Results and complications of the Baha system (bone-anchored hearing aid).

The aim of this work is to reexamine our experience with the treatment of conductive and mixed hearing loss using the Baha system. The system was implanted in 47 patients (16 adults and 31 children under the age of 14), bilaterally in two cases. The causes of hypoacusis were bilateral congenital aural atresia (31 patients), bilateral chronic otitis media or outcomes of middle-ear surgery (Gillett et al. in J laryngol Otol 120:537-542, 2006), and otosclerosis (Pazzaglia et al. in Acta Orthop Scand 54:574-579, 1983). The following parameters were assessed: mean preoperative air- and bone-conduction thresholds for the frequencies of 500, 1,000, 2,000 and 4,000 Hz; mean postoperative threshold with the Baha; hearing improvement calculated by subtracting the postoperative threshold with the Baha from the preoperative threshold for air conduction in the better ear; speech audiometry test; improvement in the quality of life, calculated using the Glasgow Benefit Inventory for the adult patients and the Glasgow Children's Benefit Inventory for paediatric patients; frequency and type of surgical complications. Follow-up ranged from 6 to 38 months. The audiological results were satisfactory, with air-bone gap closure in 85.1% of cases. In terms of quality of life, assessment using the Glasgow Benefit Inventory showed a clear-cut improvement in health for all the 45 patients that answered to the questionnaires in our study. Out of the 49 operations that were performed, complications were reported in 3 cases (6.1%): 2 cases of skin regrowth around the titanium screw and one in which the abutment was not osseointegrated. The data from this study show that the Baha system offers a high percentage of success, which can significantly improve the patient's quality of life, and a low rate of complications.

Influence of extero- and proprioceptive afferents of the plantar surface in determining subjective visual vertical in patients with unilateral vestibular dysfunction.

Subjective visual vertical refers to an individual's ability to indicate what, in his or her opinion, is a perfectly vertical line in specific experimental conditions. Although the otolith organs play a key role in the perception of verticality, the contribution of other sensory systems, e.g. the visual and proprioceptive systems, cannot be overlooked. The aim of this study was to test the hypothesis that extero- and proprioceptive afferent signals, particularly from the plantar surface of the foot, can influence the temporal evolution of altered subjective visual vertical following unilateral acute vestibular dysfunction. Subjective visual vertical was studied in 40 consecutive patients: 19 females and 21 males (mean age 46.4 years). It was first measured at diagnosis (1-2 days after onset of symptoms). For this measurement, a baseline test was performed (patient standing in direct contact with the floor), followed by a provocation test with a soft support between the patient's feet and the floor. Based on a comparison between the baseline and provocation tests, the patients were divided into three groups: Group A--patients showing a significant increase (p < 0.05) in subjective visual vertical(0 )values in the provocation test compared to baseline values; Group B--patients showing a significant decrease (p < 0.05) in subjective visual vertical(0 )values in the provocation test compared to baseline values; Group C--patients showing no significant changes (p < 0.05) in subjective visual vertical(0 )values in the provocation test compared to baseline values. The baseline test was repeated at 30, 90 and 180 days. At the end of the follow-up, a persistent change in subjective visual vertical was noted in 87% of the patients from Group B, 31% of the patients from Group C but none of the patients from Group A, all of whom were able to correct the perception error during the second examination. The study demonstrates that normalisation of subjective visual vertical in subjects with unilateral vestibular lesions seems to be influenced by the possibility of exploiting extra-vestibular sensory information, particularly extero- and proprioceptive information from the plantar surface.

Linear stapler closure of the pharynx during total laryngectomy: a 15-year experience (from closed technique to semi-closed technique).

Personal experience in performing linear stapler closure of the pharynx during 70 total laryngectomies is reported. Laryngeal staplers (55 and 60 cm) with an angled handle were used, permitting vertical closure with 19 or 20 metal staples in a double row. A closed technique was initially used, but, over the years, this has gradually been replaced by the semi-closed technique to avoid trapping the suprahyoid part of the epiglottis between the jaws of the stapler. The stapler is inserted below the larynx after having separated it from all muscular and neurovascular connections, and after performing a mini-pharyngotomy at the vallecula epiglottica in order to extract the epiglottis, evert it ventrally and suture it to the hyothyroepiglottic space. The jaws of the stapler are closed and the staples are fired while the flaps of the mini-pharyngotomy are raised above the jaws. The scalpel is inserted above the stapler to remove the larynx. When the stapler is opened, the vertical linear suture of the pharynx is evident and can be examined. This procedure takes only a few minutes to perform. It guarantees a long-term stable watertight closure, dramatically reduces contamination of the operating field by pharyngeal secretions, and permits rapid healing time, greatly lowering patient management costs. In the cases presented here, there was a 1.8% rate of pharyngocutaneous fistulae in patients who were not radiated, whereas the rate was 13.1% in pre-radiated patients. In agreement with the international literature, this procedure does not increase the rate of fistulae and, in fact, it seems to reduce it. Moreover, it is particularly indicated for pre-radiated patients. Nevertheless, the Authors recommend reserving this type of procedure to cases in which, based on meticulous pre-operative assessment by means of endoscopy and imaging, the endolaryngeal site of the tumour has been assessed and there is no need for peri-operative exploration of the pharynx or tongue base.

