Multicentre study on resection margins in carcinoma of the oral cavity, oro-hypopharynx and larynx

Objective

The prognostic significance of the resection margins is still subject of conflicting opinions. The purpose of this paper is to report the results of a study on the margins in carcinoma of the oral cavity, oro-hypopharynx and larynx.

Methods

A multicentre prospective study was carried out between 2015 and 2018 with the participation of 10 Italian reference hospitals. The primary objective was to evaluate local control in patients with well-defined clinical characteristics and comprehensive histopathological information.

Results

During the study period, 455 patients were enrolled; the minimum follow-up was 2 years. Previous treatment, grading and fresh specimen examination were identified as risk factors for local control in multivariate analysis. On the basis of these results, it seems possible to delineate “risk profiles” for different oncological outcomes.

Discussion

The prognostic significance of the margins is reduced, and other risk factors emerge, which require diversified treatment and follow-up.

Conclusions

Multidisciplinary treatment with adjuvant therapy, if indicated, reduces the prognostic importance of margins. Collaboration with a pathologist is an additional favourable prognostic factor and quality indicator.

An appendix with literature review is present in the online version.

Synthesis of phenylpyrimidinones as guanylyl cyclase C inhibitors

Diarrhea is one of the most important causes of mortality in the developing world, being responsible for 2.5 million deaths each year. Many of these deaths are caused by enterotoxigenic strains of bacteria, like Escherichia coli, that produce enterotoxins that cause acute watery diarrhea, commonly defined as secretory diarrhea. Studies on symptomatic patients indicate a high prevalence of enterotoxigenic E. coli strains producing the heat-stable toxin, STa. STa is a small, cysteine-rich peptide that binds to the extracellular receptor domain of guanylyl cyclase C (GCC), located at the luminal membrane of intestinal epithelial cells. GCC and its endogenous peptide ligands, guanylin and uroguanylin, play a key role in balancing water absorption and hydration of the intestinal lumen, as exemplified by the finding that loss of GCC function causes severe dehydration of the intestinal lumen, culminating in intestinal obstruction. From a mechanistic viewpoint, reduction of GCC activity offers an efficient approach to limit enterotoxigenic E. coli- provoked secretory diarrhea. Inhibition of GCC-mediated cGMP production would not only reduce anion secretion, but would also restore NHE3 activity, resulting in a comprehensive antidiarrheal action. In the present study, two novel phenylpyrimidinone derivatives were simultaneously synthesized and tested for their ability to block STa-induced CFTR activity in T84 cells.

Mastoidectomy dimensions for direct acoustic cochlear implantation: a human cadaveric temporal bone study

The objective of the present paper was to acquire information about the mastoidectomy size necessary to obtain an optimal placement of the direct acoustic cochlear implant actuator and fixation system. Ten human cadaveric temporal bones were dissected and implanted with direct acoustic cochlear implant. Mastoidectomy size was determined after implantation in each temporal bone. A bone bed for the receiver/stimulator, mastoidectomy and a large posterior tympanotomy were drilled out. The mastoidectomy was progressively enlarged posteriorly in small steps until the actuator template was judged adequately oriented to enable passage of the rod through the posterior tympanotomy without any contact with the bony walls. The distance between different landmarks in the mastoidectomy was measured. All measured values showed a high degree of consistency, with limited median absolute deviation values. One of the most critical measure, i.e. the distance between the posterior margin of the mastoidectomy to the superior rim of the bony external ear canal wall, ranged from 13 to 16 mm with a median value of 15 mm. Prior knowledge of the ideal size of the mastoidectomy for direct acoustic cochlear implant facilitates the positioning of the fixation system and may save time during implant surgery.

Vestibular dehiscence syndrome caused by a labyrinthine congenital cholesteatoma

A 40-year-old man presented with conductive hearing loss and pressure- and sound-related vestibular symptoms. Computed tomography and diffusion-weighted magnetic resonance imaging revealed the presence of a cholesteatoma involving the vestibular labyrinth. The patient underwent a canal-wall-up tympanoplasty, which revealed evidence of a disruption of the vestibular labyrinth and a wide dehiscence of the vestibule, which was immediately resurfaced. At the 2-month follow-up, the patient's pressure- and sound-related vestibular symptoms had disappeared. Pure-tone audiometry showed a reduction in the air-bone gap with a slight deterioration of bone conduction and an improvement in the air-conduction threshold. Fistulization of the otic capsule produces a "third window," which can lead to a dehiscence syndrome. One possible cause is a cholesteatoma of the middle ear or petrous bone. When the vestibule is invaded by a cholesteatoma, hearing is almost invariably lost, either pre- or postoperatively. However, in our case, wide opening of the vestibule resulted in hearing preservation.

Is the middle fossa approach the treatment of choice for intracanalicular vestibular schwannoma?

OBJECTIVES:

To compare the 2 surgical techniques most commonly used during vestibular schwannoma (VS) surgery, i.e., the middle fossa (MF) and the retrosigmoid-transmeatal (RS-TM) routes, when hearing preservation is attempted.

STUDY DESIGN:

A longitudinal study of a series of consecutive patients operated on with the 2 techniques by the same surgeon was conducted. Selection criteria included tumor confined to the internal auditory canal (IAC) with a length ranging from 4 to 12 mm and hearing class A or B. Patients were alternately assigned to 1 of the 2 groups regardless of auditory class and distance of the tumor from the IAC fundus. Thirty-five subjects were operated on with the RS-TM technique and 35 via the MF route.

