Correlation between cephalometric variables and obstructive sleep apnoea severity in children.

AIM: Alterations in craniofacial growth have been associated with obstructive sleep apnoea in children. The main objectives of this study were to analyse the correlation between cephalometric variables and Obstructive Apnea/Hypopnea Index (OAHI) in order to investigate if craniofacial features may influence the severity of obstructive sleep apnoea and to study the correlation between upper nasopharyngeal width and maxillomandibular skeletal discrepancy in sagittal and vertical plane. MATERIALS AND METHODS: Study Design: Correlations between cephalometric variables and obstructive sleep apnoea/hypopnea index and between upper airways space and maxillomandibular skeletal discrepancy were investigated. Forty-seven children with obstructive sleep apnoea diagnosed by overnight sleep study (polysomnography) underwent a lateral radiograph, orthodontic and ear-nose-throat examinations. Cephalometric analysis according to Kirjavainen has been performed to define skeletal and upper airways variables. STATISTICS: Spearman's correlation analysis was performed between OAHI and all cephalometric variables. Pearson's correlation analysis was performed between cephalometric variables of upper airway space and cephalometric variables related to maxillomandibular discrepancy. Chi-square test was used to compare occlusal features with adenoidal and tonsillar hypertrophy. Kruskal-Wallis rank test was used to compare OAHI with occlusal variables and adenotonsillar hypertrophy. RESULTS: The results show a positive correlation between OAHI and maxillomandibular discrepancy measured by ANB angle (rho=0.32; p=0.023). A significant correlation was found between upper nasopharyngeal width and vertical maxillomandibular skeletal discrepancy: 1) ad1-PNS were correlated to Mandibular Plane/Sella- Nasion angle (r=-0.36; p=0.012), Palatal Plane/Mandibular Plane angle (r=-0.39; p=0.007), and Posterior-Anterior Facial Height % (r=0.29; p=0.045); 2) ad2-PNS was correlated to Palatal Plane/Mandibular Plane angle (r=-0.39; p=0.007). No statistically significant differences were found in non-parametric tests between OAHI and occlusal variables or adenoidal and tonsillar hypertrophy. CONCLUSIONS: The present study shows a significant correlation between maxillomandibular discrepancy and the severity of OSA. Moreover, the reduction of nasopharyngeal width was correlated to maxillomandibular hyperdivergent growth pattern. These results support the presence of a correlation between sleep-disordered breathing and craniofacial features even if the cause-effect relation is still unclear. Based on these evidences, we suggest the importance of orthodontic evaluation in the management of paediatric OSA.

Emerging and re-emerging infectious disease in otorhinolaryngology.

SUMMARY: Emerging and re-emerging infectious disease in otorhinolaryngology (ENT) are an area of growing epidemiological and clinical interest. The aim of this section is to comprehensively report on the epidemiology of key infectious disease in otorhinolaryngology, reporting on their burden at the national and international level, expanding of the need of promoting and implementing preventive interventions, and the rationale of applying evidence-based, effective and cost- effective diagnostic, curative and preventive approaches. In particular, we focus on i) ENT viral infections (HIV, Epstein-Barr virus, Human Papilloma virus), retrieving the available evidence on their oncogenic potential; ii) typical and atypical mycobacteria infections; iii) non-specific granulomatous lymphadenopathy; iv) emerging paediatric ENT infectious diseases and the prevention of their complications; v) the growing burden of antimicrobial resistance in ENT and the strategies for its control in different clinical settings. We conclude by outlining knowledge gaps and action needed in ENT infectious diseases research and clinical practice and we make references to economic analysis in the field of ENT infectious diseases prevention and care.

Effects of simultaneous palatal expansion and mandibular advancement in a child suffering from OSA.

This clinical report describes a child suffering from obstructive sleep apnoea (OSA) and class II skeletal malocclusion with maxillary contraction and anterior open bite. He presented moderate obstructive sleep apnoea with large impact on quality of life of patient and parents. He was treated using an innovative orthodontic device (Sleep Apnea Twin Expander) to simultaneously carry out palatal expansion and mandibular advancement. After orthodontic therapy, the OSA-18 questionnaire demonstrated an improvement of the main respiratory symptoms, while cardiorespiratory sleep study revealed a reduction in obstructive sleep apnoea events. Post-treatment, clinical assessment and cephalometric analysis showed a reduction of sagittal maxillary discrepancy and an extension of upper airway space. In conclusion, this case report suggests that orthodontic treatment might be a valuable alternative treatment in children with obstructive sleep apnoea related to craniofacial anomalies.

Functional study on Boswellia phytosome as complementary intervention in asthmatic patients.

