Dysphagia in neurological diseases: a literature review.

Dysphagia is defined as an impairment of this complex and integrated sensorimotor system. It is estimated that 400,000 to 800,000 individuals worldwide develop neurogenic dysphagia per year. Neurogenic dysphagia is typically occurring in patients with neurological disease of different etiologies. A correct and early diagnosis and an appropriate management of dysphagia could be useful for improving patient's quality of life and may help to prevent or delay death. In the present review, we discuss thoroughly the anatomy and physiology of swallowing and also the pathophysiological mechanisms involved in impaired swallowing, as well as the diagnosis, management, and potential treatments of neurogenic dysphagia. Assessment of neurogenic dysphagia includes medical history, physical exam, and instrumental examinations (fiberoptic endoscopic evaluation of swallowing, videofluoroscopic swallowing study, electromyography). Pharmacological treatment of these problems includes oral anticholinergic drugs. Surgical myotomy of the cricopharyngeal muscle showed an important improvement of oropharyngeal dysphagia associated to upper esophageal sphincter hyperactivity. Chemical myotomy of the upper esophageal sphincter by local injections of botulinum toxin type A into the cricopharyngeal muscle has been proposed as an alternative less invasive and less unsafe than surgical myotomy.

The role of peak nasal and oral inspiratory flow in the evaluation of patients with sleep-related breathing disorders.

BACKGROUND: Sleep-related breathing disorders (SRBD) are common reported disorders in the adult population. The nose plays an important role in the development of SRBD; thus, the measurement of nasal respiratory function remains an important step in the management of these patients. Peak nasal inspiratory flow (PNIF) is a useful tool to assess nasal airflow and it has recently been studied together with peak oral inspiratory flow (POIF). OBJECTIVE: The aim of the present study was to evaluate the role of PNIF and POIF in an adult population of patients affected by SRBD. METHODOLOGY: Seventy consecutive adult patients with SRBD were included in the present study. All patients were evaluated with home-based sleep studies (type III), PNIF, POIF, SNOT-22 questionnaire, Epworth Sleepiness Scale test and VAS for nasal obstruction. RESULTS: Although PNIF and POIF showed to correlate with each other, no correlations were observed between Apnea Hypopnea index (AHI) and PNIF, POIF or NPI (PNIF/POIF). A further analysis showed a marginal correlation between SNOT- 22 and AHI and between SNOT-22 and POIF. Furthermore, in a multivariate analysis, also POIF marginally correlated with some of the sleep- related SNOT-22 items. CONCLUSIONS: In the present study neither PNIF nor POIF were found to be associated with OSAS severity. However, POIF values correlated better than PNIF with sleep related symptoms suggesting that POIF could be a more useful parameter for upper airway assessment in patients with SRBD. In addition, a correlation between OSAS severity, in terms of AHI, and SNOT-22 total score has been reported.

Olfactory and rhinological evaluations in SARS-CoV-2 patients complaining of olfactory loss.

Since December 2019, a novel coronavirus SARS-CoV-2 (Covid-19) outbreak emerged in China and spread rapidly in several countries. As of April 5, 2020, 1.218.474 cases were confirmed with 65.884 deaths worldwide (1). The clinical manifestations of Covid-19 range from asymptomatic carrier status to severe pneumonia. In a study of 7,736 Covid-19 patients in China, of all the clinical symptoms, hyposmia was not reported in any patient(2). Anyway, it is now clear that olfactory dysfunction may also be present in these patients(3) as the only or prevalent manifestation(4).

Botulinum toxin therapy: functional silencing of salivary disorders.

Botulinum toxin (BTX) is a neurotoxic protein produced by Clostridium botulinum, an anaerobic bacterium. BTX therapy is a safe and effective treatment when used for functional silencing of the salivary glands in disorders such as sialoceles and salivary fistulae that may have a post-traumatic or post-operative origin. BTX injections can be considered in sialoceles and salivary fistulae after the failure of or together with conservative treatments (e.g. antibiotics, pressure dressings, or serial aspirations). BTX treatment has a promising role in chronic sialadenitis. BTX therapy is highly successful in the treatment of gustatory sweating (Frey's syndrome), and could be considered the gold standard treatment for this neurological disorder.

Outcome predictors of treatment effectiveness for fungal malignant external otitis: a systematic review.