RESULTS:

No significant differences in auditory and facial nerve function results between the 2 techniques were observed. The RS-TM approach, however, showed better facial nerve results at discharge. VS size, IAC enlargement, and, particularly, the distance from the IAC fundus were found to influence the postoperative results more than the type of approach itself.

CONCLUSIONS:

The MF approach has been described as being the better technique for VS surgery in terms of auditory results. However, this claim lacks statistical substantiation because no prospective studies are to be found in the literature. The present longitudinal investigation shows that the MF approach does not afford any particular advantages over the RS-TM route in terms of auditory results in intracanalicular VS, with the exception of tumors reaching the IAC fundus.

Variability in the perilymphatic diffusion of gadolinium does not predict the outcome of intratympanic gentamicin in patients with Ménière's disease

OBJECTIVES/HYPOTHESIS

To assess the utility of imaging in planning intratympanic (IT) gentamicin (Gent) treatment in Ménière's disease (MD), we compared the dosage and outcomes of ITGent with the severity and extent of endolymphatic hydrops (EH), as evaluated by three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) sequence in a 3-T magnetic resonance imaging (MRI) unit, after IT gadolinium administration.

STUDY DESIGN

Retrospective review.

METHODS

A total of 18 patients (10 males and 8 females; age, 28-78 years; median age, 53.2 years) with definite MD participated in the investigation. The duration of the disease ranged from 8 months to 9 years (median, 2 years), with a prevalence of vertigo spells ranging from 0.8 to 8 per month (median, 2.2), as calculated in the last 6 months. A 3D-FLAIR MRI was performed 24 hours after IT injection of diluted gadobutrol. ITGent injection was performed within a variable period of time, from 1 week to 3 weeks after 3D-FLAIR MRI. The degree and extension of EH as evaluated by 3D-FLAIR MRI were compared with the number of injections necessary to cure vertigo attacks. Vertigo results, functional level scale modifications, variations in caloric excitability, and pure-tone average modifications.

RESULTS

No statistically significant correlation was observed between severity of EH and outcomes of ITGent administration.

CONCLUSIONS

The hypothesis of a reduced effect of Gent administered intratympanically in the presence of severe EH, owing to obstacled diffusion along the perilymphatic compartments, has not been confirmed in the present investigation.

Inhibitory effects of bromelain, a cysteine protease derived from pineapple stem (Ananas comosus), on intestinal motility in mice

BACKGROUND

Bromelain (BR) is a cysteine protease with inhibitory effects on intestinal secretion and inflammation. However, its effects on intestinal motility are largely unexplored. Thus, we investigated the effect of this plant-derived compound on intestinal contractility and transit in mice.

METHODS

Contractility in vitro was evaluated by stimulating the mouse isolated ileum, in an organ bath, with acetylcholine, barium chloride, or electrical field stimulation. Motility in vivo was measured by evaluating the distribution of an orally administered fluorescent marker along the small intestine. Transit was also evaluated in pathophysiologic states induced by the pro-inflammatory compound croton oil or by the diabetogenic agent streptozotocin.

KEY RESULTS

Bromelain inhibited the contractions induced by different spasmogenic compounds in the mouse ileum with similar potency. The antispasmodic effect was reduced or counteracted by the proteolytic enzyme inhibitor, gabexate (15 × 10(-6)  mol L(-1) ), protease-activated receptor-2 (PAR-2) antagonist, N(1) -3-methylbutyryl-N(4) -6-aminohexanoyl-piperazine (10(-4) mol L(-1) ), phospholipase C (PLC) inhibitor, neomycin (3 × 10(-3) mol L(-1) ), and phosphodiesterase 4 (PDE4) inhibitor, rolipram (10(-6)  mol L(-1) ). In vivo, BR preferentially inhibited motility in pathophysiologic states in a PAR-2-antagonist-sensitive manner.

CONCLUSIONS & INFERENCES

Our data suggest that BR inhibits intestinal motility - preferentially in pathophysiologic conditions - with a mechanism possibly involving membrane PAR-2 and PLC and PDE4 as intracellular signals. Bromelain could be a lead compound for the development of new drugs, able to normalize the intestinal motility in inflammation and diabetes.

Continuous retrograde monitoring of the facial nerve during cerebellopontine angle surgery: normative data

An alternative technique for the continuous monitoring of the facial nerve, monopolar recording of facial nerve antidromic potentials (FNAPs), on 10 subjects undergoing retrosigmoid vestibular neurectomy for Meniere's disease is described. To elicit FNAPs bipolar electrical stimulation of the marginalis mandibulae was performed. Stimulus intensity ranged from 0 to 10 mA with a delivery rate of 7/second. Antidromic potentials were recorded with a silver wire monopolar electrode positioned intracranially on the proximal portion (root entry zone) of the acoustic-facial bundle. Bipolar recordings with two silver electrodes were also performed from different nerves in the cerebellopontine angle to define the specific origin of the action potentials. FNAP. amplitude increased as a function of stimulus intensity. The average latency was 3.35 milliseconds (range 3.0 to 3.7 ms). Action potentials recorded intracranially during electrical stimulation of the marginal nerve originated specifically from the facial nerve. FNAP recording is therefore a promising technique for the continuous intraoperative monitoring of the facial nerve during cerebellopontine angle surgery.

