Adjuvant treatment with a symbiotic in patients with inflammatory non-allergic rhinitis.

Inflammatory non-allergic rhinitis (INAR) is characterized by the presence of an inflammatory infiltrate and a non-IgE-mediated pathogenesis. This retrospective, controlled, multicentre study investigated whether a symbiotic, containing Lactobacillus acidophilus NCFM, Bifidobacterium lactis, and fructo-oligosaccharides (Pollagen®, Allergy Therapeutics, Italy), prescribed as adjunctive therapy to a standard pharmacological treatment, was able to reduce symptom severity, endoscopic features, and nasal cytology in 93 patients (49 males and 44 females, mean age 36.3±7.1 years) with INAR. The patients were treated with nasal corticosteroid, oral antihistamine, and isotonic saline. At randomization, 52 patients were treated also with symbiotic as adjunctive therapy, whereas the remaining 41 patients served as controls. Treatment lasted for 4 weeks. Patients were visited at baseline, after treatment, and after 4-week follow-up. Adjunctive symbiotic treatment significantly reduced the percentages of patients with symptoms and endoscopic signs, and diminished inflammatory cells. In conclusion, the present study demonstrates that a symbiotic was able, as adjuvant treatment, to significantly improve symptoms, endoscopic feature, and cytology in patients with INAR, and its effect may be long lasting.

Ancillary therapy of intranasal T-LysYal® for patients with allergic, non-allergic, and mixed rhinitis.

Allergic rhinitis (AR) is caused by an IgE-mediated inflammatory reaction. Non-allergic rhinitis (NAR) is characterized by a non-IgE-mediated pathogenesis. Frequently, patients have the two disorders associated: such as mixed rhinitis (MR). Hyaluronic acid (HA) is a fundamental component of the human connective tissue. HA may exert anti-inflammatory and immune-modulating activities. Recently, an intranasal HA formulation was proposed: a supramolecular system containing lysine hyaluronate, thymine and sodium chloride (T-LysYal®). This randomized study investigated whether intranasal T-LysYal® (rinoLysYal®, Farmigea, Italy) was able to reduce symptom severity, endoscopic features, and nasal cytology in 89 patients (48 males and 41 females, mean age 36.3±7.1 years) with AR, NAR, and MR. Patients were treated with intranasal T-LysYal® or isotonic saline solution as adjunctive therapy to nasal corticosteroid and oral antihistamine for 4 weeks. Patients were visited at baseline, after treatment and after 4-week follow-up. Intranasal T-LysYal® treatment significantly reduced the quote of patients with symptoms, endoscopic features, and inflammatory cells. In conclusion, the present study demonstrates that intranasal T-LysYal® is able, as ancillary therapy, to significantly improve patients with AR, NAR, and MR, and its effect is long lasting.

Intranasal T-LysYal® as adjunctive therapy for patients after functional endoscopic sinus surgery.

Functional Endoscopic Sinus Surgery (FESS) is a common day surgery technique for upper airway disorders. Hyaluronic acid (HA) is a fundamental component of the human connective tissue. HA may exert reparative, anti-inflammatory and immune-modulating activities. Recently, a new intranasal HA formulation has been proposed: a supramolecular system containing lysine hyaluronate, thymine and sodium chloride (T-LysYal®). This randomized study investigated whether intranasal T-LysYal® (RinoLysYal®, Farmigea, Italy) was able to reduce symptom severity, endoscopic features, and nasal cytology in 83 patients (49 males and 34 females mean age 45.4±6.2 years) treated with FESS. All patients were treated with isotonic saline solution for 4 weeks, and a sub-group (active group) was also treated with intranasal T-LysYal®. Patients were visited at baseline, after treatment, and after 4-week follow-up. Intranasal T-LysYal® treatment significantly reduced the quote of patients with symptoms, endoscopic features, and inflammatory cells in comparison to isotonic solution. In conclusion, the present study demonstrates that intranasal T-LysYal® is able to significantly improve patients after FESS and its effect is long lasting.

Assessment of biofilm by nasal cytology in different forms of rhinitis and its functional correlations.

