Paroxysmal positional vertigo: the role of age as a prognostic factor.

Aim of this study was to examine possible relationships between several clinical aspects of paroxysmal positional vertigo and factors better defined as "intrinsic" to the patient, above all age. The disorder can affect essentially all age groups; nevertheless, the onset of age-linked degenerative processes, such as vascular damage, can have a negative influence--at least in theory--on the pathogenic mechanisms of cupulolithiasis or canalolithiasis. The study was based on the review of 566 patients with the typical form of paroxysmal positional vertigo. Based on age, the patients were divided into two groups, respectively < or =50 years and > 50 years. For the purposes of this study, a series of clinical-laboratory conditions associated with the risk of, or clear, vascular damage were also considered. The results indicate that if there are no clinical or case-history elements that can be attributed to an aetiological hypothesis, the clinical behaviour of paroxysmal positional vertigo is not affected by the age factor. However, the existence of generic vascular damage, hypothesised by the presence of the above-mentioned conditions, influences certain clinical aspects of the disorder, particularly recovery time, the trend of the active phase and the number of relapses. In conclusion, paroxysmal positional vertigo with a presumed vascular aetiology, the incidence of which increases with age, presents a worse prognosis, not only with respect to the "idiopathic" form in childhood but also the "idiopathic" type in the elderly. The lithiasic model responds well to pathogenic interpretation requirements, which envisage macular degeneration with a vascular component. However, the observation, via imaging, of diffuse ischaemic lesions in critical areas of the brainstem and the cerebellum in many "vascular" patients, does not exclude the possibility of alternative pathogenic mechanisms that, in the final analysis, can lead to compromised VOR on a central level.

Identifying congenital hearing impairment. Personal experience based on selective hearing screening.

If all degrees of permanent uni- or bilateral hypoacusis are taken into consideration, hearing impairment is the most common congenital disease. Early detection of permanent infantile hearing impairment has become extremely important in preventive medicine, since steps can be taken with hearing aids and rehabilitation to ensure better development of language and higher cognitive functions. Aim of this study is to provide a critical review of the time of diagnosis of hypoacusis at our audiology laboratory, where two methods were used to screen hearing of children with/without risk indicators. Results of approximately 10 years' work were re-examined during which time outpatient screening was conducted on children referred by colleagues in neonatology and paediatrics. All were carriers of congenital risk indicators associated with sensorineural and/or conductive hearing loss, based on the Joint Committee on Infant Hearing findings, or were suspected of being hypoacusic even if they had no known congenital risk factors. Hearing screening was conducted in hospital on newborns with no risk factors, within the first few days of birth. Results of the present study showed that when selective hearing screening was performed, the mean age of high-risk patients diagnosed with hypoacusis was slightly higher than that in international guidelines. Moreover, these patients represent approximately half the hypoacusic population identified in the study period. The other half of congenital hypoacusic subjects identified had no risk indicators and there was a significant delay in diagnosis due to later manifestation of symptoms indicating hypoacusis, and thus, in turn, delayed referral for hearing tests. In contrast, subjects without risk indicators who underwent in-hospital hearing screening and proved to be hypoacusic, were diagnosed early. In our experience, however, universal screening has considerable disadvantages, such as difficulty in covering the entire population, difficulty in follow-up after discharge from hospital, and last, but by no means least, significant organisational and professional commitments, making it impossible to perform in all hospitals. In order to ensure effective hearing screening for congenital hearing loss and, thus permit prompt identification of hypoacusic children, use of hearing aids and rehabilitation screening should incorporate two aspects. First, selection should be compulsory, thereby reducing waiting time between collecting case histories and performing outpatient tests; second, hospital screening of children without risk factors should be performed whenever possible. Integrating these two aspects would make it possible to approach the "utopia" of universal hearing screening.

Paroxysmal positional vertigo: short- and long-term clinical and methodological analyses of 794 patients.

