The impact of Allergic Rhinitis in clinical practice: An International Survey

Allergic rhinitis (AR) is a frequent disease caused by an IgE-mediated inflammation of the nose and characterized by typical symptoms. Diagnostic workup is directed to document the production of specific IgE (sensitization). Clinical management aims to relieve symptoms, resolve allergic inflammation, use medications, and potentially induce allergen tolerance, using allergen immunotherapy (AIT). The current survey was conducted in 17 International ear nose throat experts using a questionnaire with 20 questions concerning the practical management of AR patients. It was administered in the 2020 summer. The large majority (94%) of participants use the ARIA classification in clinical practice. On average, subjects with suspected AR represent half of the patients who turn to the ENT experts; 80% have the confirmed diagnosis. Most of the experts use both cutaneous and serum assay to document IgE production. Antihistamines are prescribed in 59% of AR patients, intranasal corticosteroids in 69%, non-adrenergic decongestants in 88%, nasal lavage in 88%, and AIT in 22%. About 68% of AR patients had turbinate hypertrophy, which requires surgery in 62% (mostly surgical decongestion). In conclusion, the current International Survey demonstrated that AR is a common disorder worldwide, the diagnostic workup is mainly based on IgE assessment, and the therapeutic approach is also based on non-pharmacological remedies.

Prevention and treatment of upper respiratory diseases in the pandemic COVID-19 era

In the pandemic coronavirus disease 2019 (COVID-19) era, the need to use preventive-curative treatments is compelling. A series of non-pharmacological compounds, including oligo-elements, vitamins, nutraceuticals, and bacteriotherapy, might affect the risk of COVID-19, both reinforcing the immune system and improving the inflammation resolution during respiratory infections. Non-pharmacological remedies are very popular and usually have no relevant side effects. Bacterial and natural products may potentiate the immune system against respiratory viruses. Moreover, these compounds also exert antiinflammatory and antioxidant activity. Consequently, these non-chemical remedies could be prescribed to build up the immune defence and adequately treat the upper respiratory infection. In this way, natural compounds could be used to manage people in the pandemic COVID-19 era.

Bacteriotherapy in children with recurrent upper respiratory tract infections

OBJECTIVE

Children with recurrent upper-airway infections (UI) represent a social issue for their economic burden and negative impact on families. Bacteriotherapy is a new therapeutic strategy that could potentially prevent infections. The current study tested the hypothesis that recurrent UI may be prevented by bacteriotherapy.

PATIENTS AND METHODS

This open study was conducted in an outpatient clinic, enrolling 80 children (40 males, mean age 5.26±2.52 years) suffering from recurrent UI. Children were treated with a nasal spray containing Streptococcus salivarius 24SMB and Streptococcus oralis 89a, 2 puffs per nostril twice a day for a week; this course was repeated for 3 months. The evaluated parameters were: number of UI and number of school and work absences; these outcomes were compared with those recorded in the past year.

RESULTS

The mean number of UI significantly diminished: from 5.98 (2.30) in the past year to 2.75 (2.43) after treatment (p<0.0001). The number of school and work absences significantly diminished (from 4.50±2.81 to 2.80±3.42 and from 2.33±2.36 to 1.48±2.16 respectively; p<0.0001 for both).

CONCLUSIONS

This preliminary experiment suggests that bacteriotherapy using Streptococcus salivarius 24SMB and Streptococcus oralis89a nasal spray could prevent recurrent UI in children.

Modulation of opportunistic species Corynebacterium diphtheriae, Haemophilus parainfluenzae, Moraxella catarrhalis, Prevotella denticola, Prevotella melaninogenica, Rothia dentocariosa, Staphylococcus aureus and Streptococcus pseudopneumoniae by intranasal administration of Streptococcus salivarius 24SMBc and Streptococcus oralis 89a combination in healthy subjects

OBJECTIVE

Probiotics S. salivarius 24SMBc and S. oralis 89a comprised in the nasal spray Rinogermina are known to exert inhibition of harmful pathogens and ameliorate the outcome of patients with chronic upper airways infections. In this study, for the first time, the effect of this formulation on the modulation of the microflora of healthy subjects was evaluated, with particular interest on pathobionts and pathogens present.

PATIENTS AND METHODS

Metagenomic identification and quantification of bacterial abundances in healthy subjects were carried out by means of Ion Torrent Personal Machine. In particular, nasal swabs were sampled one, two and four weeks after seven days of treatment with Rinogermina.

RESULTS

The modulation of the abundance of pathobionts and pathogenic species (i.e., Corynebacterium diphtheriae, Haemophilus parainfluenzae, Moraxella catarrhalis, Prevotella denticola, Prevotella melaninogenica, Rothia dentocariosa, Staphylococcus aureus and Streptococcus pseudopneumoniae) was characterized and a significant temporary decrease in their presence was identified.

CONCLUSIONS

The beneficial effects of S. salivarius 24SMBc and S. oralis 89a nasal intake was assessed but seemed to be restricted in specific temporal windows. Thus it would be interesting to evaluate also this positive impact of longer administration of this probiotic formulation.

The role of bacteriotherapy in the prevention of adenoidectomy

OBJECTIVE

Adenoidectomy is a surgical procedure with potential adverse events. Effective nonsurgical therapy could reduce patient risk and harm. The aim of this study was to evaluate the role of bacteriotherapy to reduce the necessity of adenoid surgery.

