A goitrous model for Bartolomeo Vivarini (1432-1499)

INTRODUCTION

Bartolomeo Vivarini (Venezia 1432c.-Venezia 1499c.) was an Italian painter during the Renaissance. The artist was widely influenced by Andrea Mantegna, whose opera was characterized by personages with anatomical details meticulously described.

MATERIALS AND METHODS

Some of the most valued paintings of Bartolomeo Vivarini were analyzed. Purpose of the present article is to describe these artworks focusing on female personages represented with thyroid swelling.

RESULTS

A recurring female model in Vivarini's artworks is portrayed with a goitrous neck. This might display a real prevalence of thyroid diseases among young women in the Renaissance age (e.g. postpartum thyroiditis).

CONCLUSIONS

Representation of goiter in the artworks of Vivarini and Mantegna reflects the increased anatomic accuracy and knowledge developed in art since Renaissance and Baroque.

THU0221 EVIDENCE FOR A PATHOGENIC ROLE OF EXTRA-FOLLICULAR, IL-10 PRODUCING CCR6+B-HELPER T-CELLS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

IL-10 plays a key role in systemic lupus erythematosus (SLE) pathogenesis, promoting B-cell response. IL10 is mainly secreted by regulatory T-cells, but follicular helper T-cells (TFH), also produce it. We previously identified a subset of CCR6+IL-7R+T-cells in human tonsils providing IL-10-dependent B-cell help. These CCR6+T-cells were able to produce IL-10, inducing IgG production.

Objectives:

to investigate a possible role of CD4+CCR6+IL7R+T-cells in SLE pathogenesis.

Methods:

37 patients fulfilling the ACR criteria for SLE have been included. Disease activity was assessed by 2k-SLEDAI. PBMC were analyzed by flow cytometry, using specific lineage markers. CCR6+IL7R+T-cells purified from total PBMC of SLE patients or healthy donors (HD) were co-cultured with autologous CD20+B-cells. IL-10, Il-17, total IgG and anti-dsDNA antibodies titers in patients serum and culture supernatants were assessed by ELISA. Embedded sections of lymph nodes from 8 SLE patients were analyzed by immunofluorescence (IF).

Results:

IL10 levels were significantly higher in SLE patients (Fig 1A). CD4+CCR6+IL7R+T-cells were significantly increased in SLE, in particular in those with higher disease activity and higher IL10 levels. CD4+CCR6+IL7R+T-cells levels associated with anti-dsDNA positivity. CCR6+IL7R+T-cells of SLE patients induced production of IgG and anti-dsDNA IgG (in anti-dsDNA + patients) from autologous B-cells, providing spontaneous help for autoantibody productionex vivo(Fig 1B-C). The IF study of lymph nodes of SLE patients showed that IL-10-producing CCR6+T-cells were highly abundant and co-localized with B-cells at follicle margins.

Fig 1

Conclusion:

our study revealed a novel population of extra-follicular B-helper T-cells, which produce IL-10 and could play a prominent pathogenic role in SLE. Further studies will clarify if this potentially pathogenic cell population might represent a possible future therapeutic target.

References:

[1]Facciotti F. J Allergy Clin Immunol. 2016; Geginat J. Semin Immunol. 2019; Tsokos GC. Nat Rev Rheumatol. 2019

Tab 1:

SLE patients characteristics

(n=37)DemographicsFemale/Male, n37/5Age, years, median (IQR)44 (38-49)Disease duration, years, median (IQR)19 (11-26)Lab testsANA86%*anti-dsDNA (%)46% medium/high titre41%Disease activity and clinical manifestations SLEDAI-2K, median (min-max)3.5 (0-24) Moderate/high activity19%Ongoing therapyPrednisone dose mg/day, median (IQR)7,5 mg (2,5 – 20)hydroxychloroquine78%Immunosuppressants87%Fig 2

Disclosure of Interests: :

