Drugs inducing hearing loss, tinnitus, dizziness and vertigo: an updated guide

OBJECTIVE

The awareness of audio-vestibular side effects of drugs, such as hearing loss, tinnitus, dizziness and vertigo, has widely increased in the recent years. The present guide represents an update of the previous documents published by the authors in 2005 and 2011 on drug-induced ototoxicity and vestibulotoxicity.

MATERIALS AND METHODS

The authors performed a comprehensive analysis of audio-vestibular side effects of commercially available drugs based on the British National Formulary, a pharmaceutical reference book that contains a wide range of useful information and advice on prescription and pharmacology.

RESULTS

Commercially available drugs and their active principles have been classified based on their audio-vestibular side effects, as reported by the pharmaceutical companies and/or health agencies. Drugs have been categorized based on the field of application, the therapeutic indication and the pharmacological properties.

CONCLUSIONS

General practitioners, otolaryngology, neurology and audiology specialists should be aware of possible audio-vestibular side effects of drugs, such as hearing loss, tinnitus, dizziness and vertigo. The present guide represents a practical tool to rapidly identify potential audio-vestibular side effects of drugs as reported by the pharmaceutical companies and/or health agencies.

The role of cytokines in head and neck squamous cell carcinoma: A review

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common malignancy worldwide, accounting for approximately 6% of all cancer cases and responsible for an estimated 1-2% of all cancer deaths. Much research evidence has accumulated in the recent years on the changes in the expression of pro-inflammatory and, to a lesser extent, anti-inflammatory cytokines, that (i) may have a role in the malignant transformation of HNSCC, (ii) may be used as diagnostic markers in the sera of patients because of their excessive production by the tumor cells and (iii) may act as possible immunotherapeutic targets. Among pro-inflammatory cytokines, interleukin-8 (IL--8) has been reported to have an important role in cancer invasion, angiogenesis and metastasis. Recent studies have shown an increased concentration of IL--8 in patients with HNSCC and a positive association with lymph node metastasis and tumor classification, although IL--8 was not significantly associated with shorter overall survival and cancer progression-free survival. Additional evidence on the pathological mechanism of origin, invasion, and metastasis of HNSCC, as well as a better understanding of the implications of cytokines, chemokines and growth factors, are of paramount importance for the advancement of research in head and neck oncology.

Pathological and cytological changes of the nasal mucosa in acute rhinosinusitis: the role of hyaluronic acid as supportive therapy

OBJECTIVE

The aim of this study was to evaluate the reparative role of hyaluronic acid in acute rhinosinusitis (ARS).

PATIENTS AND METHODS

48 patients affected by ARS were submitted to nasal endoscopy, nasal cytology, mucociliary transport evaluation (MCTt) and visual analogue scale questionnaire (VAS) at T0, after 14-18 days (T1) and after 30-35 days (T2). The patients were randomized into two groups, A and B, and received Levofloxacin and Prednisone. Moreover, using a nebulizer ampoule for nasal douche, Group A received high molecular weight Sodium Hyaluronate (3%) plus saline solution (NaCl 0.9%) twice a day for 30 days; Group B received saline solution twice a day for 30 days.

RESULTS

At T0 only the VAS score showed differences regarding nasal discharge and post-nasal drip. At T1, in Group A MCTt and the number of bacteria were significantly lower than in Group B. The VAS score showed improvement in Group A. At T2 in Group A, MCTt and number of neutrophils were significantly lower than in Group B. The VAS score showed statistically significant differences between the two groups regarding nasal discharge.

CONCLUSIONS

In ARS patients sodium hyaluronate plus saline solution significantly improved symptoms, MCT time and reduced neutrophil count on nasal cytology.

When alarm bells ring: emergency tinnitus

OBJECTIVE

The aim of this study is to develop a diagnostic-therapeutic algorithm for those suffering from tinnitus who seek emergency aid.

MATERIALS AND METHODS

A literature review has been performed on articles from the last 30 years.

RESULTS

It is important to activate medical or surgical diagnostic and therapeutic strategies, in order to safeguard and rehabilitate the various functions affected. Psychiatric comorbidity is the most frequent pathological condition of those with serious or catastrophic tinnitus. In these cases, mortality risk is linked to suicide, morbidity to tinnitus-correlated distress.

CONCLUSIONS

Tinnitus, mainly linked to loss of hearing, is a frequent symptom among the population at large. About 7% of those affected by tinnitus turn to their doctor to solve their problem, while between 0.5 and 2% request urgent medical assistance. Their cry for help may be the result of an acute onset of tinnitus or the rapid impairment of an already chronic condition. Tinnitus is not considered an urgent ear, nose and throat (ENT) condition by the Associazione Otorinolaringologi Ospedalieri Italiani (AOOI) [Italian Association of Hospital ENT], even though there are many pathological conditions, sometimes serious, associated with tinnitus and emergency action is necessary to reduce the risk of morbidity and mortality.

