Upper Airway Disorders

of hydroxyzine and ranitidine; or (4) placebo. This was followed 2 hours later by an intravenous infusion of

vancomycin (1000 mg) for 60 mm in 200 mL of 5%

dextrose. Blood samples were obtained for serum hista-mine and vancomycin concentrations during and 60 mm-utes after the end of the infusion. Subjects were

moni-tored for blood pressure changes and development of

erythema and also were asked to report the intensity of pruritis. The study was done in a double-blind fashion. The same subjects were retested with a different antihis-tamine regimen (or placebo) after a 7-day washout.

Findings

Pretreatment with hydroxyzine alone provided signif-icant protection against vancomycin-induced erythema and pruritis (P < .05), whereas the effect of ranitidine did not differ from placebo. The combination of raniti-dine and hydroxyzine offered no advantage over hydroxy-zine alone.

Reviewer’s Comments

Vancomycin-induced red-man syndrome may occur in

up to 80% to 90% of patients receiving this drug; it is due to histamine release into the plasma. As vancomycin is used frequently for patients with penicillin allergies, the allergist may be consulted for help in treatment of these

patients. The prevention of red-man syndrome by

hy-droxyzine would be useful in the treatment of patients requiring vancomycin.

ROBERT L. ROBERTS, MD, PHD Los Angeles, CA

Upper

Airway

Disorders

PfhnnhuinInnv

RELATIONSHIP BETWEEN MILK INTAKE AND MUCUS PRODUCTION IN ADULT VOLUNTEERS CHALLENGED WITH RHINOVIRUS-2

Pinnock CB, Graham NM, Mylvaganam A, Douglas RM. Am Rev Respir Dis. 1 990;1 41:352-356.

Purpose of the Study

This study was performed to investigate the widely held belief that “milk produces mucus.”

Study Population

Included in the study were 60 adult volunteers, aged 18 to 35 years, who were nonsmokers, free of respiratory disease, and not taking regular medication.

Methods

Cross-sectional Study Design. After completing a per-sonal history and dietary questionnaire, subjects were

inoculated with Rhinovirus-2 and then lived communally for 10 days with food supplied by a caterer. At the onset of symptoms subjects were randomized to take either aspirin (4 g), paracetanol (4 g), ibuprofen (1.2 g), or placebo. Subjects recorded on a 4-point scale the severity of the following symptoms: runny nose, blocked nose, postnasal drip, loose cough, dry cough, and congestion. In addition, nasal secretion weights were measured by weighing tissues before and after use.

Findings

Fifty-six volunteers were infected successfully and shed virus on at least 4 days. Data were analyzed on 51 patients for whom satisfactory diaries were kept. There was no significant difference in overall symptoms or mucus production in the 4 treatment groups. However, patients taking aspirin, paracetamol, and ibuprofen re-ported higher nasal obstruction scores (P = .022) and experienced more nasal tubinate swelling (P = .026) than did those taking placebo. When present, a nonsignificant trend was observed for the patients’ cough to be loose with increasing dairy product intake. Of the subjects who believed before the study that milk was bad for colds, 80% believed it produced more mucus, perceived them-selves as more symptomatic, and drank less milk during the study than those who did not believe “milk makes

mucus.” However, this increased loose cough was not

accompanied by a parallel increase in the measure of mucus weights.

Reviewer’s Comments

This is the first of three reports studying the possible effects of milk intake on mucus production. The next two studies will involve 5- to 17-year-old asthmatic children and 12-month-old infants. Although the authors conclude “that no statistically significant overall association was detected between milk intake and the symptoms of mucus production in healthy adults symptomatic or asympto-matic, with rhinovirus infection.” It must be remembered that the study design was cross-sectional; if there was simultaneous and opposing association between milk in-take and mucus production, this type of study design would not be able to distinguish a difference. The authors pointed out that a negative finding in this study cannot be accepted at this time as a basis for rejecting the belief that milk produces mucus. Nevertheless this is an impor-tant study which looks at a commonly held belief and attempts to document the facts objectively. Obviously pediatricians and pediatric allergists will be extremely interested in the results of the next two studies.

