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Objective. The aim of this study is to evaluate the feasibility of the 3D exoscope in a mi-crovascular anastomosis training setting and compare it with the gold-standard technique using the operating microscope (OM). Methods. Participants were recruited among otorhinolaryngology head and neck surgery (OHNS) residents of two tertiary care hospitals. Trainees were asked to complete 4 micro-vascular end-to-end anastomoses on chicken thighs with the OM and VITOM 3D exoscope. The performances were scored by experienced microvascular surgeons; an objective evaluation of the anastomosis and a subjective assessment of the workload were conducted. Results. 8 OHNS residents were recruited. Considering the amount of time needed to complete (TTC) the anastomosis, an improvement was shown by all the participants throughout the training program. The objective evaluation of the anastomosis did not show a significant difference. No significant differences were found by analyzing the subjective workload with the different tools. Conclusions. This article represents the first attempt to compare the use of the OM and the 3D exoscope during training for microsurgery. The results of our study demonstrate the noninferiori-ty of microsurgical training obtained using the 3D exoscope compared to that offered by the OM.

Key points  SARS-CoV-2 is a possible cause of acute severe tracheitis in laryngectomees.  In our series, the clinical picture was characterized by a haemorrhagic tracheitis with a slow resolution pattern.  We observed a histological pattern of erosive inflammation of the respiratory epithelium.  Planned tracheo-bronchoscopy and tracheal toilettes are recommended to prevent critical obstruction of the airway, which can be fatal in patients with associated impairment of lung function caused by SARS-CoV-2 infection.  The present cases highlight the need for close interdisciplinary working and communication in the management of airway complications of COVID-19 infection.

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

Patterns di recidiva dopo intervento di laringectomia parziale orizzontale tipo II e III: analisi univariata e regressione logistica dei fattori di rischio.Nella scelta del trattamento chirurgico (laringectomia totale o parziale) in pazienti affetti da carcinoma laringeo, è ancora necessaria l’identificazione di una correlazione tra fattori prognostici e risultati oncologici. Una coorte multi-istituzionale di 819 pazienti affetti da carcinoma laringeo e sottoposti a laringectomia parziale orizzontale (OPHL) tipo II e tipo III dal 1995 al 2014 è stata suddivisa in base alla comparsa o meno di recidiva (108 vs 711) ed alla sede di ricomparsa di malattia (loco-regionale, locale, a distanza). Sono state analizzate, mediante analisi uni e multivariata, tredici variabili cliniche e istologiche nei due gruppi, in relazione agli esiti oncologici (OS, DFS, DSS, LSF, FFL). All’analisi multivariata quattro sono risultati i fattori determinanti rischio di recidiva: sede del tumore (maggiormente nei tumori sopraglottici), invasione cartilaginea (maggiormente se presente), invasione perineurale (maggiormente se presente) ed il tipo di OPHL (maggiormente in caso di OPHL tipo III). La conoscenza e la detezione dei fattori prognostici negativi per il rischio di recidiva (classificazione pN, interessamento cartilagineo, invasione perineurale e quindi trattamento chirurgico adottato) potrebbero aumentare le già note potenzialità delle OPHL nel trattare casi con indicazione certa dopo attenta discussione collegiale.In choosing the best surgical treatment (total or partial laryngectomy) for patients affected by laryngeal squamous cell carcinoma (SCC), it is still necessary to identify a link between prognostic factors and oncological outcomes. A retrospective analysis of clinical outcomes of 819 patients affected by laryngeal cancer who underwent OPHL type II and III between 1995 to 2014 was carried out. Focusing on recurrence and its site (local, regional or distant), our cohort has been divided in two groups: patients showing recurrence (n = 108) vs those without recurrence (n = 711). Thirteen clinical-pathological parameters have been studied by univariate and multivariate analysis to identify possible correlations between recurrence and oncological outcomes (overall survival (OS), disease free survival (DFS), disease specific survival (DSS), laryngectomy free survival (LSF), laryngectomy free freedom (FFL). In multivariate analysis, we found 4 negative prognostic factors for recurrence: site of tumour (supraglottic), cartilage invasion (if present), perineural invasion (if present) and type of OPHL (in OPHL type III). The knowledge and detection of negative prognostic factors for the risk of recurrence (pN classification, cartilage involvement, perineural invasion, and thus the type of surgical treatment adopted) could increase the already well-established potentiality of OPHLs in treating cases with a safe indication after careful discussion in the tumour board.

Objectives To develop and validate an ex-vivo dissection model suitable for open laryngeal surgery (open partial laryngectomy and total laryngectomy) training. Methods A fresh ex-vivo 6-months old ovine model was tested by experienced laryngologists and validated during two international dissection courses on open laryngeal surgery held in December 2018 and 2019. Each participant completed a survey to subjectively evaluate the dissection experience. Likewise, four experienced laryngologists rated their experience. Statistical comparison of these ratings was performed. Results The suitability of the ex-vivo ovine model for open laryngeal surgery was assessed among 28 head and neck surgeons with a mean experience of 6.3 years and 4 expert laryngologists. The feedback from all the participants was excellent with a mean overall impression of 9.5 (± 0.7 SD) and a mean recommendation score of 9.6 (± 0.6 SD) for further use. No statistically significant differences were found comparing neither the overall grade (p= 0.63) nor the recommendation rating (p= 0.24), testifying that even for expert laryngologists this remains a viable model for open laryngeal surgery training. Conclusions The complexity of open laryngeal surgery makes simulation an attractive option for developing skills that are transferrable to operating setting. Due to the anatomic resemblance with the human, the ex-vivo ovine model is herein proposed as a training model for open laryngeal surgery. Validation among beginners and expert laryngologists revealed its suitability as effective teaching means in laryngectomies.