Early diagnosis of hearing loss: otoacoustic emissions evoked by distortion products and pure-tone audiometry: Preliminary findings

OBJECTIVE

Literary studies underline the effectiveness of distortion product otoacoustic emissions (DPOAEs), which are not affected by the collaboration of the subject examined, in the early diagnosis of hearing loss. Aim of the study is to compare the objective technique of DPOAEs with respect to the pure-tone audiometry in early diagnosis of hearing loss.

MATERIALS AND METHODS

The clinical research was carried out on 852 workers. All subjects underwent pure-tone audiometry, tympanometry and distortion products.

RESULTS

The results show: a) a prevalence of subjects with impaired DPOAEs higher than the prevalence of subjects with impaired audiometries in the studied samples; and, after division by gender: b) a prevalence of subjects with impaired DPOAEs higher than the prevalence of subjects with impaired audiometries only in men; c) a prevalence of impaired DPOAEs and of impaired audiometries in men higher than in women.

CONCLUSIONS

The results suggest the higher effectiveness of DPOAEs compared to pure-tone audiometry in making an early diagnosis of hearing loss.

Deafness in Italy: an epidemiological and socio-demographic study

OBJECTIVES

Hearing loss is very common in our society, but epidemiological data on deafness in Italy is lacking. A.I.R.S. onlus (Italian Association for Research on Deafness) yearly launches the National Day for the Fight Against Deafness (NDFAD). During this events, that are held every year, it is possible to perform a free hearing test in all the facilities that have joined the initiative throughout Italy (240 hospitals joined in 2011).

AIM

to report data collected throughout the "A.I.R.S. National Day for the Fight against Deafness" of the last years, focusing in particular but not only on audiometric outcomes.

METHODS

demographic and social data, as well as audiometric outcomes, was collected on forms that have been subsequently stored in a on-line database and analyzed with MySQL and Microsoft Excel.

CONCLUSIONS

This data are important in order to describe the "hearing health" of the Italian population, and is a first step towards creating a database with epidemiological and preventive aims, a strongly felt need both at national and at regional level.

Pharmacological drugs inducing ototoxicity, vestibular symptoms and tinnitus: a reasoned and updated guide

The present work on drug-induced ototoxicity, tinnitus and vertigo represents the update and revision of a previous guide to adverse drug reactions for italian physicians (2005). The panorama of drug-induced side effects causing ototoxicity or symptoms such as tinnitus or dizziness and vertigo has enlarged in recent years, thanks to a better knowledge and a more specific attention of pharmaceutical firms and drug-control institutions. In daily clinical practice, there is a need for the family physician and the ENT specialist or audiologist (also in consideration of the possible medico-legal implications) to focus the attention on the possible risk of otological side effects. This would allow a clinical risk-benefit evaluation, weighing the possible clinical advantage in their field of competence against possible otological side-effects. The list of active ingredients and drugs is subdivided in categories based on their audiological and otoneurological side-effects, that have been signaled by the drug companies and/or ministerial notes. Drugs have also been subcategorized with regards to the field in which they are applied, the therapeutic indications and the clinical behaviour. They have also been organized in alphabetical order, for an easier consultation. The guide above, even if initially conceived for being used in Italy, also presents a more general and international interest, expecially as for as the concepts of pharmacology and the features of the active ingredients are concerned. The guide is, therefore, useful as for as we are concerned to any physician, regardless of the country he/she operates in.

Autologous serum skin test reactivity and basophil histamine release test in patients with nasal polyposis: preliminary results

An eosinophilic inflammatory process is generally observed in patients suffering from nasal polyposis (NP), however its onset has not yet been defined. It has been suggested that immune activation of inflammatory cells may be the cause. The aim of this study is to verify whether autoantibodies and/or histamine-releasing factors are present in the serum of patients suffering from NP. In fact, we assume that autoantibodies and/or histamine-releasing factors, as already demonstrated in chronic idiopathic urticaria and asthma, may be involved in the pathogenesis of NP. In this case-control analytical study 40 patients with NP and 27 control subjects underwent the in vivo autologous serum skin test (ASST). The sera from 6 patients suffering from NP and 9 control group subjects, who had all been previously studied and randomly selected, underwent basophil histamine release assay from normal donor as a pilot study. The ASST showed positive results in 55% of patients suffering from NP versus 8% of the control group (p= .00006), the basophil histamine release test (BHRT) turned out positive in all patients tested and in 11% of the control group. We found a weak positive correlation between the percentage of histamine release and the wheal diameter. ASST reactivity is very frequent in patients suffering from NP, thus suggesting the presence of histamine-releasing factors in the blood stream. The BHRT was positive in the serum of all patients, thus suggesting the presence of anti-FcepsilonRI, anti-IgE autoantibodies and/or other histamine-releasing factors, the presence of which can play a role in triggering and maintaining the eosinophilic inflammatory process in NP.

