Matteo ALICANDRI CIUFELLI - personale UniMoRe

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Matteo ALICANDRI CIUFELLI

Professore Associato
Dipartimento di Scienze Mediche e Chirurgiche Materno-Infantili e dell'Adulto

Pubblicazioni

2024 - Surgical anatomy of posterior tympanotomy: influence of the retrotympanum on round window exposure [Articolo su rivista]
Maccarrone, F.; Molinari, G.; Fermi, M.; Alicandri-Ciufelli, M.; Presutti, L.; Tassi, S.; Villari, D.; Negri, M.
abstract

Objective: To describe how the retrotympanic structures could influence the visibility of the round window niche (RWN) and of the round window membrane (RWM) during cochlear implant (CI) surgery. To investigate if a RW approach is possible even in those cases with unfavorable anatomy. Methods: Video recordings from 37 patients underwent CI were reviewed. The visibility of the RWN and RWM at different timepoints was assessed according to a modified version of the Saint Thomas Hospital classification. The structures responsible for hiding the RWN and RWM were evaluated. Results: After posterior tympanotomy 54% of cases had a limited exposure (class IIa, IIb, and III) of the RWN. After remodeling the retrotympanum, the RWN visibility achieved a significant increase, with 100% class I and IIa. Following the remodeling of RWN, a visibility >50% of the RWM surface was achieved in 100% of the cases. Conclusion: Remodeling the retrotympanum and the RWN significantly increase the exposure of the RWN and RWM respectively, allowing a RW insertion in all cases.

2023 - A response regarding the facial sinus classification: its clinical and radiologic importance [Articolo su rivista]
Wojciechowski, T.; Fermi, M.; Alicandri-Ciufelli, M.
abstract

2023 - Acquired bilateral facial palsy: a systematic review on aetiologies and management [Articolo su rivista]
Molinari, G.; Lucidi, D.; Fernandez, I. J.; Barbazza, A.; Vanelli, E.; Lami, F.; Federici, G.; Botti, C.; Presutti, L.; D'Angelo, R.; Rinaldi, R.; Alicandri-Ciufelli, M.
abstract

Objective: To systematically review the published cases of bilateral facial palsy (BFP) to gather evidence on the clinical assessment and management of this pathology. Methods: Following PRISMA statement recommendations, 338 abstracts were screened independently by two authors. Inclusion criteria were research articles of human patients affected by BFP, either central or peripheral; English, Italian, French or Spanish language; availability of the abstract, while exclusion criteria were topics unrelated to FP, and mention of unilateral or congenital FP. Only full-text articles reporting the diagnostic work-up, the management, and the prognosis of the BFP considered for further specific data analysis. Results: A total of 143 articles were included, resulting a total of 326 patients with a mean age of 36 years. The most common type of the paralysis was peripheral (91.7%), and the autoimmune disease was the most frequent aetiology (31.3%). The mean time of onset after first symptoms was 12 days and most patients presented with a grade higher than III. Associated symptoms in idiopathic BFP were mostly non-specific. The most frequently positive laboratory exams were cerebrospinal fluid analysis, autoimmune screening and peripheral blood smear, and the most performed imaging was MRI. Most patients (74%) underwent exclusive medical treatment, while a minority were selected for a surgical or combined approach. Finally, in more than half of cases a complete bilateral recovery (60.3%) was achieved. Conclusions: BFP is a disabling condition. If a correct diagnosis is formulated, possibilities to recover are elevated and directly correlated to the administration of an adequate treatment.

2023 - Cadaver Homologous Banked Fascia Lata in Skull Base Reconstruction: Preliminary Multidisciplinary Experiences [Articolo su rivista]
Alicandri-Ciufelli, M.; Serafini, E.; Pavesi, G.; Marchioni, D.; Mantovani, M.; Dallari, D.; Iaccarino, C.
abstract

Skull base reconstruction has been a widely debated issue. Both autologous and heterologous materials have been proposed, however the formers are usually preferred due to their optimal healing outcomes and integration. Nevertheless they are still associated with donor-site functional and aesthetic morbidity. The aim of this study is to report a preliminary experience of different sites defects skull base repair with Cadaver homologous banked fascia lata graft. Patients who underwent reconstruction of skull base defects with Cadaver homologous banked fascia lata between January 2020 until July 2021 were included in the study. Three patients were finally identified for the study. Patient 1 underwent combined craniotomic-endoscopic surgical access for extended anterior skull base neoplasm with subsequent repair with homologous cadaver fascia lata. Patient 2 underwent endoscopic transphenoidal surgery for sellar-parasellar neoplasm. After tumor debulking the surgical cavity was obliterated with homologous cadaver fascia lata. Patient 3 finally had politrauma with otic capsule-violating fracture with profused CSF leak. An endoscopic obliteration of external and middle ear was performed using homologous cadaver fascia lata with blind sac closure of external auditory canal. No graft displacement or reabsorption was observed in these patients at the last follow-up. Cadaver homologous banked fascia lata has proved safety, efficacy and ductility in reconstruction of different skull base defects. Level of Evidence: Level IV-retrospective cohort study.

2023 - Effects of Total Intravenous Versus Inhalational Anesthesia on Bleeding during Endoscopic Ear Surgery: Preliminary Results from a Case-Control Study [Articolo su rivista]
Molinari, G.; Reale, M.; Alicandri-Ciufelli, M.; Villari, D.; Presutti, L.; Femino, R.; Fernandez, I. J.; Lucidi, D.
abstract

Objective To assess the impact of the type of maintenance anesthesia on the bleeding conditions of the surgical field and hemodynamic parameters during endoscopic ear surgery (EES), comparing totally intravenous inhalational anesthesia (TIVA) with inhalational anesthesia (IA). Study Design Retrospective case-control study. Setting Tertiary referral center. Patients Fifteen consecutive EES cases performed with TIVA between 2019 and 2020 at our Institution were matched to a control group of patients who underwent EES with IA in the same period. Patients with American Society of Anesthesiologists IV grade, acute otitis before surgery, congenital or acquired coagulopathies, use of anti-inflammatory drugs, or antiaggregant or anticoagulant therapy in the 5 days before the intervention were excluded. Interventions Both primary and revision tympanoplasty and stapes surgery were considered. Main Outcome Measures Surgical videos were reviewed to quantify the entity of bleeding according to the Modena Bleeding Score. Hemodynamic parameters during surgery were retrospectively collected. A comparison between the two groups was performed. Results No statistically significant differences between the two groups in terms of bleeding were found at any of time point evaluated. The tympanomeatal flap elevation resulted in the bloodiest step in both groups. Hemodynamic parameters were similar in both groups (p > 0.05). Conclusions These preliminary data do not support a significant difference in bleeding conditions and hemodynamic parameters between EES patients receiving TIVA and those receiving IA. Further studies involving a higher number of patients will improve our understanding on how maintenance anesthesia with TIVA may be beneficial in terms of bleeding control as compared with IA for patients undergoing EES.

2023 - Endoscopic “retrograde” dacryocystorhinostomy: A fast route to the lacrimal sac [Articolo su rivista]
Alicandri-Ciufelli, M.; Russo, P.; Aggazzotti Cavazza, E.; Martone, A.
abstract

Endoscopic Dacryocystorhinostomy (DCR) is an established surgical technique for the management of peripheral nasolacrimal duct (NLD) obstruction. Its main points are the correct identification of the lacrimal sac and the execution of surgical procedures that allow a rapid and accurate healing of the surgical field. The main endoscopic landmarks used for the identification of the lacrimal sac are the middle turbinate and the maxillary line. However, in some cases, this procedure can be difficult due to several factors (e.g. anatomical variations, former surgery). In the present study, a variation of “classic” endoscopic DCR, named “retrograde” endoscopic endonasal DCR (rDCR), is described. rDCR is performed through the quick identification of the NLD at the level of the most anterior insertion of the inferior turbinate in the lateral nasal wall. In most cases, at this level only a very thin shell of bone is present (crack point), easily fractured by using blunt angled dissector. The duct is then followed upward along its course by removing the overlying bone in order to correctly identify the lacrimal sac and unequivocally drill along the lacrimal pathway. This technique proved to be a safe, quick and effective procedure, even in patients with difficult anatomy.

2023 - Expanded transcanal transpromontorial approach for acoustic neuroma removal [Articolo su rivista]
Molinari, G.; Chiari, F.; Presutti, L.; Fermi, M.; Fernandez, I. J.; Alicandri-Ciufelli, M.
abstract

2023 - Influence of Prior Endoscopic Sinus Surgery Extent on Dupilumab Effectiveness in CRSwNP Patients [Articolo su rivista]
Alicandri-Ciufelli, M.; Marchioni, D.; Pipolo, C.; Garzaro, M.; Nitro, L.; Dell'Era, V.; Ferrella, F.; Campagnoli, M.; Russo, P.; Galloni, C.; Ghidini, A.; De Corso, E.; Lucidi, D.
abstract

Background: Guidelines recommend that the vast majority of patients with severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) should have at least one endoscopic sinus surgery (ESS) prior to starting biologics. Because ESS can be performed with a variable extension, the aim of this study would be to evaluate the association between surgical extensiveness, as measured by ACCESS score, and outcomes collected in patients treated with Dupilumab. Materials and Methods: This is a multicentric retrospective study; patients affected by CRSwNP who were subjected to Dupilumab therapy and who underwent at least one ESS prior to Dupilumab initiation were included. ACCESS score was assigned to each patient's pre-Dupilumab CT scan. Subjective and objective parameters (SNOT-22, NPS, VAS scores, Sniffin’ Sticks) were collected before and during the administration of therapy. Statistical correlations between ACCESS scores and clinical outcomes were investigated. Results: A total of 145 patients were included; mean time from last previous ESS was 68.6 months, and on average, patients were subjected to 2.2 surgeries. Many correlations with ACCESS scores were demonstrated: better NPS at all timepoints and subjective scores (30-days SNOT-22, VAS nasal obstruction, and rhinorrhea) were achieved in patients with low ACCESS score (more extensive ESS). On the other hand, significantly worse VAS loss of smell values were demonstrated in patients with lower ACCESS scores. Conclusion: Dupilumab patients subjected to a prior extensive ESS may have reduced size of polyps and improved subjective indicators, together with a decreased chance to recover smell, when compared with patients who underwent a minimal excision. Level of Evidence: Level 3 Laryngoscope, 2023.

2023 - Multilayer Anterior Skull Base Reconstruction with Cortical Rib Bone Graft: Preliminary Experience [Articolo su rivista]
Fermi, M.; Serafini, E.; Rosti, A.; Olive, M.; Alicandri-Ciufelli, M.; Sciarretta, V.; Fernandez, I. J.; Presutti, L.
abstract

Objective: During the past decades, different methods have been described for anterior skull base reconstruction. Regarding larger skull base defects, few investigators have described the use of bone grafts to foster support and prevent frontal lobe sagging, herniation, or falling. The aim of this study is to describe the use of a rib bone graft, which could be an option in these cases due to its rigidity and dimensions. Methods: We retrospectively collected preoperative, intraoperative, and postoperative data at the last follow-up of 10 patients who underwent multilayer anterior skull base reconstruction, including rib bone graft, for large anterior cranial base defects at 2 tertiary care academic hospitals. Results: Eight patients underwent endoscopic craniectomy for sinonasal malignancies, and the other two underwent transnasal endoscopic surgery for congenital meningoencephalocele. Anterior skull base defects measured on average 3.8 cm ± 0.9 SD antero-posteriorly (range 2.5–5 cm) and 2.3 ± 0.9 SD latero-laterally (range 0.9–4 cm). Multilayer reconstruction was performed in all cases, including a rib bone graft positioned as intracranial extradural layer. No patient experienced thoracic complications during the postoperative period. No side effects related to the bone graft or meningoencephalocele occurrence were reported after a mean follow-up of 8.0 ± 6.3 months. Conclusions: The use of a cortical rib bone graft could be a safe and effective option in skull base reconstruction when managing large defects after cancer removal.

2023 - Pericranial Flap-Based Multilayer Reconstruction of Endoscopic Transcribriform Craniectomy for Sinonasal Malignancies [Articolo su rivista]
Calvaruso, F.; Lo Manto, A.; Bisi, N.; Cantaffa, C.; Basso, M.; Ferrulli, G.; Alicandri-Ciufelli, M.; Marchioni, D.
abstract

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.

2023 - Prognostic role of EAONO/JOS, STAMCO, and ChOLE Staging for Exclusive Endoscopic and Endoscopic-Microscopic Tympanoplasty [Articolo su rivista]
Fermi, M.; Bassano, E.; Villari, D.; Capriotti, V.; Calvaruso, F.; Bonali, M.; Alicandri-Ciufelli, M.; Marchioni, D.; Presutti, L.
abstract

Objective: The aim of the study is to evaluate cholesteatoma's surgical outcomes in patients treated with endoscopic ear surgery (EES) or a combined endoscopic-microscopic approach (cEMA) according to STAM, STAMCO, ChOLE, and EAONO/JOS system (EJS) classifications and staging. Study Design: Retrospective study. Setting: Monocentric study in a tertiary referral center. Methods: One-hundred sixty-eight patients who underwent EES or cEMA for cholesteatoma between 2010 and 2018 were classified according to the abovementioned classification and staging. Data on cholesteatoma's recurrence and residual rates were collected. Inferential statistical analysis was performed to evaluate surgical outcomes and the prognostic value of classifications and staging. Results: The recurrence rate was significantly lower in cholesteatomas classified in EJS stage 1 (2.6%) and STAM stage 1 (0%). A comparison of the different stages of the disease showed a significantly lower recurrence only for stage 1 versus the superior stages of both classifications. Involvement of mastoid bone was associated with a higher risk of recurrence (odds ratio [OR]: 4.12; p =.031). Attical involvement was associated with a higher risk of residual cholesteatoma (OR: 1.165; p =.046). Conclusion: EES or cEMA represents an effective treatment for middle ear cholesteatoma. The STAM classification and the EJS have shown a prognostic value, with STAM 1 and EAONO-JOS 1 stages associated with a better prognosis. Mastoid involvement represents a risk factor for recurrence. Attic localization is associated with residual disease. Localization at difficult access sites did not implicate a higher risk for recurrence or residual. ChOLE classification, Ossicular chain status, and complication status did not provide prognostic information regarding recurrence or residual cholesteatoma.

2023 - Republication of: Endoscopic "retrograde" dacryocystorhinostomy: A fast route to the lacrimal sac [Articolo su rivista]
Alicandri-Ciufelli, M.; Russo, P.; Aggazzotti Cavazza, E.; Martone, A.
abstract

2023 - The role of adjuvant therapy in pT4N0 laryngectomized patients: Multicentric observational study [Articolo su rivista]
Mattioli, F.; Serafini, E.; Lo Manto, A.; Mularoni, F.; Abeshi, A.; Lionello, M.; Ferrari, M.; Paderno, A.; Lancini, D.; Mattavelli, D.; Confuorto, G.; Marchi, F.; Ioppi, A.; Sampieri, C.; Mercante, G.; De Virgilio, A.; Petruzzi, G.; Crosetti, E.; Pellini, R.; Giuseppe, S.; Giorgio, P.; Piazza, C.; Molteni, G.; Bertolin, A.; Succo, G.; Nicolai, P.; Alicandri-Ciufelli, M.; Marchioni, D.; Presutti, L.; Fermi, M.
abstract

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.

2023 - Tumors of the Nose and Paranasal Sinuses: Promoting Factors and Molecular Mechanisms—A Systematic Review [Articolo su rivista]
Lucidi, D.; Cantaffa, C.; Miglio, M.; Spina, F.; Alicandri Ciufelli, M.; Marchioni, A.; Marchioni, D.
abstract

Sinonasal neoplasms are uncommon diseases, characterized by heterogeneous biological behavior, which frequently results in challenges in differential diagnosis and treatment choice. The aim of this review was to examine the pathogenesis and molecular mechanisms underlying the regulation of tumor initiation and growth, in order to better define diagnostic and therapeutic strategies as well as the prognostic impact of these rare neoplasms. A systematic review according to Preferred Reporting Items for Systematic Review and Meta-Analysis criteria was conducted between September and November 2022. The authors considered the three main histological patterns of sinonasal tumors, namely Squamous Cell Carcinoma, Intestinal-Type Adenocarcinoma, and Olfactory Neuroblastoma. In total, 246 articles were eventually included in the analysis. The genetic and epigenetic changes underlying the oncogenic process were discussed, through a qualitative synthesis of the included studies. The identification of a comprehensive model of carcinogenesis for each sinonasal cancer subtype is needed, in order to pave the way toward tailored treatment approaches and improve survival for this rare and challenging group of cancers.

2023 - Vestibular schwannoma removal through expanded transcanal transpromontorial approach: a multicentric experience [Articolo su rivista]
Molinari, G.; Calvaruso, F.; Presutti, L.; Marchioni, D.; Alicandri-Ciufelli, M.; Friso, F.; Fernandez, I. J.; Francoli, P.; Di Maro, F.
abstract

Purpose: Expanded Transcanal Transpromontorial Approach (ExpTTA) is an endomicroscopic technique that allow surgical excision of small and symptomatic neuromas limited to the internal auditory canal (IAC) or minimally invasive the cerebellopontine angle (CPA). ExpTTA is a safer alternative to the exclusive endoscopic technique as it allows a wider surgical field and better management of the auditory porus and CPA. Methods: We report a retrospective case series of 34 patients who underwent ExpTTA between 2017 and 2022 at the ENT Departments of the University Hospital of Modena, Bologna and Verona. Tumor size was defined according to the Koos staging and hearing function was classified according to the AAOHNS. A clinical evaluation of facial nerve (FN) function was performed using the House and Brackman scale (HBs). Results: Our cohort consists of 34 patients. At time of surgery all patients had a normal preoperative facial function. Gross total resection was achieved in all patients, without intraoperative complications, and FN continuity was preserved in all cases. No major complications were observed. Regarding post-operative FN function, at hospital discharge ten patients had impairment equal or greater than IV grade according to H&Bs. At 6 months after surgery only two patients presented with moderate/severe facial paralysis (grade IV H&Bs) and finally at 12-month follow-up all patients had a satisfactory recovery of nervous function (grade < III H&Bs). Conclusions: ExpTTA is a safe and effectively technique for treatment of small VS (Koos I, II and selected cases of Koos III) with low postoperative morbidity.

2022 - Delayed recovery from severe acute respiratory syndrome coronavirus-2 related anosmia predicts incomplete olfactory restoration [Articolo su rivista]
Fernandez, I. J.; Molinari, G.; Federici, G.; Silvestri, M.; De Corso, E.; Presutti, L.; Alicandri Ciufelli, M.; Lucidi, D.
abstract

Objective This study aimed to assess the olfactory recovery rates and patterns in a cohort of coronavirus disease 2019 positive patients, and to investigate the clinical predictors of poor long-term olfactory restoration. Methods An observational retrospective study was conducted on 146 patients between September 2020 and January 2021 at a tertiary referral hospital. Coronavirus disease 2019 positive patients with olfactory dysfunction were sent a modified version of the COVID-19 Anosmia Reporting Tool for Clinicians via e-mail. Results The difference in median recovery time between complete recovery and incomplete or no recovery was statistically significant. On multivariate analysis, the only significant factor associated with incomplete or no recovery was anosmia duration. Conclusion After a mean time of 5.6 months from severe acute respiratory syndrome coronavirus-2 infection, persistent olfactory disorders were self-reported in 36.7 per cent of patients. Complete recovery was more likely to occur within 15 days. Given the high prevalence of coronavirus disease 2019, a large number of patients are expected to suffer from long-term olfactory morbidity.

2022 - Disease-specific quality of life and psychological distress after endoscopic tympanoplasty [Articolo su rivista]
Lucidi, D.; Reale, M.; Fermi, M.; Bassano, E.; Bonali, M.; Fernandez, I. J.; Presutti, L.; Alicandri-Ciufelli, M.
abstract

Purpose: To assess the postoperative quality of life (QoL) of patients operated on for chronic otitis media (COM) and cholesteatoma by endoscopic approach, with respect to disease-specific complaints and psychological distress, using two validated questionnaires: Chronic Ear Survey (CES) and Depression Anxiety Stress Scale-21 (DASS-21). Methods: Eighty-five consecutive patients operated on for cholesteatoma and COM by endoscopic tympanoplasty from March 2018 to February 2020 filled in CES and DASS-21, within one month prior to surgery. A second administration of each questionnaire was performed at the yearly postoperative evaluation. A multivariate analysis using a linear regression model was performed to evaluate the role of the different variables associated with the questionnaires’ subscales and overall scores. Results: A significant improvement was achieved in all CES and DASS-21 subscales after endoscopic tympanoplasty. No patient showed a DASS-21 score compatible with a psychological distress both at the pre- and postoperative assessments. At multivariate analysis, the only significant factors associated with postoperative improvement in CES scores were preoperative DASS-21 “depression” score and months of follow-up. Conclusion: Endoscopic tympanoplasty shows significantly improved QoL as assessed by disease-specific and psycho-emotional questionnaires. A subjective favourable effect of fully endoscopic ear surgery was demonstrated.

2022 - Head and Neck Cancer During Covid-19 Pandemic: Was there a Diagnostic Delay? [Articolo su rivista]
Lucidi, D.; Valerini, S.; Federici, G.; Miglio, M.; Cantaffa, C.; Alicandri Ciufelli, M.
abstract

The aim of the present study is to investigate a possible delay in diagnosis and therapy administration for Head and Neck oncological patients, during the Sars-Cov2 pandemic and to compare the median tumor stage (MTS) at presentation. This is a retrospective review on patients who presented at the University Hospital of Modena with a newly diagnosis of Head and Neck cancer (HNC), comparing the first pandemic period (from March 1st, to October 15th 2020) to the same period of 2019. The time in days from the diagnostic suspicion to the beginning of the treatment, hereafter referred to as delay in treatment initiation (DTI), and the tumor stage were calculated for all the enrolled patients. Mean percentage of reduction of the clinical and surgical activities was − 25.8% (range: − 66–1.5%), with higher percentages in phase 1 for all the analyzed activities. 125 HNC patients were enrolled in the analysis as the study group, compared with a cohort of 140 patients from the previous year. The MTS was III for both groups, however a significant statistical difference was determined in the stage comparison, p = 0.023. When DTI was analyzed no statistically significant differences were appreciated. A more advanced stage at presentation was demonstrated at our institution for HNC patients during the first phase of the Covid-19 pandemic in 2020. However, a statistically significant delay in time between diagnosis and therapy administration was not assessed, thus confirming the maintenance of a high level of care even in the COVID-19 era.

2022 - Hearing Results in Patients with No Ossicular Chain Reconstruction and Factors Influencing the Outcome [Articolo su rivista]
Alicandri-Ciufelli, M.; Cantaffa, C.; Presutti, M. T.; Villari, D.; Lucidi, D.; Marchioni, D.
abstract

Introduction Ossiculoplasty is aimed at improving or maintaining the conductive portion of hearing in patients subjected to otologic surgery. However, satisfying hearing is frequently observed after tympanoplasty even in the absence of ossicular chain reconstruction. Aims of this article would be to evaluate hearing outcomes, in terms of pure tone average air-bone gap (PTA-ABG), in patients subjected to tympanoplasty for middle ear disease whose ossicular chain has not been reconstructed, and then to investigate factors influencing those outcomes. Materials and Methods Retrospective chart review of patients who underwent ear surgery from year 2003 to 2021 at the Otolaryngology-Head and Neck surgery department of the University Hospital of Modena was performed. Audiometric test results from patients who did not receive any ossicular chain reconstruction were collected and analyzed. Setting Tertiary University referral center. Results The mean patients' follow-up was 34.1 months. Overall, mean PTA-ABG in the study population was 23.5 dB. Integrity of stapes superstructure, malleus handle and malleus head, together with the use of tragal cartilage graft over autologous temporalis fascia to reconstruct the tympanic membrane were found to be significantly associated with better hearing outcomes, as demonstrated by lower PTA-ABG values. Stapes superstructure was found to be associated with more favorable outcomes in multivariate analysis, net of confounding factors. Conclusion Good hearing performance can be obtained in patients subjected to middle ear surgery, even if the ossicular chain is not reconstructed. Presence of ossicular chain remnants and the use of a rigid material for tympanic membrane reconstruction are the factors that seem to most favorably influence hearing outcomes after surgery for middle ear disease.