Funder: Università degli Studi di Trieste, PURPOSE: The aim of this study is to evaluate the prognostic value of pre-treatment advanced lung cancer inflammation index (ALI) in patients with HPV-negative HNSCC undergoing up-front surgical treatment. METHODS: The present multi-centre, retrospective study was performed in a consecutive cohort of patients who underwent upfront surgery with or without adjuvant (chemo)-radiotherapy for head and neck squamous cell carcinoma (HNSCC). Patients were stratified by ALI, and survival outcomes were compared between groups. In addition, the prognostic value of ALI was compared with two other indices, the prognostic nutritional index (PNI) and systemic inflammatory index (SIM). RESULTS: Two hundred twenty-three patients met the inclusion criteria (151 male and 72 female). Overall and progression-free survival were significantly predicted by ALI < 20.4 (HR 3.23, CI 1.51-6.90 for PFS and HR 3.41, CI 1.47-7.91 for OS). Similarly, PNI < 40.5 (HR = 2.43, 95% CI: 1.31-4.51 for PFS and HR = 2.40, 95% CI: 1.19-4.82 for OS) and SIM > 2.5 (HR = 2.51, 95% CI: 1.23-5.10 for PFS and HR = 2.60, 95% CI: 1.19-5.67 for OS) were found to be significant predictors. Among the three indices, ALI < 20.4 identified the patients with the worst 5-year outcomes. Moreover, patients with a combination of low PNI and low ALI resulted to be a better predictor of progression (HR = 5.26, 95% CI: 2.01-13.73) and death (HR = 5.68, 95% CI: 1.92-16.79) than low ALI and low PNI considered alone. CONCLUSIONS: Our results support the use of pre-treatment ALI, an easily measurable inflammatory/nutritional index, in daily clinical practice to improve prognostic stratification in surgically treated HPV-negative HNSCC.

International audience; Background: The clinical presentation of European patients with mild-to-moderate COVID-19 infection is still unknown. Objective: To study the clinical presentation of COVID-19 in Europe. Methods: Patients with positive diagnosis of COVID-19 were recruited from 18 European hospitals. Epidemiological and clinical data were obtained through a standardized questionnaire. Bayesian analysis was used for analysing the relationship between outcomes. Results: A total of 1,420 patients completed the study (962 females, 30.7% of healthcare workers). The mean age of patients was 39.17 ± 12.09 years. The most common symptoms were headache (70.3%), loss of smell (70.2%), nasal obstruction (67.8%), cough (63.2%), asthenia (63.3%), myalgia (62.5%), rhinorrhea (60.1%), gustatory dysfunction (54.2%) and sore throat (52.9%). Fever was reported by 45.4%. The mean duration of COVID-19 symptoms of mild-to-moderate cured patients was 11.5 ± 5.7 days. The prevalence of symptoms significantly varied according to age and sex. Young patients more frequently had ear, nose and throat complaints, whereas elderly individuals often presented fever, fatigue and loss of appetite. Loss of smell, headache, nasal obstruction and fatigue were more prevalent in female patients. The loss of smell was a key symptom of mild-to-moderate COVID-19 patients and was not associated with nasal obstruction and rhinorrhea. Loss of smell persisted at least 7 days after the disease in 37.5% of cured patients. Conclusion: The clinical presentation of mild-to-moderate COVID-19 substantially varies according to the age and the sex characteristics of patients. Olfactory dysfunction seems to be an important underestimated symptom of mild-to-moderate COVID-19 that needs to be recognized as such by the WHO.

Purpose: The role of tracheostomy in COVID-19-related ARDS is unknown. Nowadays, there is no clear indication regarding the timing of tracheostomy in these patients. Methods: We describe our synergic experience between ENT and ICU Departments at University Hospital of Modena underlining some controversial aspects that would be worth discussing tracheostomies in these patients. During the last 2weeks, we performed 28 tracheostomies on patients with ARDS due to COVID-19 infection who were treated with IMV. Results: No differences between percutaneous and surgical tracheostomy in terms of timing and no case of team virus infection. Conclusion: In our experience, tracheostomy should be performed only in selected patients within 7- and 14-day orotracheal intubation.

International audience; The purpose of this study was to evaluate the clinical features of mild-to-moderate coronavirus disease 2019 (COVID-19) in a sample of Italian patients and to investigate the occurrence of smell and taste disorders. Infected individuals with suspected (clinical diagnosis) or laboratory-confirmed COVID-19 infection were recruited. Patients completed a survey-based questionnaire with the aim of assessing their epidemiological and clinical characteristics, general otorhinolaryngological symptoms, and smell and taste disorders. A total of 294 patients with mild-to-moderate COVID-19 completed the survey (147 females). The most prevalent general symptoms included fever, myalgia, cough, and headache. A total of 70.4% and 59.2% of patients reported smell and taste disorders, respectively. A significant association between the two above-mentioned disorders was found (rs: 0.412; P

