A two-year course of specific immunotherapy or of continuous antihistamine treatment reverse eosinophilic inflammation in severe persistent allergic rhinitis.

Aim of the study was to evaluate the effect of a 2-year course of subcutaneous specific immunotherapy or continuous oral antihistamine treatment on the eosinophilic inflammation in nasal secretions of patients with severe persistent allergic rhinitis caused by house dust-mites. After informed consent, 31 rhinitis patients, sensitive to dust-mite antigens, were enrolled: 12 were randomly assigned to specific immunotherapy (group A), 11 to continuous oral antihistamine (cetirizine) treatment (group B), and 8 to an oral antihistamine (cetirizine) on demand (group C). Nasal scrapings were performed with a cotton-tipped swab and cells counted before and after 24 months of therapy. Intercellular adhesion molecule-1 and eosinophil cationic protein expression in cytological smears were assessed by immuno-histochemistry. All patients completed the study. The percentage of inflammatory cell types was comparable in the 3 groups at the beginning of the study. Eosinophils, identified as cells expressing eosinophil cationic protein, significantly decreased dropping to zero after 2 years of treatment in groups A and B, while no change was observed in group C. Expression of intercellular adhesion molecule-1 also decreased significantly in groups A and B, but not in group C. This decrease was associated with a significant reduction in epithelial shedding. In the 2-year period studied, specific subcutaneous immunotherapy and continuous oral antihistamine treatment were found to be effective in reducing eosinophilic infiltration and adhesion molecule expression in the nasal mucosa of patients with persistent allergic rhinitis. Furthermore, immunotherapy was more effective in controlling epithelial disruption while antihistamines appeared to be more active in controlling nasal inflammation. Both treatments induced a significant decrease in intercellular adhesion molecule-1 expression in epithelial cells and also a dramatic reduction of eosinophil cationic protein positive staining. These parameters can be considered useful means for controlling the state of persistent inflammation which is typical of persistent respiratory allergy. Nasal scraping was demonstrated to be a simple and safe procedure for monitoring some nasal inflammation parameters.

State and trait anxiety in women affected by allergic and vasomotor rhinitis.

It is still debatable whether anxiety and depression in patients affected by rhinitis could play a role in the genesis of the disease, whether they are a consequence of the symptoms. The aim of this study was to evaluate anxiety levels in both state and trait forms, and depression, in patients affected by allergic (AR) and vasomotor rhinitis (VMR). A total of 45 women, 24 AR and 21 VMR were compared with 64 healthy nonallergic women matched for age and sociodemographic characteristics. All subjects were administered the State and Trait Anxiety Inventory (STAI) and the Zung self-rating depression scale. The percentage of subjects with high levels of state anxiety was significantly higher in AR (p<0.005) and VMR (p<0.01) with respect to controls. The percentage of subjects with high levels of trait anxiety was significantly higher in AR (p<0.001) and VMR (p<0.05) than controls. There was no significant difference in depression between AR and VMR and controls. No significant difference was found in state anxiety, trait anxiety, or depression between AR and VMR. In conclusion, anxiety in patients with rhinitis is present both as a state and as a trait, at least when measured with the STAI.

Aerodynamic findings in esophageal voice.

OBJECTIVE: To define the perceptive and aerodynamic characteristics of esophageal voice in relation to different rehabilitation modalities. DESIGN: Cross-sectional study comparing perceptive and aerodynamic variables in 3 subject groups. SETTING: Referral center. SUBJECTS: A total of 19 subjects who underwent total laryngectomy were divided into groups A and B. Group A consisted of 13 subjects (who required speech therapy)-8 good speakers (subset A(1) who were >80% intelligible) and 5 mediocre speakers (subset A(2) who were <70% intelligible). Group B consisted of 6 subjects with a tracheoesophageal prosthesis (who were >90% intelligible). MAIN OUTCOME MEASURES: Perceptive variables included phonatory pauses and stomal noise. Aerodynamic variables included maximum phonation time, phonatory flow, phonatory volume, postphonatory volume, intensity, and articulatory pressure. RESULTS: Phonatory pauses and stomal noise statistically differentiated group A from group B and good speakers from mediocre speakers. Phonation time, phonatory volume, and phonatory flow were statistically higher in group B subjects compared with group A subjects. Postphonatory volume was significantly higher in group A. Intraoral pressure and postphonatory volume were statistically higher in subset A(2) subjects compared with subset A(1) subjects while maximum phonation time was significantly higher in subset A(1) subjects compared with subset A(2) subjects. CONCLUSIONS: In subset A(1) subjects a positive ratio between phonatory volume and phonatory flow was maintained with an adequate phonation time. In subset A(2) subjects a reduced phonatory volume was associated with a more rapid dispersion of phonatory flow, lower duration of phonation, and frequent pauses; stomal noise and consonant hyperarticulation worsened the voice performance in this group. In group B subjects the positive ratio between phonatory volume and phonatory flow represented the prerequisite of speech without frequent pauses.

