Paolo Tummino

Background: Hyperbaric oxygen therapy (HBOT) is proposed as an adjunct in two sinonasal conditions of high morbidity: acute invasive fungal rhinosinusitis (AIFRS) and post-radiotherapy injury. Methods: We conducted a narrative review and reported it against SANRA; PubMed/MEDLINE was searched (1980–2026; 1414 records screened, 589 retained), with Cochrane, society guidance and reference screening. Results: No randomised trial has tested HBOT against sinonasal endpoints in either indication. In AIFRS the dedicated evidence is four uncontrolled series (n = 27, level 4); none reports how many candidates were unfit to pressurise, the largest synthesis did not identify HBOT as a survival predictor, and the only randomised experiment—murine—was negative. Mycology guidance supports it with marginal strength only (C; quality III), and hyperbaric indication lists omit it. For radiation injury, Cochrane 2023 reports low-certainty benefit in head-and-neck tissue, but HOPON found no reduction in osteoradionecrosis after dentoalveolar surgery (6.4% vs. 5.7%; OR 1.13, 95% CI 0.14–8.92), and pooled DAHANCA-21/NWHHT2009-1 data were non-significant (70% vs. 51% healing); all sinonasal use is extrapolated from the mandible. Middle-ear, not sinus, barotrauma is the commonest ENT complication. Conclusions: HBOT is mechanistically coherent and may be considered case-by-case within a multidisciplinary team, but it is not a standard of care in either indication; the algorithm offered here is unvalidated.

Background/Objectives: Patients with pre-existing chronic obstructive pulmonary disease (COPD) and/or chronic heart failure (CHF) are a particularly high-risk surgical population in whom postoperative pulmonary complications (PPCs) drive a disproportionate share of morbidity, prolonged stay and mortality. Prehabilitation—the structured optimization of functional reserve during the preoperative interval—has emerged as a proactive, largely non-pharmacological strategy to raise that reserve before the surgical insult. Yet the evidence base is organized predominantly by surgical procedure and enrolled in mixed populations, so the patients with the least physiological reserve—those with established COPD or CHF—remain comparatively understudied. This narrative review takes the comorbidity, rather than the incision, as its organizing axis. Methods: We summarize the pathophysiology that links chronic cardio-respiratory disease to perioperative respiratory failure; appraise the principal non-pharmacological interventions, with the respiratory components (inspiratory muscle training, pulmonary rehabilitation, breathing techniques) as the core and exercise, nutritional, psychological, and smoking-cessation elements as the multimodal context; and re-read the surgical evidence through the lens of the underlying disease. Results: A cross-surgical meta-analysis indicates that preoperative exercise training reduces PPCs (relative risk ≈ 0.52) with no significant difference in effect across surgery type or training modality, supporting a comorbidity-centered rather than procedure-centered framework. We address practical determinants of implementation—timing, patient selection, adherence, home-based and telemonitored delivery, and low-resource applicability—and highlight two cross-cutting problems: heterogeneity of intervention prescription and the lack of standardized PPC definitions. Conclusions: The scarcity of disease-specific evidence is itself the central finding, revealing a mismatch between clinical risk and research investment.

Patients with pre-existing chronic obstructive pulmonary disease (COPD) and/or chronic heart failure (CHF) are a particularly high-risk surgical population in whom postoperative pulmonary complications (PPCs) drive a disproportionate share of morbidity, prolonged stay and mortality. Prehabilitation—the structured optimization of functional reserve during the preoperative interval—has emerged as a proactive, largely non-pharmacological strategy to raise that reserve before the surgical insult. Yet the evidence base is organized predominantly by surgical procedure and enrolled in mixed populations, so the patients with the least physiological reserve—those with established COPD or CHF—remain comparatively understudied. This narrative review takes the comorbidity, rather than the incision, as its organizing axis. We summarize the pathophysiology that links chronic cardio-respiratory disease to perioperative respiratory failure; appraise the principal non-pharmacological interventions, with the respiratory components (inspiratory muscle training, pulmonary rehabilitation, breathing techniques) as the core and exercise, nutritional, psychological and smoking-cessation elements as the multimodal context; and re-read the surgical evidence through the lens of the underlying disease. A cross-surgical meta-analysis indicates that preoperative exercise training reduces PPCs (relative risk ≈ 0.52) with no significant difference of effect across surgery type or training modality, supporting a comorbidity-centred rather than procedure-centred framework. We address practical determinants of implementation—timing, patient selection, adherence, home-based and telemonitored delivery, and low-resource applicability—and highlight two cross-cutting problems: heterogeneity of intervention prescription and the lack of standardized PPC definitions. The scarcity of disease-specific evidence is itself the central finding, revealing a mismatch between clinical risk and research investment.