Enhancement of lysosomal glycohydrolase activity in human primary B lymphocytes during spontaneous apoptosis.

It has been shown that lysosomes are involved in B cell apoptosis but lysosomal glycohydrolases have never been investigated during this event. In this study we determined the enzymatic activities of some lysosomal glycohydrolases in human tonsil B lymphocytes (TBL) undergoing in vitro spontaneous apoptosis. Fluorimetric methods were used to evaluate the activities of beta-hexosaminidases, alpha-mannosidase, beta-mannosidase, alpha-galactosidase, beta-glucuronidase and alpha-fucosidase. Results show that in TBL during spontaneous apoptosis, there is a significant increase in the activity of beta-hexosaminidases, alpha-mannosidase, beta-mannosidase and beta-galactosidase. Also beta-glucuronidase and alpha-fucosidase activities increase but not in a significant manner. Further studies on beta-hexosaminidases revealed that also mRNA expression of the alpha- and beta-subunits, which constitute these enzymes, increases during spontaneous TBL apoptosis. When TBL are protected from apoptosis by the thiol molecule N-acetyl-L-cysteine (NAC), there is no longer any increase in glycohydrolase activities and mRNA expression of beta-hexosaminidase alpha- and beta-subunits. This study demonstrates for the first time that the activities and expression of some lysosomal glycohydrolases are enhanced in TBL during spontaneous apoptosis and that these increases are prevented when TBL apoptosis is inhibited.

Paroxysmal positional vertigo: the role of age as a prognostic factor.

Aim of this study was to examine possible relationships between several clinical aspects of paroxysmal positional vertigo and factors better defined as "intrinsic" to the patient, above all age. The disorder can affect essentially all age groups; nevertheless, the onset of age-linked degenerative processes, such as vascular damage, can have a negative influence--at least in theory--on the pathogenic mechanisms of cupulolithiasis or canalolithiasis. The study was based on the review of 566 patients with the typical form of paroxysmal positional vertigo. Based on age, the patients were divided into two groups, respectively < or =50 years and > 50 years. For the purposes of this study, a series of clinical-laboratory conditions associated with the risk of, or clear, vascular damage were also considered. The results indicate that if there are no clinical or case-history elements that can be attributed to an aetiological hypothesis, the clinical behaviour of paroxysmal positional vertigo is not affected by the age factor. However, the existence of generic vascular damage, hypothesised by the presence of the above-mentioned conditions, influences certain clinical aspects of the disorder, particularly recovery time, the trend of the active phase and the number of relapses. In conclusion, paroxysmal positional vertigo with a presumed vascular aetiology, the incidence of which increases with age, presents a worse prognosis, not only with respect to the "idiopathic" form in childhood but also the "idiopathic" type in the elderly. The lithiasic model responds well to pathogenic interpretation requirements, which envisage macular degeneration with a vascular component. However, the observation, via imaging, of diffuse ischaemic lesions in critical areas of the brainstem and the cerebellum in many "vascular" patients, does not exclude the possibility of alternative pathogenic mechanisms that, in the final analysis, can lead to compromised VOR on a central level.

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

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

[Balance disorders in the elderly]. / I disturbi dell'equilibrio nell'anziano.

In the elderly patient, instability is a syndrome in which a loss of balance, during ambulation or while standing, can give rise to falls, with consequent disability and morbidity. Maintaining the correct static and dynamic balance is known to be the result of the synergetic functioning of different systems. In old age, however, the efficiency of these mechanisms is impaired because of the physiological process of aging, which affects all of the organs and systems of the human body. Besides that, different concomitant causes such as cardiovascular and dysmetabolic pathologies, chronic pharmacological therapies etc. contribute to the aging of our organism. The object of this study was to evaluate 40 subjects, 21 males and 19 females, aged between 70 and 86, who were referred to us with craniofacial trauma consequent to a fall. Upon hospitalization, all of the patients were asked to fill in a questionnaire evaluating the incidence of the vertigo symptom as a possible cause of the falls. All of the subjects underwent the following clinicoinstrumental examinations: standard audiometric evaluation, vestibular tests, neurological and ophthalmic examination. Careful appraisal of the results obtained enabled us to conclude that balance disorders in the elderly patient are due to the synergetic action of three factors: aging, concomitant diseases and environmental factors. In conclusion, we can affirm that balance disorders giving rise to a fall in the elderly are attributable to the concomitance of different factors that determine a clinical state of imbalance, defined by some Authors with the term "presbivertigo". It follows that a suitable diagnostic protocol must be employed, comprising a detailed medical, pharmacological and functional history, a study both of the environmental conditions in which the patient lives and the modalities according to which the traumatic event occurred. It is, last of all, indispensable that steps be taken to improve these environmental conditions, such as choosing flooring materials, light fixtures, stairs, bathroom furnishings and suitable footwear promoting proper foot placement and support on the ground.

