Current Issue
Volumes and Issues
For Authors
Manuscript Guidelines
Review Process
Conflict of Interest
Copyright
About the Journal
Editorial Board
Aim and Scope
Policy and Ethical Guidelines
Promotion of the Journal
Print-Version Subscription
Publisher and Contact Information
Contact Information
Sign in as an AUTHOR/REVIEWER
REVIEW PAPER
MIDDLE EAR MUSCLE DYSFUNCTION AS THE
CAUSE OF MENIERE’S DISEASE
1
John Curtin School of Medical Research, Australian National University, Canberra,
Australia
A - Research concept and design; B - Collection and/or assembly of data; C - Data analysis and interpretation; D - Writing the article; E - Critical revision of the article; F - Final approval of article;
Publication date: 2017-09-30
Corresponding author
Andrew Bell
Andrew Bell, JCSMR, 131 Garran Road, Australian National University, Canberra, ACT 2601, Australia, e-mail: andrew.bell@anu.edu.au
Andrew Bell, JCSMR, 131 Garran Road, Australian National University, Canberra, ACT 2601, Australia, e-mail: andrew.bell@anu.edu.au
J Hear Sci 2017;7(3):9-25
KEYWORDS
ABSTRACT
The symptoms of Meniere’s disease form a distinct cluster: bouts of vertigo, fluctuating hearing loss, low-frequency tinnitus, and a feeling of
pressure in the ear. Traditionally, these signature symptoms have pointed to some sort of pathology within the inner ear itself, but here the
focus is shifted to the middle ear muscles. These muscles, the tensor tympani and the stapedius, have generally been seen as serving only a
secondary protective role in hearing, but in this paper they are identified as vigilant gate-keepers – constantly monitoring acoustic input and
dynamically adjusting hearing sensitivity so as to enhance external sounds and suppress internally generated ones. The case is made that this
split-second adjustment is accomplished by regulation of inner ear pressure: when the middle ear muscles contract they push the stapes into
the oval window and increase the pressure of fluids inside the otic capsule. In turn, hydraulic pressure squeezes hair cells, instantly adjusting
their sensitivity. If the middle ear muscles should malfunction – such as from cramp, spasm, or dystonia – the resulting abnormal pressure
will disrupt hair cells and produce Meniere’s symptoms.
A wide-ranging review of Meniere’s disease and the middle ear muscles reinforces the link between the two. Since every striated muscle is
prone to dystonia – an involuntary contraction involving derangement of its underlying control loop – middle ear muscle dystonia would
lead to elevated pressure and abnormal hair cell function. The hypothesis is based on recognizing that the inner ear is a hydrostat – a cavity filled with fluid whose pressure is controlled by the middle ear muscles. Since the fluid is incompressible, even a slight contraction of the
muscles can increase the pressure in the labyrinth to 3 kPa. The effect of such a pressure on the sensing cells within is crucial. Outer hair cells
carry an internal turgor pressure of about 1 kPa, behaving physically like inflated balloons, and hence contraction of the middle ear muscles
can instantly overcome internal cellular pressure, switch off ion channels, and reduce hearing sensitivity.
This paper brings together supporting evidence and sets out major implications for Meniere’s disease, including possible treatments.
REFERENCES (117)
1.
Stahle J, Klockhoff I. Diagnostic procedures, differential diagnosis, and general conclusions. In: Pfaltz CR, editor. Controversial Aspects of Meniere’s Disease. New York: Thieme; 1986.
2.
Alford BR. Diagnostic controversies. In: Pfaltz CR, editor. Controversial Aspects of Meniere’s Disease. New York: Thieme; 1986, p. 60–69.
3.
House WF. Meniere’s disease: an overview. In: Harris JP, editor. Meniere’s Disease. Amsterdam: SPB Academic; 1999, p. 399–408.
4.
Gurkov R, Pyyko I, Zou J, Kentala E. What is Meniere’s disease? A contemporary re-evaluation of endolymphatic hydrops. J Neurol, 2016; 263: S71–S81.
5.
Brownell WE. Outer hair cell electromotility and otoacoustic emissions. Ear Hear, 1990; 11: 82–92.
6.
Lopez-Escamez JA, Carey J, Chung W-H, Goebel JA, Magnusson M. Diagnostic criteria for Meniere’s disease. J Vestib Res, 2015; 25: 1–7.
7.
