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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.

Background The COVID-19 pandemic has made wearing face masks a common habit in public places. Several reports have underlined the increased difficulties encountered by deaf people in speech comprehension, resulting in a higher risk of social isolation and psychological distress. Purpose To address the detrimental effect of different types of face masks on speech perception, according to the listener hearing level and background noise. Research Design Quasi-experimental cross-sectional study. Study Sample Thirty patients were assessed: 16 with normal hearing [NH], and 14 hearing-impaired [HI] with moderate hearing loss. Data Collection and Analysis A speech perception test (TAUV) was administered by an operator trained to speak at 65 dB, without a face mask, with a surgical mask, and with a KN95/FFP2 face mask, in a quiet and in a noisy environment (cocktail party noise, 55 dB). The Hearing Handicap Index for Adults (HHI-A) was administered twice, asking subjects to complete it for the period before and after the pandemic outburst. A 2-way repeated-measure analysis of variance was performed. Results The NH group showed a significant difference between the no-mask and the KN95/FFP2-mask condition in noise (p = 0.01). The HI group showed significant differences for surgical or KN95/FFP2 mask compared with no-mask, and for KN95/FFP2 compared with surgical mask, in quiet and in noise (p Conclusion Face masks have a detrimental effect on speech perception especially for HI patients, potentially worsening their hearing-related quality of life.

The aim of this study was to evaluate the CO2 waveguide laser (WG CO2 laser) with flexible fiber (Lumenis Ltd., Yokneam, Israel) in the treatment of oral and oropharyngeal cancers, specifically focusing on postoperative outcomes, pain, and quality of life (QoL). Eighty-one patients, 43 women and 38 men, with oral or oropharyngeal cancer who consecutively underwent transoral resection by WG CO2 laser from August 2015 to April 2020 were retrospectively enrolled. Resections were performed in super pulsed mode with a power setting ranging between 3 and 10 W. Data about frozen sections, reconstruction, complication rate, length of hospital stay, tracheostomy rate and time to decannulation, nasogastric feeding tube rate and time to oral feeding, pain, and QoL were reviewed. Continuous variables were presented as mean and standard deviation. Concordance between intraoperative frozen section examination and definitive histology was calculated using Cohen’s K test of agreement. The mean length of hospital stay was 13 days. The feeding tube rate was 81%; the tracheostomy rate was 35%; the feeding tube was left in place for 8 days on average, and the time to decannulation was 9 days. The only complication was a postoperative bleeding in 4 patients. The median postoperative pain score measured by the Numeric Pain Rating Scale on postoperative days 1, 3, and 5 was 0 and there was a constant decrease in painkiller use over the days. The overall mean composite QoL score was 77 ± 14, with excellent results in saliva, taste, pain, and speech domains. Frozen section evaluation had a specificity of 99% and a negative predictive value of 98%. WG CO2 laser is a good and safe tool for transoral tailored resection of oral and oropharyngeal cancers. It ensures a good overall QoL and guarantees fast recovery and a very low postoperative pain.

Objectives Although the reliability of frozen sections for the intraoperative assessment of complete tumour excision has been established, the best location for collection and the impact of the type of sampling are still debated. We retrospectively investigated the reliability of frozen sections when collected from the surgical bed as tissue strips representative of the whole superficial margin and as a bowl of tissue underlying the resection site for deep margin, and the possibility of relying on frozen section negativity to consider resections complete. Materials and methods Frozen section reliability was calculated by comparing histology before and after formalin embedding and then categorised by sampling type, in 182 patients undergoing transoral resection of oral cancer. Results Comparing frozen and permanent histology, sensitivity, specificity and accuracy were 69%, 98% and 96%, respectively; categorisation by sampling type failed to produce statistically significant differences. Based on frozen section negativity after formalin embedding, complete resections were obtained in 91.7% of patients with multiple-strip and bowl frozen sections. Conclusion Frozen sections collected as tissue strips and bowl are as reliable as point sampling in the intraoperative guidance of surgical resections. They effectively provide for margin enlargement, thereby increasing the surgeon's confidence that negative margins are clear.