"En-bloc" removal of small- to medium-sized acoustic neuromas with retrosigmoid-transmeatal approach

Surgery of acoustic neuroma (AN) has significantly refined over the past years due to a series of advances in diagnostics and surgical technique. Electrophysiologic investigation performed during surgery has greatly contributed to this progress, increasing the surgeon's understanding of the mechanism of damage and suggesting various changes in his or her surgical strategy.In this context, the advantages of the retrosigmoid "en-bloc" removal of small to medium size ANs have been examined in the present study. At the ENT Department of the University of Verona, 103 subjects with AN were operated on, from January 1990 to December 1995, with a retrosigmoid-transmeatal approach. Eighteen subjects (17.4%) presented pure a intracanalar (IC) tumor and 85 (82.6%) had both IC and extracanalar (EC) involvement. All the IC tumors (n = 18) and 70 of the IC-EC neuromas with an EC size less than 25 mm are reported in this paper for a total of 88 patients. The first 48 patients were operated on via the classic procedures described in the literature, characterized by removal of the tumor after "debulking" and limited exposure of the internal auditory canal (IAC). The following 40 subjects were operated on according to the technique of "en-bloc" removal of the tumor and wide exposure of the IAC.In the "en-bloc" group the tumor was first detached from the cerebellar flocculus and the pons, when necessary. The tumor was not debulked to preserve the anatomic relationship with the nerves and to facilitate identification, cleavage and dissection of the tumor from the neural structures. Thereafter, the posterior wall of the IAC was drilled out and opened in a circumferential range from 180 to 270 degrees . The IAC dura was subsequently opened, and the distal end of the AN along with the vestibular nerves were identified. The vestibular nerves were sectioned in the distal portion of the IAC and dissected with the tumor from the underlying facial and cochlear nerves. Dissection continued medially to the IAC porus. The AN was progressively dissected from the cochlear and facial nerves in the cerebellopontine angle (CPA) with multiple direction maneuvers, as required by the characteristics and degree of adherence to the neural structures.The anatomic and functional results obtained with this new procedure ("en-bloc" removal) were compared with the classic "debulking" technique. The statistical analysis shows an improvement in postoperative outcome for both auditory and facial nerve function. The "en-bloc" removal procedure along with the wide exposure of the content of the IAC and electrophysiologic monitoring of the seventh and eighth cranial nerves are, in our experience, the recommended strategies for improving outcomes in small to medium size ANs.

Synthesis and in vitro pharmacological evaluation of a new series of 5-HT1A 5-HT2A and 5-HT2C receptor ligands containing a norbornene nucleus

A series of 4-substituted piperazine derivatives bearing a norbornene nucleus have been prepared and their affinity for serotonin 5-HT1A, 5-HT2A and 5-HT2C receptors has been evaluated. Compounds showing the highest affinity have been selected and evaluated on dopaminergic (D1 and D2) and adrenergic (alpha1 and alpha2) receptors. The combination of structural elements (heterocyclic nucleus, oxyalkyl chain and 4-substituted piperazine) known to be critical in order to have affinity on serotonin receptors and the proper selection of substituents led to compounds with higher receptor specificity and affinity. In binding studies, several molecules showed affinity in nanomolar range towards 5-HT1A, 5-HT2A and 5-HT2C receptors and moderate to no affinity for other relevant receptors (D1, D2, alpha1 and alpha2). Compound 2q 4-[2-[4-(3,4-dichlorophenyl)piperazin-1-yl]ethoxy]-4-aza-tricyclo[5.2.1.02,6]dec-8-ene-3,5-dione (Ki = 1.13 nM), was the most active and selective derivative for the 5-HT2C receptor with respect to other serotonin, dopaminergic and adrenergic receptors. Moreover, compound 3p showed mixed 5-HT2A/5-HT2C activity with affinity values in nanomolar range.

Synthesis of 6beta-D-glucosyl and 6-nitroxy (-)-galanthamine derivatives as acetylcholinesterase inhibitors

Galanthamine is an alkaloid approved for the treatment of Alzheimer's disease. In this paper the syntheses and the anticholinesterase activities of new glucosyl and nitroxy derivatives substituted on position 6 are reported. Compounds 2, 3 and 5 presented a percentage of inhibition of 35.22%, 47.48% and 67.89% respectively.

Fat graft myringoplasty after unsuccessful tympanic membrane repair

The objective of the present study was to evaluate the efficacy of fat graft myringoplasty in repairing residual or recurrent tympanic membrane perforation. A retrospective analysis was performed on 31 patients, aged 25-57 years (mean 43.3), submitted to myringoplasty revision using fat graft. Fourteen were males and 17 females. Perforation size ranged from 1 to 5 mm. Follow-up time ranged from 4 to 62 months (mean 26 months). Fat graft myringoplasty was performed under local anesthesia, using ear lobe fat in 26 patients and abdominal fat in five patients closure of tympanic membrane perforation was achieved in 87.1% of ears. No modification of the hearing level was evidenced at the statistical analysis. Fat graft myringoplasty is a safe, effective and minimally invasive procedure, suitable to repair small residual/recurrent perforations of the tympanic membrane. The angiogenic properties of the fat are ideal to overcome the poor vascular supply in the vicinity of the tympanic membrane perforation.

