Colistin-based Treatment of Multidrug-resistant Gram-negative Bacterial Pulmonary Infections After Lung Transplantation.

BACKGROUND: Lung transplantation (LT) is a viable option for a select group of patients with end-stage lung disease. However, infections are a major complication after LT, accounting for significant morbidity and mortality. Several germs may be responsible; multidrug-resistant Gram-negative (MDR-GN) bacteria are emerging. Colistin is widely used in the treatment of these infections and is administered by inhalation and/or parenterally. At our institution, in patients with tracheostomy, colistin is administered by direct instillation in the airway during bronchoscopy. We reviewed a series of patients who underwent LT complicated by postoperative MDR-GN bacterial pulmonary infection. METHODS: From January 2015 to May 2017, 26 lung transplants were performed. In the postoperative course, 14 (54%) developed MDR-GN bacterial infection; respiratory specimen culture, blood tests, and chest X-ray were considered. Colistin was the only antibiotic usable. Thirteen patients received intravenous (IV) colistin; in the subgroup of patients with tracheostomy, colistin was instilled directly in the airway, and 6 patients received inhaled colistin. RESULTS: Seven patients needed tracheostomy. Pseudomonas aeruginosa was the predominant infection (86%), with Acinetobacter baumanii seen in 2 cases (14%). An early clinical-laboratory response was observed in 9 patients (64%). White blood cell count and C-reactive protein values improved (P = .02 and P = .001, respectively). A significant reduction in bacterial load was observed on microbiologic bronchoalveolar lavage specimens. CONCLUSION: Colistin instilled directly in the airway did not show side effects. The combination of IV and inhaled/instilled colistin could be a useful treatment option for MDR-GN infections after LT.

Transtympanic steroids in refractory sudden hearing loss. Personal experience.

The treatment of choice for sudden sensorineural hearing loss is still lacking. Many drugs have been used over the years, with varying results and steroids have proven to be effective in clinical trials, albeit systemic administration is associated with untoward side-effects and cannot be used in all patients. The transtympanic approach presents two main advantages: first, it allows higher concentrations in the inner ear environment and, second, it minimizes systemic absorption. Aim of the present investigation was to establish the effectiveness of transtympanic steroid treatment for sudden sensorineural hearing loss in patients in whom conventional treatment had failed. For this purpose, a prospective, non-randomized study was designed to evaluate hearing improvement in sudden sensorineural hearing loss patients treated with transtympanic steroids. A solution of methyl-prednisolone and sodium bicarbonate was administered, via a transtympanic injection, in 10 patients. Hearing levels were evaluated before treatment and on days 1, 7 and 30, thereafter. Improvement in hearing was observed in 70% of patients, moreover, in patients not usually considered amenable to this kind of treatment. Transtympanic steroid treatment is an effective and safe option for patients with sudden sensorineural hearing loss when conventional treatment regimens have failed. Further studies are needed to define the optimal dosage, route of administration and type of steroids.

Acoustic neuroma: correlations between morphology and otoneurological manifestations.

Forty-two patients with acoustic neuroma (AN) were studied to determine whether different types of neuroma could be correlated with specific signs and symptoms of the disease. Based on gadolinium-enhanced TI-weighted MRI sequences, the 42 cases of AN could be divided into three groups, either by size (small: 11.9%, medium: 50%, and large: 38.1%) or by site of origin of the tumour (lateral: 16.7%, intermediate: 69%, and medial: 14.3%). Relations were found between the size and the site of origin of the neuromas and certain clinical, audiological and vestibular findings. The clinical presentation seemed to vary with the site of origin and the size of the tumour: patients with lateral neuromas generally had small tumours, sometimes only located in the internal auditory canal (IAC), and presented early subjective hearing loss while patients with medial neuromas had larger tumours which grew without causing significant audiological symptoms. Normal hearing function was seen only in the patients with medial ANs; however, a significant relation between the size or the site of origin of the AN and the average hearing threshold was not demonstrated. The sensitivity of the stapedial reflex test (SR) was higher for lateral ANs. Anomalies in the brainstem auditory evoked potentials (BAEPs) did not seem to be related to either the size or the site of origin of the AN. The vestibular tests demonstrated a higher frequency of central vestibular involvement in the large tumours, while normal function was more frequent in the lateral tumours. In the group studied the combination of BAEPs and vestibular tests allowed us to identify all the ANs with an optimal level of sensitivity.

