Comparison between unilateral PNIF and rhinomanometry in healthy and obstructed noses

AIMS

Peak Nasal Inspiratory Flow (PNIF) is an easy method to assess nasal patency. Normative unilateral PNIF data in adults have been proposed. The study purpose was to compare PNIF and unilateral PNIF values to total and unilateral nasal resistances measured by anterior active rhinomanometry (AAR) in subjects with and without nasal obstruction to see whether unilateral PNIFis sensitive to detect nasal obstruction.

METHODS AND RESULTS

Measurements of PNIF, unilateral PNIF and AAR were performed in 125 volunteers. Seventy of them were healthy subjects not complaining of nasal symptoms and entered into the study as the'normal' group. The other group consisted of fifty-five symptomatic subjects.Data were analysed to show the correlation between PNIF, unilateral PNIF and nasal resistances. The ability of PNIF and AAR in predicting pathologies were compared by receiver operating characteristic (ROC) analysis indicating that PNIF and AAR have a similar and significant power to discriminate pathologic from healthy subjects.

CONCLUSION

The measurement of unilateral PNIF could be a helpful method to support the diagnosis of nasal blockage also in those cases with single nostril obstruction, but, in cases of doubt, AAR should also be performed to improve diagnostic accuracy.

Management of complex pediatric burn scars in a humanitarian collaboration

Burn scars still represent a challenge to the reconstructive surgeon. Their management requires a specific expertise and set up involving the possibility of long term rehabilitation and follow up. Cases encountered in humanitarian missions present additional issues. Often the local environment is not suitable for an appropriate treatment plan, requiring the case to be transferred to a foreign country for surgical care as part of an integrated international and multidisciplinary management. We present the case of a three year-old patient injured in a bomb explosion during the Arab Spring and suffering from severe scar contracture limiting thoracic and upper limb movement. After initial consultation at distance, transfer to our country was organized and an intensive surgical and rehabilitative program was carried out over three months. After five months, the patient returned to his home country where a supportive network had been set up for continued rehabilitation, ensuring follow up for over a year and ultimate success.

N-butanol olfactory threshold and nasal patency before and after palatal expansion in children. A preliminary study

OBJECTIVES

Olfaction is based on the function of the nasal olfactory receptors. Children can well detect and respond to odors in order to have information about food and environment. Rapid maxillary expansion seems to improve dental class and increase nasal patency correcting oral respiration in children. Nevertheless, there are no studies demonstrating that expansion in pediatric patients could influence olfactory sensitivity. The aim of this study was to evaluate olfactory threshold and nasal patency in children aged from 6 to 12 years before and after rapid maxillary expansion.

METHOD

N-butanol olfactory thresholds, anterior active rhinomanometry, and peak nasal inspiratory flow were measured in 12 children (6-12 years) before (T0), 20 days (T1), and 6 months after rapid maxillary expansion application (T2).

RESULTS

A significant lower olfactory threshold was found comparing T2 and T0 N-butanol olfactory threshold values (p=0.038). Peak nasal inspiratory flow showed a significant improvement both at T1 and T2, with respect to T0 values (p=0.043 and p=0.0001, respectively). T2 nasal resistances showed a trend towards a significant reduction when compared with T1 values (p=0.15).

CONCLUSION

This pilot study suggested that rapid maxillary expansion may lead to improved N-butanol olfactory thresholds, at least 6 months after palatal expansion. Furthermore, rapid maxillary expansion seems to improve peak nasal inspiratory flow values, and finally although with lower sensitivity, reduce nasal resistances as measured by rhinomanometry.

The EGFR-mTOR pathway and laryngeal cancer angiogenesis

Epidermal growth factor receptor (EGFR) is a trans-membrane tyrosine kinase taking part in cell transformation and tumor progression. One of the downstream pathways controlled by EGFR involves the mammalian target of rapamycin (mTOR), a proto-oncogene activated in several cell functions. Recent evidence seems to confirm that both EGFR and mTOR regulate angiogenesis. The aim of this study was to investigate the expression of EGFR and mTOR in laryngeal squamous cell carcinoma (LSCC) cells in a retrospective clinical setting and their correlation with tumor neo-angiogenesis, judged on the grounds of CD105-assessed microvascular density (MVD), and prognosis. We considered 76 consecutive patients with LSCC treated with surgery alone. Immunohistochemical expressions of EGFR, mTOR, and CD105 were measured using image analysis and findings underwent statistical analysis using univariate and multivariate models. We found that nodal status correlated significantly with patient prognosis in terms of disease-free survival (DFS) (p = 0.01). There was a strong direct correlation between mTOR and EGFR expression (p = 0.0003), and between mTOR and CD105-assessed MVD (p = 0.0025). Patients with a CD105-assessed MVD >5.28 % had a significantly higher recurrence rate (RR) (p = 0.026), and a significantly shorter DFS (p = 0.025). On multivariate analysis, only N stage [hazard ratio (HR) 3.54, p = 0.009] and CD105-assessed MVD (HR 2.87, p = 0.027) maintained their independent prognostic significance in terms of DFS. Judging from our promising findings, the EGFR-mTOR pathway should be investigated further to understand its role in LSCC neo-angiogenesis.

