Why Does General QoL Tend to Worsen Over Time Following Septoplasty Even in the Absence of Worsening Nasal Symptoms?

Septoplasty is one of the most frequent surgical procedures performed by head and neck surgeons. Despite surgical correction, some patients are not satisfied with their postoperative outcomes. Only a few papers report data on the long-term quality of life of patients after septoplasty, and none over 36 months. This follow up study on 68 surgical procedures aims to evaluate the differences between short term and long-term quality of life after septoplasty using a disease specific quality of life questionnaire, the NOSE, and a general health status questionnaire, the SF-36. We found a statistically significant decrease of the total long-term SF-36 scores, but we did not find changes of the NOSE scores compared with the short-term scores. These results indicated that patients perceived a worsening of their quality of life after more than 36 months following septoplasty, even in the absence of specific nasal symptoms. We could speculate that the preoperative general health performance was erroneously attributed to specific nasal symptoms, probably incorrectly emphasized or that patients did not correctly remember the preoperative clinical status. This research pointed out the importance of patients' selection and of a thorough evaluation of their preoperative expectations before surgical planning.

Cross-cultural adaptation and Italian validation of chronic otitis media outcome test 15 (COMOT-15).

OBJECTIVE: Chronic suppurative otitis media (CSOM) may result in a serious impairment of the quality of life (QoL). The most relevant characteristics of CSOM are well represented in the "Chronic Otitis Media Outcome Test 15" questionnaire (COMOT-15). The aim of the study was to translate and adapt the COMOT-15 questionnaire into Italian. METHODS: This is a prospective study conducted on 52 Caucasian Italian-speaking patients with CSOM and 52 controls. The linguistic adaptation of the COMOT-15 consisted of the translation of the English version into Italian and reliability assessment of the translation. Psychometric measurements included internal consistency and test-retest reliability. RESULTS: Cronbach's α was 0.95. The test-retest reliability showed a strong positive correlation for total score and all subscales. Age and gender had no influence on the scores. The correlation between the COMOT-15 and the pure tone average showed a significant association for the scale "Hearing Function". CONCLUSIONS: The Italian COMOT-15 questionnaire provides good internal consistency and is suitable for QoL evaluation in Italian-speaking patients suffering from CSOM. In addition, it is able to evaluate the subjective symptoms perceived by patients.

A multimodal diagnostic approach to inverted papilloma: Proposal of a novel diagnostic flow-chart.

PURPOSE: Inverted papilloma (IP) is a tumor usually arising from sinonasal cavities, with tendency for recurrence and possible malignant transformation. Along with endoscopy, computed tomography (CT) and magnetic resonance imaging (MRI) play a crucial role in defining preoperative staging, tumor origin, and possible differential diagnosis, with significant repercussions on therapeutic planning. However, at present no consensus has been reached concerning IP diagnostic workup. Aim of this study is to assess CT and MRI sensitivity and specificity in identifying IP imaging hallmarks, evaluating their global diagnostic accuracy in order to define a novel diagnostic flowchart. METHODS: We retrospectively analyzed multimodal imaging of patients with histologically confirmed IP and mimics. Two neuroradiologists in consensus retrospectively rated the presence of typical imaging features of IP, both on CT and MRI scans. Sensitivity, specificity and diagnostic accuracy were assessed for both the techniques. Final results were expressed as ROC curves and relative areas under the curve (AUC). RESULTS: The AUC considering CT parameters were 0.42, whereas the AUC considering MRI parameters were 0.54. Combining the 2 techniques and limiting the evaluation to the most distinctive features such as focal hyperostosis and CCP, the AUC was 0.79. CONCLUSION: MRI can provide better tissue characterization and higher diagnostic accuracy in case of suspected IP, whereas CT is more useful in determining bony involvement. Here we propose a possible diagnostic flowchart for IP, based on the assumption that the combination of the imaging techniques allows to optimize the clinical assessment and the subsequent therapeutic planning.

Skull Base Fungal Osteomyelitis: A Case Report and Review of the Literature.

