Cerebellar haemorrhage mimicking acute peripheral vestibulopathy: the role of the video head impulse test in differential diagnosis.

Dizziness and vertigo without neurological signs are typically due to a peripheral vestibular disease. Although the most common causes are benign, differential diagnosis must include potentially life-threatening central diseases such as cerebrovascular pathologies. A systemic clinical approach needs a careful work-up, bedside examination and appropriate instrumental investigation. The head impulse test (HIT) allows qualitative clinical assessment of canalar function; it has some limitations such as subjective evaluation, mainly in patients with a spontaneous nystagmus. A new device has been recently developed consisting of an infrared video camera (video-HIT) to provide quantitative instrumental assessment of the high-frequency vestibular-ocular reflex (VOR) gain. By reporting a case of cerebellar haemorrhage mimicking an acute peripheral vestibulopathy, the authors suggest that video-HIT may be considered a useful tool in differential diagnosis between vestibular neuritis and cerebellar vascular disease in patients with severe acute vertigo without central signs.

Primary paraganglioma of thyroid gland: a clinicopathologic and immunohistochemical study with review of the literature.

Primary paraganglioma of the thyroid is a very rare neuroendocrine tumour. Only 24 cases have been reported in the Literature. A case of a primary paraganglioma of the thyroid is presented in order to provide a review of the Literature, an update on current knowledge and to emphasize the key diagnostic role of immunohistochemistry. A 63-year-old female presented with a 6-month history of right-sided solitary thyroid nodule. Ultrasonography and fine needle aspiration biopsy were not diagnostic. The patient underwent right hemithyroidectomy. The tumour cells showed a strongly positive staining for chromogranin A, synaptophysin and neuron specific enolase, whereas S-100 protein was positive in sustentacular cells. A diagnosis of primary paraganglioma of the thyroid was made. Radiotherapy for suspected local tumour persistence was planned. At 18-months follow-up, the patient is alive without evidence of recurrence. This case highlights the need to include primary paraganglioma of the thyroid in the differential diagnosis of neuroendocrine intra-thyroidal tumours. Immunohistochemistry is essential for diagnosis. Surgery is the treatment of choice.

Wegener's granulomatosis: an update on diagnosis and therapy.

Wegener's granulomatosis (WG) is a unique clinicopathological disease characterized by necrotizing granulomatous vasculitis of the respiratory tract, pauci-immune necrotizing glomerulonephritis and small-vessel vasculitis. Owing to its wide range of clinical manifestations, WG has a broad spectrum of severity that includes the potential for alveolar hemorrhage or rapidly progressive glomerulonephritis, which are immediately life threatening. WG is associated with the presence of circulating antineutrophil cytoplasm antibodies (c-ANCAs). The most widely accepted pathogenetic model suggests that c-ANCA-activated cytokine-primed neutrophils induce microvascular damage and a rapid escalation of inflammation with recruitment of mononuclear cells. The diagnosis of WG is made on the basis of typical clinical and radiologic findings, by biopsy of involved organ, the presence of c-ANCA and exclusion of all other small-vessel vasculitis. Currently, a regimen consisting of daily cyclophosphamide and corticosteroids is considered standard therapy. A number of trials have evaluated the efficacy of less-toxic immunosuppressants and antibacterials for treating patients with WG, resulting in the identification of effective alternative regimens to induce or maintain remission in certain subpopulations of patients. Recent investigation has focused on other immunomodulatory agents (e.g., TNF-alpha inhibitors and anti-CD20 antibodies), intravenous immunoglobulins and antithymocyte globulins for treating patients with resistant WG.

Myoepithelioma of a minor salivary gland of the cheek: case report.

Myoepithelioma is a rare neoplasm of the salivary glands, generally occurring in the parotid gland and less often in the minor accessory salivary gland of the oral cavity. The histological appearance includes solid, myxoid and reticular growth patterns. Vimentin and S-100 protein are very sensitive but non-specific immunohistochemical markers of neoplastic myoepithelium. Conservative surgery is the treatment of choice. A case of myoepithelioma of the minor salivary gland of the cheek with low grade malignancy is described, focusing on clinical behaviour, histopathological and immunohistochemical features and differential diagnosis.

