Cholesteatoma vs granulation tissue: a differential diagnosis by DWI-MRI apparent diffusion coefficient.

PURPOSE: To diagnose cholesteatoma when it is not visible through tympanic perforation, imaging techniques are necessary. Recently, the combination of computed tomography and magnetic resonance imaging has proven effective to diagnose middle ear cholesteatoma. In particular, diffusion weighted images have integrated the conventional imaging for the qualitative assessment of cholesteatoma. Accordingly, the aim of this study was to obtain a quantitative analysis of cholesteatoma calculating the apparent diffusion coefficient value. So, we investigated whether it could differentiate cholesteatoma from other inflammatory tissues both in a preoperative and in a postoperative study. METHODS: This study included 109 patients with clinical suspicion of primary or residual/recurrent cholesteatoma. All patients underwent preoperative computed tomography and magnetic resonance imaging with diffusion sequences before primary or second-look surgery to calculate the apparent diffusion coefficient value. RESULTS: We found that the apparent diffusion coefficient values of cholesteatoma were significantly lower than those of non cholesteatoma. In particular, the apparent diffusion coefficient median value of the cholesteatoma group (0.84 × 10- 3 mm2/s) differed from the inflammatory granulation tissue (2.21 × 10- 3 mm2/s) group (p < 2.2 × 10- 16). Furthermore, we modeled the probability of cholesteatoma by means of a logistic regression and we determined an optimal cut-off probability value of ~ 0.86 (specificity = 1.0, sensitivity = 0.97), corresponding to an apparent diffusion coefficient cut-off value of 1.37 × 10- 3 mm2/s. CONCLUSIONS: Our study has demonstrated that apparent diffusion coefficient values constitute a valuable quantitative parameter for preoperative differentiation of cholesteatomas from other middle ear inflammatory diseases and for postoperative diagnosis of recurrent/residual cholesteatomas.

Cyberknife® system: a new therapeutic strategy for sinonasal solitary extramedullary plasmacytomae.

Sino-nasal solitary extramedullary plasmacytoma (EMP) is a rare neoplasm with unpredictable progression to multiple myeloma. To improve the precision of irradiation delivery, preserving the healthy surrounding tissue and critical structures we used a CyberKnife® for the treatment of sinonasal solitary extramedullary plasmacytoma. We present the first case of sinonasal-EMP treated with CyberKnife®-stereotactic radiotherapy (SRT) with a complete remission without adverse events. Based on the post-therapeutic results and healthy tissue preservation, we believe that CyberKnife®-SRT represents a good therapeutic option for the treatment of sinonasal-EMP.

Sodium hyaluronate improves quality of life and nasal endoscopy features in preschool children with upper respiratory tract infections.

The aim of this prospective, randomised study was to evaluate the effects of nasal douches with sodium hyaluronate on clinical and endoscopic variables, on parental perception of their child’s health-related quality of life (HR-QoL), and on parental workdays lost in preschool recurrent upper respiratory tract infections (URTIs). Children aged 2-6 years with recurrent or persistent URTIs underwent at baseline the evaluation of upper respiratory tract symptoms in the previous two weeks, and nasal endoscopy. Parents of enrolled children were assessed for self-perception of their children’s HR-QoL using a standardised questionnaire. The same variables were reassessed after a 2-week treatment with either 9 mg sodium hyaluronate plus saline solution or saline alone by nasal douches. Forty of the 48 children enrolled completed the study (22 assigned to the combined treatment). Compared to baseline, the combined treatment resulted in a significant reduction of the prevalence of children with missed daycare days (45% vs 14%, p=0.04) and of parents with workdays lost (36% vs 5%, p=0.02), and in a significant improvement of HR-QoL score (3.7 vs 2.8, p=0.004). At endoscopy, the secretion and mucosal oedema score significantly improved after the combined treatment (6 vs 2, p < 0.001), and there was a trend towards a reduction of the adenoid hypertrophy score (p=0.06). No clinical, HR-QOL or endoscopy changes were found in the saline group. In preschool children with recurrent or persistent URTIs, sodium hyaluronate by nasal douche significantly improves endoscopic features. Additional benefits include the children’s HR-QoL and daycare attendance, and parental work.

