Surgical Approaches to Petrous Apex Cholesterol Granulomas: A Systematic Review and Network Meta-analysis

OBJECTIVE

To compare the outcomes of different surgical approaches to petrous apex cholesterol granulomas (PACG).

DATA SOURCES

PubMed, Embase, Google Scholar, Cochrane, and Web of Science.

REVIEW METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses-Network Meta-analyses guidelines, databases were searched from inception to November 31, 2022. Studies comparing two or more approaches were included. Reviews and population studies were excluded. The main outcome measures were the resolution of symptoms, serviceable hearing, complication, and revision rates.

RESULTS

The search yielded 2132 studies. After applying inclusion and exclusion criteria, 15 studies remained, consisting of 214 patients treated with lateral approaches (n = 182) or anterior endonasal approaches (n = 32). The efficacy of lateral and anterior endonasal approaches in achieving symptom resolution was comparable (73% vs. 68%, p = 0.5). Both exhibited similar rates of complications (33% vs. 37%, p = 0.3), albeit with distinct profiles. Lateral approaches were associated with higher rates of facial palsy and sensorineural hearing loss (44% vs. 18%, p = 0.03). Anterior endonasal approaches demonstrated higher rates of epistaxis and cerebrospinal fluid leak (15% vs. 1%, p = 0.001). Anterior endonasal approaches exhibited lower revision rates (OR: 0.35, 95% CI: 0.14-0.88). The placement of a stent in both approaches was associated with higher symptom resolution (OR: 5.12, 95% CI: 1.05-9.97) and lower revision rates (OR: 0.71, 95% CI: 0.33-0.92).

CONCLUSIONS

Anterior endonasal approaches yield lower revision rates compared to lateral approaches for PACG. Both approaches demonstrate similar effectiveness in symptom resolution and comparable rates of complications, with distinct profiles. Facial nerve and hearing status are important factors that should be addressed when selecting the approach. Stenting is beneficial.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1540-1550, 2024.

[FIRST YEAR EXPERIENCE OF TERTIARY MULTIDISCIPLINARY NEUROTOLOGY (DIZZINESS AND BALANCE) CLINIC]

INTRODUCTION

BACKGROUND

Dizziness is a common condition that accounts for an estimated 5% of primary care clinic visits. The differential diagnosis is extensive, which may involve the inner ear, central and peripheral nervous system and the cardiovascular system among others. While routine cases can be diagnosed and treated with primary (general practitioner) or secondary (otolaryngologists (medicine in the community, there are many cases in which it is advisable to refer patients to a tertiary dizziness clinic. These cases include: unclear diagnosis, lack of improvement after medication or physiotherapy, medical comorbidities in which the central compensation process has been affected, chronic dizziness, bilateral vestibular disorder and more. Therefore, we established a multidisciplinary clinic (MDC) in a tertiary referral center at the Rambam Healthcare Campus.

OBJECTIVES

To investigate the first year of the tertiary MDC neurotology clinic.

METHODS

Retrospective cohort of all patients examined at the tertiary MDC.

RESULTS

The first 123 consecutive patients (62% women) aged 56 years on average (19-85years, ±16) seen in the MDC from October 1, 2020 to October 31, 2021 are reported. Prior to assessment, 79 (64%) patients had been referred by an ENT doctor in the community with an unclear cause of dizziness; 49 (40%) patients experienced ongoing symptoms for years and 61 (50%) patients had dizziness on a daily basis. A total of 56 )46%) patients were found to have a peripheral vestibular cause for their dizziness and 67 (54%) patients had a central or other causes. More than one cause of dizziness and/or imbalance was noted in 20 (36%) of patients. Among the common peripheral vestibular causes were benign paroxysmal positional vertigo (BPPV) and Meniere's disease, and the central and functional disorders included vestibular migraine and persistent postural perceptual dizziness (PPPD). The frequency and intensity of symptoms were reduced in 29 patients of the 33 (88%) who underwent vestibular physiotherapy in the MDC as opposed to 8 (50%) patients in the community (p <0.05). Physiotherapy was found to be more effective in patients younger than 65 years old, and with less than six months of symptoms (p <0.05). However, patients with a medical history of neurological or cardiovascular problems are less likely to improve (p <0.05).