2022 - Management of parapharyngeal space tumors with transparotid–transcervical approach: analysis of prognostic factors related with disease-control and functional outcomes [Articolo su rivista]
Fermi, M.; Serafini, E.; Ferri, G.; Alicandri - Ciufelli, M.; Presutti, L.; Mattioli, F.
abstract

Purpose: Different therapeutic strategies have been developed to improve surgical and functional outcome of parapharyngeal space (PPS) neoplasms. The transparotid–transcervical approach (TTa) is a valid surgical option to manage most PPS tumors. Its short- and long-term disease control and cranial nerve (c.n.) function outcomes have not been discussed extensively. Methods: All patients who underwent TTa over a 10-year period at a tertiary academic center were retrospectively reviewed. Data about preoperative imaging, clinical presentation, tumor’s size, location and histology, and postoperative oncological and functional results were registered and analyzed. Results: Sixty patients matched the inclusion criteria. Most of the lesions were benign (71.7%), involved the prestyloid PPS (63.3%) and measured more than 30 mm (75%). Fifty-two (86.7%) lesions were resected en-bloc. Clear margins were achieved in 91.7% of the cases, with positive margins solely associated with malignancy (p = 0.008). Post-operative c.n. function was satisfactory, with X c.n. function significantly associated with the retrostyloid location (p =.00) and neurogenic tumors (p = 0.02). Local disease-control was achieved in 96% of the cases after a median follow-up of 46 (± 19.7–82.0 IQR) months. Conclusions: The TTa was safe and effective, achieving a satisfactory local control rate. Nevertheless, malignancies maintain a higher rate of positive margin due to their infiltrative nature and the complex anatomy of the PPS. In such cases, multiportal approaches might be more effective. However, post-operative c.n. function remained satisfactory, irrespective of lesions’ size and histopathologic behavior. A higher X c.n. deficit rate was observed in retrostyloid and neurogenic lesions.

2022 - Occlusal splint therapy in patients with Ménière’s disease and temporomandibular joint disorder [Articolo su rivista]
Monzani, D.; Baraldi, C.; Apa, E.; Alicandri Ciufelli, M.; Bertoldi, C.; Roggla, E.; Guerzoni, S.; Marchioni, D.; Pani, L.
abstract

SUMMARY Objective. This retrospective study aimed to verify the outcomes of stabilising occlusal splint therapy prescribed to 22 patients with unilateral definite Ménière’s disease and comorbid temporomandibular joint disorder. Methods. The results of a battery of audiometric and vestibular tests were recorded before and after 6 months of treatment, as well as the scores of disease-specific questionnaires. Results. The average hearing threshold in the affected ear and the acoustic immittance were unchanged. No spontaneous and positional nystagmus were recorded. Caloric hyporesponsiveness and vestibular myogenic evoked responses did not vary. No changes of stabilometric body sway parameters in eyes opened condition and with optokinetic stimulation delivered to the unaffected labyrinth were observed. A significant reduction was recorded in eyes closed condition and with the optokinetic stimulation toward the affected ear. The Tinnitus Handicap Inventory, the Situational Vertigo Questionnaire and the Numeric Pain Rating Scale scores improved. The number of vertigo attacks was reduced. Conclusions. Occlusal splint therapy is a favourable option to reduce aural symptoms of Ménière’s disease and comorbid temporomandibular joint disorder, even if its pathophysiological mechanism remains elusive.

2022 - Quality of Life after Surgical Treatment for Chronic Otitis Media: A Systematic Review of the Literature [Articolo su rivista]
Lucidi, D.; Cantaffa, C.; Nocini, R.; Martone, A.; Alicandri-Ciufelli, M.; Marchioni, D.; Presutti, L.; Molinari, G.
abstract

This systematic review aims to (a) define what instruments are available to measure quality of life (QoL) in patients undergoing tympanoplasty for chronic otitis media (COM) and what is the most commonly selected timing to do so; (b) compare outcomes from different surgical techniques; and (c) describe any reported correlation between subjective and functional results. This review was conducted following the PRISMA statement recommendations. Of the 151 articles screened, 24 were included. Most studies had a prospective design. The mean age at surgery was 44.5 years. A microscopic retroauricular approach was the most common surgical technique. Most articles included both primary and revision surgeries. The most commonly used questionnaire was the Glasgow Benefit Inventory (GBI), followed by the Chronic Ear Survey (CES), the Chronic Otitis Media Outcome Test 15 (COMOT-15) and the Zurich Chronic Middle Ear Inventory (ZCMEI-21). Questionnaires were administered about 12 months after surgery in most studies. Ten studies reported possible associations between hearing results and QoL. QoL assessment after COM surgery variably relies on disease-specific and non-specific questionnaires. Patients are usually evaluated 12 months after surgery, and this appears to be a suitable timing to contrast the possible bias effect of different tympanoplasty techniques associated with different healing times. A comparison between QoL outcomes in different surgical approaches cannot be made, as several influencing factors have not been detailed in the included studies. Few studies have investigated the correlation between subjective and objective outcomes of tympanoplasty for COM so far.

2022 - Quality of life in vestibular schwannoma: a comparison of three surgical techniques [Articolo su rivista]
Lucidi, Daniela; Cristoforo, Fabbris; Raffaele, Cerullo; Stefano Di Gioia, ; Calvaruso, Federico; Monzani, Daniele; ALICANDRI CIUFELLI, Matteo; Marchioni, Daniele; Presutti, Livio
abstract

Objective Through years, interest in quality of life (QoL) among patients affected by vestibular schwannoma (VS) has increased. The expansion of the indications for endoscopic ear surgery allowed the development of the transcanal transpromontorial surgery (TTS) for VS removal. The objective of the present study was to assess QoL in a cohort of VS patients operated on by translabyrinthine (TL), retrosigmoid (RS) and TTS approach. Methods The study was conducted on 111 patients who underwent surgery for VS between January 2017 and January 2020 at two different institutions. Patients fulfilled three questionnaires during follow-up: Glasgow Benefit Inventory, Depression Anxiety Stress Scales-21 and Penn Acoustic Neuroma Quality-Of-Life. The association between sex, age, date of surgery, tumor size, post-operative facial nerve (FN) function and QoL outcomes was assessed. Results An overall subjective impairment was demonstrated in all groups. Age, Koos staging and FN functions were associated to distinct QoL outcomes. Conclusions QoL decreases in patients surgically treated for VS. The TTS may allow improved scores in many domains, confirming to be a subjectively well-tolerated technique.

2022 - Surgical Training on Ex Vivo Ovine Model in Otolaryngology Head and Neck Surgery: A Comprehensive Review [Articolo su rivista]
Fermi, M.; Chiari, F.; Mattioli, F.; Bonali, M.; Molinari, G.; Alicandri-Ciufelli, M.; Anschuetz, L.; Fernandez, I. J.; Presutti, L.
abstract

Background: Nowadays, head and neck surgical approaches need an increased level of anatomical knowledge and practical skills; therefore, the related learning curve is both flat and long. On such procedures, surgeons must decrease operating time as much as possible to reduce the time of general anesthesia and related stress factors for patients. Consequently, little time can be dedicated for training skills of students and young residents in the operating theater. Fresh human cadavers offer the most obvious surrogate for living patients, but they have several limitations, such as cost, availability, and local regulations. Recently, the feasibility of using ex vivo animal models, in particular ovine ones, have been considered as high-fidelity alternatives to cadaveric specimens. Methods: This comprehensive review explores all of head and neck otolaryngology applications with this sample. We analyzed studies about ear surgery, orbital procedures, parotid gland and facial nerve reanimation, open laryngeal and tracheal surgery, microlaryngoscopy procedures, laryngotracheal stenosis treatment, and diagnostic/operative pediatric endoscopy. For each different procedure, we underline the main applications, similarities, and limitations to human procedures so as to improve the knowledge of this model as a useful tool for surgical training. Results: An ovine model is easily available and relatively inexpensive, it has no limitations associated with religious or animal ethical issues, and it is reliable for head and neck surgery due to similar consistencies tissues and neurovascular structures with respect to humans. However, some other issues should be considered, such as differences about some anatomical features, the risk of zoonotic diseases, and the absence of bleeding during training. Conclusion: This comprehensive review highlights the potentials of an ex vivo ovine model and aims to stimulate the scientific and academic community to further develop it for other applications in surgical education.

2022 - Taste impairment after endoscopic stapes surgery: Do anatomic variability of chorda tympani and surgical technique matter?: Post-operative dysgeusia after EStS [Articolo su rivista]
Molinari, G.; Reale, M.; Bonali, M.; Anschuetz, L.; Lucidi, D.; Presutti, L.; Alicandri Ciufelli, M.
abstract

Purpose: To investigate how the anatomical configuration of the oval window region (OWR) influences the management of the chorda tympani (ChT) and the curetting of adjacent bony structures, in a setting of patients undergoing endoscopic stapes surgery (EStS); to assess the incidence of early and late post-operative dysgeusia and to identify anatomical and surgical factors influencing taste function after EStS. Methods: Surgical video recordings of 48 patients undergoing EStS for otosclerosis between January 2019 and July 2020 were retrospectively revised, to classify the anatomical variability of selected middle ear structures and the management strategies for the ChT. Clinical records of included patients were reviewed for subjective early and late post-operative taste impairment using a 5-point Likert-scale. Results: The most common configuration of the OWR was type III. The extension of the bony curettage resulted inversely proportional to the exposure of the OWR. The long-term rate of preserved post-operative taste function was 85%. Displacement of the ChT was necessary in 43/48 cases (90%), mostly medially (36/48, 75%). Conclusion: Bone curetting during EStS does not correlate with post-operative taste impairment. Despite 100% ChT preservation rate, dysgeusia may occur in a minority of patients, with no apparent relationship to anatomical variability or intraoperative management of the ChT. The use of CO2 laser could have a role in increasing the risk of post-operative dysgeusia after EStS.

2022 - Technique for foreign-body removal with the use of transnasal endoscopic prelacrimal approach - A case report [Articolo su rivista]
Alicandri-Ciufelli, M.; Calvaruso, F.; Presutti, L.; Molinari, G.
abstract

The Rationale: Foreign body (FB) in the nasal cavities is a frequent cause of otolaryngology emergency consultation that sometimes requires surgical treatment. When there is involvement of the posterolateral wall of the maxillary sinus (MS) and of the pterygopalatine fossa (PPF), conventional techniques such as antrostomy and medial endoscopic maxillectomy may not allow sufficient domination of the surgical field. Patient Concerns: We report the case of a woman who suffered from intranasal trauma with epistaxis and pain. Diagnosis: A computed tomography scan revealed a metallic FB at the level of the right posterolateral wall of the MS, PPF, and greater wing of the sphenoid bone. Treatment and Outcome: A minimally invasive transnasal endoscopic prelacrimal approach was chosen for its removal. Take-away Lessons: The postoperative recovery was rapid and without complication.

2022 - Validation of the Modena bleeding score in endoscopic sinus surgery [Articolo su rivista]
Alicandri-Ciufelli, M.; Pingani, L.; Maccarrone, F.; Anschuetz, L.; Mariano, D.; Galeazzi, G. M.; Presutti, L.; Molinari, G.
abstract

Introduction: The Modena bleeding score is a categorical rating scale that allows the assessment of the surgical field in relation to bleeding during endoscopic surgery. It has recently been presented and validated in the field of endoscopic ear surgery by the present authors. The Modena bleeding score provides five grades for rating the surgical field during endoscopic procedures (from grade 1 − no bleeding to grade 5 − bleeding that prevents every surgical procedure except those dedicated to bleeding control). Objective: The aim of this study was to validate the Modena bleeding score in the setting of endoscopic sinus surgery. Methods: Fifteen three-minute videos of endoscopic sinus surgery procedures (each containing three bleeding situations) were evaluated by 15 specialists, using the Modena bleeding score. Intra and inter-rater reliability were assessed, and the clinical validity of the Modena bleeding score was calculated using a referent standard. Results: The data analysis showed an intra-rater reliability ranging from 0.6336 to 0.861. The inter-rater reliability ranged from 0.676 to 0.844. The clinical validity was α = 0.70; confidence limits: 0.64 − 0.75, corresponding to substantial agreement. Conclusion: The Modena bleeding score is an effective method to score bleeding during endoscopic sinus surgery. Its application in future research could facilitate the performance and efficacy assessment of surgical techniques, materials or devices aimed to bleeding control during endoscopic sinus surgery.

2021 - An Integrated (Microscopic/Endoscopic) Dissection Ear Surgery Course [Articolo su rivista]
Alicandri Ciufelli, M.; Fermi, M.; Molinari, G.; Fernandez, I. J.; Bonali, M.; Villari, D.; Presutti, L.
abstract

Traditionally, otologic surgical training consisted of microscopic cadaveric dissections. However, during the last decades the endoscope has significantly changed the surgical perspective in the otologic field. Thus, the modern ear and lateral skull base surgeon should master the entire spectrum of endoscopic and microscopic approaches, with the aim of tailoring the procedure and guaranteeing the best possible functional outcome. This work proposes a step-by-step guided and illustrated dissection course, including indications for the setup of the cadaver lab and the integration of the microscope and endoscope to enhance the use of both instruments. The alternation of the endoscope and microscope allows the novice to train the correct handling of the instruments in the surgical field under both optical views. This aspect is of utmost importance since it is not advisable to start off a technique without practicing the other one, as both are important and complementary in the modern otologic surgery setting.

2021 - Endoscopic Anatomy of the Chorda Tympani: Systematic Dissection, Novel Anatomic Classification, and Surgical Implications [Articolo su rivista]
Molinari, Giulia; Yacoub, Abraam; ALICANDRI CIUFELLI, Matteo; Monzani, Daniele; Presutti, Livio; Caversaccio, Marco; Anschuetz, Lukas
abstract

Hypothesis: A transcanal endoscopic approach enables visualization of the variable course of the chorda tympani inside the middle ear. Background: The chorda tympani is the longest intrapetrous branch of the facial nerve. Despite having been investigated in several studies, a description of its tympanic tract from an endoscopic point of view is lacking in the literature. Methods: We performed transcanal endoscopic dissections of 44 human cadaveric head and ear specimens. The entry point of the chorda tympani into the middle ear was classified into four categories according to its location, and as covered or dehiscent according to its appearance. The chordal eminence (CE) was defined as absent, shallow, intermediate, prominent, or fused, based on its shape and extension. The relationship of the chorda tympani to adjacent bony and ligamental structures was assessed. Results: The tympanic tract of the chorda tympani was divided into three portions. The periannular segment was dehiscent in 54.5% of specimens, with type II being the most frequent entry point configuration (52.3%). In the interossicular segment, the nerve consistently passed lateral to the incus and medial to the malleus. The course of the intrapetrous segment was independent from the conformation of the tensor fold and supratubal recess. Conclusion: The transcanal endoscopic approach allows a detailed description of tympanic segment of the chorda tympani. Novel anatomic classifications of the chorda tympani and CE are proposed herein to highlight their possible surgical implications during otologic procedures.

2021 - Endoscopic tympanoplasty type I for tympanic perforations: analysis of prognostic factors [Articolo su rivista]
Fermi, M.; Maccarrone, F.; Villari, D.; Palermo, F.; Alicandri Ciufelli, M.; Ghirelli, M.; Presutti, L.; Bonali, M.
abstract

Purpose: To assess the anatomical and functional outcomes of endoscopic transcanal tympanoplasty type I for tympanic membrane perforations. Methods: Eight hundred thirty-five patients who underwent tympanoplasty between January 2011 and January 2019 were selected. Patients with tympanic membrane perforation treated with a transcanal endoscopic tympanoplasty type 1 and a follow-up period longer than 6 months have been retrospectively reviewed. The presence of cholesteatoma or ossicular chain dysfunctions were considered exclusion criteria. Eighty-one patients were included in the present study population. The main outcome was the rate of overall graft success. Secondary outcomes included hearing results. Prognostic factors related to both the abovementioned outcomes were assessed. Results: Overall, 66 patients (81.5%) had a successful graft at the last follow-up evaluation. Mean follow-up was 22.1 (range 6–104) months. The anterior quadrants were entailed by the perforation in 62 (76.5%) cases. The overall success rate with cartilage (or cartilage and perichondrium) was 91.2% (p < 0.01). The median preoperative and postoperative ABG were 18.7 (13.4–25.6) and 7.5 (2.5–12.5), respectively, revealing a significant median improvement of 11.2 (p < 0.001). The type of graft and the postoperative tympanic membrane status were significantly associated with the audiologic outcome with p = 0.01 and p = 0.02, respectively. Conclusions: Endoscopic tympanoplasty type I is a reliable technique with reasonable anatomic and audiologic results. Tympanic membrane grafting with cartilage (or cartilage and perichondrium) guarantees a higher rate of perforation closure and satisfactory hearing results. Anterior eardrum perforations can be successfully and safely managed with transcanal endoscopic approach avoiding postauricular approach and canalplasty.

2021 - Functional Results and Learning Curve of Endoscopic Stapes Surgery: A 10-Year Experience [Articolo su rivista]
Lucidi, D.; Molinari, G.; Reale, M.; Alicandri Ciufelli, M.; Presutti, L.
abstract

Objectives/Hypothesis: To assess hearing outcomes and complications of endoscopic stapes surgery by a single surgeon in a 10-year period, to compare these data with conventional microscopic procedures by the same operator, and to describe the learning curve of endoscopic stapedotomy. Study Design: Retrospective study. Methods: This is a retrospective study on patients who underwent endoscopic stapes surgery performed by the same senior surgeon, experienced both in microscopic and endoscopic techniques, between January 2009 and December 2018. Audiological data were compared, and intraoperative and postoperative complications were collected. The surgeon's last 30 cases of microscopic stapedotomy were enrolled as the control group. The results of the first 100 endoscopic stapes surgeries were analyzed separately to create a cumulative sum (CUSUM) control chart for learning curve assessment. Results: One hundred seventy-eight endoscopic and 30 microscopic stapes surgeries were included. In the endoscopic group, the mean postoperative air–bone gap was 8.2 dB. No significant differences between the endoscopic and microscopic preoperative and postoperative values were reported. A total of eight complications (4.5%) were observed in the endoscopic cohort, although in the control group, no complication occurred. The mean surgical time was 51.9 minutes in the endoscopic group versus 48.2 minutes in the microscopic group (P >.05). No association between stapedotomy success and the increasing number of procedures was found. Conclusions: Our article demonstrates that functional results from endoscopic stapes surgery are similar to those from microscopic stapes surgery in terms of both safety and efficacy. After gaining endoscopic experience, the surgical duration of stapes surgery will be adequate starting from the first cases. Level of Evidence: 4 Laryngoscope, 2020.

2021 - Letter to the editor: “Meniere's disease and migraine: more than a simple association” [Articolo su rivista]
Alicandri Ciufelli, M.; Molinari, G.
abstract

2021 - Open laryngeal surgery training on ex-vivo ovine model: Development and dissection experience [Articolo su rivista]
Fermi, M.; Mattioli, F.; Ghirelli, M.; Maccarrone, F.; Molteni, G.; Presutti, L.; Alicandri-Ciufelli, M.
abstract

Objectives: To develop and validate an ex-vivo dissection model suitable for open laryngeal surgery (open partial laryngectomy and total laryngectomy) training. Methods: A fresh ex-vivo 6-months old ovine model was tested by experienced laryngologists and validated during two international dissection courses on open laryngeal surgery held in December 2018 and 2019. Each participant completed a survey to subjectively evaluate the dissection experience. Likewise, four experienced laryngologists rated their experience. Statistical comparison of these ratings was performed. Results: The suitability of the ex-vivo ovine model for open laryngeal surgery was assessed among 28 head and neck surgeons with a mean experience of 6.3 years and 4 expert laryngologists. The feedback from all the participants was excellent with a mean overall impression of 9.5 (± 0.7 SD) and a mean recommendation score of 9.6 (± 0.6 SD) for further use. No statistically significant differences were found comparing neither the overall grade (p= 0.63) nor the recommendation rating (p= 0.24), testifying that even for expert laryngologists this remains a viable model for open laryngeal surgery training. Conclusions: The complexity of open laryngeal surgery makes simulation an attractive option for developing skills that are transferrable to operating setting. Due to the anatomic resemblance with the human, the ex-vivo ovine model is herein proposed as a training model for open laryngeal surgery. Validation among beginners and expert laryngologists revealed its suitability as effective teaching means in laryngectomies.

2021 - Prelaminated flaps in head and neck cancer reconstructive surgery: A systematic review [Articolo su rivista]
Fermi, Matteo; Bassano, Edoardo; Molinari, Giulia; Alicandri-Ciufelli, Matteo; Scarpa, Alfonso; Presutti, Livio; De Santis, Giorgio; Mattioli, Francesco
abstract

Prelamination is a reconstructive technique providing fasciomucosal or composite flaps with low donor-site morbidity. We conducted a systematic review of retrospective studies to assess the application of prelaminated flaps in reconstructive surgery of head and neck cancer patients, and to evaluate the advantages and disadvantages of this technique.

2021 - Relationship Between the Cochlear Aqueduct and Internal Auditory Canal: Surgical Implications for Transcanal Transpromontorial Approaches to the Lateral Skull Base [Articolo su rivista]
Molinari, G.; Yacoub, A.; Bonali, M.; Wimmer, W.; Alicandri Ciufelli, M.; Caversaccio, M.; Presutti, L.; Anschuetz, L.
abstract

HYPOTHESIS: The cochlear aqueduct (CA) is subject to considerable anatomical variability. We hypothesize a topographical relationship between the CA and the internal auditory canal (IAC). BACKGROUND: The CA represents the lower limit of dissection during transcanal transpromontorial approaches to the lateral skull base due to its close relationship to the lower cranial nerves and jugular vein. METHODS: Three-dimensional models from high-resolution computed tomography scans of normal human temporal bones were created using threshold-based segmentation. The CA was classified into four categories. Five points were determined on the three-dimensional models to measure the surgically relevant relationships. RESULTS: Segmentation was performed on 26 high-resolution computed tomography scans. The average length of the virtual and visual part of the CA was 6.6 mm (SD ±1.7 mm) and 5.5 mm (SD ±1.3 mm) respectively. The mean distance between the IAC and the medial end of the visual part of the CA was 3.8 mm (±0.7 mm), while the average distance between the IAC and the lateral end was 1.4 mm (±0.6 mm). The distance between the visual part of the CA and the IAC increased by 0.25 mm per from the fundus of the IAC. CONCLUSION: A close relationship between the CA and the IAC could be established, despite the anatomical variability of the CA. The distance between CA and IAC increases by 0.25 per mm from the fundus to the porus of the IAC. These findings quantify the inferior limit of dissection of the transcanal transpromontorial approach to the lateral skull base.

2021 - Surgical multidisciplinary approach of orbital complications of sinonasal inflammatory disorders [Articolo su rivista]
Presutti, L.; Lucidi, D.; Spagnolo, F.; Molinari, G.; Piccinini, S.; Alicandri Ciufelli, M.
abstract

Orbital infection complicating sinonasal inflammatory disorders may lead to serious sequelae, including blindness and death, if untreated. Communication between the otorhinolaryngologist, neuroradiologist, ophtalmologist, neurosurgeon and maxillo-facial surgeon is critical and time-sensitive for a successful treatment. The large majority of pre-septal cellulitis cases resolves after broad-spectrum antibiotic therapy. Also orbital cellulitis has been found responsive to pharmacological approach in most cases. The management of the subperiosteal abscess (SPA) is more controversial. An aggressive surgical approach is always recommended also in case of cavernous sinus thrombosis. In cases of surgical indication, debate is still open on the timing and the approach (endoscopic or external). The surgeon should be prepared to convert an endoscopic approach to an external one if needed and this should be included in the informed consent. Decompression of one or more orbital walls may be necessary if orbital pressure remains elevated. Immediate surgery is indicated in children with large SPA or orbital abscesses (OA), or in immune-compromised patients. Moreover, any worsening in the ophthalmological function must be carefully considered as a landmark in candidacy to surgery.

2021 - The Tensor Tympani Tendon: A Hypothetical Site of Origin of Congenital Cholesteatoma [Articolo su rivista]
Maccarrone, F.; Molinari, G.; Alberici, M. P.; Cesinaro, A. M.; Villari, D.; Alicandri Ciufelli, M.; Tassi, S.; Negri, M.
abstract

Multiple theories have been discussed about the etiopathogenesis of congenital middle ear cholesteatoma (CMEC) and its specific site of origin. The intraoperative identification of the precise location of the keratinous mass is important to guarantee its complete removal, in order to reduce the risk of recurrence. This study proposes the tensor tympani tendon (TTT) as a possible site of origin of CMEC. All CMECs treated between 2013 and 2019 were reviewed. Only Potsic stage I lesions were included. Preoperative radiologic images were compared to intraoperative findings. Three removed TTT were sent for histologic evaluation. Seven patients were included (M:F = 3:4). Preoperative CT images were classified as type A in 2 cases (28.6%) and type B in 5 cases (71.4%). At intraoperative evaluation all CMEC sacs were found pedunculated on the TTT. The histologic examinations confirmed the connection between the cholesteatomatous sac and the TTT. According to the correlation of imaging, intraoperative findings and histology, we proposed that the TTT could be the primary site from which CMEC originates.