[Audiological and neuropsychological development study in a sample of school children from a low-iodine area of the Central Apennines that is endemic for cretinism]. / Studio audiologico e dello sviluppo neuropsichico in un campione di scolari di un'area a basso apporto iodico dell'Appennino Centrale con cretinismo endemico.

We have evaluated neuropsychic development in 70 normal schoolchildren in an area of severe endemic goitre and cretinism in the Central Apennines (Montefeltro). In each subject we have studied auxological, psychometric and audiometric parameters, together with tympanograms and stapedial reflexograms. Auxological data were in the normal range, as were the stapedial reflexograms and tympanograms. On the contrary, 54.8% of the sample performed below the 25th percentile in psychometric tests (Raven test PM-47), being also 22.8% below the 5th percentile. Audiometric data showed a neurological hearing impairment in 3.1% of the children tested, as compared with 0.28% in the area of Pisa. These data point out that an impairment of central nervous system function still persists in this area of severe endemic goitre.

Hearing and vestibular disturbances in Behçet's syndrome.

In order to evaluate the prevalence of audiovestibular disturbances in Behçet's syndrome, we submitted 20 consecutive patients and 20 control subjects to detailed audiologic and vestibular examination in the last 3 years. A sensorineural hearing loss was found in 12 patients, 2 of whom revealed sudden deafness. Two other patients with neuro-Behçet's syndrome showed a vestibular function deficit, and 3 others exhibited altered caloric stimulation test results. Two of these last patients also revealed a simultaneous bilateral auditory deficit. HLA typing showed the presence of the B51 antigen in 10 of the 14 patients with ear involvement, while only 3 of the 6 patients without ear involvement were HLA-B51-positive. Results suggest that audiovestibular involvement is common in Behçet's syndrome: sudden deafness may be the first sign of ear disturbance; vestibular lesions may represent an early sign of neuro-Behçet's syndrome; and the HLA-B51 antigen is associated with ear involvement. Otoneurologic study can reveal hidden brain stem lesions in Behçet's patients during flare-ups of the disease, even without obvious signs of neurologic deficits.

Giant neck neoplasm. Case report.

Giant latero-cervical neoplasias usually originate in the parotid gland, as slow-growing adenomas, in subjects who take little care of their personal health. Giant adenomas of submandibular gland are very rare. These neoplasias involve prevalently male sex (male/female ratio: 2/1) and usually occur between 20 and 40 years of age. Signs of malignant transformation may be observed in the adenomatous epithelial component in a percentage ranging from 1% to 10% of cases. The case is reported of a giant malignant latero-cervical neoplasia originating from a pleomorph adenoma of the submandibular gland. The diagnostic work-up and treatment protocol are described.

[Progressive sensorineural hearing loss from infectious agents]. / Ipoacusie neurosensoriali progressive da agenti infettivi.

The progressive sensorineural hearing loss due to infectious causes can involve different etiological agents like bacteria, viruses, protozoons or mycetes. These infectious agents can act in various ways: directly through a labyrinthitis that may destroy the neuroepithelium; through an ischaemic process secondary to a septic embolus; or through a thrombus. In some cases the damage can occur in a meningitis context, because of the passage of the germ in the inner through the nerves, the vases or the labyrinthine liquids. Bacterial meningitis is one of the causes of progressive sensorinueral hearing loss. Among bacteria, the Mycobacterium Tuberculosis has nowadays acquired a remarkable importance which is also due to its considerable diffusion, despite modern therapy, and to its association with HIV infection. Bacteria can also cause a labyrinthitis acting directly on the inner ear: among these, Treponemas Pallidum, a spirochaete which causes syphilis and Borrelia Burgdorferi, a spirochaete that causes Lyme Disease, must be mentioned. The viruses that are certainly involved in the etiology of progressive sensorineural hearing loss are Cytomegalovirus and Rubella virus. The virus usually causes a labyrinthitis after the viraemia, wich may be due to the passage of the virus from the blood to the endolymph, through the stria vascularis with the consequent infection of the sensorial cells of the organ of Corti. Less frequently the viral damage to the inner ear can occur after a vasculitis, a meningitis or an alteration of the cell-mediated immunity. Progressive sensorineural hearing loss can also occur because of some congenital viral infections such as those caused by Cytomegalovirus and Rubella virus. More recently even the Human Parvovirus B19 seems to have been involved. This virus seems to act through autoimmune and/or immunologic processes, like that causing sudden hearing loss in Lassa fever. Another viral infection which can nowadays more frequently be considered among the cause of progressive hearing loss is HIV. In the HIV infection the neurological toxic lesions due to the administered ototoxic drugs are added up to the damages caused by the opportunistic infectious agents (virus, bacterium, protozoon mycete). However, in these patients HIV itself could be the cause of the auditory and vestibular lesions. More rarely, a progressive hearing loss may be due to the action of a protozoon or mycete only.