Cardiac arrhythmias complicate 20–50% of surgical procedures and contribute substantially to perioperative morbidity, mortality, and healthcare costs, with postoperative atrial fibrillation (POAF) being the most frequent form. Their genesis reflects the convergence of surgical stress, anaesthetic agents, autonomic imbalance, systemic inflammation, and electrolyte disturbances, explaining the limited efficacy of single-mechanism interventions. This narrative review synthesises contemporary evidence on pathophysiology, risk stratification, prevention, acute management, and emerging technologies, emphasising individualised, patient-tailored approaches. MEDLINE, Embase, and Cochrane CENTRAL were searched (January 2010–January 2026), prioritising randomised trials, meta-analyses, and guidelines. Contemporary risk stratification integrates clinical scores, biomarkers, and electrocardiographic parameters; machine-learning models show moderate discrimination (pooled AUC 0.84) and may enable more personalised prediction pending external validation. Evidence-based prophylaxis—beta-blockade, magnesium, selective amiodarone, and emerging anti-inflammatory strategies such as colchicine—reduces POAF in high-risk populations, while acute management is guided by haemodynamic status and individual risk. Anticoagulation follows CHA₂DS₂-VASc stratification, although optimal timing and duration remain undefined. Wearable monitoring, AI-based detection, and atrial-selective agents show clinical promise. Systematic, personalised integration of risk assessment, prophylaxis, monitoring, and management offers the clearest path to reducing arrhythmia-associated morbidity.

Background. Hyperbaric oxygen therapy (HBOT) delivers 100% oxygen at supra-atmospheric pressure, producing tissue hyperoxygenation, enhanced phagocytic killing, neoangiogenesis, and immunomodulation. Although HBOT is well established in head-and-neck practice, its specific role in sinonasal disease remains poorly systematised. Objective. To reappraise the rationale, evidence, and practical implementation of HBOT in two cardinal sinonasal indications—acute invasive fungal rhinosinusitis (AIFRS) and post-radiotherapy sinonasal damage—through a rhinology-centred, multidisciplinary lens. Methods. Narrative review of articles published in PubMed/MEDLINE, Scopus, Embase, and the Cochrane Library between 1 January 1980 and 31 March 2026, conducted following the SANRA framework and combining MeSH terms for HBOT with sinonasal, mucormycosis, osteoradionecrosis, and skull-base keywords. Results. In AIFRS, HBOT addresses the angioinvasive ischaemic core, restores oxidative neutrophil killing, and potentiates amphotericin B; observational data—including the recent COVID-19-associated mucormycosis (CAM) experience—suggest a survival benefit when HBOT is added early to surgical and antifungal therapy. In post-radiotherapy injury, HBOT reverses Marx's hypoxic–hypocellular–hypovascular triad, supporting healing of osteoradionecrosis (maxillary and skull-base), soft-tissue radionecrosis, and reconstructive procedures in the irradiated bed. Sinus barotrauma, the most frequent rhinological complication, is largely preventable with structured pre-treatment ENT assessment. Conclusions. HBOT is a mechanistically well-founded, well-tolerated adjunct with a favourable safety profile when delivered by a multidisciplinary team. Sinonasal-specific prospective registries and pragmatic randomised trials are urgently needed.

Cardiac arrhythmias complicate 20–50% of surgical procedures and contribute substantially to perioperative morbidity, mortality, and healthcare costs, with postoperative atrial fibrillation (POAF) being the most frequent form. Their genesis reflects the convergence of surgical stress, anaesthetic agents, autonomic imbalance, systemic inflammation, and electrolyte disturbances, explaining the limited efficacy of single-mechanism interventions. This narrative review synthesises contemporary evidence on pathophysiology, risk stratification, prevention, acute management, and emerging technologies, emphasising individualised, patient-tailored approaches. MEDLINE, Embase, and Cochrane CENTRAL were searched (January 2010–January 2026), prioritising randomised trials, meta-analyses, and guidelines. Contemporary risk stratification integrates clinical scores, biomarkers, and electrocardiographic parameters; machine-learning models show moderate discrimination (pooled AUC 0.84) and may enable more personalised prediction pending external validation. Evidence-based prophylaxis—beta-blockade, magnesium, selective amiodarone, and emerging anti-inflammatory strategies such as colchicine—reduces POAF in high-risk populations, while acute management is guided by haemodynamic status and individual risk. Anticoagulation follows CHA₂DS₂-VASc stratification, although optimal timing and duration remain undefined. Wearable monitoring, AI-based detection, and atrial-selective agents show clinical promise. Systematic, personalised integration of risk assessment, prophylaxis, monitoring, and management offers the clearest path to reducing arrhythmia-associated morbidity.