2021 - The effect of tracheostomy on swallowing function in open partial horizontal laryngectomies: Preliminary experience [Articolo su rivista]
Lucidi, D.; Botti, C.; Fermi, M.; Luppi, M. P.; Alicandri-Ciufelli, M.; Presutti, L.; Mattioli, F.
abstract

Objective. Tracheostomy is required to ensure a safe airway in open partial horizontal laryngectomies. The presence of the tracheostomy tube can contribute to post-operative dysphagia. This study aimed to evaluate the effects of a circumferential tracheostomy technique on swallowing. Methods. Aretrospective study was conducted of patients who underwent open partial horizontal laryngectomies between April 2018 and June 2019. Patients were divided into two groups based on the tracheostomy technique: group 1hadtwo stitches from the inferior tracheal ring to the skin; group 2hadcircumferential fixation of the trachea to the skin. Demographic information, surgical data, post-operative rehabilitation course and complication details were collected and analysed. Results. Twenty-four patients were enrolled. Patients in group 2 had significant improvement in the initial phases of swallowing rehabilitation. Conclusion. Tracheostomy with anchorage of the trachea to the skin by circumferential stitches could allow early removal of the tracheal tube, with a betters wallowing outcome.

2021 - Transcanal Endoscopic Management of Glomus Tympanicum: Multicentric Case Series [Articolo su rivista]
Fermi, M.; Ferri, G.; Bayoumi Ebaied, T.; Alicandri-Ciufelli, M.; Bonali, M.; Badr El-Dine, M.; Presutti, L.
abstract

OBJECTIVE: The aim of this study was to report a multicentric surgical experience in the exclusive endoscopic management of glomus tympanicum (GT). STUDY DESIGN: Retrospective case series review at two institutions. SETTING: Tertiary referral centers. PATIENTS: The study included 30 patients who underwent exclusive transcanal excision of GT between 2010 and 2017 at the two referral centers. INTERVENTIONS: Exclusive endoscopic transcanal excision of GT type A1, A2, and B1 (modified Fisch-Mattox classification). All surgical procedures were performed by two senior surgeons (L.P.; M.B.). MAIN OUTCOME MEASURES: For each procedure, intraoperative features of the disease, postoperative complications, and functional outcomes were evaluated. Recurrent or residual diseases were clinically and radiologically assessed during the follow-up period. RESULTS: None of the patients treated with transcanal endoscopic approach (TEA) experienced intraoperative complications, nor required conversion to microscopic approach. Gross total resection (GTR) was obtained in 90% of the cases, while a near total resection was advocated when the residual pathology had a close relationship with the internal carotid artery. Mean hospitalization time was 1.6 (±0.8 SD) days and no postoperative complications were reported. No recurrences were reported in the GTR group after a mean follow-up period of 38.1 (±28.7 SD) months. CONCLUSIONS: Middle ear paragangliomas with no mastoid involvement (Class A1, A2, and B1) can be safely managed by means of a transcanal endoscopic approach. Low rate of postoperative complications, short hospitalization, and high rate of gross total resection demonstrate that TEA is a safe and effective procedure.

2021 - Use of Foley catheter in control of internal carotid hemorrhage during endoscopic endonasal surgery [Articolo su rivista]
Alicandri-Ciufelli, M.; Maccarrone, F.; Botti, C.; Pavesi, G.; Presutti, L.
abstract

Internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) are rare life-threatening events. We describe a technique to manage ICA injuries based on the use of Foley catheters.A 26-year-old female underwent endoscopic transnasal trans-sphenoidal removal of pituitary adenoma. Cerebrospinal fluid leak occurred 4 days postoperatively. During repair procedure, accidental injury of ICA occurred. Emergency nasal packing through positioning of four Foley urologic catheters was successfully performed to stop bleeding. The patient did not report neurologic deficits.In author's opinion, Foley catheters are suitable to obtain immediate bleeding control since they are rapidly available and easily usable.

2021 - Use of IMAGE1 S technology for detection of cholesteatoma in endoscopic ear surgery: a retrospective case series on 45 patients [Articolo su rivista]
Lucidi, D.; Fernandez, I. J.; Martone, A.; Molinari, G.; Bonali, M.; Villari, D.; Alicandri Ciufelli, M.; Presutti, L.
abstract

Purpose: To evaluate the role of selected modalities of Storz Professional Image Enhancement System (IMAGE1 S) in differentiating cholesteatoma during endoscopic ear surgery (EES); to assess the potential usefulness of IMAGE1 S in recognition of cholesteatoma residuals at the end of EES. Methods: A retrospective study on 45 consecutive patients who underwent EES for cholesteatoma between March 2019 and November 2019 at a tertiary referral center was performed. For each case, Spectra A and Spectra B filters were applied intra-operatively. When examining the surgical field, a switch from white light (WL) to IMAGE1 S was performed to detect cholesteatoma and differentiate it from non-cholesteatomatous tissue. When the IMAGE1 S pattern was suspicious for the presence of cholesteatoma, images of the field under both enhancement modalities were taken and the targeted lesions were sent for histologic analysis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of IMAGE1 S were calculated. A final recognition of the surgical field using the selected filters was performed to detect any possible cholesteatomatous residuals. Results: Detection of cholesteatoma by IMAGE1 S selected filters revealed the following data: sensitivity 97%, specificity 95%, PPV 95%, NPV 97%. On three occasions, there was no correspondence between enhanced endoscopy and histology. In 5 out of 45 cases (11%), cholesteatoma residuals, which had not been identified at WL inspection at the end of the procedure, were detected by IMAGE1 S. Conclusion: Our results suggest a potential role for IMAGE1 S Spectra A and B filters in EES for cholesteatoma surgery. We propose the integration of IMAGE1 S as a final overview of the surgical cavity for recognition of cholesteatomatous residuals.

2020 - A case-control study of visually evoked postural responses in childhood with primary headaches [Articolo su rivista]
Baraldi, C; Gherpelli, C; Alicandri Ciufelli, M.; Monzani, D.; Pini, L. A.; Pani, L.; Guerzoni, S.
abstract

Background: Disorientation, nausea, confusion, dizziness, and displacement are frequently complained by headache-suffering children. Anyhow, the cause of these symptoms is still unclear, and a dysfunction of vestibular pathways or their alteration due to central pain pathways hyper-activation, has been proposed. The aim of this study is to use posturography to explore the balance function of headache-suffering children during pain-free periods. Methods: Posturography was performed on 19 migraineurs, 11 tension-type headache sufferers, and 20 healthy controls. Posturographic measures were performed during headache-free periods under different conditions: with eyes opened, eyes closed, and during right and left optokinetic stimulation. The last 2 conditions were used to mimic unreliable visual signals that can confound vestibular system. Results: During eyes-closed conditions, headache-suffering children displayed higher displacements than healthy controls, since statokinesiogram surface was higher in tension-type headache sufferers and migraineurs compared with controls (P value = 0.0095). Romberg’s index, indicating the overall stability of the subject, was lower in healthy controls than in headache sufferers (P = 0.0139), thus suggesting a vestibular impairment in the seconds. Moreover, both during right and left optokinetic stimulation, the statokinesiogram length was higher in headache-suffering children (P < 0.0001). Thereafter, statokinesiogram surface was higher in migraineurs during right optokinetic stimulation (P = 0.0388) than in tension-type headache sufferers when stimulation was directed on the opposite side (P = 0.0249). Conclusions: These results suggest a central alteration of vestibular pathways in headache-suffering children, that makes balance function more dependent from visual inputs than healthy subjects, even in inter-ictal phases.

2020 - Anatomic and radiologic relationships of neck structures to cervical spine: Implications for anterior surgical approaches [Articolo su rivista]
Alicandri-Ciufelli, M.; Fermi, M.; Molinari, G.; Cavazza, E. A.; Billi, A. M.; Giliberto, G.; Cavalleri, F.; Pavesi, G.; Presutti, L.
abstract

The position of the pharyngolaryngeal framework is very important in choosing the best surgical approach for cervical spine disease. The aim of the present paper is to investigate the position of the hyoid bone and cricoid cartilage in relation to the cervical spine. Moreover, the surgical implications for anterior transcervical approaches to the upper spine and the prevertebral space are discussed. To minimise complication rates and increase surgical effectiveness, the location and extent of the cervical spine disease should be evaluated in the context of the patient’s specific anatomy. A retrospective analysis of 100 cervical spine MRIs was conducted. Patients with diseases that could alter anatomic relationships of cervical structures were excluded. The mid-sagittal view of the hyoid and the inferior margin of the cricoid cartilage were projected perpendicularly to the anterior surface of the cervical vertebrae. The distance between these two landmarks was measured on the same view. The distribution of hyoid projections ranged between C2-C3 and C4-C5 intervertebral space, while the cricoid cartilage ranged between C4-C5 and C7-T1 intervertebral spaces. The mean distance between these two landmarks was 49.1 ± 7.7 mm, with statistically significant differences between males and females. The position of the cricoid cartilage significantly influenced the length of the pharyngolaryngeal framework, while the position of hyoid did not. A wide range of variability in the position of the hyoid bone and the cricoid cartilage in relation to cervical levels exists. This implies that an a priori association of a cervical level to neck structures at risk might be inaccurate. The use of these easily identifiable landmarks on pre-operative imaging may help to guide the choice among different anterior surgical approaches to cervical spine and reduce the risk of surgical complications.

2020 - Correlation of Radiologic Versus Endoscopic Visualization of the Middle Ear: Implications for Endoscopic Ear Surgery [Articolo su rivista]
Bonali, M.; Fermi, M.; Alicandri-Ciufelli, M.; Mattioli, F.; Villari, D.; Presutti, L.; Anschuetz, L.
abstract

OBJECTIVES: To determine the limits of visualization during transcanal endoscopic ear surgery (EES) by correlating the relationship between radiologic and endoscopic anatomy using angled optics. METHODS: Radiology and endoscopic visualization of tensor fold, protympanum, facial sinus (FS), sinus tympani (ST), subtympanic sinus (STS), hypotympanum, and aditus ad antrum were analyzed using a transcanal approach in 30 human temporal bones specimens with different angled endoscopes (0 degree, 45 degrees, 70 degrees) to check for the full visualization of these regions. High-resolution computed tomography (CT) was performed prior to dissection to classify retrotympanic anatomy. According to previously published descriptions, FS, ST, and STS were classified into types A, B, and C depending on their morphology relative to the mastoid segment of the facial nerve. These radiologic findings were compared to endoscopic visualization of these same structures using a Chi-squared test. RESULTS: Visualization of the posterior wall of three different retrotympanic areas was significantly associated (FS p < 0.01; ST p < 0.01; STS p = 0.02) with the radiologic classification and endoscopic optical angle. Angled endoscopy improved visual access to the other subsites, especially the aditus ad antrum and the tensor fold (>70% with 45 degrees and 70 degrees). CONCLUSION: Complete visual access to the hidden recesses of the middle ear can be achieved using angled endoscopes (45 degrees and 70 degrees). We observed a statistically significant association of endoscopic visualization to radiologic description of the retrotympanum on CT and the optical angle used. The prediction of the endoscopic exposure of the retrotympanum from the preoperative CT is possible. Even with the use of 70 degrees lens, retrotympanum is not fully visualized on transcanal endoscopy if a type C retrotympanic recesses (posterior and medial to the facial nerve) is present. This represents a technical limit of exclusive transcanal EES.

2020 - Cutaneous Metastasis from Cervical Spinal Chordoma: Case Report and Literature Review [Articolo su rivista]
Berlucchi, Silvia; Nasi, Davide; Zunarelli, Elena; Valluzzi, Adelaide; ALICANDRI CIUFELLI, Matteo; Presutti, Livio; Pavesi, Giacomo
abstract

Chordomas are rare primary tumors of the bone that arise from embryonic notochord. They are locally aggressive tumors with high tendency for post-surgical recurrence. On the contrary, distant metastases are rare. When occurring, they involve lungs, liver, lymph nodes, and bones. Skin and subcutaneous tissue involvement is even rarer and usually occurs by direct extension of the primary tumor or by local recurrence. Then, distant cutaneous metastasis from chordoma is an exceptional finding, with less than 20 cases reported in the literature. All the cutaneous metastases described derive from sacral chordomas, except for two cases in which the source of metastasis are skull-base chordomas.

2020 - Does microscopic experience influence learning curve in endoscopic ear surgery? A multicentric study [Articolo su rivista]
Lucidi, D.; Fernandez, I. J.; Botti, C.; Amorosa, L.; Alicandri-Ciufelli, M.; Villari, D.; Presutti, L.
abstract

Objective: The aim of the present study was to illustrate the learning curve of endoscopic type-1 tympanoplasty comparing experts in microscopic otology versus neophyte surgeons. Methods: Eight ear surgeons, from tertiary referral centers, who had performed at least 30 endoscopic type 1 tympanoplasties were included in the study. Demographic data and medical records regarding the first 30 endoscopic type-1 tympanoplasties were retrospectively collected by each surgeon. A 14-questions survey focused on subjective aspects of the learning curve was administered. Surgeons were divided in two groups: one with previous experience in microscopic ear surgery (group 1) and one with no previous experience in ear surgery (group 2). The learning curve of endoscopic type 1 tympanoplasty was compared between the groups. Results: Mean surgical time was 89.2 min in group 1 vs. 79.5 min in group 2 (p < 0.01). When divided in 5 surgeries-steps, the only significant difference was appreciated in the first 5 surgeries with a longer mean time in group 1 vs. group 2 (+28.4 min; p < 0.05). Conclusions: Surgeon's previous experience may influence the EES learning curve. Our results show that the first 5 surgical procedures are more challenging for surgeons experienced in microscopic surgery, subsequently the curve progression improves sharply and appears reversing the initial trend by the end of the 30 surgeries.

2020 - Endoscopic facial nerve decompression in post-traumatic facial palsies: pilot clinical experience [Articolo su rivista]
Alicandri Ciufelli, M.; Fermi, M.; Di Maro, F.; Soloperto, D.; Marchioni, D.; Presutti, L.
abstract

Purpose: Post-traumatic facial nerve (FN) paralysis might need surgical decompression in selected patients. Different microscope-based surgical techniques are described in the literature such as the transmastoid, the middle cranial fossa and the translabyrinthine approach. The effectiveness of the transcanal endoscopic approach (TEA) in managing such condition has never been described and its possible indications has to be defined. Methods: Retrospective multi-centric case series of patients with post-traumatic FN paralysis surgically treated with TEA. From July 2013 to July 2017, 6 patients underwent TEA for post-traumatic FN paralysis with involvement of the second genu and/or the tympanic segment of the nerve. The surgical technique is described step by step, with focus on anatomic landmarks. Post-operative outcomes are specified in terms of FN postoperative function and audiologic results. Results: The TEA showed to recover a House–Brackmann grade I–II FN function in 83.2% of the patient. Post-operative air–bone gap significantly improved; whereas, the pure-tone average bone conduction did not differ significantly. Conclusions: TEA represents a viable option for the treatment of post-traumatic facial palsy in patients with radiologic evidence of tympanic segment and/or perigeniculate region involvement with no involvement of the mastoid segment of the FN. Transcanal endoscopic facial nerve decompression is a safe and effective approach in highly selected cases. Level of evidence: 4.

2020 - Epinephrine Use in Endoscopic Ear Surgery: Quantitative Safety Assessment [Articolo su rivista]
Alicandri-Ciufelli, M.; Molinari, G.; Beckmann, S.; Caversaccio, M.; Presutti, L.; Anschuetz, L.
abstract

Introduction: The management of bleeding in exclusive endoscopic ear surgery (EES) is largely dependent on epinephrine use. However, to date its suitability and safety have not been assessed. The aim of the present study would be to assess the safety profile of topical application and/or local infiltrationof diluted epinephrine during EES regarding the intra- A nd postoperative periods. We hypothesize that epinephrine may be safely used during EES. Methods: Retrospective analysis of 90 EES cases performed at the University Hospital of Modena, Italy. Patient's charts and video recordings of the operations were assessed. Results: Epinephrine was used in all cases for hemostatic purposes as following: (1) diluted epinephrine (1:200,000) injection: Mean 1.2 mL (range: 0-3.5) corresponding to 0.006 mg (range 0-0.018), and (2) topical application (1:1,000) directly in the surgical field: Mean 7 cottonoids (range: 0-18) corresponding to mean 0.56 mg (range: 0-1.44). No major cardiovascular adverse effects were assessed. Only 2 intraoperative hypertensive events were recorded. One sensorineural hearing loss was observed in a case of cholesteatoma involving the stapes; no facial palsy occurred during the study period. Conclusion: The combined use of local injection and topical epinephrine is a safe and effective strategy to control bleeding in exclusive EES, when used within the dilutions and quantities reported in this study.

2020 - Evaluation of Performance and Tolerability of Nebulized Hyaluronic Acid Nasal Hypertonic Solution in the Treatment of Chronic Rhinosinusitis [Articolo su rivista]
Monzani, Daniele; Molinari, Giulia; Gherpelli, Chiara; Michellini, Laura; Alicandri-Ciufelli, Matteo
abstract

Nasal solutions are part of the recommended therapy of chronic rhinosinusitis (CRS). Formulations containing hyaluronic acid (HA) may represent a promising topical treatment in CRS patients in light of the anti-inflammatory and protective effect of HA on the sinonasal mucosa.

2020 - Food-induced stimulation of the antisecretory factor to improve symptoms in Meniere’s disease: our results [Articolo su rivista]
Scarpa, A.; Ralli, M.; Viola, P.; Cassandro, C.; Alicandri-Ciufelli, M.; Iengo, M.; Chiarella, G.; de Vincentiis, M.; Cavaliere, M.; Cassandro, E.
abstract

Purpose: Specially processed cereals (SPC) that increase endogenous antisecretory factor (AF) synthesis have been proposed to improve symptoms of Meniere’s disease (MD) with controversial results. The aim of this study was to evaluate the effects of SPC in patients with definite unilateral MD and compare the results to a treatment protocol with intravenous glycerol and dexamethasone. Methods: Thirteen patients with unilateral MD were treated with SPC and 13 patients were treated with intravenous glycerol and dexamethasone for 12 months. Audio-vestibular evaluation was performed before (T0) and at the end of the treatments (T12). The number of vertigo spells were evaluated before and after therapy and the Efficacy Index (EI) was calculated. Questionnaires for hearing loss (HHIA), tinnitus (THI) and quality of life (TFL) were administered. Results: EI decreased in the SPC group in the second semester compared to the first although not significantly (p = 0.6323). There was a significant reduction for THI score in the SPC group at T12 (p = 0.0325). No significant differences were found between the two groups at T0 (p = 0.4723), while a significant difference was found at T12 (p = 0.0041). Quality of life showed an improvement in daily activities in the SPC group compared to infusion therapy group. Conclusion: Our study shows a reduced number of vertigo attacks and a positive effect on the discomfort generated by tinnitus and quality of life in patients with unilateral MD treated with SPC and when compared to patients treated with intravenous glycerol and dexamethasone. No effects on hearing thresholds were noted in both groups.

2020 - Pharyngo-esophageal perforations after anterior cervical spine surgery: management and outcomes [Articolo su rivista]
Ghirelli, Michael; Molinari, Giulia; Rosini, Maria; De Iure, Federico; Gasbarrini, Alessandro; Mattioli, Francesco; Alicandri-Ciufelli, Matteo; Presutti, Livio
abstract

To report about the diagnosis, surgical treatment and post-operative management of pharyngo-esophageal perforations (PEP) after anterior cervical spine (ACS) surgery in 17 patients.

2020 - Spontaneous Nasal Cerebrospinal Fluid Leak Repaired With Single-Layer Mucoperichondrial Graft: Long-term Results [Articolo su rivista]
Alicandri Ciufelli, M.; Fermi, M.; Rosa, M. S.; Garzaro, M.; Presutti, L.
abstract

Background: Spontaneous cerebrospinal fluid leak (sCSFL) has been historically related to obesity and elevated intracranial pressure (ICP), with a lower rate of success of endoscopic repair reported in the literature. Moreover, defects related to this condition have been largely repaired with multilayer reconstructions and pedicled flaps. Long-term postoperative results have not been appropriately discussed yet. Objective: The aim of this study is to investigate the outcome of a cohort of patients treated with single-layer mucoperichondrial graft. Methods: A retrospective review of clinical records of a consecutive series of patients who underwent endonasal endoscopic surgery for sCSFL was carried out at a tertiary care referral center for skull base pathologies. All patients underwent reconstruction with single-layer mucoperichondrial free graft. Local flap failures and postoperative outcomes, in terms of recurrence of sCSFL or brain herniation, were registered. Results: Neither intraoperative nor perioperative complications were reported. Definitive closure was achieved in 27 of 29 (93%) patients after the first attempt, while in 2 cases, a revision surgery was required. In both of these, an inadequate position of the graft was detected and was repaired likewise with the same mucoperichondrial graft. None of the patients required postoperative lumbar drain placement. After a median follow-up period of 57 months, only 1 patient developed a meningocele without CSFL about 2 years after surgery at the contralateral lateral recess of the sphenoid sinus. None of the patients reported symptoms referable to elevated ICP nor underwent ventricular derivation. Conclusions: Single-layered mucoperichondrial free graft was safe and effective in the majority of the examined patients. In 7% of the study population, a surgical revision was necessary due to local failure of the graft. However, during long-term follow-up, only 1 case of recurrent meningocele without CSFL was reported in a patient who presented borderline ICP.

2020 - Transcanal Transpromontorial Approach to Lateral Skull Base: Maximal Area of Exposure and Surgical Extensions [Articolo su rivista]
Yacoub, A.; Wimmer, W.; Molinari, G.; Alicandri Ciufelli, M.; Presutti, L.; Caversaccio, M.; Anschuetz, L.
abstract

Objective: To determine the possible surgical extensions and maximal area of exposure (AOE) achievable through the transcanal transpromontorial approach (TTA) to the internal auditory canal (IAC) and cerebellopontine angle. We hypothesize a possible extension of indication for this minimally invasive approach to the lateral skull base. Methods: In this experimental anatomic study, the expanded TTA was first carried out in 4 temporal bones to define the anatomic boundaries of the maximal exposure, from 2 perspectives, the middle ear and the porus of the IAC. Consecutively, these identified boundaries were translated on segmented 3-dimensional (3D) surface models of 32 temporal bone high-resolution computed tomography scans. Results: The dissections performed were the basis followed during the determination of the AOE on the 3D surface models. The measurements revealed that the AOE at the middle ear was 152.9 ± 33.6 mm2, whereas it was 151.9 ± 24.8 mm2 at the porus of the IAC. The mean superoinferior and anteroposterior extensions at the middle ear were 14.7 ± 2.5 mm and 16.9 ± 2.5 mm, respectively. On the other hand, the mean superoinferior and anteroposterior extensions at the IAC porus were 10.3 ± 1.3 mm and 18.5 ± 1.9 mm, respectively. Conclusions: Consistent with the minimally invasive approaches, the AOE is limited; however, if compared with traditional approaches, it appears of considerable size. Our results may assist the surgeon in the selection process of the appropriate candidates for the TTA and to tailor the approach to the disease.

2020 - Treatment of Recurrent Tracheocutaneous Fistulas in the Irradiated Neck with a Two Layers-Two Flaps Combined Technique [Articolo su rivista]
Pignatti, M.; Sapino, G.; Alicandri-Ciufelli, M.; Canzano, F.; Presutti, L.; De Santis, G.
abstract

The development of a tracheocutaneous fistula (TCF) is a well-documented complication after tracheostomy, especially in chronic morbid patients, in whom tubes or cannulas are left in place over time, or in irradiated patients. Surgical treatments are therefore needed which range from simple curettage and dressings to local skin flaps, muscle flaps and, in the more complex cases, microsurgical free tissue transfers. We present a novel combined technique used to successfully treat recurrent TCFs in irradiated patients, involving a superiorly based turnover fistula flap and a sternocleidomastoid transposition flap.

2019 - Correlation between pre-operative CT findings and intra-operative features in pediatric cholesteatoma: a retrospective study on 26 patients [Articolo su rivista]
Molteni, G.; Fabbris, C.; Molinari, G.; Alicandri-Ciufelli, M.; Presutti, L.; Paltrinieri, D.; Marchioni, D.
abstract

Objective: To assess the predictive value of pre-operative CT imaging in pediatric patients affected by cholesteatoma of the middle ear, comparing pre-operative CT findings to intra-operative features. Methods: A retrospective study was performed on a population of 26 pediatric patients who underwent tympanoplasty for middle ear cholesteatoma at the Otorhinolaryngology Departments of Verona and Modena University Hospitals between December 2011 and June 2018. Comparison between pre-operative CT images and intra-operative findings (assessed from video recording) was made focusing on the involvement of specific structures: ossicular chain, tegmen tympani, labyrinthine fistula, facial nerve, and temporal bone involvement. CT sensitivity, specificity, positive and negative predictive values were calculated. Results: Overall, 28 surgical procedures were evaluated. No statistically significant differences were encountered between CT images and intra-operatory findings regarding the selected parameters. Conclusions: Based on our study, pre-operative temporal bone CT scan is a valuable tool for the assessment of pediatric patient candidates for cholesteatoma surgery given the absence of statistically significant differences between radiologic and intra-operative findings. The present findings might support the indication to routinely perform temporal bone CT scan in children with cholesteatoma as part of pre-surgical plan. Level of evidence: III.