PATIENTS AND METHODS

This experimental study was conducted as an open study in 44 children (30 males and 14 females, mean age 4.9 years) who were candidates for adenoidectomy and tympanocentesis as treatment for adenoidal hypertrophy and otitis media with effusion. Twenty-two children were treated with Streptococcus salivarius 24SMB and Streptococcus oralis 89a nasal spray, administered as 2 puffs per nostril twice a day for a week for 3 months (study group). The other half of the children was treated with hypertonic saline nasal lavage on the same schedule (control group). Tympanometry and adenoid size assessment were evaluated throughout the intervention period.

RESULTS

In the study group, 6/22 children required surgery, compared to 20/22 children in the study group (p<0.0001). The clinical change in the treated children was a significant reduction of adenoid size (p<0.0001) and improvement of middle ear effusion measured with tympanometry (p<0.0001).

CONCLUSIONS

Bacteriotherapy with Streptococcus salivarius 24SMB and Streptococcus oralis 89a nasal spray could significantly reduce the need for adenoid surgery.

Obstructive sleep apnea syndrome in the pediatric age: the role of the anesthesiologist

OBJECTIVE

Childhood obstructive sleep disordered breathing (SDB) is a sleep-related upper airway obstruction that degrades sleep quality, ventilation and/or oxygenation; obstructive sleep apnea syndrome (OSAS) is one of the most common causes of SDB in children. The aim of this review is to evaluate the role of the anesthesiologist in pediatric OSAS.

MATERIALS AND METHODS

A literature review has been performed on the following topics: clinical aspects of pediatric OSAS, preoperative investigations including questionnaires, clinical parameters, laboratory polysomnography and home sleep apnea testing, anesthesiologic preoperative management, anesthesiologic perioperative management, anesthesiologic postoperative management including postoperative analgesia, postoperative nausea and vomiting (PONV), and post-tonsillectomy bleeding.

RESULTS

OSAS in children is a distinct disorder from the condition that occurs in adults; adenoidectomy and tonsillectomy are the first line of therapy in these patients. Even if these surgical procedures are frequently performed, they represent a great challenge for surgeons and anesthesiologists and are associated with a substantially increased risk of morbidity and mortality.

CONCLUSIONS

The role of the anesthesiologist is pediatric OSAS is crucial before, during and after surgery, as pediatric patients are at higher risk of preoperative, perioperative and postoperative adverse events including airway obstruction, PONV, and bleeding.

Lateral osteotomy plus hump resection vs hump re-modeling without lateral osteotomy: impact on frontal nasal view

This article reviews the personal experience and evolution of osteotomy approach in the last years of practice to obtain a natural appearance of the nasal pyramid in the frontal view. The aim is to analyse the long-term results after rhinoplasty on nasal width in two different cohorts of patients subjected to lateral osteotomy plus hump resection vs. hump re-modeling without lateral osteotomy considering the impact on frontal nasal view and how this relates to changes observed over time in the nasal width and contour. The study was carried out between January 2010 and December 2013, considering 42 patients undergoing primary rhinoplasty. Comparisons were made between the change in the dorsal width of the nasal pyramid at the level of the medial canthi, at the level of the inferior margin of the orbital rim, of ventral width of the nasal pyramid at the level of the medial canthi and at the level of the inferior margin of the orbital rim. In the first group, we found significant postoperative mean widening of the intercanthal dorsal width and narrowing of the ventral, while in the second group there was significant postoperative mean narrowing of the dorsal width both at level of the medial canthi and the anterior junction of the nasal bones. Our analysis seems to point out that dorsal grafting is useful for re-shaping the nasal profile with a persistent and harmonious correction of the dorsal frontal dimension of the nose. Simple hump removal/repositioning may be considered in selected instances to avoid lateral osteotomies. It also seems of paramount importance to tailor osteotomies according to nasal bone anatomy: large, strong and curved bones deserve aggressive narrowing by lateral and medial continuous osteotomies without periosteal elevation, although this approach may be insufficient to narrow the upper dorsal aspect of the nose.

Hearing and cognitive impairment: a functional evaluation of associative brain areas in patients affected by Alzheimer's disease

Auditory dysfunction observed in patients with cognitive diseases is probably due to the alteration of some brain areas involved in sound stimulus processing. The present study aimed to investigate differences in such processing and in connectivity of the primary auditory cortex in patients affected by Alzheimer's disease (AD) and in normal subjects. We examined 131 diagnosed AD patients and a control group (CG) of 36 normal subjects. After a complete clinical investigation, focused on hearing function, all subjects underwent a brain FDG PET/CT. AD subjects vs CG showed reduced glucose consumption in BA 6,7,8,39, whereas we did not find differences in the primary auditory cortex. In AD, connectivity analyses showed a positive correlation of the primary auditory cortex with BA 6,8,21,31,39,40,42 and a negative correlation with BA 19, cerebellum and basal ganglia. Our findings suggest that neurological evaluation of patients with hearing loss might allow earlier (preclinical) identification of those affected by cognitive impairment.

