Valerio Damiani

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.

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.

Efficacy and safety of ketoprofen lysine salt mouthwash versus benzydamine hydrochloride mouthwash in acute pharyngeal inflammation: A randomized, single-blind study

BACKGROUND Pharyngodynia, or sore throat, is one of the symptoms most frequently reported by patients to primary care physicians. OBJECTIVE The purpose of this study was to compare the efficacy and tolerability of mouthwash formulations of ketoprofen lysine salt (KLS), an anti-inflammatory agent, and benzydamine hydrochloride (BH), a local anesthetic, in patients with acute inflammation of the pharyngeal cavity. METHODS In this randomized, multicenter, parallel-group, single-blind study, patients (who were blinded) were assigned to receive undiluted BH 15 mL (22.5 mg) or KLS 10 mL (160 mg) diluted in 100 mL of water. Both agents were gargled twice daily until pain remission or up to 7 days. A physical examination of the oropharyngeal cavity was performed, and severity of edema and hyperemia was assessed after 3 days of treatment and, if symptoms had not resolved, after pain remission. RESULTS Of the 241 patients (120 KLS, 121 BH), 239 were included in the safety analysis and 232 were in the intent-to-treat population. The differences between groups in the duration of analgesic effect after the first dose of drug and the time course of pain were found to be statistically significant (P = 0.006 and P = 0.017, respectively), favoring KLS. Adverse drug-related effects reported included numbness of the tissues in the oral cavity, sensation of tingling in the tissues in the oral cavity, dry mouth, thirst, and nausea. A significantly greater proportion of BH-treated patients reported adverse events (P = 0.001 for all adverse events and drug-related adverse events). CONCLUSIONS KLS mouthwash exerts a significantly longer first-application analgesic action with significantly greater local tolerability than BH in patients with pharyngeal pain of inflammatory and/or infectious origin.

Atopy: pediatric ENT manifestations in children.

OBJECTIVE The aim of the present study is to discuss the basics of atopy in children in relationship to the principal ENT allergic disorders such as allergic rhinitis, rhinosinusitis and their impact on lower airways, allergic otitis media, and oral cavity focusing on their natural history. METHODS An updated and exhaustive review of principal literature on these topics is performed, underlining the constant but growing interest evoked by these disorders most of all the possible sequelae or complications. Considering the different districts which can be selectively or simultaneously affected by the allergic sensitisation, diagnosis can be a really hard task; in this paper, we tried to draw an integrated diagnostic approach to atopic children and some guidelines for a correct therapeutic approach. CONCLUSIONS Atopic disorders could expose young patients to years of chronic diseases that interferes with their development and with many important aspects of their lives. For these reasons, and considering the high social and medical costs of this disease, it is extremely important to adequately treat allergic pathologies from the early phases of its natural history. Moreover, we cannot forget that an appropriate therapy of allergic pathologies should not be only able to decrease symptoms but, it should also be able to improve patients health related quality of life.

Eustachian Tube and Otitis Media

Upper airways pathologies represent extremely common medical problems in children, and from the daily clinical practice clearly emerges that alterations of rhinopharyngeal homeostasis can produce nasal symptoms and otitis media as well. Nose and middle ear are, in fact, not independent entities, but they belong to a system of contiguous organs including the nose, Eustachian tube, palate, rhino- pharynx, middle ear and mastoid cells, the so called rhinopharyngotubal unit The key element of this anatomo-physiological unit is, considering its multiple functions, certainly the Eustachian tube.

Recurrent and chronic inflammations of Waldeyer's ring in childhood: infectious, structural and immunological features

