Giovanni Ralli

Idiopathic benign paroxysmal vertigo in children, a migraine precursor

Vertigo and dizziness are common conditions in the adult population that can be rarely seen during childhood; only a few articles describing vertigo in children can be found in literature. Although many causes of vertigo in adulthood occur also in childhood, their frequency may be different. A typical example is benign paroxysmal positional vertigo, the most common peripheral vestibular disorder in adults, which occurs quite uncommonly in children. Furthermore, many common diseases causing vertigo in children may be unique for this population, such as benign paroxysmal vertigo (BPV) of childhood. At present, BPV is defined as a migraines equivalent, a precursor of migraine or a periodic syndrome of childhood. The International Headache Society also studied this form of vertigo and included the Benign Paroxysmal Vertigo in section 1.3.3. of the International Classification of Headaches (ICHD-2). The present review analyzes recent patho-physiological and clinical evidences regarding idiopathic BPV in children.

Bell's palsy and its recurrences

SummaryThe purpose of this study was to evaluate the incidence and the prognosis of patients with recurrences of Bells palsy. Yanagiharas classification of recurrent palsies was used, and all palsies were separated into five different types. A total of 304 patients with Bells palsy were examined. The recurrent ipsilateral attacks (i.e., the unilateral recurrent palsies) showed a worse prognosis when compared with the non-recurrent palsies. In contrast, the recurrent attacks involving the contralateral facial nerve (bilateral alternating palsies) presented a better facial recovery. In reviewing the recurrent cases, the stapedial reflex demonstrated no prognostic value. Our results suggest that in presenting data of Bells palsy it is advisable to differentiate the recurrences from the common (non-recurrent) palsies.

Distortion product otoacoustic emissions in Ménière's disease

Distortion product otoacoustic emissions (DPOAEs) are an objective, non-invasive measure for evaluating outer hair cell (OHC) activity. In this study DPOAEs were measured in 70 patients affected by Ménières disease (MD). In addition 58 out of 70 patients performed both an audiometric threshold evaluation pre- and post-glycerol administration (i.e. glycerol test) and DPOAEs pre- and post-osmotic drug assumption. The purpose of this combined form of testing was to explore the effects of glycerol on the active non-linear mechanisms of the cochlea. More than 60% of the ears with MD emitted DPOAEs despite the presence of an average hearing threshold level above 40 dB (HTL). Changes in the DPOAE baseline measures were observed in 32.4% of cases after glycerol administration. Patients were divided in four groups according to the different pattern of DPOAEs shown after the glycerol test. In particular, three-quarters of cases showed a significant increase in DPOAE amplitude, one-quarter of patients, who initially did not express DPOAEs, eventually did after intake of the osmotic agent, while no decreased DPOAEs were observed in these series. The different expressions of DPOAEs should be associated with the evolutive phases of MD. In addiction, elucidation of the relationship between DPOAEs and the stages of MD was an outcome of this test.

A Higher CD105-Assessed Microvessel Density and Worse Prognosis in Elderly Patients With Laryngeal Carcinoma

OBJECTIVES To ascertain the prognostic role of endoglin (CD105)-assessed microvessel density (MVD) in patients older than 65 years with laryngeal squamous cell carcinoma (LSCC), and whether this MVD differed in the elderly patients from younger adult controls. DESIGN Retrospective clinicopathologic investigation. SETTING Academic tertiary referral center. PATIENTS Fifty-seven consecutive elderly patients with LSCC and 19 younger adult controls. MAIN OUTCOME MEASURE Image analysis of immunohistochemical reactions. RESULTS In LSCCs in elderly patients, N+ stage correlated with a shorter disease-free survival (DFS) (P < .001). A higher CD105-assessed MVD was associated with disease recurrence (P = .006). The DFS was shorter in elderly patients whose CD105 expression was greater than 9.6% than in patients whose CD105 expression was 9.6% or less (P = .001). Among the elderly patients with tumors staged as N0, a higher CD105-assessed MVD correlated with disease recurrence (P = .006) and a shorter DFS (P = .001). CD105-assessed MVD in LSCC occurring in elderly patients did not differ from the situation observed in younger adult controls (P = .74). CONCLUSIONS In LSCC occurring in elderly patients, CD105-assessed MVD may be a useful N-stage independent, angiogenic prognostic marker for pinpointing: (1) patients at higher risk of disease recurrence; and (2) patients with N0 tumors at higher risk of early recurrence, who may benefit from more aggressive therapy.

