Francesco Maria Passali

Treatment of inferior turbinate hypertrophy: a randomized clinical trial

In the past 130 years, many surgical procedures for turbinate reduction have been developed. We analyzed the long-term efficacy of 6 of these surgical techniques (turbinectomy, laser cautery, electrocautery, cryotherapy, submucosal resection, and submucosal resection with lateral displacement) over a 6-year follow-up period. We randomly divided 382 patients into 6 therapeutic groups and surgically treated them at the Department of Otorhinolaryngology of the University of Siena. After 6 years, only submucosal resection resulted in optimal long-term normalization of nasal patency and in restoration of mucociliary clearance and local secretory IgA production to a physiological level with few postoperative complications (p < .001). The addition of lateral displacement of the inferior turbinate improved the long-term results. We recommend, in spite of the greater surgical skill required, submucosal resection combined with lateral displacement as the first-choice technique for the treatment of nasal obstruction due to hypertrophy of the inferior turbinates.

Foreign bodies in the airways: A meta-analysis of published papers

BACKGROUND Very recently, some attempts have been made to start a systematic collection of foreign bodies (FB) in view of using them to characterize the risk of chocking in terms of size, shape and consistency of the FB. However, most of the epidemiologic evidence on foreign bodies in children comes from single-center retrospective studies, without any systematic geographical and temporal coverage. This paper is aimed at providing an estimate of the distribution of foreign bodys injuries in children according to gender, age, type of FB, site of obstruction, clinical presentation, diagnostic/therapeutic procedures, complications, as emerging from a meta-analytic review of published papers. METHODS A free text search on PubMed database ((foreign bodies) OR (foreign body)) AND ((aspiration) OR (airways) OR (tracheobronchial) OR (nasal) OR (inhalation) OR (obstruction) OR (choking) OR (inhaled) OR (aspirations) OR (nose) OR (throat) OR (asphyxiation)) AND ((children) OR (child)) finalized to identify all English written articles referring to foreign body inhalation over a 30 years period (1978-2008) was performed. The target of the analysis has been defined as the proportion of injuries as reported in the studies, stratified according to children demographic characteristics, type of FB, site of obstruction. The pooled proportions of FB were calculated using the DerSimonian and Laird approach. RESULTS 1699 papers were retrieved and 1063 were judged pertinent; 214 English written case series were identified, among them 174 articles were available and have been included in the analysis. Airway foreign body most commonly occurs in young children, almost 20% of children who have inhaled foreign bodies being between 0 and 3 years of age. Organic FB, particularly nuts, are the most documented objects while, among inorganic FBs, the greatest pooled proportion has been recorded for magnets, which can be particularly destructive in each location. Non specific symptoms or a complete absence of symptoms are not unusual, justifying mistaken or delayed diagnosis. Acute and chronic complications seem to occur in almost 15% of patients. CONCLUSIONS Even if an enormous heterogeneity among primary studies seems to exist and even if the absence of variables standardized definitions across case series, including class age definition and symptoms and signs descriptions, seriously impairs studies comparability, our results testify the relevant morbidity associated with foreign body inhalation in children, stressing the importance of preventive measures.

Nasal decongestants in the treatment of chronic nasal obstruction: efficacy and safety of use

Nasal decongestants are the most powerful drugs in the reduction of nasal obstruction. Despite their large use, local and systemic adverse reactions are frequent. The authors focus on the pharmacology of these kinds of drugs in light of the most recent knowledge on nasal pathophysiology. The ultrastructural anatomy of nasal mucosa explains the complexity of the possible interactions between the sympathomimetics and imidazoles derivates, and the submucosal layer. Nasal obstruction is one of the most frequent clinical problems that otorhinolaryngologists encounter daily, both in adults and children. All possible predisposing conditions to nasal obstruction are documented along with the better ways to diagnose them through nasal functionality tests. Active anterior rhinomanometry, acoustic rhinometry and the determination of mucociliary transport time represent, together with nasal endoscopy, the gold standard for an accurate diagnosis and the follow-up of the patient to cure. An updated review of the most significant works in this field and the best treatment protocol to avoid adverse effects, such as rhinitis medicamentosa, are reported.

Structural and Immunological Characteristics of Chronically Inflamed Adenotonsillar Tissue in Childhood

ABSTRACT Recurrent or chronic adenotonsillar infections mainly affect children and frequently involve otherwise healthy subjects. Therefore, having excluded systemic immunological deficiencies, this disease may be due to a local dysfunction of the epithelial structures at either the rhino or oropharyngeal level. The aim of the present investigation was to analyze structural and immunological aspects of tonsils and adenoids in subjects who underwent adenotonsillectomy because of recurrent inflammatory episodes with fever. Histological studies and analyses of the cytokine patterns were carried out in palatine tonsils and adenoid samples from 105 patients who underwent adenoidectomy and bilateral extracapsular tonsillectomy for chronic inflammatory hypertrophy of these organs; 46 of the 105 cases examined presented hyperkeratosis of the crypt epithelium; in the remaining 59, the epithelium was hyperplastic with no signs of keratosis. Scanning electron microscopy revealed a continuous epithelial surface of polygon-shaped flattened cells with fissures towards the cryptic depressions. Titration of interleukin-1β and tumor necrosis factor alpha in serum and tissues demonstrated higher concentrations in the adenotonsillar specimens, whereas the rise in interleukin-6 was more modest.

