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The treatment of Menierè's disease (Md) with intratympanic gentamicin has rapidly become one of the most widespread alternatives to surgery in this disorder. Numerous studies, employing different protocols, have reported the use of this antibiotic in the treatment of disabling forms of Md, with success rates in the control of vestibular symptoms varying from 73 to 100%, associated with a rate of hearing complications varying from 0 to 75%. We have reported the results of a preliminary experience carried out in 10 patients affected by monolateral Md who were managed with ablation treatment effected with a mixture of gentamicin and human fibrin glue. Upon follow-up examination after one year, all of the patients presented a marked reduction in vestibular reflectivity on the side treated. The vertigo score was zero in all of the patients, showing that the vertigo symptoms were entirely under control. When patients were asked to rate their disability, vertigo was assessed as completely under control in 7 patients and substantially under control in the remaining 3. None of the patients presented any loss of hearing. On the basis of this experience, we propose a standardized protocol which, using an extremely low overall dose of gentamicin, enables elevated success rates to be obtained with the lowest possible number of injections, thus minimizing the risks to hearing. Intratympanic gentamicin associated with a fibrin carrier in Md appears to enable a standardized dose of the drug to be employed, resulting in a decided reduction in the number of administrations and in the overall dose of the drug applied. This makes it possible, with equal benefits in vertigo control, to significantly minimize any hearing loss.

Grave's ophthalmopathy is an inflammatory, autoimmune disorder often associated with Grave's disease. The inflammatory infiltration involves the retrobulbar fatty tissue and the extrinsic eye muscles, causing proptosis, extraocular muscle dysfunction and often diplopia. Orbital decompression is an effective treatment in such cases, particularly when resistant to drugs and external radiation therapy. This work compares the results of orbital decompression performed by removing: a) the medial and lateral walls (Mourits technique) in 10 patients (19 orbits) and b) the medial and lower walls (Walsh-Ogura technique) in 17 patients (31 orbits). The results show that removing the floor of the orbit enables better reduction of proptosis but more easily leads to post-operative diplopia. Thus it proves necessary to combine the two techniques, modifying the surgical approach on a case-by-case basis.

Progressive sensorineural hearing loss (PSNHL) is an important clinical entity that can develop rapidly and evolve to deafness. The causes of PSNHL can be divided into hereditary, developmental, infectious, autoimmune, metabolic, vascular, neoplastic, toxic and degenerative, even if the origin of the hearing impairment often remains unknown and a diagnosis of idiopathic PSNHL is made. In order to establish the etiology of the hypoacusia or to rule out any known etiology of PSNHL and to diagnose an idiopathic form, a detailed family, physiological and medical history has to be obtained, including history of pregnancies. A careful audiological and otoneurological evaluation should also be carried out, followed by laboratory tests. Furthermore, a complete otoneurological evaluation is required, with puretone audiometry, speech audiometry, impedance audiometry and study of the stapedial reflex, brainstem auditory evoked potentials and vestibular examination. Finally, patients with PSNHL must undergo neuroradiological examination (computerized tomography of petrosal bone, cerebral magnetic resonance and inner ear magnetic resonance); ophthalmological, rheumatological and neuropsychiatric (in childhood) advices should be sought, while other advices may be required on the basis of a particular clinical suspicion. When the etiology is established, therapy must be based on specific treatment for the cause of the hearing deficit; for example, hormonal therapy in alterations of thyroid function, antibiotic treatment in bacterial infections, calcium-antagonist and antiaggregant drugs in the vascular forms, corticosteroids or cyclophosphamide or other immunosuppressive drugs in PSNHL associated with systemic autoimmune diseases. In idiopathic hearing loss, treatment must be started in the absence of important contraindications. The therapeutic protocol that we use in such cases is the following: methylprednisolone boluses, 500 mg/day for three consecutive days, and subsequently oral treatment gradually tapering off in association with a cycle of hyperbaric therapy. Patients showing clinical and historical indications are also treated with intravenous glicerolo, calciparina and/or antiaggregant and calcium-antagonist drugs.

