Prospective multicentre study on barbed reposition pharyngoplasty standing alone or as a part of multilevel surgery for sleep apnoea.

OBJECTIVES: The aim of this study was to demonstrate in a prospective multicentre study that Barbed Reposition Pharyngoplasty (BRP) procedure is safe and effective in management of obstructive sleep apnoea/hypopnea syndrome (OSAHS) patients. DESIGN: Prospective study. SETTING: Multicentre study. PARTICIPANTS: Patients suffering from obstructive sleep apnoea. MAIN OUTCOMES MEASURES: Values of postoperative apnoea-hypopnea index (AHI), oxygen desaturation index (ODI), epworth sleepiness scale (ESS). RESULTS: 111 Barbed Reposition Pharyngoplasty procedures standing alone or as a part of multilevel surgery for OSAHS, performed between January and September 2016, were analysed in 15 different centres. The average hospitalisation period was 2.5 ± 0.5 days. The mean patient age was 46.3 ± 10.5 years. The average body mass index at the time of the procedure was 27.9 ± 3.2, and the majority of the patients were men (83%). The mean preoperative and postoperative apnoea/hypopnea index was 33.4 ± 19.5 and 13.5 ± 10.3, respectively (P < .001). The mean preoperative and postoperative ESS score was 10.2 ± 4.5 and 6.1 ± 3.6, respectively (P < .001). The mean preoperative and postoperative ODI were 29.6 ± 20.7 and 12.7 ± 10.8, respectively (P < .001). CONCLUSIONS: Patients undergoing BRP standing alone or as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation for success with minimal morbidity.

Obstructive sleep apnea syndrome in the pediatric age: the role of the pneumologist.

OBJECTIVE: This review paper aims to summarize the current state of knowledge on the role of the pneumologist in the diagnosis and respiratory treatment of children affected by obstructive Sleep Disordered Breathing (SDB). MATERIALS AND METHODS: A literature review has been performed on the following topics: obstructive SDB and its clinical entities, indications for respiratory treatment of pediatric SDB, and Continuous Positive Airway Pressure (CPAP) and Noninvasive Positive Pressure Ventilation (NIPPV) treatment approach to obstructive SDB. RESULTS: OSDB is related to obesity, craniofacial pathologies, neuromuscular disorders and, most commonly, oadenotonsillar hypertrophy. Adenotonsillectomy is the first-choice treatment in children with obstructive apnea secondary to adenotonsillar hypertrophy. CPAP and NIPPV are recommended in cases where Obstructive Sleep Apnea (OSA) persists after surgery or when surgery is contraindicated. Treatment interventions are usually implemented gradually by separately addressing each abnormality that would predispose to obstructive SDB, then reevaluating after each intervention to detect any residual disease and to assess the need for additional treatment. CONCLUSIONS: Many pediatric patients continue to experience problems and symptoms such as hypersomnia and apnea after adenotonsillectomy and need CPAP/NIPPV treatment. Current knowledge is still incomplete, especially with regard to the mechanisms of pathogenesis of pediatric OSA, the factors affecting pediatric OSA, and the phenotypic variability of the disease. A better understanding of these aspects would contribute to the development of new therapies.

Obstructive sleep apnea syndrome in the pediatric age: the role of the otorhinolaryngologist.

OBJECTIVE: Obstructive sleep apnea (OSA) is the primary indication for tonsillectomy, one of the most common pediatric surgical procedures, commonly performed in association with adenoidectomy. The objective of this review article is to evaluate the role of the otorhinolaryngologist in pediatric OSA. MATERIALS AND METHODS: A literature review has been performed on the following topics: peculiarities of sleep-disordered breathing in pediatric age; discrimination of sleep disorders; adenotonsillar hypertrophy; surgical techniques; adjuvant surgical procedures. RESULTS: The role of the otorhinolaryngologist in pediatric OSA is important for the evaluation of the upper airways and of essential biometric and polysomnographic data and for indication and execution of appropriate surgical treatment. In the majority of healthy children, adenotonsillectomy for OSA results in a dramatic improvement in respiratory parameters as measured by polysomnography. When post-surgical residual OSA occurs, it is essential to monitor patients by means of drug-induced sleep endoscopy (DISE). CONCLUSIONS: Otolaryngologic assessment is of paramount importance to correctly classify a child with OSA. Correct inspection of the upper airway and quantification of the quality of sleep through polysomnography lead to the right therapeutic choice. Knowledge of different surgical techniques helps to deal with residual OSA after studying the obstruction sites by drug-induced sedation endoscopy.