Nasal cytological assessment after crenotherapy in the treatment of chronic rhinosinusitis in the elderly.

Chronic rhinosinusitis (CRS) determines irreversible alterations of the nasal mucosa with consequent impairment of ciliary movements and, therefore, mucociliary clearance (MCC). People of all ages can be affected by CRS but the elderly are subjects at the highest risk. CRS in the elderly with an age-related physiological impairment of nasal respiratory function, often accompanied by other chronic diseases, requires additional therapies to be added to the numerous daily medications. Since the currently available therapies for CRS include the use of drugs that can have adverse effects and contraindications, crenotherapy could represent a therapeutic option. Indeed, because the adverse effects and contraindications of crenotherapy are scarce, it can be safely used in elderly patients with comorbidities. The aim of this study is to evaluate the nasal cytological assessment after crenotherapy in elderly subjects with CRS. Two groups, comprising a total of 84 elderly subjects with CRS, were treated with crenotherapy with sodium chloride sulphate hyperthermal water rich in mineral salts (group I, n=49) and saline solution (group II n=35). Cytological assessment for both groups took place at baseline (T0) and 1 month after treatment (T30). At T30 the nasal cytological assessment showed statistically significant improvements in the ciliary motility and in the count of neutrophils and spores in group I, but not in group II. Conversely, there were no significant differences in the count of eosinophils, mast cells, bacteria and biofilm in either group. Our data for the first time focused on the role of crenotherapy in the improvement of cytological assessment of CRS in the elderly.

Stapedotomy: functional results with different diameter prostheses.

Developments in surgical technique and, more importantly, the use of increasingly sophisticated biocompatible prostheses have meant that good results can be achieved for otosclerosis sufferers in terms of restored hearing and very little postsurgical discomfort. We set out to assess whether the diameter of the prostheses used for stapedotomy (platinum piston/polytetrafluoroethylene, i.e. Teflon) has any effect on surgical outcome. Two groups of otosclerotic patients were selected, and these underwent stapedotomy surgery during the second phase of the disease. A piston-Teflon type prosthesis was used, 5.50 mm in terms of length but of different diameters (group A: 0.4 mm; group B: 0.6 mm). All the patients underwent the same pure-tone audiometry test before surgery, and then at 1 week and 1 month after surgery, to assess function. We compared air conduction after surgery with bone conduction before surgery. The data collected was analysed using the χ(2) (p < 0.05) test. This analysis showed that the results obtained with a 0.4-mm prosthesis or a 0.6-mm prosthesis are almost identical. There was no statistically significant difference in terms of hearing results when comparing either average tonal threshold or when analysing audiometric data frequency by frequency. It can be concluded, therefore, that in stapedotomy surgery, functional recovery is not affected by the diameter of the prosthesis used. A smaller diameter prosthesis is, however, the one of choice when the facial nerve is prominent or the oval window particularly narrow.

Qualitative and quantitative measurement of the singing voice.

OBJECTIVE: The aim of the study was to clarify the mechanisms underlying the singing voice. PATIENTS AND METHODS: Forty-eight professional opera singers underwent flexible and rigid endoscopy, spectrographic analysis and perceptual evaluation. RESULTS: The data provided by voice analysis were not as clear and relevant to the aim of our study as those commonly obtained for speech evaluation. Laryngoscopy with rigid and flexible fiber optics and the singing power ratio (SPR) measurement provided more applicable data. Indeed, the former allowed us to assess laryngeal position, the glottic pattern and vocal tract modifications during the actual singing performance. The latter, already recommended by other authors as a reliable vocal emission index, also yielded more relevant information in comparison with the assessment of voice quality. Specifically, SPR provided data directly correlated to both the years of singing activity and the vocal category of each singer (the higher the singing pitch, the wider the vocal extension). More importantly, the data fully reflected the subjective assessment of each phoniatrician. CONCLUSIONS: We suggest that the SPR indices can be used as the electroacoustic equivalent of the subjective judgment of vocal focus.

Septoplasty: is it possible to identify potential "predictors" of surgical success?