Human olfactory sensitivity for bourgeonal and male infertility: a preliminary investigation

Olfactory receptor (OR) expression is also present in the sperm cells and could mediate sperm chemotaxis. OR1D2 was the first OR expressed in the testis demonstrated to be involved in chemotaxis and to be expressed also in the nose with a similar behavior. Bourgeonal is the OR1D2 most potent known agonist. Infertility affects ~15 % of couples in western countries and sometimes it is unexplained. This pilot study compared the bourgeonal olfactory thresholds, the ability of sperm to sense the bourgeonal and the frequency of 13 single nucleotide polymorphisms (SNPs) of OR1D2 gene in nine males suffering of unexplained infertility with a control group of 15 healthy males. The mean olfactory threshold for bourgeonal was statistically different between the study group (10.5 ± 3.7; median 12.3) and the control group (14.0 ± 2.8; median 15.5) (p = 0.006). Statistical analysis showed a significantly higher percentage of spermatozoa that migrated toward the capillaries filled with bourgeonal in the control group compared to the study group (p < 0.0001). Sperm migration was equally inhibited in both groups of subjects when, together with bourgeonal, capillaries were filled with undecanal, a strong bourgeonal inhibitor (p = 0.42). The 13 SNPs of OR1D2 revealed a statistically significant difference for allele and genotype frequency of rs769423 in study group versus control group (p = 0.02). The present preliminary study seems to confirm the important role of OR1D2 both in nose and spermatozoa and may explain the idiopathic infertility of the study group. Further studies on larger series are mandatory to confirm our preliminary evidence.

Nasal dysfunction induced by chlorinate water in competitive swimmers

AIMS

Swimmers commonly complain of nasal symptoms probably due to mucosal irritation caused by chlorinated water. The aim of the present prospective study was to investigate changes in nasal function and cytology in a cohort of 15 volunteer competitive swimmers, as compared with a control group of 15 competitive athletes practicing other sports.

METHODS

Olfactory threshold for n-butanol was measured in a population of competitive swimmers. Changes in nasal function and cytology were compared between the two groups of volunteer competitive athletes.

RESULTS

There were no significant differences between the two groups in terms of mean 20-Item Sino-Nasal Outcome Test scores, peak nasal inspiratory flow, pulmonary peak expiratory flow, or total nasal resistance on anterior active rhinomanometry. Nasal mucociliary transport time (MCTt) was significantly shorter for the non-swimmers than for the swimmers. The mean olfactory threshold for n-butanol in the swimmers was significantly lower than in the other group of athletes.

CONCLUSIONS

Data seem to confirm the utility of MCTt in studying nasal mucosa damage caused by chlorinated water. The present results also support the hypothesis of a role for the olfactory threshold in evaluating damage to the olfactory mucosa exposed to chlorinated water.

Case report of cholesteatoma recurrence with Bezold's abscess presenting as a deep neck infection

Cervical masses are a common clinical finding, but differential diagnosis is often challenging. Acute neck swellings are often due to deep cervical space infections that have originated at oral or oropharyngeal sites. Deep neck infections originating elsewhere are not rare; however, they are difficult to diagnose, and their origins remain obscure in 20% of cases. Neck swellings that originate in the middle ear are very rare, with only a few reported in the scientific literature. Here we report an atypical case of Bezold's abscess caused by the recurrence of a middle ear cholesteatoma. In patients with neck swelling and a history of primary cholesteatoma of the middle ear, otolaryngologists should consider regional recurrence of disease a possibility even several years after the primary surgery.

Nasal functional modifications after physical exercise: olfactory threshold and peak nasal inspiratory flow

STATEMENT OF PROBLEM

The respiratory nasal effects of physical exercise have been extensively investigated; on the other hand there are no data regarding olfactory threshold modification after aerobic physical exercise.

METHODS

The present prospective study investigated the modifications in nasal respiratory flows and olfactory thresholds after controlled aerobic physical exercise in a cohort of 15 adult, healthy volunteers. The Peak Nasal Inspiratory Flow (PNIF), and the Sniffin’ Sticks olfactory threshold test were used for our determinations.

MAIN RESULTS

The mean PNIF after physical exercise was significantly higher than the mean PNIF value found before physical exercise. Statistical analysis ruled out any significant difference between mean olfactory thresholds pre vs post physical exercise.

PRINCIPAL CONCLUSIONS

These outcomes confirmed PNIF sensitivity and reliability also in determining the changes in nasal patency occurring after physical exercise. The active vasoconstriction of nasal mucosa associated with the reduction of blood flow to the olfactory epithelium due to physical exercise may be compensated for by the increase of olfactory molecules that reach the olfactory mucosa because of nasal mucosal shrinkage: this mechanism could explain the stability of mean olfactory threshold after physical exercise.

Anosmia associated with hearing loss and benign positional vertigo after head trauma

It is well known that head trauma may cause hearing loss, which can be either conductive or sensorineural. Benign paroxysmal positional vertigo and olfactory dysfunction due to head trauma are also well known. The association between sensorineural hearing loss and anosmia, following head trauma, is extremely rare. Two rare cases of post-traumatic occurrence of hearing loss, olfactory dysfunction and benign positional vertigo are reported and the pathophysiology of the association between sensorineural hearing loss, anosmia and benign paroxysmal positional vertigo, after head injury, are briefly discussed. ENT specialists should, in the authors' opinion, be aware of the possible association between anosmia, sensorineural hearing loss and benign paroxysmal positional vertigo after head injury, even in the absence of skull fracture.

The role of survivin expression in the differential diagnosis of laryngeal (glottic) verrucous squamous cell carcinoma

AIMS

Laryngeal verrucous squamous cell carcinoma (VSCC) is a highly differentiated carcinoma (SCC) whose histological diagnosis has many pitfalls in particular considering small biopsies: multiple glottic biopsies may be necessary to conclude for a malignant or benign lesion (papillary hyperplasia). Survivin is a member of the inhibitor of apoptosis protein family. Survivin over-expression has been demonstrated in laryngeal SCCs. The aims of the present study have been to evaluate for the first time survivin expression in glottic VSCC and investigate the potential role of survivin expression in the differential diagnosis of laryngeal VSCC.

METHODS

Survivin expression was determined in 11 consecutive cases of glottic VSCC, in 24 cases of glottic papillary hyperplasia, and in 23 cases of SCC.

RESULTS

Nuclear survivin reaction predominated in laryngeal VSCCs, papillary hyperplasias, and SCCs. Mean survivin expressions in the VSCC basal layer, hyper-proliferative areas of laryngeal papillary hyperplasia, and SCC were 62.7%, 68.3%, and 70.0%, respectively. Mean survivin expression was 15.6% in VSCC parakeratosis and 1.5% in papillary hyperplasia parakeratosis (p<0.001).

