ESPLORAZIONE CLINICA E MORFO-FUNZIONALE DEL PAZIENTE CON IPOACUSIA IMPROVVISA

ESPLORAZIONE CLINICA E MORFO-FUNZIONALE DEL PAZIENTE CON IPOACUSIA IMPROVVISA L’ipoacusia improvvisa (Sudden SensoriNeural Hearing Loss - SSNHL) è un segno indiretto di danno cocleare secondario a cause sconosciute e viene definita come una perdita neurosensoriale di almeno 30 dB, che colpisce almeno 3 frequenze contigue e che si sviluppa in un arco di tempo compreso tra le poche ore ed i 3 giorni. La causa della SSNHL rimane sconosciuta in oltre il 90% dei casi; le ipotesi eziologiche elaborate in merito sono molte, ma le principali sono quella virale, quella vascolare, quella legata alla rottura delle membrane labirintiche e la causa auto-immunitaria. La RM ha assunto un ruolo diagnostico sempre maggiore nel corso degli ultimi anni, anche grazie all’introduzione di macchine a più elevata risoluzione (3T versus 1,5T), l’applicazione di nuove sequenze (3D-FLAIR) e lo studio attento del significato del mezzo di contrasto (gadolinio), che hanno permesso di incrementare l’accuratezza diagnostica anche nei confronti di lesioni intra-cocleari fino ad ora raramente visualizzate, quali l’emorragia cocleare o la rottura delle membrane labirintiche. Forniamo la nostra esperienza relativa a 23 pazienti con SSNHL, studiati secondo un protocollo unificato, in cui è stato valutato più approfonditamente il ruolo della RM 3D-FLAIR come elemento diagnostico e prognostico. In un piccolo sottogruppo di pazienti, l’analisi si è incentrata anche sulla ricerca di autoanticorpi contro la coclina per lo studio del ruolo dell’auto-immunità nella patogenesi della SSNHL. La RM 3D-FLAIR fornisce elementi interessanti dal punto di vista diagnostico (alta correlazione sede-clinica, alta correlazione danno-segnale RM); i nostri dati si inseriscono in modo congruo nella letteratura esistente sull’argomento. Lo studio degli autoanticorpi contro la coclina rappresenta una via di ricerca in via di sviluppo molto promettente, da applicare in tutti i pazienti con ipoacusia, ed in particolare ai pazienti con SSNHL

Role of perfusion CT in the evaluation of functional primary tumour response after radiochemotherapy in head and neck cancer: Preliminary findings

Objective: To report the initial results of a prospective study aimed at evaluating the CT perfusion parameter changes (ΔPCTp) of the primary tumour after radiochemotherapy (RCT) in head and neck cancer (HNC) and to correlate with positron emission tomography (PET)/CT response. Methods: Eligibility criteria included HNC (Stage III-IV) candidates for RCT. Patients underwent perfusion CT (PCT) at baseline and at 3 weeks and 3 months after treatment. Blood volume, blood flow, mean transit time (MTT) and permeability surface (PS) product were computed. Moreover, PET/CT was performed at baseline and 3 months after treatment. The ΔPCTp were evaluated between baseline and 3-week/3-month evaluations, whereas PET/CT response was based on the maximum standardized uptake value changes according to the European Organization for Research and Treatment of Cancer criteria. Results: Between July 2012 and July 2015, 25 patients were enrolled. A significant reduction of all CT tumour perfusion parameters (PCTp) was observed from the baseline to after RCT (p<0.001). Specifically, a significant reduction was shown at 3 weeks for all PCTp except MTT (from 6.18 to 5.14s; p=0.722). Differently, a significant reduction of all PCTp (p<0.001) including MTT (from 6.18 to 2.24s; p=0.001) was shown at 3 months. Moreover, the reduction of PS resulted in a significant prediction of PET/CT response at 3 months (p=0.037) with the trend also at 3 weeks (p=0.099) at the multivariate analysis. Conclusion: Our preliminary findings seem to show that almost all PCTp are significantly reduced after RCT, whereas PS seems to come out as the strongest factor in predicting the PET/CT response. Advances in knowledge: This article provides information on the potential useful role of PCT in evaluating tumour response after both early and late RCT

