Is it possible to diagnose Posterior Semicircular Canal BPPV from the sitting position? The role of the Head Pitch Test and the upright tests along the RALP and LARP planes.

PURPOSE: The diagnosis of benign paroxysmal positional vertigo (BPPV) involving the posterior semicircular canal (PSC) is traditionally entrusted to positioning tests where patients are rapidly brought in the supine position. This prospective study aims to define the role of a diagnostic protocol for PSC-BPPV including only upright tests. MATERIALS AND METHODS: 109 patients with PSC-BPPV were enrolled. The Head Pitch Test (HPT) was carried out first. If uneventful, the patient's head was turned 45° to each side and bent back-and-forth along the plane aligning either with the right anterior-left posterior (RALP) or left anterior-right posterior (LARP) canals, thus performing the upright RALP / upright LARP (uRALP/uLARP) test. Nystagmus observed was used to predict the diagnosis, which was therefore confirmed by Dix-Hallpike tests. RESULTS: PSC-BPPV could be correctly diagnosed in 75.2% of cases with the sole HPT and in 87.2% of cases by adding the uRALP/uLARP test (Upright Protocol). The time elapsed from symptoms onset was closely related to the protocol sensitivity, as it reached 100% (64/64) in acute patients while decreased to 68.9% (31/45) in cases evaluated after 7 days (p < 0.001). CONCLUSIONS: Upright maneuvers could correctly diagnose PSC-BPPV in most cases. uRALP/uLARP test demonstrated to improve the sensitivity of the HPT, mainly in recent-onset BPPV.

Alcohol binge-drinking damage on the vestibulo-oculomotor reflex.

PURPOSE: Binge drinking is associated with several adverse effects in multiple organs. This study aimed at evaluating the effects of a binge-like-drinking on the vestibulo-oculomotor reflex (VOR) using the video Head Impulse Test (vHIT) and the functional Head Impulse Test (fHIT). METHODS: Eleven healthy men (age range 32-35 years) with moderate drinking habits and no history of vestibular dysfunction were enrolled. A preliminary assessment of breath alcohol concentration (BrAC) to check for zero alcohol value and a pre-intake evaluation of VOR using the vHIT and the fHIT were carried on. Then, the subjects were asked to take drinks with different alcohol content (8-40% ethanol by volume) according to their choice, consuming at least 5 standard drinks. Volunteers stopped drinking after 3 h. After a further 30 min, post-intake BrAC measurements and VOR analysis were repeated. RESULTS: After alcohol intake, vHIT recorded an overall significant reduction of VOR gain (0.82 ± 0.07 on both sides) although the outcomes were below the normal range only in the four subjects with the highest blood alcohol levels. The post-intake fHIT outcomes were substandard in 9 participants, with a significant deterioration in performance (% of exact answers = 84.54 ± 11.05% on the left, 83.18 ± 14.53 on the right). CONCLUSIONS: Binge drinking severely affects VOR; fHIT seems more sensitive than vHIT in the assessment of VOR function for complex vestibular lesions, such as those determined by ethanol, suggesting that fHIT could support vHIT in vestibular dysfunction assessment.

Predictive markers of long-term recurrence in chronic rhinosinusitis with nasal polyps.

BACKGROUND: In last years, many attempts were made to recognize chronic rhinosinusitis with nasal polyps (CRSwNP) phenotypes focusing on identifying relevant key pathogenic molecules. Polyps recurrence rate ranges from 4% to 60%, so it's clear that not all clinical and immunologic factors associated with recurrence are known. OBJECTIVE: We investigate the inflammatory profile in patients with long term recurrent and non-recurrent CRSwNPs and if a specific profile is associated with recurrence, comparing eosinophilic, neutrophilic and lymphocytic infiltration, as well as IL-5 and IL-8 expression to long term recurrence rate. METHODS: This prospective study included 44 adult patients with CRSwNP treated with endoscopic sinus surgery between 2008 and 2010. Long term follow-up data (8-10 years) indicated that among 44 patients, 18 (40.1%) experienced long term recurrence of nasal polyposis needing maximal medical treatment or revision surgery. We realized two groups: one with patients who didn't present long term recurrence (26 patients) and another with patients who presented long term recurrence (18 patients) and in both groups eosinophilic, neutrophilic and lymphocytic infiltration and IL-5 and IL-8 expression were measured. RESULTS: The parameters that reached statistical significance (p < 0.05) comparing the two groups were eosinophilic infiltration and IL-5 expression, whereas neutrophilic and lymphocytic infiltration, as IL-8 expression didn't show any significant difference. Asthma and aspirin intolerance seemed significantly more frequent in patients with recurrence, while allergy presented not statistically significant difference between two groups. CONCLUSIONS: We can conclude that high eosinophilic infiltration and high IL-5 expression in CRSwNP correlate with higher rate of long term recurrence, while neutrophilic and lymphocytic infiltration, and IL-8 expression don't correlate with it. These findings provide the opportunity to improve our ability to predict the prognosis of surgical intervention, although it is still needed to explore the optimal predictor of outcome in CRSwNP.

