Clinical and histopathological characterization of eczematous eruptions occurring in course of anti IL-17 treatment: a case series and review of the literature

Background: Real-life data often highlight the side effects of certain drugs not previously reported in randomized controlled trials (RCTs).Objective: To describe cutaneous inflammatory eruptions in psoriatic patients treated with an anti IL-17A agent (secukinumab or ixekizumab).Methods: Retrospective analysis of a cohort of patients with chronic plaque psoriasis who started an anti IL-17A agent between September 2016-February 2019 and who developed cutaneous inflammatory eruptions during treatment. A systematic review of similar events reported in the literature was performed.Results: Data of 468 patients were reviewed and 27 cutaneous inflammatory eruptions of 27 (5.8%) patients were collected. The eruptions appeared after a mean of 16.9 ± 17.0 weeks of therapy showing a classical acute eczema in 11 patients (40.7%), an atopic dermatitis-like rash in 11 patients (40.7%) and a psoriasiform eruption in 5 patients (18.5%). Histopathology of 12/27 cases showed epidermal spongiosis in all these variants.Conclusion: We described the clinic-pathologic features of some eczematous eruptions occurring in psoriatic patients, 3-4 months after treatment initiation with an anti IL-17A agent. Further investigations are needed to explain this phenomenon, that might be defined a paradoxical adverse event, based upon the role of IL17 in eczema pathogenesis.

Prognostic Factors of Cervical Lymph Node Metastasis in Head and Neck Squamous Cell Carcinoma

Aims and background

The metastatic spread of squamous cell carcinoma of the head and neck (SCCHN) to the cervical lymph nodes is a negative prognostic factor in terms of survival. We have used multivariate analysis to identify the possible prognostic significance of a number of clinical and pathological characteristics in relation to possible involvement of the cervical lymph nodes in a series of 396 patients.

Method

396 patients with SCCHN were studied. Variables regarding the patient, the carcinoma and histology were analysed by multivariate analysis using BMDP's PLR programme.

Results

Some variables appear to represent predisposing factors for tumor spread to the lymph nodes: tumor site (supraglottic larynx: P=0.005; base of the tongue: P=0.02; hypopharynx: P=0.02), grading (P=0.001), and a number of histological parameters (lower degree of histological differentiation: P=0.001; vascular permeation: P=0.04; perineural invasion: P<0.05; prevalently plasmocytic infiltrate: P<0.05).

Conclusion

The identification of cases at risk for metastasis can be improved by the assessment of prognostic factors, with a consequent improvement in treatment strategies.

Carcinoma of the External Auditory Meatus and Middle Ear. Results of the Treatment of 28 Cases

Aims

The authors report their experience on the treatment of 28 cases of middle ear (3) and external auditory meatus (EAM) cancers (25) with surgery and/or radiation therapy. According to histologic type, there were 23 squamous cell carcinomas, 4 basal cell carcinomas and 1 adenocystic carcinoma.

Methods

Surgery alone was performed in 2 cases, surgery combined with radiotherapy in 11 cases, and radiotherapy alone in 15 cases. Postoperative radiation therapy dose ranged between 4500 and 5500 cGy; the definitive dose was 6000-7000 cGy. The median follow-up was 61 months.

Results

Complete respons rate 6 weeks after the end of the treatment, evaluated by CT scan, was 85.7% (24/28). Definitive local control was obtained in 20/28 cases for the primary site and in 26/28 cases for the neck. Nine of the 10 recurrences were retreated with low-dose radiotherapy combined with surgery, chemotherapy or hyperthermia. A new local control was obtained in 2 cases. Four patients were lost during the follw-up at 13, 14, 17 and 23 months after the end of the treatment. The survival rate was 54% (13/24); disease-free survival was 50% (11/22).

Conclusions

Despite a not very aggressive treatment, our results are quite good.

Prognostic Significance of the Expression of Immuno-Histochemically Detectable Differentiation Markers in Laryngeal Carcinomas

Expression of immunocytochemically detectable markers in 100 cases of laryngeal carcinomas, homogeneous for staging and treatment, was correlated with clinical evolution of the disease. Follow-up for a minimum of 5 years was obtained in all cases. Paraffin sections were re-cut and stained in immunoperoxidase with monoclonal KL1, detecting medium-to-low molecular weight keratins, and with monoclonal HMFG2, revealing a surface glycoprotein. Expression of KL1-related antigen did not correlate with prognosis, whereas cases extensively positive for monoclonal HMFG2 (more than 50% cells stained) had a significantly better recurrence-free rate. In a group of tumors classified as Grade 3 (histologically poorly differentiated) and expressing a low degree of HMFG2-detectable surface glycoprotein (< 50 % cells stained), a high rate of recurrences (93%) was observed. This study indicates that the combined use of morphologic and biologic (immunohistochemical) criteria may constitute an independent parameter of primary importance in predicting the evolution of laryngeal carcinomas.

