Centripetal approach to the facial nerve in parotid surgery: personal experience.

There is particular interest in parotid surgery on account of the close relationship between the gland and the extrapetrous facial nerve. The seventh cranial nerve is generally located by means of an anterograde or proximal surgical identification technique aimed at identifying the facial nerve at its point of exit from the stylomastoid canal. There are very few reports in the literature on retrograde or centripetal identification techniques, which may be adapted to the morphology of the neoformation limiting surgical access, in order to isolate the nerve from its peripheral rami. The present report deals with personal clinical experience, describing a technique for retrograde detection of the facial nerve. Between 1990 and 2001, 313 parotid surgery procedures were performed at the ORL Clinic of the Università del Piemonte Orientale in Novara. In 308/313 cases, corresponding to 98% of the operations, the technique chosen for the identification of the extrapetrous facial nerve was anterograde, proximal or centrifugal; in 5 cases alone, retrograde or centripetal exploration of the orbicular branch was undertaken, on account of difficulty in locating the main trunk, due to the presence of a post-inflammatory fibrosis in three patients and a stylomastoid emergency, arising from a malignant neoformation, in the other two. The decision to resort to the identification of the orbicular nerve of the eye is supported by the regular course and adequate size of this facial branch in its peripheral area, which enable it to be easily located.

Acute complicated sphenoiditis in childhood. Case report and literature review.

In ENT practice, acute uncomplicated sphenoiditis is rarely diagnosed: very often diagnosis is involved for multiform and unspecific symptomatology, such as to sham nervous, visual and upper respiratory tract diseases. Only a careful differential diagnostics and an instrumental investigation consents to realise quickly a specific treatment, avoiding some complications, still frequent. This case-report, underlines that the polyspecialists' co-operation is necessary to make a correct diagnosis, and to avert important and dangerous complications into shapes of sphenoiditis.

[Bacteremia in tonsillectomy: Sluder's technique versus dissection. Preliminary results]. / Batteriemia in corso di tonsillectomia: tecnica di Sluder versus dissezione. Risultati preliminari.

Fifty-one patients undergoing elective tonsillectomy for recurrent acute tonsillitis, 21 by dissection tonsillectomy (41%), and 30 guillotine tonsillectomy (59%). Positive post-operative blood cultures were obtained in 22 patients (43%), but only 4 in the dissection group (19%) and in 18 of the guillotine group (60%). Streptococci (21.5%) and Staphylococci (9.8%) are the commonest organisms cultured. This data are suggestive for the necessity of an antibiotic prophylaxis before tonsillectomy.

Post-thyroidectomy superior laryngeal nerve injury.

Voice dysfunction after thyroidectomy may be caused by damage to laryngeal nerves or lesions to strap muscles with laryngo-tracheal movement impairment. Injury to an external branch of the superior laryngeal nerve (EBSLN) is sometimes difficult to recognize clinically and its electromyographic incidence ranges from 0% to 58%. In this study we evaluated, 12-18 months postoperatively, 45 patients who had undergone thyroid surgery (6 total lobectomy, 5 subtotal thyroidectomy, and 34 total thyroidectomy), using a subjective interview, laryngeal videostroboscopy and spectrographic analysis with a multidimensional voice program. Vocal parameters included fundamental frequency, jitter, shimmer, noise-to-harmonic-ratio (NHR) and degree of sub-harmonics. Laryngeal electromyography (LEMG) of the cricothyroid (CT) muscles was performed in 21 subjects with voice problems (35 EBSLNs) using a modified method for the CT recording. In 3 patients of this group (14%) LEMG documented a unilateral EBSLN injury. Easy voice fatigue and decreased pitch range were the most common symptoms after surgery. Average values of vocal parameters pre- and postoperatively in patients without neural damage (n = 42) were: jitter 0.64% and 0.78%, shimmer 3.25% and 3.54%, and NHR 0.12% and 0.13%, respectively (P > 0.05). Acoustic analysis revealed altered patterns in some patients with no objective evidence of damage to EBSLNs, suggesting an extralaryngeal cause of vocal dysfunction, such as laryngo-tracheal fixation or lesions to strap muscles. We conclude that laryngeal videostroboscopy and spectrographic analysis are very useful to assess voice problems after thyroidectomy, including in patients without LEMG-proven neural lesions, in order to suggest early speech rehabilitation, especially in professional voice users.

