Sino-Nasal Anatomical Variations in Rhinogenic Headache Pathogenesis.

Rhinogenic headache (RH) is a widespread pain syndrome but its pathogenesis and treatment are still unclear. Some authors recognize a correlation between RH and mucosal contact points or some other sinonasal anatomical variations. The authors conducted a retrospective case-control study to analyze the correlation between radiological findings and clinical symptoms.One hundred-nineteen adults with Para-Nasal Sinuses Computed Tomography (PNS-CT) scans were included: 64 patients who have originally undergone PNS-CT scan as part of rhinogenic headache workup (Group A), and 55 controls in whom PNS-CT scans were obtained for other purposes (Group B). All subjects were asked to report their symptoms using a headache scoring system. PNS-CT scans of all subjects were analyzed for presence of mucosal contact points, middle turbinate concha bullosa (MTCB) and frontoethmoidal cells.The most common anatomical abnormality found in our series was MTCB, reported in 60.9% of patients in Group A and 41.8% of those in Group B. A statistically significant prevalence was found in Group A compared to Group B regarding the presence of MTCB (P = 0.037) and Type II (P = 0.016) and Type III (P = 0.039) frontoethmoidal cells. No statistically significant difference (P >0.05) was found between Group A and Group B regarding the presence of mucosal contact points at each site.Multiple anatomical variations in nasal and paranasal sinuses may cause a rhinogenic headache with different characteristics. Some of these, such as concha bullosa of middle turbinate or type II and III Kuhn cells, have shown a significant association with rhinogenic headache. No statistically significant association was found between presence of headache and mucosal contact points and type I and IV frontal cells. These findings can be very helpful for the surgeons that want to deal with the treatment of RH.

Transnasal approach to the orbital apex and cavernous sinus.

OBJECTIVES: The aim of this study was to provide the anatomic rationale for a transnasal approach to the orbital apex and cavernous sinus, and to evaluate its applicability and efficiency. METHODS: One hundred patients with lesions of the orbital apex, cavernous sinus, optic nerve, clivus, parapharyngeal space, infratemporal fossa, or pterygopalatine fossa were reviewed over a 10-year period. All patients underwent an endoscopic transnasal approach to the orbital apex and cavernous sinus. The surgical technique required a standard endoscopic sinus surgery set. The possible complications were recorded and classified as intraoperative or postoperative. RESULTS: There were complications in 8 cases: 4 intraoperative and 4 postoperative. The intraoperative complications included rupture of the internal carotid artery in 1 patient and cerebrospinal fluid leak in 3 patients. All intraoperative complications were resolved during surgery. The postoperative complications were transitory eyelid ptosis in 2 patients (resolved in 6 months) and transitory diplopia with immediate deficit of the medial rectus muscle in 2 patients (completely resolved in 1 month). CONCLUSIONS: With the use of this technique, the surgeon can precisely identify the position of the surgical instrument without losing his or her way, thereby significantly reducing the rate of complications.

Function preservation using transoral laser surgery for T2-T3 glottic cancer: oncologic, vocal, and swallowing outcomes.

Aim of this study was to retrospectively analyze oncologic and functional results of a cohort of T2 and selected T3 glottic tumors treated by transoral laser surgery (TLS). Eighty-nine patients affected by T2 and T3 glottic tumors were treated by TLS from 2005 to 2010 at an academic institution by Type V cordectomies using an "en bloc" or, more frequently, a "piece-meal" technique depending on a number of variables. Kaplan-Meier curves were used to evaluate 5-year overall, disease-specific survivals, local control with laser, and organ preservation rates. Univariate analysis of the impact of different variables was performed. At least 1 year after surgery, we examined: subjective voice evaluation by voice handicap index (VHI), perceptive analysis by GRBAS scale, objective measurements with multidimensional voice program (MDVP), swallowing assessment with the M.D. Anderson Dysphagia Inventory (MDADI), videonasal endoscopic evaluation of swallowing (VEES), and videofluoroscopy (VFS). Fifty-nine patients were pT2 and 30 pT3. The 5-year overall, disease-specific survivals, local control with laser, and organ preservation rates were 92.4, 98.7, 68.5, and 82.1 %, respectively. VHI mean score was 20 (mild dysphonia). Mild and moderate dysphonias were detected by GRBAS in 82 and 18% of patients, respectively. Mean values of Jitter, Shimmer, and noise-to-harmonic ratio by MDVP resulted 7.87%, 24.8%, and 0.37, respectively. Mean value of MDADI was 95.75. Only 2% of patients at VEES and 4% at VFS showed tracheal aspiration. Our results highlight that T2 and selected T3 glottic tumors treated by TLS have favorable oncologic and functional outcomes.

