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The EU member States have started to implement the long discussed European Water Framework Directive. This Directive seeks to protect and improve the terrestrial environment through a sustainable use of water resources and introduction of protective measures. The water resources authority of each defined river basin district is required to analyze the water environment and introduce measures to improve it if necessary. Such an analysis is carried out for the Piemonte Region, Italy, with emphasis on agricultural and industrial load to the groundwater and surface water system. The region covers an area of more than 25.000 km2 and several water resources numerical tools have been applied as support for the planning. Models for plant growth and nitrogen consumption, groundwater and surface water flow and quality and overall water and solute balances are introduced. The models are applied to investigate various schemes for reorganization and/or rationalization of the water use in the region with a focus on the overall water management and water budget as well as water quality. The paper describes the development of the various models for the Piemonte Region.

The wide availability of gadolinium-enhanced magnetic resonance imaging (MRI-Gd) has led to the discovery of an increasing number of small and less symptomatic acoustic neuromas in elderly patients. We conducted a retrospective study in order to obtain data on outcomes and complications associated with different management strategies that would be useful in establishing a management guideline. We identified 44 patients aged 65 to 77 years with acoustic neuromas who had been managed with either surgery or simple observation with MRI-Gd imaging. Of the entire group, 36 patients had tumors larger than 1 cm, and they underwent surgery (most via the translabyrinthine approach). Complete removal of the tumor was achieved in 34 of these patients (94.4%). At the 1-year follow-up, grade VI facial nerve paralysis was evident in only two of 35 evaluable patients (5.7%). Postsurgical complications occurred in five patients (13.9%), including one death. The remaining eight patients had tumors 1 cm or smaller, and they were managed with periodic MRI-Gd scanning. At the 5-year follow-up, no tumor growth was seen in six of these patients. The other two patients exhibited a tumor growth rate of less than 2 mm per year. No patient in the observation group required surgical intervention.

To evaluate the effect of ipsilateral and contralateral low-frequency (250 Hz) narrow-band noise (NBN) on the temporary threshold shift (TTS) induced by a 2 kHz tone in young normally hearing subjects with a functioning auditory efferent system.Sixteen young volunteers served as subjects. All the subjects were young (20-30 years), disease-free and had a medical history negative for otological disease, noise exposure and use of ototoxic drugs. They had normal hearing [thresholds of 125-8,000 Hz below 20 dB hearing level (HL)], transient-evoked otoacoustic emissions and contralateral suppression. The subjects were randomly assigned to one of three different groups. Subjects in Group A (n = 5) were exposed to a 90 dB HL 2 kHz pure tone for 10 min. Subjects in Group B (n = 6) were exposed to a 90 dB HL 2 kHz pure tone and an ipsilateral 45 dB HL 250 Hz NBN for 10 min. Subjects in Group C (n = 5) were exposed to a 90 dB HL 2 kHz pure tone and a contralateral 45 dB HL 250 Hz NBN for 10 min. The right ear served as the test ear. The TTS 2 min after the end of the exposure (TTS2) was measured in all subjects at 2, 3 and 4 kHz.TTS, in Group A was significantly higher at 3 kHz (p = 0.011) and at 4 kHz (p = 0.003) than TTS2 in Group B. At 4 kHz, TTS2 in Group C was significantly higher (p = 0.013) than TTS2 in Group B. Although TTS2 in Group C was lower than TTS2 in Group A, this difference was not significant. The presence of an ipsilateral low-frequency NBN significantly reduced TTS2 induced by a 90 dB HL 2 kHz tone. A contralateral low-frequency NBN reduced TTS2 in this group of subjects; however, the reduction was not significant.The results of this study show that an ipsilateral low-intensity, low-frequency (250 Hz) NBN can give protection from a TTS induced by a 2 kHz tone. Contralateral low-frequency NBN did not induce any protective effect.

