Does the addition of a second daily session of hyperbaric oxygen therapy to intratympanic steroid influence the outcomes of sudden hearing loss?

The aim of this study is to investigate whether, in addition to intratympanic steroid therapy, additional hyperbaric oxygen therapy (HBOT) sessions per day (twice a day for 5 days) is more useful than one session per day for 10 days in patients affected by severe and profound idiopathic sudden sensorineural hearing loss (ISSNHL). A total of 55 patients affected by unilateral severe and profound ISSNHL were recruited. Two protocols were adopted. In the first, 27 patients (13 with profound and 14 with severe hearing loss) underwent one session of HBOT per day for 10 days, 6 days a week. An HBOT session comprised a period of 14 minutes air compression followed by 90 min at 2.4 atm absolute (ATA) followed by a decompression period of 15 min in oxygen. Patients breathed 100% oxygen through an appropriate mask checked for leaks. Patients were given 0.4 ml of 62.5 mg/ml of intratympanic prednisolone during the first three days of the protocol. In the second protocol, 28 patients (10 with profound and 18 with severe hearing loss) received 10 sessions of HBOT, twice a day for five days, 2.4 ATA 90 min 100% oxygen. The intratympanic injections of prednisolone were given between the two sessions of HBOT during the first three days of the protocol. Since there were no significant differences in hearing outcomes between the two protocols, the present study shows that the protocol of two sessions of HBOT per day is a valid treatment and equally effective as the one HBOT session per day, but with shorter treatment time.

Chronic cerebrospinal venous insufficiency in patients with Ménière's disease.

To analyze the presence of chronic cerebrospinal venous insufficiency parameter and vascular abnormalities, in the internal jugular veins (IJVs) and/or vertebral veins in sitting and supine posture, in patients with Meniere's disease compared to healthy general population. A prospective study on 32 patients affected by definite Ménière was performed from February 2012 to January 2013. All subjects underwent an echo-color Doppler examination of the cerebrospinal venous flow. 21 of the 32 Menieric patients showed a statistically significant reflux in the intracranial veins versus healthy (65.6 vs 25%; P < 0.001). A high prevalence of IJVs stenosis with hemodynamic changes (increased velocity or absence of flow) was observed (66.7 vs 33.3%; P < 0.05). The other parameters considered did not show statistically significant differences among the two groups. The results obtained showed a vascular pattern of cerebrospinal venous system present in patients affected by definite Meniere. This vascular impairment significantly affects the vascular areas more directly involved in the venous drainage of the inner ear. Thus venous stasis may be considered a further pathogenetic mechanism for development of Meniere's disease.

Contralateral implantation in children affected by postimplant meningitis.

This study was designed to investigate the indication and advantages of contralateral implantation after postimplant meningitis (piM). Speech perception assessment, most comfortable levels and high-resolution computer tomography were used to monitor cochlear fibrosis/ossification and clinical changes in outcomes in 5 children affected by meningitis after a variable-time post-cochlear implantation. Ipsilateral ossification was found in 3 children, 1 of whom developed delayed contralateral ossification. These children were implanted on the contralateral side as they all showed deterioration of hearing performance. Results from the present paper and literature analysis suggest that, (1) piM can induce ipsilateral and contralateral ossification, (2) meningitis-induced cochlear ossification is more prone to develop in the presence of a normal cochlear structure and (3) contralateral implantation after piM has proven to be effective in restoring performance when a full electrode insertion is accomplished.

Type I tympanoplasty with island chondro-perichondral tragal graft: the preferred technique?

OBJECTIVE: This retrospective, comparative study aimed to assess anatomical and functional results in a group of adults undergoing type I tympanoplasty for subtotal tympanic membrane perforation, using two different types of graft. SUBJECTS AND METHODS: The study included 106 patients affected by chronic otitis media, who underwent underlay type I tympanoplasty, 53 using an autologous chondro-perichondral tragal graft and 53 using temporalis fascia. Anatomical and functional outcomes were evaluated over time. RESULTS: Audiometric results comparing the cartilage and fascia groups at six months and one year after surgery showed no statistically significant differences. Assessment of anatomical outcomes indicated a greater number of complications in the fascia group. CONCLUSION: Functional results indicate the validity of the cartilage tympanoplasty, while anatomical results indicate a slightly better outcome in terms of graft re-perforation and retraction, compared with temporalis fascia at one-year follow up. These results suggest that the cartilage technique is preferable for type I tympanoplasty.

