Francesco Dispenza

Cystic vestibular schwannoma: classification, management, and facial nerve outcomes.

Objective: Review of postoperative morbidity and facial nerve outcomes of cystic vestibular schwannoma (CVS) patients compared with solid vestibular schwannoma (SVS) patients and a proposal for a new CVS classification system. Study Design: Retrospective review. Setting: Tertiary care facility. Patients: Ninety-six patients with surgically treated CVS (1998-2008). Outcomes were assessed in a subpopulation of 57 patients with greater than or equal to 1-year follow-up compared with 57 SVS patients. Intervention: Fifty-six CVS patients underwent the enlarged translabyrinthine approach with transapical extension (Type I), and 1 patient underwent a transcochlear/transzygomatic approach. Main Outcome Measure: Preoperative and postoperative (at least 1 yr) House-Brackmann facial nerve (HBFN) grade evaluation. Results: Favorable HBFN grades (I-III) were observed in 46 (81%) CVS patients, and unfavorable HBFN grades (IV-VI) were seen in 11 (19%) CVS patients. Comparison of tumor size and 1-year HBFN grades showed significant, moderate to strong, Pearson correlation (0.38). Comparison of long-term facial nerve outcomes with a sample of 57 matched SVS patients showed no significant difference (p = 0.74). When the tumor was adherent to the facial nerve and a dissection plane could not be developed between the cyst wall and the nerve, only subtotal resection could offer the CVS patients a normal facial nerve outcome. Conclusion: In most CVS cases, complete resection should be foreseen. Central and thick-walled tumors can be removed in almost all cases. However, when peripheral thin-walled, adherent, cystic tumors are confronted and the cysts are medially or anteriorly located, we recommend subtotal resection, leaving portions of the cyst walls on neurovascular structures and on the facial nerve. This surgical strategy allows us to improve facial nerve outcomes and to reduce complications.

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.

Audiologic profile of infants at risk: Experience of a Western Sicily tertiary care centre

OBJECTIVE To identify the incidence of sensorineural hearing loss (SNHL) on infant at risk and to classify the degree and type of hearing loss describing the main causes associated in Western Sicily. To compare single TEOAE and combined TEOAE/ABR techniques studying the referral rate, the false-positive and false-negative rates through concordance test (κ coefficient), sensitivity (TPR) and specificity (TNR) for each protocol. METHODS From January 2010 to June 2011, 412 infants at risk, ranging from 4 to 20 weeks of life, transferred to Audiology Department of Palermo from the births centers of Western Sicily, underwent to audiological assessment with TEOAE, tympanometry and ABR. The following risk factors were studied: family history of SNHL, consanguinity, low birth weight, prematurity, cranio-facial abnormality and syndromes associated to SNHL, respiratory distress, intensive care in excess of 5 days (NICU), pregnant maternal diseases, perinatal sepsis or meningitis, hyperbilirubinemia, ototoxic drugs administration. RESULTS Forty-seven infants (11.41%) were diagnosed with SNHL; median corrected age at final audiological diagnosis was 12 weeks. SNHL resulted moderate in 44.68%, severe in 10.64% and profound in 21 cases with a significant difference in family history and NICU infants (p<0.0001). As the number of coexisting risk factors increases, the percentage value of SNHL in infants (χ(2)=12.31, p=0.01, r(2)=0.98) and the degree of hearing loss (χ(2)=13.40, p=0.0095, r=0.92) also increase. The study of single TEOAE and combined TEOAE/ABR showed a statistical difference (χ(2)=14.89, p<0.001) with a low concordance value (κ=0.87) confirming the importance of combined techniques for NICU group (κ=0.86) where four cases (0.97%) of auditory neuropathy were diagnosed. CONCLUSION This study demonstrates the necessity to implement a neonatal hearing screening program in Western Sicily because of the high percentage of SNHL in infants at risk. Family history of HL is an independent significant risk factor for SNHL easily diagnosed through single TEOAE technique. Combined TEOAE/ABR is the gold standard for NICU babies which are at risk for auditory neuropathy. Coexisting risk factors are an additional risk factor for HL.