The aim of this review is to summarise literature data on clinical aspects and traditional management of fungal malignant external otitis (FMEO), and to identify potential predictive factors of positive treatment outcome. Articles were initially selected based on their titles or abstracts. Full articles were then retrieved and further scrutinised according to predetermined criteria. Reference lists of selected articles were searched for any missed publications. The selected articles were methodologically evaluated. Of an initial 143 references, 14 were selected that focalised on the management of FMEO. The majority of studies demonstrated a correlation between treatment effectiveness, assessed as symptom resolution, and clinical and management variables: abstention from surgical debridement, absence of facial palsy, Aspergillus spp. as causative pathogen and absence of imaging findings at diagnosis and follow-up. The effectiveness of FMEO treatment depends on the assessment of cranial nerve state, the causative pathogen and imaging findings. Above all, absence of facial nerve palsy, Aspergillus spp. and absence of radiological signs at diagnosis and during follow-up correlate with symptom resolution. The fact that conservative treatment may be associated with a better outcome than surgical debridement could purely reflect that patients with more aggressive and advanced illness required debridement, whereas milder disease was treated conservatively. Thus, caution should be advised in the interpretation of data due to the need for further trials on the topic.

The eminent anatomists who discovered the upper oesophageal sphincter.

OBJECTIVE: To discover the anatomist who first identified the upper oesophageal sphincter. METHOD: The authors searched dozens of antique anatomy textbooks kept in the old section of the 'Vincenzo Pinali' Medical Library of Padua University, looking for descriptions of the upper oesophageal sphincter. RESULTS: The oesophageal sphincter was drawn correctly only in 1601, by Julius Casserius, in the book De vocis auditusque organis historia anatomica… (which translates as 'An Anatomical History on the Organs of Voice and Hearing …'), and was properly described by Antonio Maria Valsalva in 1704 in the book De aure humana tractatus… ('Treatise on the Human Ear …'). CONCLUSION: Anatomists Casserius and Valsalva can be considered the discoverers of the 'oesophageal sphincter'.

N-butanol olfactory threshold and nasal patency before and after palatal expansion in children. A preliminary study.

OBJECTIVES: Olfaction is based on the function of the nasal olfactory receptors. Children can well detect and respond to odors in order to have information about food and environment. Rapid maxillary expansion seems to improve dental class and increase nasal patency correcting oral respiration in children. Nevertheless, there are no studies demonstrating that expansion in pediatric patients could influence olfactory sensitivity. The aim of this study was to evaluate olfactory threshold and nasal patency in children aged from 6 to 12 years before and after rapid maxillary expansion. METHOD: N-butanol olfactory thresholds, anterior active rhinomanometry, and peak nasal inspiratory flow were measured in 12 children (6-12 years) before (T0), 20 days (T1), and 6 months after rapid maxillary expansion application (T2). RESULTS: A significant lower olfactory threshold was found comparing T2 and T0 N-butanol olfactory threshold values (p=0.038). Peak nasal inspiratory flow showed a significant improvement both at T1 and T2, with respect to T0 values (p=0.043 and p=0.0001, respectively). T2 nasal resistances showed a trend towards a significant reduction when compared with T1 values (p=0.15). CONCLUSION: This pilot study suggested that rapid maxillary expansion may lead to improved N-butanol olfactory thresholds, at least 6 months after palatal expansion. Furthermore, rapid maxillary expansion seems to improve peak nasal inspiratory flow values, and finally although with lower sensitivity, reduce nasal resistances as measured by rhinomanometry.

The superior laryngeal nerve injury of a famous soprano, Amelita Galli-Curci.

The superior laryngeal nerve (SLN) has been attributed much less clinical significance than the recurrent laryngeal nerve. It has sometimes been described as the 'neglected' nerve in thyroid surgery, although injury to this nerve can cause significant disability. The external branch of the SLN is the only motor supply to the cricothyroid muscle, which increases the tension of the ipsilateral vocal fold during highfrequency phonation, particularly in women and voice professionals. Damage to this nerve can manifest as ipsilateral cricothyroid muscle paralysis, and clinical symptoms may include a hoarse, breathy voice, frequent throat clearing, vocal fatigue or diminished vocal frequency range, especially when rising pitch. SLN paralysis can be a significant issue for those whose careers depend largely on a full range of voice. The famous opera soprano, Amelita Galli-Curci, suffered SLN injury during thyroid surgery with distressing consequences.

