New surgical technique for endoscopic management of anterior glottic web.

OBJECTIVES: In this study we report a new endoscopic technique for the management of anterior glottic web (AGW). Previously, various procedures with endoscopic or open surgical approaches have been described for the treatment of symptomatic AGW. We present an original, highly effective endoscopic technique that seems to have several advantages over traditional approaches. METHODS: We used this novel technique in a preliminary series of four patients. Using a CO2 laser, a curvilinear mucosal flap based on the web is elevated from the superior surface of one vocal chord. The web is divided, and the flap is sutured at the inferior surface of the opposite vocal chord, ensuring that no raw surfaces will be left exposed on this side of the larynx. We accurately describe the technique, displaying diagrams of the surgical steps. RESULTS: In three cases, a restoration of the laryngeal airway, with complete resolution of the AGW, was achieved. A limited residual web persisted close to the anterior commissure in the fourth patient. CONCLUSIONS: The new endoscopic technique utilized in our preliminary series of patients is a simple, repeatable, and effective surgical procedure for managing AGW.

Reduction incidence of myocardial infarction associated with a national legislative ban on smoking.

AIM: The aim of the present study was to assess change in admissions for acute myocardial infarction (AMI) in the period immediately subsequent to the coming into force of law no. 3/2003 ''Protection of the health of non-smokers''. METHODS: Four Italian regions (Piedmont, Friuli Venezia Giulia, Lazio and Campania) took part in the study. Data regarding admissions for AMI were taken from the daily discharge papers of patients aged between 40 and 64 (cod. ICD9-CM 410.), in the period 10 January-10 March 2001-2005. Repeated admissions were excluded. Admission rates standardised by age and overall total, and specifically by region, age and gender were calculated. The hypothesis of a significant reduction between 2005 and 2004 was also checked. RESULTS: The results showed a decrease in the number of cases and in the standardised rates between 2004 and 2005. The number of admissions estimated with a linear regression model for 2005 was significantly higher than that really observed (+13%). The decrease between the 2005 and 2004 rates was noteworthy for all four regions. Analysis by gender shows that the effect is observed only in male patients and in the age classes 45-49 and 50-54. CONCLUSION: This study shows that there has been an appreciable reduction in the incidence of heart attacks in the period immediately subsequent to the coming into force of the non-smoking Law in the populations surveyed, and that this reduction mainly regards men of working age. The reduction reverses a trend that has been evident for a number of years, namely that of a decidedly upward trend in the number of admissions for AMI.

Surgical management of surgery and radiation induced peristomal neck ulcerations.

UNLABELLED: PROBLEMS/OBJECTIVE: Non-healing cervical skin ulcerations with concomitant necrosis of the subcutaneous tissue and muscle is a rare but feared complication of radiotherapy that can arise in cervical regions. Constant erosion of the surrounding tissue by the expansion of the necrotic front can threaten important structures. Very few reports in the literature deal with the surgical management of these injuries. METHODOLOGY: This paper reports on two cases of non-healing, slow-growing cervical ulcerations that occurred as a result of radiotherapy and surgery. RESULTS: After unsuccessful conservative treatment, definitive surgical repair was performed to achieve reparation of the defect and protect deep structures. The onset and characteristics of the ulcerations as well as the reconstructive options are discussed. CONCLUSIONS: In the treatment of surgery and radiotherapy induced chronic cervical wounds, non surgical medical treatment should be always attempted for at least 6 months, and should always include hyperbaric oxygen therapy. If conservative methods fail, surgical repair by means of transposition of well vascularized tissue is mandatory to prevent serious complications such as major vessel rupture or fistulas.

The Italian register of cardiovascular diseases: attack rates and case fatality for cerebrovascular events.

