1000 Days: The "WeCare Generation" Program-The Ultimate Model for Improving Human Mental Health and Economics: The Study Protocol

INTRODUCTION

The COVID-19 pandemic stressed the necessity of a new resilience of the human population and health system. The "WeCare Generation" program is a new proposal of territorial intervention, with a new paradigm, on the diseases of the human body and mind.

BACKGROUND

In recent decades, the independent strands of investigation on brain plasticity and early trauma consequences have demonstrated that traumatic experiences in the period from pregnancy to the age of 3 years have an enormous impact on an individual's future development, and both physical and mental health. Research shows that adverse child experiences (ACEs) are associated with a strong risk of conditions such as: harmful alcohol use, smoking, illicit drug use, high body-mass index, depression, anxiety, interpersonal violence, cancer, type 2 diabetes, cardiovascular diseases, stroke respiratory diseases and, as a consequence, to a high financial cost in Italy and also across Europe (1-9% GDP) and the USA (total annual costs estimated to be USD 581 billion in Europe and USD 748 billion in North America). All this suggests that an early intervention on that traumatized-slice of population leads to multiplied savings.

METHODS

A multi-center, randomized, controlled trial was designed. The parents of the future neonatal population (from pregnancy to delivery) with trauma will be enrolled, and randomized to treatment, or control arm. The article describes in detail how the primary outpoint (cost to the national health system), and some secondary outpoints, will be collected.

DISCUSSION

An overall rate of return on investment (ROI) statistically significant 13.0% per annum with an associated benefit/cost ratio (BCR) of 6.3 is expected as the primary outcome of the "WeCare Generation" program. Our proposed model predicts a new medical paradigm aiming to empower new generations, with a strong return on economy and health.

Algorithm for Individual Prediction of COVID-19-Related Hospitalization Based on Symptoms: Development and Implementation Study

BACKGROUND

The COVID-19 pandemic has placed a huge strain on the health care system globally. The metropolitan area of Milan, Italy, was one of the regions most impacted by the COVID-19 pandemic worldwide. Risk prediction models developed by combining administrative databases and basic clinical data are needed to stratify individual patient risk for public health purposes.

OBJECTIVE

This study aims to develop a stratification tool aimed at improving COVID-19 patient management and health care organization.

METHODS

A predictive algorithm was developed and applied to 36,834 patients with COVID-19 in Italy between March 8 and the October 9, 2020, in order to foresee their risk of hospitalization. Exposures considered were age, sex, comorbidities, and symptoms associated with COVID-19 (eg, vomiting, cough, fever, diarrhea, myalgia, asthenia, headache, anosmia, ageusia, and dyspnea). The outcome was hospitalizations and emergency department admissions for COVID-19. Discrimination and calibration of the model were also assessed.

RESULTS

The predictive model showed a good fit for predicting COVID-19 hospitalization (C-index 0.79) and a good overall prediction accuracy (Brier score 0.14). The model was well calibrated (intercept -0.0028, slope 0.9970). Based on these results, 118,804 patients diagnosed with COVID-19 from October 25 to December 11, 2020, were stratified into low, medium, and high risk for COVID-19 severity. Among the overall study population, 67,030 (56.42%) were classified as low-risk patients; 43,886 (36.94%), as medium-risk patients; and 7888 (6.64%), as high-risk patients. In all, 89.37% (106,179/118,804) of the overall study population was being assisted at home, 9% (10,695/118,804) was hospitalized, and 1.62% (1930/118,804) died. Among those assisted at home, most people (63,983/106,179, 60.26%) were classified as low risk, whereas only 3.63% (3858/106,179) were classified at high risk. According to ordinal logistic regression, the odds ratio (OR) of being hospitalized or dead was 5.0 (95% CI 4.6-5.4) among high-risk patients and 2.7 (95% CI 2.6-2.9) among medium-risk patients, as compared to low-risk patients.

CONCLUSIONS

A simple monitoring system, based on primary care data sets linked to COVID-19 testing results, hospital admissions data, and death records may assist in the proper planning and allocation of patients and resources during the ongoing COVID-19 pandemic.