Auditory brainstem implant (ABI): new frontiers in adults and children

Previous studies have considered only patients with neurofibromatosis type 2 (NF2) older than 12 years as candidates for an auditory brainstem implant (ABI). Our study expands the potential criteria to include both children and adult subjects with other cochlear or cochlear nerve malfunctions who either would not benefit at all from a cochlear implant (eg, cochlear nerve aplasia or avulsion) or whose benefit was or would be severely compromised (eg, cochlear ossification, cochlear fracture).

STUDY DESIGN

In our department, over the period from April 1997 to September 2002, 29 patients, 20 adults and 9 children, were fitted with ABIs. Their ages ranged from 14 months to 70 years. Thirteen subjects had tumors, 10 NF2 and 3 solitary vestibular schwannoma, and 16 patients had a variety of nontumor (NT) cochlear or cochlear nerve diseases. A retrosigmoid-transmeatal approach was used in T and a retrosigmoid approach in NT patients. The electrode array was inserted into the lateral recess of the fourth ventricle and correct electrode positioning was monitored with the aid of electrically evoked auditory brainstem responses (EABRs).

RESULTS

Correct implantation was achieved in all patients. No complications were observed due to implantation surgery or related to ABI activation or long-term use. Auditory sensations were induced in all patients with various numbers of electrodes (from 5 to 15). Different pitch sensations were identifiable with different electrode stimulation. Closed-set word recognition, open-set sentence recognition, and speech tracking scores achieved by the patients are reported in detail. The auditory performance of the patients showed significantly better outcomes than controls (Multicentric European clinical investigations on ABI with NF2).

CONCLUSION

We have shown that the indications for the ABI can be extended to include NT patients with severe cochlear and/or cochlear nerve abnormalities. The degree of auditory benefit varies as a function of the underlying pathological conditions, with NT subjects exhibiting significantly better outcomes than the T patients.

Derivatives as 5HT1A Receptor Ligands-Past and Present

Serotonin is a neuromediator, well-know for its implication in mood regulation, anxiety, depression and, insomnia as well as in normal human function such as sleep, sexual activity and appetite. In this way, serotonin (5-hydroxytryptamine, 5-HT) is one of the most attractive targets for medicinal chemists and pharmaceutical companies. Among 5-HTRs, the 5-HT1A subtype is the best studied, and it is generally accepted that it is involved in psychiatric disorders such as anxiety and depression. Several structurally different compounds are known to bind 5-HT1A receptor sites such as aminotetralins, ergolines, arylpiperazines, indolylalkylamines, aporphines and aryloxyalkyl-amines. In this review, we report an overview of the 5-HT1A receptor ligands, belonging to different chemical classes.

Cochlear implant failure: is an auditory brainstem implant the answer?

OBJECTIVE

To investigate the auditory rehabilitative results achieved in five patients with cochlear implants (CIs) who subsequently received, due to poor results, auditory brainstem implants (ABIs).

MATERIAL AND METHODS

Between April 1997 and March 2003, 37 patients (age range 14 months to 70 years) were fitted with ABIs in our ENT Department. Fourteen subjects had neurofibromatosis type 2 and 23 were non-tumor patients who had cochlea or cochlear nerve disease. Five subjects had previously been treated with a CI and received an ABI owing to the poor results achieved. One child had bilateral undiagnosed cochlear nerve aplasia and one was suffering from auditory neuropathy; three adults had total cochlear ossification.

RESULTS

The open-set sentence recognition score (auditory-only mode) 6-8 months after ABI activation ranged from 0% to 100% in adults. In 1 subject the speech-tracking score was 56 words/min with the ABI. The two children who had achieved no hearing ability with their CI were able to detect sounds and words as early as 3 months after activation of the ABI.

CONCLUSION

CI failure as a result of anatomical abnormalities can be remedied by an ABI.

Middle fossa versus retrosigmoid-transmeatal approach in vestibular schwannoma surgery: a prospective study

OBJECTIVE

To compare the advantages, disadvantages, and results obtained with the middle fossa and retrosigmoid-transmeatal approaches during pure intracanalar vestibular schwannoma surgery in an attempt to preserve hearing.

STUDY DESIGN

Prospective study of patients treated from 1998 to 2001.

SETTING

Tertiary care referral center.

PATIENTS

Patients with intracanalar vestibular schwannoma (size ranging from 4 to 12 mm), 25 operated on with the retrosigmoid-transmeatal technique and 25 via the middle fossa route.

MAIN OUTCOME MEASURES

Facial nerve and auditory function were examined at 1 year with both techniques. Auditory results were also evaluated as a function of tumor size, distance from the internal auditory canal fundus, and internal auditory canal enlargement.

RESULTS

The results indicated no significant difference in facial nerve and auditory function results between the two techniques. The retrosigmoid-transmeatal approach, however, yielded better facial nerve function results at discharge. Postoperative hearing was better when the distance from the fundus was greater than 3 mm, when the size of the vestibular schwannoma was equal to or less than 7 mm, and when the internal auditory canal enlargement was less than 3 mm.

CONCLUSIONS

The middle fossa approach does not afford any particular advantages over the retrosigmoid-transmeatal approach in terms of auditory results. Facial nerve function is less satisfactory in the short term, when the middle fossa route is used, but can be improved by decompression and gentle displacement of the facial nerve in its labyrinthine portion.