BACKGROUND: The Italian register of cardiovascular diseases is a surveillance system of fatal and nonfatal cardiovascular events in the general population aged 35-74 years. It was launched in Italy at the end of the 1990 s with the aim of estimating periodically the occurrence and case fatality rate of coronary and cerebrovascular events in the different geographical areas of the country. This paper presents data for cerebrovascular events. METHODS: Current events were assessed through record linkage between two sources of information: death certificates and hospital discharge diagnosis records. Events were identified through the ICD codes and duration. To calculate the number of estimated events, current events were multiplied by the positive predictive value of each specific mortality or discharge code derived from the validation of a sample of suspected events. Attack rates were calculated by dividing estimated events by resident population, and case fatality rate at 28 days was determined from the ratio of estimated fatal to total events. RESULTS: Attack rates were found to be higher in men than in women: mean age-standardized attack rate was 21.9/10,000 in men and 12.5/10,000 in women; age-standardized 28-day case fatality rate was higher in women (17.1%) than in men (14.5%). Significant geographical differences were found in attack rates of both men and women. Case fatality was significantly heterogeneous in both men and women. CONCLUSIONS: Differences still exist in the geographical distribution of attack and case fatality rates of cerebrovascular events, regardless of the north-south gradient. These data show the feasibility of implementing a population-based register using a validated routine database, necessary for monitoring cardiovascular diseases.

Rehabilitation protocol of dysphagia after subtotal reconstructive laryngectomy.

Dysphagia is a constant complication of subtotal reconstructive laryngectomy, due to modifications in the anatomy and in sensitivity of the larynx and pharynx. The reduced sphincteric activity of the larynx can enhance aspiration with a higher risk of pneumonia. In our opinion, the presence of the tracheotomy tube in the first weeks after surgery interferes with proper mobility of the laryngo-tracheal axis during swallowing, as it anchors the trachea to the skin. We have conducted swallowing rehabilitation, without the tracheotomy tube, ready to aspirate eventual saliva or food debris dropping into the trachea. This protocol has been applied in 33 patients undergoing subtotal reconstructive laryngectomy and better patient compliance and swallowing performance were observed. The period to recover complete autonomous oral intake is less than one month and none of these patients showed signs or symptoms of aspiration pneumonia during hospitalisation or follow-up. This rehabilitation protocol is, therefore, a valid and effective alternative to other well-known procedures.

Evolution of elective neck dissection in N0 laryngeal cancer.

Management of cervical lymph node metastasis is one of the most challenging problems facing clinicians dealing with head and neck cancer. A retrospective evaluation has been made of results in N0 laryngeal cancer patients treated from 1978 to date by comparing historical data reported in related papers previously published by our institution. The medical records of 2207 consecutive patients with cN0 SCC of the larynx were used as the source of data in the present study. Together with primary treatment, 759 (34.4%) received at least unilateral elective neck dissection, while the remaining 1448 (65.6%) were admitted to a wait-and-see protocol. Overall, in the electively dissected patients (ED): 128 (16.9%) cases were submitted to classical radical neck dissection, while 403 (53.1%) cases were submitted to functional neck dissection (FND) and 228 (30.0%) cases to jugular node dissection (JND, removing Level II, III and IV). In 125 of the ED group, a neck procedure on the contralateral N0 neck was associated, of which 15 were RNDs, 35 FNDs and 75 JNDs, respectively. Based on this large series population, the change in the philosophy was evaluated concerning elective neck treatment in N0 laryngeal cancer, from RND through FND towards JND. As far as concerns the reliability as a staging procedure, no statistically significant difference was found between RND, FND and JND (p = 0.794). The 5-year neck recurrence rate, as estimated by the Kaplan Meier, method, for all ED patients, was 7.7%. No significant difference in the rate of 5-year neck recurrence was detected between RND, FND and JND groups (p = 0.178). In the survival curves, no differences, in terms of actuarial survival by Kaplan Meier analysis, were observed, in our series, as far as concerns type of elective neck dissection performed (p = 0.222). In conclusion, following a critical revision of 25 years' experience, at our Institution, in the management of cN0 necks in laryngeal cancer patients, definitive changes were observed in the surgical approach to the treatment of occult disease in cN0 cases. JND, compared to more extensive neck dissections, did not show statistically significant differences in terms of neck control (p = 0.233), in terms of impact on survival (p = 0.122) and in terms of accuracy as staging procedure (p = 0.794).