CONCLUSIONS

Survivin expression was significantly higher in parakeratosis areas of laryngeal VSCC than in parakeratosis areas of laryngeal papillary hyperplasia. Immunohistochemical determination of survivin expression in parakeratosis areas may be a promising tool to substantiate differential diagnosis between glottic VSCC and papillary hyperplasia.

CD105-assessed micro-vessel density is associated with malignancy recurrence in laryngeal squamous cell carcinoma

AIMS

Angiogenesis is essential for malignancies growth. CD105 is a proliferation-associated protein abundantly expressed in angiogenic endothelial cells. The aim of this study has been to determine the expression of CD105 in laryngeal squamous cell carcinoma (SCC) and to investigate the role of CD105-assessed mean vascular density (MVD) in predicting patients' prognosis.

METHODS

The sections of 43 consecutive cases of laryngeal SCC were stained with mouse monoclonal antibody CD105. All the measures were performed by a computer-based image analysis system. The percentage of the fields occupied by CD105-assessed micro-vessels was determined.

RESULTS

The mean CD105-assessed MVD were 11% and 6% in laryngeal SCC with and without malignancy recurrence, respectively. Multivariate logistic regression stated that CD105-assessed MVD was significantly related to disease recurrence (p=0.030).

CONCLUSIONS

Our preliminary results suggest that CD105-assessed MVD may be a valuable parameter for predicting patients having an increased risk of developing laryngeal carcinoma loco-regional recurrence.

Difficulties in the fixation of prostheses for voice rehabilitation after laryngectomy

In most patients with advanced or recurrent laryngeal or hypopharyngeal cancer, total laryngectomy is indicated. This means the loss of three main functions: phonation; respiration; and the prevention of aspiration during deglutition. Laryngectomy patients have various options to restore phonation: an oesophageal voice; an electrolaryngeal voice; or a tracheo-oesophageal voice. In the last case a silicone rubber shunt valve is placed in the tracheo-oesophageal wall and phonation is generated when exhaled air is forced through the oesophagus and neopharynx. This method is widely applied in Western Europe. In this paper we review the literature on fixation problems with shunt valves, tracheostoma valves and heat and moisture exchange (HME) filters. Tracheo-oesophageal speech without a valve is not considered. Despite 22 years of experience with the implantation of tracheo-esophageal shunt valves and many improvements in the design, problems still remain, such as biofilm formation with subsequent leakage through the valve, the need for frequent and inconvenient replacements, fistula enlargement leading to leakage around the device and reduced fixation, and infections. The high cost of shunt valves is a drawback to their use worldwide. To enable hands-free speech, different types of tracheostoma valve have been developed. These valves are fixed to the skin or to the tracheostoma by means of an intra-tracheal device. An HME filter is used to protect the airway and maintain physiological balance. Such devices are only suitable for a selected group of patients as fixation to the skin or trachea can be a major problem. Speaking and coughing cause pressure increases, which often result in mucous leakage and disconnection of the valve and/or HME filter. Recommendations are made for future improvements in fixation techniques.

Treatment of complications of parotid gland surgery

Although several reports in the literature have documented the surgical technique, and the oncological outcome achieved with parotidectomy, only a few articles have described the complications of parotid gland surgery and their management. Several complications have been reported in parotid surgery. We re-classified the complications of parotidectomy in intra-operative and post-operative (early and late). The commonest complications after parotidectomy are temporary or permanent facial palsy and Frey's syndrome.

Current opinions in sialolithiasis diagnosis and treatment

The introduction, 15 years ago, of extracorporeal shock wave lithotripsy in the treatment of salivary gland calculi, has changed the therapeutic approach in these patients. Aim of this study was to evaluate the efficacy of lithotripsy in sialolithiasis, after 10 years follow-up. A review has been made of the literature to establish current opinions in diagnosis and treatment of sialolithiasis. The role of ultrasonography, radiography and, in particular, of sialomagnetic resonance imaging in diagnosis of salivary lithiasis has been evaluated. The greater efficiency of the extracorporeal shock wave lithotripsy treatment for parotid, compared to submandibular calculi, has been demonstrated (57% versus 33%). In 68% of our patients, lithotripsy was resolutive after 10 years. Ultrasonograpy should be considered first choice examination in diagnosis of salivary calculi. Sialo-magnetic resonance imaging is a recent, non-invasive diagnostic procedure with the advantage of no radiation exposure, and with better definition of anatomical and functional state of glandular parenchyma and duct, compared to other available techniques.

Nuclear expression of maspin is associated with a lower recurrence rate and a longer disease-free interval after surgery for squamous cell carcinoma of the larynx

AIMS

Maspin, a protein belonging to the serpin superfamily, is the product of a tumour suppressor gene. Tissue distribution studies have shown maspin expression in normal mammary epithelial cells, in the placenta, prostate, thymus, testis, oral cavity, small intestine, skin, and cornea. Maspin is expressed but down-regulated in human breast, prostatic, and colonic cancers but apparently up-regulated in pancreatic, ovarian, and gastric cancers. Only two studies concerning maspin expression in head and neck carcinomas are available. The present study is the first attempt to determine maspin expression in laryngeal carcinoma.

