Ear nose and throat (ENT) aspects of Obstructive Sleep Apnea Syndrome (OSAS) diagnosis and therapy. / Sindrome delle Apnee Ostruttive nel Sonno (OSAS): aspetti diagnostici e terapeutici otorinolaringoiatrici.

This article analyzes the role played by the ear, nose and throat (ENT) specialist in the diagnosis and treatment of the Obstructive Sleep Apnea Syndrome (OSAS). DIAGNOSIS: The instrumental methods of investigation of otolaryngology expertise are fiberoptic rhinolaryngoscopy and sleep endoscopy. To better define and treat OSAS it is essential to define location, extension and degree of obstruction. The major limitation of rhinolaryngoscopy is that it is conducted while the patient is awake. Sleep endoscopy was introduced to address this issue: it is an endoscopic examination conducted during pharmacologically induced sleep (midazolam, propofol). Surgical treatment: The applicability of surgical treatment is limited: it is not efficient for every patient and not to the same extent. Surgical therapy is based on the detection and correction of the site of obstruction, although in most cases the obstruction sites are located at different levels. The surgical approach usually follows a path characterized by "subsequent steps". According to Stanford University Powell-Riley Protocol the first phase includes: nasal surgery, palate surgery (UPPP, LAUP Laser Assisted uvulopalatoplasty, UvuloPalatalFlap UPF) and tongue base surgery (tongue suspension, genioglossus advancement, hyoid suspension) that could either be executed individually or associated. Four-six months after surgery a physical and polysomnography examination should be performed. In case of symptoms persistence, the surgeon could move on to phase II surgery as recovery therapy. The phase II surgery includes: maxillo-mandibular advancement, tongue base resection and tracheotomy. In selected cases a Phase II surgery could be planned at the beginning of treatment.

Singing voice: acoustic parameters after vocal warm-up and cool-down.

Purpose: The aim of this study was to evaluate the effect of the vocal warm-up and cool-down on the singing voice through Fundamental Frequency (F0), Jitter, Shimmer and harmonics-to-noise ratio (HNR).Methods: Thirty-two female singing students were recorded four times while uttering the vowel [a] for at least 5''. The first two recordings were collected before and after a vocal warm-up session and the last two before and after a vocal cool-down session. Between those sessions the participants underwent an intense vocal activity.Results: Results showed significant variations in the average values of the parameters measured. The mean value of the F0 after intense vocal activity turned to be higher than the one measured before the warm-up session, as well as the mean F0 measured after singing compared to the one measured after the vocal warm-up. On the other end, the mean F0 after the vocal cool-down resulted to be lower than that measured before. After the vocal warm-up session Jitter and Shimmer decreased while HNR increased. In addition, a decrease was detected in comparison with the average value of Jitter and Shimmer before vocal warm-up and after vocal cool-down, whereas HNR increased. There was also a decrease between the Shimmer before the vocal warm-up and after an intense phonatory activity while HNR increased.Conclusions: Our study highlights the effect of the vocal warm-up on acoustic parameters. The reduction in F0 observed after the cool-down session confirms its positive effect in helping professional vocal recovery and reducing vocal fold tension.

Nasal septum angiofibroma: a rare condition with an unusual onset.

The characteristics of extra-nasopharyngeal angiofibromas tend to be different from angiofibromas of the nasopharynx according to patient gender, patient age, prevalence, affected site, pathogenesis, and clinical and epidemiological features. We report a case of an extra-nasopharyngeal angiofibroma in a 28-year-old man referred to the ENT Clinic for right-sided epistaxis, airflow impairment and nasal swelling. The right nostril was completely occluded works by a reddish-yellow mass that bled easily. The computed tomography scan revealed an "inhomogeneous solid lesion in the nasal fossa". With the patient under general anesthesia, the formation in the anterior portion of the right side of the nasal septum was removed up to its vascular base. Although electrical cauterization efficiently controlled the bleeding, we abraded the sub-perichondral area to prevent further bleeding as well as recurrence. The histological exam report confirmed the diagnosis of angiofibroma. As in our case, epistaxis is commonly the presenting sign of angiofibroma. Yet its onset was peculiar, given that the bleeding started with a low impact trauma. The nasal swelling was also a relevant feature as well as the breathing impairment. Although uncommon, nasal septal angiofibromas should considered in patients with epistaxis.

Influence of allergic rhinitis in children and adolescents with recurrent headache.

INTRODUCTION: Migraine and allergies are a common occurrence. The aim of this study was to investigate the relationship between respiratory allergy and migraine in childhood. MATERIALS AND METHODS: We screened 800 children for headache and its characteristics. After that we investigated the presence of allergy performing prick tests, rhinoscopy, endoscopy, rhinomanometry, cytology and mucociliary clearance tests. RESULTS: Out of 800 children screened, 96 suffered from headache. Among these, 67 suffered from both headache and allergy. We found a significant correlation between allergy and headache onset in the morning and headache onset in the evening in non-allergic subjects. The average duration of a headache attack was independent from the presence of allergy, as well as the frequency of the cephalalgy attacks, and location of the pain. Prodromal symptoms connected with headache were reported to be: dizziness, aura, sparkling scotoma, nausea and vomiting, and they were associated with absence of allergy. We also found a relationship between female gender and headache onset, but in teenagers only. Paracetamol or FANS were used in the majority of cases, but antihistamine therapy and/or topical nasal sprays were also reported. DISCUSSION: For an effective diagnostic and therapeutic approach to migraine, the pediatrician should take into account atopy and its related allergic manifestations requiring a consultation with an otorhinolaryngologist or allergist if necessary. Our findings also stress the potential role of medicines that are not usually administered in migraine attacks, such as antihistamines or topical decongestant nasal sprays.