Maria Gerosa: None declared, Federica Facciotti: None declared, Paola Larghi: None declared, Roberto Bosotti: None declared, Chiara Vasco: None declared, Nicola Gagliani: None declared, Chiara Cordiglieri: None declared, Elsa Rottoli: None declared, Alessandra Emiliana Penatti: None declared, Lorenza Maria Argolini: None declared, Bhavna Karnani: None declared, Yasushi Kobayashi: None declared, Mauro Bombaci: None declared, Jan Piet Van Hamburg: None declared, Roberta Gualtierotti: None declared, Stefano Gatti: None declared, Sara Torretta: None declared, Lorenzo Pignataro: None declared, Sander W. Tas: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Sergio Abrignani: None declared, Massimiliano Pagani: None declared, Fabio Grassi: None declared, Pier Luigi Meroni: None declared, Richard Flavell: None declared, Jens Geginat: None declared

Exacerbations and Pseudomonas aeruginosa colonization are associated with altered lung structure and function in primary ciliary dyskinesia

BACKGROUND

Recurrent bacterial infections of the respiratory tract are one of the major clinical features of the primary ciliary dyskinesia (PCD), a rare genetic disease due to malfunctioning of motile cilia. Chronic infections and persistent inflammation of the respiratory system result in progressive lung disease. Aim of the study was to highlight the main factors associated with clinical, functional and anatomical deterioration in PCD patients.

METHODS

We retrospectively analyzed data from 58 patients with PCD, 37 adults and 21 children. The demographic and clinical data, forced expiratory volume at 1 s (FEV1) and forced vital capacity (FVC), sputum microbiology and imaging results (chest CT scores-modified Bhalla) were recorded. Patients were stratified according to the number of exacerbations (< 2/year vs ≥ 2/year) and chronic Pseudomonas aeruginosa (PA) colonization. The possible correlations between lung function and chest CT scores were assessed; we also evaluated the correlation between these parameters and the severity scores for bronchiectasis (BSI, FACED and e-FACED).

RESULTS

Chest CT scores showed a significant correlation with FEV1 (p = 0.0002), age (p <  0.0001), BMI (p = 0.0002) and number of lung lobes involved (p <  0.0001). PA colonization had an overall prevalence of 32.6%: no significant difference in FEV1 between PA colonized and non-colonized patients was found (p = 0.70), while chest CT score was significantly worse in chronic PA colonized patients (p = 0.009). Patients with a high number of exacerbation (≥ 2/year) were older (p = 0.01), had lower FEV1 (p = 0.03), greater number of lobes involved (p < 0.001) and worse CT score than patients with low number of exacerbations (p = 0.001); they also had higher prevalence of PA chronic bronchial infection (33.3% versus 13.6%, p = 0.10). Multivariable linear regression analyses adjusted for gender, age and BMI showed positive associations between PA colonization and number of exacerbations with severity of disease (number of lobes involved, CT score, BSI, FACED, and e-FACED).

CONCLUSIONS

In our PCD population the number of exacerbations (≥ 2/year) and PA colonization were the two most relevant factors associated with severity of disease.

3D video-assisted trans-oral removal of deep hilo-parenchymal sub-mandibular stones

The aim of this paper is to describe the intra-operative findings and surgical results of the first application of 3D high-definition (HD) endoscopic support to the trans-oral surgical treatment of five patients with deep hilo-parenchymal sub-mandibular stones who underwent clinical and ultrasonographic (US) follow-up examinations at one month after the procedure. Five patients undergoing 2D-HD video-assisted transoral surgery for the same condition were used as controls. The results were classified as successful (US - demonstrated complete clearance) or unsuccessful (US - demonstrated total or partial persistence). Visual analogue scales (VAS) were used post-surgically to evaluate the sharpness and brightness of the 2D and 3D images on the screen and stereoscopic depth perception (SDP) of the 3D-HD endoscope. Successful stone removal and significant subjective improvement (lack of obstructive symptoms) was obtained in all but one of the patients in the 3D group, in whom the one-month US evaluation revealed a residual 3 mm asymptomatic hilo-parenchymal stone that was successfully treated by sialendoscopy-assisted intra-corporeal laser lithotripsy. Wharton’s duct and the lingual nerve were identified and preserved in all cases. The mean 3D-HD VAS results were brightness 7 (range 6-8), sharpness 7.8 (range 7-9) and SDP 8.2 (range 8-9); the mean 2D-HD results were brightness 7.8 (range 7-9) and sharpness 7 (range 7-8). Our findings confirm the safety and efficacy of conservative transoral surgical treatment of hilo-parenchymal sub-mandibular stones. From a surgeon’s perspective, 3D-HD guided exploration of the oral floor seems to provide a better view of Wharton’s duct and the lingual nerve, especially near the sub-mandibular parenchyma. The 3D-HD video-assisted transoral removal of deep hilo-parenchymal sub-mandibular stones can therefore be considered a useful new means of preserving the function of an obstructed salivary gland.

