Treatment of rhinosinusitis: the role of surgery.

The treatment of rhinosinusitis in children is mostly medical. Surgery is indicated in few but important exceptions: orbital or intracranial complications of acute rhinosinusitis not responding to medical therapy, chronic rhinosinusitis (CRS) with persisting sinonasal infection and purulent discharge, cystic fibrosis, ciliary diskinesia, dacryocystitis due to sinusitis and resistant to medical treatment, fungal rhinosinusitis. According to recent data, 50 percent of ENT specialist perform an adenoidectomy to manage CRS before endoscopic sinus surgery (ESS). ESS techniques introduced in mid 90s, has significantly modified the treatment of complications of acute rhinosinusitis and of selected cases of chronic recurrent infections. ESS consists of minimally invasive surgical procedure as middle meatal antrostomy and anterior ethmoidectomy. Evidence suggests that adenoidectomy and ESS are the most frequent surgical procedure performed in RS management.

Implant-prosthetic rehabilitation after excision of hard palate gland carcinoma.

In Summer 2002, a patient with frequent epistaxis was admitted to the San Gerardo Hospital. Local examination showed a big mass in the nasal fossa. TC and RMN revealed a diffuse erosion of the palatal bone and infiltration of the maxilla. The tumor was removed and histological examination showed a gland carcinoma. The young age of the patient and the need of an adequate bone reconstruction led to use osteoperiosteal calf bone graft. Subsequently, using local anesthesia, 6 implants were positioned. After normal healing and the period of osteointegration, a Toronto bridge was made on implants that the patient wears with no problem.

The reversed ipsilateral acoustic reflex: clinical features and kinetic analysis.

OBJECTIVE: The reversed ipsilateral acoustic reflex (RIAR) has been the subject of few studies in the past literature and the nature of this "reflex" response is not yet completely understood. It can be observed in different diseases, all of which result from inactivity of the stapedial reflex (SR). We aimed to investigate the occurrence of the RIAR in different diseases. MATERIAL AND METHODS: An extensive clinical investigation of the RIAR was carried out. RESULTS: The RIAR was found to be present in 100% of ears lacking an effective SR arc. Its amplitude is modulated by the air pressure level in the external ear canal whilst its sign is constantly positive and never reverses. CONCLUSION: Kinetic analysis of the RIAR suggests the existence of a single underlying phenomenon while the interaction of the RIAR with the SR may explain the complex morphology frequently observed in the normal ipsilateral acoustic reflex.

The intriguing association between prematurity and neonatal isolated submandibular suppurative sialadenitis.

Submandibular suppurative sialadenitis occurring as an isolated lesion in the neonatal period is extremely rare. A case of a preterm newborn, who developed an isolated submandibular suppurative sialadenitis is described. A literature review highlighting salient points on this topic is also presented. In particular, an important role of prematurity in the etiology of this pathological condition is shown and discussed.

[Indications for selective arterial embolization in the treatment of epistaxis]. / Le indicazioni all'embolizzazione arteriosa selettiva nel trattamento dell'epistassi.

After posterior packing has failed, the treatment of choice for severe, recurrent posterior epistaxis is arterial ligature, usually through a transantral approach to the Internal Maxillary artery (LTA) or selective percutaneous embolization (EP). The advantages and disadvantages of each technique are discussed by various Authors. A critical review of the literature brings to light the discrepancies between the results of various studies: in a series by Strong et al. and in a review of the literature EP proved more effective than LTA (90-94% vs. 85-89%). On the contrary, using personal data Cullen and Tami reported that the results are analogous. As regards complications, these proved slightly more frequent, but minor, with LTA while the rare complications with EP were more serious. The per-patient costs fundamentally depend on the type of hospital management and the availability of a treatment center; the results of the various studies are not analogous in this regard. The specific indications for the choice of which technique to use include: LTA: ethmoid artery hemorrhage, severe arteriosclerosis of the carotid compartment and allergy to the contrast medium; EP: cardiovascular instability, severe anemia and all conditions which are contraindications for general anesthesia. In the cases studied by the Authors, of the total 203 patients admitted to hospital for posterior epistaxis between May 1995 and November 1999, 12 (5.9%; on the average 2.6 pt/yr) showed values lower than those found at other Centers. A total of 13 EP procedures were performed and the result was positive (stopping the hemorrhage) in 11 (91.7%). In one post-traumatic case there was a recurrence which could not be controlled by EP and thus the Authors resorted to surgical ligature. All the patients underwent fibroscopy after the posterior packing was removed and before establishing the indications for EP. A full 50% of the patients treated showed arterial hypertension and in all patients except the one with multiple traumas, the pre-embolization angiography showed the presence of submucosal teleangiectasia in the site of the epistaxis. This report supports the hypothesis that, in the presence of triggering factors (hypertension, pregnancy), untreatable epistaxis is sustained by a submucosal vascular malformation. On the other hand, it also asserts that although the patient evaluation to determine the EP treatment was less invasive than that used in other Centers, it was able to identify the patients with this malformation, thus validating the clinical criteria used.

Anatomical reconstruction versus camouflage of the inferior two thirds of the nasal septum.