Analysis of the impact of professional involvement in evidence generation for the HTA Process, subproject "cochlear implants": methodology, results and recommendations.

The aim of Health Technology Assessment (HTA) is to provide decision-makers, distributors and recipients with information on the effectiveness, cost and impact of health technologies. The present study constitutes a subproject within the wider project "Analysis of the impact of professional involvement in evidence generation for the HTA process", which is part of the strategic programme "Transfer of the results of the research in clinical practice and organisation of healthcare services", coordinated by Laziosanità - Agency of Public Healthcare of the Lazio Region and AgeNaS (National Agency for Regional Healthcare Services). The objectives of the present subproject (cochlear implants) are as follows: a) to produce a report regarding the health impact of cochlear implants (CI) on their recipients, through a systematic review of literature and extensive selection of relative studies, combining the outcomes with metanalytical techniques. Output: report on the indications of usage in the groups of population for which benefits are controversial; b) to create a registry of patients using cochlear implants. The registry should contain a selection of anagraphic and clinical information relative to patient follow-up in order to assess factors associated with safety and impact on cochlear implant users. This source of information is essential for future observational studies. This was divided into 4 phases: 1(st) phase: definition of key participants in the assessment process; 2(nd) phase: definition of methods and timing of "Aims" (definition of the objective); 3(rd) phase: definition of the methods and times of the "assessment process", 4(th) phase: production of the final report. From the analysis of systematic reviews and italian and international guidelines, the Working Group members approved recommendations on the following topics: results after CI in children in relation to age at implantation, bilateral CI in children, CI in deaf children with associated disabilities, CI in adults with advanced age, bilateral CI in adults and CI in adults with pre-lingual deafness. These recommendations have also been evaluated by the Consulting Committee members and approved with minimal suggestions.

Systematic review of the literature on the clinical effectiveness of the cochlear implant procedure in adult patients.

The aim of this systematic review was to summarize the results of scientific publications on the clinical effectiveness of the cochlear implant (CI) procedure in adults. The members of the Working Group first examined existing research evidence from the national and international literature and main international guidelines. They considered as universally accepted the usefulness/effectiveness of unilateral cochlear implantation in severely-profoundly adult patients. Accordingly, they focused their attention on the systematic reviews addressing clinical effectiveness and cost/efficacy of CI procedures, with particular regard to the most controversial issues for which international consensus is still lacking. The following aspects were evaluated: monolateral CI in advanced-age adult patients; bilateral (simultaneous/sequential) CI vs. unilateral CI and vs. bimodal stimulation; benefits derived from the monolateral CI procedure in adult patients with prelingual deafness. With regard to CI in elderly patients, the selected studies document an improvement of the quality of life and perceptive abilities after CI, even if the benefits were found to be inferior in patients over 70 years at the time of surgery. Thus, from the results of the studies included in the review, advanced age is not a contraindication for the CI procedure. With respect to unilateral CI, bilateral CI offers advantages in hearing in noise, in sound localization and less during hearing in a silent environment. However, high interindividual variability is reported in terms of benefits from the second implant. With regard to CI in prelingually deaf adults, the selected studies document benefits deriving from the CI procedure in terms of improvement of perceptive abilities and in the quality of life after CI, as well as subjectively perceived benefits. However, there is high interindividual variability and the study sample is limited.

A registry for the collection of data in cochlear implant patients.

The need to optimize the use of all the information that modern technological tools have made available to the physician ENT/audiologist has increasingly emerged within the Italian scientific community. Towards this purpose, it is necessary to create a registry of the patients using cochlear implants (CIs). This registry will include a homogeneous summary of the information deriving from multiple sources related to daily clinical practice, in order to assess auditory benefits, safety and reliability in patients with cochlear implants, and organization over the national territory. The primary objectives relative to the above-mentioned analysis are to assess the impact of the use of cochlear implants on patient health, to ensure traceability of the devices currently used, monitoring their safety and reliability over time, to guarantee access of the technique in clinical and organizational conditions that can allow the best possible benefits. The aspects concerning implementation of the registry were discussed extensively during the first meetings of the Working Group (WG). In particular, owing to the complexity and high costs related mainly to the development of the technological aspects and the need to involve technological partners external to the WG, and to respect current privacy laws, the WG members decided that the project should be limited to proposal of a paper registry to be implemented at a later stage, possibly within the framework of successive research projects. During meetings, the WG members discussed various aspects of implementation of the registry, and in particular the scientific features connected to objectives, inclusion criteria, and structure of the forms needed for data collection and organizational aspects. A registry is proposed herein.

