Anatomic variations of the round window niche: radiological study and related endoscopic anatomy.

PURPOSE: In the last decades, literature has shown an increasing interest in round windows (RW) anatomy due to its pivotal role in deafness surgery. The high variability of this anatomical region, with particular regard to the round windows niche (RWN), has been studied by several authors through different methods of investigation. The aim of the present research was to radiologically examine the morphological variability of the RWN and to link the imaging findings to the endoscopic view. METHODS: High-resolution CT scans of 300 temporal bones without neuro-otological pathologies were retrospectively reviewed by 2 neuroradiologist and 1 ENT surgeon who independently evaluated the RWN morphological variations. To link the radiological to the endoscopic data, 45 cadaveric human temporal bones were submitted to a radiological evaluation and to an otoendoscopy conducted through a posterior tympanotomy approach. RESULTS: Three variants of the RWN were detected on coronal CT scan reconstructions: 155 "cylindrical-type", 97 "j-type" and 48 "truncated cone-type". For each radiological type the endoscopic findings showed a specific endoscopic position of the RW chamber, which results in different degrees of RW membrane visibility when analysed through a posterior tympanotomy approach. CONCLUSIONS: To the best of our knowledge, this is the first description of the above-mentioned RWN radiological variations supported by endoscopic data. This study suggests an additional anatomical evaluation that could be useful to predict the RW membrane visibility through a posterior tympanotomy approach. Further studies are required to support the clinical implications of our observations.

[Analysis of the working population applying to the clinic for the psycological job environmental discomfort relating to employment at AUSL of Romagna - Rimini]. / Analisi della popolazione lavorativa afferente all'ambulatorio per il Disagio psicologico nell'Ambiente di Lavoro dell'AUSL della Romagna - Sede di Rimini.

OBJECTIVES: The Occupational Physician in accordance with the Prevention and Protection of AUSL Romagna (Rimini) has enabled for some years, a Clinic for the psychological job environmental discomfort addressed to employment, with expressions of the psychophysical disorders, caused by work related stress. Health is defined by the current legislation as a state of psychophysical and social wellbeing. METHODS: The main purpose of Clinic for the psychological distress in working environment is to provide listening space and psychological support for employees. In order to assure this support, the Occupational Physician can activate the collaboration with the Psychologist of Clinic for the Psychological Evaluation in support to the formulation of the fitness for work. RESULTS: The data analyzed are those in the period between November 2010 and 2014, concerning the accesses to the Clinic for the psychological distress in working environment and in order to the developments of the paths undertaken by the workers. CONCLUSIONS: The Clinic for the psychological distress in working environment represents an effort into the individual improvement and a possible answer to the reckoning of the risk for work related stress.

Translabyrinthine vestibular neurectomy and simultaneous cochlear implant for Ménière's disease.

BACKGROUND: Surgical management of Ménière's disease (MD) is recommended in case of medical and intratympanic treatment failures. Translabyrinthine vestibular nerve section has been considered the gold standard for denervation procedures in order to control vertigo attacks, although at the cost of sacrificing residual hearing. To the best of our knowledge, no work has been published with regard to a group of patients submitted to translabyrinthine vestibular neurectomy and simultaneous cochlear implant for MD. The aim of the present study was to assess the effectiveness of translabyrinthine vestibular nerve section and simultaneous cochlear implant in a prospective study. METHODS: All adult patients (over 18 years of age) with a diagnosis of intractable unilateral definite MD and useless residual hearing function were enrolled after medical and intratympanic treatment failures. Pre- and postoperative otoneurological evaluation concerned: frequency of vertigo attacks, head impulse test and caloric testing, pure tone average and speech perception audiometry in quiet conditions, tinnitus handicap inventory test, functional level scale and rate of vertigo control, dizziness handicap inventory test, and MD patient-oriented severity index. At least 6 months of follow-up were needed to be enrolled in the study. RESULTS: Four patients were included in the study. Translabyrinthine vestibular nerve section and simultaneous cochlear implant seemed to considerably improve the disabling effects of MD, achieving a good control of vestibular symptoms (mean pre/postoperative vertigo attacks per month: 16.5/0), resolving hearing loss (mean pre/postoperative pure tone average in the affected ear: 86.2/32.5 dB), improving the tinnitus (mean pre/postoperative tinnitus handicap inventory test: 77.2/6), and finally increasing the overall quality-of-life parameters. CONCLUSIONS: In our preliminary report, translabyrinthine vestibular nerve section and simultaneous cochlear implant showed encouraging results in order to definitively control both vestibular and cochlear symptoms during the same therapeutic procedure.

