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The awareness of audio-vestibular side effects of drugs, such as hearing loss, tinnitus, dizziness and vertigo, has widely increased in the recent years. The present guide represents an update of the previous documents published by the authors in 2005 and 2011 on drug-induced ototoxicity and vestibulotoxicity.The authors performed a comprehensive analysis of audio-vestibular side effects of commercially available drugs based on the British National Formulary, a pharmaceutical reference book that contains a wide range of useful information and advice on prescription and pharmacology.Commercially available drugs and their active principles have been classified based on their audio-vestibular side effects, as reported by the pharmaceutical companies and/or health agencies. Drugs have been categorized based on the field of application, the therapeutic indication and the pharmacological properties.General practitioners, otolaryngology, neurology and audiology specialists should be aware of possible audio-vestibular side effects of drugs, such as hearing loss, tinnitus, dizziness and vertigo. The present guide represents a practical tool to rapidly identify potential audio-vestibular side effects of drugs as reported by the pharmaceutical companies and/or health agencies.

Literary studies underline the effectiveness of distortion product otoacoustic emissions (DPOAEs), which are not affected by the collaboration of the subject examined, in the early diagnosis of hearing loss. Aim of the study is to compare the objective technique of DPOAEs with respect to the pure-tone audiometry in early diagnosis of hearing loss.The clinical research was carried out on 852 workers. All subjects underwent pure-tone audiometry, tympanometry and distortion products.The results show: a) a prevalence of subjects with impaired DPOAEs higher than the prevalence of subjects with impaired audiometries in the studied samples; and, after division by gender: b) a prevalence of subjects with impaired DPOAEs higher than the prevalence of subjects with impaired audiometries only in men; c) a prevalence of impaired DPOAEs and of impaired audiometries in men higher than in women.The results suggest the higher effectiveness of DPOAEs compared to pure-tone audiometry in making an early diagnosis of hearing loss.

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

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

Epistaxis represents one of the most common ENT emergencies. In this paper, the authors report their experience in treating some cases of severe epistaxis by super-selective embolization of the afferent vessels of the nasal fossae.A retrospective study of 22 patients with severe recurrent epistaxis (1 anterior and 21 posterior). All patients had been treated unsuccessfully with repeated anteroposterior nasal packing, and presented significant secondary anaemia. Selective embolization procedures were performed under local anaesthesia. An arterial introducer is inserted into the femoral artery -generally the right one- and diagnosis as well as treatment are performed with the same guide catheter. In all cases, the terminal branches of the facial artery and of the internal maxillary artery on the side on which the haemorrhage occurred were embolized. Moreover the contralateral internal maxillary artery was always embolized as well, in order to prevent immediate recurrence of hypervascularisation of the mucosa through anastomotic paths.In all patients, complete devascularisation was achieved in the areas of the embolized arteries at the nasal mucous membranes, arresting the epistaxis. None of the cases experienced complications attributable to treatment.Superselective arteriography with embolization can be considered as the method of choice in treating severe epistaxis because it can be performed under local anaesthesia and can easily be repeated if the first procedure is not successful. Moreover, it is at least as effective as ligation of the internal maxillary artery, if not more so, but it has a significantly lower complication rate which is destined to fall as the quality of the materials being used continues to improve.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The fact that neoplasms of the cranial base or metastases of nasopharyngeal tumors may cause palsy of nerves which pass through the jugular and anterior condylar foramina has been well documented. On the other hand, very little has been reported about the traumatic causes of these diseases, probably because they are often underestimated or misdiagnosed. In this paper, the Authors report four cases of palsy of the last four cranial nerves caused by various kinds of trauma: glossopharyngeal thermo-rhizotomy, bullet wound, closed cranial trauma, neck surgery. The main symptom immediately following a lesion is mechanical dysphagia which causes inhalation of food and saliva and may sometimes require surgery, such as tracheotomy or cricopharyngeal myotomy. The most lasting symptom is dysphonia, which can only be treated by speech therapy. Because of the importance of these damaged functions, the above symptoms must be studied more thoroughly, also keeping in mind the modern techniques of surgical and non-surgical speech rehabilitation.

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