Tongue Base Reduction with Thyro-Hyoido-Pexy (TBRTHP) vs. Tongue Base Reduction with Hyo-Epiglottoplasty (TBRHE) in mild-severe OSAHS adult treatment. Preliminary findings from a prospective randomised trial.

In a preliminary prospective randomised study, a series of 5 patients submitted to classic Tongue Base Reduction with Hyo-Epiglottoplasty (TBRHE according to Chabolle et al., 1998) is compared to a series of 7 patients submitted to a modified version of Chabolle's procedure. The changes introduced in the new surgical technique can be summarised as follows: a) lower neck skin incision; b) different neurovascular bundle identification; c) submucosal tongue base muscle resection; d) variation of the caudal hyoid stabilisation, already described by the Authors in 2008 (Tongue Base Reduction with Thyro-Hyoido-Pexy). The objective has been primarily to compare the feasibility, functional effectiveness and overall tolerability of the modified procedure. In this preliminary study Tongue Base Reduction with Thyro-Hyoido-Pexy has proven to be an easy and rapid procedure, with shorter post-operative functional recovery and comparable polysomnographic and neuro-psychological short time results.

Role of skin-lined tracheotomy in obstructive sleep apnoea syndrome: personal experience.

Permanent tracheotomy was the first surgical procedure proposed for the treatment of severe obstructive sleep apnoea syndrome and is still the only surgical option that ensures, even in very severe cases, complete elimination of apnoea and, in turn, clinical remission. Improved knowledge of the causes of obstructive sleep apnoea syndromes and the increasing therapeutic options (instrumental, medical and surgical) have resulted in cases requiring tracheotomy as the only indispensable therapeutic option becoming more rare. At present, the only indications are in very occasional conditions of life-threatening obstructive sleep apnoea syndromes and in patients on whom continuous positive airway pressure is not tolerated or is not effective (severe deoxygenation or hypercapnia, severe respiratory disorder index, severe obstructive sleep apnoea syndrome-related arrhythmias, severe excessive daytime sleepiness, heart diseases or ischaemic encephalopathy exacerbated by obstructive sleep apnoea syndromes, obstructive pneumopathy exacerbated by obstructive sleep apnoea syndromes, severe obstructive sleep apnoea syndromes with few chances of resolution with other surgical procedures or failure of the latter). Moreover, it is the only therapeutic solution in rare nocturnal laryngeal stridor due to multisystemic atrophy (in which obstructive sleep apnoea syndrome is due to nocturnal laryngospasm of neurologic origin). Therapeutic tracheotomy must be permanent (tracheostomy) and, therefore, preferably carried out with a specific technique (skin-lined tracheotomy), able to guarantee greater stability, less risk of granulation tissue, wider opening of the tracheostomy, sufficient reversibility. In our experience, very few patients (10 cases) withsleep disorder breathing have been submitted to skin-lined tracheotomy. Of these, the majority were submitted to surgery for severe apnoea due to nocturnal laryngospasm on account of multisystemic atrophy (n = 7), while only 3 cases of obstructive sleep apnoea syndromes were submitted to skin-lined tracheotomy, i.e., 0.7% of the 424 patients operated on for obstructive sleep apnoea syndrome and 1.7% of the 175 operated on for severe, or very severe, obstructive sleep apnoea syndromes (RDI > 40). Skin-lined tracheotomy was not followed by important complications and expected results were achieved with immediate disappearance of daytime symptoms and considerable improvement in nocturnal apnoea. Besides sleep-related disorders, numerous clinical situations with indications for a permanent tracheotomy may benefit from the skinlined technique, such as severe laryngeal or tracheal stenoses, laryngeal diplegias, miasthenia gravis, lateral amyotrophic sclerosis, intractable aspiration, severe emphysema.

Temporary tracheotomy in the surgical treatment of obstructive sleep apnea syndrome: personal experience.

