testing with 1:100 then 1:10 dilution. The present study reports quite a small group of patients with very modestly positive skin test to egg extract. Until there is more experience with mumps-measles-rubella testing in egg-allergic patients, probably the more conservative “Red Book” protocol should be followed.
MARY ELLEN FRIEDMAN, MD Downey, CA
Treatment
THE EFFECT OF CAT REMOVAL ON ALLERGEN CONTENT IN HOUSEHOLD-DUST SAMPLES
Wood RA, Chapman MD, Atkinson NF, Eggleston PA. J
Allergy C/in Immunol. 1 989;83:730-734.
Methods
In 15 homes, samples of house dust were collected from a one square meter of carpeted area using a hand-held vacuum cleaner at baseline and at 4- to 5-week intervals during a 9- to 43-week period after removal of a cat. Samples were sieved to produce fine dust and extracted in borate-buffered saline. They were then analyzed for the major cat allergen Fel d I with a two-site radio-immunoassay using monoclonal antibodies. As a control, all samples were also analyzed for Der p I and Der
f
I, the major allergens of dust-mites.Findings
Preliminary studies demonstrated that the extraction and assay techniques were highly reproducible. The var-iability in weekly dust samples from homes with or with-out cats was found not to be statistically significant. In contrast, with regular vacuuming, the levels of Fel d I in sequential dust samples from the 15 homes from which cats were removed gradually declined. By the 20th week after cat removal, levels in 8 homes were within or very close to the upper 95% confidence limit of about 1 FDA unit/g dust of the 10 control homes without cats. Median Fel d I content was 61.2 U/g initially and fell to 44.7 at 4 weeks, to 4.2 at 10 weeks, to 1.8 at 15 weeks, and to 0.7 at 32 weeks.
Three homes were steam cleaned; no added benefit was seen. In two homes, aggressive environmental control measures (removal of all carpets and furniture) resulted in rapid declines in Fel d I content (26.6 U/g to unde-tectable and 472 U/g to 4.4 U/g in 1 and 4 weeks, respectively). Three homes demonstrated persistent ele-vations of cat allergen for 20 or more weeks. Median Der p I and Der
f
I levels remained stable. The authors conclude that it generally takes longer than previously suspected to reduce cat allergen levels to those found in homes without cats.Reviewer’s Comments
Fel d I, the major cat allergen, is produced in cat’s salivary glands and sebaceous glands of cat’s skin. It is a major cause of perennial allergic rhinitis and allergic
asthma. This study demonstrates that a trial of tempo-rary removal of a cat from a home to evaluate allergic symptoms is likely to be of little value. As an aside, I think that it would have been interesting to see the effect on the mean data calculations of excluding the two homes in which aggressive measures resulted in rapid declines of cat allergen.
DAVID E. GRAFT, MD Minneapolis, MN
Upper
Airway
Disorders
Pathophysiology
INFLAMMATORY MEDIATORS IN CHRONIC OTITIS MEDIA WITH EFFUSION
Skoner DP, Stillwagon PK, Casselbrandt ML, et al. Arch Otolaryngol Head Neck Surg. 1 988;1 14:1131-1133.
Purpose of Study
This study was conducted to define the role of inflam-matory mediators in chronic middle ear disease.
Methods
One hundred and two patients, aged 1 to 23 years (mean age 4.9 years), with persistent otitis media with effusion unresponsive to antimicrobial therapy, were studied. Fluid was obtained during insertion of tympan-otomy tubes and cultured and assayed for histamine, neutrophil chemotactic factor of anaphylaxis, and/or 13,14-dihydro-15-keto-prostaglandin F2a(a prostaglandin metabolite). Twenty-two patients also had their plasma evaluated.
Findings
All the mediators were higher in the middle ear effu-sions than in the plasma. The mean histamine content of the mucoid secretions was significantly higher than that of purulent and serous effusions. Twenty-two per-cent of the effusions yielded pathogenic organisms. The highest histamine levels were found in the effusions positive for Haemophilus influenzae.
Conclusion
these mediators, their significance in otitis media with effusion and the role of the mast cell.