Comparative efficacy and safety of roxithromycin and clarithromycin in upper respiratory tract infections.

Roxithromycin 300 mg once daily was compared with clarithromycin 250 mg b.i.d. in an open randomized trial in 200 patients with upper respiratory tract infection: sinusitis, pharyngotonsillitis, and otitis media. Average treatment duration was 9 days. Roxithromycin was more effective (p less than 0.01) particularly in otitis media and pharyngotonsillitis, and better tolerated (only 4% side effects, p less than 0.05).

Sequenced scintigraphy: a morphological and functional study of the salivary glands.

The use of scintigraphy in sequenced registration shows that there are three fundamental stages in the intraglandular turnover of the radionuclide: 1. At very early stage (between 3 min. and 15 min.), the major salivary glands could be clearly distinguished; 2. At the stage immediately following (between 20 min. and 35 min.), both the parotid and submaxillary glands were already less well defined; while in the mouth projection zone, quite intense radioactivity, connected with a progressive accumulation of the radionuclide in the minor salivary glands, was seen; 3. Within an hour after injection, maximum captation took place in the minor salivary glands, while both the parotid and the submaxillary glands were hardly distinct. These three stages are strictly related to the three phases of behavior of the radionuclide in each salivary gland; arrival, accumulation, dismissal. Then, each documented variation from the normal pattern will indicate a determined functional anomaly related to defined disease of the salivary glands. The sequenced scintigrraphy offers a functional study of the salivary glands from which it is possible to obtain many elements of practical clinical utility.

Efficacy and tolerability of brodimoprim in otitis.

Eighty adult patients affected by acute bacterial otitis media were selected and randomized into two balanced groups of treatment: 1) brodimoprim 200 mg tablets at the dosage of 2 tablets in single dose on the first day and one tablet on the following days; 2) josamycin 500 mg tablets at the dosage of 3 tablets/day. The average duration of treatment was 8 days: all patients completed the trial. The symptoms were evaluated by score method (on the 3rd, 7th and on the last day of therapy) and a thermometric curve was made daily. Microbiological examination of the exudate was performed in the patients with auricular discharge (28), at the beginning of the treatment and 7 days after the end of therapy. The tolerability was assessed through registration of side effects. Brodimoprim resulted more effective in the reduction of hypoacusis and tinnitus; other symptoms demonstrated higher percentage reductions in the group under brodimoprim therapy. Bacteriological exams were negative at the second checkup, except in 6 patients (3 per group). Side effects were reported in 5 patients (12.5%) treated with brodimoprim and in 9 (22.5%) treated with josamycin. Abnormal values in laboratory tests were not observed.

Neurogenic tumors of the head and neck in children.

Soft tissue tumors make up 63% of all tumors in children. Tumors of the sympathetic chain make up 7.4% of tumors arising in children (nine new cases a year for every million children in USA) while neurofibrosarcomas make up 3.4% (2.4 new cases per year for every million children). There is a certain difference between the frequency of benign forms (rather elevated) and that of malignant forms (rather low). Diagnosis is possible by echo-scan, computed tomography, magnetic resonance imaging and fine-needle aspiration biopsy. As regards therapy, surgical resection represents the treatment of choice. In our experience, 35 neurogenic tumors in pediatric patients (8-16 years), arising in head and neck spaces, were observed and treated in the period 1976 and 1995. Twenty-six cases were schwannomas, six were neurofibromas and three were olfactory neuroblastomas. All the patients underwent surgery. Sacrifice of the affected nerve was necessary in 12 cases (all neurofibromas and eight neurinomas). In one case of olfactory aesthesioneuroblastoma a combined approach (extra-intracranial approach) was employed. Two patients are alive and disease-free with 5 and 7 years follow-up. As regards dysfunctional pathology following surgical resection, we report definitive facial nerve palsy in two cases, permanent laryngeal palsy in six cases, tongue dysfunction in one case and cheek hypoaesthesia in one case.

