Is it possible to diagnose Posterior Semicircular Canal BPPV from the sitting position? The role of the Head Pitch Test and the upright tests along the RALP and LARP planes.

PURPOSE: The diagnosis of benign paroxysmal positional vertigo (BPPV) involving the posterior semicircular canal (PSC) is traditionally entrusted to positioning tests where patients are rapidly brought in the supine position. This prospective study aims to define the role of a diagnostic protocol for PSC-BPPV including only upright tests. MATERIALS AND METHODS: 109 patients with PSC-BPPV were enrolled. The Head Pitch Test (HPT) was carried out first. If uneventful, the patient's head was turned 45° to each side and bent back-and-forth along the plane aligning either with the right anterior-left posterior (RALP) or left anterior-right posterior (LARP) canals, thus performing the upright RALP / upright LARP (uRALP/uLARP) test. Nystagmus observed was used to predict the diagnosis, which was therefore confirmed by Dix-Hallpike tests. RESULTS: PSC-BPPV could be correctly diagnosed in 75.2% of cases with the sole HPT and in 87.2% of cases by adding the uRALP/uLARP test (Upright Protocol). The time elapsed from symptoms onset was closely related to the protocol sensitivity, as it reached 100% (64/64) in acute patients while decreased to 68.9% (31/45) in cases evaluated after 7 days (p < 0.001). CONCLUSIONS: Upright maneuvers could correctly diagnose PSC-BPPV in most cases. uRALP/uLARP test demonstrated to improve the sensitivity of the HPT, mainly in recent-onset BPPV.

Correction to: Is there a relation between sudden sensorineural hearing loss and white matter lesions?

In the original publication, fifth author's surname was incorrectly published as "Diacinto". The correct surname should read as "Diacinti".

Approach to residual dizziness after successfully treated benign paroxysmal positional vertigo: effect of a polyphenol compound supplementation.

PURPOSE: To assess if a polyphenol compound supplementation (Vertigoval®) could improve residual dizziness earlier after benign paroxysmal positional vertigo (BPPV) and relieve patients from this disabling symptomatology. METHODS: In this prospective, multicentric study, 127 patients were randomized in the treatment group (TG), who received a 60-day supplementation, while 131 patients were randomized in the control group (CG), who did not receive any medication. The dizziness handicap inventory (DHI) score, static posturography, and the visual analog scale (VAS) for both dizziness (D-VAS) and nausea/vomit (N/V-VAS) were used as measures of outcome at baseline and after 30 and 60 days. Patients were asked about efficacy and tolerance to the treatment. Side effects were examined. RESULTS: A statistically significant greater decrease was established in the TG for DHI, D-VAS, and N/V-VAS compared to the CG. On the other hand, static posturography did not show statistical differences between the two groups, though a better clinical improvement after 60-day supplementation was shown in the TG in comparison to the CG. We counted mild side effects in only 2 patients. Most patients reported an excellent or good efficacy and tolerance to the treatment. CONCLUSION: Residual dizziness is a frequent condition of unknown origin that manifests as persistent disabling imbalance after successful repositioning maneuvers for BPPV. The decreasing postural control can affect the quality of life, contributing to falling and psychological problems. The supplementation with the polyphenol compound used in our study is safe, manageable, and appeared to be able to reduce subjective symptoms and improve instability earlier, decreasing the risk of potential complications.

Is there a relation between sudden sensorineural hearing loss and white matter lesions?

PURPOSE: Sudden sensorineural hearing loss (SSNHL) has similarities to conditions with vascular etiologies such as myocardial infarction and cerebral stroke. Thus, it could be considered as an early sign of a vascular disease and not only a specific local condition. Chronic hypoperfusion in the brain districts leads to a chronic ischemic damage, called cerebral small vessel disease (CSVD), detectable with brain magnetic resonance imaging (MRI). METHODS: The authors used CSVD to establish the presence of vascular risk factors in individuals with SSNHL and used the Fazekas score scale to classify them. RESULTS: Our study showed that individuals with SSNHL aged between 48 and 60 years have 26% more probability to have a Fazekas score higher than 1 compared to the general population. Individuals younger than 28 years showed a statistically significant negative correlation to have a Fazekas score higher than 0. The higher is the Fazekas score, the less is the probability of hearing recovery. The medium hearing-recovery probability is 46%. This decreases by 16% for every increase of score in the Fazekas scale. In the present study, the recovery probability decreased from 80% in individuals younger than 48 years with a score of 0 to 14% in individuals with a Fazekas scores of 3 and 4. CONCLUSIONS: The authors assessed a higher prevalence of CSVD compared to the general population in patients aged between 48 and 60 years with SSNHL. Moreover, they assessed that the presence of CSVD is related to a decreased probability of recovery, as it has already been demonstrated for stroke.