Skull base osteomyelitis (SBO) is an invasive infection refractory to therapy, closely linked with malignant otitis externa (MOE). It is characterized by a mild clinical presentation that can delay cross-sectional imaging considered as the key to revealing it. Skull base osteomyelitis typically affects elderly diabetics and immunocompromised patients (>70 years). It most commonly has an otogenic origin due to an extension of MOE. The prognosis can be very poor without the administration of adequate and timely therapy at an early disease stage. Nowadays, Pseudomonas aeruginosa remains the most common pathogen associated with SBO. Fungi are a rare cause of MOE. This report documents a rare case of otogenic SBO caused by Candida parapsilosis in a diabetic patient, with persistent otologic symptoms as clinical onset and resistance to medical treatment. Fungal MOE has more subtle symptoms and is more aggressive than its bacterial counterpart. When MOE is resistant to antibacterial drugs, this should raise the suspicion of a fungal etiology of MOE. The current guidelines do not exhaustively describe the diagnosis, antifungal drugs of choice, and optimum duration of treatment. The description of these rare clinical cases should help with the multidisciplinary management of this disease in order to optimize the diagnosis and therapeutic protocol.

Malignant Otitis External: Our Experience and Literature Review.

BACKGROUND Malignant external otitis (MEO) is an invasive infection that can involve the external auditory canal and the skull base up to the contiguous soft tissues. Considering the changing face of MEO, we reviewed cases of MEO treated in our Ear Nose Throat (ENT) clinic - University Federico II of Naples between 2018 and 2019 to evaluate the current epidemiology of the condition and to assess the state of art on diagnosis, therapeutic and follow-up management in our patients. CASE REPORT We present the cases of three male patients with Type 2 diabetes mellitus who complained of long-lasting otorrhea and pain, with clinical suspicion of MEO. In all cases, ear swab was positive for Pseudomonas aeruginosa. All our patients received a 6-week course of intravenous ciprofloxacin, piperacillin, and tazobactam, with rapid clinical symptoms improvement and complete recovery at 1-year follow-up. CONCLUSIONS MEO is difficult to treat due to the lack of standardized care guidelines. Patients with MEO often present with severe otalgia, edema, otorrhea, and facial nerve paralysis. Clinicians must suspect MEO in elderly diabetic and immunocompromised patients with persistent otalgia after external otitis. Imaging (computed tomography and magnetic resonance imaging) can play synergistic roles in the management of MEO. To evaluate eradication of the disease, clinicians have to assess clinical symptoms and signs as well as radiological imaging and inflammatory markers.

The role of endogenous Antisecretory Factor (AF) in the treatment of Ménière's Disease: A two-year follow-up study. Preliminary results.

PURPOSE: To evaluate the effects of increased endogenous Antisecretory Factor (AF) synthesis using specially processed cereals (SPC) in a sample of patients with defined unilateral Meniere's disease (MD), compared to the results of a treatment protocol of intravenous glycerol and dexamethasone. MATERIALS AND METHODS: Twenty-six patients with unilateral MD were divided in 2 groups and treated with SPC and with intravenous glycerol and dexamethasone for 24 months. Audio-vestibular evaluation was performed before (T0) and every six months. The number of vertigo spells were evaluated before and after therapy and the Efficacy Index (EI) was calculated. Questionnaires for hearing loss, tinnitus and quality of life were administered. RESULTS: EI decreased in the SPC group after 18 (T18) (p = .0017) and 24 (T24) months of therapy (p = .0111). There was a significant reduction for tinnitus score in the SPC group at T24 (p = .0131). No significant differences were found between the two groups at T0 (p = .4723), while a significant difference was found at T24 (p = .0027). Quality of life showed a significant improvement in daily activities in the SPC group (p = .0033) compared to the infusion therapy group. No statistically significant changes in PTA thresholds were found in both groups between T0 and T24. CONCLUSION: The preliminary results of our study show a significant reduction of vertigo spells and a positive effect on tinnitus severity and on quality of life in patients with unilateral MD treated with SPC and when compared to patients treated with intravenous glycerol and dexamethasone. No effects on hearing thresholds were noted in both groups.

Clinical management of extrapleural septal solitary fibrous tumor: A case report.