Does cervical range of motion affect the outcomes of canalith repositioning procedures for posterior canal benign positional paroxysmal vertigo?

PURPOSE: Canalith repositioning procedure (CRP) for posterior canal benign positional paroxysmal vertigo (BPPV), also known as Epley maneuver, is a common procedure for the treatment of BPPV. This maneuver entails flexion, extension and rotation of the patient's neck. This study aims to investigate the impact of cervical range of motion (C-ROM) on CRP efficacy. MATERIALS AND METHODS: The study included 47 patients with posterior canal BPPV treated by CRP. The procedure was considered successful if vertigo and nystagmus disappeared at the post-treatment evaluation. If CRP resulted ineffective, it was repeated up to three times per session. C-ROM was measured at BPPV diagnosis before treatment. Patients were followed up for 30 days. RESULTS: The first CRP was successful in 29 patients (61.7%), while it was ineffective in 18 patients (38.3%) requiring multiple repositioning maneuvers. Patients who needed two or more CRP showed lower C-ROM in extension (p = .003) and flexion (p = .042), and earlier recurrences (p = .006). Univariate regression analysis showed that lower cervical extension was significantly associated with the failure of the first CRP (OR: 0.899, 95% CI 0.831-0.973, p = .008). CONCLUSIONS: Our data suggest that a reduced C-ROM can require multiple CRPs to successfully treat BPPV and increase the risk of early recurrences.

Assistance Dogs for Persons with Hearing Impairment: A Review.

The use of dogs to help people with disabilities has been known for a long time. Assistance dogs carry out a variety of practical tasks for disabled people with appropriate and targeted training, including assisting deaf persons or people with profound hearing loss. The benefits of assistance dogs for persons with hearing impairment (hearing dogs) include a) improved ability to carry out daily tasks through the codified reporting of sounds proper of everyday life and/or of dangerous situations and b) psychosocial aspects such as companionship and sense of protection. The benefits derived from the use of assistance dogs for persons with hearing impairment are less studied compared to those of assistance dogs employed for other disabilities. Moreover, the role of hearing dogs may appear rather controversial considering technological advances in the field of surgical or prosthetic rehabilitation for people with hearing impairment. This article aims to review features and training of hearing dogs, the effects of their employment and legislative aspects for their owners.

Case report: human papilloma virus type 120-related papillomatosis mimicking laryngeal carcinoma.

INTRODUCTION: The relationship between human papilloma virus (HPV) and upper respiratory tract pathology was better understood in recent years and represents now an issue of particular interest in carcinogenesis and in immunocompromised host. We describe a case in which a rare genotype HPV-related papillomatosis mimics laryngeal carcinoma in an immunocompromised host. METHODS: A 54-year-old woman with a history of HIV-HCV coinfection and anal and laryngeal cancer successfully treated some years before was hospitalized for severe dyspnea, cough and dysphagia. Fiberoptic endoscopic evaluation raised the suspicion of tumor relapse showing the presence of a large glottic-supraglottic ulcerated mass. Several laryngeal biopsies demonstrated koilocytosis and p16 expression, according to a possible HPV infection, and focal figures of mild dysplasia of epithelium. 18 F-FDG PET/CT did not show high glycolytic activity at laryngeal level. An invasive upper respiratory tract papillomatosis in an immunocompromised host was suspected because of the patient's clinical improvement after antiretroviral therapy. CONCLUSION: Pharyngeal swab and oral rinse harboured the same HPV120 genotype sequence, a betapapillomavirus of recent description and not yet related to any similar clinical presentations.