An auto-immune progressive sensorineural hearing loss (PSNHL) can occur as one of the clinical features of systemic immune-mediated disorders, such as Cogan's syndrome, Behçet's disease, Wegener's granulomatosis, mixed cryoglobulinaemia, systemic sclerosis, systemic lupus erythematosus, giant cell arteritis, panarteritis nodosa, relapsing polychondritis, unclassified systemic vasculitides, etc, or as a distinct clinical entity, the so-called auto-immune inner ear disease. The clinical evolution of the hearing loss during the course of the systemic disease is extremely variable (slowly progressive versus rapidly progressive), while the auto-immune inner ear disease is usually characterized by a rapidly developing (weeks or months) progressive hearing loss. In both cases a timely clinical assessment and treatment can positively affect the prognosis of the hypoacusia. To date, no laboratory test will give a sure diagnosis of autoimmune hearing loss and only a good response to corticosteroid and/or cytostatic treatment can indirectly confirm this diagnosis. The laboratory tests that are usually performed can be divided into aspecific and specific tests, the latter evaluating the immune-mediated response to the specific inner ear antigen. Evaluation of the aspecific parameters sometimes shows high values of erythrocyte sedimentation rate and C-reactive protein, but often no alteration of the inflammation parameters is observed. However, the specific tests seem to achieve higher sensibility and sensitivity but to date they are not available in clinical practice. In this study we examined a group of 13 patients affected with bilateral idiopathic PSNHL who underwent Western Blot, which is a specific test for the inner ear antigen. A positive result was found in 53.8% of the cases; in particular, all 3 patients who had an improvement of hearing loss with corticosteroid treatment, and therefore were probably suffering from auto-immune progressive hearing loss, had a positive result to the Western Blot test.

Otosclerosis is a bone dysplasia limited to the otic capsule causing abnormal resorption and redeposition of bone. The existence of the entity "pure labyrinthine otosclerosis" or "cochlear otosclerosis" is not accepted by all authors; however, there is clinical and histologic evidence to support the existence of a progressive sensorineural hearing loss due to otospongiotic-otosclerotic lesions of the labyrinthine capsule, although diagnosis of this condition may be difficult. The involvement of the inner ear is described as degenerative changes in the spiral ligament, stria vascularis, organ of Corti, and cochlear neurons. The most frequent audiometric configuration is a "bite-type" curve, but flat or rising shapes can also be observed; speech discrimination appears unusually good for a pure sensorineural hearing loss and recruitment is frequently absent. A cochlear otosclerosis should be suspected when there is a family history of otosclerosis, the onset of the hearing loss occurs from the third to fifth decade, and worsening of the hearing loss is observed during periods of intense hormonal and endocrine activity, a positive Schwartze sign is present and bilateral sensorineural loss is associated with signs of unilateral stapedial ankylosis. A definitive diagnosis of cochlear otosclerosis can be made only with computed tomography, which allows a quantitative assessment of the involvement of the labyrinthine capsule by spongiotic or sclerotic areas. The factors to be considered are: otosclerotic foci 1 mm or more in diameter and a density different from that of the normal otic capsule, partially or completely erased contour of the capsule, double ring effect, bony neoformation in the labyrinthine spaces, and increased thickness of the cochlear capsule. The medical management of cochlear otosclerosis is based on sodium fluoride, in association with calcium and vitamin D; some authors have also proposed diphosphonates as inhibitor agents of bone resorption. Surgery may be useful only in those patients presenting a hearing loss so severe that the bone threshold cannot be evaluated and a gap between air and bone conduction cannot be excluded; in these cases stapes operations can improve hearing to a level that may be useful in hearing aid application.

Prevalence of progressive sensorineural hearing loss in childhood seems to be extremely variable, as percentages reported range from 4 to 30%. Differences in the criteria employed for identifying the deterioration, in the groups of patients, and the age range, could explain this wide range of reported figures. The etiology of the progressive sensorineural hearing loss in infants can be hereditary or acquired. Hereditary causes are divided into syndromic and non-syndromic, whereas the acquired causes include congenital or acquired infection (syphilis, cytomegalovirus, rubella virus and toxoplasma infections, bacterial meningitis and acquired viral infections) and congenital inner ear anomalies (Mondini's dysplasia, large vestibular aqueduct, large cochlear aqueduct). Other acquired causes such as disorders of the metabolism, chronic use of ototoxic drugs, autoimmune diseases, perilymphatic fistula and head or acoustic trauma are less common. The age of onset of deterioration shows a great variability because even the congenital hearing losses may occur late after birth. The progressive evolution seems to be binaural in most patients, but more commonly it presents interaural differences, and when the hearing deficit is initially asymmetrical the deterioration is usually greater in the ear which appeared least affected in the first audiogram. Furthermore, at the different frequencies, there is a tendency to a greater deterioration at the frequencies initially least affected, but some authors are not in agreement because they report a uniform pattern of progression in the range of 0.5 to 4 kHz with no modification of the audiometric shape in most of the examined patients.