METHODS AND RESULTS

Maspin expression was evaluated in 21 cases of laryngeal carcinoma consecutively treated with an exclusively surgical approach with a follow-up period longer than 24 months. The expression of p53, p27 and MIB-1 was also studied. Two patterns of distribution of maspin in laryngeal neoplastic cells were found. Cytoplasmic expression of maspin was identified in 47.6% of the cases. Nuclear maspin positivity was determined in 47.6% of the cases. A statistically significant difference in nuclear maspin expression between the group of patients without carcinoma recurrence and the group with evidence of recurrence was demonstrated (P = 0.039). Log rank test analysis showed a statistically significant direct correlation between nuclear maspin expression and disease-free intervals after surgical treatment calculated in months (P = 0.028). A significant inverse correlation was disclosed between nuclear maspin staining and MIB-1 (P = 0.028). A trend of increasing p27 expression was noted in cases with positive nuclear maspin expression. Nuclear maspin expression was not statistically correlated with p53 expression. A trend towards direct correlation between cytoplasmic maspin expression and squamous cell carcinoma histological grade (G) was apparent. Cytoplasmic maspin expression did not correlate with p53, MIB-1 or p27 expression.

CONCLUSIONS

These preliminary results suggest that nuclear location of maspin is a good prognostic factor in laryngeal carcinoma.

Facial nerve paralysis secondary to acute otitis media in infants and children

Nowadays, facial paralysis is an uncommon complication of acute inflammation of the middle ear, with an estimated incidence of 0.005%; it was not so rare in the pre-antibiotic era, occurring in 0.5-0.7% of middle ear inflammatory processes. We would like to highlight this complication of acute otitis media, a common paediatric complaint. We present three new cases of facial palsy in children with acute otitis media and discuss the etiological mechanisms and different approaches to the treatment; a flow chart for facial paralysis in acute otitis media is also presented. Our three patients recovered completely after mastoidectomy (first two cases) and myringotomy with antibiotic therapy (third case). Facial paralysis is an uncommon complication of otitis media which requires appropriate care. Following our experience and revision of literature on the subject, antibiotic therapy and myringotomy are the first-line procedures. Surgery should be employed in case of acute or coalescent mastoiditis, suppurative complications and lack of clinical regression.

Deep neck infection: a present-day complication. A retrospective review of 83 cases (1998-2001)

Deep neck infections are less and less frequent today than in the past. Nevertheless, their complications are often life-threatening. The present study reviews the experience of the Department of Otolaryngology and Head and Neck Surgery of Padua with deep neck infections during the period from 1998 to 2001. Eighty-three patients (55 males and 28 females) were retrospectively considered. The site of origin of deep neck infection was identified in 76 patients (91%). The most common cause was dental infection, occurring in 35 cases (42%). In 12 cases (14%) deep neck infection was a complication of oropharyngeal infection. The relatively high incidence of Peptostreptococcus sp, Streptococcus viridans, Streptococcus intermedius and constellatus isolation was consistent with the high rate of odontogenic cases. Surgery was advocated as the treatment for any infection of the deep neck spaces. The recent series has demonstrated that medical treatment did not seem to increase complication rates or mortality. Our tailored approach (medical or medical and surgical) based on clinical and radiological evidence was successful in 97% of the patients.

[The surgery of the tip of the nose]

Surgery of the nasal tip has stimulated the creation of more surgical techniques than any other aspect of rhinoplastic surgery, to achieve an improved shape that seems natural while enhancing the balance and harmony of the face. The region described as tip of the nose is extremely varied from person to person, because of the different shape of its anatomical structures. For that reason to obtain a good result is necessary for the surgeon the perfect knowledge of the anatomy, the acquisition of surgical concepts and technical skill. The purpose of this paper is to describe the anatomy, the surgical technique and the principal method to correct the most common defects of the nasal tip; some of these proposed by many Authors are also discussed critically. Concerning the anatomy, the Authors describe the upper and the lower lateral cartilages, the lateral and medial crura of the alar cartilages, that form the "dome", the sesamoid complex: smaller cartilage that support the lateral crus, the septum cartilage, their ligaments and the maxillary spine. Are also exposed some concepts regarding the weak triangle of Converse and, in general, the soft tissues of the nasal tip. They also described some basilar incisions to approach the tip cartilage: marginal, intercartilaginous, intracartilaginous and transfixion. This surgical techniques allow to modified the cartilages that can be corrected in different manner. Some of these modifications concerning alar cartilages, septal cartilage, area of dome cartilage, and the most common techniques to operated on it, eversion and luxation, are also exposed. The last part of the paper concerning: a) the exposition of some anesthetical problems and their surgical approach; b) the description and discussion of some surgical techniques proposed in the literature by many Authors. Regarding the most common necessities to modified the nasal tip we include: a) to change the tip projection: in its two opposite directions, increasing and decreasing, where the first purpose is one of the most difficult objectives in tip surgery, using the medial cruras or in more difficult cases a colummellar strut; b) to reduce tip fullness, that normally requires a partial resection and/or a weakening of the lateral crura; c) to alter tip rotation: normally to obtain a upward, rarely for a down ward rotation to increase the length of the nose. In this case all these modifications are described following the theoretical concept of tripod, where the nasal tip is considered mechanically as a tripod with a lower leg represented by the medial crura and the two upper legs of the two lateral cruras.

Treatment of patients with arthrosis of the temporomandibular joint by infiltration of sodium hyaluronate: a preliminary study

Patients with degenerative disease of the temporomandibular joint (TMJ) who did not respond to conservative medical therapy (splint therapy, selected grinding or physiotherapy) can be treated by arthrocentesis, which is associated with intra-articular injections of sodium hyaluronate (Hyalgan). In this study, we treated ten dysfunctional patients with degenerative joint disease (DJD) who had been diagnosed clinically and had had the diagnosis confirmed by MRI. All subjects presented impaired mouth opening, joint pain at rest and on movement and impaired masticatory efficiency. We performed one cycle of five infiltrations with joint arthrocentesis and the injection of sodium hyaluronate at weekly intervals. The following parameters were assessed before and after infiltration and at follow-up after 6 months: mouth opening (with a mean of between 36.5 mm and 41.9 mm); sideways movements (to the right 4.9 mm to 8.9 mm and to the left 4.7 mm to 9.2 mm); pain at rest (VAS=1.8 to 0.5) and on movement (VAS=7.8 to 1.1); masticatory efficiency (VAS=5.7 to 8.6); subjective judgement of the functional TMJ limitation level (from 2.8 to 0.8); judgement of efficacy (from 2.4 to 3.2); judgement of tolerability to the therapy (from 2.0 to 3.1). The therapeutic benefits observed can be attributed both to joint arthrocentesis and to the characteristics of sodium hyaluronate itself. All the parameters considered revealed a statistically significant positive variation that persisted over time ( P<0.05). The results obtained by this minimally invasive, fast and easy technique proved to be valid and lasting. This infiltration technique using sodium hyaluronate looks very promising for patients affected by symptomatic DJD who do not respond to conservative medical therapy, reflecting similarly encouraging findings in the orthopaedic treatment of degenerative knee pathology.