Cross-cultural Adaption and Validation of the Zurich Chronic Middle Ear Inventory Translated Into Italian (ZCMEI-21-It)-a Prospective Multicenter Study.

OBJECTIVE: There are no instruments available to comprehensively assess health-related quality of life (HRQoL) in chronic otitis media (COM) in Italian-speaking countries. The Zurich chronic middle ear inventory (ZCMEI-21) is a well-established instrument for the assessment of HRQoL in COM. The objective of this study was to translate and cross-culturally adapt the ZCMEI-21 into Italian and validate this questionnaire for measuring HRQoL in patients with COM. STUDY DESIGN: Prospective multicenter study. SETTING: Three University hospitals (northern Italy, central Italy, southern Italy). PATIENTS: Adult patients suffering from COM (n = 128). INTERVENTION: Following international guidelines, the ZCMEI-21 was translated into Italian (ZCMEI-21-It). Validation was performed by psychometric test statistics. Moreover, ZCMEI-21-It total and subscale scores were compared and correlated with 1) the scores of the original validation study, 2) to a question that directly addresses HRQoL, and 3) to the scores of the EQ-5D-5L, a generic questionnaire assessing HRQoL. RESULTS: From three study centers, a total of 128 patients with COM were included. Cronbach's α was 0.86 indicating a high reliability. Between the ZCMEI-21-It total score and the question that directly addresses HRQoL, we found a strong correlation (r = 0.62, p < 0.0001). Between the ZCMEI-21-It total score and the EQ-5D-5L scores, we expectedly found moderate correlations (descriptive system score: r = 0.39, p < 0.0001; visual analog scale: r = 0.30, p = 0.008). CONCLUSION: We translated the ZCMEI-21 questionnaire into Italian and validated the ZCMEI-21-It in a prospective multicenter study. The ZCMEI-21-It is the first instrument that comprehensively assesses relevant dimensions of HRQoL in Italian-speaking patients affected by COM.

Ocular vestibular evoked myogenic potentials and intravestibular intralabyrinthine schwannomas.

Intravestibular intralabyrinthine schwannomas (ILSs) are uncommon benign tumors that arise from the saccular, utricular, and lateral and superior ampullary nerves. According to the literature, there is an average delay of 8 years between the onset of symptoms and diagnosis. The diagnosis is based on an audiovestibular examination and magnetic resonance imaging (MRI). We describe a case of intravestibular ILS in which we included the ocular vestibular evoked myogenic potentials (oVEMPs) test in the diagnostic workup. The oVEMPs test is a relatively new neurophysiologic diagnostic modality that evaluates the superior vestibular pathway and the ascending contralateral pathway through the vestibulo-ocular reflex. In our case, a 65-year-old man presented with progressive right-sided sensorineural hearing loss, dizziness, and tinnitus and fullness in his right ear. Audiovestibular examination and MRI detected an intravestibular ILS on the right. We found that oVEMPs were absent on the contralateral side, which contributed to the diagnostic process. The detection of oVEMPs can provide detailed information on the functionality of the macula of the utricle and the lateral and superior ampullary nerves, with a precise identification of the affected area. Based on our findings, we discuss the role of oVEMPs in the diagnosis of an intravestibular ILS.

Cortactin and phosphorylated cortactin tyr421 and tyr466 expression in supraglottic laryngeal carcinomas and lymph node metastases.

BACKGROUND: The most important adverse prognostic factor for laryngeal squamous cell carcinoma (LSCC) is the presence of cervical lymph node metastases. The supraglottic area of the larynx is richly supplied with lymphatics, and 25%-75% of supraglottic carcinomas metastasize in neck lymph nodes. Cortactin is a multidomain protein related to actin cytoskeleton regulation, podosome and lamellipodia formation, integrin signaling, axon guidance and extracellular matrix degradation. Cortactin is involved in metastasis formation because of its role in cell mobility. The present study focused mainly on the role of cortactin and phosphorylated cortactin (residues tyr421 and tyr466) expression and subcellular localization in primary supraglottic LSCCs and their cervical lymph node metastases. METHODS: The immunohistochemical expression of cortactin, p-Y466-cortactin and p-Y421-cortactin was assessed in 38 primary supraglottic LSCCs and 10 lymph node metastases. The statistical approach included bootstrapping analysis. RESULTS: Despite a significantly higher expression of cortactin in carcinoma cells than in adjacent normal laryngeal mucosa, no associations emerged between prognosis and the expression of cortactin or its isoforms in supraglottic LSCC. Statistical analysis found cortactin expression higher in less-differentiated LSCCs (p = 0.03). A significant direct correlation was found between cortactin and p-Y466-cortactin levels (p = 0.031), and between p-Y466-cortactin and p-Y421-cortactin levels (p = 0.001). CONCLUSIONS: Cortactin expression in carcinoma cells and its known involvement in the EGFR pathway suggest a role for this protein as a target for LSCC therapy. Further prospective studies are needed to investigate the potential of cortactin, p-Y466-cortactin and p-Y421-cortactin expression as markers of response to treatment (particularly EGFR-directed agents) in LSCC.

