Upper Airway Disorders

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SUPPLEMENT 293 allergic rhinitis is present) with increasing allergen

skin test reactivity, but not for chronic rhumtis. Reviewer’s Comments

Dr Turkeltaub appears to be the only living

inhab-itant of the known universe who used erythema as

the sole criteria for a positive skin test response.

Erythema diameters of 10 mm would be considered

very equivocal in most skin test grading systems.

Nevertheless, the results clearly point to the impor-tance of allergy in childhood asthma. The adults with

only asthma do not show associations with skin test

reactions probably because the study did not

distin-guish those with adult onset-type asthma, which is

usually nonallergic. Those who reacted only to indoor

allergens and those with chronic rhinitis showed no

association with skin text reactivity most likely be-cause the most important perennial indoor allergen,

house dust mite, was not included in the panel of

allergens tested.

ALLEN D. ADINOFF, MD Aurora, CO

EFFECTS OF MATERNAL DIET DURING LATE

PREGNANCY LACTATION ON THE

DEVELOPMENT OF IgE AND EGG-MILK-SPECIFIC IgE ANTIBODIES IN INFANTS

Lilja G, Dannaeus A, Foucard T, Graff-Lonnevig V, Johansson SCO, Oman H. Clin Exp Allergy. 1991;21:195-202.

Purpose of the Study

This study attempts to define the risk of developing

food allergy during the third trimester and early

breast-feeding ages. Study Population

The study population included 162 pregnant

women with respiratory allergies who gave birth to

166 newborns. Methods

The pregnant women were assigned randomly to a late pregnancy diet, with either “reduced” or “high”

quantity of cow milk and eggs. Serum samples were

obtained at birth, 2, 6, and 18 months of age and

analyzed for total IgE and egg/milk-specific IgE and

IgG. Skin tests to ovalbumin, ovomucoid, and

j3-lactoglobulin were done at 6 and 18 months of age.

Findings

Serum IgE levels and egg/milk-specific IgE and IgG

did not differ between the “reduced’ and the “high”

groups. A claim is made for a relationship between

IgE and IgG antibody response for egg but not for

milk. This is based on the presence of serum IgE to

ovomucoid along with significant higher serum IgG

to ovomucoid at 6 and 18 months. There was good

correlation between radioallergosorbent and

skin-prick tests. The development of clinically noted atopy

was no different between the two groups. The authors

note “determinations of IgG antibody levels to food

allergens have only a limited value.’ Reviewer’s Comments

This study pessimistically supports the thesis that the atopic infant can’t be deterred from its genetic

programming. However, the restriction of egg/milk

was relative, and other potential sensitizers (food and inhalant) were not controlled. A suggestion of “high’

and “low’ responders with IgE and IgG to specific

foods is only hypothetical because this was not

sup-ported by the ovalbumin of i3-lactoglobulin data.

Perhaps the measurement of IgG antibody to food

should be considered of limited value even in

re-search!

CLIFTON T. FURUKAWA, MD Seattle, WA

Upper

Airway

Disorders

PATHOPHYSIOLOGY

LARYNGEAL CHANGES DURING EXERCISE AND

EXERCISE-INDUCED ASTHMA

Hurbis CG, Schild JA. Ann Otol Rhinol Laryngol.

1992;100:34-37.

Purpose of the Study

This study was performed to determine the effect of exercise on the larynx in healthy and asthmatic patients.

Study Population

Thirty subjects aged 18 to 35 years were studied. There were 15 healthy subjects and 15 with only exercise-induced asthma.

Methods

All subjects had an endoscopic examination of their

laryngeal area where photographic images were

re-corded for measurement of inspiratory and expiratory glottic areas. All were then exercised at 75% to 85% of their predicted maximum heart rate for 8 minutes, breathing cold dry air. Laryngoscopy and pulmonary functions were performed after 8 minutes of exercise and again after 5 minutes of rest.

Findings

In healthy individuals and in asthmatic patients

whose forced expiratory volume changed less than

5%, the laryngeal opening increased in size, whereas

asthmatics whose forced expiratory volume dropped

in excess of 5% showed a narrowing of the glottic area.

