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Purpose Stapes surgery, despite the introduction of lasers and endoscopes, still represents a challenging procedure. Recently introduced 3-dimensional exoscopes have known advantages in otological surgery. This study aims to evaluate exoscopes role in stapes surgery, both from a surgical perspective and on the educational profile. Methods Seven consecutive otosclerosis patients underwent single-sided endaural laser stapedotomy with a 4K 3-dimensional exoscope. The surgical setting allowed all operating room personnel 3-dimensional vision. Pre- and postoperative pure tone audiometry and air-bone gaps, and information on the postoperative course and complications were systematically collected. An informal ergonomic evaluation was carried out by the operating room personnel and an informal didactic evaluation was provided by the trainees. A comparable group of microscope-assisted stapedotomy patients undergoing the same procedures and evaluations was chosen as a control group. Results Outcomes were solid in all patients, median air-bone gap decreased from 26.5 to 10 dB at the 3-month evaluation (p = 0.01, Wilcoxon’s test). No vertigo, tinnitus, or facial palsy was reported. The median operating time was 40 min. The compact design and configuration of the exoscope allowed more practical management of the operating theater. All personnel had the chance for a better understanding of the procedure and trainees felt more confident when asked to identify surgical landmarks and procedure steps. Audiological outcomes, operative times, and complication rates were not different between study and control groups. Conclusion Though further validation and systematic comparison with microscope- and endoscope-assisted stapedotomy are required, the exoscope proved a safe, practical, and educational tool.

Purpose Loss of smell decreases the quality of life and contributes to the failure in recognizing hazardous substances. Given the relevance of olfaction in daily life, it is important to recognize an undiagnosed olfactory dysfunction to prevent these possible complications. Up to now, the prevalence of smell disorders in Italy is unknown due to a lack of epidemiological studies. Hence, the primary aim of this study was to evaluate the prevalence of olfactory dysfunction in a sample of Italian adults. Methods Six hundred and thirty-three participants (347 woman and 286 men; mean age 44.9 years, SD 17.3, age range 18–86) were recruited from 10 distinct Italian regions. Participants were recruited using a convenience sapling and were divided into six different age groups: 18–29 years (N = 157), 30–39 years (N = 129), 40–49 years (N = 99), 50–59 years (N = 106), > 60 years (N = 142). Olfactory function, cognitive abilities, cognitive reserve, and depression were assessed, respectively, with: Sniffin’ Sticks 16-item Odor Identification Test, Montreal Cognitive Assessment, Cognitive Reserve Index, and the Beck Depression Inventory. Additionally, socio-demographic data, medical history, and health-related lifestyle information were collected. Results About 27% of participants showed an odor identification score Conclusion This study provides data on the prevalence of olfactory dysfunction in different Italian regions.

Giant Cell Arteritis (GCA), or Horton’s Arteritis, is a chronic form of vasculitis of the large and medium vessels, especially involving the extracranial branches of the carotid arteries, in particular, the temporal artery, with the involvement of the axillary, femoral and iliac arteries too. Arterial wall inflammation leads to luminal occlusion and tissue ischemia, which is responsible for the clinical manifestations of the disease. : A substantial number of patients affected by GCA present head and neck symptoms, including ocular, neurological and otorhinolaryngological manifestations. : The aim of this article is to present pathogenesis, clinical aspects and treatment approaches of GCA manifestations.

Introduction:To our knowledge, few papers have addressed preoperative evaluation of the impact of adenoid hypertrophy (AH) on the pathogenesis of eustachian tube dysfunction (ETD) in children with otitis media with effusion (OME).Aim:The aim of this study was 2-fold: first, to evaluate ETD using tubomanometry and Eustachian Tube Score 7 (ETS-7), in a group of children having AH; second, to assess the clinical impact of adenoidectomy on the ETD of these patients.Methods:Fifty patients, aged 4 to 15 years, underwent adenoidectomy based on various parameters: size of the adenoids causing canal obstruction (grades 1-4), the presence of OME, and recurrent episodes of rhinosinusitis. The function of the eustachian tube was evaluated using ETS-7 before and after surgical treatment. The patients were followed up for 6 months.Results:Forty children presented ETD. Of these, 36 had a grade 4 AH. The preoperative mean value for ETS-7 was 6.62. The mean postoperative ETS-7 score showed a value of 9.60 with a statistical difference compared to the preoperative value ( P = .0015).Conclusions:Adenoid hypertrophy has a high impact on the frequency of ETD. In the patients observed in the present study, the ETS-7 score appeared to be a valid tool for assessing ETD both preoperatively and postoperatively. Adenoidectomy seemed to be effective in improving ETD as well as middle ear ventilation.