2019 - Erratum to “Surgical outcomes in the treatment of temporal bone cerebrospinal fluid leak: A systematic review” [Auris Nasus Larynx 45 (2018) 903–910](S038581461730994X)(10.1016/j.anl.2018.03.006) [Articolo su rivista]
Gioacchini, F. M.; Cassandro, E.; Alicandri Ciufelli, M.; Kaleci, S.; Cassandro, C.; Scarpa, A.; Re, M.
abstract

The publisher regrets that the abstract was missing in the original publication of this article. The publisher would like to apologise for any inconvenience caused. Objective: Temporal bone CSF leak represents a rare condition that may be associated to some particular symptoms as hearing loss, otorrhea and tinnitus. In the opinion of many authors a surgical treatment is mandatory to avoid serious consequences as meningitis. Middle cranial fossa (MCF), transmastoid (TM) and combined approaches are all described to manage this condition. The objective of this paper was firstly to analyze the overall outcomes of this surgery. Our second aim was to make a comparison between different surgical modalities on the basis of their rate of success and complications. Methods: A search thorough Ovid MEDLINE was organized in January 2017 to enroll all eligible articles. A statistical analysis of the obtained data was performed. Results: Thirtythree studies comprising a total of 873 procedures were included. The overall rate of success resulted 95.6% (94.1–96.8). The rate of major complications analyzed for 818 procedures was 3.4% (2.3–4.8). Subgroups analysis showed a success rate of 97.1% (90.7–99.5) for TM approach. A success rate of 94.1% (89.1–97.3) was calculated for MCF approach. Combined procedure (TM + MCF) showed a success rate of 97.9% (92.9–99.7). Conclusion: The results of our review showed as the surgical treatment for CSF leak of temporal bone origin represents a safe option with high rate of success. Moreover our statistical data suggested that no significant differences are present in terms of outcomes between the analyzed surgical approaches.

2019 - Gusher in stapes surgery: a systematic review [Articolo su rivista]
Alicandri-Ciufelli, M.; Molinari, G.; Rosa, M. S.; Monzani, D.; Presutti, L.
abstract

Objective: The aim of this study is to perform a systematic literature review on the occurrence of gusher during stapes surgery, to understand its surgical management and outcomes. Methods: The PRISMA standard was applied to identify English, Italian or French-language studies, related to stapes surgery and mentioning gusher or perilymphatic leak. Full-texts lacking information on the management of gusher and/or the post-operative hearing outcome were excluded. Results: Twenty-four articles were eventually included. Seventy-six patients were involved in the qualitative synthesis. The management of gusher mostly consisted in covering the oval window and/or filling the tympanic cavity, with absorbable and autologous graft materials. Packing of the external auditory canal was reported in 51 patients (67%). Gusher was related to complete/profound loss of hearing in 25% of the cases and to a worsening of hearing function in 31% of patients. In 19% of patients an improvement in hearing tests was reported; in 28% the hearing function was unchanged. Post-operative vestibular symptoms were reported in 7 patients, and were mainly mild and transient. The absence of vestibular symptoms was underlined in 9 cases, while in 79% of the patients the authors did not provide information. Conclusion: The unexpected occurrence of gusher during stapes surgery represents a relevant issue for the otologic surgeon. Its management most commonly consists in plugging the oval window and the tympanic cavity. In most of the cases, a stapes prosthesis could be positioned. The results on hearing and vestibular functions are widely variable.

2019 - Low-dose intratympanic gentamicin administration for unilateral Meniere's disease using a method based on clinical symptomatology: Preliminary results [Articolo su rivista]
Scarpa, A.; Ralli, M.; Cassandro, C.; Gioacchini, F. M.; Alicandri-Ciufelli, M.; Viola, P.; Chiarella, G.; de Vincentiis, M.; Cassandro, E.
abstract

Purpose: There are many therapeutic options for Meniere's disease (MD); intratympanic (IT) gentamicin has been proposed for intractable cases although controversy about dosage and method exists. The purpose of this study was to assess the efficacy and safety of low-dose IT gentamicin on vertigo attacks in MD using a clinical symptomatology-based method in which administration was repeated only if vertigo attacks recurred, with a 2-week interval between injections. Materials and methods: Forty-eight patients with unilateral intractable MD were included in the study. All patients received one to five IT injections with 0.5 ml of 10 mg of gentamicin (80 mg/2 ml) with an interval of 2 weeks between injections. Vertigo attacks were evaluated before and after therapy and categorized into classes A–F according to the 2015 Equilibrium Committee criteria. Audiovestibular assessment with pure tone audiometry, vestibular bed-side examination and video head impulse test was performed. Results: Before treatment patients had an average of 4.4 vertigo attacks/month; after treatment the average number decreased to 0.52. The majority of patients (77%) reached Class A vertigo control with 5 or less gentamicin injections. VOR gain was unaffected in the healthy side and significantly reduced in the affected side. No hearing deterioration was found in all treated patients. Conclusions: Low-dose IT gentamicin administration based on clinical symptomatology can produce a satisfactory control of vertigo attacks after treatment; such protocol had an effect mainly on the vestibular function as demonstrated by the significant reduction in VOR gain in the affected side avoiding a cochlear damage.

2019 - Management of Jugular Bulb Injuries during Endoscopic Ear Surgery: Our Experience [Articolo su rivista]
Ferri, G.; Fermi, M.; Alicandri Ciufelli, M.; Villari, D.; Presutti, L.
abstract

Objectives The main objective of this article is to describe endoscopic management of intraoperative massive bleeding from jugular bulb injury during exclusively transcanal endoscopic procedures for middle ear pathologies. Design Case series with chart review. Setting Tertiary referral center. Participants We retrospectively reviewed two patients who experienced jugular bulb injury during endoscopic transcanal approach for glomus tympanicum and chronic otitis media. The surgical videos and charts were carefully investigated and analyzed. Main Outcome Measures Feasibility and suitability of exclusive endoscopic management of jugular bulb bleeding and description of surgical maneuvers that should be performed to obtain safe and effective hemostasis. Results In both patients, jugular bulb bleeding was progressively controlled by means of exclusive endoscopic approach with no need to convert to microscopic approach. None of the cases required a second surgeon helping in keeping the endoscope during hemostatic maneuvers. Both patients had a normal postoperative period with no recurrence of hemorrhage. Conclusions Endoscopic management of jugular bulb bleeding is feasible by using the technique described with reasonable efficacy and with no additional risk or morbidity to the procedure. Knowledge of anatomy and its variants, preoperative evaluation of imaging, and the ability of the surgeon to adapt the surgical technique to the specific case are recommended to prevent vascular complications during endoscopic ear surgery.

2019 - Neuroendoscopic Aspiration of Blood Clots in the Cerebral Aqueduct and Third Ventricle During Posterior Fossa Surgery in the Prone Position [Articolo su rivista]
Feletti, Alberto; Stanzani, Riccardo; Alicandri-Ciufelli, Matteo; Giliberto, Giuliano; Martinoni, Matteo; Pavesi, Giacomo
abstract

During surgery in the posterior fossa in the prone position, blood can sometimes fill the surgical field, due both to the less efficient venous drainage compared to the sitting position and the horizontally positioned surgical field itself. In some cases, blood clots can wedge into the cerebral aqueduct and the third ventricle, and potentially cause acute hydrocephalus during the postoperative course.

2019 - Plaut-Vincent’s Ulcerative Gingivitis and Tonsillitis [Articolo su rivista]
Maccarrone, F.; Alicandri-Ciufelli, M.
abstract

2019 - Rating surgical field quality in endoscopic ear surgery: proposal and validation of the "Modena Bleeding Score" [Articolo su rivista]
Alicandri-Ciufelli, M; Pingani, L; Mariano, D; Anschuetz, L; Molinari, G; Marchioni, D; Bonali, M; Galeazzi, Gm; Presutti, L.
abstract

PURPOSE: To develop and validate a bleeding score that could be applied in endoscopic ear surgery (EEarS). METHODS: A prospective validation study was performed. A new bleeding score, called "Modena Bleeding Score" (MBS), was created by the authors. It provides five grades for rating the surgical field during EEarS procedures (from grade 1-no bleeding to grade 5-bleeding that prevents every surgical procedure except those dedicated to bleeding control). A preliminary "face validity" was performed by 18 ENT specialists to assess possible misunderstandings in interpreting the scale. Then, 15 videos of endoscopic ear surgery procedures, each divided into three parts (t0, t1, and t2), were subsequently evaluated by 15 specialists, using MBS. The videos were randomly selected and assigned. Intra-rater reliability and inter-rater reliability were calculated. The clinical validity of the instrument was calculated using a referent standard (i.e., four ENT experts whose ratings were compared to those obtained by the former sample). RESULTS: The face validity showed a good consensus about the clarity and comprehension of the scale; both intra and inter-rater reliability demonstrated good performance (intra-rater reliability ranged from 0.741 to 0.991 and inter-rater reliability was 0.790); clinical validity also showed positive values, ranging from 0.75 to 0.93. CONCLUSIONS: MBS has proved to be an effective method to rate surgical field during EEarS, with good-to-excellent performances. Its use would possibly help comparisons of groups in clinical trials or comparisons between studies.

2019 - The endoscopic anatomy of the cochlear hook region and fustis: Surgical implications [Articolo su rivista]
Anschuetz, L.; Alicandri-Ciufelli, M.; Wimmer, W.; Bonali, M.; Caversaccio, M.; Presutti, L.
abstract

The cochlear hook region can be considered as the interface between the middle and inner ear. The identification of surgically-relevant endoscopic landmarks of this anatomical entity and assessment of their clinical value is still lacking in the literature. Procedures like cholesteatoma surgery and minimal invasive endoscopic approaches to the lateral skull base may particularly benefit from these considerations. We hypothesize that the spatial orientation of anatomical landmarks in the cochlear hook can be expressed in angles and are reproducibly identifiable by transcanal otoendoscopy. Therefore, endoscopic dissection of the cochlear hook region was performed in 32 temporal bone specimens. Topographic anatomy was documented and analysed. We performed computed tomography of 28 specimens to assess the region in three-dimensional reconstructions. The mean angle between the round window and the basal scala tympani was assessed 25.9° in endoscopic and 28.2° in three-dimensionally reconstructed models. The fustis was recognised as a reliable landmark for the basal turn. A mean angle of 155.4° to the basal scala tympani was assessed. A slight bulging without obstruction of the basal turn was observed in 5 cases. The utility of the revealed anatomical details was assessed in minimal invasive endoscopic lateral skull base approaches. In conclusion, we described the angles between anatomical landmarks of the cochlear hook region. Moreover, the angle as recorded through an endoscope was found to be reliable compared to three-dimensional reconstructions from computed tomography.

2018 - Acquisition of surgical skills for endoscopic ear and lateral skull base surgery: A staged training programme [Articolo su rivista]
Alicandri-Ciufelli, M.; Marchioni, D.; Pavesi, G.; Canzano, Federica; Feletti, A.; Presutti, L.
abstract

Endoscopic ear surgery is radically changing the treatment of several middle and inner ear pathology, but its learning presents well-known manual and technical difficulties. The aim of this paper is be to present a training programme based on a modular model of increased difficulties. The experience from 2007 to 2016 at the University Hospital of Modena and University Hospital of Verona was reviewed and analysed for further considerations and to establish stages of training. The increasing experience of expert surgeons who deal with this kind of surgery represented the main guide to establish the steps and progression of training. In addition, the potential risk of damage of vascular structures or nerves represents fundamental criteria for progression toward higher levels. Some not-mandatory skills were also suggested for stage of difficulty. Five stages of training were deemed appropriate for progressive learning of endoscopic ear and lateral skull base surgery, ranging from simple middle and external ear procedures to surgery of inner ear and internal auditory canal. Mastering of each level is suggested before attempting procedures at a higher level, in particular for procedures involving lateral skull base. Standardisation and adoption of modular incremental training are expected to facilitate improvement of otolaryngologists and neurosurgeons starting with endoscopic middle ear and lateral skull base surgery. Adherence to such a programme during the growth phase may potentially decrease the rate of complications, making the training programme safer.

2018 - Complications in endoscopic ear surgery [Articolo su rivista]
Marchioni, Daniele; Rubini, Alessia; Gazzini, Luca; Alicandri-Ciufelli, Matteo; Molinari, Giulia; Reale, Marella; Presutti, Livio
abstract

Objective: The aim of this study was to examine the premise that endoscopic ear surgery (EES) is associated with a low rate of complications (intraoperative and postoperative). Study Design: Retrospective review at two institutions. Setting: Tertiary referral center. Patients: The study included 825 patients who underwent exclusive EES between 2008 and 2016 at the Otorhinolaryn-gology-Head and Neck Surgery Department of Modena University Hospital, and between 2014 and 2016 at the Otorhinolaryngology-Head and Neck Surgery Department of Verona University Hospital. Interventions: Exclusive endoscopic ear surgery between 2008 and 2016 (tympanoplasties, second look or revision tympanoplasties, myringoplasties, stapedoplasties, canalplasties, ossiculoplasties, and exploratory tympanotomies). All surgical procedures were performed by two experienced surgeons. Main Outcome Measure: For each procedure, intraoperative, and early and delayed postoperative complications were evaluated. Results: The most common ear pathologies for which patients were sent for EES were cholesteatoma (33.6%), chronic otitis media (36.3%) and otosclerosis (26.8%). There was no case of major intraoperative complications such as injury to the dura or vascular structures. We observed minor intraoperative complications in 4.1% of the cases. Only 1.3% of patients experienced early postoperative complications. Delayed complications affected less than 1% of the cohort. Conclusions: Data from this study confirm the safety of the endoscopic technique, with very low complication rates, indicating that EES is a reliable therapeutic option, in particular, for tympanoplasties, myringoplasties, and stapedoplasties, as well as second look procedures. We have reported our experience with EES morbidity so that it can be compared with data from other centers using the same sur gical technique.

2018 - Facial sinus endoscopic evaluation, radiologic assessment, and classification [Articolo su rivista]
Alicandri-Ciufelli, Matteo; Fermi, Matteo; Bonali, Marco; Presutti, Livio; Marchioni, Daniele; Todeschini, Alessandra; Anschuetz, Lukas
abstract

Objectives: To describe facial sinus anatomy from an endoscopic perspective and present a radiologic classification. Methods: Facial sinus was studied by endoscopy and high-resolution computed tomography (HRCT) scan in 39 temporal bones that underwent exclusive transcanal endoscopic approach. A radiomorphologic classification based on the relationship between the facial sinus and the mastoid portion of the facial nerve is created as follows. In type A facial sinus, the pneumatization of the facial sinus did not extend medially or posteriorly to the mastoid portion of the facial nerve. In type B facial sinus, the pneumatization extended posteriorly to the mastoid portion of the facial nerve. In type C facial sinus, the pneumatization extended posteriorly and medially to the mastoid portion of the facial nerve. Results: In all the specimens that underwent HRCT (n = 31), facial sinus could be identified, and its depth classified, in relation to the facial nerve. In this group, 58% type A, 29% type B, and 13% type C facial sinuses were identified. In all the specimens (n = 39), the facial sinus could be assessed by means of an exclusive endoscopic transcanal approach, and anatomical variants of the chordiculus, previously known as chordal ridge, could be described: ridge (39%), bridge (18%), incomplete (15%), and absent (28%). Conclusion: Endoscopic exploration of the retrotympanum guarantees a very good exposure of the facial sinus, allowing detailed anatomic descriptions of its conformation and relationships with other structures. Improvement in our knowledge of its anatomy might decrease the possibility of residual disease during cholesteatoma surgery. Angled endoscopes (e.g. 45 °, 70 °) can guarantee a better view of the facial sinus. Level of Evidence: NA. Laryngoscope, 128:2397–2402, 2018.

2018 - Middle ear microvascularization: an âin vivoâ endoscopic anatomical study [Articolo su rivista]
Alicandri-Ciufelli, Matteo; Guarino, Pierre; Fabbri, Filippo; Cunsolo, Elio Maria; Presutti, Livio; Anschuetz, Lukas
abstract

Purpose: To describe the in vivo vascularization of middle ear by an endoscopic point of view, particularly focusing on the medial wall of tympanic cavity and incudostapedial region (ISR). Study design: Case series with surgical videos review and anatomical description. Methods: 48 videos from exclusive endoscopic middle ear surgery performed at the University Hospital of Modena from November 2015 to July 2017 were reviewed. Data about anatomy of vessels, and blood flow direction (BFD) were collected in an appropriate database for further analyses. Results: 48 cases were included in the present study. In 18/48 patients (37,5%), a clearly identifiable inferior tympanic artery (ITA) was present, running just anteriorly to the round window (RW), with a superior BFD (65% of cases) from the hypotympanic region toward the epitympanum. Some promontorial variants were described in 67% of cases and the most common finding was a mucosal vascular network with a multidirectional BFD. On the ISR, an incudostapedial artery (ISA) was detected in 65% of cases with BFD going from the long process of the incus (LPI) toward the pyramidal eminence in the majority of cases. Conclusion: The vascular anatomy and BFD of the medial wall of the tympanic cavity can be easily studied in transcanal endoscopy. ITA (with a superior BFD in most cases) and ISA (with a main BFD from the incus to the stapes) are the most constant identifiable vessels.

2018 - Novel Surgical and Radiologic Classification of the Subtympanic Sinus: Implications for Endoscopic Ear Surgery [Articolo su rivista]
Anschuetz, Lukas; Alicandri-Ciufelli, Matteo; Bonali, Marco; Fermi, Matteo; Caversaccio, Marco; Presutti, Livio; Marchioni, Daniele
abstract

Objective: The aim of this study is to describe the endoscopic anatomy of the subtympanic sinus (STS), establish a classification according to its extension regarding the level of the facial nerve (FN), and assess the feasibility of the transcanal endoscopic approach to the STS. Study Design: Experimental anatomic research. Setting: Temporal bone laboratory. Methods: We performed endoscopic dissection of 34 human whole head and ear block specimens. Of those, 29 underwent high-resolution computed tomography. The STS was classified according to its extension regarding the level of the FN: type A, no extension medial to the FN; type B, extension to the medial limit of the FN; type C, extension of the sinus medially and posteriorly from the FN into the mastoid cavity. Results: The majority of cases (n = 21, 72%) showed a shallow type A STS. We observed a deep type B configuration in 6 cases (21%) and a type C in 2 cases (7%). The STS was completely exposable with a 0° endoscope in 44% of the specimens. Using a 45° endoscope, we gained complete insight in 79%. However, in 21% of the cases, the posteromedial extension of the STS was too deep to be completely explored by an endoscopic transcanal approach. Conclusion: The majority of the STS is shallow and does not extend medially from the FN. This morphologic variant allows complete transcanal endoscopic visualization. In more excavated STS, a complete endoscopic exploration is not achievable, and a retrofacial approach may be adopted to completely access the STS.

2018 - Surgical outcomes in the treatment of temporal bone cerebrospinal fluid leak: A systematic review [Articolo su rivista]
Gioacchini, Federico Maria; Cassandro, Ettore; Alicandri-Ciufelli, Matteo; Kaleci, Shaniko; Cassandro, Claudia; Scarpa, Alfonso; Re, Massimo
abstract

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2018 - The Impact of the Transcanal Endoscopic Approach and Mastoid Preservation on Recurrence of Primary Acquired Attic Cholesteatoma [Articolo su rivista]
Presutti, Livio; Anschuetz, Lukas; Rubini, Alessia; Ruberto, Marco; Alicandri-Ciufelli, Matteo; Dematte, Marco; Caversaccio, Marco; Marchioni, Daniele
abstract

We aim to investigate the factors associated with recurrent disease following surgery for primary acquired attic cholesteatoma. We hypothesize that minimal invasive, mucosal sparing operation techniques have beneficial effects on the outcome in terms of recurrence.

2018 - Unravelling the risk factors that underlie oral and oropharyngeal surgery in elderly [Articolo su rivista]
Molteni, G; Valerini, S; Alicandri-Ciufelli, M; Sprio Phd, A E; Crosetti, E; Berta, G N; Presutti, L; Succo, G
abstract

Oral squamous cell carcinoma (OSCC) diagnoses in elderly patients are expected to double in the next 20 years. Current guidelines suggest surgery as a preferred approach, but elderly patients are hardly considered suitable to challenging surgical treatments. Using a multicentric retrospective analysis, we evaluated the outcomes of 99 patients affected by OSCC and aged at least 70, who underwent to either transoral procedures (TP), open neck resection without (OR) or with reconstruction (ORR). In our cohort, overall survival was significantly hampered by concomitant diseases and postsurgical complications, whose development is driven by the former. Thus, our findings support the growing acceptance that chronological age alone should not be a sufficient contraindication for aggressive surgery in the treatment of OSCC. However, elderly patients affected by OSCC are undoubtedly delicate surgical candidates and accurate selection prior to surgery with curative intent is mandatory.

2017 - Bilateral congenital cholesteatoma: Surgical treatment and considerations [Articolo su rivista]
Marchioni, Daniele; Rubini, Alessia; Gonzalez-Navarro, Mauricio; Alicandri-Ciufelli, Matteo; James, Adrian; Presutti, Livio
abstract

Objectives To describe a multicenter study regarding surgical management of bilateral congenital cholesteatoma (BCC) and underline the importance of endoscopes in the management of this condition. In BCC, hearing preservation is more crucial than in unilateral cases. The endoscopic approach allows complete removal of cholesteatoma via a minimally invasive technique offering low residual disease rates while preserving the normal physiology of the middle ear and possibly the ossicular chain. Study design Retrospective chart and surgical video review of patients with BCC who underwent surgery at Otolaryngology Department of Modena and Verona University Hospitals and the Hospital for Sick Children, Toronto. Methods From 2002 to November 2016, six patients were identified with bilateral congenital cholesteatoma and included in this study. Pre-operative assessments, surgical treatments and outcomes were collected and described. Results The median age at presentation was 4 years (range 2â7 years). A microscopic post auricular tympanoplasty was performed in two ears, four underwent a canal wall up mastoidectomy procedure and in the other six a transcanal endoscopic approach (TEA) was used. No intra- or post-operative complications were observed in any patients. The mean follow up period was 54.5 months. Conclusions When both ears are involved with congenital cholesteatoma, it is particularly important to use a minimally invasive technique that preserves normal ossicular and mastoid structure and function whenever possible. In many cases this can be achieved with TEA, even in young children. In addition the endoscope allows good surgical control of cholesteatoma removal from hidden recesses.

2017 - Emergencies in otolaryngology: Head and neck surgery [Capitolo/Saggio]
Guarino, P.; Alicandri Ciufelli, M.; Presutti, L.
abstract

2017 - Exclusive endoscopic transcanal transpromontorial approach: a new perspective for internal auditory canal vestibular schwannoma treatment [Articolo su rivista]
Feborl-hns, ; Pavesi, G; Marchioni, D; Alicandri-Ciufelli, M; Rubini, A; Masotto, B; Presutti, L.
abstract

2017 - Expanded transcanal transpromontorial approach to the internal auditory canal and cerebellopontine angle: a cadaveric study [Articolo su rivista]
Presutti, Livio; Bonali, Marco; Marchioni, Daniele; Pavesi, G; Feletti, A; Anschuetz, L; Alicandri Ciufelli, M.
abstract

The aim of this paper is to describe and evaluate the feasibility of an expanded endoscopic transcanal transpromotorial approach (ExpTTA) to the internal auditory canal and the cerebellopontine angle. To this end, we performed a cadaveric dissection study in September 2015. In total, 2 heads (4 sides) were dissected focusing on anatomical landmarks and surgical feasibility. Data from dissections were reviewed and analysed for further consideration. In all 4 sides of the cadavers the procedure was feasible. In all cadavers, it was necessary to extensively drill the temporo-mandibular joint and to calibrate the external ear canal to allow adequate room to manoeuver the instruments and optics and to comfortably access the cerebellopontine angle. In addition, thorough skeletonisation of the carotid artery and the jugular bulb were necessary for the same purpose. In conclusion, ExpTTA appeared to be successful to access the internal auditory canal and cerebellopontine angle region. Potential extensive and routine application of this type of approach in lateral skull base surgery will depend on the development of technology and surgical refinements and on the diffusion of skull base endoscopic skills among otolaryngologists and neurosurgical community.

2017 - Expanded transcanal transpromontorial approach to the internal auditory canal: Pilot clinical experience [Articolo su rivista]
Presutti, Livio; Alicandri Ciufelli, Matteo; Bonali, Marco; Rubini, Alessia; Pavesi, Giacomo; Feletti, Alberto; Masotto, Barbara; Anschuetz, Lukas; Marchioni, Daniele
abstract

The aim of this study was to describe and evaluate the feasibility of an expanded transcanal transpromontorial approach, developed from the exclusive endoscopic transcanal transpromontorial approach.

