Follow-up clarifications concerning the authors' reply to the 'look at the elephant!' comment on 'prevalence of temporomandibular disorders in adult obstructive sleep apnoea patients: A cross-sectional controlled study'.

OSAS and TMDs represent multifactorial nosologic entities, whose central, functional and psycho-social aspects are gaining growing attention within the scientific community. In our previous commentary, we wanted to point out that structural aspects should not be forgotten in a clinical and research context. The inherent complexity of the matter could make it difficult to quantify the exact contribution of every single factor. The multifaceted nature of OSAS and TMDs pathophysiology could sustain several phenotypes in both conditions, and the anatomic parameters may assume different weights according to each phenotype, possibly justifying literature discrepancies. Thus, a patient with a co-existing OSAS and TMD (umbrella terms per se, each of them including different pathophysiological and clinical characteristics) represents an even greater challenge to researchers and practitioners. The scientific and therapeutic community should keep on looking for evidence to offer the best possible answers to such daring questions, in the most collaborative and fruitful way.

Human papillomavirus infection and non-oropharyngeal head and neck cancers: an umbrella review of meta-analysis.

OBJECTIVE: The causative and prognostic roles of human papillomavirus (HPV) in non-oropharyngeal squamous cell carcinoma of the head and neck are uncertain. This umbrella review assessed the strength and quality of evidence and graded the evidence derived from published meta-analyses on this subject. DATA SOURCES: MEDLINE, Embase, and the Cochrane Library were searched. Meta-analyses of observational studies and randomized trials were included. REVIEW METHODS: Evidence of association was graded according to the established criteria: strong, highly suggestive, suggestive, weak, or not significant. RESULTS: 15 meta-analyses were evaluated. The association with HPV was highly suggestive of oral (OR = 2.40, [1.87-3.07], P < 0.00001) and nasopharyngeal cancers (OR = 17.82 [11.20-28.35], P < 0.00001). Improved survival emerged only in hypopharyngeal carcinoma and was confirmed in studies in which only p16 + cancers were considered. CONCLUSION: HPV infection may increase the risk of oral cavity and nasopharyngeal cancer. However, the prognosis was not influenced, except in hypopharyngeal carcinoma.

Comparison of different treatments for HPV+ oropharyngeal carcinoma: a network meta-analysis.

INTRODUCTION: Treatment of human papillomavirus (HPV)-related head and neck squamous cell carcinoma (HNSCC) is rapidly evolving. Despite either surgery or radiotherapy (RT), with or without chemotherapy (CT), being acceptable in intermediate and locally advanced diseases, there is uncertainty regarding the best treatment option for these patients. Therefore, we performed a network meta-analysis (NMA) to compare the relative efficacy of different treatments for HPV+ oropharyngeal carcinoma. MATERIAL AND METHODS: Randomized clinical trials that enrolled adults with non-metastatic HPV+ oropharynx cancer and provided data about overall survival (OS) and/or progression-free survival (PFS) and/or locoregional control and distant metastases (LRC and DM) were included. Fixed- or random-effects models were fit using a Bayesian approach to NMA. Between-group comparisons were estimated using hazard ratios (HRs) with 95% credible intervals (CrIs). The primary outcome was OS. RESULTS: A total of 844 citations were screened; 11 randomized clinical trials were included (HPV+ stage III-IV cancer, mainly oropharynx carcinomas). Nine treatment arms were compared. Radiotherapy (altered or standard fractionation) + triweekly cisplatin (HR 3.8; 95% CrIs 0.29-65 and 0.3; 95% CrIs 0.03-2.51) was superior to RT in term of OS (P score = 0.42 and 0.16). Radiotherapy with low and high cisplatin doses appeared similar (HR 1.57; 95% CrIs 0.19-12.72). Altered fractionation or standard RT + 3-weekly cisplatin are the 2 highest-ranked options in terms of PFS (P score = 0.35 and 0.34). CONCLUSIONS: This meta-analysis confirms the role of cisplatin added to RT as the best option for HPV+ oropharyngeal carcinoma. RT+ 3-weekly cisplatin is likely to be the best radical treatment in terms of OS and PFS.