Septoplasty is one of the most frequent surgical procedures performed by otolaryngologists. Despite successful surgical correction, many patients are not satisfied with their outcomes. So far, in clinical practice there is no consensus of opinion about the reliability of objective measurements of nasal patency and the correlation between objective measurements and subjective nasal patency symptoms. This study aims to assess the reasons for patient dissatisfaction after septoplasty and optimise pre-operative diagnostic management to predict surgical outcomes. We analysed 494 patients undergoing septoplasties with turbinoplasty by subjective Nasal Obstruction Symptom Evaluation questionnaire (NOSE) and objective active anterior rhinomanometric measurements before surgery and after 6 months. In our series, 17% had postoperative septal re-displacement; all patients had an anterior deviations at baseline. We found that the type of septal deviation, anterior vs posterior, was a significant predictor of postoperative functional improvement, whereas demographic characteristics as age, gender and smoke habit were not. Our data suggest that the anterior segment of the nasal septum was the most critical area for nasal airway resistance and more difficult to manage because it is likely to re-displace vs the posterior one and for this reason it represents a negative predictor of postoperative satisfaction.

Overexpression of chromatin assembly factor-1/p60 predicts biological behaviour of laryngeal carcinomas.

This study analysed the immunohistochemical expression of the CAF-1/p60 protein in laryngeal cancers. CAF-1/p60 assumes an independent discriminative and prognostic value in laryngeal neoplasms; the presence of this protein in carcinoma in situ compared with laryngeal precancerous and larynx infiltrating tumours. We assessed the immunohistochemical expression of CAF-1/p60 in 30 cases of moderate and/or severe dysplasia, 30 cases of carcinoma in situ and 30 cases of laryngeal squamous cell carcinoma (LSCCs). CAF-1/p60 expression increased significantly according to the high index of neoplastic cellular replication; therefore, CAF-1/p60 was overexpressed in neoplastic cells and its moderate-severe expression is correlated with poorer prognosis compared to less expression. In conclusion, overexpression of the CAF-1/p60 protein is related to a risk of higher morbidity and mortality and is a reliable independent prognostic index of laryngeal carcinoma. CAF1-p60 protein overexpression can be used in cancer management as an indicator of malignant evolution, especially in carcinoma in situ.

An "ex vivo model" contributing to the diagnosis and evaluation of new drugs in cystic fibrosis.

Cystic fibrosis (CF) is an autosomal recessive disease caused by mutations in the cystic fibrosis transmembrane regulator (CFTR) gene. About 2000 mutations have been described so far. We setup an ex vivo model of human nasal epithelial cells (HNECs) to study CF patients testing the effect of novel mutations and molecular therapies. We performed sampling (by brushing), followed by culture and analysis of HNECs using a series of molecular techniques. We performed 50 brushings from CF patients and controls. Using cultured cells, we: i) demonstrated the widely heterogeneous CFTR expression in patients and in controls; ii) defined the splicing effect of a CFTR mutation; iii) assessed the CFTR gating activity in patients bearing different mutations; iv) demonstrated that butyrate significantly enhances CFTR expression. Based on our data, we can conclude: 1) HNEC brushing is performed without anaesthesia and is well tolerated in all CF patients (children and adults); 2) HNECs can be preserved for up to 48 hours before culture allowings multicentre studies; 3) HNECs culture can be considered a suitable model to study the molecular effects of new CFTR gene mutations and/or uncertain meaning specific mutations of carriers; 4) an ex vivo model of HNECs may be used to evaluate, before human use, the effect of new drugs on patients' cells bearing specific CFTR mutations; 5) the methodology is adequate for a quantitative measurement, by fluorescence, of the CFTR gating activity of the HNECs from patients with different genotypes identifying: a) CF patients bearing two severe mutations with an activity < 10% (compared to controls - 100%); b) CF patients bearing at least a mild mutation with an activity of 10-20%; c) CF carriers (heterozygous subjects) with an activity between 40-70%.

Mathematical model for preoperative identification of obstructed nasal subsites.