2017 - Management of Bleeding in Exclusive Endoscopic Ear Surgery: Pilot Clinical Experience [Articolo su rivista]
Anschuetz, Lukas; Bonali, Marco; Guarino, Pierre; Fabbri, Filippo B.; Alicandri-Ciufelli, Matteo; Villari, Domenico; Caversaccio, Marco; Presutti, Livio
abstract

Objective: Transcanal exclusive endoscopic ear surgery requires the management of the endoscope and the surgical instruments in the external auditory canal. Bleeding in this narrow space is one of the most challenging issues, especially for novice endoscopic ear surgeons. We aim to assess the severity and occurrence of bleeding and describe strategies to control the bleeding during endoscopic ear surgery. We hypothesize that bleeding is reasonably controllable in endoscopic ear surgery. Study Design: Case series with chart review. Setting: Tertiary referral center. Subjects and Methods: We retrospectively assessed 104 consecutive cases of exclusive endoscopic ear surgery at the University Hospital of Modena, Italy. The surgical videos and the patient charts were carefully investigated and analyzed. Results: Hemostatic agents included injection of diluted epinephrine (1:200,000, 2% mepivacaine), cottonoids soaked with epinephrine (1:1000), mono- or bipolar cautery, washing with hydrogen peroxide, and self-suctioning instruments. The localization of bleeding in the external auditory canal was most frequently the posterior superior part, and inside of the middle ear, it was the pathology itself. Statistical analysis revealed significant differences comparing the mean arterial pressure and the type of intervention among bleeding scores. Conclusion: The management of bleeding in endoscopic ear surgery is feasible through widely available hemostatic agents in reasonable frequency. This study gives an instructive overview on how to manage the bleeding in the exclusive endoscopic technique. Even the highest bleeding scores could be managed in an exclusively endoscopic technique.

2017 - Transcanal surgery for vestibular schwannomas: a pictorial review of radiological findings, surgical anatomy and comparison to the traditional translabyrinthine approach [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Federici, Gaia; Anschuetz, Lukas; Pavesi, Giacomo; Todeschini, Alessandra; Presutti, Livio; Marchioni, Daniele
abstract

The most popular approaches for vestibular schwannoma (VS) removal are retrosigmoid, middle cranial fossa and translabyrinthine (TL). All require a certain degree of invasivity, bone removal, or brain manipulation. Recently, the authors described the transcanal transpromontorial approaches (TTA), which allow the inner ear to be accessed directly through the external auditory canal (EAC), either with a microscopic (Expanded TTA, or ExpTTA) or even an exclusive endoscopic technique (Endoscopic TTA, or EndoTTA). The advantages compared to traditional approaches are a direct view of the internal auditory canal (IAC) from lateral to medial, very little or no superficial tissue dissection and very little petrous bone drilling. In summary, from an anatomical point of view, they could be considered to be minimally invasive approaches. The radiologic outcome and the anatomical correspondence of these new approaches are described so as to share with the readers the possible radiologic findings and to compare and differentiate them from classic transpetrous approaches such as the TL approach.

2016 - Atypical mycobacteriosis involving parotid and para-retropharyngeal spaces [Articolo su rivista]
Bonali, Marco; Mattioli, Francesco; Alicandri Ciufelli, Matteo; Presutti, Livio
abstract

The incidence of retro-parapharyngeal localization of cervical adenitis due to non-tuberculous mycobacteria is very rare. We present a case of an 18-months-old child with an involvement of parapharyngeal and retropharyngeal areas, right parotid and submandibular regions by atypical mycobacteriosis in the CT and MRI scan. The masses were surgically removed and the frozen-section histological exam upheld their atypical mycobacterial origin.

2016 - Endoscopic Management of Attic Cholesteatoma: Long-Term Results [Articolo su rivista]
Alicandri Ciufelli, Matteo; Marchioni, Daniele; Kakehata, Seiji; Presutti, Livio; Villari, Domenico
abstract

The main application of endoscopic surgery relies on the middle ear cholesteatoma surgical treatment, although for a definitive validation and acceptance by scientific community, long-term results are needed about recurrent and residual rates of the pathology. The aim of the present paper was to analyze the single institution experience with the long-term results of surgical treatment of attic cholesteatoma.

2016 - If it can be done, it should be done,… or not? Response to Prof. Grotenhuis [Articolo su rivista]
Feletti, Alberto; Alicandri Ciufelli, Matteo; Pavesi, Giacomo
abstract

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2016 - In reference to A New Theory on the Pathogenesis of Acquired Cholesteatoma: Mucosal Traction [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Marchioni, Daniele; Presutti, Livio
abstract

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2016 - Is Ménière’s disease the ‘inner ear migraine’? A neurovascular region-based hypothesis supported by epidemiological appraisal and pathophysiological considerations [Articolo su rivista]
Alicandri Ciufelli, M.; Aggazzotti-Cavazza, E.; Cunsolo, E.; Marchioni, D.; Monzani, D.; Genovese, E.; Presutti, L.
abstract

Migraine (MG) and Ménière’s disease (MD) are idiopathic pathologies, but share several clinical, epidemiological, and genetic characteristics. Based on some considerations with regard to the pathophysiology and epidemiology of both MG and MD, the authors hypothesize that MG and MD could be interpreted as different neurovascular regional manifestations of the same pathology. An interpretation of MG and MD as the same phenomenon involving different brain regions could inspire and stimulate researchers studying aspects linking what has already been discovered in both fields, e.g. pathogenetic mechanisms or therapeutic development.

2016 - Letter to the Editor "Is endoscopic ear surgery an alternative to the modified Bondy technique for limited epitympanic cholesteatoma?" by Prasad et al [Articolo su rivista]
Alicandri Ciufelli, Matteo; Anschuetz, Lukas; Presutti, Livio; Villari, Domenico; Marchioni, Daniele
abstract

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2016 - Mutation screening of the Otop1 gene in familial benign positional paroxysmal vertigo [Articolo su rivista]
Monzani, D.; Fancello, T.; Alicandri Ciufelli, M.; Genovese, E.; Tarugi, P.; Cavazza, E. A.; Percesepe, A.
abstract

Objectives: Benign paroxysmal positional vertigo (BPPV) is a sporadic disorder in the vast majority of cases, although a familial, benign, recurrent form, in which the disease segregates in an autosomal dominant fashion has been described. After the evidence for a role of a novel murine gene, Otop1, in knock-out tlt (tilted) and mlh (Mergulhador) mice, lacking the perception of gravity and linear motion and showing a vestibular disorder due to non-syndromic agenesis of both utricular and saccular otoconia, we aimed at verifying the role of the human analogue of the Otop1 gene in BPPV pathogenesis in familial cases of BPPV, collected in our tertiary university referral centre. Methods: Starting in 2007, families with at least two living members thought to have BPPV were considered for inclusion in the present study. The cases were both retrospectively and prospectively identified over the following two years. Results: Seven familial aggregations of BPPV were identified and Otop1 mutation screening showed the presence of a heterozygous mutation in one family, c.1013G> C p.Arg338Pro, which was considered possibly deleterious using the prediction software. It was absent in 100 control alleles, but was also found in two as yet unaffected relatives. Conclusions: The results of a mutation screening of the Otop1 gene in familial cases of BPPV do not support a major role of the gene in the pathogenesis of the disease.

2016 - Outcomes and complications in superior semicircular canal dehiscence surgery: A systematic review [Articolo su rivista]
Gioacchini, FEDERICO MARIA; ALICANDRI CIUFELLI, Matteo; Kaleci, Shaniko; Scarpa, Alfonso; Cassandro, Ettore; Re, Massimo
abstract

Superior semicircular canal dehiscence (SSCD) represents a rare condition that may be associated to some particular symptoms as vertigo, autophony, and Tullio phenomenon. In those patients who present severe symptoms surgical treatment is required. Middle fossa craniotomy and transmastoid approaches are both described. Concerning repairing techniques, plugging and/or resurfacing are typically used to close the defect. Our aim was first to analyze the overall outcomes and complications of this surgery. Our second aim was to make a comparison between the different surgical modalities to investigate the eventual advantages and disadvantages.

2016 - Prognostic factors in stage IV oropharyngeal squamous cell carcinoma: the "punto" experience [Articolo su rivista]
Piccinini, Alessia; ALICANDRI CIUFELLI, Matteo; Ghidini, Angelo; Vincenti, Vincenzo; Ferri, Teore; Presutti, Livio
abstract

  Squamous Cell Carcinoma (SCC) of Oropharynx is often diagnosed in advanced stages. Treatment options have improved during recent years, however the choice of most appropriate treatment is still controversial. Prognostic factors can help to optimize the care. This study investigate the role of 9 potential prognostic factors, including HPV status, in Oropharyngeal SCC.

2016 - The Eustachian Tube Redefined [Articolo su rivista]
Tarabichi, Muaaz; Poe, Dennis S; Nogueira, João Flávio; Alicandri Ciufelli, Matteo; Badr El Dine, Mohamed; Cohen, Michael S; Dean, Marc; Isaacson, Brandon; Jufas, Nicholas; Lee, Daniel J; Leuwer, Rudolf; Marchioni, Daniele; Patel, Nirmal; Presutti, Livio; Rivas, Alejandro
abstract

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2016 - The Fully Endoscopic Acoustic Neuroma Surgery [Articolo su rivista]
Marchioni, Daniele; Carner, Marco; Rubini, Alessia; Nogueira, João Flávio; Masotto, Barbara; ALICANDRI CIUFELLI, Matteo; Presutti, Livio
abstract

Surgical approaches to vestibular schwannomas (VS) are widely known and extensively recorded. For the first time, an exclusive endoscopic approach to the internal acoustic canal (IAC) was described and used to safely remove a cochlear schwannoma involving IAC in March 2012. The aim of this article was to summarize indications and technique to treat intracanalicular VS by transcanal/transpromontorial endoscopic approach. Because management of intracanalicular VSs is complex and strongly debated, this kind of therapeutic option in the appropriate and selected cases could modify classic concepts of the management of this pathology.

2016 - The prognostic value of cyclin D1 expression in head and neck squamous cell carcinoma [Articolo su rivista]
Gioacchini, FEDERICO MARIA; ALICANDRI CIUFELLI, Matteo; Kaleci, Shaniko; Magliulo, Giuseppe; Presutti, Livio; Re, Massimo
abstract

The correlation between cyclin D1 overexpression and the clinical outcome of head and neck cancer is not defined. The aim of this meta-analysis was to evaluate the prognostic value of cyclin D1 in patients with head and neck cancer. A search thorough Ovid MEDLINE was performed to enroll all eligible articles. Twenty-two studies comprising a total of 1,929 patients with different head and neck cancers were included. Cyclin D1 overexpression was significantly associated with lymph node metastasis [OR 2.25; 95 % confidence interval (CI) 1.76-2.87] and worse disease-free survival (OR 3.06; 95 % CI 2.42-3.87]. Subgroup analysis revealed that cyclin D1 overexpression correlated significantly with nodal metastasis for laryngeal cancer (OR 2.26; 95 % CI 1.61-3.16) and was a significant poor predictor for nasopharyngeal cancer (OR 4.44; 95 % CI 1.89-10.42). Our meta-analysis suggests that cyclin D1 overexpression could represent an important prognostic indicator for patients with head and neck cancer.

2016 - Transaqueductal trans-Magendie fenestration of arachnoid cyst in the posterior fossa [Articolo su rivista]
Feletti, Alberto; Alicandri Ciufelli, Matteo; Pavesi, Giacomo
abstract

Neuroendoscopy is currently recommended as the first choice to treat posterior fossa arachnoid cysts. It has proven to be effective, providing improved outcome, and safe, having a low complication rate. Compared to craniotomy and shunt placement, it has lower surgical morbidity, minimizing or avoiding risks of subdural fluid collections, shunt infection, malfunction, overdrainage, and dependence. Usually, rigid scopes maneuvered through a suboccipital approach are used. When symptomatic obstructive hydrocephalus develops, CSF diversion is the first aim of surgery.

2015 - Clinical presentation and treatment outcomes of thyroglossal duct cysts: a systematic review [Articolo su rivista]
Gioacchini, F. M.; Alicandri-Ciufelli, M.; Kaleci, S.; Magliulo, G.; Presutti, L.; Re, M.
abstract

The aim of the present review was to analyze the main clinical signs and symptoms observed in patients with thyroglossal duct cysts (TGDCs). Secondarily we investigated the outcomes following the different types of treatment of TGDCs in children and adults. Three selected strings were run on the PubMed database to retrieve articles on these topics. A double cross-check was performed on citations and full-text articles were identified using the study inclusion and exclusion criteria. A meta-analysis was performed of the data obtained. Overall, 356 articles were identified; 24 (comprising a total of 1371 subjects) satisfied the inclusion and exclusion criteria. On the basis of the meta-analysis, the presence of a neck cystic mass was the main clinical presentation of TGDCs, with a mean rate of 75% (95% confidence interval 72-79%). The mean local wound infection rate was 4% (95% confidence interval 3-6%), this being the most frequent complication following treatment. The mean rate of overall recurrence was 11% (95% confidence interval 9-14%). The Sistrunk procedure appears to be the better choice for the therapy of TGDCs to avoid recurrences. Further studies on larger cohorts of patients regarding the minimally invasive treatment options would be helpful to elucidate and endorse their utilization in selected cases.

2015 - Endoscopic assisted cochlear implants in ear malformations [Articolo su rivista]
Marchioni, Daniele; Soloperto, Davide; Guarnaccia, MARIA CONSOLAZIONE; Genovese, Elisabetta; ALICANDRI CIUFELLI, Matteo; Presutti, Livio
abstract

The aim of present study is to describe the use of the endoscopic assisted cochlear implant approach in cases with severely malformed temporal bones and with anomalous anatomy of the inner ear and tympanic cavity. Eight patients with malformed middle and inner ear and bilateral profound hearing loss were operated using an endoscopic assisted cochlear implant procedure at our tertiary university referral center between January and September 2013. Five patients received a cochlear implant using a suprameatal endoscopic assisted approach. A chart review of clinical data and videos from the operations was performed. All procedures were re-analyzed and codified. In all patients, discharge from hospital was on the third day post-surgery. No immediate or late postoperative complications were noted. The current mean follow-up is 6 months, with range between 4 and 12 months. This approach proved to be successful in cochlear implant placement. It guaranteed a very good control on the facial nerve, even in cases with difficult anatomical conditions, mainly thanks to the endoscopic procedure. It also permitted an appropriate anatomical orientation of the abnormal middle ear with a direct safe cochleostomy, when the round window position would have been difficult to treat using a traditional approach.

2015 - Endoscopic transcanal corridors to the lateral skull base: Initial experiences [Articolo su rivista]
Marchioni, Daniele; ALICANDRI CIUFELLI, Matteo; Rubini, Alessia; Presutti, Livio
abstract

Surgical approaches to the lateral skull base, internal auditory canal (IAC), and petrous bone are widely known and have been extensively recorded. Despite the benign nature and limited dimensions of lesions located in this anatomical region, extirpative surgical approaches are often required to reach and remove the disease. The aim of present report was to describe our initial experiences with minimally invasive endoscopic approaches to the lateral skull base.

2015 - FDG-PET/CT appearance of injected silicone particles (VOX Implants®) in head and neck tissues [Articolo su rivista]
Piccinini, Alessia; ALICANDRI CIUFELLI, Matteo; Ghidini, Angelo; Bergamini, Giuseppe; Vincenti, Vincenzo; Bacciu, Andrea; Ferri, Teore; Cesinaro, Anna Maria; Presutti, Livio
abstract

Objetives: In head and neck surgery, Positron Emission Tomography/Computed Tomography imaging (FDG-PET/CT) is often used to identify primary tumor site in patients with unknown primary carcinoma, to predict response after chemoradiotherapy and in some cases, to detect recurrence. To rehabilitate swallowing after surgery in patients with persistent dysphagia, an injectable suspension of silicone (VOX® Implants) can be used to reduce the gaps in the neoglottis. The purpose of this report is to document the PET appearance of PDMS in a series of 3 patients who underwent partial laryngectomy  with subsequent VOX® Implants injection.

2015 - Facial nerve grading scales: systematic review of the literature and suggestion for uniformity [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Pavesi, Giacomo; Presutti, Livio
abstract

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2015 - Letter to the Editor: Gamma Knife radiosurgery for vestibular schwannoma [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Pavesi, Giacomo; Presutti, Livio
abstract

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2015 - Nimodipine in otolaryngology: from past evidence to clinical perspectives [Articolo su rivista]
Monzani, Daniele; Genovese, Elisabetta; Pini, Luigi Alberto; DI Berardino, F; Alicandri Ciufelli, Matteo; Galeazzi, Gian Maria; Presutti, Livio
abstract

As L-type voltage-gated calcium channels (VGCCs) control Ca(2+) influx and depolarisation of cardiac and vascular smooth muscle, they represent a specific therapeutic target for calcium channel blockers (CCBs), which are approved and widely used to treat hypertension, myocardial ischaemia and arrhythmias. L-type currents also play a role in calcium entry in the sensory cells of the inner ear. In hair cells of both cochlea and labyrinth, calcium cytoplasmic influx is the first physiological process that activates complex intracellular enzymatic reactions resulting in neurotransmitter release. Excessive calcium ion entry into sensory cells, as a consequence of L-VGCCs malfunction is responsible for over-activation of phospholipase A2 and C, protein kinase II and C, nitric oxide synthase and both endonucleases and depolymerases, which can cause membrane damage and cellular death if the cytoplasmic buffering capacity is overcome. Nimodipine, a highly lipophilic 1-4 dihydropyridine that easily crosses the brain-blood barrier, is generally used to reduce the severity of neurological deficits resulting from vasospasm in patients with subarachnoid haemorrhage. Moreover, due to its selective blocking activity on L-channel calcium currents, nimodipine is also suggested to be an effective countermeasure for cochlear and vestibular dysfunctions known as channelopathies. Indeed, experimental data in amphibians and mammalians indicate that nimodipine has a stronger efficacy than other CCBs (aminopyridine, nifedipine) on voltage-dependent whole-cell currents within hair cells at rest and it is the only agent that is also effective during their mechanically induced depolarisation. In humans, the efficacy of nimodipine is documented in the medical management of peripheral vestibular vertigo, sensorineural hearing loss and tinnitus, even in a pathology as complex as Ménière's disease. Nimodipine is also considered useful in the prophylaxis of damage to the facial and cochlear nerves caused by ablative surgery of cerebellopontine tumours; it has been recently hypothesised to accelerate functional recovery of recurrent nerve lesions during thyroid cancer surgery. Further trials with adequate study design are needed to test the efficacy of nimodipine in the treatment of vertigo due to cerebrovascular disease and vestibular migraine.

2015 - Prognostic value of Bcl-2 expression in squamous cell carcinoma of the larynx: a systematic review [Articolo su rivista]
Gioacchini, FEDERICO MARIA; ALICANDRI CIUFELLI, Matteo; Rubini, Corrado; Magliulo, Giuseppe; Re, Massimo
abstract

The aim of this systematic review was to determine the prognostic value of Bcl-2 immunostaining in patients affected by laryngeal squamous cell carcinoma. An appropriate search was conducted on PubMed to retrieve articles dealing with this topic. A double cross-check was performed on citations and full-text articles by 2 investigators independently to review all manuscripts and perform a comprehensive quality assessment. Of 115 abstracts identified, 15 articles were included. These studies reported on 1,150 patients with histologically confirmed diagnosis of laryngeal squamous cell carcinoma. Only a few studies showed a statistical correlation between Bcl-2 immunohistochemical expression and at least 1 of the clinical and histopathological parameters considered by the authors. Moreover, these findings were also discordant between them. Overall the studies analyzed suggested that Bcl-2 expression was statistically connected with N stage (2/14), grading (2/14), disease-free survival (3/14) and overall survival (5/14). Interestingly, all of the 3 studies investigating the relation between Bcl-2 and radioresistance showed significant results in terms of recurrence-free survival and overall survival. Our review strongly suggests that the immunohistochemical staining of Bcl-2 does not correlate with tumoral aggressiveness and prognosis of patients affected by laryngeal squamous cell carcinoma and treated with primary surgery. However, an interesting connection of this protein could be demonstrated with tumoral radioresistance. Further, high-quality prospective studies should be carried out to confirm this hypothesis.

2015 - Radiological assessment of the sinus tympani: temporal bone HRCT analyses and surgically related findings [Articolo su rivista]
Marchioni, Daniele; Valerini, Sara; Mattioli, Francesco; Alicandri Ciufelli, Matteo; Presutti, Livio
abstract

To evaluate the morphology of the sinus tympani (ST) based on computed tomography (CT) scans (axial view), describing the findings in a cohort of 148 patients (296 ears), and classifying the prevalence according to our ST classification. To evaluate the surgical prevalence based on the type of ST. To calculate the sensibility and positive predictive value (PPV) of high-resolution computed tomography (HRCT) scans for ST involvement by cholesteatoma.

2015 - Response to Letter to the Editor Regarding "The Role of Endoscope in Lateral Skull Base Surgery: Fact Versus Fiction" [Articolo su rivista]
Presutti, Livio; Alicandri Ciufelli, Matteo; Rubini, Alessia; Gioacchini, Federico Maria; Marchioni, Daniele
abstract

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2015 - The clinical relevance of Ki-67 expression in laryngeal squamous cell carcinoma [Articolo su rivista]
Gioacchini, FEDERICO MARIA; ALICANDRI CIUFELLI, Matteo; Magliulo, G.; Rubini, C.; Presutti, Livio; Re, M.
abstract

The aim of this study was to determine the prognostic value of Ki-67 immunostaining in patients affected by laryngeal squamous cell carcinoma. A systematic review was carried out in a tertiary university referral center. An appropriate string was run on PubMed to retrieve articles dealing with Ki-67 immunohistochemical staining and laryngeal squamous cell carcinoma. A double cross-check was performed on citations and full-text articles by two investigators independently to review all manuscripts and perform a comprehensive quality assessment. Of 85 abstracts identified, 18 articles were included. These studies reported on 1,342 patients with histological confirmed diagnosis of laryngeal squamous cell carcinoma. Most studies showed a statistical association between Ki-67 immunohistochemical expression and at least one of the clinical and histopathological parameters considered by the authors. Overall the studies analyzed suggested that the tumoral proliferative index was statistically connected respectively with T stage (2/18), N stage (4/18), grading (6/18), disease-free survival (10/18) and overall survival (4/18). Our review strongly suggests that immunohistochemical staining of Ki-67 correlates with tumoral aggressiveness and worse prognosis in patients affected by laryngeal squamous cell carcinoma. Further high-quality prospective studies should be carried out to confirm our finding and determine the eventual differences between cancers of specific laryngeal subsites.

2015 - The outcomes of endoscopic dacryocystorhinostomy in children: A systematic review [Articolo su rivista]
Gioacchini, Federico Maria; Alicandri Ciufelli, Matteo; Kaleci, Shaniko; Re, Massimo
abstract

To systematically review and discuss the published results about the application of endoscopic dacryocystorhinostomy in treating children with nasolacrimal duct obstruction.

2015 - The round window region and contiguous areas: endoscopic anatomy and surgical implications [Articolo su rivista]
Marchioni, Daniele; Alicandri Ciufelli, Matteo; Pothier, David D; Rubini, Alessia; Presutti, Livio
abstract

The round window region is a critical area of the middle ear; the aim of this paper is to describe its anatomy from an endoscopic perspective, emphasizing some structures, the knowledge of which could have important implications during surgery, as well as to evaluate what involvement cholesteatoma may have with these structures. Retrospective review of video recordings of endoscopic ear surgeries and retrospective database review were conducted in Tertiary university referral center. Videos from endoscopic middle ear procedures carried out between June 2010 and September 2012 and stored in a shared database were reviewed retrospectively. Surgeries in which an endoscopic magnification of the round window region and the inferior retrotympanum area was performed intraoperatively were included in the study. Involvement by cholesteatoma of those regions was also documented based on information obtained from the surgical database. Conformation of the tegmen of the round window niche may influence the surgical view of round window membrane. A structure connecting the round window area to the petrous apex, named the subcochlear canaliculus, is described. Cholesteatoma can invade the round window areas in some patients. Endoscopic approaches can guarantee a very detailed view and allow the exploration of the round window region. Exact anatomical knowledge of this region can have important advantages during surgery, since some pathology can invade inside cavities or tunnels otherwise not seen by instrumentation that produces a straight-line view (e.g. microscope).

2015 - The transcanal transpromontorial corridor to treat cochlear schwannomas [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Marchioni, Daniele; Presutti, Livio
abstract

N/D

2014 - Aesthetic comparison between synthetic glue and subcuticular sutures in thyroid and parathyroid surgery: a single-blinded randomised clinical trial [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Piccinini, Alessia; Grammatica, Alberto; Molteni, G; Spaggiari, Alan; DI Matteo, S; Tassi, S; Ghidini, Angelo; Izzo, L; Gioacchini, F. M; Marchioni, D; DI Saverio, S; Presutti, Livio
abstract

The aim of our study was to compare, in terms of aesthetic results, the use of synthetic glue to intradermal absorbable sutures in postthyroidectomy and parathyroidectomy wound closure in a single blinded, randomised, per protocol equivalence study. From September 2008 to May 2010, patients undergoing thyroid or parathyroid surgery (with an external approach) at the Otolaryngology Department of the University Hospital of Modena were assessed for eligibility. In total, 42 patients who had had synthetic glue application on surgical incisions (A) and 47 patients who had subcuticular sutures on their surgical incisions (B) were enrolled. The mean of the endpoint (based on the Wound Registry Scale) of group A at 10 days was 1.4, while that in group B (based on the Stony Brook Scar Evaluation Scale) was 2.9. Statistically significant (p = 0.002) and clinically significant (difference of the means = 1.5) differences in the aesthetic results were found between groups A and B at 10 days, with better results in group B. On the other hand, at 3 months, the mean of the endpoint in group A was 3.1 while that in group B was 2.8; no statistically significant (p = 0.62) or clinically significant (difference in means = 0.3) differences were found between groups A and B. In conclusion, synthetic glue differs from subcuticular suture in post-thyroidectomy or post-parathyroidectomy incision for early aesthetic results, with better outcomes for subcuticular sutures. At 3 months, there were no differences in aesthetic outcomes between groups. Moreover, sex, incision length, age, cold/hot blade and correspondence of the incision with a wrinkle in the skin did not seem to influence aesthetic outcomes with this type of incision.