Gurkov R, Flatz W, Louza J, Strupp M, Ertl-Wagner B, Krause E. Herniation of the membranous labyrinth into the horizontal semicircular canal is correlated with impaired caloric response in Meniere’s disease. Otol Neurotol, 2012; 33: 1375–79.
8.
Ruckenstein MJ. Pathophysiology of Meniere’s disease. In: Ruckenstein MJ, editor. Meniere’s Disease: Evidence and outcomes. San Diego: Plural; 2010, p. 13–24.
9.
Pfalz CR, Thomsen J. Symptomatology and definition of Meniere’s disease. In: Pfaltz CR, editor. Controversial Aspects of Meniere’s Disease. Stuttgart: Thieme; 1986, p. 2–7.
10.
Van de Heyning PH, De Valck CFJ, Boudewyns A, Cammaert T, Casteleyn S, Deggouj N, et al. Meniere’s disease. Belgian ENT, 2007; 3, Suppl 6: 11–20.
11.
Merchant SN, Adams JC, Nadol JB. Pathophysiology of Meniere’s syndrome: are symptoms caused by endolymphatic hydrops? Otol Neurotol, 2005; 26: 74–81.
12.
Mattox DE. Unsolved mysteries of Meniere’s disease. In: Harris JP, editor. Meniere’s Disease. The Hague: Kugler; 1999, p. 409–18.
13.
Ruckenstein MJ. Future directions. In: Ruckenstein MJ, editor. Meniere’s Disease: Evidence and outcomes. San Diego: Plural; 2010, p. 155–6.
14.
Gacek RR, Gacek MR. Meniere’s disease as a manifestation of vestibular ganglionitis. Am J Otolaryngol, 2001;22: 241–50.
15.
Pullens B, Verschuur HP, Benthem PP. Surgery for Meniere’s disease (review). Cochrane Database of Systematic Reviews, 2013: CD005395.
16.
Pyykko I, Nakashima T, Yoshida T, Zou J, Naganawa S. Meniere’s disease: a reappraisal supported by a variable latency of symptoms and the MRI visualisation of endolymphatic hydrops. BMJ Open, 2013; 3: e001555.
17.
Hain TC. Meniere’s disease treatments that may be placebos. Available from www.dizziness-and-balance.com/disorders/menieres/menieres_placebo.htm. Accessed 2017 Jul 27.
18.
Bell A. How do middle ear muscles protect the cochlea? Reconsideration of the intralabyrinthine pressure theory. J Hear Sci, 2011; 1(2): 9–23.
19.
Hallpike CS, Cairns H. Observations on the pathology of Meniere’s syndrome. J Laryngol Otol, 1938; 53: 625–55.
20.
Pfaltz CR. A tentative retro- and prospective outline. In: Pfaltz CR, editor. Controversial Aspects of Meniere’s Disease. New York: Thieme; 1986, p. 138–47.
21.
Elliott SJ, Ni G, Verschuur CA. Modelling the effect of round window stiffness on residual hearing after cochlear implantation. Hear Res, 2016; 341: 155–67.
22.
Kemp DT. Stimulated acoustic emissions from within the human auditory system. J Acoust Soc Am, 1978; 64: 1386–91.
23.
Kirikae I. An experimental study on the fundamental mechanism of bone conduction. Acta Otolaryngol, 1959; Suppl 145: 1–111.
24.
Goodhill V. The conductive loss phenomenon in post-stapedectomy perilymphatic fistulas. Laryngoscope, 1967; 77: 1179–90.
25.
Borg E, Counter SA, Rösler G. Theories of middle-ear muscle function. In: Silman S, editor. The Acoustic Reflex: Basic principles and clinical applications. New York: Academic Press; 1984, p. 63–99.
26.
Marchbanks RJ, Reid A. Cochlear and cerebrospinal fluid pressure: their inter-relationship and control mechanisms. Br J Audiol, 1990; 24: 179–87.
27.
Ivarsson A, Pedersen K. Volume–pressure properties of round and oval windows. Acta Otolaryngol, 1977; 84: 38–43.
28.
Simmons FB. Variable nature of the middle ear muscle reflex. Int Audiol, 1964; 3: 136–46.
29.
Wickens B, Floyd D, Bance M. Audiometric findings with voluntary tensor tympani contraction. J Otolaryngol – Head Neck Surg, 2017; 46: 2.
30.
