Impacts of conservative treatment on the clinical manifestations of obstructive sleep apnea-systematic review and meta-analysis.

INTRODUCTION: Obstructive sleep apnea (OSA) is a chronic disease with a high populational prevalence that is characterized as airway closure during sleep. Treatment is multidisciplinary and varies according to each case. Continuous positive airway pressure (CPAP), oral appliances, and surgery are the primary therapeutic options. Non-invasive conservative treatments such as sleep hygiene, positional therapy, physical exercises, and weight loss aim to reduce the worsening of the disease while being complementary to the invasive primary treatment. OBJECTIVE: To analyze the impact of non-invasive conservative therapies on the clinical manifestations of OSA syndrome (OSA), compared with other interventions. METHOD: This was a systematic review with meta-analysis. The searches were performed without filters for the time period, type of publication, or language. Randomized clinical trials on subjects over 18 years of age diagnosed with untreated OSA were included. Responses to non-invasive conservative treatment were compared with responses to the primary intervention. Primary outcomes were assessed using the Epworth Sleepiness Scale and/or Functional Outcomes of Sleep Questionnaire (FOSQ). RESULTS: A total of eight studies were included in the review. The heterogeneity of the effect was estimated at 89.77%. Six studies compared conservative treatment with CPAP, one with oral appliances, and one with oropharyngeal exercises. Using the Epworth Sleepiness Scale measurements, the standardized difference in the estimated means, based on the random-effects model, was 0.457 (95% CI (1.082 to 0.169)) and the mean result did not differ significantly from zero (z = 1.43; p = 0.153). The conservative therapies assessed in this study improved the subjective quality of sleep, although the post-treatment ESE scores did not show significant results. The reduction in AHI and better outcomes in the evaluated domains, as well as in cognition and mood, were superior in the groups that received CPAP and IOD. CONCLUSION: The most commonly used treatments of choice for OSA are invasive, including the use of CPAP, oral appliances, and surgeries, being the most utilized options. This study demonstrated that non-invasive conservative treatments, such as sleep hygiene, yield results as effective as invasive treatments. Further studies are needed to confirm this result and to predict whether invasive treatment can be used as the primary treatment or only as a supplement.

Fixed combination of cinnarizine and dimenhydrinate in the prophylactic therapy of vestibular migraine: an observational study.

Vestibular migraine (VM) is one of the most frequent causes of episodic vertigo, with a lifetime prevalence of 0.98%. Prophylactic therapy includes calcium channel blockers, beta-blockers, antiepileptic drugs and antidepressants. We studied the association of cinnarizine 20 mg and dimenhydrinate 40 mg (Arlevertan) in a group of 22 patients affected by definite VM. Proposed therapy included one tablet twice a day for 1 month, which was repeated three times with 1 month of interval between drug intake; results were compared with those of a control group of 11 VM patients who asked to observe only lifestyle measures for migraine. The main outcome was the number of vertigo and headache crises in the 6 months before therapy and in the 6 months of follow-up. Subjects performing Arlevertan presented during the 6 months of therapy a decrease of vertigo attacks from 5.3 to 2.1 and of headaches from 4.3 to 1.7 (p < 0.0001); 68% of these subjects reported a decrease of at least 50% of vertigo attacks, while 63% of headaches. Conversely, vertigo attacks decreased from 3.5 to 2.2 and headaches from 2.6 to 2 in patients observing only lifestyle; 18% of these subjects reported a decrease of at least 50% of vertigo crises and 27% of headaches. Our data do not differ from those of previous works assessing efficacy of different prophylactic therapies for VM and reporting consistent reduction of vertigo spells in a rate of patients ranging from 60 and 80%.

Cocaine induced midline destructive lesions.