Treatment of bilateral vocal cord paralysis following permanent recurrent laryngeal nerve injury

Bilateral vocal cord paralysis is a serious illness requiring emergency intervention to resolve the potentially life-threatening respiratory distress. Several surgical procedures were proposed to help improve the airway and to eliminate the tracheostoma in those patients with permanent paralysis. All the procedures have their own advantages and disadvantages. We conducted a retrospective study of 30 patients affected by bilateral vocal cord paralysis following total thyroidectomy. All the patients underwent total thyroidectomy for benign thyroid pathology. In 26 patients (86.6%), cord paralysis occurred during the perioperative stage; and in the remaining 4 cases (13.3%), it occurred within the following 6 months. We treated all these bilateral recurrent laryngeal nerve paralysis patients with arytenoidectomy alone in 5 patients and arytenoidectomy with concomitant true and false posterior cordectomy in the remaining 25 patients. Twenty-four of the 25 patients who underwent the combined procedures (96%) reported subjective respiratory improvement and were decannulated within 60 days, being able to return to their normal daily activities. This study demonstrates that arytenoidectomy associated with posterior cordectomy is a satisfactory surgical treatment of bilateral vocal cord paralysis because it leads to a considerable and stable enlargement of the breathing space.

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.

Sudden Sensorineural Hearing Loss as Prodromal Symptom of Anterior Inferior Cerebellar Artery Infarction

Sudden sensorineural hearing loss is a clinical condition characterized by a sudden onset of unilateral or bilateral hearing loss. In recent years sudden deafness has been frequently described in association with anterior inferior cerebellar artery (AICA) infarction generally presenting along with other brainstem and cerebellar signs such as ataxia, dysmetria and peripheral facial palsy. The authors report a rare clinical case of a 53-year-old man who suddenly developed hearing loss and tinnitus without any brainstem or cerebellar signs. Computed tomography of his brain was normal, and the audiological results localized the lesion causing deafness to the inner ear. Surprisingly, magnetic resonance imaging showed an ischemic infarct in the right AICA territory. This case represents the fifth in the literature to date but it confirms that AICA occlusion can cause sudden deafness even without brainstem or cerebellar signs. Therefore, we recommend submitting the patient for neuroimaging, as an emergency, in order to exclude infarction of the AICA territory. By doing this, it may be possible to limit the extent of the lesion by commencing early therapy.

Management of chronic otitis by middle ear obliteration with blind sac closure of the external auditory canal.

Objective: Description of a technique of middle ear obliteration (MEO) with blind sac closure of the external auditory canal with discussion of the indications for its use in cases of recalcitrant chronic otitis and in far advanced disease. Patients: All patients underwent otologic examination and audiologic and radiologic assessments in a quaternary center. Results: Fifty-three cases of MEO were analyzed. For 9 patients, primary surgery was performed. One case of residual disease was identified. The minimum follow-up was 2 years. Conclusion: The decision to perform a MEO is one that is made only rarely. However, this is a technique that should be part of every otologists armamentarium. Whereas the indications for its use are more straightforward in an ear with unserviceable hearing, a MEO is occasionally required in an ear with good cochlear reserve due the severity of disease. All of our patients managed by MEO have had an improvement in their quality of life and a high rate of successful eradication of disease.

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.

Primary Non-Hodgkins lymphoma of the parotid gland

UNLABELLED Primary malignant lymphomas in the salivary glands are relatively rare. Clinical presentation is not characteristic and the disease is often overlooked resulting in diagnosis and treatment delays. AIM To stress the importance of the diagnostic process and combined management, we present a series of eight patients with malignant lymphoma of the parotid who were diagnosed only after surgery and managed with radiation and chemotherapy. METHODS Retrospective series of patients with primary malignant lymphoma of the parotid gland managed with radiotherapy and diagnostic surgical partial resection. RESULTS After treatment completion we achieved a loco-regional control rate of 87.5%. Toxicity was charted according to the Common Toxicity Criteria and it was seen in six patients (75%). Six patients are still alive without evidence of recurrent disease in their last follow-up. CONCLUSION Our study confirms that primary early stage Non-Hodgkin Lymphoma of the parotid gland is a disease with an excellent prognosis and a good local control rate, with minimal morbidity.

Management of naso-septal deformity in childhood: Long-term results

OBJECTIVE The classical teaching advocates a conservative approach for children presenting with various naso-septal deformities. It may not be appropriate especially when it causes nasal obstruction to the growing child. This study has two main purposes: to contribute in identifying the correct selection criteria for surgical management of pediatric patients and in selecting the most appropriate surgical technique. MATERIAL AND METHOD We reviewed a series of 46 cases of post-traumatic septal and naso-septal deformity not managed promptly or with recurrence of nasal deviation, following bones fracture correction alone. The mean follow-up was 10 years. RESULTS Patients with naso-septal deformity managed only by septoplasty had accentuation of nasal pyramid deformity; those treated by septorhinoplasty showed a good aesthetic and functional result after long-term follow-up. CONCLUSION Our series results demonstrated that the best results were obtained when we correct all evident alterations of nasal septum and pyramid at a single stage. Unsuccessful results seen in our first group suggest that immediate correction of septum alone with delayed management of nasal pyramid deformity leads to a poorer outcome.