The planning of experimental studies for evaluation of nasal airflow is particularly challenging given the difficulty in obtaining objective measurements in vivo. Although standard rhinomanometry and acoustic rhinometry are the most widely used diagnostic tools for evaluation of nasal airflow, they provide only a global measurement of nasal dynamics, without temporal or spatial details. Furthermore, the numerical simulation of nasal airflow as computational fluid dynamics technology is not validated. Unfortunately, to date, there are no available diagnostic tools to objectively evaluate the geometry of the nasal cavities and to measure nasal resistance and the degree of nasal obstruction, which is of utmost importance for surgical planning. To overcame these limitations, we developed a mathematical model based on Bernoulli's equation, which allows clinicians to obtain, with the use of a particular direct digital manometry, pressure measurements over time to identify which nasal subsite is obstructed. To the best of our knowledge, this is the first study to identify two limiting curves, one below and one above an average representative curve, describing the time dependence of the gauge pressure inside a single nostril. These upper and lower curves enclosed an area into which the airflow pattern of healthy individuals falls. In our opinion, this model may be useful to study each nasal subsite and to objectively evaluate the geometry and resistances of the nasal cavities, particularly in preoperative planning and follow-up.

A miRNA signature suggestive of nodal metastases from laryngeal carcinoma.

The discovery that miRNAs are frequently deregulated in tumours offers the opportunity to identify them as prognostic and diagnostic markers. The aim of this multicentric study is to identify a miRNA expression profile specific for laryngeal cancer. The secondary endpoint was to identify specific deregulated miRNAs with potential as prognostic biomarkers for tumour spread and nodal involvement, and specifically to search for a miRNA pattern pathognomonic for N+ laryngeal cancer and for N- tissues. We identified 20 miRNAs specific for laryngeal cancer and a tissue-specific miRNA signature that is predictive of lymph node metastases in laryngeal carcinoma characterised by 11 miRNAs, seven of which are overexpressed (upregulated) and four downregulated. These results allow the identification of a group of potential specific tumour biomarkers for laryngeal carcinoma that can be used to improve its diagnosis, particularly in early stages, as well as its prognosis.

Otorhinolaryngology-related tuberculosis.

Data from personal case histories, from 1984 to 2000 inclusive, are reported in order to contribute to a better understanding of some of the clinical and epidemiological ENT associated TB aspects. Analysis of these data shows that: (1) Like the pulmonary form, ENT localizations are increasing due to the traditional risk factors (immigration, poverty, immunodeficiency, drug addiction). (2) They are generally clinically primitive forms (which are found in extrapulmonary regions as the first expression of tubercular disease) and typically affect young people with a slight prevalence among females. Lymph gland localizations are the most frequent.

Mucoepidermoid carcinoma of the base of tongue.

Mucoepidermoid carcinoma (MEC) is the most common malignant, locally-invasive tumour of the salivary glands, and accounts for approximately 35% of all malignancies of the major and minor salivary gland. Minor salivary glands are scattered in different areas of the oral cavity such as palate, retromolar area, floor of the mouth, buccal mucosa, lips and tongue. MECs of tongue base are not common. We present a rare case of MEC localised at the tongue base in a 42-year-old Caucasian woman and discuss the histopathological types, management and review the literature. Adequate intra-oral excision was the treatment of choice in this case and in low-grade MEC. Prognosis of MEC is a function of the histological grade, adequacy of excision and clinical staging.

Diffusion weighted MR imaging of primary and recurrent middle ear cholesteatoma: an assessment by readers with different expertise.

INTRODUCTION AND PURPOSE: Diffusion weighted imaging (DWI) has been proven to be valuable in the diagnosis of middle ear cholesteatoma. The aims of our study were to evaluate the advantage of multi-shot turbo spin echo (MSh TSE) DWI compared to single-shot echo-planar (SSh EPI) DWI for the diagnosis of cholesteatoma. MATERIAL AND METHODS: Thirty-two patients with clinical suspicion of unilateral cholesteatoma underwent preoperative MRI (1.5T) with SSh EPI and MSh TSE. Images were separately analyzed by 4 readers with different expertise to confirm the presence of cholesteatoma. Sensitivity, specificity, diagnostic accuracy, and positive (PPV) and negative predictive values (NPV) were assessed for each observer and interrater agreement was assessed using kappa statistics. Diagnosis was obtained at surgery. RESULTS: Overall MSh TSE showed higher diagnostic accuracy and lower negative predictive value (NPV) compared to conventional SSh EPI. Interreader agreement between the observers revealed the superiority of MSh TSE compared to SSh EPI. Interrater agreement among all the four observers was higher by using MSh TSE compared to SSh EPI. CONCLUSION: Our findings suggest that MSh TSE DWI has higher sensitivity for detection of cholesteatoma and lower probability of misdiagnosis. MSh TSE DWI is useful in guiding less experienced observers to the diagnosis.

