Total intravenous anaesthesia in endoscopic sinus-nasal surgery.

Aim of this randomized study (64 patients) was to improve the control of bleeding during functional endoscopic sinusal surgery by means of controlled hypotension achieved through either total intravenous anaesthesia using remifentanyl and propofol (27 patients), or inhaled using isoflurane and fentanyl (37 patients). The following parameters were monitored before administration of anaesthesia (T0), then after 15 (T1), and 30 minutes (T2): systolic, diastolic, and mean arterial pressure; heart rate; concentration of tele-exhaled carbon dioxide (PetCO2) and percentage of peripheral saturation of haemoglobin (SPO2); bleeding according to the Fromme-Boezaart scale at T2. Mean arterial pressure values were maintained between 60-70 mmHg throughout surgery. At T0, systolic arterial pressure, diastolic arterial pressure and mean arterial pressure values were seen to overlap in the two groups. Both types of anaesthesia were effective in reducing the pressure values of T0-T1 and T1-T2 trends (p<0.0001). Systolic arterial pressure at T1 is lower with total intravenous anaesthesia compared to isoflurane and fentanyl (p=0.02). PetCO2 and heart rate show a decreasing trend independently of the type of anaesthesia employed. In conclusion, the hypotensive effect of total intravenous anaesthesia and of isoflurane and fentanyl is equivalent, but only total intravenous anaesthesia is effective in reducing bleeding during functional endoscopic sinusal surgery.

360-Degree canalith repositioning procedure for the horizontal canal.

OBJECTIVES: To evaluate the efficacy of modifications to the standard canalith repositioning procedure (CRP) in the treatment of benign positional vertigo (BPV) of the horizontal semicircular canal (HSC). STUDY DESIGN AND SETTING: Prospective trial of 72 patients with BPV of the HSC treated with a modified 360-degree CRP. RESULTS: 51 of the 62 patients treated for canalolithiasis made a complete recovery (82.2%) after a single 360-degree CRP. CONCLUSIONS AND SIGNIFICANCE: It is proposed a full 360-degree rotation of the HSC involved. It is essential to begin rotation of the patient departing from the affected side towards the healthy side, especially for canal side cupulolithiasis and for canalithiasis of the ampullar branch of the HSC. The head resting on the chest at angle of 30-degree during rotating encourages free-floating debris in the HSC to move into the utricle. Instead of using an oscillator for oscillation of the mastoid bone the head is shaken manually.

Test-retest reliability of the VOR as measured via Vorteq in healthy subjects.

To determine the reliability of the vestibolo-ocular reflex test measured via Vorteq, 16 subjects underwent head-autorotation test at the frequencies 1-5 Hz. All patients underwent the re-test. No linear correlation was observed between the measurements, i.e., no repeatability of the same measurements at the various frequencies. The Head Auto-Rotation Test by Vorteq has demonstrated advantages: patients are not disturbed by the active head movements; the full test protocol, lasts only a few minutes; the method enables the vestibolo-ocular reflex to be evaluated at high head-rotation frequencies. However, the test has disadvantages: poor test-retest inter-individual repeatability, wide standard deviations of results with heterogeneous inter-individual spread with regard to phase and asymmetry values especially at high rotation frequencies. In the light of the above findings, it can be seen that the test-retest of the Vorteq system is not sufficiently reliable and hence cannot be used in clinical practice.

Betahistine dihydrochloride in the treatment of peripheral vestibular vertigo.

The present study compares the efficacy and safety of betahistine dihydrochloride to that of a placebo in recurrent vertigo resulting from Meniere's disease (MD) or in paroxysmal positional vertigo (PPV) of probable vascular origin. The design was double-blind, multicentre and parallel-group randomised. Eleven Italian centres enrolled 144 patients: 75 of the patients were treated with betahistine (41 MD/34 PPV) and 69 with placebos (40 MD/29 PPV). The betahistine dosage was 16 mg twice per day for 3 months. Compared to the placebo, betahistine had a significant effect on the frequency, intensity and duration of vertigo attacks. Associated symptoms and the quality of life also were significantly improved by betahistine. Both the physician's judgement and the patient's opinion on the efficacy and acceptability of the treatment were in agreement as to the superiority of betahistine. The effective and safe profile of betahistine in the treatment of vertigo due to peripheral vestibular disorders was confirmed.