Conclusions

The normal enlargement of the glottic space allows

for less resistance, making the increase of minute

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ALLEN T. SEGAL, MD Dallas, TX

TREATMENT

294 ALLERGY AND IMMUNOLOGY

volume that is demanded by exercise less

energy-intense. The moderate asthmatic, on the other hand,

has a decrease in size to further increase the work of

breathing. The benefits of such an increase may be

an endogenous method to apply positive

end-expir-atory pressure, thus keeping airways open.

Comments

As I read this I couldn’t help think of the asthmatic

who is so hard to manage with laryngeal spasm.

Perhaps these people have an exaggerated and

pro-longed physiologic response.

THAD H. Joos, MD Grosse Pointe Woods, MI

THE EFFECT OF INDOOR AIR POLLUTANTS ON

OTITIS MEDIA AND ASTHMA IN CHILDREN

Daigler GE, Markello SJ, Cummings KM. Laryngoscope.

1991;101:293-296.

This study was designed to investigate the

relation-ship between exposure to indoor pollutant sources

and the risk of having otitis media or asthma in

children.

Patients came from a private pediatric practice

dur-ing an 8-month period. There were 169 children seen

with two or more separate episodes of otitis. There

were 171 children either hospitalized with asthma or

seen in the office two or more times with asthma.

Controls were 342 children seen for routine health

maintenance.

Methods

A questionnaire designed to assess exposure to air

pollutants was mailed to all 682 children’s families with a 74.5% response.

Findings

Compared to controls, patients with otitis and those

with asthma were more likely to be male and to have

been born prematurely or with breathing problems.

Those with asthma tended to be older and to have a

family history of asthma, allergic rhinitis, or otitis.

There did not seem to be significant difference

among the groups in type or age of homes or the use

of electric heat, fireplaces, and gas cooking. Patients

with asthma were more likely to use humidifiers, but

that was consistent with physician instructions. Those with asthma did have a significantly higher incidence

of pets in the home as well as maternal smoking.

There was a correlation in the otitis group with the

use of wood-burning stoves.

Most of the pollutant sources assessed by this study were not associated with disease, specifically formal-dehyde, dust, or nitrous oxide.

Reviewer’s Comments

The authors point out that more objective means

are necessary to measure pollutant exposure than by

questionnaire. More accurate relationships between

pollution and disease then can be identified if they, indeed, exist. We must await future studies.

PEDIATRIC SINUSITIS

Duplechain JK, White JA, Miller RH. Arch Otolaryngol Head Neck Surg. 1991;117:422-426.

This study was performed to determine the efficacy

of endoscopic sinus surgery compared with

conven-tional surgery in pediatric patients.

The charts of 32 children who were treated for

recurrent sinusitis during a 2-year period were

re-viewed retrospectively.

Methods

All 32 patients had undergone sinus surgery by

both endoscopic and conventional techniques, and

their families were contacted by means of a question-naire regarding the efficacy of the endoscopic proce-dure.

Findings

The data gathered by the questionnaires showed a

favorable response to the endoscopic procedure in

the following parameters: postoperative pain, length of recovery, nasal discharge, frequency of upper res-piratory tract infections, nasal congestion, taste,

head-ache, night cough, daily comfort, and number of

school days missed. Eighty-six percent of the parents

favored the endoscopic surgical method to other

forms of treatment.

The authors reported less blood loss with the

en-doscopic technique, as well as a lack of operative complications.

The authors conclude that endoscopic sinus surgery is safe, effective, and well-tolerated in pediatric pa-tients.

All their patients were cared for by a pediatric allergist and/or pulmonologist at the time of surgery.

It is comforting to know that when our best efforts

fail in these stubborn cases of recurring/chronic si-nusitis, there is a safe and effective surgical option, even in the little ones.

ALLEN T. SEGAL, MD Dallas, TX

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SUPPLEMENT 295

RANDOMIZED, CONTROLLED TRIAL

COMPARING LONG-TERM SULFONAMIDE

THERAPY TO VENTILATION TUBES FOR OTITIS

MEDIA WITH EFFUSION

Bernard PAM, Stenstrom RJ, Feldman W, Durieux-Smith A. Pediatrics. 1991;88:215-222.