[Complications in thyroid surgery]. / Le complicanze della chirurgia tiroidea.

Today, when performed applying stringent technique, thyroid surgery can be considered a procedure with low risk of post-surgical complications. Post-surgical hypoparathyroidism is frequent (1.6-53.6% of the cases) although most of these cases are temporary, linked to functional stupor of the parathyroid glands and/or other reversible factors. Analysis of the literature has shown that preservation of 3 or more parathyroid glands is a highly positive (95%) predictive factor for normal post-operative calcemia. The incidence of recurrent definitive paralysis ranges around 0.3-2% of the nerves at risk of iatrogeneous lesions and is usually correlated with thyroid histology and with the extension and type of ablative treatment performed. The authors retrospectively consider a 10-year case study of 218 patients (222 surgical procedures, of which 17 undergoing surgery twice) analyzing endocrinological, hemorrhagic and neurological complications and paying particular attention to any vocal dysfunctions arising at a later date, even in the absence of an ascertained neurological deficit. Considering 116 total and subtotal thyroidectomies, the percentages of acute hypoparathyroidism (AH) and definitive hypoparathyroidism (DH) were, respectively, 43.9% and 6%. Four of the 7 cases of DH presented one of the factors known to increate the risk of complications: malignant thyroid histology, second surgery and/or lymph node dissection. As regards neurological sequele, the authors report an incidence of recurrent definitive paralysis of 1.8% (3 out of 35 nerves at risk examined using EMG of the cricothyroid muscle). Spectroacoustic analysis of samples from 42 subjects showed an alteration in the vocal parameters considered (jitter, shimmer, NHR and DSH) in 14-27% of the cases, even in the absence of any laryngeal nerve deficit. It may be that iatrogeneous lesions and/or scarring of prethyroid strap muscles, known to play a role in phonation mechanisms, are implicated in determining post-thyroidectomy vocal dysfunctions, seen even in patients with anatomfunctionally intact laryngeal nerves.

[Cystic lymphangioma in the head and neck region]. / I linfangiomi cistici cervico-facciali.

Cystic lymphangioma or hygroma (CL) is a rare benign pathology of the lymphatic system characterized by multiple cystic, often non-communicating concamerations. Such lesions are most often seen in infancy and in 80% of the cases they appear within the first two years of life. They arise most commonly in the neck. CL usually tends to grow slowly and rarely regresses spontaneously. Infection and/or hemorrhage can lead to a rapid increase in size, possibly obstructing the initial portion of the upper aero-digestive tract. In the present study four patients (age range 12 months to 21 years) with head and neck CL, two with parotid primary site, were observed and treated by surgery. The lesions were studied using such imaging techniques as the color Doppler, CT and NMR. The latter permitted accurate pre-operative staging which is essential to defining and "mapping" the individual cystic concamerations. Surgery gave good results in 3 cases while in one case of multiple recurrences repeated post-operative sclerotherapy proved necessary leading to a partial reduction in the lesion. Despite the fact that numerous therapeutic options have been presented over the years, most authors today agree that the treatment of choice in cases of CL is surgery. Preparation for surgery must include accurate study with NMR, an indispensable technique for such pathologies as the T2 weighted sequences give very precise mapping. Surgical exeresis should be selective for the lesion while preserving the adjacent vascular-nervous structures.

[Indications and methods for rhino-pharyngo-laryngeal fibroscopy in children]. / Indicazioni e metodiche della fibroscopia rinofaringolaringea in età pediatrica.

Flexible rhinopharyngolaryngoscopy (RFL) has now definitively replaced rigid endoscopy in the diagnosis of VADS in children owing to its ease of use and handling, also in the case of patients who are not wholly cooperative. RFL also enables the morphology and laryngeal function to be evaluated in children without risks for the patient provided the operator complies with a few simple precautions during diagnosis. During elective diagnosis, the patient must be in a fasting state and must not present uncompensated coagulopathies. The main indications for RFL are dyspnea, dysphonia and stridor, given that the VADS regions can be easily displayed. The current limits of this method are the impossibility of allowing therapeutic interventions and the impossibility of passing beyond the glottic level without local anesthesia.