Usefulness of virtual endoscopic three-dimensional reconstructions of the middle ear.

This work uses a new programme for producing 3D radiological images acquired by means of CT which enables the internal surfaces of the examined structures to be visualized. This new method, which is able to navigate inside organs in a similar way to fibreoptic endoscopy, is known as virtual endoscopy. CT examinations of the temporal bone were carried out using spiral equipment and endoscopic 3D processing was carried out on a separate workstation equipped with a volume-rendering programme. Once the technical parameters necessary for obtaining a representation of the internal surfaces had been defined, a simulation of a virtual otoscopy was conducted by moving the virtual endoscope from the external auditory canal through the annulus to the tympanic cavity. The simulation can be obtained either by moving the endoscope by hand, using the mouse, or by defining a path along which the software automatically creates an endoscopic 3D reconstruction. The images thus obtained are projected sequentially to give a "movie" effect, i.e. a continuous progression of the endoscope. The average time required to conduct the procedure ranges from 20 to 30 min. A virtual endoscopic visualization of the middle ear was obtained which, in particular, generated images of the tympanic cavity with the ossicular chain. In our experience, virtual otoscopy shows the anatomy of the structures of the tympanic cavity in excellent detail and may be considered complementary to CT, providing useful images enabling better visual representation and understanding of this complex structure. Although clinical applications of the technique remain to be defined it may have a role to play in presurgical diagnostic evaluation of the ossicular chain, epitympanum and retrotympanum.

Surgical treatment of tracheostomal stenosis.

HYPOTHESIS: Stenosis of the tracheostome is a frequent complication following total laryngectomy; the problems created by tracheostomal stenosis are the result of reduced airflow and consequent turbulence. Many authors have studied etiological factors for the onset of stomal stenosis, and a number of procedures have been recommended for the surgical correction of such stenosis. STUDY DESIGN: A prospective analysis of 12 patients who underwent surgical correction of stomal stenosis is presented. METHODS: At the Institute of Clinical Otolaryngology we have recently defined a surgical technique for the correction of stomal stenosis that combines radial incisions, V-shaped flaps, and interposing flaps. This technique enables us to correct all the types of stenosis, and we have treated 12 patients to date. RESULTS: To date, the average follow-up has been 17 months (range, 3-36 mo), and the results are encouraging. Early stenosis of the tracheostoma reappeared in one patient, who had successful repeat surgery with the same technique. CONCLUSIONS: Early results suggest the routine use of this surgical technique in the treatment of stomal stenosis.

Benign positional vertigo without detectable nystagmus.

OBJECTIVES: To demonstrate that for treatment of benign positional vertigo it is not necessary to identify a positional nystagmus. STUDY DESIGN: Prospective trial of 43 patients with positional vertigo without clinical evidence of positional nystagmus who were treated with a modified canal-repositioning maneuver. METHODS: Results were compared with the results obtained in the treatment of posterior semicircular cupolo-canalithiasis with typical positional nystagmus with the same repositioning maneuver. RESULTS: Treatment of 43 patients with positional vertigo without positional nystagmus resulted in a 60.46% (26/43) complete recovery rate and a 6% (3/43) persistence of disorder rate compared with a 90% complete recovery rate obtained in 90 patients with typical benign positional paroxysmal vertigo (with positional nystagmus). CONCLUSIONS: What is attempted by this work is to confirm that through clinical evaluation based on history and positioning tests alone, one can obtain acceptable results in treatment of supposed canalithiasis without having detected the pathognomonic nystagmus.

External osteotomy in rhinoplasty.

OBJECTIVES: To compare external and internal lateral osteotomy in rhinoplasty. STUDY DESIGN: Retrospective review and study on cadavers. METHODS: One hundred forty-two patients who underwent aesthetic rhinoplasty were examined. The following criteria were taken into consideration: edema and ecchymosis around the eyes, the degree of closure of the roof, symmetry and level of fractures, solidity of the bone pyramid, and any scarring at the access point of the osteotome. In the last 25 patients who had surgery, a nasal endoscopy with optical fibers was carried out to evaluate any damage to the mucosa caused by the 2-mm osteotome. Furthermore, to compare the two routes in vivo, for five of these patients a lateral osteotomy was carried out externally for one side and internally for the other. Lateral osteotomy were performed on five cadavers by an external route on one side and by an internal one on the other. A midface degloving procedure was performed to expose the osteotomy sites. RESULTS: Edema and ecchymosis were always much less severe in patients who were treated with external osteotomy. The control of the fracture line was always excellent. Endoscopic evaluation and study on cadavers revealed damages to the mucosa caused from the internal osteotomy and a better control of fracture line in external osteotomy. CONCLUSIONS: External osteotomy is an easy and precise approach. Because the fracture is of a greenstick type, the bone stumps are stable. The reduced bleeding reduces the formation of edemas and ecchymosis around the eyes. The damage to the nasal mucosa is minimal, and the cutaneous scars are virtually invisible a month after surgery.

