Use OF NBI for the assessment of clinical signs of rhino-pharyngo-laryngeal reflux in pediatric age: Preliminary results.

OBJECTIVES: Laryngopharyngeal reflux (LPR) is a complex problem in pediatric population: diagnosis and clinical presentation are still controversial. Classic white light endoscopy shows some pathognomonic signs of LPR in children, such as thickening of pharyngo-laryngeal mucus, the cobblestoning aspect of pharyngeal mucosa, arytenoid edema/hyperemia, nodular thickening/true vocal cord edema, hypertrophy of the posterior commissure, subglottic edema. The NBI (Narrow Band Imaging) technology, generally used in oncology, allows to study neoangiogenesis and hypervascularization of the mucosa, common aspects in both chronic inflammation and neoplastic transformation. The aim of our study was to evaluate the added value of this technology in identifying the main laryngopharyngeal reflux sign in a pediatric population. METHODS: We evaluated at the Otolaryngology Unit of the "Fondazione Policlinico A. Gemelli" hospital and the Airway Surgery Unit of the "Bambino Gesù" Children's Hospital 35 patients aged from 2 months to 16 years divided into two groups in the period between November 2017 and May 2018. Group A included patients with clinical suspicion of LPR after gastroenterologist evaluation and Group B included patients who underwent an endoscopic evaluation for the assessment of recurrent respiratory symptoms such as stridor, recurrent croup, wheezing and persistent cough. We performed an endoscopic evaluation by white light and NBI for each patient, comparing the results of both methods to evaluate signs of pharyngo-laryngeal reflux and to calculate the value of reflux finding score (RFS). RESULTS: The analysis of the data showed: for Group A an average value of RFS with white light of 11,84 (range 8-17, standard deviation 2,52 ±â€¯0,57) and with NBI of 13,63 (range 10-17, standard deviation 2,13 ±â€¯0,49); for Group B the analysis of the data showed an average value of RFS with white light of 10,06 (range 8-14, standard deviation 2,32 ±â€¯0,58) and with NBI of 12,50 (range 9-18, standard deviation 2,63 ±â€¯0,65). The comparison between the two methods resulted significant. Furthermore evaluation by NBI allowed to highlight other signs of pharyngo-laryngeal reflux, characteristic of pediatric age and not included in RFS, in particular cobblestone aspect of the hypopharingeal mucosa, phlogosis of the tonsillar crypts and adenoid surface, hyperemia and hypervascularization of subglottic and tracheal mucosa. CONCLUSION: Although still preliminary our results represent an interesting starting point for further studies, because they underline the potentiality of NBI endoscopy in LPR evaluation and how this technology could improve the identification of reflux signs.

Emerging and re-emerging infectious disease in otorhinolaryngology.

SUMMARY: Emerging and re-emerging infectious disease in otorhinolaryngology (ENT) are an area of growing epidemiological and clinical interest. The aim of this section is to comprehensively report on the epidemiology of key infectious disease in otorhinolaryngology, reporting on their burden at the national and international level, expanding of the need of promoting and implementing preventive interventions, and the rationale of applying evidence-based, effective and cost- effective diagnostic, curative and preventive approaches. In particular, we focus on i) ENT viral infections (HIV, Epstein-Barr virus, Human Papilloma virus), retrieving the available evidence on their oncogenic potential; ii) typical and atypical mycobacteria infections; iii) non-specific granulomatous lymphadenopathy; iv) emerging paediatric ENT infectious diseases and the prevention of their complications; v) the growing burden of antimicrobial resistance in ENT and the strategies for its control in different clinical settings. We conclude by outlining knowledge gaps and action needed in ENT infectious diseases research and clinical practice and we make references to economic analysis in the field of ENT infectious diseases prevention and care.

Biofilm in voice prosthesis: A prospective cohort study and laboratory tests using sonication and SEM analysis.