In reply to "Commentary to: Endoscopic and clinical benefits of hyaluronic acid in children with chronic adenoiditis and middle ear disease", by Zhengcai Lou

Some considerations will be expressed in consideration of the commentary previously published. In particular, we underline that no other medications were administered to the patients during the study period and any clinical evaluation was postponed in case of acute upper respiratory tract infection in the previous 14 days. We strongly advocate antibiotic treatment during any acute otitis media episode, and we agree that topically administered hyaluronic acid should be considered as a supporting treatment, "complementary to traditional therapies" in children with recurrent disease.

Nasal cytology in children: scraping or swabbing?

Nasal cytology has become a valuable tool in the assessment of a multitude of nasal pathologies in children. Collection methods differ significantly and even though the use of the nasal curette is regarded as the most reliable in adults, most practitioners use the nasal swab in children. However, no studies have validated the reliability and supposed better tolerability of the latter. We have compared these two sampling methods regarding their tolerability and analysed the diagnostic accuracy of the cotton nasal swab (NSW) to identify nasal cytotypes and rhinitis phenotypes, using nasal scraping (NSC) for comparison. In a multicentric prospective study we recruited 208 children and performed nasal cytology by means of NSW and NSC. Microscopic evaluating of the nasal cytotypes was performed and tolerability of NSW and NSC was tested. Our data revealed a significantly inferior diagnostic accuracy of NSW compared to NSC regarding reliability and cell counts. Our study is the first to shed light on the role of the sampling tools for pediatric nasal cytology. We documented a poor diagnostic accuracy of NSW, thus suggesting using only the nasal curette in clinical practice. Furthermore, tolerability did not differ between the two, refuting the common thesis that swabs are to be preferred when doing nasal cytology in children.

Salivary lithotripsy in the era of sialendoscopy

The traditional management of obstructive salivary disorders has been replaced by minimally-invasive gland-preserving techniques including shock-wave lithotripsy, sialendoscopy, interventional radiology and endoscopically video-assisted trans-oral and cervical stone retrieval, of which sialendoscopy is considered to be the method of first choice. Primary endoscopically controlled stone extraction without prior fragmentation is only possible in 15-20% of cases; in more than 80%, fragmentation is necessary because of the size, impactation and location of the stone, or an alternative treatment such as transoral duct surgery or combined approaches are required. Moreover, about 10-20% of all stones cannot be adequately accessed by means of a sialendoscope or any alternative surgical method and, in such cases, extra-corporeal shock wave lithotripsy (ESWL) is the treatment of choice. However, in endoscopically accessible stones, ESWL is being gradually replaced by endoscopically assisted intra-corporeal techniques, including endoscopically guided laser and pneumatic intracorporeal lithotripsy. We describe the currently most widely used techniques for salivary lithotripsy, including ESWL, and endoscopically guided laser, electrohydraulic, electrokinetic and pneumatic intra-corporeal lithotripsy, and discuss their indications given the widespread use of advanced rehabilitative sialendoscopy and combined therapeutic approaches.

Combined effect of genetic variants in the GluN2B coding gene (GRIN2B) on prefrontal function during working memory performance

BACKGROUND

The GluN2B subunit of N-methyl-d-aspartate receptors is crucially involved in the physiology of the prefrontal cortex during working memory (WM). Consistently, genetic variants in the GluN2B coding gene (GRIN2B) have been associated with cognitive phenotypes. However, it is unclear how GRIN2B genetic variation affects gene expression and prefrontal cognitive processing. Using a composite score, we tested the combined effect of GRIN2B variants on prefrontal activity during WM performance in healthy subjects.

METHOD

We computed a composite score to combine the effects of single nucleotide polymorphisms on post-mortem prefrontal GRIN2B mRNA expression. We then computed the composite score in independent samples of healthy participants in a peripheral blood expression study (n = 46), in a WM behavioural study (n = 116) and in a WM functional magnetic resonance imaging study (n = 122).