[HIV infection and nosocomial risk: experience at the ORL Clinic of Pisa]. / L'infezione da HIV e il rischio nosocomiale: esperienza della clinica ORL di Pisa.

The risk of nosocomial risk of HIV infection and the problem of preventative measures to adopt has been modifying how workers in the health field deal with patients. In fact, the increased spreading of HIV infections within our population has led to the establishment of a national protocol of preventative measures by which no patient can be considered "safe". Consequently, the likelihood that contact with any patient can lead to infection causes the health care worker to look upon the patient as a potentially dangerous enemy, thus leading to a decline in the quality of health care. On the other had, although the risk of a health care worker being infected by HIV during routine work is low, preventative measures must be taken both during examination and during surgery. Unanimous agreement exists in regard to what measures are to be taken to prevent cutaneous and mucosa exposure of workers whenever the risk of accidentally coming into contact with the blood and/or other biological fluids exists. On the other hand, the use of an anti-HIV screening for all patients in order to distinguish between infected and non infected subjects is still subject to debate. Some feel such screening is unacceptable because it would deny sero-positive patients adequate care and could give rise to both false positives and false negatives while others propose routine screening feeling it to be helpful both to those who are sero-positive and to health care workers.(ABSTRACT TRUNCATED AT 250 WORDS)

[Histological and ultrastructural aspects of oto-mastoid cholesteatoma in children]. / Caratteri istologici ed ultrastrutturali del colesteatoma otomastoideo del bambino.

Cholesteatomas were intraoperatively removed from subjects under 14 years of age presenting widespread cholesteatoma with bone erosion. The samples were studied under light and transmission electron microscopy in order to consider the features of inflammation and bone erosion. The results showed that the perimatrix of cholesteatoma in children is rich in mononuclear inflammatory elements and generally presents the features of chronic, as well as acute, inflammation. The perimatrix infiltrates and erodes the surrounding bone. Next to the resorption areas many areas were observed having new bone the surface of which is lined with osteoblasts. The new bone formation activity is marked in these cases of childhood cholesteatoma and appears to be an attempt at spontaneous repair which is thwarted by the persistence of inflammation.

[Lyophilized bone homografts in reconstructive surgery of the middle ear]. / Omotrapianti ossei liofilizzati nella chirurgia ricostruttiva dell'orecchio medio.

The authors present their experience with stored lyophilized bone allografts utilized in middle ear reconstructive surgery. The implants were cut from the cortical substance of the long bone in subjects deceased. A demineralization in 0.6 N HCl solution was performed in order to induce osteoinductive capacity to the bone matrix. From November 1986 to December 1988 this material was utilized in 45 operations: 31 canal up techniques; 7 canal down techniques; 4 anatomical and functional rehabilitation of old radical cavities. Good anatomical results without perforation of the tympanic membrane and without signs of inflammation or retraction were obtained in 33 cases (79%). Furthermore, no extrusion was observed in cases with retraction of the graft and protrusion of the prosthesis. In cases in which the homografts were utilized for ossiculoplasty, the post-operative air-bone gap was 21 dB and the mean hearing gain was 15 dB. The histological examination of two homografts, removed 13-18 months after implantation, appeared to be coated with normal mucosa and to contain areas of active bone formation.