Auditory Brainstem Implant in Posttraumatic Cochlear Nerve Avulsion

Patients aged over 12 years with neurofibromatosis type 2 are considered candidates for an auditory brainstem implant (ABI). This study extends the indication criteria of ABI to subjects with profound hearing loss due to damaged cochleas and/or cochlear nerves (CNs) following head injuries. In our department, over the period from April 1997 to November 2002, 32 patients, 23 adults and 9 children, were fitted with ABIs. Their ages ranged from 14 months to 70 years. These patients were suffering from a variety of tumor (13 subjects) and nontumor CN or cochlear diseases (19 subjects). Six patients, 5 adults and 1 child, had profound hearing loss following head injury. Their mean age was 25 years (range: 16-48 years). Five were male and 1 female. The retrosigmoid approach was used in all 6 patients. The electrode array was inserted into the lateral recess of the fourth ventricle and correct electrode positioning was monitored with the aid of electrically evoked auditory brainstem responses and neural response telemetry. Correct implantation was achieved in all patients. No complications were observed due to implantation surgery or related to ABI activation and stimulation of the cochlear nuclei. At activation, an average of 9.8 electrodes (range 5-13) were switched on without side effects. One to 6 electrodes were activated in the following sessions after time periods ranging from 2 to 16 months. All patients achieved auditory-alone-mode closed-set word recognition scores ranging from 40 to 100%; 3 had auditory-alone-mode open-set sentence recognition scores of 60-100%; 2 of these even had speech-tracking performance scores of 38 and 43 words, respectively, showing an ability to engage in normal conversation and converse over the phone. The present study demonstrates that the ABI is a useful rehabilitation instrument in subjects with damaged cochleas and/or CN avulsion following head injury who are unamenable or poorly responsive to auditory rehabilitation using cochlear implants.

Hearing restoration with auditory brainstem implant in three children with cochlear nerve aplasia

OBJECTIVE

To verify the possibility of auditory habilitation in children with aplasia and hypoplasia of the cochlear nerve by direct electrical stimulation of the cochlear nuclei with an auditory brainstem implant.

STUDY DESIGN

Retrospective case review.

SETTING

Study conducted at the Ear, Nose, and Throat Department of the University of Verona, Italy.

PATIENTS

Three children, aged 4, 3, and 2 years, respectively, with severe bilateral cochlear malformations and cochlear nerve aplasia have received an auditory brainstem implant at this institution in the past 2 years.

INTERVENTION

The classic retrosigmoid approach was used. Correct positioning of the electrodes was evaluated using electric auditory brainstem responses and neural response telemetry. Before the patients were discharged, high-resolution computed tomography with a bone algorithm reconstruction technique was performed to evaluate electrode placement. The auditory brainstem implant was activated 30 to 60 days after implantation.

RESULTS

No postoperative complications were observed. To date, 21, 18, and 8 electrodes, respectively, have been activated in the three children. The first patient, 12 months after activation, had achieved good environmental sound awareness, good speech detection, and some speech recognition. The second child, 8 months after activation, had achieved good environmental sound awareness and moderate speech detection. The third patient, 1 month after activation, had obtained good environmental sound awareness.

CONCLUSION

This study indicates that auditory brainstem implantation is technically feasible in children with cochlear nerve aplasia. The early results suggest the possibility of achieving auditory habilitation with auditory brainstem implantation in this population.

Auditory brainstem implantation: the University of Verona experience

OBJECTIVE

We sought to describe the advantages of the retrosigmoid-transmeatal (RS-TM) approach in the application of auditory brainstem implants (ABIs) in adults with monolateral and bilateral vestibular schwannoma (VS) and in children with cochlear nerve aplasia.

STUDY DESIGN

We conducted a retrospective case review.

SETTING

The study was conducted at the ENT Department of the University of Verona, Italy.

PATIENTS

Six adult patients (5 men and 1 woman) with neurofibromatosis type 2 (NF2) were operated on for VS removal with ABI. An additional patient had a unilateral VS in the only hearing ear. Tumor size ranged from 12 to 40 mm. In addition, 2 children received ABIs for bilateral cochlear nerve aplasia.

INTERVENTION

An RS-TM approach was used in all VS patients, and an RS approach was used in the subjects with cochlear nerve aplasia. After tumor excision, landmarks (VII, VIII and IX cranial nerves, choroid plexus) for the foramen of Luschka were carefully identified. The choroid plexus was then partially removed and the tela choroidea divided and bent back; the floor of the lateral recess of the fourth ventricle and the convolution of the dorsal cochlear nucleus became visible. In the 2 subjects with no cochlear nerve, the choroid plexus and VII and IX cranial nerves were used as landmarks. The electrode array was then inserted into the lateral recess and the correct position was monitored with the aid of electrically evoked auditory brainstem responses (EABR) and neural response telemetry (NRT).

RESULTS

Correct implantation was possible in all patients. Auditory sensations were induced in all patients with various numbers of electrodes. Different pitch sensations could be identified with different electrode stimulation.

CONCLUSIONS

We believe that the RS approach is the route of choice for patients who are candidates for ABI due to the easy and clear access to the cochlear nucleus area. This route avoids some of the drawbacks of the translabyrinthine approach, such as mastoidectomy, labyrinthectomy, sealing of the cavity and posterior fossa with abdominal fat, and contamination from the middle ear. For this reason, it is the route of choice in children with cochlear nerve aplasia or severe cochlear malformation and in adults with complete ossification of the cochlea or cochlear nerve disruption due to cranial trauma.