Intratympanic gentamicin treatment 'as needed' for Meniere's disease. Long-term analysis using the Kaplan-Meier method.

In recent years, several titration or on-demand protocols using low-dose repeated intratympanic (IT) gentamicin injections have been adopted for the vertigo control in unilateral medical refractory Menière's disease (MD). Because of the frequent recurrence and the need to treat the patients several times, it is difficult to strictly follow the 1995 AAO-HNS criteria to classify the results. The Kaplan-Meier analysis provides an effective and simpler method to address these concerns. We report the results of a long-term study (7 years) on a large population of MD patients (174) treated with on-request low-dose delayed IT gentamicin injections analysed using the Kaplan-Meier survival method. Effective vertigo control was obtained with a single injection in 40.2% of the patients (excellent responders) and with repeated injections (2-9) in 43.7% of the patients (moderate responders). Only six patients (3.5%) needed to be submitted to vestibular neurectomy because of the persistence of vertigo attacks (non-responders). A subgroup of 22 patients (12.6%) reporting a late recurrence of vertigo attacks after an initial vertigo-free interval lasting more than 2 years (short-term responders) were successfully treated with a further cycle of injections. In no cases, we observed significant signs of cochlear or vestibular toxicity. Kaplan-Meier survival analysis provided an excellent method for reporting treatment success or failure in patients followed for variable length of time with our kind of protocol.

Feasibility of Using the Video-Head Impulse Test to Detect the Involved Canal in Benign Paroxysmal Positional Vertigo Presenting With Positional Downbeat Nystagmus.

Positional downbeat nystagmus (pDBN) represents a relatively frequent finding. Its possible peripheral origin has been widely ascertained. Nevertheless, distinguishing features of peripheral positional nystagmus, including latency, paroxysm and torsional components, may be missing, resulting in challenging differential diagnosis with central pDBN. Moreover, in case of benign paroxysmal positional vertigo (BPPV), detection of the affected canal may be challenging as involvement of the non-ampullary arm of posterior semicircular canal (PSC) results in the same oculomotor responses generated by contralateral anterior canal (ASC)-canalolithiasis. Recent acquisitions suggest that patients with persistent pDBN due to vertical canal-BPPV may exhibit impaired vestibulo-ocular reflex (VOR) for the involved canal on video-head impulse test (vHIT). Since canal hypofunction normalizes following proper canalith repositioning procedures (CRP), an incomplete canalith jam acting as a "low-pass filter" for the affected ampullary receptor has been hypothesized. This study aims to determine the sensitivity of vHIT in detecting canal involvement in patients presenting with pDBN due to vertical canal-BPPV. We retrospectively reviewed the clinical records of 59 consecutive subjects presenting with peripheral pDBN. All patients were tested with video-Frenzel examination and vHIT at presentation and after resolution of symptoms or transformation in typical BPPV-variant. BPPV involving non-ampullary tract of PSC was diagnosed in 78%, ASC-BPPV in 11.9% whereas in 6 cases the involved canal remained unidentified. Presenting VOR-gain values for the affected canal were greatly impaired in cases with persistent pDBN compared to subjects with paroxysmal/transitory nystagmus (p < 0.001). Each patient received CRP for BPPV involving the hypoactive canal or, in case of normal VOR-gain, the assumed affected canal. Each subject exhibiting VOR-gain reduction for the involved canal developed normalization of vHIT data after proper repositioning (p < 0.001), proving a close relationship with otoliths altering high-frequency cupular responses. According to our results, overall vHIT sensitivity in detecting the affected SC was 72.9%, increasing up to 88.6% when considering only cases with persistent pDBN where an incomplete canal plug is more likely to occur. vHIT should be routinely used in patients with pDBN as it may enable to localize otoconia within the labyrinth, providing further insights to the pathophysiology of peripheral pDBN.