[Antileukotrienes in the prevention of postoperative recurrence of nasal polyposis in ASA syndrome]. / Gli antileucotrieni nella prevenzione delle recidive post-chirurgiche della poliposi nasale in ASA-syndrome.

There is a high incidence of post-surgical recurrences of nasal polyps (NP) in patients suffering from the ASA Syndrome. The numerous theories as to the pathogenesis of the ASA Syndrome include an increase in lipoxygenase-mediated arachidonic acid metabolism, with the subsequent hyperproduction of leukotrienes (LT), and an inhibition of the cycloxygenase. Therefore, based on the information acquired on the immunobiological action mechanism of montelukast, a cysteinyl-LT receptor antagonist, it appeared worth testing the effectiveness of this substance in preventing post-surgical NP recurrences in a group of ASA Syndrome patients. After taking a case history, filling out a questionnaire scoring nasal symptoms, undergoing rhinoendoscopy and rhinomanometry, 40 patients suffering from ASA-Syndrome and NP (age range 30-72 years) were recruited for the study. They were uniformly classified according to Lund and Mackay using high resolution CT of the nose and paranasal sinuses performed after at least 1 month of nasal medical treatment. All the patients underwent microendoscopic anterior-posterior ethmoidectomy and bilateral maxillary antrostomy. After removing the nasal packing, the only treatment administered was 10 mg of montelukast/die for 6 months, with the drug suspended for 1 months after the first 3 months of treatment. The monthly follow-up included rhinoendoscopy, rhinomanometry and the questionnaire to score symptoms. After the seventh month a new CT was performed and compared with the pre-operative CT. In a control group of subjects, homogeneous with the test group, momethasone furoate nasal spray was administered at a dose of 100 mcg per nostril/die and loratadin tablets 10 mg/die. The results obtained in the patients treated with montelukast were analogous with those obtained in the second group, and during follow-up all patients showed total absence of any local recurrence, good nasal patency and no significant nasal symptom score on the questionnaire. In no case did the comparative CT, performed after the seventh month, show any signs of recurrence. The patients taking the montelukast reported a significant reduction in the use of steroids and bronchodilator inhalants during the course of the study than did the second group; indeed the number of asthmatic episodes dropped and they reported an improvement in the quality of life. Based on these results, the authors suggest that the use of montelukast in the treatment of post-surgical NP recurrences in ASA Syndrome is possible and advisable, even in synergetic association with the treatment administered to the second group. The positive results also support the hypothesis of altered arachidonic acid metabolism and call attention to the role of cysteinyl-LT in the pathogenesis of the ASA Syndrome.

Pauci-symptomatic large epidermoid cyst of cerebellopontine angle: case report.