P0 antigen detection in sudden hearing loss and Ménière's disease: a new diagnostic marker?

Objective—To evaluate the presence of IgG autoantibodies against the P0 antigen in patients affected by sudden hearing loss and Ménières disease (MD). Material and Methods—All patients underwent a tonal audiometric evaluation, tympanometry, evaluation of the stapedial reflex threshold with decay time, determination of auditory brainstem responses and a complete vestibular assessment involving evaluation of spontaneous and positional nystagmus (Frenzel glasses), a head thrust test and a caloric test (Fitzgerald–Hallpike technique). Blood samples were drawn from all patients for the immunologic assessment of IgG antibodies against the P0 antigen (30-kDa protein) of guinea pig inner ear extracts using a Western blot assay. Results—Ten patients affected by sudden hearing loss showed specific IgG antibodies against the P0 protein. Specifically, the P0 positive band was detectable in 5/45 patients with unilateral auditory impairment and in 5/5 of those with bilateral forms of auditory impairment. Among MD patients, the P0 positive band was detectable only in those with bilateral audiovestibular impairment (n=10). Interestingly, in none of the 35 patients affected by monolateral MD were specific IgG antibodies against the P0 protein detectable. Conclusion—The positive reactions to P0 in all bilateral MD and bilateral sudden hearing loss patients found in this study strongly indicate that these pathologies are the result of an ongoing autoimmune process directed against specific antigens of the inner ear.

Inactivation of Human Salivary Glutathione Transferase P1-1 by Hypothiocyanite: A Post-Translational Control System in Search of a Role

Glutathione transferases (GSTs) are a superfamily of detoxifying enzymes over-expressed in tumor tissues and tentatively proposed as biomarkers for localizing and monitoring injury of specific tissues. Only scarce and contradictory reports exist about the presence and the level of these enzymes in human saliva. This study shows that GSTP1-1 is the most abundant salivary GST isoenzyme, mainly coming from salivary glands. Surprisingly, its activity is completely obscured by the presence of a strong oxidizing agent in saliva that causes a fast and complete, but reversible, inactivation. Although salivary α-defensins are also able to inhibit the enzyme causing a peculiar half-site inactivation, a number of approaches (mass spectrometry, site directed mutagenesis, chromatographic and spectrophotometric data) indicated that hypothiocyanite is the main salivary inhibitor of GSTP1-1. Cys47 and Cys101, the most reactive sulfhydryls of GSTP1-1, are mainly involved in a redox interaction which leads to the formation of an intra-chain disulfide bridge. A reactivation procedure has been optimized and used to quantify GSTP1-1 in saliva of 30 healthy subjects with results of 42±4 mU/mg-protein. The present study represents a first indication that salivary GSTP1-1 may have a different and hitherto unknown function. In addition it fulfills the basis for future investigations finalized to check the salivary GSTP1-1 as a diagnostic biomarker for diseases.

Nasal Allergy and Otitis Media: A real correlation?

OBJECTIVES The correlation between middle ear pathology and nasal allergy has been debated for almost 30 years. This study aimed to evaluate the relationship between otitis media with effusion (OME) and persistent allergic rhinitis symptoms versus intermittent rhinitis in children. METHODS The study included 100 atopic children (52 boys, 48 girls) aged 5-9 years with otological symptoms who were patients of the University of Siena Hospital, Italy. Ear, nose and throat evaluations, tympanometry, skin prick tests (SPTs), mucociliary transport time (MCTt) and Eustachian tube function tests were performed. RESULTS The SPTs revealed 50 children sensitised to Dermatophagoides pteronyssinus, 34 to grass pollen and 16 to Parietaria. Of all patients, mild symptoms were intermittent in 19 children and persistent in 18; moderate/severe symptoms were intermittent in 22 and persistent in 41. Tubal dysfunction was present in 25 children, whereas middle ear effusion was present in 45 children undergoing myringotomy. The MCTt was slower in the persistent group (21 ± 2 mins) versus the intermittent group (16 ± 2 mins) with a significant difference (P <0.01). Mean eosinophil cationic protein (ECP) values in the middle ear effusions of children who had undergone myringotomy were 251 ± 175.2 μg/L, and mean ECP blood values were 25.5 ± 16.3 μg/L, with significant differences (P < 0.001). CONCLUSION There was a significant association between OME, delayed MCTt, ECP values in middle ear effusion and persistent symptoms of allergic rhinitis. These results suggest a direct involvement of the middle ear mucosa as a target organ in persistent forms.

