- Maurizio Bignami, M.D. FACSAssociate Professor University of InsubriaHead Dept. of Specialized Surgeries University o... moreMaurizio Bignami, M.D. FACSAssociate Professor University of InsubriaHead Dept. of Specialized Surgeries University of InsubriaHead Dept. of Otorhinolaryngology ASST-Settelaghi-Vareseedit
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BackgroundThe purpose of this study was to assess survival, prognostic factors, and complications in a cohort of patients with intestinal‐type adenocarcinoma (ITAC) treated with transnasal endoscopic surgery ± radiotherapy... more
BackgroundThe purpose of this study was to assess survival, prognostic factors, and complications in a cohort of patients with intestinal‐type adenocarcinoma (ITAC) treated with transnasal endoscopic surgery ± radiotherapy (RT).MethodsPatients with ITAC who underwent endoscopic surgery ± RT at 2 tertiary centers were retrospectively reviewed. Overall survival (OS) and event‐free survival were calculated, and statistically significant variables were entered in a multivariate Cox regression model. Complications were also analyzed.ResultsOne hundred‐sixty‐nine patients were included. Major complications occurred in 9.5% of patients. Adjuvant RT was delivered in 58.6% of patients. Five‐year OS and event‐free survival were 68.9% and 63.6%, respectively. Advanced pT classification, high‐grade, and positive surgical margins were independently predictive of poor survival.ConclusionEndoscopic surgery ± RT is a valid treatment option in most cases of ITAC. When compared with series based on e...
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After traumatic events (accidental or surgical), the respiratory tract activates specific and prolix repairing mechanisms which tend to claw back the primitive differentiated state. The attempt of reactivation of the normal tissue... more
After traumatic events (accidental or surgical), the respiratory tract activates specific and prolix repairing mechanisms which tend to claw back the primitive differentiated state. The attempt of reactivation of the normal tissue functions is called 'remodeling' and its aim is to reinstate the modeling mechanisms that existed before the damaging event or the pathology's establishment. Endoscopic sinus surgery represents the gold standard treatment for inflammatory, malformative, benign, and, in selected cases, malignant diseases. The surgical technique is commonly described as minimally invasive as the nostrils are used as an access route and therefore does not leave any external scars. Currently, the surgical procedures, even though minimally invasive regarding the way in, are in fact widely destructive towards the surgical target. The healing process and re-epithelialization will depend on the amount of bony tissue that has been exposed and it will be important to str...
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Despite the therapeutical advances of the last decade, nasal polyposis represents still a problem for rhinology, practitioners. A number of hypotheses have been formulated about its etiopathogenesis, but no one is confirmed, so that... more
Despite the therapeutical advances of the last decade, nasal polyposis represents still a problem for rhinology, practitioners. A number of hypotheses have been formulated about its etiopathogenesis, but no one is confirmed, so that nowadays therapy continues to be only symptomatic and does not cure definitively the underlying pathology. Recurrences are frequent and discourage both the practitioner and the patient. Purpose of this paper is to illustrate Authors' therapeutical rationale aimed to reestablish nasal flow, reduce rhinorrhea, improve olfaction, decrease rhinosinusinusal infection rate and maintain as long as possible such a symptomatic improvement. These targets are best achieved by a combination of medical and surgical treatments in order to optimize the results and reduce the side-effects of both the therapeutical options. Moreover the treatment should be tailored on each patient and follow up should be careful and performed at regular interval. Authors reviewed the...
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To evaluate the necessity of reconstructing the eroded bony boundaries after mucocele marsupialization when the mucoperiosteum has been spared. Retrospective review of 308 patients treated for a sinonasal mucocele. Of these, 116 showed... more
To evaluate the necessity of reconstructing the eroded bony boundaries after mucocele marsupialization when the mucoperiosteum has been spared. Retrospective review of 308 patients treated for a sinonasal mucocele. Of these, 116 showed areas of bone reabsorption in their preoperative computed tomography (CT) scan. Of 116 patients showing one or more areas of bone reabsorption who underwent marsupialization of the mucocele, whether using a purely endonasal endoscopic approach or a combined approach, the common factor was that the mucoperiosteum of the paranasal sinus had always been spared and the eroded bone had never been reconstructed. After rigorous selection, 12 adult patients were enrolled to undergo a postoperative CT scan in order to verify what had happened to the eroded bone at least 3 years following the surgical marsupialization of the mucocele. In 66,6% of patients, the postoperative CT scan showed complete self-reconstruction of bone that had previously been eroded by the mucocele. No enophthalmus, meningocele, or other facial deformities were noted in our selection group, despite not having undergone surgical reconstruction of the bone. Even taking into account the small number of patients enrolled in the present study, indications are that there is no need to reconstruct the eroded bone, as would appear from our results that sparing the mucoperiosteum is enough to enable the bone to regenerate. Nevertheless, larger scale studies of the subject are merited. 4. Laryngoscope, 2015.