Acoustic features of voice in patients with severe hearing loss.

OBJECTIVE: The aim of this study was to evaluate changes in the acoustic features of voice in patients with sensorineural hearing loss. DESIGN: Thirty male patients, between 35 and 53 years of age with postlingual bilateral symmetric severe sensorineural hearing loss, were included (group A). As a control group (group B), 30 normal-hearing male adults, aged 38 to 51 years, were identified. SETTING: ENT Department, University of Genoa (Italy). METHODS: Phonetically balanced sentences and sustained vowels a, e, and i were digitally recorded with the Multidimensional Voice Program (Kay Elemetrics) in all subjects. MAIN OUTCOME MEASURES: The parameters estimated were the average of fundamental frequency (F0), jitter percent (jitter), shimmer, noise to harmonics ratio (NHR), voice turbulence index (VTI), soft phonation index (SPI), degree of voicelessness (DUV), degree of voice breaks (DVB), and peak amplitude variation (vAm). RESULTS: Compared to the control group, in group A, the following acoustic parameters presented a statistically significantly higher value (p < .05) of F0 (137.2 Hz vs 120.0 Hz), jitter (1.93% vs 0.67%), shimmer (6.67% vs 3.81%), NHR (0.19 vs 0.10), SPI (12.9 vs 8.76), DVB (2.12% vs 0.01%), DUV (9.53% vs 0.51%), and vAm (23.12 % vs 12.06%). In group A, F0 was also significantly higher in the balanced sentences (126 Hz vs 111 Hz). CONCLUSIONS: This study demonstrates that hearing loss affects voice production by changing its parameters, especially in subjects with marked hearing loss.

Efficacy and safety of ribosome-component immune modulator for preventing recurrent respiratory infections in socialized children.

Attending day care is associated with recurrent respiratory infections (RRIs) and asthma. Ribosomal immunotherapy may confer protection against RRIs in children. This study was designed to assess the efficacy of a ribosome-component immune modulator (RCIM) as preventive treatment of respiratory infections in socialized children aged ≤5 years, with or without a history of frequent RRI. In a multicenter, Italian, randomized, double-blind, placebo-controlled, parallel-group study, 164 socialized day care center children (mean age, 3.8 ± 1.1 years) were treated with RCIM or placebo for 6 months and followed-up for additional 6 months. Outcomes are presented for the intent-to-treat population. In socialized children with five or less RRIs (n = 95; 49 RCIM and 46 placebo, group A) the duration of the infectious episodes was significantly shorter with RCIM than with placebo (6 months, 3.7 ± 2.1 versus 4.5 ± 1.9 days, p = 0.040; 12 months, 3.6 ± 2.0 versus 4.7 ± 2.5 days, p = 0.015). The proportion of patients reporting no respiratory infectious episodes with RCIM at 6 and 12 months was also significantly larger in group A (20.4% versus 4.4% placebo; p = 0.028). No such differences were found in children with more than five RRIs in the preceding year (n = 63; 32 RCIM and 31 placebo, group B). In all children, general well-being improved significantly more under RCIM than under placebo (11.6 ± 1.8% versus 10.2 ± 1.8%; p = 0.002). No statistically significant between-treatment differences were observed for other end points. Both treatments were similarly well tolerated. Six-month treatment with RCIM effectively prevented the 12-month risk of RRIs in children <5 years old and with five or less RRIs in the preceding year.

Ribosomal therapy in patients with pharyngolaryngeal reflux.