[Bilobed flap in the reconstruction of cheek defects]. / Il lembo bilobato nella ricostruzione dei difetti della guancia.

The bilobed flap is a reliable means for the reconstruction of facial defects in one stage. This reconstruction technique has been applied on a 69-years-old man affected by carcinoma of the cheek, involving overhanging skin and underlying oral mucosa. Stensen's duct reconstruction was also performed with a vein graft and, 8 months later, deviation of the rima oris was corrected by inserting a goretex strip at the level of the upper lip elevator muscle. The present work considers the bilobed flap as a means for cheek defects reconstruction compared with other reconstruction techniques.

Modified particle repositioning procedure.

OBJECTIVES: To evaluate the efficacy of modifications to traditional particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo. STUDY DESIGN: Prospective trial of 118 patients with cupolocanalithiasis of the posterior canal treated with three different canal-repositioning techniques. METHODS: Results were compared with the maneuvers employed and the statistical importance of rotating patients by 360 degrees along their longitudinal axis and head shaking on reaching each single position were evaluated. RESULTS: Treatment of patients with our maneuver, which, in comparison with traditional repositioning maneuvers, was modified by breaking the procedure up into seven positions and rotating patients by 360 degrees along their longitudinal axis, gives a higher, but not statistically significant, number of treatment successes (84.5%) than the traditional Parnes maneuver (60%) (P = .154); treatment of a third group of patients with our modified particle repositioning maneuver with the addition of head-shaking on reaching each single position gives a higher (95.6%), statistically significant number of treatment successes than traditional Parnes maneuver (P = .00011). CONCLUSIONS: The success rates achieved from modified particle repositioning maneuvers are statistically significant. Onset or persistence of dizziness, which patients frequently complain of after liberatory maneuvers, affects only 5.6% of the patients treated. This low incidence is statistically correlated to head-shaking.

Oncological and functional results by horizontal glottectomy in laryngeal carcinomas.

BACKGROUND: The aim of this study is to describe the indications, surgical technique and results of horizontal glottectomy in laryngeal carcinomas. MATERIALS AND METHODS: Twenty patients suffering from differentiated glottal carcinoma (15 T1b and 5 T1a) were treated between 1985 and 1994. A classic horizontal glottectomy, with some modifications, not extended to the ventricular fold or to the arytenoid, was performed in every patient. All patients followed a postoperative rehabilitative program. Time of feeding tube removal, decannulation and voice production were considered. RESULTS: No local recurrence was recorded in any of the patients, however follow up on 4 cases was only three years. No postoperative radiotherapy was used. Two patients died from cardiovascular causes. Post-operative average times were: discharge from hospital after 10.5 days; feeding tube removal after 7 days; decannulation after 9.5 days. No major pulmonary complications nor laryngeal stenosis following surgery was recorded. In all patients adequate voice production was achieved. CONCLUSIONS: Our results show that horizontal glottectomy is a safe procedure in the treatment of laryngeal cancer. Local control of disease, provided case selection is very accurate, can reach 100%. Rapid and excellent laryngeal function may thus be obtained and the voice production is adequate in every patient.

Pre-operative evaluation of cervical adenopathies in tumours of the upper aerodigestive tract.