Between 1995 and 2001, eight Italian clinical centres used the same diagnostic and therapeutic protocol in order to assess the clinical progress of paroxysmal positional vertigo and the benefits of an appropriate follow-up in prevention of relapse. The study population comprises 794 patients affected by paroxysmal positional vertigo. The study protocol comprised diagnostic staging including a complete otoneurological test, an anamnestic questionnaire aimed at identifying any possible risk factor, a blood test in basal conditions and monitoring of blood pressure. If necessary, more specific instrumental tests have been carried out. Appropriate rehabilitative manoeuvres were performed from 1 to 3 times within the same session. The patient was checked 3-5 days later: in the presence of a positive result, the treatment was repeated; if negative, patients were seen at clinical follow-up 7, 30, 180 and 365 days after recovery. Wherever possible, patients have been contacted 2 years after the first treatment and asked to answer a questionnaire and to attend for a clinical check-up. The incidence of paroxysmal positional vertigo appeared to be higher in females and in patients aged 50-70 years, being low in patients under 30. In 88.8% of cases posterior semicircular canals showed a significant involvement; in 6.8% of cases, only involvement of lateral semicircular canals; monolateral (2.7%) and bilateral (1.7%) multicanalar forms were rare. Paroxysmal positional vertigo forms involving posterior semicircular canals have been treated with Semont (simplified by Toupet), Epley, Parnes Price-Jones manoeuvres; those, involving lateral semicircular canals with Vannucchi-Vicini forced position and "barbecue" or Gufoni manoeuvre. Whilst all these manoeuvres were equally effective, longer recovery times have been observed in paroxysmal positional vertigo forms involving lateral semicircular canals when the Vannucchi-Vicini forced position was ineffective. Any relapses have been evaluated at least 15 days after a negative clinical pattern. Possible involvement of other semicircular canals (recurrence) some time after the first onset has been considered separately. Follow-up at 6 months showed recurrence in 12.4% of cases, while being chronic in 1.5% of cases. Only 9.3% of cases showed recurrence at 6 months, no statistically significant difference being observed between vertical (8.9%) and lateral canal (9.6%), forms. Relapses occurred in 3.1% of cases, in one third of which at least two risk factors were detected.

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.

Retrospective study on precancerous laryngeal lesions: long-term follow-up.

The classification and the most appropriate treatment of dysplastic lesions of the larynx continue to be controversial issues. Aim of present study was to evaluate the incidence of precancerous lesions of larynx, their potential to evolve in relation to grade of dysplasia, and the most appropriate treatment. The study is based on the review of a series of 207 patients (157 (75.9%) male, 50 (24%) female) with keratosis of the laryngeal epithelium, with or without dysplasia. Patients were divided into four groups, according to Friedmann's classification (1986), based on presence and grade of any dysplasia. The follow-up period ranged from approximately 7 to 16 years. With regard to progression of the disease, 159 of the 185 patients considered were cured following initial treatment (85.9%), whereas 26 (14.1%) had recurrences. Of the latter, 19 had a single recurrence and 7 had multiple recurrences. Progression to carcinoma occurred in a total of 12 cases, above all in patients with the highest grades of dysplasia. Results emerging from this study confirm not only that dysplastic lesions of the larynx have the potential to evolve into frankly malignant lesions, but also that this capacity to evolve is significantly correlated with grade of dysplasia of the covering epithelium. Therefore, the histological classification of precancerous lesions of the larynx, based on the presence or absence of atypical cells and on their severity, is clearly valid from a clinical standpoint, representing, above all, an important prognostic factor. As far as treatment is concerned, mucosal stripping at site of the lesion is considered to be the treatment of choice for precancerous lesions of the larynx. Nevertheless, in patients presenting keratosis with a higher grade of dysplasia, it is mandatory to consider more aggressive treatment.

[Ki67 and p53 in laryngeal epithelial lesions: correlations with risk factors]. / Ki67 e p53 nelle lesioni epiteliali della laringe: correlazione con i fattori di rischio.

Laryngeal carcinoma-the prototype of epithelial tumors in the head and neck region-has been the greatest source of information on the biological behavior of such neoplasms. Many Authors have suggested that smoke, and to a lesser extent alcohol, play a role in the genesis of this carcinoma although the exact biological mechanism for such involvement is still not clear. The present study analyzed two important biological indicators (p53 and Ki67) in benign and malignant epithelial lesions of the larynx in an attempt to obtain information on what mechanism correlates the risk factors with the neoplasm. In a group of 172 patients, an in vivo sampling of cells was taken during microlaryngoscopy. These cells were then tested using the immunocytochemical method and the results showed that the neoplastic tissue was significantly more positive to these markers than the pre-cancerous tissues and benign lesions. Moreover, there was also an interesting correlation between the degree of positivity to p53 and exposure to smoke, and to a lesser extent to alcohol, in the oncological patients. Together with other similar results found in the literature, these results hint at a possible explanation for the carcinogenic power of smoke in the larynx and, in general, in the upper respiratory-digestive tract.

[Otoacoustic distortion products in infants and adults: a comparative study]. / I prodotti di distorsione otoacustici nel neonato e nell'adulto: analisi comparativa.