Primary cerebellopontine angle (CPA) cholesteatoma grows slowly and silently in the subarachnoidal spaces. The diagnosis is often late, when the lesion has reached large dimensions. Surgical removal is the only available therapy. Fifteen consecutive cases of CPA cholesteatoma managed at a tertiary otoneurosurgical referral unit between September 1985 and April 1999 were reviewed. The study population, consisting of seven males and eight females, had a mean age of 44 years of age (range 21-69) at the time of surgery. The clinical, audiological and radiological presentations were examined. The tumours were classified according to the Moffat classification of CPA cholesteatomas. In 67 per cent of cases the presenting symptom was related to the vestibulo-cochlear nerve. The average duration of symptoms was 23 months (ranging from one month-10 years). The hearing preservation approaches were utilized the most (11 cases), while the translabyrinthine approach alone, or in association with a middle fossa craniotomy, was performed in four cases. Tumour removal was total in 12 cases and subtotal in three cases. In cases undergoing hearing preservation surgery the mean pre-operative pure tone average (PTA) for the frequencies 0.5, 1, 2, and 3 kHz was 19.3 dB HL (SD 13.84) and the mean pre-operative speech discrimination score (SDS) was 89.8 per cent (SD 5.97). In 44.4 per cent of patients the hearing was preserved and the mean post-operative PTA was 20.29 dB HL (SD 15.84). In five patients post-operative complications occurred. No peri- or post-operative death occurred in this series, one patient developed a recurrence 15 years after the initial surgery.

1. Rea TH, Modlin RL. Leprosy. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller A, Leffell DJ, editors. Fitzpatrick’s Dermatology in General Medicine. New York: McGraw-Hill Professional, 2008. pp. 1786– 1796. 2. Walker SL, Lockwood DN. Leprosy. Clin Dermatol 2007;25:165–172. 3. Armour KS, Scolyer RA, Barnetson RS. Borderline lepromatous leprosy presenting as a single cutaneous plaque. Australas J Dermatol 2005;46:181–183. 4. Shen J, Zhou M, Li W, Yang R, Wang J. Features of leprosy transmission in pocket villages at low endemic situation in China. Indian J Lepr 2010;82:73–78. 5. Liu D, Li G, Huang W, Gao J, Yue C, Xiao Q. Analysis of newly detected Leprosy cases and misdiagnosis in Wuhan (1990–2004). Lepr Rev 2009;80:410–415.Blackwell Publishing LtdOxford, UK

The aim of this paper was to address some of the unanswered questions regarding management of facial nerve paralysis in temporal bone fractures (TBF), such as the outcomes after late facial nerve decompression surgery. The study design was a retrospective review of a consecutive clinical series. Thirteen patients who underwent late decompression surgery for facial nerve paralysis due to TBF involving the perigeniculate ganglion region were analyzed. Patients were operated on 27-90 days after trauma. A transmastoid extralabyrinthine approach was used in all cases. Facial nerve-sheath slitting was performed routinely. Normal or subnormal facial nerve function (HB 1 or HB 2) was achieved in 7/9 cases (78%) evaluated at > or = 1 year after surgery. Good functional results were also obtained in two patients operated on 3 months after trauma. Bases on the outcomes observed in the present series, in patients unable to be operated on early, presenting 1 to 3 months with >95% denervation on EnoG, facial nerve decompression may have a beneficial effect.

We present results at 2 years follow-up of a group of 15 patients with Meniere's disease treated with a low concentration of intratympanic gentamicin (IG group), compared with a group of 15 patients who refused any surgical treatment (NH group). IG was administered according to a predetermined and fixed schedule consisting of 2 doses of 0.5 ml gentamicin solution, pH 7.8, injected once a week, with a drug concentration of 20 mg/ml; the total dose of gentamicin was < or = 20 mg. Additional doses of IG were administered only in patients who had recurrence of vertigo. The results were evaluated following the American Academy of Otolaryngology Head and Neck Surgery 1995 criteria for reporting Meniere's disease treatment results by means of interviews, audiologic and vestibular evaluations, and a questionnaire based on a six-point functional level scale. Seven of the 15 IG patients had recurrence of vertigo after the second injection and received a third dose of IG. Four patients had recurrence of vertigo after the third infiltration; three subjects received a fourth dose and one refused additional injection. At 2 years follow-up, 93% of the IG patients had complete (class A) or substantial (class B) control of vertigo. Only 47% of the NH patients had no vertigo or were substantially improved. Hearing deteriorated in 7% of the IG group and in 40% of the NH group. Tinnitus disappeared or improved in 20% of the IG patients and in 27% of the NH patients; 40% of the IG patients and 27% of the NH patients reported that their aural pressure was abolished. The present study demonstrates that, in patients with Meniere's disease, 0.5 ml doses of gentamicin solution, with a concentration of 20 mg/ml, injected intratympanically once a week minimize the risk of hearing loss in the treated ear, permitting complete control of vertigo in more than half of cases after 2 doses and in almost all subjects (93%) after 4 doses.