Approach to the correction of drooping tip: common problems and solutions

The drooping tip deformity is both a bothersome aesthetic feature and functional impairment of the nose. Both static and dynamic factors may affect tip appearance and it seems logical to take into account these factors when planning correction of drooping tip. Many studies have examined this topic, but its treatment remains controversial. In order to make nasal tip surgery successful, it is useful to identify the keystone anatomical characteristics of the tip itself. Naso-labial angle, nostril axis, tip rotation angle according to Frankfort plane and columellar-facial angle may be measured to assess nasal tip position. The present study focuses on the authors' personal experience on the key anatomic changes of the nose that deserve correction and on the main surgical steps needed to achieve consistent results when dealing with a drooping tip. Pre- and post-operative nasal tip rotation and projection were studied. Correction of the drooping tip was accomplished by an open or closed septorhinoplasty approach according to patient's needs. The surgical techniques mostly employed for tip repositioning was septum straightening (41/41) and tongue-in-groove (36/41 cases) (87.8%). A columellar strut was used in 8/41 (19.51%) cases. LLC cephalic resection was applied in 29/41 patients (70.73%), LLC re-orienting sutures were made in 18/41 cases (43.9%) and lateral crural overlay was needed in 2/41 (4.8%). The key anatomic changes of the nose that deserve correction and the surgical steps needed to ease the often intriguing pre-operative decision-making process are reviewed.

Pathogenesis of chronic rhinosinusitis in patients affected by β-thalassemia major and sickle cell anaemia post allogenic bone marrow transplant

OBJECTIVES

Sickle cell anemia (SCA) and β -thalassemia major are well-recognized beta-globin gene disorders of red blood cells associated to mortality and morbidity included bone morbidities due to ineffective erythropoiesis and bone marrow expansion, which affect every part of the skeleton. While there are an abundance of described disease manifestations of the head and neck, the manner of paranasal sinuses involvement and its relations to β-thalassemia and SCA process was not studied yet. Therefore, the aim of this study was to investigate a possible increased risk of rhinosinusitis and the real pathogenetic mechanism of it, comparing these two hematological diseases using msCT, gold standard for paranasal sinuses evaluation.

METHODS

A retrospective analysis of 90 patients affected by β-thalassemia major or SCA (respectively 59 and 31) underwent allogeneic bone marrow transplantation (BMT), and 44 control subjects was performed. Both patient categories and control group have been subjected to hematological and radiological evaluation using 64-multidetector-row CT scanner without contrast injection.

RESULTS

Statistical analysis reveals that patients of the two study groups exhibit a significantly increased risk of sinusitis in comparison with the normal controls (RR: 3.55 for β-thalassemic pediatric subjects; RR: 3.35 for SCA pediatric subjects). A significant difference (p < 0,5) was found between the β -thalassemic patients on the one side, and SCA and control group on the other side, with regard to the evaluation of the typical anatomic alteration of maxillary sinus: β-thalassemic children had significant increase in the bone thickness of anterior and lateral sinus walls and significant reduction in volume and density compared to SCA patients and control group, with normal conditions of these parameters.

CONCLUSIONS

In these hematological patients, there is an increased incidence of sinonasal infections due their therapy-induced immunosuppression post transplantation. In β-thalassemic patients, furthermore, the specific anatomical variants play an important confounding factor in radiological interpretation of CT images. Therefore, a cranio-facial CT scan evaluation could be a useful tool in the management of upper airway infections after BMT and should be a routinely exams in order to avoid useless surgical or antibiotic approaches.

Radiological and clinical difficulties in the management of chronic maxillary sinusitis in β Thalassemic paediatric patients

INTRODUCTION

Beta thalassemia is a blood dyscrasia that caused a marked expansion of active marrow spaces and extramedullary haematopoiesis results. In these patients various alterations and abnormalities affects different body areas, including increased risk of sinusitis. The marrow expansion in the facial bones results in delay in pneumatisation of the sinuses, overgrowth of the maxillae, and forward displacement of the upper incisors with skeletal deformities. In current literature, maxillary sinuses are not deeply evaluated by CT scan studies in these kind of patients. The aim of our study was to investigate the presence of maxillary sinuses abnormalities by the use of CT in patients with beta-thalassemia major and to compare these findings with a control group free from this disease.

MATERIALS AND METHODS

A retrospective analysis of 22 paediatric patients with beta-thalassemia major and 22 control subjects without sinonasal diseases was performed. CT was done using a 64-multidetector-row CT scanner without contrast injection, obtained in axial plane using thin-slice technique. Evaluated parameters were: bone thickness of the lateral and anterior wall, density and volume of the maxillary sinuses.

RESULTS

Significant difference was found between the study group and control group in the evaluation of all the parameters examined. The maxillary sinus of β thalassemic patients was smaller respect of controls, the bone was more dense and thick in the side and anterior wall. Beta-thalassemic patients have a relative risk of 2.87 to develop a maxillary sinusitis.

DISCUSSION

In these patients there is an increased incidence of sinonasal infections due to the abnormal development of cranio facial skeleton. These bone alterations might confuse the physicians and lead to an increased rate of sinusitis diagnoses.

Impact of adjuvant chemotherapy on time to relapse in cholangiocarcinoma

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Background: Biliary tract cancer is a rare malignancy with poor prognosis. Surgery is the only potential curative approach, but even if surgical intervention is performed correctly the relapse risk remains very high. In adjuvant setting only few randomized trials using no standard treatments and producing controversial data are reported in literature.

Methods: This is a retrospective analysis on 144 consecutive biliary tract cancer patients (pts), undergone potentially curative resection in our institution (109 pts with R0 surgery and 31 pts with R1 surgery). The series included 57 intrahepatic cholangiocarcinomas (ICC), 68 extrahepatic cholangiocarcinomas (ECC), 19 gallbladder cancers (GBC) (Table). Median age was 63, 80 pts were males and 64 pts were females. 80 (60 R0 and 20 R1) out of 144 pts received adjuvant chemotherapy and the remaining 64 pts (49 R0 and 15 R1) started a follow-up program. Adjuvant chemotherapy schedule was gemcitabine 1000 mg/m2 at day 1, 8, 15 every 28, for six months.