Unilateral Enlarged Vestibular Aqueduct Syndrome and Bilateral Endolymphatic Hydrops.

Enlarged vestibular aqueduct (EVA) syndrome is a common congenital inner ear malformation characterized by a vestibular aqueduct with a diameter larger than 1.5 mm, mixed or sensorineural hearing loss that ranges from mild to profound, and vestibular disorders that may be present with a range from mild imbalance to episodic objective vertigo. In our study, we present the case of a patient with unilateral enlarged vestibular aqueduct and bilateral endolymphatic hydrops (EH). EH was confirmed through anamnestic history and audiological exams; EVA was diagnosed using high-resolution CT scans and MRI images. Therapy included intratympanic infusion of corticosteroids with a significant hearing improvement, more evident in the ear contralateral to EVA. Although most probably unrelated, EVA and EH may present with similar symptoms and therefore the diagnostic workup should always include the proper steps to perform a correct diagnosis. Association between progression of hearing loss and head trauma in patients with a diagnosis of EVA syndrome is still uncertain; however, these individuals should be advised to avoid activities that increase intracranial pressure to prevent further hearing deterioration. Intratympanic treatment with steroids is a safe and well-tolerated procedure that has demonstrated its efficacy in hearing, tinnitus, and vertigo control in EH.

Elderly patients at higher risk of laryngeal carcinoma recurrence could be identified by a panel of two biomarkers (nm23-H1 and CD105) and pN+ status.

Laryngeal squamous cell carcinoma (LSCC) recurrences are very difficult to manage in elderly patients (age ≥65 years), because treatment carries significant morbidity and mortality. The aim of this study was to develop a panel of parameters (clinicopathological variables or biomarkers) to improve our ability to detect elderly patients at higher risk of LSCC recurrence. Maspin, nm23-H1, and CD105 were investigated using immunohistochemistry on surgical specimens from 46 elderly patients treated for LSCC. After univariate analysis identified parameters associated with LSCC recurrence, a multivariate prognostic model was constructed. At univariate analysis, a higher recurrence rate was significantly associated with nm23-H1 nuclear expression in carcinoma cells ≤2.0% (p = 0.01), CD105 expression in intratumoral vascular endothelial cells ≥5.28% (p = 0.04), and pN+ status (p = 0.04). Multivariate modeling confirmed that nuclear nm23-H1 ≤2.0% (p = 0.009) and CD105 ≥5.28% (p = 0.013) had a negative prognostic significance in terms of disease recurrence, while pN+ status showed a trend toward significance (p = 0.05). We thus obtained a panel comprising two biomarkers and neck lymph node status that revealed an excellent discriminatory power [AUC (ROC) of 0.81] in terms of the risk of LSCC recurrence. The panel achieved a specificity of 96% and a positive predictive value of 93%. We identified a panel with an excellent discriminatory power in identifying elderly patients at higher risk of recurrence after treatment for LSCC. These patients would benefit from a more aggressive primary treatment.

The importance of the number of reflux episodes in the diagnosis of laryngopharyngeal reflux disease.

OBJECTIVE: The aim of this study is to evaluate the sensitivity parameters of the percentage of time the pH is <4 and >7, as well as the total number of laryngopharyngeal reflux episodes in 24 hours, in patients with suspected laryngopharyngeal reflux disease. STUDY DESIGN: Retrospective controlled study. SETTING: University hospital. SUBJECTS AND METHODS: The study was conducted on 46 patients with laryngopharyngeal reflux disease and 58 healthy controls. Patients and controls underwent 24 hours of dual-probe pH monitoring of the distal and cervical esophagus. Patients completed a Reflux Symptom Index questionnaire and underwent esophageal manometry. Data concerning the percentage of time the pH was <4 and >7 and the number of reflux episodes registered at the cervical esophagus were collected and evaluated. RESULTS: The percentage of time the pH is <4 and the number of laryngopharyngeal reflux episodes seem to be a reliable diagnostic laryngopharyngeal reflux criterion reaching satisfactory sensitivity (81% and 83%, respectively). Although the pH >7 parameter appeared statistically different between the 2 groups (P < .001), the sensitivity of the test appeared to be poor (55%). CONCLUSION: Our study demonstrates the importance of the absolute number of laryngopharyngeal reflux episodes in 24 hours in the diagnosis of patients with suspected laryngopharyngeal reflux, proposing it as a new diagnostic criterion.