From an anatomical standpoint, the support of the inferior two thirds of the nose is ensured by the cartilaginous septum. Usually, the reconstruction of total loss of the quadrangular cartilage is performed with some success by means of camouflage procedures such as L-shaped struts or cantilever grafts. In this article we report on four patients who presented with severe collapse of the inferior two thirds of the nose. Although the cartilage was completely gone, the septal linings were intact on both sides. An anatomical reconstruction of the quadrangular cartilaginous septum was performed, harvesting a cartilaginous rib graft, carving it to reproduce the septal plate, and suturing it to the nasal spine. The short- and long-term follow-up showed satisfactory aesthetic and functional results, with good height of the nasal profile, adequate tip projection, and patency of the airways. No evidence of similar reports on this particular technique has been found in the literature.

[Catarrhal otitis media in children and air travel]. / Otite media catarrale in età pediatrica e volo aereo.

Fifteen children with otitis media with effusion were followed before and after air travel. The purpose of the study was to determine if the young patients who fly with otitis media with effusion are at risk for the development of "barotitis". No children with otitis media became symptomatic, though same normal ears did become symptomatic. The authors describe the physiopathological details of this different findings.

[Audiologic evaluation of patients with thalassemic syndromes treated with desferrioxamine B]. / Valutazione audiologica in pazienti affetti da sindromi talassemiche trattati con desferossamina B.

Following various articles in literature which have appeared in the last 3 years regarding the neurotoxicity of desferrioxamine B we studied, from the auditory functionality point of view, 95 patients affected with transfusion-dependent thalassemic syndromes, under regular chelation treatment with desferrioxamine B. Our results lead us to conclude that at standard doses, between 40 and 60 mg/Kg/day, desferrioxamine B does not demonstrate a neurotoxicity enough to cause an organic deficit in the auditory sphere, while maintaining therapeutic efficacy.

[New methods for audiometric evaluation in childhood]. / Nuove metodiche per la valutazione audiologica in età infantile.

Impaired speech learning, mental retardation and alterations of affectivity and behaviour may be the consequences of profound neonatal deafness. The authors emphasize the importance of detecting the newborns at audiological risk and screening the neonates in order to get an early diagnosis and treatment of the affection, at least within the first year of life, to avoid or reduce the consequences of hearing loss; then they describe the procedure commonly in use at present for neonatal hearing screening and a number of available different diagnostic tools (electrodermal audiometry, heart rate audiometry--with the possibility of autoregressive analysis--respiration audiometry, autoregressive analysis of EEG, acoustic impedance measurements with study of the acoustic reflex, auditory response cradle which is also named CRIB-O-GRAM).

Some effects of the stimulus repetition rate on N1 and N2 in transtympanic and surface recordings.

The early auditory evoked electrical activity has been recorded in man at the promontory (transtympanic approach) and on the scalp vertex-mastoid derivation), in response to clicks delivered at different rates. Latency and amplitude of the first two peaks (N1 and N2), as a function of the repetition rate, have been measured and compared. The differences between the latencies of transtympanic and surface N1 are very small, at any rate, with a maximum value of 0.08 msec. In the transtympanic recording, the latency difference between N2 and N1 is constant throughout the whole range of rate values, from 3 to 100 clicks per second. In the surface responses, on the contrary, the latency difference between N2 and N1 tends to increase as the rate is increased. The amplitude of the transtympanic N2 is consistently reduced at click rates above 20-50 per second (more markedly than the amplitude of N1), while the amplitude of the surface N2 is much more insensitive to the rate increase. Some implications of these results are discussed with respect to the origin of N2 in the two recording conditions.

The evolution of the vestibular apparatus according to the age of the infant.

In 56 full-tem A.G.A. infants and in 27 infants of a minimal age of 15 days with a neurological "risk" (full-term small for gestational age, S.G.A.), the nystagmic response to vestibular stimulation (rotatory and torsion swing test) was examined. A delay in the appearance of a response to the labyrinthic stimulus and a persistence of the prevalence of the slow phase of the nystagmus appeared clearly higher in the "risk" infants. The statistical difference of the response between the two groups was highly significant. This allowed us to conclude that the vestibular test appears to the one of the most useful in evaluating the sensorial maturation of S.G.A. infants.

Intensity and frequency discrimination monitored by evoked response audiometry: clinical application.

Delta 1 and delta f repetitive stimuli superimposed on continuous 0.5-, 1- and 4-kHz carrier tones were administered to 20 normally hearing persons, 8 adults with sensorineural hearing loss, 10 adults with conductive hearing loss and 22 children subjected to evoked response audiometry (ERA) for assessment of hearing acuity. The intensity modulation depth ranged from + 1 to 10 dB. In the subjects with normal hearing and in the adult patients, three carrier tone levels were used whenever possible: 20, 40, and 60 dB SL. The frequency modulation depth ranged from -1 to -10% of the carrier tone frequency. The same levels for the carrier tone were used: 20, 40, and 60 dB SL. With a carrier tone level of 20 dB SL, a clear-cut vertex response was noted in 80% of the tests carried out in the normal adults with 5-dB delta i stimuli and with delta f stimuli of -3 to -5% in magnitude; the same figures are valid for the patients with sensorineural and conductive hearing loss. The patients with sensorineural hearing loss showed a tendency to give vertex responses with lower delta i stimuli than subjects with normal hearing. However, this difference was not statistically significant. According to our results, the children tested can be roughly divided into two groups, the first including subjects with responses to delta i stimuli of +5 and +10 dB and delta f stimuli of -5% and -10%; the second group including subjects with no clear-cut responses to these stimuli.