JAMES P. KEMP, MD San Diego, CA

INFLUENCE OF NASAL ALLERGIC REACTIONS ON THE CLEARANCE OF MIDDLE EAR EFFUSION

Purpose of the Study Study Population The purpose of this study was to determine the effect

of nasal allergic reactions on the clearance of middle ear effusion (MEE) using an animal model.

Methods

A group of guinea pigs were sensitized passively and subsequently challenged intranasally. In about a third of these animals an immunocomplex-mediated otitis media with effusion (OME) was induced.

Findings

Following intranasal antigen challenge, the guinea pigs showed sneezing, hypersecretion, and oral breathing. His-tologically, there was mast cell and eosinophilic infiltra-tion in the mucous membranes lining the nasal cavity, nasopharynx, and pharyngeal orifice of the eustachian tube. In those animals in which MEE was induced, the effusion persisted for at least 26 days but not as long as 36 days. Histologic changes seen in the mucous mem-branes lining the tympanic cavity and eustachian tube of

ears with MEE resembled changes previously seen in

immunocomplex-mediated OME rather than type 1

a!-lergic reactions. Ears that were not inoculated with

im-munocomplex did not develop MEE. From this study and a previous one they found that the eustachian tube is involved in type 1 allergic reactions of the nose and that the tubal dysfunction is transient, without culminating in MEE. Furthermore they feel that it is unlikely that type 1 allergy is a causal factor for OME. The present study clearly showed that nasal allergic reactions inter-fere with the clearance of MEE and that repeated attacks do not cause MEE. They feel that treatment of allergy, combined with the treatment of OME, is recommended in patients having both nasal allergy and OME.

Reviewer’s Comments

This study confirms that allergic rhinitis can affect the ears, but that is unlikely to cause OME without some other as yet undefined factor(s). If a patient has both allergic rhinitis and OME, both must be dealt with.

ALLEN T. SEGAL, MD Dallas, TX

PROGNOSIS OF SECRETORY OTITIS MEDIA IN RELATION TO VISCOELASTICITY OF EFFUSION IN CHILDREN

Takeuchi K, Majima Y, Hirata K, Morishita A, Hattori M, Sakakura Y. Ann Otol Rhinol Laryngol. 1989;98:443-446.

Purpose of the Study

This study was performed to determine if the visco-elasticity of middle ear effusion (MEE) was related to the ultimate outcome of serous otitis media in children.

The MEE from 93 ears in 69 children with serous otitis

media who were treated only with myringotomy under

local anesthetic every 1 to 2 months was collected. These children were followed up for at least 1 year with serial tympanograms.

Methods

The viscoelasticity of the MEE was measured by an oscillating sphere magnetic rheometer and reported in hertz for elasticity and dynamic viscosity.

Findings

Patients with hertz values for elasticity in the 6.31 to 63.1 range and dynamic viscosity in the 0.631 to 6.31

range cleared 84% of the time within 4 months. All

patients regardless of their values were not clear in 1 year. Measuring the viscoelasticity of MEE can be useful in determining the prognosis and, to a degree, treatment of serous otitis media in children.

Reviewer’s Comments

The approach to treatment of serous otitis media by frequent myringotomy is certainly foreign to current methods in the United States, but it may warrant closer scrutiny. The determination of the viscoelasticity of the MEE sounds like a worthwhile procedure and perhaps should be done when ventilating tubes are inserted.

THAD H.

JooS,

THE MICROBIOLOGY OF CHRONIC SINUS DISEASE IN CHILDREN WITH RESPIRATORY ALLERGY

Goldenhersh MJ, Rachelefsky GS, Dudley J, Brill J,

Katz RM, Rohr AS, Spector

SL, Siegel

SC, Summanen

P, Baron EJ, Finegold S. J Allergy Clin Immunol. 1 990;85: 1030-1039.

Purpose of the Study

The study was performed in an attempt to identify both the prevalent organism in the paranasal sinuses of children with respiratory allergies and chronic sinusitis and to determine the most effective first-line therapy.