Gas-containing otogenic brain abscess

BACKGROUND Gas-containing brain abscesses are very rare. Two mechanisms may be responsible for the presence of intracavitary gas: bacterial fermentation or penetration through an abnormal communication between the exterior and the intracranium. The need to search for this potential communication is considered an indication for open surgery. We report the case of a surgically treated gas-containing brain abscess originating from an undiagnosed chronic otitis media. CASE DESCRIPTION A 54-year-old man developed acute neurologic deterioration, becoming comatose within 24 hours. A contrast-enhanced computed tomography (CT) scan disclosed a gas-containing cystic mass in the right temporal lobe. Urgent surgical decompression revealed the presence of an abscess, which was excised. During the same surgery, we performed a radical mastoidectomy, removing a previously undiagnosed attic cholesteatoma. Neither procedure revealed a discontinuity of the floor of the middle cranial fossa. Cultures grew a mixed flora. Antibiotics were administered for 6 weeks. The patient made a complete neurologic recovery. CONCLUSION This report demonstrates that otogenic brain abscesses may contain gas due to fermentation of nonclostridial bacteria.

The Importance of the Number of Reflux Episodes in the Diagnosis of Laryngopharyngeal Reflux Disease

Objective The aim of this study is to evaluate the sensitivity parameters of the percentage of time the pH is <4 and >7, as well as the total number of laryngopharyngeal reflux episodes in 24 hours, in patients with suspected laryngopharyngeal reflux disease. Study Design Retrospective controlled study. Setting University hospital. Subjects and Methods The study was conducted on 46 patients with laryngopharyngeal reflux disease and 58 healthy controls. Patients and controls underwent 24 hours of dual-probe pH monitoring of the distal and cervical esophagus. Patients completed a Reflux Symptom Index questionnaire and underwent esophageal manometry. Data concerning the percentage of time the pH was <4 and >7 and the number of reflux episodes registered at the cervical esophagus were collected and evaluated. Results The percentage of time the pH is <4 and the number of laryngopharyngeal reflux episodes seem to be a reliable diagnostic laryngopharyngeal reflux criterion reaching satisfactory sensitivity (81% and 83%, respectively). Although the pH >7 parameter appeared statistically different between the 2 groups (P < .001), the sensitivity of the test appeared to be poor (55%). Conclusion Our study demonstrates the importance of the absolute number of laryngopharyngeal reflux episodes in 24 hours in the diagnosis of patients with suspected laryngopharyngeal reflux, proposing it as a new diagnostic criterion.

Anchored myringoplasty for total perforation with malleus adhesion to the promontory.

INTRODUCTION In the normal ear the distance between the tympanic membrane at the umbo and the middle ear mucosa at the level of the promontory is at least 2.5 mm. This distance influences the vibratory properties of the middle ear. If the inferior aspect of the malleus approaches or is fixed to the promontory, a significant impairment of the conductive mechanism occurs. Adhesions between the inferior aspect of the malleus handle and the promontory are occasionally present in patients with ear drum perforations. This condition can be isolated or, more commonly, associated with adhesions in other sites of the ossicular chain. Only a few cases have been reported in the literature and the overall incidence of this phenomenon is not known. According to Schuknecht, the adhesions of the malleus to the promontory in the presence of chronic tympanic membrane perforation are caused by the unopposed pull of the tensor tympani muscle leading to medial displacement of the manubrium. The fixation of the malleus handle to the promontory can also be the result of a diffuse atrophy and retraction of the tympanic membrane secondary to tubal dysfunction according to the retraction theory. Pathologies of the middle ear, such as adhesions of the umbo to the promontory, have been recently classified by Sultan. In order to surgically treat such a condition the intervention must include the repair of the tympanic membrane and its correct relocation in the middle ear cavity. A variety of myringoplasty techniques have been described in the past 30 years to repair large tympanic membrane perforations. So far the results documented in these studies are very promising and the surgical technique continues to be updated. Primrose and Kerr were able to improve graft tension by using an anterior tunnel created under the annulus. Gristwood and Venables described an underlay myringoplasty creating two anterior tunnels for graft stabilization. Sauvage et al. presented a surgical technique that included the creation of a large anterior flap for stabilizing the fascia. In addition, thin Silastic has often been used to avoid the formation of new adhesions.