Nail involvement as a negative prognostic factor in biological therapy for psoriasis: a retrospective study

BACKGROUND

Psoriasis (Pso) has a strong impact on quality of life and a positive association has been reported between nail psoriasis (NP) and more severe disease, together with a longer duration of skin lesions. The treatment of NP represents a challenge and biological therapy can be recommended for severe disease.

OBJECTIVE

The first end point of this retrospective study was to evaluate the time to achieve Psoriasis Area Severity Index (PASI) 75 in patients with and without NP treated with biological therapy. The second end point was to evaluate the efficacy of biological therapy to improve NP.

METHODS

A total of 127 patients (88 men and 39 women) with moderate to severe Pso referring to our Service between 2007 and 2014 were included. Inclusion criteria were age ≥18 years and a 24 week treatment. The outcome variable was achievement of PASI 75 at 24 weeks with and without NP. All patients were treated with topical therapy and one of four different biological treatments: adalimumab (44.09%), etanercept (18.11%), infliximab (13.39%) and ustekinumab (24.41%). Physical examinations were performed every 4 weeks, and at each visit, the clinician assessed the PASI and Nail Psoriasis Severity Index (NAPSI).

RESULTS

At multivariate Cox regression analysis, a smaller proportion of patients with NP achieved PASI 75 at 24 weeks than patients without NP when adjusted for the epidemiological, clinical features and biological treatment received. With all biological drugs, the NAPSI score began to improve already after 8 weeks (from 18.53 at week 0-2.83 at week 24).

CONCLUSION

Patients with NP reach PASI 75 more slowly than patients without NP. Clinicians should therefore consider that treatment with a biological agent may require a longer period before reaching a satisfying therapeutical goal. Nevertheless, adalimumab, infliximab, ustekinumab and etanercept demonstrated their equal effectiveness in reducing the NAPSI score.

Hyperbaric oxygen therapy as salvage treatment for sudden sensorineural hearing loss: a prospective controlled study

The most commonly used treatment for sensorineural sudden hearing loss (SSHL) in clinical practice is the administration of steroids; however, a favorable result is not always obtained. We studied 58 patients who failed to recover after primary treatment with IV steroids, 44 of these met our inclusion criteria (mean age 50.7, 27 males, range 30-74). We treated 23 patients (mean age 47.3, 16 males, age range 22-74) with hyperbaric oxygen therapy (HBO) (2.5 ATA for 60 min for 15 treatments), while 21 (mean age 54.5, 11 males, age range 22-71) patients refused to be treated and served as a non-randomized control group. Patients treated with HBO had a mean improvement of 15.6 dB (SD ± 15.3), with 1 of them completely healed, 5 with a good recovery, 10 with a fair recovery and 7 unchanged. Patients who were not treated had a spontaneous mean improvement of 5.0 dB (SD ± 11.4) with 3 patients with a good recovery, 1 patient with a fair recovery and 17 patients unchanged. Mean improvement was significantly better in patients treated with HBO compared to controls (p = 0.0133). Patients with worst hearing had the greater degree of improvement whether or not they were treated in the first 10 days after the onset of the hearing loss or between 11 and 30 days. In conclusion, hyperbaric oxygen therapy can lead to significant improvement of pure tone hearing thresholds in patients with SSHL who failed primary corticosteroid treatment and are within 4 weeks of the onset of deafness.

[Differential diagnosis in fibro-osseous lesions of facial bones: report of a case of ossifying fibroma and review of literature]

Ossifying fibroma is a relatively rare, benign neoplasm of non-odontogenic origin, affecting the facial bones, and prevalently localized in the mandible, but which can also appear in the maxilla, paranasal sinuses and peripheral bones. Its growth is generally very slow and it is usually asymptomatic, for which it often manages to reach a considerable size. An incidental diagnosis during orthopantography, on the other hand, is not infrequent. The diagnosis, which is fundamentally made by utilizing conventional x-rays and CT and NMR scans, may present several controversial aspects and is not to be disjointed from the clinical and anatomopathological aspects, for which close interdisciplinary collaboration is required in many cases. In effecting a differential diagnosis, the possibility of inflammatory lesions, other fibrous-osseous lesions (in particular, fibrous dysplasia) and benign or malignant neoplasms must be taken into consideration. The present work presents a case of ossifying fibroma of the maxilla that is emblematic in its clinical, radiological and histopathological aspects. It also discusses problems connected with classification and differential diagnosis, in particular with respect to fibrous dysplasia, which are important in determining the proper therapeutic approach.

Effects of anatomical constraints on tumor growth

Competition for available nutrients and the presence of anatomical barriers are major determinants of tumor growth in vivo. We extend a model recently proposed to simulate the growth of neoplasms in real tissues to include geometrical constraints mimicking pressure effects on the tumor surface induced by the presence of rigid or semirigid structures. Different tissues have different diffusivities for nutrients and cells. Despite the simplicity of the approach, based on a few inherently local mechanisms, the numerical results agree qualitatively with clinical data (computed tomography scans of neoplasms) for the larynx and the oral cavity.