BACKGROUND: Carcinomas of the upper aerodigestive tract are characterized by a high incidence of local metastasis in the neck. The presence of lymph node metastasis represents the most unfavorable prognostic factor for these tumors. A diagnostic routine is needed in order to identify the highest number of neck metastasis, thereby optimizing the selection of patients eligible for surgical neck treatment and reduce costs and length of hospital stay. MATERIALS AND METHODS: Our study analyzes the sensibility, specificity, and diagnostic accuracy of clinical examination, echography (US), computed tomography (CT) in cervical metastasis detection by comparing them with the histopathological examination of the neck dissection specimens (pN) in 53 patients suffering from carcinoma of the upper aerodigestive tract. RESULTS: Clinical examination: sensibility 82.1%; specificity 80%; diagnostic accuracy 81.1%; US with a cut off point for minimal adenopathy diameter of 0.5 cm 92.8% sensibility, 60% specificity, 77.3% diagnostic accuracy; US with cut off point 1 cm 82.1% sensibility, 80% specificity, 81.1% diagnostic accuracy; US with cut off point 1 cm, also considering round shape or multiplicity of the adenopathy: 82.1 sensibility, 80% specificity, 81.1% diagnostic accuracy; CT with cut off point 0.5 cm: 92.8% sensibility, 32% specificity, 64.1% diagnostic accuracy; CT with cut off point 1 cm: 85.7% sensibility, 64% specificity, 75.4% diagnostic accuracy; CT with cut off point 1 cm, also considering central necrosis, extracapsular spread, multiplicity of the adenopathy 89.2 sensibility, 60% specificity, 75.5% diagnostic accuracy. CONCLUSIONS: By relating the results obtained from preoperative methods to the anatomopathological analysis of the surgical specimens we can draw the following conclusions: a) a neck positive to palpation in a subject with carcinoma of the upper aero digestive tract must be submitted to neck dissection. Such patients have an 81.1% likelihood of having a metastasis. In these patients the use of radiologic studies of the neck must be restricted to cases with uncertain involvement of retropharingeal, mediastinic, paratracheal lymph nodes or in the follow-up after treatment; b) a neck negative to palpation in a subject with carcinoma of the upper aero digestive tract, must be further investigated. The US and the CT must use a cut-off point of 1 cm to consider a neck positive. Radiologic criteria for malignancy, i.e., multiplicity, roundish shape, central necrosis and capsular invasion do not significantly increase the diagnostic accuracy of the radiographic methods; c) the combined use of US and CT does not offer significant advantages in the detection of metastasis, in any case CT is preferable when primary tumor has to be evaluated; d) the assessment of patients that are negative to palpation and to US and to CT must consider the parameters linked with primary tumor, such as site and size, Broder's grading, Invasive Cell Grading, and thickness.

[Treatment of sudden hearing loss]. / La terapia della sordità improvvisa idiopatica.

A total of 27 patients affected by sudden idiopathic deafness (SID) and 3 with sudden idiopathic anacousia (SIA) were treated within 10 days of onset of the disorder. The treatment consisted of intramuscular or per os administration of corticosteriods for 10 days and the simultaneous administration of carbogene for 5 days. At the 5th day of corticosonic treatment, if audiometry did not reveal complete recovery, the treatment was associated for 7 days with Destrane 500 ml. The cases included neurosensorial deafness of 30 dB or more over at least 3 adjacent frequencies and arising over a 12 hour period. Soft cord deafness was not included in the study. The following variables were analyzed: 1) patient age; 2) extent of the hearing loss: average tone threshold for the frequencies of 500 -1000-2000 Hz equal to or better than 70 dB HL (group A); tone threshold ranging between 71 and 89 dB HL (group B), tone threshold ranging from 90 to 110 dB HL (group C), anacousia (group D); 3) audiometric curve; 4) presence or lack of vertigo. After treatment 25 subjects (83%) indicated a recovery ranging from good to complete. It is significant that among this 83% there were 12 subjects, 9 with profound deafness and 3 with anacousia. The therapeutic association adopted made it possible to achieve two-fold activity: anti-edemagene and hemorheological. The most highly implicated etiology for SID was viral causing not only neural but also endothelial damage and leading to acute microcirculatory insufficiency.

Gentamicin ototoxicity: histological and ultrastructural alterations after transtympanic administration.

The histological and ultrastructural appearances of the inner ear vestibulum were studied after transtympanic administration of gentamicin in guinea-pigs. The animals were treated with a single transtympanic dose (0.2 cm3) of 4% gentamicin sulphate solution in the right ear; the left one was considered as control. After 7 days they were sacrificed and the vestibula of both inner ears were removed to be examined both by light and electron microscopy. In the treated inner ear damage was not always evident at light microscopical level, even if a case of complete disepithelialization of cristae ampullares was found. The examination by TEM revealed evident damage in the vestibular non-sensorial cells, such as severe cellular vacuolation, whereas sensorial elements presented heterochromatinic thickenings and cytoplasmic wrinkling, as compared to controls. The tunica fibrosa presented an irregular fibrillar plot, as well as that of the myelinic lamellae in the vestibular nerve fibres.