Adenoid-cystic carcinoma (cylindroma) of the pyriform sinus in pediatric age.

Adenoid cystic tumors or cylindromas are malignant tumors typical of salivary tissue which often develop in minor salivary glands and, according to some authors, also in common mucosa glands. In these cases such tumors are particularly malignant owing to the frequency in which they re-occur locally and develop distant metastases. The authors report a case of a cylindroma of the pyriform sinus in a young child. An accurate review of the literature did not reveal any previous reports of analogous cases of cylindroma in the pyriform sinus of such a young subject. This finding created notably difficult problems with regard to therapy planning. After discussion of problems, conservative surgery is indicated as the most suitable treatment in these cases, considering that chemotherapy and radiation therapy alone are not highly effective in treating cylindromas and, furthermore, they are contraindicated because of the young age of the patient.

Conservative trans-mandibular approach in the surgical treatment of tumors of the parapharyngeal space.

The authors suggest a conservative transmandibular approach for the surgical treatment of large latero-pharyngeal tumors extending towards the base of the skull. This technique, which may seem more radical and complex is, however, a more logical and conservative approach; and, owing to the excellent surgical field, it is able to keep the delicate surrounding structures intact and to reduce the risk of hemorrhagic and/or neurological complications.

Malignant hemangiopericytoma of the nasal cavity. Report of a case and review of the literature.

Haemangiopericytoma is only rarely localized in the nasal cavity. The authors' experience with one case has prompted them to review the literature critically, in order to understand better the most appropriate diagnostic procedures and therapeutic measures.

Thornell's approach for arytenoidectomy in the surgical treatment of bilateral abductor paralysis; personal experience and results.

Surgical treatment of bilateral abductor paralysis of the vocal cords is still a question for debate, as can be seen by a review of the relevant literature. The authors describe their modification of Thornell's technique, as used in 12 cases of recurrent paralysis, and they suggest a variant to the basic method which has been proved to cause minimal trauma, is simple to carry out and has produced excellent results.

[Anterior commissure in the spreading of the glottic cancer: classification, prognosis and therapy]. / La commissura anteriore nell'evoluzione dei tumori del piano glottico: considerazioni classificative, prognostiche e terapeutiche.

Laryngeal tumors involving anterior commissure have a particularly aggressive behaviour. Prognosis and therapy of these tumors is quite different depending on the type and the extension of commissural involvement. In spite of these considerations, present TNM classifications (UICC/AJCC) of laryngeal tumors do not consider anterior commissure in the spreading of glottic cancer. To obviate this problem, Fini-Storchi (1993) proposed an anatomic-oncological definition of anterior commissure (AC) and, on it, a classification (additional to TNM system) of AC involvement (AC1-AC2-AC3). We marginally modified Fini-Storchi classificative criteria and, according to them, we performed e re-classification of laryngeal tumors with anterior commissure involvement, we observed in our Department between 1977 and 1991 (255 cases). In particular we treated 190 AC1 (74.5%), 40 AC2 (15.6%), 25 AC3 (9.8%). For each AC category, different therapeutical options are presented and discussed. Long term results (minimum follow-up: 38 months) are evaluated and efficacy of AC classification is checked.

[Glottic-hypoglottic laryngectomy in the treatment of laryngeal tumors]. / La laringectomia glottico-ipoglottica nel trattamento dei tumori della laringe.