OBJECTIVE: The combination of inhaled corticosteroids (ICS) and long-acting beta-agonists (LABAs) is recommended for the treatment of patients with mild-to-severe persistent asthma. However, given the lack of definite and safe therapies, complementary or alternative medicines are frequently used by asthmatic patients in combination with standard treatments. PATIENTS AND METHODS: A group of asthmatic subjects have been enrolled in this multicenter study; after having verified the compliance to their current medical therapy (ICS + LABAs), the subjects have been randomized to receive Casperome® 500 mg/day or no additional treatment for a period of 4 weeks. They were also asked to keep track of the number of inhalations required per day and any adverse events through a daily form. RESULTS: A total of 32 subjects were enrolled in the study. Subjects receiving Casperome® 500 mg/day in addition to the standard ICS + LABAs treatment showed a decrease in the number of inhalations needed compared to patients who did not receive Casperome® therapy. The treatment was well tolerated and only mild-moderate adverse events were registered. CONCLUSIONS: The use of Casperome® 500 mg/day is beneficial for asthmatic patients as it helps reduce the need for inhalation therapy with ICS + LABA.

Adenotonsillectomy for obstructive sleep apnea in children with Prader-Willi syndrome.

The aim of our study was to evaluate the efficacy of adenotonsillectomy for the treatment of obstructive sleep apnea syndrome (OSA) in pediatric patients with Prader-Willi syndrome (PWS), and to describe the postoperative complications. Five patients (4 males; median age, 4.4 years; range, 1.6-14.2 years) were studied. All patients underwent an overnight cardiorespiratory sleep study. All patients had adenotonsillar hypertrophy (ATH), and two were also obese. The preoperative obstructive apnea/hypopnea index (AHI; median and range) was 12.2 (9.0-19.9) events/hr; the mean oxygen saturation was 95 (79-96)%; the nadir oxygen saturation was 71 (58-78)%; and the oxygen desaturation index (ODI) was 15.8 (11.4-35.9) events/hr. Preoperatively, patients were classified as having moderate to severe OSA. A second sleep study, performed 16 (3-43) months after adenotonsillectomy, showed a significant decrease in AHI (P = 0.009) and ODI (P = 0.009). Mean and nadir oxygen saturation did not differ significantly postsurgery (P = 0.188, P = 0.073, respectively). Four out of five children showed at least one postoperative complication. Difficult awakening from anesthesia, hemorrhages, and respiratory complications requiring reintubation and/or supplemental oxygen administration were observed. In conclusion, patients with PWS and OSA who underwent adenotonsillectomy showed a significant decrease in AHI and number of oxygen desaturations.

[Buruli ulcer. A case report]. / L'ulcera di Buruli. Caso clinico.

The authors report a case of skin infection, Buruli ulcer, which is widespread in several parts of Africa: Ghana, Uganda, Ivory Coast, Senegal and most central African countries. This infection is caused by Mycobacterium ulcerans which belongs to the non-tubercular species Mycobacterium. It resembles Mycobacterium tuberculosis in colour and morphology, but differs in its speed of growth, its nutritional requirements, its capacity to produce pigments with enzymatic activities, its heat sensitivity and its resistance to anti-tubercular agents. Mycobacterium infection follows the percutaneous inoculation of the latter and appears as a painless, erythematous nodule that develops central necrosis and ulceration. Initially, the lesion appears as skin necrosis leading to the ulceration of the dermis and epidermis. The histological lesion shows a coagulative necrosis of the deep dermis and epidermis with destruction of the nerves and blood vessels; interstitial edema is also present. Healing is accompanied by a granulomatous response and the affected area is generally covered by a depressed scar. The authors initially treated the case in question using a conservative approach. A gel (Intrasite Gel) was used whose properties allowed the destruction of necrotic tissue present on the ulcer bed and the stimulation of granulation tissue formation. The layer of gel was in turn covered with a triple layer of polyurethane which enabled the humidity of the lesion to be maintained constant, thus promoting healing and acting as a barrier against external germs. This treatment enabled the skin lesion to be completely sterilised in about 30 days using new dressings every 3 days. Surgical treatment then led to complete healing after a further 20 days.

QT interval and QT dispersion in systemic sclerosis (scleroderma).