Solitary fibrous tumor (SFT) is a rare neoplasm arising from the pleura, although it can sometimes affect extrapleural sites, including the head and neck. The sinonasal involvement is exceptional. Recent literature defines the SFT as a single spectrum of mesenchymal tumors, including hemangiopericytoma, which is currently considered a cellular phenotypic variant. The current case describes a rare case of a nasal septal SFT. The mass was embolized and then removed through endonasal endoscopic surgery. Histopathologic examination demonstrated positive immunoreactivity for CD34, and negative for keratin and S100 protein confirming the diagnosis of benign nasal SFT. After two years of follow-up, no relapse was observed. Diagnostic assessment of SFT requires nasal endoscopy, imaging and histopathological examination and a long time follow up is mandatory.

Unusual Localization of an Emergent Bacterium, Raoultella ornithinolytica.

Raoultella ornithinolytica is a bacterium belonging to the family Enterobacteriacae. It is a rare but emergent cause of human pathologies especially in immunocompromised patients. We described the first case in the literature of isolated external otitis sustained by Raoultella ornithinolytica in an immunocompetent host. A 54-year-old Caucasian man with a history of previous myringoplasty came to our attention reporting otalgia and otorrhea. We performed right ear swab for culture examination, meanwhile we started empirical therapy with topic administration of neomycin, without any clinical improvement. The cultural examination showed the presence of a Raoultella ornithinolytica infection. After ten days of treatment with oral ciprofloxacin and topic levofloxacin, there was the complete resolution of pain and inflammation. Raoultella ornithinolytica must be taken into consideration as an emergent cause of human infection, also in case of external otitis. Infection can be severe and can occur both in immunocompromised and in immunocompetent hosts. Culture test is mandatory to choose the proper therapy and avoid potential severe complications.

Apparent diffusion coefficients for predicting primary cholesteatoma risk of recurrence after surgical clearance.

PURPOSE: Beside the well-known accuracy of non-EPI DWI techniques and relative ADC maps in detecting cholesteatomatous tissue, ADC can also represent a useful tool for stratifying cholesteatoma risk of recurrence. Aim of this study is to test the role of ADC in determining risk of recurrence for primary middle ear cholesteatoma, proposing stratification based on pre-operative mean (mADC) and normalized (nADC) ADC values. METHODS: In this prospective study, 60 patients with primary unilateral middle ear cholesteatoma underwent a three-years-long follow-up to assess the presence of recurrent disease after macroscopically complete excisional surgery. Baseline MRI examination mADC and nADC values in the group with early evidence of recurrent cholesteatoma were compared to the group with no evidence of recurrence by using T statistics. RESULTS: ADC values on pre-operative MRI examination were lower in cholesteatomas with early evidence of recurrence, and statistical significance was slightly higher for nADC compared to mADC measurements. We also determined a cut-off between the two groups, proposing stratification in high-risk of recurrence cholesteatomas (mADC≤ 1000 or nADC< 1.3) and low-risk cholesteatomas (mADC>1000 or nADC≥1.3). CONCLUSIONS: ADC values resulted discriminating in identifying cholesteatomas with higher risk of early recurrence, both for mean and normalized ADC, with optimized tissue characterization and outcome prediction.

Food-induced stimulation of the antisecretory factor to improve symptoms in Meniere's disease: our results.

PURPOSE: Specially processed cereals (SPC) that increase endogenous antisecretory factor (AF) synthesis have been proposed to improve symptoms of Meniere's disease (MD) with controversial results. The aim of this study was to evaluate the effects of SPC in patients with definite unilateral MD and compare the results to a treatment protocol with intravenous glycerol and dexamethasone. METHODS: Thirteen patients with unilateral MD were treated with SPC and 13 patients were treated with intravenous glycerol and dexamethasone for 12 months. Audio-vestibular evaluation was performed before (T0) and at the end of the treatments (T12). The number of vertigo spells were evaluated before and after therapy and the Efficacy Index (EI) was calculated. Questionnaires for hearing loss (HHIA), tinnitus (THI) and quality of life (TFL) were administered. RESULTS: EI decreased in the SPC group in the second semester compared to the first although not significantly (p = 0.6323). There was a significant reduction for THI score in the SPC group at T12 (p = 0.0325). No significant differences were found between the two groups at T0 (p = 0.4723), while a significant difference was found at T12 (p = 0.0041). Quality of life showed an improvement in daily activities in the SPC group compared to infusion therapy group. CONCLUSION: Our study shows a reduced number of vertigo attacks and a positive effect on the discomfort generated by tinnitus and quality of life in patients with unilateral MD treated with SPC and when compared to patients treated with intravenous glycerol and dexamethasone. No effects on hearing thresholds were noted in both groups.