Concha bullosa related headache disability.

OBJECTIVE: Rhinogenic headache (RH) is a headache or facial pain syndrome secondary to mucosal contact points in the sino-nasal cavities, in the absence of inflammatory signs, hyperplastic mucosa, purulent discharge, sino-nasal polyps or masses. It may result from pressure on the nasal mucosa due to anatomical variations among which the pneumatization of the middle turbinate, concha bullosa, a variant of the development of ethmoidal cells, is the most commonly observed. Clinical practice suggests a close correlation between concha bullosa, mucosal contacts and rhinogenic headache, with high impact on the QoL. However diagnostic and therapeutic difficulties still remain. Aim of the present study is to evaluate the impact of medical or surgical care on the QoL of patients suffering from concha bullosa related headache from the patients' perspective. PATIENTS AND METHODS: One-hundred-two subjects with concha bullosa and headache anamnesis were randomized into two groups and given medical or surgical treatment. To assess the Quality of life (QoL) we used visual analogue scale and for the first time, the migraine disability score before and after treatment. RESULTS: After treatment the severity of the headache decreased as well as the discomfort in the surgical group compared with medical group. CONCLUSIONS: The improvement of symptoms and QoL suggests that the endoscopic surgical plastic may promote the rapid resolution of concha bullosa related headache improving the and reducing health care costs.

[Vocal physiopathology]. / Fisiopatologia vocale.

Cordectomies usually result in alteration of the glottic sphincter which in turn effects the activity of the entire larynx bringing about different types of dysphonia according to the resulting scarring pattern in the glottic floor and to the functional recompensation made by the cordectomized patients themselves. Today, study of those anatomic dynamics which determine voice typology in cordectomized patients is possible thanks to various means: synthesis of data obtained from psycho-perspective analyses of the vocal product, video-fiber-laryngoscopic observation of the vocal tract and spectrographic study. The above-mentioned examinations show how the type of dysphonia in these patients is determined by the various combinations of different scarring patterns, which also depend on the entity of surgical exeresis, and the position taken on by various laryngeal district during phonation? The authors present paradigmatic clinical cases in order to demonstrate the different phonatory capabilities achieved by patients who had undergone either cordectomy or cordectomy extended to the ventricle and false vocal cords.

[The clinical presuppositions and results of logopedic therapy]. / I presupposti clinici ed i risultati della terapia logopedica.

Logopedic therapy is proposed in helping cordectomized patients learn to best use pneumo-phonal structures to compensate for the glottic insufficiency often resulting from this type of surgery. Rehabilitation showed be initiated as soon as possible following surgery before the patients starts using compensation mechanisms negative for voice quality. However, precisely those patients often receive therapy tardively when the anatomo-functional results have already been consolidated and the voice quality is poor. The rehabilitation discussed uses classical feed back mechanisms through which the subjects learn to recognise those factors which enable them to better their voice quality. The type of exercises to be employed depends on whether or cordectomy extended to the ventricle and to false vocal cord. On the farmer case, the principle aim of therapy is that of nearing the healthy vocal cord to the neocord through appropriate exercises. On the better case, instead, the main vocal compensation is the result of the perfect coordination of expiratory energy and the activity of the healthy vocal cord. In fact, in extended cordectomized patients, in the light of the modest amount of scarring, it is necessary to cause the healty voice cord to shift entirely towards and beyond the median line as to as compensate for a sphincteric loss. The authors report two clinical case, particularly difficult from a rehabilitation point of view, in which, relatively speaking, in light of the initial voice conditions, satisfactory results were obtained.

[Anatomo-functional study of 37 patients with monolateral chord paralysis]. / Studio anatomo-funzionale su 37 pazienti affetti da paralisi cordale monolaterale.