Cost-effectiveness strategies in OSAS management: a short review.

Obstructive sleep apnoea (OSAS) is an underdiagnosed chronic disease with a high prevalence in adults. It is becoming a significant social problem, since it is associated with a worsening in quality of life and increase in mortality. The cost-effectiveness ratio of diagnostic and therapeutic management of OSAS is a strategic issue to counteract the expected increasing demand of objective testing. OSAS patients with any clinical evidence of comorbidities must be studied using simplified and less expensive systems such as Home Sleep Testing (HST). On the other hand, Sleep Laboratory Polysomnography (PSG) is the gold standard to manage OSAS patients with comorbidities. It should be pointed out that the use of HST can lead to incorrect diagnosis in poorly selected OSAS subjects. This short review discusses various topics for the proper diagnosis and treatment of OSAS in view of epidemiological factors and results in terms of costs and social benefit of the disease. Whatever the strategy chosen and/or the organisational model adopted for managing OSAS, it cannot and should not take into account only cost-effectiveness. Long-term prospective studies evaluating cost-effectiveness ratios and outcomes of OSAS treatment of hospital management models versus home care models are needed.

[Efficacy and distribution pattern of the medical device Prima Difesa on rhinosinusal area]. / Efficacia e modalità di distribuzione del presidio medico Prima Difesa sul distretto rinosinusale.

AIM: Common cold is the commonest form of acute rhinitis and the first pathology of the upper airways. Viruses, the main responsible of this pathology, carry out their cytopathic effect on the ciliated cells of the airways mucosa. Mucociliary transport shows their dangerous effect. The aim of our study is to evaluate the effect of the medical device Prima Difesa on the functioning of the mechanism thanks to its composition and its distribution modality in the nasal cavities. MATERIALS AND METHODS: The present study has been performed on three groups of subjects with their informed consent: Group A (30 healthy subjects: 19 M, 11 F; 18-36 yrs, mean age: 29.1 yrs), Gruppo B (30 patients affected by rhinosinusal pathology: 7 M, 13 F; 19-38 yrs, mean age 30.7 yrs) and Group C (20 healthy subjects: 12 M, 8 F; 20-40 yrs, mean age: 32.2 yrs). The protocol of administration for the Group A and B, in order to evaluate the efficacy of Prima Difesa, consisted of 2 puff per nostril of Prima Difesa 4 times a day over 15 days. The follow-up of patients belonging to Grup A and Group B was articulated in three consecutive visits, each consisting of: anterior rhinoscopy, active anterior rhinomanometry, measurement of mucociliary transport (TMCt). The C patients underwent only one administration of the device to the extent of evaluating through endoscopy its distribution modality in the nasal cavities. RESULTS: The results show that clinical effects, evaluated in term of improvement of MCTt and in term of decreasing of nasal resistance, are particularly clear in patients with alterations of these parameters caused by rhinosinusal pathologies. The device can reach the "key" areas of rhinosinusal pathologies that are: middle turbinate and osteomeatal complex. Beside, the percentage of diffusion, about 30% of the middle turbinate head, justifies its clinical effect. CONCLUSIONS: The medical device Prima Difesa has resulted to be able in interfering with the correct maintenance and performance of the Mucociliary Transport mechanism, that represents an important aspecific machinery for the local defence of nasal mucosa by microbial injuries.

Extra-laryngeal manifestations of gastro-oesophageal reflux.

Of the various otorhinolaryngological disorders for which it has been recognized that gastro-oesophageal reflux is a possible causal or associated aetiological factor, those manifestations localized in the rhino-sinus and auricular district are certainly the "least studied". Herein, therefore, these manifestations are described, focusing on the physio-pathological aspects and the more important pathogenic hypotheses of the cough, as well as other lung manifestations.

[Rhinosinusitis: etiopathogenesis and antimicrobial therapy, an update]. / Le rinosinusiti: aggiornamenti in tema di eziopatogenesi e antibioticoterapia.

The aim of the current study is to underline once again the etiopathogenetic aspects of rhinosinusitis, by a revision of most significative and updated study in otorhinolaryngologic literature to guide the right management of this disease. The focal role of ostio-meatal complex is reported; epidemiological data on old and emergent pathogens are described together with their role on acute or chronic or recurrent rhinosinusitis pathogenesis. According to recent evidence based medicine documents, diagnostic criteria and methodologies are reported to control surgical and medical long-term results. On the bases of the current etiopathogenetic concepts, medical treatment is suggested. The central role of medical management is based on the choice of antimicrobial treatment. The fundamental concepts on pharmacocinetic and pharmacodinamic are reported, togther with updated data on antimicrobial resistance.