Upright BPPV Protocol: Feasibility of a New Diagnostic Paradigm for Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo Compared to Standard Diagnostic Maneuvers.

Background: The diagnosis of benign paroxysmal positional vertigo (BPPV) involving the lateral semicircular canal (LSC) is traditionally entrusted to the supine head roll test, also known as supine head yaw test (SHYT), which usually allows identification of the pathologic side and BPPV form (geotropic vs. apogeotropic). Nevertheless, SHYT may not always allow easy detection of the affected canal, resulting in similar responses on both sides and intense autonomic symptoms in patients with recent onset of vertigo. The newly introduced upright head roll test (UHRT) represents a diagnostic maneuver for LSC-BPPV, supplementing the already-known head pitch test (HPT) in the sitting position. The combination of these two tests should enable clinicians to determine the precise location of debris within LSC, avoiding disturbing symptoms related to supine positionings. Therefore, we proposed the upright BPPV protocol (UBP), a test battery exclusively performed in the upright position, including the evaluation of pseudo-spontaneous nystagmus (PSN), HPT and UHRT. The purpose of this multicenter study is to determine the feasibility of UBP in the diagnosis of LSC-BPPV. Methods: We retrospectively reviewed the clinical data of 134 consecutive patients diagnosed with LSC-BPPV. All of them received both UBP and the complete diagnostic protocol (CDP), including the evaluation of PSN and data resulting from HPT, UHRT, seated-supine positioning test (SSPT), and SHYT. Results: A correct diagnosis for LSC-BPPV was achieved in 95.5% of cases using exclusively the UBP, with a highly significant concordance with the CDP (p < 0.000, Cohen's kappa = 0.94), regardless of the time elapsed from symptom onset to diagnosis. The concordance between UBP and CDP was not impaired even when cases in which HPT and/or UHRT provided incomplete results were included (p < 0.000). Correct diagnosis using the supine diagnostic protocol (SDP, including SSPT + SHYT) or the sole SHYT was achieved in 85.1% of cases, with similar statistical concordance (p < 0.000) and weaker strength of relationship (Cohen's kappa = 0.80). Conclusion: UBP allows correct diagnosis in LSC-BPPV from the sitting position in most cases, sparing the patient supine positionings and related symptoms. UBP could also allow clinicians to proceed directly with repositioning maneuvers from the upright position.

The role of the T-N tract in advanced stage tongue cancer.

BACKGROUND: We investigated the role of the soft tissue tract between the primary tumor and the neck lymph nodes, the "T-N tract," in patients with tongue squamous cell carcinoma at an advanced stage. METHODS: We performed a compartmental tongue surgery in 233 patients. Cumulative incidence of relapses and overall survival curves were compared by T-N tract involvement. Multivariate Cox proportional hazards models were used to assess the independent role of T-N tract. RESULTS: At 4 years of follow-up, patients with disease in the T-N tract experienced a significantly more distant recurrence (40%) than did patients without T-N tract involvement (22%; P = .02). Multivariate Cox models indicate a significant almost triple risk of distant metastases (hazard ratio [HR], 2.70; 95% CI, 1.01-7.19; P = .05) and double risk of death (HR, 2.09; 95%CI, 1.13-3.85; P = .02) in patients with "T-N tract involvement." CONCLUSIONS: Our data show that the T-N tract plays an important role in prognosis and survival in patients with tongue cancer.

[Burnout and mobbing risk for health professionals]. / Rischio burnout e mobbing per gli operatori sanitari di una azianda territoriale.

Burnout is one important consequence of worker stress and is associated with lower moral, reduced job performance, low productivity, absenteeism, job turnover. The aim of this study was to evaluate the burnout level and all its related aspects among health professionists in the Rimini county. All personnel described their experiences in the Maslach Burnout Inventory test (791 questionnaires) and in the Mobbing Perception test (791 questionnaires). The median age of the workers was 38.5 years, 151 were male and 640 female, about 93% were full time workers. On average health professionists reported to have a good relationship with patients, a good work expectations but to experience a relatively high stress index. This study underlined the importance to improve occupational conditions adopting staff-support interventions for the management of stress and conflicts among heath operators.