Helmholtz HLFv. The mechanism of the ossicles and the membrana tympani [trans J. Hinton]. New Sydenham Society Series. 1874; 62: 97–155.
31.
Mascarello F, Carpene E, Veggetti A, Rowlerson A, Jenny E. The tensor tympani muscle of cat and dog contains IIM and slowtonic fibres: An unusual combination of fibre types. J Muscle Res Cell Motil, 1982; 3: 363–74.
32.
Shearer WM. Speech: behavior of middle ear muscle during stuttering. Science, 1966; 152: 1280.
33.
Klockhoff I, Anderson H. Reflex activity in the tensor tympani muscle recorded in man: Preliminary report. Acta Otolaryngol, 1960; 51: 184–8.
34.
Baloh RW. Robert Barany and the controversy surrounding his discovery of the caloric reaction. Neurology, 2002; 58: 1094–9.
35.
Watanabe K, Ishida H, Okubo J, Nakamura H. Influence of pressure loading to the external auditory canal on standing posture in normal and pathological subjects. Adv Oto-Rhino-Laryngol, 1988; 42: 72–6.
36.
Cherchi M, Hain TC. Provocative maneuvers for vestibular disorders. In: Eggers SDZ, Zee DS, editors. Vertigo and Imbalance: Clinical neurophysiology of the vestibular system: Elsevier; 2009, p. 111–34.
37.
Wilson JP. Evidence for a cochlear origin of acoustic re-emissions, threshold fine-structure and tonal tinnitus. Hear Res, 1980; 2: 233–52.
38.
Rowan D, Kapadia S, Lutman ME. Does static ear canal pressure influence pure tone pitch perception? Acta Otolaryngol, 2004; 124: 286–9.
39.
39 Buki B, Chomicki A, Dordain M, Lemaire JJ, Wit HP, Chazal J, et al. Middle-ear influence on otoacoustic emissions. II: Contributions of posture and intracranial pressure. Hear Res, 2000; 140: 202–11.
40.
Harrison MS, Naftalin L. Meniere’s Disease: Mechanism and management. Springfield, IL: Charles C. Thomas; 1968.
41.
House JW, Doherty JK, Fisher LM, Derebery MJ, Berliner KI. Meniere’s disease: Prevalence of contralateral ear involvement. Otol Neurotol, 2006; 27: 355–61.
42.
Kitahara M. Bilateral aspects of Meniere’s disease. Acta Otolaryngol Suppl, 1991; 485: 74–7.
43.
Roitman R, Talmi YP, Finkelstein Y, Silver S, Sadov R, Zohar Y. Acoustic trauma-induced Meniere’s syndrome. ORL J Otorhinolaryngol Relat Spec, 1989; 51: 246–50.
44.
Pau HW, Punke C, Zehlicke T, Dressler D, Sievert U. Tonic contractions of the tensor tympani muscle: A key to some non-specific middle ear symptoms? Hypothesis and data from temporal bone experiments. Acta Otolaryngol, 2005; 125: 1168–75.
45.
Fraser PJ, Shelmerdine RL. Dogfish hair cells sense hydrostatic pressure. Nature, 2002; 415: 495–96.
46.
Bell A. The pipe and the pinwheel: is pressure an effective stimulus for the 9+0 primary cilium? Cell Biol Int, 2008; 32: 462–68.
47.
Klockhoff I. Impedance fluctuation and a “tensor tympani syndrome”. Fourth International Symposium on Acoustic Impedance Measurements; 1981; Lisbon: Universidade Nova de Lisboa.
49.
Westcott M, Sanchez TG, Diges I, Saba C, Dineen R, McNeill C et al. Tonic tensor tympani syndrome in tinnitus and hyperacusis patients: a multi-clinic prevalence study. Noise Health, 2013; 15: 117–28.
50.
Loader B, Beicht D, Hamzavi J-S, Franz P. Tenotomy of the middle ear muscles causes a dramatic reduction in vertigo attacks and improves audiological function in definite Meniere’s disease. Acta Otolaryngol, 2012; 132: 491–97.
51.
Franz P, Hamzavi JS, Schneider B, Ehrenberger K. Do middle ear muscles trigger attacks of Ménière’s disease? Acta Otolaryngol, 2003; 123: 133–37.
52.