Cartilage tympanoplasty: how to reduce surgery time.

In the last few years, cartilage has been the preferred material for reconstruction of the tympanic membrane, particularly in the case of allergy, re-perforation, or total or subtotal perforation. The mechanical characteristics of cartilage offer the advantage of high resistance to retraction and re-perforation. This paper describes two original techniques which reduce cartilage tympanoplasty surgery time, involving a 0.3 mm thick cartilage-perichondrium composite graft to repair the tympanic membrane.

The importance of intra-operative imaging during cochlear implant surgery.

Two unusual cases of cochlear implant (CI) surgery complication are reported: introduction of the electrode array into the superior semicircular canal with normal morphology and a growing amplitude of neural potential (neural response imaging, NRI) during intra-operative monitoring control. In the first case, a two-year-old patient affected by congenital sensorineural profound deafness was bilaterally implanted with two Clarion 90 k devices and intra-operative electrophysiological and radiological controls were performed. After introduction of the array in the right side NRI was performed and a neural potential was found only on two apical electrodes. Radiological intra-operative control with antero-posterior trans-orbital plain films was performed to assess the position of the electrodes inside the cochlea. Radiography showed the electrode array in the superior semicircular canal in the right ear. The electrode array was removed and reinserted correctly. In the second case, a 72-year-old man underwent left cochlear implantation for sensorineural profound deafness of unknown origin. Intra-operative electrophysiological testing (NRI) showed the presence of neural potential on three tested channels. In this case, as routinely employed since 2006, an intra-operative static fluoroscopy control was performed, this showed the electrode array in the superior semicircular canal. The electrode array was removed and reinserted correctly. In conclusion, intra-operative monitoring tests during CI surgery play different roles: measurement of impedances and NRI can evaluate the integrity of implant electrodes and the status of the electrode cochlea interface, but they cannot be the only way to confirm correct positioning of the array. In our opinion the intra-operative radiological check is helpful during CI surgery, especially when there is any doubt about correct electrode insertion.

Air-collection behind the ear: a rare complication in cochlear implant surgery.

A rare case of cochlear implant surgery complication is described: air collection behind the ear. A 61-year-old male with a 20-year history of progressive bilateral profound sensorineural hearing loss underwent cochlear implant surgery on the left ear with Clarion Hi-Res 90K (Advanced Bionics, Sylmar, CA, USA). Ten days after surgery, the patient presented visible tumefaction behind the ear corresponding to the receiver-stimulator. Ultrasonography, with a probe of 30 MHz, of the surface behind the ear showed formation of probable liquid content but aspiration with a 20-gauge needle yielded 30 cm3 of air without blood or pus. An unusual case is described of a minor complication occurring in an adult cochlear implant patient presenting a swelling behind the ear that was found to be collected air. Although ultrasonography can be useful to evaluate localization of swelling behind the ear and to differentiate between liquid and solid collection, it is not useful for identification of air collection. The Eustachian tube test can show an abnormally patent tube and prevent this complication.

Hibernoma of the para-glottic space: an unusual tumour of the larynx.

Hibernoma is an unusual tumour of brown adipose tissue. Brown adipose tissue is common in mammalian hibernating animals and acts as a thermogenic organ. A first case of hibernoma was reported in 1906 by Merkel. This tumour usually arises in the back, shoulder region, mediastinum, retroperitoneum and in the neck. The neck location of hibernomas is rare and only 18 cases of cervical hibernoma have been reported in the English literature. A 48-year-old male with hoarseness and soft voice, present for 8 months, showed a lesion involving the anterior part of the right vocal fold, with no impaired mobility. This is the first case to be reported of laryngeal hibernoma located in a vocal fold, originating from the white fat tissue of the paraglottic space. Moreover, this report could be evidence of the development of hibernoma from white adipose tissue.

Cavernous haemangioma of external ear canal.

OBJECTIVES: The aim of this study was to document the occurrence of a cavernous haemangioma of the external auditory canal, and to review the literature on this pathology. METHODS: We report the clinical presentation, imaging studies, surgical procedure and histological findings for a cavernous haemangioma of the external auditory canal. RESULTS: This patient represents the fourth reported case of cavernous haemangioma affecting only the external auditory canal. A cavernous haemangioma of the external auditory canal, not affecting the tympanic membrane, was surgically removed, without post-operative complications. CONCLUSIONS: Cavernous haemangioma of the external auditory canal is a rare otological pathology. Computed tomography imaging is important in order to precisely define and localise the site and size of the lesion. Histological examination is necessary for the correct diagnosis of the pathology.

