Endoscopic dacryocystorhinostomy with and without silicone intubation: 4 years retrospective study.

The objective of this study is to assess different outcomes between endoscopic dacryocystorhinostomy (En-DCR) with and without silicone intubation. We retrospectively analyzed 84 patients (89 procedures), suffering from chronic epiphora for primary acquired nasolacrimal duct obstruction, treated with En-DCR and divided into two groups depending on silicone stent intubation. The surgical outcomes were evaluated at 7 post-operative controls using Munk's score criteria. Functional success was defined as absence of epiphora, no further episodes of dacryocystitis, and a patent ostium after fluorescein irrigation. 45 En-DCR with stent and 44 En-DCR without stent were performed. Success rate after 18 months follow-up were, respectively, 82.2 % in the stent group and 88.6 % in the non-stent group (OR 0.59) with no statistical differences. The ostial size reduction has been reported in higher percentage in the stent group, mainly due to peristomal granuloma (OR 3.64), scar tissue formation (OR 2.25), and turbinoseptal synaechia (OR 1.76). The benefits of non-intubation are less patient discomfort, reduced surgical time and costs, simpler follow-up regimen and less intubation-associated complications. En-DCR without silicone stent intubation should be the first choice of procedure, stent intubation should be reserved in selected cases with poor local conditions pre and intra-operatively assessed.

Results and complications of the Baha system (bone-anchored hearing aid).

The aim of this work is to reexamine our experience with the treatment of conductive and mixed hearing loss using the Baha system. The system was implanted in 47 patients (16 adults and 31 children under the age of 14), bilaterally in two cases. The causes of hypoacusis were bilateral congenital aural atresia (31 patients), bilateral chronic otitis media or outcomes of middle-ear surgery (Gillett et al. in J laryngol Otol 120:537-542, 2006), and otosclerosis (Pazzaglia et al. in Acta Orthop Scand 54:574-579, 1983). The following parameters were assessed: mean preoperative air- and bone-conduction thresholds for the frequencies of 500, 1,000, 2,000 and 4,000 Hz; mean postoperative threshold with the Baha; hearing improvement calculated by subtracting the postoperative threshold with the Baha from the preoperative threshold for air conduction in the better ear; speech audiometry test; improvement in the quality of life, calculated using the Glasgow Benefit Inventory for the adult patients and the Glasgow Children's Benefit Inventory for paediatric patients; frequency and type of surgical complications. Follow-up ranged from 6 to 38 months. The audiological results were satisfactory, with air-bone gap closure in 85.1% of cases. In terms of quality of life, assessment using the Glasgow Benefit Inventory showed a clear-cut improvement in health for all the 45 patients that answered to the questionnaires in our study. Out of the 49 operations that were performed, complications were reported in 3 cases (6.1%): 2 cases of skin regrowth around the titanium screw and one in which the abutment was not osseointegrated. The data from this study show that the Baha system offers a high percentage of success, which can significantly improve the patient's quality of life, and a low rate of complications.

Influence of extero- and proprioceptive afferents of the plantar surface in determining subjective visual vertical in patients with unilateral vestibular dysfunction.

Subjective visual vertical refers to an individual's ability to indicate what, in his or her opinion, is a perfectly vertical line in specific experimental conditions. Although the otolith organs play a key role in the perception of verticality, the contribution of other sensory systems, e.g. the visual and proprioceptive systems, cannot be overlooked. The aim of this study was to test the hypothesis that extero- and proprioceptive afferent signals, particularly from the plantar surface of the foot, can influence the temporal evolution of altered subjective visual vertical following unilateral acute vestibular dysfunction. Subjective visual vertical was studied in 40 consecutive patients: 19 females and 21 males (mean age 46.4 years). It was first measured at diagnosis (1-2 days after onset of symptoms). For this measurement, a baseline test was performed (patient standing in direct contact with the floor), followed by a provocation test with a soft support between the patient's feet and the floor. Based on a comparison between the baseline and provocation tests, the patients were divided into three groups: Group A--patients showing a significant increase (p < 0.05) in subjective visual vertical(0 )values in the provocation test compared to baseline values; Group B--patients showing a significant decrease (p < 0.05) in subjective visual vertical(0 )values in the provocation test compared to baseline values; Group C--patients showing no significant changes (p < 0.05) in subjective visual vertical(0 )values in the provocation test compared to baseline values. The baseline test was repeated at 30, 90 and 180 days. At the end of the follow-up, a persistent change in subjective visual vertical was noted in 87% of the patients from Group B, 31% of the patients from Group C but none of the patients from Group A, all of whom were able to correct the perception error during the second examination. The study demonstrates that normalisation of subjective visual vertical in subjects with unilateral vestibular lesions seems to be influenced by the possibility of exploiting extra-vestibular sensory information, particularly extero- and proprioceptive information from the plantar surface.