Adjuvant radiotherapy influences the survival of patients with squamous carcinoma of the head and neck who have poor prognoses

The treatment of carcinoma of the head and neck in recent years has improved significantly, chiefly thanks to progress in surgery and radiotherapy. Despite these advances, the survival statistics reported in the literature show no appreciable evidence of radical improvement. The aims of this study were to evaluate the impact on survival achieved with the combination of surgical and postoperative radiotherapy in patients with advanced head and neck carcinomas and to identify the prognostic value of several host- and tumor-related factors that can influence the results of combined treatment. We retrospectively reviewed the medical records of 394 patients with stage III and IV carcinoma of the head and neck, of whom 170 (43%) underwent surgery alone and 224 (57%) received combined surgery and postoperative radiotherapy. The 394 patients were stratified for a set of variables including the patient's condition, the characteristics of the tumor, and the modality of treatment. Univariate analysis revealed that coexistent medical diseases, the size and site of the primary lesion, the stage of the tumor, and certain pathologic features had a negative impact on survival. Multivariate analysis showed that the removal of lymph nodes and postoperative radiotherapy can have a positive influence and can improve the prognosis. We compared the survival rates of the patients treated with surgery alone with those of the patients who underwent combined treatment, and we observed that the two survival curves were comparable, even if there was a bias because the combined treatment group consisted of patients with negative prognostic factors. The meaning of these results, compared with data from the literature, has been discussed.

A physical-based model for the simulation of neoplastic growth and metastasis

BACKGROUND AND OBJECTIVES

It is possible to formulate models capable of reproducing the main details of the physical processes involved in the evolution of biological systems. The complexity of the problem requires to begin with a simple and universal model for the description of the cellular growth, to be adapted successively to the local conditions found in clinically observed neoplastic growths.

METHODS

A model based on the Local Interaction Simulation Approach (LISA) has been formulated for the simulation of growth, diffusion, and metastasis of neoplasms. The vascularization is described by a blood vessel located on one edge of the specimen in which a constant and homogeneous flow is assumed. A nutrient density is defined to mimic the blood flow within the tissue.

RESULTS

Photograms taken at proper times may identify the main characteristics of the tumor evolution and describe its volume variations in a transversal section. Furthermore, it is possible to monitor constantly the volume of the neoplasm and of the necrotic tissue as a function of time, as well as the portion of cells that have migrated in the blood vessel.

CONCLUSIONS

In spite of strong simplifying assumptions, the model presents good qualitative agreement with clinical data, which may be further improved by more detailed information about cancer cells properties or local vascular system patterns.

Treatment of malignant neoplasms of the parotid gland

In this study we evaluated the effects of surgical and radiotherapy treatment on local control in 126 patients with malignant tumors of the parotid gland. The most frequently observed malignant tumors were high-grade tumors (68%). Surgical treatment was performed in 81 patients (83.5%). Total conservative parotidectomy was the most frequent procedure (74%), and radiotherapy was performed in 81 patients (83.5%). The global survival rate was approximately 54% at 5 years, whereas disease-free survival was 47% at 5 years. No statistically significant difference in survival rate was found between conservative (52% at 5 years) and radical treatment of the seventh cranial nerve (43% at 5 years). The incidence of recurrent cancer was 25.7% (25 of 97), of which 88% developed during the first 2 years. We report some of the clinical and histologic factors that can influence the prognosis of the disease.

Carcinoma of the larynx in the elderly: analysis of potentially significant prognostic variables

The incidence reported for carcinomas of the head and neck currently peaks between the sixth and seventh decades of life. In this retrospective study we were interested in learning whether age is a potentially significant prognostic factor for survival. We considered a set of variables in a series of 134 patients, divided into two groups; between 65 and 70 years of age, and older than 70. Stage I-II tumors were present in 44 patients, while locally advanced lesions (stages III-IV) were present in 90. Statistical analysis of survival was performed using the actuarial survival rates according to Kaplan-Meier; significance was evaluated using the log-rank test. Multivariate analysis was performed according to the Cox logistic regression model to determine the prognostic significance of any of the variables. Univariate analysis was performed on a series of variables regarding the patient, tumor and treatment. In the younger group, age appeared to be a favorable prognostic factor. Tumor size had a significant effect on disease-free survival, both globally and between the two groups (p < 0.05). Lymph node status substantially influenced the five-year survival rate (p = 0.001). Tumor invasion of the lymph nodes led to a difference between the two groups. Survival was lower in the younger than in the older group. There was a significant difference (p < 0.01) in survival between patients who had undergone surgery (75%) and those who received radiotherapy alone (33%). Multivariate analysis of these variables showed that disease stage, and treatment of lymph nodes were both significant (p = 0.0016 and p = 0.0002, respectively). Survival rates for the so-called "young elderly" (65-70 years) are generally higher than that for those aged 70 and over. Following accurate and comprehensive assessment by the anesthesiologist and the internist, and appropriate adjustment of the patient's nutritional and metabolic status, combined radical surgery and radiotherapy can and must be performed. Minimal palliative interventions, in the belief that tumor growth is biologically less aggressive in the elderly patient, should be avoided.