Kinesio Taping in Dysphonic Patients.

OBJECTIVE: Kinesio taping (KT) is a method of elastic bandaging that produces a biomechanical effect on the organism. This study aims to evaluate its use in dysphonic patients tratment, as integrated part of speech therapy. STUDY DESIGN: Randomized controlled MATERIALS AND METHODS: Fifteen dysphonic patients were given the option to complement the speech therapy treatment with KT (DG1). 15 dysphonic patients suffering from similar conditions (DG2) who underwent traditional speech therapy were the control group. RESULTS: After treatment, both DG1 and DG2 obtained a statistically significant improvement for jitter and noise-to-harmonic ratio (P >0.05) and showed an improvement in Voice Handicap Index (VHI) total (VHIt), VHI functional (VHIf), VHI emotional (VHIe), and VHI physical (VHIp). However, the improvement was statistically significant for VHIt (P =0.0102), VHIe (P =0.0349), and VHIp (P =0.0366) in DG1, and only in VHIt (P =0.0466) in DG2. In DG1, P had a lower value than in DG2 for VHIt, VHIe, and VHIp. In DG2, there were a few patients who after therapy had a VHIt higher than before therapy, whereas this did not occur in DG1. CONCLUSIONS: As expected, this study confirms the benefits of speech therapy. Although KT is not a substitute for speech therapy, our preliminary results and patients' favorable response to KT encouraged us to continue with our studies on a larger scale. Further studies are required to better define the role of KT in speech therapy and evaluate its real effect over its placebo effect.

Objective Evaluation of Presbyphonia: Spectroacoustic Study on 142 Patients with Praat.

OBJECTIVES: Presbyphonia is the sequence of physiological events related to the process of senility of the vocal folds. The aim of our analysis was to provide deeper knowledge of presbyphonia, raising awareness of this condition as well as giving basic suggestions on how to treat related vocal alterations. STUDY DESIGN: This is a randomized study. METHODS: In 2015, we conducted a study on 182 subjects. Each participant underwent an ENT examination (video-laryngo-stroboscopy and subjective acoustic analysis using the General degree of dysphonia; degree of voice Instability; degree of voice Roughness; degree of voice Breathiness; degree of voice Asthenia; degree of voice Strain (GIRBAS) scale) and a logopedic examination (anamnesis, medical history, and acoustic voice analysis using the free software Praat). RESULTS: The comparison between the voice of young people and the seniors showed significant differences for the following Praat-analyzed acoustic parameters: modal fundamental frequency (F0) in women (P < 0,0001), fraction of locally unvoiced frames (P < 0,0001), number of voice breaks (P < 0,0001), jitter local (P < 0,0001), jitter local abs (P < 0,0001), jitter rap (P < 0,0001), jitter ppq5 (P < 0,0001), shimmer local (P < 0,0001), shimmer local dB (P < 0,0001), shimmer apq3 (P < 0,0001), shimmer apq5 (P < 0,0001), mean N/H (P < 0,0001), and mean H/N (P < 0,001), for both sexes. CONCLUSIONS: The Praat was confirmed to be a useful tool to detect the existence of the variation of the speech parameters in relation to aging and to quantify statistically significant differences that show a general deterioration in the voice quality, defined numerically. This might lead to a phoniatric treatment or speech therapy, which could improve patients' quality of life, leading to better vocal performance and social and communicative interaction.

Hearing loss in mild OSAS and simple snoring patients.

Introduction Obstructive Sleep Apnea Syndrome (OSAS) is characterized by recurrent episodes of prolonged partial or complete obstruction of the upper airways. Several study groups studied the effect of snoring and OSAS on auditory function, showing an increase in the incidence of hearing loss in apneic patients, an earlier onset and/or a degree of hearing loss deeper than in peers. The aim of our study is to evaluate the audiological performance of a population of simple-snoring patients and patients suffering from mild OSAS, and the impact that such pathological condition can have on the auditory function, considering the significant levels of chronic noise. Materials and Methods Data was collected by analyzing audiometric exams on snoring patients and a control group of non-snoring patients. Our study included simple snoring patients without OSAS (AHI < 5) or with low level of OSAS (5< AHI < 15). Possible hearing loss was classified in a crescent scale (A-B-C-D-E), from greater to minor auditory performance, according to the indications of the national protocol of occupational medicine for evaluation of hearing loss in patients exposed to chronic noise. Results We have found independence between simple snorers, mild-OSAS snorers and non-snoring patients compared to the scale of hearing performance classification. Conclusions Our results show a distribution of hearing loss in the different groups that appear independent of the presence or absence of snoring, complicated or uncomplicated by mild OSAS.