Metabolic, hormonal and vascular disorders are considered to cause hearing dysfunction such as progressive sensorineural hearing loss (PSNHL). The diseases most commonly associated with PSNHL are diabetes mellitus, congenital and acquired hypothyroidism, chronic renal failure, chronic labyrinthine ischemia determined by non-hematologic factors (tissue perfusion pressure, blood vessel diameter) or by hematologic factors (blood viscosity and/or rigidity of the red blood cells). In this study a review of data on the relationship between these clinical disorders and the presence and deterioration of the hearing function was carried out. PSNHL seems to be significantly associated with diabetes mellitus, in particular the mitochondrial type: a progressive deterioration of the hearing function is reported in 60% of the patients suffering from this type of disease with mitochondrial mutations. Regarding hypothyroid disorders, the data do not support a pathogenetic link between PSNHL and acquired hypothyroidism, whereas in subjects with congenital hypothyroidism both clinical and experimental results indicate a progressive damage of hearing function if the thyroid disorder is not treated early in life. Also, in patients with chronic renal failure the hearing thresholds seem to be significantly worse than in control subjects, particularly in patients undergoing dialysis, whereas the effect of kidney transplantation on auditory function is still not understood. Finally a relationship between PSNHL and chronic labyrinthine ischemia due to alterations of hematologic factors (increase of blood viscosity and/or increase of rigidity of the red blood cells) has been reported by several authors. However, data on high blood pressure and hyperlipoproteinemia as causes of deterioration of hearing acuity are controversial, and it is often difficult to understand whether the progressive hearing deficit is due only to these factors or also to the elderly age of patients.

Allergic Fungal Sinusitis (AFS) is a newly recognized form of benign, non invasive sinusitis the histopathologic features of which are similar to those of allergic bronchopulmonary aspergillosis. AFS is a rare condition. However, because treatment and prognosis vary widely, it is important that this disorder be recognized and differentiated from chronic bacterial sinusitis and other forms of fungal sinusitis. AFS does not discriminate by age although it is primarily found in young adults. AFS patients are usually atopic, often having a history of asthma and nasal polyposis. Many have suffered from the symptoms of chronic sinusitis for years while others have had multiple sinus surgery. Radiographs reveal the involvement of multiple sinuses, often with bone destruction. Laboratory findings support an allergic state with a marked increase in eosinophilia and total IgE. At times RAST testing proves positive for fungi and immediate cutaneous reactivity to fungi is also present. Histologic review of the sinus contents reveals characteristic "allergic mucin", with numerous eosinophiles, Charcot-Leyden crystals and fungal hyphae, without any fungi tissue invasion. A wide variety of fungal agents has been implicated, although the majority belong the Dematiacee family. Those patients with allergic mucin but no documented fungi are indicated as having AFS-like syndrome. The pathogenesis of AFS is uncertain. There is controversy in the literature as to what role hypersensitivity (Gell and Coombs type I and type III responses) in infection play. To date current therapeutic recommendations include complete exenteration of all allergic mucin. Adjunctive, short-term systemic steroids often prove useful and nasal steroid spray should be continued for long term. Systemic antifungal agents are not recommended in AFS. Recurrence is common and thus close clinical, endoscopic and radiographic follow-up is important. The clinicopathologic features of one patient with AFS are reported and etiopathogenetic problems are discussed. The presented case showed a positive culture with negative immunological testing (RAST-positive and immediate cutaneous reactivity to fungal antigen), thus confirming the pathogenetic hypothesis of the saprophytic fungal growth in an atopic patient.

Bacterial meningitis is an infection of the central nervous system involving quite a number of neurological sequelae the most common of which is hearing impairment. To assess the incidence of audiological deficit the authors evaluated retrospectively 20 patients, between 4 months and 11 years of age, observed at the Pediatric Clinic at the University of Pisa between 1988 and 1993. A clinical-neurological examination and a complete auditory assessment (using BAEPs and impedence audiometry) has been performed in every patient between 1 and 18 months after they left hospital. 4 children had persisting neurological sequelae, 3 patients developed sensorineural hearing loss and one child visual impairment and seizures. Haemophilus Influenzae was responsible for 2 cases of sequelae and Streptococcus Pneumoniae for the other 2 cases. The number of days of illness before hospitalization and the institution of an antibacterial treatment, persistence of fever and deviation from the normal level of consciousness and persistence of neck rigidity were not correlated with the presence of sequelae. No correlation has been found between sensorineural hearing loss and the kind of antibacterial therapy. It's advisable that every child, following bacterial meningitis, should undergo a complete and repeated audiological assessment to detect any lesser impairments and/or unilateral losses that may damage the development of speech and language in any way.