Surgery or Radiotherapy for Early Stages Carcinomas of the Glottic Larynx

Aims and Background

The choice of treatment in limited squamous cell carcinoma of the glottic larynx often depends on individual and tumor factors. Data of the literature clearly show that surgery and radiotherapy tend to give identical results in terms of survival. We examined 196 cases of T1-T2/N0 cancers of the glottic larynx. We review the literature and discuss the indications and the efficacy of the various available treatments.

Methods and Study Design

196 consecutive cases of T1-T2/N0 cancers of the glottic larynx were examined. In 54.5% the tumor was confined to the vocal cord; in 38.2% it extended to the anterior commissure, in 4.6% to the arytenoid cartilage and in 2.5% to the floor of the ventricle. We performed partial laryngeal surgery in 41.3% (81 cases). Radiotherapy alone was employed in 58.6% (115 cases).

Results

In T1a and T1b cases there was no statistically significant difference in 5-year disease-free survival. In T2 cases the NED survival of patients who underwent partial laryngectomies (90% of cases) was significantly better (P <0.05) than among patients given radiotherapy (73%). NED survival at 5 years in patients with the primary tumor on a vocal cord, ventricle or anterior commissure was 78%, 80% and 81%, respectively, with no statistically significant difference among the various sites. It is possible that involvement of the anterior commissure exposes patients to greater risk of recurrence when radiotherapy alone is used (5 out of 23 cases, 21.7%, compared to 3 out of 52 cases, 5.7%, among our surgically treated patients).

Conclusions

When the tumor is confined to the vocal cord and mobility is not impaired (T1a), surgery and radiotherapy give comparable results, and the latter yields a better functional outcome. When the anterior commissure is involved, recurrences appear to be less likely after surgery. In T2 glottic carcinoma, surgery gives better results than radiotherapy alone. In any event, the choice of treatment should be patient-specific and based on a careful analysis of the factors involved in each case.

Lymphnode metastasis in head and neck squamous cells carcinoma: multivariate analysis of prognostic variables

Cervical lymphnodes metastatization by the squamous cell carcinoma of the head and neck is well known as a prognostic negative factor as far as survival is concerned. Multivariate analysis has been used on 207 cases of head and neck squamous cell carcinomas (HNSCC) in order to identify the possible prognostic significance of a group of clinical and histopathological characteristics, aiming to find a correlation with the possible occurrence of cervical lymphnodes. Two hundred and seven patients (168 males and 39 females, mean age: 62 years) with SCCHN were studied. They underwent surgery alone and radiotherapeutic associated treatment. Variables regarding the patient, carcinoma and histology were analysed: age, sex, smoking and alcohol consumption, performance status, concomitant internal pathologies (cardiopathies, hepatopathies, broncho-pneumopathies, metabolic disorders), site and size of primary tumor (T stage), number and size of laterocervical lymph node localization (clinical N stage), grading, vascular permeation, perineural infiltration. Multivariate analysis of prognostic factors was performed using BMDP's PLR programme. Some variables showed a great risk of lymphnode metastasis; among sites: supraglottic larynx (p = 0.05), base of the tongue (p = 0.04), hypopharynx (p = 0.05); some histological parameters as lower degree of histological differentiation (p = 0.02), the presence of vascular permeation (p = 0.06) and perineural invasion (p = 0.07) appear to represent predisposing factors for the onset of adenopathies. By considering prognostic factors as shown, it is possible to better identify metastasis risk cases, that leads to improved therapeutical strategies.

Extrathoracic airway dysfunction in cough associated with gastroesophageal reflux

BACKGROUND

Cough associated with gastroesophageal reflux (GER) may originate in extrathoracic airway receptors made hypersensitive by acid-induced mucosal injury.

OBJECTIVE

We investigated the role of laryngeal disease and dysfunction in the pathogenesis of GER-associated cough in nonasthmatic patients.

METHODS

Seven patients with GER-associated cough were compared with 7 patients with GER but no cough. The patients underwent fiberoptic endoscopy for assessment of laryngitis and esophagitis (expressed by scores); esophageal manometry; 24-hour pH monitoring; lung function tests; and histamine inhalation challenge with assessment of bronchial threshold (concentration provoking 10% fall in FEV1 [PC10]), extrathoracic airway threshold (concentration provoking 25% fall in the maximal midinspiratory flow [PC25MIF50]), and cough threshold (concentration provoking 5 or more coughs PCcough). The patients were reevaluated after 3 months of medical treatment for GER.

RESULTS

Patients with cough, compared with those without cough, had significantly higher laryngitis scores (P = .002), lower esophageal sphincter pressures, longer time with pH below 4 (P = .003), greater number of episodes of reflux longer than 5 minutes (P = .016), longer esophageal clearance time (P = .048), and significantly lower PC25MIF50 (P = .005) and PCcough (P = .008) values. Laryngitis score was significantly inversely related to either PCcough (P < .001) or PC25MIF50 (P <.01) but not to PC10. Laryngitis score, PC25MIF50, and PCcough were all closely related to GER severity. After GER treatment, laryngitis, PC25MIF50, and PCcough were all significantly improved.