RESULTS

Five polymorphisms were associated with GRIN2B expression: rs2160517, rs219931, rs11055792, rs17833967 and rs12814951 (all corrected p < 0.05). The score computed to account for their combined effect reliably indexed gene expression. GRIN2B composite score correlated negatively with intelligence quotient, WM behavioural efficiency and dorsolateral prefrontal cortex activity. Moreover, there was a non-linear association between GRIN2B genetic score and prefrontal activity, i.e. both high and low putative genetic score levels were associated with high blood oxygen level-dependent signals in the prefrontal cortex.

CONCLUSIONS

Multiple genetic variants in GRIN2B are jointly associated with gene expression, prefrontal function and behaviour during WM. These results support the role of GRIN2B genetic variants in WM prefrontal activity in human adults.

Nasal nitric oxide in children with recurrent acute otitis media

Recently, reduced Nasal nitric oxide (nNO) nNO levels have been reported in children with adenoidal hypertrophy predisposing to chronic nasosinusal inflammation. Given the strict anatomic and physiopathologic link between the nasopharyngeal and middle ear compartments, and considering the high prevalence of otitis prone children among those affected with chronic adenoiditis, we designed a study aimed to test any possible difference in nNO levels between non-allergic children with and without recurrent acute otitis media (RAOM) associated with chronic adenoiditis. The study involved 54 children with RAOM (44.4% males; mean age= 7.5±3.5 years) and 51 children without RAOM (47.4% males; mean age= 7.0±3.8 years). nNO levels were significantly reduced in children with RAOM compared to children without RAOM (676.9±250.7 ppb vs 831.8±320.4 ppb, respectively; p= 0.02). Our results could be related to reduced NO production by the ciliated paranasal, nasopharyngeal and middle ear epithelium and the impaired sinusal ostial and Eustachian tube patency due to chronic inflammation, and seem to confirm the involvement of NO pathway in recurrent upper airway infections related to impaired ciliated respiratory mucosa.

Airborne nitric oxide and nasal cytology in patients with chronic rhinosinusitis and nasal polyps

Nitric oxide (NO) is involved in eosinophilic inflammation. The fraction of exhaled nitric oxide (FENO) is increased in chronic rhinosinutis with nasal polyps (CRSwNP), whereas nasal NO (nNO) is reduced in chronic rhinosinutis. Nasal cytology can detect eosinophilic inflammation in CRSwNP. We aimed to describe the baseline rhinocytological characteristics and NO (FENO and nNO) levels in patients with CRSwNP, and assess their possible correlations. This longitudinal study involved 37 consecutive adult outpatients with CRSwNP and 36 healthy controls. They underwent a complete clinical otolaryngological assessment, measurement of FENO and nNO levels, and nasal scraping in order to collect material for nasal cytology. Disease severity was evaluated by means of endoscopic and Lund-Mackay radiological scores. Median FENO level was higher (p less than 0.001) in CRSwNP (28.3 ppb, 95%CI 13.0-33.6 ppb) than in the controls (7.5 ppb, 95%CI 6.1-8.9 ppb). Median nNO levels were lower (255.7, 95%CI 199.7-311.6 vs 385.5, 95%CI 345.0-425.9 ppb; p less than 0.001), and were lower in the patients with severe endoscopic obstruction (p=0.05). Lund-Mackay scores positively correlated with median FENO levels (R=0.11; p=0.05), and inversely with median nNO levels (R=-0.31; p=0.04). Metachromatic nasal cytotypes were more prevalent among CRSwNP patients who had previously undergone surgery (p=0.05). The number of metachromatic elements in the patients with CRSwNP positively correlated with their median FENO levels (R=0.24; p=0.002). Our results confirm the dynamic interplay between the upper and lower airways in patients with CRSwNP. FENO/nNO and nasal cytology can be useful for detecting and monitoring nasal inflammation in CRSwNP.