Cochlear implant (CI) surgery is generally safe and associated with a limited number of complications, among which the extrusion of the receiver/stimulator (R/S) or the electrode misplacement and migration might require a CI re-implantation. The aim of this pilot study is to describe a new technique to firmly fix the R/S using the Mitek suture anchors system (Depuy Mitek Surgical Products, Inc. Raynham, Massachusetts). We tested two different models and in our experience, the web of suture created with this device can improve the stability of the bond of the R/S to the underlying curved bone surface. So, this system resulted in a less laborious manner keeping low the complication rate.

To evaluate whether a repeated canalith repositioning procedure (CRP) influences the residual symptoms and the rate of recurrence of benign paroxysmal positional vertigo (BPPV) in patients with post-CRP dizziness. Materials and methods: In this retrospective study, we analyzed 292 patients at the referral center for ENT diseases with a first episode of BPPV treated with a single CRP following clinical practice guidelines. In 178 patients (67.9%) who presented dizziness after BPPV recovery at the follow-up visit, 94 patients underwent CRP (treated group) and 84 did not (non-treated group). A subjective evaluation of vertigo was made by way of a questionnaire. The rates of recurrence of BPPV and residual dizziness were statistically compared between the treated and the non-treated groups; survival analysis was carried out as well. Results: In an observational period ranging from 1 to 6 years, BPPV recurred in 122 subjects (46.6%) of the investigated population. Among the patients with residual dizziness, the difference in rate of recurrence of BPPV between the treated group and the non-treated group was not statistically significant (p = 0.84). The treated group presented a significantly higher rate of recovery from dizziness compared to the non-treated group (p < 0.001). Conclusions: A repeated CRP in patients with post-CRP dizziness increased the rate of recovery from dizziness but had no influence on BBPV recurrence. evaluate whether a repeated canalith repositioning procedure (CRP) influences the residual symptoms and the rate of recurrence of benign paroxysmal positional vertigo (BPPV) in patients with post-CRP dizziness.

PURPOSE: In a previous study, we gave a surgical description of a group of lymph nodes in the submandibular area at risk of remaining undissected during neck dissection (ND) for which we have proposed the term "perimarginal nodes" (PMNs) due to their proximity to marginal mandibular nerve (MMN). The aim of this study is to evaluate prevalence of PMNs involvement in oral cavity squamous cell cancer (OCSCC) and to verify if metastases are related to primary tumor characteristics or to the state of the neck. METHODS: We recruited a total of 39 consecutive patients diagnosed with OCSCC candidate to ND. Histological characteristics of PMNs were analyzed and the incidence of metastases in relation to the primary tumor characteristics were noted. RESULTS: PMNs were found to be involved with metastases in 8 patients (20.5%). No characteristic of the primary tumor seems to influence the metastatic involvement of the PMNs. CONCLUSIONS: PMNs represent a frequent site of micro-metastases in patients diagnosed with OCSCC regardless of other characteristics of the primary tumo