BACKGROUND: Recently, it has been reported that nasal cytology in light microscopy can identify biofilms, which appear as cyan-stained "Infectious Spots". We assessed by the same method and in the same population, the presence of biofilms in different nasal disorders, and estimated if a correlation with the functional grade of obstruction existed. METHODS: Subjects suffering from different nasal disorders, after a detailed clinical history and ENT examination, underwent nasal fibroendoscopy, skin prick test, rhinomanometry and nasal cytology. The presence of biofilm was linked to the type ofdisease and to the grade of obstruction. RESULTS: Among 1,410 subjects previously studied, the infectious spot was found in 107 patients (7.6%), and this percentage reached 55.4% in subjects with cytologic signs of infectious rhinitis (presence of bacteria/fungi). Biofilms were largely more frequent in patients with adenoid hypertrophy (57.4%), followed by nasal polyposis (24%), chronic rhinosinusitis (9.5%) and non-allergic rhinitis (7.6%). Nasal cytology was normal in the remaining patients, where no infectious spot was detectable. Statistical analysis showed that nasal resistances were significantly higher in presence of biofilms in patients with adenoid hypertrophy (p = 0.003), nasal polyposis (p < 0.001), chronic rhinosinusitis (p = 0.018) and septal deviation (p = 0.001). CONCLUSION: The results demonstrate that biofilm is present not only in infectious rhinitis, but also in inflammatory and/or immune-mediated diseases. The presence of biofilms significantly correlates with the degree of nasal obstruction as assessed by rhinomanometry.

Diode laser in the treatment of epistaxis in patients with hereditary haemorrhagic telangiectasia.

Periodic and spontaneous nosebleed is the most common clinical manifestation of hereditary haemorrhagic telangiectasia (HHT), present in 95% of patients suffering from this syndrome. The purpose of this retrospective study was to evaluate the effectiveness and safety of diathermocoagulation of telangiectasia on the nasal mucosa with a diode laser in the treatment of epistaxis in patients with HHT. From 2005 to 2010, 24 patients diagnosed with HHT and with mild-severe nosebleed were treated in our hospital with diode laser. Patients were given a pre- and post-operation evaluation questionnaire to determine the frequency and severity of nosebleed, the recurrence-free period of time after treatment and quality of life. We compared the pre- and post-operation haemoglobin values three months after the last treatment. After treatment, a decrease in the weekly frequency and entity of nosebleed was observed, together with substantial improvement in the quality of life and an increase in haematic haemoglobin. Diode laser treatment of telangiectasia on nasal mucosa represents a valuable, safe, effective and repeatable therapeutic option in treating mild and severe nosebleed, and it is associated with improvement in quality of life from psychological, social and clinical points of view.

Nasal cytology: the "infectious spot", an expression of a morphological-chromatic biofilm.

The purpose of this study was to describe some "morphological-chromatic" patterns (i.e. spots of cyan colour) identified during the study of nasal cytology in patients with both bacterial and fungal infectious rhinological disorders. These peculiar aspects strongly suggest the presence of a microscopic biofilm. We retrospectively examined 1,410 nasal cytology specimens from subjects who underwent clinical-instrumental investigations (history, ENT visit, nasal endoscopy and nasal cytology) from January to August 2010. The control samples were represented by 30 subjects not suffering from infectious rhinological diseases. The presence of particular spots of "cyan" was found in colour in 107/1,410 rhinocytograms (7.6%), within which bacterial colonies and/or fungal spores were found. We called these coloured spot formations "infectious spots" (IS). The positivity to periodic acid Schiff (PAS) staining confirmed the polysaccharide nature of the coloured spots and allowed us to relate them to biofilms. This study demonstrates, for the first time, that nasal cytology performed by optical microscope can play an important role in detecting biofilms.

Role of nasal cytology.

Nasal cytology represents a valid method in the differential diagnosis of allergic and non-allergic nasal diseases, as it is simple, safe, non-invasive, cost-effective, and easy to perform both in the medical and paediatric office. In particular, through cytological investigation it is possible to diagnose a group of non-allergic infective rhinitis that still today constitutes a vague aspect of the clinical-diagnostic-therapeutic approach to eosinophilic non-allergic rhinitis (NARES), non-allergic rhinitis mast cell (NARMA), neutrophilic non-allergic rhinitis (NARNA), and eosinophil-mast cell non-allergic rhinitis (NARESMA). Preventive treatment of nasal diseases, when guided by rhinocytograms, leads to a favorable clinical and time-dependent outcome. These advantages are reflected in a better quality of life and in a reduction in National Health Service costs, without chronic evolution of the disease to complications.

Nasal-sinus polyposis: clinical-cytological grading and prognostic index of relapse.