Study Population

Methods

Diagnosis

Each patient was evaluated by a complete blood count and differential, quantitative immunoglobulins, IgG sub-classes, and nasal smear. Sinus aspirates were cultured for aerobic and anaerobic organisms and sensitivities. Radiographs were done on initial entry, 2 weeks after aspiration and irrigation, and if still abnormal, 4 weeks after.

Findings

1 1 of 12 patients had received at least 2 antibiotics for 5 or more weeks. 10 of 12 patients had bilateral maxillary sinusitis; 2 of 12 had right-sided sinus disease.

Gram stains of sinus aspirates were generally negative for bacteria. 5 of 12 had pure growth of Moraxella catar-rhalis (4 were /3-lactamase positive). 4 of 12 grew mixed species to include the following organisms: M catarrhalis, Streptococcus species, Peptostreptococcus mixed with

Streptococcus viridans. All M catarrhalis were susceptible to cefotoxin, erythromycin, amoxicillin/clavulanate, and trimethoprim/sulfamethoxazole. Three patients’ sinuses yielded no growth. 9 of 12 patients received culture-directed therapy after irrigation. 10 of 12 improved by 2 weeks after the procedure, and the remaining 2 improved after 3 weeks. All had clearing of sinuses by roentgeno-gram within 4 weeks.

Conclusions

The authors stated that the microbiology of chronic sinusitis in allergic children has not been studied ade-quately. In nonallergic children, Streptococcus pneumo-niae, Haemophilus influenzae, and M catarrhalis predom-mate. In contrast to adults with chronic sinusitis, anaer-obes are an uncommon organism in children. All patients responded rapidly to aspiration and irrigation with cul-ture-directed antibiotics. The authors recommended treating allergic children who had chronic sinusitis with an initial 3-week therapy directed against common path-ogens, especially M catarrhalis. If a patient did not re-spond completely, starting another antibiotic for 3 weeks was appropriate. If the sinusitis still persisted at that time, they urged aspiration and irrigation of sinuses with culture-directed antibiotics.

Reviewers’ Comments

This study, although it represents a small study pop-ulation, demonstrates the significance of /3-lactamase-positive M catarrhalis in the aspirates of children with chronic sinusitis. Most of these patients were somewhat recalcitrant to therapy, and it is interesting to postulate that the mechanical irrigation of the sinuses was the actual factor to cause improvement of these children. The authors recommendation of sinus irrigation in the cases which have not responded to 2 adequate courses of anti-microbial agents is certainly one to consider strongly in these cases.

ALMA M. HERRERA, MD Mobile, AL

RUSSELL J. Hopp, DO Omaha, NE

NASAL EOSINOPHILIA IN ALLERGIC AND NON-ALLERGIC RHINITIS: USEFULNESS OF THE NASAL SMEAR IN THE DIAGNOSIS OF ALLERGIC RHINITIS

Lans DM, Alfano N, Rocklin R. Allergy Proc. 1 989;1 0:275-280.

Purpose of the Study

This study was conducted to determine prospectively the frequency of nasal eosinophilia (NE) in patients in whom having allergic rhinitis (AR), nonallergic rhinitis, and other atopic conditions not involving the respiratory tract have been diagnosed.

Study Population

The study included 1 10 adult patients aged 19 to 72

years who came to Tufts-New England Medical Center

Allergy Clinic. Patients on local or systemic steroids and those with chronic rhinitis with polyposis and/or aspirin sensitivity were excluded.

Methods

All patients had complete history, physical, and skin testing. Sinus roentgenograms and nasal cultures were done if sinusitis or polyposis were suspected. Patients who had negative skin tests were classified as having vasomotor rhinitis if nasal polyps and sinusitis were ruled out. Patients who had asthma, with and without rhinitis, were included. Nasal smears were done by gently scraping the inferior aspect of the inferior nasal turbinate with the rhinoprobe. Eosinophilia was considered to be present if greater than 20% of the cell population consisted of eosinophils.