CONCLUSIONS

These findings suggest that GER-associated cough is strongly associated with laryngeal disease and dysfunction consequent to acid reflux injury in nonasthmatic patients.

[Therapeutic strategies for the treatment of parotid gland malignancies]

Parotid gland neoplasms include a quite heterogeneous group of histotypes with markedly different biological characteristics and evolution, thus requiring different forms of treatment. The present study evaluated the effects surgery and radiotherapy have on local disease control, survival rates and onset of locoregional recurrences. 126 malignant parotid tumors were examined (59 males, 67 females; age range 11 to 88 years; mean age 62 years) with a minimum of 1 year follow-up. The most malignant tumors were those most frequently seen in this case study (68%). Surgery was performed in 81 subjects (83.5%). Conservative total parotidectomy was the procedure most frequently performed (60/81, 74%). The overall 5-year survival rate was around 54% while 47% were "disease-free" patients at 5 years. When the subjects were broken down into 2 groups according to the degree of malignancy (high or low), the survival curve for disease-free subjects showed some differences (respectively 52% and 42%). The choice of treatment for the primary T significantly affect survival. Radiotherapy alone proved much less satisfactory than surgery (p < 0.01). The 5-year survival rate following a combination of surgery and subsequent radiotherapy was 52%, while it was 47% for those treated by surgery alone. An examination of the type of surgery performed revealed a difference in survival between those treated with preservation of the VII cranial nerve (52% at 5 years) and the more radical surgery (43% at 5 years) although this difference was not statistically significant. The incidence of recurrence was 25.7% (25 cases out of 97), of which 88% arose within the first 2 years. In conclusion, it has been seen that malignant parotid gland neoplasms are highly aggressive and the treatment of choice appears to be surgery plus radiotherapy whenever the clinical-biological features of the neoplasm warrant it. The surgical approach to the facial nerve should be as conservative as possible, reserving utmost radicality for the most advanced cases compromising the adjacent structures.

[Laryngeal myoblastoma in childhood]

Laryngeal tumors originating in the nerves are extremely rare, particularly in infants. Indeed, this type of neoplasm normally arises in adult males. Only 10 cases have been described in the 5 to 17 year age range. The present work reports a clinical case of granulous tumor of the larynx in an 11-year-old boy. Histologically this tumor showed cells which preserved their original structure and were in close relation with the nerve fibers, but not with the myocytes. Their metabolic activity was similar to that of the nerve cells. The neurogenic origin of the neoplastic granulous cells shows the presence of neuroectodermic cytoplasmic S-100 specific for cells derived from the neural crest. The boy manifested ingravescent dyspnea due to the presence of a myoblastoma in the right laryngeal ventricle. A thyrotomic approach was adopted because of the significant size of the neoplasm although it was possible to perform conservative surgery given that the lesion was benign. The authors underline the polymorphic histology of this neoplasm and the importance of the type of surgery which should both avoid widespread demolition since the neoplasm is benign and, at the same time, prevent recurrences.

[Evaluation of various phonatory parameters in laryngectomized patients: comparison of esophageal and tracheo-esophageal prosthesis phonation]

Today there is increased need for an objective comparison between the various post-total laryngectomy phonatory rehabilitation techniques. This survey involves 20 patients who, after total laryngectomy, underwent rehabilitation using the esophageal voice (n = 10) or through the application of a secondary tracheal-esophageal prosthesis (n = 10). The multivariate analysis indicated that the only phonatory parameter which differed significantly between the two types of voice was the maximum phonation time (MPT) (p < 0.01). The MPT was markedly longer in patients with the tracheal-esophageal prosthesis. In patients with prosthesis, the Mann-Whitney test highlighted better figures for the following parameters: MPT (p = 0.0003), GP (maximum number of words that can be read in one breath) (p = 0.009), maximum intensity level (MIL) (p = 0.019), Shimmer (p = 0.008) and noise-to harmonics ratio (NHR) (p = 0.049). Furthermore, the Spearman test proved there is a relationship between MIL and GP, and between Pitch and Shimmer. Therefore, the tracheal-esophageal prosthesis seems to offer better phonatory energy and phonatory duration for every breath. However, these methods of objective inquiry need to be further developed so that comparison-among the different authors and among the different rehabilitation methods-can be made easier than it is now.

[Evaluation of the cochlear aqueduct patency: comparison of 2 noninvasive techniques]