This longitudinal and prospective study aimed at investigating the influence of some parameters,including nasal cytology and clinical findings (such as asthma, atopy, acetylsalicylic acid (ASA) sensitivity, ASA associated with asthma), as risk factor of post-surgical relapse of nasal-sinus polyps. One hundred sixty-one consecutive patients (92 males and 69 females, mean age 47 years), affected by bilateral nasal polyposis and who had undergone surgical nasal polypectomy (endoscopic FESS), were examined post-surgically at least every 6 months for a period of 10 years. Endoscopic exam and nasal cytology exam were carried out on all patients and their case histories were carefully examined. The association eosinophilic-mast cell cellularity and the contemporary presence of asthma + ASA sensitivity showed the highest level of relapse (OR 4.5). In conclusion, cytological data in association with certain clinical parameters can predict a high risk prognosis of relapse.

Nasal irrigation with lavonase as ancillary treatment of acute rhinosinusitis: a pilot study.

A wide variety of nasal irrigation systems are currently available for improving nasal symptoms, but few studies have compared their effectiveness with respect to patient age and type of nasal disease. This pilot study aims to compare the efficacy of two irrigation systems in 20 patients (12 males and 8 females; age range, 19-54 years; mean age, 36) with acute rhinosinusitis and treated only with antibiotic (levofloxacin 500 mg/day for 10 days) and topical nasal decongestant (naphazoline 2 puffs in each nostril twice daily for 7 days). Patients were randomly assigned to the treatments, using either a nasal syringe (10 mL saline solution, 3 times daily for 14 days) (Group 1) or the recently available Lavonase system (250 mL saline solution sac, twice daily for 14 days) (Group 2). Work-up included history, evaluation of signs and symptoms (nasal obstruction, rhinorrhea), nasal endoscopy, and anterior rhinomanometry. Nasal irrigation with the Lavonase system was found to be more effective in reducing symptoms, as all significantly diminished (p<0.05). In addition, the Lavonase system significantly decreased nasal resistances (p<0.05). This preliminary study shows that the ancillary treatment of acute rhinosinusitis with Lavonase may be useful.

Non-allergic rhinitis with eosinophils and mast cells constitutes a new severe nasal disorder.

Three main types of inflammatory Non-Allergic Rhinitis (NAR) have been defined: NAR infiltrated by eosinophils (NARES), by mast cells (NARMA), and by neutrophils (NARNE). A new particular type has been characterized with current infiltration by eosinophils and mast cells (NARESMA). The aim of this study is to evaluate the clinical and functional characteristics in patients with NARES, NARMA, NARNE, and NARESMA and to define the latter. One hundred and seventy-six NAR patients were prospectively and consecutively evaluated: 52 patients with NARES, 38 with NARMA, 36 with NARNE, and 50 with NARESMA. Clinical features, Quality of Life (QoL), and rhinomanometry were evaluated in all of them. QoL was significantly different in the 4 groups. NARESMA patients had the worst QoL. Nasal function and QoL in NARESMA patients were significantly correlated. Significant associations were shown with both nasal polyps and asthma in NARESMA patients. This study provides the first evidence that NARESMA constitutes a new type of NAR and is a particularly severe disorder.

Quality of life in non-allergic rhinitis depends on the predominant inflammatory cell type.

Three main types of inflammatory Non-Allergic Rhinitis (NAR) have been defined: NAR infiltrated by eosinophils (NARES), by mast cells (NARMA), and by neutrophils (NARNE). In the absence of studies that investigated the Quality of Life (QoL) in NAR, the present work is aimed at evaluating the Quality of Life of patients with NARES, NARMA, and NARNE. One hundred thirty one (131) NAR patients were prospectively and consecutively evaluated: 54 patients with NARES, 38 with NARMA, and 39 with NARNE. Their history, nasal infiltration and rhinomanometry were characterized, and Quality of Life (using 2 instruments) was evaluated, and associated to clinical and histological features. Quality of Life was significantly different in the 3 groups (p less than 0.001); NARES patients had the worst Quality of Life. Nasal resistances were significantly higher in the NARES group. Significant associations were shown in NARES patients between Quality of Life and nasal function. This study provides the first evidence that Quality of Life is impaired in NAR as well as in allergic rhinitis. Furthermore, Quality of Life impairment differs among the various forms of NAR, and there is a correlation with the cellular infiltrating type.