Findings

Sixty-one patients had classic AR and 26 (43%) had NE. None of 11 patients with nonallergic rhinitis had NE. 2 of 14 patients who reacted to dust or mite had NE (14%). Of 12 patients with other allergic diseases not involving upper respiratory tract (urticaria, food allergy, asthma without rhinitis, atopic dermatitis, and stinging insect reaction) only one had NE (atopic dermatitis with peripheral eosinophilia). None of 18 control patients had NE. 5 of 13 asthmatics with rhinitis (38%) had NE.

Conclusions

Reviewer’s Comments

This study nicely demonstrates that, although a posi-tive nasal smear for eosinophils is found in only 43% of cases with probable AR, it is a highly specific test. The fact that only one patient without allergic rhinitis had NE fully supports this contention. Thus a positive nasal smear associated with positive skin tests clearly indicates a diagnosis of AR if the history itself is inconclusive.

JAY E. SELCOW, MD West Hartford, CT

ABNORMAL

MAXILLARY

SINUS RADIOGRAPHS

IN

CHILDREN: DO THEY REPRESENT BACTERIAL INFECTIONS?

Arruda LK, Mimica IM, Sole D, Weckx LLM, Schoettler J, Heiner DC, Naspitz CK. Pediatrics. 1 990;85:553-558. Purpose of the Study

The purpose of the study was to establish whether abnormal maxillary sinus roentgenograms in sympto-matic children represented bacterial infection.

Study Population

The study included 33 children with chronic tonsillitis and/or adenoid enlargement without previous diagnosis of sinusitis.

Methods

Puncture of the maxillary sinus was performed with surgery for adenoidectomy and/or tonsillectomy, and the aspirates were cultured.

Findings

Streptococcus pneumoniae was isolated from 8 (67%) of 12 patients whose roentgenograms showed completely opacified maxillary sinus; 21 patients (29%) had normal maxillary sinus radiographs and also had various varieties of streptococcus or staphylococcus recovered, and bacte-rial titers were greater than 10 colonies per mL in all but one positive culture. No anaerobes were isolated. A his-tory of bronchial asthma with the presence of nasal purulent secretions, elevated blood eosinophils, and ele-vated serum IgE were associated more frequently with children who had complete opacification of the maxillary sinus. Serum IgG2 levels were low in 29% of the children, but there was no correlation between low IgG2 levels and positive cultures from maxillary sinus aspirates.

Reviewer’s Comments

Children with complete radiologic opacification of the maxillary sinuses had bacterial infection in 70% of the cases. Their symptoms were usually inapparent such that physicians did not consider the diagnosis of sinusitis.

This highly significant study verifies that children with complete opacification of the maxillary sinus should be

treated with antibiotics relative to clinical symptoms to avoid potential complications of sinusitis in the pediatric group.

Treatment

CHRISTOPHER RANDOLPH, MD Waterbury, CT

THE EFFECT OF INTRANASAL NEDOCROMIL SODIUM ON VIRAL UPPER RESPIRATORY TRACT INFECTIONS IN HUMAN VOLUNTEERS

Barrow GI, Higgins PG, Al-Nakib W, Smith AP, Wenham RBM, Tyrrell DAJ. Clin Exp Allergy. 1990;20:45-51.

Purpose of the Study

This study was conducted to determine if nedocromil can reduce clinical symptoms and performance impair-ment associated with the common cold.

Study Population

Included in the study were nonallergic adults aged 18 to 50 years.

Methods

Two viral groups were used: rhinovirus and coronavi-rus. After an examination and blood tests with normal results and a 2-day quarantine from any ill persons, the volunteer’s nose was sprayed with (blinded, randomly chosen) nedocromil or placebo, 4 times a day for 7 days (28 doses). One hour after the fifth dose, the virus chal-lenge was done. For rhinovirus, this was 100 median tissue culture infective doses (TCID50) of human RV9, followed by a dose of RV14 1 hour later. For coronavirus, a single challenge of 750 TCID of strain 229E was used.

Findings

Symptom scores and nasal secretions were reduced significantly for the rhinovirus group, which had nedo-cromil (20 subjects) versus placebo (19 subjects). Al-though not significant, there was a favorable trend for the coronavirus group, which had nedocromil (27 sub-jects) versus placebo (26 subjects). Performance tests were significantly less impaired for all patients who de-veloped a cold but were on nedocromil, versus those on placebo.

