Deficiency in interferon production by leukocytes from children with recurrent respiratory infections

In vitro interferon production by peripheral blood mononuclear cells from 50 children suffering from recurrent upper respiratory tract infections was examined, and compared with that of 50 healthy children. Five respiratory pathogenic viruses and Mycoplasma pneumoniae were used as inducers. Cells from every child responded to at least three out of the six inducers by interferon production. As a group, cultures prepared from patient cells showed decreased production of IFN when stimulated with adeno, rhino, corona or RS viruses or with the mycoplasma. Similar trend between the two groups of children was seen as regards influenza A virus induced IFN production in leukocyte cultures. These results corroborate our previous findings that relative deficiency in interferon production appears to be inducer-specific, and suggest that this phenomenon may have a role in the pathogenesis of recurrent respiratory infections.

Vaccination and otitis media

Acute otitis media (AOM) caused by Streptococcus pneumoniae, Haemophilus influenzae or Moraxella catarrhalis may induce specific systemic and/or local immune responses, which may protect from otitis media caused by the same bacteria. However, earlier clinical trials with pneumococcal capsular polysaccharide vaccines have not been successful in preventing AOM. Recently developed pneumococcal polysaccharide-protein conjugates proved immunogenic even in infants, and a heptavalent pneumococcal CRM 197 conjugate vaccine gave a 57% reduction in the number of pneumococcal AOM episodes caused by the vaccine serotypes in infants in Finland. H. influenzae causing AOM is noncapsulated, and like M. catarrhalis, calls for another kind of vaccine development. Suitable vaccine candidates are not yet available but are under development and being tested for immunogenicity and safety. In some trials influenza vaccines have shown protection from AOM during respective viral epidemics. Passive immunoprophylaxis might be an important alternative for immunocompromised children, although this approach has not been successful so far. Mucosal immunization and the advent of DNA and gene technology will open new interesting prospects in the future.

The pure-tone hearing thresholds of otologically healthy 14-year-old children

The mean pure-tone air conduction (AC) and bone conduction (BC) hearing thresholds (HT) of 534 randomly selected, caucasian, white, urban children with normal otoscopy, otomicroscopy and impedance audiometry, i.e. normal middle ear function, are presented here. Children with pathological middle ear findings or abnormal impedance audiometry were excluded. The average age was 13.8 years, SD 0.5, at the date of examination. The mean air conduction thresholds varied between 0.6 dB at 1 kHz and 9.9 dB at 6 kHz, and the bone conduction thresholds varied between -1.1 dB at 0.5 kHz and 1.1 dB at 4 kHz. The pure-tone average (PTA) (the average of AC hearing thresholds of 0.5, 1 and 2 kHz) of all ears was 1.5 dB. Ninety to ninety-eight per cent of pure-tone AC hearing thresholds at frequencies of 0.5-4 kHz were between -5 dB and 10 dB. The distributions are presented and compared.

Clinical outcome of acute pneumococcal otitis media and serum antibody responses to pneumococcal pneumolysin and polysaccharides in children

Serum antibody responses to pneumococcal antigens and their relationship to the clinical outcome were determined in a prospective study of 121 children with acute otitis media (AOM). Pneumococcus positive children with a pneumolysin response more often had a recurrence and middle ear effusion (MEE) after 1 month than did the non-responders (p = 0.005 and p = 0.04, respectively). All the children who responded to pneumolysin also had clinically strong symptoms and signs of AOM. Children who responded to pneumococcal polysaccharides developed otitis media with effusion within a 6-month follow-up period more often than did the non-responders (p = 0.005). The results of this study suggest that children with pneumococcal AOM and an antibody response to the intracellular pneumococcal protein pneumolysin behave clinically differently from children with an antibody response to polysaccharides.

Factors associated with the development of recurrent acute otitis media--the significance of choosing the right and accurate dependent and independent variables in the multivariate analysis

The results of univariate and multivariate statistical analysis were compared in identifying predictive factors of the development of recurrent acuta otitis media (RAOM) after an initial episode of acute otitis media (AOM) in 121 children. Univariate correlations between the development of RAOM and potential risk factors were analysed, and variables at p < 0.10 were incorporated into the stepwise multiple logistic regression analysis. The comparisons between the univariate and multivariate analysis in identifying the predictive factors were made and the importance of changing the dependent variables in the multivariate analysis was analysed. It seems that univariate analysis is over-sensitive, but multivariate analysis is over-conservative in finding possible predictors of RAOM. Choosing the right and accurate dependent and independent variables in the multivariate analysis is extremely important, when this method is used.

Efficacy of a pneumococcal conjugate vaccine against acute otitis media

BACKGROUND

Ear infections are a common cause of illness during the first two years of life. New conjugate vaccines may be able to prevent a substantial portion of cases of acute otitis media caused by Streptococcus pneumoniae.

METHODS

We enrolled 1662 infants in a randomized, double-blind efficacy trial of a heptavalent pneumococcal polysaccharide conjugate vaccine in which the carrier protein is the nontoxic diphtheria-toxin analogue CRM197. The children received either the study vaccine or a hepatitis B vaccine as a control at 2, 4, 6, and 12 months of age. The clinical diagnosis of acute otitis media was based on predefined criteria, and the bacteriologic diagnosis was based on a culture of middle-ear fluid obtained by myringotomy.