ADC Benchmark Range for Correct Diagnosis of Primary and Recurrent Middle Ear Cholesteatoma.

OBJECTIVES: Magnetic resonance imaging (MRI) and in particular diffusion-weighted imaging (DWI) have been broadly proven to be the reference imaging method to discriminate between cholesteatoma and noncholesteatomatous middle ear lesions, especially when high tissue specificity is required. The aim of this study is to define a range of apparent diffusion coefficient (ADC) values within which the diagnosis of cholesteatoma is almost certain. METHODS: The study was retrospectively conducted on a cohort of 124 patients. All patients underwent first- or second-look surgery because primary or secondary acquired cholesteatoma was clinically suspected; they all had preoperative MRI examination 15 days before surgery, including DWI from which the ADC maps were calculated. RESULTS: Average ADC value for cholesteatomas was 859,4 × 10-6 mm2/s (range 1545 × 10-6 mm2/s; IQR = 362 × 10-6 mm2/s; σ = 276,3 × 10-6 mm2/s), while for noncholesteatomatous inflammatory lesions, it was 2216,3 × 10-6 mm2/s (range 1015 × 10-6 mm2/s; IQR = 372,75 × 10-6 mm2/s; σ = 225,6 × 10-6 mm2/s). Interobserver agreement with Fleiss' Kappa statistics was 0,96. No overlap between two groups' range of values was found and the difference was statistically significant for p < 0.0001. CONCLUSIONS: We propose an interval of ADC values that should represent an appropriate benchmark range for a correct differentiation between cholesteatoma and granulation tissue or fibrosis of noncholesteatomatous inflammatory lesions.

In Vivo Biofilm Formation, Gram-Negative Infections and TAS2R38 Polymorphisms in CRSw NP Patients.

OBJECTIVES: Among the predisposing factors implicated in the immune response to airway bacterial infections, genetic variations of the bitter taste receptor TAS2R38, which is expressed in the cilia of the human sinonasal epithelial cells, seem to be associated with susceptibility to chronic rhinosinusitis (CRS) and in vitro biofilm formation. Polymorphisms in TAS2R38 generate two common haplotypes: the nonfunctional AVI (Alanine, Valine, Isoleucine) and the functional PAV (Proline, Alanine, Valine) alleles, with the latter protecting against gram-negative sinonasal infections. The aim of this study is to investigate for the first time the relevance of TAS2R38 genetic variants in the susceptibility to bacterial infections associated with in vivo biofilm formation in chronic rhinosinusitis with nasal polyps (CRSwNP) patients. STUDY DESIGN: A prospective study on 100 adult patients undergoing functional endoscopic sinus surgery (FESS) for CRSwNP. METHODS: Propylthiouracile (PROP) testing and TAS2R38 genotyping were applied to characterize patients for receptor functionality. Sinonasal mucosa samples were processed for microbiological examination and biofilm detection. RESULTS: The nonfunctional genotype is more frequent among CRS patients than in the general population (25% vs. 18.4%, P = 0.034). Airway gram-negative infections are primarily associated with the AVI haplotype (88.9% vs. 11.1% PAV/PAV-functional genotype, P = 0.023). Biofilm formation is prevalent in CRS patients with the AVI nontaster phenotype (62.5% vs. 33.3% PAV taster or supertaster phenotype, P = 0.05). CONCLUSION: Our findings confirm an inverse correlation between TAS2R38 functionality and gram-negative infections in Italian patients with CRSwNP. In addition, for the first time we demonstrated a relationship between in vivo microbial biofilm and TAS2R38 receptor variants. LEVEL OF EVIDENCE: 2b. Laryngoscope, 128:E339-E345, 2018.

Cortical representation of different taste modalities on the gustatory cortex: A pilot study.