Variations in cephalo-rachidian fluid pressure can be transmitted to the middle ear through the cochlear aqueduct (CA). This gives us a non-invasive manner to evaluate any changes in fluid pressure by measuring middle ear impedance (impedancemetry). The present study compared two indirect methods for measuring intracranial pressure: a) impedancemetry during evoked jugulo-tympanic reflex (JTR) and b) study of the tympanic membrane (TM) fine motility using a MMS-10 analyzer. The latter is a new procedure involving the indirect evaluation of the fluid pressure. In fact, when the CA is open the labyrinthine fluid pressure is transmitted to the oval window, the stapes platina and, finally, to the tympanic membrane where it can be measured with an MMS-10 unit. This equipment can measure nanoliter shifts in the TM. In particular, comparison between the clinostatic and orthostatic tympanic motility measurements enable one to establish whether the CA is patent or not. In the present study 15 subjects were examined using both a) impedancemetry during jugular compression and b) analysis of the TM shift using an MMS-10 unit. In 14 of the 15 cases there was good correlation between the data obtained using both methods: in all but one case it proved possible to record a JTR-induced variation in impedance whenever the MMS-10 indicated that the CA was open. The results suggest that, in clinical practice, the two methods can be used in parallel for non-invasive monitoring of variations in intracranial pressure in patients with neurological involvement. On the other hand, in the E.N.T. field these techniques could be used to study inner ear pathologies causing dynamic alterations of the endolabyrinth fluids (endolymphatic hydrops, labyrinthine fistula).

Damage of the pharyngeal mucosa and hyperresponsiveness of airway in sinusitis

BACKGROUND

In sinusitis bronchoconstriction is supposed to originate from pharyngobronchial reflexes triggered by seeding of the inflammatory process into the pharynx.

OBJECTIVE

Our aim was to evaluate whether in sinusitis bronchial and extrathoracic airway (EA) dysfunction correlate with morphologic abnormalities of the pharyngeal mucosa.

METHODS

We performed histamine inhalation challenge, nasal lavage, and nasopharyngeal biopsies in 24 nonasthmatic patients with exacerbation of chronic sinusitis. The histamine PC20 was the threshold of bronchial responsiveness, and that causing 25% fall in maximal midinspiratory flow was the threshold of EA responsiveness (PC25MIF50). Thresholds of 8 mg/ml or less were assumed to indicate bronchial hyperresponsiveness (BHR) or EA hyperresponsiveness (EAHR). PC20 and PC25MIF50 values were related to clinical data, nasal lavage fluid eosinophils, pharyngeal epithelium and basement membrane thickness, and density of submucosal vessels and nervous fibers.

RESULTS

The PC20 was closely related to PC25MIF50 (p = 0.0004). Ten patients had EAHR, 9 had combined EAHR and BHR, and 5 had neither EAHR nor BHR. EAHR was strongly associated with epithelial thinning, and BHR with long-standing sinusitis, a lower PC25MIF50, increased submucosal nerve density and increased nasal lavage fluid eosinophils.

CONCLUSIONS

Our findings suggest that in nonasthmatic patients with sinusitis, pharyngeal damage may contribute to airway dysfunction by favoring the access of irritants to submucosal nerve endings, with activation of constrictive reflexes to the EA. Proliferation of sensory neurons, consequent to long-lasting pharyngeal inflammation, may cause more severe EA narrowing and activate pharyngobronchial reflexes.

[Identification of clinical, biological and prognostic factors in recurring squamous cell carcinoma of the head and neck]

Many studies have been performed to determine some prognostic factors for malignant head and neck tumors. Defining the clinical and biological features would enable one to predict the progression of the disease and plan treatment. The aim of the present study has been to identify what host and neoplasm characteristics provide prognostic indication of possible recurrences. A group of 380 patients with squamous cell carcinoma of the head and neck was studied. The neoplasm was located in the following sites: 257 larynx-hypopharynx, 69 oropharynx, 54 oral cavity. At the present time 309 of these subjects are still alive and disease free while 71 have had recurrences. Analyses were performed on various variables regarding the patient, neoplasm and histology. Multivariante analysis of these prognostic factors was performed using the PLR-BMDP program. The time of recurrence in the primary tumor site and at the lymph node level was evaluated using the Kaplan-Meier method. Of the 28 variables analyzed 16 had no effect on the probability of recurrence. Two variables reduced the risk of recurrence: age over 61 years (p < 0.05) and primarily intra and peritumoral lymphocyte infiltration (p = 0.06). Of the data regarding the patient, age lower than 61 years and presence of associated internal pathologies (i.e. bronchial pneumonia and hepatitis) appeared to significantly facilitate the appearance of recurrence. The characteristics of the neoplasm which appear to effect recurrences are: tumor site (hypopharynx), presence of lymph node metastases, morphological elements of tissue spread (vascular invasion, plasmocyte infiltration), capsular breakdown, positive margins and post-operative infection. In conclusion, it can be asserted that technical development of multifactorial analysis has made it possible to identify important prognostic factors and quantify their impact on the evolution of a neoplasm.

[The use of indwelling phonatory valve in the rehabilitation of laryngectomized patients: preliminary results in 30 patients]

The creation of a tracheo-esophageal fistula, and subsequent positioning of a voice button, has greatly improved the patients' ability to communicate and is the treatment of choice for many. The literature indicates that the success rate for this technique is in the 56-90% range. The present study presents the preliminary results obtained in a group of 30 laryngectomy patients for whom a Provox or Blom-Singer-Indwelling voice button were inserted at a later date. Of these 21 (70%) had undergone pre- or post-operative radiotherapy. On the average insertion of the voice button took place 36 months after the laryngectomy while it was approximately 40 months after radiotherapy. Patient selection was based on widely accepted criteria. In particular, the following factors were take into consideration: patient motivation, positive Taub test, dynamic features of the esophageal wall, video fluoroscopy evaluation. For the Provox voice button the patient was hospitalized for 24 hours while with the Blom-Singer-Indwelling device it was 72 hours. In addition, with the latter device, oral feeding was restored somewhat later although this depends on the difference in positioning. The results of the present study are in line with those presented by other authors. In particular, the immediate success rate was 83% while the long-term success rate reached 96%.

