Background. Transsphenoidal surgery is the treatment of choice for Cushing’s disease. Successful surgery is associated with subnormal postoperative serum cortisol concentrations and cortisoluria levels, which may guide decisions regarding immediate reoperation. Remission is defined as the biochemical reversal of hypercortisolism with the re-emergence of diurnal circadian rhythm. Methods. A single-center prospective cohort study was conducted among thirty-three patients who underwent transsphenoidal pituitary surgery for Cushing’s disease. Postoperative surgical outcomes, daily morning cortisolemia, and 24 h urinary-free cortisol from the first to the fifth morning were evaluated. Results. All patients underwent surgery, with a remission rate of 81.2%. Of the 26 patients who achieved early remission, 92% remained in remission. Two patients (7.7%) showed recurrence of Cushing’s disease during a mean follow-up of 81.7 months. Early postoperative hypocortisolism suggests complete removal of the tumor, correlating with high rates of remission (p < 0.001). Also, in 12.5% of patients with early cortisol values >138 nmol/L, there was a gradual late remission. Conclusions. In our cohort of patients, the endoscopic transsphenoidal approach was safe and effective in the treatment of Cushing’s disease. We demonstrated that serum and urinary cortisol concentrations did not experience significant fluctuations from the first to the fifth day. This constitutes an accurate predictor of durable remission, comprising a distinctive finding in the intermediate term by our team.

Background: Currently, the standard design of the skin component of abdominal soft-tissue flaps recommended for head and neck reconstruction encompasses the upper and lower periumbilical region to include the maximum number of myocutaneous perforators. Yet, this flap design precludes the harvest of bilateral flaps and the use of the contralateral area in case of flap failure. Aim: We aimed at proving the long-term safety of infraumbilical abdominal free flaps in terms of abdominal wall integrity. Methods: Consecutive subjects who underwent reconstruction of composite cervico-facial defects with infraumbilical free flaps between 2008 - 2020 were enrolled. After surgery, patients were followed up at three-month intervals to evaluate the incidence of any complications at the donor site. Results: 25 patients underwent reconstruction with free flaps from the lower abdomen. A total of 35 abdominal flaps were performed; ten patients underwent bilateral flap harvest. Marginal abdominal skin necrosis occurred in 3 patients. Abdominal bulge occurred in one case; neither hernia nor abdominal wall weakness was encountered at a median follow-up of 12 months. Conclusions: The infraumbilical region is a safe donor area of free flaps for head and neck reconstruction that preserves abdominal wall firmness and provides a satisfactory cosmetic result at the donor site.

Air pollution (AP) represents one of the main environmental threats to public health and exposure to AP has been connected to upper airway (UA ) disease. We evaluated the relationships between the ENT urgent referrals recorded at the Hospital of Padua and the daily levels of particulate matter (PM) as well as other environmental factors in a single year. Patients with UA disorders were included in the study group while those referred for facial trauma or foreign body inhalation formed the control group. Daily PM concentrations, meteorological data and the concentrations of the commonest aeroallergens were obtained. 6368 patients formed the study group and 910 the control one. The concentration of compositae allergens showed a positive effect on the total number of admissions ( p = 0.001). PM 10 did not demonstrate an effect on the total number of admissions or either the study or control groups admissions ( p = 0.25). Alternaria positively influenced admissions of patients in the study group ( p = 0.005). Significant relationships were found between the following: PM 10 measured on the seventh day before A&E admission and rhinosinusitis ( p = 0.007), PM 10 on the fifth day and laryngitis ( p = 0.01), PM 10 on the second day and otitis media ( p = 0.03), PM 10 on the admission day and epistaxis ( p = 0.0198). Our study confirms the causal relationship between aeroallergen concentration and ENT admissions. The levels of PM 10 at specific days preceding A&E admission correlated with certain UA disorders. This study strongly points towards the harmful effects of pollution and climate change on UA disease.

Transorbital approaches are genuinely versatile surgical routes which show interesting potentials in skull base surgery. Given their "new" trajectory, they can be a very useful adjunct to traditional routes, even being a valid alternative to them in some cases, and add valuable opportunities in selected patients. Indications are constantly expanding, and currently include selected intraorbital, skull base and even intra-axial lesions, both benign and malignant. Given their relatively recent development and thus unfamiliarity among the skull base community, achieving adequate proficiency needs not only a personalized training and knowledge but also, above all, an adequate case volume and a dedicated setting. Current, but mostly future, applications should be selected by genetic, omics and biological features and applied in the context of a truly multidisciplinary environment.