CONCLUSIONS

A tertiary neurotology clinic of a multidisciplinary team can provide proper care in persistent dizziness and/or unclear diagnosis. Vestibular physiotherapy plays a crucial role in the management of a dizzy patient, and hence it should be started as soon as possible.

A higher frequency of physical activity is associated with reduced rates of SARS-CoV-2 infection

BACKGROUND

Physical activity (PA) is associated with health benefits. Previous studies have shown that regular PA decreases the incidence of viral respiratory tract infections, but data on severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection are unavailable.

OBJECTIVES

The objective of this study is to examine the association between PA frequency and SARS-CoV-2 infection.

METHODS

A population-based cross-sectional study was conducted on data from 1 February 2020 to 31 December 2020, using the registry of Leumit Health Services (LHS), a national health maintenance organisation in Israel. All LHS patients aged 18 to 80 years who underwent at least one RT-PCR test for SARS-CoV-2 during the study period were included. We examined the association between PA frequency (hours per week) and being tested positive for SARS-CoV-2.

RESULTS

Of 113,075 subjects tested for SARS-CoV-2 by RT-PCR (mean age 41.6 years, 54.4% female), 17,465 (15%) were positive. In the SARS-CoV-2-negative group, significantly more subjects were engaged with PA than in the SARS-CoV-2-positive group [crude odds ratio (OR) for any PA 0.75 (95% confidence interval (CI) 0.72-0.77)]. After adjusting for possible confounders, PA frequency had a significant negative association with the likelihood of being SARS-CoV-2 positive (adjusted OR 0.67, 95% CI 0.64-0.68). Moreover, as the frequency of PA increased, the ORs of being SARS-CoV-2-positive decreased (occasional PA: OR 0.71, 95% CI 0.67-0.74; PA 1-3 times/week: OR 0.62, 95% CI 0.58-0.65 and PA > 3 times/week: OR 0.54, 95% CI 0.49 - 0.59).

CONCLUSION

Our large population-based study in patients undergoing SARS-CoV-2 RT-PCR testing showed that a higher frequency of PA is associated with a lower rate of positive test results.

A Novel Bone Conduction Hearing System May Improve Memory Function in Children with Single Side Hearing loss: A Case-Control Study

OBJECTIVES

To evaluate the effects of an adhesive adapter prosthesis (AAP) on memory function in pediatric subjects with single side hearing loss (SSHL).

MATERIALS AND METHODS

Case-control study. 19 pediatric subjects with mild to moderate SSHL treated with AAP and 15 subjects with normal hearing (control group) were included in this study. Working and short-term memory functions were tested in all subjects, in silence and noise conditions. In SSHL subjects, tests were performed before the AAP was applied (T0) and at 1-month (T1) follow-up. The control group was tested once.

RESULTS

AAP significantly improved working memory function in noise as measured at T1 (p<0.01) compared with T0, but T1 scores in children with SSHL remained significantly different from the ones of the control group (p<0.01). AAP also significantly improved short- term memory function test scores at T1 compared with T0 (p<0.01), but despite being in the normal range for the subjects' age, the scores remained significantly different from those of the control group (p<0.01).

CONCLUSION

In pediatric subjects with mild, moderate, and moderate-severe SSHL, restoration of bilateral hearing through AAP improved short-term memory function and working memory function in noise, as measured at 1 month follow-up; however, AAP did not seem to lead to a full restoration of such functions as measured by a comparison with healthy controls. Further studies with longer follow-ups might help elucidate whether AAP can elicit further improvements in memory functions.

The Pathology of the Vestibular System in CANVAS

OBJECTIVE

To describe the site of lesion responsible for the severe, bilateral, symmetrical, selective loss of vestibular function in Cerebellar Ataxia with Neuronopathy and Vestibular Areflexia Syndrome (CANVAS), an adult-onset recessively-inherited ataxia, characterized by progressive imbalance due to a combination of cerebellar, somatosensory, and selective vestibular impairment with normal hearing.

METHODS

Histologic examination of five temporal bones and the brainstems from four CANVAS patients and the brainstem only from one more, each diagnosed and followed from diagnosis to death by one of the clinician authors.