Loader B, Beicht D, Hamzavi J-S, Franz P. Tenotomy of the stapedius and tensor tympani muscles reduces subjective dizziness handicap in definite Meniere’s disease. Acta Otolaryngol, 2013; 133: 368–72.
53.
Bürkner K. Die Fortschritte in der Therapie der Ohrkrankheiten im letzen Decennium (1870–1879). Archiv für Ohrenheilkunde, 1882; 19: 1–27.
54.
Albu S, Babighian G, Amadori M, Trabalzini F. Endolymphatic sac surgery versus tenotomy of the stapedius and tensor tympani muscles in the management of patients with unilateral definite Meniere’s disease. Eur Arch Otorhinolaryngol, 2015; 272: 3645–50.
55.
Hidaka H, Honkura Y, Ota J, Gorai S, Kawase T, Kobayashi T. Middle ear myoclonus cured by selective tenotomy of the tensor tympani: Strategies for targeted intervention for middle ear muscles. Otol Neurotol, 2013; 34: 1552–58.
56.
Bhimrao SK, Masterson L, Baguley D. Systematic review of management strategies for middle ear myoclonus. Otolaryngol Head Neck Surg, 2012; 146: 698–706.
57.
Steffen TN, Nixon JC, Glorig A. Stapedectomy and noise. Laryngoscope, 1963; 73: 1044–60.
58.
Burns EM, Harrison WA, Bulen JC, Keefe DH. Voluntary contraction of middle ear muscles: Effects on input impedance, energy reflectance and spontaneous otoacoustic emissions. Hear Res, 1993; 67: 117–27.
59.
Angeli RD, Lise M, Tabajara CC, Maffacioli TB. Voluntary contraction of the tensor tympani muscle and its audiometric effects. J Laryngol Otol, 2013; 127: 1235–37.
60.
Bance M, Makki FM, Garland P, Alian WA, van Wijhe RG, Savage J. Effects of tensor tympani muscle contraction on the middle ear and markers of a contracted muscle. Laryngoscope, 2013; 123: 1021–27.
61.
Rock EH. Objective tinnitus and the tensor tympani muscle. International Tinnitus Journal, 1995; 1: 30–37.
62.
Thalen E, Wit H, Segenhout H, Albers F. Inner ear pressure changes following square wave intracranial or ear canal pressure manipulation in the same guinea pig. Eur Arch Otorhinolaryngol, 2002; 259: 174–79.
63.
Salt AN, Rask-Andersen H. Responses of the endolymphatic sac to perilymphatic injections and withdrawals: Evidence for the presence of a one-way valve. Hear Res, 2004; 191: 90–100.
64.
Paparella MM. Methods of diagnosis and treatment of Meniere’s disease. Acta Otolaryngol Suppl, 1991; 485: 108–19.
65.
Densert B, Sass K, Arlinger S. Short term effects of induced middle ear pressure changes on the electrocochleogram in Meniere’s disease. Acta Otolaryngol, 1995; 115: 732–37.
66.
Nadol JB. Positive Hennebert’s sign in Meniere’s disease. Arch Otolaryngol Head Neck Surg, 1977; 103: 524–30.
67.
Sugawara K, Kitamura K, Ishida T, Sejima T. Insertion of tympanic ventilation tubes as a treating modality for patients with Meniere’s disease: A short- and long-term follow-up study in seven cases. Auris Nasus Larynx, 2003; 30: 25–28.
68.
Park JJ-H, Chen Y-S, Westhofen M. Meniere’s disease and middle ear pressure: Vestibular pressure after transtympanic tube placement. Acta Otolaryngol, 2009; 129: 1408–13.
69.
Stephens DDG, Ballam HM. The sono-ocular test. J Laryngol Otol, 1974; 88: 1049–59.
70.
Frenckner P. Some viewpoints on the operative treatment in Meniere’s disease. Arch Otolaryngol, 1952; 55: 420–33.
71.
Nodar RH, Graham JT. An investigation of frequency characteristics of tinnitus associated with Meniere’s disease. Arch Otolaryngol, 1965; 82: 28–31.
72.
Douek E, Reid J. The diagnostic value of tinnitus pitch. J Laryngol Otol, 1968; 82: 1039–42.
73.
Pujol R, Lenoir M, Ladrech S, Tribillac F, Rebillard G. Correlation between the length of outer hair cells and the frequency coding of the cochlea. In: Cazals Y, Demany L, Horner K, editors. Auditory Physiology and Perception, Advances in the Biosciences vol 83. Oxford: Pergamon; 1992, p. 45–51.