Purpose: Locoregional recurrence of thyroid carcinoma is relatively common and reported rate are between 5 and 20%. Cervical nodes are usually involved, especially at the central compartment. The management of recurrent thyroid carcinoma at central compartment still remains challenging because of higher incidence of complication rate. The aim of the study is to evaluate the survival and complications rate after revision surgery. Methods: Retrospective cohort study on a group of patients that underwent revision surgery for persistent or recurrent thyroid carcinoma from January 1, 2003 to December 31, 2017. Survival outcomes were calculated using Kaplan–Meier method. Significant variables on univariate analysis were subjected to a Cox proportional hazards regression multivariate model. Results: Fifty-two patients involved, 22 male (40%) and 30 female (60%). Mean age was 54years old (range 24–85). Mean follow-up was 79 months, median follow-up was 85 months, with a range between 8 and 153months. The 5-year overall survival was 90.8% while at 10years it was 69.8%. The 5-year disease-specific survival was 93.5%, while at 10years it dropped to 77.9%. The rate of recurrent laryngeal nerve paralysis and persistent hypocalcemia in our series were 1.3% and 5.9%, respectively. No evidence of thoracic duct, esophageal or laryngeal and tracheal injury was found in this case series. Regarding prognostic factors, univariate and multivariate analysis highlighted as statistically significant: the aggressive histological variants, the presence extranodal extension or soft-tissue metastasis. Conclusion: The surgical option remains the gold standard in locoregional recurrences of thyroid carcinoma and should be performed by experienced surgeons to reduce postoperative complications.

Introduction Salivary gland malignancies are rare neoplasms whose management has been evolving over the last two decades. Nevertheless, patient outcomes have not improved accordingly. Objective In the present paper, factors and variables that could influence Overall, Disease-Specific and Disease-Free Survival, and Loco-Regional Control were analyzed. Methods Chart data from 74 patients who underwent parotid gland surgery were retrospectively analyzed and stratified for tumor histology, grading, size, pT stage, pN stage, extracapsular spread, involved salivary gland lobe, and age at diagnosis. Major outcomes were estimated at 5 years by Kaplan–Meier curves. Results Advanced stage, high grade, and lymph nodes involvement greatly impaired patient outcomes. Furthermore, in our cohort, the age at diagnosis ≥ 55 was a cause of poorer disease survival likely due to a different distribution in tumor histotypes between older and younger patients. Despite the two groups were homogeneous for the numerosity of squamous cell carcinomas, older patients were more rarely affected by mucoepidermoid and acinic cell carcinomas, which have generally better prognosis. Finally, patients aged ≥ 55 had a more frequent pathological involvement of the deep lobe of the parotid gland if compared to the younger counterpart. Conclusion The rarity of some salivary gland tumor histotypes requires further high-number series to fully understand the prognostic factors for both patient survival and recurrence development. In our cohort, the age at diagnosis ≥ 55 raises concerns that play crucial roles in disease survival shortening.

Oral squamous cell carcinoma (OSCC) diagnoses in elderly patients are expected to double in the next 20 years. Current guidelines suggest surgery as a preferred approach, but elderly patients are hardly considered suitable to challenging surgical treatments. Using a multi-centric retrospective analysis, we evaluated the outcomes of 99 patients affected by OSCC and aged at least 70, who underwent to either transoral procedures (TP), open neck resection without (OR) or with reconstruction (ORR). In our cohort, overall survival was significantly hampered by concomitant diseases and postsurgical complications, whose development is driven by the former. Thus, our findings support the growing acceptance that chronological age alone should not be a sufficient contraindication for aggressive surgery in the treatment of OSCC. However, elderly patients affected by OSCC are undoubtedly delicate surgical candidates and accurate selection prior to surgery with curative intent is mandatory.Chiarire i fattori di rischio che sottendono la chirurgia del cavo orale e dell’orofaringe negli anziani.Nei prossimi vent’anni è previsto che il numero di diagnosi di carcinoma del cavo orale nel paziente anziano raddoppi. L’approccio chirurgico resta la terapia d’elezione sebbene sia dibattuto se esso possa essere praticabile negli anziani anche nei casi più demolitivi. Attraverso un’analisi retrospettiva multicentrica, abbiamo valutato 99 pazienti ultra-settantenni affetti da carcinoma della cavità orale sottoposti a chirurgia transorale, o resezione open con o senza ricostruzione. Nella nostra coorte, la sopravvivenza dei pazienti è stata negativamente influenzata dalla presenza di comorbidità e dallo sviluppo di complicanze post-operatorie. Inoltre, la comparsa di tali complicanze è stata posta in diretta correlazione con la presenza di una o più patologie concomitanti nel quadro clinico del paziente. Tuttavia, sebbene il paziente anziano sia un candidato delicato per approccio chirurgico ed un’accurata selezione sia quindi necessaria, i nostri risultati suggeriscono che l’età anagrafica non debba essere considerata una controindicazione sufficiente ad escludere a priori pazienti anziani candidati a trattamento chirurgico.

Background The purpose of this retrospective study was to identify subcategories in cT3 to cT4a supraglottic/glottic cancers, describing their different spreading patterns, and local and locoregional recurrence modes. Methods Four hundred eighty-nine patients who underwent open partial horizontal laryngectomies (OPHLs) were retrospectively classified as: subcategory I (anterior pT3 with normal arytenoid mobility); subcategory II (posterior pT3 with impaired/absent mobility); subcategory III (anterior pT4 with normal mobility); and subcategory IV (posterior pT4 with impaired/absent mobility). Results Five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), locoregional, local control, freedom from laryngectomy, and laryngectomy-free survival were significantly better in anterior tumors (subcategories I and III) when compared with the corresponding posterior ones (subcategories II and IV). Conclusion Anterior cT3 tumors are manageable by OPHL, and this approach could also be proposed in the treatment of early anterior cT4aN0. Despite promising results, OPHLs should be considered under investigation in posterior cT3 tumors due to clinical and biological behavior similar to cT4a tumors.

