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Purpose: Corneal neurotization (CN) is a novel, potentially curative surgical procedure for the treatment of neurothophic keratopathy (NK). Patients with severe NK can present with corneal opacification requiring optical keratoplasty, which would likely fail without a proper trophic support of corneal nerves in the recipient cornea., Methods: This is a pilot study on 4 patients undergoing keratoplasty after CN. Pre- and postoperative data at 12, 24 months and at the last follow-up were collected for the examination of (i) best corrected visual acuity (BCVA), (ii) slit lamp examination and photograph acquisition with and without fluorescein staining, (iii) corneal aesthesiometry, (iv) in vivo confocal microscopy of the central cornea. Neurophysiological study of the corneal reflex before corneal graft and at last follow up was performed., Results: Four female patients (47.25 ± 5.06 y.o.) underwent keratoplasty after CN (3 penetrating keratoplasty, 1 deep anterior lamellar keratoplasty). The mean interval between CN and keratoplasty was 22 (± 12) months. The mean graft survival time was 42 (± 25) months. Graft follow-up ranged from 72 to 132 months. At the final follow-up, BCVA was improved in 2 out of 4 patients. The mean corneal sensitivity was 11.9 ± 8.3 mm at last follow-up. In vivo confocal microscopy confirmed the presence of functioning nerves at the last follow-up in all patients. NK-related complications occurred in 3 eyes (2 persistent epithelial defect, 1 corneal melting). The former complication was successfully treated by autologous serum eye drops while the latter required repeated keratoplasty., Conclusions: Keratoplasty is a viable strategy to improve visual acuity in patients with corneal opacity who underwent CN for the treatment of NK. Even in the presence of functioning corneal nerves before keratoplasty, surgeons should be aware of the increased rate of NK-related complications that could require the need for repeated procedure.

This study evaluates the quality and readability of informed consent documents generated by AI platforms ChatGPT-4 and Bard Gemini Advanced compared to those written by a first-year oral surgery resident for common oral surgery procedures. The evaluation, conducted by 18 experienced oral and maxillofacial surgeons, assessed consents for accuracy, completeness, readability, and overall quality. ChatGPT-4 consistently outperformed both Bard and human-written consents. ChatGPT-4 consents had a median accuracy score of 4 [IQR 4-4], compared to Bard's 3 [IQR 3-4] and human's 4 [IQR 3-4]. Completeness scores were higher for ChatGPT-4 (4 [IQR 4-5]) than Bard (3 [IQR 3-4]) and human (4 [IQR 3-4]). Readability was also superior for ChatGPT-4, with a median score of 4 [IQR 4-5] compared to Bard and human consents, both at 4 [IQR 4-4] and 4 [IQR 3-4], respectively. The Gunning Fog Index for ChatGPT-4 was 17.2 [IQR 16.5-18.2], better than Bard's 23.1 [IQR 20.5-24.7] and the human consents' 20 [IQR 19.2-20.9]. Overall, ChatGPT-4's consents received the highest quality ratings, underscoring AI's potential in enhancing patient communication and the informed consent process. The study suggests AI can reduce misinformation risks and improve patient understanding, but continuous evaluation, oversight, and patient feedback integration are crucial to ensure the effectiveness and appropriateness of AI-generated content in clinical practice., Competing Interests: Declaration of competing interest All authors report no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background/Objectives: Chronic graft-versus-host disease (cGVHD) and oral lichen planus (LPO) are chronic inflammatory conditions with similar oral manifestations. This study aimed to assess whether serum and salivary cytokines (IL-1α, IL-6, IL-17) could serve as reliable biomarkers for cGVHD. Methods: A prospective cohort study was conducted involving cGVHD patients, LPO patients, and healthy controls. Cytokine levels in serum and saliva were measured by ELISA and compared across the groups using the Kruskal-Wallis test. Results: IL-17 levels were significantly elevated in the serum of cGVHD patients compared to LPO patients and controls ( p < 0.05). However, IL-6 and IL-1α did not show significant differences among the groups. A comparison of salivary samples between the three groups did not reach statistical significance ( p > 0.05). Conclusions: This study suggests that IL-17 could be a potential biomarker for cGVHD-related inflammation, warranting further investigation. Salivary samples do not seem to be a reliable biological marker for the diagnosis of cGVHD. The findings underline the need for larger studies to validate these preliminary results.