Look at the elephant! Commentary on 'Prevalence of temporomandibular disorders in adult obstructive sleep apnoea patients: A cross-sectional controlled study'.

The relationship between obstructive sleep apnoea (OSA) and temporomandibular disorders (TMDs) is complex. Research has shown controversial evidence. The recent study by Bartolucci et al. titled 'Prevalence of temporomandibular disorders in adult obstructive sleep apnoea patients: A cross-sectional controlled study' reported no clear associations between the two conditions. However, it does not take into account the occlusal and mandibular features of the patients, which may justify the hypothetical coexistence of OSA and TMD in a subset of cases. In this letter, we discuss these aspects and possible biases that could have impaired the results.

Dornase alfa as postoperative therapy in cystic fibrosis sinonasal disease.

OBJECTIVE: To determine the benefit of nasally inhaled dornase alfa in patients with cystic fibrosis and nasal symptoms. DESIGN: Double-blind placebo-controlled trial. SETTING: Cystic Fibrosis Regional Center of Campania at the University of Naples "Federico II." PATIENTS: A total of 24 patients with cystic fibrosis and chronic sinusitis. INTERVENTIONS: Patients underwent sinonasal surgery during a 3-year period and received once-daily doses of either dornase alfa (2.5 mg) or hypotonic saline solution (5 mL) beginning 1 month after surgery and for a 12-month period. MAIN OUTCOME MEASURES: Primary outcomes were nasal-related symptoms and nasal endoscopic appearance; secondary outcomes were forced expiratory volume in 1 second, nasal computed tomography findings, and saccharine clearance test results. Patients were evaluated before and after treatment. RESULTS: After surgery, all outcomes were significantly improved for each treatment at 1 month (P<.05); primary outcomes were improved at 24 and 48 weeks in the group receiving dornase alfa (P<.05), and at 12 weeks in the group receiving placebo. Secondary outcomes were better in the dornase alfa group (P<.01) than in the placebo group at 12 months except for the saccharine clearance test results. In particular, median relative difference in forced expiratory volume in 1 second between dornase alfa and placebo was significantly improved in the dornase alfa group (P<.01). CONCLUSIONS: Nasally inhaled dornase alfa can be effective in patients with cystic fibrosis and sinonasal disease who do not respond to conventional therapy after surgical treatment. Further studies should be carried out to determine the long-term effect on sinus disease, recurrence of polyps, and quality of life.

The 11th nerve syndrome in functional neck dissection.

OBJECTIVES: Assessment of the incidence of shoulder joint disability and evaluation of the role of a personal postoperative physical rehabilitative protocol therapy in reducing pain and shoulder dysfunction and improving the quality of life (QOL) of patients who have undergone functional neck dissection (FND) associated with total laryngectomy. SETTING, DESIGN, AND OUTCOME MEASURES: Sixty laryngectomees who had undergone FND were divided into two groups (A and B). Group A received physical therapy after surgery. Clinical evaluation was done according to the Constant modified questionnaire, including physical assessment of passive and active shoulder movement and information regarding patients' QOL. Bilateral quantitative electromyography (Q-EMG) of scapulohumeral muscles was carried out on all patients. Results were evaluated by Student t test and multivariate analysis to find out which variables were important in predicting pain and return to work. RESULTS: Six months after surgery, the patients in group A had better results concerning passive forward elevation (P = 0), shoulder active motility (P = 0), pain (P <.001), working and recreational activity (P = 0), and score of Constant (P = 0) compared with the patients in group B. From a multivariate analysis of clinical parameters important in predicting pain, significant predictors (P <.01) were shown to be global shoulder active motility, active forward elevation, abduction, active external rotation, internal rotation hand to back, working and recreational activity, and score of Constant. Regarding return to work, a significant predictor (P <.01) was the score of Constant. Electromyography work-up showed deterioration in early postoperative periods and improvements in late postoperative periods. CONCLUSION: The post-surgical variable clinical picture of shoulder disability is related not only to the accessory nerve injury, but also to the secondary glenohumeral stiffness resulting from the scapulohumeral girdle muscles weakness and postoperative forced immobility. Physical therapy aimed to early recover passive motion and to avoid the occurrence of joint fibrosis has been shown to have a real contributory role in decreasing shoulder complaints and improving the patients' QOL.