SARS-CoV-2 transmission in the Lombardy Region: the increase of household contagion and its implication for containment measures

This study aimed at the identification of the settings linked to SARS-CoV-2 transmission through the analysis of clusters and small outbreaks detected by the Lombardy Region surveillance system during the second epidemic wave. Comparing the data before and after the introduction of restrictive measures (night curfew, partial closure of schools and businesses, smart working), we observed a significant decrease of infections in workplaces, social gatherings, coffee shops, restaurants, and sports centers; contagion in schools decreased from 9.8% to 3.4%, in hospitals environments and nursing homes from 5.2% to 2%; domestic infections increased instead from 72.8% to 92.7%. These results suggest that containment measures have been effective in controlling virus circulation in the community but not at the household level and might inform future interventions, including the establishment of structures (Covid Hotels) for the isolation infected people. At the same time, they raise awareness on the risk of transmission among family members and during households social gatherings. (www.actabiomedica.it)

[The use of RCGO triggers in the obstetric - gynecological procedures: the impact on the reduction of adeverse events. The experience of the Lombardia Region]

The last few weeks of pregnancy are critical to a baby's health because important organs, including the brain and lungs, are not completely developed until the end of pregnancy. The adverse events during labor and childbirth can have very serious physical, psychological and financial consequences for the child, the family, health professionals and the whole community. These events can be reduced through interventions aimed at improving the safety and quality of care, based on evidence-based knowledge, guidelines and practices that must be widely and effectively applied. This work reports the experience of the Lombardy Region on improvement actions in the obstetric and gynecological procedures for the reduction of adverse events and sentinel events through the monitoring and management of the RCGS trigger tool.

[Macrosomic infants: clinical problems at birth and afterward]

Macrosomic infants (birth weight >4000 g) show increased risk for shoulder dystocia and associated injuries, hypoglycemia and respiratory distress. Higher risk is directly related to neonatal birth weight. High birth weight is also associated with increased risk of developing metabolic syndrome later in life. However the relation between birth weight and later-life metabolic syndrome in not linear, but "U" shaped.

Air- and bone-conducted vestibular evoked myogenic potentials (VEMPs) in otosclerosis: recordings before and after stapes surgery

Aim of the study was to investigate, in a randomized prospective trial, air-conducted vestibular evoked myogenic potentials (AC-VEMPs) and bone-conducted vestibular evoked myogenic potentials (BC-VEMPs) before and after successful stapedotomy. Enrolled in the study were 41 consecutive patients (32 female, 9 male; mean age 36 years) (42 ears) with otosclerosis. Audiological evaluations and diagnosis of otosclerosis were made according to the guidelines of the Committee on Hearing and Equilibrium. Successful stapedotomy was carried out in all otosclerotic ears. Air- and bone-conducted 4-frequency pure tone average (4-PTA), air-bone gap (ABG), AC- and BC-VEMPs were evaluated pre- and post-operatively. As far as concerns results, pre-operatively, AC- and BC-VEMPs could be recorded in 9 (21.4%) and 16 (38.1%) otosclerotic ears, respectively. Lower ABG was detected in patients with AC-VEMPs in comparison to those in whom air-conducted potentials (p = 0.032) could not be elicited. At 12-month post-operative follow-up, AC-VEMPs were present in 11 (26.2%) ears, while BC-VEMPs could be elicited in 15 (35.7%) cases. Reduced bone-conduction 4-PTA was observed in patients with BC-VEMPs in comparison to those without recordable bone-conducted potentials pre- and post-operatively (p = 0.003 and p = 0.005, respectively). A significantly (p = 0.022) lower air-conducted 4-PTA was measured post-stapedotomy in patients with BC-VEMPs in comparison to those without elicitable bone-conducted potentials. In conclusion, VEMPs reduced elicitability, in otosclerosis, is likely due to conductive hearing loss and inner ear impairment.