CONCLUSIONS: Our data confirm the induction of specific and nonspecific immune responses of the upper respiratory tract mucosa and the consequent improvement of its physiology, through an oral ribosomal therapy in patients with pharyngolaryngeal reflux disease (PLRD). OBJECTIVES: The aim of this study was to investigate the efficiency and applicability of oral ribosomal immunotherapy in adult patients with PLRD. METHODS: One hundred adult patients with PLRD were enrolled. The patients were equally divided, at random, into two groups (A and B): group A patients underwent ribosomal prophylaxis with Immucytal® (one tablet daily, 8 days a month for 3 months), while group B received a placebo (same dosage for the same period). At the beginning, at the end, and 6 months after the beginning of the therapy, all patients underwent medical history, ENT examination, nasal-pharynx-laryngoscopy with optic fiber, plasma levels of immunoglobulins class E, A, G, M, subjective assessment of symptoms on a 10 cm visual analog scale (VAS), reflux symptoms index, and reflux finding score. RESULTS: At the end and 6 months after the beginning of the treatment, all the patients in group A presented a significant (p < 0.05) improvement of almost all the different items analyzed.

Audiometric characteristics in patients with noise-induced hearing loss after sodium enoxaparin treatment.

OBJECTIVES: The aim of this study was to evaluate the effect of sodium enoxaparin treatment on patients with noise-induced hearing loss. METHODS: Sixty patients with noise-induced hearing loss were included and randomly divided into two numerically equal groups. Group A underwent therapy with sodium enoxaparin for 10 days, followed by an additional 10 days of treatment after 10 days of no treatment. Group B received placebo as a control. Before treatment, at the end of treatment, and 2 months after the end of treatment, all patients underwent evaluation by laboratory tests, pure tone audiometry, transient evoked otoacoustic emissions (TEOAEs) testing, distortion product otoacoustic emissions (DPOAEs) testing, and auditory brain stem response testing. RESULTS: In contrast to group B, at the end of the treatment in group A pure tone audiometry showed a significant (p < 0.05) improvement of the audiometric thresholds at 0.5, 1, 2, 4, and 8 kHz. Depending on the air and bone conduction thresholds, TEOAEs and DPOAEs, which had previously been absent, were evoked at the frequencies examined. These improvements were confirmed at last follow-up. We found no significant differences in auditory brain stem responses or laboratory results. CONCLUSIONS: These preliminary data encourage further studies to collect additional evidence on the effect of sodium enoxaparin in preventing the development of noise-induced hearing loss.

Efficacy of a topical suspension of bacterial antigens for the management of chronic suppurative otitis media.

The aim of this study was to compare the efficacy and safety of a topical suspension of bacterial antigens for the management of chronic suppurative otitis media (CSOM). Two-hundred ten patients with CSOM were enrolled in this study. The patients were divided into two numerically equal groups and randomized to receive a topical suspension of bacterial antigens, Lantigen B (group A), or placebo (group B), according to the following protocol: 5 drops thrice a day for 12 consecutive weeks in the external acoustic duct. The topical suspension of bacterial antigens and placebo were administered by identical, anonymous dispensers in order to maintain double-blind conditions. Before, at the end and 3 months, and after the end of the treatment, all patients who entered in the study underwent pure tone audiometry, microscopic examination of ears, microbiological examination of the ear swab, aural suctioning and subjective assessment of symptoms by visual analog scale. In group A, we saw a statistically significant improvement in the different items measured. A topical suspension of bacterial antigens was significantly more effective than placebo in the treatment of CSOM.

Day-case stapedotomy: is it a viable option?

CONCLUSIONS: Stapedotomy is, in our opinion, the technique of choice in stapes surgery. The precision of this technique allows clinicians to perform the surgical procedure in day surgery under local anesthesia. OBJECTIVES: There is a strong emphasis on increasing the number of elective day surgery cases, especially in the patients' best interest, as it decreases the likelihood of late cancellation and hospital-acquired morbidity. A prospective study was performed to determine whether stapes surgery for otosclerosis could be performed safely in an outpatient setting. METHODS: We present a series of stapes surgery cases for otosclerosis performed on a day-case basis. We performed a classic stapedotomy in 9 patients, a reverse classic step stapedotomy in 2 patients, a partial reverse classic step stapedotomy in 11 patients, and a hemi-stapedectomy in two patients. RESULTS: Three of 24 patients (12.5%) treated with classic stapedotomy, 1 patient with partial reverse classic step stapedotomy, and 1 patient with hemi-stapedectomy were formally admitted to the hospital after surgery (length of stay, 23 h). The indications were vertigo (two patients) and asthenia (one patient). These patients were treated under general anesthesia. Two of these patients resided more than 250 km away from the hospital.

