Giovanni Carlo Modugno

Transsphenoidal endoscopic approach in the treatment of Rathke's cleft cyst.

OBJECTIVE:In this study, the usefulness of the transsphenoidal endoscopic approach in the treatment of a Rathke’s cleft cyst is reported. METHODS:Between June 1998 and December 2002, 22 patients affected by sellar-suprasellar Rathke’s cleft cysts were treated using a transsphenoidal endoscopic approach. Fourteen patients experienced pituitary dysfunction (64%), five experienced visual impairment (23%), and three reported headaches (14%). RESULTS:The patient follow-up ranged from 8 to 60 months (mean, 33 mo). Pituitary function was restored only in the four patients with hyperprolactinemia, whereas visual impairment and headache improved in all patients. However, when present before surgery, hypopituitarism was unaffected by surgery. Two patients experienced permanent diabetes insipidus (one of them before surgery). Only one recurrence was observed in a 13-year-old girl at 12 months after surgery, and it was treated using a new transsphenoidal endoscopic approach. CONCLUSION:The transsphenoidal endoscopic approach represents a straightforward and mini-invasive approach for the drainage and biopsy of a Rathke’s cleft cyst.

Conservative Management of Vestibular Schwannomas : An Effective Strategy

Objectives: Stimulated by the availability of a larger sample of patients and a longer follow‐up period, we update our experience with conservative management of vestibular schwannomas.

Endoscopic treatment of benign tumors of the nose and paranasal sinuses.

OBJECTIVE: The endoscopic approach can be successfully employed for the treatment of benign tumors such as fibroosseus and vascular lesions, pleomorphic adenomas, gliomas, and schwannomas. STUDY DESIGN AND SETTING: Nineteen patients diagnosed with benign tumors of the nasal cavity and paranasal sinuses and treated using an endoscopic approach were retrospectively reviewed. The endoscopic approach was used exclusively in 15 cases and was associated with an external approach in 4 cases (due to an intracranial extension of the tumor in 3 patients and its location at the level of the anterior wall of the frontal sinus in the last case). RESULTS: The resection of the lesions was radical in 18 patients and subtotal in 1 case. The mean follow-up was 27 months and only 1 recurrence (5%) was observed in the juvenile angiofibroma group 20 months postoperatively. CONCLUSION AND SIGNIFICANCE: In selected cases, endoscopic surgery can be considered an effective treatment for the resection of benign tumors involving the sinonasal tract.

Prevalence of tinnitus in patients withhypertension and the impact of different anti hypertensive drugs on the incidence of tinnitus: A prospective, single-blind, observational study.

BACKGROUND Tinnitus is a common symptom in audiology and neurologypatients. Controversial data have been reported in the literature about the prevalence of tinnitus in hypertensive patients, whereas its relationship with the extent of blood pressure (BP) control has not been substantially explored. OBJECTIVE The aim of this study was to determine the prevalence of tinnitus in hypertensive patients, and the impact of different antihypertensive drugs on the incidence of tinnitus in these patients. METHODS This prospective, single-blind, observational study was conducted at the Hypertension Clinic, St. Orsola-Malpighi Hospital, Bologna, Italy. Patients aged 18 to 75 years with uncontrolled hypertension and receiving antihypertensive therapy were enrolled. Patients were asked to complete a standardized questionnaire to assess the presence, frequency, and duration of tinnitus and the apparent effect of their antihypertensive treatment on it. Patients considered by the investigator to have tinnitus, regardless of their audiologic condition, underwent a complete clinical cardiovascular examination, including supine systolic BP (SBP) and diastolic BP measurement and standard 12-lead electrocardiography. Twelve-hour ambulatory BP monitoring was also performed, and patients were asked to record, using patient diaries, times of the onset and resolution of tinnitus that occurred during those 12 hours. From these data, correlations between the onset of tinnitus and BP were calculated. RESULTS A total of 476 patients participated in the study (283 men, 193 women). Of these, 84 (17.6%) patients reported occasional or prolonged spontaneous tinnitus, whereas 392 (82.4%) reported no tinnitus. The incidence of tinnitus was significantly higher in patients receiving diuretics (72/265 [27.2%]) compared with those receiving angiotensin lI receptor blockers (5/37 [13.5%]), α-blockers (12/55 [21.8%]), or 3-hydroxy-3-methylglutaryl coenzyme A reduc tase inhibitors (9/73 [12.3%]) (all, P < 0.05). Mean (SD) SBP was significantly higher in patients without tinnitus compared with those with it (143.2 [11.1 ] vs 140.6 [10.3] mm Hg; P < 0.005). In 10 (11.9%) patients with tinnitus, the onset was correlated with a sudden decrease in SBP (<140 mm Hg). CONCLUSIONS In this study of tinnitus in patients receiving antihypertensivetherapy, tinnitus was found in 17.6% of patients. Tinnitus was associated with the use of diuretics and with low SBP. Further studies are needed.

Small acoustic neuromas: monitoring the growth rate by MRI.