OBJECTIVE: The objective of the study was to compare the biofilm growing pattern and its morphological extent on silicone and a teflon-like material using a sonication process and a Scanning Electron Microscope (SEM). DESIGN: A prospective cohort study and a laboratory study. SETTING: Otolaryngology -Head and Neck surgery Department and the Microbiology Institute. PARTICIPANTS: The participants included fifteen laryngectomised patients with phonatory prostheses, which were removed because of device failure, and two different kinds of phonatory prostheses from the laboratory (Provox 2 and ActiValve) that were artificially colonised by Candida albicans. MAIN OUTCOME MEASURES: Tracheo-oesophageal puncture (TEP) is currently considered the gold standard for post-laryngectomy voice rehabilitation. "Leakage" represents the most common cause of substitution and is generated by biofilm colonisation of the prosthesis by mixed mycotic and bacterial agents. New biomaterials have been developed that are deemed to be more resistant to the colonisation of micro-organisms and material deformation. RESULTS: The devices showed colonisation by mixed bacterial flora (Staphylococci 13%, Streptococci 9%, and Haemophilus influenzae 5%) and by yeasts (Candida albicans 12%). Moreover, we observed a different distribution of biofilm layers in Provox ActiValve (22.56%) compared to Provox 2 (56.82%) after experimental colonisation by the previously isolated Candida strain. CONCLUSION: Resident microbiological species from the upper airways unavoidably colonise the polymer surfaces, and no strategies have been effective except for the manipulation of the chemical-physical properties of the device's polymer. Our study confirms that Provox ActiValve, which is made with a fluoroplastic material (teflon-like), is less subject to in vitro colonisation by Candida, and thus showed a higher clinical resistance to biofilm and a longer lifespan. The sonication seems to significantly improve the knowledge of bacterial and mycotic flora in biofilm colonisation. The design of a device for the daily cleaning capable to reach and brush the oesophageal flange of the prosthesis preserving the valve mechanism could represent a practical and simple help in this still unsolved problem.

Comorbidities and recurrence of benign paroxysmal positional vertigo: personal experience.

OBJECTIVE: The aim of this study is to evaluate the correlation between clinical features of benign paroxysmal positional vertigo (BPPV) and age, sex, trauma, presence of one or more comorbidities such as cardiovascular, neurological, endocrinological, metabolic, psychiatric diseases. DESIGN: Retrospective review of medical records (chart review). STUDY SAMPLE: A total of 475 patients aged from 14 to 87 years, affected by BPPV. RESULTS: Recurrence of BPPV occurred in 139/475 patients (29.2%). The recurrence rate was significantly higher in female and older patients. Comorbidities were present in 72.6% of subjects with recurrent BPPV vs. 48.9% of patients with no recurrence (p < 0.01). Forty-two patients (8.8%) reported a cranial trauma as a triggering event. Post-traumatic patients showed a significantly higher persistence rate (45.2%) compared to patients affected by non-traumatic BPPV (20.5%). Recurrence rates are overlapping between the two groups. CONCLUSION: Our results confirm the association between recurrence of BPPV and age, female sex, and presence of comorbidities. The correlation is stronger in patients affected by multiple associated diseases; the most frequently involved pathologies are psychiatric disorders, followed by neurological and vascular diseases. Collecting a complete medical history is important for prognostic stratification and detection of potential underlying pathological conditions.

Drug-induced sleep endoscopy as a selection tool for mandibular advancement therapy by oral device in patients with mild to moderate obstructive sleep apnoea.