RESULTS

All five temporal bones showed severe loss of vestibular ganglion cells (cell counts 3-16% of normal), and atrophy of the vestibular nerves, whereas vestibular receptor hair cells and the vestibular nuclei were preserved. In contrast, auditory receptor hair cells, the auditory ganglia (cell counts 51-100% of normal), and the auditory nerves were relatively preserved. In addition, the cranial sensory ganglia (geniculate and trigeminal), present in two temporal bones, also showed severe degeneration.

CONCLUSIONS

In CANVAS there is a severe cranial sensory ganglionopathy neuronopathy (ganglionopathy) involving the vestibular, facial, and trigeminal ganglia but sparing the auditory ganglia. These observations, when coupled with the known spinal dorsal root ganglionopathy in CANVAS, indicate a shared pathogenesis of its somatosensory and cranial nerve manifestations. This is the first published account of both the otopathology and neuropathology of CANVAS, a disease that involves the central as well as the peripheral nervous system.

Nutraceuticals as immune-stimulating therapy to fight COVID-19. Combination of elements to improve the efficacy

COVID-19 pandemic has underlined that unknown viral infections, which jump from animals to humans, can be extremely dangerous. In case of new viruses as SARS-CoV2, available drugs can fail to contrast the virus aggressiveness leading patients to death. Long time is necessary to create a vaccine, but immediate solutions are necessary to stop the mortality COVID-19 related. We have learned that the immune-system is the key to reduce the severity of COVID-19 and, through its modulation, it has been possible saving people's life. In this short communication, we discuss the use of nutraceuticals to modulate and stimulate the immune answer for reducing the severity of COVID-19 symptoms. The nutraceuticals are safe and can be administered to all ages. In addition, combination of natural anti-viral elements and immune-stimulating molecules already successfully tested against others upper-respiratory tract infections-could be efficient against SARS-CoV2. We believe that these natural molecules could really be a valid ally against COVID-19, especially in this moment in which a SARS-CoV2 vaccine is still not available.

Peripheral Vestibular Organ Degeneration After Temporal Bone Fracture: A Human Otopathology Study

OBJECTIVES/HYPOTHESIS

Vestibular symptoms are a common sequela of temporal bone fractures (TBFs). The mechanisms of injury to the peripheral vestibular system following TBF, however, are not well described. Herein, we aimed to investigate the histopathology of the peripheral vestibular system in patients who sustained TBFs.

STUDY DESIGN

Retrospective human specimen analysis.

METHODS

Specimens from the National Temporal Bone Pathology Registry with (cases) and without (controls) TBFs were evaluated. Specimens were analyzed by light microscopy for vestibular hair cell and/or dendritic degeneration, presence of endolymphatic hydrops, blockage of the endolymphatic duct, and number of Scarpa ganglion cells (ScGCs) in the superior and inferior vestibular nerves.

RESULTS

Seven temporal bones (TBs) from five individuals with TBFs, and seven TBs from six age-matched individuals without a history of head injury met inclusion and exclusion criteria. All fractures involved the otic capsule. Severe degeneration of the cristae was identified in the semicircular canals in all TBF cases. The utricular and saccular maculae showed mild to severe degeneration in the TBF cases. Vestibular hydrops (n = 2 TBs) and blockage of the endolymphatic duct (n = 3 TBs) were also present in the TBF cases. There was a decrease of 52.6% in the mean total ScGC count in the TBF cases (n = 3 TBs) compared to age-matched controls (n = 7 TBs, P = .015). There was a mean loss of 53% of the ScGCs in the superior vestibular nerve and a mean loss of 52.3% of the ScGCs in the inferior vestibular nerve compared to age-matched controls (P = .033 and P = .021, respectively).

CONCLUSIONS

In a cohort of patients with TBFs, there were distinct peripheral vestibular changes including reduction of ScGCs.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:752-760, 2020.

Human Otopathology of Cochlear Implant Drill-out Procedures

OBJECTIVE

Human otopathology following drill-out procedures for cochlear implantation (CI) in cases with labyrinthitis ossificans (LO) has not been previously described. This study uses the high sensitivity of histopathology to (1) evaluate surgical drill-out technique with associated intracochlear findings and (2) quantify spiral ganglion neuron populations in a series of patients with LO who underwent CI.

STUDY DESIGN

Retrospective otopathology study.

SETTING

Otopathology laboratory.

SUBJECTS AND METHODS

Temporal bone (TB) specimens from cases with evidence of preoperative intracochlear fibroossification that required a drill-out procedure for CI electrode array insertion were included. All cases were histopathologically evaluated and 3-dimensional reconstructions of the cochleae were performed to interpret drilling paths and electrode trajectories.