La misura della qualità della vita in pazienti con otite media suppurativa cronica: Adattamento in Italiano del œChronic ear survey

SUMMARY The chronic ear survey (CES) is a sensitive and disease specific quality of life (QoL) measurement tool in patients with chronic suppurative otitis media (CSOM). It is a 13-item survey that evaluates the frequency, duration and severity of problems associated with this disease. It is composed of three subscales that describe activity restrictions, symptoms and medical resource utilisation. Based on patients answers, it is possible to obtain a score resulting in a scale ranging from 0 to 100; the highest indicates the best health, while the lowest denotes poor health. The questionnaire was originally created in English. The aim of this study is to validate the CES questionnaire in Italian (CES-I). Translation was made following international guidelines. The application follows the stages of translation from English to Italian and linguistic adaptation, and grammatical and idiomatic equivalence review. The CES-I and the Short Form Health Survey 36 (SF-36) questionnaires were administered to 54 patients with CSOM. A cross-sectional design was used to examine the internal consistency (Cronbachs alpha) and concurrent validity (Pearsons product moment correlation). To confirm the external validity of CES-I, Pearson correlation coefficient, considering the total score and single subscales of CES and the 8 scales of the SF-36, was calculated. Cronbachs alpha coefficient for internal consistency was 0.737. The intraclass correlation coefficient, measured through mixed effects, was 0.737 (95% CI: 0.600–0.835, p < 0.001) for average measures and 0.412 (95%CI: 0.273–0.559, p < 0.001) for individual measures. According to our results, CES-I is a reliable tool for evaluation of QoL in patients with CSOM among the Italian-speaking population.

Day-case stapedotomy: is it a viable option?

Abstract Conclusions: Stapedotomy is, in our opinion, the technique of choice in stapes surgery. The precision of this technique allows clinicians to perform the surgical procedure in day surgery under local anesthesia. Objectives: There is a strong emphasis on increasing the number of elective day surgery cases, especially in the patients’ best interest, as it decreases the likelihood of late cancellation and hospital-acquired morbidity. A prospective study was performed to determine whether stapes surgery for otosclerosis could be performed safely in an outpatient setting. Methods: We present a series of stapes surgery cases for otosclerosis performed on a day-case basis. We performed a classic stapedotomy in 9 patients, a reverse classic step stapedotomy in 2 patients, a partial reverse classic step stapedotomy in 11 patients, and a hemi-stapedectomy in two patients. Results: Three of 24 patients (12.5%) treated with classic stapedotomy, 1 patient with partial reverse classic step stapedotomy, and 1 patient with hemi-stapedectomy were formally admitted to the hospital after surgery (length of stay, 23 h). The indications were vertigo (two patients) and asthenia (one patient). These patients were treated under general anesthesia. Two of these patients resided more than 250 km away from the hospital.

Post-traumatic camel-related benign paroxysmal positional vertigo

INTRODUCTION Benign paroxysmal positional vertigo (BPPV) is a common form of dizziness. The causes of BPPV are not yet known but a relationship between the onset of vertigo and head trauma has been found. Among the causes of head injury related to BPPV, dropping off a camel has not been reported in literature yet. CASE REPORT We describe two cases of persons that fell off a camel during a safari in Middle East countries. After the fall they reported vertigo symptoms that were not interpreted as BPPV. When they returned to Italy, due to symptoms persistence, they were referred to our ENT practice: we found evidence of BPPV. In a case it was a bilateral BPPV (bBPPV). DISCUSSION Falling off a camel may be a relevant cause of BPPV. We suggest a correct evaluation of the labyrinth for BPPV with the appropriate diagnostic maneuvers and, if necessary, a treatment with repositioning maneuvers.