Serum 25-hydroxyvitamin D levels in children with recurrent tonsillitis living in Milan

Involvement of 25-hydroxyvitamin D in the etiopathogenesis of tonsillar disease in children is still debated; this study assesses possible differences in serum 25-hydroxyvitamin D levels between 309 Caucasian children (58.1% males; mean age 55.7 ± 31.0 months) living in Milan with a history of recurrent tonsillitis (RT) and healthy controls. Mean serum 25(OH)D levels were significantly reduced in the children with a history of RT (22.0 ± 8.7 ng/mL vs 24.6 ± 7.8 ng/mL; p=0.03), and the proportion of children with insufficient or deficient serum 25(OH)D levels was higher in the RT group (81.5% and 6.5% respectively) than in the control group (75.1% and 3.5%) (not significant). The multivariable model created to test the independent association between serum 25(OH)D levels and a history of RT after adjusting for age and season showed that the association was not significant. Our study failed to find any significant reduction in serum 25(OH)D levels after adjustment for age and season in a case series of children with RT in comparison with healthy controls, which suggests that vitamin D does not play a relevant role in the etiology of pediatric tonsillar infections.

Role of biofilm in children with recurrent upper respiratory tract infections

Recurrent respiratory tract infections (RRTIs) are very common in children and a major challenge for pediatricians. In the last few years, bacterial biofilms have been linked to RRTIs and antibiotic resistance, and have raised serious concerns regarding the therapeutic management of recurrent middle ear diseases, chronic rhinosinusitis, and recurrent pharyngotonsillitis. This paper aims to review the new insights into biofilm-related upper respiratory tract infections in children and possible therapeutic strategies. It focuses on the clinical implications for recurrent disease and on studies in pediatric patients. Analysis of the literature showed that the involvement of bacterial biofilm in recurrent upper airway tract infections is an emerging problem that may lead to serious concerns about infection control. Despite the large amount of research within this field, detailed insight into the complex structure of bacterial biofilms and the ultrastructural and biochemical mechanisms responsible for its evasion of the immune system and resistance to treatments is currently lacking. In the future, additional emphasis should be placed on biofilm management as a component of therapeutic strategies. This goal can be attained by finding feasible methods for detecting biofilms in vivo and identifying effective methods for administering treatments that eradicate preexisting bacterial biofilms or hinder bacterial adhesion to respiratory cells.

Arterial microanastomoses on the reverse flow of the internal carotid artery reverse flow: an extreme solution in free-flap revascularisation. How we do it

Microvascular free tissue transfer in head and neck reconstruction requires suitable recipient vessels, which are frequently compromised by prior surgery, radiotherapy, or size of the tumour. A surgical description of an arterial free flap pedicle anastomosis on the reverse internal carotid arterial flow in a vessel-depleted neck is presented. A 66-year-old male with a relapse of hypopharyngeal squamous cell carcinoma previously treated with both surgical and radiation therapy for carcinoma of the tongue and the larynx was successfully reconstructed using a free forearm flap with reverse internal carotid arterial flow. The involvement of the carotid glomus and prior surgery excluded the other vessels as recipients. The forearm free flap survived without any complications. This procedure can be considered an alternative rescue technique for salvage reconstruction in a vessel-depleted neck.

Chorda tympani nerve, may it have a role in stabilizing middle ear pressure?

The chorda tympani (ChT) is a mixed nerve, branch of the facial nerve, crossing the middle ear and containing the preganglionic parasympathetic axons that innervate the sublingual and submandibular glands. The maintenance of a correct middle ear pressure (MEP) is essential for normal ear functions; its regulation has a sophisticated neural control mainly provided by middle ear receptors (tympanic plexus, TP) and Eustachian tube (ET). The information provided by chemoreceptors and baroreceptors of the TP is transmitted to the nuclei of the solitary tract (NST) and then a neural circuit promotes the activation of ET muscles. We hypothesize that the information provided by the TP may modulate submandibular and sublingual glands activity through a neural pathway involving the NST, the superior salivatory nucleus (SSN) and finally the ChT. According to our hypothesis, sudden perturbations of the MEP may stimulate saliva production with consequent swallowing, opening of the Eustachian tube and endotympanic pressure rebalancing.

Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children

Allergic rhinitis (AR) is a very common childhood disease that is associated with a significant reduction in the patients' quality of life. Its treatment combines educating the patients and their parents, immunotherapy and drug administration. However, even the best approach does not relieve the symptoms of a number of patients. Alternative therapies are particularly needed for children because the fear of adverse events frequently reduces parental compliance to the prescribed drugs, and immunotherapy is less easy to administer than in adults. In this prospective investigator-blinded study we evaluated whether children, with a documented history of seasonal grass pollen-related AR, benefit from nasal irrigation by assessing the effects on nasal signs and symptoms, on middle ear effusion and on adenoidal hypertrophy. We randomized children aged 5 to 9 years (median age 82 months) to normal saline or hypertonic saline (a 2.7% sodium chloride solution), administered twice-daily using a disposable 20 ml syringe, or no treatment. Nasal symptoms (rhinorrhea, itching, sneezing, nasal obstruction), swelling of turbinates, adenoid hypertrophy or middle ear effusion were assessed at baseline and after 4 weeks of treatment. Two hundred and twenty children (normal saline: 80; hypertonic saline: 80; no treatment: 60) completed the study. After four weeks, all the considered items were significantly reduced in the group receiving hypertonic saline (P < 0.0001), whereas in the group receiving normal saline only rhinorrhea (P = 0.0002) and sneezing (P = 0.002) were significantly reduced. There was no significant change in any of the items in the control group. The duration of oral antihistamines was significantly lower in the children receiving hypertonic saline than in those treated with normal saline or in controls. No adverse events were reported and parental satisfaction and compliance with the procedure were globally very good, regardless of the solution used. Using our procedure, hypertonic saline is effective, inexpensive, safe, well tolerated and easily accepted by children with seasonal grass pollen-related AR and their parents. Our data suggest that nasal irrigation with hypertonic saline might be included in the wide spectrum of therapies recommended for grass-pollen AR.

A retrospective evaluation of microbiology of acute otitis media complicated by spontaneous otorrhea in children living in Milan, Italy

PURPOSE

To evaluate the microbiology of acute otitis media (AOM) with otorrhea due to spontaneous tympanic membrane perforation (STMP) in children living in Milan, Italy.

METHODS

We evaluated middle ear fluid (MEF) specimens taken from children affected by AOM associated with STMP and otorrhea between January 2001 and December 2011. The fluid was collected by means of direct swab sampling, sent for culture, and processed within 4 h.

RESULTS

A total of 705 specimens were obtained from 458 children (233 boys; mean age ± SD 28.3 ± 19.9 months), and were positive for bacteria in 487 cases (69.1 %). The most frequently cultured infectious agent in single-pathogen cultures was Haemophilus. influenzae (51.0 %), followed by Streptococcus pneumoniae (19.4 %), Streptococcus pyogenes (17.4 %), and Staphylococcus aureus (10.7 %). After adjusting for the sub-period of data collection, age, gender, and previous full heptavalent pneumococcal conjugate vaccine (PCV-7) schedule, it was found that the prevalence of H. influenzae slightly increased in 2008-2010, and the prevalence of S. pneumoniae significantly decreased over time (p = 0.02).

CONCLUSIONS

AOM with STMP is a particular form of AOM in which S. pyogenes plays a significant causative role although, as in uncomplicated cases, H. influenzae and S. pneumoniae retain their etiological importance. The frequency of the detection of S. aureus in MEF deserves further study because this pathogen can give rise to severe clinical problems. Finally, although the use of PCV-7 was relatively efficacious, the benefit of pneumococcal vaccination would be increased by vaccines including a larger number of serotypes.

Exhaled nitric oxide levels in children with chronic adenotonsillar disease

Exhaled nitric oxide (eNO) is a highly reactive biological mediator that has recently been associated with chronic tonsillar disease in adults, but there are no published data concerning eNO levels in their pediatric counterparts. The aim of this study is to measure mean eNO levels in children with chronic adenotonsillitis or adenotonsillar hypertrophy, and assess the effects of potential confounding factors. Children aged 3-17 years were divided into three groups (chronic adenotonsillitis, adenotonsillar hypertrophy and controls). Their eNO levels were measured in accordance with the international guidelines, and their other clinical and anamnestic characteristics were recorded. The mean eNO level in the children with chronic adenotonsillitis was slightly higher than that in the other groups, but there was no statistically significant between-group difference. Age (p=0.009), allergy (p=0.05) and body mass index (p=0.03), but not the mean grade of adenoidal or tonsil hypertrophy, were all statistically related to mean eNO levels. These preliminary results indicate the lack of an increase in mean eNO levels in children with chronic adenotonsillar disease, with no substantial difference between children with chronic adenotonsillitis and those with adenotonsillar hypertrophy.