Subglottic cancers and glottic cancers with subglottic extension are considered extremely serious because they are not easily detected and are normally quite advanced when diagnosed. Furthermore these cancers spread rapidly beyond the larynx to the lymph nodes (cervical and recurrential chains). Total laryngectomy is elective surgery in the treatment of subglottic cancer. However, in selected cases, small tumors may also be treated successfully with partial glottic-subglottic laryngectomy. The aim of this paper is to present a personal experience with partial surgery in the treatment of subglottic cancer. The surgical operation consists of the resection of both vocal cords, the subglottic region and the cricoid cartilage with the proximal tracheal rings. The larynx is reconstructed through a tracheal-thyroid approach. The surgical technique is illustrated and the authors' experience discussed.

[Laryngeal T4 carcinomas. The possibility of conservative treatment. Long-term oncological and functional results]. / Carciomi T4 della laringe:P possiblitià di trattamento conservativo. Risultati oncologici e funzionali a distanza.

The term laryngeal T4 carcinoma is applied to a heterogeneous group of neoplasias which may be treated following various surgical approaches. The elective therapy in dealing with many of these tumours (minimal cartilage involvement, marginal hypopharyngeal extension, supra-glottic cancer with oro-pharyngeal extension) is that of a conservative approach. Our clinical experience with regard to 276 T4 laryngeal tumours is presented in this paper. Oncological and functional results with partial surgery are reviewed and discussed and long-term results obtained with widened total laryngectomy (plus Radio and/or Chemotherapy) are presented.

Neuroplasticity of auditory cortex after stape surgery for otosclerosis: a magnetoencephalographic study.

Aim of the present study was to investigate the tonotopic reorganization of the primary auditory cortex in otosclerotic patients following functional stapedioplasty. Characteristics of auditory cortex activation have been evaluated in a series of 10 otosclerotic patients before and after surgery. In these patients, a magnetoencephalographic recording of evoked magnetic fields has been performed by means of tone-burst monoaural stimulation with frequency octaves between 250 and 2000 Hz. Brain topography of cortex response generators (wave N100m) in patients with otosclerosis has been compared with that observed in a control group of 10 healthy subjects: changes before and after surgery have also been correlated with the functional result as far as concerns improvement in hearing. A significant reduction has been observed in the cortical tonotopic extension in response to the acoustic stimulus in patients "pre-surgery" in comparison with controls: after surgery, tonotopic mapping showed an increase, dimensions becoming comparable to those in control subjects. This increase in size was found to be significantly correlated with duration of the post-operative period. Data emerging from the present study suggest that the cortical auditory areas in man are involved in a "plastic" functional reorganization following changes in the receptor or peripheral deprivation. Reduction in the cortical tonotopic mapping resulting from prolonged lowering of auditory "input" is modified by reorganization of the cortex after the recovery of auditory function: this process occurs over a period of a few weeks.

[Use of the economic evaluation in the comparison of different vaccination programs against Haemophilus influenzae type b disease]. / Uso della valutazione economica per il confronto di diverse strategie vaccinali contro la malattia invasiva da Emofilo influenza tipo B.

Although economic evaluation offers a relevant contribution to the health policy's choices, only few studies appeared so far on its application to the field of vaccinations. The present study compares several hypotheses of vaccination strategies in order to evaluate the opportunity to introduce a vaccination program against Haemophilus influenzae b infection. The vaccination strategies are evaluated in terms of costbenefits, cost-effectiveness and cost-utility. The results show that the highest benefits could be obtained performing mass vaccination in the age-group 0-5 years. Actually this hypothesis, compared to other, offers the best compliance and externalities; furthermore it has the highest ethical value.

[Gastric ulcer in the infant: clinical contribution]. / L'ulcera gastrica del lattante: contributo clinico.

The authors, after a short review on the etiopathological classification and the clinical exordium of the gastric ulcer in infancy, report a relapsing case nevertheless the therapy with cimetidine and antacid drugs. Furthermore they note the importance of the careful anamnesis and early and repeated occult blood stool tests to value for eventual gastric fiberendoscopy.