The abdominal wall has showed many advantages as a donor site in head and neck reconstruction given its constant pattern of dominant perforators. Currently, standard design of the skin component of composite soft-tissue flaps recommended for head and neck reconstruction encompasses the lower and upper periumbilical region thus increasing the overall vascularization of the flap. We report on the safety of the harvest of abdominal soft-tissue free flaps from the infraumbilical region.A retrospective charts review was performed. Consecutive subjects who underwent microsurgical reconstruction of composite defects of the Head & Neck with infraumbilical free flaps between January 2008-January 2020 were enrolled.After surgery, patients were followed up at three-month intervals to evaluate the incidence of complications and the long-term outcome at the donor site.25 patients underwent reconstruction with free flaps harvested from the lower abdomen. A total of 35 abdominal flaps (20 VRAM, 15 DIEAP) were performed; ten patients underwent bilateral flap harvest and abdominoplasty was performed to achieve direct closure. Marginal abdominal skin necrosis occurred in 3 patients postoperatively. Abdominal bulge occurred in one case; neither hernia nor abdominal wall weakness were not encountered at a median follow-up of 12 months (IQR 6; 27).  The results of the study confirm that the infraumbilical region is a safe donor area of free flaps for head and neck reconstruction that preserves abdominal wall firmness and improves ultimate functional and aesthetic outcomes at the donor site.

OBJECTIVE:To evaluate rates of epiphora after transection and marsupialization of the nasolacrimal duct (NLD) during endoscopic sinus and skull base surgery.INTRODUCTION:The nasolacrimal canal forms part of the medial wall of the maxillary sinus. Transecting the NLD is sometimes necessary for tumor resection or surgical access to maxillary sinus and infratemporal fossa pathology. There is no consensus for the endoscopic management of the NLD when only the duct is transected without involving the nasolacrimal sac.METHODS:Medical records of 29 patients from 2 academic institutions who underwent endoscopic sinus and skull base surgery with transection of the NLD were retrospectively reviewed. Whether the duct was marsupialized or simply transected was recorded, and the postoperative rate of epiphora was calculated.RESULTS:Mean age was 59 years (range, 14-86 years). Mean follow-up was 10.5 months (range, 1-33 months). The NLD was marsupialized in 16 (55%) and simply transected in 13 (45%) patients. Six patients underwent postoperative radiation. No patients in the marsupialization group had epiphora postoperatively, all with Munk score of 0. One patient in the transection group developed postoperative epiphora with Munk score of 1. Pathology included inverted papilloma (8), acute on chronic inflammation (6), B-cell lymphoma (3), juvenile nasopharyngeal angiofibroma (2), squamous cell carcinoma (2), Schneiderian papilloma (2), metastatic melanoma (1), HPV-related carcinoma (1), adenocarcinoma (1), benign epithelial cyst (1), adenoid cystic carcinoma (1), and erosive chronic sinusitis without nasal polyposis (1).CONCLUSION:Management after transection of the NLD varies widely. The duct may be simply transected or marsupialized, or a formal dacryocystorhinostomy can be performed. The surgeon must also choose whether to place a stent. Based on our small series and review of the literature, marsupialization or simple transection of the NLD results in a low rate of postoperative epiphora in the setting of endoscopic sinus and skull base surgery.

SUMMARY Disregarding the widely used division of skull base into anterior and lateral, since the skull base should be conceived as a single anatomic structure, it was to our convenience to group all those approaches that run from the antero-lateral, pure lateral and postero-lateral side of the skull base as “Surgery of the lateral skull base”. “50 years of endeavour” points to the great effort which has been made over the last decades, when more and more difficult surgeries were performed by reducing morbidity. The principle of lateral skull base surgery, “remove skull base bone to approach the base itself and the adjacent sites of the endo-esocranium”, was then combined with function preservation and with tailoring surgery to the pathology. The concept that histology dictates the extent of resection, balancing the intrinsic morbidity of each approach was the object of the first section of the present report. The main surgical approaches were described in the second section and were conceived not as a step-by-step description of technique, but as the highlighthening of the surgical principles. The third section was centered on open issues related to the tumor and its treatment. The topic of vestibular schwannoma was investigated with the current debate on observation, hearing preservation surgery, hearing rehabilitation, radiotherapy and the recent efforts to detect biological markers able to predict tumor growth. Jugular foramen paragangliomas were treated in the frame of radical or partial surgery, radiotherapy, partial “tailored” surgery and observation. Surgery on meningioma was debated from the point of view of the neurosurgeon and of the otologist. Endolymphatic sac tumors and malignant tumors of the external auditory canal were also treated, as well as chordomas, chondrosarcomas and petrous bone cholesteatomas. Finally, the fourth section focused on free-choice topics which were assigned to aknowledged experts. The aim of this work was attempting to report the state of the art of the lateral skull base surgery after 50 years of hard work and, above all, to raise questions on those issues which still need an answer, as to allow progress in knowledge through sharing of various experiences. At the end of the reading, if more doubts remain rather than certainties, the aim of this work will probably be achieved.