Mepolizumab for chronic rhinosinusitis with nasal polyps (SYNAPSE): in-depth sinus surgery analysis

Background: Patients with severe chronic rhinosinusitis with nasal polyps (CRSwNP) often require repeat sinus surgery. Mepolizumab reduced the need for sinus surgery in the SYNAPSE trial; this analysis sought to provide a more in-depth assessment of surgery endpoints in SYNAPSE. Methods: SYNAPSE was a double-blind Phase III trial (NCT03085797) in adults with recurrent, refractory, severe, CRSwNP eligible for repeat sinus surgery despite standard of care treatments and previous surgery. Patients were randomized (1:1) to mepolizumab 100 mg subcutaneously or placebo, plus standard of care, every 4 weeks for 52 weeks. Time to first inclusion on a waiting list for sinus surgery and time to first actual sinus surgery (both up to week 52) were assessed; the latter endpoint was also analyzed post hoc according to time since last sinus surgery before study screening and baseline blood eosinophil count. Results: Among 407 patients (mepolizumab: 206; placebo: 201), mepolizumab versus placebo reduced the risk of being included on a waiting list for sinus surgery (week 52 Kaplan–Meier probability estimate [95% confidence interval]: 13.9% [9.8%, 19.5%] vs. 28.5% [22.7%, 35.4%]). Mepolizumab versus placebo reduced the risk of sinus surgery irrespective of time (<3 vs ≥3 years) since patients' last sinus surgery prior to study screening (hazard ratios [95% confidence intervals] 0.28 [0.09, 0.84] and 0.50 [0.26, 0.98], respectively) and baseline blood eosinophil count. Conclusions: Mepolizumab reduced the risk of further sinus surgery in patients with recurrent, refractory, severe CRSwNP, irrespective of the patient baseline characteristics assessed

Sense of smell in chronic rhinosinusitis: A multicentric study on 811 patients

Introduction: The impairment of the sense of smell is often related to chronic rhinosinusitis (CRS) with or without nasal polyps (CRSwNP, CRSsNP). CRSwNP is a frequent condition that drastically worsens the quality of life of those affected; it has a higher prevalence than CRSsNP. CRSwNP patients experience severe loss of smell with earlier presentation and are more likely to experience recurrence of their symptoms, often requiring revision surgery. Methods: The present study performed a multicentric data collection, enrolling 811 patients with CRS divided according to the inflammatory endotype (Type 2 and non-Type 2). All patients were referred for nasal endoscopy for the assessment of nasal polyposis using nasal polyp score (NPS); Sniffin' Sticks olfactory test were performed to measure olfactory function, and SNOT-22 (22-item sinonasal outcome test) questionnaire was used to assess patients' quality of life; allergic status was evaluated with skin prick test and nasal cytology completed the evaluation when available. Results: Data showed that Type 2 inflammation is more common than non-type 2 (656 patients versus 155) and patients suffer from worse quality of life and nasal polyp score. Moreover, 86.1% of patients with Type 2 CRSwNP were affected by a dysfunction of the sense of smell while it involved a lesser percentage of non-Type 2 patients. Indeed, these data give us new information about type-2 inflammation patients' characteristics. Discussion: The present study confirms that olfactory function weights on patients' QoL and it represents an important therapeutic goal that can also improve patients' compliance when achieved. In a future - and present - perspective of rhinological precision medicine, an impairment of the sense of smell could help the clinician to characterize patients better and to choose the best treatment available

Diagnostic therapeutic assistance pathway (PDTA) of type 2 chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a complex and heterogeneous disorder whose etiopathogenetic picture is not yet completely known and is classically divided into CRS with (CRSwNP) and without nasal polyps (CRSsNP). But today the distinction is made with type 2 and nontype 2 variants. A rational and defined pathway for the diagnosis of chronic rhinosinusitis is an indispensable means to be able to arrive at a correct identification of the patient. This typing is essential to be able to arrive at the correct course of treatment, which turns out to be different for different types of patients. For this reason, the realization of a diagnostic therapeutic pathway represents a fundamental way for the otolaryngologist specialist but not only, since today diagnostics has a multidisciplinary framework. In the present work, precise indications have been developed to arrive at a correct diagnosis. The various diagnostic pathways and processes to arrive at a correct therapeutic framing have been highlighted. Therapy ranging from medical therapy to surgical therapy without neglecting the new biological therapies. It does not represent a guideline but a diagnostic method that can be adapted to all the various territorial realities