Differential expression and topography of adhesion molecules in laryngeal and oropharyngeal carcinomas

This work describes the different patterns of expression of integrins and extracellular matrix proteins in normal and transformed mucosa in laryngeal and oropharyngeal carcinomas. Samples from each tumor group were sectioned and examined by immunohistochemistry using monoclonal antibodies raised against integrin chains (alpha2, alpha3, alpha6, beta1 and beta4) and their ligands (laminins 1 and 5, collagen type IV and two fibronectin isoforms: ED-A and ED-B). Controls were provided by samples of tumor-free laryngeal and oropharyngeal mucosa that had been removed during the surgical procedure. We found that the known distinct topographical pattern of integrins and the continuity of basement membrane components was altered in both groups but that the extent of changes was significantly more marked in oropharyngeal tumors, which are known to be more infiltrating and diffusive and to have a bad prognosis. These molecular patterns of expression can be used as an additional prognostic factor as they suggest a greater biological tumor aggressiveness of oropharyngeal tumors. We suggest that performing immunohistochemical analysis on biopsy samples may help in selecting the correct therapeutic strategy for these tumors and enable more accurate follow-up. The above-mentioned molecules may become part of the diagnostic toolbox of head and neck surgical pathologists.

Bezold's abscess in children: case report and review of the literature

The introduction of antibiotics in the treatment of suppurative otitis media has significantly decreased the incidence of complications. Reports of Bezold's abscess secondary to this disorder are rare, particularly in infants and young children, in whom mastoid bone pneumatization is not yet complete. We present a case of Bezold's abscess occurring in a child aged 18 months. The literature is reviewed and methods to accurately diagnose this complication are emphasized.

Langerhans' cell histiocytosis: temporal bone involvement

In Langerhans' cell histiocytosis, radiological findings on temporal bone involvement show destructive bone lesions involving the mastoid, with the squamous part and middle ear less affected. Computed tomography (CT) is the preferred imaging modality for describing the extent of temporal bone involvement. CT also has an important role in monitoring disease activity and response to treatment. Bone scintigraphy seems to be less sensitive than radiography in detection of these lesions.

Role of nasal valve in the surgically corrected nasal respiratory obstruction: evaluation through rhinomanometry

The aim of this study was to evaluate the improvement of nasal flow and the fall of nasal resistance in 50 patients that underwent rhinoseptoplasty in our department and discuss the relative importance of valvular and septal deformities in nasal airway obstruction. Fifty consecutive patients underwent rhinoseptoplasty to improve nasal obstruction caused by severe septal deviation, external or internal valvular incompetence, or any combination of the three. We excluded patients with minor septal curvatures, septal perforations, or turbinate hypertrophy. Preoperative and postoperative rhinomanometry was performed on all 50 patients. In all 50 patients, septal and/or valvular surgery lowered nasal resistance in 90% of cases. Septoplasty alone with medial and basal osteotomies did not improve nasal flow (p < 0.4), whereas the correction of valvular obstruction alone increased nasal airflow in a statistically significant way (p < 0.0001). Moreover, patients with both valvular incompetence and septal deviation represented the group in which the greatest preoperative obstruction and the greatest postoperative improvement occurred. Nasal valvular function should be assessed with rhinomanometry in all preoperative rhinoplasty patients with airway obstruction. In many cases, valvular effects may surpass septal deviation as the primary cause of nasal airflow obstruction.

Tympanic membrane displacement analyser tracing modifications induced by glycerol in Menière's disease

The aim of the study was to detect inner ear fluid pressure changes induced by glycerol in Menière's disease (MD) by means of a tympanic membrane displacement analyser (TDA). The study group consisted of 25 MD patients. The Vi (maximum inward displacement of the tympanic membrane) and the Vm (mean displacement of the tympanic membrane) were measured at 10, 20 and 25 dB above the stapedial reflex threshold. Each patient received therapy based on glycerol. The control group consisted of 20 patients with non-hydropic sudden hearing loss. At 20 and 25 dB above stapedial threshold MD patients had lower Vi values before therapy. After glycerol, we observed a Vi increasing in the hydropic ears in 68-96 per cent of patients. Since a Vi improvement implies a reduction of perilymph pressure, our results confirm the effectiveness of Vi in detecting specific action of glycerol in MD.

Violence against women and the assaulted staff action program

Women have been subjected to high rates of victimization at home, in the community, and at work. An earlier study found female inpatient staff to be at risk for same-gender patient assaults in psychiatric hospitals and female community residential staff to be at increased risk for assaults from male patients in residences. This study sought to revisit the original 2-year findings during a subsequent 6-year period. Inpatient and community assault data were gathered within the context of the Assaulted Staff Action Program (ASAP), a post-incident crisis response approach. Female inpatient staff were again found to be at increased risk in both inpatient and community settings. However, in this second study, female community residential staff were found to be at increased risk for assault from both male and female patients. The findings and their implications are discussed.