Results: Median time to relapse (TTR) in the treatment group and in the follow-up group were 18 months and 11 months respectively (p=0.038). No grade 3-4 chemotherapy-related adverse events were observed and only grade 1-2 thrombocytopenia occurred. This hematologic toxicity did not affect treatment dose intensity.

Conclusions: Our preliminary retrospective analysis suggests a significant advantage of adjuvant treatment on TTR in radically resected biliary tract cancer patients, although further placebo-controlled double blind trials are required.

[Table: see text]

No significant financial relationships to disclose.

Not just an individual journey: social aspects of recovery

BACKGROUND

Recent literature on recovery describes the process as deeply personal and unique to each individual. While there are aspects of recovery that are unique to each individual, this article argues that focusing solely on these overlooks the fact that recovery unfolds within a social and interpersonal context.

MATERIALS

Drawing from qualitative data, this article describes aspects of recovery that involve the contributions of others, the social environment and society.

DISCUSSION

These aspects of recovery include relationships, adequate material conditions and responsive services and supports.

CONCLUSION

The authors consider the implications of these social factors for transforming psychiatric research and theory as well as for recovery-orientated practice.

Not just an individual journey: social aspects of recovery

BACKGROUND

Recent literature on recovery describes the process as deeply personal and unique to each individual. While there are aspects of recovery that are unique to each individual, this article argues that focusing solely on these overlooks the fact that recovery unfolds within a social and interpersonal context.

MATERIALS

Drawing from qualitative data, this article describes aspects of recovery that involve the contributions of others, the social environment and society.

DISCUSSION

These aspects of recovery include relationships, adequate material conditions and responsive services and supports.

CONCLUSION

The authors consider the implications of these social factors for transforming psychiatric research and theory as well as for recovery-orientated practice.

Functional outcome of auditory implants in hearing loss

The auditory implant provides a new mechanism for hearing when a hearing aid is not enough. It is the only medical technology able to functionally restore a human sense i.e. hearing. The auditory implant is very different from a hearing aid. Hearing aids amplify sound. Auditory implants compensate for damaged or non-working parts of the inner ear because they can directly stimulate the acoustic nerve. There are two principal types of auditory implant: the cochlear implant and the auditory brainstem implant. They have common basic characteristics, but different applications. A cochlear implant attempts to replace a function lost by the cochlea, usually due to an absence of functioning hair cells; the auditory brainstem implant (ABI) is a modification of the cochlear implant, in which the electrode array is placed directly into the brain when the acoustic nerve is not anymore able to carry the auditory signal. Different types of deaf or severely hearing-impaired patients choose auditory implants. Both children and adults can be candidates for implants. The best age for implantation is still being debated, but most children who receive implants are between 2 and 6 years old. Earlier implantation seems to perform better thanks to neural plasticity. The decision to receive an implant should involve a discussion with many medical specialists and an experienced surgeon.

Experimental and clinical aspects of the efferent auditory system

The discovery of active mechanisms in the cochlea and the efferent auditory pathways from the brain to the cochlea demonstrated the existence of a modulation of the auditory input in the central nervous system (CNS). Otoacoustic emissions (OAEs) are weak signals that can be recorded in the ear canal and are considered a byproduct of an active process from the outer hair cells (OHCs) to the basilar membrane. The efferent auditory system plays an inhibitory role on the activity of OHCs; its stimulation reduces auditory nerve response, basilar membrane motility and OAEs amplitude. Indirect stimulation by contralateral sound is also inhibitory; a reduction of OAEs amplitude can be recorded and such an effect disappears after olivocochlear bundle section. The efferent system seems to play a role in detection of signals in noise, protection in noise-induced cochlear damage, development of hearing and processing of complex auditory signals. With respect to clinical application, OAEs suppression after contralateral auditory stimulation seems to be the only objective and non-invasive method for evaluation of the functional integrity of the medial efferent system, and, therefore, for evaluation of the structures lying along its course, at least up to the level of inferior colliculi.

Variations of Neck Structures after Supracricoid Partial Laryngectomy: A Multislice Computed Tomography Evaluation

BACKGROUND

Surgery of laryngeal cancer used to profoundly alter the anatomy of the cervical region. Accurate anatomo-embryologic studies and repeated surgical trials allowed recognition of the cricoarytenoid complex as the smallest anatomofunctional unit able to maintain all the laryngeal functions.

OBJECTIVES

The aim of this study was to determine whether significant variations of neck anatomical parameters exist after partial laryngectomy, and to analyze whether some of these parameters are associated with a positive functional outcome.

METHODS

Out of 48 patients treated with a surgical technique according to Mayer-Piquet (cricohyoidoepiglottopexy, CHEP) over a 6-year period, 18 patients were enrolled in the study. Patients were all males with a mean age of 60 years. Cervical structures and their relationships were measured by computed tomography, and the measurements before and after surgery were compared.

RESULTS

Our data showed that hyoid bone is modified, both in morphology and position during CHEP. More specifically the relation of the hyoid bone to other neck structures (identified by the alpha-angle) is modified. The neolarynx and trachea undergo a caudocranial shift. All diameters of the cricoid cartilage remain unchanged after surgery. The position of the epiglottis after CHEP, in particular its relation with the arytenoid cartilage, is closely related to swallowing function outcome and recovery time.

CONCLUSIONS

Our study showed that these structures, and more specifically the relations among them, undergo significant variations after CHEP. Our results identify some parameters, i.e. the alpha-angle, width of the hyoid bone and position of the epiglottis, that may predispose to a positive functional outcome after surgery.