EMLA(®) cream as local anesthetic for radiofrequency turbinate tissue reduction.

Radiofrequency volumetric tissue reduction is a minimally invasive technique in the treatment of turbinate hypertrophy and is generally performed under local anesthesia. However, perioperative discomfort and pain are common side effects and studies concerning the technique of choice to anesthetize the nasal mucosa in this procedure are lacking. The aim of this prospective controlled trial is to assess the effectiveness of EMLA(®) cream as a topical anesthetic for radiofrequency volumetric tissue reduction of inferior turbinates comparing its effect with that obtained using a traditional anesthetic technique. 200 consecutive patients undergoing volumetric tissue reduction with topical anesthesia were enrolled. Patients were divided into two groups: Group A included 100 patients treated by placing cotton pledgets soaked with lidocaine 10% in the inferior meatus followed by the injection of 2% lidocaine into the head of the inferior turbinate; Group B included 100 patients treated with EMLA(®) cream. Patients were evaluated before and after surgery using rhinomanometry for obstructive symptoms. Four VAS about pain, troublesome swallowing, choking sensation and intraoperative anxiety were submitted to each patient immediately after surgery and after 2 months to assess various aspects of perioperative discomfort. A significant increase of nasal airflow was observed without differences between the two groups. Subjective evaluation regarding perioperative discomfort showed significant differences between Groups A and B immediately after surgery although it was less pronounced 2 months later. The results of this study suggest that EMLA(®) cream is an efficient tool in obtaining an adequate anesthetic effect in this procedure.

Audiovestibular Findings in Patients with Concurrent Superior Canal Dehiscence and Vestibular Schwannoma.

OBJECTIVE: To describe the clinical-instrumental findings in case of concurrent superior canal dehiscence (SCD) and ipsilateral vestibular schwannoma (VS), aiming to highlight the importance of an extensive instrumental assessment to achieve a correct diagnosis. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Five patients with concurrent SCD and VS. INTERVENTION: Clinical-instrumental assessment and imaging. MAIN OUTCOME MEASURE: Clinical presentation, audiovestibular findings, and imaging. RESULTS: The chief complaints were hearing loss (HL) and unsteadiness (80%). Other main symptoms included tinnitus (60%) and pressure-induced vertigo (40%). Mixed-HL was identified in three patients and pure sensorineural-HL in 1, including a roll-over curve in speech-audiometry in two cases. Vibration-induced nystagmus was elicited in all cases, whereas vestibular-evoked myogenic potentials showed reduced thresholds and enhanced amplitudes on the affected side in three patients. Ipsilesional weakness on caloric testing was detected in three patients and a bilateral hyporeflexia in one. A global canal impairment was detected by the video-head impulse test in one case, whereas the rest of the cohort exhibited a reduced function for the affected superior canal, together with ipsilateral posterior canal impairment in two cases. All patients performed both temporal bones HRCT scan and brain-MRI showing unilateral SCD and ipsilateral VS, respectively. All patients were submitted to a wait-and-scan approach, requiring VS removal only in one case. CONCLUSION: Simultaneous SCD and VS might result in subtle clinical presentation with puzzling lesion patterns. When unclear symptoms and signs occur, a complete audiovestibular assessment plays a key role to address imaging and diagnosis.

Posterior Semicircular Canal Dehiscence with Vestibulo-Ocular Reflex Reduction for the Affected Canal at the Video-Head Impulse Test: Considerations to Pathomechanisms.