The Da Vinci robotic surgical system is increasingly being used by head and neck surgeons in transoral approaches for head and neck cancer. Our experience using the Da Vinci system for transoral robotic-assisted surgery (TORS) is presented. The feasibility of TORS for lesions involving the anterior portion of C1-C2 and the cranio-cervical junction has been evaluated from an anatomical viewpoint in a cadaveric laboratory. Two patients treated using the Da Vinci system to reach C1-C2 benign lesions are presented. The anatomical cadaveric study showed that this approach is safe and feasible. The first two cases which we describe confirmed the advantages of the Da Vinci system in the anterior approach to the cervical spine and allowed the limitations of this procedure to be assessed. TORS may be useful to reach anterior lesions of the cervical spine localized at the level of C1 and C2: first, for removal of small benign and well-delineated lesions; and second, for diagnostic purposes with biopsy of large lesions. Further studies and new instruments are needed to confirm the safety and results of this approach in terms of morbidity.

Objectives To analyze the long-term objective, perceptive, and subjective outcomes after endoscopic polydimethylsiloxane (PDMS) injection laryngoplasty in unilateral vocal fold paralysis. Study design A retrospective study carried out between January 2008 and January 2012. Setting Head and Neck Department, University Hospital of Modena, Modena, Italy. Methods This was a retrospective analysis of 26 patients with unilateral vocal fold paralysis who underwent endoscopic injection of PDMS under general anesthesia. A voice evaluation protocol was performed for all patients, which included videolaryngostroboscopy, maximum phonation time, fundamental frequency, analysis of the harmonic structure of the vowel /a/ and the word /aiuole/, Grade of Dysphonia, Instability, Roughness, Breathiness, Asthenia, and Strain scale, and Voice Handicap Index. The protocol was performed before surgery, in the immediate postoperative period, and at least 3 years after surgery. The mean follow-up period was 73 months (range 39–119 months). Results The statistical analysis showed a significant improvement (P < 0.01) for all of the objective, perceptive, and subjective parameters by comparison between the preoperative and long-term follow-up data; moreover, no statistically significant difference was found between the postoperative and long-term follow-up data. This indicates that injection laryngoplasty with PDMS guarantees long-lasting effects over time. No complications were reported in our series. Conclusion Injection laryngoplasty with PDMS can be considered to be a minimally invasive and safe technique for the treatment of unilateral vocal fold paralysis. Moreover, it allows very good and stable results to be obtained over time, avoiding repeated treatments and improving the quality of life of the patients.

Summary Objectives Vocal fold paralysis can have an important impact on a patient's quality of life. The goal of this study was to compare, in terms of vocal improvement and motility recovery, the post-vocal treatment results of our patients with unilateral vocal fold paralysis (UVFP) when treatment was started early (within 4 weeks from injury) versus intermediate (from 4 to 8 weeks) or delayed (at least 8 weeks after injury) treatment. Study Design An 11-year retrospective study of patients with UVFP who underwent multidimensional diagnostic-therapeutic assessment. Methods In total, 171 patients with UVFP were included in our study, divided into three groups who underwent early (first group), intermediate (second group), or delayed (third group) voice treatment. All patients underwent voice therapy based on forcible exercises supplemented by manipulations and maneuvers. Results Of the 171 patients with UVFP, 106 (62%) recovered vocal fold motility. Of these 106 patients, 51/78 (65%) were in the first group, 30/49 (61%) in the second group, and 25/44 (56%) in the third group. A significant (P < 0.0001) reduction in fundamental frequency (Fo) was present in the first group with a manifest improvement in the mean values of Jitter (Jitt%; P = 0.001), Shimmer (Shim%; P < 0.0001), and noise-to-harmonic ratio (NHR; P < 0.0001). A significant (P < 0.0001) reduction in Fo was found in the second group with a manifest improvement in Jitt% (P < 0.001), Shim% (P < 0.0001), and NHR (P < 0.0001). For the third group, no values were statistically significant apart from the improvement in NHR (P < 0.001). Conclusions This study confirms the importance of early rehabilitation underlining the non-functional vocal recovery in patients who started treatment later than 8 weeks after injury.

We study the existence of small amplitude oscillations near elliptic equilibria of autonomous systems, which mix different normal modes. The reference problem is the Fermi-Pasta-Ulam beta-model: a chain of nonlinear oscillators with nearest-neighborhood interaction. We develop a new bifurcation approach that locates secondary bifurcations from the unimodal primary branches. Two sufficient conditions for bifurcation are given: one involves only the arithmetic properties of the eigenvalues of the linearized system (asymptotic resonance), while the other takes into account the nonlinear character of the interaction between normal modes (nonlinear coupling). Both conditions are checked for the Fermi-Pasta-Ulam problem.