Reviewer’s

Comments

attacks and in therapy directed toward the prevention of asthma associated with respiratory infections.

CLIFTON T. FURUKAWA, MD Seattle, WA

POSTERIOR SUBCAPSULAR CATARACTS

ASSOCIATED

WITH NASAL

OR INHALATION

CORTICOSTEROIDS

Fraunfelder Fr, Meyer SM. Am J Ophthalmol. 1 990;1 09:489-490.

Purpose

of the

The purpose of this study was to evaluate the incidence of posterior capsular cataracts in patients using nasal or inhaled corticosteroids.

Study Population

Twenty-one patients (16 to 72 years of age) were

obtained from review of the National Registry of Drug-induced Ocular Side Effects.

Methods

Information was obtained on patients reported to have developed posterior capsular cataracts possibly associated with the use of nasal or inhaled beclomethasone dipro-pionate.

Findings

Most patients had used the medication for more than 5 years and often at higher than the recommended dos-ages of 42 g to 84 zg three times per day. The results were obtained by review of records of patients demon-strated to have posterior capsular cataracts. One patient also was receiving dexamethasone, and 9 had received an undetermined course of systemic steroids.

Reviewer’s

Comments

Although this retrospective report is of a small popu-lation and many of these patients had also received systemic corticosteroids, it is an interesting observation and certainly something to consider when treating pa-tients with long-term nasal or inhaled steroids. Systemic

absorption and hypothalamic-pituitary adrenal axis

suppression has been observed in patients receiving higher than recommended dosages, and the possibility of individual variation of absorption among different pa-tients also exists.

ALMA M. HERRERA, MD Mobile, AL

SINUS DISEASE

IN PATIENTS

WITH SEVERE

CYSTIC

FIBROSIS: RELATION TO PULMONARY

EXACERBATION

Umetsu

DT, Moss RB, King VV, Lewiston

NJ.

Lancet.

1 990;335:1 077-1078.

Purpose

of the Study

The purpose was to investigate if there is a relationship between sinus disease and lower respiratory tract disease in cystic fibrosis (CF) and whether aggressive manage-ment of sinus disease would improve pulmonary status.

Study Population

Four adult patients with CF (3 male), mean age of 26 years (range 18 to 35 years of age) were selected because of “severe pulmonary disease” (mean FVC 43% of pre-dicted), “a high frequency of hospital admission,” head-ache and wheezing, and unresponsiveness to

conven-tional treatment. The mean Shwachman score was 50

(range 33 to 63), indicating moderate to severe disease. All had nasal congestion and complete opacification of maxillary and ethmoid sinuses on roentgenography. None had nasal polyps. Three complained of postnasal drip. The allergy status was not specified, and three had wheez-ing. Three were on maintenance Prednisone (average daily dose, 37 mg/day; range, 10 to 60 mg/day).

Methods

Preoperatively, they received in-hospital

anti-Pseu-domonas antibiotics intravenously for 5 to 15 days. No further details were given. All had bilateral Caldwell-Luc procedures with antral windows. Three had

ethmoidec-tomy, and one had sphenoidectomy. The sinuses were

lavaged with anti-Pseudomonas antibiotics. Sinus mate-rial from all patients grew Pseudomonas aeruginosa. Each patient was treated by his/her physician. There was no

standardization of management or separate control

group. The 6 months pre- and postoperation were com-pared.

Findings

The three patients with wheezing had “substantially less wheezing” and headache was “substantially improved in all patients after surgery.” The mean FVC was un-changed postoperatively. Oral Prednisone was reduced postoperatively from a mean of 37 to 16 mg/day. The

mean number of hospital days decreased from the

6-month preoperative period to the 6-month postoperative period in each patient (mean 58 vs 28 days). The obser-vation periods began at different months for each of the patients.

Reviewer’s

Comments

The authors note that this was a pilot study. There was an impressive decrease in steroid use and days in the hospital, but no change in FVC. Although the authors invoke the analogy of the improvement in asthma usually seen with better control of sinus disease, it is not clear that we are seeing the same effect here. Although we have no good explanation for the results, perhaps we should be more aggressive in the management of sinusitis in CF. It certainly warrants further study in patients with less impaired lung function and perhaps in those without wheezing.