Abstract Objective: To evaluate certain infectious, structural and immunological aspects of the adenoids and tonsils in patients submitted to adenotonsillectomy due to chronic inflammation or massive hypertrophy. Materials and methods: In the first phase, bacterial flora and lymphocytic population were analyzed in the tonsils and adenoids removed from 19 children; in the second phase, histological studies and analysis of the cytokine pattern were carried out in palatine tonsils and adenoids from 105 patients submitted to adenoidectomy and bilateral extracapsular tonsillectomy. Results: The presence of Haemophilus influenzae, Streptococcus pneumoniae and S beta-hemolytic was comparable in both tissues; the most frequently isolated pathogen being H. influenzae. A higher percentage of T3 and T4 lymphocytes was observed in adenoids than in the tonsils. Histologically, of the 105 cases examined, 46 presented hyperkeratosis of the crypt epithelium; in the remaining 59, the epithelium was hyperplastic with no signs of keratosis. A comparison of findings, in serum and tissues, showed a higher concentration of interleukin (IL)-1β and tumor necrosis factor-alpha (TNF-α) in the adenotonsillar specimens, whereas the rise in IL-6 was more modest. Conclusions: The impaired immunological reactivity of the tonsils would appear to be mediated by a change in the epithelial compartment which results in impaired antigen uptake rather than by the lymphatic compartment which only reacts to the repeated stimuli. The high levels of cytokines lead, with repeated infectious stimuli, to activation and proliferation of endothelial cells and fibroblasts which result, with time, in the progressive replacement of immunologically active tissue with fibrotic tissue which is, therefore, immunologically silent.

The Rhinological Diagnosis in the Management of Otitis Media

When approaching to middle ear pathologies, clinician has not only to manage the audiological and auricular problems, but he necessarily has to consider the multiple and complex etiopathogenetic links that exist among the organs constituting the rhinopharyngotubal unit. According to our 20 years experience in the field of the Rhinology, and bearing in mind the emergent role of nasal allergy in the pathogenesis of otitis media, we suggest a three step diagnostic approach for the evaluation of the rhinopharyngotubal district in both adults and children.

Modifications of moxifloxacin concentrations in plasma and tonsillar tissue after multiple administration in adults

Abstract Purpose : To evaluate modifications of moxifloxacin (MFX) concentrations in tonsillar tissue and plasma up to 24 h after three oral doses of 400 mg, and to assess the safety and tolerability of this drug in adult patients with chronic or recurrent tonsillitis undergoing tonsillectomy. Methods : Twenty-nine patients with normal renal and hepatic function were randomly placed into five groups according to the time between the last moxifloxacin dose administered and the time of sampling (group A: 2 h, group B: 3 h, group C: 6 h, group D: 12 h, group E: 24 h). Plasma, from heparinized venous blood, and tissue concentrations were determined using a validated HPLC assay with fluorescence. Results : Mean levels of moxifloxacin in the tonsillar tissue were on average at least 2-fold with respect to the correspondent values in the plasma. The time profile in tissue seems to be very similar to that in plasma. In particular, the peak concentration in the tissue occurred at the same time (hour 3) as in plasma, having a ratio of about three (2.85) in favour of the tissue mean level. No drug-related adverse effects developed in any of the patients. Conclusions : Moxifloxacin was well tolerated by all patients and achieves a good penetration in tonsillar tissue, which compares favourably with that reported for other fluoroquinolones.

Aetiological Considerations on Chronic Sinusitis and Therapeutic Consequences

The therapeutic rationale of acute or chronic rhinosinusal inflammatory disease must necessarily be based on the correct identification of the microbiological agents involved in causing the sinus affection. In our experience, Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are the germs responsible for most of the acute forms found in our country, in adults and children alike. In 1997, the FDA approved the use of antibiotics such as amoxicillin/clavulanic acid, clarithromycin, cefuroxime axetil, loracarbef and levofloxacin for acute forms. According to our experience, the administration of amoxicillin/clavulanic acid would appear to be particularly effective, also in the relapse of chronic forms. Regarding the duration of antibiotic treatment, consensus is practically unanimous. In acute rhinosinusitis, the therapy should be given for at least 10 days at full dosage. The duration of treatment may be extended up to 14 days at the physician’s discretion in the more serious cases of infection and in the case of debilitated patients. In the chronic forms, the common literature indicates a therapy targeted at eradication of coagulase-positive and coagulase-negative staphylococci and anaerobes having a duration of less than 5 weeks. In our opinion, chronic histological modifications of the sinoidal mucosa represent conditions of risk for the appearance of acute episodes, which should necessarily be treated with medical therapy. When the acute episodes recur with incessant regularity, leading to important problems and causing a decrease in quality of life, then functional surgery should be considered.