RESULTS

Of the children who were enrolled, 95.1 percent completed the trial. With the pneumococcal vaccine, there were more local reactions than with the hepatitis B vaccine but fewer than with the combined whole-cell diphtheria-tetanus-pertussis and Haemophilus influenzae type b vaccine that was administered simultaneously. There were 2596 episodes of acute otitis media during the follow-up period between 6.5 and 24 months of age. The vaccine reduced the number of episodes of acute otitis media from any cause by 6 percent (95 percent confidence interval, -4 to 16 percent [the negative number indicates a possible increase in the number of episodes]), culture-confirmed pneumococcal episodes by 34 percent (95 percent confidence interval, 21 to 45 percent), and the number of episodes due to the serotypes contained in the vaccine by 57 percent (95 percent confidence interval, 44 to 67 percent). The number of episodes attributed to serotypes that are cross-reactive with those in the vaccine was reduced by 51 percent, whereas the number of episodes due to all other serotypes increased by 33 percent.

CONCLUSIONS

The heptavalent pneumococcal polysaccharide-CRM197 conjugate vaccine is safe and efficacious in the prevention of acute otitis media caused by the serotypes included in the vaccine.

Intralesional electrodesiccation of syringomas

BACKGROUND

Syringomas are common, benign adnexal tumors. In the periorbital area, they pose a cosmetic dilemma for both patients and physicians alike. Many different therapeutic modalities potentially can cause scarring, and recurrences are common.

OBJECTIVE

To develop a treatment method that minimizes scarring and subsequent recurrences.

METHOD

Each syringoma is treated with short bursts of high frequency low voltage electrodesiccation delivered with a fine needle electrode that is inserted into the center of the syringoma, as deeply as the reticular dermis.

RESULTS

Twelve patients treated over a 4-year period showed no permanent adverse effects postoperatively and no recurrences.

CONCLUSIONS

Intralesional electrodesiccation is a safe, nonscarring and, reliable method that can be used to eradicate periorbital syringomas.

Prognosis of acute otitis media: factors associated with poor outcome

Factors associated with poor outcome of acute otitis media (AOM) were analysed in 131 children aged 1/4 to 7 1/2 (median 2 1/2) years. After AOM, altogether 37 (28%) of the children had poor outcome: 15 children (12%) clinical failure (unimprovement or worsening of pre-treatment signs and symptoms within 2 weeks of onset of therapy) and 31 (24%) persistent middle ear effusion (MEE) > or = 1 month post-treatment. Of the different variables studied in multivariate analysis, age < 2 years (p < 0.01), history of allergic skin or respiratory symptoms (p = 0.02), > or = 6 h duration of pre-treatment earache (p = 0.01) and B. catarrhalis in MEE (p = 0.05) were associated with clinical failure. Children with previous adenotomy or unilateral AOM had no failures. Persistence of MEE at 1 month was associated with age < 2 years (p = 0.05), otitis proneness (p = 0.03), bilaterality of AOM (p < 0.01) and S. pneumoniae in MEE (p = 0.01) in univariate but not in multivariate analysis.

Prognosis of acute otitis media. Factors associated with the development of recurrent acute otitis media

Clinical factors associated with the development of recurrent acute otitis media (RAOM) (> or = 3 recurrences during 6 months' follow-up period) after acute otitis media (AOM) were analysed in 121 children aged 3 months to 7 years (median 2 years 6 months). After AOM, 19 (16%) children had primary recurrence (pre-treatment signs and symptoms firstly improved or cured, but worsened or recurred within 30 days' post-treatment) and 33 (27%) developed RAOM during 6 months' follow-up period. It seemed that children < 2 years of age (p = 0.04), children with bilateral disease (p = 0.007), strong infection status (p = 0.05), primary clinical failure (p = 0.04) and development of primary recurrence after AOM (p = 0.001) were significantly related to the development of RAOM in univariate analysis, but only children < 2 years of age (OR 1.5, 95% CI 1.0-5.7, p = 0.04) and the development of primary recurrence (OR 5.1, 95% CI 1.8-14.1, p = 0.002) related to the development of RAOM in multivariate analysis. None of the bacteria cultured from middle ear effusion were related to the development of RAOM.