Outcomes of uvulopalatopharyngoplasty with harmonic scalpel after failure of continuous positive airway pressure in sleep apnea syndrome.

CONCLUSIONS: Our data highlight that uvulopalatopharyngoplasty (UPPP) with harmonic scalpel (HS) is a reliable treatment in selected patients affected by obstructive sleep apnea (OSA) and users of continuous positive airway pressure (CPAP). OBJECTIVES: The aim of this paper was to verify the efficacy and applicability of UPPP with HS in the treatment of patients affected by OSA and users of CPAP. METHODS: A total of 21 patients with a retropalatal obstruction and users of CPAP underwent UPPP with HS and were evaluated (before and 6 months after surgery) using the apnea/hypopnea index (AHI); oxygen desaturation index ≥4% (ODI(4)); Epworth Sleepiness Scale (ESS); snoring level (SL); subjective assessment of the postoperative pain on postoperative days 1, 3, and 10; and number of days until return to solid food. RESULTS: Six months after surgery: AHI decreased significantly (p < 0.05) from 31.8 ± 2.83 to 9.0 ± 0.68; ODI(4) was 2.1 ± 0.4 vs a preoperative value of 24.0 ± 1.9; ESS scores were also significantly decreased (p < 0.05) from 14.0 ± 3.7 to 4.7 ± 2.2; SL was significantly lower (p < 0.05) 1.6 ± 0.3 vs 7.9 ± 0.8. Postoperatively, patients experienced lower levels of pain and the median of time to return to normal diet was 3 days.

Endoscopic transnasal cauterization of the anterior ethmoidal artery.

CONCLUSIONS: In our experience, the technique described can be applied independently according to the specific patient's anatomy and disease, allowing simple, easy, and safe identification of the anterior ethmoidal artery (AEA). OBJECTIVES: The aim of this study was to provide the anatomic rationale for endoscopic cauterization of the AEA and to present our surgical approach to AEA in the treatment of severe nasal bleeding. METHODS: A retrospective study reviewed 300 endoscopic transnasal AEA cauterizations, over a 20-year period from 1991 to July 2010, at the Instituto Felippu, Sao Paolo, Brazil. All surgeries were carried out under general anesthesia and with the help of a rigid 30° endoscope. RESULTS: The AEA was identified in all the patients treated. In 299 patients we found the AEA located at the level of the horizontal portion of the frontal bone into the anterior ethmoidal canal; in 88 (29.4%) of these patients the canal bone was partially open and in 211 (70.6%) it was completely closed. In only one patient, we found a dehiscent AEA. No patients presented short-term failure and/or long-term failure.

Deleterious sucking habits and atypical swallowing in children with otitis media with effusion.

OBJECTIVE: The aim of this study was to investigate the possible correlation between otitis media with effusion, bad sucking habits and atypical swallowing in children affected by otitis media with effusion. METHODS: 65 children, aged from 7 to 12 years, observed in the ENT Department of the "La Sapienza" University of Rome, were enrolled in the study group (group A). All children were affected by otitis media with effusion for more than 3 months. As control group, 60 healthy children, aged from 7 to 12 years were identified (group B). All the children underwent medical history, with evaluation of the sucking habits, ENT examination, tympanometry, orthodontic examination and evaluation of swallowing. In the orthodontic examination the variables analyzed were: maximum mouth opening, right and left mandibular lateral movements and mandibular protrusion. Atypical swallowing was considered to occur when lip activity produced strong tension in the perioral musculature, and/or the tip of the tongue was placed or pushed against the anterior teeth during swallowing. RESULTS: In the group A, atypical swallowing was found in 33/65 subjects out of the 65 children (50.7%). In the control group (group B) 16/60 children (26.6%) showed atypical swallowing. Compared with group B, deleterious sucking habits were significantly higher (p<0.05) in the study group (28/65 vs. 12/60). In both the study and control group, deleterious sucking habits were present in almost all children with atypical swallowing (28/33 in group A and 12/16 in group B). CONCLUSIONS: Our data suggest a correlation between otitis media with effusion, deleterious sucking habits and prevalence of atypical swallowing.