The stereoselective [2+2] cycloaddition reaction between the chiral tricarbonyl(eta(6)arene) chromium(0) complexed imines 1 and 6 and phthalimidoketene affords tricarbonyl (eta(6)arene)chromium(0) complexed 3-phthalimido-2-azetidinones 3, 7 and 8, both in racemic and enantiopure form. Decomplexation and the cleavage of the phthalimido group give 3-amino-4-substituted-2-azetidinones 5 and 10. Some insights into the stereochemical outcome of the [2+2] cycloaddition process are discussed. (C) 2003 Elsevier Ltd. All rights reserved

The aim of our study was to compare, in terms of aesthetic results, the use of synthetic glue to intradermal absorbable sutures in postthyroidectomy and parathyroidectomy wound closure in a single blinded, randomised, per protocol equivalence study. From September 2008 to May 2010, patients undergoing thyroid or parathyroid surgery (with an external approach) at the Otolaryngology Department of the University Hospital of Modena were assessed for eligibility. In total, 42 patients who had had synthetic glue application on surgical incisions (A) and 47 patients who had subcuticular sutures on their surgical incisions (B) were enrolled. The mean of the endpoint (based on the Wound Registry Scale) of group A at 10 days was 1.4, while that in group B (based on the Stony Brook Scar Evaluation Scale) was 2.9. Statistically significant (p = 0.002) and clinically significant (difference of the means = 1.5) differences in the aesthetic results were found between groups A and B at 10 days, with better results in group B. On the other hand, at 3 months, the mean of the endpoint in group A was 3.1 while that in group B was 2.8; no statistically significant (p = 0.62) or clinically significant (difference in means = 0.3) differences were found between groups A and B. In conclusion, synthetic glue differs from subcuticular suture in post-thyroidectomy or post-parathyroidectomy incision for early aesthetic results, with better outcomes for subcuticular sutures. At 3 months, there were no differences in aesthetic outcomes between groups. Moreover, sex, incision length, age, cold/hot blade and correspondence of the incision with a wrinkle in the skin did not seem to influence aesthetic outcomes with this type of incision.L'obiettivo del nostro lavoro è stato di confrontare, in termini di risultati estetici, l'uso di colla sintetica con l'uso di suture intradermiche riassorbibili nella chiusura delle ferrite post tiroidectomia e post paratiroidectomia mediante uno studio in singolo cieco, randomizzato per protocollo di equivalenza. Da settembre 2008 a maggio 2010, i pazienti sottoposti a tiroidectomia o a paratiroidectomia (con approccio esterno) presso il Dipartimento di Otorinolaringoiatria del Policlinico di Modena sono stati valutati per l'ammissione nello studio. In totale 42 pazienti che avevano ricevuto l'applicazione di colla sintetica sulle loro incisioni chirurgiche (A) e 47 pazienti che avevano avuto suture intradermiche sulle loro incisioni chirurgiche (B) sono stato arruolati nello studio. La media dell'end point (in base alla Wound Registry Scale) del gruppo A a 10 giorni è stata di 1.4, mentre quella del gruppo B (in base alla Stony Brook Scar Evaluation Scale) è stata di 2,9. Una differenza statisticamente significativa (p = 0.002) e clinicamente significativa (differenza delle medie = 1,5) nei risultati estetici è stata riscontrata tra i gruppi A e B a 10 giorni, con migliori risultati per il gruppo B. D'altra parte, a 3 mesi, la media dell'end point nel gruppo A è stata di 3.1 mentre quella nel gruppo B è stata di 2.8; nessuna differenza statisticamente significativa (p = 0,62) o clinicamente significativa (differenza in medie = 0.3) è stata trovata tra i gruppi A e B. In conclusione la colla sintetica differisce dalla sutura intradermica nell'incisione post tiroidectomia o post paratiroidectomia per quanto riguarda i primi risultati estetici che risultano essere migliori con le suture intradermiche. A 3 mesi, non c'erano più differenze in termini di risultati estetici tra i due gruppi. Inoltre il sesso, la lunghezza dell'incisione, l'età, il tipo di lama (fredda o calda), e la corrispondenza dell'incisione con una piega cutanea non sembrano influenzare i risultati estetici con questo tipo di incisione.

Introduction: Bednar aphthae are infected wounds caused by trauma, localized to the hard palate in infants. They do not require specific treatment because they regress spontaneously in a few days. They often remain undiagnosed; other times, because of the pain they caused, they may worsen the nursing. Case report: We describe the clinical case of a healthy infant of 2 months, fed with formula, who has 2 aphthous lesions in the oral cavity associated with irritability and inconsolable crying during feeding. We excluded the influence of infectious factors or underlying diseases. The hypothesis of a traumatic factor was supported by the anatomical features of aphthae and then confirmed by the gradual resolution of lesions after some advices on breastfeeding. Conclusions: Our intent is to provide a photographic record of Bednar aphthae, which are quite common but often misdiagnosed also because of lacking of photographic material. Improved knowledge of this condition helps physicians in the differential diagnosis of a traumatic condition that is not as unusual as it seems in newborns. © 2012 Elsevier Inc. All rights reserved.

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Good knowledge of anatomy is fundamental for every surgeon. Middle ear anatomy is really complex and sometimes is challenging for otologists, who need to explore every single compartment for a radical removal of pathology. With introduction of the endoscope in middle ear surgery, anatomy of middle ear spaces has become wider and clearer due to a better magnification and to the possibility to look "behind the corner". This article is a review of the state-of-art of endoscopic middle ear anatomy with description of every compartment, with particular attention to ventilation pathways and middle ear folds. © 2011 Association of Otolaryngologists of India.