INCREASED

CILIARY

BEATING

FREQUENCY

OF

NASAL

MUCOSA

FOLLOWING

IMMUNOTHERAPY

FOR

ALLERGY

Ohashi Y, Nakai Y, Ikeoka H, Furuya II, Esaki Y, Kato

S.

Purpose

of the Study

This study was performed to examine the effect of

immunotherapy in patients with allergic rhinitis second-ary to house dust mite and the ciliary beating function (CBF) of their nasal mucosa.

Study Population

Included were 40 patients who had perennial allergic rhinitis without seasonal variation and who were skin test positive to Dermatophagoides farinae.

Methods

The patient group was divided into two groups of 20. One group received only antihistamines to control symp-toms, while the other patients were placed on immuno-therapy for D farinae. Before entering into the treatment phase, all patients had suitable ciliary specimens obtained and these had CBF determined.

Findings

About 1 year after treatment was begun, a follow-up ciliary biopsy was obtained and CBF determined. Clinical assessment of symptoms showed a 45% favorable re-sponse in the antihistamine group, whereas a 75% favor-able response was observed in the immunotherapy pa-tients.

With regard to CBF, no change was noted in the antihistamine group, whereas 50% of the immunotherapy control had a significant increase in CBF.

Conclusions

Although CBF is not the only factor in mucous clear-ance from the respiratory tree, it is an important one. More study is needed to define further the role of im-munotherapy on the mucociliary activity of nasal mucosa.

Reviewer’s

Comments

A remarkable work to my way of thinking; since, at least at our institution, ciliary activity has been a most difficult investigation.

THAD IL.

JooS,

Lower

Airway

Disorders

Purpose of the Study

The purpose of this study was to make a comparison of the seasonal variation in asthma hospitalizations with mortality in the United States.

Study Population

Hospitalization (hospital discharges) data were

ob-tamed from the National Hospital Discharge Survey

(sampling approximately 7% of US hospitals). Mortality data (death certificates) were obtained from the US Vital Records information system. Both encompassed the 5-year period, January 1, 1982 to December 21, 1986, and included data from all US residents.

Methods

Data were based on the recording of diagnostic code 493 of the International Classification of Diseases, Ninth Revision as either the cause of death or first-listed dis-charge diagnosis. Hospitalization and mortality rates were calculated using annual population estimates from the US Bureau of the Census. Data were compiled by age, sex, race, and region of the country.

Findings

General Trends. During the 5-year period asthma was reported as the principal discharge diagnosis for an esti-mated 458 000 hospitalizations annually (averaging 38 000 per month), with an average discharge rate of 1.92 per 1000 population. The highest rates were seen in children younger than 5 years old (4.47 per 1000 popula-tion) and for adults older than 65 years (3.32 per 1000 population). Hospitalization rates for nonwhites were nearly three times higher than those for whites. During the same 5-year period, there were 18 114 deaths due to asthma reported in all age groups in the US (average 300 per month), with an average annual mortality rate of 1.52 per 100 000 population. Death rates increased with age, from 0.17 per 100 000 population in children younger than 5 years to 6.71 per 100 000 population in adults older than 65 years of age. Death rates for nonwhites were nearly twice those of whites. Overall mortality rates increased 25% from 1982 to 1986.

Seasonal Trends. For patients older than 35 years of age, the seasonal pattern in hospitalization was approxi-mated closely by the seasonal mortality pattern. Both peaked in the winter months, extending into the early spring (January through April). For younger patients 5 to 34 years old, the seasonal hospitalization data showed a large peak in the fall (September through November) and a small peak in March. But mortality data in this age group showed the peak in the summer months (June through August) with another increase in November. A disproportionate number of these deaths did not occur in hospitals.

SEASONAL

TRENDS

IN U.S. ASTHMA

HOSPITALIZATIONS AND MORTALITY

Weiss

KB.

Conclusion

1991;87;992

Pediatrics

Upper Airway Disorders

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