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.

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.

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.

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.

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.

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.

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

OBJECTIVES: Sickle cell anemia (SCA) and ß -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 ß-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 ß-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 ß-thalassemic pediatric subjects; RR: 3.35 for SCA pediatric subjects). A significant difference (p < 0,5) was found between the ß -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: ß-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 ß-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.

The hump columellar strut: a reliable technique for correction of nasal tip underprojection.

Nasal tip under projection is often found in rhinoplasty cases both for congenital or post-traumatic deformity. Nasal trauma may result in alteration of the external and internal nasal structures with following aesthetic impairment and difficulties in breathing. Post-traumatic surgery is frequent, but restoration of pre-traumatic form and function remains a challenge. The present paper describes a new method to increase tip projection by a columellar strut harvested from the autologous nasal bone and cartilage of the resected hump. A total of 15 cases (11 women/4 men, mean age 32.6 ± 12.3 years) of major tip projection/misalignment abnormalities to be corrected by increased nasal tip projection were drawn, and all underwent closed or open rhinoplasty with the placement of a bony columellar strut harvested from the resected hump of the patient. Short and long-term advantages of this procedure are to be underlined. Harvesting is routinely performed during dorsal resection and preparation of the graft is easy. Differently from bone of the vomer or the inferior turbinate, this is cortical bone straight in shape and rigid in framework, and therefore ideal to gain reliable tip support overtime. No additional harvesting areas are needed. Placement of this bony strut is carried out in the standard fashion without additional dissection or further procedures. Long-term follow-up shows maintained projection over time. This graft can be combined with various grafting or suturing techniques usually applied according to each surgeon's experience and the needs of each patient.

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.

Radiological and clinical difficulties in the management of chronic maxillary sinusitis in ß 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 ß 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.

Multivariate prognostic factors analysis for second-line chemotherapy in advanced biliary tract cancer.

BACKGROUND: The role of second-line chemotherapy (CT) is not established in advanced biliary tract cancer (aBTC). We investigated the outcome of aBTC patients treated with second-line CT and devised a prognostic model. METHODS: Baseline clinical and laboratory data of 300 consecutive aBTC patients were collected and association with overall survival (OS) was investigated by multivariable Cox models. RESULTS: The following parameters resulted independently associated with longer OS: Eastern Cooperative Oncology Group performance status of 0 (P<0.001; hazard ratio (HR), 0.348; 95% confidence interval (CI) 0.215-0.562), CA19.9 lower than median (P=0.013; HR, 0.574; 95% CI 0.370-0.891), progression-free survival after first-line CT ≥ 6 months (P=0.027; HR, 0.633; 95% CI 0.422-0.949) and previous surgery on primary tumour (P=0.027; HR, 0.609; 95% CI 0.392-0.945). We grouped the 249 patients with complete data available into three categories according to the number of fulfilled risk factors: median OS times for good-risk (zero to one factors), intermediate-risk (two factors) and poor-risk (three to four factors) groups were 13.1, 6.6 and 3.7 months, respectively (P<0.001). CONCLUSIONS: Easily available clinical and laboratory factors predict prognosis of aBTC patients undergoing second-line CT. This model allows individual patient-risk stratification and may help in treatment decision and trial design.

Endoscopic removal of supernumerary tooth from the nasal cavity of a child: a case report.

INTRODUCTION: A case report showing the removal of a supernumerary tooth from the nasal cavity by means of an endoscopic approach is presented. MATERIALS AND METHODS: A 9-year-old healthy child presented to our department because of the right central incisor which appeared clinically rotated. The observation of orthopantomography revealed the presence of a supernumerary tooth in the anterior maxilla with the crown positioned towards the nasal floor. The maxillary CT demonstrated a quite close relationship of the tooth with the nasal cavity, so a nasal approach was planned. RESULTS: Under general anesthesia the supernumerary tooth was removed by means of an endoscopic approach from a nostril. During the extraction the adjacent structures were unharmed. The postoperative course was uneventful. CONCLUSIONS: This case report suggests that in case of supernumerary teeth positioned close to the nasal cavity, trans-nasal endoscopy may represent a valid alternative to more demolishing traditional surgery.

Aberrant splicing and expression of the non muscle myosin heavy-chain gene MYH14 in DM1 muscle tissues.

Myotonic dystrophy type 1 (DM1) is a complex multisystemic disorder caused by an expansion of a CTG repeat located at the 3' untranslated region (UTR) of DMPK on chromosome 19q13.3. Aberrant messenger RNA (mRNA) splicing of several genes has been reported to explain some of the symptoms of DM1 including insulin resistance, muscle wasting and myotonia. In this paper we analyzed the expression of the MYH14 mRNA and protein in the muscle of DM1 patients (n=12) with different expansion lengths and normal subjects (n=7). The MYH14 gene is located on chromosome 19q13.3 and encodes for one of the heavy chains of the so called class II "nonmuscle" myosins (NMHCII). MYH14 has two alternative spliced isoforms: the inserted isoform (NMHCII-C1) which includes 8 amino acids located in the globular head of the protein, not encoded by the non inserted isoform (NMHCII-C0). Results showed a splicing unbalance of the MYH14 gene in DM1 muscle, with a prevalent expression of the NMHCII-C0 isoform more marked in DM1 patients harboring large CTG expansions. Minigene assay indicated that levels of the MBNL1 protein positively regulates the inclusion of the MYH14 exon 6. Quantitative analysis of the MYH14 expression revealed a significant reduction in the DM1 muscle samples, both at mRNA and protein level. No differences were found between DM1 and controls in the skeletal muscle localization of MYH14, obtained through immunofluorescence analysis. In line with the thesis of an "RNA gain of function" hypothesis described for the CTG mutation, we conclude that the alterations of the MYH14 gene may contribute to the DM1 molecular pathogenesis.

Early subclinical cochlear dysfunction in myotonic dystrophy type 1.

BACKGROUND: Myotonic dystrophy type 1 (DM1) is an autosomal-dominant inherited disorder clinically characterized by variable systemic manifestations. Among clinical features of the disease, 'precocious presbyacusis' has been previously reported. The underlying mechanism of this auditory impairment remains still poorly understood. Hearing is an active process located in the cochlea, where the outer hair cells (OHCs) play an important role in sound perception through a 'contractile' like movement resembling skeletal muscle fibers dynamics. OHCs status has not yet been investigated in DM1 patients. OHCs integrity can be assessed by measuring transient-evoked otoacoustic emissions (TEOAE), a non-invasive, repeatable, and objective quantitative tool. METHODS: We recruited 25 patients with a genetically confirmed diagnosis of DM1, and 28 age-matched control subjects. All of them underwent a routine audiological evaluation and TEOAE recordings. RESULTS: We detected a high prevalence of sensorineural high-frequency hearing loss (HFHL) in DM1 patients, significantly different if compared to control subjects. Interestingly, the accurate analysis of DM1 recorded data showed a marked impairment of TEOAE both in HFHL+ and unexpectedly in HFHL- group. Cochlear dysfunction was restricted to frequencies above 2000 Hz in the HFHL- group, but it extended to 1000 Hz in HFHL+ DM1 patients. CONCLUSIONS: Our study indicates that cochlear impairment in DM1 is present, even in patients without evidence of hearing loss at a standard audiometric analysis. Hence, in the current clinical practice, an assessment of cochlear function by TEOAE recording may be useful in DM1 patients to identify precocious signs of cochlear dysfunction.

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.

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.

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.

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.