GARY RACHELEFSKY, MD Los Angeles, CA
SECRETORY IgA AND BACTERIAL ADHERENCE TO NASAL MUCOSAL CELLS
Kurono Y, Fujiyoshi T, Mogi
G.
Ann Oto/ Rhinol Laryngo/. 1 989;98:273-277.Purpose of Study and Methods
In works by other authors, specific bacterial adherence to mucosal cellular walls correlated well with clinical disease. With Streptococcus pyogenes the M-protein of its cellular wall is essential for adherence.
Study Population
Nasal mucosal cells were collected from 25 normal controls and 29 patients with chronic sinusitis. In addi-tion, nasal secretions were obtained and analyzed for secretory IgA antibodies and specific anti-M-protein ac-tivity to the S pyogenes. S pyogenes were incubated with both cell isolates.
Findings
The chronic sinusitis group showed more abundant S pyogenes adherent to the nasal cells, and the
anti-M-antibody properties of the secretory IgA were reduced.
Reviewer’s Comments
Although specific treatment modalities must await, this type of investigation is yet another piece in the puzzle that helps us understand this trying group of patients.
THAD H. JooS, MD Grosse Pointe Woods, MI
CHLAMYDIAL DISEASE PATHOGENESIS: OCULAR HYPERSENSITIVITY ELICITED BY A GENUS-SPECIFIC 57-kd PROTEIN
Morrison RP, Lyng K, CaIdwell HD. J Exp Med.
1 989;1 69:663-675.
Purpose of Study
This study was conducted to identify the chlamydial antigen(s) in the Triton X-100 extract responsible for intense inflammatory response(s) that lead to the devel-opment of blinding trachoma.
1. Animal studies suggest that trachoma blindness may be mediated immunologically (delayed hypersensitivity).
2. The Triton X-100 extract from both Chlamydia trachomatis and Chkzmydia psittaci elicits ocular delayed hypersensitivity reaction in guinea pigs and monkeys.
3. Four antigens found in the Triton X-100 extract are LPS, MOMP, and 45-kd and 57-kd antigens.
4. Previous studies indicated that LPS (the major component of Triton-100) and MOMP do not cause delayed hypersensitivity.
Methods
Organisms. Fifteen serovars of C trachomatis and two strains of C psittaci.
Model. The conjunctivae from male and female Hartley guinea pigs from chlamydial-free colonies were innocu-lated with 10 ID50 of organism which subsequently were culture-negative by 4 weeks.
Antigen. The appropriate antigen (Triton X-100, 45-kd, or 57-kd) solution was placed in the conjunctival sac at 6 to 8 weeks after initial infection.
Hypersensitivity. Conjunctival hypersensitivity was as-sessed by clinical scale (hyperemia and edema) serially beginning at 2 hours and continuing until 72 hours postchallenge.
Histology. Infected upper and lower lids were removed, fixed, and stained.
Findings
Chlamydial Proteins. The chlamydial proteins show that 57-kd and 45-kd antigens were genus-specific.
Ocuk.tr Hypersensitivity. The major constituent extract of Triton X-100, ie, LPS, failed to elicit ocular hypersen-sitivity. Further, the 57-kd antigen, but not the 45-kd antigen, elicited ocular inflammation when placed topi-cally on the conjunctivae. The response was identical in intensity to that of the Triton X-100 extract itself. The Triton X-100 extract, which had both 45-kd and 57-kd proteins removed, elicited a weak (but not negative) response.
Histologic Examination. Peak inflammation was noted to occur at 24 hours. The inflammatory response elicited by the Triton X-100 extract and the purified 57-kd pro-tein were identical, consisting of lymphoid hyperplasia with a mononuclear macrophage and lymphocytic infil-trate. The 24-hour delay and the type of infiltrate were noted to be consistent with ocular delayed hypersensitiv-ity. The inflammatory response to the extract without the 57-kd and 45-kd protein was much milder and was characterized by polymorphonuclear cells rather than mononuclear cells.
Reviewers’ Comments
autoimmune arthritis. These findings may be critical in understanding the pathogenesis of chronic chlamydial disease.