[Salvage surgery fot advanced head and neck cancer]. / Il trattamento chirurgico di salvataggio nei carcinomi avanzati della testa e del collo.

Advanced head & neck cancer, after a first treatment, has an high rate of relapse locally or in the lymph nodes. Aim of present study is to value the option and the results in salvage surgery of 62 patients (55 male, 7 female, mean age 53,2) with cancer of the larynx and pyriform sinus, previously treated by surgery or radiotherapy; 45,2% showed relapse on T side, 25,5% in the nodes, 29% both. During follow-up, 3,2% showed a second primitive cancer, 9,6% still present disease. Overall survival rate is 72,6% after 3 years (86,2% for early cancers, 54,5% in advanced ones), 50.6% after 5 years (65,5% for early, 36,4% in advanced). Laryngeal cancers presented better survival rate (54% at 5 years) after salvage surgery than ipopharynx (33% at 5 years). Therefore in ipophaynx cancers we think it is useful to programme aggressive treatment also in early cancer. In our experience in larynx recurrence suvracricoid surgery is really suitable.

Music perception in cochlear implant recipients: comparison of findings between HiRes90 and HiRes120.

CONCLUSIONS: Increased spectral resolution via implementation of perceptual channels with HiRes120 (PSP) would seem to provide better perception of music than with standard HiRes, mainly from the point of view of music appreciation as recorded via the questionnaire. More specific tests are required for appreciation of timbre, preferably by application of protocols based on perceptual attributes using rating scales, which would not be biased by knowledge of music. OBJECTIVE: The objective of this study was to verify the hypothesis whereby the implementation of perceptual channels in HiRes120 may lead to an improvement in the perception of music, owing to an increase in spectral resolution. SUBJECTS AND METHODS: Music perception was studied in 12 adult subjects, making a comparison between performance with HiRes90 and HiRes120 with perceptual channels. Quality of perception, loudness and rhythm were all assessed via a questionnaire. Further tests included timbre recognition trials and pitch ranking. RESULTS: Whereas there was a significant improvement in appreciation of music as seen by the questionnaire, timbre and pitch trials seemed to be biased by various subjective factors and require further study using different criteria.

Another reason for intra-operative imaging during cochlear implantation.

OBJECTIVE: We report a case of a rare cochlear implant complication: the introduction of the electrode array into the superior semicircular canal, with intra-operative measurements of neural response reactions suggesting reasonable functioning of the implant. CASE REPORT: A two-year old patient affected by congenital, profound, sensorineural deafness underwent bilateral cochlear implantation at the ENT clinic of the 'La Sapienza' University of Rome. Two Clarion 90k devices were implanted, and electrophysiological and radiological checks were performed. After the introduction of the array in the right side, neural response imaging was performed, and a neural potential was found only on two apical electrodes, at a stimulation intensity of 431 clinical units. The situation differed on the left side, where neural response imaging was present at a stimulation intensity of 300 clinical units on the two electrodes tested (one apical electrode (number three), and one middle electrode (number nine)). Intra-operative radiological assessment with a transorbital plain films was performed as usual in order to assess the position of the electrodes inside the cochlea. This radiography showed the electrode array to be in the superior semicircular canal in the right ear. CONCLUSION: Intra-operative monitoring tests during cochlear implant surgery play different roles; measurement of impedances and neural response imaging can evaluate the integrity of implant electrodes and the status of the electrode-cochlea interface, but it must not be the sole way in which correct positioning of the array is confirmed. In our opinion, intra-operative radiological assessment is mandatory during cochlear implant surgery.

Assessment of intracochlear electrode position and correlation with behavioural thresholds in CII and 90K cochlear implants.

CONCLUSION: The image quality of 64-MDCT provided excellent definition of the fine osseous structures and individual electrode contacts. Evaluation of electrode distances revealed a more focused stimulation for the Helix contacts, with better optimization of pulse width and frequency of stimulation. OBJECTIVES: A multi-slice CT scan was performed postoperatively to evaluate electrode distance from the modiolus and variability of fitting parameters (M level) for two different types of cochlear implant electrode carriers, CII and 90K implants with 1J and Helix electrode carriers. MATERIALS AND METHODS: The electrode's position in different cochlear implant (CI) electrodes, Advanced Bionics 90K 1J and Helix, was assessed postoperatively in 20 adult patients by means of a 64-MDCT scanner. Axial, coronal, and oblique 0.3 mm multiplanar reconstructions (MPRs) were obtained and datasets were analyzed to assess the intracochlear position and distance from the surface of the electrodes to the bony edge of the modiolus. Patients' fitting characteristics were gathered at the time the CT was performed and correlated to intracochlear measurements. RESULTS: Determination of contact distances confirmed smaller average values for the Helix at the apex and medial segments. Helix electrodes were closer to the modiolus in all segments. Likewise, M level determination showed lower values for the Helix carrier, confirming a more focused stimulation and better optimization of pulse width and frequency of stimulation.