Obstructive sleep apnoea syndrome: a new paradigm by chronic nocturnal intermittent hypoxia and sleep disruption.

Obstructive sleep apnoea syndrome (OSAS) is associated with severe cerebro-cardiovascular morbidity and mortality. It is an independent risk factor for atherosclerosis, arterial thrombosis and metabolic syndrome, and recently has been associated with an increased incidence of cancer and death. A causal link between OSAS and atherosclerosis has been partially established. Recent research on atherosclerosis in OSAS has focused on thrombotic tendency and blood viscosity, providing new insight into disease mechanisms. Hypoxia is a critical pathophysiological element in OSAS that leads to intensive sympathetic activity, in association with inflammation, oxidative stress and procoagulant activity. Hypoxia and the induction of oxidative stress can simultaneously represent an underlying mechanism in the pathogenesis of cancer development and progression. This mini-review will discuss the latest findings on the association and potential relationship between OSA and pathological vascular sequelae.

Linkage of DFNB1 to non-syndromic neurosensory autosomal-recessive deafness in Mediterranean families.

Recent studies show a susceptibility locus (DFNB1) responsible for non-syndromic neurosensory autosomal-recessive deafness (NSRD) mapping to the pericentromeric region of chromosome 13q. In order to better understand the frequency with which DFNB1 is the gene for deafness in our patient population and the role of DFNB1 in Caucasians, we performed a genetic linkage study with four microsatellite markers linked to DFNB1 in a total of 48 independent Mediterranean families, of which 30 and 18 were of Italian and Spanish descent, respectively. A maximum two-point lod score of 7.28 was found with marker D13S115 at a recombination frequency of theta 0.1. Significant lod scores were also obtained for D13S143, D13S292 and D13S175. Genetic heterogeneity was confirmed using the HOMOG program which indicated absence of linkage to DFNB1 in approximately 21% of the sample. This study clearly demonstrates that DFNB1 plays an important role in 79% of Mediterranean families with NSRD. Furthermore, results from multipoint analysis predict that the DFNB1 gene maps between markers D13S175 and D13S115 which are separated by approximately 14.2 cM.

[Behavior of impedance of the middle ear during rapid changes in barometric pressure]. / Andamento dell'impedenza dell'orecchio medio durante variazioni rapide della pressione barometrica.

The first results on the dynamic behaviour of middle ear impedenzometric variations starting from an altitude of 3,000 mt and descending constantly by about 1,500 mt/min to sea level, are reported. The research was carried out in a hypobaric chamber, under simulated flight conditions, using the equipment of the Aeronautics and Space Medicine Studies and Research Centre of the Air Force. Evaluation of the results obtained in subjects trained for rapid descents and in others not so trained suggests that the technique used is a useful aid in the diagnosis of the tubal conditions of subjects who are to be subjected to rapid ascents and descents.

[Behavior of the impedance of the middle ear and of the stapedius reflex under static conditions of barometric depression]. / Andamento dell'impedenza dell'orecchio medio e del riflesso stapediale in condizioni statiche di depressione barometrica.

The authors present the preliminary results of a range of their aero-space medicine studies, carried out in hypobaric chamber, in simulated flight and at different atmospheric pressures, to asses the tubal function in normal hearing people. The tympanometric determination through a Z072 Madsen inpendenzometer in static and dynamic conditions of barometric depression gave a clear and exact indications about the impedence variation capacity of the middle ear in similated flight, giving homogenous data which allow the use of this method in flying recruitment aptitude test routine.

[The use of an automatic device for recording the recovery time from auditory fatigue in flight personnel exposed to noise]. / Considerazioni sull'impiego della registrazione automatica del tempo di recupero della pratica uditiva (P.A.T.) nel personale aeronavigante esposto a rumore.

The results of a study conducted on individuals exposed to aeronautical environment noise (flight personnel, runway operators, mechanics etc.) are reported. A particular suprathreshold automatic audiometric technique, called P.A.T. (automatic Peyser test) was used because there was evidence that it was more trustworthy than other suprathreshold tests and because this test permits a graphic follow-up of the dynamic evolution of "uditive fatique" phenomenon. The conclusion is drawn with this method it is possible to evaluate more precisely both the entity of the damage and on possible suffering of Corti's organ in individuals exposed to noise, and the simplicity of the test is underlined. Moreover the test is advantageous because it can be done using the normal routine diagnostic apparatus.

[Rationale of the use of COX-2 inhibitors in ENT pathologies]. / Razionale d'uso dei cox-2 inibitori nelle affezioni ORL.