Orthodontist-otorhinolaryngologist: an interdisciplinary approach to solve otitis media

AIM

This was to investigate in oral breathing children with an associated atypical pattern of swallowing and otitis media, the effects of rapid maxillary expansion on nasal airway resistance and conductive hearing loss.

MATERIALS AND METHODS

This study examined 24 children (16 males and 8 females) in early mixed dentition period, with an age range of 6-8 years (mean age 7 years), diagnosed with otitis media from the otorhinolaryngology Department of "Tor Vergata" Hospital. The young patients were seen in the Department of Orthodontics, Faculty of Dentistry University of Rome "Tor Vergata". All the subjects had an open mouth breathing pattern with a secondary atypical swallowing mode and a conductive hearing loss resulting from otitis media. The therapeutic approach was to apply a RPE fixed appliance (Butterfly expander).

RESULTS

Follow up showed that after rapid maxillary expansion there was nasal resistance reduction, increased nasal airflow and improvement in conductive hearing loss. CONCLUSION Rapid maxillary expansion has been used for both dental and rhinological purposes in the belief that clinically significant reductions in nasal resistance to airflow and an improvement in conductive hearing loss occur predictably.

Evaluation of abnormalities of orthostatic postural control in systemic sclerosis

OBJECTIVE

Systemic sclerosis (SSc) is a multi-systemic disease of unknown etiology characterized by damage to the small arteries, arterioles and capillaries. The documented occurrence of various neuropathies in SSs patients led us to hypothesize that there is a potential for postural control impairments in such disease. This study was aimed at evaluating the orthostatic postural control of SSc patients who do not manifest balance or hearing symptoms.

METHODS

Postural stability was assessed in 36 female SSc patients by means of a static computerized posturography technique. Their immunological and microvascular condition were evaluated by means of blood tests and microcapillaroscopy of the digital vessels. Posturography and microcapillaroscopy were performed before and after treating the patients with Iloprost. In order to compare results, posturography was also carried out on a control group composed of 10 healthy women of similar age. Both groups were studied in two different sensory conditions, i.e. with eyes opened and with eyes closed.

RESULTS

Posturography results showed relevant differences in body sway between patients and control subjects. Fourier spectral analysis of body sway showed that, independently from visual control, SSc patients exhibit a higher level of low/middle frequency oscillations (both on the lateral and the anteroposterior axis). No relationship was established between disease stage and postural performance.

CONCLUSION

This study seems to indicate a subtle neurophysiological dysfunction in the orthostatic postural control of female SSc patients. Further tests on the somatosensory neurological function of SSc patients may help support the above mentioned findings.

Role of dynamic posturography (Equitest) in the identification of feigned balance disturbances

Clinico-instrumental criteria to reliably detect simulated vertigo remain to be defined. Computed dynamic posturography (Equitest) has been used to identify additional factors to distinguish simulated, from real vertigo. The present study population comprised 23 normal subjects and 16 patients with documented vestibular impairment. Normal subjects were also studied during a state of simulated vertigo. In malingerers, the Equilibrium Score and the Composite Equilibrium Score showed a statistically significant reduction in all test conditions as compared to normal subjects, patients and "non-malingerers". Upon Sensory Analysis, statistically significant differences were found for the somatosensory component between malingerers and "non-malingerers". In 20/23 cases, Strategy Score values recorded in malingerers were 2 Standard Deviations lower than the mean obtained in "non-malingerers" in at least one of the six test conditions. By combining the latter observation with Goebel's 1st criterion it was possible to differentiate malingerers from non-malingerers with 86.9% sensitivity and 89.7% specificity. The Equitest, therefore, in combination with conventional methods, provides the clinician with an important tool, in the identification of a state of simulated vertigo.

Effects of contralateral white noise stimulation on distortion product otoacoustic emissions in myasthenic patients

Myasthenia gravis (MG) induces a reduction of transient evoked otoacoustic emissions (TEOAEs) and distortion product otoacoustic emissions (DPOAEs) that reverses partially after administration of an acetylcholinesterase (AChE) inhibitor. In normal subjects a contralateral acoustic stimulation (CAS) produces an amplitude reduction of TEOAEs and DPOAEs. This effect, called contralateral suppression (CS), is mediated by the efferent auditory system. Twenty subjects affected by MG underwent DPOAE recording with and without contralateral white noise in a drug-free baseline period ('basal') and 1 h ('post') after administration of a reversible AChE inhibitor. In 'basal' condition CAS did not induce significant DPOAE amplitude changes but a paradoxical slight increase was observed. After drug administration, CAS produced a significant decrease of DPOAE amplitudes for middle frequencies (f(2) between 1306 and 2600 Hz). In normal controls CAS caused a significant decrease (P<0.001) for all frequencies. The amount of CS in controls and in the MG 'post' condition was not significantly different. The increased acetylcholine (ACh) availability following drug consumption seems to partially restore outer hair cell function and enhances their electromotility; a further influx of ACh due to CAS yields to restoration of the CS. These findings also suggest that DPOAEs may be useful in the diagnosis of MG and for monitoring the effectiveness of treatment.