Objectives: The aim of the present study is to document and analyze the ossicular chain preservation rate in patients affected by acquired primary cholesteatoma with epitympanic involvement and with preoperative intact ossicular chain. Study Design: A retrospective case series in a tertiary university referral center. Methods: From January 2006 to February 2010, at the Otolaryngology Department of the University Hospital of Modena, 68 patients affected by acquired primary cholesteatoma with attic involvement underwent exclusive endoscopic transcanal tympanoplasty. In April 2010, we performed a retrospective chart and video review of these patients. Patients in whom the ossicular chain was found to be intact and not involved by the pathology at the beginning of the operation were included in the study. A cholesteatoma staging was introduced based on tympanic subsite involvement by pathology. Results: Out of 68 patients affected by acquired primary cholesteatoma and who underwent exclusive endoscopic transcanal tympanoplasty, 23 had intraoperative integrity of the ossicular chain (17 male and 6 female subjects; mean age, 40 yr) and were included in the study. An inverse correlation was found between number of subsites involved and chain preservation (Spearman rank correlation coefficient, r = -1; p = 0.017). Medial attic involvement was the factor that most negatively influenced the likelihood of chain preservation. Conclusion: Middle ear endoscopic techniques may increase the likelihood of ossicular chain preservation during cholesteatoma surgery. Medial attic involvement and a high number of subsites involved represent the most significant negative factors for chain preservation. The rate of residual disease requires more thorough evaluation in the future to validate the results. Copyright © 2011 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

Parapharyngeal space (PPS) tumors are rare and benign in 80% of cases. Since surgeons first resected this anatomical region, the surgical approach to PPS bulks has been a hot topic due to their shape and the important structures involved. We present a series of patients treated with a transcervical or transcervical-transparotid approach to benign PPS tumors without mandibulotomy. Between May 2003 and March 2009, 18 patients (11 male and 7 female) with benign PPS tumors underwent a surgical resection, avoiding mandibulotomy. Average age of the patients was 49 years (range 3-76), average tumor size was 5.5 × 4 × 3 cm and histological examination of the resected tumors showed: seven pleomorphic adenomas of the deep parotid lobe, four schwannomas, two mycobacteriosis, two paragangliomas of the vagus nerve, one lipoma, one neurofibroma and one cavernous hemangioma. Seven patients underwent a transcervical approach, while 11 patients underwent a transcervical-transparotid approach. Excision of benign PPS tumors is possible without mandibulotomy even in the case of a large tumor mass, but exposure with the mandible in situ is certainly poor. Avoiding mandibulotomy reduces patient morbidity and hospital stay. In our experience, mandibulotomy can be avoided in most cases of benign PPS tumors leaving this procedure for malignant tumors or in patients with very poor exposure. © 2011 Springer-Verlag.

Objectives/Hypothesis: Although middle ear aeration is certainly related to eustachian tube (ET) function, other anatomic factors may play an important role in ventilation of these spaces, particularly the epitympanum. Study Design: A prospective case series study group with retrospective case series comparison. Methods: Eight patients affected by non-selfcleaning attic retraction pockets or attic cholesteatoma of the middle ear and normal tubal function (verified by type A tympanogram or Williams' test) underwent endoscopic surgery. Anatomic findings were noted and collected, with particular attention paid to middle ear folds. A control group was used for comparison. The prevalence of an isthmus blockage with a complete tensor fold in pathologic ears was compared between the study group and control group. Results: The higher prevalence of an isthmus blockage associated with a complete tensor fold in the study group was found to be statistically significant (P = .001). Conclusions: A selective epitympanic dysventilation syndrome is hypothesized; normal ET function seems to be insufficient for complete ventilation of the middle ear, and an open tympanic isthmus or an incomplete tensor fold may be necessary for epitympanic recess ventilation. The selective epitympanic dysventilation syndrome would consist of the contemporary presence of the following four conditions: attic retraction pocket or cholesteatoma, normal tubal function tests, complete epitympanic diaphragm, and isthmus blockage. © 2010 The American Laryngological, Rhinological and Otological Society, Inc.

Objectives: Patients undergoing endoscopic middle ear surgery require reconstruction procedures that are able to give adequate functional results, with particular attention to ventilation of middle ear routes and mastoid tissue preservation. Study Design: Outcome research on a prospective case series in a tertiary university referral center. Methods: A case series of 27 patients with attic retraction pockets underwent endoscopic middle ear surgical procedures. Three kinds of tympanoplasty were selected and performed. Results: In all 27 subjects, it was possible to preserve the mastoid bone and the epitympanic-mastoid mucosa by performing a transcanal endoscopic approach. In total, 21 of 27 (77.7%) subjects presented no recurrence of the disease at 20.1 months mean follow-up. Conclusions: Three main types of endoscopic tympanoplasty can be performed for surgical treatment of attic retraction pockets, preserving as much as possible the ventilation routes, physiology, and anatomy of the middle ear. © 2010 The American Laryngological, Rhinological and Otological Society, Inc.

The objective of this study was to document functional results and to compare objective and subjective voice measures after endoscopic laryngoplasty with injection of polydimethylsiloxane (PDMS) for the treatment of unilateral vocal fold paralysis, and to verify PDMS biocompatibility in vocal fold. The design used was a longitudinal prospective study. Fifteen patients with unilateral vocal fold paralysis underwent endoscopic injection of PDMS in general anesthesia. Accurate voice evaluation protocol (acoustic and aerodynamics analyses, GIRBAS [Grade, Instability, Roughness, Breathiness, Asthenia, and Strain] scale, videostrobolaryngoscopy, and Voice Handicap Index test) before, after surgery, and at follow-up time was performed. The median follow-up was 21.7 months (range, 6-35). Data obtained were statistically significant. All acoustic, aerodynamics, perceptive, and subjective evaluations showed a significant improvement. No complications due to PDMS were reported. Functional results were found comparable to framework surgery. Endoscopic injection laryngoplasty with PDMS is a safe and long-term option for treatment of unilateral vocal fold paralysis. © 2010 The Voice Foundation.