2014 - Combined approach for tegmen defects repair in patients with cerebrospinal fluid otorrhea or herniations: our experience [Articolo su rivista]
Marchioni, Daniele; Bonali, Marco; ALICANDRI CIUFELLI, Matteo; Rubini, Alessia; Pavesi, Giacomo; Presutti, Livio; Bonali, Marco
abstract

Objectives To describe our departmental experience in the surgical repair of tegmen tympani defects using a combined transmastoid/minicraniotomic approach. Design Retrospective review of videos from surgery and patients' charts. Setting Tertiary university referral center. Participants Twenty-two patients who underwent surgical repair of tegmen defects associated with cerebrospinal fluid (CSF) leakage and/or meningocele/meningoencephalocele by a combined transmastoid/minicraniotomic approach. Main Outcome Measures A retrospective review of videos of surgery and charts of patients with tegmen tympani or tegmen antri defects and CSF leakage, temporal lobe encephalocele, and/or meningoencephalocele. Results All patients underwent the combined approach and had their defects closed, without significant intraoperative or postoperative complications. Conclusions Mastoidectomy with temporal minicraniotomy represents an effective approach in patients with tegmen tympani dehiscence; the advantages of this technique are the control of the floor of the middle cranial fossa and the possibility to reach bony defects located anteriorly without manipulation of the ossicular chain and temporal lobe.

2014 - Combined endoscopic-microscopic approach for vestibular schwannoma removal: outcomes in a cohort of 81 patients [Articolo su rivista]
Presutti, L; Magnaguagno, F; Pavesi, G; Cunsolo, E; Pinna, G; Alicandri-Ciufelli, M; Marchioni, D; Prontera, A; Gioacchini, Fm
abstract

Patients affected by vestibular schwannomas typically report a number of symptoms and minor disabilities after surgery. Therefore, surgeons dealing with this pathology should also try to achieve a good QoL for patients who have undergone tumour removal. The aim of this study was to analyse QoL in subjects undergoing surgery for vestibular schwannomas and to try to establish a relationship with both the tumour size and post-surgical alterations (e.g. facial motor dysfunctions, difficulties in balance, persistence of headache and tinnitus). A retrospective analysis was performed on a consecutive series of 81 patients affected by vestibular schwannomas and treated by a combined microscopic-endoscopic approach. Three groups of patients were identified on the basis of tumour size. Group 1 (lesions < 25 mm) with 31 patients (38%); Group 2 (lesions > 26 mm and < 40 mm) with 39 patients (48%); Group 3 (lesions > 41 mm) with 11 patients (14%). Data obtained with the Short Form Questionnaire showed a statistically significant difference in QoL in those undergoing intervention compared with a control group of healthy subjects. The Glasgow Benefit Inventory Questionnaire showed that 25 (31%) patients felt better, 11 (14%) felt similarly, and 45 (55%) felt poorer health conditions in comparison to the pre-surgical period. Concerning the relationship between preservation of facial nerve function and QoL, using the Glasgow Health Status Inventory, it appeared that only 34% of subjects with good facial nerve function (RGS grade I-II) complained of worsening of QoL, while 45% of those with serious facial nerve injury (RGS grade IV-V) referred poorer QoL. Moreover, the possibility of recovery of facial nerve function during the months following surgery was clearly highlighted by our analysis. Our study confirmed the close relation between tumour size and post-surgical QoL, which is worse for patients affected by larger lesions.

2014 - Combined lateral microscopic/endoscopic approaches to petrous apex lesions: pilot clinical experiences [Articolo su rivista]
Presutti, Livio; ALICANDRI CIUFELLI, Matteo; Rubini, Alessia; Gioacchini, FEDERICO MARIA; Marchioni, Daniele
abstract

Surgical treatment of lesions involving the temporal bone, petrous apex, or internal auditory canal is usually performed using the classical microscopic approach that necessitates wide external incisions and soft tissue dissection. At present, the main application of endoscopic surgery is in the surgical treatment of middle ear cholesteatoma, but with the natural evolution of the technique, there will be an increasing number of applications in lateral skull base surgery.

2014 - Ecthyma gangrenosum in a newborn causing external otitis with complete facial nerve palsy [Articolo su rivista]
Gioacchini, FEDERICO MARIA; Baccarani, Alessio; Villari, Domenico; Postacchini, Valentina; ALICANDRI CIUFELLI, Matteo
abstract

Ecthyma gangrenosum (EG) involving the external ear canal is an unusual presentation.

2014 - Endoscopic cochlear implant procedure [Articolo su rivista]
Marchioni, Daniele; Grammatica, Alberto; ALICANDRI CIUFELLI, Matteo; Genovese, Elisabetta; Presutti, Livio
abstract

The objective was to asses the feasibility of the endoscopic technique for cochlear implant (CI) positioning avoiding mastoidectomy and to discuss the benefits and drawbacks of the technique. The study design is a surgical procedure description and prospective case series report. From December 2011 to October 2012, six patients underwent endoscopic CI. All cases were selected based on CT and MRI studies. All surgical steps were analyzed; intra-and post-operative complications were noted. The length of time for each surgical procedure was recorded. The surgical procedure was described step by step focusing on the anatomy of the round window (RW) niche, analyzing the critical point during the dissection. The timing of the surgical procedures was 120 ± 21 (mean ± SD) min. In 1/6 patients, intra-operative injury of the chorda tympani occurred. In all cases, an endoscopic identification was performed and the anatomical details of the RW niche were noted. In 6/6 cases, a RW niche magnification was performed endoscopically. 5/6 cases showed a normal conformation of the RW. In 1/6 patients, obliteration of the RW niche was found. In 4/6 patients, an endoscopic cochleostomy through the RW was performed. In 1/6 patients, a difficult insertion of the array was observed. The current follow-up is 7.3 months (SD ± 3.7). No post-operative short- or long-term complications were noted in this series. Endoscopic CI is a safe and viable technique with a low rate of complications and with good outcomes.

2014 - Partial laryngectomies: when the problem is the pexy [Articolo su rivista]
Ruberto, Marco; ALICANDRI CIUFELLI, Matteo; Grammatica, Alberto; Marchioni, Daniele; Bergamini, Giuseppe; Presutti, Livio
abstract

To analyse the complications related to pexy, the main clinical manifestations that may raise suspicions of a pexy line rupture/detachment, the most suitable diagnostic technique and the optimum treatment to resolve this complication. This is a retrospective chart review in tertiary university referral centre. Medical charts of patients with oncological laryngeal pathologies admitted to the Otolaryngology Department of the University Hospital of Modena between May 2003 and March 2012 were analysed. Ten patients with rupture of the pexy were identified and included in the present study. The clinical manifestations were dysphagia, alteration of sensitivity of hypopharyngeallaryngeal structures, fever, infection and diastasis of surgical wounds, bleeding, dysphonia and aspiration pneumonia. Rupture of the pexy was diagnosed through endoscopic evaluations, radiological techniques or directly in the operating room during revision surgery of the earlier operation. Surgical treatments, coupled with effective swallowing rehabilitation, allowed progressive functional recovery. Patients were hospitalised until recovery of laryngeal functions was complete. In conclusion, pexy line rupture is one of the complications in the post-operative period of partial laryngectomies. Certain clinical manifestations may indicate this complication, helping the surgeon to establish an early diagnosis and administer prompt treatment.

2014 - Prevalence and diagnosis of vestibular disorders in children: a review [Articolo su rivista]
GIOACCHINI, FEDERICO MARIA; ALICANDRI CIUFELLI, Matteo; KALECI, SHANIKO; Magliulo, Giuseppe; Re, Massimo
abstract

To systematically review and discuss the main pathologies associated with vertigo and dizziness in children, paying particular attention to recent advances in diagnosis and therapy.

2014 - Results of endoscopic middle ear surgery for cholesteatoma treatment: a systematic review [Articolo su rivista]
Presutti, Livio; ALICANDRI CIUFELLI, Matteo
abstract

Traditional surgery for cholesteatoma of the middle ear is performed by microscopic approaches. However, in recent years endoscopic instrumentation, techniques and knowledge have greatly improved, and in our opinion endoscopic surgical techniques will gain increasing importance in otologic surgery in the future. The aim of this study was to focus on outcomes obtained using endoscopic surgery for the treatment of middle ear cholesteatoma. A systematic review of the literature was performed. A total of 7 articles comprising 515 patients treated exclusively with endoscope or with a combined technique were found. During post-surgical follow-up, 48 (9.3%) patients showed a residual or recurrent pathology. Despite the small number of patients analyzed in our review, the outcomes of this technique appear to be promising. In particular, concerning the rates of recurrences and residual disease, endoscopic middle ear surgery appears to guarantee similar results in comparison to classic microscopic approaches with the advantage of performing minimally invasive surgery.

2014 - The role of antibiotic therapy and nasal packing in septoplasty [Articolo su rivista]
GIOACCHINI, FEDERICO MARIA; ALICANDRI CIUFELLI, Matteo; KALECI, SHANIKO; Magliulo, Giuseppe; Re, Massimo
abstract

Both systemic antibiotic therapy and nasal packing are used frequently in septoplasty. Nevertheless, there is still great disagreement among authors around the real advantages with regard to the efficacy of both of these procedures in septal surgery. The aim of the present review was to evaluate the more recent data published on this topic. One appropriate string was run on PubMed to retrieve articles dealing with the topics mentioned above. A double cross-check was performed on citations and full-text articles found using the selected inclusion and exclusion criteria. Overall, the articles we analyzed indicated the poor utility of routine antibiotic therapy and nasal packing during septoplasty, the latter procedure producing more complications than advantages. In conclusion, on the basis of the recent literature, the use of systemic antibiotic prophylaxis and nasal packing in septal surgery seems to be a non-rational procedure.

2013 - A step backward: the “Rough” facial nerve grading system [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Piccinini, Alessia; Grammatica, Alberto; Salafia, Francesca; Ciancimino, Cristel; Cunsolo, Eliomaria; Pingani, Luca; Rigatelli, Marco; Genovese, Elisabetta; Monzani, Daniele; Gioacchini, FEDERICO MARIA; Marchioni, Daniele; Presutti, Livio
abstract

Several modalities currently exist to rate the degree of facial function clinically but even though it has significant limitations, the most widely used scale is the House-Brackmann grading system (HBGS). A simplified scale is introduced here, the 'Rough' Grading System (RGS - Grade I: normal movement; Grade II: slight paralysis; Grade III: frank paralysis with eye closure; Grade IV: frank paralysis without eye closure; Grade V: almost complete paralysis with only slight movements; Grade VI: total paralysis). The aim of the present study was to verify the interrater reliability and the interscale validity of this simplified grading system. STUDY DESIGN: Scale validation study based on a prospective cohort. METHODS: Fifty patients with facial palsy, consecutively referred to our department were filmed while performing some codified facial movements. Then two independent groups (one rating using the HBGS, the other rating using the RGS) assigned a grade after reviewing the videos. The time required for the rating was also noted. RESULTS: The HBGS showed a mean value of interrater agreement of 0.46 while the RGS showed a mean value of 0.59. The concurrent validity between HBGS and RGS ranged from 0.86 to 0.90 (p < 0.001 for every comparison). There was no statistically significant difference between HBGS and RGS in the mean time taken for rating (p = 0.15). CONCLUSIONS: The RGS reached an adequate level of interrater reliability, higher than the HBGS. The correlation between the two scales is high and the times required for rating are similar. The present results may justify the use of the RGS in routine clinical practice. LEVEL OF EVIDENCE: N/A

2013 - Beyond the middle ear: endoscopic surgical anatomy and approaches to inner ear and lateral skull base [Articolo su rivista]
Presutti, Livio; Nogueira, João Flávio; ALICANDRI CIUFELLI, Matteo; Marchioni, Daniele
abstract

Currently, the main application of endoscopic surgery relies on the middle ear cholesteatoma surgical treatment. However, in the natural evolution of the technique there are the steps toward of lateral skull base surgery and treatment of pathologic conditions of pertous bone. The endoscopic approaches to lateral skull base are (1) a transcanal exclusively endoscopic approach or (2) combined approaches (microscopic endoscope-assisted), including transotic, infralabyrinthine, and suprameatal translabyrinthine.

2013 - Cochlear schwannoma removed through the external auditory canal by a transcanal exclusive endoscopic technique [Articolo su rivista]
Presutti, Livio; ALICANDRI CIUFELLI, Matteo; Cigarini, Elisa; Marchioni, Daniele
abstract

Surgical approaches to the inner ear and internal auditory canal (IAC) are widely known and extensively recorded. The most popular can be classified as retrosigmoid, transmastoid-translabyrinthine, and middle cranial fossa approaches. For the first time, an exclusive endoscopic approach to the IAC is described here, used to remove a cochlear schwannoma involving both the IAC and labyrinth. The operation provided a direct transcochlear intradural approach from lateral to medial and from external to internal auditory canal, without any external incision. The pathology was totally removed, and the postoperative outcome of the facial nerve was grade II (House-Brackmann grading system) at 3-month follow-up.

2013 - Endoscopic anatomy and ventilation of the epitympanum [Articolo su rivista]
Marchioni, Daniele; Piccinini, Alessia; ALICANDRI CIUFELLI, Matteo; Presutti, Livio
abstract

The use of an endoscope with varied angulations has allowed the surgeon to explore areas that were often not visualized using standard microscopic procedures. The endoscope has improved knowledge of the complex anatomy of mucosal fold and improved functional interventions in middle ear inflammatory disorders during middle ear surgery; intraoperative evaluation of middle ear anatomy during endoscopic surgery for inflammatory disorders helps surgeon visualize anatomic blockages of the middle ear ventilation trajectories. This article discusses the anatomy of the epitympanum and the ventilation patterns and pathophysiology of epitympanic retraction.

2013 - Endoscopic management of attic cholesteatoma: a single-institution experience [Articolo su rivista]
Marchioni, Daniele; Villari, Domenico; Mattioli, Francesco; ALICANDRI CIUFELLI, Matteo; Piccinini, Alessia; Presutti, Livio
abstract

At present, the main application of endoscopic surgery is in the surgical treatment of middle ear cholesteatoma; however, for definitive validation and acceptance by scientific community, results are needed regarding recurrent and residual rates of the condition. This article analyzes the single-institution experience from results of surgical treatment of attic cholesteatoma.

2013 - From external to internal auditory canal: Surgical anatomy by an exclusive endoscopic approach [Articolo su rivista]
Marchioni, D.; Alicandri-Ciufelli, M.; Mattioli, F.; Nogeira, J. F.; Tarabichi, M.; Villari, D.; Presutti, L.
abstract

Surgical approaches to the inner ear and internal auditory canal (IAC) are well known and well documented. The objective of this study is to analyze the morphology, and surgical and anatomic findings of an exclusive endoscopic transcanal approach (EETA) to the IAC. Cadaveric dissections were performed on 11 temporal bones, approaching the internal auditory meatus directly through the external ear canal and avoiding mastoidectomy. In all cases, it was possible to dissect the internal carotid artery and jugular bulb with a 0° endoscope, and with good control of these two structures. The medial wall of the bony labyrinth guaranteed good landmarks for IAC dissection, such as the spherical recess, and the labyrinthine tract of the facial nerve. The IAC can be thoroughly visualized in the cadaver using EETA, avoiding mastoidectomy, extensive temporal bone tissue removal and external incisions. Clinically based reports will be required in future to strengthen our preliminary results. © 2012 Springer-Verlag.

2013 - Prevalence of ventilation blockages in patients affected by attic pathology: a case-control study [Articolo su rivista]
Marchioni, Daniele; Mattioli, Francesco; ALICANDRI CIUFELLI, Matteo; Presutti, Livio
abstract

Using a retrospective video evaluation of exclusive endoscopic middle ear procedures, we analyzed the different anatomical and pathological findings between patients with attic disease or cholesteatoma and patients without attic disease.

2013 - Surgical margins in head and neck squamous cell carcinoma: what is 'close'? [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Bonali, Marco; Piccinini, Alessia; Marra, Laura; Ghidini, Angelo; Cunsolo, Elio Maria; Maiorana, Antonino; Presutti, Livio; Conte, Pier Franco
abstract

The aim of this systematic review is to evaluate the definition of close margin in head and neck squamous cell carcinoma (HNSCC), and its possible prognostic significance. An appropriate string was run on PubMed to retrieve articles discussing the 'close' surgical margin issue in HNSCC. A double cross-check was performed on citations and full-text articles retrieved. In total, 348 articles were identified. Further references were included by using the option "Titles in your search terms" option in PubMed. 15 papers were finally included for qualitative synthesis. In vocal cord surgery of HNSCC, a close margin could be considered to be ≤1 mm, in the larynx ≤5 mm, in the oral cavity ≤4 mm, and in the oropharynx ≤5 mm. In each patient, the choice of extent of close margin should be balanced against general condition, tumor stage, and functional issues to indicate appropriate adjuvant therapy.

2013 - Transcanal endoscopic treatment of benign middle ear neoplasms [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; PRESUTTI, Livio; MARCHIONI, Daniele; GIOACCHINI, FEDERICO MARIA; BONALI, MARCO
abstract

The application of endoscopic surgery for middle ear pathologies is rapidly increasing. At present, its main application is in the treatment of middle ear cholesteatoma. This report describes the application of this technique as treatment for some benign lesions that may involve the middle ear cleft. A retrospective chart review of six patients who underwent exclusive endoscopic tympanic cavity surgery for benign neoplasms was performed between November 2011 and January 2012. Based on charts, images, and surgical reports, data from the patients were summarized for further consideration. All of the six lesions were in the tympanic cavity without involvement of the mastoid region. An exclusive endoscopic transcanal approach was used in all cases. No patient showed signs or symptoms of pathology recurrence. Endoscopic transcanal excision of benign tympanic cavity neoplasms represents a safe procedure, with minimal morbidity and without external incisions or mastoidectomies.

2013 - Voice and swallowing after partial laryngectomy: Factors influencing outcome [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Piccinini, Alessia; Grammatica, Alberto; Chiesi, Andrea; Bergamini, Giuseppe; Luppi, Maria Pia; Nizzoli, Federica; Ghidini, Angelo; Tassi, Sauro; Presutti, Livio
abstract

Background The purpose of this study was to assess the factors influencing swallowing and phonatory results after partial laryngectomy. Methods We carried out a medical chart review of patients who underwent partial laryngectomies between June 2003 and November 2010, focusing on functional outcomes. Results Thirty-two patients were enrolled. No statistically significant difference was found in the comparison of phonatory outcomes of patients with preservation of both arytenoids; the results of the Yanagihara classification were significantly different (p =.015) in patients with an atypical neoglottis; radiotherapy statistically significantly influenced only the mean fundamental frequency (p =.035). The type of partial laryngectomy does not seem to affect the deglutition results; radiotherapy statistically significantly affected the dysphagia score (DS; p =.03), penetration aspiration (p =.02), and MD Anderson Dysphagia Inventory (MDADI; p =.02). Conclusion Horizontal supraglottic laryngectomy and supracricoid partial laryngectomy give the same swallowing results. The presence of both arytenoids does not influence the final outcome compared to patients in whom only 1 arytenoid is preserved. Postoperative radiotherapy only influences the swallowing function. © 2012 Wiley Periodicals, Inc.

2012 - A clockwork ear [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Soloperto, Davide; Palma, Silvia; Marrara, Antonino; Genovese, Elisabetta
abstract

Objective tinnitus refers to a tinnitus that can also be heard by the examiner. It is a relatively rare condition, and can be misdiagnosed or neglected. Some causes of objective tinnitus are head and neck vascular malformations, or muscular myoclonus of the tensor tympani, stapedial, or palatal muscles. The case of an 11-year-old girl with an objective tinnitus lasting from 1 year is herein presented, and the diagnostic workup performed in this unusual case is described.

2012 - Bronchial selective ventilation in a wide tracheocutaneous fistula [Articolo su rivista]
Marchioni, A.; Mattioli, F.; Piccinini, A.; Marchioni, D.; Alicandri-Ciufelli, M.; Monelli, M.; Presutti, L.
abstract

We present the treatment and management of a wide tracheocutaneous fistula after tracheotomy correlated with excessive cuff pressure in a 36-year-old woman with cerebral palsy since infancy in which persistent type II respiratory failure required continuous ventilatory support. We discuss the surgical treatment adopted for the management of this particularly wide lesion. At the end of surgery, mechanical ventilation through a tracheal cannula was hindered by the reduced length of the residual trachea below the tracheotomy. The need to guarantee mechanical ventilation to the patient led to the implementation of a cuff securing system in the two main bronchi. We describe the approach that may be attempted under extreme conditions, when traditional ventilation methods cannot be applied for anatomical reasons. © 2012.

2012 - Effect of a fixed combination of nimodipine and betahistine versus betahistine as monotherapy in the long-term treatment of Ménière's disease: a 10-year experience [Articolo su rivista]
Monzani, Daniele; Barillari, M. R; ALICANDRI CIUFELLI, Matteo; Aggazzotti Cavazza, E; Neri, Vincenzo; Presutti, Livio; Genovese, Elisabetta
abstract

Despite an abundance of long-term pharmacological treatments for recurrent vertigo attacks due to Ménière's disease, there is no general agreement on the their efficacy. We present the results of a retrospective study based on a 10-year experience with two long-term medical protocols prescribed to patients affected by Ménière's disease (diagnosed according to the American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium guidelines) who completed treatments in the period 1999-2009. A total of 113 medical records were analysed; 53 patients received betahistine-dihydrochloride at on-label dosage (32 mg die) for six months, and 60 patients were treated with the same regimen and nimodipine (40 mg die) as an add-therapy during the same period. Nimodipine, a 1,4-dihydropyridine that selectively blocks L-type voltage-sensitive calcium channels, has previously been tested as a monotherapy for recurrent vertigo of labyrinthine origin in a multinational, double-blind study with positive results. A moderate reduction of the impact of vertigo on quality of life (as assessed by the Dizziness Handicap Inventory) was obtained in patients after therapy with betahistine (p < 0.05), but a more significant effect was achieved in patients treated by combined therapy (p < 0.005). In the latter group, better control of vertigo was seen with a greater reduction of frequency of attacks (p < 0.005). Both protocols resulted in a significant improvement of static postural control, although a larger effect on body sway area in all tests was obtained by the fixed combination of drugs. In contrast, no beneficial effect on either tinnitus annoyance (as assessed by the Tinnitus Handicap Inventory) and hearing loss (pure-tone average at 0.5, 1, 2, 3 kHz frequencies of the affected ear) was recorded in patients treated with betahistine as monotherapy (p > 0.05), whereas the fixed combination of betahistine and nimodipine was associated with a significant reduction of tinnitus annoyance and improvement of hearing loss (p < 0.005). It was concluded that nimodipine represents not only a valid add-therapy for Ménière's disease, and that it may also exert a specific effect on inner ear disorders. Further studies to investigate this possibility are needed.

2012 - Herpes zoster oticus: a clinical model for a transynaptic, reflex pathways, viral transmission hypotheses [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Genovese, Elisabetta; Monzani, Daniele; Presutti, Livio; Aggazzotti Cavazza, Elisa
abstract

Reactivation of the varicella-zoster virus (VZV) along the sensory nerves innervating the ear, including the geniculate ganglion, is responsible for herpes zoster oticus (HZO). In some cases, HZO is associated with polyneuropathy of the cranial nerves, although the mechanism of this involvement is not known. To explain this phenomenon and based on some clinical considerations, the present authors hypothesize an intersynaptic spread of VZV along the reflex pathways of the brainstem

2012 - Mastoid: a vestigial function in humans? [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Gioacchini, FEDERICO MARIA; Marchioni, Daniele; Genovese, Elisabetta; Monzani, Daniele; Presutti, Livio
abstract

At the present time, the function of the mastoid remains unknown. One of the main hypotheses accredited in the literature interprets the mastoid as a pressure buffer. Other theories underline the role of the mastoid mucosa in pressure regulation by transmucosal gas exchanges. The question is what advantage does air reabsorption and the creation of a certain degree of negative pressure that mastoid seems to produce, bring to the middle ear and hearing? In the authors' opinion, it is possible that the mastoid, or, in general, every kind of mucosa contained in the middle ear of mammals, would act to create a quite constant, although slight, negative pressure to obtain favorable compliance and impedance conditions in the middle ear to hear and transmit high frequency sounds and ultrasounds. The Eustachian tube, in this perspective, would compensate excessive values of negative pressure. Clearly, that function of mastoid pneumatization in humans would have lost its role, due to the absence of a sensorineural system to analyse ultrasounds.