[Bovine costal cartilage as material for otologic reconstruction: anatomo-functional results]. / La cartilagine costale bovina come materiale di ricostruzione in otologia: risultati anatomo-funzionali.

The Authors present their experience in using bovine cartilage as otological material reconstruction. Cartilage of the ribs is to collect from selected bred cattle and is first placed in an antibiotic solution for 3 days and then in a 70% ethyl alcohol in which it is stored for 20 days before being utilized. One hundred-nineteen cartilage heterografts have been implanted in the middle ear since January 1989. We report the results of 86 cases which were included in a followed study for at least 12 months. Bovine cartilage was used in 47 canal up techniques, 28 canal down techniques and 11 anatomic and functional rehabilitation of old radical cavities. The result prove most encouraging. In 74 cases we observed good anatomical results characterized by a new, intact eardrum with no sign of inflammation or a cavity lined with normal epithelium. No extrusion was found. Removal of cartilage implanted after a year enabled us observe the high tolerance of the graft and to carry out further histological examination. The histological findings indicated normal and intact cartilagineous matrix, lined with fibrous tissue and mucosa with no evidence of condrocytes. In cases in which the heterografts were utilized for ossiculoplasty, the post-operative air-bone gap was 11.1 dB and the mean hearing gain was 26.3 dB. Moreover, bovine cartilage is easily obtainable and available in pieces of sizes necessary for specific purposes in otologic surgery. Cartilage heterografts might well be a good alternative to autologous and homologous cartilage grafts.

Positron emission tomography (PET) in the staging of head neck cancer: comparison between PET and CT.

Standard pre-treatment clinical staging (TNM) of head and neck squamous cell carcinoma includes clinical and instrumental objective examination of primary tumour and of the cervical lymph nodes (inspection, palpation of neck, panendoscopy, biopsy of tumour, fine needle aspiration of nodes) and computed tomography or magnetic resonance imaging. Albeit, this procedure presents diagnostic limitations in the identification of approximately 1/3 of T1, of small sized nodes and in the diagnosis of metastases. Positron emission tomography-fluorodesoxy-glucose imaging, in the diagnostic workup of these cases, appears to offer an important contribution, however, its use is limited due to poor availability of this equipment and the high cost of the examination. In the present study, a comparison is made of results of standard clinical staging and positron emission tomography-fluorodesoxy-glucose in 22 patients with head and neck carcinoma prior to surgical treatment, with the results of pathological staging (pTNM) carried out on surgical specimens. In the staging of the tumour, computed tomography shows a sensitivity of 71% and positron emission tomography of 81%. In the staging of nodes, computed tomography imaging shows a sensitivity of 73%, a specificity of 57% and an accuracy of 68%, whereas positron emission tomography shows a sensitivity of 93%, a specificity of 100% and an accuracy of 95%. Furthermore, positron emission tomography identified 1/5 occult tumours and one tumour revealed at objective endoscopic examination, but not by computed tomography. The risk of occult nodes following positron emission tomography was found to be 7%. Overall, these results are in keeping with those reported in the literature, thus confirming the usefulness of positron emission tomography-fluorodesoxy-glucose in identifying occult tumours and nodes, in which computed tomography appears to be limited. Indications of positron emission tomography-fluorodesoxy-glucose may play a role in the choice of therapeutic options for the clinically N0 neck.

Lethal midline granuloma: a case of Ki-1 lymphoma.

Lethal midline granuloma syndrome (LMG) is the clinical term generally used to describe a rare clinical entity of unknown cause characterized by a progressive and often fatal ulceration and destruction of the upper airway involving the nose, the paranasal sinuses and the soft tissues of the face. The following histopathologic entities have always been grouped under the term LMG: Wegener granulomatosis (WG), non-Hodgkin lymphoma, polymorphic reticulosis (PR) and idiopathic midline destructive disease (IMDD). Today in order to begin an adequate therapy a differential diagnosis is necessary. The progresses in clinical immunology and immunohistochemistry and cytophotometric findings are useful to define the LMG syndrome better. First of all the LMG must be discriminated from localized WG occurring in the midface. Serologic examinations of patients with WG in its active form show a high percentage of autoantibodies against cytoplasmic structures in leucocytes and monocytes. Moreover a review of the literature allows us to suppose that cases described as IMDD and PR are indeed a large evolutionary spectrum from almost benign to fatal malignant lymphoma. We report a case of Ki 1-lymphoma presenting as LMG syndrome.