Objectives: To evaluate the clinical performance of an auto-crosslinked gel obtained from hyaluronic acid (ACP-based gel) as an anti-adhesive agent and/or augmentative agent in vocal cord surgery for the treatment of vocal fold (VF) atrophy, sulcus vocalis, and postsurgery scarring as well as its tolerability at short- and long-term follow-up. Study Design: This was a prospective multicenter trial conducted between 2007 and 2009. Setting: Academic center. Subjects and Methods: Inclusion criteria were patients with glottic gap due to previous endoscopic phonosurgery, VF scars, vocal cord atrophy, and sulcus vocalis. Forty patients who underwent endoscopic injection of hyaluronic acid under general anesthesia were enrolled. Two different injections sites were used: the thyroarytenoid muscle in cases of glottic gap for augmentative purposes, and the lamina propria for treatment of scars and sulcus vocalis. A voice-evaluation protocol was performed before surgery, at the first follow-up visit (3 mo), and at the final follow-up (12 mo). Results: Follow-up data at three months were available for 38 patients, while data at 12 months follow-up were available for 27 patients. No side effects, hematoma, or infection and allergic reactions were reported in either the perioperative or postoperative period. Patients had statistically significant improvement in voice parameters compared with the baseline data at the first follow-up visit and at the 12-month follow-up. Conclusion: ACP-based gel seems to be a new tool in the challenging treatment of VF scarring, functioning as both an anti-adhesive product and an augmentation agent. Improvements in all glottal parameters and in both objective and subjective evaluation of voice performance were observed. © 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation.

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“Hide and seek” with antineutrophil cytoplasmic antibodies Matteo Alicandri-Ciufelli, MD, Gabriele Molteni, MD⁎, Maria Teresa Mascia, MD, Elisabetta Genovese, MD, Livio Presutti, MD Department of Otolaryngology-Head and Neck Surgery, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy Department of Rheumatology, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy Received 19 April 2009

Objectives: To describe middle ear ventilation route blockage, relieved during middle ear endoscopic surgery, and to analyze its association with mastoid hypopneumatization/sclerotization. Study design: Prospective case series with intraoperative analyses, and with a case-control computed tomographic scan comparison. Methods: Intraoperative findings during endoscopic middle ear surgery are described. Patients with middle ear ventilation route blockage were included in the study group (22 patients), while patients without middle ear ventilation route blockage were included in the control group (16 patients). An intra-patient and inter-group comparison of evaluated mastoid pneumatization was performed from the preoperative computed tomographic scans. Results: Middle ear ventilation route blockage was classified into three types (A, B, C) according to intraoperative findings. Intrapatient and intergroup comparisons showed that the presence of blockages of middle ear ventilation trajectories is associated with a statistically significantly higher prevalence of hypopneumatization/ sclerotization of the mastoid in the study group, a typical sign of middle ear dysventilation pathologies. Conclusions: Intraoperative evaluation of the middle ear anatomy during endoscopic surgery for inflammatory pathology allows us to clearly visualize the presence of anatomic blockages of the middle ear ventilation trajectories. These blockages might provoke a sectorial dysventilation of the middle ear, with consequent reduction of pneumatization of the mastoid. Further studies will be able to clarify to what extent selective dysventilation phenomena could be a principal factor in influencing middle ear pressure homeostasis. © 2010 Elsevier Inc. All rights reserved.

Background. We conducted this longitudinal prospective study to illustrate a surgical technique for swallowing rehabilitation of patients after partial laryngectomy. Methods. Nine patients with persistent swallowing impairment after partial laryngectomy were included in the study. Evaluation of swallowing was performed by fiberoptic endoscopic evaluation of swallowing (FEES), and was quantified using 2 scales: a dysphagia score and a modified penetration-aspiration scale. The site of bolus inhalation was identified. Polydimethylsiloxane (PDMS) was injected into the neoglottis to fill these passages, and to obtain a certain continence of the organ. Results. Mean follow-up was 25 months (range, 5–39). All patients showed an improvement both in the dysphagia score and in the modified penetration-aspiration scale. Average improvement was 2.6 points in the dysphagia score (p = .0042) and 2.1 points in the modified penetration-aspiration scale (p = .0043). Conclusion. PDMS injection can be considered as an option in surgical rehabilitation of swallowing in patients who underwent partial laryngectomy. © 2009 Wiley Periodicals, Inc. Head Neck, 2009

case report

We report an unusual case of "collision metastasis". In a single lymph node, we found a metastatic mass composed of two immunohistochemically distinct components originating from two primary tumors: a papillary microfollicular thyroid cancer and an unknown primary squamous cell carcinoma. The clinical features and immunohistochemical profile are reported. Collision phenomena in oncology are extremely rare and pose diagnostic and management challenges which are discussed. © 2008 Elsevier Ireland Ltd. All rights reserved.

Objective: To document the efficacy of polydimethylsiloxane (PDMS) injections in patients with swallowing disorders after partial supracricoid laryngectomy; to assess the importance of quality-of-life (QOL) outcome in oncologic patients. Subjects and Methods: The study included 11 patients with swallowing disorders after partial laryngectomy and appropriate rehabilitation. They were treated with endoscopic injection of PDMS; QOL was investigated with four questionnaires (M.D. Anderson Dysphagia Inventory, Performance Status Scale for Head and Neck Cancer, Performance Karnofsky Scale, and Voice Handicap Index-10) before and after surgical treatment and further rehabilitation. Results: A significant improvement in QOL of all 11 patients was seen after endoscopic injection. The impact of this treatment on the social life of patients was considerable. Conclusion: Swallowing disorders and speech problems are quite common complications of partial laryngectomy. QOL in oncologic patients is a mandatory outcome measure. PDMS injection showed an improvement in the everyday life of selected patients. © 2009 American Academy of Otolaryngology-Head and Neck Surgery Foundation.

