Alfredo Lo Manto

Background: Oncological surgery of the parotid gland or of the temporal bone may require the contemporary sacrifice of the facial nerve (FN). In such cases, the immediate repair of the sacrificed FN is recommended. The aim of this study is to evaluate the impact of facial rehabilitation (FR) and, secondarily, of post-operative radiotherapy (PORT) on the FN outcome after FN sacrifice and reconstruction via cable graft. Methods: This is a multicentric retrospective study including patients affected by malignant tumors whose surgical excision required FN sacrifice and contextual FN reconstruction with a cable graft. Other FN reconstruction techniques were excluded. FN function was assessed using both House–Brackmann and Sunnybrook grading systems. Results: A total of 28 patients were included. Most of the patients underwent a total parotidectomy. The greater auricular nerve was the main donor for cable graft. FR and PORT were performed in 22 and 15 patients, respectively. In particular, 20 patients underwent neuro-muscular retraining (NMR). Patients who underwent FR had better FN outcomes compared to those who did not (p = 0.02 at 12 months and p = 0.0002 at 24 months). In contrast, there was no statistically significant difference between patients who underwent PORT and those who did not (p > 0.05). Pre-operative FN palsy is a risk factor of worse FN function outcomes after cable graft. Conclusions: Our study, even though it was limited to only 28 cases, may demonstrate that cable graft failure is not due to PORT, as widely believed among clinicians, but to the absence of a rehabilitation program. Moreover, we suggest that the key to obtaining the best possible FN function results after FN sacrifice is the association of a technically correct FN reconstruction with a proper and targeted FR.

Objective: Open partial horizontal laryngectomies (OPHLs) represent a comparable alternative to total laryngectomy and nonsurgical protocols in selected cases. While short‐term functional outcomes of OPHLs have been widely investigated, few have focused on the effect of aging on residual laryngeal structures.Study Design: Retrospective cohort study.Setting: Tertiary care academic center.Methods: Patients who underwent OPHLs after at least 1 year follow‐up and optimal functional rehabilitation were included in the study.Swallowing function was assessed according to PAS (Penetration aspiration scale) and Pooling scores. Spectrogram analysis of voice was conducted according to Yanagihara classification and acoustic parameters were also recorded. Subjective questionnaire data about phonation and swallowing were also recorded. Data obtained were compared among patients according to age at time of surgery, evaluation and duration of follow‐up.Results: Ninety‐seven patients were enrolled with a mean age at surgery and evaluation of 63 and 70 years old, respectively. Median follow‐up length was 5 years. OPHL type II was mostly performed. No significant correlation was observed between most of the analyzed variables and patient's age at the time of surgery and at the time of evaluation. Some acoustic parameters were negatively correlated with follow‐up length, while Jitter, NHR (Noise‐Harmonic Ratio), and Global grade and Roughness were significantly higher in patients >65 years old.Conclusion: Patients who complete rehabilitation reach equally good results as their younger peers with stability over time. Finally, the effects of aging on residual larynx are of minor entity compared to the nonoperated patients.Level of Evidence: Level IV‐retrospective cohort study.

Objective: Diffusion of endoscopic techniques for the resection of ethmoid bone malignancies through a transcribriform approach (TA) has raised new challenges regarding reconstruction options to reduce post‐operative complications. Although there is consensus on the advantages of vascularized flaps over free grafts for large defects, no standard protocol exists on reconstruction procedures. In addition, although the pedicled nasoseptal flap has been extensively discussed, few studies have been published on extranasal pedicled flaps. The aim of this manuscript is to provide a detailed description of a reconstruction technique for large anterior skull base defects with the pericranial flap as part of a multilayered reconstruction. Moreover, patients treated with this approach were retrospectively assessed for post‐operative complications.Methods: A detailed description of the reconstruction procedure as performed in our departments is provided. Pictures depicting the main surgical steps are also included. In addition, preliminary functional results from a retrospective series of patients who underwent a TA and subsequent pericranial flap‐based multilayer reconstruction for ethmoid roof malignancies between 2016 and 2022 at two institutional centers are reported.Results: 16 patients were included in the study. Nine patients (56.3%) underwent adjuvant radiotherapy. Two patients had a biochemically‐confirmed postoperative CSF leak. Only one of the two patients required surgical revision. During follow‐up (mean 13 months), no other early nor delayed complications were observed.Conclusion: A standardized surgical technique with pericranial flap as part of a multilayered reconstruction for large anterior skull base defects following resection of sinonasal malignancies is proposed, which appears to be a safe choice when endonasal flaps are not available.Level of Evidence: Level 4 Laryngoscope, 133:2942–2947, 2023

Background: Distant metastasis (DM) development in Oropharyngeal Squamous Cell Carcinoma (OPSCC) represents an important prognostic factor. The identification of a phenotype of metastatic patients may better define therapeutic and follow‐up programs.Methods: We included 408 patients with OPSCC, non‐metastatic at the time of diagnosis, and treated with curative intent. The Overall Survival (OS) analyses were performed and the impact of developing DM on survival was analyzed through Cox proportional‐hazard regression model.Results: 57 (14%) patients develop DM. 302 (74%) were p16+ OPSCC and 35 of them experienced DM. Advanced clinical stage, smoking, p16‐status, response to primary treatment, and loco‐regional relapse influence the DM rate. Only in the p16+ group, DM onset results in a greater impact on OS (p < 0.0001). Lung metastases have a better OS compared to non‐pulmonary ones (p = 0.049).Conclusion: This retrospective study shows a possible stratification of OPSCC patients based on the risk of the development of DMs.