The Authors present their experience in using bovine cartilage as otological material reconstruction. Cartilage of the ribs is to collect from selected bred cattle and is first placed in an antibiotic solution for 3 days and then in a 70% ethyl alcohol in which it is stored for 20 days before being utilized. One hundred-nineteen cartilage heterografts have been implanted in the middle ear since January 1989. We report the results of 86 cases which were included in a followed study for at least 12 months. Bovine cartilage was used in 47 canal up techniques, 28 canal down techniques and 11 anatomic and functional rehabilitation of old radical cavities. The result prove most encouraging. In 74 cases we observed good anatomical results characterized by a new, intact eardrum with no sign of inflammation or a cavity lined with normal epithelium. No extrusion was found. Removal of cartilage implanted after a year enabled us observe the high tolerance of the graft and to carry out further histological examination. The histological findings indicated normal and intact cartilagineous matrix, lined with fibrous tissue and mucosa with no evidence of condrocytes. In cases in which the heterografts were utilized for ossiculoplasty, the post-operative air-bone gap was 11.1 dB and the mean hearing gain was 26.3 dB. Moreover, bovine cartilage is easily obtainable and available in pieces of sizes necessary for specific purposes in otologic surgery. Cartilage heterografts might well be a good alternative to autologous and homologous cartilage grafts.

Cholesteatomas were intraoperatively removed from subjects under 14 years of age presenting widespread cholesteatoma with bone erosion. The samples were studied under light and transmission electron microscopy in order to consider the features of inflammation and bone erosion. The results showed that the perimatrix of cholesteatoma in children is rich in mononuclear inflammatory elements and generally presents the features of chronic, as well as acute, inflammation. The perimatrix infiltrates and erodes the surrounding bone. Next to the resorption areas many areas were observed having new bone the surface of which is lined with osteoblasts. The new bone formation activity is marked in these cases of childhood cholesteatoma and appears to be an attempt at spontaneous repair which is thwarted by the persistence of inflammation.

The authors present their experience with stored lyophilized bone allografts utilized in middle ear reconstructive surgery. The implants were cut from the cortical substance of the long bone in subjects deceased. A demineralization in 0.6 N HCl solution was performed in order to induce osteoinductive capacity to the bone matrix. From November 1986 to December 1988 this material was utilized in 45 operations: 31 canal up techniques; 7 canal down techniques; 4 anatomical and functional rehabilitation of old radical cavities. Good anatomical results without perforation of the tympanic membrane and without signs of inflammation or retraction were obtained in 33 cases (79%). Furthermore, no extrusion was observed in cases with retraction of the graft and protrusion of the prosthesis. In cases in which the homografts were utilized for ossiculoplasty, the post-operative air-bone gap was 21 dB and the mean hearing gain was 15 dB. The histological examination of two homografts, removed 13-18 months after implantation, appeared to be coated with normal mucosa and to contain areas of active bone formation.

The risk of nosocomial risk of HIV infection and the problem of preventative measures to adopt has been modifying how workers in the health field deal with patients. In fact, the increased spreading of HIV infections within our population has led to the establishment of a national protocol of preventative measures by which no patient can be considered "safe". Consequently, the likelihood that contact with any patient can lead to infection causes the health care worker to look upon the patient as a potentially dangerous enemy, thus leading to a decline in the quality of health care. On the other had, although the risk of a health care worker being infected by HIV during routine work is low, preventative measures must be taken both during examination and during surgery. Unanimous agreement exists in regard to what measures are to be taken to prevent cutaneous and mucosa exposure of workers whenever the risk of accidentally coming into contact with the blood and/or other biological fluids exists. On the other hand, the use of an anti-HIV screening for all patients in order to distinguish between infected and non infected subjects is still subject to debate. Some feel such screening is unacceptable because it would deny sero-positive patients adequate care and could give rise to both false positives and false negatives while others propose routine screening feeling it to be helpful both to those who are sero-positive and to health care workers.(ABSTRACT TRUNCATED AT 250 WORDS)

The proposed technique for purification and concentration of secretory IgA has been applied to intestinal wash fluids obtained by clisma from 15 patients under bacterial extracts treated (COLOPTENE-DEBAT). The collected data show that the technique is suitable for routinary use and the bacterial extracts do increase the amount of IgA in the intestinal contents.

Trypsinized cells from rabbit kidney can be kept at -195, 8 degrees C indefinitely. When necessary, propagation in monolayer cultures is readily obtained as primary cultures, provided that some conditions be respected: 1) only glass culture flask must be used. Falcon plastic vessels do not allow cell attachment in this type of primary culture 2) the lag period is particularly long: it taken about 20 days before the beginning of cell multiplication 3) fetal calf serum is toxic for the cells in the 2nd and 3rd change of the culture medium, during the lag period.