Purpose: We recently described a novel surgical procedure to reinnervate the lacrimal gland in neurodeprivative dry eye disease and reported the 1-year outcomes of patients treated accordingly. The purpose of this paper is to describe the long-term outcomes of this innovative surgical technique., Methods: Monocentric cross-sectional study including consecutive patients affected by facial palsy with an absolute deficiency of tear secretion (Schirmer test 0 mm/5 min) who underwent lacrimal gland neurotization, as previously described. Before surgery (T0) and at the last follow-up visit (T1), the following parameters were evaluated: tear film break-up time (TBUT), corneal fluorescein staining (Oxford score), Schirmer test type I, usage of tear substitutes (daily number of instillation). At T1, subjective satisfaction with surgery was collected and tear film osmolarity (TFO) was measured in both operated and contralateral eye. Corneal sensitivity was performed at T0 and T1 in patients who underwent neurotization of both lacrimal gland and cornea due to the concomitant presence of neurotrophic keratopathy (trigeminal nerve palsy)., Results: Data from 9 patients (4 M, 5 F; mean age 47.1 ± 17.1 years) who underwent lacrimal gland neurotization and were followed up for an average time of 87 months (± 15) (range 60-108) were analyzed. The study procedure was combined in all cases with facial reanimation, while corneal neurotization was performed in 4 cases. At T1, the mean value of Schirmer test was significantly higher compared to T0 (5.8 ± 2.0 vs 0 ± 0 mm/5 min; p < 0.0001). TBUT and corneal fluorescein staining were significantly better compared to baseline (respectively, 2.4 ± 1.8 vs 1.2 ± 0.6 s, p = 0.04 and 1.7 ± 0.8 vs 3.1 ± 0.6, p = 0.0004). TFO was not significantly different between operated eye and contralateral one (306.7 ± 9.5 mOsm/L vs 308.9 ± 11.3 mOsm/L, p = 0.67). The mean daily number of tear substitute instillations was lower at T1 compared to T0 (12 ± 7 vs 21.8 ± 4.3; p = 0.011). Overall, all patients were satisfied with surgery at T1 (very satisfied: n = 3 and satisfied: n = 6). No major postoperative complications were recorded throughout the entire follow-up., Conclusion: Lacrimal gland neurotization through the sural nerve is a safe and effective procedure with stable favorable outcomes in the long term., Competing Interests: Declarations. Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ethics Committee of the University of Milan and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent: Informed consent was obtained from all individual participants included in the study. Conflict of interest: All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The widespread diffusion of Artificial Intelligence (AI) platforms is revolutionizing how health-related information is disseminated, thereby highlighting the need for tools to evaluate the quality of such information. This study aimed to propose and validate the Quality Assessment of Medical Artificial Intelligence (QAMAI), a tool specifically designed to assess the quality of health information provided by AI platforms., Methods: The QAMAI tool has been developed by a panel of experts following guidelines for the development of new questionnaires. A total of 30 responses from ChatGPT4, addressing patient queries, theoretical questions, and clinical head and neck surgery scenarios were assessed by 27 reviewers from 25 academic centers worldwide. Construct validity, internal consistency, inter-rater and test-retest reliability were assessed to validate the tool., Results: The validation was conducted on the basis of 792 assessments for the 30 responses given by ChatGPT4. The results of the exploratory factor analysis revealed a unidimensional structure of the QAMAI with a single factor comprising all the items that explained 51.1% of the variance with factor loadings ranging from 0.449 to 0.856. Overall internal consistency was high (Cronbach's alpha = 0.837). The Interclass Correlation Coefficient was 0.983 (95% CI 0.973-0.991; F (29,542) = 68.3; p < 0.001), indicating excellent reliability. Test-retest reliability analysis revealed a moderate-to-strong correlation with a Pearson's coefficient of 0.876 (95% CI 0.859-0.891; p < 0.001)., Conclusions: The QAMAI tool demonstrated significant reliability and validity in assessing the quality of health information provided by AI platforms. Such a tool might become particularly important/useful for physicians as patients increasingly seek medical information on AI platforms., (© 2024. The Author(s).)

Purpose: This study evaluates the efficacy of two advanced Large Language Models (LLMs), OpenAI's ChatGPT 4 and Google's Gemini Advanced, in providing treatment recommendations for head and neck oncology cases. The aim is to assess their utility in supporting multidisciplinary oncological evaluations and decision-making processes., Methods: This comparative analysis examined the responses of ChatGPT 4 and Gemini Advanced to five hypothetical cases of head and neck cancer, each representing a different anatomical subsite. The responses were evaluated against the latest National Comprehensive Cancer Network (NCCN) guidelines by two blinded panels using the total disagreement score (TDS) and the artificial intelligence performance instrument (AIPI). Statistical assessments were performed using the Wilcoxon signed-rank test and the Friedman test., Results: Both LLMs produced relevant treatment recommendations with ChatGPT 4 generally outperforming Gemini Advanced regarding adherence to guidelines and comprehensive treatment planning. ChatGPT 4 showed higher AIPI scores (median 3 [2-4]) compared to Gemini Advanced (median 2 [2-3]), indicating better overall performance. Notably, inconsistencies were observed in the management of induction chemotherapy and surgical decisions, such as neck dissection., Conclusions: While both LLMs demonstrated the potential to aid in the multidisciplinary management of head and neck oncology, discrepancies in certain critical areas highlight the need for further refinement. The study supports the growing role of AI in enhancing clinical decision-making but also emphasizes the necessity for continuous updates and validation against current clinical standards to integrate AI into healthcare practices fully., (© 2024. The Author(s).)

Objective: To investigate the accuracy of Chat-Based Generative Pre-trained Transformer (ChatGPT) in answering questions and solving clinical scenarios of head and neck surgery., Study Design: Observational and valuative study., Setting: Eighteen surgeons from 14 Italian head and neck surgery units., Methods: A total of 144 clinical questions encompassing different subspecialities of head and neck surgery and 15 comprehensive clinical scenarios were developed. Questions and scenarios were inputted into ChatGPT4, and the resulting answers were evaluated by the researchers using accuracy (range 1-6), completeness (range 1-3), and references' quality Likert scales., Results: The overall median score of open-ended questions was 6 (interquartile range[IQR]: 5-6) for accuracy and 3 (IQR: 2-3) for completeness. Overall, the reviewers rated the answer as entirely or nearly entirely correct in 87.2% of cases and as comprehensive and covering all aspects of the question in 73% of cases. The artificial intelligence (AI) model achieved a correct response in 84.7% of the closed-ended questions (11 wrong answers). As for the clinical scenarios, ChatGPT provided a fully or nearly fully correct diagnosis in 81.7% of cases. The proposed diagnostic or therapeutic procedure was judged to be complete in 56.7% of cases. The overall quality of the bibliographic references was poor, and sources were nonexistent in 46.4% of the cases., Conclusion: The results generally demonstrate a good level of accuracy in the AI's answers. The AI's ability to resolve complex clinical scenarios is promising, but it still falls short of being considered a reliable support for the decision-making process of specialists in head-neck surgery., (© 2023 The Authors. Otolaryngology–Head and Neck Surgery published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objective: The indications for and approaches to extracapsular dissection for parotid gland benign tumours are debated in the literature. This study retrospectively evaluates a single site's short- and long-term results with a standardised extracapsular dissection approach to benign parotid tumours., Methods: A retrospective review of a single institution's records identified cases with extracapsular dissection as the primary surgery for non-recurrent benign parotid tumours. A total of 194 eligible patients were identified (124 women and 70 men, age 47.75 ± 15.62 years). Pre-, intra- and post-surgical data were reviewed for complications and recurrences., Results: Histology reported pleomorphic adenoma in 165 patients, Warthin's tumour in 28 patients and both in one patient. Mean follow up was 36 ± 16 months (range, 12-84 months). The incidences of complications following extracapsular dissection were temporary ( n = 13) and permanent ( n = 0) facial nerve dysfunction, Frey's syndrome ( n = 1)) and recurrences ( n = 5). These rates align with prior literature., Conclusion: This case series shows how a standardised approach to extracapsular dissection for benign parotid tumours yields favourable results, supporting a progressive change of strategy towards reduced invasiveness.