Purpose Laryngopharyngeal reflux (LPR) is a frequent condition in Obstructive Sleep Apnoea (OSA) patients and different studies have been published in the last years about this topic. A review of the published literature regarding LPR in OSA patients has been reported. A meta-analysis to evaluate the incidence of LPR in OSA patients and correlate LPR positivity with OSA patients' characteristics has been performed. Methods A comprehensive review of the English language literature about LPR in OSA patients was performed using the most important electronic databases (PubMed, EMBASE, the Cochrane Library etc.). A total of 10 papers studying LPR in OSA were assessed and considered eligible for the meta-analysis. Results The data analysis regarding 870 identified OSA patients showed that 394 patients were LPR +, while 476 were LPR-. The meta-analysis showed no statistical difference regarding the AHI value between LPR + patients and LPR- patients (p = 0,3). Mean BMI was more higher in LPR + patients than in the patients without LPR, showing a significant statistical difference (p = 0.001). Conclusion Current international literature demonstrates a high incidence of LPR (45.2%) in OSA patients. The severity of AHI in OSA patients would not seem to correlate with the presence of laryngopharyngeal reflux. The OSA patients with LPR showed a higher BMI compared with LPR- patients.

The sense of smell has a high impact on the quality of life. The aim of the present study was to investigate olfactory dysfunction in patients with obstructive sleep apnoea syndrome (OSAS) and correlate the severity of disease with olfactory dysfunction. The relationships between nasal obstruction, nasal mucociliary cleareance and olfactory tests were also evaluated. Sixty patients with a diagnosis of OSAS were enrolled and underwent olfactory function evaluation. In all patients olfactory performance was tested with the Sniffin' Sticks method. Mucociliary transport times and anterior rhinomanometry were performed to identify eventual nasal obstruction and deficits in nasal mucociliary clearance. Olfactory dysfunction was present in 22 (36.6%) patients of the study group: of these, hyposmia was present in 19 (86.4%) and anosmia in 3 (13.6%). The mean TDI score in the study group was 30. A strong correlation between the olfactory dysfunction and severity of sleep apnoea measured using the AHI was found. Patients with OSA would seem to have a high incidence of olfactory dysfunction. The degree of olfactory dysfunction appears to be related to the severity of disease. However, other co-factors such as nasal obstruction and reduced mucociliary clearance might also play a role in of the aetiology of this condition.Valutazione olfattiva di pazienti affetti da sindrome delle apnee ostruttive del sonno.Il senso dell’olfatto ha un alto impatto sulla qualità della vita. Lo scopo di questo studio è stato quello di investigare la disfunzione olfattiva in pazienti con sindrome delle apnee ostruttive del sonno (OSA) e correlare la gravità della malattia con la perdita di olfatto. Inoltre, è stata valutata la relazione esistente tra ostruzione nasale, cleareance mucociliare nasale e i risultati dei test olfattivi. Sessanta pazienti con diagnosi di OSA sono stati arruolati in questo studio e hanno eseguito una valutazione olfattiva. In tutti i pazienti la valutazione olfattiva è stata eseguita attraverso lo Sniffin’ Sticks test. Il tempo di trasporto mucociliare e una rinomanometria anteriore sono stati eseguiti per identificare una possibile ostruzione nasale e un deficit nella cleareance mucociliare. Una disfunzione olfattiva era presente in 22 (36,6%) pazienti dello studio. In questi pazienti con disfunzione olfattiva l’iposmia era presente in 19 (86,4%) casi e l’anosmia in 3 (13,6%) casi. Il TDI medio del gruppo di studio presentava uno score di 30. Si è riscontrata una correlazione statistica tra la disfunzione olfattiva e la severità delle apnee notture misurata con AHI. I pazienti con OSA sembrerebbero avere un’alta incidenza di disfunzione olfattiva. Il grado di disfunzione olfattiva sembrerebbe essere correlato alla gravità della malattia. Tuttavia, altri fattori come una ostruzione nasale e una ridotta cleareance mucociliare sembrerebbero avere un ruolo nell’eziologia di questa condizione.