[Role of gastroesophageal reflux in precancerous conditions and in squamous cell carcinoma of the larynx: our experience]. / Ruolo del reflusso gastroesofageo nelle precancerosi e nel carcinoma squamocellulare della laringe: nostra esperienza.

The major risk factors for the onset of precancerous lesions and squamous cell carcinoma of the larynx are, above all, tobacco smoke, alcohol abuse and exposure to viral and toxic agents. In recent years, however, gastro-esophageal reflux (GER) has also aroused significant interest not only as carcinogen but also as co-carcinogen in association with smoking and alcohol consumption. The purpose of the present work is to provide an objective evaluation of the presence of distal and proximal esophageal reflux using multi-electrode pH monitoring in patients with precancerous lesions of the larynx and laryngeal and pharyngolaryngeal neoplasms. A total of 24 patients consecutively hospitalized during 2000 were evaluated: 20 with squamous cell carcinoma of the larynx and/or pharynx-larynx and 4 with precancerous vocal cord lesions. All the patients provided a case history using a validated questionnaire and underwent electronic videolaryngoscopy and 24-hour pH monitoring. Data analysis showed that in 83.3% of the cases (20/24) pH monitoring was indicative of pathological GER and 63.7% of these patients had no complaints related to reflux. Moreover, 7/24 patients have had a previous gastrectomy (Billroth II) strictly related to the presence of bile reflux. The Authors conclude that, according with recent literature, pH monitoring data further indicate that patients with precancerous or neoplastic pharyngeal-laryngeal lesions present often a positive history of GER, even though no direct cause-effect relationship can yet be established because of the co-existence of other important risk factors such as smoking and alcohol consumption. Additionally, the achlorhydria found in 7/24 patients with an history of gastrectomy could suggest a possible, as yet unproven, role of other reflux components--in particular, of bile (alkaline) and chlorhydro-peptic (acid) components--as a risk factor or co-factor for tonset of precancerous and/or neoplastic lesions of the larynx.

Per-oral excision of a pharyngeal branchial cyst after MRI study.

A per-oral approach to pharyngeal branchial cysts is possible, and ideal when they are placed medially to the pharyngeal constrictors and no fistular duct is connected to the mass. At present MRI is found to be the best means of achieving the correct diagnosis of morphology and site.

[Evoked otoacoustic emissions in noise-induced hearing loss]. / Le otoemissioni acustiche evocate nella ipoacusia da trauma acustico cronico.

The Authors evaluated patterns of click-evoked otoacoustic emissions (EOE) in a group of 184 patients exposed to noise in their working environment. The aim of the study was to detect changes in EOE patterns in this group compared to the EOE of healthy subjects. The clinical history of each subject was recorded and otoscopy, pure tone audiogram and impedance tests (tympanometry, stapedial reflex threshold) were carried out in all patients. Noise-induced hearing loss found in 97 patients, unilateral sensorineural hearing loss in 17, other hearing disorders in 24 and normal auditory threshold in 46. EOE recording was carried out in the group of patients with noise-induced hearing loss (97), in the group with normal threshold (46) and in a control group of 15 healthy subjects. EOE recording was obtained using the ILO 88 Otodynamic Analyzer. We introduce a probe into the external ear canal using a non-linear click stimulus (intensity at approximately 85 dB spl) at a 20/sec. rate with a 20 msec. window. Normal EOE were found in the control group. Abnormal EOE were found in 79 cases (81%) of the noise-induced hearing loss group, and in 22 (48%) of the normal threshold group. These data show that noise-exposed subjects have alterations of EOE such as threshold shift missing frequency bands, even in absence of an auditory threshold shift. When EOE were present, the frequency spectrum often showed lack of emissions at high frequencies. This study confirms that cochlear exposure to noise may produce significant alterations of EOE and that this test may be considered highly sensitive in detecting early cochlear damage in chronic acoustic trauma. Therefore, EOE may be used in screening and follow-up of high risk populations such as noise-exposed subjects.