It is estimated that 10% of intra-cranial tumours are localized in the cerebellopontine angle and internal auditory canal and early symptoms of the different histological forms are almost identical. Acoustic neuroma account for 90% and meningioma for 5-10% of these tumours, while a small percentage of rare tumours exist, the most frequent being epidermoid cyst, also known as congenital cholesteatoma or keratoma. The case is reported here of a large epidermoid cyst of the right cerebellopontine angle, and the clinical-radiological course is reviewed. The patient, a 35-year-old, male, initially presented an episode of objective rotatory vertigo, and a history of right ear fullness, of a few months' duration, with normal otoscopy. Audiometric test was normal in left ear, while slight pantonal sensori-neural hypoacusia was observed in the right ear. The impedenzometric findings were normal as was the vestibular test. Auditory brainstem evoked response showed an increased latency of fifth wave. Gadolinium-enhanced magnetic resonance imaging of brain revealed the presence of a voluminous epidermoid cyst occupying the extra-axial side of the right cerebellopontine cistern with superior extension into the cistern. Due to the low-grade of symptoms, we had chosen to wait and not perform surgery immediately, with otologic and vestibular test-controls every 6 months, with cerebral magnetic resonance imaging to control extension of the mass, without radiation exposure for the patient. One year after diagnosis, at the last control, otofunctional findings were not modified and repeat magnetic resonance imaging did not demonstrate important variations compared to the first. Thus, the choice not to proceed with surgery was justified since surgery is burdened by the risk of important complications. At magnetic resonance imaging, the epidermoid cyst, unlike the majority of intra-cranial tumours, such as acoustic neuroma and meningioma, does not show gadolinium-enhancement; this again supporting the important role of magnetic resonance imaging in the differential diagnosis of intra-cranial neoformations. It is, therefore, worthwhile stressing the validity of the approach, step by step, in the diagnosis of patients with otologic symptoms, together with the importance of magnetic resonance imaging that, in comparison with computed tomography, allowed us to exactly assess the growth rate of the mass and to "wait and see" without risks and without radiations for the patient.

[Difficulties in the clinical, radiological and therapeutic evaluation of the initial stage of mucormycosis of the rhinosinus]. / Difficoltà nella valutazione clinica, radiologica e terapeutica della mucormicosi rino-orbitaria in fase iniziale.

The initial diagnosis and subsequent treatment of rhino-orbital mucormycoses is quite difficult, particularly because the patient may find it difficult to accept aggressive therapeutic protocols, even when free of any endocranial involvement. The authors draw inspiration from a clinical case of rhino-orbital mucormycosis in a patient suffering from decompensated type I diabetes mellitus to discuss the main clinical-diagnostic and therapeutic aspects of this disorder. Timely medical-surgical treatment proves extremely important for prognosis, preventing the intracranial extension of the lesion which is the cause of death in 80% of such cases. As regards the diagnostic protocol, careful clinical, radiological monitoring with CT and NMR--in strict interdisciplinary cooperation between otorhinolaryngologist, radiologist, ophthalmologist, microbiologist and histopathologist--is especially important. Radical surgery, at times demolition, associated with correction of the metabolic decompensation, systemic therapy with Amphotericin B and localbi-weekly medication for three months constitutes the best therapeutic protocol for treatment of this disorder.

[Primary tuberculosis of the middle ear: description of 2 cases and review of the literature]. / Tubercolosi primitiva dell'orecchio medio: descrizione di due casi e revisione della Letteratura.

Recently, a recrudescence of tuberculosis (TBC) as been found, even in Western world and in Italy, most likely in relation to the increase in immigration from developing countries and to the pathologies that cause immunodepression. The present paper reports two cases of primitive TBC of the middle ear, both coming under observation for facial paralysis. These cases highlight the clinical-therapeutic features of this disease, the difficulty in diagnosis and the need to include TBC in the differential diagnosis of phlogistic processes of the middle ear. The clinical-diagnostic features of presented cases focus attention on the consideration of TBC in the differential diagnosis of chronic otitis, particularly in presence of unusual symptoms, such as facial paralysis, and in case of otitis with rapid onset, unresponsive to conventional treatment. In one case, first examination of the ear showed normal tympanic membrane (absence of any tympanic perforation) and normal timpanometry; these facts steered diagnosis away from a middle ear phlogosis pathology. Both cases showed how radiological semeiology, CT and NMR are not enough to diagnose the nature of the disorder, particularly in case of cholesteatoma. Moreover, both patients were in good general conditions at the time of the examination, they didn't show history of previous immunodepression or other risk factors. The cases reported call attention to the aspecific characteristics of the onset of primitive tuberculous otitis media and difficulty in making a diagnosis. They underline the need for post-operative anti-tuberculous chemotherapy which provided a rapid and definitive resolution of infectious process.

Psychological profile of dysfunctional dysphonia.