[Glandular tumors of the middle ear: a case of primary ceruminous adenoma]. / Tumori ghiandolari dell'orecchio medio: un caso di adenoma ceruminoso primitivo.

Primitive glandular neoplasms of the middle ear are a rare entity. Under this definition epithelial neoplasms are classified according to structure as adenomas or adenocarcinomas, with intact tympanic membrane. Review of the literature shows that four histopathological patterns can be identified among these neoplasms: adenoma, adenocarcinoma, ceruminous adenoma and ceruminous adenocarcinoma. The present work describes a case of primitive ceruminous adenoma of the middle ear (6 cases have been reported in the literature) discovered during exploratory tympanotomy performed on a presumed otitis media which had not responded to medical treatment. The case description is followed by a review of the literature on the subject. The rarity of such neoplasms arises from this review as well as the fact that the histogenesis of ceruminous neoplasms of the middle ear is not clearly defined. Further study is required and more reports need be made in order to establish the best therapeutic approach to such neoplasms. It is the authors' opinion that the term "ceruminoma" is a generic term and not a clear definition and that its use in labeling the most various neoplasms of the middle and external ear must be abandoned.

Prognosis and therapy of early acute idiopathic auditory failure.

The prognostic value of some otovestibular parameters was evaluated in 46 cases of acute idiopathic hypoacusis (AIH) and 12 cases of acute idiopathic anacusis (AIA) observed within 7 days of the onset. Recovery in AIH is predicted by some otoneurological parameters as mean pure-tone hearing threshold (PTA) for 500, 1,000 and 2,000 Hz, stapedial reflex and severe vertigo. None of these measures alone seems to have prognostic value. The expected recovery rate also is reflected in the various parameters taken as a whole. Subjects with mean PTA better than 70 dB HL together with stapedius reflex present for 500 and 1,000 Hz, no decay and no vertigo have a very favourable prognosis: 86% had complete or good recovery. On the contrary, subjects with mean PTA worse than 70 dB HL and with pathological stapedius reflex have a generally unfavourable prognosis: 35% had complete or good recovery. Vertigo as a symptom does not seem in itself to have an unfavourable prognostic value. Actually, patients with severe vertigo generally have a poor recovery. Vertigo as a symptom indeed is frequently associated with a more severe sensorineural lesion. Carbogen or heparin-dextran are not an effective treatment: complete-good global recoveries obtained in AIH without any treatment, with carbogen or with heparin-dextran were, respectively, 65, 68 and 62%. As a consequence, an early therapy with these substances has no apparent value. Patients affected with AIA have a very unfavourable prognosis. All of our patients with AIA had poor recovery. For the moment we feel it is easier to reach a satisfactory prognosis rather than to institute an effective or causal therapy in acute idiopathic auditory failure.

Temporal (phase and time) disparities in lateralization.

The topic of this paper concerns the judgement of just noticeable differences (JND) and of complete lateral position for dichotic 1 000-Hz stimuli with phase or onset time or delay differences and for a click. The 1 000-Hz sinusoids had 30 ms steady state with 10 or 50 ms rise/decay time and were presented at 50 dB HL in listeners with normal hearing. For every value of delta phi, delta onset or delay, the presentation consisted of blocks of 20 trials and the JND was determined as the phase or onset time or delay differences producing 80% of correct responses (forced choice). The intracranial 1 000-Hz tone image with long disparities was evaluated for 90, 180 and 270 degrees delta phi, for 250, 500 and 750 microseconds delta onset and for 250, 500 and 750 microseconds delay. Our results demonstrate that the interaural time differences with suitable headphone onset cues have a negligible effect on JND in pure-tone lateralization tests; the JND for a 1 000-Hz tone is based on phase cues only. With 180 and 270 degrees phase shifts, the interaural onset time differences, with 10 ms rise-fall time, become critical and override phase information. The JND for clicks on the contrary is based on time cue only. The intracranial click image with long disparities and duality threshold was evaluated.