[Chemotherapy of head and neck carcinomas]

In most cases head and neck tumors manifest themselves on a local-regional level giving rise to highly mutilating pathologies with psycho-social repercussions. Surgery and radiotherapy are effective treatments for limited neoplasms (stage I-II). On the other hand, after surgery and/or radiotherapy, the treatment of locally advanced tumors (stage III-IV) or local recurrences and/or distant metastases is still problematic. For this reason chemotherapy, initially used only as a palliative, is today associated with other treatments to achieve better results both in terms of survival and disease-free time spans. Hence chemotherapy must be considered part of any multimodal primary treatment for advanced squamous cell carcinoma of the head and neck. In fact, numerous clinical studies have clearly demonstrated that adjuvant or neoadjuvant chemotherapy has a highly relative affect on survival in locally advanced diseases and that the incidence of distant metastases is reduced. This is not, however, followed by a similar reduction in local recurrences which are often the cause of death in such patients. It would, on the other hand, appear that survival is improved with integrated radio-chemotherapy. Immunochemotherapy, which has not as yet provided significant clinical results in cases of advanced tumors and/or metastases, must still be evaluated in the treatment of locally limited neoplasms. Organ preservation, which proves feasible in the larynx, leads one to hope it can be applied in other head and neck sites. The future balance leans in favor of the multidisciplinary approach and multi-center studies must be performed so that an adequate number of cases can be gathered over a brief period. This will make it possible to answer those questions and, at times, illusions which accompany chemotherapy in the treatment of advanced head and neck tumors.

[Carcinoma of the base of the tongue: a case series]

A carcinoma of the base of the tongue is diagnosed with difficulty and therapy offers a poor clinical prognosis. Between November 1988 and April 1993 45 patients were evaluated (38 men and 7 women, mean age 60 years). These patients were in poor clinical conditions and advanced clinical stage. Surgical treatment alone or in association with radiotherapy was employed in 17 patients. In the remaining patients radiation therapy alone or associated with chemotherapy was employed. Three-year overall actuarial survival was 39.5% and 3-year NED survival was 21%. Certain prognostic factors were evaluated: T stage, lymph nodes, TNM staging, extension to near anatomical areas and treatment. A Cox multivariate regression analysis revealed that clinical N stage was significant for prognosis (3-year overall actuarial survival was 76.9% for NO and 28% in subjects with clinical nodes). Subjects with neoplasm extension to pharyngo-laryngeal area could have better prognosis and, a finally, patients treated with surgery alone or in association with other treatment would achieve better local control than others.

Prognostic factors for head and neck tumor recurrence

The introduction of new treatment methods has stimulated the identification of further prognostic factors capable of defining the clinical and biological characteristics of the tumor type in question and improving treatment programming. The aim of this study was to identify which characteristics of the host and tumor are of prognostic value in relation to the onset of locoregional tumor recurrence. A total of 396 patients were studied. The tumor site distribution can be summarized as follows: 267 laryngohypopharyngeal, 74 oropharyngeal, 55 oral cavity. Variables regarding patient, tumor and histology were evaluated for the purpose of analysis. Multivariate analysis of these prognostic factors was performed using PLR software by BMDP. Mean tumor recurrence time was 19 months. Seventeen of the 29 variables analysed did not influence the probability of tumor recurrence. Two variables reduced the risk of tumor recurrence: age > 61 years and abundant and prevalently lymphocytic intra-and peritumoral infiltrate. The study of tumor recurrence onset mechanisms is justified by its impact on the evolution of disease. The use of multivariate analysis in this study showed that some clinical and pathological characteristics of squamous cell carcinoma of the head and neck have a statistically significant impact on tumor recurrence.

Pulmonary tuberous sclerosis in a woman of child-bearing age with no mental retardation

Tuberous sclerosis is a rare disease characterized by epilepsy, mental retardation and adenoma sebaceum. We describe the case of a 29-year-old woman with a clinical history of tuberous sclerosis who also had severe hypoxaemia, multifocal hamartoma-like lesions of various extrapulmonary organs, massive hypersplenism and coagulation defects. This case emphasizes the value of high resolution computed tomography (HRCT) in patients with pulmonary tuberous sclerosis.