Electromyographic evaluation is a reliable tool for confirming facial palsy and assessing its severity. It allows differentiating facial paresis and paralysis, and further distinguishes acute palsies, still showing muscle fibrillations, from chronic cases. This article aims to show that EMG fibrillations might represent a better criterion to differentiate acute and chronic palsies than the standard 18-24 months' cut-off usually employed for classification and treatment purposes. We performed a cohort study using the eFACE tool for comparing triple innervation facial reanimation results in patients with EMG fibrillation treated <12 months, 12-18 months, and >18 months from paralysis onset. Patients showed a statistically significant post-operative improvement in all eFACE items, both in the whole sample and in the three groups. Only the deviation from the optimal score for the gentle eye closure item in group 2 didn't reach statistical significance (p = 0.173). The post-operative results were comparable in the three groups, as the Kruskal-Wallis test showed a difference only for the platysmal synkinesis item scores, which were significantly lower in group 3 (p = 0.025)., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: This study aimed to evaluate the utility of large language model (LLM) artificial intelligence tools, Chat Generative Pre-Trained Transformer (ChatGPT) versions 3.5 and 4, in managing complex otolaryngological clinical scenarios, specifically for the multidisciplinary management of odontogenic sinusitis (ODS)., Methods: A prospective, structured multidisciplinary specialist evaluation was conducted using five ad hoc designed ODS-related clinical scenarios. LLM responses to these scenarios were critically reviewed by a multidisciplinary panel of eight specialist evaluators (2 ODS experts, 2 rhinologists, 2 general otolaryngologists, and 2 maxillofacial surgeons). Based on the level of disagreement from panel members, a Total Disagreement Score (TDS) was calculated for each LLM response, and TDS comparisons were made between ChatGPT3.5 and ChatGPT4, as well as between different evaluators., Results: While disagreement to some degree was demonstrated in 73/80 evaluator reviews of LLMs' responses, TDSs were significantly lower for ChatGPT4 compared to ChatGPT3.5. Highest TDSs were found in the case of complicated ODS with orbital abscess, presumably due to increased case complexity with dental, rhinologic, and orbital factors affecting diagnostic and therapeutic options. There were no statistically significant differences in TDSs between evaluators' specialties, though ODS experts and maxillofacial surgeons tended to assign higher TDSs., Conclusions: LLMs like ChatGPT, especially newer versions, showed potential for complimenting evidence-based clinical decision-making, but substantial disagreement was still demonstrated between LLMs and clinical specialists across most case examples, suggesting they are not yet optimal in aiding clinical management decisions. Future studies will be important to analyze LLMs' performance as they evolve over time., (© 2024. The Author(s).)

Facial palsy can severely compromise quality of life, significantly altering the harmony and symmetry of the face, which can be restored by surgical rehabilitation. The aim of the study was the quantification of facial symmetry following facial reanimation. Fifteen consecutive adult patients were surgically treated through triple innervation for reanimation of flaccid unilateral facial paralysis (contralateral facial nerve, masseteric nerve, and hypoglossal nerve) and fascia lata graft for definition of the nasolabial sulcus. In the preoperative stage and at least 11 months after the surgical treatment, three-dimensional facial images were recorded through stereophotogrammetry in a neutral (rest) position, and with Mona Lisa and full-denture (maximum) smiles. Labial commissure inclination relative to the interpupillary axis, and a surface assessment of local facial asymmetry at rest and while smiling were obtained for the upper, middle, and lower facial thirds. The angle between the interpupillary axis and the labial commissure significantly improved in post-surgical acquisitions, regaining symmetry at rest (t-test; p < 0.001). Facial symmetry increased significantly when passing from pre-to postsurgical facial scans, from the lower to the upper facial third, and from the full smile to the rest position (ANOVA; p < 0.001). After treatment, the full smile recovered more symmetry than the other two expressions. In summary, surgical treatment significantly reduced facial asymmetry, but this reduction differed significantly among the various animations and facial thirds. The results of this study confirmed clinical findings of significant static and dynamic improvements in facial symmetry after triple innervation reanimation surgery., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The objective of this manuscript was to review the indications, efficacy, and safety of a 585 nm pulsed dye laser (PDL) in non-malignant laryngeal lesions. Following the PRISMA statement recommendations, three independent authors searched for articles published in PubMed/MEDLINE, the Cochrane Library, Google Scholar, Scielo, and Web of Science. A bias analysis was performed following NICE guidance tools. From the 506 identified publications, 19 observational studies met the inclusion criteria. The PDL improves vocal quality objectively and subjectively in vascular lesions ( p < 0.005) and improves vocal quality in patients with dysplasia/leukoplasia without changing the natural history of the disease compared to other treatments. Reinke's edema and granulomas require an average of 1.5 PDL sessions for resolution. Treatment of recurrent respiratory papillomatosis requires multiple sessions, with complete remission achieved in 50-70% of patients. Regardless of the lesion, the tolerance of the procedure under local anesthesia is exceptional (84-97%), and the results in terms of regression and vocal quality are promising. The complication rate is minimal, and the procedure does not interfere with other treatment alternatives. There is no consensus on laser settings. The lack of consistent use in evaluating vocal outcomes, whether objective or subjective, prevents the comparability between studies. The 585 nm pulsed dye laser appears to be an effective and safe therapeutic option in patients with non-malignant laryngeal pathology. Future controlled studies are needed to compare the 585 nm pulsed dye laser with other lasers or cold instrument procedures.

