Precision treatment of post pneumonectomy unilateral laryngeal paralysis due to cancer.

Aim: The aim of this study is to assess the efficacy of external laryngeal medialization acquired through a Gore-Tex implant in a 45 patients affected by unilateral vocal fold paralysis in abduction after pneumonectomy. Method: The cohort of patients was made up of 30 male (73.1%) and 11 female patients (26.9%) with an average age of 66.7 years in a range between 46 and 78 years. Results: The results were analyzed with the objective and subjective analysis of voicing and swallowing. In 95.2% of cases, voice and swallow improvement with statistically significant evidences. Conclusion: We can conclude that Gore-Tex implantation is a simple, reproducible and minimally invasive procedure for management of selected cases of vocal fold unilateral paralysis in the abductory position.

The senile functional evolution of the larynx after supracricoid reconstructive surgery.

Supracricoid partial laryngectomy is a relevant organ-preserving surgical technique used for the treatment of early or locally advanced laryngeal tumors with an oncologic outcome comparable with that of total laryngectomy. This reconstructive surgery is certainly technically feasible also in the elderly, but the problem is postoperatively as the patient may lack the will and strength to be successfully rehabilitated. The goal was to evaluate functional outcomes, in a maximum follow-up period of ten years from the end of the postoperative follow-up, in a cohort of elderly patients to look at the senile evolution of the laryngeal post surgical function comparing the amount of resection and grade of possible impairment of swallowing and phonatory parameters. A group of 33 patients were selected for a retrospective study aimed at evaluating the long-term evolution of laryngeal functionality after surgery, with the baseline at 5 years from the end of follow-up. All the patients had three-monthly visits for a period up to ten years, during which the objective and subjective swallowing and phonatory parameters were recorded, analyzed and, at the end of the study, compared with baseline. The results suggest that long-term post surgical functional problems may develop also in the neolarynx where the effects of the reconstructive surgery, on speech and swallowing, are largely stabilized. The presence of arytenoid resection had significantly impacted on the occurrence of aspiration even if the overall number of dysphagic patients was not statistically significant compared to baseline.

Heat shock proteins and hormesis in the diagnosis and treatment of neurodegenerative diseases.

Modulation of endogenous cellular defense mechanisms via the vitagene system represents an innovative approach to therapeutic intervention in diseases causing chronic tissue damage, such as in neurodegeneration. The possibility of high-throughoutput screening using proteomic techniques, particularly redox proteomics, provide more comprehensive overview of the interaction of proteins, as well as the interplay among processes involved in neuroprotection. Here by introducing the hormetic dose response concept, the mechanistic foundations and applications to the field of neuroprotection, we discuss the emerging role of heat shock protein as prominent member of vitagene network in neuroprotection and redox proteomics as a tool for investigating redox modulation of stress responsive vitagenes. Hormetic mechanisms are reviewed as possibility of targeted therapeutic manipulation in a cell-, tissue- and/or pathway-specific manner at appropriate points in the neurodegenerative disease process.

Effects of guidelines on adeno-tonsillar surgery on the clinical behaviour of otorhinolaryngologists in Italy.

BACKGROUND: Several guidelines on adeno-tonsillar disease have been proposed in recent years and some discrepancies in relation both to clinical manifestations and indications for surgical treatment have emerged. The aim of the study was to verify what influence (adeno)-tonsillectomy guidelines have had on the clinical behaviour of ENT specialists in Italy. Our study is a retrospective and multi-centre case series with chart review. METHODS: The survey involved 14,770 children, aged between the ages of 2 and 11, who had undergone adeno-tonsillar surgery between 2002 and 2008 in fourteen Italian tertiary and secondary referral centres. Anova test was used for the statistical analysis, assuming p < 0.05 as the minimum statistical significance value. RESULTS: The frequency of adeno-tonsillar surgeries did not change significantly (p>0.05) during the study period and following the Italian policy document publication. Overall, adeno-tonsillectomy was the most frequent intervention (64.1%), followed by adenoidectomy (31.1%) and tonsillectomy (4.8%). The indications for surgery did not change significantly for each of the operations (p>0.05), with the exception of adeno-tonsillectomy in case of feverish episodes due to acute recurrent tonsillitis ≥ 5 without nasal obstruction (decreased p= 0.010) , even when the feverish episodes due to acute recurrent tonsillitis were < 5 over the last year. Nasal obstruction was associated with feverish episodes due to acute recurrent tonsillitis in 65.2% of operated cases, while otitis media had been diagnosed in 43.3% of the patients studied. CONCLUSIONS: The recommendations first developed in Italy in a 2003 policy document and then resumed in guidelines in 2008, were not implemented by ENT units involved in the survey. The study highlights the fact that the indications for adeno-tonsillar operations are based on the overall clinical presentation (comorbidity) rather than on a single symptom. Guidelines are necessary to give coherent recommendations based on both the findings obtained through randomized controlled trials and the data collected from observational studies.