Distortion Products (DP) are otoacoustic emissions evoked by emitting two pure tones. The principle advantage of this method vs. transient evoked otoacoustic emissions is the specificness of frequency. The purpose of the present work was to determine whether this technique could be applied in objective study of cochlear function in infants. This was done by setting standard data for infants and comparing them with the data obtained in a control population of adults. The input/output functions of the DP and the DP audiograms for 8 f2 frequencies ranging from 696 to 6006 Hz were studied in a group of 15 healthy, full-term infants. The data obtained were statistically compared to the data taken from a control group of 8 normal hearing adults. The infants showed significantly more intense DPs in the intermediate frequencies, with a greater detection threshold and dynamic range. On the other hand, at the high frequencies the amplitude of infant DPs was the same or lower than (f2 = 5005) those found in the adults. These differences can partially be attributed to the fact that the outer auditory channel is smaller in infants thus the probe and the middle ear are better matched. There is significantly greater background noise in infant DPs, particularly at low frequencies. This may be due to the fact that the skin of the outer auditory duct--which acts as a low-pass filter allowing suction and movement of the cervical muscles to contaminate the tracing--is thinner in infants. In conclusion, the study of DPs has shown its potential in the study of cochlear function in infants because it is non invasive and objective, it can be performed quickly and shows frequency specificness. Unfortunately, it cannot be considered a valid method for determining cochlear function at the low frequencies.

ABR and HIV-induced impairment of the central nervous system.

This in vivo study used Auditory Brainstem Responses (ABR) to evaluate nerve transmission integrity in the course of HIV infection. 48 normoacoustic HIV+ patients (40 men, 8 women) and 10 healthy age, sex and risk-factor matched controls underwent Brainstem Evoked Auditory potentials using a standard technique. Potentials were tested at cadences of 11 and 51 stimuli per second. ANOVA and Student's T test were used for inter Center for disease Control (CDC) classes and CDC classes vs control analysis of the values of the principal wave latencies (I, III, V) and interpeak intervals (I-III, III-V, I-V). Significant impairments in nerve transmission, shown best at the 51 pps cadence, were present from the earliest stages of HIV infection and worsened as the disease progressed. These results suggest that the upper part of the brainstem may be the main target of involvement in the tract being tested. Since electrophysiological tests allow detection of nervous dysfunction in subjects while still asymptomatic, these procedures could be usefully employed in order to better define the real onset of brain damage in HIV-1 seropositive patients and monitor the speed with which these lesions evolve.

[Sudden idiopathic hearing loss. Case reports in the course of ten years]. / L'ipoacusia improvvisa idiopatica. Presentazione di una casistica decennale.

The authors present a retrospective case study of 132 subjects with sudden-onset hearing loss who had been observed during the course of 10 years. The results were compared with those available in the literature. These patients were divided into two subgroups based on age: over or under 40. The hearing loss was divided into 4 subgroups according to audiogram morphology. Then the presence, and entity, of any recovery in hearing was evaluated. There was no preference for sex while the greatest incidence was found in the VI and VII decade of life. The audiohistograms obtained when the patients were admitted to the hospital and 2 months later indicated an improvement in the hearing threshold localized above-all in the medium-low frequencies. This confirms a better evolution in those forms localized in the apex of the cochlea. The threshold of 60 dB HL is the dividing line between a totally favorable prognosis and a partially or totally unfavorable prognosis. This indirectly confirms that the intensity of the initial hearing damage is an important prognostic factor. From the morphological point of view the forms with the best evolution appear to be those with a flat or rising morphology. The forms with descending morphology do not present a favorable evolution although those with a threshold around 8000 Hz are worse than those with a threshold of 4000 Hz. As regards age no significant differences were found in the evolution of hearing loss between subjects under and over 40. In conclusion, the essential characteristics of sudden-onset hearing loss are as yet poorly defined. There are so many variables affecting the onset and evolution of hearing loss that it proves impossible to perform any statistically valid analysis which includes them all. To date the elements able to provide some degree of prognostic prediction are the audiogram morphology and the entity of the initial hearing loss.

[Results and considerations regarding auditory neonatal screening based on the use of transient evoked otoacoustic emission]. / Risultati e considerazioni a proposito di uno screening audiologico neonatale basato sull'impiego delle otoemissioni acustiche evocate transienti.