Thrombin and PAR-1 activating peptide increase iNOS expression in cytokine-stimulated C6 glioma cells

Thrombin (THR) plays a key role in the brain under physiological and pathological conditions. Several of the biological activities of thrombin have been shown to be mainly driven through activation of protease-activated receptor-1 (PAR-1)-type thrombin receptor. Here we have studied the effect of THR and PAR-1-activating peptide (PAR1-AP), SFLLRN, on cytokine-induced expression of inducible nitric oxide (iNOS), a prominent marker of astroglial activation using the rat C6 glioma cells. In this cell line, THR (1-10 U/mL) and PAR1-AP (1-100 microM) induced a significant concentration-dependent increase both of IFN-gamma- (250 U/mL) or TNF-alpha- (500 U/mL) induced NO release. The observed increase of NO production was related to an enhancement of iNOS expression as measured in cell lysates prepared from different treatments by using SDS-PAGE followed by western blot analysis. The effect of THR, but not that of PAR1-AP, was significantly inhibited by hirulog(TM) (60 microg/mL), a specific and stochiometric THR inhibitor or by cathepsin-G (40 mU/mL), an inhibitor of PAR-1. In conclusion our data suggest a role for THR through activation of PAR-1 in the induction of astroglial iNOS, and further support the hypothesis that THR may function as an important pathophysiological modulator of the inflammatory response.

Synthesis by microwave irradiation and binding properties of novel 5-HT(1A) receptor ligands

This work reports the synthesis by microwave irradiation and the binding tests on the 5-HT(1A), 5-HT(2A) and 5-HT(2C) receptors of new substituted piperazines in order to identify selective ligands for 5-HT(1A) subtype receptor. Conventional heating and microwave irradiation of the reactions was compared. Synthesis by microwave irradiation gave the desired compounds in better yields than those obtained by conventional heating. The overall times for the syntheses were considerably reduced. Some resulting active compounds (29 and 39) were characterised by a good selectivity profile for the 5-HT(1A) subtype receptor. The more active compounds were selected and further evaluated for their binding affinities on D(1), D(2) dopaminergic and alpha(1), alpha(2) adrenergic receptors. The compound with higher affinity and selectivity for the 5-HT(1A) over all the considered receptors was the 3-[4-[4-(1,2,3,4-tetrahydronaphthyl)-1-piperazinyl]butan]-benzotriazinone (-)29 (5-HT(1A) K(i)=36 nM, other receptors not active).

Hearing habilitation with auditory brainstem implantation in two children with cochlear nerve aplasia

Patients with aplasia and hypoplasia of the cochlear nerve have no chance of having their hearing restored by stimulating the periphery of the auditory system using the traditional cochlear implant. A possible approach to auditory rehabilitation may be direct electrical stimulation of the cochlear nuclei with an auditory brainstem implant (ABI). Recently, two children, aged 4 and 3 years, respectively, with bilateral severe cochlear malformations and cochlear nerve aplasia received an ABI. The present paper reports the technique and the preliminary results of this experience. The classic retrosigmoid approach was used. The correct position of the electrodes was estimated with the aid of EABRs and neural response telemetry (NRT). No postoperative complications were observed. High-resolution CT scans with a bone algorithm reconstruction technique were taken postoperatively to evaluate electrode placement before discharge. The ABI was activated 30 days after implantation in both patients. To date 16 and 13 electrodes, respectively, have been activated in the two children. Three months after activation the first patient had achieved good environmental sound awareness, good speech detection and some speech discrimination. The second child, 1 month after activation, had achieved good environmental sound awareness and moderate speech detection. To the best of our knowledge this is the first report of patients with hypoplasia of the cochlea and aplasia of the cochlear nerve, aged below 5 years and treated with an ABI.

Synthesis of substituted benzamides as anti-inflammatory agents that inhibit preferentially cyclooxygenase 1 but do not cause gastric damage

Parsalmide (5-amino-N-butyl-2-(2-propynyloxy) benzamide) (5a), is a non-steroidal anti-inflammatory drug (NSAID), commercialised in Italy until 1985 with the brand name of Synovial(R), that has been widely used to treat arthritic patient. In addition, it was shown to spare gastric mucosa. Here we have synthesised a series of novel substituted benzamides, related to Parsalmide, and have evaluated their activity in vitro on COX-1 and COX-2 as well as in vivo in the carrageenin-induced rat paw edema, a classical in vivo anti-inflammatory assay. Compounds 5b, 11a and 11b, which showed a favourable profile in vitro and in vivo, were screened in comparison with Parsalmide for gastrointestinal (GI) tolerability in vivo in the rat. Results obtained showed that Parsalmide and compound 11b inhibited both COX-1 and COX-2 in vitro as well as they were active in vivo. Both compounds were devoid of gastric effect at the efficacious dose. In addition, both prevented indomethacin-induced gastric damage. Thus, these compounds may guide the definition of a new leading structure with anti-inflammatory activity that may allow designing new safer NSAIDs.