Cytology in the diagnosis of rhinosinusitis.

Nasal cytology is a diagnostic tool currently used in rhinology, with the aim of assessing cell changes in the nasal epithelium exposed to irritant or inflammatory agents. Its rationale is based on the knowledge that nasal mucosa of healthy individuals is constituted by four cytotypes (ciliata, mucipara, striata, and basalis) and does not show other cells except, rarely, neutrophils and, very rarely, bacteria. In this view, the detection of a given cell type different from these is a sign of possible pathology. The advantage and the diffusion of nasal cytology were increased by a number of factors such as the easiness of performance, the non-invasiveness allowing repetition (which is often needed in the efficacy monitoring of medical or surgical treatment of nasal diseases), and the low cost. This makes nasal cytology particularly feasible for application in children. The cytological feature characterizing infectious inflammation is the presence of abundant bacteria, which may be found in extracellular tissue and also inside neutrophils as a result of phagocytosis. In such clinical condition it is important to monitor the disease with cytological controls to verify the significant decrease, or the disappearance of inflammatory cells, which indicates the resolution of the pathology.

Acoustic analysis of voice in patients treated by reconstructive subtotal laryngectomy. Evaluation and critical review.

Aim of this investigation was to analyse the voice in a group of 20 patients submitted to supracricoid partial laryngectomy (cricohyoidopexy, sparing two arytenoids) by the Multi Dimensional Voice Programme acoustic analysis system. Results revealed the following sound characteristics: high rate of noise, lack of periodic component of the signal, high rate of segments with no sound signal, vocal segments with marked air-turbulent flow, variation amplitude and frequency coefficients doubled compared to normal values, average fundamental frequency, if present, extremely variable and unsteady. These results show that the phonatory ability of the residual larynx, due to the altered anatomo-physiology of the structure after surgery, has to be completely re-estimated. In fact, the residual larynx determines a definitely reduced periodic acoustic signal, rich in noise and which can not be modulated. Good phonatory results of this treatment are basically due to preservation of a still understandable (but not perfect!) speech which, by ensuring the subjects' speech ability, overcomes and has little influence on the really poor quality of the vocal signal in these patients. However, the patient obtains a "new voice" as far as concerns acoustic features and this is very important for communication and social life. Moreover, the possibility of objectively estimating acoustic vocal function ability allows monitoring of the trend and results of possible speech therapy and/or phonosurgical rehabilitation treatment which should start from new anatomical and physiological bases, as well as from the new physical acoustic mechanism of signal production.

Treatment of recurrent epistaxis in HHT.

No optimal treatment modality is currently available for the treatment of recurrent epistaxis in HHT. In this review, different therapeutic concepts are discussed together with their pathophysiologic background. Patients often profess a preventive effect for nasal ointments and use packings which can be self-administered in the case of bleeding. An effective first-line treatment for physicians is the endonasal laser coagulation or argon plasma coagulation. A second line surgical procedure is septodermoplasty according to Saunders which can provide long-lasting relief if performed correctly. There have been reports on antifibrinolytic agents and hormones, but their efficacy has yet to be determined.

"Conditional" neck dissection in management of laryngeal carcinoma.

It is well known that malignant laryngeal tumours can extend from their site of origin into tributary lymph nodes, depending on their location and size. Management protocols almost always include concomitant surgical treatment of both the tumour and cervical nodes. When palpable lymph nodes are present, dissection is mandatory but there is no general agreement on the option of choice in clinically N0 patients. Elective neck dissection, following the current indications, is necessary in most cases of N0 laryngeal cancer, but the number of bilateral dissections may be limited. In tumours of only one hemilarynx or extending slightly beyond it, metastatic involvement is more likely to be on the same side as the lesion although there is no absolute certainty that it will be. In these cases, and especially in supraglottic tumours, occult metastatic spread may also penetrate into the contralateral lymph nodes of the neck. The present report deals with the results of a surgical strategy to limit bilateral elective dissection, based on the following criteria. In supraglottic tumours of only one hemilarynx or extending slightly beyond it, the presence of ipsilateral node metastases is highly predictive of a concomitant involvement of the contralateral nodes. In these supraglottic tumours, only in cases with post-operative serial positive histology of the uni-ipsilateral dissected cervical lymph nodes, has contralateral elective neck dissection ("conditional dissection") been performed. "Conditional dissections" led to a reduction of approximately 70% of elective bilateral neck dissections.