Fully implantable Otologics MET Carina device for the treatment of sensorineural hearing loss. Preliminary surgical and clinical results.

Middle ear implants overcome some of the common problems of conventional hearing aid technology, such as feedback, signal distortion, ear canal occlusion and associated issues. The Otologics MET Carina, Boulder, CO, USA, is a fully implantable hearing prosthesis designed to address the amplification needs of adults (> 18 years of age), with moderate to severe sensorineural hearing loss and normal middle ears, providing a mechanical direct stimulation of middle ear ossicles. Recently, it has been successfully used also in patients with conductive hearing loss. In the present report, personal surgical and clinical experience with the fully implantable Carina is described in 5 adults with moderate to severe sensorineural hearing loss, operated upon between November 2007 and May 2008 in the ENT Unit, University of Pisa. Mean follow-up was 10.2 months of device use (range 7-13). Surgery was performed under general anaesthesia, in approximately 3 hours, with no surgical complications in any of the patients. In these 5 cases, no significant post-operative variation was observed in hearing thresholds, either for air or bone conduction, indicating absence of surgical damage to the cochlea. All patients showed improvements in hearing thresholds, in free field and in speech perception abilities, with the device functioning, moreover, they reported subjective benefits. With regard to post-operative adverse effects, no cases of extrusion of the device, device failure, loss of external communication or increased charging times were observed. Problems of feedback noise occurred, which were resolved with minor fitting adjustments in 4 cases, while a second operation was required to change the microphone position in the other patient. The present results, in agreement with those reported in the literature, confirm that the Otologics MET Carina is viable treatment for moderate to severe sensorineural hearing loss and, in selected cases, may represent an alternative to conventional hearing aids.

TORPs and PORPs: causes of failure.

We review the main causes of failure using total and partial ossicular replacement prostheses in staged intact canal wall tympanoplasty. Most failures may be prevented by using a few surgical devices. Otherwise, when a graft perforation or a hearing impairment occurs, it requires another operation for new grafting and to replace the prosthesis.

[Use of fibrin glue in microsurgery of the ear. An analysis of operations at the Pisa ENT Clinic]. / Die Anwendung des Fibrinklebers in der Mikrochirurgie des Ohres. Eine Analyse der Eingriffe in der HNO-Klinik Pisa.

The authors report the indications for and methods of application of fibrin glue in reconstructive microsurgery of the middle ear. On the basis of 180 interventions, they describe in detail the use of fibrin glue in myringo- and tympanoplasty for correct fixing of grafts. Furthermore, they illustrate the particular use of fibrin glue in reconstruction of the incudostapedial joint, in covering eroded areas of the lateral semicircular canal and in one case of perilymph gusher.

Quantification of the parameters of the acoustic reflex in normal ears.

Measurement of the acoustic stapedial reflex parameters has proved to be a useful tool for evaluating the function of the acoustic-facial reflex. However, there is no agreement about the definitions of the parameters; moreover, most of the data have been obtained by manual measurement methods. The authors describe a computerized analytical method which permits the parameters to be measured according to the definitions and methods suggested by others and according to the new analytical method described, which is performed on the basis of the derivative of the stapedial reflex curve. The two methods are compared in 40 normal subjects.

[Sudden deafness and Behçet's disease]. / Surdité brusque et maladie de Behçet.

Behçet's disease is a multisystemic vasculitis of unknown aetiology. Generally, it is characterized by recurrent aphthous stomatitis, recurrent genital ulcers, uveitis with hypopion. Recently some authors reported that patients with Behçet's disease show frequently audio-vestibular involvement. We observed a 40 year-old man (case A) and a 66 year-old woman (case B) affected by Behçet's disease for more than 10 years, showing a sudden deafness occurring during an exacerbation of the disease. In both cases there was a sensorineural hearing-loss, unilateral or bilateral. One patient received early high-dose cortisone therapy. General symptoms and audiovestibular function, both have completely recovered.