Synthesis of novel anti-inflammatory peptides derived from the amino-acid sequence of the bioactive protein SV-IV

SV-IV is a basic, thermostable, secretory protein of low Mr (9758) that is synthesized by rat seminal vesicle (SV) epithelium under strict androgen transcriptional control. This protein is of obvious pharmacological interest because it has potent nonspecies-specific immunomodulatory, anti-inflammatory, and pro-coagulant activities. In evaluating the clinical relevance and the possible use in medicine of SV-IV, we became interested in the study of its structure-function relationships and aimed to identify in its polypeptide chain specific peptide fragments possessing the marked anti-inflammatory properties of the protein not associated with other biological activities (pro-coagulation and immunomodulation) typical of this molecule. By using two different experimental approaches (the fragmentation of the protein into peptide derivatives by chemical methods and the organic synthesis on solid phase of selected peptide fragments), data were obtained showing that in this protein: (a) the immunomodulatory activity is related to the structural integrity of the whole molecule; (b) the anti-inflammatory activity is located in the N-terminal region of the molecule, the 8-16 peptide fragment being the most active; (c) the identified anti-inflammatory peptide derivatives do not seem to possess pro-coagulant activity, even though this particular function has been located in the 1-70 segment of the molecule.

Retrosigmoid approach for auditory brainstem implant

The present paper reports our experience with the surgical retrosigmoid-transmastoid (RS-TM) technique for implanting auditory brainstem implants (ABIs). From April 1997 to August 1998, four patients with neurofibromatosis type 2 (NF2) were operated on for vestibular schwannoma removal with ABI implantation. The subjects (three men and one women) ranged in age from 22 to 31 years. Tumour size ranged from 12 to 30 mm. A classical RS-TM approach was performed. After tumour excision, identification of landmarks (VIIth, VIIIth and IXth cranial nerves, choroid plexus) to the foramen of Luschka was carefully carried out. The choroid plexus was partially removed and the tela choroidea divided and deflected. The floor of the lateral recess of the fourth ventricle and the convolution of the dorsal cochlear nucleus became visible. The electrode array was then inserted into the lateral recess and placed in the correct position with the help of electrically-evoked auditory brain stem responses. Auditory sensations were induced in all patients with various numbers of electrodes. Different pitch sensations could be identified with different electrode stimulation. Details of the results are presented. In our series, the RS-TM approach represents the elective route for ABI insertion.

Cough threshold in reflux oesophagitis: influence of acid and of laryngeal and oesophageal damage

BACKGROUND

Gastro-oesophageal reflux is often associated with cough. Patients with reflux show an enhanced tussive response to bronchial irritants, even in the absence of respiratory symptoms.

AIM

To investigate the effect of mucosal damage (either oesophageal or laryngeal) and of oesophageal acid flooding on cough threshold in reflux patients.

PATIENTS

We studied 21 patients with reflux oesophagitis and digestive symptoms. Respiratory diseases, smoking, and use of drugs influencing cough were considered exclusion criteria.

METHODS

Patients underwent pH monitoring, manometry, digestive endoscopy, laryngoscopy, and methacholine challenge. We evaluated the cough response to inhaled capsaicin (expressed as PD5, the dose producing five coughs) before therapy, after five days of omeprazole therapy, and when oesophageal and laryngeal damage had healed.

RESULTS

In all patients spirometry and methacholine challenge were normal. Thirteen patients had posterior laryngitis and eight complained of coughing. Twenty patients showed an enhanced cough response (basal PD5 0.92 (0.47) nM; mean (SEM)) which improved after five and 60 days (2.87 (0.82) and 5.88 (0.85) nM; p<0.0001). The severity of oesophagitis did not influence PD5 variation. On the contrary, the response to treatment was significantly different in patients with and without laryngitis (p = 0.038). In patients with no laryngitis, the cough threshold improved after five days with no further change thereafter. In patients with laryngitis, the cough threshold improved after five days and improved further after 60 days. Proximal and distal oesophageal acid exposure did not influence PD5. Heartburn disappeared during the first five days but the decrease in cough and throat clearing were slower.

CONCLUSIONS

Patients with reflux oesophagitis have a decreased cough threshold. This is related to both laryngeal inflammation and acid flooding of the oesophagus but not to the severity of oesophagitis. Omeprazole improves not only respiratory and gastro-oesophageal symptoms but also the cough threshold.

Synthesis of new 1,2,3-benzotriazin-4-one-arylpiperazine derivatives as 5-HT1A serotonin receptor ligands

A series of novel 1,2,3-benzotriazin-4-one derivatives was prepared and evaluated as ligands for 5-HT receptors. Radioligand binding assays proved that the majority of the novel compounds behaved as good to excellent ligands at the 5-HT1A receptor, some of which were selective with respect 5-HT2A and 5-HT2C receptors. Six analogues (1a, 2a, 2b, 2c, 2e and 2i) were selected and further evaluated for their binding affinities on D1, D2 dopaminergic and alpha1-, alpha2-adrenergic receptors. A o-OCH3 derivative (2e) bound at 5-HT1A sites with subnanomolar affinity (IC50 = 0.059 nM) and shows high selectivity over all considered receptors and may offer a new lead for the development of therapeutically efficacious agents.