This study compares the effectiveness of medical

management with sulfisoxazole for 6 months and

surgery with ventilation tube placement in terms of

treatment failures, and side effects in patients with long-standing middle ear effusion.

1 25 subjects were enrolled after having met the

following criteria: (1) ages 2.5 to 7 years; (2) middle

ear effusion exceeding 3 months as determined by

tympanogram and otoscopic examination; (3)

two-physician documentation of failure of antibiotics for acute otitis media or otitis media with effusion for at least 10 days in the preceding 3 months; (5) hearing loss of at least 25 decibels, air conduction at two or more frequencies in at least one ear; (6) bone conduc-tion threshold within normal limits; (7) otomicros-copic evidence of middle ear effusion in at least one

ear; (8) air/bone gap of greater than 15 decibels at

frequencies with elevated air conduction thresholds. Exclusion criteria included cervicofacial

abnormal-ity, documented immune deficiency, documented

al-lergy to sulfonamides, previous ventilation tubes

(VT), or documented speech delay. Methods

Following an informed parental consent, subjects

were randomized to “medical’ treatment consisting of

sulfisoxazole (75 mg/kilo in two doses) for 6 months

or “surgical treatment,’ in which they underwent

bilateral myringotomy and insertion of VTs. Subjects

were seen at 2, 4, 6, 12, and 18 months following

entry into the study and were judged success or failure at 6-, 12-, and 18-month points.

Treatment failure was defined as one of the follow-ing: (1) persistent or recurrent middle ear effusion and associated hearing loss of greater than 25 decibels at greater or equal to two frequencies in at least one ear; (2) allergic reactions to sulfonamides; (3) three or

more episodes of acute otitis media over a 6-month

period of the study. Findings

Analysis of data utilizing a modified Chi technique

revealed that a greater proportion of the surgical

patients than medical patients were treatment

suc-cesses over the three time points analyzed simulta-neously. In terms of hearing, surgical subjects were hearing significantly better than medical subjects at 2 and 4 months, but not at 6, 12, and 18 months. There were no differences in the incidence of acute otitis

media at any time point. Side effects were noted in

9.2% of medical subjects and consisted mainly of skin

rash, while one or more complications occurred in

50% of the surgical patients and included otorrhea,

myringosclerosis, superinfection, and foreign body

reaction. Retreatment, either medical or surgical, was

required in 67% of medical and 48% of surgical

subjects.

Conclusion

Although surgical treatment with VT proved

slightly superior in terms of overall success, 33% of

subjects who were candidates for VT were treated

successfully with prophylactic sulfonamides. There

were no significant differences in hearing threshold 6 to 18 months after each treatment modality. On the

other hand, VT placement was more often fraught

with complications, including myringosclerosis,

which may be important in the long run. Although

the final answer is not yet in, these investigators recommend a 6-month trial of antibiotics before con-sidering VT placement.

This is an excellent example of a cooperative ven-ture between pediatric and ear, nose, and throat spe-cialties. Although the study was not blinded or

pla-cebo-controlled, both of which would have been

dif-ficult, the design was sound and the study carefully done. These data strongly suggest that prophylactic antibiotics over a longer period should be tried before subjecting the child to surgery where there is potential

risk and increased cost. I agree with the author’s

suggestion that therapeutic doses of more potent an-tibiotics for the first 3 to 4 weeks (similar to treating a sinus infection, which not infrequently coexist) and

then using a prophylactic regimen may be even more

effective and needs careful scrutiny in the future.

Lower

Airway

Disorders

PATHOPHYSIOLOGY

STANLEY P. GAwrr, MD Orange, CA

RELATIONSHIP OF PARENTAL SMOKING TO

WHEEZING AND NONWHEEZING LOWER

RESPIRATORY TRACT ILLNESSES IN INFANCY

Wright AL, Holberg C. I Pediatr. 1991;118:207-214.

Purpose of the Study

This study was designed to establish the impact of

parental smoking on lower respiratory tract illness.

A large cohort of infants was followed up prospec-tively from birth.

Methods

Illnesses were diagnosed by physicians using the

agreed-on criteria and parental smoking histories

were obtained by questionnaire. Lower respiratory tract illnesses were differentiated into wheezing and

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1992;90;293

Pediatrics