Treatment with laser CO2 cordectomy and clinical implications in management of mild and moderate laryngeal precancerosis.

All the classification of precancerous lesions are based on the progression of specific histopathological characteristics, which in turn considers the grade of epithelial hyperplasia and dysplasia, nevertheless the transformation of laryngeal keratosis into carcinoma occurs through progressive modifications of normal epithelium in keratosis without dysplasia, to the point of degenerating into carcinoma in situ. The treatment of laringeal precancerosis has not yet defined a gold standard: according to some authors, a simple excision biopsy may be sufficient, others, instead, perform the stripping of the involved vocal cord, while others yet perform vaporization by means of CO2 laser. The aim of this paper is to evaluate and possibly validate the treatment of mild and moderate laryngeal dysplasia (LIN1-2) by CO2 laser, with particular attention to oncological and functional results. Fifty-eight patients (44 males and 14 females, mean age 54.3 years) affected by mild and moderate dysplasia (32 LIN I and 26 LIN II) diagnosed by a bioptic exam, were treated by performing a CO2 laser cordectomy (following the European Society of Laryngology's criteria). Before surgery to the patients was given a questionnaire to identify primary risk factors such as smoking, alcohol use and gastroesophageal reflux, were also handed a Vocal Performance Questionnaire. In all patients was performed a pH measurement over a 24-h period, a voice evaluation using a Kay digital Strobe 920. 84% of patients were smokers; the presence of reflux was reported in 11 patients (19%). The 32 LIN1 cases treated with type I cordectomy determined four recurrences (12.4%), of which two LIN1, one LIN2 and one carcinoma in situ. Of the 26 LIN2 cases examined, the 12 treated with type 1 cordectomy generated 1 recurrence alone with the presence of an invasive carcinoma (T1a) (8.3%), while no recurrences were reported in the group of 14 LIN2 cases treated with type II cordectomy. 93.1% (54/58) of cases showed a complete closing of the glottal plane over time. Considering the results in terms of disease control, and functional outcomes, our experience suggests subepithelial cordectomy (ELS I) for LIN 1 and subligament cordectomy (ELS II) for LIN 1 recurrences; therefore we suggest subligament cordectomy (ELS II) in LIN 2 cases.

Distortion product otoacoustic emissions in otosclerosis: intraoperative findings.

The aim of the study was to investigate changes in middle ear dynamic characteristics caused by both otosclerosis and stapes surgery (platinotomy, prosthesis positioning, ossicular chain maneuver) and to evaluate distortion product otoacoustic emissions (DPOAEs) before and following surgery. The study included 15 patients (12 women, 3 men; mean age 51 years; range 32-69 years) with advanced otosclerosis. All the patients were evaluated with the use of pure-tone audiograms (preoperatively, 5 and 30 days after surgery), stapedial reflexes (preoperatively), and DPOAE recordings (preoperatively, at the end of surgery, and 5 and 30 days after surgery). Changes in the hearing thresholds and in the DPOAE amplitudes were compared. Preoperative tests showed conductive hearing loss, with a mean air-bone gap of 36.6 dB HL ranging from 0.25 to 1 kHz, and no stapedial reflexes were detected. DPOAEs were not measurable preoperatively, and they were detected only in 2 patients at the end of surgery, with low amplitudes in a narrow frequency range. No significant changes occurred in DPOAEs 5 days postoperatively. A month after surgery, improvement in conductive hearing loss was observed; the mean air-bone gap from 0.25 to 1 kHz was 12.9 dB HL, whereas the higher frequencies were still affected by the disease. DPOAEs increased in amplitude in 4 patients, but this was not significant. It remains unclear why DPOAEs are not detected despite a subjective hearing improvement and a sufficiently closed air-bone gap at least in middle and low frequencies. The results of our study show that DPOAEs cannot replace behavioral threshold tests; they may only be included in a battery of tests for a complete clinical follow-up for efficiency monitoring after stapes surgery.