Maxillo-ethmoidal chloroma in acute myeloid leukaemia: case report.

Chloroma, also called Granulocytic Sarcoma or Myeloid Sarcoma, is a rare malignant extra-medullary neoplasm of myeloid precursor cells. It is usually associated with myelo-proliferative disorders but its appearance may precede the onset of leukaemia. Chloroma may be found in several extracranial sites. Involvement of the head and neck region is uncommon. Differential diagnosis is often difficult and includes acute lymphoblastic leukaemia, large cell NHL, lymphoblastic lymphoma and Ewing's sarcoma. The case is presented of a maxillo-ethmoidal chloroma occurring in a case of poor prognosis acute myeloid leukaemia, emphasizing the clinical and cyto-histological features and problems concerning differential diagnosis.

[Surgical treatment of inferior turbinate hypertrophy with argon plasma: a long-term follow-up in 157 patients]. / Tratamiento quirúrgico de la hipertrofia de cornetes inferiores con plasma de argón: estudio a largo plazo con 157 pacientes.

Surgical treatment of the inferior turbinate in patients with chronic hypertrophic rhinitis that does not respond to medical treatment is a well established procedure. CO2 laser, YAG laser, KTP laser, conventional electrocautery, cryotherapy, chemosurgery and turbinectomy or submucosal turbinectomy have been performed for the removal of nasal obstruction. Argon Plasma Coagulation (APC) is a new, innovative technique in Otorhinolaryngology which is based on high-frequency electrocoagulation with an argon-gas source. The shorter surgical times, the absence of hemorrhagic complications and, in rhinosurgery, not requiring any kind of nasal packing are remarkable. Between March and November 2000, a group of 157 patients with symptoms of nasal obstruction due to hypertrophic inferior turbinates were treated using APC, at the Otorhinolaryngology Surgical Department of the Hospital of Dolo (Venice). The follow-up period was 24 months. Rhinomanometry was performed to objectively measure the nasal obstruction and to verify the postoperative improvement. The Student t-test was used for statistical data. After 24 months, 87% (p < 0.001) of patients reported to have a better nasal airflow than before the operation. None of the patients needed a nasal packing after APC surgery. We review and discus the indication, advantages, complications, controversies and long-term results of the treatment with APC in rhinosurgery.

Tratamiento quirúrgico de la hipertrofia de cornetes inferiores con plasma de argón: estudio a largo plazo con 157 pacientes / Surgical treatment of inferior turbinate hypertrophy with argon plasma: a long-term follow-up in 157 patients

La obstrucción nasal crónica es una alteración que se observa con frecuencia y que en muchos casos está causada por una hipertrofia de cornetes inferiores. Si hay una respuesta inadecuada al tratamiento médico conservador, debemos realizar una reducción en el tamaño de los cornetes. Existen varias técnicas: coagulación mono o bipolar, reducción parcial del cornete mediante el conchotomo o las tijeras, cirugía láser mediante Nd: YAG, CO 2 o KTP. La coagulación mediante plasma de argón (APC) es una técnica nueva basada en una corriente eléctrica de alta frecuencia y una fuente de gas argón. La rapidez en la realización de la técnica, la ausencia de complicaciones hemorrágicas, así como la no necesidad de ningún tipo de taponamiento la hacen muy interesante para cirugía nasal. Entre marzo y noviembre de 2000, un grupo de 157 pacientes con síntomas de obstrucción nasal debida a hipertrofia de cornetes inferiores fueron tratados mediante APC. Se realizaron revisiones a la semana y al 1, 3, 6, 12 y 24 mes. Se practicó una rinomanometría para verificar objetivamente si la hipertrofia de cornetes era debida a una hipertrofia mucosa. Después de 24 meses, el 87 por ciento (p menor 0,01) de los pacientes refirieron tener mejor flujo nasal que antes de la operación. Ningún paciente precisó taponamiento después de la cirugía. Se revisan y discuten las indicaciones, ventajas, complicaciones, controversias y resultados a largo plazo en el tratamiento con APC en rinocirugía (AU)