The authors describe their experience of the treatment of hemorrhoidal disease using a circular stapler in order to evaluate the effectiveness of this technique.They describe the surgical technique used in a comparative study carried out at Modena Policlinic. A transversal mucohemorrhoidal transection is performed using a circular stapler above the anorectal joint, enabling radical surgery to be completed in a single stage with a rapid and mini-invasive technique. This technique associates the resection of hemorrhoidal nodules and prolapsed mucosa with fixing the residual mucosa to the anal canal and correcting the hypertension and hematic stasis in the venous spaces by breaking the terminal branches of the superior hemorrhoidal artery. Both male and female patients were enrolled in the study, aged over 18 years old, presenting second, third and fourth degree hemorrhoidal prolapse with indications for surgery. The analysis of the long-term follow-up for possible late complications in the 60 selected cases will be reported in a later work.The technique is easy, rapid and causes moderate pain. The postoperative complications are negligible.A hospital stay limited to a few hours, rapid physical recovery and the absence of out-patient treatment required by this surgical technique, which is comparable to an internal closed hemorrhoidectomy, all offer undoubted advantages, also of a psychological and social nature which amply justify the higher economic and management cost linked to the use of a surgical stapler.

The stria vascularis (SV) of 3-, 8- and 18-month-old C57 mice was examined with a fluorescence microscope in order to evaluate the capillary density and vessel diameter. The capillary density was significantly reduced in 18-month-old mice compared to 3-month-old (P

Recent investigations have demonstrated that in animal models repeated exposures to mid-intensity noise induce a progressive reduction of the temporary threshold shift (TTS) following the exposures. This phenomenon is named "conditioning" and it is actually able to reduce the permanent threshold shift (PTS) following exposure to high intensity noise; this finding is named "toughening". In the present work the fundamental steps of the research concerning the toughening are reviewed and the biological mechanisms supposed to be underlying this phenomenon discussed. The few preliminary results of the studies on humans are also reported.

The purpose of this study was to examine the relationship between aging and suprathreshold auditory function in the chinchilla, a rodent with a relatively long life span and a range of hearing similar to that of humans. Subjects were six 11-12-year-old chinchillas and six young controls. Tests of auditory function utilized evoked potential (EVP) recordings from electrodes implanted in the inferior colliculus and measurements of 2f1-f2 distortion product otoacoustic emissions (DPOAEs). Tests of frequency resolution (EVP tuning curves for a 2 kHz probe tone), temporal resolution (EVP forward masking functions using a 2 kHz probe tone), cochlear non-linearity (remote masking), and a DPOAE 'tone challenge', in which DPOAEs at six frequencies were monitored before and after each of five 1-min exposures to a 2 kHz tone at 80 dB SPL, were performed. The results indicate that aged chinchillas can exhibit deficits in suprathreshold tests of auditory function even when the test stimulus is in a region of relatively normal-hearing sensitivity. The results support the notion that aging, independent of hearing loss, can influence suprathreshold auditory function.

Objective To evaluate the clinical features in a large cohort of pediatric patients with genetically confirmed hereditary hemorrhagic telangiectasia (HHT) and to identify possible predictors of arteriovenous malformation (AVM) onset or clinical significance. Study design Prospective cross-sectional survey of all children subjected to screening for AVMs in the multidisciplinary HHT center. All patients proved to be carriers of endoglin mutations or activin A receptor type-II-like kinase 1 mutations, defined as HHT1 and HHT2, respectively. A full clinical-radiological protocol for AVM detection was adopted, independent from presence or absence of AVM-related symptoms. Results Forty-four children (mean age, 10.3 years; range, 1-18) were subjected to a comprehensive clinicalradiologic evaluation. This investigation disclosed cerebrovascular malformations in 7 of 44 cases, pulmonary AVMs in 20 of 44 cases, and liver AVMs in 23 of 44 cases. Large visceral AVMs were found in 12 of 44 children and were significantly more frequent in patients with HHT1. Only large AVMs were associated with symptoms and complications. Conclusions Children with HHT have a high prevalence of AVMs; therefore, an appropriate clinical and radiological screening protocol is advisable. Large AVMs can be associated with complications in childhood, whereas small AVMs probably have no clinical risk. (J Pediatr 2013;163:179-86).