The role of balloon sinuplasty in the treatment of sinus headache

INTRODUCTION Headache attributed to rhinosinusitis, commonly called sinus headache (SH), is probably one of the most prevalent secondary headaches. The purpose of our study was to examine further sinus headache comparing the effect of conventional functional endoscopic sinus surgery and the balloon sinuplasty. MATERIAL AND METHODS Eighty-three consecutive patients were enrolled from 2009 to 2012, who were diagnosed sinus headache according the diagnostic criteria of AAO-HNS and of HIS. 40 patients were randomized to Conventional Endoscopy Sinus Surgery for frontal sinus (ESS Group), 35 to balloon sinuplasty of frontal sinus (BS Group). RESULTS The mean operative time was 65 ± 15 min for ESS group patients and 32 ± 7 min for 23 patients (BS1 Group) and 55 ± 18 min for 12 treated with hybrid technique (BS2 Group). The preoperative mean of SNOT-22 scores improved from 28.6 ± 1.2 in ESS group and 27.3 ± 0.8 in BS group to a 1-month postoperative scores of 14.5 ± 0.6 in ESS group and 10.3 ± 0.5 in BS group and to a 6-month postoperative scores of 7.8 ± 0.6 and 5.3 ± 0.3, respectively (p<0.0001). The headache scores base on analog visual scale improved from a preoperative mean of 6.5 ± 0.3 in ESS group and 7.1 ± 0.4 in Bs group to a 1-month postoperative scores of 5.4 ± 0.4 in ESS group and 5.5 ± 0.4 in BS group and to a 6-month postoperative scores of 2.7 ± 0.5 and 1.2 ± 0.1, respectively, representing a statistically significant reduction in headache score in both group. CONCLUSION Our data prove that improvement in headache can be expected in patients treated with balloon catheter.

Restoration of immune-mediated sensorineural hearing loss with sodium enoxaparin: a case report.

The aim of the study was to assess the efficacy of sodium enoxaparin in the treatment of autoimmune sensorineural hearing loss. A small number of patients with unilateral sensorineural hearing loss were selected and divided randomly into two numerically equal groups (groups A and B) if they fulfilled the inclusion criteria, i.e. being between 20 and 65 years of age, had been affected by systemic lupus erythematosus, had presented with a hearing loss of at least 30 dB of audibility threshold involving the medium frequencies (2000-4000 Hz), and had provided informed consent. Group A received sodium enoxaparin while group B (control) received placebo. In group A, all patients except one showed an improvement in hearing after sodium enoxaparin treatment. In group B, no patients showed an improvement in auditory function. In conclusion, our results underline the important role of sodium enoxaparin in the therapeutic management of this disease. The low number of patients suggests that further studies are required to confirm this initial data but this study suggests that sodium enoxaparin provides encouraging results in the treatment of autoimmune sensorineural hearing loss.

Preliminary Findings from Our Experience in Anterior Palatoplasty for the Treatment of Obstructive Sleep Apnea

Objectives Obstructive sleep apnea (OSA) is a common disorder affecting at least 2% to 4% of adult population characterized by the collapse of the pharyngeal airway. It is well established that retropalatal region is the most common site of obstruction. Consequently, many surgical techniques have been introduced. The purpose of this study is to present our preliminary results in the anterior palatoplasty (AP) compared with results of uvulopalatal flap (UPF). Methods Thirty-eight consecutive patients with mild-moderate OSA were prospectively enrolled into a randomised surgical protocol. Surgical success was measured primarily by satisfactory reduction in snoring, as reported by snoring assessment questionnaire (SQ) of sleep partners. Secondary outcomes measures included improvement in the Epworth Sleepiness Scale (ESS) scores, changes in the magnitude of pharyngeal collapse, and postoperative pain intensity. Results The ESS after AP improved from a preoperative value 8.5±3.7 to a postoperative mean of 4.9±3.2 (P<0.001) after UPF improved from a preoperative value of 8.1±3.5 to 5.2±3.2 postoperatively (P<0.001). The results of satisfactory reduction in the volume of snoring and response at polysomnographic data were also similar in both procedures. We reported a statistically significant difference of the collapse noted at Müller manoeuvre that improved from 2.7±1.0 on average, to 1.1±0.9 (P<0.001) after AP and with a lesser extent, (from 2.8±1.1 on average to 1.8±1.1; P<0.05), after UPF. The mean duration of pain was 10.8 days for UPF patients and 7.1 days for AP patients. The mean pain score in the first 3 days, was 6.8 in UPF patients and 5.1 in AP patients. Conclusion The subjective and objective improvements evidenced may suggest how AP is far superior to other techniques aimed at creating a palatal fibrotic scar. In the light of these results we can suggest AP procedure as more practical and comfortable when compared to UPF.