Alessandro De Stefano

Otoneurological management of petrous apex cholesterol granuloma.

OBJECTIVE The aim of the study is to review the management of petrous apex cholesterol granuloma. The surgical approaches for drainage or total removal and the wait and see policy were analyzed, and outcomes were evaluated. METHODS Retrospective charts of 27 patients managed for petrous apex cholesterol granuloma with a minimum follow-up of 12 months were analyzed in a quartenary skull base center. Presenting symptoms and signs were recorded, and radiologic imaging was evaluated. Management options included wait and see policy and surgery by several approaches. RESULTS The mean age of patients affected by the lesion was 38.8 years. The mean follow-up was 56.7 months. Patients complained of hearing loss, vertigo, tinnitus, diplopia, hemifacial spasm, trigeminal neuralgia, and facial paresthesia. Twelve patients were managed by wait and see policy, and in this category, only one lesion showed growth during the follow-up. Depending upon size and location, 15 patients were surgically treated by infralabyrinthine approach (9 patients), infratemporal type B approach (3 patients), combined infratemporal type B transotic approach (2 patients), and transotic approach (1 patient). One recurrence was recorded during the follow-up. CONCLUSIONS Radiologic evaluation is required for diagnosis and management. Patients with good hearing can be treated by infralabyrinthine approach. Infratemporal fossa type B approach is advocated in patients with extensive disease and internal carotid artery involvement. Wait and see policy is recommended for asymptomatic cases. Drainage and permanent ventilation are the goals of treatment. Complete removal is indicated in selected cases where placement of drainage tube is not feasible.

Benign paroxysmal positional vertigo following whiplash injury: a myth or a reality?

OBJECTIVE The aim of the study was to evaluate the true incidence, diagnosis, and treatment of benign paroxysmal positional vertigo (BPPV) arising after whiplash injury and to distinguish this type of posttraumatic vertigo from other types of dizziness complained after trauma. METHODS This was a retrospective study comprising patients referred to our center after whiplash injury. The patients were evaluated with neurotologic examination including bedside and instrumental tests. A Dizziness Handicap Inventory evaluating the symptoms of patients was submitted before and after treatment and was evaluated. The BPPV patients were separately evaluated from those with cervicogenic vertigo, and a comparison between our data about idiopathic BPPV was done. RESULTS Eighteen patients of whiplash who had BPPV were evaluated. The mean age was 38.2 years. BPPV was the cause of vertigo in 33.9% of total whiplash patients. In 16 cases, the posterior semicircular canal was involved; the lateral semicircular canal was involved in 2 cases. The instrumental neurotologic assessment did not show any alteration of either vestibulospinal reflexes or dynamic ocular movements. Duration of symptoms before treatment ranged from 3 to 26 days. A total of 55.5% of patients had relief from their symptoms after first repositioning maneuver. The Dizziness Handicap Inventory score improved in all patients treated with repositioning maneuvers, but no difference emerged with idiopathic BPPV data. CONCLUSION BPPV after whiplash injury could be unveiled with a simple bedside examination of peripheral vestibular system, and a treatment could be done in the same session. The diagnosis of posttraumatic BPPV is not different from the idiopathic form, but the treatment may require more maneuvers to achieve satisfactory results.

Spontaneous nystagmus in benign paroxysmal positional vertigo

OBJECTIVE The purpose of this study was to evaluate the presence and eventually to study the features of spontaneous nystagmus (Ny) in our patients with diagnosis of benign paroxysmal positional vertigo (BPPV). PATIENTS AND METHODS We retrospectively reviewed the clinical records of patients who presented with vertigo spells and were managed at our tertiary care referral center. Patients with only idiopathic BPPV presenting with typical vertigo spells and positioning Ny characteristic of the disease were included in this study. To investigate the positioning Ny, we studied the patients in the sitting position, during the head shaking test, and during the Dix-Hallpike test and the McClure-Pagnini test (Ny provoked by rotation of the head in a supine patient). Ny responses in all patients were observed using infrared videoscopy. RESULTS We managed 412 patients affected by BPPV. Of the 412 patients, 292 (70.87%) were diagnosed to be having posterior canal-BPPV and 110 (26.99%) patients had horizontal canal-BPPV (HC-BPPV). The remaining 10 patients (2.44%) were identified to have anterior canal-BPPV. Spontaneous Ny in sitting position was observed, by infrared videoscopy, only in the patients affected by HC-BPPV. CONCLUSION Spontaneous Ny in BPPV can be observed with infrared videoscopy in patients affected by HC-BPPV. The origin of this Ny is most likely due to a natural inclination of horizontal semicircular canal with respect to the horizontal plane. This Ny stops after flexion of the head in neutral position, and for this reason, it should be considered as a seemingly spontaneous Ny. This Ny, in our experience, is observed in most HC-BPPV patients but does not indicate the need for a different management protocol or any different prognostic value of HC-BPPV.