PURPOSE: Review of the literature concerning cocaine induced midline destructive lesions (CIMDL). METHODS: We reviewed the English literature regarding CIMDL involving the nose and its surrounding structures. The review is based on a search of the US National Library of Medicine (PubMed) online database from January 1st, 1982 to March 31st, 2013. RESULTS: CIMDL is a pathology that mimics systemic diseases with positive anti-neutrophil cytoplasmic antibodies (ANCA). The prevalence of CIMDL is considered to be about 4.8% among cocaine users. Clinical manifestations include hyposmia, facial pain, crusting, ulcers, nasal septal perforation, palatal perforation, sinus wall destruction, orbital erosion and damage of the anterior skull base. The presence of ANCA directed against human neutrophil elastase (HNE) is the most distinguishing feature of CIMDL. Toxicological tests, indirect immunofluorescence microscopy, antigen specific solid assay testing, histopathological analysis, apoptosis assay and MRI imaging concur in the clinical identification of CIMDL. The pathogenesis of CIMDL is poorly understood and implicates inflammatory, infective, proapoptotic and autoimmune mechanisms. CONCLUSION: CIMDL must be readily recognized by clinicians to provide appropriate treatment. Immunosuppressive therapy has no role in the treatment of CIMDL. Only abstinence can interrupt the progression of the disease.

Non-vestibular head and neck schwannomas: a 10-year experience.

Schwannomas are rare and slow growing tumours, arising from Schwann cells which provide myelin; less than 1% of them degenerate into a malignant state. Although most studies are based on acoustic schwannomas, the majority of these tumours are non-vestibular and extracranial. Up to 45% of them can be localised in head and neck districts, where they represent a diagnostic challenge because they are in differential diagnosis with lipoma, brachial cyst, paraganglioma and adenopathy. Between February 2002 and September 2012 our experience considers 18 patients affected by schwannomas localised in the neck in 14 cases, in the oral cavity in 2 cases, in the upper lip in 1 case and finally in the nose in 1 case. A painless neck mass was the major symptom referred, as well as dysphonia and oral pain. Ultrasound scan with fine needle aspiration biopsy was done in half of the group and was diagnostic in 30%, whereas magnetic resonance imaging was diagnostic in 77%, confirming its primary role in diagnostic work-up. The surgical approach was mainly by cervical incision and the intraneural extracapsular enucleation was the technique used without nerve injury in 89% of cases. Follow-up period was 6-120 months and no evidence of relapse was registered.

Management of obstructive pathology of the salivary glands in elderly patients: a preliminary study.

BACKGROUND: Obstructive pathology is a benign condition of the salivary glands that can affect elderly and co-morbid people. Sialoendoscopy is a minimally invasive surgical procedure with a success rate comparable to standard sialoadenectomy and has the advantage that it can be performed under local anaesthesia. METHODS: This study aimed to assess sialoendoscopy benefits in elderly patients unfit for general anaesthesia. A group of elderly patients (aged 65 years or more) undergoing sialoendoscopy under local anaesthesia were evaluated. Age, co-morbidities, surgical time, hospital stay, and complication and recurrence rates were assessed. RESULTS: Nineteen sialoendoscopies were performed in 18 elderly patients with a mean age of 69.7 ± 5.6 years, with some of them suffering from multiple co-morbidities. Surgery was successful in 16 patients, while surgery was unsuccessful in 2 patients because of intraglandular stones. The average surgical duration was 54.5 ± 30.1 minutes, and all patients were discharged 2-3 hours after surgery. No post-operative complications were found and only one patient had recurrence during follow up. CONCLUSION: Sialoendoscopy under local anaesthesia is a safe and effective procedure in elderly patients who are more prone to complications.

Transmeatal low-level laser therapy for chronic tinnitus with cochlear dysfunction.