OBJECTIVES: To measure QT interval and QT dispersion, and to evaluate possible relationships between these measurements, heart rate variability parameters, and early myocardial involvement in patients with systemic sclerosis (SSc). DESIGN: Prospective study. SETTING: Tertiary care centre, University 'La Sapienza', Rome, Italy. SUBJECTS: Thirty-eight patients with SSc (35 females and three males, mean age 47 +/- 11 years), 19 patients with the diffuse form of disease and 19 with the limited form, and 17 healthy controls (11 females and six males, mean age 43 +/- 10 years) were studied. INTERVENTIONS: Both patients and control subjects underwent resting 12-lead electrocardiogram and 24-hour Holter monitoring. Moreover, resting myocardial scintigraphy with 99 m Tc-sestamibi was performed in all SSc patients. MAIN OUTCOME MEASURES: Bazett's formula was used to obtain rate corrected value of QT interval (QTc). QT and QTc dispersion were defined as the difference between maximum and minimum QT or QTc interval, respectively. Twenty-four-hour heart rate variability was analysed both in the frequency and in the time domain. RESULTS: Twenty-three SSc patients (60.5%) had myocardial resting perfusion defects (group A) and 15 (39.5%) did not (group B). Maximum QTc interval, QT and QTc dispersion were significantly increased in SSc patients compared to the control subjects. No significant differences between group A and group B were observed for all QT measurements. Furthermore, maximum QTc interval, QT dispersion and QTc dispersion were significantly increased in group A patients compared to the control group. Total power, low-frequency, and high-frequency values were significantly lower in all SSc patients, whether in group A or group B, than in control subjects. On the other hand, low-frequency/high-frequency ratio was similar in all groups. Heart rate variability in time domain analysis showed no statistically significant differences between groups. CONCLUSIONS: Patients with SSc have increased QTc interval, QT dispersion, and QTc dispersion. The role of autonomic nervous system and myocardial involvement on ventricular repolarization in patients with SSc needs further investigation.

Noninvasive assessment of myocardial involvement in patients with systemic sclerosis: role of signal averaged electrocardiography.

OBJECTIVE: To assess the role of late ventricular potentials (LVP) in detecting early myocardial involvement in patients with systemic sclerosis (SSc). METHODS: Seventy-seven patients with SSc (68 women, 9 men, mean age 50 +/- 13 yrs) and 33 control subjects (18 women, 15 men, mean age 46 +/- 10 yrs) underwent resting electrocardiogram (ECG), 24 h Holter monitoring, complete echocardiographic and Doppler echocardiographic examination, and signal averaged ECG at high pass setting of 40 Hz, with the low pass fixed at 250 Hz. Patients with SSc underwent resting myocardial scintigraphy and radionuclide angioventriculography. RESULTS: The prevalence of LVP at 40 Hz was 20.5%. Compared to control subjects, patients with SSc showed higher prevalence of septal infarction pattern (p = 0.05), complex ventricular arrhythmias (p = 0.03), pulmonary arterial hypertension (p < 0.001), and LVP (p = 0.02). Forty-four patients with SSc (57.1%) had resting perfusion defects by myocardial scintigraphy. Fourteen of 15 patients with LVP showed perfusion defects compared to 29 of 58 without LVP (p = 0.002). Linear regression analysis showed that myocardial perfusion defect score was significantly correlated to either the filtered QRS duration, or the duration of low amplitude signals < 40 microV of the terminal QRS, or the root mean square voltage of the last 40 ms of the QRS complex. After a mean followup period of 20 months, 8 patients died. In 2 patients who died suddenly, LVP were present. CONCLUSION: Signal averaged ECG is a sensitive and inexpensive technique in the clinical assessment and followup of patients with SSc.

[A rare case of endotympanic hemangioma]. / Su di un raro caso di emangioma endotimpanico.

Hemangiomas affectioning the external ear canal or the tympanic membrane have rarely been described. Only a very few cases are reported in world literature conarn these vascular tumors involving the middle ear space. The Authors report a rare case of a right endotympanic hemangioma associated with ossicular dysmorphism, resulting in conductive unilateral hearing loss, in a 9 year-old girl with cutaneous hemangiomas of the face. The Authors review Literature and discuss the possible pathogenetic implications of the intraoperatory findings.

Rhinopharyngeal angiofibroma in the pediatric age group. Clinical-statistical contribution.

The authors had the chance of treating two cases of rhinopharyngeal angiofibroma before the age of puberty, and were thus stimulated to re-examine the incidence of such neoplasms in the pediatric age group, i.e. under 12 years of age. From their clinical statistical studies, and in the light of their personal experience, they were able to make the following observations. 12.9% of angiofibromas occur by the age of 12 years. These tumours present a shorter period of symptomatological evidence with respect to those which occur later. They are histologically characterized by a greater richness of cellular and vascular components with respect to those of a fibrous nature. Among the equipment used in radiology, computerized axial tomography showed itself extremely useful. The paralateronasal path is the most commonly used among surgical paths, as it is able to throw more light on tumour. The frequency with which the neoplastic mass relapses during operation is proportionally greater the earlier the primitive tumour occurs.

[Congenital pharyngo-oesophageal diverticulum in the newborn. Case report (author's transl)]. / Diverticule congénital pharyngo-oesophagien chez le nouveau-né. A propos d'une cas.

The Authors describe a case of congenital diverticulum of hypopharynx in a newborn. The lesion, early recognised, is successfull treated with surgical removal by a transcervical approach. The revision of the literature confirms the extreme rarity of this affection in the newborn and the correlated mortality if not early diagnosed and then confused with an atresia of the oesophagus it often simulates whose symptomatology.