Corrigendum to “Endothelial function and cardiovascular risk in patients with Idiopathic Sudden Sensorineural Hearing Loss” [Atherosclerosis 225 (2) (2012) 511e516] Marco Matteo Ciccone *, Francesca Cortese , Mariangela Pinto , Concetta Di Teo , Fara Fornarelli , Michele Gesualdo , Antonia Mezzina , Evelina Sabatelli , Pietro Scicchitano , Nicola Quaranta b a Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy b Section of Otolaryngology, Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy

Background Several ultramicroscopic studies have confirmed the presence of biofilms in ENT diseases, such as chronic rhinosinusitis, nasal polyposis or adenoid hypertrophy. Recently, it has been reported that light microscopy nasal cytology can identify biofilms, which appear as cyan-stained “Infectious Spots.” Methods Subjects suffering from a wide spectrum of nasal disorders, after a detailed clinical history and ENT examination, underwent nasal fibroendoscopy, skin prick test, rhinomanometry and nasal cytology. Results 1410 subjects were studied. The infectious spot was present in 107 of them (7.6%) patients; this percentage reached 55.4% in 193 patients who had clear cytologic signs of infectious rhinitis. Biofilms were largely more frequent in patients with adenoid hypertrophy (57.4%), followed by nasal polyposis (24%), chronic rhinosinusitis (9.5%) and non-allergic “cellular” rhinitis (7.6%). Nasal cytology was normal in the remaining patients, with no infectous spot detectable. Statistical analysis showed that nasal resistances were significantly higher in presence of biofilms in patients affected by adenoid hypertrophy (P = 0.003), nasal polyposis (P < 0.001), chronic rhinosinusitis (P = 0.018) and septal deviation (P = 0.001). Conclusions The results demonstrate that biofilms are not present only in infectious rhinopathies, but also in inflammatory and/or immune-mediateddiseases. Biofilms were more frequent in patients with higher degree of nasal obstruction as assessed by nasal endoscopy (grade III and IV adenoids and stage-3 polyposis) and rhinomanometry. Nasal cytology, by allowing the identification of biofilms represents a useful diagnostic tool with promising research implications.

SUMMARY Sensorineural hearing loss of immune-mediated origin may be present as a symptom in systemic autoimmune diseases or may occur as a primary disorder without other organ involvement (auto-immune inner ear disease). The diagnosis of auto-immune inner ear disease is still predicated on clinical features and to date specific diagnostic tests are not available. We report a case of right-sided sudden hearing loss in a female patient in which the clinical manifestations, in addition to ANA positivity and hypocomplementaemia allowed us to hypothesize an auto-immune inner ear disease. The immunosuppressive treatment with cyclosporine-A was capable of a recovery of the hearing that, however, occurred progressively with normalization of the hearing function after 1 year of treatment. cyclosporine-A could be proposed as a therapeutic option in case of auto-immune inner ear disease allowing the suspension of corticosteroids that, at high dose, expose patients to potentially serious adverse events.

The concept that autoimmunity may damage the inner ear was introduced by McCabe in 1979. Audiovestibular symptoms may occur in isolation or may be mediated by vasculitis in patients affected by systemic autoimmune disorders. Sensorineural hearing loss (SNHL) is typical in Cogan's syndrome but occurs less frequently in Beçhet's syndrome and in systemic necrotizing vasculitides. Patients affected by immune-mediated profound SNHL represent ideal candidates for cochlear implantation as these patients become deaf after years of hearing. The disease itself and the medication taken may, however, influence the prognosis of cochlear implantation in these patients. We retrospectively evaluated the pre- and intraoperative findings as well as the postoperative course and performance of a group of five patients affected by a systemic vasculitis syndrome who received a cochlear implant. Implantation was successful in all patients, no complications occurred and excellent postoperative speech perception was achieved. We conclude that cochlear implantation in patients affected by immune-mediated inner ear disorders is effective although the long-term results remain to be evaluated.

