Elisabetta Zanoletti

Purpose: Report the updated version of retrolabyrinthine meatotomy (RLM) to the whole internal auditory canal in hearing preservation surgery (HPS) via retrosigmoid approach (RS) in sporadic vestibular schwannoma (VS). Methods: Description of surgical technique of VS removal with microscopic RS approach and RLM. Fifty-six consecutive patients with intrameatal or small (up to 15 mm extrameatal size) sporadic VS, with fundus free or fundus involved by the tumor, and good hearing at diagnosis, who underwent HPS, were retrospectively reviewed. Elective (protocol) indication for HPS was ≤ 10 mm size, ≤ 30 PTA, and ≥ 70 SDS. Results: Complete VS removal was achieved in all 56 cases, with no residual tumor or recurrence. The overall hearing preservation rate was 64% (36/56 patients), and 66% (28/42 patients) in protocol cases. Hearing outcome in fundus free vs. fundus involved cases did not show significant difference. At one-year postoperative follow-up, facial nerve function was House-Brackmann (HB) grade 1 or 2 in 54/56 patients (96%) and grade 3 in 2/56 patients (4%). The rate of relevant complications was 11% (6/56), with nasal CSF leak being the most frequent; no permanent sequelae occurred. Conclusions: Microscopic RLM with three-dimensional view is a convenient option to expose the internal auditory canal up to the fundus and to remove VS irrespective of fundus involvement.

Background and Objectives: Facial nerve palsy (FNP) remains a clinically relevant complication after vestibular schwannoma (VS) resection. Recovery trajectories vary according to the severity of neural injury and early postoperative facial function. This study aimed to characterize the temporal pattern of facial nerve recovery during the first postoperative year and to explore factors associated with favorable long-term function. Materials and Methods: We retrospectively analyzed 51 adult patients who developed FNP after VS surgery between 2020 and 2023. Facial nerve function was assessed using the House–Brackmann (HB) grading system and the Sunnybrook Facial Grading System (SBFGS) at discharge and at 1, 3, 6, and 12 months postoperatively. Longitudinal changes were analyzed using non-parametric repeated-measures methods with effect-size estimation. Favorable 12-month facial nerve function was defined as HB grade I–II. Given the limited number of unfavorable outcomes, associations with 12-month recovery were explored using parsimonious Firth-penalized logistic regression models. Results: At discharge, 45.1% of patients had HB II, 29.4% HB III–IV, and 25.5% HB V–VI. Facial function improved significantly during follow-up. Median SBFGS total score increased from 58.0 at discharge to 99.0 at 12 months (Friedman χ² = 118.78, df = 4, p < 0.001; Kendall’s W = 0.58), while HB grade also improved significantly (χ² = 107.48, df = 4, p < 0.001; W = 0.53). At 12 months, 37/51 patients (72.5%) achieved HB I–II and none remained in the HB V–VI category. Synkinesis, defined as an SBFGS synkinesis subscore > 0, was observed in 10/51 patients (19.6%) at 6 months and 19/51 (37.3%) at 12 months. HB grade and SBFGS score at discharge were strongly inversely correlated (Spearman ρ = −0.943, p < 0.001) and were therefore evaluated in separate models. After adjustment for age and tumor size, each one-grade increase in discharge HB was associated with lower odds of favorable 12-month function (OR 0.30, 95% CI 0.11–0.58; p < 0.001), whereas each 10-point increase in discharge SBFGS was associated with higher odds of favorable function (OR 1.90, 95% CI 1.32–3.53; p < 0.001). Conclusions: Facial nerve function showed substantial longitudinal improvement during the first year after VS surgery. Early postoperative facial function was independently associated with 12-month outcome in exploratory penalized regression analyses. Recovery may continue over several months, supporting prolonged functional surveillance, while the independent contribution of rehabilitation and the effect of nerve grafting require evaluation in larger prospective cohorts.