Central nervous system tissue heterotopia of the nose: case report and review of the literature

The authors present a case of heterotopic central nervous system tissue observed in an 81-year-old male in the form of an ethmoidal polyp. A review of the literature indicates that this is a rare condition characterised by a connective tissue lesion with astrocytic and oligodendrocytic glial cells, which may be located outside the nasal pyramid in some cases and inside the nasal cavity in others. The most important diagnostic aspect involves differentiating these from meningoencephalocele, which maintains an anatomical connection with central nervous system tissue. Contrast-enhanced imaging is essential for diagnosis, as in cases of heterotopic central nervous system tissue, it will demonstrate that there are no connections with intra-cranial tissue. Endoscopic excision is the treatment of choice.

Radiotherapy alone for local tumour control in esthesioneuroblastoma

Esthesioneuroblastoma is an uncommon tumour. Due to its low incidence, this neoplasm is difficult to evaluate and its treatment remains a matter of debate. Although the role of post-operative radiation is relatively well-defined, little is reported regarding the role of radiotherapy as the only treatment modality. A retrospective analysis of the literature has been conducted. With reference to the treatment of esthesioneuroblastoma, 55 patients submitted only to radiotherapy have been selected from publications of internationally indexed literature between 1979 and 2006. According to the Kadish classification, 6 patients were in stage A, 12 in stage B, and 37 in stage C. Response to therapy for each stage was assessed. There was no evidence of disease in: 6/6 stage A patients with a median follow-up period of 103.6 months, 7/12 stage B patients with a median followup period of 120 months, and 7/37 stage C patients with a median follow-up period of 77.3 months. A total of 27 patients died due to tumour-related causes and 5 due to intercurrent disease, while 3 patients were alive with disease (local recurrence and cervical lymph node metastasis). In conclusion, esthesioneuroblastoma is a malignant tumour which grows both locoregionally and distantly. For this reason, despite the satisfying results regarding response to radiotherapy alone in stage A patients, irradiation should be used only in early lesions arising below the cribriform plate, whereas all other cases require aggressive and multimodal therapy.

[A case of lymphoepithelial cyst (branchial cyst) in an elderly patient: diagnosis differential, treatment and literature review]

We present a case of lateral cervical cyst stressing the difficulties about the diagnosis. The international guidelines for the management of lateral neck cysts in the over 40s' age group are taken in consideration. Our case is a 74 years old male patient with a 6 month history of a cervical swelling. We consider this case rare for the age of patient and the absence of malignancy.

Linear stapler closure of the pharynx during total laryngectomy: a 15-year experience (from closed technique to semi-closed technique)

Personal experience in performing linear stapler closure of the pharynx during 70 total laryngectomies is reported. Laryngeal staplers (55 and 60 cm) with an angled handle were used, permitting vertical closure with 19 or 20 metal staples in a double row. A closed technique was initially used, but, over the years, this has gradually been replaced by the semi-closed technique to avoid trapping the suprahyoid part of the epiglottis between the jaws of the stapler. The stapler is inserted below the larynx after having separated it from all muscular and neurovascular connections, and after performing a mini-pharyngotomy at the vallecula epiglottica in order to extract the epiglottis, evert it ventrally and suture it to the hyothyroepiglottic space. The jaws of the stapler are closed and the staples are fired while the flaps of the mini-pharyngotomy are raised above the jaws. The scalpel is inserted above the stapler to remove the larynx. When the stapler is opened, the vertical linear suture of the pharynx is evident and can be examined. This procedure takes only a few minutes to perform. It guarantees a long-term stable watertight closure, dramatically reduces contamination of the operating field by pharyngeal secretions, and permits rapid healing time, greatly lowering patient management costs. In the cases presented here, there was a 1.8% rate of pharyngocutaneous fistulae in patients who were not radiated, whereas the rate was 13.1% in pre-radiated patients. In agreement with the international literature, this procedure does not increase the rate of fistulae and, in fact, it seems to reduce it. Moreover, it is particularly indicated for pre-radiated patients. Nevertheless, the Authors recommend reserving this type of procedure to cases in which, based on meticulous pre-operative assessment by means of endoscopy and imaging, the endolaryngeal site of the tumour has been assessed and there is no need for peri-operative exploration of the pharynx or tongue base.