2012 - Otolaryngology fantastica: the ear, nose, and throat manifestations of Munchausen's syndrome [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Moretti, Valentina; Ruberto, Marco; Monzani, Daniele; Chiarini, Luigi; Presutti, Livio
abstract

OBJECTIVES/HYPOTHESIS: Munchausen's syndrome (MS) is a form of severe, chronic, factitious disorder with physical symptoms. Some essential features define MS, such as recurrent, feigned, or simulated illness; peregrination (traveling or wandering); pseudologia fantastica; and drug abuse. Munchausen's syndrome by proxy (MSBP) classically involves a parent or other caregiver who inflicts injury or induces illness in a child. The aim of the present study was to summarize and study the main ear, nose, and throat (ENT) manifestations of MS and MSBP.STUDY DESIGN: A systematic literature review carried out in a tertiary university referral center.METHODS: An appropriate string was run on PubMed to retrieve articles dealing with ENT manifestations of MS and MSBP. A double cross-check was performed on citations and full-text articles found using selected inclusion and exclusion criteria.RESULTS: In total, 24 articles were finally included in the study, describing 30 cases of MS or MSBP involving the ENT region; 15/30 (50%) cases involved the face, most often presenting as facial pain or facial swelling; and 7/30 (23.3%) cases presented with symptoms involving the ear. Six cases out of 30 (20%) were MSBP.CONCLUSIONS: MS and MSBP may present with symptoms involving the head and neck area, particularly the face and external ear canal. The ENT specialist should suspect MS in patients with strange and long-lasting symptoms, so as to avoid misdiagnosis and unnecessary treatments that waste time and money in the healthcare sector.

2012 - Radiology quiz case 2. Imperforate right submandibular duct [Articolo su rivista]
Bonali, Marco; ALICANDRI CIUFELLI, Matteo; Presutti, Livio
abstract

no abstract

2012 - Response to "ossicular chain preservation in epitympanic cholesteatoma surgery: The modified bondy technique" [Articolo su rivista]
Marchioni, D.; Alicandri Ciufelli, M.; Molteni, G.; Villari, D.; Monzani, D.; Presutti, L.
abstract

2012 - Tympanoplasty: an up-to-date pictorial review [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Marchioni, Daniele; Grammatica, Alberto; Soloperto, Davide; Carpeggiani, Paolo; Monzani, Daniele; Presutti, Livio
abstract

The indications for tympanoplasty are mainly chronic ear pathologies, such as cholesteatoma, atelectasis and chronic tympanosclerotic otitis. Usually, modification of the mastoid and temporal tissues in general mostly involves bone work, which means bone removal by burs or appropriate bone curettes. It is for this reason that, in both the pre- and postoperative periods, the computed tomography (CT) scan is the primary radiological tool for studying the middle-ear, and temporal bone structures and pathologies. The aim of this review is to illustrate the most up-to-date postoperative results for tympanoplasty, including the emerging endoscopic techniques. The present work focuses on the five types of tympanoplasty that are likely to be encountered by the radiologist: radical surgery; open tympanoplasty; closed tympanoplasty; closed endoscopic tympanoplasty; and open endoscopic tympanoplasty. Understanding and interpreting temporal bone images in relation to the different types of surgery are important, especially at the postoperative stage, because of the high risk of recurrence of middle-ear pathologies, and a good working knowledge of surgical changes is fundamental for distinguishing iatrogenic bone demolition from complications and new pathological foci.

2011 - Atypical neoglottis after supracricoid laryngectomy: a morphological and functional analysis [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Piccinini, Alessia; Bergamini, Giuseppe; Ruberto, Marco; Ghidini, Angelo; Marchioni, Daniele; Presutti, Livio
abstract

The objective of this study was to analyze atypical neoglottis after supracricoid subtotal laryngectomy (SSL) from a morphological and functional point-of-view using retrospective case series reviewin a Tertiary university referral center setting. From May 2003 until January 2010, 106 patients underwent SSL (CHEP, CHP, THEP, THP) for laryngeal cancer, in the Otolaryngology Department of the University Hospital of Modena. We performed a retrospective analysis of recorded videos in our database of patients who underwent SSL. Patients with atypical neoglottis were included in the study. Six patients with atypical neoglottis were identified and morphologically evaluated. The functional outcomes were collected and analyzed. Atypical neoglottis may form after SSL, in particular in the case of CHEP. In most cases, these atypical conformations are due to anomalous positioning of the epiglottis, or involvement of the lateral pharyngeal wall in the sphincteric and vibratory function of the neoglottis. Atypical neoglottis formation seems to guarantee adequate functional outcomes in terms of vocal and swallowing performance.

2011 - Endoscopic open technique in patients with middle ear cholesteatoma [Articolo su rivista]
Marchioni, Daniele; Villari, Domenico; ALICANDRI CIUFELLI, Matteo; Piccinini, Alessia; Presutti, Livio
abstract

The objective of this study was to describe an endoscopic open "centrifugal" technique used to treat middle ear cholesteatoma with antral and periantral extension, using a retrospective chart and video review of a case series performed in a university tertiary referral center. Charts and videos of patients who underwent middle ear endoscopic surgery from January 2007 to September 2009 were reviewed. Patients who were treated with endoscopic "centrifuge" open techniques were included in the study. Surgical indications were collected and the surgical technique described. The final study group consisted of 12/150 subjects (9 males and 3 females with a mean age of 40 years). All 12 patients who underwent endoscopic open tympanoplasty had antral, periantral or mastoid involvement of cholesteatoma with or without posterior canal wall erosion. They had sclerotic mastoids with the presence of the antrum and, in some cases, small periantral mastoid cells. In 9/12 patients, external auditory canal reconstruction was performed with a cartilage graft. In 3/12 patients, canal reconstruction was not performed. No subjects required a meatoplasty of the external auditory canal. Endoscopic "centrifugal" open techniques can be an option in the surgical management of middle ear cholesteatoma involving antral and periantral mastoid cells, in the case of sclerotic mastoids. Further study will be necessary to examine the long-term consequences of the endoscopic "centrifugal" open technique. Level of evidence: 2C. © 2011 Springer-Verlag.

2011 - Horizontal glottectomy: is it an out-of-date procedure? [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Monzani, Daniele; Presutti, Livio; Molteni, Gabriele; Mattioli, Francesco; Bergamini, Giuseppe; Tassi, Sauro; D'Angeli, Ilaria; Izzo, Paolo; Izzo, Luciano
abstract

Purpose: The aim of the study is to illustrate our experience with horizontal glottectomy (HG), reviewing the indications and results of this uncommon partial laryngectomy. Materials and Methods: It is a retrospective study. We completed a chart review of patients who underwent partial laryngectomy between May 2003 and June 2010. Patients who underwent HG were included in the study. Data obtained were collected and analyzed. Results: Seven male patients were included in the study (mean age was 78 years; range, 69-88 years). In all cases, the TNM classification was pT1bN0M0 apart from one patient who had pT1N1MO. Three patients had a moderately differentiated neoplasm (G2), whereas 4 patients had a well-differentiated tumor (G1). Tracheotomy tube removal, oral feeding, and voice analysis have been evaluated and reported in the study. Mean follow-up was 16 months. Conclusions: Horizontal glottectomy might be a worthwhile treatment option in selected patients nowadays. In older patients with anterior commissure involvement, this procedure guarantees adequate functional and good oncological results. This study may possibly help surgeons dealing with glottic cancer involving the anterior commissure because we believe that some patients could benefit from HG, even in this radiotherapy and transoral laser surgery "era." (C) 2011 Elsevier Inc. All rights reserved.

2011 - MR evaluation of PDMS injections in head and neck tissues: a pilot study [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Ligabue, Guido; Grammatica, Alberto; Bergamini, Giuseppe; Marchioni, Daniele; Ghidini, Angelo; Genovese, Elisabetta; Presutti, Livio
abstract

To describe the magnetic resonance (MR) appearance of polydimethylsiloxane (PDMS) injections in the head and neck region.Retrospective review of MR images from a case series.MR images of 10 patients, who underwent PDMS injections at our department, were reviewed. Data from imaging were collected and analyzed.After injection, PDMS can be identified in MR images, particularly in T2-weighted images in the early stages. Its MR characteristics are similar to silicone in other regions, but with time, its appearance can change.The integration of PDMS with tissues may also be reflected in changes in MR appearance, as a result of an increased amount of fibrous tissue in the region injected. Radiologists and ENT specialists may benefit from knowledge of the MR characteristics and variability in appearance of PDMS in human tissues for improving image interpretation.

2011 - Ossicular Chain Preservation After Exclusive Endoscopic Transcanal Tympanoplasty: Preliminary Experience [Articolo su rivista]
Marchioni, Daniele; ALICANDRI CIUFELLI, Matteo; Molteni, Gabriele; Villari, Domenico; Monzani, Daniele; Presutti, Livio
abstract

Objectives: The aim of the present study is to document and analyze the ossicular chain preservation rate in patients affected by acquired primary cholesteatoma with epitympanic involvement and with preoperative intact ossicular chain. Study Design: A retrospective case series in a tertiary university referral center. Methods: From January 2006 to February 2010, at the Otolaryngology Department of the University Hospital of Modena, 68 patients affected by acquired primary cholesteatoma with attic involvement underwent exclusive endoscopic transcanal tympanoplasty. In April 2010, we performed a retrospective chart and video review of these patients. Patients in whom the ossicular chain was found to be intact and not involved by the pathology at the beginning of the operation were included in the study. A cholesteatoma staging was introduced based on tympanic subsite involvement by pathology. Results: Out of 68 patients affected by acquired primary cholesteatoma and who underwent exclusive endoscopic transcanal tympanoplasty, 23 had intraoperative integrity of the ossicular chain (17 male and 6 female subjects; mean age, 40 yr) and were included in the study. An inverse correlation was found between number of subsites involved and chain preservation (Spearman rank correlation coefficient, r = -1; p = 0.017). Medial attic involvement was the factor that most negatively influenced the likelihood of chain preservation. Conclusion: Middle ear endoscopic techniques may increase the likelihood of ossicular chain preservation during cholesteatoma surgery. Medial attic involvement and a high number of subsites involved represent the most significant negative factors for chain preservation. The rate of residual disease requires more thorough evaluation in the future to validate the results.

2011 - Parapharyngeal space tumors without mandibulotomy: our experience [Articolo su rivista]
Presutti, Livio; Molteni, Gabriele; Chiarini, Luigi; ALICANDRI CIUFELLI, Matteo; Malve', Laura; Marchioni, Daniele; Ghidini, Angelo; Tassi, Sauro
abstract

Parapharyngeal space (PPS) tumors are rare and benign in 80% of cases. Since surgeons first resected this anatomical region, the surgical approach to PPS bulks has been a hot topic due to their shape and the important structures involved. We present a series of patients treated with a transcervical or transcervical-transparotid approach to benign PPS tumors without mandibulotomy. Between May 2003 and March 2009, 18 patients (11 male and 7 female) with benign PPS tumors underwent a surgical resection, avoiding mandibulotomy. Average age of the patients was 49 years (range 3-76), average tumor size was 5.5 × 4 × 3 cm and histological examination of the resected tumors showed: seven pleomorphic adenomas of the deep parotid lobe, four schwannomas, two mycobacteriosis, two paragangliomas of the vagus nerve, one lipoma, one neurofibroma and one cavernous hemangioma. Seven patients underwent a transcervical approach, while 11 patients underwent a transcervical-transparotid approach. Excision of benign PPS tumors is possible without mandibulotomy even in the case of a large tumor mass, but exposure with the mandible in situ is certainly poor. Avoiding mandibulotomy reduces patient morbidity and hospital stay. In our experience, mandibulotomy can be avoided in most cases of benign PPS tumors leaving this procedure for malignant tumors or in patients with very poor exposure.

2011 - Radiology quiz case 2. Giant rhinosinusal empty mucocele [Articolo su rivista]
Mattioli, Francesco; ALICANDRI CIUFELLI, Matteo; Trebbi, Marco; Molteni, Gabriele; Presutti, Livio
abstract

ab breve dell'art

2011 - Surgical Anatomy of Transcanal Endoscopic Approach to the Tympanic Facial Nerve [Articolo su rivista]
Marchioni, Daniele; ALICANDRI CIUFELLI, Matteo; Piccinini, Alessia; Genovese, Elisabetta; Monzani, Daniele; Tarabichi, Muaaz; Presutti, Livio
abstract

Objectives/Hypothesis: Until recently, tympanic facial nerve surgery had been performed using microscopic approaches, but in recent years, exclusive endoscopic approaches to the middle ear have increasingly been used, particularly in cholesteatoma surgery. The aim of this report was to illustrate the surgical anatomy of the facial nerve during an exclusive endoscopic transcanal approach. Study Design: Retrospective video review of cadaveric dissections and operations on living patients in a tertiary university referral center. Methods: Between November 2008 and July 2010, a total of 12 endoscopic cadaveric dissections were performed by an exclusive endoscopic transcanal approach. All dissections were recorded and stored in a database. In July 2010, video recordings from those dissections were reviewed, and the anatomic variations and accessibility of the tympanic facial nerve were studied and noted. Two further video recordings from living patients affected by middle ear chronic disease were also included in our study. Results: In all 14 subjects, the transcanal endoscopic approach guaranteed direct access to the entire tympanic segment of the facial nerve after ossicular chain removal, allowing decompression of the nerve from the geniculate ganglion and the greater petrosal nerve to the second genu of the facial nerve. As in microscopic techniques, the cochleariform process and transverse crest (cog) may represent useful landmarks. Conclusions: The tympanic facial nerve can be thoroughly visualized by an exclusive endoscopic transcanal approach, even in poorly accessible regions such as the second genu and geniculate ganglion. Further clinically based reports may strengthen our preliminary results.

2011 - The contribution of selective dysventilation to attical middle ear pathology [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Genovese, Elisabetta; Presutti, Livio; Marchioni, Daniele; Grammatica, Alberto; Aggazzotti Cavazza, Elisa
abstract

Epitympanic primary cholesteatoma represents a challenge for ENT surgeons. Its exact pathogenesis is still unknown because of the very complex anatomy of this region. Until now, only a few authors have described this region and tried to hypothesize the causes that could lead to cholesteatoma genesis. We hypothesize the existence of a selective dysventilation of the epitympanic region based on the presence of various mucosal folds occluding air ventilation from the middle ear to the epitympanum, through the epitympanic isthmus, causing a negative epitympanic pressure and consequently cholesteatoma formation. All the anatomic findings were obtained with the aid of 0 and 45 angled surgical endoscopes. From our findings, patients affected by an epitympanic cholesteatoma often have a total isthmus blockage that completely isolates the whole epitympanum from the middle ear, causing a deficit of oxygenation of the mucosa that normally should be guaranteed by the Eustachian tube and which always works physiologically in these patients. This is confirmed by the tympanogram test where we observed how the pressure at the level of the tympanic cavity was normal, whereas the epitympanic pressure was selectively negative. In conclusion, selective epitympanic dysventilation syndrome consists of the concomitant presence of a series of complete or incomplete epitympanic diaphragms and ME isthmus blockage causing negative epitympanic pressure, and leading to the formation of a retraction pocket or cholesteatoma associated with normal Eustachian tube function

2011 - The role of early voice therapy in the incidence of motility recovery in unilateral vocal fold paralysis [Articolo su rivista]
Mattioli, Francesco; Bergamini, Giuseppe; ALICANDRI CIUFELLI, Matteo; Molteni, Gabriele; Luppi, Maria Pia; Nizzoli, Federica; Grammatica, Alberto; Presutti, Livio
abstract

OBJECTIVES. Vocal fold paralysis can have a significant impact on a patient's quality of life. The aim of this study was to analyze, in terms of vocal improvement and motility recovery, the post-vocal treatment results of patients with unilateral vocal fold paralysis (UVFP) who underwent early voice therapy. Study design. A 7 years prospective study of patients with an UVFP who underwent our multidimensional diagnostic-therapeutic assessment. MATERIAL AND METHODS. Seventy-four patients with UVFP were included in the study. All patients underwent a voice therapy based on forcible exercises supplemented by manipulations and maneuvers. A pre and post-treatment objective voice evaluation and self-assessment was made.

2010 - "Hide and seek" with antineutrophil cytoplasmic antibodies [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Molteni, Gabriele; Mascia, Maria Teresa; Genovese, Elisabetta; Presutti, Livio
abstract

Wegener Granulomatosis (WG) is a rare disease that can manifest initially with recurrent facial palse in the absence of any other symptom and in this case diagnosis could be missed for a long time. WG should be considered in all cases of multipe cranial palsy with unknown origin. This is a case report interesting for many specialist physicians ( ENT, ophthalmologists, rheumatologists, pneumologists)

2010 - Auto-crosslinked hyaluronan gel injections in phonosurgery [Articolo su rivista]
Molteni, Gabriele; Bergamini, Giuseppe; Ricci Maccarini, Andrea; Marchese, Caterina; Ghidini, Angelo; ALICANDRI CIUFELLI, Matteo; Luppi, Maria Pia; Presutti, Livio
abstract

To evaluate the clinical performance of an auto-crosslinked gel obtained from hyaluronic acid (ACP-based gel) as an anti-adhesive agent and/or augmentative agent in vocal cord surgery for the treatment of vocal fold (VF) atrophy, sulcus vocalis, and postsurgery scarring as well as its tolerability at short- and long-term follow-up.

2010 - Endoscopic evaluation of middle ear ventilation route blockage [Articolo su rivista]
Marchioni, D.; Mattioli, F.; Alicandri-Ciufelli, M.; Molteni, G.; Masoni, F.; Presutti, L.
abstract

Objectives: To describe middle ear ventilation route blockage, relieved during middle ear endoscopic surgery, and to analyze its association with mastoid hypopneumatization/sclerotization. Study design: Prospective case series with intraoperative analyses, and with a case-control computed tomographic scan comparison. Methods: Intraoperative findings during endoscopic middle ear surgery are described. Patients with middle ear ventilation route blockage were included in the study group (22 patients), while patients without middle ear ventilation route blockage were included in the control group (16 patients). An intra-patient and inter-group comparison of evaluated mastoid pneumatization was performed from the preoperative computed tomographic scans. Results: Middle ear ventilation route blockage was classified into three types (A, B, C) according to intraoperative findings. Intrapatient and intergroup comparisons showed that the presence of blockages of middle ear ventilation trajectories is associated with a statistically significantly higher prevalence of hypopneumatization/ sclerotization of the mastoid in the study group, a typical sign of middle ear dysventilation pathologies. Conclusions: Intraoperative evaluation of the middle ear anatomy during endoscopic surgery for inflammatory pathology allows us to clearly visualize the presence of anatomic blockages of the middle ear ventilation trajectories. These blockages might provoke a sectorial dysventilation of the middle ear, with consequent reduction of pneumatization of the mastoid. Further studies will be able to clarify to what extent selective dysventilation phenomena could be a principal factor in influencing middle ear pressure homeostasis. © 2010 Elsevier Inc. All rights reserved.

2010 - Endoscopic tympanoplasty in patients with attic retraction pockets [Articolo su rivista]
Marchioni, Daniele; ALICANDRI CIUFELLI, Matteo; Molteni, Gabriele; Genovese, Elisabetta; Presutti, Livio
abstract

OBJECTIVES:Patients undergoing endoscopic middle ear surgery require reconstruction procedures that are able to give adequate functional results, with particular attention to ventilation of middle ear routes and mastoid tissue preservation.STUDY DESIGN:Outcome research on a prospective case series in a tertiary university referral center.METHODS:A case series of 27 patients with attic retraction pockets underwent endoscopic middle ear surgical procedures. Three kinds of tympanoplasty were selected and performed.RESULTS:In all 27 subjects, it was possible to preserve the mastoid bone and the epitympanic-mastoid mucosa by performing a transcanal endoscopic approach. In total, 21 of 27 (77.7%) subjects presented no recurrence of the disease at 20.1 months mean follow-up.CONCLUSIONS:Three main types of endoscopic tympanoplasty can be performed for surgical treatment of attic retraction pockets, preserving as much as possible the ventilation routes, physiology, and anatomy of the middle ear

2010 - Forestier disease: Single-center surgical experience and brief literature review [Articolo su rivista]
Presutti, L.; Alicandri-Ciufelli, M.; Piccinini, A.; Trebbi, M.; Marchioni, D.; Ghidini, A.; Ruberto, M.
abstract

Objectives: We describe the experience of our otolaryngology department in the treatment of Forestier disease, particularly regarding the diagnostic process, surgical treatment, and postoperative outcomes. Methods: The charts of 12 patients who underwent surgical treatment of Forestier disease between January 1, 2003, and January 1, 2009, were analyzed. All patients were subjected to clinical, radiologic, and endoscopic evaluation that confirmed the presence of cervical osteophytes. All patients were treated by a right-sided prevascular transcervical approach to remove cervical osteophytes. A literature review on Forestier disease was also carried out. Results: One case of immediate postoperative hemorrhage was reported. During the postoperative follow-up, ranging from 1 to 5 years, all patients underwent cervical radiography and fiberoptic laryngoscopy that confirmed no evidence of recurrence, and all patients remained asymptomatic. Conclusions: A prevascular transcervical right-sided approach seems to be an effective treatment for surgical removal of hyperostosis in Forestier disease, with an acceptable rate of complications and recurrence. © 2010 Annals Publishing Company. All rights reserved.

2010 - Inferior retrotympanum revisited: an endoscopic anatomic study [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Genovese, Elisabetta; Presutti, Livio; Marchioni, Daniele; Piccinini, Alessia
abstract

AbstractObjectives/Hypothesis:To describe the inferior retrotympanic anatomy from an endoscopic perspective.Study Design:This was an anatomic study on a retrospective case series.Methods:During November 2009 and December 2009, videos from endoscopic middle ear procedures carried out between June 2007 and November 2009 and stored in our database were retrospectively reviewed. Surgeries in which the inferior retrotympanic region was visualized were included in the study. Accurate descriptions of the anatomic findings were made for each ear included in the study group.Results:The final study group consisted of 25 videos from 25 ear procedures. In 14/25 subjects, a bony ridge connecting the inferior portion of the styloid prominence to the anterior and inferior lip of the round window niche (Proctor's sustentaculum promontory) was identified and renamed the finiculus (from the Latin finis, -is: borderline), representing the ideal limit between the inferior retrotympanum and hypotympanum. In 14/25 patients, a complete sinus subtympanicus could be identified, lying between the subiculum and finiculus.Conclusions:Endoscopic exploration of the middle ear might guarantee a very good exposure of the inferior retrotympanum, allowing detailed anatomic descriptions of this hidden area. Improvement in our knowledge of its anatomy might decrease the possibility of residual disease during cholesteatoma surgery.

2010 - Intermittent self-limiting epistaxis: not always a triviality [Articolo su rivista]
Molteni, Gabriele; ALICANDRI CIUFELLI, Matteo; Romualdi, Pietro; Genovese, Elisabetta; Presutti, Livio
abstract

Intermittent self-limiting epistaxis: not always a triviality

2010 - Introduction. Round Table S.I.O. National Congress [Articolo su rivista]
Presutti, Livio; ALICANDRI CIUFELLI, Matteo
abstract

Round table

2010 - Lateral endoscopic approach to epitympanic diaphragm and Prussak's space: a dissection study [Articolo su rivista]
Marchioni, D.; ALICANDRI CIUFELLI, Matteo; Grammatica, A.; Mattioli, F.; Genovese, Elisabetta; Presutti, Livio
abstract

Introduction Until now, anatomic descriptions of the epitympanic diaphragm and Prussak’s space have been performed using a microscope. The aim of this study is to thoroughly describe and review the epitympanic diaphragm and the anatomy of Prussak’s space from an endoscopic point of view. Study design Cadaver dissection study. Setting Tertiary referral university center. Materials and methods The anatomy of four temporal bones dissected using an endoscope was studied. The most important findings were noted and described. Results Endoscopic cadaveric dissection of the middle ear allows a very good visualization of the epitympanic diaphragm, Prussak’s space and middle ear anatomy in general. Conclusion Endoscopic exploration and thorough knowledge of the complex fold anatomy may improve ‘functional’ interventions in middle ear inflammatory pathology during middle ear surgery, particularly in the case of selective dysventilation

2010 - Pyramidal eminence and subpyramidal space: An endoscopic anatomical study [Articolo su rivista]
Marchioni, D.; Alicandri-Ciufelli, M.; Grammatica, A.; Mattioli, F.; Presutti, L.
abstract

Objectives/Hypothesis: To describe retrotympanic endoscopic anatomy, especially the pyramidal eminence and contiguous spaces. Study Design: This was an anatomical study on a prospective case series. Methods: The anatomy of the retrotympanum was studied by endoscopy in nine patients affected by cholesteatoma who underwent tympanomastoid surgery and in six temporal bone dissections. Results: Pneumatization of the sinus tympani and posterior tympanic sinus or both, noted in 12 ears out of 15, may give rise to a recess beneath the pyramidal eminence, which we have called the subpyramidal space. This space can manifest with a variable degree of depth, shape, or extent depending on the shape and dimensions of the pyramidal eminence. Conclusions: Endoscopic exploration of the middle ear may guarantee a very good exposure of retrotympanic structures, allowing detailed anatomical descriptions of hidden areas. Improvement in our knowledge of the anatomy may decrease the possibility of residual disease during cholesteatoma surgery. © 2009 The American Laryngological, Rhinological and Otological Society, Inc.