Major salivary gland diseases. Multicentre study.

This multicentre study involved 28 Italian ORL Centres responding to a questionnaire sent by us which allowed recruitment of a high large number of cases of parotid neoplasms observed over a 10-year period. Statistical data obtained partly confirmed previous findings. Benign tumours account for 80% of case histories with a relationship 1:4 M/F, the most frequent being pleomorphic adenoma (57.3% of cases), followed by Warthin's tumour (32.4%), this rating not having been confirmed in case histories (8-10%) in the literature. Malignant tumours instead were fewer in number compared to the literature (14% vs 25-30%); the most frequent being mucoepidermoid carcinoma (18.2%) of which 44% G1, 33% G2 and 23% G3. Adenoid-cystic carcinoma was observed in 15.3% and < or = 10% for all the other most frequent histological malignant neoplasms. Diagnostic work-up included echotomography and fine-needle aspiration biopsy, less used imaging techniques were computed tomography, magnetic resonance imaging, Sialo-computed tomography. During this multicentre investigation more widespread use of imaging techniques has, however, been observed. The greater use of ecotomography and of fine-needle aspiration biopsy was due to simplicity of application and low cost offering good sensitivity and specificity. Surgical treatment of benign tumours consisted, in 50% of cases, in superficial paroditectomy and in approximately 30% of total paroditectomy. Enucleoresection was limited to approximately 15% of neoplasms, enucleation to <10% of cases with only 2% of pleomorph adenoma due to the well-known anatomo-pathological characteristics which may lead to relapse. For malignant neoplasms, total parotidectomy was performed in approximately 50% of cases, while in the remaining 50% an almost equal rate of superficial parotidectomy was carried out and enlarged parotidectomy, with or without sacrificing the facial nerve, which was rebuilt in 60% of cases. The lateral neck dissection most frequently carried out was of functional type in 54% and selective type in 46% with removal of levels I-III and II-IV in approximately 60% of cases. Sentinel lymph node was observed in a limited number of centres. When no clinically evident lymph nodes were present (NO) considering the tumour histotype, two thirds of patients underwent surgery or radiotherapy, while in the remainder the wait-and-see attitude was prefered. Post-operative-complementary radiotherapy was very frequently performed instead of chemotherapy. Oncological results obtained were compared with those reported in the literature: in fact for all benign neoplasms relapse ratings are about 5%, while for malignant tumours the worst prognosis was in squamous cell carcinoma with median of 37.7 on survival and metastasis rate of 16.5%. Finally, mucoepidermoid carcinoma tumours showed best survival, followed by adenoid-cystic carcinoma with ranges, respectively, 83 and 81.

Hereditary haemorrhagic telangiectasia: state of the art.

Hereditary haemorrhagic teleangiectasia (HHT) or Rendu-Osler-Weber disease is a genetic autosomal-dominant disorder characterised by the presence of vascular telangiectases in mucocutaneous tissues, visceral organs and the Central Nervous System. Pulmonary arteriovenous malformations have a variable incidence rate ranging between 15-33%, and the safest treatment is transcatheter embolotherapy. Haemmorrhages from the gastrointestinal tract occur in 10-40% of patients with HHT localized in duodenum and colon and can be treated with endoscopy and laser coagulation, but this procedure is not efficacious for vascular anomalies in small intestine since this site cannot be easily reached. The prevalence of cerebrovascular malformations in hereditary haemorrhagic telangiectasia patients is 5-27%, and there are several types described including telangiectasias, cavernous angiomas, arteriovenous malformations, and aneurysms. Cerebrovascular malformations can be treated by: neurovascular surgery, embolization, and stereotactic radiosurgery, but the appropriate course of action for dealing with asymptomatic cerebrovascular malformations is still debated. The most common symptom in HHT patients is epistaxis, which can sometimes be so profuse that it requires multiple transfusions and iron supplementation. Nose bleeds begin before 10 years of age and become more severe in later decades. A multitude of different treatments are available, tailored to the severity of epistaxis. These include: hormonal therapy with oestrogens, application of fibrine tissue sealant, laser coagulation, embolization and septal dermoplasty using Saunder's technique. Aim of this study is to review diagnostic and therapeutic techniques, since continuous growth and danger of these arteriovenous malformations require early diagnosis, adequate treatment, prolonged follow-up and screening of the family.