The purpose of the present study was to evaluate the long-term auditory results in the ears of patients suffering from unilateral Ménière's disease (Md) who had undergone retrolabyrinthine vestibular neurotomy (RVN) associated with endolymphatic sac (ES) surgery. Retrospective evaluation was performed on 45 patients with unilateral Md who had undergone RVN between 1982-1997. All patients had previously been treated with medical therapy for at least 6 months without showing any response. The forms of ES surgery performed were as follows: simple ES decompression (ESD) in 15 patients, chronic endolymphatic mastoid shunt (EMS) using a sylastic sheet in 15 ears and ES exclusion (ESE) of the proximal section in the remaining 15 patients. Evaluation of the results was performed using the parameters indicated by the "Committee on Hearing and Equilibrium"--AAO-HNS 1995. Comparison of the average post-operative and preoperative PTAs revealed a worsening of 9.2 dB (sd: +/- 17.1) in the ESE group. This variation was statistically significant (p0.05). When the individual patients were evaluated, the PTA remained unchanged in 10 cases (67%) in the ESD group, in 13 (87%) in the EMS group and in 10 (67%) in the ESE group. In no case did hearing improve. Statistical analysis did not reveal any significant difference between the three groups of patients. Tinnitus, present prior to surgery in all patients, disappeared or improved in 6 patients (40%) in the ESD group, in 6 (40%) of the EMS group and in 5 (33%) of the ESE group. The differences between groups were not significant. The sensation of plugged ears, present prior to surgery in 11 patients in the ESD and EMS groups and in 13 patients in the ESE group disappeared or improved respectively in 9 (82%), 10 (91) and 11 (85%) of the patients. The 10 remaining patients who did not have the sensation of plugged ears prior to surgery did not refer its appearance after surgery. Again for this symptom the difference between groups was not significant. The results of this research would appear to indicate that in patients with Md, evolution of the hearing symptoms observed after RVN can be improved by applying an EMS. This finding must be validated in a larger sampling.

We describe a unique case of an intracranial extension of acquired cholesteatoma. Previous reports have described cholesteatoma extension through the middle fossa plate and into the middle cranial fossa, but to our knowledge ours is the first report of a case in which the sac herniated into the temporal lobe and overlying dura from a site far lateral to the otic capsule. The findings on magnetic resonance imaging were most unusual, and we call the radiologic characteristics of the mass in this case the “billiard pocket sign.” We also discuss the possible mechanisms that produced such an image.

Proximal pharyngolaryngeal reflux now appears to be strictly related to symptoms and clinical patterns frequently encountered in clinical ORL practice and which are, more often than not, differentiated from classical gastro-oesophageal reflux disease. The aim of the study was to evaluate the incidence of the symptoms and clinical signs of gastro-oesophageal reflux disease, together with the symptomatologic response to a cycle of acid suppression treatment with proton pump inhibitors in a non-selected population comprising consecutive patients coming to the outpatient unit of the Laryngology Clinic of Università Cattolica of Rome between June and December 2001, all of whom had been examined by the same practitioner. Of the 1300 patients evaluated, 52 presented a clinical history and chronic pharyngolaryngeal symptoms strongly indicative of gastro-oesophageal reflux disease. All selected patients were prescribed a two-month regimen of acid suppression therapy (20 mg Omeprazole twice daily, sufficient to confirm the clinical suspicion of pharyngolaryngeal reflux ex adiuvantibus (Omeprazole test), at the same time obtaining a satisfactory response in the symptomatology, as laid out in the guidelines emerging from the 1997 Consensus Conference Report on pharyngolaryngeal reflux. The same patients were later interviewed by telephone to evaluate the effectiveness of treatment, exclusively in terms of improvement in the symptoms. Analysis of the data from the 33 who answered the telephone questionnaire revealed a complete symptomatological response in 24 (72.7%), partial response in 4 (12.1%) and no response in 5. The Authors stress that, despite the known limits of this treatment, linked to proton pump inhibitors resistance, the "Omeprazole test", on account of excellent tolerability, lack of adverse effects and, above all, non-invasive nature, is feasible in the preliminary evaluation to confirm clinical suspicion of gastro-oesophageal reflux disease in outpatients, especially when a large-scale pH-metric multielectrode investigation is not possible. Furthermore, despite the many epidemiological, aetiopathogenetic, clinico-diagnostic and therapeutic aspects which remain to be clarified, there is no doubt that gastro-oesophageal reflux disease on account of the particular clinical features, directly involves the ORL specialist not only in the diagnostic, but also in the therapeutic phase.