Comparison of repositioning maneuvers for benign paroxysmal positional vertigo of posterior semicircular canal: advantages of hybrid maneuver.

OBJECTIVE The prevalence of benign paroxysmal positional vertigo (BPPV) is becoming more frequent in elderly population. The presence of comorbid factors has to be considered before assessment as well as before commencing any repositioning treatment. Our aims were evaluation of the maneuvers efficacy and evaluation of the applicability of hybrid maneuver (HM) in patients with physical limitation. STUDY DESIGN AND SETTING This is a randomized study in 2 tertiary referral centers. INTERVENTION This is a therapeutic intervention. PATIENTS All consecutive patients with diagnosis of BPPV of posterior canal matching the inclusion criteria were enrolled. Patients underwent treatment soon after the initial diagnosis in all cases with a repositioning maneuver. The maneuver was casually selected among Semont, Epley, and hybrid. Patients were divided into 3 groups according to the maneuver adopted. RESULTS Eighty-eight patients with posterior canal BPPV were enrolled for treatment. Fisher exact test showed that no statistical differences exist between HM and other maneuvers in terms of efficacy. Latency of repositioning nystagmus appeared longer in HM in comparison with other maneuvers (P < .05). Efficacy of maneuvers used for BPPV decreases in case of cupulolithiasis (P < .0001). We found no relationship between age, sex, and length of disturbance on response to maneuvers. CONCLUSIONS All maneuvers evaluated demonstrated similar efficacy. The HM, as our data showed, allows us to obtain a good percentage of success similar to most maneuvers used. It is also more comfortable for the patients with hip or neck functional limitation allowing an effective treatment of the posterior canal BPPV.

Intraoperative Cochlear Nerve Monitoring in Vestibular Schwannoma Surgery – Does It Really Affect Hearing Outcome?

Objective: The objective of this study was to examine the usefulness of intraoperative cochlear nerve monitoring (ICNM) in the preservation of normal and social hearing in vestibular schwannoma (VS) removal. Methods: A retrospective chart review was conducted. Of 1315 patients operated for VS between June 1988 and December 2005, 150 patients were subjected to hearing preservation surgery. Among these, 99 patients with preoperative normal and social hearing (class A and B in the modified Sanna classification) and with a small tumor <1.5 cm in size were included in the analysis. The difference in hearing preservation rates between patients operated with and without ICNM was statistically examined using Fisher’s exact test. An initial analysis was conducted for the total group. Patients were then divided into two subgroups according to the surgical approach (middle cranial fossa and retrosigmoid-retrolabyrinthine). The effectiveness of ICNM in each subgroup was analyzed. Results: The hearing preservation rate was 26.7% in cases operated with ICNM and 20.8% in cases without ICNM. The difference did not reach statistical significance (p = 0.79). In subgroup analyses, the ICNM did not prove to contribute to the significantly higher hearing preservation rate. Conclusions: ICNM did not increase the ratio of patients with postoperative normal and social hearing in VS surgery.

Sudden Sensorineural Hearing Loss: Results of intratympanic steroids as salvage treatment

OBJECTIVE The aim of the present study was to verify the efficacy and the safety of intratympanic dexamethasone to treat sudden sensorineural hearing loss as salvage therapy. MATERIALS AND METHODS A prospective study was conducted on patients affected by idiopathic sudden hearing loss who were treated before with some systemic therapy, but without recovery of the hearing The patients able to undergo the study, but who refused salvage treatment were considered as control group. A solution of Dexamethasone 4 mg/ml was then injected through the posterior-inferior quadrant filling completely the middle ear. The follow-up in the following 6 months included an audiogram every month. RESULTS The number of patients treated with salvage therapy was 36. The patients who refused treatment were further 10. The salvage treatment was done with a mean delay of 24.3 days from the onset of symptoms. Mean hearing threshold after the onset of sudden hearing loss at PTA was 66.5 dB. After the failed treatment the mean PTA was 59.6 dB. The mean PTA after the intratympanic steroid administration was 46.8 dB, with a mean improvement of 12.8 dB. No hearing change was noted in the 10 patients who refused salvage therapy. The patients that assumed systemic steroid as first therapy showed a better PTA threshold after the salvage intratympanic treatment (p<0.01). A significant difference (p<0.05) of hearing recovery was evidenced between non-smoker patients and those with smoking habit. CONCLUSIONS Our data showed that a salvage treatment with intratympanic dexamethasone should be suggested to all patients who failed the first systemic treatment. The systemic steroid therapy done before the salvage treatment seems to exert a protective role for the inner ear, as shown by our series. On the contrary the smoke habit is a negative prognostic factor in the hearing recovery.