Diagnosis
BRIAN K. GREENBERG, MD
ROGER KOBAYASHI, MD Los Angeles, CA
NASAL HYPERREACTIVITY TO NEWSPAPERS
Theander C, Bende M. C/in Exp Allergy. 1989;19:57-58.
Purpose of Study
There is a significant number of people who experience symptoms of the upper respiratory tract while reading the newspaper. Is this a reaction to the printing ink or to the paper dust?
Study Population
Fifteen nonallergic patients with vasomotor rhinitis and a history of nasal symptoms (sneezing, itching, nasal blockage, and watery discharge) related to newspaper were studied. A control group consisted of six healthy volunteers.
Methods
Each subject was exposed first to printing ink and then, 30 to 60 minutes later, to paper dust. The printing ink was inhaled by nasal breathing for 1 minute over a bottle of fresh liquid ink. The paper dust was sniffed into each nasal cavity in a standardized amount (2 to 6 mg). Nasal symptoms were noted and scored, and total nasal airway resistance was measured using anterior rhinoman-ometry at 0, 15, and 30 minutes postexposure.
Findings
Exposure to the printing ink did not increase nasal symptoms among the patients with a history of newspa-per sensitivity. On the other hand, paper dust did cause a significant increase in symptoms immediately after exposure as well as 15 and 30 minutes after exposure. The control group did not react to either printing ink or paper dust. Nasal airway resistance did not show any significant changes after either stimulant. Patients de-scribed nasal discharge and sneezing as the most trouble-some symptoms.
Conclusions
1. Patients with vasomotor rhinitis and newspaper sensitivity appear to be reacting to paper dust and not to printing ink.
2. Nasal discharge and sneezing are the most trouble-some symptoms in these sensitive patients.
3. The vasomotor reaction to newspapers is probably reflex-mediated leading to the reflex symptoms of
sneez-ing, discharge, and nasal irritation and not to mucosal congestion and edema; thereby, no change in nasal airway resistance occurs.
Reviewer’s Comments
For patients with a history of difficulty reading the newspaper we now have a more specific answer to their question of “What exactly am I reacting to?” However, before telling them it has to be the paper dust and not the ink, this study needs to be repeated with a few design modifications. Subjects were always challenged with pa-per dust before being challenged with ink. To ensure a priming effect is not occurring, the opposite order needs to be performed. Furthermore, the dust challenge was direct insufflation of 2 to 6 mg of dust into the nose; the ink challenge was only inhalation “by nasal breathing for 1 minute over a bottle of fresh ink.” These two challenges may not be equivalent. Furthermore, how do we know that the dust challenge is really stimulating what the reader is doing when reading the newspaper? More ink on paper needs to be written (and smelt) before the “issue” is settled as to whether it is the paper, the ink, or both, creating the problem.
MICHAEL J. WELCH, MD San Diego, CA
QUANTITATIVE BACTERIAL CULTURES AND
9-LACTAMASE
ACTIVITY
IN CHRONIC
SUPPURATIVE
OTITIS MEDIA
Brook I, Yocum P. Ann Oto/ Rhinol Laryngol.
1 989;98:293-297.
Purpose of Study, Study Population, and Methods
Middle ear aspirates from both ears of 54 children suffering from chronic otitis media with perforation were collected, cultured, and analyzed for j3-lactamase activity. These children all had received a variety of antibacterial agents in the recent past.
Findings
1. Bacterial flora differed from the right to the left ear in 39% of patients.
2. 13-Lactamase activity was noted in 79% of the iso-lates.
3. The most common bacteria noted were Bacteroides melaninogenicus group, Pseudomonas aeruginosa, Kleb-siella pneumoniae, and Staphylococcus aureus.
Reviewers’ Comments
In this group of children and even some with lesser troubles, the need for careful culture and specific therapy if available is essential. Locally (Detroit, MI) we are seeing an increasing number of 3-lactamase-producing
bacteria.
SUBACUTE SINUSITIS IN CHILDREN Purpose of Study
Wald ER,
Byers C, Guerra N, Casselbrant M, Beste D.J Pediatr. 1 989;1 15:28-32.