Potential nerve damage following contact with a piezoelectric device.

OBJECTIVES: The aim of the study was to assess the extent of the potential nerve damage following prolonged contact with a piezoelectric device. METHODS: The study was conducted with 30 patients; all of the patients had cervical metastatic lymph nodes at levels II, III, and IV (N2b) and a negative evaluation for metastatic disease (MO). The patients underwent radical neck dissection. After its skeletonization, the spinal nerve was exposed directly to ultrasonic activation with a piezoelectric device for various times (5, 10, and 20 seconds) and with different inserts (OP3 insert and OT7 insert). The axonal damage was graded from 0 to 3 as follows: 0, no damage; 1, minor axonal damage; 2, severe axonal damage but not covering the entirety of the nerve fascicles; 3, severe axonal damage covering the entirety of the nerve fascicles. RESULTS: Histologic examination showed no evidence of damage to the perineurium and axons after 5 and 10 seconds of exposure to ultrasonic activation with each insert. CONCLUSIONS: Our histologic data highlight the selective action of the piezoelectric device, which reduces the risk of accidental nerve damage in otolaryngological bone surgery.

A prognostic multigene classifier for squamous cell carcinomas of the larynx.

Survival after diagnosis of laryngeal cancer has not improved over the last 20 years. Selection of patients for radio- and chemotherapy or surgery or follow-up strategies based on a prognostic classifier could improve survival without unduly extending radical surgery. We performed microarray gene expression analysis and developed a four-gene classifier for laryngeal cancer using Prediction Analysis of Microarray and leave-one-out cross validation. A four-gene classifier containing the non-coding gene H19, the histone HIST1H3F and the two small nucleolar RNAs, SNORA16A and SNORD14C was developed that assigns cases to low and high risk classes. The high risk class has a relative risk of 6.5 (CI=1.817-23.258, Fisher exact test p<0.0001). The maternally imprinted gene H19 is the top classifier gene.

Nasal tactile sensitivity in allergic rhinitis.

CONCLUSION: These preliminary data show a decrease in nasal tactile sensitivity and point out interesting aspects of the nasal chronic inflammatory condition in allergic rhinitis. OBJECTIVES: The aim of this study was to evaluate the effects of allergic rhinitis on nasal tactile sensitivity during the intercritical period. METHODS: A total of 70 patients aged between 18 and 67 years (average 42 years), with a positive history of allergy caused by seasonal outdoor allergens, were included (group A). Patient outcome was assessed by the nasal monofilament test: a set of 20 Semmes-Weinstein monofilaments was used to detect nasal sensitivity for both nasal cavities. The sensitivity threshold was recorded as the minimum monofilament size with which patients could detect at least two of three stimuli. RESULTS: When compared to the control group (group B), subjects in group A required a significantly (p < 0.05) higher stimulus to trigger a touch response in the monofilament test, for both the inferior (195.1 ± 0.39 mg vs 67.7 ± 0.19 mg) and middle turbinate (108.7 ± 0.23 mg vs 67.7 ± 0.19 mg).

The role of three-dimensional CT in the evaluation of nasal structures and anomalies.

Traditionally, computed tomography (CT) is the primary radiographic method to analyze the morphology of the craniofacial bones: Because of the many overlapping anatomical structures, it is difficult and sometimes impossible to evaluate craniofacial bones three-dimensionally (3D) with these images. For this reason, the aim of this paper has been to evaluate and demonstrate the importance of CT scans integrated by three-dimensional reconstructions (3D-CT) volume rendering imaging for the accurate understanding of the nasal pyramid morphology in the evaluation of patients submitted to secondary rhinoseptoplasty. Twenty patients enrolled for a secondary rhinoseptoplasty, underwent a preoperative evaluation through 3D-CT volume rendering imaging. This technique allowed a prefect reconstruction of the nasal structures at the level of the valve, as well as the medial and lateral walls of the nasal fossa in all of its components (bone and cartilage). In our experience, the 3D-CT volume rendering imaging studies improve the preoperative evaluation of structures and anomalies which are hard to evaluate by the anterior rhinoscopy and/or nasal endoscopy: alar and lateral cartilages, interdomal distance, tip morphology, valvular configuration, loss of bone-cartilaginous substance, etc. All of these points are important during the preoperative planning of secondary rhinoseptoplasty.