RESULTS

Five TB specimens were identified, of which 4 underwent drill-out of the basal turn of the cochlea and 1 underwent a radical cochlear drill-out. In multiple TBs, drilling was imprecise with resultant damage to essential structures. Two TBs showed injury to the modiolus, which was associated with substantially decreased or even absent neuronal populations within these areas. In addition, 2 cases with inadequate drill-out or extensive LO of the basal turn resulted in extracochlear placement of electrode arrays into the vestibule due to persistent obstruction within the basal turn.

CONCLUSION

Otopathology highlights the challenges of drill-out procedures in cases of LO. Imprecise drilling paths, due to distortion of normal cochlear anatomy, risk injury to the modiolus and adjacent neurons as well as extracochlear placement of electrode arrays, both of which may contribute to poorer hearing outcomes.

Peripheral Vestibular System Histopathologic Changes following Head Injury without Temporal Bone Fracture

Objective

Vestibular symptoms such as dizziness and vertigo are common after head injury and may be due to trauma to the peripheral vestibular system. The pathophysiology of peripheral vestibular symptoms following head injury without temporal bone (TB) fracture, however, is not well understood. Herein, we investigate the histopathology of the peripheral vestibular system of patients who sustained head injury without a TB fracture.

Study Design

Otopathology study.

Setting

Otopathology laboratory.

Subjects and Methods

TB of subjects with a history of head injury without TB fractures were included and evaluated by light microscopy. Specimens were assessed for qualitative and quantitative characteristics, such as number of Scarpa’s ganglion cells in the superior and inferior vestibular nerves, vestibular hair cell and/or dendrite degeneration in vestibular end organs, presence of vestibular hydrops, and obstruction of the endolymphatic duct.

Results

Five cases (n = 5 TBs) had evidence of vestibular pathology. There was a decrease of 48.6% (range, 40%-59%) in the mean count of Scarpa’s ganglion cells as compared with that of normative historical age-matched controls. Moderate to severe degeneration of the vestibular membranous labyrinth was identified in the posterior, superior, and lateral canals in several cases (50%, n = 4 TBs). The maculae utriculi and sacculi showed mild to severe degeneration in 2 cases. Additional findings include vestibular hydrops (25%, n = 2 TBs) and blockage of the endolymphatic duct (n = 1 TB).

Conclusions

Otopathologic analysis of patients with a history of head injury without TB fracture demonstrated peripheral vestibular otopathology. Future studies are necessary to determine if otopathology findings are directly attributable to head injury.

Nucleolus vs Nucleus Count for Identifying Spiral Ganglion in Human Temporal Bone

OBJECTIVES

Spiral ganglion (SG) counting is used in experimental studies conducted on age-, noise-, and drug-induced sensorineural hearing loss, as well as in the assessment of cochlear implant performances. Different methods of counting have been reported, but no definite standardization of such procedure has been published. The aim of our study is to identify the best method to count human spiral ganglions (SGs).

MATERIALS AND METHODS

By identification of nuclei or nucleoli as described by Schucknect, seven researchers with different experience levels counted SGs in 123 human temporal bones (TBs). Data on time of post-mortem bone removal post-mortem, methods of specimen's fixation, decalcification, and coloration were collected to test their possible influence on human tissue. Percentage, two-tailed t-test, Spearman's test, and one-way ANOVA were used to analyze the data.

RESULTS

Nucleoli were identified in 61% of cases, whereas nuclei were recognized in 100% of cases (p<0.005). Nucleoli presence in all four segments in the same temporal bone (TB) was observed in 69 cases (92%), whereas nuclei were identified in all four segments in 103 cases (83.7%) (p<0.001). The junior investigators requested a double check by the seniors in 25 (20.3%) cases for identifying and counting nucleoli, whereas the senior researchers showed no doubts in their identification and count. The only parameter positively affecting nucleoli identification in tissue preparation was bone removal for <12 h with respect to longer post-mortem time (p<0.001).

CONCLUSION

We suggest counting nuclei, rather than nucleoli, for spiral ganglion computation because of easier recognition of nuclei, especially in case of investigator's limited experience.