[An updated guide on drugs inducing ototoxicity, tinnitus and vertigo]

The argument of the iatrogenic side effects of pharmacological origin that can cause ototoxic effects or only disacustic symptoms like the tinnitus, without consequent degenerative effects, is enlarged in these last years. It is because of the great knowledge based on the careful attention from the pharmaceutical institutions which are responsible for the control of medicines and drugs. In the medical practice and in that specialty field born the need to gather, also in consideration of the possible medico-legal implications, those elements which will suppose the risk of otologic side effects. This will allow the physicians to evaluate the possible clinical advantage of a treatment, in their own field of competence, balancing them with their possible side effects in the otologic field. For this purpose, we have elaborated some updated lists of drugs with possible side effects of ototoxicity, tinnitus and vertigo; furthermore, we considered these drugs as could theoretically have influence on the auditory neurochemical progressing since they have excitatory or inhibitory action on the neurotransmitters and their receptors, but not signaled by the sources of institutional information.

Balance disorders in headache patients: evaluation by computerized static stabilometry

OBJECTIVES

The aim of the study was to investigate the occurrence of equilibrium disturbances in headache patients, during the interictal period, by computerized static stabilometry.

MATERIALS AND METHODS

Sixty-seven patients were studied: 35 with migraine without aura (MwoA), 12 with tension-type headache (TTH) in the episodic form (ETTH) + MwoA, and 20 with only TTH [10 ETTH + 10 chronic (CTTH)]. The stabilometric parameters considered were: statokinesigram length (L) and surface (S) in open (EO) and closed (EC) eyes conditions with/without occlusal bite, EC with head retroflexion (ECR), and optokinetic stimulation (OKN).

RESULTS

The alteration of at least one of the stabilometric parameters was observed in 45 patients (67.2%): 21 MwoA, 8 ETTH + MwoA, and 16 TTH (8 ETTH + 8 CTTH).

CONCLUSION

In TTH patients (ETTH, CTTH, ETTH + MwoA), the stabilometric findings show a proprioceptive alteration induced by cervicofacial muscle contraction, which was peripheral in origin. In MwoA patients the alterations appear under OKN and support a control impairment in involuntary oculomotility of central origin.

Enzyme-ultracytochemical study of adenylate and guanylate cyclases in normal and pathologic human nasal mucosa

The ultracytochemical localization of adenylate cyclase (AC) and guanylate cyclase B (GC-B) and C (GC-C) activity was studied after stimulation with pituitary adenylate cyclase activating peptide, C-type natriuretic peptide and guanylin, respectively, in normal human respiratory nasal mucosa and mucosa of nasal polyps. To demonstrate these enzymatic activities, we employed enzyme-ultracytochemical methods for electron microscopy. Both normal and pathologic nasal mucosa contained AC, GC-B and GC-C activity. In the upper portion of respiratory epithelium, the enzymes were detected on ciliary and microvillar membranes. In ciliary membranes, GC-B was the predominant form expressed. In goblet cells and in glands of the lamina propria, enzymatic activities were localized mainly on plasma membranes and on membranes lining secretory granules. The results did not reveal any evident differences between the enzymatic activities in normal and pathological nasal mucosa and suggest complementary activities for these enzymes and their stimulators in the regulation of mucociliary transport and glandular secretion.

Giant cell granuloma of the maxilla: case report

Giant cell granuloma is an uncommon bony lesion in the head and neck region, most commonly affecting the maxilla and mandible. Although it is a benign disease process, it can also be locally destructive. Surgery is the traditional and still the most accepted treatment for giant cell granuloma. The case described here involved the maxilla which was treated with surgical excision, followed by local injection of steroids.

Treatment of severe epistaxis by superselective embolization: a review of 22 cases

OBJECTIVES

Epistaxis represents one of the most common ENT emergencies. In this paper, the authors report their experience in treating some cases of severe epistaxis by super-selective embolization of the afferent vessels of the nasal fossae.

PATIENTS AND METHODS

A retrospective study of 22 patients with severe recurrent epistaxis (1 anterior and 21 posterior). All patients had been treated unsuccessfully with repeated anteroposterior nasal packing, and presented significant secondary anaemia. Selective embolization procedures were performed under local anaesthesia. An arterial introducer is inserted into the femoral artery -generally the right one- and diagnosis as well as treatment are performed with the same guide catheter. In all cases, the terminal branches of the facial artery and of the internal maxillary artery on the side on which the haemorrhage occurred were embolized. Moreover the contralateral internal maxillary artery was always embolized as well, in order to prevent immediate recurrence of hypervascularisation of the mucosa through anastomotic paths.

RESULTS

In all patients, complete devascularisation was achieved in the areas of the embolized arteries at the nasal mucous membranes, arresting the epistaxis. None of the cases experienced complications attributable to treatment.