A suitable test for identifying high risk adult patients of moderate-severe obstructive sleep apnea syndrome

The aim of this study was the evaluation of the usefulness of a 7-items questionnaire, Rome Questionnaire (RQ), in identifying adult patients at risk of obstructive sleep apnoea syndrome (OSAS). 136 adults (76 M, 60 F) with snoring were enrolled. Each patient underwent to an overnight polysomnography (PSG) study and the patient's bed partner answered the "RQ". RQ survey items mainly addressed the presence and frequency of snoring behaviour, breathing pauses, sore throat, oral breathing and wake time sleepiness. Of the 136 initial patients, 111 (63 M, 48 F; mean age 54.6 +/- 10.84) with a complete PSG examination were included in the study. They were divided according to apnea-hypopnea index (AHI) into two groups: group A with a primary snoring or mild OSAS (AHI < or = 15) and group B with moderate-severe OSAS (AHI > 15). The RQ final score was 25.27 +/- 16.1 for group A and 42.29 +/- 15.2 for group B, with a statistically significant (p < 0.0001) difference. Analyzing the RQ score of group B (moderate-severe OSAS) we surprisingly noticed that most of patients (66%) showed an high RQ score (> 40). No patients with moderate-severe OSAS showed a RQ score < 20 and for every point scored in the questionnaire there is an extra 1.07 (0.7%) risk of belonging to group B. Group B showed a mean body mass index (BMI) of 31.53 (+/- 4.95), significantly (p < 0.001) higher than BMI of group A (26,86 +/- 3.28) and BMI results a good predictive factor (p = 0.013) of mild-severe OSAS. In conclusion, the "RQ", together with BMI, seems to be an useful tool to make a selection of the patients at higher risk of moderate-severe OSAS, who need a prompt PSG evaluation. Our findings will require further validation in larger sample of subjects.

Benign paroxysmal positional vertigo: diagnosis and treatment

Benign paroxysmal positional vertigo (BPPV) has been recognized as the most common vestibular disorder; it is a term coined in 1952 by Dix and Hallpike, and it is most commonly used to describe a disease with a characteristic clinical presentation believed to be caused by free-floating particles leaving the macula and entering one of the semicircular canals, usually the posterior one, more rarely the horizontal or superior ones. A lot of studies showed as the prevalence is higher in females than in males with a ratio of 2:1; furthermore, prevalence increases with the age: the mean age at onset is 54 years, with a range of 11 to 84 years. The most important clinical manifestations of BPPV are: vertigo, lightheadedness, dysequilibrium and sometimes nausea, vomiting, pallor and sweating. The diagnosis of BPPV is very simple through the Dix-Hallpike test or the diagnostic Semont's maneuver; the increasing information about the BPPV's pathogenesis has led most authors to consider the rehabilitative therapy, and in particular the so-called Semont's "liberatory" maneuver, as the first choice treatment of BPPV, in relation to its quickness and efficacy. In this treatment the debris are moved from the posterior semicircular canal to another location within the vestibular labyrinth. In our review we consider the possible pathogenesis of this disease and the best therapies, like repositioning maneuvers, in a patient affected by BPPV.

[Peripheral facial palsy in middle ear surgery: case report and review of literature]

We present a case of a patient who experienced right facial palsy after being operated for otosclerosis. Seventeen years before our patient had yet undergone the same operation on the contralateral ear and had presented a facial palsy. We also report another case of facial palsy and middle ear damage after an operation for otosclerosis. Facial palsy is a rare complication of middle ear surgery. It is probably caused by a viral relapse and it recedes after few weeks if a proper therapy is administrated to the patient. Thus we deem it is useless to perform immediately advanced, invasive and expensive tests. On the contrary we believe that it is useful, in those cases in which an otosclerotic patient has a history of herpes simplex virus infection, to administer a preventive antiviral therapy before the operation.