Posterior semicircular canal dehiscence (PSCD) has been demonstrated to result in a third mobile window mechanism (TMWM) in the inner ear similar to superior semicircular canal dehiscence (SSCD). Typical clinical and instrumental features of TMWM, including low-frequency conductive hearing loss (CHL), autophony, pulsatile tinnitus, sound/pressure-induced vertigo and enhanced vestibular-evoked myogenic potentials, have been widely described in cases with PSCD. Nevertheless, video-head impulse test (vHIT) results have been poorly investigated. Here, we present six patients with PSCD presenting with a clinical scenario consistent with a TMWM and an impaired vestibulo-ocular reflex (VOR) for the affected canal on vHIT. In two cases, an additional dehiscence between the facial nerve and the horizontal semicircular canal (HSC) was detected, leading to a concurrent VOR impairment for the HSC. While in SSCD, a VOR gain reduction could be ascribed to a spontaneous "auto-plugging" process due to a dural prolapse into the canal, the same pathomechanism is difficult to conceive in PSCD due to a different anatomical position, making a dural herniation less likely. Alternative putative pathomechanisms are discussed, including an endolymphatic flow dissipation during head impulses as already hypothesized in SSCD. The association of symptoms/signs consistent with TMWM and a reduced VOR gain for the posterior canal might address the diagnosis toward PSCD.

Tracheostomal stenosis clinical risk factors in patients who have undergone total laryngectomy and adjuvant radiotherapy.

Adjuvant chemotherapy, advanced age, smoking, cardiopathies, diabetes, local infections, impaired immunocompetence, and malnutrition are potential cofactors in the genesis of aberrant wound healing and may thus play an important role in the genesis of tracheostomal stenosis. The aim of the study is to analyse the influence of the above-mentioned local and systemic risk factors in determining tracheostomal stenosis in patients who have undergone total laryngectomy and adjuvant radiotherapy. In 79 % of the cases, tracheostomal stenosis occurred within 12 months of surgery. Diabetes mellitus and local infection were the only factors that showed a statistically significant difference according to univariate and multivariate analysis. Diabetes mellitus and the related tracheostomal infection may be considered as risk factors for TS in patients who have undergone total laryngectomy and adjuvant radiotherapy.

Glycyrrhizin and Mannitol Nasal Therapy: Cytological and Clinical Outcomes in Chronic Rhinitis.

Introduction Chronic rhinitis (CR) represents a widespread inflammation with a high incidence in the general population. Although it is generally considered a benign condition, CR has a relevant impact on quality of life and requires a specific treatment approach. Objective The aim of the present study was to investigate the efficacy of glycyrrhizin and mannitol intranasal treatment on chronic rhinitis using cytological analysis and subjective evaluation of symptoms. Methods A total of 55 patients suffering from chronic rhinitis were enrolled in the present study, 34 with allergic rhinitis (AR) and 21 with nonallergic rhinitis (NAR). The severity of four different nasal symptoms was determined by using a visual analogue scale (VAS). Specimens obtained by nasal scraping were collected for cytological analysis. Data were acquired before and after a 30-day treatment with glycyrrhizin and mannitol nasal spray. Statistical analyses were performed. Results The VAS scores for all four nasal symptoms considered in the present study, as well as for neutrophil cells, reduced significantly after therapy in both allergic and nonallergic patients. The number of eosinophils was not significantly lower in nonallergic patients. Conclusion A 30-day topical treatment with glycyrrhizin and mannitol may improve nasal symptoms and reduce inflammatory cells in the nasal mucosa in patients with chronic rhinitis without significant contraindications. Further studies could support our results and would better clarify all the aspects of this treatment.

Low-Frequency Air-Bone Gap and Pulsatile Tinnitus Due to a Dural Arteriovenous Fistula: Considerations upon Possible Pathomechanisms and Literature Review.