DISCUSSION AND CONCLUSION

Superselective arteriography with embolization can be considered as the method of choice in treating severe epistaxis because it can be performed under local anaesthesia and can easily be repeated if the first procedure is not successful. Moreover, it is at least as effective as ligation of the internal maxillary artery, if not more so, but it has a significantly lower complication rate which is destined to fall as the quality of the materials being used continues to improve.

[Ki67 and p53 in laryngeal epithelial lesions: correlations with risk factors]

Laryngeal carcinoma-the prototype of epithelial tumors in the head and neck region-has been the greatest source of information on the biological behavior of such neoplasms. Many Authors have suggested that smoke, and to a lesser extent alcohol, play a role in the genesis of this carcinoma although the exact biological mechanism for such involvement is still not clear. The present study analyzed two important biological indicators (p53 and Ki67) in benign and malignant epithelial lesions of the larynx in an attempt to obtain information on what mechanism correlates the risk factors with the neoplasm. In a group of 172 patients, an in vivo sampling of cells was taken during microlaryngoscopy. These cells were then tested using the immunocytochemical method and the results showed that the neoplastic tissue was significantly more positive to these markers than the pre-cancerous tissues and benign lesions. Moreover, there was also an interesting correlation between the degree of positivity to p53 and exposure to smoke, and to a lesser extent to alcohol, in the oncological patients. Together with other similar results found in the literature, these results hint at a possible explanation for the carcinogenic power of smoke in the larynx and, in general, in the upper respiratory-digestive tract.

Distortion product otoacoustic emmissions 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 Meniere's disease (MD). In addition 58 out of 70 patients performed both an audiometric threshold evaluation pre- and postglycerol 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.

Distortion-product otoacoustic emissions and glycerol testing in endolymphatic hydrops

OBJECTIVES/HYPOTHESIS

Aural fullness is a frequent symptom of endolymphatic hydrops. Its evaluation may provide valuable information on the initial stage of development of endolymphatic hydrops.

STUDY DESIGN

The present investigation was specifically designed to ascertain the ability of the glycerol test, combined with pure tone audiometry and distortion product otoacoustic emissions (DPOAEs) testing, to diagnose endolymphatic hydrops early and to identify patients who may evolve toward Meniere's disease. For these purposes, patients who complained about aural fullness as their only audiologic symptom were selected.

METHODS

This investigation consisted of 19 consecutive patients with unilateral or bilateral aural fullness who received no treatment. Each patient underwent glycerol testing measured with conventional pure tone audiometry and with both DPOAEs. For the traditional pure-tone glycerol test, a hearing improvement of at least 10 dB, at the lower two or three frequencies (125, 250, and 500 Hz), was judged as a positive result. For the DPOAE glycerol test, a smaller positive difference (5 dB) for at least three frequencies was interpreted as an ameliorative fluctuation.

RESULTS

The outcomes of the glycerol tests (24 ears examined) showed variable patterns. Seven ears showed no significant changes of either the pure-tone audiogram or DPOAE. In seven other ears, the comparison of the traditional glycerol test and the DPOAE glycerol test indicated an improvement in both measures. Another seven ears showed negative glycerol tests, whereas DPOAE responses gradually recovered reaching levels significantly higher than those recorded before glycerol administration. The three remaining ears showed contrasting results.

CONCLUSIONS

Patients with aural fullness in the absence of other associated symptoms may potentially be in the initial stages of Meniere's disease. This notion is confirmed by the present findings showing a high rate (58%) of positive glycerol tests in the selected patients. The importance of DPOAE testing is supported by their ability to detect minimal dysfunction, possibly representing endolymphatic hydrops that goes undetected by routine pure-tone audiometry.

[Hashimoto's thyroiditis and thyroid cancer: a report of a clinical case and a review of the literature]

Considerable controversy exists concerning the existence of statistically significant relationship between Hashimoto's disease and thyroid cancer, since there is very discordance in the incidence reported in literature, ranging from 0.5% by Crile and Hazard (5) to as high as 22.5% by Hirabayashi and Lindsay (9). Within this context, the authors present a clinical case of a patient who previously underwent lobectomy for a nodular papillary cancer of the thyroid. The histological diagnosis after "totalization" procedure proved to be Hashimoto's thyroiditis on a previous cancer. Starting from this case, an accurate review of the existing literature is carried out and some pathogenetic theories are proposed on the correlation between this two lesions.