Synthesis and biological activity of pseudopeptides inhibitors of Ras farnesyl transferase containing unconventional amino acids

A study was performed on the structure-activity relationships of a series of phenol derivatives, CVFM analogs, derived from the two most active compounds of a first series (1A and 1B) of inhibitors of Ras farnesyl transferase (FTase) that we have recently described. We report the synthesis and the activity of a second series of compounds in which the phenylalanine residue was replaced by unconventional aromatic and non-aromatic amino acids, with varying electronic, lipophilic, steric and conformational properties. The compounds showed to be significantly less active than reference compounds against FT, with the only exception of derivative 3A (IC50 = 3 microM), which is slightly more active than 1A but not 1B. Subsequently we tested the effects of compounds 1A, 1B and 3A, 3B on the anchorage-dependent growth of two epithelial cell lines of rats, FRTL-5 and the same line v-Ha-ras transformed. Compound 3A derived from lead compound 1A, showed an appreciable selectivity against transformed cells. In contrast, compounds derived from derivative 1B had only a modest cellular activity.

Synthesis and in vitro activities of NK-1 antagonists derived from L-tryptophan

A study of structure-activity relationships of a series of L-tryptophan derivative NK-1 antagonist was performed using 3,5-bis(trifluoromethyl)benzyl ester of N-acetyl-L-Tryptophan (IV) as a starting point. The ester moiety was replaced with several amidic functions while the N-acetyl group (Ac-) was retained (compounds 1-8) or changed into a benzyloxycarbonyl group (Z-) (compounds 9-16). The compounds were tested on guinea pig ileum longitudinal muscle, rat colon muscolaris mucosae, and rat everted portal vein, representative of tachykinin NK-1, NK-2 and NK-3 receptors, respectively. Both, Ac- and Z-series showed generally moderate antagonist activity on tachykinin NK-1 receptors with respect to the reference drug IV. The most potent term was compound 2 (Ac-Trp-N(CH3)CH(CH3)Ph with S-configuration at the C-terminus) which exhibited pA2 values of 7.0, 4.2 and 4.4 on NK-1, NK-2 and NK-3 sites, respectively.

Intraoperative monitoring of facial nerve antidromic potentials during acoustic neuroma surgery

The present paper presents monopolar recording of facial nerve antidromic potentials as an alternative technique to facial electromyography for the continuous monitoring of the facial nerve during acoustic neuroma surgery. The investigation involved 22 patients undergoing acoustic neuroma surgery via a retrosigmoid approach (tumour sizes ranging from 5 to 28 mm). Bipolar electrical stimulation of the marginalis mandibulae was performed to elicit facial nerve antidromic potentials. Stimulus intensity ranged from 2 to 6 mA with a delivery rate of 7/sec. A silver wire monopolar electrode positioned intracranially on the proximal portion of the acoustic facial bundle was used to record antidromic potentials. To define the specific origin of the action potentials and acquire normative data, monopolar and bipolar recordings of facial nerve antidromic potentials were performed in 15 subjects undergoing retrosigmoid vestibular neurectomy for Meniere's disease. The average facial nerve antidromic potential latency was 4.2 (+/- 0.6) msec in subjects with acoustic neuroma and 3.3 (+/- 0.2) msec in subjects with Meniere's disease. Facial nerve antidromic potentials furnished near real-time information about intraoperative facial nerve damage and postoperative facial nerve function during acoustic neuroma surgery. Facial nerve antidromic potentials may provide additional information to conventional EMG. They allow the use of endplate blockers, yield quantitative estimation of facial nerve conduction properties in terms of amplitude and latency, and allow actual continuous monitoring of the facial nerve.

Middle ear function in rheumatoid arthritis: a multiple frequency tympanometric study

OBJECTIVE

To evaluate the modifications in the mechanical properties of the middle ear in rheumatoid arthritis by assessing its resonance frequency.

METHODS

Thirty patients with rheumatoid arthritis (RA) aged 20 to 68 years (mean age 45.8 +/- 12.4 yrs) were investigated by multiple frequency tympanometry and their data were compared with those obtained in a control group of 48 subjects aged from 19 to 65 years.

RESULTS

Normal values, calculated at the 95th percentile from the control group, ranged from 800 to 1250 Hz. Eleven RA patients (36.6%) displayed abnormal resonance values. These findings were monolateral in 9 patients and bilateral in 2 (in all a total of 13 ears). Nine out of 13 ears with abnormal multiple frequency tympanometry data were characterized by an increase in resonance and 4 by a decrease.

CONCLUSION

These findings were attributed to abnormal acoustic impedence of the middle ear and indicate a possible involvement of the ossicular diarthroses in RA. Our study suggests that RA may involve the incudo-malleolar and incudo-stapedial joints, altering the ossicular mechanisms in response to static air pressure modifications.

[The "BTE"(basic knowledge--training--execution) method for teaching-learning surgical procedures]

For teaching-learning operative procedures the authors propose a new method ("KTE" method) in three progressive phases (step "K" or "basic knowledge"; step "T" or "training"; step "E" or "execution") that allow the student to achieve gradually the psychomotorial adaptation needed for the correct execution of surgical procedures. After preliminary study of the general features of the procedure (step B1) the student learns its operative features (step B2) on appositely constructed didactical tools ("Self-learning and learning maintenance boxes") that, together with the "observational" training (step A1), allow him to create in his mind an "operation image" and then, following an "operative" simulators training (step A2), to pass from that image to its carrying out (psychomotorial adaptation) that in the last phase (steps E1 and E2) concludes in the partial or complete execution of the surgical procedure in the patient. This didactic method can be apply to classic or endoscopic surgery and even to a lot of not surgical practical procedures.