Nowadays oral appliance therapy is recognised as an effective therapy for many patients with primary snoring and mild to moderate obstructive sleep apnoea (OSA), as well as those with more severe OSA who cannot tolerate positive airway pressure (PAP) therapies. For this reason, it is important to focus on objective criteria to indicate which subjects may benefit from treatment with a mandibular advancement device (MAD). Various anthropometric and polysomnographic predictors have been described in the literature, whereas there are still controversies about the role of drug-induced sleep endoscopy (DISE) and advancement bimanual manoeuvre as predictor factors of treatment outcome by oral device. Herein, we report our experience in treatment of mild moderate OSA by oral appliance selected by DISE. We performed a single institution, longitudinal prospective evaluation of a consecutive group of mild moderate patients with obstructive sleep apnoea syndrome who underwent DISE. During sleep endoscopy, gentle manoeuvre of mandibular advancement less than 5 mm was performed. In 30 of 65 patients (46.2%) we obtained an unsuccessful improvement of airway patency whereas in 35 of 65 patients (53.8%) the improvement was successful and patients were considered suitable for oral device application. Because 7 of 35 patients were excluded due to conditions interfering with oral appliance therapy, we finally treated 28 patients. After 3 months of treatment, we observed a significant improvement in the Epworth medium index [(7.35 ± 2.8 versus 4.1 ± 2.2 (p < 0.05)], in mean AHI [(21.4 ± 6 events per hour versus 8.85 ± 6.9 (p < 0.05)] and in mean ODI [(18.6 ± 8 events per hour to 7 ± 5.8 (p < 0.05)]. We observed that the apnoea/hypopnoea index (AHI) improved by up to 50% from baseline in 71.4% of patients selected after DISE for MAD therapy. In the current study, mandibular advancement splint therapy was successfully prescribed on the basis not only of severity of disease, as determined by the subject's initial AHI, but also by DISE findings combined with results of gentle mandibular advancement manoeuvre allowing direct view of the effects of mandibular protrusion on breathing spaces in obstruction sites, and showing good optimisation of selection of patients for oral device treatment.

Uncommon surgical emergencies in neonatology.

Objective. Over the past decade, multiple factors have changed the pattern of neonatal surgical emergencies. An increase in prenatal screenings and the development of neonatal tertiary care centres have changed the clinical approach to these kids. Materials and methods. Between 1995 to 2011 were retrospectively reviewed 34 patients with diagnosis of uncommon rare neonatal surgical emergencies at our institute. We analyzed: sex, gestational age, weight at birth, primary pathology, prenatal diagnosis, associated anomalies, age and weight at surgery, clinical presentation, start of oral feeding and hospitalization. The follow-up was performed at 6,12, 24 and 36 months. Results. There were 21 male and 13 female. The gestational age ranged between 28 and 36 weeks. The weight at birth ranged between 700 and 1400 grams. Oral feeding was started between 4th and 10th postoperative day. The average hospitalization was about 70.47 days. To date, all patients have finished the followup. They are healthy. Conclusion. The outcome of the patients with uncommon surgical emergencies is different based on the etiology. Overall survival is generally good but is influenced by the associated anomalies.

Preoperative distraction in children: hand-held videogames vs clown therapy.

Anxiety in children undergoing surgery is characterized by feelings of tension, apprehension, nervousness and fear which may manifest differently. Postoperative behavioural changes such as nocturnal enuresis, feeding disorders, apathy, and sleep disturbances may stem from postoperative anxiety. Some Authors pointed out that over 60% of children undergoing surgery are prone to developing behavioural alterations 2 weeks after surgery. Variables such as age, temperament and anxiety both in children and parents are considered predictors of such changes.1 Studies were published describing how psycho-behavioural interventions based on play, learning and entertainment in preparing children for surgery, may reduce preoperative anxiety. Clown-therapy is applied in the most important paediatric facilities and has proved to diminish children's emotional distress and sufferance, as well as consumption of both analgesics and sedatives and to facilitate the achievement of therapeutic goals. The aim of our study was to evaluate the efficacy of clown-therapy during the child's hospital stay, with a view to optimizing treatment and care, preventing behavioural alterations and enhancing the child's overall life quality.

Hyoid myotomy without suspension: a surgical approach to obstructive sleep apnoea syndrome.

The aim of this study was to verify if hyoid myotomy without hyoid suspension is effective in surgical treatment of obstructive sleep apnoea syndrome (OSAS). We recruited six patients with OSAS, aged between 34 to 60 years, with retropalatal and retrolingual upper airway obstruction, non-obese (BMI < 27) and non-compliant to continuous positive airway pressure therapy. Pre-surgical clinical and instrumental evaluations included clinical examination, cephalometry, polysomnography (PSG) and sleep endoscopy. Surgical treatment included nasal surgery, uvulopalatopharyngoplasty, tonsillectomy and hyoid myotomy without hyoid suspension. Follow-up evaluations were performed with serial PSGs, performed early (one week after surgery), and at 1, 6 and 18 months after surgery. We observed that surgery was followed by immediate normalisation of breathing parameters evaluated by PSG that persisted after 18 months. Thus, hyoid myotomy without suspension combined with nasal and palatal surgery may be considered a valid treatment of non-obese OSAS patients with retrolingual and retropalatal collapse. Furthermore, we suggest that hyoid bone suspension, binding it to mandibular or to thyroid cartilage, might be unnecessary in selected cases.