2010 - Radiology quiz case 2. Bilateral tortuous internal carotid arteries (ICAs) [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Piccinini, Alessia; Marchese, Caterina; Mattioli, Francesco; Presutti, Livio
abstract

carotid artery

2010 - Selective epitympanic dysventilation syndrome [Articolo su rivista]
Marchioni, Daniele; ALICANDRI CIUFELLI, Matteo; Molteni, Gabriele; Artioli, FRANCA LAURA; Genovese, Elisabetta; Presutti, Livio
abstract

OBJECTIVES/HYPOTHESIS:Although middle ear aeration is certainly related to eustachian tube (ET) function, other anatomic factors may play an important role in ventilation of these spaces, particularly the epitympanum.STUDY DESIGN:A prospective case series study group with retrospective case series comparison.METHODS:Eight patients affected by non-self-cleaning attic retraction pockets or attic cholesteatoma of the middle ear and normal tubal function (verified by type A tympanogram or Williams' test) underwent endoscopic surgery. Anatomic findings were noted and collected, with particular attention paid to middle ear folds. A control group was used for comparison. The prevalence of an isthmus blockage with a complete tensor fold in pathologic ears was compared between the study group and control group.RESULTS:The higher prevalence of an isthmus blockage associated with a complete tensor fold in the study group was found to be statistically significant (P = .001).CONCLUSIONS:A selective epitympanic dysventilation syndrome is hypothesized; normal ET function seems to be insufficient for complete ventilation of the middle ear, and an open tympanic isthmus or an incomplete tensor fold may be necessary for epitympanic recess ventilation. The selective epitympanic dysventilation syndrome would consist of the contemporary presence of the following four conditions: attic retraction pocket or cholesteatoma, normal tubal function tests, complete epitympanic diaphragm, and isthmus blockage.

2010 - Subarcuate canal and artery: A case report [Articolo su rivista]
Grammatica, A.; Alicandri-Ciufelli, M.; Molteni, G.; Marchioni, D.; Presutti, L.
abstract

Variations in the course of the subarcuate artery (SAA) and of its related funnel are infrequent and asymptomatic. We present a case of a 15-year-old girl with a preverbal severe bilateral hearing loss and a subarcuate canal with an unusual course and atypical correlation with the adjacent anatomical structures, particularly with the lateral semicircular canal and the facial nerve. The variation proposed in this case, not previously reported in the literature consulted, can have important implications during middle ear surgical procedures, particularly for the retro-facial tympanoplasty approach: in fact otologic surgeons should consider any kind of variation of the SAA in surgical planning to avoid unexpected hemorrhages. The CT-scan, particularly HRCT, is a very useful tool for the study of intrapetrous vessels and their funnels, and should be considered mandatory in the case of a posterior approach to the tympanic cavity.

2010 - Surgical rehabilitation [Articolo su rivista]
Bergamini, Giuseppe; Presutti, Livio; Alicandri Ciufelli, Matteo; Masoni, F.
abstract

abstract obblig

2010 - Therapy of unilateral vocal fold paralysis with polydimethylsiloxane injection laryngoplasty: our experience [Articolo su rivista]
Bergamini, G; ALICANDRI CIUFELLI, Matteo; Molteni, Gabriele; Villari, D; Luppi, Mp; Genovese, Elisabetta; Presutti, Livio
abstract

The objective of this study was to document functional results and to compare objective and subjective voice measures after endoscopic laryngoplasty with injection of polydimethylsiloxane (PDMS) for the treatment of unilateral vocal fold paralysis, and to verify PDMS biocompatibility in vocal fold. The design used was a longitudinal prospective study. Fifteen patients with unilateral vocal fold paralysis underwent endoscopic injection of PDMS in general anesthesia. Accurate voice evaluation protocol (acoustic and aerodynamics analyses, GIRBAS [Grade, Instability, Roughness, Breathiness, Asthenia, and Strain] scale, videostrobolaryngoscopy, and Voice Handicap Index test) before, after surgery, and at follow-up time was performed. The median follow-up was 21.7 months (range, 6-35). Data obtained were statistically significant. All acoustic, aerodynamics, perceptive, and subjective evaluations showed a significant improvement. No complications due to PDMS were reported. Functional results were found comparable to framework surgery. Endoscopic injection laryngoplasty with PDMS is a safe and long-term option for treatment of unilateral vocal fold paralysis.

2009 - "Collision" metastasis from unknown primary squamous cell carcinoma and papillary microcarcinoma of thyroid presenting as lateral cervical cystic mass [Articolo su rivista]
Mattioli, F; Masoni, F; Ponti, Giovanni; Rossi, G; Masoni, Francesco; ALICANDRI CIUFELLI, Matteo; Presutti, Livio
abstract

We report an unusual case of "collision metastasis". In a single lymph node, we found a metastatic mass composed of two immunohistochemically distinct components originating from two primary tumors: a papillary microfollicular thyroid cancer and an unknown primary squamous cell carcinoma. The clinical features and immunohistochemical profile are reported. Collision phenomena in oncology are extremely rare and pose diagnostic and management challenges which are discussed.

2009 - CT morphological evaluation of anterior epitympanic recess in patients with attic cholesteatoma [Articolo su rivista]
Marchioni, Daniele; Mattioli, Francesco; Cobelli, Milena; Todeschini, Alessandra; ALICANDRI CIUFELLI, Matteo; Presutti, Livio
abstract

The objective of this study is to analyze the possible variations in size and shape of the AER in the ear affected by acquired cholesteatoma versus the healthy ear in the same patient. A total of 22 patients affected by acquired cholesteatoma were included in our study. A CT morphological evaluation of both ears (pathologic and non-pathologic) was made. Measures of the AER were done, on axial plane, parallel to incudomalleal axis for the deepest anterior-to-posterior (AP) diameter and perpendicular to this line for the maximum transverse (T) diameter, selecting the most inferior cut that showed the Cog in its entirety. A third superior-inferior (SI) measure was done, on coronal plane from the tegmen tympani to the cochleariform process. Comparisons between the mean of AP, T and SI in affected ears versus non-affected have been carried out using a paired t test. The AER measurement was considerably smaller in affected ears than in the non-affected ones. Mean AP +/- DS was 5.1 (1.46) versus 3.1 (0.90), P values <0.0001. Mean T +/- DS was 4.1 (0.74) versus 3.2 (0.74), P values <0.0014. Mean SI +/- DS was 4.0 (1.01) versus 2.0 (0.82), P values <0.0001. In conclusion, based on our results, the AER in an affected ear seems smaller than in a non-affected one. Whether a hypovolumetric AER could be a congenital morphological condition predisposing cholesteatoma despite adequate aeration of the epitympanic compartment, on the contrary the presence of membranous and/or ligamentous folds could exclude the AER from the posterior epitympanic space and from the protympanum, predisposing it for attical dysventilation, should be clarified in further studies.

2009 - Critical literature review on the management of intraparotid facial nerve schwannoma and proposed decision-making algorithm [Articolo su rivista]
ALICANDRI CIUFELLI, Matteo; Marchioni, Daniele; Mattioli, Francesco; Trani, Margherita; Presutti, Livio
abstract

Management of intraparotid facial nerve schwannomas (IFNS) is very challenging because the diagnosis is often made intra-operatively and in most cases, resection could lead to severe facial nerve (FN) paralysis, with important aesthetic consequences. Articles in the English language focused on the management of FN schwannoma have been selected and critically reviewed. A decision-making algorithm is proposed. In the case of type A or B neoplasms, or in case of a pre-operative FN House-Brackmann (HB) grade IV or worse, the authors would favor a resection of the IFNS and (where necessary) a reconstruction of the nerve. In the case of pre-operative HB grade III or better and type C or D neoplasms, patients would undergo an intra-operative biopsy to rule out malignancy, and a possible conservative management could be adopted. Localization and adherences of IFNS, as well as pre-operative FN function are important factors that must be considered in the decision-making process for IFNS to optimize the functional outcomes.

2009 - Endoscopic approach to tensor fold in patients with attic cholesteatoma [Articolo su rivista]
Marchioni, D.; Mattioli, F.; Alicandri-Ciufelli, M.; Presutti, L.
abstract

Conclusion. The endoscopic approach to attic cholesteatoma allows clear observation of the tensor fold area and consequently, excision of the tensor fold, modifying the epitympanic diaphragm. This permits good removal of cholesteatoma and direct ventilation of the upper unit, preventing the development of a retraction pocket or attic cholesteatoma recurrence, with good functional results. Objectives. An isthmus block associated with a complete tensor fold is a necessary condition for creation and development of an attic cholesteatoma. During surgical treatment of attic cholesteatoma, tensor fold removal is required to restore ventilation of the attic region. Use of a microscope does not allow exposure of the tensor fold area and so removal of the tensor fold can be very difficult. In contrast, the endoscope permits better visualization of the tensor fold area, and this aids understanding of the anatomy of the tensor fold and its removal, restoring attic ventilation. Patients and methods. In all, 21 patients with limited attic cholesteatoma underwent an endoscopic approach with complete removal of the disease. Patients with a wide external ear canal were operated through an exclusively endoscopic transcanal approach; patients with a narrow external ear canal or who were affected by external canal exostosis were operated through a traditional retroauricular incision and meatoplasty followed by the endoscopic transcanal approach. Results. In 18/21 patients, the endoscope permitted the discovery of different anatomical morphologies of the tensor fold. Sixteen patients presented a complete tensor fold (one with an anomalous transversal orientation), one patient presented an incomplete tensor fold and one patient presented a bony ridge in the cochleariform region. In all 16 cases of complete tensor tympani fold, the fold was removed and anterior epitympanic ventilation was restored. The ridge bone over the cochleariform process was also removed with a microdrill. © 2009 Informa UK Ltd.

2009 - Facial nerve schwannoma [Articolo su rivista]
Presutti, Livio; Grammatica, Alberto; ALICANDRI CIUFELLI, Matteo; Marchioni, Daniele; Cunsolo, Elio Maria
abstract

non disponibile

2009 - Giant retropharyngeal liposarcoma [Articolo su rivista]
Alicandri-Ciufelli, M.; Mattioli, F.; Molteni, G.; Trebbi, M.; Presutti, L.
abstract

2009 - Quality of life in patients treated with PDMS injection for swallowing disorders [Articolo su rivista]
Molteni, Gabriele; Ghidini, Angelo; Bergamini, Giuseppe; ALICANDRI CIUFELLI, Matteo; Mattioli, Francesco; Luppi, Maria Pia; Presutti, Livio
abstract

To document the efficacy of polydimethylsiloxane (PDMS) injections in patients with swallowing disorders after partial supracricoid laryngectomy; to assess the importance of quality-of-life (QOL) outcome in oncologic patients.

2009 - Rehabilitation of swallowing with polydimethylsiloxane injections in patients who underwent partial laryngectomy [Articolo su rivista]
Bergamini, G.; Alicandri-Ciufelli, M.; Molteni, G.; De Siati, D. R.; Luppi, M. P.; Marchioni, D.; Presutti, L.
abstract

Background. We conducted this longitudinal prospective study to illustrate a surgical technique for swallowing rehabilitation of patients after partial laryngectomy. Methods. Nine patients with persistent swallowing impairment after partial laryngectomy were included in the study. Evaluation of swallowing was performed by fiberoptic endoscopic evaluation of swallowing (FEES), and was quantified using 2 scales: a dysphagia score and a modified penetrationaspiration scale. The site of bolus inhalation was identified. Polydimethylsiloxane (PDMS) was injected into the neoglottis to fill these passages, and to obtain a certain continence of the organ. Results. Mean follow-up was 25 months (range, 5-39). All patients showed an improvement both in the dysphagia score and in the modified penetration-aspiration scale. Average improvement was 2.6 points in the dysphagia score (p = .0042) and 2.1 points in the modified penetration-aspiration scale (p = .0043). Conclusion. PDMS injection can be considered as an option in surgical rehabilitation of swallowing in patients who underwent partial laryngectomy. © 2009 Wiley Periodicals, Inc.

2009 - Tonsillar swelling: always a simple diagnosis? [Articolo su rivista]
Alicandri-Ciufelli, Matteo; Molteni, Gabriele; Villari, Domenico; Mattioli, Francesco; Presutti, Livio
abstract

2009 - Transcanal endoscopic approach to the sinus tympani: A clinical report [Articolo su rivista]
Marchioni, D.; Mattioli, F.; Alicandri-Ciufelli, M.; Presutti, L.
abstract

OBJECTIVES: To investigate the anatomic limitations of the endoscopic transcanal approach to sinus tympani (ST), in particular, how this approach might allow a complete visualization of the ST recesses and to propose a morphologic classification of the ST using computed tomography and to examine if this could be useful for the surgeon in preoperative planning to decide the type of approach to the ST. STUDY DESIGN: Case series. PATIENTS AND METHODS: Forty patients affected by middle ear disease with ST involvement were included in our study. All patients underwent a preoperative computed tomographic scan of the temporal bone. All patients underwent tympanomastoid surgery with intraoperative use of the endoscope. We assessed the variation in depth of the ST area, analyzing the posterior and medial extension of the medial boundary of the ST, and performing a radiomorphologic classification of the ST. RESULTS: Of the 40 patients, it has been possible to describe the detailed morphology of the shape of the ST in 38. We classified the depth of the ST into 3 types based on radiologic findings: Type A (a limited ST), Type B (a deep ST), and Type C (a deep ST with a posterior extension). Of 35 ST of Types A and B, there was good exposure of the medial boundary of the sinus using a transcanal endoscopic approach in 33 (94.2%), whereas in 3 (60%) of 5 patients of Type C, it was not possible to explore the complete depth of the sinus, especially the ST portion under and posterior to the facial nerve. CONCLUSION: The transcanal endoscopic approach to the ST is indicated in ST of Types A and B. In ST of Type C, it is not always possible to have good control of the ST; in these cases, a posterior retrofacial approach is suggested. © 2009 Otology & Neurotology, Inc.

2009 - Transnasal endoscopic treatment of cerebrospinal fluid leak: 17 years' experience [Articolo su rivista]
Presutti, Livio; Mattioli, Francesco; Villari, Domenico; Marchioni, Daniele; ALICANDRI CIUFELLI, Matteo
abstract

Aim of this report is to describe the long-term results of endoscopic endonasal repair of cerebrospinal fluid leak using a septal mucoperichondrial graft. A case series of 52 patients operated for cerebrospinal fluid rhinorrhea between 1990 and 2006 is presented. All patients underwent surgical treatment for endoscopic endonasal closure of a cerebrospinal fluid leak using a septal mucoperichondrial graft. No lumbar drain and fluorescein tests were used. The intra-operative localization of the fistula was aided by Valsalva's manoeuvre by the anaesthetist. The success rate, after the first attempt, was 88.5% (46/52 patients); for the remaining 11.5% (6/52 patients), a second attempt was necessary which proved successful in 5 cases, raising the overall success rate to 98.1% (51/52 patients). Relapse occurred in only one case (1.9%), after the second attempt. In conclusion, a free mucoperichondrial graft offered good results for cerebrospinal fluid leak repair. In the Authors' experience, a high success rate can be achieved without the use of intrathecal fluorescein and lumbar drain.

2008 - A case of syryngocystadenoma papilliferum (SCAP) involving middle ear, presenting with otomastoiditis and cerebral abscess [Articolo su rivista]
Presutti, L.; Alicandri-Ciufelli, M.; Mattioli, F.; Marchioni, D.; Costantini, M.
abstract

Syryngocystadenoma papilliferum (SCAP) is an uncommon cutaneous adnexal neoplasm of apocrine gland origin. Until now, fewer than 200 cases have been reported in international literature, of which 12 cases involved the external ear. No cases of SCAP involving the middle ear have been reported. We describe a case of SCAP of external and middle ear, presenting with otomastoiditis and cerebral abscess; this aggressive behavior, never reported for a benign adenoma of the external or middle ear, could lead to a differential diagnosis with cholesteatoma or malignancies. © 2007 Elsevier Ireland Ltd. All rights reserved.

2008 - Endoscopic management of acquired cholesteatoma: our experience [Articolo su rivista]
Presutti, Livio; Marchioni, Daniele; Mattioli, Francesco; Villari, Domenico; Alicandri-Ciufelli, Matteo
abstract

The purpose of this study was to examine the utility of using an endoscope in cholesteatoma surgery and to demonstrate how it allows a reduction in the incidence of residual disease.

2008 - Exclusive endoscopic removal of a planum sphenoidale meningioma: A case report [Articolo su rivista]
Presutti, L.; Trani, M.; Alicandri-Ciufelli, M.; Marchioni, D.
abstract

Midline suprasellar meningiomas have traditionally been removed through transcranial approaches. Endoscopic endonasal approaches have already been described for the removal of tuberculum sellae meningiomas (Cook), but their exclusive use for planum sphenoidale meningiomas has never been reported. A case report of a planum sphenoidale meningioma removed through a transnasal endoscopic approach is presented: the goal of this technique is tumor control with minimal morbidity. The anterior skull base defect has been reconstructed with a pedicled mucosa flap from nasal septum (Hadad-Bassagasteguy flap). The postoperative course was uneventful, and no sign of recurrence was noticed at the MRI control performed after 3 months. © Georg Thieme Verlag KG Stuttgart.

2008 - Large infratemporal fossa trigeminal schwannoma: A case report [Articolo su rivista]
Presutti, L.; Alicandri Ciufelli, M.; Trani, M.
abstract

Trigeminal schwannomas with exclusive extracranial involvement (Type E) are rare neoplasms: only 19 cases have been reported in international literature. We report a case of a large (5 cm × 4 cm × 3.5 cm) extracranial trigeminal schwannomas: the neoplasm extensively involved the infratemporal fossa, the pterygopalatine fossa and the infraorbital canal. Diagnosis has been pre-operatively made by a biopsy performed with a Caldwell-Luc approach, although imaging (particularly MRI with gadolinium) was strongly orientative. Neoplasm was treated by a combined endoscopic transnasal and transmaxillary approach. At the radiologic follow-up, made after 3 and 6 months from the operation, the schwannoma did not show any sign of recurrence. © 2008 Elsevier Ireland Ltd. All rights reserved.

2008 - Middle turbinate preservation versus middle turbinate resection in endoscopic surgical treatment of nasal polyposis [Articolo su rivista]
Marchioni, Daniele; ALICANDRI CIUFELLI, Matteo; Mattioli, Francesco; Marchetti, Alessio; Jovic, Gordana; Massone, Federica; Presutti, Livio
abstract

Relapse in patients affected by nasal polyposis and subjected to endoscopic surgery appears to be a relevant feature. Surgical treatment shows a significant increase in quality of life in all the patients aside from surgical technique used. Our results show a better control of relapse of nasal pathology in patients subjected to more radical surgery (group B) vs patients subjected to conservative surgery on middle turbinate (group A). Allergic patients in group B had a smaller number of relapses during the follow-up period compared with allergic patients in group A and this was statistically significant.

2008 - Surgery of septal perforations [Articolo su rivista]
Presutti, Livio; ALICANDRI CIUFELLI, Matteo; Marchioni, Daniele; Ghidini, Angelo; Villari, Domenico
abstract

abstract septal

2008 - Wnt pathway, angiogenetic and hormonal markers in sporadic and familial adenomatous polyposis-associated juvenile nasopharyngeal angiofibromas (JNA) [Articolo su rivista]
Ponti, Giovanni; Losi, Lorena; Pellacani, Giovanni; G. B., Rossi; Presutti, Livio; Mattioli, Francesco; Villari, Domenico; L., Wannesson; ALICANDRI CIUFELLI, Matteo; P., Izzo; M., De Rosa; P., Marone; Seidenari, Stefania
abstract

Juvenile nasopharyngeal angiofibroma (JNA) is a rare, invasive, and locally destructive tumor of the nasopharynx. The Writ pathway, angiogenctic and hormonal factors are involved in the pathophysiology of JNA; it can result in an extracolonic manifestation of familial adenomatous polyposis (FAP) or in a sporadic tumor. All patients who underwent resection of JNA between 1991 and 2006 at the University of Modena and Reggio Emilia were studied to identify immunohistochemical markers of associated FAP syndrome. Paraffin-embedded JNA samples were analyzed immunohistochemically for the expression of adenomatous polyposis coli (APC), beta-catenin, E-cadherin, androgen receptor, and vascular endothelial growth factors receptor (VEGFR(2)). In one out of the 4 (25%) young patients affected by JNA the diagnosis of FAP syndrome linked to APC mutation was made. All of the sporadic and familial JNA tumors showed nuclear staining of beta-catenin, whereas altered APC expression was seen only in FAP-associated JNA. All cases were stained with VEGFR(2). A combined clinical, immunohistochemical, and biomolecular screening may be useful for the identification of FAP among patients with a diagnosis of JNA. The Writ pathway can be involved in the JNA pathogenesis either by somatic mutations of beta-catenin or by germline APC mutations. As the VEGFR has an important impact on the pathogenesis of JNA, we suggest that a targeted therapy with monoclonal antibodies against VEGFR might lead to a specific chemoprevention and treatment of these tumors and their recurrences.

2007 - Intraparotid facial nerve schwannoma: Literature review and classification proposal [Articolo su rivista]
Marchioni, D.; Alicandri Ciufelli, M.; Presutti, L.
abstract

Objective: The aim of this review was to assess and describe the pathological characteristics of intraparotid facial nerve schwannoma, in order to facilitate correct prognostic evaluation and appropriate therapeutic decision making. Study design and setting: The literature was reviewed regarding involvement of the various portions of the facial nerve. A classification is proposed, based on anatomical and pathological evaluations, which can supply important information on facial functional outcomes. Results: From this study, two important characteristics of facial nerve schwannoma emerged: the schwannoma may be capable of surgical dissection from the facial nerve, leaving the latter anatomically preserved; or it may be tightly bound to the nerve, in which case it must be removed along with a variable section of nerve tract, followed by reconstruction. Conclusions: The extent of the neoplasm and the involvement of different branches of the facial nerve are very important elements to consider when evaluating prognosis and therapy. Significance: To emphasise the usefulness of a classification, based on anatomical and pathological evaluation, which can supply information about post-operative facial function. © 2007 JLO (1984) Limited.

2007 - Nasal septal perforations: Our surgical technique [Articolo su rivista]
Presutti, L.; Alicandri Ciufelli, M.; Marchioni, D.; Villari, D.; Marchetti, A.; Mattioli, F.
abstract

Objective: The aim of this paper was to describe our surgical technique for the treatment of nasal septal perforations. Study and design: We studied 31 patients with nasal septal perforation treated with an endoscope-assisted technique, based on a bilateral dissection of monopedicled mucosal flaps from the nasal fossa floor, sutured at the edge of the perforation previously unstuck, without any graft interposed between the two mucosal layers. Results: In our experience with 31 patients, the use of this technique led to the persistent closing (with follow-up for at least one year) of 96.3% of the perforations smaller than 3 cm. Conclusions: Our technique has the advantage of an endonasal approach, without any external incision, and the use of monopedicled flaps from the nasal fossa floor without any graft interposition, avoiding any other surgical procedure and morbidity in the donor site of the graft. The use of nasal endoscopy permits superior precision in all surgical steps. Significance: The high success rate in perforations smaller than 3 cm seems to confirm the effectiveness of this technique. © 2007 American Academy of Otolaryngology-Head and Neck Surgery Foundation.

2006 - Obstructive sleep apnea syndrome in patients with normal body weight: Pathophysiologic, clinical and therapeutic aspects [Articolo su rivista]
Marchioni, D.; Trebbi, M.; Alicandri Ciufelli, M.; Presutti, L.
abstract

The prevalence of obstructive sleep apnea syndrome (OSAS) in the general population is considerably high. The epidemiologically most important factor is obesity, since increased adipose tissue leads to alterations in upper airway anatomy and function that can trigger the mechanisms underlying the syndrome. While the bulk of published studies focus on OSAS in patients with an elevated body mass index (BMI), few have investigated the anatomical and pathophysiologic implications of OSAS in patients with normal body weight. In a previous study, the authors found that among these patients the primary anatomic anomaly contributing to the onset of OSAS was hypertrophy of the base of tongue, while septal deviation was a concurrent cause of the syndrome. Morphometric and physiologic studies have highlighted several other differences between OSAS sufferers with normal and those with elevated BMI. With this review the authors describe the anatomic, functional, clinical and therapeutic aspects of OSAS in patients with normal body weight.

Università degli studi di Modena e Reggio Emilia

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