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BACKGROUND AND IMPORTANCE: To describe a transnasal endoscopic route to the jugular foramen and the endoscopic anatomy of the infratemporal fossa. CLINICAL PRESENTATION: Endoscopic transnasal dissection of the infratemporal fossa was... more
BACKGROUND AND IMPORTANCE: To describe a transnasal endoscopic route to the jugular foramen and the endoscopic anatomy of the infratemporal fossa. CLINICAL PRESENTATION: Endoscopic transnasal dissection of the infratemporal fossa was performed in 3 injected fresh heads (1 head only in arteries and 2 heads in arteries and veins). Two other double-injected specimens were dissected externally (2 of them side laterally and 1 anteriorly) to compare the different views and better understand the 3-dimensionality of the region. Detailed endoscopic anatomy of the infratemporal fossa was clearly observed. The realization of a septal and posterior maxillary window allows surgeons to gain space to the jugular foramen. The ability to manage the vessels, especially the veins, and identify the muscles is mandatory. The fundamental role of the vidian canal in targeting the anterior genu of the internal carotid artery is confirmed. The role of the maxillary and mandibular branches of the trigeminal ...
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Research Interests: Medicine, Endoscopy, Humans, Cholesterol, Female, and 5 moreClinical Sciences, Aged, Time Factors, Petrous bone, and Bone Diseases
The aim of this study was to illustrate the anatomy of the medial compartment of the orbit by comparing the endoscopic transnasal perspective with the external ones. 8 orbits from 5 double-injected heads were carefully dissected. An... more
The aim of this study was to illustrate the anatomy of the medial compartment of the orbit by comparing the endoscopic transnasal perspective with the external ones. 8 orbits from 5 double-injected heads were carefully dissected. An endoscopic anterior transconjunctival dissection was performed in one orbit while an endoscopic transnasal intraconal dissection was conducted in 3 orbits. External dissections (from medial, superior and anterior perspective) were also performed. The role of the medial rectus muscle is emphasised. It represents the first important landmark encountered, covering all the other structures during transnasal approaches. By displacing it, the medial intraconal space with its contents becomes visible: the ophthalmic artery and related branches, the superior ophthalmic vein, the nasociliary nerve and, in the deepest part of the medial compartment, the optic nerve. The medial compartment of the orbit can be addressed transnasally. By displacing the medial rectus muscle, it is possible to gain adequate space for the instruments and to control all of the medial compartment, including the medial aspect of the optic nerve.
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Aim:To report our experience with endoscopic, endonasal management of sinonasal haemangiopericytoma.Materials and methods:Retrospective review of the medical records of 10 patients undergoing endoscopic, endonasal surgery for sinonasal... more
Aim:To report our experience with endoscopic, endonasal management of sinonasal haemangiopericytoma.Materials and methods:Retrospective review of the medical records of 10 patients undergoing endoscopic, endonasal surgery for sinonasal haemangiopericytoma of the nose and paranasal sinuses, between 1997 and 2008.Results:Five men and five women were included. Their mean age at surgery was 59 years. All patients underwent endoscopic, endonasal resection of their tumour. Major post-operative complications were encountered in only one patient (stroke). Local recurrence was diagnosed in only one patient (10 per cent), who subsequently underwent a combined resection (endoscopic and external) with orbital exenteration.Conclusions:Sinonasal haemangiopericytomas are rare tumours that are usually benign. The mainstay of treatment is wide surgical excision with free resection margins. Nowadays, the great majority of patients can be treated using a purely endoscopic, endonasal approach.