Surgical treatment of the inferior turbinate in patients with chronic hypertrophic rhinitis that does not respond to medical treatment is a well established procedure. CO2 laser, YAG laser, KTP laser, conventional electrocautery, cryotherapy, chemosurgery and turbinectomy or submucosal turbinectomy have been performed for the removal of nasal obstruction. Argon Plasma Coagulation (APC) is a new, innovative technique in Otorhinolaryngology which is based on high-frequency electrocoagulation with an argon-gas source. The shorter surgical times, the absence of hemorrhagic complications and, in rhinosurgery, not requiring any kind of nasal packing are remarkable. Between March and November 2000, a group of 157 patients with symptoms of nasal obstruction due to hypertrophic inferior turbinates were treated using APC, at the Otorhinolaryngology Surgical Department of the Hospital of Dolo (Venice). The follow-up period was 24 months. Rhinomanometry was performed to objectively measure the nasal obstruction and to verify the postoperative improvement. The Student t-test was used for statistical data. After 24 months, 87% (p < 0.001) of patients reported to have a better nasal airflow than before the operation. None of the patients needed a nasal packing after APC surgery. We review and discus the indication, advantages, complications, controversies and long-term results of the treatment with APC in rhinosurgery (AU)

Argon plasma surgery for treatment of inferior turbinate hypertrophy: a long-term follow-up in 157 patients.

Chronic nasal obstruction is a common disorder, mostly caused by hypertrophic inferior turbinates. In cases of nonresponse to conservative medical management, the surgical reduction of the inferior turbinates is often required. Surgical techniques for the reduction of hyperplastic nasal turbinates include monopolar or bipolar coagulation, partial or total reduction of the turbinates with a conchotome or scissors and laser surgery with Nd:YAG, CO(2) or KTP. Argon plasma coagulation (APC) is a new, innovative technique in otorhinolaryngology which is based on high-frequency electrocoagulation with an argon gas source. The fast and short surgery times, the absence of hemorrhagic complications and, in rhinosurgery, the complete abstention from any kind of nasal packing are remarkable. Between March and November 2000, a group of 157 patients with symptoms of nasal obstruction due to hypertrophic inferior turbinates were treated using APC, at the Otorhinolaryngology Surgery Department of the Hospital of Dolo (Venice). The follow-up period was 24 months. Rhinomanometry was performed to objectively measure the nasal obstruction and to verify the postoperative improvement. The Student t test was used for statistical data. After 24 months, 87% (p < 0.001) of the patients reported to have a better nasal airflow than before the operation. None of the patients needed a nasal packing after APC surgery. The indication, advantages, complications, controversies and long-term results of the treatment with APC in rhinosurgery are reviewed and discussed.

[The application of argon plasma coagulation (APC) in surgical treatment of inferior turbinates]. / L'applicazione dell'Argon Plasma Coagulation (APC) nella chirurgia dell'ipertrofia dei turbinati inferiori.