Dupilumab in the treatment of severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP): A multicentric observational Phase IV real-life study (DUPIREAL)

Background Chronic rhinosinusitis with nasal polyps (CRSwNP) is associated with significant morbidity and reduced health-related quality of life. Findings from clinical trials have demonstrated the effectiveness of dupilumab in CRSwNP, although real-world evidence is still limited. Methods This Phase IV real-life, observational, multicenter study assessed the effectiveness and safety of dupilumab in patients with severe uncontrolled CRSwNP (n = 648) over the first year of treatment. We collected data at baseline and after 1, 3, 6, 9, and 12 months of follow-up. We focused on nasal polyps score (NPS), symptoms, and olfactory function. We stratified outcomes by comorbidities, previous surgery, and adherence to intranasal corticosteroids, and examined the success rates based on current guidelines, as well as potential predictors of response at each timepoint. Results We observed a significant decrease in NPS from a median value of 6 (IQR 5–6) at baseline to 1.0 (IQR 0.0–2.0) at 12 months (p &lt; .001), and a significant decrease in Sino-Nasal Outcomes Test-22 (SNOT-22) from a median score of 58 (IQR 49–70) at baseline to 11 (IQR 6–21; p &lt; .001) at 12 months. Sniffin' Sticks scores showed a significant increase over 12 months (p &lt; .001) compared to baseline. The results were unaffected by concomitant diseases, number of previous surgeries, and adherence to topical steroids, except for minor differences in rapidity of action. An excellent-moderate response was observed in 96.9% of patients at 12 months based on EPOS 2020 criteria. Conclusions Our findings from this large-scale real-life study support the effectiveness of dupilumab as an add-on therapy in patients with severe uncontrolled CRSwNP in reducing polyp size and improving the quality of life, severity of symptoms, nasal congestion, and smell

A silicone nasal swab for the treatment of severe and recalcitrant epistaxis in hereditary hemorrhagic telangiectasia: An alternative to surgical nostril closure

Background: Epistaxis is the most common symptom in patients with hereditary hemorrhagic telangiectasia (HHT). In severely affected cases, cessation of the nasal airflow seems to be the only long-term effective treatment. Such procedure deeply affects patient's quality of life (QoL) and is sometimes refused. Methods: This study investigated the effectiveness of a tailored silicone nasal swab on 2 patients affected by HHT and severe epistaxis. Results: In both cases, we observed a good clinical effect, with significant reduction of epistaxis and improved QoL. Conclusions: Our preliminary results indicate that the silicone nasal swab can be considered an effective way of treating severe epistaxis in patients with HHT. Its advantages, in terms of maintained airflow patency, reversibility, and improved QoL, are highlighted. © 2011 Elsevier Inc. All rights reserved

Successful application of transoral robotic surgery in failures of traditional transoral laser microsurgery: Critical considerations

Aims: To assess the role of transoral robotic surgery (TORS) in managing failures of conventional transoral laser microsurgery (TLM) in cases with difficult laryngeal exposure. Methods: Retrospective analysis of 3 patients with difficult laryngeal exposure treated with TORS. All 3 cases failed to be managed by conventional TLM after repeated attempts by experienced surgeons. In 2 cases, the initial disease was laryngeal cancer treated by a cricohyoidoepiglottopexy, with an obstructing residual epiglottis. The last case was a bilateral Reinke disease submitted to repeated TLM procedures, producing multiple supraglottic and glottic scars. In all cases, the difficult exposure was produced by a combination of concurrent elements including insufficient mouth opening, short and stiff neck, macroglossia and high-positioned larynx. Results: Two patients were exposed by means of a Davis Meyer mouth gag. The other patient was managed by a Feyh-Kastenbauer device. The key of the success was the possibility to work 'around the corner' (30° angle view) where straight alignment of the larynx was impossible. Conclusions: Where possible, a TORS approach should be considered complementary to TLM in cases of very difficult or even impossible conventional transoral laryngoscopic approach. © 2014 S. Karger AG, Basel