[Transtympanic gentamicin in Ménière's disease: evaluation of the quality of life]

Different methods have been proposed for the management of intractable Ménière's disease. Over the past years a selection has been made based on the effectiveness and the side effects of the surgical techniques and only a few procedures are routinely used in modern practice. After a period of success, endolymphatic sac surgery is now being progressively abandoned in the aftermath of criticism on its real effectiveness. Vestibular neurectomy is considered an effective method for relieving vertigo but it is an invasive procedure and the risk of complications is not absent. Transtympanic gentamicin is now considered a real alternative approach to the treatment of vertigo in Ménière's disease. The literature reports a high incidence of success with this method, similar to that of vestibular neurectomy, and the only complication being some hearing loss encountered in a few cases. Strategies differ in the gentamicin treatment of Ménière's disease. In the past gentamicin was administered on a daily basis until an effect on the labyrinth was seen. Recently some authors have administered lower amounts of gentamicin for just two or there days. Such treatment appears to control vertigo equally well without causing labyrinthine areflexia although this is not supported in the literature by prolonged follow-ups. The authors discuss the results obtained with a low dosage transtympanic administration of gentamicin in a series of 29 patients followed up for two years. The impact of this form of therapy on quality of life was evaluated through a questionnaire prepared following the criteria of the American Academy of Otolaryngology Head and Neck Surgery. In all cases, the score improved at the end of follow-up.

[Objective evaluation of dysphonia. Possibilities and limitations]

Today clinical evaluation of the presence and extent of dysphonia is still essentially based on subjective-perceptive criteria. The lack of objectivity and the one-sidedness of such an approach reinforces the desire for a quantitative, objective determination of dysphonia which could aid in making an modern, unequivocal evaluation of the presence, extent and variations in time of this disorder both upon onset and after treatment. The purpose of the present research was to determine the reliability, possibilities and limitations of an objective, parametric procedure to evaluate both the normal and pathological voice. This procedure is based on the detection of the relationship between the noise and harmonic portions in the voice (the Yumoto H/N ratio). The study involved a group of 208 subjects (148 with dysphonia and 60 normal) and the procedure was applied using computerized digital sonography and dedicated algorithms. The results of this research showed that the vocal analysis procedure developed by Yumoto is not only simple but also highly sensitive, providing an objective study of dysphonia. In fact, the comparison between the average H/N ratio recorded in our patients (1.697 dB) is significantly different from that recorded in the normal subjects (11.169 dB) (p < 0.001). This also showed a clear discrimination between the two groups with no borderline or overlapping data found. The initial evaluation does not appear to establish a relationship between abnormal H/N ratio values and the type of pathology although greater morphological destruction of the vocal cords corresponds to worse vocal quality and therefore increased noise. For the data obtained to be valid, a necessary condition is the application of a strict, precise, correct sampling and analysis method following well-defined rules. Finally, the values obtained can serve as a basis for the construction of an objective instrumental voice measurement protocol that can be used in forensic evaluation of dysphonia. Standardization of the regulations is essential to such a project.

[Cricohyoidoepiglottopexy : deglutition in 44 cases]

The present work reviews the authors personal experience and applies a meta-analysis of the data in the literature (approximately 800 cases) to better focus on the opportunities and difficulties involved in the Majer-Piquet technique. Particular attention is focused on the problems involved in deglutition. The study involves 44 patients who underwent cricohyoidoepiglottopexy (CHEP) between 1989 and 1998. Given that surgical and rehabilitation techniques have been refined over the years, to better analyze the functional results, the data were separated into two subsequent periods. Of the 23 patients who underwent surgery between 1989 and 1992 (group I), 6 were benefited from bilateral preservation of the arytenoids while this was only possible in two of the 21 cases operated in the second period from 1993 to 1998 (group II). Functional rehabilitation was started earlier in the second group and was routinely monitored with digital viedeofluorography. The average recovery time was 34 days for group I and 27 days for group II. The tracheostomy closed in an average 91 days vs. the 13 days found by the meta-analysis of the literature. The authors normally leave the tracheostoma in place for a long time, even when closed with an easily removed plug, and only perform plastic surgery when the patient has shown stable deglutition for several weeks. The naso-gastric tube was removed from both groups of patients after an average 16 days while the review of the literature shows an average 21 days. On the whole the authors record good deglutition in 41 of the 44 cases (93.18%) with adequate deglutition in the remaining 3 cases. Likewise the literature reports good deglutition in 86.4% of the cases. The only difference found between the two groups of patients was a quicker recovery in the second group; there were no qualitative differences. The results are described and discussed. In conclusion, the present experience places CHEP in favorable light as long as the limits inherent to the method are recognized. However, these limitations relegate the technique to a "sporadic" role and the review of the literature appears to confirm this attitude.

Pharyngocutaneous fistula as a complication of total laryngectomy: review of the literature and analysis of case records

Pharyngocutaneous fistula is the most common complication of total laryngectomy. The management of this problem increases hospitalization time and delays initiation of postoperative radiotherapy, where indicated. To identify factors predisposing to the development of pharyngocutaneous fistula, we reviewed the postoperative courses of 293 patients who underwent total laryngectomy at our clinic. General factors taken into account were concurrent diseases such as diabetes, liver diseases, or chronic anemia; local factors included radiotherapy before and after surgery, preoperative tracheostomy, type of cervical lymph node removal, and method of pharyngeal closure. We then compared our data with those reported in the literature by other authors. Last, we applied the Fisher exact test to a correlation we found between the higher incidence of fistula in patients with diabetes, liver diseases, or anemia. The local factor that turned out to be statistically most significant for the development of fistula was preoperative radiotherapy.

[Videofluoroscopic study of deglutition in patients with multiple sclerosis]

Multiple sclerosis is a neurological disease that affects the I/II motor neurons of the CNS and its symptoms include oropharyngeal dysphagia. The onset and course of this dysphagia significantly conditions the progression of the disease. The present study evaluates the incidence on deglutition and type of alterations in a sampling of 10 multiple sclerosis patients of which 4 showed clinical signs of dysphagia. The results, obtained by combining quantitative (clinical severity) and qualitative (functional alterations) parameters showed that 9 of the 10 patients (90%) presented radiological abnormalities in the progression of the bolus. The conclusion drawn is that the high prevalence of dysphagia in multiple sclerosis, even if not always manifest clinically, justifies drawing up a standard protocol for radiological evaluation and clinical follow-up in order to screen those patients at greater risk of pulmonary complications and delay them as long as possible.