OBJECTIVES: To establish the efficacy of low-level laser therapy for tinnitus. METHODS: We performed a prospective, randomized double-blind study on 60 outpatients with tinnitus presenting sensorineural hearing loss in the affected ear. They were randomly divided into two groups, the first performing active laser therapy 20 min a day for 3 months with a 650-nm, 5-mW soft laser (group L), the second using a dummy device which duplicated all aspects of active laser therapy except for the activation of the laser beam (group C). One subject in both groups dropped out due to an increase in tinnitus loudness. Two more patients in each group ceased to comply with the protocol due to familiar problems. RESULTS: The Tinnitus Handicap Inventory (THI) was considered the main outcome measure; no statistical difference was detected between the 2 groups in the THI total score (p = 0.97), and its functional (p = 0.89), emotional (p = 0.89) and catastrophic (p = 0.89) subscales. Moreover, a visual analog scale for self-perceived loudness of the tinnitus showed no difference between the groups (p = 0.69). Regarding psychoacoustic parameters, the minimum masking level showed no difference (p = 0.42), while loudness expressed in sensation level exhibited lower values in group L (p = 0.0127). Group L subjects also presented a decreased rate of hyperacusis (p = 0.02). No changes were detected in the audiometric threshold in both groups. CONCLUSIONS: Soft laser therapy demonstrated no efficacy as a therapeutic measure for tinnitus.

Anastomosis of nasal mucosal and lacrimal sac flaps in endoscopic dacryocystorhinostomy.

Endoscopic dacryocystorhinostomy (DCR) is a well-established alternative to external approaches in the treatment of nasolacrimal canal obstruction. From July 2004 to December 2008, 92 endoscopic DCRs were performed on 88 patients at the Department of Otorhinolaryngology, San Raffaele Hospital, Milan. All patients were affected by chronic dacryocystitis with epiphora. Preoperative work-up included Jones tests, lacrimal pathways irrigation, nasal endoscopy, and imaging evaluation by computed tomography. The technique involved anastomosis of nasal mucosal, lacrimal sac flaps and a large bony ostium. A silicone tube was inserted in all patients that remained for a period of 3 months. The first endoscopic intervention was successful in 91.30% of patients. After a second revision endoscopic DCR, the overall success rate raised to 95.65%. Anastomosis of nasal mucosal between lacrimal sac flaps plays a key role in endoscopic DCR with a high success rate both in primary nasolacrimal obstructions and in revision cases.

Simultaneous pleomorphic adenoma of the parapharyngeal space and contralateral submandibular gland. Case report.

Herein the case is reported of a synchronous parapharyngeal space pleomorphic adenoma arising from the pharyngeal prolongation of the parotid gland and the contralateral submandibular gland, diagnosed in a young Caucasian female. Case reports and recent literature are presented. Upon physical examination, asymmetry of the lower part of the right side of the face with overlying intact skin, and a submucosal firm swelling, filling the ipsilateral side of the oropharyngeal wall, involving the right tonsillar bed which was medially displaced was immediately recognizable. The patient did not complain of dysphagia. Palpating the left submandibular region, a painless, mobile, rounded mass, 10 mm in diameter, apparently located in the submandibular gland, was detected. Magnetic resonance imaging showed that both lesions were well-defined and encapsulated. The surgical approach is discussed. Cytological diagnosis was that of a typical pleomorphic adenoma. To the best of our knowledge this is the second case report in the English literature of a concomitant pleomorphic adenoma located both in the parapharyngeal space and the submandibular gland.

The supraclavicular artery island flap (SCAIF) in head and neck reconstruction: an Italian multi-institutional experience.

The supraclavicular artery island flap (SCAIF) is a thin and pliable pedicled flap that is easy and quick to harvest. Thanks to its particular features and high reliability, it is best indicated for the elderly or most fragile patients. SCAIF is very versatile, as it can be used for reconstruction of oral cavity, oropharynx, hypopharynx, facial and cervical skin and tracheostomal defects. We began using this flap in four Italian tertiary referral centres, with several indications, both as first treatment and as salvage surgery. The aim of the study was to demonstrate the easy reproducibility of the flap among four different centres. A series of 28 patients underwent head and neck reconstructions with SCAIF with no recorded complications during flap harvesting. After the very first cases, harvesting time was approximately 45 minutes; 24 patients had successful flap integration at the recipient site, while the remaining 4 suffered from partial flap necrosis, two of whom needed revision surgery. Other minor complications were reported at the recipient site, always at the most distal and most delicate portion of the flap. Donor site was always closed primarily, with only three cases of partial suture dehiscence. We only selected the most fragile patients for SCAIF reconstruction, such as the elderly or those with one or more comorbidities; for this reason, we reported some serious systemic complications and one intraoperative death. SCAIF is an easy reproducible flap, with multiple possible indications. Its use as an alternative to free flaps in the head and neck region is nowadays under discussion. Its use should be encouraged among head and neck surgeons thanks to its various advantages.