Post laryngectomy speech rehabilitation outcome in elderly patients.

The aim of our work has been to evaluate the different options of tracheoesophageal voice rehabilitation in over 70-year-old patients, who had undergone laryngectomy, assessing advantages and drawbacks of this method of vocal recovery. A retrospective study has been carried out. This has included 40 subjects, all aged more than 70 years old, who have been referred to tracheoesophageal voice rehabilitation. It has been realized a phonatory fistula between trachea and esophagus with prosthesis positioning by means of a primary puncture in 18 cases and it has been realized a secondary puncture in 22 cases. The results gathered in these patients were compared with data obtained from a group made of 39 patients, less than 70 years of age that therefore represented our control group. In primary tracheoesophageal puncture (TEP), the short-term success was 67 %, while in the 22 cases who underwent secondary TEP, the short-term success was 64 %. After 2 years from TEP, the long-term success was 82.5 %. In the control group, the short-term success was 65 % in primary TEP and 73 % in secondary TEP. After 2 years from TEP, the long-term success was 77 %. The evaluation of the results has shown the absence of a statistically significant difference both as regards complications incidence, during and after surgery (p > 0.9) and as regards overall success ratio of prosthesis implants between the two groups (p > 0.7). The possibilities of tracheoesophageal recovery of elderly patients do not show dissimilarities in comparison with the results in younger subjects.

Detection of serum IgA to HSV1 and its diagnostic role in sudden hearing loss.

A viral etiology of sudden hearing loss has been hypothesized by many authors. HSV1 neurotropism and its involvement in sudden hearing loss has implicated HSV1 as one of the most accredited etiological agents. A non-invasive method such as the titration of HSV1-specific IgA was evaluated to determine the role of HSV1 as a possible cause sudden hearing loss. A prospective study was carried out by titration of serum IgA to HSV1 in 93 patients and in a control group of 50 healthy subjects and 35 subjects suffering from recent herpes labialis reactivation. Statistical analysis of the results disclosed that IgA titers to HSV1 higher than 1:80 are suggestive for the association of HSV1 infection and sudden hearing loss. Moreover, acyclovir therapy was effective in 81% of patients who showed high specific IgA titers. Overall, the titration of specific serum IgA to HSV1 can be a useful tool to determine the viral etiology of certain cases of sudden hearing loss. This method is simple to perform and minimally invasive. It can lead to a rapid presumptive diagnosis and to prompt specific therapy, reducing the need for corticosteroids.

Gastroesophageal reflux disease and postlaryngectomy tracheoesophageal fistula.