[Post-parotidectomy Frey's syndrome. Treatment with botulinum toxin type A]

The Frey's syndrome, manifest after parotid trauma, is characterized by head and neck hyperemia and abundant sweating of the hyperemic skin in response to gustatory stimuli. The use of the botulin toxin to treat the symptoms in patients with Frey's syndrome has been described in numerous studies. For some time up until now our Center has achieved excellent results using the group A botulin toxin to overcome the hypertonus of the cricopharyngeal muscle in patients who had undergone laryngectomy and were rehabilitated with voice button. We have sought to extend the use of this toxin to Frey's syndrome, a relatively frequent complication of parotidectomy. A total of 86 patients participated in the study: 41 males (47.6%) and 45 females (52.4%) ranging in age from 25 to 77 years (average age 51 years). Of these patients 7 (8.1%) had undergone post-operative radiotherapy. Of the 86 patients studied, 18 referred significant symptoms in terms of abundance and frequency. The syndrome was considered severe if the symptoms were present at each meal and if the patient indicated a significant worsening of his quality of life. Intermittent episodes were indicated by 22 patients. The remaining 46 (43.5%) did not complain of any symptoms. The exact extension of the cervicofacial gustatory sweating was evaluated using the Minor test and the involved region was divided into 1 square centimeters sections. The amount of skin surface involved ranged from 10 to 80 square centimeters. The type A neurotoxin was frozen and was reconstituted with a sterile saline solution at a final concentration of 2.5 UI/0.1 ml. The intracutaneous infiltration was performed without anesthesia, infiltrating 0.1 ml of solution, containing 2.5 UI of toxin into the center of each 1 square centimeters section. Statistical analysis was performed to evaluate the potential relationship between how long the treatment was effective, incidence of recurrence, seriousness of the crises and the following variables: age, sex, histology, cutaneous surface involved, injected dose of botulin toxin and post-operative radiotherapy. In the group of 18 patients with severe symptoms (20.9%) the benefit was immediate in all cases although the recurrence rate was 50%. The Frey's syndrome symptoms disappeared within 7 days of infiltration. In the group of 22 patients with less severe involvement (25.5%), the treatment gave positive, definitive results in 16 patients (72.7%). Those patients whose symptoms persisted were treated a second time with an infiltration of 2.5 UI per square centimeters. We feel that the use of the type A botulin toxin is the most appropriate treatment for the Frey's syndrome. In fact, such treatment offers the following advantages: it is effective within 7 days, has limited side effects, can be applied on an outpatient basis, is inexpensive and is positively considered by the patients.

[Human olfactory mucosa biopsy with endoscopic technique: clinical and structural observations on neurosensory epithelium rearrangement]

Optical and electron microscopy have been widely used to study the structural features of olfactory epithelium in several Vertebrate species. To date, however, understanding of histopathological alterations in the human olfactory neuroepithelium has been quite limited due to the difficulty in obtaining well preserved, intact fragments of mucosa. The recent introduction of endoscopic biopsy techniques has made it possible to analyze this epithelium in greater detail. In the present work, endoscopic biopsy has been performed on samples from 10 rhinologically healthy subjects. The technique used proved quite simple and did not present any risks or complications. Moreover, all samples were well preserved, as confirmed by histology. In addition, the histological pictures suggest that normal rearrangement of neuroepithelium is not an uniform process but takes place following a zone pattern with distinct dynamics between neurosensorial and support cells. Greater diffusion of this technique would not only make it possible to use different techniques to gain more detailed knowledge of tissue structure, ultrastructure and dynamics in human neuroepithelium, but it would also provide improved diagnostic and forensic evaluation in cases of anosmia, disosmia and hyposmia.

[Revascularized jejunum loop in hypopharyngeal reconstruction: oncological and functional results]

The aggressiveness of hypopharyngeal cancer makes broad resectioning of the circular pharyngolaryngoesophageal segments necessary, followed by reconstruction to restore the anatomical gap created as fully as possibly creating a neoesophagus with thin walls that can easily be released. Over the years several procedures have been fine tuned for reconstruction of the upper digestive tract employing transposed viscera, miocutaneous pedunculated flaps, revascularized fascio-cutaneous or visceral free flaps. Currently the revascularized jejunum loop is one of the most commonly used methods in the reconstruction of the hypopharynx. Its popularity is due to some anatomical and physiological advantages: it requires transposition of a brief intestinal tract anatomically well adapted to the reconstruction site, ensuring rapid functional recovery. The authors report the oncological and functional results obtained in 25 patients who underwent circular pharyngolaryngectomy followed by reconstruction with a revascularized jejunum loop. The percentage of transplant survival was 90% and local and general complications were reduced to a minimum. The functional results--both in terms of deglutition and phonation--were satisfactory while patient survival (6-37 months follow-up) was in line with that reported by other authors for the same tumor (47%). Although prognosis for hypopharyngeal-esophageal neoplasms is still quite poor, this experience shows that circular pharyngolaryngectomy followed by reconstruction with autotransplant of the jejunum is an excellent choice since it offers the patient a prompt, acceptable functional recovery and a fair quality for his remaining life.