Background: Auditory brainstem responses (ABRs) are widely used for objective hearing threshold estimation in both adults and children. Click and CE-Chirp stimuli differ substantially in cochlear activation and neural synchrony, yet their relative performance in patients with ski-sloping hearing loss remains insufficiently characterized, particularly with regard to pediatric diagnostic implications. Methods: This study compared ABRs elicited by click and CE-Chirp stimuli in adults with ski-sloping sensorineural hearing loss. The same comparison was also performed in a pediatric cohort including hearing-impaired and normal-hearing children. Adult subjects were further stratified according to audiometric configuration (DROP 1 kHz vs. DROP 2 kHz). ABR thresholds, wave V latency, amplitude, and detectability were analyzed across stimulus types and intensity levels. Associations between ABR thresholds and behavioral audiometric measures were also examined. Results: In adults with ski-sloping hearing loss, CE-Chirp stimulation yielded significantly lower ABR threshold estimates than click stimulation, particularly in the DROP 2 kHz subgroup, and showed stronger correlations with behavioral pure-tone averages across low-, mid-, and high-frequency ranges. Wave V latencies were consistently shorter with CE-Chirp stimulation, while wave V amplitudes did not differ significantly between stimuli at suprathreshold levels. In children, ABR thresholds obtained with CE-Chirp were generally equal to or lower than those obtained with clicks, although statistical significance was limited by sample size. CE-Chirp stimulation was associated with shorter wave V latencies in both hearing-impaired and normal-hearing children and produced larger wave V amplitudes at selected suprathreshold intensities in hearing-impaired children. Conclusions: Click and CE-Chirp stimuli provide complementary information in ABR assessment. While click stimulation remains essential for robust waveform identification, CE-Chirp stimulation appears to offer advantages in threshold estimation and neural synchrony, particularly in ski-sloping hearing loss and pediatric evaluations. Discrepancies between click- and CE-Chirp-derived ABR thresholds should not be attributed solely to maturational or synchrony-related factors but may warrant further frequency-specific audiological assessment to optimize diagnosis and rehabilitation strategies.

Background/Objectives: As precision medicine advances, attention to sex and gender determinants across epidemiological and clinical domains has intensified. However, in the audio-vestibular field, knowledge on sex- and gender-related aspects remains relatively limited. The main aim of this review has been to analyze the available gender medicine-based evidence in vestibular disorders. In particular, our investigation considered the following: (i) pathophysiology and clinical presentation, including differences in predominant signs and symptoms, diagnostic modalities and findings, underlying biological mechanisms associated with vestibular disorders across sex-specific groups; (ii) prognostic variables, including response to treatment, recovery rates, and long-term functional outcomes; (iii) the potential role of sex- and gender-specific diagnostic and therapeutic approaches in the management of vestibular disorders. Methods: Our protocol was registered on PROSPERO (CRD42025641292). A literature search was conducted screening PubMed, Scopus and Web of Science databases. After removal of duplicates and implementation of our inclusion/exclusion criteria, 67 included studies were identified and analyzed. Results: Several studies reported a higher incidence of vestibular dysfunctions among females, with proposed associations involving hormonal fluctuations, calcium metabolism and vitamin D. Estrogen receptors within the inner ear and their regulatory effects on calcium homeostasis have been proposed as potential mechanisms underlying these sex-specific differences. Furthermore, lifestyle factors, comorbidities and differential health-seeking behaviors between males and females may also modulate disease expression and clinical course. Conclusions: Gender-specific variables could not be independently analyzed because none of the included studies systematically reported gender-related data, representing a limitation of the available evidence. Current evidence suggests the presence of sex-related differences in the epidemiology and clinical expression of vestibular disorders, but substantial gaps remain regarding mechanisms, outcomes, and clinical implications. Future research should prioritize prospective, adequately powered studies specifically designed to assess sex and gender influences, integrating biological, psychosocial, and patient-reported outcomes, and adopting standardized sex- and gender-sensitive reporting frameworks.