The role of drug-induced sleep endoscopy in the diagnosis and management of obstructive sleep apnoea syndrome: our personal experience.

Nowadays, drug-induced sleep endoscopy (DISE) is performed widely and its validity and reliability has been demonstrated by several studies; in fact, it provides clinical information not available by routine clinical inspection alone. Its safety and utility are promising, but still needs to be improved to reach the level of excellence expected of gold standard tests used in clinical practice. Our study compares the results of clinical and diagnostic evaluation with those of sleep endoscopy, evaluating the correlation between clinical indexes of routine clinical diagnosis and sites of obstruction in terms of number of sites involved, entity of obstruction and pattern of closure. This study consists in a longitudinal prospective evaluation of 138 patients who successfully underwent sleep endoscopy at our institution. Patients were induced to sleep with a low dose of midazolam followed by titration with propofol. Sedation level was monitored using bispectral index monitoring. Our results suggest that the multilevel complete collapse was statistically significantly associated with higher apnoea hypopnea index values. By including partial sites of obstruction greater than 50%, our results also suggest that multilevel collapse remains statistically and significantly associated with higher apnoea hypopnoea index values. Analyzing BMI distribution based on number of sites with complete and partial obstruction there was no significant difference. Finally, analyzing Epworth Sleepiness Score distribution based on number of sites with complete obstruction, there was a statistically significant difference between patients with 3-4 sites of obstruction compared to those with two sites or uni-level obstruction. In conclusion, our data suggest that DISE is safe, easy to perform, valid and reliable, as previously reported. Furthermore, we found a good correlation between DISE findings and clinical characteristics such as AHI and EPS. Consequently, adequate assessment by DISE of all sites of obstruction is very important, not only in patients with low-moderate AHI and EPS, but also in patients with a high AHI or/and high EPS, in particular to plan multilevel surgery that in these latter situations is more demanding since success may be harder to achieve.

Intrauterine volvulus with malrotation: prenatal diagnosis.

Volvulus is a very rare condition which consists of the rotation of the small intestine and the proximal colon around the superior mesenteric artery, leading to complete intestinal obstruction and ischemic vascular damage. The frequency of this condition is 1 in 6000 live births. We report a case of midgut vovulus with malrotation with a prenatal diagnosis at the end of the week 33. We describe the importance of prenatal echotomographic diagnosis which offers the possibility of performing differential diagnosis. Additionally, it is important to remember that the prognoses of these patients depend on the length of remaining intestine, the location of the intestinal obstruction, the presence of meconium peritonitis, the possibility of associated malformations, but above all, on birth weight and level of prematurity.

Topical application of isosorbide dinitrate in patients with persistent constipation after pull-through surgery for Hirschsprung's disease.

AIMS: The aim of this study was to evaluate the anal manometric changes and the clinical effects after topical application of isosorbide dinitrate (ISDN) in patients with persistent constipation after pull-through surgery for Hirschsprung's disease (HD). METHODS: We studied 3 children (2 males and 1 female), aged 2, 3 and 5 years respectively, who had undergone the Soave-Boley surgical procedure for HD and who suffered from persistent constipation after operation. We performed a pre- and postoperative anorectal manometry study and we applied ISDN paste (1 mg/kg two times daily) in the anal region for three weeks. All patients were followed-up and re-evaluated at 1, 3, and 6 months. RESULTS: All patients showed an improvement of symptoms, with an average of 4 spontaneous evacuations per week. Prior to the topical treatment, the medium pressure was 115.6 mmHg (range 102 - 130 mmHg), the maximum pressure was 160 mmHg (range 145 - 175 mmHg), and the medium length of the high pressure zone was 1.8 cm (range 1.5 - 2.0 cm). At the 6 month follow-up, the medium pressure was 57.3 mmHg (range 52 - 61 mmHg, a decrease of 54.4 %), the maximum pressure was 98 mmHg (range 88 - 107 mmHg; a decrease of 38.7 %), and the medium length of the high pressure zone was 1.6 cm (range 1.4 - 1.8 cm; a decrease of 11.1 %). CONCLUSIONS: Topical treatment with ISDN is a valid therapeutic alternative to an anal myotomy in patients with persistent constipation after pull-through surgery for HD. However, a greater number of cases and a longer follow-up are necessary to confirm the validity of our experience.