For over 20 years, argon plasma coagulation (APC) has been used in open surgery, in laparoscopy and in thoracoscopy for the haemostasis of superficial haemorrhages and for the resection of parenchymatous tissue. This technique is based on the use of a high-frequency current that ionizes an inert gas, the argon; the emission of this latter generates a thermocoagulative effect that is selectively exerted on the superficial surfaces of the mucosa involved. In otorhinolaryngology, it may be seen as a valid alternative to traditional surgical techniques, to a mono- or bipolar electric surgical knife, and to laser surgery. From March to November 2000, 157 patients affected by "inferior turbinate hypertrophy non-responsive to ordinary medical therapy" underwent devitalizing APC surgery. In 20% of the cases (30 patients), the operation was performed under local anaesthesia. In no case was a nasal tampon employed. Twelve months after the operation, 87% of the patients treated (136 cases) had fully resumed normal nasal respiratory functionality, with marked improvement in the air flow and reduction of the unilateral nasal resistance during rhinomanometric evaluation. There were post-operative complications in 2% of the patients (3 cases), all of which were successfully handled through APC (2 cases of epistaxis on the 7th and 9th post-operative day, and 1 case of turbino-septal synechia). In the 13% of the patients (21 cases) in whom the results had been partial or unsatisfactory, the cause of the limited efficacy of the treatment was connected with an improper use of the instrumentation, lack of compliance on the part of the patient, or a concomitant psycofunctional pathology. The statistical study, accomplished via Student's t test, confirmed that the difference between the unilateral nasal resistance values present before the procedure and those measured during the 1-month follow-up were highly significant (t = 11.126, p < .001). The same significant correlation was ascertained between the pre-operative nasal resistance values and those ascertained post-operatively, respectively at 3, 6 and 12 months (p < .001).

[Results of videonystagmographic (VNG) analysis in vestibular post-traumatic pathology]. / Resultados del análisis videonistagmográfico (VNG) en la patología vestibular post-traumática.

From February 1998 to July 1999, 569 patients affected by vestibular disorders--following a whiplash injury and/or a cranial trauma--were studied. The neuro-otological examination included a tonal audiometry, brain stem auditory evoked potentials, clinical and instrumental vestibular tests (caloric test, rotatory test, assessment of visually guided eye movements). The study of eye movements was conducted with the support of the Ulmer video-oculographical system. The aim of the research was to analyse, both from a qualitative and a quantitative perspective, the vestibular and clinical findings. Particular emphasis was laid on the incidence of the "up-beating" nystagmus in different categories of patients, all supported by a statistical study. As a result, an etiopathogenetical hypothesis of the nystagmus was advanced, based on altered otolithic and cervical inputs. At the same time, the importance of the video-nystagmographical system was stressed, to the extent that it leads to a standardised and objective analysis, fundamental for clinical and forensic aspects.

[Carcinosarcoma of the larynx: immunohistochemical study, clinical considerations, therapeutic strategies]. / Il carcinosarcoma della laringe: studio immunoistochimico, considerazioni cliniche, strategie terapeutiche.

Carcinosarcoma is a rare laryngeal neoplasm accounting for less than 1% of all malignancies involving this organ. Given its double epithelial, mesenchymal nature, this neoplasm is described in the literature in many ways: sarcomatoid carcinoma, variants of squamous cell carcinoma with fused cells, pseudoscarcoma, pleumorphous carcinoma, polypoid carcinoma, metaplastic carcinoma. Although not invalidating, cytokeratin positive immunohistochemistry is fundamental for diagnosis. Given the different histopathological pictures, the rareness and heterogeneous natural history of such tumors, it is not surprising there is as yet no agreement as to the treatment of choice. An accurate analysis of the literature indicates that both the therapeutic approach and prognosis are the same as those found for normal squamous cell carcinoma. The authors describe a case of laryngeal carcinosarcoma, analyzing the clinical-therapeutic aspects, histopathological features and immunohistochemistry of this rare neoplasm.

Resultados del análisis videonistagmográfico (VNG) en la patología vestibular post-traumática / Results of videonystagmographic (VNG) analysis in vestibular post-traumatic diseases

Estudiamos 569 pacientes que sufrieron síndrome vertiginoso secundario a traumatismo craneal o cervical en el período comprendido entre febrero de 1998 a julio de 1999. El examen audiovestibular comprendió una audiometría tonal, potenciales evocados auditivos del tronco cerebral, examen otorrinolaringológico clínico e instrumental (pruebas calóricas, rotatorias, videonistagmograma y test de posturografía estática). El estudio oculomotor se realizó con un sistema de videonistagmografía Ulmer. El objetivo del trabajo es analizar, tanto de forma cualitativa como cuantitativa, los datos vestibulométricos y semiológicos recogidos. Queremos remarcar la incidencia estadísticamente significativa del nistagmo "up-beating" en las diversas categorías de pacientes. Proponemos una hipótesis etiopatogénica del citado nistagmus basada en una alteración de la información propioceptiva cervical y un patrón anómalo de estimulación de los otolitos. Subrayamos además la importancia del sistema videonistagmográfico que permite un análisis estandarizado y objetivo tanto con fines clínicos como médicolegales (AU)