It is the aim of the study to provide a detailed intraoperative assessment of the masseteric nerve and the facial branch of the smiling muscles complex through the same superficial musculoaponeurotic system (SMAS) incision. This observational retrospective study aimed to define the straightest and safest surgical route to identify the facial nerve for the smiling muscles complex and the masseteric nerve, using distance from the tragus and zygomatic arch as anatomical landmarks. 30 patients were included in the study. The mean distance from the tragus to the masseteric nerve was 40.03 mm, the mean distance from the zygomatic arch was 12.24 mm, and the mean depth from the SMAS was 10.84 mm. Data were consistent, with little variation. The distance from the zygoma was found to be higher in male patients. There was a positive correlation between the depth to the nerve and the distance from the zygoma, but no correlation between body mass index and the other parameters studied. Within the limitations of the study it seems that the proposed standardized direct approach to the masseteric nerve is a reproducible technique that may be used to increase the safety of the procedure, reduce the operating time, and decrease the amount of dissection and related postoperative scarring, thereby fostering positive results., Competing Interests: Declaration of competing interest None., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Paranasal sinus fungus balls (PSFB) are a common form of surgically treatable, noninvasive mycosis. To date, no guidelines have standardized PSFB treatment or management of difficult cases (eg, immunocompromised or fragile patients). The clinical consensus statement presented herein aims to provide a comprehensive management guide to PSFB based on current evidence., Methods: A multidisciplinary, international panel of 19 specialists judged statements in 3 rounds of a modified Delphi method survey. Statements encompassed the following PSFB management issues: definition, diagnostic workup; treatment indications and modalities; and follow-up. Otolaryngologists, maxillofacial surgeons, infectious disease specialists, and transplant physicians were considered the target audience., Results: Among the 23 statements, 7 reached strong consensus and 16 reached consensus. Consensus was reached on the definition, diagnosis, and treatment modalities for PSFB. Postoperative follow-up modalities and scenarios with bacterial superinfection were the most debated issues., Conclusion: Until further data are available, these points provide a framework for the management of PSFB. Moreover, PSFB should be considered a noninvasive mycosis that is not necessarily symptomatic or related to odontogenic conditions. Although diagnosis may be incidental, endoscopy and single imaging (computed tomography or magnetic resonance imaging, with distinctive features) are required for diagnosis, whereas contrast medium would allow for differential diagnosis. Although treatment of PSFB should be considered mandatory before sinus augmentation and is recommended for symptomatic patients, immunosuppressed patients, or patients with planned immunosuppression, watchful waiting could be considered for asymptomatic patients with chronic rhinosinusitis who are provided with appropriate advice and assessment., (© 2022 The Authors. International Forum of Allergy & Rhinology published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngic Allergy and American Rhinologic Society.)

Facial paralysis decreases eye protection mechanisms leading to ocular problems up to corneal ulceration, and blindness. This study aimed to evaluate the outcomes of periocular procedures for recent facial paralysis. Medical records of patients with unilateral recent complete facial palsy who did periocular procedures at the Maxillofacial Surgery Department of San Paolo Hospital (Milan, Italy) between April 2018 and November 2021 were retrospectively reviewed. 26 patients were included. All patients were evaluated 4 months after surgery. The first group included 9 patients who underwent upper eye lid lipofilling and midface suspension with fascia lata graft; they had no ocular dryness symptoms and no need for eye protection measures in 33.3% of cases, significant reduction of ocular symptoms and need for eye protection measures in 66.6% of patient, 0-2 mm lagophthalmos in 66.6% and 3-4 mm lagophthalmos in 33.3%. The second group of 17 patients who underwent upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy, had no ocular dryness symptoms and no need for eye protection measures in 17.6% of patient, significant reduction of ocular symptoms and need for eye protection measures in 76.4% of patient, 0-2 mm lagophthalmos in 70.5%, 3-4 mm lagophthalmos in 23.5% and one patient 5,8%had 8 mm lagophthalmos and persistent symptoms. No ocular complication, cosmetic complain or donner site morbidity were reported. Upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy decrease ocular dryness symptoms and need for eye protection measures and improve lagophthalmos: the association of the reinnervation with these complementary techniques is therefore highly recommended in order to immediately protect the eye., Competing Interests: Declaration of competing interest None., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Using the wording "facial reanimation," surgeons mean restoring movements to the paralyzed face. According to the condition of mimic muscle, facial palsy can be classified as recent (mimic muscle still alive) and chronic (atrophy of mimic muscle) palsy. The treatment is quite different because in the former group the mimic muscles can be still used so long as a new motor source would be connected to the damaged facial nerve. In the latter group, muscular transplantation is needed to substitute the atrophied mimic muscles of the middle part of the face. In both cases, the neural impulse that makes the muscles (mimic muscle in the former, transplanted muscle in the latter) move come from a new motor nerve. Nowadays, the masseteric nerve is widely used as a new motor source in recent facial reanimation; the same nerve has also a main role in the treatment of both chronic facial palsy where it is used as the new nervous stimulus for the new transplanted muscle and facial paresis where the nervous stimulus coming from the masseteric nerve is used to empower the stimulus coming from the injured facial nerve. The masseteric nerve can be usually connected directly to the facial nerve without the interposition of a nerve graft, with a faster reinnervation. Moreover, the use of the masseteric nerve gives no morbidity to the masticatory functions., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: No specific interventions have been reported for the treatment of severe neurodeprivative dry eye disease owing to facial nerve palsy. We describe herein the feasibility of a novel surgical procedure to reinnervate the lacrimal gland and report the preliminary outcomes of the first series of patients who were treated accordingly., Methods: Prospective interventional case series including consecutive patients affected by facial palsy with absolute deficiency of tear secretion who underwent lacrimal gland neurotization. A sural nerve vertical cross-face graft was used to connect the lacrimal gland with the parasympathetic branch of the lingual nerve directed to the contralateral submandibular gland., Results: Lacrimal neurotization was performed uneventfully in 10 patients (4 M, 6 F; mean age 47.1 ± 17.1 years). In all cases, the procedure was combined with facial reanimation, while corneal neurotization was performed in 4 cases. One year postoperatively, mean values of a Schirmer test increased significantly compared with baseline values (7.56 ± 7.84 vs. 0 ± 0 mm/5 min; P = 0.02), while the mean daily number of instillation of tear substitutes decreased significantly (21.8 ± 4.5 vs. 7.1 ± 2.2; P = 0.009). Overall, all patients were satisfied with surgery (very satisfied: n = 7 and satisfied: n = 2). No major postoperative complications occurred., Conclusions: Vertical cross-face using a sural nerve graft to connect the lacrimal gland with the contralateral submandibular gland is a novel technique for treating patients with facial nerve palsy and severe neurodeprivative dry eye disease. This surgery both performed alone and combined with corneal neurotization is able to improve tear secretion and decrease the need for frequent instillations of tear substitutes., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Intranasal cocaine is known to potentially lead to midline destructive lesions. The present systematic review was undertaken to systematically define the localization of cocaine-induced midline destructive lesions and their prevalence and to propose a practical classification of these lesions., Methods: A PRISMA-compliant systematic review was performed in multiple databases with criteria designed to include all studies published until March 2021 providing a precise definition of cocaine-induced midline lesions in humans. We selected all original studies except case reports. After duplicate removal, abstract and full-text selection, and quality assessment, we reviewed eligible articles for lesion localization, patients' demographics, exposure to cocaine, and relationship with external nose destruction., Results: Among 2593 unique citations, 17 studies were deemed eligible (127 patients). All studies were retrospective case series. The destructive process determined a septal perforation in 99.2% of patients. The distribution prevalence decreased from the inferior third of the sinonasal complex (nasal floor and inferolateral nasal wall, respectively, 59% and 29.9% of patients) to the middle third (middle turbinate and ethmoid, 22.8% of patients), and ultimately to neurocranial structures (7.9% of patients). Nasal deformities were inconsistently reported across reviewed studies. Cocaine use duration, frequency, and status were reported only occasionally., Conclusion: Based on the distribution prevalence observed, we propose a four-grade destruction location-based classification. Future prospective studies following the evolution of cocaine-induced lesions are needed to validate our classification, its relationship with lesion evolution, and whether it represents a reliable tool for homogeneous research results reporting., (© 2022. The Author(s).)