Case-control studies on malignant sinonasal tumors and occupational risk factors are generally weakened by non-occupational confounders and the selection of suitable controls. This study aimed to confirm the association between sinonasal malignant tumors and patients' occupations with consideration for sinonasal inverted papillomas (SNIPs) as a control group. Thirty-two patients affected by adenocarcinoma (ADC) and 21 non-adenocarcinoma epithelial tumors (NAETs) were compared to 65 patients diagnosed with SNIPs. All patients were recruited in the same clinical setting between 2004 and 2016. A questionnaire was used to collect information on non-occupational factors (age, sex, smoking, allergies, and chronic sinusitis) and occupations (wood- and leather-related occupations, textile industry, metal working). Odds ratios (OR) with 95% confidence intervals (CI) associated with selected occupations were obtained by a multinomial and exact logistic regression. Between the three groups of patients, SNIP patients were significantly younger than ADC patients (p = 0.026). The risk of NAET increased in woodworkers (OR = 9.42; CI = 1.94⁻45.6) and metal workers (OR = 5.65; CI = 1.12⁻28.6). The risk of ADC increased in wood (OR = 86.3; CI = 15.2⁻488) and leather workers (OR = 119.4; CI = 11.3⁻1258). On the exact logistic regression, the OR associated to the textile industry was 9.32 (95%CI = 1.10⁻Inf) for ADC, and 7.21 (95%CI = 0.55⁻Inf) for NAET. Comparing sinonasal malignant tumors with controls recruited from the same clinical setting allowed demonstrating an increased risk associated with multiple occupations. Well-matched samples of cases and controls reduced the confounding bias and increased the strength of the association.

Background The jugular foramen (JF) is the anatomic connection between the endo- and the esocranium. It presents three different tissue layers: the brain parenchyma with a dural layer, the bone of the skull base, and the neurovascular structures at the interface with the neck. Primary tumors originating from the JF are class C jugular paragangliomas, schwannomas, and meningiomas. Tumors involving the JF from adjacent sites are moreover chondrosarcomas, chordomas, endolymphatic sac tumors, metastasis, and malignant tumors with perineural spread from the head and neck district. Surgery is often challenging, and aimed at the balance between the therapy purpose and the intrinsic morbidity of each surgical approach.

BACKGROUND:Occupational exposure to chromium is carcinogenic for human respiratory system. Due to the low incidence of sinonasal malignancies, there is still a paucity of evidence to confirm that chromium(VI) exposure is a cause of nasal cancer. OBJECTIVES:To report on a sinonasal cancer (SNC) of rare occupational origin, increasing the awareness on epidemiological knowledge of occupational exposures to chromium compounds. METHODS:We describe a case of a 64-year-old chrome plater who worked in the galvanic industry in the early 1970s. After a latency period of 39 years, he was diagnosed with sinonasal undifferentiated carcinoma (SNUC). A brief review of the literature was conducted. RESULTS:A thorough occupational history revealed a 4-year-long occupational exposure to chromium(VI) during a magnesium cylinder plating process involved in computer production. The patient underwent endoscopic endonasal removal of the SNUC. He is alive with no evidence of disease at 40-month follow-up. Our literature review identified 8 papers concerning 40 cases of chrome-induced sinonasal tumors. The maximum relative risk of SNC developing in chromium-exposed workers was 15.4. CONCLUSIONS:When dealing with patients diagnosed with SNC, the possibility of an underlying occupational risk is worth further investigation. Because chromium exposure is rare, and the incidence of SNUC is low, any information emerging on clinical and exposure-related aspects of SNCs in chrome plating workers can contribute to adding evidence on the possible causal relationship between chromium and sinonasal malignancies.

Background: In ancient times, dizziness was divided into two different forms: ílingos (true and proper vertigo) and skotódinos (vertigo associated with blurred vision). For centuries, it was considered as a cerebral affection: the otologic aetiology remained unthinkable. At the end of the sixteenth century, we find the first written documentation of the otovestibular triad pathognomonic for endolymphatic hydrops: the jurist Bonaventura Angeli from Ferrara, thanks to his symptoms' description, can rightfully be considered the first patient with Ménière's syndrome whom we have historical information. From that, the anatomical and physiological studies of balancing system continued: after Valsalva, a first evolution of medical thinking came with the recognition of the presence of liquid, and not air, inside the labyrinth. With Flourens, the principle that the semicircular canals were a vestibular organ, began to emerge.Purpose: The rationale to perform this research lied in the need to investigate a fascinating chapter of the history of medicine, regarding a difficult subject of otorhinolaryngology: the vestibular system.Methods: We collected a variety of documents, from Ancient Greek time to nineteenth century, related to the studies of vestibular pathologies, highlighting the earliest evidences of the association between hearing disorders and balance complaints. The finally selected papers were methodologically evaluated.Results: Because of the frequent association between vestibular and hearing disorders, the hypothesis that ear could be involved both in the sense of hearing and balance gradually advanced across the centuries, until Prosper Ménière's observations: from 1861 onwards, vertigo was recognized not only as a brain alteration, but also as an otologic disorder.Conclusions: Although there has been an obvious medical developments regarding the inner ear function, labyrinthine disorders remain a challenging field yet to be explored.

Sinonasal cancers (SNCs) are rare neoplasms, accounting for about 3 % of head and neck cancers, with squamous cell carcinoma (SCC) and adenocarcinoma (ADC) as the most common subtypes. ADCs present strong associations with occupational wood dust exposure. Preventive measures have progressively reduced wood dust concentrations in workplaces but no study has evaluated the effectiveness of such interventions. Few studies indicate associations between ADC and exposure to solvents, which is common in the shoe industry, but this hypothesis still needs confirmation.