[Sudden idiopathic hearing loss. Case reports in the course of ten years]

The authors present a retrospective case study of 132 subjects with sudden-onset hearing loss who had been observed during the course of 10 years. The results were compared with those available in the literature. These patients were divided into two subgroups based on age: over or under 40. The hearing loss was divided into 4 subgroups according to audiogram morphology. Then the presence, and entity, of any recovery in hearing was evaluated. There was no preference for sex while the greatest incidence was found in the VI and VII decade of life. The audiohistograms obtained when the patients were admitted to the hospital and 2 months later indicated an improvement in the hearing threshold localized above-all in the medium-low frequencies. This confirms a better evolution in those forms localized in the apex of the cochlea. The threshold of 60 dB HL is the dividing line between a totally favorable prognosis and a partially or totally unfavorable prognosis. This indirectly confirms that the intensity of the initial hearing damage is an important prognostic factor. From the morphological point of view the forms with the best evolution appear to be those with a flat or rising morphology. The forms with descending morphology do not present a favorable evolution although those with a threshold around 8000 Hz are worse than those with a threshold of 4000 Hz. As regards age no significant differences were found in the evolution of hearing loss between subjects under and over 40. In conclusion, the essential characteristics of sudden-onset hearing loss are as yet poorly defined. There are so many variables affecting the onset and evolution of hearing loss that it proves impossible to perform any statistically valid analysis which includes them all. To date the elements able to provide some degree of prognostic prediction are the audiogram morphology and the entity of the initial hearing loss.

DPOAE modifications induced by pure tone overstimulation in guinea pigs

Distortion Product Otoacoustic Emissions (DPOAEs) shows a vulnerability to acoustic overstimulation that is easily detectable by changes in amplitude, frequency distribution and time course. The frequency-specific changes in DPOAE provide more information than the more general changes in click evoked otoacoustic emissions. In this work five anesthetized guinea pigs were examined for changes DPOAE after exposure to pure tones. The noise was a 110 dB SPL pure tones for 45 minutes and the fatiguing tone centered on the geometric mean (GM) of primaries or 2/3 of GM. The most measurable effects were obtained in the latter conditions. The main DP level reduction lasts about one hour after exposure, but the complete recovery is observable only after 24 hours. The frequency distribution of fatiguing effects on the DP- audiogram shows a remarkable fine tuning and a pattern like a low-pass filter. After four hours, in one guinea pig, it is observable an enhancement of the DP amplitude, compared to the pre-exposure level; in another guinea pig, a second overstimulation produced a more extensive and time-lasting effects than the first exposure.

[Analysis of otoacoustic distortion products in a group of otosclerotic patients]

There is indication that middle ear pathologies can affect otoacoustic emissions (OAE) to varying degrees. In fact, since acoustic emissions are recorded in the outer ear duct, the energy transfer mechanisms both up and downstream of the middle ear must be intact. OAE distortion products (DP) enable one to analyze cochlear response by frequency and to verify the retrograde response as a function of frequency. In the present work this method was used to test otosclerosis patients. A group of 45 patients with otosclerosis was tested to determine whether the OAE-DP could be identified and measured. Subsequently the characteristics of these DPs were analyzed in a group of 18 subjects who had previously undergone stapedectomy. All the results obtained were compared with those from a control group of normal hearing subjects with normal emissions and free of any E.N.T. pathology. In approximately half of the cases (53%) in the otosclerosis patient group it was possible to detect clearly evident DPs. Obviously, the DP-Gram differed greatly and average amplitude was lower than those found in normal subjects. Indeed, there was no signal at all at the lower and middle frequencies reflecting a hearing loss typical of cases of otosclerosis. Most (58%) of the otosclerosis patients who had successfully undergone stapedectomy recorded valid DPs. The DP-Gram frequency range was much broader (750-4000 Hz) than in those who had not undergone surgery. Moreover the lower and mid frequency amplitudes were significantly better. The data obtained are quite encouraging and suggest that DP should be studied in depth in patients with otosclerosis.

Diagnosing nasal hyperreactivity with positional rhinomanometry

Positional rhinomanometry is a physiologic method for estimating nasal resistance, which is variable, difficult to predict, and linked to vasomotor activity of the functional system culminating in the turbinate valves. Thirty subjects suffering from allergic rhinitis, 25 patients affected by aspecific rhinitis, and 40 healthy controls underwent positional rhinomanometry. Test positions included the seated (baseline), supine, and recumbent (homolateral and contralateral to the nasal fossa under examination). In patients with perennial allergic rhinitis and in those with aspecific rhinitis, positional rhinomanometry elicited two pathologic responses: either an average percentage rise of more than 80% in nasal resistance in the supine and homolateral and contralateral recumbent positions compared with basal values, or a paradoxical fall in the supine and homolateral recumbent positions.