Objectives/hypothesis The purpose of the present study was to show our preliminary results regarding the endoscopic ear surgery application in malleostapedotomy surgery. Study design Case series. Methods Six patients (four females and two males) who underwent endoscopic ear surgery as revision surgery for otosclerosis were enrolled in this study. For endoscopic malleostapedotomy surgery, rigid angled endoscopes at 0 ° and 30 ° with a length of 14 cm and an outer diameter of 3 and 4 mm were used. A superelastic nitinol stapes prosthesis was used to connect the malleus neck to the oval window. Results During endoscopic ear surgery, a lateral ossicular chain fixation was present in all cases. The mean operative time in the study group was 81 minutes (range, 73-89 minutes). A statistically significant difference between preoperative and postoperative hearing findings was observed (P = .007). No cases of sensorineural hearing loss or persistent vertigo were observed in the study sample. No cases of prosthesis displacement or prosthesis extrusion occurred after a mean follow-up of 11.5 months. Conclusions In 100% of treated cases, the endoscope proved to be adequate for the visualization of the malleus handle and incus, and of their possible abnormalities. Despite the difficulty related to endoscopic single-handed work, none of the surgical steps of endoscopic malleostapedotomy were considered not feasible by endoscopic ear surgery. Level of evidence 4. Laryngoscope, 2611-2614, 2018.

The aim of the study is to evaluate the Eustachian tube functionality in a group of aviators to underline a subclinical dysfunction and the related risk of ear fullness or barotitis. Hypobaric chamber allows to simulate the pressure variation of the flight. This prospective study enrolled 42 aviation pilots, members of the Italian Air Force, to whom were evaluated Eustachian tube functionality by Tubomanometry, patients subjective assessments concerning feasibility of Valsalva's and Toynbee's clinical symptoms, tympanometry, and objective Valsalva before and after exposure to hypobaric chamber. The new Eustachian tube score (ETS-7) was also calculated for each pilot before and after exposure to hypobaric chamber. Results of our examination showed that: before chamber exposition, in 92.8 % of pilots, an ETS-7 of eight or more was found bilaterally. In three (7.2 %) cases, a unilateral ETS-7 ≤ 7 was found and two of those had a positive history. After undergoing the hypobaric chamber session, the evaluation of ETS-7 showed only 19 % of pilots with an ETD score ≤7, in particular three bilateral and five unilateral cases. Three of those pilots were clinically positive: two airmen reported persistent fullness, while the other one had a barotitis. Therefore, the combined use of TMM and ETS-7 before and after hypobaric chamber exposure appears to be a reliable method for assessing the functional capacity of the Eustachian tube in aviators, the stressful effect of flight on it, to exclude subjects at increased risk of ear pain, fullness, or barotrauma.

Granulomatosis with polyangiitis (GPA) is an autoimmune systemic necrotizing small-vessel vasculitis associated with the presence of anti-neutrophil cytoplasmic antibodies (ANCA). Oto-neurological manifestations of ANCA-associated vasculitis according to PR3-ANCA positivity and MPO-ANCA positivity are usually reported. Facial nerve palsy is usually reported during the clinical course of the disease but it might appear as the presenting sign of GPA. Necrotizing vasculitis of the facial nerve 'vasa nervorum' is nowadays the most widely accepted etiopathogenetic theory to explain facial damage in GPA patients. A central role for PR3-ANCA in the pathophysiology of vasculitis in GPA patients with oto-neurological manifestation is reported. GPA requires prompt, effective management of the acute and chronic manifestations. Once the diagnosis of GPA has been established, clinicians should devise an appropriate treatment strategy for each individual patient, based on current clinical evidence, treatment guidelines and recommendations.

Vitiligo is a common chronic acquired disease of pigmentation whose etiology is unknown, which usually occurs with asymptomatic whitish patch or macule. Although several hypotheses have been proposed in the literature, the leading theory is still the auto-immune etiology linked to specific genetic mutations. Vitiligo can also be associated with several autoimmune diseases, including autoimmune thyroid diseases, alopecia areata, and halo nevi. Sensorineural hearing loss was reported in several vitiligo patients due to a reduction in the number of melanocytes contained in the membranous labyrinth of the inner ear. Because of its complexity, several therapeutic options are available to treat this systemic disease.

Common variable immunodeficiency (CVID) represents the most frequent primary immunodeficiency, often encountered in the ENT clinical practice. The clinical spectrum of CVID is quite broad, but otitis media are certainly among the most common clinical manifestations. This prospective study enrolled 60 patients (34 males, 26 females) with a previous diagnosis of CVID with the aim of performing an otologic evaluation and a more precision characterization of incidence, diagnosis, and treatment of otitis media in this group of patients. In consideration that Eustachian tube dysfunction (ETD) could be the 'primum movens' of otitis media, we wanted to assess whether a Eustachian tube dysfunction was present in these patients. Besides, we propose a possible diagnostic algorithm of middle ear pathologies to use in all cases of primary antibody deficiency patients. Results of our otologic examination showed that: 5 % of patients had chronic suppurative otitis media, 25 % bilateral otitis media with effusion and 10 % reported unilateral OME with associated contralateral ETD. There was bilateral isolated ETD and unilateral isolated ETD in 5 and 15 % of patients, respectively. All patients with unilateral OME had associated contralateral ETD. Finally, 40 % of patients were bilaterally negative at otoscopic examination and all otologic tests.