74.
Hinchcliffe R. Emotion as a precipitating factor in Menière’s disease. J Laryngol Otol, 1967; 81: 471–75.
75.
Thomsen J, Bretlau P. General conclusions. In: Pfaltz CR, editor. Controversial Aspects of Meniere’s Disease. New York: Thieme; 1986, p. 120–36.
76.
Brownell WE, Manis PB. Structures, mechanisms, and energetics in temporal processing. In: Popper AN, Fay RR, editors. Perspectives on Auditory Research. New York: Springer; 2014, p. 9–44.
77.
Bell A. The cochlea, surface acoustic waves, and resonance. In: Jabbari E, Kim D-H, Lee LP, Ghaemmaghami A, Khademhosseini A, editors. Handbook of Biomimetics and Bioinspiration. Singapore: World Scientific; 2014, p. 719–41.
78.
Hudspeth AJ. Integrating the active process of hair cells with cochlear function. Nature Rev Neurosci, 2014; 15: 600–14.
79.
Cooper NP, Guinan JJ. Efferent insights into cochlear mechanics. In: Shera CA and Olson ES, editors. What Fire is in Mine Ears: Progress in Auditory Biomechanics. Melville, NY: American Institute of Physics; 2005, p. 396–402.
80.
Chertoff ME, Brownell WE. Characterization of cochlear outer hair cell turgor. Am J Physiol Cell Physiol, 1994; 35: C467–79.
81.
Brownell WE. How the ear works: Nature’s solutions for listening. Volta Review, 1997; 99: 9–28.
82.
Kakehata S, Santos-Sacchi J. Membrane tension directly shifts voltage dependence of outer hair cell motility and associated gating charge. Biophys J, 1995; 68: 2190–97.
83.
Frolenkov GI. Regulation of electromotility in the cochlear outer hair cell. J Physiol, 2006; 576.1: 43–48.
84.
Elemans CPH, Mead AF, Jakobsen L, Ratcliffe JM. Superfast muscles set maximum call rate in echolocating bats. Science, 2011; 333: 1885–88.
85.
Rome LC. Design and function of superfast muscles: New insights into the physiology of skeletal muscle. Annu Rev Physiol, 2006; 68: 193–221.
86.
Ladich F. Sound-generating and -detecting motor system in catfish: Design of swimbladder muscles in doradids and pimelodids. Anat Rec, 2001; 263: 297–306.
87.
Goodhill V. Sudden deafness and round window rupture. Laryngoscope, 1971; 81: 1462–74.
88.
Rask-Andersen H, Kinnefors A, Svedberg M, Illing R-B. The human round window: A perilymph pressure regulator? Audiological Medicine, 2004; 3: 182–92.
89.
Walsted A, Salomon G, Thomsen J, Tos M. Hearing decrease after loss of cerebrospinal fluid: A new hydrops model? Acta Otolaryngol, 1991; 111: 468–76.
90.
Juhn SK. Regulation of inner ear fluids composition. In: Pfalz CR, editor. Controversial Aspects of Meniere’s Disease. New York: Thieme; 1986, p. 10–15.
91.
Tjernström Ö, Casselbrant M, Harris S, Ivarsson A. Hearing improvement in attacks of Meniere’s disease treated with pressure chamber. Adv Oto-Rhino-Laryngol, 1979; 25: 54–60.
92.
Tjernström Ö. Pressure chamber treatment. In: Pfaltz CR, editor. Controversial Aspects of Meniere’s Disease. New York: Thieme; 1986, p. 96–98.
93.
Tjernstrom O. Further studies on alternobaric vertigo. Acta Otolaryngol, 1974; 78: 221–31.
94.
Corey VB. Change in pitch of sustained musical note by clenching of the jaws of the observer. J Acoust Soc Am, 1950; 22: 640.
95.
Mom T, Gilain L, Avan P. Effects of glycerol intake and body tilt on otoacoustic emissions reflect labyrinthine pressure changes in Meniere’s disease. Hear Res, 2009; 250: 38–45.
96.
Bell A. Circadian and menstrual rhythms of spontaneous otoacoustic emissions from human ears. Hear Res, 1992; 58: 91–100.