Stapes surgery in relation to age

This prospective study aims to evaluate the efficacy of stapedotomy in relation to age. Eighty-four ears of 82 consecutive patients who underwent stapedotomy were studied. Patients were divided into five groups according to their age. In each patient, we evaluated the pre- and postoperative auditory thresholds, according to the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology - Head and Neck Surgery guidelines. Statistically significant (P < 0.05) differences between the pre- and postoperative air conduction thresholds were observed in all groups. Statistically significant reductions of air-bone gap were observed at lower-medium frequencies (250, 500 and 1000 Hz) in the elderly as well as in the younger patients. We did not find a higher susceptibility of the inner ear to surgical trauma in the elderly in comparison to the younger patients. Our data show that stapedotomy results in older adults are comparable to those obtained in the younger, without an increased incidence of complications.

What is vertigo?

Vertigo is one of the types of dizziness with dysequilibrium, presyncope and lightheadedness. But what does vertigo mean? Vertigo indicates a sensation of false movement (generally described like a rotation) but sometimes the patient can describe it like a sensation of tilt. Instead, the word dizziness indicates a sensation of disturbed relation to surrounding objects in space with feelings of rotation or whirling characteristic of vertigo as well as non-rotatory swaying, weakness, faintness and unsteadiness characteristic of giddiness. In our review we describe, after brief considerations about functional anatomy of the vestibular system, the most important cause of vertigo considering the duration of the symptom; moreover we underline the importance of anamnesis and of the objective examination for a correct differential diagnosis of a dizzy patient. As to objective examination we describe the most important characteristics of nystagmus, that is the only objective sign in vertigo, of central and peripheral origin. At last we consider the most efficacious therapies, like as medications (specific and aspecific), surgery (conservative and destructive) and rehabilitation, in relation the characteristics and the causes of vertigo.

Benign paroxysmal positional vertigo: a comparative prospective study on the efficacy of Semont's maneuver and no treatment strategy

PURPOSE

The present study investigates the efficacy of Semont's repositioning liberatory maneuver by comparing it with no-treatment in a population of patients with benign paroxysmal positional vertigo (BPPV).

MATERIALS AND METHODS

In this randomised, controlled, 6-month efficacy trial, 40 patients affected by BPPV were treated with Semont's maneuver. Outcomes were measured subjectively by patients about their Activities of Daily Living (ADL) and quality of life, based on the "Vestibular Disorders Activities of Daily Living Scale". Results were compared to those obtained in 40 non-treated BPPV patients.

RESULTS

During the first month of the study, 92.5% of patients of Semont's group resolved their symptoms. Cure rates with Semont's maneuver were significantly higher than those obtained with no-therapy (92.5% versus 37.5%). Within a six month follow-up, relapse rates were lower among patients treated with Semont's maneuver than among the no-treated ones (5% versus 60%). All patients with a resolution of symptoms and a negative Dix-Hallpike's test presented a great improvement in daily activities and quality of life.

CONCLUSIONS

BPPV is easy to solve with a successful repositioning maneuver. Since BPPV is a very common cause of vertigo and can represent a medical emergency, we believe that it is of interest for every general practitioner to be able to promptly recognize this frequent balance disorder and to be able to treat a patient affected by BPPV with a safe repositioning maneuver.

Unilateral endolymphatic hydrops: what about the contralateral ear?

INTRODUCTION

The early recognition of incipient Meniere's disease (MD) in the asymptomatic ear of a patient with known unilateral disease has profound implications for patient management and follow-up, but the criteria for a right and precocious diagnosis is still controversial.

MATERIALS AND METHODS

We evaluated forty-nine patients with MD, selected according to Committee on Hearing and Equilibrium guidelines. All patients underwent laminar tonal audiometry, stapedial reflex study, Glycerol dehydration test, Auditory Brainstem Response (ABR) vestibular examination. MRI was performed in 14 patients.

RESULTS

A raised hearing threshold in the contralateral ear was found in 27 patients, but only 7 (14.3%) fulfilled the requirements to be considered affected by bilateral MD. The average delay of occurrence in the contralateral ear was 7 years (from 5 to 12 years). The glycerol test was positive only in 4 patients with unilateral MD and moderate hearing loss. It was not positive in any case of bilateral MD. The membranous endolymphatic duct and sac is not well visualised with MRI on the affected side in the majority of patients.