Low-frequency air-bone gap (ABG) associated with pulsatile tinnitus (PT) and normal impedance audiometry represents a common finding in patients with third window syndromes. Other inner disorders, including Meniere's disease (MD), perilymphatic fistula and intralabyrinthine schwannoma, might sometimes result in a similar scenario. On the other hand, PT is frequently associated with dural arteriovenous fistula (DAVF), while conductive hearing loss (CHL) is extremely rare in this clinical setting. A 47-year-old patient was referred to our center with progressive left-sided PT alongside ipsilateral fullness and hearing loss. She also experienced headache and dizziness. Otoscopy and video-oculographic examination were unremarkable. Conversely, a detailed instrumental audio-vestibular assessment revealed low-frequency CHL with normal impedance audiometry, slight left-sided caloric weakness, slightly impaired vestibular-evoked myogenic potentials on the left and normal results on the video-head impulse test, consistent with an MD-like instrumental profile. Gadolinium-enhanced brain MRI revealed an early enhancement of the left transverse sinus, consistent with a left DAVF between the left occipital artery and the transverse sinus, which was then confirmed by angiography. A trans-arterial embolization with Onyx glue was performed, resulting in a complete recession of the symptoms. Post-operatively, the low-frequency ABG disappeared, supporting the possible role of venous intracranial hypertension and abnormal pressure of inner ear fluids in the onset of symptoms and offering new insights into the pathomechanism of inner ear CHL.

Malignant trichilemmal carcinoma misdiagnosed with parotid gland malignant tumor.

Malignat proliferating trichilemmal tumor (MPTT) are rare tumors usually presenting in photo-exposed areas, especially on the face, scalp, neck,and dorsal part of the hand. Differential diagnosis include squamous cell carcinoma, basal-cell carcinoma, keratoacanthoma and malignant nodular melanoma, so that only incisional biopsy can lead to pre-operative diagnosis. We present case MPTT misdiagnosed with parotid gland malignant tumor that underwent radical surgical excision and adijuvant radiotherapy.

Surgical treatment of nasal non-melanoma skin cancer using full-thickness skin graft: can antiplatelet therapy be related to a better result?

AIM: The aim of this retrospective study is to evaluate if antiplatelet therapy in elderly patients undergoing surgical excision of nasal non-melanoma skin cancer and contemporary reconstruction with full-thickness skin graft can be related to a better vitality of the graft and consequently improved aesthetic result. MATERIALS AND METHODS: Patients affected by BCC or SCC of the nose that underwent surgical excision and contemporary reconstruction with full-thickness skin graft were divided into two groups according to antiplatelet therapy. Medications were performed 7 and 15 days after surgery. To asses engraftment, we clinically evaluated the percentage of vital flap recognizing 3 different results: less than 20%, between 20% and 80%, and more than 80% of vital surface. Finally, patients were asked to express a subjective evaluation of the aesthetic result using a numeric scale ranging from 1 to 10. Statistical analyses were performed with SPSS 15.0 for Windows. RESULTS: Twenty-four of the 36 eligible patients took antiplatelet therapy (Group 1). Statistical analysis was very close to demonstrate a significant difference between the two groups after the first evaluation (X2= 3.6; p-value = 0.0578) and it showed a clear significant difference between the two groups after the second evaluation (X2 = 13.5692 e p-value = 0.0002). The average value of the subjective evaluation conducted only on 32 of 36 patients, was 9.12. Any significant difference was observed between the two groups (p-value >0.1). CONCLUSIONS: Our preliminary results seem to suggest that antiplatelet therapy in elderly patients with non-melanoma skin cancer of the nose treated with surgical excision and contemporary reconstruction with fill-thickness skin graft could favor the graft vitality with low risk of bleeding. Further studies will be useful to determinate if antiplatelet drugs can be prescribed in the perioperative period to selected patients presenting risk factors for wound healing to increase the chances of engraftment. KEY WORDS: Antiplatelet Therapy, Non Melanoma Skin Cancer, Skin Graft.

Impaired Vestibulo-Ocular Reflex on Video Head Impulse Test in Superior Canal Dehiscence: "Spontaneous Plugging" or Endolymphatic Flow Dissipation?

