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The high number of marginal mandibular nerve (MMN) anatomical variants have a well-known clinical significance due to the risk of nerve injury in several surgical procedures. The aim of this study was to find and systematize the available anatomical data concerning this nerve. The PubMed and Scopus databases were investigated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All studies reporting extractable data on the origin, course, splitting, anastomosis and relationship of the MMN with the mandible or the facial vessels were included. We included 28 studies analyzing 1861 halves. The MMN had one (PP = 35% 95% CI:18-54%), two (PP =35% 95% CI:18-54%), three (PP = 18% 95% CI:0-35%), or four branches (PP = 2% 95% CI:0-8%). Anastomosis with the great auricular nerve, transverse cervical nerve, mental nerve, and other branches of the facial nerve were defined. The origin of the MMN in relation to the parotid and the mandible was variable. The MMN nearly always crossed the anterior facial vein laterally (PP = 38% 95% CI:9-72% if single, PP = 57% 95% CI:22-90% when multiple); its relation with other vessels was less constant. At least one branch of the MMN was found below the inferior border of the mandible (IBM), with a PP of 39% (95% CI:30-50%). The MMN has high anatomical variability and it is more often represented by one or two branches; its origin is frequently described at the parotid apex and above the IBM, although in its course at least one branch often runs below the IBM. Its most frequent anastomosis is with the buccal branch of the facial nerve. Clin. Anat., 33:739-750, 2020. © 2019 Wiley Periodicals, Inc.

Piecemeal resection provides an innovative conceptual tool for margins surveillance because it entails the intraoperative evaluation of the whole resection margins and not just sample points, which should result in a better control of deep margins compared to en bloc resection. Although it is recognized that the intraoperative use of narrow band imaging (NBI) results in a better control of superficial margins, in this exploratory study we investigated whether NBI and piecemeal resection could be used in combination to improve margin control at both superficial and deep levels. Because piecemeal resection is based on frozen section analysis, we wanted to verify its reliability compared to definitive histological examination.The status of resection margins in a group of patients with oral and oropharyngeal cancers treated with NBI and laser CO2 piecemeal resection (group 1) was compared with that of an historical group of patients (group 2) treated with NBI and conventional en bloc resection. In group 1, sensitivity, specificity, and positive and negative predictive values were used to verify the rate of concordance between frozen section and definitive histology.The difference between deep positive margins in the two groups was statistically significant (P = 0.042). The high sensitivity and specificity (94.6% and 94.7%, respectively) of frozen section analysis also demonstrated its reliability in the examination of larger samples corresponding to the whole margin.Even if our findings are limited by the small number of patients, we are confident that the combined use of NBI and piecemeal resection could represent an attractive surgical strategy to improve margin control.2b Laryngoscope, 129:1810-1815, 2019.

Rhinopharyngeal swab collection is used to test patients for COVID-19; unfortunately, the false negative rate is around 30% in symptomatic patients, and maybe even higher in asymptomatic ones. A correct swab collection is consequently critical. Swabs are usually performed by dedicated personnel, but at the present moment, the methods for its training are not standardized. In a Letter to the Editor recently published in the European Archives of Otorhinolaringology, Tagliabue et al. describe the training method used in their Institution: the personnel dedicated to swab collection increases its confidence with the procedure by observing endoscopic anatomy, while an otolaryngologist performs rigid endoscopy. Although we found this paper interesting, we think that the author's proposal has timing and financial drawbacks that should be considered in daily activity, especially in an emergency period like the pandemic we are experiencing. In this Letter to the Editor, we discuss some pre-analytic and analytic issues that should be considered while performing rhinopharyngeal swabs, and we propose the use of a mannequin to train personnel, thus reducing the risk of infection for health workers, and patient's discomfort.