Background: Implantological procedures aimed at rehabilitating upper jaw edentulous patients (dental implant placement and/or maxillary sinus grafting) can sporadically result in sinusitis. In these patients, endoscopic sinus surgery is the most commonly employed treatment, but clinical scenarios and comprehensive management strategies are extremely heterogeneous across studies., Objective: We sought to systematically define treatment strategies and related success rates for sinusitis following dental implantation, detailing different current treatment choices and concepts., Methods: Adopting a PRISMA-compliant review framework, systematic searches were performed in multiple databases using criteria designed to include all studies published until November 2020 focusing on the treatment of human sinusitis following dental implantation. We selected all original studies, excluding case reports, specifying treatment modalities with objective treatment success definitions. Following duplicate removal, abstract and full-text selection, and quality assessment, we reviewed eligible articles for treatment modalities and success rates, which were pooled in a random-effects meta-analysis., Results: Among 581 unique citations, eight studies (181 patients) were selected. Seven studies were retrospective case series. All studies relied on endoscopic sinus surgery, often coupled with intraoral accesses, and assessed therapeutic success endoscopically. The pooled treatment success rate was 94.7% (95% confidence interval, 91.5%-98%). Failures were treated in seven of 15 cases with further antibiotic therapies and in another seven cases with surgical revision. A single patient was lost to follow-up., Conclusions: Endoscopic sinus surgery appears to be the most frequent treatment of choice for sinusitis following dental implantation, with excellent success rates. The protean clinical picture drawn from the selected studies calls for the standardization of diagnostics and definitions in this field to enable direct comparisons between the results of different studies. The role of postoperative antibiotic therapies, which have been employed unevenly across studies, should also be prospectively investigated., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: The aim of this study is to describe techniques, results, and open issues of corneal neurotization (CN) for the treatment of neurotrophic keratopathy (NK)., Methods: An overview of the most important studies of CN is provided. The 2 main surgical approaches (namely, direct CN and indirect CN) with specific advantages and disadvantages are described. The results regarding changes of corneal sensitivity and clarity, visual acuity, and in vivo confocal microscopy metrics are summarized. Ex vivo studies with histopathology of the neurotized cornea are reported. Intraoperative and early and late postoperative complications are described along with current open issues to be further clarified., Results: Corneal sensitivity improves after both direct and indirect CN. Corneal reinnervation allows the healing of NK in almost the totality of the operated eyes, determining a corresponding improvement of corneal clarity and visual acuity. Regeneration of corneal nerve fibers is confirmed by means of either in vivo confocal microscopy or ex vivo histopathology. Few self-limiting complications are reported during the postoperative course. Current open issues concern the identification of the technique of choice, the use of autograft or allograft, and the timing of CN either when performed alone or when combined with other surgeries., Conclusions: CN represents a game-changing surgical procedure for NK, which has the potential to restore corneal sensitivity in all stages of the disease regardless of the mechanism of denervation. Further long-term results are needed to confirm its efficacy over time. The design of randomized clinical trials comparing CN with noninterventional therapies could further validate the adoption of this technique., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Paranasal sinus fungus ball is a common non-invasive mycosis with excellent long-term surgical treatment results. The present systematic review and meta-analysis were undertaken to define current treatment concepts and success rates in paranasal sinus fungus ball treatment., Methods: Systematic searches were performed in multiple databases with criteria designed to include all studies published until May 2020 focusing on paranasal sinuses fungus ball treatment in humans. We selected studies including at least 10 patients, specifying treatment modalities, providing a minimum 6-month follow-up, and objectivating treatment success. After duplicate removal, abstract and full-text selection, and quality assessment, we reviewed eligible articles for treatment modalities and success rates. Success rates were pooled in a random effect meta-analysis and compared according to the use of intraoperative sinus lavages and postoperative antibiotics., Results: Among 740 unique citations, 14 studies were deemed eligible. Most (n = 11) were retrospective case series. All studies relied on endoscopic sinus surgery. Intraoperative lavages were proposed in 10 studies and postoperative antibiotics in 7 (for all patients in 5 studies and for selected patients in 2). No significant heterogeneity was observed between results (Cochran's Q P  = .639, I 2 test = 0). Treatment success rate was 98.4% (95% confidence interval 97.4%-99.3%). Intraoperative sinus toilette and postoperative antibiotics didn't significantly improve the success rate., Conclusion: Endoscopic sinus surgery shows excellent results in fungus ball treatment. Further prospective studies might help further reducing antibiotics prescriptions in these patients and improve their management.

