A review of recent literature on functional MRI and personal experience in two cases of definite vestibular migraine.

The pathophysiology of vestibular migraine (VM) is at present poorly understood. Functional magnetic resonance imaging (fMRI), a technique that measures brain activity by detecting changes associated with blood flow oxygenation, has been used to study neural pathways involved in VM pathophysiology. In this study, we summarize results of previous fMRI studies in VM patients, both during and between vertigo attacks. Moreover, we report our experience in two patients with definite VM, who underwent fMRI during a visual stimulation in a vertigo-free period. Compared with 15 matched healthy controls, fMRI demonstrated activation of brain areas related to integration of visual and vestibular cues (increased activation of the paracentral lobule and bilateral inferior parietal lobule and decreased activation of the left superior frontal gyrus, head of the caudate nucleus, left superior temporal gyrus, left parahippocampal gyrus, and right lingual gyrus). Our results partially confirm those of other authors, reporting increased activation of multimodal association brain areas (BA 40, BA 31/5) and decreased activation of occipital regions In addition, we also found a decreased activation of fronto-temporal areas, such as the parahippocampal region, functionally involved in space memory and navigation.

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.

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.

[Acebutolol in the treatment of stress-reactive hypertension. A medium term open study]. / L acebutololo nel trattamento dell'ipertensione arteriosa reattiva da sforzo. Studio aperto a medio termine.

In eleven subjects with normal blood-pressure, but with reactive blood-hypertension revealed by bicycle ergometer testing, oral acebutolol in single daily dose of 400 mg was administered. The controls performed after thirty days of treatment have pointed out a significant improvement of the anomaly and a good compliance of the subjects at the therapy.

[Hypotension caused by effort]. / L'ipotensione da sforzo.

Authors report cases of blood hypotension during ergometer testing (inadequate or non-increase, reduction of blood-pressure values during effort, symptomatic hypotension after effort), observed to the re-examination of 3238 bicycle ergometer testing. His usefulness in diagnosis, prognosis and therapy is described.

[Value of the Di Maria leads in the electrocardiographic diagnosis of posterior myocardial infarct]. / Validità delle derivazioni di Di Maria nella diagnosi elettrocardiografica di infarto del miocardio posteriore.

Authors retain, on the basis of their experiences, that right chest leads proposed by Di Maria for the infer-posterior and postero-basic myocardium wall study can overall be useful in those cases which had posterior myocardial infarction and where standard leads did not show variations or showed untrustworthy variations. Therefore Authors also supported by vectorcardiographic findings, recommend the routine use of Di Maria leads.

[Treatment in the event of antibiotic prophylaxis failure in gynecologic surgery. A retrospective study of 20 cases]. / Sul trattamento in caso di fallimento dell'antibiotico-profilassi in chirurgia ginecologica. Esame retrospettivo di 20 casi.

A retrospective study was performed of the type of treatment used in 20 patients undergoing gynecological surgery in whom antibiotic prophylaxis with Mezlocillin (2 g i.v.) had failed. Patients were subdivided into three groups: A) Initial therapy with Mezlocillin (8 patients, 2 g/die i.m.) or Cefotetan (2 patients, 2 g/die i.m.) and subsequent addition of Gentamicin (8 patients, 240 mg/die i.m.) or Tobramycin (2 patients, 200 mg/die i.m.) and subsequently Metronidazole (7 patients, 1.5 g/die per os). B) Therapy with Imipenem/Cilastatin (6 patients, 1.5 g/die i.m.). C) Therapy with Imipenem/Cilastatin (4 patients, 1.5 g/die i.m.) after a variety of antibiotics: Cotrimoxazole (Trimethoprim 160 mg/die and sulphamethoxazole 800 mg/die per os), Pefloxacin (800 mg/die per os), Cefotetan (2 g/die i.m.) and Mezlocillin (2 g/die i.m.). Time taken to lower temperature was shorter in Group B (3.5 days) compared to Group A (6.8 days) and Group C (10 days). Postoperative hospital stay was also shorter in Group B (9 days) compared to Group C (16.5 days) and Group A (11.1 days). The immediate administration of an antibiotic active against Gram+ and Gram- germs, aerobes and anaerobes is therefore useful in the event of failure of antibiotic prophylaxis, rather than the use in succession of associations of antibiotics with a limited spectrum.