SPET monitoring of auditory cortex activation by electric stimulation in a patient with auditory brainstem implant

Auditory cortex activation following multifrequency acoustic stimulation has been evaluated by means of single photon emission tomography (SPET) in one patient before and after an auditory brainstem implant (ABI). No activation could be observed after acoustic stimulation before ABI. After ABI stimulation in the coronal and axial slices, the activation within the temporal cortex contralateral to the stimulated ear was twice (43.76%) that of normal controls (23.94 +/- 2.74%). This marked difference was not present in other selected cortical auditory areas (homolateral temporal, homolateral and contralateral parietal cortices). The temporal cortex was also examined with six consecutive sagittal slices from 18.75 mm up to 56.25 mm lateral to the midline. A very strong activation (51.20%) compared with that of normal controls (9.94 +/- 7.45%) was detected in the 25.26-mm sagittal slice of the temporal cortex contralateral to the stimulated side. The remaining sagittal slices showed an almost normal post-stimulatory activation. As the 25.26-mm sagittal slice corresponds to the medial part of the auditory temporal cortex, its activation suggests that electrode stimulation is concentrated on the region of the cochlear nucleus in which the neurons that transduce high frequencies are located. SPET can be considered useful, in combination with electric auditory-evoked potentials, to obtain information on ABI placement and function, effectiveness of acoustic stimulation, degree of cortical stimulation and tonotopic spatial distribution of auditory cortex activation.

Age-related histopathological changes of the stria vascularis: an experimental model

The stria vascularis (SV) of 3-, 8- and 18-month-old C57 mice was examined with a fluorescence microscope in order to evaluate the capillary density and vessel diameter. The capillary density was significantly reduced in 18-month-old mice compared to 3-month-old (P<0.001) and to 8-month-old (P<0.001) mice. The difference between 3- and 18-month-old mice was significant for the basal, middle and apical cochlear turns, while the difference between 8- and 18-month-old mice was significant only for the middle and basal turns. Vessel diameter within the whole SV was significantly reduced in all turns in 18-month-old mice (P<0.01) versus 3-month-old animals, while vessel diameter was reduced only in the basal turn in 8-month-old versus 3-month-old mice. The results suggest that previously described histopathological changes in the organ of Corti of C57 mice may be related to modifications of strial capillaries.

Effect of ageing on otoacoustic emissions and efferent suppression in humans

Transiently evoked otoacoustic emissions (TEOAEs) without and with contralateral acoustical stimulation, were recorded on 52 subjects ranging from 20 to 78 years. Subject selection was based on the hearing levels from 0.5 to 4 kHz being better than 25 dB HL, normal tympanograms and stapedial reflexes, presence of TEOAEs in at least one ear and no history of otological disease, noise exposure, ototoxic drugs, metabolic disease associated with hearing loss or a family history of hearing loss. The ear with better audiological thresholds was selected as the test ear. If there was no difference between the ears, the ear with stronger TEOAEs was selected. Subjects were divided into five age groups: 20-34 years (n=12, mean age 23.7), 35-44 (n=11, mean age 39.7), 45-54 (n=8, mean age 48.1), 55-64 (n=10, mean age 60), 65-78 (n=11, mean age 71). TEOAEs were never absent in the first two groups, but they were absent in two ears in the 45-54 group, and in one ear of the 55-64 and 65-78 groups. Mean TEOAE amplitude decreased with age, but the differences between the five groups were not significant. Contralateral white noise suppressed emission amplitude, but the amount of suppression was not significantly different between the five groups. A linear regression analysis showed a significant correlation between age and hearing levels, and a negative correlation between age and TEOAE amplitude. In addition, a significant negative correlation between hearing threshold and TEOAE amplitude was evident. No effect of age on the amplitude of the efferent suppression was found.

Postural control and glycerol test in Ménière's disease

Ménière's disease is a clinical disorder, characterized by fluctuating hearing loss, recurrent spontaneous episodic vertigo, tinnitus and aural fullness, which may be defined as the idiopathic syndrome of endolymphatic hydrops. The most important test for diagnosis of Ménière's disease is the glycerol test. This is a simple and rapid method and several authors have confirmed its efficiency for identifying endolymphatic hydrops. This test provides information on the cochlear response to the osmotic changes produced by glycerol in the inner ear, whereas modifications in the vestibular labyrinth are usually not evaluated. The aim of this study was to evaluate the effects of glycerol on postural control during attacks of Ménière's disease, and to correlate this data with data on cochlear function. After the glycerol test, an improvement in postural control was recorded in 70% of patients, with all patients reporting a recovery of vertigo. The impairment of postural control during endolymphatic hydrops could be related to a pressure increase in the labyrinth, which interferes with the normal dynamics of the endolymph, and a rapid functional recovery could occur during an osmotic depletion. Dynamic posturography improves the sensitivity of the glycerol test and may therefore be useful in the diagnosis and staging of Ménière's disease.

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.

Postural control in horizontal benign paroxysmal positional vertigo

Sixteen patients affected by benign paroxysmal positional vertigo of the horizontal semicircular canal (BPPV-HSC) were investigated by means of dynamic posturography (DP) and during bithermal caloric stimulation. Data were compared to data from 40 patients with benign paroxysmal positional vertigo of the posterior semicircular canal (BPPV-PSC) and 20 healthy controls. No postural deficit was observed before or after a liberative Lempert's manoeuvre when patients were compared to control subjects. BPPV-PSC postural scores were significantly impaired compared to scores from the BPPV-HSC group. A residual significant postural impairment was also observed after a successful liberative manoeuvre in the BPPV-PSC group. Electronystagmographic recordings before recovery revealed significant hypoexcitability of the affected ear in 8/16 patients of the BPPV-HSC group. After the liberative manoeuvre, a symmetric bilateral response to caloric stimulation was recorded in all patients. Three main conclusions can be drawn from the present data. First, disorders of the horizontal semicircular canal do not change postural control. Second, dynamic posturography can detect the postural imbalance due to posterior semicircular canal dysfunction even after resolution of paroxysmal vertigo attacks. Third, utricular dysfunction can be ruled out as a cause of the residual postural deficit observed in BPPV-PSC patients. Therefore the recovery delay observed even 1 month after the liberative manoeuvre in the BPPV-PSC-group might be due to the persistence of small amounts of residual debris in the canal, to paralysis of ampullar receptors, or to the time needed for central vestibular re-adaptation.