The objective of this study is to evaluate the incidence of pathologic gastroesophageal reflux in laryngectomized patient with phonatory prosthesis, analyzing potential related problems and appraising, at the same time, the effectiveness of a therapeutic protocol. A retrospective study was conducted on 43 phonatory prosthesis patients who had problems with regard to recurrent tracheoesophageal granulations, the need of frequent prosthesis replacement, within a 3-month period, and unsatisfactory vocal results. Such patients underwent physical examination of the fistula region and of the neopharynx and were submitted to esophagogastroduodenoscopy. Moreover the group of patients underwent a therapeutic protocol and were re-evaluated posttreatment, examining fistula region both on the tracheal side and on the esophageal side through videolaryngostroboscopy. Of the 43 recruited patients 13 (30%) presented tracheoesophageal granulations, 20 (46.5%) unsatisfactory vocal results and 10 (23.5%) frequent prosthesis replacement, within a 3-month period, due to abnormal biofilm development. In particular, of the 13 patients who had recurrent granulations, the evaluation results revealed the presence of gastroesophageal reflux disease (GERD) in 6 cases (46%). In the group of patients presenting unsatisfactory vocal results GERD was shown in 13 cases (65%). In the third group of patients GERD was found in two cases (20%). The overall analysis of the data gathered, allowed to identify GERD in 21 (49%) of the 43 patients submitted to the study. The results posttreatment indicated, in the first group, the disappearance or a significant (>75%) volume reduction of such formation in five cases (38%, p = 0.002). In the second group an overall improvement in the quality of voice was displayed at least for 12 patients (60%, p = 0.0001). Finally in the last group an increase of the prosthesis life was recorded in four (40%, p = 0.05) of the ten patients who had the need of prosthesis replacement within 3 months. Also the 22 GERD negative cases (51%) underwent the treatment, therefore representing the control group, whose posttreatment results showed substantial modifications in just two cases (9%). The data obtained suggest a high degree of correlation between the presence of pathologic gastric reflux and the partial or total prosthesis failure. The introduction of a specific therapeutic protocol has allowed to improve the quality of prosthesis (QoP) in 22 of the 43 patients (p < 0.001) who had a pathologic condition of the fistula and of the prosthesis.

Multi-disciplinary clinical protocol for the diagnosis of bulbar amyotrophic lateral sclerosis.

INTRODUCTION AND OBJECTIVES: The objective of this study was to examine the role of different specialists in the diagnosis of amyotrophic lateral sclerosis (ALS), to understand changes in verbal expression and phonation, respiratory dynamics and swallowing that occurred rapidly over a short period of time. MATERIALS AND METHODS: 22 patients with bulbar ALS were submitted for voice assessment, ENT evaluation, Multi-Dimensional Voice Program (MDVP), spectrogram, electroglottography, fiberoptic endoscopic evaluation of swallowing. RESULTS: In the early stage of the disease, the oral tract and velopharyngeal port were involved. Three months after the initial symptoms, most of the patients presented hoarseness, breathy voice, dysarthria, pitch modulation problems and difficulties in pronunciation of explosive, velar and lingual consonants. Values of MDVP were altered. Spectrogram showed an additional formant, due to nasal resonance. Electroglottography showed periodic oscillation of the vocal folds only during short vocal cycle. Swallowing was characterized by weakness and incoordination of oro-pharyngeal muscles with penetration or aspiration. CONCLUSIONS: A specific multidisciplinary clinical protocol was designed to report vocal parameters and swallowing disorders that changed more quickly in bulbar ALS patients. Furthermore, the patients were stratified according to involvement of pharyngeal structures, and severity index.

Management of dysphagia in multiple sclerosis: current best practice.

INTRODUCTION: Multiple sclerosis (MS) is characterized by extreme variability in both severity and clinical course. It can show severe disabling symptoms, and among them dysphagia is frequently described. However, its management still represents a challenge in the daily care. Areas covered: In this review, we will focus on the clinical recognition and therapeutic strategies to identify and manage dysphagia in people with MS. In the view of a personalized approach, different interventions should be tailored to every single patient. Expert commentary: Multidisciplinary evaluation is mandatory in MS management, and dysphagia represents a perfect model of taking care of a disabling symptom in a chronic disease. Further research is required to better organize a personalized and long-term management of dysphagia phenomenon, through the different subtypes of MS.

Prospective study on the cytological aspects of the nasal respiratory epithelium in premenopausal women taking 30 mcg ethinylestradiol and 3 mg drospirenone oral contraceptive.