[Enema-induced intestinal perforation. A case report]. / Perforazione intestinale da clisma di pulizia. Descrizione di un caso clinico.

Constipation is a frequent clinical condition in pediatric age, with a low frequency of evacuation and emission of voluminous and hardened stools. In the most serious cases enemas became necessary, and are usually carried out without trouble. Nevertheless, traumatic events of great importance can take place, leading the patient to urgent surgical observation. The clinical case of a girl suffering from birth from chronic constipation is reported. The girl underwent a colostomy according to Mikulitz's technique on the descending colon, due to a rectal perforation induced during an enema. After the re-canalisation and the contemporaneous resection of 18 cm of the dolicho-sigmoid colon (which was most likely the cause of chronic constipation) the girl presented a normal defecatory rhythm.

[Traumatic gut perforation (seat-belt syndrome): a case report]. / Perforazione intestinale da trauma addominale chiuso (seat-belt syndrome): descrizione di un caso clinico.

Seat belts have dramatically reduced the severity of traumas in car accidents. On the other hand, specific lesions have appeared, related to seat belt use. These lesions are defined as "seat belt syndrome". The Authors describe an intestinal medio-ileal perforation due to seat belts in a child.

Laparoscopic diagnostic exploration of the vaginal processus in the pediatric age. Preliminary experiences.

BACKGROUND: Laparoscopic surgical procedures, employed even in the paediatric age, bearing both diagnostic and therapeutic value, are currently used in the evaluation of peritoneal-vaginal duct patency during surgery for controlateral inguinal hernia or other diseases requiring opening of abdominal wall. METHODS: From January 1996 to December 2000, at the Department of Pediatric Surgery of the University of Siena a prospective study protocol has been performed to evaluate the effectiveness of laparoscopy versus traditional surgery in showing patency of peritoneal-vaginal duct. RESULTS: From our study we have been able to see how this laparoscopic procedure is well tolerated by children and parents, and is lacking in clinical complications. Patency of peritoneal-vaginal duct has been pointed out in 21.73% of cases. This result is in line with the international literature; in fact, the majority of authors have found a negative controlateral exploration in 50-80% of patients examined, thus confirming the uselessness of routine surgical controlateral inguinal exploration in hernia cases. CONCLUSIONS: The use of diagnostic laparoscopy in the study of peritoneal duct patency is a rapid and relatively easy technique, practically without intra- and peri operative risks. It allows an easy solution of the diagnostic doubt, without the need to necessarily perform a traditional explorative surgical procedure.

Relapsing acute pancreatitis due to duodenal duplication in an 8-year-old child. Case report.

The authors present the diagnostic and therapeutic evolution of a case of duodenal duplication complicated by acute recurring pancreatitis in a eight-year-old boy. Abdominal pain and vomiting represented important clinical signs associated with a previous history of inexplicable episodes of acute pancreatitis. Abdominal US scan and NMR were able to diagnose the duodenal duplication preoperatively. Initial treatment was conservative in the attempt to resolve the acute pancreatitis episode. Partial exeresis and derivation of the duplication in the duodenal lumen was subsequently performed. Diagnosis was confirmed by histological examination. Currently, at 6 months after intervention, the patient is clinically asymptomatic and negative at US scan follow-up.

[Idiopathic constipation in children: 10-year experience]. / La stipsi idiopatica in età pediatrica: 10 anni di esperienza.