Surgery of otosclerosis in the elderly

Auditory results following stapes surgery in 26 patients with otosclerosis >60 years of age at the time of surgery were compared with those obtained in 140 patients <60 years undergoing stapes surgery during the same time period. Stapedotomy was performed in all cases. The mean follow-up period was 29 months. Hearing results as judged by postoperative air-bone gaps were as good in the older age group as in the younger patients. Moreover, complications of surgery, such as postoperative formation of perilymphatic fistula, did not occur more frequently in elderly vs younger patients. On the basis of the results obtained, it is concluded that stapes surgery should be offered to elderly patients with the same indications as younger patients with otosclerosis.

Auditory brainstem and cochlear implants: functional results obtained after one year of rehabilitation

Very little information has been published on the clinical outcome of auditory brainstem implants (ABI). The present paper evaluates results obtained in a patient affected by a bilateral acoustic neuroma in type II neurofibromatosis who received an implant during removal of the residual tumor. One year later surgical revision of the ABI was necessary because no auditory sensation was obtained after ABI activation. Twelve months after the surgical revision, 12 electrodes out of 15 evoked auditory sensation. The results of rehabilitation were compared with those obtained in a group of eight postlingually deaf patients with cochlear implants (CI). Twelve months postoperatively the CI patients identified 97.7 +/- 5.1% of bisyllabic words in a closed set while the ABI patient identified 86%. CI patients recognized 87.1 +/- 11.3% of sentences and 81.3 +/- 14.8% of words with contextual cues while the ABI patient recognized 75% and 65% respectively. Speech recognition improved more slowly in the ABI patient than in the CI patients and his scores for open-set words and sentences without lip reading and contextual cues were poorer. Although the results obtained in the ABI patient were not as good as those obtained in the CI patients, the ABI patient said his quality of life was improved.

Vestibulo-ocular reflex modification after virtual environment exposure

Immersion in an illusory world is possible by means of virtual reality (VR), where environmental perception is modified by artificial sensorial stimulation. The application of VR for the assessment and rehabilitation of pathologies affecting the vestibular system, in terms of both diagnosis and care, could represent an interesting new line of research. Our perception of reality is in fact based on static and dynamic spatial information perceived by our senses. During head movements in a virtual environment the images on the display and the labyrinthine information relative to the head angular accelerations differ and therefore a visuo-vestibular conflict is present. It is known that mismatches between visual and labyrinthine information may modify the vestibulo-oculomotor reflex (VOR) gain. We studied the post-immersion modifications in 20 healthy subjects (mean age 25 years) exposed to a virtual environment for 20 min by wearing a head-mounted display. VOR gain and phase were measured by means of harmonic sinusoidal stimulation in the dark before, at the end of and 30 min after VR exposure. A VOR gain reduction was observed in all subjects at the end of VR exposure which disappeared after 30 min. Our data show that exposure to a virtual environment can induce a temporary modification of the VOR gain. This finding can be employed to enable an artificial, instrumental modification of the VOR gain and therefore opens up new perspectives in the assessment and rehabilitation of vestibular diseases.

The role of cholinergic transmission in outer hair cell functioning evaluated by distortion product otoacoustic emissions in myasthenic patients

Outer hair cells (OHCs) are the source of otoacoustic emissions, following a tropomyosin-miosin-dependent contraction, which are regulated by the olivocochlear bundle via the release of acetylcholine (ACh). ACh acts on ACh receptors (AChR) located on the OHC post-synaptic membrane. In myasthenia gravis (M.G.) neuromuscular transmission is reduced due to the action of AChR autoantibodies. It has previously been shown that M.G. induces a reduction in transient evoked otoacoustic emissions (TEOAEs), which is reversed after administration of a cholinesterase (AChE) inhibitor. Distortion product otoacoustic emissions (DPOAEs) were recorded before and 60 min after oral administration of 60 mg pyridostigmine bromide in 25 patients with normal hearing affected by M.G. The results were compared with those from 25 age-matched normal controls. Mean values of DPOAE amplitude in myasthenic patients were significantly (p < 0.05) lower at all frequencies before drug administration. All patients showed an overall significant (p < 0.05) increase in DPOAE amplitude after drug administration, although without reaching the control values. Such a recovery was more evident and highly significant (p < 0.01) for middle and high frequencies and could be explained by a higher concentration of ACh receptors in the basal and middle cochlear turns. These data seem to confirm the role of ACh in the neurotransmission of the auditory efferent system and may represent a new in vivo model for the investigation of the physiology of this system.