Objectives Optimal laryngeal exposure during transoral laryngeal surgery is fundamental. We aimed to evaluate the reliability of a recently proposed score (Laryngoscore) in predicting difficult laryngeal exposure (DLE) in an independent cohort of patients undergoing elective microlaryngoscopy. We also verified the relation between DLE, surgeon's expertise, and difficult intubation, and investigated possible areas for score improvement. Study design Prospective validation study. Methods A total of 136 patients were preoperatively evaluated using the Laryngoscore. Patients were divided into three classes according to patient position, type of laryngoscope, and need for external counterpressure to expose the anterior commissure. Based on their mean scores, two groups were identified: good laryngeal exposure (GLE) and DLE. A receiver operating characteristic curve with the Youden index was used to calculate the optimal cutoff value. The χ2 and Fisher exact test were used to correlate GLE and DLE to the surgeon's expertise and difficult intubation. The intraoperative anatomical parameters underlying DLE were also recorded. Results The optimal cutoff value for differentiating GLE and DLE was 4, which identified 80.6% of DLE cases. No statistically significant difference in GLE and DLE distribution was found between surgeons (P = 0.43). The correlation between difficult intubation and DLE was statistically significant (P = 0.03). The intraoperative parameters determining DLE were epiglottis characteristics (floppy, tight, or short), bulky abdomen and chest, bulky tongue base, mobile teeth, and a narrow laryngeal aditus. Conclusion The Laryngoscore is reliable for detecting DLE preoperatively. The inclusion of additional parameters may allow a more complete assessment and maximize its diagnostic accuracy. Level of evidence 2b Laryngoscope, 129:1438-1443, 2019.

Minimally invasive surgery for laryngeal cancer is nowadays the goal of all larynx surgeons. Transoral laser microsurgery is a widespread and standardized technique that has made it possible to reduce surgical morbidities and hospitalization and to spare laryngeal function. Nonetheless, it has some limitations, which may be exceeded by using new optical and cutting devices as in TransOral UltraSonic Surgery. Areas covered: The aim of this paper is to identify current knowledge about ultrasonic scalpel (US) application in transoral laryngeal surgery and to deduce reasonable indications and contraindications of the tool. Expert opinion: Transoral laryngeal surgery with US is feasible and allows for 'angulated' dissections with higher hemostatic capacity than the CO2 laser. When coupled with an endoscope, surgeons have the possibility to angulate the laryngeal exposure from the inside, reducing blind areas. Nonetheless, US blades are quite bulky, thermal damage is higher than that produced by CO2 laser, and its use should be avoided where the functional result is more closely related to the amount of resected tissue. Tumors limited to the suprahyoid larynx are the current indications for US surgery.

Background The purpose of this study was to assess the efficacy of intraoperative nerve integrity monitoring (NIM) to prevent marginal mandibular nerve injuries during neck dissection. Methods This prospective study compared 36 patients undergoing NIM-assisted neck dissection from July 2014 to March 2015 to a cohort of 35 patients subjected to neck dissection over an identical period of time before the technique was introduced. We also assessed possible correlations between marginal mandibular nerve injuries and other factors, such as anthropometric measurements, presence of clinical neck metastases, type of neck dissection, and site of primary tumor. Results The incidence of marginal mandibular nerve paralyses was significantly lower among the group of patients undergoing NIM-assisted neck dissection (P = .021). There was no significant difference in the duration of the procedure, and the technique resulted in a limited increase of cost. No other factor seemed to influence the onset of marginal mandibular nerve palsy. Conclusion In our opinion, NIM is a valuable aid for preventing marginal mandibular nerve injuries during neck dissection.

PURPOSE In a previous pilot study we observed that intra-operative narrow-band imaging (NBI) helps achieve clear superficial resection margins. The aim of this study was to verify if the use of intra-operative NBI can help to obtain tailored resections and if it is influenced by the lesion site, aspects not investigated in our previous study. MATERIALS AND METHODS The resection margins of 39 oral and 22 oropharyngeal squamous cell carcinomas were first set at 1.5cm from the macroscopic lesion boundary (white light, WL, tattoo). Then, the superficial tumor extension was more precisely defined with NBI, giving rise to three possible situations: NBI tattoo larger than the WL tattoo, NBI tattoo coinciding with the WL tattoo, or NBI tattoo smaller than the WL tattoo. For each of these situations the space comprised between the NBI and WL tattoos was defined "NBI positive", "NBI null", and "NBI negative", respectively. Resections were performed following the outer tattoo. The number of clear superficial resection margins, and the pathological response on the "NBI-positive" and the "NBI-negative" areas were recorded. RESULTS We obtained 80.3% negative superficial resection margins. NBI provided a more precise definition of superficial tumor extension in 43 patients. Sensitivity, specificity, positive and negative predictive values were 94.4%, 64%, 79.1% and 88.9%, respectively; a test of proportions demonstrated they were not influenced by tumor site. CONCLUSIONS NBI could allow for real-time definition of superficial tumor extension with possible tailored resections and fewer positive superficial resection margins; it is not influenced by tumor site.