Surgical plugging of the superior semicircular canal (SSC) represents an effective procedure to treat disabling symptoms in superior canal dehiscence (SCD), despite resulting in an impaired vestibulo-ocular reflex (VOR) gain for the SSC. On the other hand, SSC hypofunction on video head impulse test (vHIT) represents a common finding in patients with SCD exhibiting sound/pressure-induced vertigo, a low-frequency air-bone gap (ABG), and enhanced vestibular-evoked myogenic potentials (VEMPs). "Spontaneous canal plugging" has been assumed as the underlying process. Nevertheless, missing/mitigated symptoms and/or near-normal instrumental findings would be expected. An endolymphatic flow dissipation has been recently proposed as an alternative pathomechanism for SSC VOR gain reduction in SCD. We aimed to shed light on this debate by comparing instrumental findings from 46 ears of 44 patients with SCD exhibiting SSC hypofunction with post-operative data from 10 ears of 10 patients with SCD who underwent surgical plugging. While no difference in SSC VOR gain values was found between the two groups (p = 0.199), operated ears developed a posterior canal hypofunction (p = 0.002). Moreover, both ABG values (p = 0.012) and cervical/ocular VEMP amplitudes (p < 0.001) were significantly higher and VEMP thresholds were significantly lower (p < 0.001) in ears with SCD compared to operated ears. According to our data, canal VOR gain reduction in SCD should be considered as an additional sign of a third window mechanism, likely due to an endolymphatic flow dissipation.

Vestibular assessment in sudden sensorineural hearing loss: Role in the prediction of hearing outcome and in the early detection of vascular and hydropic pathomechanisms.

Introduction: Predicting hearing outcome in sudden sensorineural hearing loss (SSNHL) is challenging, as well as detecting the underlying pathomechanisms. SSNHL could be associated with vestibular damage since cochleo-vestibular structures share the same vascularization, along with being in close anatomical proximity. Whereas viral inflammations and autoimmune/vascular disorders most likely represent the involved aetiologies, early-stage Menière's disease (MD) can also present with SSNHL. Since an early treatment could beneficially influence hearing outcome, understanding the possible etiology plays a pivotal role in orienting the most appropriate treatment. We aimed to evaluate the extent of vestibular damage in patients presenting with SSNHL with or without vertigo, investigate the prognostic role of vestibular dysfunctions on hearing recovery and detect specific lesion patterns related to the underlying pathomechanisms. Methods: We prospectively evaluated 86 patients with SSNHL. Audio-vestibular investigation included pure-tone/speech/impedance audiometry, cervical/ocular-VEMPs, vHIT and video-Frenzel examination. White matter lesions (WML) were evaluated on brain-MRI. Patients were followed-up and divided into "SSNHL-no-vertigo," "SSNHL+vertigo" and "MD" subgroups. Results: Hearing was more impaired in "SSNHL+vertigo" patients who exhibited either down-sloping or flat-type audiograms, and was less impaired in "MD" where low frequencies were mostly impaired (p < 0.001). Otolith receptors were more frequently involved than semicircular canals (SCs). Although the "SSNHL-no-vertigo" subgroup exhibited the lowest vestibular impairment (p < 0.001), 52% of patients developed otolith dysfunctions and 72% developed nystagmus. Only "MD" subjects showed anterior SC impairment and upbeating spontaneous/positional nystagmus. They more frequently exhibited cervical-VEMPs frequency tuning (p = 0.036) and ipsilesional spontaneous nystagmus (p < 0.001). "SSNHL+vertigo" subjects presented with more frequently impaired cervical-VEMPs and posterior SC and with higher number of impaired receptors (p < 0.001). They mainly exhibited contralesional spontaneous and vibration-induced nystagmus (p < 0.05) and only they showed the highest WML score and "vascular" lesion patterns (p < 0.001). Concerning the outcomes, hearing was better in "MD" and worse in "SSNHL+vertigo" (p < 0.001). Hearing recovery was mostly affected by cervical-VEMPs impairment and the number of involved receptors (p < 0.05). Patients with "vascular" lesion patterns presented with the highest HL degree and WML score (p ≤ 0.001), while none of them exhibited a complete hearing recovery (p = 0.026). Conclusions: Our data suggest that vestibular evaluation in SSNHL can provide useful information on hearing recovery and underlying aetiologies.

Post-Infectious Acute Cerebellar Ataxia Treatment, a Case Report and Review of Literature.