97.
de Kleine E, Wit HP, Van Dijk P, Avan P. The behavior of spontaneous otoacoustic emissions during and after postural changes. J Acoust Soc Am, 2000; 107: 3308–16.
98.
Plester D. Surgery of Meniere’s disease. In: Pfaltz CR, editor. Controversial Aspects of Meniere’s Disease. New York: Thieme; 1986, p. 104–12.
99.
Buki B, de Kleine E, Wit HP, Avan P. Detection of intracochlear and intracranial pressure changes with otoacoustic emissions: A gerbil model. Hear Res, 2002; 167: 180–91.
100.
Pennings R, Van Wijhe RG, Majdalawieh O, Alian WA, Bance M. Is there a correlation between tensor tympani spasm and low-frequency hearing loss? [abstract]. Annual Canadian Society of Otolaryngology – Head & Neck Surgery Meeting, 2009, p. 63.
101.
Mukerji SM, Windsor AM, Lee DJ. Auditory brainstem circuits that mediate the middle ear muscle reflex. Trends Amplif, 2010; 14: 170–91.
102.
Simmons FB. Perceptual theories of middle ear muscle function. Ann Otol, 1964; 73: 724–29.
103.
Salt AN, DeMott JE. Longitudinal endlolymph movements and endocochlear potential changes induced by stimulation at infrasonic frequencies. J Acoust Soc Am, 1999; 106: 847–56.
105.
Yonovitz A, Harris JD. Eardrum displacement following stapedius muscle contraction. Acta Otolaryngol, 1976; 81: 1–15.
106.
Han Y, Wang J, Fischman DA, Biller HF, Sanders I. Slow tonic muscle fibers in the thyroarytenoid muscles of human vocal folds: A possible specialization for speech. Anat Rec, 1999; 256: 146–57.
107.
Ramirez Aristeguieta LM, Ballesteros Acuna LE, Sandoval Ortiz GP. Tensor veli palatine and tensor tympani muscles: anatomical, functional and symptomatic links. Acta Otorrinolaringol Esp, 2010; 61: 26–33.
108.
Kierner AC, Zelenka I, Lukas JR, Aigner M, Mayr R. Observations on the number, distribution and morphological peculiarities of muscle spindles in the tensor tympani and stapedius muscle of man. Hear Res, 1999; 135: 71–77.
109.
Borg E. Acoustic middle ear reflexes: a sensory-control system. Acta Otolaryngol Suppl, 1972; 304: 1–34.
110.
Rosales RL, Dressler D. On muscle spindles, dystonia and botulinum toxin. Eur J Neurol, 2010; 17 (Suppl 1): 71–80.
111.
Neychev VK, Gross RE, Lehericy S, Hess EJ, Jinnah HA. The functional anatomy of dystonia. Neurobiol Dis, 2011; 42: 185–201.
112.
Brownell WE. What is electromotility? The history of its discovery and its relevance to acoustics. Acoustics Today, 2017; 13(1): 20–27.
113.
Ramirez LM, Ballesteros LE, Sandoval GP. Topical review: Temporomandibular disorders in an integral otic symptom model. Audiology, 2008; 47: 215–27.
114.
Eisen MD. Historical perspectives. In: Ruckenstein MJ, editor. Meniere’s Disease: Evidence and outcomes. San Diego: Plural; 2010, p. 1–6.
115.
Kobrak F. Study on pathophysiological factors in clinical otosclerosis. Pract Otorhinolaryngol (Basel). 1948; 10: 423–48.
116.
Tonndorf J. The mechanism of hearing loss in early cases of endolymphatic hydrops. Ann Otol Rhinol Laryngol, 1957; 66: 766–84.
117.
Storper IS. Meniere’s syndrome. In: Rowland LP, Pedley TA, editors. Merritt’s Neurology (12th ed). Philadelphia: Lippincott Williams & Wilkins; 2010, p. 963–66.
Share
RELATED ARTICLE
We process personal data collected when visiting the website. The function of obtaining information about users and their behavior is carried out by voluntarily entered information in forms and saving cookies in end devices. Data, including cookies, are used to provide services, improve the user experience and to analyze the traffic in accordance with the Privacy policy. Data are also collected and processed by Google Analytics tool (more).
You can change cookies settings in your browser. Restricted use of cookies in the browser configuration may affect some functionalities of the website.
You can change cookies settings in your browser. Restricted use of cookies in the browser configuration may affect some functionalities of the website.