Purpose The use of suture anchors has been described in orthopedic, hand, oculoplastic, temporomandibular joint and in aesthetic surgery, but no study reports the use of the Mitek® anchors (Depuy Mitek Surgical Products, Inc. Raynham, Massachusetts) for fixing the free flaps used in oncologic oral and oropharyngeal reconstruction. Materials and Methods In this prospective non-randomized study, 9 patients underwent surgical resection of oral or oropharyngeal cancer followed by a free flap reconstruction; mini anchors were used to fix the flap directly to the bone. We collected data regarding the patients, the tumor stage, the surgical procedure, the radiotherapy and the number of anchors used. Results The average follow-up was 28 months (range 24–38).We observed no complications with trans-oral, sub-mandibular and trans-mandibular approach in both oral and oropharyngeal reconstructions. All anchors became osteo-integrated and no complications occurred after radiotherapy. Conclusions In our opinion this device favors free flap adhesion to the bone. We registered no postoperative complications related to the use of the device which looks suitable for use in irradiated tissues. The radiotherapy did not cause any long-term complications related to the use of Mitek® mini bone anchors.

No published study has analyzed the prognostic factors of surgically treated oral squamous cell carcinoma (OSCC) in relation to both survival and quality of life (QoL). The aim of this study was to analyze postoperative QoL in relation to survival to identify which parameters can predict the long-term outcome allowing the best QoL. STUDY DESIGN: This retrospective cohort study considered 167 patients affected by OSCC treated surgically at the Otolaryngology Department of Cattinara Hospital (Trieste, Italy) by a single surgeon. We collected data about the main prognostic factors and the postoperative QoL 12 month after surgery. RESULTS: The 5-year overall survival rate was equal to 68.1%, and the 5-year disease-specific survival was 77.8%. In this sample, 32% of patients also underwent adjuvant chemoradiotherapy. On stepwise Cox regression, the best predictors of disease-specific survival were the N stage (P

Narrow-band imaging (NBI) is an optical technique enhancing mucosal vasculature. The aim of this study is to assess the effectiveness of rigid NBI endoscopy in the early detection of second primaries or local recurrences after treatment for oral (OSCC) and oropharyngeal squamous cell carcinoma (OPSCC), its advantage over standard white-light (WL) endoscopy, and the influence of previous radiotherapy, the learning curve, and lesion site. Between January 2013 and June 2015, 195 patients treated for OSCC or OPSCC with surgery alone (group A) or radiotherapy with or without surgery and/or chemotherapy (group B) underwent additional follow-up assessments using NBI. Sensitivity, specificity, positive/negative predictive values (PPV and NPV), and accuracy for detecting second primaries or local recurrences were calculated for patients with at least two NBI assessments. The effect of previous radiotherapy was determined by test of proportions and that of the learning curve and lesion site with Fisher's exact test. 138/195 patients were included in the analysis. NBI sensitivity, specificity, PPV, NPV, and accuracy for groups A and B were 89.5 vs 100%, 85.2 vs 81.5%, 65.4 vs 69.7%, 96.3 vs 100%, and 86.3 vs 87%, respectively. The diagnostic gain of NBI was 88.2% in group A and 69.6% in group B. The learning curve was the main source of false positives (p = 0.025), whereas radiotherapy and lesion site were uninfluential (p = NS). NBI appears useful for follow-up after treatment for OSCC or OPSCC, its performance being affected only by the learning curve and not by previous treatment or lesion site.

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