From February 1998 to July 1999, 569 patients affected by vestibular disorders--following a whiplash injury and/or a cranial trauma--were studied. The neuro-otological examination included a tonal audiometry, brain stem auditory evoked potentials, clinical and instrumental vestibular tests (caloric test, rotatory test, assessment of visually guided eye movements). The study of eye movements was conducted with the support of the Ulmer video-oculographical system. The aim of the research was to analyse, both from a qualitative and a quantitative perspective, the vestibular and clinical findings. Particular emphasis was laid on the incidence of the "up-beating" nystagmus in different categories of patients, all supported by a statistical study. As a result, an etiopathogenetical hypothesis of the nystagmus was advanced, based on altered otolithic and cervical inputs. At the same time, the importance of the video-nystagmographical system was stressed, to the extent that it leads to a standardised and objective analysis, fundamental for clinical and forensic aspects (AU)

[Up-beating nystagmus in craniocervical trauma: a videooculographic assessment of 569 cases]. / Il nistagmo "up-beating" nei traumi cranici e del rachide cervicale: studio videooculografico di 569 casi.

Between February 1998 and July 1999 a total of 569 patients with vertigo subsequent to cranial and/or cervical trauma underwent otovestibular study: tonal audiometry, auditory brain stem evoked potentials, clinical and instrumental otovestibulogical examination (bithermal test, rotatory test, visuooculomotory test and static stabilometry). Oculomotory analysis was performed using the Ulmer videooculographic system. The purpose of this work was to analyze both the quality and quantity of the vestibulometric and semiotic data obtained. Emphasis is placed on the significant incidence of "up-beating" nystagmus in the various categories of patients, supported by a statistical study. Then a hypothesis for the etiopathogenesis of such nystagmus is proposed, based on an alteration in the cervical proprioceptive information and on an abnormal otolitic input pattern. Moreover, the importance of the videonystagmographic system is underlined as it permits the standardized, objective analysis essential for both clinical and forensic purposes.

[Treatment approaches to benign paroxysmal positional vertigo. Clinical features in 228 cases of posterior and lateral canalolithiasis]. / Strategie terapeutiche nelle vertigini parossistiche posizionali benigne. Considerazioni cliniche su 228 casi di canalolitiasi posteriore e laterale.

After having discussed the etiopathogenesis, epidemiology and physiopathology of Benign Paroxysmal Positional Vertigo (BPPV), the authors present their case study covering audiovestibology out-patients treated in the last two years: 228 cases of canalotithiasis-derived BPPV, both posterior (186 cases) and lateral (42 cases). These patients were diagnosed and treated between July 1996 and July 1998 and account for 15% of the 1550 patients complaining of balance and postural disorders seen during that period. Analysis of the results shows BPPV epidemiological data that are practically the same those reported in the literature: greater incidence in females, predominance of posterior canalolithiasis and optimal use of the canalith repositioning techniques. The authors reconfirm the effectiveness of the Semont maneuver and its variations in the treatment of those forms involving the posterior semicircular canal (97% healing). As regards BPPV due to lateral canalolithiasis. The authors feel the vestibular "barbecue" rehabilitation techniques suggested by Lempert--i.e. a 270 degrees rotation starting from the decubitus position on the pathological side, rather than Baloh's traditional 360 degrees rotation--is most suitable for the treatment of BPPV stemming from lateral canalolithiasis. The Lempert technique provided satisfactory results (76% healing) and a reduction in the number of failures (24%).