BACKGROUND: This study was conducted to determine the effects of the monophasic oral contraceptive (OC) containing 30 mcg ethinylestradiol (EE) and 3 mg drospirenone (DRSP) on the nasal respiratory epithelium in premenopausal women. STUDY DESIGN: Fifty premenopausal women participated in the prospective study. Baseline endovaginal ultrasound examination and blood test to measure serum progesterone to confirm an ovulatory cycle were performed. The cytologic changes on the nasal respiratory epithelium were evaluated with the maturation index, performed during the follicular, periovular and luteal phases of the menstrual cycle, and on the sixth cycle of pill intake. RESULTS: The maturation indexes of the nasal smears were higher during both the follicular and periovular phases than during the luteal phase of the menstrual cycle (p<.05). Women on the OC pill had similar changes in the nasal epithelium as those seen during the follicular phase (p NS), and less than the periovular phase (p<.05) and higher than the luteal phase (p<.05). The maturation index of the nasal respiratory epithelium seems to depend on the variation of the ovarian steroids during the menstrual cycle and on the iatrogenic effects of oral contraception. CONCLUSIONS: DRSP+EE seems to provoke cytological changes that are different from previously shown gestodene plus EE.

Otologic findings in children with gastroesophageal reflux.

BACKGROUND: Nearly 90-95% of children with drool have physiologic gastroesophageal reflux (GER) that usually resolves by 12-15 months of age; however, 5-10% of children with drool have pathologic GER. Of these children, most recover clinically by 18 months of age without therapy, yet 10% develop chronic, recurrent gastroesophageal reflux disease (GERD) with sequelae. The respiratory symptoms associated with GER consist mainly of bronchial asthma and laryngospasm, but often include a persistent cough of unknown aetiology, obstructive apnoea, and an obstructive respiratory syndrome confined to the nasopharynx. Gastric acid reflux, enters the adenoids, causes oedema of the tubal orifices, and later leads to relapsing diseases of the middle ear in children. AIM AND SCOPE: To evaluate the incidence of otologic manifestations in children with GER and the efficacy of treatment, comparing two different groups of children (i.e., treated versus untreated). SUBJECTS AND METHODS: From January 2005 to November 2006, audiologic screening of newborns and suckling children (0-24 months of age) at risk for auditory illnesses was held at the University Department of Otolaryngology in Catania. Seventy-three children (average age, 13 months) were selected after failing acoustic otoemissions for chronic bilateral catarrhal pathology involving the middle ear (tympanometry type B) and were positive for at least one of the different signs of GER at the time of history-taking. The children were randomised and subdivided into two groups: (1) a group of 40 children (27 females and 13 males; average age, 12 months) who received treatment; and (2) a group of 29 children (16 males and 13 females; average age, 14 months) who did not receive treatment. Four children were lost to follow-up after completing the study. All children enrolled in the study underwent a rhinopharynxlaryngeal fibroscopy with flexible optics, a gastric ultrasound scan after clinical observation, and a multi-channel pH-metry for 18-24h. RESULTS: Findings obtained by rhinopharynxlaryngeal fibroscopy showed that 82% of cases had diffuse hyperaemia involving the entire rhinopharyngeal mucosa and 13% of the cases had arytenoidal hyperaemia. Resolution and improvement of the reflux occurred in 52.5 and 40% of the cases in the treated group, respectively, versus complete resolution and an improvement in symptoms of 45 and 30% of cases, respectively, in the control group. CONCLUSIONS: The hypothesis of a correlation between reflux and chronic middle otitis of the serous-mucous type was confirmed in the present study. Adopting a preventive treatment strategy may be useful in reducing the possibility of ear involvement.

Autoimmune Ear Disease: Clinical and Diagnostic Relevance in Cogan's Sydrome.

The autoimmune inner ear disease is a clinical syndrome with uncertain pathogenesis that is often associated to rapidly progressive hearing loss that, especially at the early stages of disease, may be at monoaural localization, although more often it is at binaural localization. It usually occurs as a sudden deafness, or a rapidly progressive sensorineural hearing loss. In this study a particular form of autoimmune inner ear disease is described, Cogan's syndrome. Cogan's syndrome is a chronic inflammatory disorder that most commonly affects young adults. Clinical hallmarks are interstitial keratitis, vestibular and auditory dysfunction. Associations between Cogan's syndrome and systemic vasculitis, as well as aortitis, also exist. We report a case of a young woman who presented audiological and systemic characteristics attributable to Cogan's syndrome. In the description of the case we illustrate how the appearance and evolution of the disease presented.

