Clinical practice guideline on the management of vestibular schwannoma.

INTRODUCTION: Vestibular schwannoma (VS) is the most common tumour of the cerebellopontine angle. The greater accessibility to radiological tests has increased its diagnosis. Taking into account the characteristics of the tumour, the symptoms and the age of the patient, three therapeutic strategies have been proposed: observation, surgery or radiotherapy. Choosing the most appropriate for each patient is a frequent source of controversy. MATERIAL AND METHODS: This paper includes an exhaustive literature review of issues related to VS that can serve as a clinical guide in the management of patients with these lesions. The presentation has been oriented in the form of questions that the clinician usually asks himself and the answers have been written and/or reviewed by a panel of national and international experts consulted by the Otology Commission of the SEORL-CCC. RESULTS: A list has been compiled containing the 13 most controversial thematic blocks on the management of VS in the form of 50 questions, and answers to all of them have been sought through a systematic literature review (articles published on PubMed and Cochrane Library between 1992 and 2023 related to each thematic area). Thirty-three experts, led by the Otology Committee of SEORL-CCC, have analyzed and discussed all the answers. In Annex 1, 14 additional questions divided into 4 thematic areas can be found. CONCLUSIONS: This clinical practice guideline on the management of VS offers agreed answers to the most common questions that are asked about this tumour. The absence of sufficient prospective studies means that the levels of evidence on the subject are generally medium or low. This fact increases the interest of this type of clinical practice guidelines prepared by experts.

Parálisis facial: guía de práctica clínica de la Sociedad Española de ORL / Facial paralysis: Clinical practice guideline of the Spanish Society of Otolaryngology

La parálisis de Bell es la forma más común de paresia o parálisis facial. Sin embargo, no todos los pacientes con parálisis facial tienen una parálisis de Bell. Otras causas frecuentes incluyen las secuelas del tratamiento del neurinoma del VIII par, el cáncer de cabeza y cuello, la iatrogenia, el zóster ótico y los traumatismos. El abordaje de cada una de estas situaciones es totalmente diferente. El objetivo de esta guía es servir de consejo para el tratamiento y el seguimiento de los pacientes con parálisis facial. Nuestra idea es que la guía sea práctica, haciendo hincapié en recomendaciones efectivas y útiles en el manejo diario de los pacientes. Esta guía ha sido promovida por la Sociedad Española de ORL y escrita por médicos con experiencia en la enfermedad del nervio facial, incluyendo al menos un especialista de cada comunidad autónoma. Redactada en un formato de preguntas y respuestas, incluye 56 cuestiones relevantes relacionadas con el nervio facial

Bell's palsy is the most common diagnosis associated with facial nerve weakness or paralysis. However, not all patients with facial paresis/paralysis have Bell's palsy. Other common causes include treatment of vestibular schwannoma, head and neck tumours, iatrogenic injuries, Herpes zoster, or trauma. The approach to each of these conditions varies widely. The purpose of this guideline is to provide clinicians with guidance on the treatment and monitoring of patients with different causes of facial paralysis. We intend to draft a practical guideline, focusing on operationalised recommendations deemed to be useful in the daily management of patients. This guideline was promoted by the Spanish Society of Otolaryngology and developed by a group of physicians with an interest in facial nerve disorders, including at least one physician from each Autonomous Community. In a question and answer format, it includes 56 relevant topics related to the facial nerve

Facial paralysis: Clinical practice guideline of the Spanish Society of Otolaryngology. / Parálisis facial: guía de práctica clínica de la Sociedad Española de ORL.

Bell's palsy is the most common diagnosis associated with facial nerve weakness or paralysis. However, not all patients with facial paresis/paralysis have Bell's palsy. Other common causes include treatment of vestibular schwannoma, head and neck tumours, iatrogenic injuries, Herpes zoster, or trauma. The approach to each of these conditions varies widely. The purpose of this guideline is to provide clinicians with guidance on the treatment and monitoring of patients with different causes of facial paralysis. We intend to draft a practical guideline, focusing on operationalised recommendations deemed to be useful in the daily management of patients. This guideline was promoted by the Spanish Society of Otolaryngology and developed by a group of physicians with an interest in facial nerve disorders, including at least one physician from each Autonomous Community. In a question and answer format, it includes 56 relevant topics related to the facial nerve.