Purpose of Study
Sinusitis is receiving increasing recognition as a cause of significant morbidity in childhood. Duration of symp-toms has been divided into three stages: (1) acute, 2 to 4 weeks; (2) subacute, 2 to 4 weeks to 2 to 3 months; and (3) chronic, greater than 2 to 3 months. The purpose of this study was to identify the bacteriologic pathogens involved in subacute sinusitis.
Study Population
Forty children aged between 2 and 12 years with per-sistent nasal discharge (87%), cough (92%), fevers (25%), headache (55%), and/or foul breath (50%) lasting be-tween 30 and 120 days were studied. All had radiographic evidence of maxillary sinusitis: opacification, 4 mm of mucosal thickening or air-fluid levels. None had nasal allergies or asthma. Before the study, 62.5% had had some antibiotic treatment.
Methods
Transnasal maxillary sinus punctures were performed on 52 sinuses. Secretions obtained either by puncture, or when necessary by irrigation, were Gram-stained and cultured for aerobic and anaerobic organisms. A positive culture was defined as i0 colony-forming units/mL. Findings
Positive sinus aspirates were found in 65% of the children. The most commonly found organisms were Streptococcus pneumoniae, Haemophilus influenzae, (nontypable), and Branhamella catarrhalis. Of the iso-lates 29% were f3-lactamase-producing, mostly from the patients who had previously received antibiotics. Corre-lation of x-ray findings with positive cultures showed positive cultures in 82% of sinuses showing opacification, in 53% showing mucosal thickening, and in 2 of 7 normal x-rays (?).
Reviewers’ Comments
The pathogens involved in acute and subacute sinusitis are very similar. The authors recommend treating previ-ously untreated patients with amoxicillin for at least 10 days. The finding of positive cultures in children with “normal” x-rays is somewhat disturbing. The study needs to be replicated in children with nasal allergies.
MARY ELLEN FRIEDMAN, MD Downey, CA
SIGNIFICANCE OF OPACIFICATION OF THE
MAXILLARY
AND
ETHMOID
SINUSES
IN INFANTS
Glasier CM, Mallory GB Jr, Steele RW. J Pediatr. 1989;1 14:45-50.
The purpose of the study was to determine the signif-icance of radiographic sinus opacification in infants.
Study Population
The study population consisted of 100 infants from birth to 12 months of age who received a computerized tomography scan for indications other than sinusitis.
Methods
Computerized tomography scans of the maxillary and ethmoid sinuses were done prospectively in conjunction with routine cranial computerized tomography in 100 infants with indications other than sinusitis. Concomi-tant clinical history was determined as well as a physical exam of the upper respiratory tract performed. The scans were categorized as normal with findings of an aerated cavity without internal tissue density, opacified contain-ing soft tissue, and hypoplastic if it lacked a definable sinus cavity. They were further classified as nonaerated or normal with hypoplastic included in the nonaerated category. In infants who were considered to have illness of the upper respiratory tract, there is history or physical examination evidence of significant nasal discharge, pharyngitis, or nasal mucosal hyperemia.
Findings
Of the patients less than 2 months of age, 13 (81%) had antral hypoplasia. Of 9 infants with hypoplastic ethmoid air cells 7 (78%) were less than 2 months of age. Over all, 70 of 100 infants had hypoplastic or opacified maxillary sinuses. Of these, 64% had abnormal comput-erized tomographies excluding hypoplasia. There was a positive correlation between the findings in the maxillary and ethmoid sinuses 80% ofthe time (93 of 116) in infants older than 2 months of age, but only 49% of the time (40 of82) in the sinuses ofthe younger subjects. The majority of patients with positive history or positive examination findings for upper respiratory tract infection had opaci-fled maxillary (87%) and ethmoid (67%) sinuses. How-ever, 67% of patients without upper respiratory tract infection on clinical examination had opacified maxillary of ethmoid (46%) sinuses. The incidence of abnormal maxillary or ethmoid sinus computerized tomography findings in the upper respiratory tract-positive or -nega-tive groups did not differ statistically (x2 P > .05).