Otopathologic Changes in the Cochlea following Head Injury without Temporal Bone Fracture

Objective

Hearing loss following temporal bone (TB) fracture may result from direct transection of the middle and inner ear. The pathophysiology of hearing loss due to head injury without TB fracture, however, is not well understood. Few reports describe otopathologic findings. Herein, we investigate the pathologic findings of patients who sustained a head injury without evidence of a TB fracture.

Study Design

Otopathology study.

Setting

Otopathology laboratory.

Subjects

Subjects with a history of head injury without TB fracture.

Methods

The TBs of patients with head injury were evaluated by light microscopy. Inner ear anatomy was evaluated, including counts of spiral ganglion cells (SGCs), hair cells, pillar cells, atrophy of the stria vascularis, and the presence of endolymphatic hydrops. SGC counts were compared with those of historical age-matched controls.

Results

All cases (N = 6 TBs) had evidence of inner ear pathology. Of the 6 cases, 2 (33%) had severe loss of hair cells in all 3 turns of the cochlea, and 4 (67%) cases demonstrated moderate to severe loss at the basal turn of the cochlea. Four cases had scattered atrophy of the stria vascularis, and 3 (50%) had cochlear hydrops. The number of total SGCs was decreased, with an average 53% loss (range, 25%-79%) as compared with controls. The SGC count loss was evenly distributed along Rosenthal’s canal.

Conclusions

Patients with a history of head injury without TB fracture demonstrate inner ear pathology. Further studies are necessary to determine if otopathology findings are directly attributable to trauma.

Otopathologic evaluation of temporalis fascia grafts following successful tympanoplasty in humans

OBJECTIVE

Temporalis fascia is a commonly used graft material in tympanoplasty; however, little is known about how the histological structure of fascia remodels postimplantation. Herein, we aim to quantify the pre- and postoperative microstructure of temporalis fascia and compare histological findings to the native tympanic membrane (TM).

METHODS

Temporal bone specimens having undergone successful subtotal or total drum replacement using temporalis fascia were identified (n = 3). Surgically prepared preimplantation temporalis fascia (PreTF, n = 4) and normal TMs (n = 5) were used as controls. Multiple measurements of thickness of PreTF and of normal and fascia reconstructed TMs at the mesotympanum and hypotympanum were obtained. Collagen fiber patterns of normal and reconstructed TMs were histologically described.

RESULTS

In cases of fascia tympanoplasty, the mean time of surgery to death was 16 years (range 8-28 years). All cases contained an aerated middle ear without residual perforation. There was no significant difference between the thickness of PreTF and fascia of reconstructed TMs (234.9 ± 144.9 μm vs. 162.9 ± 71.9 μm, P = 0.1). The lamina propria and total thicknesses of controls (59.8 ± 39.3 μm and 83.7 ± 42.4 μm, respectively) were thinner than the PreTF and fascia-reconstructed TMs, respectively, in all cases (P ≤ 0.001, P ≤ 0.001). Reconstructed TMs contained a thick, longitudinal fiber structure that was qualitatively similar to PreTF.

CONCLUSION

Based on human temporal bone specimens, temporalis fascia does not significantly remodel, change thickness, or change fibrous structure following successful tympanoplasty. Results have implications for selection and surgical preparation of graft materials in TM reconstruction.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:E351-E358, 2018.

Systematic review of hearing loss after traumatic brain injury without associated temporal bone fracture

OBJECTIVE

While hearing loss following temporal bone fracture is a well-described phenomenon, few data exist on auditory dysfunction in patients with traumatic brain injury (TBI) without temporal bone fracture. Herein, we aim to systematically review hearing loss after TBI without bony fracture and describe its etiologies.

DATA SOURCES

Pubmed, Embase, Cochrane databases.

REVIEW METHODS

A systematic review of the literature from 1966 to January 2017 was performed using Preferred Reporting Items for Systematic Reviews and Meta-analyses recommendations. Data were obtained from studies that investigated hearing loss in TBI without skull fracture according to an a priori protocol with inclusion and exclusion criteria. Variables included type and severity of hearing loss, as well as pathophysiology of hearing loss.

RESULTS

There were 13 studies with 773 patients that met study criteria. Overall, there was one prospective cohort study, four retrospective cohort studies, two case-control studies, and six case reports. The studies with the highest level of evidence report a change in hearing of at least 10-15 dB across a range of frequencies in as many as 58% percent of TBI patients without bony fracture, which was transient or chronic. The mechanism/severity of injury may impact the rate of hearing loss.