The authors present a 5-year clinical experience in audiological screening performed at the neonatal center of the Policlinico of Perugia, Italy. The study was performed using an IL088 Otodynamics unit produced by Bray & Kemp. A total of 1328 newborns (2656 ears) were tested on the 4th day of life and during spontaneous sleep. None of the children had any audiological risk factors. The test was repeated one month later for all subjects who lacked Transient Evoked Otoacoustic Emissions and in many cases ABR testing was performed by 3 months of age. The authors present the undoubted advantages of the present method which include the fact that it is a) easy to perform, b) non invasive, c) sensitive and d) effective. They then discuss the main problems which arose during the course of the screening and advance some solutions. For the most part these problems involved the high number of false positives (13.1%) and the high percentage of subjects who were lost to subsequent controls (approximately 6% of the total population). The number of false positives could be reduced by using a linear acoustic stimulation (rather than the non-linear stimulation which is the default parameter for the machine). Such a linear stimulation can improve the signal-to-noise ratio, thus making it possible to adopt a reproducibility index lower than the 70% presently used (however, this brings with it the risk of including a certain number of false negatives). Finally, they discuss the possibility of only retesting those subjects with bilateral lack of TEOAEs, thus reducing the number of check-ups to be performed a month later.

[Otoacoustic distortion products in sensorineural hearing loss in the cochlea]. / I prodotti di distorsione otoacustici nelle ipoacusie neurosensoriali di natura cocleare.

The purpose of the present work was to assess distortion-product otoacoustic emissions (DPOAE) in cochlear hearing loss and in its various morphologies. A total of 19 patients (30 ears) were selected for the study. They showed various pictures of neurosensorial hearing loss which were localized within the frequency range normally examined during audiometric tonal threshold testing. The DPOAEs were recorded using a Bray and Kemp ILO 92 instrument. The DPOAEs of several frequencies (750,1000,1500,2000,3000,4000 and 6000 Hz) were examined using an f2 tone of 696, 1001, 1587, 2002, 3147, 4004 and 6348 Hz, respectively. The results were as follows: a) At certain frequencies the overlap between hearing loss and the absence of, or reduction in, DPOAE amplitude was virtually total. b) There was a modest correlation between the degree of hearing loss and decrease in, or absence of, DPOAEs although there was a spectrum of intermediate hearing losses where the DPOAEs varied widely from one individual to another (this spectrum ranged from 10 to 45 dB HL on the audiometric tonal test). c) The absence of DPOAEs at 750 Hz is unable to predict hearing loss for this frequency as, at this frequency, there can be a lack of DPOAEs even when the 750 Hz audiometric threshold level is normal. Finally, what emerged from this study was that DPOAEs prove quite useful to complement the study of auditory brainstem responses (ABR), now universally accepted as the means for early diagnosis of hearing loss in children. In fact, ABRs provide precise data regarding a frequency field which is socially less important in terms of verbal communication and the development of spoken language. It is, however, unable to explore individual frequencies.

Diagnosing nasal hyperreactivity with positional rhinomanometry.

Positional rhinomanometry is a physiologic method for estimating nasal resistance, which is variable, difficult to predict, and linked to vasomotor activity of the functional system culminating in the turbinate valves. Thirty subjects suffering from allergic rhinitis, 25 patients affected by aspecific rhinitis, and 40 healthy controls underwent positional rhinomanometry. Test positions included the seated (baseline), supine, and recumbent (homolateral and contralateral to the nasal fossa under examination). In patients with perennial allergic rhinitis and in those with aspecific rhinitis, positional rhinomanometry elicited two pathologic responses: either an average percentage rise of more than 80% in nasal resistance in the supine and homolateral and contralateral recumbent positions compared with basal values, or a paradoxical fall in the supine and homolateral recumbent positions.

Benign paroxysmal positional vertigo of posterior semicircular canal: results in 160 cases treated with Semont's maneuver.

One hundred sixty patients affected by benign paroxysmal positional vertigo of the posterior semicircular canal were treated with Semont's maneuver. Complete recovery after only one session was achieved in more than 50% of cases. After a maximum of five sessions, almost all patients had recovered; only 8 needed another kind of rehabilitation. No drug therapy was required for any patient.

[Evoked otoacoustic emissions using clicks in detection of deafness in young children]. / Les oto-émissions acoustiques provoquées (OEAP) par des transitoires dans le dépistage de la surdité du jeune enfant.

Click-evoked otoacoustic emissions (EOAEs) are sounds emitted by the cochlea due to active outer hair cell contraction following stimulation of the stereocilia. The purpose of this study was to evaluate the use of testing for EOAEs as a valid auditory screening method in newborns, and 1074 healthy fullterm babies (2148 ears) with an Apgar score higher than 8 at birth were examined. EOAEs were elicited 4 days after birth and a correlation index higher than 70% represented normal response criteria. If there was no response, EOAEs and brainstem response potentials were tested at the age of one month. On the fourth day after birth. EOAEs specificity and efficiency were found to be 92.3% and 92.4% respectively, while sensitivity was 100%. Specificity and efficiency at one month were rated at 100%. The use of EOAEs offers numerous advantages over traditional auditory screening methods, thus suggesting that this technique is suitable for the mass-screening of infants.