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Maxillofacial district osteomas are benign lesions with very slow growth. The most frequent localization is the frontal sinus, about 57% of all paranasal cavity osteomas; less frequently, they can be located in the ethmoidal sinus or... more
Maxillofacial district osteomas are benign lesions with very slow growth. The most frequent localization is the frontal sinus, about 57% of all paranasal cavity osteomas; less frequently, they can be located in the ethmoidal sinus or sphenoidal and maxillary. Etiology has not completely clarified yet; nevertheless, there are 3 main pathogenetic theories: osteogenic, traumatic, and infective. Open procedures represent the gold standard, but there is still an unsolved debate for the best treatment option. Endoscopic techniques offer an alternative approach, enabling closer and more direct visualization of the anatomy as well as avoiding damage to surrounding structures. In our study, we analyzed all patients treated with endoscopic approach for paranasal sinus osteomas in the ENT unit of the University of Varese and compared them with patients treated for the same pathology with open surgery in the Maxillo-facial Department of the University of Rome "La Sapienza." The purpose of the work was to compare the advantages and disadvantages of the 2 procedures. In conclusion, this study underlines the importance of flexibility in surgical approach decision, which must fit the different issues of the pathology and of the patient.
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Research Interests: Dentistry, Surgery, Radiation Therapy, Adolescent, Medicine, and 15 moreEndoscopy, Prospective studies, Humans, Female, Male, Squamous Cell Carcinoma, Paranasal Sinuses, Clinical Sciences, Aged, Oral Squamous Cell Carcinoma (OSCC), Adult, Adenocarcinoma, Nose Neoplasms, Disease Free Survival, and Ethmoid Sinus
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We report a case of a left fronto-temporo-parietal subdural haematoma that emerged as a complication of an endonasal endoscopic resection of a sinonasal adenocarcinoma of the left ethmoidal region. During the first surgical intervention,... more
We report a case of a left fronto-temporo-parietal subdural haematoma that emerged as a complication of an endonasal endoscopic resection of a sinonasal adenocarcinoma of the left ethmoidal region. During the first surgical intervention, following oncological principles, the dura mater above the ethmoidal plate was removed and a skull base plasty was performed. In the post-operative phase a massive cerebrospinal fluid leak was observed and a revision duraplasty was performed the following day. Subsequently the patient was discharged on day 8 with no signs of CSF leakage. At the three month follow-up MR examination a subdural haematoma was observed and then treated by the neurosurgeon in a standard fashion. The collection was quite asymptomatic and discovered accidentally. We strongly advise the role of early post-op neuroimaging in every patient undergoing skull base procedures. We maintain that a massive CSF leak, that causes a significant reduction of intracranial pressure, should be managed as a surgical emergency, in order to reduce the risk of subdural haematoma.
Research Interests: Neurosurgery, Cancer, Magnetic Resonance Imaging, Medicine, Endoscopy, and 15 moreCerebrospinal Fluid, Case Report, Humans, Male, Clinical Neurology, Clinical Sciences, Middle Aged, Lessons Learned, Neurosciences, Leak, Intracranial Pressure, Adenocarcinoma, Cerebrospinal Fluid Leak Repair, Neoplasm metastasis, and Ethmoid Bone
We studied 12 pediatric patients with congenital or acquired anterior skull base defects. All subjects underwent surgery owing to progressive symptoms. The endoscopic endonasal approach is a new method in the treatment of this pathology... more
We studied 12 pediatric patients with congenital or acquired anterior skull base defects. All subjects underwent surgery owing to progressive symptoms. The endoscopic endonasal approach is a new method in the treatment of this pathology in children. Twelve children had surgery to correct anterior skull base defects: seven patients with a spontaneous anterior basal meningoencephalocele and five with posttraumatic cerebrospinal fluid (CSF) leakage. The defects were repaired using the endoscopic endonasal approach, which combined with the fluorescein diagnostic test, detects the exact location of the skull base defect. Different closure techniques were used to obtain a permanent graft, depending on the type, location, and size of the defect. An intraoperative fluorescein test confirmed the absence of CSF leakage after surgery. The follow-up period ranged from 3 to 72 months. Symptoms resolved in all patients after surgery and none of them experienced complications or recurrence of CSF leakage. Postoperative magnetic resonance scans showed that the defect had successfully been repaired in all patients. The surgical treatment of skull base defects in children reduces life-threatening risks, which include infections, CSF leaks, and enlargement or trauma of the sac. The endoscopic technique minimizes surgical scars and has little impact on brain tissue. The endoscopic endonasal approach to the anterior skull base helps to preserve the physiology of the nose and sinuses and reduces the impact on the still developing splanchnocranium in pediatric patients. It ensures a definitive repair of the defect and requires a very short inpatient period.