Day-case stapedotomy: is it a viable option?

CONCLUSIONS: Stapedotomy is, in our opinion, the technique of choice in stapes surgery. The precision of this technique allows clinicians to perform the surgical procedure in day surgery under local anesthesia. OBJECTIVES: There is a strong emphasis on increasing the number of elective day surgery cases, especially in the patients' best interest, as it decreases the likelihood of late cancellation and hospital-acquired morbidity. A prospective study was performed to determine whether stapes surgery for otosclerosis could be performed safely in an outpatient setting. METHODS: We present a series of stapes surgery cases for otosclerosis performed on a day-case basis. We performed a classic stapedotomy in 9 patients, a reverse classic step stapedotomy in 2 patients, a partial reverse classic step stapedotomy in 11 patients, and a hemi-stapedectomy in two patients. RESULTS: Three of 24 patients (12.5%) treated with classic stapedotomy, 1 patient with partial reverse classic step stapedotomy, and 1 patient with hemi-stapedectomy were formally admitted to the hospital after surgery (length of stay, 23 h). The indications were vertigo (two patients) and asthenia (one patient). These patients were treated under general anesthesia. Two of these patients resided more than 250 km away from the hospital.

Deleterious sucking habits and atypical swallowing in children with otitis media with effusion.

OBJECTIVE: The aim of this study was to investigate the possible correlation between otitis media with effusion, bad sucking habits and atypical swallowing in children affected by otitis media with effusion. METHODS: 65 children, aged from 7 to 12 years, observed in the ENT Department of the "La Sapienza" University of Rome, were enrolled in the study group (group A). All children were affected by otitis media with effusion for more than 3 months. As control group, 60 healthy children, aged from 7 to 12 years were identified (group B). All the children underwent medical history, with evaluation of the sucking habits, ENT examination, tympanometry, orthodontic examination and evaluation of swallowing. In the orthodontic examination the variables analyzed were: maximum mouth opening, right and left mandibular lateral movements and mandibular protrusion. Atypical swallowing was considered to occur when lip activity produced strong tension in the perioral musculature, and/or the tip of the tongue was placed or pushed against the anterior teeth during swallowing. RESULTS: In the group A, atypical swallowing was found in 33/65 subjects out of the 65 children (50.7%). In the control group (group B) 16/60 children (26.6%) showed atypical swallowing. Compared with group B, deleterious sucking habits were significantly higher (p<0.05) in the study group (28/65 vs. 12/60). In both the study and control group, deleterious sucking habits were present in almost all children with atypical swallowing (28/33 in group A and 12/16 in group B). CONCLUSIONS: Our data suggest a correlation between otitis media with effusion, deleterious sucking habits and prevalence of atypical swallowing.

Vestibular evoked myogenic potential in vestibular neuritis.

This study wants to show the diagnostic value of vestibular evoked myogenic potential (VEMP) in the diagnosis of vestibular neuritis (VN), independently of the caloric test results. Twenty patients were enrolled with acute vertigo caused by VN. VEMP was tested with the binaural simultaneous stimulation method. Surface electromyographic activity was recorded in the supine patients from symmetrical sites over the upper half of each sternocleidomastoid muscle, with a reference electrode on the lateral end of the upper sternum. During the acute attack, 8 days, 1 month and 3 months after the beginning of the acute attack, all the patients underwent the following examinations: Dix-Hallpike manoeuvre, Pagnini-McClure manoeuvre, head shaking test, pure-tone audiometry, tympanometry, caloric labyrinth stimulation according to the Fitzgerald-Hallpike method and VEMP. At the last visit, the 11 patients diagnosed with superior branch vestibular neuritis did not show any improvement at the caloric labyrinth stimulation and presented VEMP on both sides with normal amplitude and latency; in the 9 cases diagnosed with inferior branch vestibular neuritis, there was an improvement of the VEMP reflex and normal caloric test. Our experience highlights that VEMP recording is applicable for patients with VN as a screening test.