Vestibular testing in patients with panic disorder and chronic dizziness.

In order to investigate the relationship between chronic dizziness and vestibular function in patients with panic disorder, in the present study neurotologic findings in 15 patients with panic disorder and chronic dizziness were compared with those in 15 patients with chronic dizziness, without panic disorder. All underwent neurotologic screening for spontaneous, positional and positioning nystagmus with head-shaking and head-thrust tests, an audiometric examination and electronystagmography with bithermal stimulation according to Freyss. A significantly higher number of patients with panic disorder and chronic dizziness showed pathological neurotologic findings in comparison to subjects with chronic dizziness only (9 and 2 patients, respectively; p < 0.05). Most patients with panic disorder showed signs of peripheral vestibular disorders. These results suggest that the complaint of dizziness in patients with panic disorder may be linked to a malfunction of the vestibular system and vestibular disorders may play a role in the pathophysiology of panic disorder. Possible mechanisms underlying this finding are discussed. In patients with panic disorder and chronic dizziness between panic attacks, a careful neurotologic examination is warranted.

Voluminous laryngeal schwannoma excision with a mini-invasive external approach: a case report.

Laryngeal schwannomas are extremely uncommon. We present a case of bulky supraglottic schwannoma with involvement of the preepiglottic and superior paraglottic spaces. Clinical findings, computed tomography and magnetic resonance images are presented. These characteristics are typical, however not specific to schwannomas. For definitive diagnosis, histology and immunohistochemistry are necessary. We present an external mini-invasive approach that allowed us to both obtain diagnosis and provide definitive treatment for this kind of voluminous laryngeal tumour.

Palate perforation differentiates cocaine-induced midline destructive lesions from granulomatosis with polyangiitis.

Cocaine abuse occasionally causes extensive destruction of the osteocartilaginous structures of the nose, sinuses and palate, which mimics the clinical picture of other diseases associated with necrotising midfacial lesions. The differentiation of cocaine-induced midline destructive lesions (CIMDL) and limited granulomatosis with polyangiitis (GPA) may be difficult, particularly if patients do not readily admit substance abuse. We studied 10 patients with CIMDL and palate perforation referred to our Unit between 2002 and 2015. All cases underwent nasal endoscopy, sinus CT or MRI and ANCA test. In 8 patients, a nasal biopsy was performed. The PubMed database was searched to review all cases of palate perforation described in patients affected by CIMDL or GPA. All 10 cases presented with septal perforation and inferior turbinate destruction. We found hard palate perforation in 7 patients, soft palate perforation in 2 patients, and perforation of both in one patient. ANCA testing was negative in 8 patients and positive in 2, with C-ANCA and P-ANCA specificity, respectively. A review of the English literature identified palate perforation in 5 patients with GPA and in 73 patients with CIMDL. The presence of palate perforation in patients with MDL may represent a clinical marker that strongly favors CIMDL over GPA.

Enhanced recovery program (ERP) in major laryngeal surgery: building a protocol and testing its feasibility.