Horizontal glottectomy (HG) is a particular type of partial laryngectomy indicated for exclusive glottic tumor with anterior commissure involvement. The purpose of this study is to systematically review the literature about functional and oncological outcome of HG. This systematic review adhered to the recommendations of the PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-analysis) 2009 guidelines. Articles mentioning patients undergoing HG for laryngeal squamous cell carcinoma were included. A total of 14 articles were selected and reviewed from 19 identified. The whole study population consisted of 420 patients who underwent HG. Three hundred and thirty-nine patients out of 359 were staged as T1. The range of post-operative follow-up was 5 months to 10 years. Fifty-five recurrences were experienced, being local, regional and distant in 35, 12 and 8 patients, respectively. Laryngeal preservation rate was 93.6%. Nasogastrict tube was removed on average after 10.1 days. The tracheostomy was maintained for 11.3 days. Mean hospitalization lasted for 11.7 days. According to the results of this systematic review, HG is an oncologically safe surgical option for T1a–T1b glottic tumors with oncological outcomes comparable to other treatment. HG could be a good therapeutical choice whenever poor laryngeal exposure and/or patient’s refusal of radiotherapy are encountered, or when patient’s medical history represents a contraindication for radiation therapy.

Background: To retrospectively evaluate oncological outcomes in two groups of patients with pT4aN0 glottic SCC treated with total laryngectomy (TL) and neck dissection (ND) who underwent postoperative radiotherapy or exclusive clinical and radiological follow‐up.Methods: It includes patients with pT4N0 glottic SCC who underwent TL and unilateral or bilateral ND with or without PORT. Divided in two comparison groups: the first group underwent adjuvant RT (TL‐PORT); the second group referred to clinical and radiological follow‐up (TL).Results: PORT was associated with a better OS while no differences were found in terms of DSS. A better local control is achieved when PORT is administered while no differences in terms of regional and distant control rates were found. Bilateral ND positively impacts on the regional control while the PNI negatively impact the regional control.Conclusions: A tailored PORT protocol might be considered for pT4N0 glottic SCC treated with TL and ND, both considering the ND's extent and presence of PNI.

Objective: This study aims to prospectively compare endoscopic, radiological, and pathological features of a cohort of patients with glottic laryngeal squamous cell carcinoma (LSCC) undergoing open partial horizontal laryngectomy (OPHL) type II/III or total laryngectomy to better understand the reliability of preoperative endoscopy and computed tomography (CT) to predict the inferior paraglottic space (iPGS) involvement.Methods: We prospectively compared the endoscopic, radiological, and pathological findings in patients with glottic LSCC who underwent OPHL II/III, or total laryngectomy.Results: Endoscopy achieved a diagnostic accuracy of 87.2% for the anterior iPGS (iPGSa) and 86.1% for the posterior iPGS (iPGSp). There was no statistically significant difference in terms of histopathologic iPGSa involvement between reduced (85%—17/20 pts) and absent (92%—24/26 pts) vocal cord mobility (p = 0.39). CT alone did not improve the diagnostic performance of the endoscopy, reaching a diagnostic accuracy of 62.9% and 73.7% for the iPGSa and iPGSp, respectively. When endoscopy and CT were combined, the diagnostic performance improved for the iPGSp, achieving a sensitivity (Se), specificity (Spe), positive predictive value (PPV), and negative predictive value (NPV) of 100%, 89.8%, 68.7%, and 100%, respectively. On the contrary, the combination of CT and endoscopy improved only the Se and NPV for the iPGSa with respect to the sole endoscopic assessment.Conclusions: Whenever motility impairment is present, a histopathologic invasion of the iPGS should be suspected. Endoscopic assessment of laryngeal motility achieved a satisfactory value of Se, Spe, PPV, and NPV in predicting the involvement of the iPGS. CT scan is still the mainstay imaging technique in the clinical staging of patients with LSCC.Level of Evidence: 4 Laryngoscope, 133:1184–1190, 2023

Introduction Labyrinthine fistula is one of the most frequent complications of cholesteatoma (CHO), occurring in about 8% of cases in the literature. In about 90% of cases, it is located at the level of the lateral semicircular canal, and its clinical manifestation includes vertigo, nystagmus and positive Hennebert and Tullio signs. The management of lateral semicircular canal fistula (LSCF) secondary to CHO classically requires a retroauricular access by performing a canal wall-up (CWU) or canal wall-down (CWD) mastoidectomy. However, in case of a CHO confined to the tympanic cavity causing a LSCF on the ampullar arm, a transcanal exclusive endoscopic approach could be considered. Aims The aim of this study is to describe the feasibility of a transcanal exclusive endoscopic approach in the management of a CHO confined to the tympanic cavity causing a LSCF on the ampullar arm. Methods From January 2019 to December 2020, three patients with LSCF secondary to mesotympanic CHO underwent transcanal exclusive endoscopic ear surgery repair at the Department of Otolaryngology-Head and Neck Surgery, University Hospital of Modena, Italy. Results This technique was successfully employed to treat LSCF in all three cases and was planned as a two-stage surgery, performing ossiculoplasty after 12–18 months. Functional outcomes were also satisfactory: complete eradication of CHO, hearing preservation and complete resolution of symptoms. Conclusions In case of a CHO confined to the tympanic cavity causing an LSCF on the ampullar arm, a transcanal exclusive endoscopic approach could be considered as a feasible and safe technique.