Purpose: SARS-CoV-2 vaccines are a key step in fighting the pandemic. Nevertheless, their rapid development did not allow for testing among specific population subgroups such as pregnant and breastfeeding women, or elaborating specific guidelines for healthcare personnel working in high infection risk specialties, such as otolaryngology (ORL). This clinical consensus statement (CCS) aims to offer guidance for SARS-CoV-2 vaccination to this high-risk population based on the best evidence available., Methods: A multidisciplinary international panel of 33 specialists judged statements through a two-round modified Delphi method survey. Statements were designed to encompass the following topics: risk of SARS-Cov-2 infection and use of protective equipment in ORL; SARS-Cov-2 infection and vaccines and respective risks for the mother/child dyad; and counseling for SARS-CoV-2 vaccination in pregnant, breastfeeding, or fertile healthcare workers (PBFHW). All ORL PBFHW were considered as the target audience., Results: Of the 13 statements, 7 reached consensus or strong consensus, 2 reached no consensus, and 2 reached near-consensus. According to the statements with strong consensus otorhinolaryngologists-head and neck surgeons who are pregnant, breastfeeding, or with childbearing potential should have the opportunity to receive SARS-Cov-2 vaccination. Moreover, personal protective equipment (PPE) should still be used even after the vaccination., Conclusion: Until prospective evaluations on these topics are available, ORL-HNS must be considered a high infection risk specialty. While the use of PPE remains pivotal, ORL PBFHW should be allowed access to SARS-CoV-2 vaccination provided they receive up-to-date information., (© 2021. The Author(s).)

Background: Odontogenic sinusitis affects a significant proportion of patients with paranasal sinus infections. Nevertheless, no shared diagnostic criteria for this condition have yet been implemented and published studies differ in their definition of the disease., Objective: The present systematic review of the literature was undertaken to characterize and analyze the different diagnostic criteria currently employed for odontogenic sinusitis., Methods: Systematic searches for studies published between 2009 and 2019 were performed in Medline, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov databases. Search criteria were designed to identify all studies focusing, even partially, on odontogenic sinusitis. Human original studies except single case reports published in the English, French, German, Spanish, or Italian language were included. We removed duplicate abstracts and conducted full-text reads, data extraction, and quality assessment procedures (using the Oxford Centre for Evidence-based Medicine levels of evidence and National Heart Lung and Blood Institute Study Quality Assessment Tools). We reviewed articles for diagnostic criteria, both in terms of definition and etiology identification., Results: Among 1,000 unique citations, 63 studies were deemed eligible. Most articles (n = 45) were retrospective case series; a single randomized clinical trial was available. Only 49 studies reported diagnostic criteria, yet relied marginally on published guidelines (n = 10 articles) for identifying sinusitis, often choosing instead to develop their own clinical (n = 15 articles), endoscopic (n = 12 articles), and/or radiologic (n = 30 articles) criteria. For odontogenic focus identification, 14 papers required a multidisciplinary evaluation, 11 papers required a time relationship between dental procedures and sinusitis, 24 papers required oroscopy and/or dental evaluation, and 53 papers required computed tomography., Conclusions: Current diagnostic criteria for odontogenic sinusitis are extremely heterogeneous. Establishing shared diagnostic criteria aimed at defining both sinusitis and related odontogenic foci would spur collaboration between investigators and support more comprehensive outcomes evaluations together with a better understanding of treatment options.

Background: Odontogenic sinusitis (ODS) is distinct from non-odontogenic rhinosinusitis, and often requires multidisciplinary collaboration between otolaryngologists and dental providers to make the diagnosis. The purpose of this study was to develop international multidisciplinary consensus on diagnosing ODS., Methods: A modified Delphi method was used to assess for expert consensus on diagnosing bacterial ODS. A multidisciplinary panel of 17 authors with ODS expertise from 8 countries (8 otolaryngologists, 9 dental specialists) was assembled. Each author completed 2 of 3 surveys (2 specialty-specific, and 1 for all authors). Thirty-seven clinical statements were created, focusing on 4 important diagnostic components: suspecting ODS; confirming sinusitis in ODS; confirming different dental pathologies causing ODS; and multidisciplinary collaborative aspects of diagnosing ODS. Target audiences were all otolaryngologists and dental providers., Results: Of the 37 clinical statements, 36 reached consensus or strong consensus, and 1 reached no consensus. Strong consensus was reached that certain clinical and microbiologic features should arouse suspicion for ODS, and that multidisciplinary collaboration between otolaryngologists and dental providers is generally required to diagnose ODS. To diagnose ODS, otolaryngologists should confirm sinusitis mainly based on nasal endoscopic findings of middle meatal purulence, edema, or polyps, and dental providers should confirm dental pathology based on clinical examination and dental imaging., Conclusion: Based on multidisciplinary international consensus, diagnosing ODS generally requires otolaryngologists to confirm sinusitis, and dental providers to confirm maxillary odontogenic pathology. Importantly, both dental providers and otolaryngologists should suspect ODS based on certain clinical features, and refer patients to appropriate providers for disease confirmation., (© 2021 ARS-AAOA, LLC.)