¿Es el oído medio el primer filtro de selección frecuencial? / Is the middle ear the first filter of frequency selectivity?

Introducción y objetivos: La cóclea es considerada el primer filtro de selección frecuencial en la vía auditiva debido a la acción contráctil de las células ciliadas externas. Sin embargo numerosas evidencias en animales de experimentación, algunas anatómicas (conexiones entre la vía auditiva y los núcleos motores de los músculos del oído medio) y otras fisiológicas, apuntan a que el oído medio pudiera ser el primer filtro gracias al cual comienza a discriminarse un determinado sonido de un entorno ruidoso. Métodos: En colaboración con el Departamento de Ingeniería Mecánica de la Escuela Técnica Superior (ETS) de Ingenieros Industriales de la Universidad de Valladolid (UVa) hemos desarrollado y puesto a punto un nuevo admitancímetro capaz de analizar los cambios de impedancia que ocurren en el oído medio humano en función de la frecuencia. Con él hemos cuantificado la variación de la impedancia del oído en 7 voluntarios otológicamente sanos sometidos a diferentes entornos sonoros. Resultados: Hemos hallado que la impedancia del oído no es constante sino que la atención que los sujetos explorados ofrecen para discriminar una conversación en un ambiente ruidoso hace que la impedancia del oído varíe en las frecuencias agudas. Conclusiones: A la vista de los resultados consideramos que el oído medio no es un mero actor pasivo durante la audición sino que la contracción de los músculos endotimpánicos hacen posible variaciones de la impedancia de forma que la frecuencia de resonancia del oído se desplace hacia frecuencias agudas mejorando la discriminación de la palabra en ambientes ruidosos (AU)

Introduction and objectives: The cochlea has traditionally been considered as the first frequency selection filter in the auditory pathway due to the contraction of its external ciliated cells. Yet, much evidence has emerged from work carried out during experiments with animals, some of which is anatomical (connections between the auditory pathway and motor nuclei of the middle ear muscles) and other physiological, which indicates that the middle ear might be the first filter through which specific sounds from noisy environments may initially be isolated. Methods: In cooperation with the Department of Mechanical Engineering of the Technical School of Industrial Engineering at the University of Valladolid (UVa) we have developed and refined a new admittance meter capable of evaluating changes in impedance that occur in the human middle ear depending on frequency. Using this device we have measured variation in impedance in 7 otologically healthy volunteers submitted to a varied range of sound environments. Results: We have found that hearing impedance is not constant but rather that the attention offered by the examined subjects when following a conversation in a noisy environment leads to variations in hearing impedance at high frequencies. Conclusions: In the light of these findings we feel that the middle ear does not play a merely passive role in hearing but rather that the contraction of the endotympanic muscles makes possible variations in impedance such that the resonance frequency of the ear shifts towards higher frequencies, thus enhancing sound discrimination in noisy environments (AU)

[Is the middle ear the first filter of frequency selectivity?]. / Es el oído medio el primer filtro de selección frecuencial?

INTRODUCTION AND OBJECTIVES: The cochlea has traditionally been considered as the first frequency selection filter in the auditory pathway due to the contraction of its external ciliated cells. Yet, much evidence has emerged from work carried out during experiments with animals, some of which is anatomical (connections between the auditory pathway and motor nuclei of the middle ear muscles) and other physiological, which indicates that the middle ear might be the first filter through which specific sounds from noisy environments may initially be isolated. METHODS: In cooperation with the Department of Mechanical Engineering of the Technical School of Industrial Engineering at the University of Valladolid (UVa) we have developed and refined a new admittance meter capable of evaluating changes in impedance that occur in the human middle ear depending on frequency. Using this device we have measured variation in impedance in 7 otologically healthy volunteers submitted to a varied range of sound environments. RESULTS: We have found that hearing impedance is not constant but rather that the attention offered by the examined subjects when following a conversation in a noisy environment leads to variations in hearing impedance at high frequencies. CONCLUSIONS: In the light of these findings we feel that the middle ear does not play a merely passive role in hearing but rather that the contraction of the endotympanic muscles makes possible variations in impedance such that the resonance frequency of the ear shifts towards higher frequencies, thus enhancing sound discrimination in noisy environments.