[Pharyngeal cysts of branchial origin, a review of the literature and a clinical case report]. / Cisti faringee di origine branchiale, revisione della letteratura e presentazione di un caso clinico.

Nasal pharyngeal swellings are very often treated without a previous complete clinical examination of the patient and of the disease site. For this reason the recurrence rate of this pathology is quite high. The causes for this phenomenon are likely due to the benign aspect of the tumor and the easy approach to the pharynx. Leaving aside the therapeutical aspect, there are also multiple theories concerning the etiology of pharyngeal cyst based on epidemiological and histopathological observations. Branchiogenic origin very likely seems to be the cause of cystic swelling arising at the lateral side of the pharynx, between the Eustachian tube and the posterior tonsillar pillar. Examination of the case review collected from literature, revealed that diagnostic and therapeutical procedures performed by various authors seem to be very haphazard, ranging from simple physical examination and puncture draining to CT and/or MRI scanning and external trans-mandibular approach to the cyst. The authors describe one case of a subject with a pharyngeal branchial cyst, who had been previously undergone puncture drainage. The correct diagnosis was achieved through MRI and cytologic examination of the fluid aspirated from the cyst. With MRI it was possible to make a correct topo-diagnosis, which localized the position of the cyst in the left pharyngo-tonsillar recesses, medial to the pharyngeal constrictor muscles. MRI also confirmed the absence of fistulous ducts connected to the cyst. These clinical and laboratory data induced us to use an intra-oral approach to the cyst, which was removed by blunt dissection. Physical examination and MRI were repeated six months later and showed the complete removal of the cyst and the presence of a synechia between the upper part of the left posterior pillar and the pharyngeal wall. No further treatment was given because of the absence of symptoms. The authors stress the importance of less invasive surgery in the case of pharyngeal cyst possible after detailed monitoring of the disease site with modern computed tomography CT, MRI.

Head and neck trauma in sporting activities. Review of 208 cases.

Head and neck injuries due to sports and games represent 22.7% of all injuries admitted to the E.N.T. Department of the University of Perugia between 1980 and 1988. Epidemiological and causative factors of these injuries are examined by the authors, together with their treatment: the majority of accidents occurred during soccer games as a consequence of collisions between players. In these cases the most frequently recorded lesion was a nasal fracture. Other sporting activities were responsible for more serious injuries to the maxillo-facial bony, cartilaginous and soft tissue structures. Good results were achieved both on the anatomical and functional planes, except for a few cases of facial disruption and multiple mandibular fractures. The authors stress the importance of preventive measures, consisting of periodical medical check-ups, an adequate level of umpiring and the wearing of protective equipment, such as helmets and masks.

Post-traumatic paralytic syndromes of the jugular and condylar foramina.

The fact that neoplasms of the cranial base or metastases of nasopharyngeal tumors may cause palsy of nerves which pass through the jugular and anterior condylar foramina has been well documented. On the other hand, very little has been reported about the traumatic causes of these diseases, probably because they are often underestimated or misdiagnosed. In this paper, the Authors report four cases of palsy of the last four cranial nerves caused by various kinds of trauma: glossopharyngeal thermo-rhizotomy, bullet wound, closed cranial trauma, neck surgery. The main symptom immediately following a lesion is mechanical dysphagia which causes inhalation of food and saliva and may sometimes require surgery, such as tracheotomy or cricopharyngeal myotomy. The most lasting symptom is dysphonia, which can only be treated by speech therapy. Because of the importance of these damaged functions, the above symptoms must be studied more thoroughly, also keeping in mind the modern techniques of surgical and non-surgical speech rehabilitation.

Auditory brain-stem (ABRs) and middle latency auditory responses (MLRs) in the prognosis of severely head-injured patients.

Auditory brain-stem responses (ABRs) were studied in 66 subjects with severe head trauma. Middle latency responses (MLRs) were also recorded in 22 of them. Patients were carefully selected to avoid conditions such as pre-existing or acute deafness, hypothermia or ethanol intoxication. In order to evaluate the usefulness of potentials in predicting recovery, patients were classified according to the Glasgow Coma Scale (GCS). ABR tracings were classified into 5 groups and MLR into 2 groups. The recovery was good in the presence of a type 1 ABR, poor in the presence of types 3, 4 and 5. Concerning type 2 ABR, the outcome is related to the MLR type, and to the presence of an electrophysiological improvement within the first 3 months following trauma. The reliability of ABR and MLR in predicting the outcome of severe head injury appears to be greater than other usually considered clinical and instrumental data (age, GCS, CT scan, EEG).