Therapeutic approaches to pediatric pseudotumor cerebri: New insights from literature data.

The pseudotumor cerebri syndrome (PTCS), also known as idiopathic intracranial hypertension (IIH), is characterized by signs and symptoms of increased intracranial pressure such as headache and cranial nerve palsies, in the absence of any space-occupying mass. This condition commonly affects overweight women of childbearing age, even if it is also frequent in men and children. Children with PTCS may present with atypical signs and symptoms, with a different prognosis compared to adults. However, the treatment is the same for both children and adults, even if there are no strict treatment guidelines in regards. All treatment strategies in children are based on retrospective studies and none has been evaluated in prospective or randomized controlled trial studies. This review focuses on literature data on PTCS treatment in children.

Expression pattern of estroprogestinic receptors in sinonasal inverted papilloma.

Inverted papilloma (IP) is a locally destructive, benign neoplasm of the nose and paranasal sinuses with a high tendency for recurrence, a significant potential for malignancy, and an etiology that today is still uncertain. The expression of hormonal receptors in neoplastic tissues has been the focus of intensive research for its potential diagnostic, prognostic, and therapeutic significance. The aim of this study was to assess the potential estroprogestinic receptor expression in patients undergoing sinus surgery for IP. A retrospective study was carried out, on surgical specimens of 73 patients who underwent endoscopic sinus surgery for first manifestation of sinonasal IP (primitive IP group) and in 21 subjects who had developed a recurrence (relapsed IP group). The results of the immunohistochemical analysis of the first group showed the absence of receptor expression for PGR in all cases analyzed and the presence of a low positivity for ER in 11 cases (P > 0.082). Similarly, in the second group the results showed a low presence of ER receptors in 3 of the 21 cases (P > 0.068), while there was no evidence of PGR receptors in the examined samples. In addition, in 11 of the cases only 3 were considered positive (27.2%) showing a recurrence during follow-up (P > 0.068).Our results suggest that the sinonasal IP is a benign tumor independent of estrogen and progesterone, and the receptors for these hormones are therefore unsuitable as predictors of relapse or possible prognostic indicators and therapeutic targets.

The watch-pat in pediatrics sleep disordered breathing: Pilot study on children with negative nocturnal pulse oximetry.

OBJECTIVES: The main purpose of this study was to determine the efficacy of Watch-PAT in Pediatric Sleep Disordered Breathing (PSDB) diagnosis in children with symptoms suggestive of PSDB, in which the nocturnal pulse oximetry was negative according to the Brouilette criteria. METHODS: We enrolled 28 patients aged between 5 and 12 years (mean age: 7.75 ± 1.69), who underwent the registration with Watch-PAT, that utilizes the Peripheral Arterial Tone (PAT), AHI, RDI, body position, snoring, pulse oximetry and actigraphy. RESULTS: Recording Watch-PAT was indicative of PSDB in 10/28 (35.7%) patients; when it was placed the threshold of AHI > 1 the number of positive patients for PSDB increased to 17/28 (60.7%). Exists a positive correlation between pat-RDI (rho = 0.798, p = 0.005) and the snoring > 40% of the time (rho = 0.656, p < 0.001) were correlated with the pat-AHI values. CONCLUSION: The recording Watch-PAT appears to permit the defection of a certain number of SDB that might escape to the clinical evaluation and pulse oximetry only.

Multicenter research into the quality of life of patients with advanced oropharyngeal carcinoma with long-term survival associated with human papilloma virus.

The treatment of advanced-stage oropharyngeal squamous cell carcinoma may utilize various modes, including combining surgery with chemoradiotherapy (CTRT), or primary CTRT followed by rescue surgery. In previous literature it has been revealed how patients treated with combined modes report a low quality of life (QoL) and severe consequences following surgery, radiotherapy and chemotherapy, in the short and in the long-term. The decrease in the QoL of patients treated with high-intensity multi-modal strategies highlights the necessity of modifying treatments, particularly for young HPV-positive patients, where an increased survival rate has already been reported. The modified treatment for HPV-positive tumors in the tonsils and at the base of the tongue is based on the deintensification of therapies aiming to reduce toxicity and thereby improve QoL in the long term, whilst still maintaining therapeutic effectiveness. The aim of the present study was to evaluate the QoL in patients with a long-term survival, who were treated with combined therapy for squamous cell tumors in the tonsils and at the base of the tongue, and to compare the results observed in HPV-positive and HPV-negative patients. According to statistical analysis, differences in the general QoL and in the single scales of the European Organization for the Research and Treatment of Cancer questionnaires were not correlated with the type of therapy selected for the particular patient. QoL considered the presence of HPV, the type of treatment, the subregion of the tonsils vs. the base of the tongue and the disease stage at the time of diagnosis, and was determined to be non-influential with regard to these specific variables.