A retrospective comparison between two groups of patients who underwent one-step or two-step triple innervation was performed to reveal the role of scar tissue in axonal regeneration. The surgical technique used was the same in all cases, but the first group underwent a one-time triple innervation procedure, while patients in the second group underwent delayed performance of neurorrhaphies between the distal ends of the cross-face grafts and the terminal branches of the injured facial nerve. The Wilcoxon signed-rank test for paired groups showed a statistically significant improvement in both facial symmetry and voluntary movements in both groups of patients. Separately, the Mann-Whitney test confirmed no statistically significant difference between the two groups regarding the restoration of facial symmetry and voluntary movements, and the development of postoperative synkinesis. A comparison of median values for each spontaneous parameter between the groups revealed greater effectiveness of the two-step surgery, with both blinking and laughing demonstrating better results. The greater effectiveness of the double-step technique in restoring spontaneous movements strongly supports the use of a two-stage triple innervation technique in patients with facial palsy., Competing Interests: Declaration of competing interest None., (Copyright © 2021 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: To analyze the comparative safety and efficacy of two techniques of corneal neurotization (CN) (direct corneal neurotization [DCN] vs indirect corneal neurotization [ICN]) for the treatment of neurotrophic keratopathy (NK)., Design: Multicenter interventional prospective comparative case series., Methods: This study took place at ASST Santi Paolo e Carlo University Hospital, Milan; S.Orsola-Malpighi University Hospital, Bologna; and Santa Maria alle Scotte University Hospital, Siena, Italy. The study population consisted of consecutive patients with NK who underwent CN between November 2014 and October 2019. The intervention procedures included DCN, which was was performed by transferring contralateral supraorbital and supratrochlear nerves. ICN was performed using a sural nerve graft. The main outcome measures included NK healing, corneal sensitivity, corneal nerve fiber length (CNFL) measured by in vivo confocal microscopy (IVCM), and complication rates., Results: A total of 26 eyes in 25 patients were included: 16 eyes were treated with DCN and 10 with ICN. After surgery, NK was healed in all patients after a mean period of 3.9 months without differences between DCN and ICN. Mean corneal sensitivity improved significantly 1 year after surgery (from 3.07 to 22.11 mm; P < .001) without differences between the 2 groups. The corneal sub-basal nerve plexus that was absent before surgery in all patients, except 4, become detectable in all cases (mean CNFL: 14.67 ± 7.92 mm/mm 2 1 year postoperatively). No major complications were recorded in both groups., Conclusions: CN allowed the healing of NK in all patients as well as improvement of corneal sensitivity in most of them thanks to nerve regeneration documented by IVCM. One year postoperatively, DCN and ICN showed comparable outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The recent Italian outbreak of coronavirus disease 2019 led to an unprecedented burden on our health care system. Despite head and neck-otolaryngology not being a front-line specialty in dealing with this disease, our department had to face several specific issues. Despite a massive reallocation of resources in the hospital, we managed to keep the service active, improving safety measures for our personnel, specifically during common otolaryngologic maneuvers known to produce aerosols. Furthermore, we strived to maintain our teaching role, giving residents an inclusive role in managing the response to the emergency state, and we progressively integrated our inactive specialists into other service rotations to relieve front-line colleagues' burden. Specific issues and management decisions are discussed in detail in the article.

Purpose: To use an automated morphometric analysis system of in vivo confocal microscopy (IVCM) images for evaluating reinnervation occurring at the subbasal nerve plexus (SNP) after direct corneal neurotization (DCN) and to further report neurophysiological and histopathological findings., Methods: Prospective interventional case series including 3 eyes with neurotrophic keratitis that underwent DCN. Deep anterior lamellar keratoplasty was performed 18 months after DCN in patient 1. The following evaluations were performed before and at 3, 6, and 12 months after DCN: clinical evolution of keratitis; corneal sensitivity; IVCM images of the SNP analyzed with "ACCMetrics;" neurophysiological study of corneal reflex. Protein gene product 9.5 immunofluorescence staining assay and transmission electron microscopy were conducted on the neurotized button excised during deep anterior lamellar keratoplasty., Results: Complete healing was obtained in all patients by 3 months postoperatively. Corneal sensitivity was absent preoperatively in all eyes and improved after surgery, reaching an average value of 30 mm 1 year postoperatively. The corneal SNP was not visible at IVCM in any of the cases preoperatively and became visible by 3 months postoperatively, showing IVCM metrics comparable to normal contralateral eyes at 1 year. In all cases, neurophysiological evaluation showed a partial recovery of the electrical activity of the cornea. In patient 1, protein gene product (PGP) 9.5 staining of neurotized cornea showed nerve fascicles at the SNP, whereas transmission electron microscopy showed amyelinic nerve axons and nerve endings., Conclusions: The corneal SNP exhibited IVCM metrics comparable to the normal contralateral eye 1 year after DCN. Ex vivo histopathological assessment of neurotized corneas confirmed the presence of nerves with normal ultrastructure.