Angiosarcoma of the hypopharynx.

Angiosarcoma is a tumour of endothelial origin rarely found in the head and neck. A case of angiosarcoma of the pyriform sinus, treated by surgery and post-operative radiotherapy, is reported, providing a cue for discussion of the diagnostic, clinical and pathological peculiarities of the tumour in the light of personal experience and the published data.

Recovery time of the temporary threshold shift for delayed evoked otoacoustic emissions and tone bursts.

The recovery time of temporary threshold shift after 1-kHz tone bursts delayed evoked otoacoustic emissions (DEOE) after the same stimulus were studied after auditory fatigue (AF) with a pure tone (0.75 kHz, 10 min, 95 dB HL) in 20 normal-hearing subjects aged 19-23 years. Close similarities were observed in the two experimental conditions. Since DEOE are transmitted to the outer ear via structures independent of the fibers of the afferent acoustic pathway and their synapses, it may be supposed that changes in the motile activity of the outer hair cells caused by AF could be partly responsible for their production and could constitute an active intracochlear mechanism taking part in this phenomenon. It may also be supposed that the effects of this active mechanism could be superimposed on those produced by a passive intracochlear mechanism consisting of the traveling wave induced in the basilar membrane by the perilymph owing to the movements of the stapes.

Are delayed evoked oto-acoustic emissions (DEOE) solely the outcome of an active intracochlear mechanism?

Post-mumps and post-measles hearing losses are a result of the destruction of Corti's organ. Both the basilar and the Reissner membranes are unimpaired. In 11 subjects with post-mumps (8 cases) and post-measles (3 cases) unilateral anacusis, DEOE with a mean amplitude lower than that of the contralateral normal ear with the same sensation level were observed with 0.5, 1 and 2 kHz tone-bursts and air conduction stimulation. These findings lend credit to the view that DEOE could in part be produced by a passive intracochlear mechanism, probably a consequence of the basilar membrane travelling wave induced by the displacement of the perilymph. In a normal ear, this passive mechanism could be superimposed by an active mechanism linked to the contractile activity of the outer hair cells (OHC) which modulates and increases the travelling wave depth.

Delayed oto-acoustic emissions evoked by bone-conduction stimulation: experimental data on their origin, characteristics and transfer to the external ear in man.

1) BCEOE have been obtained in subjects with normal hearing by 1 kHz tone-bursts; 2) the morphology of BCEOE varies from one subject to another, and is stable over the course of time. BCEOE do not display a linear relation between their amplitude and the intensity of the stimulus, whose spectral composition is the same as theirs; 3) by contrast with ACEOE, whose mean threshold is the same as that of the subjective tonal threshold for the same stimulus presented by the same stimulation modality, BCEOE threshold, on overage, is about 10 dB HTL higher; 4) this difference in threshold is not due to interference on the part of the controlateral ear, via the efferent fibres, since it is also observed in persons with unilateral anacusis. It is probably the outcome of unilateral competitive inhibition between two stimuli presented to the same ear at the same time. By bone-conduction stimulation in fact, when the meatus is occluded by the probe, as in our experimental situations, Corti's organ is reached by a supplementary contingent of mechanical energy generated by the vibration of the bony part of the meatus and transmitted by air conduction; 5) ACEOE cannot be obtained in otosclerotic subjects whereas they appear after surgery. BCEOE are obtained before surgery and increase in amplitude post-operatively; 6) the findings mentioned in point 5) clearly demonstrate that the ossicular chain plays an important, but not an essential role in the transfer of EOE from the inner to the external ear.

Damage risk from personal cassette players.

Studies of the listening habits of personal cassette player users have been carried out in both Southampton and Turin. The results have been compared with other researches carried out independently in London and Nottingham. Patterns of noise exposure have been examined and estimates of hearing damage risk hypothesised. Habitual users of such devices could suffer adverse effects and should be aware of the symptoms associated with temporary threshold shifts in hearing.