Pier Giorgio Giacomini

Body sway in diabetic neuropathy.

OBJECTIVE To evaluate the influence of peripheral neuropathy on body sway assessed by posturography. RESEARCH DESIGN AND METHODS The age-matched study subjects included 10 insulin-dependent diabetes mellitus (IDDM) patients with peripheral neuropathy (DN), 23 IDDM patients without peripheral neuropathy (D) according to the San Antonio Consensus Conference guidelines, and 21 control subjects (C). All subjects with symptoms and/or clinical signs of postural instability were excluded from the study. RESULTS The trace surface was significantly larger in the DN than in the C and D groups (P < 0.05), and the trace length was longer in the DN than in the C and D groups (P < 0.01). Mean velocity was faster in the DN than in the other two groups (P < 0.001). A direct relationship was found between the parameters of posturography and some parameters of the nerve conduction velocity. CONCLUSIONS Diabetic patients with peripheral neuropathy demonstrate a relative deficit in their ability to maintain posture. Posturography allows an early disclosure of the failure of postural control.

Long-Term Postural Abnormalities in Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is a disorder in which patients suffer from acute rotatory vertigo due to the presence of free otoconial debris migrating into one or more semicircular canals during head movements and resulting in abnormal stimulation of the ampullary crest. A prolonged loss of equilibrium of unclear origin is also present. Static posturography is a useful tool for the study of postural control systems and their role in these abnormalities. The aim of the present study was to evaluate the frequency of body sway and long-term instability of BPPV patients by posturography frequency analysis. Twenty patients with canalithiasis of the posterior semicircular canal and 20 normal controls were subjected to static posturography. Informed consent was obtained from all subjects. Patients were tested 1 h after diagnosis, and 3 days and 12 weeks after the characteristic Epley repositioning maneuver. Patients with BPPV showed significantly increased body sway both on lateral (X) and anteroposterior (Y) planes compared to normal subjects. Corporal oscillation with a broad-frequency spectrum was observed in both closed and open eye tests. The repositioning maneuver decreased the X plane body sway, while the anteroposterior sway was unchanged. Twelve weeks after treatment, a normalization of the anteroposterior sway was observed. Results of this study suggest that the long-term postural disturbance associated with BPPV differs from the acute disequilibrium that subsides after canalith repositioning: the former is a sagittal plane/broad spectrum body sway, while the latter is primarily a frontal plane/low frequency sway. The Epley maneuver was shown to reduce frontal sway, a postural abnormality that might therefore be linked to posterior semicircular canal function. Conversely, the observed sagittal body sway was only partially relieved by the restoration of canal function, and therefore, may be more related to the chronic dizziness observed in these patients.

Contribution of Central Neuropathy to Postural Instability in IDDM Patients With Peripheral Neuropathy

OBJECTIVE To evaluate the contribution of central neuropathy on postural impairment observed in diabetic patients with peripheral neuropathy. RESEARCH DESIGN AND METHODS Central sensory and motor nervous propagation, nerve conduction velocity, and static posturography were assessed in the following age-matched subjects: 7 IDDM patients with peripheral neuropathy (group DN), 18 IDDM patients without peripheral neuropathy (group D), and 31 control subjects (group C). Somatosensory-evoked potentials (SEPs) during tibial nerve stimulation were recorded, and the spine-to-scalp sensory central conduction time (SCCT) was evaluated. Motor-evoked potentials (MEPs) were recorded from leg muscles during magnetic transcranial brain stimulation, and the scalp-to-spine motor central conduction time (MCCT) was evaluated. The following posturographic parameters were calculated from the statokinesigram: trace length, trace surface, velocity of body sway with its standard deviation, and VFY (a parameter derived from the velocity variance and the anteroposterior mean position of the body). RESULTS SCCT was significantly higher in the DN group than in the C and D groups (P < 0.001). MCCT was similar in all groups. Posturographic parameters were all significantly impaired in the DN group (P < 0.01). While posturographic parameters showed a direct relationship with some parameters of peripheral nerve conduction, no correlations were observed with SEP and MEP central conduction time. These results were also confirmed by logistic regression, which indicates peripheral neuropathy as the only implicating factor in postural instability (odds ratio 0.22, 95% CI 0.07–0.75) after data reduction by means of factor analysis. CONCLUSIONS Although diabetic patients with peripheral neuropathy show a delay in central sensory conduction, postural instability may be fully explained by the presence of peripheral neuropathy.