Enhanced recovery programs (ERP) represent a multimodal approach to perioperative patient care. The benefits of ERP are well demonstrated in colorectal surgery and Enhanced Recovery After Surgery (ERAS®) programs, that epitomise the ERP concept, have being introduced in different specialties, including vascular, gastric, pancreatic, urogynecologic and orthopaedic surgery. However, no ERP has been proposed for head and neck surgery. We developed an expert-opinion-based ERP for laryngeal surgery based on the key principles of colorectal surgery ERAS®. Twenty-four patients undergoing major laryngeal surgery (total and partial laryngectomies or surgical removal of oropharyngeal tumour with muscle flap reconstruction) were treated according to such an ERP protocol, which differed under several respects from our previous standard practice (described in 70 consecutive patients who underwent major laryngeal surgery before ERP implementation. The adherence rate to the different ERP items is reported. Adherence to ERP items was high. Nutritional assessment, antibiotic prophylaxis, postoperative nausea and vomit (PONV) prophylaxis and postoperative speech therapy targets were applied as required in 100% of cases. Some ERP items (antibiotic prophylaxis, intraoperative infusion rate, and postoperative speech therapy) were already frequently implemented before ERP adoption. Postoperative medical complications occurred in 8.3% of patients. Our expert opinion-based ERP protocol for major laryngeal surgery proved feasible. The degree of benefit deriving from its implementation has yet to be assessed.

Vestibular function in HIV patients: preliminary report.

Main purpose of this study was to evaluate vestibular function, focusing attention on percentage of peripheral damage in 30 HIV positive patients (23 male, 7 female), age range 26-68 years, belonging to Categories A-C of CDC classification of infection, underwent electronystagmography with bithermic stimulation according to Freyss (125 cc of water at 30 degrees C and 44 degrees C in 30 sec). The angular velocity of slow phase was considered as the main value of labirinthine functionality. Peripheral vestibular damage has been found in 35.7% of Class A patients; a similar percentage of peripheral signs was found in Classes B and C, where, on the contrary, increased central vestibular signs were observed. In order to evaluate equilibrium in these patients, a Dynamic Gait Index (DGI) test was performed. Scores were >21 points in 85.7% of Class A patients and decreased in Classes B and C.

Parapharyngeal space tumours: video-assisted minimally invasive transcervical approach.

The purpose of the present study was to evaluate the advantages of a video-assisted, minimally invasive transcervical approach to benign and malignant parapharyngeal space (PPS) tumours. Ten patients affected by benign and malignant PPS neoplasms underwent a combined transcervical and video-assisted minimally invasive approach, using Hopkins telescopes. We describe the operative technique and perform a review of the literature. Definitive histology revealed 3 pleomorphic adenomas, 2 schwannomas, 2 metastatic papillary thyroid carcinomas, one carcinoma ex pleomorphic adenoma, one cavernous haemangioma and one basal cell adenoma. Mean tumour size was 37.2 mm (range: 19-60). Operation time ranged from 75 min to 185 min (mean: 146.7). One case was converted to transcervical-transparotid approach. Patients were discharged on postoperative day 2-5. One patients presented hypoglossal nerve paresis. The minimally invasive video-assisted transcervical approach is safe and feasible for selected benign and malignant PPS tumours. Furthermore, it offers harmless dissection in a deep and narrow space, accurate haemostasis and continuous control of critical anatomic structures.

Oncological and complication assessment of CO2 laser-assisted endoscopic surgery for T1-T2 glottic tumours: clinical experience.

Several therapeutic options are used for treatment of early stage glottic carcinoma (Tis/T1/T2): open partial laryngectomy (OPL), radiotherapy and CO2 laser-assisted endoscopic surgery. Laser surgery has gradually gained approval in the management of laryngeal cancer. We present our experience in endoscopic laser surgery for early stage glottic carcinomas. This was a retrospective analysis of 72 patients with T1-T2 glottic cancer treated with laser cordectomy between 2006 and 2012. All patients had at least a 36-month follow-up period. Percentages for disease-specific survival, disease-free survival (DFS) and laryngeal preservation rates were 98.6%, 84.7% and 97.2% respectively. Considering neoplastic features that could predict long-term oncological outcome, tumoural involvement of anterior commissure and pathological staging (pT) significantly correlate with local recurrence (p = 0.021 and p = 0.035) and with a lowered DFS (p = 0.017 and p = 0.023). Other variables such as clinical staging, type of cordectomy, involvement of other structures and surgical margin status showed no significant impact on oncological endpoints. CO2 laser surgery is a reliable technique for T1-T2 glottic cancer considering oncological outcomes. The recurrence rate seems to be affected by involvement of anterior commissure and pT stage.