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Background Because of a better understanding of the anatomy from an endoscopic perspective, the acquisition of surgical experience, and concomitant technological advances, endoscopic resection of the anterior skull base (ASB) and... more
Background Because of a better understanding of the anatomy from an endoscopic perspective, the acquisition of surgical experience, and concomitant technological advances, endoscopic resection of the anterior skull base (ASB) and overlying dura has now become a reality, opening new possibilities in the management of sinonasal malignancies. Here, the authors review a series of 62 patients, the largest reported to date, who underwent endoscopic transnasal craniectomy (ETC) and endoscopic dural repair for the management of selected sinonasal malignancies. Special emphasis is placed on the surgical technique, technical tricks, choice of materials for endoscopic dural repair, postoperative management, and complications. Methods From 2004, 62 patients underwent ETC at two referral hospitals, which extended anteroposteriorly from the frontal sinus to planum sphenoidale and laterolaterally from the nasal septum to the lamina papyracea (unilateral resection, n = 28; 45%) or from papyracea to...
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Objective: Poorly differentiated NECs and ONBs are rare sinonasal malignancies showing overlapping morphological features, with difficult differential diagnosis. Notwithstanding, the two histotypes differ significantly in therapeutic... more
Objective: Poorly differentiated NECs and ONBs are rare sinonasal malignancies showing overlapping morphological features, with difficult differential diagnosis. Notwithstanding, the two histotypes differ significantly in therapeutic strategies and prognosis. Design: Retrospective analysis of patients treated for NEC and ONB from 1999 to 2011 at our Institute. Material and Methods: We performed a revision of histopathological slides, taking advantage of a specific immunohistochemical staining. Results: The patients eligible for present analysis were 28 (12 male and 16 female), from 14 to 79 years old (mean, 55.7 years). The 22 cases of ONB underwent endoscopic endonasal resection (EER) with adjuvant IMRT; the 6 cases of NEC were treated with induction chemotherapy followed by EER with adjuvant IMRT. ONBs were characterized by immunohistochemical positivity for synaptophysin (SYN), chromogranin A (CgA), and S100 in sustentacular cells, whereas they were negative for the cytokeratins (CKs). NECs show strong and diffuse immunoreactivity for CK 8/18 and SYN with low CgA and CKAE1/AE3 expression, without S100-positive sustentacular cells. We found misdiagnosis in three cases of ONBs that showed immunophenotypical features of NECs. The recurrence rates, after a mean follow-up of 60 months (range, 1-153 months), were 2/3 (66.7%) for the misdiagnosed group, 2/19 (10.5%) for the confirmed ONBs, and 2/6 (33.3%) for the NECs. Conclusion: In our experience, these recent advances in histopathological differential diagnosis between NEC and ONB seem to be crucial to properly plan adjuvant or neoadjuvant treatment and also to predict the prognosis of patients. Larger case series are needed to validate these preliminary result
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The management of Non-Functioning Pituitary Adenoma (NFPA) invading the cavernous sinus (CS) is currently a balancing act between the surgical decompression of neural structures, radiotherapy and a wait-and-see policy. We undertook a... more
The management of Non-Functioning Pituitary Adenoma (NFPA) invading the cavernous sinus (CS) is currently a balancing act between the surgical decompression of neural structures, radiotherapy and a wait-and-see policy. We undertook a retrospective review of 56 cases of NFPA with CS invasion treated through an endoscopic endonasal approach (EEA) between 2000 and 2010. The Knosp classification was adopted to describe CS involvement using information from preoperative MRI and intraoperative findings. Extent of resection and surgical outcomes were evaluated on the basis of postoperative contrast-enhanced MRI. Endocrinological improvement and visual outcomes were assessed according to the most recent consensus criteria. EEA was performed using direct para-septal, trans-ethmoidal-sphenoidal or trans-ethmoidal-pterygoidal-sphenoidal approach. Visual outcomes improved in 30 (81%) patients. Normalization or at least improvement of previous hypopituitarism was obtained in 55% of cases. A gros...