[Inverted acoustic reflex: an analysis of its morphological characteristics in different physiological and pathological situations]. / Reflejo acústico invertido: análisis de sus características morfológicas en distintas situaciones fisiológicas y patológicas.

INTRODUCTION AND OBJECTIVES: Inverted acoustic reflex (IAR) or inverted acoustic effect is the name given to the positive deflexion observed during the carrying out of an admittancemetry when the ear is subjected to a high intensity sound, rather than the typical negative deflexion due to the contraction of the middle ear musculature. The objective of the paper is to analyze the morphology of the IAR by relating it to the situations (physiological or pathological) in which this effect appears with the aim of establishing a pathogenic hypothesis. METHODS: We study the admittance traces obtained in 50 patients on stimulating the ear with high sound intensities (between 100 and 110 dBs HL) in different situations (ageing, death, otosclerosis, facial palsy, perception hypoacusia and normoacusia). We analyse the morphologies of the resulting traces as well as the on-set and off-set latencies of the reflexes. RESULTS: The morphology and latency parameters are similar in all cases in which IAR appears, regardless of the physical conditions of the ear but always with the prior condition of the absence of any contraction of the stapes bone muscle. The inverted acoustic effect does not disappear after deep muscular relaxation induced by anaesthesia and is present in corpses at a time when neural activity can no longer take place. CONCLUSIONS: Although some of the characteristics of IAR cannot be explained by purely mechanical hypotheses, the appearance of this effect in a corpse and its non-disappearance with muscular relaxation means that we consider its origin to be a purely mechanical effect not mediated by any muscular reflex contraction in the human middle ear.

Reflejo acústico invertido: análisis de sus características morfológicas en distintas situaciones fisiológicas y patológicas / Inverted acoustic reflex: An analysis of its morphological characteristics in different physiological and pathological situations

Introducción y objetivos: Se denomina reflejo o efecto acústico invertido (RAI) a la deflexión positiva observada durante la realización de una admitanciometría al someter al oído a un sonido de intensidad elevada, en vez de la típica deflexión negativa debida a la contracción de la musculatura del oído medio. El objetivo del trabajo es analizar la morfología del RAI relacionándola con las situaciones (fisiológicas o patológicas), en las que este efecto aparece con el fin de establecer una hipótesis patogénica. Métodos: Estudiamos los trazados admitanciométricos obtenidos en 50 pacientes al estimular el oído con elevadas intensidades sonoras (entre 100 y 110dB HL) en distintas situaciones (envejecimiento, muerte, otosclerosis, parálisis facial, hipoacusia de percepción y normoacusia). Analizamos las morfologías de los trazados resultantes así como las latencias de aparición y de cese (on-set y off-set) de los reflejos. Resultados: La morfología y los parámetros de latencia son similares en todos los casos en los que el RAI aparece, independientemente de las condiciones físicas del oído, pero siempre con el condicionante previo de ausencia de contracción del músculo del estribo. El RAI no desaparece tras la relajación muscular profunda inducida por la anestesia y está presente en el cadáver cuando ya no puede aparecer actividad neural alguna. Conclusiones: Aunque algunas de las características del RAI no se pueden explicar sirviéndonos de forma exclusiva de hipótesis mecánicas, la aparición de ese efecto en el cadáver y la no desaparición con la relajación muscular hace que consideremos su origen como un efecto puramente mecánico no mediado por contracción refleja muscular alguna en el oído medio humano (AU)

Introduction and objectives: Inverted acoustic reflex (IAR) or inverted acoustic effect is the name given to the positive deflexion observed during the carrying out of an admittancemetry when the ear is subjected to a high intensity sound, rather than the typical negative deflexion due to the contraction of the middle ear musculature. The objective of the paper is to analyze the morphology of the IAR by relating it to the situations (physiological or pathological) in which this effect appears with the aim of establishing a pathogenic hypothesis. Methods: We study the admittance traces obtained in 50 patients on stimulating the ear with high sound intensities (between 100 and 110dBs HL) in different situations (ageing, death, otosclerosis, facial palsy, perception hypoacusia and normoacusia). We analyse the morphologies of the resulting traces as well as the on-set and off-set latencies of the reflexes. Results: The morphology and latency parameters are similar in all cases in which IAR appears, regardless of the physical conditions of the ear but always with the prior condition of the absence of any contraction of the stapes bone muscle. The inverted acoustic effect does not disappear after deep muscular relaxation induced by anaesthesia and is present in corpses at a time when neural activity can no longer take place. Conclusions: Although some of the characteristics of IAR cannot be explained by purely mechanical hypotheses, the appearance of this effect in a corpse and its non-disappearance with muscular relaxation means that we consider its origin to be a purely mechanical effect not mediated by any muscular reflex contraction in the human middle ear (AU)

Influence of G308A polymorphism of tumor necrosis factor-alpha gene on inflammatory markers in postsurgical head and neck cancer patients with early enteral nutrition.