Open partial horizontal laryngectomies: is it time to adopt a modular form of consent for the intervention?

Nowadays, open partial horizontal laryngectomies (OPHLs) are well-established procedures for treatment of laryngeal cancer. Their uniqueness is the possibility to modulate the intervention intraoperatively, according to eventual tumour extension. An OPHL procedure is not easy to understand: there are several types of procedures and the possibility to modulate the intervention can produce confusion and lack of adherence to the treatment from the patient. Even if the surgery is tailored to a patient's specific lesion, a unified consent form that discloses any possible extensions, including a total laryngectomy, is still needed. We reviewed the English literature on informed consent, and propose comprehensive Information and Consent Forms for OPHLs. The Information Form is intended to answer any possible questions about the procedure, while remaining easy to read and understand for the patient. It includes sections on laryngeal anatomy and physiology, surgical aims and indications, alternatives to surgery, complications, and physiology of the operated larynx. The Consent Form is written in a "modular" way: the surgeon defines the precise extension of the lesion, chooses the best OPHL procedure and highlights all possible expected extensions specific for the patient. Our intention, providing these forms both in Italian and in English, is to optimise communication between the patient and surgeon, improving surgical procedure arrangements and preventing any possible misunderstandings and medico-legal litigation.

Point prevalence of vertigo and dizziness in a sample of 2672 subjects and correlation with headaches.

Vertigo and dizziness are common symptoms in the general population, with an estimated prevalence between 20% and 56%. The aim of our work was to assess the point prevalence of these symptoms in a population of 2672 subjects. Patients were asked to answer a questionnaire; in the first part they were asked about demographic data and previous vertigo and or dizziness. Mean age of the sample was 48.3 ± 15 years, and 46.7% were males. A total of 1077 (40.3%) subjects referred vertigo/dizziness during their lifetime, and the mean age of the first vertigo attack was 39.2 ± 15.4 years; in the second part they were asked about the characteristics of vertigo (age of first episode, rotational vertigo, relapsing episodes, positional exacerbation, presence of cochlear symptoms) and lifetime presence of moderate to severe headache and its clinical features (hemicranial, pulsatile, associated with phono and photophobia, worse on effort). An age and sex effect was demonstrated, with symptoms 4.4 times more elevated in females and 1.8 times in people over 50 years. In the total sample of 2672 responders, 13.7% referred a sensation of spinning, 26.3% relapsing episodes, 12.9% positional exacerbation and 4.8% cochlear symptoms; 34.8% referred headache during their lifetime. Subjects suffering from headache presented an increased rate of relapsing episodes, positional exacerbation, cochlear symptoms and a lower age of occurrence of the first vertigo/dizziness episode. In the discussion, our data are compared with those of previous studies, and we underline the relationship between vertigo/dizziness from one side and headache with migrainous features on the other.

Parapharyngeal metastases from thyroid cancer: surgical management of two cases with minimally-invasive video-assisted technique.

Metastases to parapharyngeal or retropharyngeal lymph nodes are rare in well-differentiated thyroid cancers. A review of English literature found only 112 cases reported in the last two decades, with an incidence of parapharyngeal lymph nodes metastases ranging from 0.43 to 2.5%. Surgical resection is the most effective treatment for patients with parapharyngeal lymph node metastasis from thyroid carcinoma. We describe two cases of thyroid cancer parapharyngeal lymph node metastases that were surgically removed using a traditional transcervical approach, with the help of a minimally-invasive video-assisted technique. A video-assisted minimally-invasive transcervical approach is a new technique for excision of sizable benign tumours and selected malignant tumours. The endoscopic technique allows clear identification of critical surgical landmarks that guide the dissection through the correct cleavage plane in a nearly bloodless surgical field, thus decreasing the rate of complications. In both patients postoperative follow-up showed no sequelae and recurrence after 20 and 15 months from surgery.