[Paranasal sinus mycoses]

In recent years there has been a marked increase in mycosis infections of the paranasal sinuses, attributed both to an increase in the survival of subjects at risk and improved diagnostic techniques (endoscopy, CT, MR) able to identify cases which had previously gone unrecognized and treated as aspecific chronic sinusitis. The present study involves 45 cases (4.3%) out of a total of 1050 patients who had undergone endoscopic surgery for sinusopathy between April 1994 and December 1998. Following the Katzenstein classification, the cases were broken down into non-invasive chronic mycoses or fungus ball (34 cases), allergic mycoses (7), chronic indolent invasive mycoses (3) and fulminating invasive mycosis (1 case). The mycetes most often involved was Aspergillus Fumigatus (76.9%). The recurrent symptom was facial algia, followed by nasal obstruction. Paranasal sinuses endoscopy did not modify the specific picture. CT presented such indicative signs as focal areas with non-homogeneous intensity, images of metal-like foreign bodies and endosinus calcifications in 84.4% of the cases. MR--performed in only 6 cases--always presented T2 images showing the typical signal void area corresponding to pathological lesions. All patients underwent endoscopic surgery of the paranasal sinus. The effectiveness of this treatment differed according to the clinical form. In the fungus balls surgery always resolved the pathology without requiring subsequent pharmacological treatment. In allergic mycosis, surgery improved the symptom of nasal respiratory obstruction but local drug treatment was required. With the aid of drug treatment, surgery resolved chronic indolent invasive mycoses and prevented the endocranial progression of complications. In the cases of fulminating invasive mycosis, timely surgery prevented the onset of endocranial complications and made it possible to perform antimycotic polychemotherapy to control the disease. This experience shows how important a protocol involving several different tests is in diagnosing the many clinical forms of paranasal sinus mycoses and distinguishing them from sinusopathies. Endoscopic surgery is indicated for all forms of paranasal sinus mycoses although the realistic objectives differ according to type.

[Surgical revision of the lateral nasal wall]

The purpose of rhinosinus revision through endoscopic surgery is to resolve recurrent, residual pathologies in patients with drug-resistant symptoms and to prevent ocular and endocranial complications. Surgical revision proves quite complex because of the destruction of the anatomical structures. More over the presence of tougher scare tissue which bleeds easily increases the risk of iatrogenous complications. Axial and coronal-projection tomography without contrast medium must be performed prior to surgery. Endonasal orientation is ensured by six main reference points. Three of these points--nasal septum, upper edge of the choana and upper edge of the nasolacrymal duct--are nearly always present while the others may or may not be, depending on what sort surgery has been performed. The present work gives the guidelines for a correct approach to patients who have undergone many previous procedures.

[Maxillary ameloblastoma: a case report]

Ameloblastoma is a neoplasm of odontogenic origin. Although it is considered a benign lesion it presents some peculiarities including a high local recurrence rate, particularly after conservative surgery, and a high loco-regional invasiveness. The present work describes a case of ameloblastoma of the left maxillary sinus bordering on the homolateral nasal fossa. The male patient was admitted to the E.N.T. Dept II of the University of Turin in May 1998 and underwent left radical maxillectomy. The authors also review the literature on the topic.

Staffieri tracheo-oesophageal prosthesis for voice rehabilitation after laryngectomy: an evaluation of characteristics

Experimental results on voice prostheses used for the rehabilitation of patients that have lost their vocal function after total laryngectomy are presented. The purpose is to evaluate the difference in aerodynamic behaviour between Staffieri voice prosthesis and other commercial valves (Groningen standard, Groningen low pressure, Panje, Provox). Two different equipments for flow-rate measurement were designed and built to compare the performance of the valves. The valves have been experimentally tested under different conditions of airflow through the valve and tracheal side pressure. The data allow calculation of the airflow resistance, the parameter usually used to compare the performance of valves. The valves have also been experimentally tested under different conditions of fluid flow through the valve and oesophageal side pressure (reverse flow). Comparing the airflow resistance of Staffieri valves of different length L and different angular extension of the razor-thin silt alpha, it has been observed that the parameter alpha has a significant influence on the characteristics, while the effect of the length L is negligible. The airflow resistance of the Provox, Groningen low pressure and Staffieri alpha = 270 degrees valves are comparable; the Panje and Staffieri alpha = 180 degrees have similar behaviour; while the Groningen Standard is comparable to the Staffieri alpha = 90 degrees. Regarding reverse flow, it is pointed out that for most of the valves (Staffieri and commercial valves), at different oesophageal pressures the fluid flow is smaller than the flow that can be tolerated by patients without giving problems.

[The treatment of choanal atresia]

Choanal atresia occurs in approximately 1 out of every 8000 live births. In about 60% of these cases it is unilateral and is often associated with other major craniofacial anomalies or visceral malformations such as the so-called CHARGE syndrome (i.e. Choloboma, Heart defects, choanal Atresia, Retarded growth and development, Genital anomaly, and Ear defect with deafness) first described by Pagon in 1981. In newborns the clinical manifestations of choanal atresia consist of respiratory distress strictly related to the entity of nasal obstruction. Total bilateral congenial choanal atresia must, therefore, be considered a surgical emergency since nasal obstruction impedes the suction mechanism and hence normal feeding in the newborn. For this reason, prompt surgery is mandatory. The surgical approach employed in choanal atresia consists of both the trans-nasal and trans-palatal approaches. Between 1985 and 1997 31 patients with choanal atresia were treated in our department (16 males, 15 females; age range 2 days-5.5 years; mean 11.4 months). In 25 cases (80.6%) the malformation was bilateral. Associated anomalies were seen in 8 patients (25.8% of cases). All of these patients were treated using the trans-nasal approach, under general anesthesia, and endoscopic control. In 27 cases a trocar was employed to perforate the bony atresia and a stent was then positioned. Three patients underwent contact-laser resection of the stenosis without requiring any further stent and without any complications. None of these patients developed total recurrences, although after varying amounts of time, in 8 of the 27 patients operated using the trocar (29.6% of cases) a partial reduction of the airway occurred, the substenosis requiring dilatation with progressive Hegar dilators. In the remaining cases contact-laser therapy was associated with dilation. Three of the patients were treated by laser-therapy alone and none developed a recurrence. One patient dropped out of the follow-up for other serious malformations.