Summary In a proportion of small acoustic neuroma patients, monitoring with magnetic resonance imaging shows no volumetric increase of tumour size over the years. The object of the study was to identify some indications for the clinical choice between immediate surgery (with the related risks) and watchful waiting. We performed a retrospective study of 47 non-surgically-treated patients affected by acoustic neuroma and monitored by gadolinium-enhanced MRI between January 1990 and February 1999. Six clinical variables (tumour size, sex, age, initial symptoms, ABR pattern and duration of the symptoms) were examined by univariate analysis. Chi-square test and variance analysis were performed to evaluate the statistical significance. In 30/47 (63.8%) cases, no growth was observed during the entire period of follow-up. In the remaining 17/47 (36.2%) patients, a volumetric increase was detected, most often within the first year of observation. The clinical factors examined did not significantly correlate with growth. Despite the relatively short period of observation, we believe that immediate surgery does not need to be considered mandatory for small acoustic neuromas, even in young patients. However the irregular behaviour of the tumour underlines the importance of monitoring with MRI at least once a year.

Superior semicircular canal dehiscence : A series of 13 cases

Increasingly more detailed imaging techniques have recently highlighted the frequent occurrence of bony labyrinthine dehiscence. Among them, superior canal dehiscence (SCD) has been described in a number of cases presenting different features. Here, we report a series of 13 cases, in which the detection of vestibular evoked myogenic potentials (VEMPs) in response to stimuli of abnormally low intensity as compared to normal responses led us to suspect the presence of a ‘third window effect’. An accurate HRCT investigation allowed the diagnosis of SCD. Anamnestic and symptomatologic differences seem difficult to explain, although in our opinion a dural rupture could be at the basis of the onset of pathologic manifestations after many years of silence of a probably malformative condition.

MENIERE’S DISEASE: UPDATE OF ETIOPATHOGENETIC THEORIES AND PROPOSAL OF A POSSIBLE MODEL OF EXPLANATION

Abstract Meniere’s Disease (MD) is an affection consisting of an association of sensorineural hearing loss, tinnitus and vertigo initially presenting by crises. A review of the most considered possible causative factors and pathophysiologic interpretations allows us to underline the uncertainties which still exist about the genesis of this illness. We propose a mechanistic model based on the effect of a haemodynamic imbalance leading to transient ischaemia which could have an effect on the pH of the inner ear as well as on the work of the inner ear proton pumps. It is hypothesized that under ischaemic conditions and consequent metabolic acidity a preserved proton pump activity can generate an overload of anions in the endolymphatic partition, which is a closed system, thus resulting in an enhancement of osmolarity and consequently in the formation of a hydrops resulting in the development of fluctuating hearing loss, tinnitus and vertigo which characterize Meniere’s Disease.

Endoscopic treatment of benign tumors of the nose and paranasal sinuses: a report of 33 cases.

Background The endoscopic approach can be used successfully for the treatment of benign tumors such as fibroosseous and vascular lesions, pleomorphic adenoma, glioma, meningioma, and schwannoma. Methods Thirty-three patients diagnosed with benign tumors of the nasal cavity and paranasal sinuses and treated using an endoscopic approach were reviewed retrospectively. The endoscopic approach was simple in 28 cases and associated with an external approach in 5 cases (because of an intracranial extension of the tumor in four patients and its location at the level of the anterior wall of the frontal sinus in the last case). Results The resection of the lesions was complete in 32 patients and subtotal in one case. The mean follow-up was 28 months and only two recurrences (6%) were observed in the juvenile angiofibroma group and in the case of the fibrous dysplasia associated to aneurysmal bone cyst, respectively, 20 and 24 months postoperatively. Conclusion In selected cases, endoscopic surgery can be considered an effective treatment for the resection of benign tumors involving the sinonasal tract.

Gastric type proton pump of the inner ear: Its possible involvement in labyrinthine disorders

It was recently suggested that the favourable effect of proton pump inhibitors on gastric reflux could threaten the homeostasis of the inner ear in several different ways. Moreover, when it is considered that a gastric type proton pump has been found in the inner ear, it could be hypothesized that this treatment has a direct effect. As ischaemia threatens gastric mucosa even by acid secretion, thus implying resistance of the proton pump to damaging factors, a similar kind of mechanism could be imagined in the inner ear, where it could even cause the osmotic changes possibly involved in Ménières disease hydrops. This hypothesis, if proved, could open new perspectives on some not fully understood phenomena and lead to finding more satisfactory therapeutic options.

Could vestibular evoked myogenic potentials (VEMPs) also be useful in the diagnosis of perilymphatic fistula

The role of vestibular evoked myogenic potentials (VEMPs) is at this time indisputable in the study of vestibular disorders. Furthermore, VEMPs are widely accepted as a diagnostic tool when a superior semicircular canal dehiscence (SCD) is suspected, presenting in such cases a lowering of threshold values able to raise a recordable response due to increased inner ear immittance. According to the same principle, the possibility of another kind of alteration having the same effect on the inner ear might be considered when high-resolution computed tomography has excluded the presence of an SCD. In this paper four cases are described in which high-resolution computed tomography showed normal features without any labyrinthine dehiscence and VEMP threshold values were lowered; the appropriateness of suspecting a perilymphatic fistula in such cases and resorting to VEMPs in detecting a perilymphatic fistula is discussed.