CONCLUSION

A MRI study must be included in the diagnostic protocol for MD and with improvements in this imaging modality will possibly allow detection of variations in the size of inner ear structures. Glycerol dehydration test was useful only in selected cases. A full assessment of incipient disease in the asymptomatic ear in unilateral Meniere's disease should be undertaken. A conservative approach in surgical treatment of unilateral MD is recommended because of the possibility of evolution of a bilateral form, which can occur even 10 years after the onset of the disease.

Nerve growth factor serum level is reduced in patients with sensorineural hearing impairment: possible clinical implications

Nerve growth factor (NGF) is the first and best characterised member of a family of neurotrophic factor. NGF is produced by numerous cells and it is present in physiologically relevant amounts in the bloodstream. It is known to promote the survival of peripheral sensory neurons and can be potentially useful as a therapeutic agent in neuronal system. On the both these observations we based our hypothesis that low circulating NGF might lead to sensorineural hearing loss (SNHL). To address this question we measured the levels of NGF in the bloodstream of patients affected by SNHL. The results showed that the amount of circulating NGF in these patients is significantly lower compared to levels found in patients not affected by this deficit. The results of the present study demonstrated that NGF might be a useful candidate for preventing the damage and promoting recovery or degeneration of the auditory pathways in humans.

Nasal and hearing impairment: are they linked?

Hearing impairment is the most prevalent sensory deficit in the human population. Otosclerosis and chronic otitis media are two of the most frequent causes of hearing loss of the Western world and both benefit from middle ear surgery. The success rate is high for both operations, in expert hands, but, in our clinic and in every ENT clinic, there remains a percentage of failure. Some of the most frequent post-operative complications can lead to tubal dysfunction. We believe that a correct and complete evaluation of the rhino-pharyngeal-tubal unit is very important before tympanoplasty and stapedioplasty in order to further reduce the incidence of some post-operative complications and to increase the success rate of middle ear surgery. What is well known in medicine, 'prevention is the best therapy', seems not oddly observed in ear surgery, where is usually operated the effect, while the evaluation and therapy of the causes seems to be underestimated.

[Congenital abnormalities of the temporal bone. Clinical picture and therapeutic indications]

The embryology of the ear and the different congenital anomalies depending on the arrest in development at a particular embryologic date are reviewed. The historical and the actual attitude towards surgical correction is discussed. The classification system, the evaluation and patients selection, the timing of auricular reconstruction and atresiaplasty, the preoperative evaluation, the patient and parents counselling, the surgical technique, the complications and alternative techniques are discussed.

Prospective randomized trial of low-pressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy

BACKGROUND

Postoperative shoulder-tip pain occurs frequently following laparoscopic cholecystectomy. The aim of this randomized clinical trial was to evaluate the efficacy of a low-pressure carbon dioxide pneumoperitoneum during laparoscopic surgery in reducing the incidence of postoperative shoulder-tip pain.

METHODS

Ninety consecutive patients undergoing laparoscopic cholecystectomy were randomized prospectively into low-pressure (group A) and normal-pressure (group B) laparoscopic cholecystectomy groups. Patients in group A (n = 46) underwent laparoscopic cholecystectomy with 9 mmHg carbon dioxide pneumoperitoneum during most of the operation, and those in group B (n = 44) had laparoscopic cholecystectomy with 13 mmHg pneumoperitoneum. Shoulder-tip pain was recorded on a visual analogue pain scale 1, 3, 6, 12, 24 and 48 h after operation.

RESULTS

The low-pressure pneumoperitoneum did not increase the duration of surgery. There were no significant intraoperative or postoperative complications in either group. Fourteen patients (32 per cent) in group B and five (11 per cent) in group A complained of shoulder pain (P<0.05). Mean shoulder-tip pain scores at 12 and 24 h and postoperative analgesia requirements were also significantly lower in the low-pressure laparoscopic cholecystectomy group (P<0.001).