Septoturbinal surgery in contact point headache syndrome: long-term results.

ABSTRACT Facial pain syndrome secondary to sinonasal pathology is reported by the International Headache Society (IHS) classification (1988). It is underlined that a clear and proven nasal pathology with adequate painful stimuli must be present, i.e., acute sinusitis, vacuum sinus, or other unspecified pathologies. No clear role of septal abnormalities and turbinate hypertrophy has been attributed in the genesis of pain by the IHS classification. One of the most difficult problems in dealing with patients with sinonasal headaches is the definition of the primary cause of the pain. In our experience possible guidelines are history, endoscopic evaluation, diagnostic blocks, and computed tomography. The data reported here is from a long-term follow-up study of facial pain in a group of 34 patients with facial pain and nasal obstruction due to septoturbinal contact that did not respond to medical therapy. Patients, free from sinus disease or other causes of headache, were treated by septoplasty/rhinoseptoplasty, and middle turbinate electrocauterization. Pre- and post-operative patency was assessed by endoscopic evaluation and nasal resistance was assessed by anterior rhinomanometry. Patients were interviewed regarding pre- and post-operative intensity of pain (subjective pain was evaluated using the 0–10 Visual Analogue Scale (VAS) and frequency of the facial pain. The follow-up period ranged from 12 to 47 months (mean: 26.7±8.5 months). In 25% of the cases the pain relapsed post-operatively (from two days to one year); but in only three patients (8%) the relapses were persistent. Two out of three, however, reported a decreased VAS score after surgery. These results seem to indicate septoplasty and turbinate decongestion to be a fairly good surgical option in treating facial pain due to septoturbinal contact resistant to conservative nasal therapy.

Large Nasal Septal Perforation Repair by Closed Endoscopically Assisted Approach

Options for the surgical closure of large symptomatic perforations are limited and consist of an open or closed approach using skin or mucosal flaps, with or without different grafts. The aim of this study is to review our experience in treating large nasal perforations using a closed approach with endoscopic assistance, undertaking a 3-layer reconstruction of the septum. We reviewed 14 consecutive patients with large (2–4 cm) nasal septal perforations, who were treated using an endonasal/endoscope-assisted approach. In these cases, the mucosal defect was reconstructed through a horizontal advancement of the bipedicled mucoperichondrial flaps and sutured using absorbable sutures. The cartilagineous defect was consistently reconstructed using autogenous auricular conchal grafts. Pre- and postoperative nasal symptom scores were used for the study; a decline in the number of Nasal Obstruction Symptom Evaluation Scale symptoms were recorded in 12 of 14 patients (85.7%), and visual analogue scale scores for crusting, bleeding, nasal discharge, whistling, headache, nasal pain, snoring, olfactory loss, and overall discomfort levels also decreased. It was concluded that bipedicled mucoperichondrial flaps with the insertion of auricular cartilage for a 3-layer septal reconstruction seem to give reasonably good results. The use of nasal endoscopy is an endonasal approach, which offers superior precision in all surgical steps and provides a way to obtain excellent closure of the perforation without external incisions.

Recurrent paroxysmal positional vertigo related to oral contraceptive treatment.

Benign paroxysmal positional vertigo (BPPV) is a high-prevalence vestibular end-organ disorder caused by the detachment of utricular otoconia which float in the posterior or lateral semicircular canal. In the majority of cases the etiology of BPPV is unknown and it may follow viral infection, vascular disorders or head trauma. BPPV may be recurrent, with some authors demonstrating a correlation between recurrence and female gender. We report herein on ten cases (out of 289 diagnoses of BPPV) of recurrent idiopathic BPPV, occurring in healthy women receiving oral contraceptive treatment, which ceased after treatment suspension. It has been hypothesized that the impaired water and electrolyte balance, the variations of endolymphatic pH and the impairment of glucose or lipid metabolism induced by oral contraceptive treatment may cause otoconial degeneration and subsequent otoconia detachment and BPPV. The rarity of the finding (10/289) could account for the poor attention paid to the hormonal pathogenesis of BPPV.