Constipation is a frequent clinical disorder in pediatric age and it is often difficult to resolve without a suitable diagnostic and therapeutic approach. Parents and pediatrician often underestimate this pathology, reaching the specialist only when it has already shown its complications. In the Department of Pediatric Surgery of Siena, in the last 10 years, we have activated a study centre on constipation in the pediatric age and we have developed a diagnostic and therapeutic protocol to give indications on the type of constipation and the consequent therapy. The Authors report their experience on 174 children with chronic constipation. The patients underwent a scintigraphic colonic transit time evaluation by radionuclides, an enema and an anorectal manometry. Such examinations were able to divide patients into two groups: with colonic and rectal constipation. The management consisted in common dietetic, behavioural and pharmacological treatment at first and then of specific treatment (biofeedback, prokinetic, emicolectomy), according to the type. The follow up showed recovery or improvement in 83.53% cases, unchanged clinical condition in 8.57%, aggravation in 1.9%. The Authors conclude emphasising the importance of diagnostic techniques that allow to frame correctly the pediatric patient affected by constipation. Particularly the anorectal manometry can be considered a first level examination, able to identify rectal constipation; together with scintigraphic colonic transit time that individualizes colonic constipation. The right diagnosis will be able to give a suitable therapeutic treatment.

[Cervical lymphadenitis caused by mycobacteria. Our experience]. / Linfoadeniti cervicali da micobatteri. Nostra esperienza.

BACKGROUND: Mycobacterial infections are extremely complex diseases, either due to the various clinical manifestations, or to the various involved kind of mycobacteria, or to the different sensibility to antibiotics. The authors review retrospectively their series, evaluating the management of pediatric cervical lymphadenitis due to mycobacterical etiology. METHODS: From 1975 to 1998, at the Department of Pediatric Surgery of the university of Siena, 88 children were evaluated for laterocervical lymphadenopathy. Among these, 29 children, aged from 14 months to 13 years, were diagnosed as affected with lymphoadenopathy due to mycobacteria. Therapy of choice was the association of surgery and antibiotics. This behaviour allowed us to approach both advanced lesions, in active colliquation, and progressive ones. RESULTS: Results were unquestionably positive, with a complete resolution and good esthetical results in 93.2% of cases. In 6.8% of cases there was a recurrence, which required reintervention. CONCLUSIONS: On the basis of our series, we agree with the international literature in affirming that, in cases of mycobacterial lymphadenopathy, a combined antibiotic and surgical therapy is necessary. However, controversy about such a complex and difficult pathology is opened and unsolved.

[Epididymal anomalies in cryptorchism and in persistent peritoneo-vaginal duct]. / Anomalie dell'epididimo nel criptorchidismo e nella persistenza del dotto peritoneo-vaginale.

BACKGROUND: Various percentage incidences (36-75%) of the duct system morphologic alterations in cryptorchidism syndrome have been reported in the literature. Etiopathogenic factors, responsible for this syndrome, are yet to be specified, as is their correlation with testicular descent in the scrotum and peritoneal-vaginal duct regression. METHODS: In a prospective multicentric study we have documented seminal duct anatomy in 566 children, undergoing inguinal or scrotal surgical exploration due to acute scrotal syndrome (group A, "control group"), cryptorchidism (group B), and peritoneal-vaginal duct patency syndromes (group C), for a total of 726 testicles. On the basis of anatomical configurations, explored testicles have been subdivided into three groups: normal testicles (type I), suspension anomalies (type II), obstruction anomalies (type III). Prevalence of the above anatomical configurations in the various groups has been statistically evaluated by the chi 2 test. RESULTS: Results have highlighted a significant prevalence (p < or = 0.01) of severe duct system obstructive anomalies (type III) in children with cryptorchidism (group B) and in children with vaginal duct patency (group C). These results can justify the hypothesis of a close correlation between testicle embryologic migration process in the scrotal sac and seminal duct development; this latter seems furthermore correlated with peritoneal duct regression. CONCLUSIONS: The drawn conclusion is that duct system morphologic alterations in cryptorchidism, due to their seriousness and incidence, can condition final fertility capability.