Purpose: Odontogenic sinusitis and sinonasal complications of dental disease or treatment (SCDDT) represent a heterogeneous group of conditions that often require multidisciplinary care. The present study aims to prospectively validate a classification and treatment protocol for SCDDT patients., Methods: One hundred twenty-eight consecutive patients (73 females and 45 males, mean age 52.4 years) affected by SCDDT not responding to dental and medical therapy were classified and surgically treated according to the proposed protocol. The protocol classified patients into three aetiology-based groups (preimplantologic, implantologic, and related to traditional dental diseases and procedures, respectively). The groups were further divided into classes according to the presence of oro-antral communications and/or dislocated dental hardware. Each condition was treated according to the class-related, protocol-defined treatment, by either a transnasal or combined transnasal/transoral approach. All patients were successfully classified according to our protocol. None of the proposed classes were redundant, and no condition fell outside the definitions., Results: The surgical treatment protocol proved to be adequate and effective, in that 125 of the 128 patients completely recovered after surgical treatment., Conclusions: The term SCDDT and the consequent classification proposed by the authors appear, therefore, to be nosologically correct. Furthermore, the protocol-related proposed treatment appears to be clinically sound, with a success rate nearing 98%.

Lingual nerve (LN) injury is one of the most serious consequences of oral surgery. Prompt microsurgical reconstruction of the nerve can alleviate most of those symptoms leading to satisfactory functional recovery.Thirty-five patients with partial to complete LN injury underwent surgery in the period between January 2006 and May 2015. All patients underwent a preoperative clinical and neurological evaluation with the assessment of lingual tactile and pain sensory thresholds and masseteric inhibitory reflex.All patients underwent explorative surgery and direct microneurorrhaphy of distal and proximal stumps in case of complete lesion, while the removal of traumatic neuroma and the following microneurorrhaphy of distal and proximal stumps of the injured nerve was performed in case of incomplete lesion. Nerve grafting has always been avoided because of distal stump mobilization obtained by severing the submandibular branch of the LN.All patients but 1 exhibited good recovery of tongue sensation, never complete, both clinically and electrophysiologically: recovery of the excitability of masseteric inhibitory reflex suppression components SP1 and SP2 was observed, often with increased latencies but consistent with a functional recovery.All patients feeling pain preoperatively experienced complete relief of algic symptoms.The early microsurgical approach is the most suitable choice for the treatment of LN injuries.

Segmental midface paresis with or without synkinesis reflects incomplete recovery from Bell's palsy, operations on the cranial base or parotid, or trauma, in 25%-30% of cases. To correct the deficit, the masseteric nerve was used to deliver a powerful stimulus to the zygomatic muscle complex, with the addition of a cross-face sural nerve graft to ensure more spontaneous smiling. By doing this, the orbicularis oculi muscle continues to have an appropriate stimulus from the facial nerve, and the zygomatic muscle complex is separately innervated, which considerably reduces synkinesis between the two muscle compartments. For those patients with muscular contractures of the midface, the new healthy neural stimulus relaxes muscles at rest. From January 2011 to March 2017, 20 patients presented with segmental facial paresis of the midface and were operated on using this new technique. All patients were evaluated before and after operation using Clinician-Graded Electronic Facial Paralysis Assessment (eFACE), and they showed considerable postoperative improvements in static, dynamic, and synkinetic variables. Our proposed use of the masseteric nerve to treat segmental facial paresis produces favourable results, but our initial data require confirmation by further studies., (Copyright © 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Recent facial paralyses, in which fibrillations of the mimetic muscles are still detectable by electromyography (EMG), allow facial reanimation based on giving new neural stimuli to musculature. However, if more time has elapsed, mimetic muscles can undergo irreversible atrophy, and providing a new neural stimulus is simply not effective. In these cases function is provided by transferring free flaps into the face or transposing masticatory muscles to reinstitute major movements, such as eyelid closure and smiling. In a small number of cases, patients affected by paralysis are referred late - more than 18 months after onset. In these cases, reinnervating the musculature carries a high risk of failure because some or all of the mimetic muscles may atrophy irreversibly while axonal ingrowth is taking place. A mixed reanimation technique to address this involves a neurorrhaphy between the masseteric nerve and a facial nerve branch for the orbicularis oculi, to ensure a stronger innervation to that muscle, associated with the transposition of the temporalis muscle to the nasiolabial sulcus. This gives good symmetry in the rest of the midface, while smiling movement is achievable, but not guaranteed. This one-time facial reanimation is particularly indicated for those who refuse major free-flap surgery or when that may be risky, as in previously operated and irradiated fields. More extensive procedures based on utilizing a free flap to recover smiling, while adding a cross-face nerve graft to restore blinking, may be proposed for motivated patients. Between 2010 and 2015, five patients affected by complete unilateral facial palsy underwent this technique in the Maxillofacial Surgery Department, San Paolo Hospital (Milan, Italy). Symmetry of the middle-third of the face at rest and recovery of smiling was quite good. Complete voluntary eyelid closure was obtained in all cases. Combining temporalis flap rotation and a masseteric-to-orbicularis-oculi-facial-nerve branch neurorrhaphy seems to be a valid solution for those medium-term referred patients., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Recent facial palsies are those in which fibrillations of the mimetic musculature remain detectable by electromyography (EMG). Such fibrillations generally cease 18-24 months after palsy onset. During this period, facial re-animation surgery seeks to supply new neural inputs to the facial nerve. Neural usable sources were divided into qualitative (contralateral facial nerve) and quantitative (hypoglossus and masseteric nerve), depending on the type of stimulus provided. To further improve the extent and quality of facial re-animation, we here describe a new surgical technique featuring triple neural inputs: the use of the masseteric nerve and 30% of the hypoglossus nerve fibres as quantitative sources was associated with the contralateral facial nerve (incorporated via two cross-face nerve grafts) as a qualitative source in order to restore facial movements in 24 consecutive patients. The use of two quantitative motor nerve sources together with a qualitative neural source appears to improve re-animation after facial paralysis, despite earlier doubts as to whether patients could use different nerves to produce facial movements. In fact, movement was much improved. Smiling according to emotions and blinking seem to be better assured if cross-face nerve grafting is performed in two steps rather than one., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)