Aim of the study is a retrospective analysis on the use of temporary tracheotomy in our snoring surgery experience. From September 1996 to April 2002, 1103 snoring surgery procedures have been carried out on various sites of the upper airways in 530 patients (mean age 50 years, 81% males) prevalently related to severe Obstructive Sleep Apnea Syndromes (33%). Of these patients, 472 (89%) were operated upon under general anaesthesia, whereas 58 (11%) received local anaesthesia. Of the 472 patients operated upon under general anaesthesia, 17 (3.6%) underwent temporary tracheotomy, which in 10 (2.1%) were programmed and only in 7 (1.5%) were non-programmed, having been performed in 2 cases in an emergency setting, in 3 cases in an urgency setting due to respiratory obstruction immediately after removal of intubation and in 2 cases in conditions of urgency, due to respiratory obstruction occurring during post-operative hospitalisation (both performed within 6 hours of regaining consciousness). The only complication observed was a brief laryngeal diplegia, a complication, moreover, not reported in the literature. No criteria exist concerning indications for temporary tracheotomy programmed according to the type of surgery on the hypopharynx; personal experience reveals that: a) temporary tracheotomy is frequently necessary after genioglossus advancement (3/10 operated upon for genioglossus advancement not associated with a programmed temporary tracheotomy); b) temporary tracheotomy is rarely necessary after hyoid suspension (1/98 patients being submitted to hyoid suspension not associated with programmed temporary tracheotomy). Temporary tracheotomy should, in our opinion, be taken into consideration in snoring surgery techniques, particularly in the presence of the not infrequent urgency or emergency situations occurring in patients with Obstructive Sleep Apnea Syndromes. With the use of temporary tracheotomy, no deaths occurred in the present study population.

[Sideropenic anemia and celiac disease]. / Anemia sideropenica e malattia celiaca.

Since the beginning of the use of Antigliadin Antibodies (AGA) in the screening of coeliac disease (CD) we have observed an increasing in the total number of cases diagnosed, in particular of the cases with monosymptomatic and atypical forms. Iron deficiency anemia is one of the more frequent findings that we can find in CD, either in association with other typical coeliac signs, or as an isolated expression of the disease. The first aim of our study was to determine the incidence of iron deficiency anemia in our patients affected by CD at the moment of diagnosis. The second aim was to determine the incidence of CD in a group of 96 patients attending our Pediatric Hematology department for iron deficiency anemia of unknown etiology and refractory to iron therapy. 103 patients out of our 212 coeliacs (48.5%) showed hypochromic and microcytic anemia. In the second sample we found 6 (6.2%) patients, positive in AGA and Antiendomysium Antibodies (AEA), that showed a typical coeliac picture at the jejunal biopsy. Our study confirms the high incidence of iron deficiency anemia in patients affected by coeliac disease. However the most important conclusion of our study is that a certain percentage of patients affected by hypochromic anemia of unknown etiology may be affected by coeliac disease. It is only by performing the specific screening tests (AGA and AEA) in the patients affected by iron deficiency anemia of unknown etiology, that we can diagnose this monosymptomatic expression of CD.

[Celiac disease in children with Down's syndrome]. / Malattia celiaca in bambini con sindrome di Down.

The coexistence of Down's syndrome (DS) and coeliac disease (CD) has been occasionally reported and both diseases are often related to autoimmune disorders. The pathogenetic factor that links CD and DS may be an altered immune system and/or the presence of a common genetic factor. Some epidemiological investigations, performed in patients with CD, showed an increased incidence of DS compared to the natural incidence of this abnormality in the general population. We studied the prevalence of CD in 83 individuals with DS compared to a group of 200 patients with other gastroenterologic disorders and a random scholastic sample of 500 non symptomatic children. IgG and IgA antigliadin antibodies (AGA) were determined in all patients. Antiendomysium antibodies (EmA) were investigated in all the patients of the first group, while in the other two groups, 27 and 108 cases respectively, selected by AGA positivity, were investigated for EmA. The percentage of AGA IgA positivity in the first group was 31.3% (26/83), in gastroenterologic controls 10% (20/200), in scholastic sample 2.8% (14/500), that shows a significant statistical difference. On the contrary EmA were positive in quite a similar percentage in the three groups. Duodenal [correction of Jejunal] biopsies, were performed in 11 DS patients and in 9 of the other two groups. EmA were positive only in the case with subtotal atrophy in all the groups: 5/11 in the first, 2/4 in the second, 2/5 in the third. On the contrary AGA IgA were often positive also in patients with non coeliac histologic findings.(ABSTRACT TRUNCATED AT 250 WORDS)

[Discordance in the onset of celiac disease in monozygotic twins]. / Discordanza nell'esordio di malattia celiaca in gemelli monozigoti.

Coeliac disease (CD) is a gluten intolerance caused by a combination of genetic and environmental factors such as nutrition and infections. Monozygotic twins appear to have a concordance for CD up to 71%. This paper reports a third case of late onset of CD in monozygotic twin girls. The twins were defined as monozygotic based upon paired clinical and laboratory examinations. Clinical examinations included genotypic, phenotypic and dermatoglyphic analysis, while laboratory examinations included HLA typing and blood groups. Following European Society of Pediatric Gastroenterology and Nutrition criteria, CD was diagnosed in both girls, though 4 years and 8/12 months apart. The twins achieved clinical, laboratory and histological remissions within 1 year, after the institution of a gluten-free diet. Genetic markers are undoubtedly the main precondition for CD development. Environmental factors, however, may play a more significant role in triggering the onset of disease.