BACKGROUND: Right insular cortex is involved in taste discrimination, but its functional organization is still poorly known. In general, sensory cortices represent the spatial prevalence of relevant features for each sensory modality (visual, auditory, somatosensory) in an ordered way across the cortical space. Following this analogy, we hypothesized that primary taste cortex is organized in similar ordered way in response to six tastes with known receptorial mechanisms (sweet, bitter, sour, salt, umami, CO2). DESIGN: Ten normal subjects were enrolled in a pilot study. We used functional magnetic resonance imaging (fMRI), a high resolution cortical registration method, and specialized procedures of feature prevalence localization, to map fMRI responses within the right insular cortex, to water solutions of quinine hydrochloride (bitter), Acesulfamate K (sweet), sodium chloride (salt), mono potassium glutamate + inosine 5' mono phosphate (Umami), citric acid (sour) and carbonated water (CO2). During an fMRI scan delivery of the solutions was applied in pseudo-random order interleaved with cleaning water. RESULTS: Two subjects were discarded due to excessive head movements. In the remaining subjects, statistically significant activations were detected in the fMRI responses to all tastes in the right insular cortex (p<0.05, family-wise corrected for multiple comparisons). Cortical representation of taste prevalence highlighted two spatially segregated clusters, processing two and three tastes coupled together (sweet-bitter and salt-umami-sour), with CO2 in between. CONCLUSIONS: Cortical representation of taste prevalence within the right primary taste cortex appears to follow the ecological purpose of enhancing the discrimination between safe nutrients and harmful substances.

Chemoprevention using folic acid for dysplastic lesions of the larynx.

Folate deficiency may be directly associated with carcinogenesis. Folate supplementation may reduce the risk of progression in a mucosa that is already genetically altered. The aim of the present study was to determine the role of folic acid in the treatment of mild and moderate laryngeal dysplasia recurring after surgery. The data obtained by laryngoscopy, measurement of serum folate levels and functional vocal assessment with the GIRBAS scale and VHI questionnaire were compared in patients who had received folic acid with a homogeneous group of patients with dysplasia who had not undergone any therapy. A total of 24 patients suffering from recurrence of mild or moderate laryngeal dysplasia (n=12, group A) were treated with 400 mg folic acid per os, once daily for 6 months. The patients in group B (n=12) received no treatment and were used as the control group. In group A, 7 (58%) patients exhibited a complete response, with clinically evident regression of leukoplakia, 3 (25%) displayed a partial decrease in the lesions with reduced volume of the area involved, whereas 2 patients exhibited no change. As regards patients in control group B, 8 (67%) exhibited no change, in 1 case there was a spontaneous regression, and in 3 (25%) there was disease progression with suspected malignant transformation, leading to repeat surgery. Therefore, folate deficiency may be considered to be a factor predisposing to precancerous lesions, and dietary folate supplementation may prevent and reduce the emergence of cancer.

Pleasantness of olfactory and trigeminal stimulants in different Italian regions.

Although individuals categorize odors according to their pleasantness, experience may also influence odor perception-a phenomenon that partially explains why different populations perceive odors differently. Italy, which comprises 20 regions, is characterized by very different cultures. In the present study, we investigated for the first time how Italian regional differences can affect odor perception. 254 healthy volunteers coming from northern, central, southern Italy, and Sicily, one of the two major Italian islands, were recruited in Padua, Rome, Naples, and Syracuse, respectively. Olfactory function was tested with Sniffin' Sticks identification subtest. Subjects who had a score in the range within the mean identification value ± 1 SD, in accordance with the age classes identified in the literature, were asked to judge the odor pleasantness of 20 substances. The hedonic tone of the odorants was categorized as pleasant, neutral, unpleasant, and very unpleasant. Some odorants were appreciated more in northern Italy than in the other parts of the country, whereas others were appreciated more in the south and in Sicily than in the north. Unpleasant odorants were judged less unpleasant in central Italy. Some odorants such as strawberry and vanilla were perceived similarly in all the regional areas. Our study indicates that in Italy, hedonic perception of odorants differs probably in relation with genetic, cultural, and environmental factors. Further investigation is needed to delve deeper into the factors that influence the quality odor perception amongst humans.

Strategy for the treatment and follow-up of sinonasal solitary extramedullary plasmacytoma: a case series.