The authors present a study of 37 patients affected by monolateral vocal cord paralysis in order to analyze etiology, degree of dysphonia and possible recovery of vocal function. The patients underwent the following tests: case history to determine the vocal characteristics prior to the lesion; video-laryngoscopy to define the position of the paralytic cord on the horizontal glottic plane and any compensation mechanisms; determination of the degree of dysphonia (light, moderate, severe, aphonia) on the basis of psycho-perceptive parameters; spectrography evaluated in classes (I, II, III and IV) according to Yanagihara. Analysis of the data obtained makes it possible to draw the following conclusions: the most frequent etiology encountered by the otorhinolaryngologist is surgical (particularly subsequent to thyroidectomy); the position taken by the paralytic vocal cord does not appear to determine the degree of dysphonia; during the period immediately after occurrence of the lesion (0-4 months) the vocal disorder is more intense and tends to be reduced thereafter, attenuated by a spontaneous compensation mechanism. In this regard, it must be pointed out, however, that such compensation can prove bad or even dangerous for good vocal function (falsetto voice); speech therapy makes it possible to nearly totally normalize vocal function in all patients presenting moderate dysphonia and in 60% of those with severe dysphonia. In the remaining 40% of those patients with severe dysphonia a partial improvement of vocal function was seen (from severe dysphonia to moderate dysphonia). This was determined by the fact that several negative prognostic factors came into play simultaneously in these patients (i.e. advanced age, longer time gap since the lesion occurred, position assumed by the paralytic cord) which prevented them from achieving better phonatory results.

[CO2 laser cordectomy: analysis of morpho-functional results]. / Analisi morfo-funzionale degli esiti chirurgici nei diversi tipi di cordectomia con laser a CO2.

The authors have conducted a study of a large sampling of subjects who had undergone different types of cordectomy. The purpose of this study has been to analyze the anatomo-functional variables encountered with such procedures. In particular, the following were studied: post-surgical vocal recovery; type of glottic sphincter scarring, particularly as related to the extent of surgical excision; effect commissure synecchia has on the post-operative voice, again related to type of exeresis; different types of functional compensation related to the various surgical excisions and means by which the new scarring cord is built; severity of dysphonia resulting after each type of surgery. The study involved 69 patients who had undergone different types of cordectomy: from limited procedures--the so-called submucosal cordectomies for circumscribed, superficial neoplasms--to more radical ones, performed on tumours extending to the laryngeal ventricle of one or both sides. A history was taken of all the cases and they underwent videolaryngoscopy, psychoacoustic evaluation and voice spectrography. This study revealed the following: vocal recovery is achieved within 1-3 months after surgery, particularly when the exeresis was limited; longer recovery times were required for more radical surgery; with horizontal exeresis the prognosis for sphincteric recovery--characterized by a good neocord--is better than with procedures removing structures on the vertical plane (true vocal cord + ventricle + false cord) where scarring generally proves inadequate to re-establish a satisfactory sphincter; commissure synecchia is unusual in all types of surgery and is more frequent in bilateral forms. This is not specifically responsible for aggravating the dysphonia although, except in a few cases, it can make an important contribution in limiting the glottic opening and facilitating vocal sounds; as regards functional compensation, the observations show that the larynx is able to adapt to anatomic damage, the entire organ playing a part in reducing the air space to create a more or less valid phonatory sphincter, each part in its own way. Among the most noteworthy mechanisms for functional compensation we find the cord-neocord, the glottic mechanism at the false cords and ary-arythenoid compensation. There is no direct relationship between phonatory mode and neocord conformation since not all cases achieving a satisfactory neocord actually use glottic phonation. Although the Yanagihara spectrographic classification of dysphonia cannot distinguish between severe dysphonia and aphonia, it can be applied in the objective classification of limited post-cordectomy vocal compromise. In fact, spectrography is able to document that: Type II dysphonia--light--is unusual and was only found in 2 cases with a excellent neocord and a perfect pneumo-phonic picture; Type II dysphonia--moderate--is most often found in submucosal cordectomies and in other cases of monolateral exeresis with adequate scarring; Type IV dysphonia actually corresponds to the most important forms. It is present in all types of cordectomy and is most prevalent in those with a severe adductor deficit associated with inadequate or poorly balanced supraglottic functional compensation.