Oxidative stress, nitric oxide, endothelial dysfunction and tinnitus.

To assess whether pathogenic endothelial dysfunction is involved in acute idiopathic tinnitus we enrolled 44 patients and 25 healthy volunteers. In blood from the internal jugular vein and brachial vein we determined malonaldehyde, 4-hydroxynonenal, myeloperoxidase, glutathione peroxidase, nitric oxide, L-arginine and L-ornitine, thrombomodulin (TM) and von Willebrand factor (vWF) activity during tinnitus and asymptomatic period. Higher plasma concentrations of oxidative markers and L-arginine, and lower nitric oxide and L-ornitine levels were observed in jugular blood of patients with tinnitus, there being a significant difference between brachial and jugular veins. TM and vWF activity were significantly higher in patients' jugular blood than in brachial blood. Our results suggest oxidant, TM, vWF activity production are increased and nitric oxide production reduced in brain circulation reflux blood of patients with acute tinnitus. These conditions are able to cause a general cerebro-vascular endothelial dysfunction, which in turn induce a dysfunction of microcirculation in the inner ear.

Assessment of oxidative stress markers and hearing thresholds in patients with obstructive sleep apnea-hypopnoea treated with cysteine and superoxide dismutase therapy.

BACKGROUND AND AIM OF THE WORK: In OSAHS, the hypoxia and reoxygenation cicles, maintain a state of oxidative stress, which seems to cause a change in the oxidative balance. Our aim is to compare the markers of oxidative stress with audiological findings and OSAHS severity, in OSAHS patients untreated and also treated ones, with cysteine and superoxide dismutase. METHODS: 65 patients (42 Men, 23 Women) with 30-65 years age range have been enrolled, with a mean age of 52.6 ± 13.3 years with moderate OSAHS. We have analyzed plasma and lymphocyte markers of oxidative stress (glutathione, thioredoxin and heat shock protein) and they were underwent tonal audiometry. Patients were divided in two groups: Group A (32 patients) included patients treated for 8 weeks with cysteine and superoxide dismutase; Group B (33 patients) included patients untreated. RESULTS: The research showed a significant increase in reduced glutathione levels (p<0.05) in OSAHS patients treated; conversely, it showed a decrease of oxidized glutathione level (p<0.05) in treated patients than OSAHS untreated ones. The thioredoxin values, in untreated OSAHS patients, appear to be reduced than in OSAHS patients treated (p<0.05), and that the heat shock protein values were more elevated in untreated OSAHS patients (p<0.05). Finally, it was found that a correlation exists between the severity of OSAHS and auditory dysfunction. CONCLUSIONS: The study of the oxidative stress markers has produced results which lead to support the idea that, in a personalized therapy context, the use of antioxidant therapy can cooperate effectively the first choice treatment.

A Selective Mutism Arising from First Language Attrition, Successfully Treated with Paroxetine-CBT Combination Treatment.

After immersion in a foreign language, speakers often have difficulty retrieving native-language words and may experience a decrease in its proficiency, this phenomenon, in the non-pathological form, is known as first language attrition. Self-perception of this low native-language proficiency and apprehension occurring when speaking is expected and, may sometimes lead these people to a state of social anxiety and, in extreme forms, can involve the withholding of speech as a primitive tool for self-protection, linking them to selective mutism. We report an unusual case of selective mutism arising from first language attrition in an Italian girl after attending a two-year "German language school", who successfully responded to a paroxetine-cognitive behavioral treatment (CBT) combination treatment.