Patologie nasali in pazienti affetti da syndrome delle apnee ostruttive del sonno.L’ostruzione nasale è una condizione frequentemente riportata in pazienti con sindrome delle apnee ostruttive del sonno (OSAS). L’ostruzione nasale porta alla respirazione orale, che si pensa possa destabilizzare le vie aeree superiori e aggravare l’OSAS. Tre condizioni potrebbero essere considerate come la causa dell’ostruzione respiratoria nasale: condizioni anatomiche nasali (deviazione del setto, ipertrofia dei turbinati inferiori), rinosinusite cronica (CRS) e infiammazione nasale cronica causata da rinite allergica o riniti non allergiche a cellularità. In questo studio prospettico presentiamo una valutazione di tutti questi possibili aspetti naso-sinusali in pazienti con OSAS al fine di correlare le diverse patologie nasali con l’ostruzione respiratoria nasale. Cinquanta pazienti con una diagnosi di OSAS sono stati arruolati nello studio. Nel 70% dei pazienti con OSAS, l’ostruzione nasale è stata confermata dalla valutazione clinica e dal test della respirazione con rinomanometria. Normali aspetti naso-sinusali erano presenti solo nel 20% dei pazienti con OSAS, mentre una o più condizioni patologiche naso-sinusali erano presenti nel restante 80%. L’incidenza di pazienti con OSAS con una diagnosi di rinite allergica e rinite non allergica era rispettivamente del 18% e del 26%. La rinite non allergica con neutrofili (NARNE) è stata la diagnosi più frequente nei pazienti con OSAS (20% dei casi). I risultati del presente studio supportano ed estendono l’osservazione che condizioni rinitiche sono presenti nei pazienti con OSAS. L’infiammazione della mucosa causata da queste condizioni potrebbe essere la causa della compromissione delle vie aeree superiori inducendo edema della mucosa nasale.Nasal obstruction is a frequent condition in patients with obstructive sleep apnoea (OSA). Nasal obstruction leads to mouth breathing, which is thought to destabilise the upper airway and aggravate the condition. Three conditions could be considered as the cause of the nasal breathing obstruction: anatomical conditions of the nose (septum deviation, hypertrophy of the inferior turbinates), chronic rhinosinusitis (CRS) and chronic nasal inflammation caused by allergic rhinitis or non-allergic cellular rhinitis. In this prospective study, we present an evaluation of all these possible rhino-sinusal aspects in OSA patients to correlate different nasal pathologies with nasal obstruction. Fifty patients with a diagnosis of OSA were enrolled in the study. In 70% of OSA patients, nasal obstruction was confirmed by clinical evaluation and rhinomanometry testing. Normal rhino-sinus aspects were present in only 20% of OSA patients, whereas one or more pathological rhino-sinus conditions were present in the remaining 80%. The percentage of OSA patients with a diagnosis of allergic rhinitis and non-allergic rhinitis was 18% and 26% respectively. Non-allergic rhinitis with neutrophils (NARNE) was the most frequent type of cellular rhinitis diagnosed in OSA patients (20% of cases). The results of the present study support and extend the observation that rhinitis is present in OSA patients. Mucosal inflammation caused by these conditions could be the cause of upper airway patency impairment inducing nasal mucosa swelling.

Objectives Investigate the presence of Eustachian Tube Dysfunction (ETD) in Obstructive sleep apnea (OSA) patients. Correlate the ET function and the severity of the sleep apnea syndrome. Correlate nasal resistance and nasal mucociliary clearance with the onset of ETD in these patients. Materials and methods Forty patients affected by OSA were enrolled in our clinical prospective study. Thirty patients were also investigated as a control group. All of the analyzed subjects underwent ENT examination, anterior rhinomanometry and test for mucociliary transport time. To evaluate Eustachian tube function the Eustachian tube score-7 (ETS-7) were employed. Results Twenty percent of the patients with a diagnosis of OSA had a diagnosis of ETD (ETS-7 ≤ 7) with a statistical difference with control group (p = .03). No differences regarding ETD in OSA sub-groups were found. Conclusion This study showed that ET blockage or delayed openings were found in most adult patients with OSA when evaluated by a sensible score as the ETS-7. Our data suggest that an evaluation of the Eustachian tube function should be performed in patients suffering from obstructive sleep apnea syndrome.