Flexible fibroscopy is the method of choice in the diagnosis of upper airway (UA) pathologies. Some Authors believe that it should be carried out under local anaesthesia even in children less than one year of age. In this article, the Authors report on their experience with general anaesthesia, using an airway mask that simultaneously allows the flexible endoscope to be inserted and the patient to be ventilated. The study was carried out in the period 2000-2001 in 32 subjects, 18 males and 14 females between 2 and 12 months of age who presented different degrees of stridor and dyspnoea. 18 patients were affected by laryngomalacia, 6 presented bilateral paralysis of the vocal cords, 3 had a paralysis of the left vocal cord, 3 were suffering from congenital anomalies of the epiglottis and 2 had normal larynx from the point of view of morphology and motility. The method described is easy to perform and allows the subglottid area to be carefully evaluated, prolonging, if necessary, procedure time without risking hypoventilation-induced hypoxemia; carrying out the examination on a sedated patient furthermore reduces the likelihood of complications. The Authors therefore recommend that in all infants under one year of age, endoscopy of the upper airways be effected under general anaesthesia with an airway mask, reserving the execution of the same procedure under local anaesthesia to cases involving older children.

Vestibular examination relied upon electronystagmography (ENG) for more than 50 years. This method is based on recording of nystagmus (Ny) without any possibility to see the ocular movements directly. More recently, infrared videonystagmography (VNG) entered the diagnostic protocol of vestibular disorders. VNG permits to record and visualize Ny, both in the darkness and with open eyes. Aim of the present study was to verify the possible advantages of VNG versus ENG for functional evaluation of the vestibular system in patients suffering from otoneurological disorders. To that purpose, VNG and ENG tracings were recorded in 12 patients. The preliminary results show that there are not significant differences in quantitative evaluation of Ny between the two methods. Anyhow, VNG has some technical and clinical advantages that make it the method of choice.

Efficacy of the SPEAK and ACE coding strategies was compared with that of a new strategy, MP3000™, by 37 European implant centers including 221 subjects. The SPEAK and ACE strategies are based on selection of 8-10 spectral components with the highest levels, while MP3000 is based on the selection of only 4-6 components, with the highest levels relative to an estimate of the spread of masking. The pulse rate per component was fixed. No significant difference was found for the speech scores and for coding preference between the SPEAK/ACE and MP3000 strategies. Battery life was 24% longer for the MP3000 strategy. With MP3000 the best results were found for a selection of six components. In addition, the best results were found for a masking function with a low-frequency slope of 50 dB/Bark and a high-frequency slope of 37 dB/Bark (50/37) as compared to the other combinations examined of 40/30 and 20/15 dB/Bark. The best results found for the steepest slopes do not seem to agree with current estimates of the spread of masking in electrical stimulation. Future research might reveal if performance with respect to SPEAK/ACE can be enhanced by increasing the number of channels in MP3000 beyond 4-6 and it should shed more light on the optimum steepness of the slopes of the masking functions applied in MP3000.

