in four different skull base centers. We retrospectively reviewed the technical details, complications, histology, and general outcome. The endoscopic endonasal approach was effective in removing completely intraorbital extra-intraconal tumors in 8 cases, in performing biopsies for histological diagnosis in 6 intraorbital intraconal tumors, and in draining 1 extraconal abscess. No major complications were observed; in particular, there was no optic nerve damage. Minor, temporary complications (diplopia) were seen in 3 cases; only 2 patients experienced a permanent diplopia related to medial rectus muscle impairment, in 1 case associated with enophthalmos. Our preliminary multi-centric clinical experience suggests that medially located intraorbital lesions, and in particular the infero-medial ones, can be successfully and safely managed by such an approach. The well-known advantages of the endoscopic techniques, namely the lack of external scars, less bleeding, shorter hospital stay, and fewer complications, are confirmed.

The aim of this study was to compare the incidence of complications of endoscopic sinus surgery (ESS) to the incidence of complications of traditional and microscopic sinus surgery. A meta-analysis was carried out on 28 series of patients (a total of 13,405) who had undergone ESS, 8 series of patients (3,887 in total) who had undergone traditional endonasal sinus surgery and 7 series of patients (1,630 in total) who had undergone microscopic sinus surgery. The authors used the Bayesian inference package WinBUGS operating from within the statistical computer program R (version 2.7.1). Major complications had a higher incidence after traditional sinus surgery than ESS but this fact did not cause a significant statistical difference, whereas microscopic surgery had significantly more complications than ESS (p \ 0.05). Carrying out our meta-analytic study, comparing major and minor complications of endonasal surgical approaches, was very difficult due to several methodological biases of data extraction and evaluation from studies concerning a broad timespan. Regarding major complications, we only found a significant statistical difference (p \ 0.05) between the endoscopic (1%) and the microscopic methods (2.0%), but, if we had analyzed the data considering the natural learning curve of the latest ESS surgical approach, and if we had not considered the results produced in the first 10 years (1988-1998) concerning ESS in our meta-analysis, we would have found a statistically significant difference (p \ 0.05) between the endoscopic (0.4%) and the tradi- tional (1.1%) approach as well.

The clinical and radiological findings of a patient affected by apoplexy of an adenoma located within cavernous sinus and presenting isolated Cranial Nerve (CN) VI palsy are reported. The differential diagnosis with other pathologies is debated, and pathogenesis of isolated abducens nerve palsy is investigated. The pertinent literature of this uncommon case of apoplexy is reviewed. A 59-year-old female presented sudden appearance of CN VI palsy associated to violent headache. Endocrinological assessment did not show pituitary insufficiency; MRI depicted an adenoma located within the left CS. She underwent an endoscopic endonasal procedure with extensive opening of the cavernous sinus, occupied by an ischemic adenoma. Afterward, neurological symptoms promptly resolved and the patient was discharged after 5 days. At 3 months follow-up MRI radical tumor removal was assessed, and the patient resulted neurologically intact. The review of the pertinent literature shows that apoplexy of pituitary tumor exclusively located within the Cavernous Sinus is a very uncommon event. The distinctive clinical presentation is represented by the sudden abducens nerve palsy and the absence of pituitary insufficiency and it could be explained by the vulnerability of the nerve along its course within the cavernous sinus, and by the sparing of the sellar content by the adenoma. © 2011 Springer Science+Business Media, LLC.

The advent and widespread development of endonasal endoscopic techniques have recently expanded the frontiers of skull base surgery. The reduced invasiveness, wider and adjustable visualization of the operative field, and lack of postoperative cosmetic defects are well-known advantages of the endonasal endoscopic approaches compared with traditional surgical exposures both in adults and in children. The need to avoid disruption of facial growth centers and permanent tooth roots represents a further special consideration in favor of these endoscopic techniques in children. The authors report on a case of solitary myofibroma involving the ethmoid, mesial orbits, and anterior skull base with intracranial intradural expansion in a 17-month-old girl. The occurrence of such proliferative disease along the skull base is exceedingly rare. The tumor was successfully excised via an endoscopy-assisted cranionasal approach in which a transcranial microsurgical exposure was combined with endonasal endoscopic access to ensure a radical resection and optimize skull base reconstruction. To the authors' knowledge, the patient in this case is the youngest reported patient in the literature who has undergone treatment with this surgical strategy. The outcome in this patient underscores the feasibility and safety of endoscopic endonasal surgery even in toddlers and early childhood.

PURPOSE: To assess the role of high sensitivity next-generation sequencing (NGS) of CTNNB1 for the diagnosis of adamantinomatous craniopharyngiomas (aCPs) and of BRAF for that of papillary CPs (pCPs) in routinely processed surgical samples of nonadenomatous sellar lesions. METHODS: Forty-five cases of patients operated for nonadenomatous masses of the sellar region between 2004 and 2014 were retrieved from the files of the Anatomic Pathology unit of the Bellaria Hospital in Bologna, Italy. BRAF and CTNNB1 mutation status was analyzed by NGS in samples smaller than 1 cm(3) and histological re-evaluation was performed on all cases. RESULTS: CTNNB1 mutation analysis showed a sensitivity of 86.7 % and a specificity of 96.2 % for the diagnosis of aCPs. The specificity increased to 100 % considering that in one case, initially classified as a non-CP lesion (xanthogranuloma), the identification of a CTNNB1 S47R lead to histological re-evaluation and reclassification of the lesion as aCP. BRAF mutation analysis had a sensitivity of 76.9 % and a specificity of 96.4 % for the diagnosis of pCPs. The specificity increased to 100 % considering that in one case, initially classified as a Rathke cyst, the identification of BRAF V600E lead to histological re-evaluation and reclassification of the lesion as pCP. CONCLUSIONS: This study confirms the diagnostic relevance of the molecular alterations recently identified in aCPs and pCPs and shows how the identification of BRAF and CTNNB1 mutations can be instrumental for the proper classification of samples that contain limiting amounts of diagnostic lesional tissue.

Objectives. Epistaxis is one of the most common otorhinolaryngologic emergencies representing more than 12% of conditions managed at the Ear, Nose and Throat (ENT) Emergency Consulting Room of our Otorhinolaryngologic Unit each year. The elevated frequency of this pathology makes it necessary to adopt the most effective and least expensive therapeutic strategy available. The aim of this study was to compare the efficacy, costs and morbidity of nasal packing (NP), which is the mainstay of treatment for anterior epistaxis in our ENT Emergency Consulting Room versus submucosal infiltrations of lauromacrogol (LA). Methods. A retrospective study was designed from August 2012 to April 2013 involving 53 patients suffering from anterior epistaxis. Anterior NP was used in 27 patients versus 26 patients undergoing 27 procedures performed with submucosal infiltrations of LA (or polidocanol). Outcomes for each treatment were evaluated. Patients in group 1 were treated with LA 400 injection next to the bleeding point: 0.5- to 1-mL single or multiple infiltrations with a 27-gauge needle. The whitening of the nasal mucosa around the bleeding point during infiltration was considered a marker of correct procedure in order to achieve the best results. Bilateral treatment was also performed at the same time. Patients in group 2 were treated with standard NP. Results. Bleeding recurrence was higher in the NP group even if it was not statistically significant (P=0.2935). However, the LA infiltrations were better tolerated with lower morbidity and costs as compared to NP. No complications were observed in either group. Conclusion. LA infiltrations were shown to be a viable alternative in anterior epistaxis treatment. They are safe, easy to use with good efficacy and have a low cost.