CONCLUSION

A carbon dioxide pneumoperitoneum pressure lower than that usually utilized to perform laparoscopic surgery reduces both the frequency and intensity of shoulder-tip pain following laparoscopic cholecystectomy.

Diverticulitis of the caecum and ascending colon: an unavoidable diagnostic pitfall?

PURPOSE

The infrequency of right-sided colonic diverticulitis prompted this presentation of our experiences, with emphasis on the diagnostic aspects.

PATIENTS AND METHODS

Charts and documentation regarding 20 patients who underwent surgery for diverticulitis of the caecum and/or ascending colon over 22 years were reviewed.

RESULTS

Eleven patients underwent pre-operative instrumental examinations: right-sided diverticulitis was recognized in five patients (two by barium enema, two by both ultrasonography and computerized tomography, one by all three examinations) and was suspected in another four. All diagnoses on merely clinical grounds--acute appendicitis in 10 patients and perforated peptic ulcer in one--were erroneous. Surgery consisted of 13 right standard or limited hemicolectomies, six conservative procedures and one Mickulicz' operation and subsequent right hemicolectomy. No operative deaths or long-term failures were reported.

CONCLUSIONS

In the presence of clinical features atypical of acute appendicitis, right-sided colonic diverticulitis should be taken into account; pre-operative instrumental examinations might increase diagnostic accuracy, thereby leading to a more correct therapeutic approach.

Cochlear implant. Histopathological guide to indications and contraindications: a post mortem study on temporal bones

We have studied the temporal bones of 4 deceased donors, individuals one with cochlear saccular degeneration, another with Mondini dysplasia, another with an ossification of the basal turn of the cochlea and the round window, post meningitis and the fourth who was implanted 10 years before. The indications and contraindications for cochlear implant placement are discussed.

Neurofibromatosis and brainstem implants: what to do?

The histopathological changes in the temporal bones of one donor individual deceased for complications of neurofibromatosis type 2 are studied. The different modalities of presentation of neurofibromatosis and the criteria for the differential diagnosis are presented. The possibilities of the auditory brainstem implants in this pathology are discussed.

Acoustic neuromas and meningiomas. Histopathological aspect: a post mortem study on temporal bones

The histopathological changes in the temporal bones of three deceased donors individuals, two with concomitant acoustic tumors and one with concomitant petroclival meningioma have been studied. The differences between neuromas and meningiomas are examined. The different clinical relevance and the different therapeutic guidelines are discussed.

Routine intravenous cholangiography, selective ERCP, and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy

BACKGROUND

No procedure has yet been identified as the standard for the detection and management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy.

METHODS

A prospective study involved 1305 patients undergoing elective laparoscopic cholecystectomy. Intravenous cholangiography was performed on all patients except those with jaundice or cholangitis, acute pancreatitis, or allergy to contrast material. Patients underwent endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy when there was a strong suspicion of choledocholithiasis, positive or inconclusive findings on intravenous cholangiography or allergy to contrast material with signs of possible choledocholithiasis. Intraoperative cholangiography was performed when patients did not undergo ERC or intravenous cholangiography and whenever the surgeon was in doubt about biliary anatomy or biliary clearance.

RESULTS

Two hundred thirty-one patients (17.7%) were referred for preoperative ERC; 14 of them were referred for open surgery because of failure of ERC or sphincterotomy. Only 54 patients underwent intraoperative cholangiography. Bile duct stones, detected in 186 cases (14.2%) (68 of which were asymptomatic), were removed before surgery in 162 cases (87.1%) and during surgery in 20 (10.7%). Self-limited pancreatitis occurred in 3.6% of the patients after sphincterotomy. Laparoscopic cholecystectomy was performed in 98.7% of the cases. The conversion rate was 8% if sphincterotomy had been performed previously, and 3% after standard laparoscopic cholecystectomy (p < 0.001). The morbidity rate was 5% and the mortality rate 0.08%. During the follow-up period 4 patients had retained stones that were treated endoscopically.