Conclusion
Conventional sinus radiographs are not a definitive value in diagnosis of sinusitis in infants during the first year of life, because hypoplasia of the ethmoid and max-illary sinuses is particularly common in infants less than 2 months of age and opacification of the maxillary and ethmoid sinuses is common in the absence of evidence of clinical infection by history or physical examination.
Treatment
Reviewers’ CommentsBECLOMETHASONE DIPROPIONATE AQUEOUS NASAL SPRAY FOR SEASONAL ALLERGIC RHINITIS IN CHILDREN
Kobayashi R, Tinkelman D, Reese M, Sykes RS, Pakes
G.
Ann Allergy. 1989;62:205-208.Purpose of Study
In this study, 101 children ranging in age from 5 to 13 years with seasonal allergic rhinitis received one spray in each nostril twice daily of either beclomethasone dipro-pionate aqueous (BDP-AQ) or an identical placebo spray.
Methods
The 101 pediatric patients with active symptoms of seasonal allergic rhinitis from Omaha and Atlanta areas participated in a double-blind, randomized, parallel group study. Skin tests of all patients were positive to pollens found in the study areas. Patients assigned to the BDP-AQ group received a total of 168 jg of BDP per day. Decongestants, systemic corticosteroids, and beginning hyposensitization treatment were prohibited during the study period. Physician and patient evaluations were performed using mean symptom scores for nasal obstruc-tion, rhinorrhea, sneezing, and nasal itch.
Findings
By day 4, treatment with BDP-AQ was associated with statistically significant improvement for nasal obstruc-tion, itch, and sneezing as compared to baseline. By days 8 and 15, rhinorrhea had improved. Physicians’ evalua-tion of treatment indicated that the BDP-AQ-treated patients experienced significantly greater ( P = .012) improvement as compared with placebo-treated patients. Overall, 75% of the BDP-AQ group and 58% of the placebo group were rated as having improved significantly during therapy. Analysis of ocular symptoms revealed no differences in comparison between the BDP-AQ and placebo groups. There was no difference in the incidence of adverse effects between the two groups. The most frequent side effects with BDP-AQ were transient burn-ing or stinging in the nose and headache; similar side effects occurred in the placebo group.
Conclusions
The use of BDP-AQ nasal spray at the dose of 168 zg per day (2 to 42 zg sprays twice a day) is a safe and effective treatment of seasonal allergic rhinitis in chil-dren.
Although no measurement of adrenal function was performed on patients in this study, the authors footnote several early controlled trials (1974 to 1978) where BDP was effective in the treatment of rhinitis in children without production of adrenal suppression. Physicians treating children with significant allergic rhinitis now have an alternative to using drying, drowsiness-inducing antihistamines of central nervous system-stimulating de-congestants.
BETTY MILLER, MD Daly City, CA
CHRONIC SECRETORY OTITIS MEDIA: EFFECTS OF SURGICAL MANAGEMENT
Gates GA, Avery CA, Cooper JC Jr, Prihoda TJ. Ann
Otol Rhinol Laryngol. 1 989;98:2-32.
Purpose of Study
This is a review article that stresses the surgical ap-proach to a very troublesome childhood problem.
Study Population and Methods
In an effort to find the effectiveness of adenoidectomy and tympanotomy tubes in the treatment of chronic otitis media with effusion, 491 patients who accepted some form of surgical intervention were placed randomly into one of four groups: (1) bilateral myringotomy alone, (2) tympanotomy tubes, (3) adenoidectomy and myringo-tomy tubes, or (4) adenoidectomy and tympanotomy tubes. The group was observed every 6 weeks for up to 2 years.
Findings
The results point out that adenoidectomy and tympan-otomy tubes were the preferred treatment, followed closely by adenoidectomy and myringotomy. Adenoid removal regardless of size was important according to the authors. They speculate that the removal of the adenoids helps rid the area of a harbor for bacteria. Further rec-ommendations call for a 60-day observation period before surgery is considered. During this time further antimicro-bial therapy should be used.
Reviewers’ Comments
All of us are confronted by this vexing situation. The article presents a balanced surgical approach. Other thoughts would include the sharing of our ideas and concerns with our ear-nose-and-throat colleagues over coffee and danish.