BACKGROUND: infectious mononucleosis is very common during childhood and neurological manifestations are extremely rare. However, when they occur, an appropriate treatment must be undertaken to reduce morbidity and mortality as well as to ensure appropriate management. METHODS: we describe the clinical and neurological records of a female patient with post-EBV acute cerebellar ataxia, whose symptoms rapidly resolved with intravenous immunoglobulin therapy. Afterwards, we compared our results with published data. RESULTS: we reported the case of an adolescent female with a 5-day history of sudden asthenia, vomiting, dizziness, and dehydration, with a positive monospot test and hypertransaminasemia. In the following days, she developed acute ataxia, drowsiness, vertigo, and nystagmus with a positive EBV IgM titer, confirming acute infectious mononucleosis. The patient was clinically diagnosed with EBV-associated acute cerebellitis. A brain MRI showed no acute changes and a CT scan showed hepatosplenomegaly. She started therapy with acyclovir and dexamethasone. After a few days, because of her condition's deterioration, she received intravenous immunoglobulin and demonstrated a good clinical response. CONCLUSIONS: although there are no consensus guidelines for the treatment of post-infectious acute cerebellar ataxia, early intervention with intravenous immunoglobulin might prevent adverse outcomes, especially in cases that do not respond to high-dose steroid therapy.

Endoscopic treatment of benign and malignant strictures of the cervical esophagus and hypopharynx.

OBJECTIVES: We evaluated the efficacy of endoscopic techniques employed in the management of cervical esophageal and hypopharyngeal strictures. METHODS: A series of 45 patients with cervical esophageal (35) and/or hypopharyngeal strictures (10) were included. Twenty-five patients (55.6%) with neoplastic strictures were treated for palliation alone. The stenosis was related to radiotherapy in 11 patients (24.4%) and to postsurgical complications in 9 (20%). A group of 23 patients was treated with dilation alone (group 1). A second group included 22 patients treated with insertion of a self-expandable stent after failure of dilation treatment (group 2). The swallowing test data, clinical notes, and surgical reports were reviewed. RESULTS: All of the patients showed some degree of relief of dysphagia. In group 1, 19 of the 23 patients required multiple dilation treatments to maintain normal deglutition. In group 2, 7 of the 22 patients recovered regular oral feeding after stent placement, 10 patients reported pain and foreign body sensation, 2 patients reported pain so severe that stent removal was required, and 3 patients experienced stent migration. All but 3 of the 25 patients with inoperable tumors died during follow-up, but no patients with benign stenosis died. CONCLUSIONS: The two groups showed comparable functional results. Dilation often requires multiple procedures, but is usually well tolerated. Placement of self-expandable stents is effective, but is generally less well tolerated.

Minimum Stimulus Strategy: A step-by-step diagnostic approach to BPPV.

Benign Paroxysmal Positional Vertigo (BPPV) is among the most common vestibular disorders, characterized by brief vertigo spells triggered by head position changes with abrupt onset and rapid decrease. BPPV is ascribed to otoconial matter dislodged from utricular macula and attached to the cupula of the affected semicircular canal (cupulolithiasis) or free-floating within its lumen (canalolithiasis). According to the vestibulo-ocular reflex pathophysiology, each cupular deflection, either exciting or inhibiting the corresponding ampullary afferents, generates the contraction of specific extraocular muscles couples leading to pathognomonic nystagmus. The Upright BPPV Protocol (UBP) is a diagnostic approach to BPPV conducted in the sitting position slowly bending the patient's head along the spatial axes, aiming to move canaliths by gravity within the involved semicircular canal, under continuous nystagmus monitoring by video-Frenzel goggles. UBP starts with the evaluation of pseudo-spontaneous nystagmus in the primary gaze position and continues with the upright Head Pitch Test (uHPT) by forward and backward head bendings along the pitch plane. The uHPT can indicate whether horizontal or vertical semicircular canal is involved. If horizontal canal is suspected, the upright Head Roll Test (uHRT) usually provides the diagnosis of the involved side and arm by tilting the patient's head rightward and leftward along the roll plane. Conversely, canalolithiasis involving the posterior semicircular canal can be diagnosed with the uHPT alone. Nevertheless, if necessary, the diagnostic sensitivity can be increased by head movements along the right anterior - left posterior (RALP) and left anterior - right posterior (LARP) canal planes (uRALP/uLARP test). Following the UBP, most BPPV form can be diagnosed in upright position, allowing clinicians to proceed immediately with proper physical treatment and avoiding unpleasant maneuvers to patients.