Upper airways inflammations (rhinitis, rhinosinusitis, polyposis, otitis, pharyngitis, etc) the pathologies most commonly encountered in the daily clinical practice and they represent, because of the high sanitary costs, an important social problem. The Literature suggests that almost all the symptoms, which characterize upper airways inflammations, are induced by the production of prostaglandins by cyclooxigenase (COX); it is obvious the need of a therapeutic action at this level. The non steroidal anti-inflammatory drugs (NSAID) block the activity of both COX-1 and COX-2, whereas the selective inhibitors of COX-2 (the coxibs) act only on this isoform. Actually, the therapeutic effects of both NSAIDs and coxibs are due to their actions on COX-2, while the system toxicity of NSAIDs (gastrointestinal perforation or ulcer, reduction of glomerular filtration rate, prolongation of bleeding time) is ascribable to the inference of these drugs with the COX-1. In conclusion, a correct approach to ENT inflammations must implies the use of drugs efficacious against the typical symptoms of the inflammatory process (and specifically the symptom: pain), eventually joined with an appropriate antibiotic treatment; in this context, a selective inhibitor of COX-2 short course treatment offers the double advantage of managing the inflammation and avoiding damages to the gastric mucosa.

[Quantification of communication difficulty in subjects with hearing loss: a pilot study]. / La quantificazione delle difficoltà di comunicazione del soggetto ipoacusico: studio pilota.

A brief questionnaire concerning auditory disability in every day listening was developed. The aim was to generate a simple, practical test for rehabilitational purposes. The questionnaire was administered to 255 hearing-impaired subjects coming under observation consecutively. The only requirement for participation was an expression of communicational difficulties due to adult onset of hearing loss. Some items were not applicable for all subjects. The higher scores were observed for hearing problems related to speech-in-noise. Good linear correlations were found between better-ear auditory and questionnaire score-based indexes in the 'family' and 'social' sections.

[Elaboration of a hearing disability scale]. / Elaborazione di una scala di disabilità uditiva.

On the basis of a previous pilot study a multiple-choice questionnaire about hearing disabilities was developed. The questionnaire (SDU) allowed 20 items. The answers were tailored to the single question and scaled in increasingly order of disability (form A) or in random order (form B). Modalities of administration (self-report or interview) and form (A or B) were randomized in a group of 123 adult subjects with different degree of hearing impairment. Only one factor, attributable to hearing disability, was extracted by a factor analysis. This factor explains a major variance ratio of items related to speech perception in difficult listening context. A good correlation (r = .74) was found between SDU total score and hearing threshold in the better ear. No difference in mean score, variance and time of reduction of the SDU was found between form A and B. The Authors so propose the use of form A because of a more easy compute of the total score. Self-report was more time-consuming respect to interview (11.7' vs. 8.4'). Furthermore, self-report was non possible in 13.8% of subjects for severe virus impairment and illiteracy and in 6.1% some form of support was necessary. No difference of mean score and variance between self-report and interview was found. SDU represents a tool for hearing disability evaluation useful in aural rehabilitation protocols. The principal advantage is high applicability thanks to short time required, simplicity of task and flexibility in the modality of administration.

[Allergologic evaluation in chronic rhinitis: study of 411 cases]. / La valutazione allergologica nella rinite cronica: studio su 411 casi.

The present work reports the results of an allergological evaluation performed on 411 patients suffering from chronic rhinitis alone or associated with bronchial asthma. Allergic diagnosis was based on the results of skin prick tests, serum RAST, nasal provocation, allergy avoidance diets and food provocation. 207 patients were sensitized to one or more allergens (50.4%); mean age for onset of rhinitis was 14.9. The first ten years of age proved most relevant for onset of symptoms, while late onset was significant in females. The most common reactions were to house dust mites, most likely due to the local environmental-climatic conditions which favor the growth of Dermatophagoides. Olive-sensitization was frequently found in pollen-positive subjects. Careful allergological evaluation of chronic rhinitis is very important so as to establish the best treatment and environment prophylaxis for the disease.

[The importance of upper respiratory tract shape in the treatment of chronic rhonchopathy]. / Importanza della forma delle VAS nel trattamento della roncopatia cronica.