Use of complementary and alternative medicine in children with recurrent acute otitis media in Italy

Controlling environmental factors, chemoprophylaxis, immunoprophylaxis and surgery are considered possible means of preventing recurrent acute otitis media (RAOM), but there are no available data concerning the paediatric use of complementary and alternative medicine (CAM). We evaluated the uses of CAM (homeopathy and/or herbal medicine) as means of preventing AOM in children with a history of RAOM. Eight hundred and forty Italian children with RAOM (≥3 episodes in six months) aged 1-7 years were surveyed in 2009 using a face-to-face questionnaire, filled by parents or caregivers, that explored the prevalence, determinants, reasons, cost, and perceived safety and efficacy of CAM. About one-half (46%) of the children used CAM, significantly more than the number who used immunoprophylaxis (influenza vaccine 15%; p<0.05), PCV-7 34%; p<0.05) or chemoprophylaxis (2%; p<0.001). Use of CAM in the family was the only important factor positively associated with the use of CAM in children (adjusted OR 7.94; 95% CI: 5.26-11.99). The main reasons for using CAM were a fear of the adverse effects of conventional medicine (40%) and to increase host defences (20%). CAM was widely seen as safe (95%) and highly effective (68%). CAM prescribers were paediatricians in 50.7% of cases; self-initiation was reported by 23% of respondents. CAM expenditure was between Euro 25 and Euro 50/month in 27.6% of cases and ≥ Euro 50/month in 16%. Children with RAOM should be considered among the categories of subjects likely to be using CAM. Together with the fact that paediatricians are the main prescribers, this is worrying because of the current lack of evidence regarding the efficacy, safety and cost-effectiveness of CAM in the prevention of RAOM.

Efficacy of complex herbal compound of Echinacea angustifolia (Imoviral® Junior) in recurrent upper respiratory tract infections during pediatric age: preliminary results

AIM

Among pediatric population the recurrent upper respiratory tract infections are very common. Several phytotherapies are been proposed as support therapies and, in particular, the efficacy of Echinacea angustifolia is controversial. This paper presents an evaluation of a new herbal compound in the treatment of recurrent upper respiratory tract infections in a pediatric cohort.

METHODS

An immunostimulant herbal compound of Echinacea angustifolia, Arabinogalactan, Acerola (Vitamin C), Beta- Glucan e Zinc (Imoviral® Junior) was given to 37 children affected by recurrent pharyngotonsillitis or otitis media.

RESULTS

The mean number of inflammatory episodes (i.e. tonsillitis or otitis media) during 6 months before treatment was 3±2.19, during the 6 months following treatment initiation it was 1±0.93 (P=0.04). After the complete treatment, 77% of children reported an improvement of chronic inflammatory in frequency of acute episodes. The total score of a questionnaire about life quality is improved (P=0.04). Finally, none collateral effects was occurred.

CONCLUSION

The herbal compound of echinacea, beta-glucan, vitamin c, arabinoglactan and zinc (Imoviral® Junior) can improve the quality of life in pediatric patients affected by recurrent pharyngotonsillitis and otitis media without contralateral effects.

Nasal nitric oxide in children with adenoidal hypertrophy: a preliminary study

OBJECTIVE

Nasal nitric oxide, a mediator involved in upper airway inflammation, is impaired in children with allergic rhinitis and rhinosinusitis. Normal values are 200-450 parts per billion, but no data are available concerning its levels in children with adenoidal obstruction, predisposing to chronic nasosinusal inflammation. This study aimed to: (1) measure nasal nitric oxide levels in non-allergic children with adenoidal hypertrophy and (2) assess its possible relationship with the degree of adenoidal hypertrophy and other variable (gender, age, body max index, passive smoking exposure, recurrent acute otitis media, recurrent respiratory infections, and hypertrophy of nasal turbinates).

METHODS

Eighty-one children with suspected adenoidal hypertrophy underwent nasal fibroendoscopy to assess the degree of adenoidal hypertrophy, and nasal nitric oxide on-line measurements by means of a dedicated chemiluminescence analyser.