Connexin 26 mutations in nonsyndromic autosomal recessive hearing loss: speech and hearing rehabilitation.

OBJECTIVE: Hearing loss is the most common form of sensory impairment, with approximately one infant/1000 born with profound congenital deafness. A pre-lingual bilateral sensorineural hearing impairment poses a substantial problem as it negatively impacts on the subject's ability to conduct a normal social life. The aim of the study was to observe, in a group of children affected by pre-lingual non-syndromic autosomal recessive hearing impairment: (1) the role of the possible mutation of connexin 26 in the pathogenesis of the hearing loss; (2) the audiological and clinical aspects of the hearing impairment; (3) therapy to be adopted for the different patients. METHODS: The study was carried out on 39 patients, 16 males and 23 females, aged between six and 17 years (mean 12 years), affected by non syndromic congenital deafness, presumably hereditary, referred to the out-patients audiology clinic for children of the Department of Otolaryngology of the Federico II University of Naples. RESULTS: Our study conducted on 39 children with pre-lingual bilateral sensorineural autosomal recessive deafness showed as follows: (I) from a molecular perspective: an incidence of 41% in the cases studied of mutations in the encoding of the connexin 26 gene; a prevalence in our case study of the 35delG mutation (69%). (II) The characteristics of the hearing impairments in the children studied were homogeneous, regardless of the presence or absence of a connexin 26 mutation: the hearing impairment was pre-lingual bilateral sensorineural, the impairment often involved mainly the high frequencies, but, especially in the severe forms an involvement of all the frequencies was not rare; the hearing impairments were symmetrical and non progressive in time. (III) The results of the application of prosthesis and thereafter rehabilitative language therapy are generally satisfactory but correlated of course to the severity of the hearing loss. CONCLUSION: In conclusion, we hope that further developments in the research on genetic hearing impairments will promptly result in advances in clinical practice.

Myringoplasty in simple chronic otitis media: critical analysis of long-term results in a 1,000-adult patient series.

OBJECTIVES: Investigate the recurrence of chronic otitis media after primary and revision myringoplasty, compare long-term anatomic and audiologic results of underlay and overlay myringoplasty, and examine the prognostic factors. STUDY DESIGN: Retrospective study. PATIENTS: Approximately 1,040 adult patients with chronic simple otitis media undergoing a myringoplasty (overlay and underlay) by different surgeons at a single institution (ENT Department of Bergamo Ospedali Riuniti) between May 1999 and March 2009. METHODS: The cumulative recurrence rate of chronic otitis media during 10-year follow-up period was calculated using a Kaplan-Meier survival analysis. A multivariate analysis was used to evaluate different prognostic factors based on long-term outcome in myringoplasty. RESULTS: The overall 10-year graft success rate was 78% in 1,040 patients. The 10-year recurrence rate of chronic otitis media was 15% in overlay myringoplasty and 26% using the underlay technique (p < 0.05). In revision myringoplasty, the overlay technique showed a better success rate than underlay (p < 0.05). Significant recovery was observed in the air conduction thresholds and air-bone gaps in both groups with no statistical difference between techniques (p = 0.1). Multivariate analysis demonstrated that the underlay myringoplasty technique, a pathologic contralateral ear and an anterior or subtotal perforation, using a perichondrial graft or age of surgery younger than 40 years were statistically significant (p < 0.01) factors that negatively influenced the myringoplasty outcomes. CONCLUSION: More successful outcomes in primary and revision surgery for chronic otitis media occurred using overlay myringoplasty, although there were more minor postoperative complications. Both clinical and technical variables affected the success rate of myringoplasty.