[Distortion products in Menière's disease]

Distortion Product Otoacoustic Emissions (DPOAEs) are elicited by simultaneous application of two tones to the ear canal. These emissions are a result of nonlinear mechanical characteristics of the cochlea at a specific point and have a precise mathematical relation with the frequencies of the two eliciting primary tones f1 and f2. This frequency-selective property of DPOAEs suggests that they should be regarded as useful monitor of localized cochlear function at any predetermined frequency. The present study was designed to investigate DPOAEs in patients with Menière's disease. DPOAEs were recorded before and after glycerol administration to verify if the fluctuation of the hearing threshold induced by this hyperosmotic agent causes selective changes in the activity of the outer hair cells. DPOAEs were present in patients in which the mean duration of the disease was shorter compared to those patients without measurable DPOAEs. An improvement of DPOAEs after glycerol intatte was observed in a half of our cases. The improvement of DPOAEs does not appear to be brought about by modifications of the auditory threshold induced by glycerol.

Suppression tuning characteristics of 2f1-f2 distortion product otoacoustic emissions

The 2f1-f2 distortion product otoacoustic emission (DPOAE) is suppressed by a third tone following a frequency selective pattern and outlining tuning curves which are generally similar to neural and psychophysical findings. The most effective suppressor tone lies between f1 and f2; less suppressive effects are produced by an added tone that lies in the 2f1-f2 site. The slope of iso-suppression curves is much steeper on the higher flank than on the lower flank of the suppression curve (respectively 100-115 dB/octave and 25-35 dB/octave). A suppression fine structure can be observed in the region of the tip especially for higher DPs probably connected with the fine structure of distortion products and with the instability of cochlear activity. A saturation point, around 70 dB or more has been evidenced on the growth rate functions. Continuous and interrupted suppressor presentation can induce some differences in the responses. Suppression of DPOAEs can provide a wider knowledge on active non-linear mechanisms in the cochlea, and on frequency selectivity also in a clinical context.

Laryngeal microsurgery under general anesthesia using small-bore endotracheal tubes: blood gas analysis

This study reports variations observed under general anesthesia through small-bore endotracheal tubes in PO2, PCO2, HCO3, percentage saturation of O2, and pH levels in 39 patients who underwent laryngeal microsurgery lasting from 10 to 100 minutes. The tendency to an increase in PCO2 levels reached statistical significance only at the 100th minute but did not constitute a risk for patients as values remained within the limits of "permitted hypercapnia." PO2, percentage saturation of oxygen, and HCO3 levels did not vary significantly. pH values tended to fall (respiratory acidosis) in correlation to the increase in PCO2. Small-bore endotracheal tubes can safely be used for laryngeal microsurgery when operating times are not longer than 100 minutes.

[Voluntary dilating pneumosinus (secondary hernia)]

In the present work authors describe an unusual case of pneumosinus dilatans caused willingly by a patient himself operated on a frontal-ethmoidal mucocele. They take the opportunity to summarize what it is known about the etiopathogenesis and the form of display of this uncommon disease.

[Epistaxis and climatic events]

Data concerning daily climatic conditions in the area of Perugia during 1987-1990 have been gathered and correlated to daily incidence of idiopathic nose-bleeding observed in the same area and during the same period (1064 patients on the whole). The aim was to verify the relation between climatic events and "epistaxis" phenomenon, relation that has been assumed since a long time but has never been scientifically demonstrated before. Following factors have been estimated: highest and lowest daily temperature, thermal gradient, atmospheric pressure and pressure gradient, relative humidity. Results of statistic correlations show that every climatic factors has a narrow range related to higher incidence of epistaxis and that nose-bleeding is likely conditioned by combination of critical values, as a low temperature with 4 degrees C daily gradient, a 716 mm Hg atmospheric pressure with 2 mm Hg negative gradient, a close to 100% relative humidity.

[Positional rhinomanometry in hypertrophic vasomotor chronic rhinitis: considerations before and after functional surgery of turbinates]

The Authors report their experience regarding Positional Active Rhinomanometry performed before and after surgery in hypertrophic-vasomotor chronic rhinitis. Twenty-five patients suffering of hypertrophy of the turbinates and/or nasal vasomotor disorders were examined pre-operatively and 3, 6 and 12 months after inferior submucosal turbinoplasty. Tests were performed in the seated, supina, homolateral and contralateral positions with regard to the fossa in question. Values were compared with those of forty normal subjects. Pre-operative examinations showed a large number of paradoxical responses and very high increase in nasal resistance. Postoperative values were quite similar to those of normal subjects, a demonstration of the efficacy of surgical treatment of turbinates hyper-reactivity.

[Positional rhinomanometry in specific nasal hyperreactivity]

Following up the results obtained in a previous work testing Positional Rhinomanometry in normal subjects, the authors performed this test in subjects affected with specific nasal hyperreactivity. The aim was to offer an objective evaluation of decubitus-caused variations in air flow resistance through the nasal cavities. Thirty subjects suffering from allergic rhinitis (18 from seasonal and 12 perennial allergic rhinitis) underwent Anterior Active Rhinomanometry during the intercritical period of the disease. Tests were performed in the seated, supine positions homolateral and contralateral to the fossa in question. The positional tests show a marked difference between normality and specific hyperreactivity as a consequence of paradoxical responses. Moreover it can indicate the greater increase in nasal resistance, expression of a clear disreactivity of the cavernous tissue stimulated by variations in posture and found mostly in the perennial allergic rhinitis subjects.