[Balance disorders in the elderly]. / I disturbi dell'equilibrio nell'anziano.

In the elderly patient, instability is a syndrome in which a loss of balance, during ambulation or while standing, can give rise to falls, with consequent disability and morbidity. Maintaining the correct static and dynamic balance is known to be the result of the synergetic functioning of different systems. In old age, however, the efficiency of these mechanisms is impaired because of the physiological process of aging, which affects all of the organs and systems of the human body. Besides that, different concomitant causes such as cardiovascular and dysmetabolic pathologies, chronic pharmacological therapies etc. contribute to the aging of our organism. The object of this study was to evaluate 40 subjects, 21 males and 19 females, aged between 70 and 86, who were referred to us with craniofacial trauma consequent to a fall. Upon hospitalization, all of the patients were asked to fill in a questionnaire evaluating the incidence of the vertigo symptom as a possible cause of the falls. All of the subjects underwent the following clinicoinstrumental examinations: standard audiometric evaluation, vestibular tests, neurological and ophthalmic examination. Careful appraisal of the results obtained enabled us to conclude that balance disorders in the elderly patient are due to the synergetic action of three factors: aging, concomitant diseases and environmental factors. In conclusion, we can affirm that balance disorders giving rise to a fall in the elderly are attributable to the concomitance of different factors that determine a clinical state of imbalance, defined by some Authors with the term "presbivertigo". It follows that a suitable diagnostic protocol must be employed, comprising a detailed medical, pharmacological and functional history, a study both of the environmental conditions in which the patient lives and the modalities according to which the traumatic event occurred. It is, last of all, indispensable that steps be taken to improve these environmental conditions, such as choosing flooring materials, light fixtures, stairs, bathroom furnishings and suitable footwear promoting proper foot placement and support on the ground.

[Epistaxis and climatic events]. / Epistassi e fattori meteorologici.

Data concerning daily climatic conditions in the area of Perugia during 1987-1990 have been gathered and correlated to daily incidence of idiopathic nose-bleeding observed in the same area and during the same period (1064 patients on the whole). The aim was to verify the relation between climatic events and "epistaxis" phenomenon, relation that has been assumed since a long time but has never been scientifically demonstrated before. Following factors have been estimated: highest and lowest daily temperature, thermal gradient, atmospheric pressure and pressure gradient, relative humidity. Results of statistic correlations show that every climatic factors has a narrow range related to higher incidence of epistaxis and that nose-bleeding is likely conditioned by combination of critical values, as a low temperature with 4 degrees C daily gradient, a 716 mm Hg atmospheric pressure with 2 mm Hg negative gradient, a close to 100% relative humidity.

[Pharyngeal cysts of branchial origin, a review of the literature and a clinical case report]. / Cisti faringee di origine branchiale, revisione della letteratura e presentazione di un caso clinico.

Nasal pharyngeal swellings are very often treated without a previous complete clinical examination of the patient and of the disease site. For this reason the recurrence rate of this pathology is quite high. The causes for this phenomenon are likely due to the benign aspect of the tumor and the easy approach to the pharynx. Leaving aside the therapeutical aspect, there are also multiple theories concerning the etiology of pharyngeal cyst based on epidemiological and histopathological observations. Branchiogenic origin very likely seems to be the cause of cystic swelling arising at the lateral side of the pharynx, between the Eustachian tube and the posterior tonsillar pillar. Examination of the case review collected from literature, revealed that diagnostic and therapeutical procedures performed by various authors seem to be very haphazard, ranging from simple physical examination and puncture draining to CT and/or MRI scanning and external trans-mandibular approach to the cyst. The authors describe one case of a subject with a pharyngeal branchial cyst, who had been previously undergone puncture drainage. The correct diagnosis was achieved through MRI and cytologic examination of the fluid aspirated from the cyst. With MRI it was possible to make a correct topo-diagnosis, which localized the position of the cyst in the left pharyngo-tonsillar recesses, medial to the pharyngeal constrictor muscles. MRI also confirmed the absence of fistulous ducts connected to the cyst. These clinical and laboratory data induced us to use an intra-oral approach to the cyst, which was removed by blunt dissection. Physical examination and MRI were repeated six months later and showed the complete removal of the cyst and the presence of a synechia between the upper part of the left posterior pillar and the pharyngeal wall. No further treatment was given because of the absence of symptoms. The authors stress the importance of less invasive surgery in the case of pharyngeal cyst possible after detailed monitoring of the disease site with modern computed tomography CT, MRI.