The present work provides clinical-functional findings, results and surgical complications observed in a consecutive series of 100 subjects with acoustic neuroma (AN). Analysis of the data has made it possible to draw some important conclusions. Compromised hearing is found in 90% of the ears affected by AN. Indeed the percentage of normal hearing in such cases does not exceed 5%. There is, however, no clear correlation between degree of hearing and tumor size. The symptoms of AN do not always present unilateral or asymmetrical hearing loss, unilateral tinnitus and/or dizziness. At times AN presents atypical symptoms and can even be asymptomatic. Sudden onset of unilateral hearing loss, acute vertigo, persistent monolateral tinnitus and even isolated symptoms of the V or VI cranial nerve should lead one to suspect AN. Only by applying the diagnosis of suspected AN in a large number of cases is it possible to lower the time gap between the onset of symptoms and the definitive diagnosis of AN, increasing the number of cases diagnosed while the AN is still small. Auditory brainstem responses (ABR) are still the means of choice for screening and following up subjects where AN is suspected. Reduced ABR sensitivity reported in the literature for intracanal ANs must induce further testing with magnetic resonance imaging with gadolinium in all subjects where an AN is suspected, even when the ABR is normal. Recording of transient evoked otoacoustic emissions in the presence and in the absence of contralateral white noise has proved to be a simple, inexpensive, non-invasive test for the diagnosis of suspected retrocochlear pathologies. A deficit in vestibular function is most frequently encountered when the AN is already quite large and an alteration in the smooth pursuit test is only found when the AN involves the brainstem. These data have led us to conclude that vestibular reflex studies do not play any role in early diagnosis of AN. Surgical exeresis is the treatment of choice in those cases where "watch and scan" (only hearing ear in the absence of neurological complications; AN0.5 cm in the ponto-cerebellar angle, particularly in elderly patients) is not indicated. The enlarged translabyrinthine approach is indicated in all cases of AN, no matter what the tumor size and extent of pre-operative hearing. Promptly and correctly treating intra and postoperative complications, most frequently encountered in patients with AN2 cm, reduces the mortality and morbidity to a minimum. Modern otological microsurgery and monitoring techniques make it possible to preserve the VIIth facial nerve in more than 90% of the ears, consequently preserving or nearly preserving normal VIIth nerve function 1 year after surgery in at least three out of four patients. No matter what approach is used, hearing can be preserved measurably in approximately 50% of the ears undergoing surgery and to a socially useful or nearly useful level in a significantly lower proportion of patients. In this regard the most satisfactory results are obtained when preoperative hearing is normal and the AN is2 cm.

SUMMARY The aim of this systematic review was to summarize the results of scientific publications on the clinical effectiveness of the cochlear implant (CI) procedure in adults. The members of the Working Group first examined existing research evidence from the national and international literature and main international guidelines. They considered as universally accepted the usefulness/effectiveness of unilateral cochlear implantation in severelyprofoundly adult patients. Accordingly, they focused their attention on the systematic reviews addressing clinical effectiveness and cost/efficacy of CI procedures, with particular regard to the most controversial issues for which international consensus is still lacking. The following aspects were evaluated: monolateral CI in advanced-age adult patients; bilateral (simultaneous/sequential) CI vs. unilateral CI and vs. bimodal stimulation; benefits derived from the monolateral CI procedure in adult patients with prelingual deafness. With regard to CI in elderly patients, the selected studies document an improvement of the quality of life and perceptive abilities after CI, even if the benefits were found to be inferior in patients over 70 years at the time of surgery. Thus, from the results of the studies included in the review, advanced age is not a contraindication for the CI procedure. With respect to unilateral CI, bilateral CI offers advantages in hearing in noise, in sound localization and less during hearing in a silent environment. However, high interindividual variability is reported in terms of benefits from the second implant. With regard to CI in prelingually deaf adults, the selected studies document benefits deriving from the CI procedure in terms of improvement of perceptive abilities and in the quality of life after CI, as well as subjectively perceived benefits. However, there is high interindividual variability and the study sample is limited.

The association between hearing impairment, the diagnosis of dementia, and the role of sensory therapy has been proposed for some time, but further research is needed. Current understanding of this association requires the commitment of those experts who can integrate experience and research from several fields to be able to understand the link from hearing to dementia. A workshop whose panelists included experts from many areas, ranging from ear, nose and throat (ENT) to dementia's specialists, was promoted and organized by the Giovanni Lorenzini Medical Science Foundation (Milan, Italy; Houston, TX, USA) to increase the awareness of the relationship between hearing loss and dementia, and included questions and comments following a presentation from the clinical researcher, Frank Lin, who has been evaluating the relationship between hearing loss and cognitive decline since 2009.