Botulinum toxin improves dysphagia associated with multiple sclerosis.

OBJECTIVE: To evaluate the efficacy of botulinum neurotoxin type A (BoNT/A) for severe oro-pharyngeal dysphagia associated with multiple sclerosis (MS). PATIENTS AND METHODS: BoNT/A was injected percutaneously into the hyperactive cricopharyngeal muscle of 14 dysphagic MS patients under electromyographic control. Patients were evaluated by videofluoroscopic and electromyographic examinations and by the Penetration/Aspiration Scale (PAS), at week 1, 4, 12, 16, 18, and 24 after BoNT/A injection. RESULTS: All patients showed a significant improvement in all the swallowing outcome measures. CONCLUSION: No specific treatment for oro-pharyngeal dysphagia related to MS has been described to date. Our preliminary findings suggest a potential benefit from BoNT/A treatment in MS patients with dysphagia associated with upper esophageal sphincter hyperactivity.

Anosmia associated with hearing loss and benign positional vertigo after head trauma.

It is well known that head trauma may cause hearing loss, which can be either conductive or sensorineural. Benign paroxysmal positional vertigo and olfactory dysfunction due to head trauma are also well known. The association between sensorineural hearing loss and anosmia, following head trauma, is extremely rare. Two rare cases of post-traumatic occurrence of hearing loss, olfactory dysfunction and benign positional vertigo are reported and the pathophysiology of the association between sensorineural hearing loss, anosmia and benign paroxysmal positional vertigo, after head injury, are briefly discussed. ENT specialists should, in the authors' opinion, be aware of the possible association between anosmia, sensorineural hearing loss and benign paroxysmal positional vertigo after head injury, even in the absence of skull fracture.

Treatment of complications of parotid gland surgery.

Although several reports in the literature have documented the surgical technique, and the oncological outcome achieved with parotidectomy, only a few articles have described the complications of parotid gland surgery and their management. Several complications have been reported in parotid surgery. We re-classified the complications of parotidectomy in intra-operative and post-operative (early and late). The commonest complications after parotidectomy are temporary or permanent facial palsy and Frey's syndrome.

Improvement of diabetic autonomic gustatory sweating by botulinum toxin type A.

Fourteen diabetic subjects with gustatory sweating were treated by intracutaneous injections of botulinum toxin type A into the affected facial skin areas. In all subjects, sweating (measured by Minor starch iodine test) ceased within 4 days, with the maximal follow-up time lasting 24 weeks. This therapeutic approach, which could be used to reduce the severity of diabetic gustatory sweating, appears to be long lasting, adverse effect free, and minimally invasive.

The role of gustatory flushing in Frey's syndrome and its treatment with botulinum toxin type A.

After parotid surgery, gustatory sweating and flushing occur more frequently, the former reportedly in 15-100% of cases, while no reliable data are available for the latter. Although botulinum toxin (BoNT) is effective in controlling sweating, little is known about its effect on flushing. In 17 patients suffering from Frey's syndrome after parotid surgery, we studied the gustatory flushing phenomenon as compared to gustatory sweating, analyzing their frequency, area, type of stimulus and response to BoNT administration. Cutaneous blood flow (CBF) was monitored by laser Doppler flowmetry (LDF) on affected and unaffected areas of the cheek in basal conditions and after meals, before and then 1 month after starting the BoNT injections. The Minor test was used to identify the sweating area. Flushing was observed in 7 of 17 patients after masticatory activity, spicy meals or citrus fruits. No clinical data correlated with any presence of flushing. Flushing regressed completely after BoNT administration and CBF reached similar values in the affected and unaffected sites. No adverse effects were observed. BoNT administration proved an effective and safe treatment for gustatory sweating and flushing in patients with Frey's syndrome.

Bezold's abscess in children: case report and review of the literature.

The introduction of antibiotics in the treatment of suppurative otitis media has significantly decreased the incidence of complications. Reports of Bezold's abscess secondary to this disorder are rare, particularly in infants and young children, in whom mastoid bone pneumatization is not yet complete. We present a case of Bezold's abscess occurring in a child aged 18 months. The literature is reviewed and methods to accurately diagnose this complication are emphasized.