Background/Objectives: Tumors of the cerebellopontine angle (CPA) encompass a limited range of histologies, predominantly vestibular schwannomas (VSs), meningiomas, and paragangliomas (PGLs). Their growth region threatens the cranial nerves (V–XII), brainstem, and cerebellum, possibly causing functional deficits. This review aims to synthesize clinical features and multidisciplinary treatment strategies for CPA tumors with brainstem involvement, emphasizing functional preservation alongside tumor control. Methods: A systematic PubMed search identified studies on VSs, CPA meningiomas, and intradural PGLs. Eligibility criteria included studies reporting tumor management and cranial nerve outcomes. Data extraction focused on tumor size, neurological presentation, surgical approach, adjunctive therapies, and postoperative cranial nerve function. Multidisciplinary involvement and rehabilitation strategies were noted. Results: Twenty studies (3311 patients) analyzed large VSs, showing facial nerve dysfunction in 8–53%, trigeminal neuropathy in 20–77%, and cerebellar signs in up to 79%. Microsurgery (MS) achieved variable gross total resection, while stereotactic radiosurgery (SRS) preserved facial nerve function but carried trigeminal and hydrocephalus risks. CPA meningiomas demonstrated cranial nerve displacement patterns critical for surgical planning, with transient deficits common and recovery linked to baseline function. In 388 intradural PGL cases, staged surgery combined with preoperative embolization was standard; functional preservation of lower cranial nerves was often limited. Across all histologies, multidisciplinary management and targeted rehabilitation were essential. Conclusions: Optimal CPA tumor management balances tumor control with functional preservation. VSs benefit from individualized MS or SRS based on size and mass effect. Meningioma surgery prioritizes cranial nerve preservation over radical resection. Intradural PGLs require staged vascular-conscious approaches. Multidisciplinary care and structured rehabilitation are pivotal to improving outcomes and quality of life.

Objective. To investigate safety and efficacy of the microsurgical approach to parapharyngeal space (PPS) tumour. A secondary goal was to evaluate the correspondence between preoperative and final histopathologic diagnosis after surgery. Methods. A consecutive series of primary PPS tumours treated between 1985 and 2022 in 2 tertiary referral centres with a microsurgical cervico-parotid approach was considered. The sample included 97 tumours (88 benign and 9 malignant) in 94 patients, of which 11 affected by recurrent tumours when first diagnosed at our centres. The surgical approaches, planned on the presumptive preoperative diagnosis, were pericapsular and en bloc resections (including either conservative or radical resections of the PPS).Results. Pericapsular and en bloc resections of the PPS achieved complete removal in 88 out of 97 tumours. Relapses after PPS microsurgery occurred only in 8 cases (4 pleomorphic adenomas, 2 malignant schwannomas, one melanoma, and one haemangiopericytoma). Four of the 8 relapsed cases were recurrent cases when first seen at our centres. A complete correspondence between preoperative diagnosis and final histology occurred only in the group of benign lesions classified as paraganglioma, schwannoma, or lipoma, submitted to pericapsular resection. Conclusions. Microsurgery may support the transcervical-parotid approach, by enhancing the operative space through narrow surgical corridors, improving dissection on critical cleavage planes, vessels and nerves, and allowing the exposure of both caudal and cranial extent of the lesions. In our series, pericapsular and en bloc resections of the PPS were effective in most of the included patients. In high-grade malignancies, where the morbidity of a wider resection beyond the PPS walls may include vessels and nerves, the indication should be accurately balanced.

Objective: Surgery involving the skull base has recently gained significant prominence in treatment of head and neck cancer. “En bloc temporal‐parotid resection,” as applied in primary malignancies of the external ear, should be considered as a shift in the surgical landscape of “extended total parotidectomies” to achieve negative surgical margins and decrease the risk of tumor spillage during the procedure. The purpose of this systematic review is to evaluate survival outcomes and margin status in patients with parotid malignancies involving the temporal bone and treated with temporal‐parotid resection (TPR). Data Sources: PubMed, Scopus, and Embase databases were systematically searched until 11 February 2025. Review Methods: The protocol of this investigation was registered on PROSPERO in February 2024 and the systematic review was performed according to the PRISMA method. Results: The study included 336 patients from 13 articles published between 1993 and 2019. Negative surgical margins were achieved in 74.5% of cases. After a median follow‐up of 32 months, 64.0% of patients achieved local disease control. Most patients (51.4%) experienced distant metastases during follow‐up. Three‐year overall survival (OS) and disease‐specific survival (DSS) ranged between 72.4%–57.1% and 79.0%–66.7%, respectively. Conclusion: TPR represents a viable strategy to achieve safe oncological margins and adequate local disease control in patients with parotid gland malignancies infiltrating or abutting the temporal bone. Our findings support the growing interest in TPR, highlighting the need for further studies to refine patient selection criteria, surgical techniques, and postoperative management strategies. Trial Registration: PROSPERO: CRD42024512013 Level of Evidence: NA.