A high degree of emotional maladjustment can be detected in dysfunctional dysphonia. In these patients, it is not rare to observe an immediate resolution of the phoniatric disorder, but it is equally as common to identify a significant rate of recurrence (> 10%) in the short and long term. This phenomenon may be due to poor adaptive ability in the presence of mood disorders. Aims of this study were: a. selection of a suitable instrument to identify "minor" and "major" symptoms of psychiatric nature in dysphonic subjects; b. evaluation of profile of mood disorders in dysfunctional dysphonic adults. Hopkins Symptom Check List 90 was chosen. This is a scale of self-evaluation, adapted in Italian, complete (9 dimensions) and easy to use. It is employed to evaluate the following dimensions: somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism, sleep disorders. Three groups were studied: group 1:40 patients (36 female, 4 male; aged 18-62 years, mean 42) with dysfunctional dysphonia; group 2: 20 patients (18 female, 2 male; aged 19-61 years, mean 43) with ENT disorders; group 3: 20 subjects (18 female, 2 male; aged 18-62 years, mean 42.2) as controls. In the statistical analysis, a one-way variance between the three groups and a post-hoc analysis using Schiffé test (level of significance 0.05) were carried out. Results showed significant differences between group 1 and groups 2 and 3 as far as concerns anxiety, phobia, obsessive-compulsive, interpersonal sensitivity and somatization variables. A significant difference was found only between groups 1 and 3 as far as concerns the variables: sleep disorders, depression and paranoid ideation. No significant difference emerged between the groups regarding psychoticism and anger/hostility dimensions. The present study identified a definite profile of minor personality disorders, of an anxious nature, with evidence of somatization, interpersonal sensitivity and obsessive-compulsive type traits, significantly prevailing in dysfunctional dysphonic subjects. Symptom Check List-90 has, therefore, proven to be an adequate instrument in the more complete definition of subjects affected by dysfunctional dysphonia aiming at referral to an integrated protocol which focuses on phoniatric treatment using an approach which acts upon the behavioural aspects of communication.

The hormetic role of dietary antioxidants in free radical-related diseases.

Regular consumption of cruciferous vegetables or spices is associated with a reduced incidence of cancer and reduction of markers for neurodegenerative damage. Furthermore, greater health benefit may be obtained from raw as opposed to cooked vegetables. Nutritional interventions, by increasing dietary intake of fruits and vegetables, can retard and even reverse age-related declines in brain function and cognitive performance. The mechanisms through which dietary supplementation with antioxidants may be useful to prevent free radical-related diseases is related to their ability to counteract toxic production of both reactive oxygen and nitrogen species, along with the up-regulation of vitagenes, such as members of the heat shock protein (Hsp) family heme oxygenase-1 and Hsp70. The most prominent dietary factor that affects the risk of many different chronic diseases is energy intake - excessive calorie intake increases the risk. Reducing energy intake by controlled caloric restriction or intermittent fasting increases lifespan and protects various tissues against diseases, in part, by hormetic mechanisms that increase cellular stress resistance. This biphasic dose-response relationship, referred to here as hormesis, display low-dose stimulation and a high-dose inhibition. Despite the current interest in hormesis by the toxicology community, quantitatively similar U-shaped dose responses have long been recognized by researchers to be involved with factors affecting memory, learning, and performance, as well as nutritional antioxidants and oxidative stress-mediated degenerative reactions. Dietary polyphenols present strong cytoprotective effects, however under uncontrolled nutritional supplementation gene induction effects and the interaction with detoxification responses can have negative consequences through the generation of more reactive and harmful intermediates.

[Virtual laryngoscopy of neoplastic pharyngeal and laryngeal pathology]. / La laringoscopia virtuale nelle neoplastie faringo-laringee.

PURPOSE: This study investigated the feasibility and clinical value of high-resolution virtual laryngoscopy (VL) based on helical CT data sets. MATERIAL AND METHODS: Fifteen patients with neoplastic laryngeal pathology underwent helical CT examination performed with controlled breath. The CT data were downloaded to a workstation equipped with software for three-dimensional rendering (Silicon Graphics O2, Vitrea Visualization 1.2.8). Two radiologists using Fly Through software generated both antegrade and retrograde endoluminal virtual endoscopy navigations of the larynx. The results of the radiological study were compared with conventional endoscopy findings. RESULTS AND CONCLUSIONS: Virtual laryngoscopy provided the correct diagnosis in 13 of 15 cases. VL is capable of simulating the visual findings of endoscopy in cases of laryngeal tumors and subglottic stenosis. Small and plane tumors of the vocal chords are not adequately visualized. This technique appears to be useful both as biopsy guide during conventional laryngoscopy and as a correct pre-surgery staging, particularly in stenotic tumors.