An accurate in vivo preparation of the hepatic hilum is a fundamental prerequisite for a successful multiorgan transplantation. Our preferred technique in this surgical setting is in vivo procurement in the heart-beating donor. This technique allows an effective exposition of the hilum structures and recognition of anatomical vascular variants, particularly those of the hepatic artery. Also, the cold ischemia time is drastically reduced, and the back-table preparation is left to a minimum. In this article we show the results of a consecutive series of 250 procurements.

Sodium borohydride treatment of the enantiomerically pure tricarbonyl(eta(6) -arene) chromium(0) complexed beta-lactam 7 promoted a stereoselective ring opening-ring closure reaction sequence leading to the novel dihydrobenzopyran derivative 9 in good yield. (C) 2005 Elsevier Ltd. All rights reserved.

Background. Recent reports demonstrate the efficacy of induction immunosuppression with Thymoglobulin, a potent antithymocyte polyclonal antibody, in allowing acquired tolerance by means of a tolerogenic regimen of recipient pretreatment and low-dose postoperative immunosuppression. The effect of this novel approach on recurrence of hepatitis C viral disease after liver transplantation has never been investigated. We report the preliminary results of a retrospective analysis aimed at discovering any relationship between Thymoglobulin immunosuppression and the pattern of recurrence of hepatitis C. Methods. Thymoglobulin induction plus tacrolimus monotherapy was used in a group of 22 hepatitis C virus (HCV)+ patients receiving liver transplantation; 30 HCV+ patients receiving transplants within the same year received conventional tacrolimus plus steroid immunosuppression and represented the comparison group. Results. Patient survival and acute rejection rate did not differ between the two groups. Significantly lower dosages and levels of tacrolimus were possible with Thymoglobulin, and a progressive weaning of tacrolimus monotherapy was accomplished in most patients, without major rejection complications. The HCV recurrence rate was similar in both groups, although significantly lower HCV RNA loads were obtained with Thymoglobulin pretreatment. The mean time to histologic recurrence was shorter in Thymoglobulin-treated patients; however, no significant difference was observed in mean Ishak’s histologic grading and staging of HCV recurrence. Conclusions. In our preliminary experience, a “prope” tolerogenic regimen with Thymoglobulin pretreatment and low-dose immunosuppression in liver-transplant recipients gave good protection against rejection and permitted lower HCV viral loads, whose significance in the long-term outcome of HCV patients deserves further investigation.

As reported by previous literature, the prevalence of musculoskeletal disorders is high in population of local police officers, due to several risk factors, including awkward posture, jolt/vibrations and stress. The results of our study reveal that the most common musculoskeletal symptoms among local police officers are cervicobrachial pain, low back pain and sciatica. Low-back pain is associated with tasks exposing to awkward posture of the spine (traffic policemen and policemen involved in office-based duties); cervical and upper extremity disorders are related to the exposure to vibrations and to the upper limb posture held by motorcycle police. Among postural parameters, anterior scapular plane, flat back and Barre's vertical resulted possible predictive tests of adaptation of the postural system to the symptom pain in subjects with low back pain. In conclusion, it is necessary to adopt organizational, protective and preventive measures in order to occupational health of local police officers. They include: decrease of time periods during which an awkward posture is held, breaks between duties, prescription of ergonomic shoes, use of low-weight and low-volume duty-packs, and planning of periodical osteopathic check-ups as part of the health program, aimed to uncover initial postural alterations related to musculoskeletal disorders.

Induction with thymoglobuline, a potent anti-thymocyte polyclonal antibody, has been recently reported to allow minimization of postoperative immunosuppression in organ transplantation. The relationship with recurrence of hepatitis C virus (HCV) after liver transplantation (LTx) has never been investigated. We report here on the outcome in 22 HCV+ patients receiving thymoglobuline pre-treatment and minimal immunosuppression after LTx. Patient survival and acute rejection rates were good, and remarkably low dosages and levels of immunosuppression were achieved with thymoglobuline, without exposing patients to an elevated risk of rejection. A progressive weaning of the primary immunosuppressor was also possible in the majority of patients without complications. The HCV recurrence rate was similar to what is reported in the literature, although lower HCV-RNA viral loads were obtained with thymoglobuline, with a mild histologic course. Although our results need to be validated in large cohort studies, our experience shows that minimization of immunosuppression with thymoglobuline is effective in protecting against rejection and demonstrated a positive impact on HCV recurrence that deserves further investigation.

The [2+2] Staudinger cycloaddition between the C=N double bond of 2,3-dihydrobenzoxazepines 2 and 6 and a series of acetyl chlorides gave the azetidino[4,1-d][1,4]benzo oxazepines 3 and 7, 8, respectively. In the case of enantiopure 6, the cycloaddition diastereoselectivity was markedly dependent from the substituent alpha to the imine. (C) 2004 Elsevier Ltd. All rights reserved.

La pubblicazione consiste in un saggio, inserito come postfazione a una raccolta di scritti di A. M. Cirese sulle identità locali. Il saggio ricostruisce il contesto storico e scientifico in cui si situano tali scritti, con particolare attenzione alle questioni di storia dell'antropologia italiana dal secondo dopoguerra ai primi anni ottanta