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

The prognostic significance of the resection margins is still subject of conflicting opinions. The purpose of this paper is to report the results of a study on the margins in carcinoma of the oral cavity, oro-hypopharynx and larynx.A multicentre prospective study was carried out between 2015 and 2018 with the participation of 10 Italian reference hospitals. The primary objective was to evaluate local control in patients with well-defined clinical characteristics and comprehensive histopathological information.During the study period, 455 patients were enrolled; the minimum follow-up was 2 years. Previous treatment, grading and fresh specimen examination were identified as risk factors for local control in multivariate analysis. On the basis of these results, it seems possible to delineate "risk profiles" for different oncological outcomes.The prognostic significance of the margins is reduced, and other risk factors emerge, which require diversified treatment and follow-up.Multidisciplinary treatment with adjuvant therapy, if indicated, reduces the prognostic importance of margins. Collaboration with a pathologist is an additional favourable prognostic factor and quality indicator.An appendix with literature review is present in the online version.Studio multicentrico sui margini di resezione nel carcinoma del cavo orale, faringe e laringe.Il significato prognostico dei margini di resezione è ancora oggetto di pareri discordanti. Scopo di questo scritto è riportare i risultati di uno studio sui margini nel carcinoma del cavo orale, oro-ipofaringe e laringe.È stato condotto uno studio prospettico multicentrico con la partecipazione di 10 Centri italiani, nel periodo 2015-2018, con l’obiettivo primario di valutare il controllo locale in pazienti con ben determinate caratteristiche cliniche e con disponibilità di esaurienti informazioni istopatologiche.Nel periodo in studio sono stati arruolati 455 pazienti con un follow-up minimo di 2 anni. All’analisi multivariata per il controllo locale sono risultati fattori di rischio il trattamento precedente, il grading e l’esame a fresco dello specimen. Sulla base dei risultati ottenuti è possibile delineare un “profilo di rischio” per tutti i diversi outcomes oncologici.Il significato prognostico dei margini è ridotto, altri fattori emergono come profili di rischio, che richiederebbero trattamento e follow-up diversificati.Il trattamento multidisciplinare con la terapia adiuvante se indicata, può aver ridimensionato l’importanza prognostica dei margini. La collaborazione con l’anatomopatologo è fattore prognostico favorevole supplementare ed indicatore di qualità.Appendice con revisione della letteratura nella versione online.

Interactions between SARS-CoV-2 and pharyngeal associated lymphoid tissue are thought to influence the manifestations of COVID-19. We aimed to determine whether a previous history of tonsillectomy, as a surrogate indicator of a dysfunctional pharyngeal associated lymphoid tissue, could predict the presentation and course of COVID-19.Multicentric cross-sectional observational study involving seven hospitals in Northern and Central Italy. Data on the clinical course and signs and symptoms of the infection were collected from 779 adults who tested positive for SARS-CoV-2, and analysed in relation to previous tonsillectomy, together with demographic and anamnestic data.Patients with previous tonsillectomy showed a greater risk of fever, temperature higher than 39°C, chills and malaise. No significant differences in hospital admissions were found.A previous history of tonsillectomy, as a surrogate indicator of immunological dysfunction of the pharyngeal associated lymphoid tissue, could predict a more intense systemic manifestation of COVID-19. These results could provide a simple clinical marker to discriminate suspected carriers and to delineate more precise prognostic models.COVID-19 nella popolazione tonsillectomizzata.Si ritiene che le manifestazioni dell’infezione da SARS-CoV-2 siano influenzate dalle interazioni tra il virus e il tessuto linfatico associato alla faringe. Obiettivo di questo studio è determinare se una pregressa tonsillectomia, come indicatore surrogato di disfunzione immunologica faringea, possa predire la presentazione e il decorso della COVID-19.Studio multicentrico trasversale osservazionale coinvolgente 7 centri italiani. Sono stati raccolti i dati su decorso, segni e sintomi dell’infezione da 779 adulti positivi al SARS-CoV-2, e analizzati in relazione a pregressa tonsillectomia, dati demografici e anamnestici.I pazienti con pregressa tonsillectomia hanno un maggior rischio di sviluppare febbre, raggiungere temperature oltre i 39°C, brividi e malessere generalizzato. Non si riscontrano differenze nel tasso di ospedalizzazione.Il dato anamnestico di pregressa tonsillectomia, come indicatore di disfunzione immunologica faringea, può predire una manifestazione sistemica più intensa nei pazienti affetti da COVID-19. Questi risultati possono fornire un marker clinico semplice per discriminare sospetti portatori del virus e delineare modelli prognostici più accurati.

Strips‐and‐bowl FS are meticulously collected from the entire superficial and deep margins and consequently allow assessment of the entire resection margins. Conceptually, Kim and Chiosea's proposal to expand the initial resection and leave “strips‐and‐bowl” tissue with the main resection specimen from which to collect FS is not wrong; however, in such a scenario, FS would be collected from the resected specimen, and this, in our experience, makes it more difficult to relocate the site requiring intraoperative enlargement in the case of positive FS.