CONCLUSIONS

Hearing loss after TBI in the absence of bony injury appears to be a clinically significant but poorly characterized phenomenon.

Acute Myopericarditis Complicating Acute Tonsillitis: A Prospective Study

Objectives

We describe a prospective study of 100 consecutive cases of acute tonsillitis tested for cardiac involvement. There was 1 clear-cut case of acute myopericarditis and 5 more patients with pathological findings suggesting cardiac complication.

Methods

During a 6-month period (November 2006 to April 2007), we prospectively studied 100 consecutive patients admitted to our department with acute tonsillitis for the purpose of detecting acute myopericarditis. We obtained for each patient a serial electrocardiogram and echocardiogram, and took blood samples. All blood samples were analyzed for the presence of the marker troponin 1 and for cardiac enzymes.

Results

One patient (male) had a definitive diagnosis of myopericarditis, and another 5 patients (3 of whom were female) had abnormal cardiac findings suggestive of myopericarditis.

Conclusions

Otolaryngologists should be aware of the possibility of cardiac involvement in acute tonsillitis and perform an adequate workup whenever such a possibility is suspected.

The pattern and degree of capsular fibrous sheaths surrounding cochlear electrode arrays

An inflammatory tissue reaction around the electrode array of a cochlear implant (CI) is common, in particular at the electrode insertion region (cochleostomy) where mechanical trauma often occurs. However, the factors determining the amount and causes of fibrous reaction surrounding the stimulating electrode, especially medially near the perimodiolar location, are unclear. Temporal bone (TB) specimens from patients who had undergone cochlear implantation during life with either Advanced Bionics (AB) Clarion ™ or HiRes90K™ (Sylmar, CA, USA) devices that have a half-band and a pre-curved electrode, or Cochlear ™ Nucleus (Sydney, Australia) device that have a full-band and a straight electrode were evaluated. The thickness of the fibrous tissue surrounding the electrode array of both types of CI devices at both the lower (LB) and upper (UB) basal turns of the cochlea was quantified at three locations: the medial, inferior, and superior aspects of the sheath. Fracture of the osseous spiral lamina and/or marked displacement of the basilar membrane were interpreted as evidence of intracochlear trauma. In addition, post-operative word recognition scores, duration of implantation, and post-operative programming data were evaluated. Seven TBs from six patients implanted with AB devices and five TBs from five patients implanted with Nucleus devices were included. A fibrous capsule around the stimulating electrode array was present in all twelve specimens. TBs implanted with AB device had a significantly thicker fibrous capsule at the medial aspect than at the inferior or superior aspects at both locations (LB and UB) of the cochlea (Wilcoxon signed-ranks test, p < 0.01). TBs implanted with a Nucleus device had no difference in the thickness of the fibrous capsule surrounding the track of the electrode array (Wilcoxon signed-ranks test, p > 0.05). Nine of fourteen (64%) basal turns of the cochlea (LB and UB of seven TBs) implanted with AB devices demonstrated intracochlear trauma compared to two of ten (20%) basal turns of the cochlea (LB and UB of five TBs) with Nucleus devices, (Fisher exact test, p < 0.05). There was no significant correlation between the thickness of the fibrous tissue and the duration of implantation or the word recognition scores (Spearman rho, p = 0.06, p = 0.4 respectively). Our outcomes demonstrated the development of a robust fibrous tissue sheath medially closest to the site of electric stimulation in cases implanted with the AB device electrode, but not in cases implanted with the Nucleus device. The cause of the asymmetric fibrous sheath may be multifactorial including insertional trauma, a foreign body response, and/or asymmetric current flow.

[Biofeedback treatment of irritable bowel syndrome]

Irritable bowel syndrome is a group of heterogenic complaints of functional bowel disorder in the absence of organic pathology. The pathophysiology is unclear. In most cases treatment includes symptomatic remedies, antidepressants, psychotherapy and hypnotherapy. Biofeedback has recently been introduced as a therapeutic modality. Treatment also includes relaxation techniques and guided imagery, together with computer-assisted monitoring of sympathetic arousal. Biofeedback requires active participation of patients in their healing progress and leads to symptom reduction in 2/3.