Impaired saccadic eye movement in diabetic patients: the relationship with visual pathways function

The aim of this study was to evaluate whether a correlation existed between saccadic eye movements and visual pathways function in diabetic patients. Saccadic or fast Eye Movement System (EMS) and Visual Evoked Potentials (VEPs) were assessed in 20 insulin-dependent diabetic mellitus (IDDM) patients without long-term complications and in stable metabolic control and in 21 age-matched control subjects. In IDDM patients we observed significantly (p<0.01) longer EMS latency, while EMS velocity and accuracy were similar to those of controls; VEPs showed a significant delay in N75, P100, N145 latencies and significant reduction of N75-P100 and P100-N145 amplitudes. In IDDM patients no relationships between EMS and VEP parameters were found. In conclusion, EMS latency delay suggests an impairment of the saccadic eye movement system, while impaired VEPs may be ascribed to a dysfunction of the visual pathways. The lack of correlation between VEPs impairment and EMS latency delay suggests that in our IDDM patients the delay of saccadic latency cannot be exclusively related to a visual pathways dysfuction and could be ascribed to a diffuse neuronal involvement.

A survey of the nature of trauma of post-traumatic benign paroxysmal positional vertigo

Abstract Objective: A clinical description of post-traumatic benign paroxysmal positional vertigo (t-BPPV) in a large cohort is reported, sometimes caused by apparently insignificant minor head traumas. The aim of the study was to carefully assess the prevalence of t-BPPV and the main outcomes belonging to specific traumatic events. Design: Retrospective analysis of medical records of t-BPPV cases among patients suffering from BPPV. Study sample: Among 3060 patients with a clinical diagnosis of BPPV, we reviewed 716 clinical cases in which a clear association to a traumatic event was present. Results: A traumatic event was identified in 23.4% of total enrolled BPPV patients. Some minor head traumas could be more prone to determine BPPV in females. We confirmed that t-BPPV appeared significantly more difficult to treat than idiopathic form. Posterior canal t-BPPV cases required more treatment sessions before obtaining therapeutic success, while horizontal ones recovered at most after two repositioning maneuvers. Conclusion: Post-traumatic BPPV is considered one of the most common known etiologies. An accurate understanding of trauma mechanism, gender prevalence, and therapeutic success rates of each event, could be useful in adequately treating and planning follow-up examinations.

Unusual postrhinoplasty complication: nasal dorsum cyst.

Among all the possible complications of aesthetic rhinoplasty, a rare one is the development of cystic masses on the nasal dorsum: several theories suggest that cysts develop commonly by entrapment of nasal mucosa in the subcutaneous space, but they can also originate from foreign body reactions. This report deals with two cases of nasal dorsum cysts with different pathogenesis: both patients had undergone aesthetic rhinoplasty in the past (26 years ago and 14 years ago, resp.). Both cystic masses were removed via a direct open approach and nasal reconstruction was performed successfully with autologous vomer bone. The pathologic investigations showed a foreign body inclusion cyst associated with latex rubber in the first case and a sequestration of a mucosal-lined nasal bone was not removed at the time of primary rhinoplasty in the second case. A brief review of the literature focuses on the pathophysiology and treatment options for nasal dorsal cysts following aesthetic rhinoplasty.

Atypical Facial Pain Secondary to an Unusual Iatrogenic Endonasal “Contact Point”

Dear Editor, Headache and facial pain are common complaints in clinical setting. However, among different etiologies, clinicians must think also to a possible rhinologic source of pain ⇓. Rhinosinusitis ⇓ or nasal anatomical abnormalities (e.g., large turbinate, concha bullosa, or septal spurs) can cause craniofacial pain through a “contact pressure point” mechanism between opposite mucosal surfaces ⇓. At present, the diagnosis is made mainly by identifying rhinogenic causes, but its pathogenesis is still under debate as well as the therapeutic options. We report the case of a 55-year-old woman presenting an atypical facial pain started 3 weeks after dental implant positioning on right maxillary incisor region. Pain attacks were characterized by a right recurrent orbitozygomatic pounding hurt associated to ipsilateral dull “sense of pressure.” Patients symptoms were reported as moderate to severe, lasting hours, exacerbated by nasal fossa engorgement (due to the physiological nasal cycle or postural changes), and scarcely responsive to common …