A novel venombin B from agkistrodon contortrix contortrix: evidence for recognition properties in the surface around the primary specificity pocket different from thrombin

A novel thrombin-like enzyme (named contortrixobin) has been purified to homogeneity from the venom of Agkistrodon contortrix contortrix by affinity chromatography on arginine-Sepharose, anionic exchange chromatography, and HPLC. The complete amino acid sequence has been determined by Edman degradation and by mass spectral analysis of peptides generated by enzymatic cleavage. A microheterogeneity at the level of residue 234 has been detected, as demonstrated by peptides differing for the occurrence of Pro234 ( approximately 85%) or Asp234 ( approximately 15%). Contortrixobin (i) has six disulfide bonds whose sequence positions have been determined by mass spectrometry and (ii) does not contain carbohydrates in its structure. As expected, the 234 residue sequence of contortrixobin exhibits strong homology with snake venom serine proteases acting on either fibrinogen or other blood coagulation components. The interaction of contortrixobin with chromogenic substrates indicates a higher specificity for arginine over lysine in the primary subsite and a faster attack to ester than amides. The hydrolytic activity of contortrixobin is strongly inhibited by diisopropyl fluorophosphate and to a less extent by phenylmethylsulfonyl fluoride, benzamidine, and 4', 6-diamidino-2-phenylindole; hirudin (a specific alpha-thrombin inhibitor) as well as basic pancreatic trypsin inhibitor has a small effect on contortrixobin's catalytic properties. Contortrixobin (i) preferentially releases fibrinopeptide B from human fibrinogen, (ii) activates blood coagulation Factors V and XIII with a rate 250-500-fold lower than human alpha-thrombin, and (iii) does not induce thrombocyte aggregation, intracytoplasmatic calcium ion increase in platelets, and activation of Factor VIII. Evidence for biorecognition properties different from thrombin is also reported.

Preliminary experiences with contact endoscopy of the larynx

Nine patients with laryngeal polyps, four with Reinke's edema, three with leukoplakia, one with papilloma and one with malignant tumor were studied by means of laryngeal contact endoscopy during microlaryngoscopy. This technique allowed in vivo and in situ visualization of the superficial layer of the laryngeal epithelium after staining with methylene blue. Cell structures evaluated were the size and color of the nuclei, the nucleus/cytoplasm ratio, nuclear and cytoplasmic contours, the presence of nucleoli, mitoses and keratoses, as well as the microvascular network of the mucosa and superficial cellular changes from normal to pathological. The normal squamous epithelium of the vocal cord showed a homogeneous cellular population with regular nuclear and cytoplasmic morphological characteristics and a uniform nucleus-to-cytoplasm ratio. Specific cellular epithelial patterns and several alterations of the vascular distribution were found in different pathological conditions. Cytological pictures obtained at contact endoscopy were consistent with histological findings in all the patients studied.

[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.

The role of vision on postural strategy evaluated in patients affected by congenital nystagmus as an experimental model

The role of vision in postural control is crucial and is strictly related to the characteristics of the visual stimulus and to the performance of the visual system. The purpose of this investigation was to evaluate the effects of chronically reduced visual cues upon postural control in patients affected by Congenital Nystagmus (CN). These patients have developed since birth a postural strategy mainly based on vestibular and somatosensorial cues. Fifteen patients affected by CN and 15 normal controls (NC) were enrolled in the study and evaluated by means of dynamic posturography. The overall postural control in CN patients was impaired as demonstrated by the equilibrium score and by the changes of the postural strategy. This impairment was even more enhanced in CN than in NC group when somatosensorial cues were experimentally reduced. An aspecific pattern of visual impairment and a pathological composite score were also present. Our data outline that in patients affected by CN an impairment of the postural balance is present especially when the postural control relies mainly on visual cues. Moreover, a decrease in accuracy of the somatosensory cues has a proportionally greater effect on balance than it has on normal subjects.

[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.

[Difficulties in the clinical, radiological and therapeutic evaluation of the initial stage of mucormycosis of the rhinosinus]

The initial diagnosis and subsequent treatment of rhino-orbital mucormycoses is quite difficult, particularly because the patient may find it difficult to accept aggressive therapeutic protocols, even when free of any endocranial involvement. The authors draw inspiration from a clinical case of rhino-orbital mucormycosis in a patient suffering from decompensated type I diabetes mellitus to discuss the main clinical-diagnostic and therapeutic aspects of this disorder. Timely medical-surgical treatment proves extremely important for prognosis, preventing the intracranial extension of the lesion which is the cause of death in 80% of such cases. As regards the diagnostic protocol, careful clinical, radiological monitoring with CT and NMR--in strict interdisciplinary cooperation between otorhinolaryngologist, radiologist, ophthalmologist, microbiologist and histopathologist--is especially important. Radical surgery, at times demolition, associated with correction of the metabolic decompensation, systemic therapy with Amphotericin B and localbi-weekly medication for three months constitutes the best therapeutic protocol for treatment of this disorder.

[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.

Olfactory function evaluated by SPECT

Few articles on neuroimaging techniques in the study of central and peripheral olfactory pathways are present in the literature. By Single Photon Emission Computed Tomography (SPECT), cortical perfusion increment after sensorial stimulation can be evaluated objectively. In the present research, 10 healthy adults underwent SPECT by CER.TO.96 cerebral tomograph, before and after olfactory stimulation with lavender-water. A variable degree of cortical activation was detected in all patients. Gyrus rectus (+24.5%), orbito-frontal cortex (right +26.6%, left +25.6%), and superior temporal (right +9.9%, left +5.5%) cortical areas were always activated. A slight perfusion increase was present in middle temporal (right +3.2%, left +2.1%) and parieto-occipital (right +0.4%, left +2%) regions. Five patients affected by posttraumatic anosmia were also investigated: they showed a perfusion increment markedly inferior to 0.5% in every olfactory area. SPECT is a rather diffused, easily performed technique which yields objective semi-quantitative information on brain perfusion. Hence, it can be regarded as a promising contribution in the fields of smell neurophysiology, clinical olfactometry, and medicolegal queries.