Surgical treatment of nasal septal perforations: SIR (Italian Society of Rhinology) experts opinion.

BACKGROUND AND AIM: The aim of our study has been to investigate the perception of aspects related to nasal perforation among experts in Rhinology and ENT surgeons. Our aim was reporting the situations in different Countries to improve the knowledge of colleagues interested in this topic. METHODS: A panel of experts prepared a 20-question questionnaire regarding nasal perforations and their surgical repair, that were emailed to all the members of SIR (Società Italiana di Rnologia - Italian Society of Rhinology). RESULTS: Data obtained from their answers showed that Cottle technique (64%) is the most common technique to perform septoplasty worldwide. 37% of the sample reported an occurrence of nasal septal perforation in less than 1% of patients and 75% attributed this occurrence to the skill of the surgeon, to infections, to drug use and to septal deformity. Trauma, pressure and Wegener's granulomatosis were also mentioned. The most common closure technique is the mucosal flap (75%), followed by the cartilage grafts (11%). Much less common were oral flaps, septal buttons and others. The majority agreed not to suggest septal perforation surgery in minimal (less than 3-4mm) perforations (73.5%), or limiting it to symptomatic patients (43.5%). The contraindications to repair surgery were reported to be: Wegener's granulomatosis, drug abuse, non-symptomatic perforation, its dimension and age of the patient. Septal deviation, atrophic rhinitis, smoke epistaxis and systemic diseases were also claimed. Failure in repair surgery has been observed to occur in less than 30% of cases. DISCUSSION AND CONCLUSIONS: Given the great difficulty to make random studies about controversial topics and obtain statistically significant data related to that, expert opinion shall be of great value (expert opinion, level of evidence 5).

Mometasone furoate nasal spray: a systematic review.

UNLABELLED: The inflammatory diseases of the nose, rhino-pharynx and paranasal sinuses (allergic and non allergic rhinitis, NARES; rhinosinusitis with/without nasal polyposis, adenoidal hypertrophy with/without middle ear involvement) clinically manifest themselves with symptoms and complications severely affecting quality of life and health care expenditure. Intranasal administration of corticosteroids, being fast, simple, and not requiring cooperation, is the preferred way to treat the patients, to optimize their quality of life, at the same time minimizing the risk of exacerbations and complications. Among the different topical steroids available on the market, we performed a comparative analysis in terms of effectiveness and safety between mometasone furoate (MF) and its main competitors. Searching through Pub Med and Google Scholar and using as entries "mometasone furoate", "rhinitis", "sinusitis", "asthma", "polyposis", "otitis media with effusion", and "adenoid hypertrophy" we found 344 articles, 300 of which met the eligibility criteria. Taking into account relevance and date of publication, a sample of 40 articles was considered for the review. MF effectiveness for treatment and/or prophylaxis of nasal symptoms in seasonal and perennial allergic rhinitis has been fully established with a level of evidence Ia. Even though it has not been assessed for MF in particular, topical steroids are the most appropriate treatment in mixed rhinitis and NARES. In acute rhinosinusitis (ARS) evidences support their use as mono-therapy or as adjuvant to antibiotics for reducing the recurrence rate, and decrease the usage of related prescriptions and medical consultations. In chronic rhinosinusitis (CRS) with Nasal polyposis, MF reduces polyps size, nasal congestion, improves quality of life and sense of smell and it is also effective in the treatment of daytime cough. The topical use of MF has great efficacy in the management of adenoidal hypertrophy and otitis media of atopic children. As regards the safety, MF has demonstrated an excellent safety profile: pregnant women can safely use it; no systemic effects on growth velocity and adrenal suppression have been shown; no changes in epithelial thickness or atrophy have been observed after long term administration of the drug. CONCLUSIONS: MF has been demonstrated to be effective in the treatment of the inflammatory diseases of the nose and paranasal sinuses; when compared to its competitors it shows a greater symptom control; it is a reliable treatment in the long term thanks not only to its proven efficacy, but also to its safety being on the market since more than 17 years.

Neck epidermoid cyst mimicking tuberculosis at ultrasound: Case report and review of literature.

Neck masses in children can be inflammatory, congenital or neoplastic. When a congenital cyst becomes infected repeatedly, it may mimic inflammatory disease and the diagnosis may be challenging with ultrasound. An increasing incidence of infection with non-tuberculous mycobacterial organisms has been observed in recent decades in children with cervical lymphadenopathy. An ultrasound scan performed during the infectious phase of a mass can be misleading and can lead to an incorrect diagnostic hypothesis with the risk of erroneous medical and surgical therapies. We describe a case of a lateral neck epidermoid cyst mimicking and misdiagnosed as a tuberculous lymphadenopathy at ultrasound scan and treated with primary surgical excision. After surgery, a histological diagnosis of an epidermal cyst was made. There were no signs of recurrence during the 12-month follow-up period. A review of the literature and a proposed practice pathway for lateral cervical lymphadenopathy in children is also reported.