Vestibular evoked myogenic potential in vestibular neuritis.

This study wants to show the diagnostic value of vestibular evoked myogenic potential (VEMP) in the diagnosis of vestibular neuritis (VN), independently of the caloric test results. Twenty patients were enrolled with acute vertigo caused by VN. VEMP was tested with the binaural simultaneous stimulation method. Surface electromyographic activity was recorded in the supine patients from symmetrical sites over the upper half of each sternocleidomastoid muscle, with a reference electrode on the lateral end of the upper sternum. During the acute attack, 8 days, 1 month and 3 months after the beginning of the acute attack, all the patients underwent the following examinations: Dix-Hallpike manoeuvre, Pagnini-McClure manoeuvre, head shaking test, pure-tone audiometry, tympanometry, caloric labyrinth stimulation according to the Fitzgerald-Hallpike method and VEMP. At the last visit, the 11 patients diagnosed with superior branch vestibular neuritis did not show any improvement at the caloric labyrinth stimulation and presented VEMP on both sides with normal amplitude and latency; in the 9 cases diagnosed with inferior branch vestibular neuritis, there was an improvement of the VEMP reflex and normal caloric test. Our experience highlights that VEMP recording is applicable for patients with VN as a screening test.

Comparison of postoperative pain: piezoelectric device versus microdrill.

Piezosurgery® is a recently developed system for cutting bone with microvibrations. The objective of this study was to compare the severity of pain over the first 10 postoperative days in a group of 70 patients who underwent intact canal wall mastoidectomy, with the piezoelectric device, and to compare the results with traditional method by means of microdrill (70 patients). The subjective perception of pain was evaluated on a scale from 0 to 10, such that 0 represented no pain and 10 represented maximum pain; the severity was recorded as null when the score was 0; slight, when it was 1-4; moderate, when it was 5-7; or severe, when it was 8-10. Compared with microdrill, the patients that underwent surgery with the piezoelectric device showed a significant (P < 0.05) lower postoperative pain on day 1 (52 vs. 26 patients presented a slight pain, 12 vs. 37 presented a moderate pain, and 6 vs. 7 presented a severe pain) and day 3 (68 vs. 44 patients presented a slight pain, 2 vs. 23 presented a moderate pain, and 0 vs. 3 presented a severe pain). These results highlight as the piezoelectric device is a safe and minimally invasive tool.

Water-soluble coenzyme Q10 formulation in presbycusis: long-term effects.

CONCLUSION: These findings provide the basis for understanding the duration of the effect after the last use of the drug and encourage a larger clinical trial to collect additional evidence on the effect of coenzyme Q10 (CoQ10) in preventing the development of hearing loss in subjects with presbycusis. OBJECTIVES: The aim of this study was to evaluate the long-term effects of a water-soluble formulation of CoQ10 (Q-TER) in subjects with presbycusis. METHODS: Sixty patients with presbycusis were included and divided at random into three numerically equal groups. For 30 days, group A underwent therapy with Q-TER, group B underwent therapy with vitamin E, and group C received placebo. Before, at the end, and 6 months after the end of the treatment, all patients underwent evaluation of pure tone audiometry, transient evoked otoacoustic emissions and otoacoustic products of distortion, auditory brainstem response, and speech audiometry. RESULTS: Compared with group B, at the end of the treatment in group A the pure tone audiometry showed a significant (p < 0.05) improvement of the audiometric thresholds at 1000, 2000, 4000, and 8000 Hz. This improvement was confirmed by the speech audiometry and last check. We found no significant differences in the other parameters and in group C.