Introduction. Non-melanoma skin cancers (NMSCs), including basal (BCC) and squamous cell carcinoma (SCC), are the most prevalent malignancies affecting the skin, with the head and neck region being the most common site of involvement. Surgical excision remains the primary treatment modality. The role of surgical margins in the treatment of skin SCC and BCC of the head and neck remains a subject of ongoing debate. Clear definitions and guidelines regarding adequate surgical margins, as well as their impact on recurrence rates and overall outcomes, are critical for improving clinical management. This systematic review aims to evaluate the current literature on the definitions of surgical margins for SCC and BCC of the head and neck, as well as their impact on local recurrence, disease free survival, and other patient-centred outcomes. Materials and methods. We conducted a systematic review following the PRISMA guidelines. A comprehensive search was performed across multiple databases, including PubMed and Scopus, for studies published up to December 2024. Eligible studies included those that reported on surgical margin definitions, surgical outcomes, and recurrence rates for SCC and BCC of the skin in the head and neck region. Data were extracted and analysed for margin size and oncological outcomes. Results. Following the application of inclusion and exclusion criteria, 30 studies have been retrieved for qualitative synthesis. Of these, 12 studies focused on SCC only, 14 on BCC only, and 4 on mixed histologies. Margin involvement rates ranged widely across the studies included (5-56%) as did thelocal recurrence rate (0-20%). This is associated with a variability of the surgical margin both for SCC and BCC, and of the definition of margin as close/negative at final pathology. Most studies do not define a threshold for close vs. negative margins at final pathology. All studies but one reported a significant correlation between positive margins and oncological outcomes, with particular regards to local recurrence. Conclusions. The findings highlight a lack of consensus on the optimal surgical margins for SCC and BCC of the head and neck, suggesting that margins may need to be individualised based on tumour characteristics, location, and patient factors. In particular, the anatomical complexity of the head and neck region suggests to separately address different high-risk areas as nose/midface, periauricular, and periocular with specific recommendations also concerning clinical margins.

Background: Microtia is a congenital outer ear deformity that causes the auricle to be absent or underdeveloped. It is frequently associated with external auditory canal atresia and causes hearing and psychosocial problems. Objectives: We thoroughly investigate the aspects of microtia and explore both current and innovative therapies. Methods: A systematic literature review was conducted following PRISMA guidelines, focusing on microtia and reconstruction methodologies. This review utilized three databases: PubMed, Scopus, and Web of Science. Results: The etiology involves both genetic and environmental factors and can occur as part of a syndrome or as an isolated condition. Clinically, it has esthetic and functional implications, potentially leading to conductive hearing loss. A multidisciplinary approach is essential for treatment, which includes surgical reconstruction using autologous cartilage or synthetic prostheses. Advances in bioengineering and 3D printing offer new, less invasive solutions. Conclusions: This review aims to synthesize current knowledge on microtia, focusing on tissue engineering for auricular reconstruction, identifying research gaps, evaluating techniques, and providing a resource for clinicians to improve decision-making and foster further research.

Objective: To investigate the role of intraoperative cochlear nerve (CN) electric monitoring with MED-EL intracochlear test electrode (ITE) in assessing the CN functional integrity. Setting: Tertiary referral center. Patients: Patients with intrameatal or 2 to 13 mm in the cerebello-pontine angle vestibular schwannoma (VS), not suitable for hearing preservation surgery but eligible for tumor resection via translabyrinthine approach and simultaneous cochlear implant (CI) rehabilitation. Intervention: ITE was used to register electrically evoked auditory brainstem response (eABR) before and after VS resection. All patients with anatomical preservation of CN underwent CI, regardless of eABR results, which served as the index test and was compared with postoperative sound perception by CI stimuli (gold standard test). Results: Twelve of seventeen cases allowed anatomical preservation of CN and were considered for the study. Seven of twelve cases demonstrated sound detection with CI, and six of twelve showed some degree of speech discrimination. eABR test with ITE achieved an accuracy of 66.7%, a sensitivity of 42.9%, and a specificity of 100%. Positive and negative predictive values were 100% and 55.6%, respectively. Conclusion: When eABR can be evoked with ITE, the attempt of CI was likely to be successful, whereas in cases of eABR absence, other factors should be considered to reduce unsuccessful CI and not preclude rehabilitation in patients who would benefit from CI. Further studies and longer follow-up are needed to analyze the role of ITE in VS surgery with CI.