OBJECTIVE: Although immune dysfunction in patients with cancer could be multifactorial, the immune system may be modulated by nutritional substrates and genetic background. Our study evaluated the effect of G308A polymorphism of the tumor necrosis factor-alpha (TNF-alpha) gene on inflammatory markers in patients after surgery for head and neck cancer who received early enteral nutrition. METHODS: A population of 60 patients with oral and laryngeal cancer was enrolled. At surgery patients were treated with a hyperproteic enteral diet. Perioperatively and on postoperative day 6 the following parameters were evaluated: serum values of prealbumin, transferrin, total number of lymphocytes, interleukin-6, TNF-alpha, and C-reactive protein. In addition, genotyping of G308A gene polymorphism was assessed. RESULTS: Patients' mean age was 61.1 +/- 14.6 y (four women, 56 men) with a body mass index of 25.4 +/- 5.2 kg/m(2) and a previous weight loss of 0.35 +/- 0.2 kg. Forty patients (37 men, 3 women; 66.6%) had the genotype G308/G308 (wild group) and 20 patients (19 men, 1 woman; 23.4%) had the genotype G308/A308 (mutant group). A significant increase in prealbumin and transferrin levels was detected in both groups. C-reactive protein decreased in both groups (wild group: 105.1 +/- 60 versus 53.8 +/- 62.3 mg/dL, P < 0.05; mutant group: 99.5 +/- 46 versus 43.9 +/- 51.9 mg/dL, P < 0.05). Interleukin-6 decreased in both groups (wild group: 20.1 +/- 22 versus 6.2 +/- 4.1 pg/mL, P < 0.05; mutant group: 22.3 +/- 38 versus 9.2 +/- 7.4 pg/mL, P = NS). Lymphocytes increased in both groups (wild group: 1102 +/- 468 versus 1600 +/- 537 10(3)/mL, P = NS; mutant group: 1441 +/- 739 10(3)/mL versus 1669 +/- 614 10(6)/mL, P = NS). TNF-alpha showed no changes. CONCLUSION: The G308A polymorphism of the TNF-alpha gene did not affect levels of inflammatory markers in patients after surgery for head and neck cancer who were treated with early enteral nutrition.

[Total idiopathic laryngotracheal stenosis. Treatment with mitomycin C]. / Obstrucción laringotraqueal completa idiopática. Tratamiento con mitomicina C.

This case report involves a 69-year-old woman who presented idiopathic laryngotracheal stenosis with total obstruction of the airway. Seven surgical procedures involving open field and endoscopy techniques had to be performed due to repeated re-obstructions. The novelty in this case is that success was finally obtained with the use of mitomycin C. The drug action is well known, but is interesting to report a case in which success was only obtained when we used mitomycin C.

Obstrucción laringotraqueal completa idiopática. Tratamiento con mitomicina C / Total idiopathic laryngotracheal stenosis. Treatment with mitomycin C

Exponemos el caso de una paciente de 69 años en la que se desarrolló una estenosis laringotraqueal idiopática con obstrucción completa. Se tuvo que intervenir a la paciente 7 veces, con distintas técnicas endoscópicas o abiertas, por reobstrucciones postoperatorias. Lo novedoso del caso es que el éxito final se obtuvo tras la aplicación de mitomicina C. Es conocida la acción de este fármaco, pero tiene interés mostrar un caso complejo en el que sólo se obtiene éxito cuando se aplica mitomicina C

This case report involves a 69-year-old woman who presented idiopathic laryngotracheal stenosis with total obstruction of the airway. Seven surgical procedures involving open field and endoscopy techniques had to be performed due to repeated re-obstructions. The novelty in this case is that success was finally obtained with the use of mitomycin C. The drug action is well known, but is interesting to report a case in which success was only obtained when we used mitomycin C