[Role of the tumor marker TAG-72 in head and neck neoplasms]

The serum glycoprotein TAG-72 level was determined in 34 patients with chronic laryngitis or ENT malignancy. This marker is in widespread use in cases of gynaecological and gastrointestinal malignancy. TAG-72 levels did not differ significantly either from the levels of healthy subjects or in the post-operative follow-up, so that this indicator appears to be of no clinical value in head and neck oncology.

[Mechanical sutures of the pharynx during total laryngectomy: proposal of a closed technique]

The authors present the results of a pharyngeal autosuture technique using a 55 mm linear stapler during total laryngectomy. The stapler is inserted before the larynx has been removed, but after it has been separated from its muscular and neuro-vascular connections and after it has been adequately elevated so that no part remains within the instrument jaws. This "closed" procedure is quite rapid, does not soil the operating field and is safe in the long run. The patient does not require a feeding tube since he can swallow from the third day after surgery. None of the patients treated with this technique produced either early or late fistulas, nor did they encounter any trouble in swallowing.

[Postural rhinomanometry in normal subjects]

Measurement of decubitus-caused variations in air flow resistance through the nasal cavities indicates the vascular reactivity of turbinate cavernous tissue and makes it possible to evaluate the variable component in nasal resistance; a component usually suppressed by previous pharmacological vasoconstriction. The aim of the present work has been to indicate normative values regarding variations in nasal resistance in different types of decubitus. The latter will be referenced for future studies regarding nasal vasomotor pathologies (specific or aspecific hyperreactivity). Eighty nasal cavities from normal subjects were examined by means of Anterior Active Rhinomanometry in the following positions: seated, supine, homolateral and contralateral to the fossa in question. As absolute values are highly variable even in normal subjects, the resistance variations in decubitus were expressed in percentage of basal value (seated position). In every decubitus there is an average increase in resistance due to the increased venous pressure in the cephalic area although the greatest statistical significance and lowest scattering of values is found in the supine position with 20 degrees head-trunk angle. Mean values and standard deviations are given and will be referenced for further studies on rhinopathology.

Nasal polyps: a comparative study of morphologic and etiopathogenetic aspects

16 nasal polyps belonging to 10 male subjects aged between 40 and 70, have been removed during the same number of ethmoidectomies; the polyps have been sectioned and specimens of mucosa corresponding to the pedicle and to the different parts of the body have been collected. During the operation parts of the mucosa of the inferior turbinates were removed. All the specimens have been prepared and observed at the scanning electron microscope. The epithelium of the inferior turbinates, of the small polyps and of the apical part of all polyps were almost normal. Marked alterations of the epithelial layer have been observed in bigger polyps. Surface characteristics of nasal polyps seem to be influenced by their relationship with neighbouring structures and by their position in the nasal cavity, but mostly by their size. On the basis of these findings the authors discuss the most recent etiopathogenetic theories of nasal polyps. They finally describe some peculiar findings concerning the mucosal layer of the polyps and of the inferior turbinates of three confirmed allergic subjects and discuss their possible clinical implications.

Auditory brainstem responses (ABR) in the aged

86 male subjects, aged between 60 and 86 years (M = 69.5), underwent pure-tone audiometry, impedance tests and brainstem response audiometry (BRA). Subjects have been classified into four age-related groups: 1) 34 subjects, aged between 60 and 65; 2) 22, aged between 66 and 70; 3) 22 aged between 71 and 75; 4) 8, aged between 76 and 86. They have also been classified into four groups on the basis of their mean auditory threshold at 0.5, 1, 2, 4 and 8 kHz: 1) 14 subjects with mean auditory threshold less than or equal to 30 dB HL; 2) 16, between 31 and 40; 3) 24, between 41 and 50; 4) 32, with mean auditory threshold greater than or equal to 51 dB HL. 19 normally hearing adults, aged between 28 and 42, were chosen as controls. Statistically significant correlations have been found between age and mean auditory threshold (P less than or equal to 0.001), between wave latency V and age (P less than or equal to 0.001), between wave latency V and the mean pure-tone auditory threshold at 0.5, 1, 2, 4 and 8 kHz (P less than or equal to 0.001) and between the V-I interval and age (P less than or equal to 0.001). The discrepancy between the mean auditory threshold and the ABR waveform, the overall amplitude's reduction of ABR waves and the progressive lengthening of V-I interval values, seem to indicate that age-related changes involve not only the end organ but also the brainstem auditory structures.