[Doppler ultrasonography in chronic obliterative arteriopathy of the legs]. / Ultrasonografia Doppler nelle arteriopatie obliteranti croniche degli arti inferiori.

The authors illustrate the usefulness of Doppler ultrasound in chronic arterial occlusive diseases of low limbs, and confer such method a particular importance for diagnosis, prognosis and appraisal of the therapeutical results.

Versatility of the supraclavicular pedicle flap in head and neck reconstruction.

Head and neck surgery has witnessed an increase in microvascular reconstructive procedures with free flaps over the last 20 years as they offer efficient functional recovery. Nevertheless, under certain circumstances they may be contraindicated or cannot be used. We present the use of supraclavicular pedicled flap in three patients with different recipient sites. All patients had acceptable functional and aesthetic outcomes. Donor-site morbidity was satisfactory. Supraclavicular pedicled flap is not only an alternative to free flap reconstruction, but also a first-choice option in head and neck reconstructive surgery.

Role of Montgomery salivary stent placement during pharyngolaryngectomy, to prevent pharyngocutaneous fistula in high-risk patients.

OBJECTIVE: To evaluate the incidence of pharyngocutaneous fistula after pharyngolaryngectomy with and without a Montgomery salivary stent. DESIGN: Retrospective analysis of patients with factors that predispose to the development of pharyngocutaneous fistula (i.e. disease extending to the supraglottic region, base of the tongue or pyriform sinuses, and/or radiochemotherapy). SUBJECTS: Between 2002 and 2008, 85 pharyngolaryngectomies were performed in our clinic. Of these patients, 31 were at increased risk of fistula development, of whom 45 per cent developed fistulas post-operatively. This subgroup of 31 patients was compared with a second subgroup of 22 patients at high risk of fistula development, treated between 2009 and 2011 with pharyngolaryngectomy and with a Montgomery salivary stent placed in advance during closure of the neopharynx. RESULTS: Statistical analysis showed a significant reduction in the rate of fistula development, from 45 to 9 per cent (p < 0.01), with application of the salivary stent. CONCLUSION: These data confirm the preventive effect of a salivary stent placed during pharyngolaryngectomy, for patients at high risk of fistula development.

Radial forearm free flap surgery: a modified skin-closure technique improving donor-site aesthetic appearance.

Radial forearm free flap surgery is a versatile technique that is widely adopted for microvascular reconstruction of the oral, oropharyngeal and hypopharyngeal lining. Nowadays, the technique for harvesting is standardized, while reconstruction of the forearm donor site defect is somewhat controversial. The authors describe a modified closure technique developed to reduce skin tension that provides subsequent improvement of the cosmetic appearance of the forearm donor site. A series of 43 patients undergoing radial forearm free flap (RFFF) reconstruction is presented, carried out by our ENT department between September 2007 and December 2010. The authors used a modification of the standard triangular full-thickness skin graft (FTSG) technique to close the forearm donor site on 23 patients with a new shape similar to a dagger. Using the Stony Brook Evaluation Scale, the authors analyzed the outcomes of 23 cases employing the dagger-shaped FTSG and compared these with a standard (triangular shaped) reconstructive graft used in 20 earlier patients. The new dagger-shaped graft decreases skin tension and reduces the need of multiple slits in the graft with improved aesthetic outcome; it is an effective method for repair of the forearm donor site with low tension and without the need to harvest the skin graft from the thigh. The technique is simple, reliable and requires no more time than a standard procedure.