CONCLUSIONS

Preoperative ERC followed by laparoscopy is the best approach to treatment of patients with cholecystolithiasis and suspected choledocholithiasis.

Otosclerosis and cochlear otosclerosis: a post mortem study on temporal bones

We have chosen among many temporal bones of donors deceased individuals with concomitant otosclerosis, three particular cases, one with classic otosclerosis, another with cochlear otosclerosis with concomitant oval window ankylosis and another with cochlear otosclerosis without stapes fixation. The different histopathologic features are discussed and clinical and therapeutical guidelines are proposed.

Chronic otitis media: histopathological changes: a post mortem study on temporal bones

The temporal bones of 4 deceased individuals, with concomitant chronic otitis media are studied. The various histopathological changes in the middle ear cleft are examined: suppuration, polyps, granulation tissue. The possibilities of spontaneous healing of a perforated TM and the indications of surgical treatment are discussed.

Ménière's disease. Histopathological changes: a post mortem study on temporal bones

The histopathological changes in the temporal bones of two deceased donors individuals with concomitant Ménierè's disease have been studied. In one temporal bone we have found a blockage of the endolymphatic duct by abnormal bone. The histopathological modifications and the different therapeutic options are discussed. Clinical guidelines are proposed.

Cholesteatomatous otitis media: histopathological changes. A post mortem study on temporal bones

The histopathological changes in the temporal bones of 3 deceased donors individuals with concomitant chronic cholesteatomatous otitis media have been studied. The different forms of cholesteatoma are analyzed: the primary congenital, the primary acquired and the secondary acquired. The different clinical relevance and the different therapeutic guidelines are discussed.

Menierè's disease: is it a bilateral disease?

BACKGROUND

Bilateral Meniere's disease (MD) is still controversial due to different criteria used to assess the involvement of the primarily affected ear and the contralateral one. We evaluated the percentage of bilateral forms in 49 patients with MD.

METHODS

49 patients with (MD) were studied. All were selected according to the following requirements: history, tonal audiometry, glycerol test, Auditory Brainstem Response (ABR), vestibular examination. Magnetic Resonance (MR) was performed in 14 patients.

RESULTS

A raised hearing threshold in the contralateral ear was found in 23 patients, but only 7 (14.3%) fulfilled the requirements to be considered affected by bilateral MD. The delay of occurrence in the contralateral ear was 7 years (from 5 to 12 years). Submillimeter Magnetic Resonance is determinant for differential diagnosis with Meniere-like syndromes.

CONCLUSIONS

A conservative approach in surgical treatment of unilateral Meniere's disease is recommended because of the possibility of evolution in a bilateral form, that can occur even after 10 years from the onset of the disease.

Cholesterol granuloma of the petrous apex. A post mortem study on temporal bones

Otitis media (OM) is an infection localized in the middle ear: mastoid, middle ear cavity, Eustachian tube. The classification of OM includes otitis media with effusion, otitis media without effusion, and chronic otitis media. A rare complication of chronic otitis is cholesterol granuloma of the petrous apex. It may develop in any aerated portion of the temporal bone but most commonly develops when a pathologic process obstruct the air cell tracts to the petrous apex preventing normal aeration.

Acute otitis media. Histopathological changes: a post mortem study on temporal bones

A classification of otitis media is proposed and the histopathological changes of otitis media with effusion are reviewed post mortem on two temporal bones. A case of adhesive otitis media is observed on temporal bone slides. The clinical and therapeutic aspect are examined and treatment guidelines are proposed.

Misleading clinical features in Wegener's granulomatosis. A case report

Wegener's granulomatosis is a systemic vasculitis that may present with a variety of findings and be difficult to diagnose. We report a case of a patient who presented with serous otitis media and subsequently developed a suspected primary lung tumour. Thoracotomy and pulmonary mass excision were required to establish the diagnosis. Otological manifestations of Wegener's granulomatosis, differential diagnosis, pathological findings and c-ANCA test role are discussed.