[Autonomic nervous system disturbance as a possible cause of vertigo or dizziness]

In the present study possible interactions between dizziness, or vertigo, and eventual malfunctioning of the Autonomic Nervous System were evaluated. Two groups of ten patients each were patients each were tested. All the patients had vertigo or dizziness of uncertain etiology and ten had arterious hypotension. A careful anamnestic research was carried out in order to individualize symptoms or elements which could induce dysautonomia. A series of 6 tests aimed at evaluating cardiovascular responses was performed in all the patients. Alterations were present in 65% of the test responses. In particular, results were altered in patients with arterious hypotension. The Authors, underline the effectiveness of an adequate anamnesis in identifying patients with possible dysautonomia and affirm the validity of cardiovascular tests (non-invasive, specific and sensitive in obtaining information concerning the etiology of particular forms of dizziness.

[Diffuse symptomatic polypoid lipomatosis of the colon with hyperplasia of epiploic appendices: a case report]

Diffuse and symptomatic lipomatosis of the colon, particularly when associated with hyperplasia of the appendices epiploicae, is a rare disease. We report here the case of a lean, 26-year-old woman who had polypoid lipomatosis of the colon with submucosal and subserous expression (involving the mesentery and peritoneum) associated with extreme hyperplasia of the appendices epiploicae. Her disease led to a recurrent subocclusive syndrome which required total colectomy. We discuss the case and review the literature on this subject. The particular characteristics of this case and early onset of disease would suggest that our patient was affected by a congenital lipomatous syndrome linked to mesenchymal dysplasia. Long-term monitoring will enable prompt intervention in the case of reformation of lipomatous tissue.

Extrathoracic and intrathoracic airway responsiveness in sinusitis

BACKGROUND

Asthma associated with sinusitis is supposed to be sustained by bronchoconstrictive reflexes originating in extrathoracic airway (EA) receptors.

OBJECTIVE

The study was designed to evaluate the relationship between EA responsiveness and bronchial responsiveness in sinusitis.

METHODS

We performed histamine inhalation challenge in 106 patients with chronic sinusitis, during disease exacerbation and after treatment with antimicrobials and nasal flunisolide (100 micrograms daily) for 2 weeks. Forced expiratory volume in 1 second (FEV1) and maximal mid-inspiratory flow (MIF50) were the respective indexes of bronchial and EA narrowing; the histamine concentrations causing a 20% fall in FEV1 (PC20) and 25% drop in MIF50 (PC25MIF50) were used as thresholds of bronchial and EA responsiveness. Thresholds of 8 mg/ml or less were assumed to indicate bronchial hyperresponsiveness (B-HR) or EA hyperresponsiveness (EA-HR).

RESULTS

During sinusitis exacerbation 76 patients had EA-HR, which in 46 was associated with B-HR. The values of PC20 were closely related with those of PC25MIF50 (p < 0.001). EA-HR and B-HR were strongly associated with pharyngitis. After treatment, mean PC25MIF50 and PC20 were significantly increased (p < 0.001). The improvement of PC25MIF50 was closely related to that of PC20 (p < 0.001) and to the decrease in neutrophils in nasal lavage (p < 0.05). EA-HR reversed in 58 patients and improved in 10; B-HR reversed in 29 and improved in 12.

CONCLUSIONS

Our findings suggest that in sinusitis, B-HR may be sustained by constrictive reflexes originating in pharyngeal receptors, made hypersensitive by seeding of the inflammatory process.

Impedance measurement as a noninvasive technique for the monitoring of intracranial pressure variations

In previous reports it has been demonstrated that jugular compression causes a modification of middle ear acoustic impedance; this phenomenon has been named the jugulotympanic reflex (JTR). The aim of the present study was to contribute to the understanding of the origin of this reflex. We have analyzed the middle-ear impedance modifications induced by unilateral and bilateral jugular compression in 12 normal subjects, in 12 patients afflicted with otosclerosis, in 3 patients with Menière's disease and in 6 patients demonstrating intracranial hypertension. In the latter group, the cerebrospinal fluid (CSF) pressure was simultaneously recorded. The JTR was elicited in each normal subject and in each patient affected by Menière's disease and intracranial hypertension, while it was usually absent or modified in otosclerotic patients. The absence of the JTR in otosclerotic patients and, above all, the correspondence between CSF pressure and the middle-ear impedance modification induced by jugular compression suggest that it is due to the transmission of pressure changes from the CSF to the perilymph through the cochlear aqueduct.

[Orbital and endocranial complications in acute sinusitis in childhood]

Acute infection the paranasal sinus is a rather frequent pathology in children. On the contrary, local orbital complications are rare. The employment of antibiotics reduces the incidence of complications but can sometimes conceal their appearance so that diagnosis is delayed. Orbital as well as intracranial complications of ethmoidal and maxillary sinusitis are most often encountered in childhood. Within a brief time span, 8 patients with complicated frontal and ethmoid-maxillary sinusitis were diagnosed and treated: 4 cases of periorbital cellulitis, 2 of subperiorbital abscess and 2 of orbital abscess (one of which with cavernous sinus thrombosis). Particularly relevant from the diagnostic point of view was the employment of C.T. scan which furnished an accurate definition of the orbit and its surrounding structures which influenced treatment choice. Under antibiotic cover all patients but one (who had been treated very early and had responded immediately to intensive antibiotic therapy) were treated surgically and the clinical course of the disease showed significant improvement very shortly after surgical drainage.