A higher CD105-assessed microvessel density and worse prognosis in elderly patients with laryngeal carcinoma.

OBJECTIVES: To ascertain the prognostic role of endoglin (CD105)-assessed microvessel density (MVD) in patients older than 65 years with laryngeal squamous cell carcinoma (LSCC), and whether this MVD differed in the elderly patients from younger adult controls. DESIGN: Retrospective clinicopathologic investigation. SETTING: Academic tertiary referral center. PATIENTS: Fifty-seven consecutive elderly patients with LSCC and 19 younger adult controls. MAIN OUTCOME MEASURE: Image analysis of immunohistochemical reactions. RESULTS: In LSCCs in elderly patients, N+ stage correlated with a shorter disease-free survival (DFS) (P < .001). A higher CD105-assessed MVD was associated with disease recurrence (P = .006). The DFS was shorter in elderly patients whose CD105 expression was greater than 9.6% than in patients whose CD105 expression was 9.6% or less (P = .001). Among the elderly patients with tumors staged as N0, a higher CD105-assessed MVD correlated with disease recurrence (P = .006) and a shorter DFS (P = .001). CD105-assessed MVD in LSCC occurring in elderly patients did not differ from the situation observed in younger adult controls (P = .74). CONCLUSIONS: In LSCC occurring in elderly patients, CD105-assessed MVD may be a useful N-stage independent, angiogenic prognostic marker for pinpointing: (1) patients at higher risk of disease recurrence; and (2) patients with N0 tumors at higher risk of early recurrence, who may benefit from more aggressive therapy.

Post-traumatic camel-related benign paroxysmal positional vertigo.

INTRODUCTION: Benign paroxysmal positional vertigo (BPPV) is a common form of dizziness. The causes of BPPV are not yet known but a relationship between the onset of vertigo and head trauma has been found. Among the causes of head injury related to BPPV, dropping off a camel has not been reported in literature yet. CASE REPORT: We describe two cases of persons that fell off a camel during a safari in Middle East countries. After the fall they reported vertigo symptoms that were not interpreted as BPPV. When they returned to Italy, due to symptoms persistence, they were referred to our ENT practice: we found evidence of BPPV. In a case it was a bilateral BPPV (bBPPV). DISCUSSION: Falling off a camel may be a relevant cause of BPPV. We suggest a correct evaluation of the labyrinth for BPPV with the appropriate diagnostic maneuvers and, if necessary, a treatment with repositioning maneuvers.

Clinical and audiological follow up of a family with the 8363G>A mutation in the mitochondrial DNA.

Hearing loss is relatively common in mtDNA-related disorders. While auditory function has been assessed fully in the syndrome of mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes, few studies have investigated the degree of progressive hearing deficit in individuals bearing other mtDNA mutations. We performed a 4-year clinical and audiological follow up in a family carrying the 8363G>A mutation in the mitochondrial transfer ribonucleic acid lysine (tRNA(Lys)) gene who displayed a progressive neuromuscular disease. In addition to pure tone audiometry, we considered distortion products of otoacoustic emissions, a sensitive indicator of cochlear dysfunction, as well as brainstem auditory evoked responses. A generalized increase in the auditory threshold at follow up, indicating a cochlear impairment in three cases, was noted. Distortion products of otoacoustic emissions may reveal sub-clinical cochlear dysfunction, even in oligosymptomatic patients. A complete and periodical assessment of the hearing function should be encouraged in asymptomatic relatives of patients carrying the tRNA(Lys) 8363G>A mutation.

Effects of Piezosurgery on the cochlear outer hair cells.

CONCLUSIONS: The absence of audiologic side effects highlights the reduced trauma of the piezoelectric cut, demonstrates the superiority of the Piezosurgery device in terms of safety and protection of anatomical structures and confirms its applicability in all the otologic techniques tested. OBJECTIVES: The aim of the present study was to estimate the effect of Piezosurgery on the cochlea and in particular on the cochlear outer hair cells. PATIENTS AND METHODS: We selected 60 patients with a history of otologic surgery with Piezosurgery. Before and 6 months after surgery, all the patients underwent the following instrumental examinations: pure-tone audiometry, tympanometry, transient evoked otoacoustic emissions (TEOAEs), distortion product otoacoustic emissions (DPOAEs) and auditory brainstem response (ABR). RESULTS: Piezosurgery showed its safety on the inner ear and in particular on the cochlear outer hair cells: for each instrumental examination (pure-tone audiometry, tympanometry, TEOAE, DPOAEs and ABR), no patients presented postoperative worsening.