BACKGROUND: Extramedullary plasmacytoma is a rare neoplasm characterized by monoclonal proliferation of plasma cells outside bone marrow. It accounts for 4% of all non-epithelial sinonasal tumors. According to the literature, radiotherapy is the standard therapy for extramedullary plasmacytoma. However, the conversion rate of extramedullary plasmacytoma to multiple myeloma is reported to be between 11 and 33% over 10 years. The highest risk of conversion is reported during the first 2 years after diagnosis, but conversion has been noted up to 15 years after diagnosis. Once conversion to multiple myeloma is complete, less than 10% of patients will survive 10 years. CASE PRESENTATION: We present three cases of sinonasal extramedullary plasmacytoma who underwent radiotherapy: a 61-year-old white man, a 60-year-old white man, and a 37-year-old white woman. We found long-term survival with stable disease in all three cases. CONCLUSIONS: The management of solitary extramedullary plasmacytomas of the sinonasal tract is not well established yet. However, the possibility of recurrence and progression to multiple myeloma requires a thorough follow-up protocol. Due to the absence of a standardized protocol for these tumors, we tried to design a tailored long-term follow-up scheme.

Epidermal cyst of temporal bone as a delayed complication of myringoplasty.

Epidermal cysts are benign tumors derived from the epidermis or the epithelial hair follicle filled with keratin and lipid-rich debris, typically occurring in areas with a high-density of sebaceous glands. These cysts commonly occur on the face, scalp, neck and trunk, where the sebaceous glands are more active. Their localization within the bone is extremely uncommon. The current study details the case of a 24-year-old male who presented with right otorrhea and ipsilateral hypoacusia having undergone right overlay myringoplasty for subtotal eardrum perforation. This patient represents a rare case of an epidermal cyst localized in the temporal bone (the fifth described in English-language literature), which may be considered as a complication of myringoplasty.

Effect of liposomes, vitamins A and E nasal spray in reducing the healing time after septoplasty with concurrent turbinate surgery in adolescents.

BACKGROUND: This study evaluates endoscopic and quality of life (QoL) outcomes in two groups, composed by both allergic (A) and non-allergic (N-A) adolescents undergoing septoplasty with concurrent turbinate surgery by radiofrequency treated after surgery with nasal spray containing liposomes and vitamins A and E. METHODS: This double-blind randomized study was carried out on 40 patients (22 males, 18 females, mean age 15.5±1.0 years) undergoing septoplasty and volumetric tissue reduction of inferior turbinates by radiofrequency for post-traumatic deformities and severe nasal obstruction. We enrolled 20 subjects with positive skin prick tests and 20 with negative skin prick tests (SPT) to aeroallergens. All subjects underwent the Visual Analogue Scale (VAS) questionnaire and the nasal endoscopy score by Lund and Kennedy (LK) at baseline before surgery (T0) and 15 days (T15) and 21 days (T21) after treatment. After surgery, the nose was not packed and the day after surgery all subjects were randomized into two groups, experimental arm group I (GI) and control arm group II (GII) and given the treatment, nasal spray containing liposomes composed of phospholipids, fatty acids, and vitamin A and E for group I and saline solution (sodium chloride 0.9%) for group II. RESULTS: After therapy, the VAS and LK scores were better (P<0.05) in the investigational than in the control arm in both sub-groups (A and N-A). CONCLUSIONS: Our findings suggested that liposomal, vitamins A and E nasal spray improves the QoL in the early postoperative period, both in A and N-A sub-groups.

Immunohistochemical patterns in the differential diagnosis of rhinopharyngeal granulocytic sarcoma.

Granulocytic sarcoma (GS) is a rare extramedullary manifestation of acute myeloid leukemia (AML). GS may develop simultaneously to AML or as a relapse of leukemia, particularly following allogeneic hematopoietic stem cell transplant. Subperiosteal bone, lymph nodes and skin are commonly involved, whereas rhinopharyngeal involvement is less common, with only 14 cases reported in the literature. Due to its rarity, rhinopharyngeal GS may lead to diagnostic pitfalls, particularly when it is poorly differentiated or is without concomitant marrow involvement. Thus, immunohistochemical findings play a key role in diagnosis. The current report describes a case of a 53-year-old female suffering from rhinopharyngeal GS and with a history of AML treated with chemotherapy and radiotherapy, focusing on the importance of the immunohistochemical pattern to assess the right diagnosis. Recent studies have demonstrated that the immunophenotype is of utmost importance for the diagnosis of GS. The high expression of myeloperoxidase (MPO) is common in GS; however, ~30% of GSs do not contain MPO. Therefore, the presence of other markers is required to confirm the diagnosis of GS.