Research Interests: Surgery, Magnetic Resonance Imaging, Medicine, Rhinology, Humans, and 15 moreFemale, Male, Skull Base, Hypopituitarism, Clinical Sciences, Aged, Middle Aged, Adult, Pituitary Adenoma, Retrospective Studies, Adenoma, Pituitary Neoplasms, Postoperative Complications, Cavernous sinus, and endoscopic endonasal
The surgical treatment of sinonasal malignancies is in continuous evolution. In selected patients, endoscopic resection has become a sound alternative to traditional external approaches. Further improvements are necessary to enhance the... more
The surgical treatment of sinonasal malignancies is in continuous evolution. In selected patients, endoscopic resection has become a sound alternative to traditional external approaches. Further improvements are necessary to enhance the possibilities of endoscopic transnasal resection of sinonasal malignancies. We present a case of intestinal-type adenocarcinoma of the left nasal fossa eroding the skull base that affected a 56-year-old male. The patient was surgically-treated by means of a four-hand binarial endoscopic transnasal resection using a 3D endoscopic system and neuronavigation. Surgery was completed in 5 hours without significant complications. Surgeons were able to recognize and manage anatomical structures, and to control bleeding easily thanks to the bimanual technique and 3D visualization. The new 3D scopes and the bimanual technique under the guidance of a navigation system represent an interesting solution that can overcome the traditional limits of the traditional ...
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To evaluate the feasibility of endoscopic surgery in the management of selected nasopharyngeal cancers. Three different types of nasopharyngeal endoscopic resections (NER) are described. From January 1997 to October 2008, 17 consecutive... more
To evaluate the feasibility of endoscopic surgery in the management of selected nasopharyngeal cancers. Three different types of nasopharyngeal endoscopic resections (NER) are described. From January 1997 to October 2008, 17 consecutive patients (mean age: 50 years) with previously untreated (5) or recurrent nasopharyngeal tumours (12) were treated with curative intent by pure endoscopic resection. The extent of surgical resection was classified as follows: type I NER: resection limited to the postero-superior nasopharyngeal wall; type 2 NER: resection superiorly extended to the sphenoid sinus; type 3 NER: resection with lateral extension including the cartilaginous portion of the Eustachian tube and parapharyngeal space. Type 1 NER was performed in 4 cases, type 2 in 6, and type 3 in 7. No intra- or post-operative complications were observed. Mean hospitalization time was 4 days (range: 1-7). Follow-up ranged from 10 to 138 months (mean: 41.2±38). At the time of writing, 12 (71/%) ...
Research Interests: Rhinology, Endoscopy, Humans, Female, Feasibility Studies, and 5 moreMale, Clinical Sciences, Aged, Middle Aged, and Adult
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Management of symptomatic osteomas involving the frontal sinus is challenging. Traditional external approaches have been used in the surgical management of these lesions. Recently, endonasal endoscopic surgery has become a valid... more
Management of symptomatic osteomas involving the frontal sinus is challenging. Traditional external approaches have been used in the surgical management of these lesions. Recently, endonasal endoscopic surgery has become a valid alternative to the traditional external approach in selected cases. Retrospective evaluation of the patients with symptomatic fronto-ethmoidal osteomas surgically managed in the last 10 years at a tertiary care facility. Twenty-six osteomas involving the frontal sinus were treated surgically. In 11 cases a purely endoscopic approach was performed while in 13 patients a combined procedure was used. In two patients, an exclusively external procedure was performed. No osteoma recurrence has been observed yet (mean follow up: 40 +/- 31.75 SD months). Endonasal endoscopic resection of a frontal sinus osteoma is feasible when the lesion is medial to a virtual plane through the lamina papyracea and is attached in the lower portion of the posterior wall of the front...
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Data from several centers worldwide have demonstrated that transnasal endoscopic surgery performed with or without a transcranial approach is capable of achieving radical resection of selected sinonasal malignancies. We report our... more
Data from several centers worldwide have demonstrated that transnasal endoscopic surgery performed with or without a transcranial approach is capable of achieving radical resection of selected sinonasal malignancies. We report our experience with endoscopic management of sinonasal cancers, with emphasis on naso-ethmoidal malignancies encroaching on the anterior skull base. Major series reporting results concerning the endoscopic endonasal approach with or without craniectomy for treatment of sinonasal and anterior skull base cancers were reviewed. Preoperative work-up, indications and exclusion criteria, surgical techniques, postoperative management, and adjuvant therapy are reported. In the 2 largest series analyzed, the most common malignancies were adenocarcinoma (28%), olfactory neuroblastoma (14.5%), and squamous cell carcinoma (13.5%). The 5-year disease-specific survival rate ranged from 81.9%-87%, with no major differences in the mean follow-up time (34.1 months vs. 37 month...