Are Postural Restrictions Necessary for Management of Posterior Canal Benign Paroxysmal Positional Vertigo

Objectives: An important component of management of benign paroxysmal positional vertigo (BPPV) has been the application of postural restrictions after use of a canalith repositioning maneuver (CRM) to prevent the return of otolithic debris into the posterior semicircular canal (PSC). This study was designed to explore the effectiveness of postural restrictions in patients with BPPV caused by otolithic debris in the PSC. Methods: Seventy-four adult patients with unilateral PSC BPPV were enrolled into this study. All patients were managed with a CRM — Either the modified Epley maneuver or the Semont maneuver. The patients were divided randomly into 2 groups: Group A, with postural restrictions, and group B, without postural restrictions. The statistical analysis was performed with χ2 tests and t-tests. Results: No patients in either group showed positional nystagmus in the posttreatment evaluation under infrared videonys-tagmoscopy. No patients had symptoms of vertigo after the therapy. The results of follow-up vestibular tests were normal in both groups. Conclusions: In our experience, postural restrictions do not enhance the beneficial effect of the CRMs. They do not seem to have any protective role and therefore should not be recommended as an adjunct to the treatment of PSC BPPV.

Management of laryngeal precancerous lesions.

OBJECTIVE The identification of precancerous lesions is the basis of an early diagnosis, and of a treatment that allows, in the great part of cases, the preservation of organ functions. The aims of this study were: the evaluation of the less invasive treatment for precancerous lesion of the larynx to minimize the recurrences, the estimation of number of further operation required. METHODS A prospective study was done on patients with clinical diagnosis of laryngeal precancerosis. The patients were treated by a transoral endoscopic approach with direct microlaryngoscopy (DML) doing an excision-biopsy with cold blade, consisting in excision of the whole visible lesion with vocal ligament preservation. RESULTS A recurrence of a clinically evident precancerous lesion was present in 13.2% of patients that had a laryngeal intraepithelial lesion (LIN) 1 lesion and in 28.95% of patients that had a LIN 2 lesion. CONCLUSION In order to achieve a control of a precancerous lesion, we suggest: excisional biopsy/subepithelial cordectomy (type 1 cordectomy) for LIN 1 lesions and subligament cordectomy (type 2 cordectomy) in case of LIN 2 cases. In case of recurrences of LIN 1 lesion we suggest directly a type 2 cordectomy.

Features of biopsy in diagnosis of metatypical basal cell carcinoma (Basosquamous Carcinoma) of head and neck.

Metatypical Basal Cell Carcinoma, also known as Basosquamous Carcinoma is a subtype of Basal Cell Carcinoma. It is similar to Basal Cell Carcinoma for the gross aspect and regional recurrences, but it has the capacity to spread and develop metastasis. This terrible characteristic endangers the life of the patient if it is not readily recognized by the physicians. Herein we present a report of two patients affected by BSC originating in the nasal region and external ear that after a series of devastating local recurrences metastasized to the lung and bones in one case. The true incidence of Basoquamous Carcinoma may be higher, with underreporting arising because of rarity of diagnosis and lack of awareness on the part of clinicians. Our experience suggests that a deep biopsy is often necessary to discover a BSC that appears as BCC but with local aggressive features.

Malignant paroxysmal positional vertigo

OBJECTIVE An insidious percentage of paroxysmal positional vertigo appears to be intractable with canalith repositioning maneuver and also is not self-limiting. This type of positional vertigo is sustained by the action of intracranial tumors that mimics the clinical aspects of benign paroxysmal positional vertigo.Aim of this study is to clarify the features of these forms of positional vertigo, which we indicate as malignant paroxysmal positional vertigo. METHODS We retrospectively reviewed the clinical records of all the patients who presented with vertigo spells and were managed at our tertiary care referral centre over a three years period. Two hundred and eleven patients with diagnosis of positional paroxysmal vertigo were included in the final study. RESULTS Seven patients were affected by intracranial tumors causing a positional vertigo and were classified as malignant paroxysmal positional vertigo patients after radiological and histological diagnosis. These patients were affected by an internal auditory canal mass alone or with extension in the cerebello pontine angle that mimicked a benign positional vertigo. CONCLUSION We can conclude that the clinician should keep in mind the differentiation between benign positional vertigo and malignant positional vertigo. When the patients with positional vertigo presents a strange behaviour of symptoms, nystagmus or response to the canalith repositioning maneuver a radiological investigation must be undertaken in every doubtful case.