RESULTS

Nasal nitric oxide was successfully measured in 35 patients, most of whom had levels >450 parts per billion; the values were significantly higher (p=0.031) in children with non-obstructive adenoids. There was no significant correlation with any other variable.

CONCLUSIONS

Preliminary data show above-normal nasal nitric oxide levels in children with adenoidal hypertrophy, especially those with non-obstructive adenoids. This suggests nitric oxide involvement in recurrent nasopharyngeal inflammation due to adenoidal hypertrophy.

Insights into infectious otitis media

Otitis media is a multifactorial disease. It represents a major public health burden, as it is the most common diagnosis in children and is characterized by both immediate and long-term morbidity. For years the knowledge about risk factors and microbiology of otitis media has been relatively stable. In recent years new data have been gathered regarding different microbiological aspects of otitis media. This new knowledge may contribute toward the development and implementation of therapeutic and preventive strategies.

ENT assessment in the integrated management of candidate for (maxillary) sinus lift

As stated at the 1996 Consensus Conference at Babson College, a (maxillary) sinus lift is a "safe and predictable" procedure for increasing alveolar bone height in the postero-superior alveolar regions in order to allow oral rehabilitation and restore masticatory function by means of the insertion of a dental implant even in the case of an atrophic maxilla. However, the procedure has a well-known impact on the delicate homeostasis of the maxillary sinus: the concomitant presence of systemic, naso-sinusal or maxillary sinus disease may favour the development of post-operative complications (particularly maxillary rhino-sinusitis), which can compromise a good surgical outcome. On the basis of these considerations, the management of sinus lift candidates should include the careful identification of any situations contraindicating the procedure and, if naso-sinusal disease is suspected, a clinical assessment by an ear, nose and throat specialist, which should include nasal endoscopy and, if necessary, a computed tomography scan of the maxillofacial district, particularly the ostio-meatal complex. This first preventive-diagnostic step should be dedicated to detect presumably irreversible and potentially reversible contraindications to a sinus lift, whereas the second (preventive-therapeutic) step is aimed at correcting (mainly with the aid of endoscopic surgery) such potentially reversible ear, nose and throat contraindications as middle-meatal anatomical structural impairments, phlogistic-infective diseases and benign naso-sinusal neoplasms the removal of which achieves naso-sinusal homeostasis recovery, in order to restore the physiological drainage and ventilation of the maxillary sinus. The third (diagnostic-therapeutic) step is only required if mainly infective and sinusal complications arise after sinus lift surgery, and is aimed at ensuring early diagnosis and prompt treatment of maxillary rhino-sinusitis in order to avoid, if possible, implant loss and, in particular, the related major complications. The purpose of this report is to describe these three steps in detail within the context of a multidisciplinary management of sinus lift in which otorhinolaryngological factors may be the key to a successful outcome.

Modern management of obstructive salivary diseases

Over the last fifteen years, increasing public demand for minimally-invasive surgery and recent technological advances have led to the development of a number of conservative options for the therapeutic management of obstructive salivary disorders such as calculi and duct stenosis. These include extracorporeal shock-wave lithotripsy, sialoendoscopy, laser intra-corporeal lithotripsy, interventional radiology, the video-assisted conservative surgical removal of parotid and sub-mandibular calculi and botulinum toxin therapy. Each of these techniques may be used as a single therapeutic modality or in combination with one or more of the above-mentioned options, usually in day case or one-day case under local or general anaesthesia. The multi-modal approach is completely successful in about 80% of patients and reduces the need for gland removal in 3%, thus justifying the combination of, albeit, time-consuming and relatively expensive techniques as part of the modern and functional management of salivary calculi. With regard to the management of salivary duct anomalies, such as strictures and kinkings, interventional radiology with fluoroscopically controlled balloon ductoplasty seems to be the most suitable technique despite the use of radiation. Operative sialoendoscopy alone is the best therapeutic option for all mobile intra-luminal causes of obstruction, such as microliths, mucous plugs or foreign bodies, or for the local treatment of inflammatory conditions such as recurrent chronic parotitis or autoimmune salivary disorders. Finally, in the case of failure of one of the above techniques and regardless of the cause of obstruction, botulinum toxin injection into the parenchyma of the salivary glands using colour Doppler ultrasonographic monitoring should be considered before deciding on surgical gland removal.