The aim of the present work has been to verify what role the shape of the upper respiratory tract plays in both the onset of Obstructive Sleep Apnea and those cases which do not respond to treatment. Fifty patients with 1st stage chronic rhoncopathy according to the Lugaresi classification, were examined, all of whom underwent uvulopalatopharygoplasty. Of these 32 also under went tonsillectomy and 45 had followed a diet prior to surgery. At 6 months and 2 years after surgery an endoscopy was perform with a video recorder to compare the pre- and post-operative anatomic configuration of the oropharynx. Both the patients and their partners were presented a questionnaire to evaluate the degree of satisfaction with the treatment. The average follow-up was 30 months. Diet proved effective, especially in the most severe cases of obesity, with an average Body Mass Index which dropped from 30.5 to 26 after 6 months, rising to 28 after 24 months. The IAH went from 46.0 +/- 15.4 (SD) to 15 +/- 13.3 at 6 months, and rose to 27.5 +/- 14.3 (SD) at 2 years. The degree of satisfaction of both patient and partner was 88% at 6 months and dropper to 63% after 2 years. Videoendoscopy using a flexible lens was performed to evaluate the diameter of the positive results with surgery while it was the anterior-posterior axis in 70% of those who had negative results. In this study, after surgery, the larger URT diameter was latero-lateral in 62% of the patients while preoperatively it was so in just 10%. The use of tonsillectomy associated with UPP proved necessary to modify the shape of the URT.

[Diurnal hypersomnolence and chronic snoring: an epidemiological study]. / Ipersonnolenza diurna e roncopatia cronica: indagine epidemiologica.

Excessive daytime somnolence (EDS) is highly correlated to the presence of obstructive sleep apnea syndrome (OSAS). It appears that interest in such disorders may also be extended to extraneurological fields. The Authors report the results of a study on EDS in 1,146 adult subjects seen consecutively by different physicians. Excessive Somnolence during normal activity was reported in 4.5% of the subjects studied. In a subgroup of habitual snorers, EDS was observed in 8.3% of the subjects and in 2.0% in a group of non-snorers. The subjects with EDS has a mean age and body mass index (BMI) greater than those of the control group and a higher frequency of certain performance disturbances. No sex differences were found. EDS and habitual snoring had a similar age-related trend.

[Elaboration of the hearing disability scale]. / Elaborazione di una scala delle disabilità uditive.

On the basis of a previous pilot study, a multiple-choice questionnaire regarding hearing disabilities was developed. The questionnaire (SDU) was made up of 20 items. The answers were tailored to the single question and scaled according to the increasing degree of disability (form A) or in random order (form B). Administration modality (self-report or interview) and form (A or B) were randomized in a group of 123 adult subjects with different degrees of hearing impairment. Only one factor, attributable to hearing disability, was extracted by factor analysis. This factor explains a major variance ratio of items related to speech perception in difficult listening context. A good correlation (r = .74) was found between SDU total score and hearing threshold in the better ear. No difference in mean score, variance and necessary scoring time of the SDU was found between form A and B. The Authors thus propose the use of form A because of a more easy computation of the total score. Self-report was more time consuming with respect to interview (11.7' vs. 8.4'). Furthermore, self-report was non possible in 13.8% of subjects for severe sign impairment and illiteracy and in 6.1% some form of support was necessary. No difference in mean score and variance between self-report and interview was found. SDU represent a tool for hearing disability evaluation useful in aural rehabilitation protocols. The principal advantage is high applicability thanks to the short time required, simplicity of task and flexibility of administration modality.

[The variability of functional gain and insertion gain in hearing aid fitting]. / Variabilità del guadagno funzionale e del guadagno di inserzione nell'adattamento protesico.

Functional gain (FG) and insertion gain (IG) are currently used as real ear gain measurement of hearing aids. The gain differences observed with hearing aid modifications made in order to achieve the desired prescriptive target must be greater than the variability associated with repetition of measurement in order to be really useful. Limited research is available on FG and IG intratester variability. In order to evaluate single variability factors, some studies use experimental designs not common in clinical work-up while others use equipment mot available commercially. The present study evaluates intratester variability of FG and IG (Madsen IGO 1500 equipment) in a typical clinical configuration in 42 users of behind-ear hearing aids. Mean standard deviation of FG test-retest differences was 5.19 dB. Range of variability was expressed in term of centiles. 5-- and 95-- centiles were -9.8 and 8.7 dB respectively. Mean s.d. of IG test-retest differences was 3.18 dB; 5-- and 95-- centiles were -5.2 and 6.05 dB respectively. Major variability was found at higher frequencies. High variability at lower frequencies was also found probably due to sealing problems of ear molds in the ear canal. Accord between FG and IG was also examined. A good mean correspondence in mid frequency range was found (FG-IG mean difference less than 5 dB) with large inter-subject differences between the two measurements (s.d. 11 dB).