[Products of acoustic distortion in the examination of deafness in an infant]. / Les produits de distorsion acoustique dans le dépistage de la surdité du jeune enfant.

Distortion-product otoacoustic emissions (DPOAEs) are otoacoustic emissions evoked by two pure tones. The greatest advantage of DPOAEs is their frequency specificity with respect to the eliciting bitonal stimuli. The purpose of this study was to compare DPOAEs in two populations. This paper reports input/output DPOAEs functions and DPOAE-audiograms for audiometric frequencies of f2 between 696 and 6006 Hz in a normal neonate population and in an adult control group. Fifteen healthy fullterm newborns (29 ears) and 8 normal-hearing adults (16 ears) participated as subjects. Results at medium frequencies indicate that the maximum amplitudes of the DPOAEs were generated by neonates, the detection threshold was better and the dynamic range was greater than in adults, making them potentially valid for studying cochlear functioning in infants.

[Rhinocerebral mucormycosis: a case report]. / A proposito di un caso di mucormicosi rino-cerebrale.

The Authors report a case history of rhinocerebral mucormycosis in a patient with chronic lymphatic leukaemia and recommend that therapy be based on three different approaches: treatment for the underlying disease, systematic antifungal treatment with Amphotericine B, and surgical asportation of diseased tissue. They affirm that results may be surprisingly successful, even in cases with signs of orbital-cerebral involvement which are indicative of a poor prognosis and the concomitant presence of a serous disease such as leukaemia.

[Otoacoustic distortion products in adults with normal hearing]. / I prodotti di distorsione otoacustici nei soggetti adulti normoacusici.

Distortion Product Otoacoustic Emissions (DPOEs) are otoacoustic emissions evoked by two pure equilevel tones (f1, f2) called primaries and are believed to provide frequency-specific information regarding cochlear function. We recorded DPOEs at 2f1-f2 frequency with a constant frequency ration (f2/f1 = 1.22) in 8 normal hearing subjects (16 ears, mean age 28 +/- 1.5) to establish the characteristics of these emissions in the adult population. DPOEs were measured at the following F2 frequencies and respective fp geometric mean frequencies: 696/632, 1001/904, 1501/1360, 2002/1809, 3003/2714, 4004/3626, 5005/4531 e 6006/5435 Hz. Detailed testing included the recording of DPOE "audiograms" and input-output functions depicting the relationship of the amplitudes of DPOE to primary-tone levels ranging from 25 to 70 dB SPL in 5 dB steps. The present findings are in good agreement with investigations based on evoked otoacoustic emissions published by other researchers. The average DPOE "audiograms" demonstrated a low-frequency maximum at 1501 Hz (f2)/1360 (fp) and a high-frequency peak at 5005 Hz (f2)/4531 (fp). The two maximum regions were separated by a minimum around 3003 Hz (f2)/2714 (fp). This study confirms the feasibility of DPOE measurements among adults and provide a normal baseline for this age group. DPOEs could be useful, in association with evoked otoacoustic emissions and with auditory brainstem responses, in obtaining a precise evaluation of the peripheral auditory system.

Giant cell reparative granuloma of the maxillary bone: case report and review of diagnostic criteria.

This paper reports a case of giant cell reparative granuloma of the right maxillary bone of a 13-year-old caucasian girl. It may be very difficult to distinguish this entity from other lesions of mandible, maxilla and skull bones which contain multinucleated giant cells. The differential diagnosis, especially from giant cell tumors of the bone, is discussed. Accurate diagnosis lies on correct integration of clinical, radiographical and histopathological data.

Auditory evoked potentials at 40 Hz (SSR40Hz) in post-trauma coma patients.

The authors evaluated auditory evoked steady state rest potentials at 40 Hz (SSR40Hz) in 21 post-trauma coma patients and compared their predictive value for prognosis of survival and quality of life with the results of the electroencephalogram (EEG), the computed tomography (CT) scan, and the Glasgow Coma Scale. SSR40Hz potentials recorded immediately after trauma had a maximum (100%) sensibility and specificity for a fetal prognosis and a high value for life prognosis. Consequently they appear to be a useful parameter for deciding on organ explant procedures. The EEG was more reliable in predicting a quality of life prognosis.