To evaluate olfactory function and clinical-neurological characteristics in a group of patients with mild head trauma.A total of 352 patients with MTBI underwent olfactory function evaluation. The site of head trauma, loss of consciousness20 min, memory loss, subjective presence or absence of olfaction and other clinical, neurological and radiological aspects were evaluated and compared with the olfactory dysfunction.A total of 33.5% patients enrolled in the study had an olfactory dysfunction. Eighty-seven percent of the patients had a diagnosis of anosmia whereas 13% had a diagnosis of hyposmia. Statistical analysis did not show a correlation between radiologically detected head lesions and different types of olfactory dysfunction (p 0.05). Besides, no difference between head lesion site and different olfactory dysfunction was reported (p = 0.5). Regarding olfactory sub-tests a low detection threshold was present in these patients.The possibility of olfactory dysfunction should be considered in any case of MTBI appears differently than expected, a minor head injury causes anosmia much more frequently than hyposmia.

The hypothesis that the close contiguity between the cholesterol granulomas and some rich blood sources provided the trigger to the aggressive nature of tympanomastoid cholesterol granulomas has been recently reported. To corroborate this new etiopathogenetic theory we retrospectively reviewed a series of 14 patients with primary middle ear and mastoid cholesterol granulomas and investigated the temporal bone marrow invasion and its hematopoietic potentialities and a possible cholesterol granulomas contiguity with relevant vascular structures such as the carotid artery, sigmoid jugular system, mastoid or dural vein. Eight cases did not show radiological sign of bone marrow invasion or hematopoietic potentialities visible in MRI. Besides no intraoperative vascular connections that could explain an initial bleeding source were found. Cholesterol granulomas bone marrow invasion was present in six patients. A bone marrow hematopoietic potentiality was showed in four of these patients, whereas, an evident anatomical contiguity of the cholesterol granuloma with some important temporal bone vascular structures was visible in five cases. Analysis of cardiovascular risk factors showed that four patients presented one or more of the risk factors analysed.

Objective Comparing the endoscopic and microscopic approaches in stapes surgery, and establishing the surgical approach that allows better results in terms of visualization of the middle ear structures and aids assistant's training. Materials and methods Twenty-one residents from the first to the fifth year of training in Otolaryngology were enrolled in this prospective study. A questionnaire specifically designed to investigate the understanding of middle ear anatomy, the surgical steps, and a personal opinion about endoscopic stapes surgery was submitted to each resident. Results Statistical differences between the endoscopic and microscopic approaches were evident about identification of stapes and long process of the incus (p=0.03) and stapes footplate and the oval window (p=0.03). No substantial difference between the two surgical approaches emerged regarding the visualization of the tympanic membrane and the other middle ear structures (p>0.5). A substantial difference in favor of the endoscopic approach emerged regarding the identification of the hole creation in the footplate of the stapes. Conclusion Endoscopic stapes surgery could favor an easier understanding of the surgical technique for assistants in training with little knowledge of the anatomy and surgical steps.

Purpose The aim of this study was to compare the postoperative clinical and radiological data of patients with vestibular schwannomas who were initially managed by near total resection (NTR) or subtotal resection (STR). The Ki-67 analysis results were compared with tumor regrowth to determine the presence of a correlation between this proliferative index and postoperative tumor regrowth. Study Design Seventeen adult patients (7 male, 10 female) were retrospectively reviewed. Nine (52.9%) and eight (47.1%) patients underwent NTR and STR, respectively. Postoperative clinical and radiological data associated with vestibular schwannoma growth were compared with the Ki-67 immunohistochemical analysis results. Results Evidence of clinically significant regrowth was observed in four (23.5%) patients. Patients who underwent NTR had a lower rate/incidence of tumor regrowth than did patients who underwent STR. Patients with a higher Ki-67 index had the highest tumor regrowth rates. Conclusions Our study indicates that assessment of the Ki-67 index may be useful for determining the probability of regrowth of vestibular schwannomas when only partial removal is accomplished.

Cerebrospinal fluid (CSF) leakage of the temporal bone region is defined as abnormal communications between the subarachnoidal space and the air-containing spaces of the temporal bone. CSF leak remains one of the most frequent complications after VS surgery. Radiotherapy is considered a predisposing factor for development of temporal bone CSF leak because it may impair dural repair mechanisms, thus causing inadequate dural sealing. The authors describe the case of a 47-year-old man with a massive effusion of CSF which extended from the posterior and lateral skull base to the first cervical vertebrae; this complication appeared after a partial enucleation of a vestibular schwannoma (VS) with subsequent radiation treatment and second operation with total VS resection.