Bacteriological findings and persistence of middle ear effusion in otitis media with effusion

The bacteriology of middle ear effusion (MEE) of asymptomatic otitis media with effusion (OME) was studied in 165 children, aged 5 months to 12 years, from the MEE samples obtained during tympanostomy under general anaesthesia in 1993-1994. MEE had persisted for 1 to 12 (mean 3.5) months. Major otitis pathogens (S. pneumoniae, H. Influenzae, B. catarrhalis and S. pyogenes) were cultured in 41% of the children under 2 years of age and in 17% of older children (p < 0.001). Respiratory infections and attacks of acute otitis media (AOM) during the last 6 months were also more frequent in children younger than 2 years (p < 0.001). The proportion of S. pneumoniae (25%) and H. influenzae (38%), but not of other bacteria, was higher in the children with less than 2 months' persistence of MEE as compared with those with a longer duration (8% and 3%) (p < 0.01). After 2 months, the occurrence of different bacteria remained relatively unchanged until 6 months' persistence of MEE, and thereafter no pathogens were culturable. Among the children adenotomized earlier, the proportion of those with major otitis pathogens in MEE was 8% compared with 32% in non-adenotomized children (p = 0.02). S. pneumoniae, B. catarrhalis or S. pyogenes were not culturable in any of the adenotomized children, while MEE grew them in 25% of the non-adenotomized children (p < 0.001). Since the MEE bacteriology of OME with less than 2 months' persistence resembles that of AOM, it may be that these cases represent a transitory phase between AOM and an established OME.

Extended high frequency hearing and history of acute otitis media in 14-year-old children in Finland

We studied the extended high frequency hearing of 573 white, urban, mean 13.8-year-old unselected children in Tampere, Finland. All their ear-related morbidity had been recorded since their birth and they had been examined at the ages of 7 months, 2 years, and some of them at 5 years. The extended high frequency audiometry was measured from 10 to 18 kHz, with 1 kHz steps, and the results were related to the number of attacks of acute otitis media (AOM) (0, 1-2, 3-7 and > or = 8) they had experienced. The mean pure tone hearing thresholds varied from 10.7 dB at 10 kHz to 37.0 dB at 18 kHz in the right ears and between 11.6 dB at 10 kHz and 37.4 dB at 18 kHz in the left ears. Among those with > or = 8 attacks of AOM the the thresholds were highest, the difference between them and each of the first 3 groups being statistically significant at 13 and 14 kHz. From 11 to 16 kHz the same difference was significant between the last (> or = 8 AOM) and at least 2 of the first 3 AOM groups. Numerous attacks of AOM may have a harmful effect on high frequency hearing in the long term.

Prognostication of Bell's palsy using transcranial magnetic stimulation

Transcranial magnetic stimulation (TMS) provides a method to noninvasive excitation of the facial nerve in its intracranial segment close to the internal acoustic meatus. Thus, the site of facial nerve activation with TMS is proximal to or within the site of the lesion in Bell's palsy. To evaluate the prognostic capability of TMS in unilateral Bell's palsy we examined 137 patients with this method, and compared the results with electroneuronography (ENoG). Within 0-4 days from the onset of palsy, the patients with elicitable TMS responses recovered better than those in whom TMS responses were not elicitable. If TMS was performed 5-9 days or 10-28 days after the onset of palsy, it did not provide any prognostic information. Based on amplitude side-to-side differences, ENoG did not contribute prognostic information during the first 9 days from the onset of palsy. Later on, 10-28 days after the onset of palsy, ENoG showed an increased capability to discriminate the patients with poor prognosis. Thus, elicitable facial motor response with TMS predicts good prognosis of Bell's palsy at an early stage whereas poor response with ENoG predicts less favorable prognosis at a later stage.

Virus-induced interferon production in leukocyte cultures from children with recurrent respiratory infections. A follow-up study

BACKGROUND

Lowered yields of virus-induced interferon (IFN) by leukocyte cultures were previously suggested to be associated with recurrent respiratory infections in children (Pitkaranta et al. (1993) Clin. Diagn. Virol. 1, 101-108).

OBJECTIVES

To investigate if the observed lowered IFN producing capacity was secondary to the underlying disease and, consequently, would be normalized after recovery of the child from the chain of infections.

STUDY DESIGN

Forty-eight 3-12-year-old children suffering from recurrent upper respiratory tract infections (acute otitis media included) were followed-up for 2 years. Their clinical condition and virus-induced interferon production in cultures of peripheral blood leukocytes were examined at the beginning and end of this period.

RESULTS

In 24 children the health improved strikingly during the follow-up, in 12 children a mild improvement took place, while 12 children remained constantly ill. IFN yields in cultures stimulated with corona- and respiratory syncytial viruses improved along with the clinical situation of the children. Parallel cultures induced with adeno-, influenza A or rhinoviruses did not show a similar correlation.

CONCLUSION

These results suggest that the relationship between interferon production by leukocyte cultures and recurrent infections is complex and may be virus-specific.

PCR assay for detecting Streptococcus pneumoniae in the middle ear of children with otitis media with effusion

We compared a newly developed pneumococcal polymerase chain reaction (PCR) for Streptococcus pneumoniae (Pnc) to bacterial culture in 123 middle ear effusion (MEE) samples of 123 children with otitis media with effusion (OME). For the pneumococcal PCR assay, DNA of MEE samples was purified by a QIAamp blood kit. The outer primers used amplified a 348 basepair region of the pneumolysin gene, and the inner a 208. Pnc was cultured in 14 (11%) and pneumolysin PCR was positive in 57 (46%) of the 123 MEE samples. All the culture positive samples were also PCR-positive. Both the samples with culturable Pnc and with positive pneumolysin PCR increased with shorter duration of OME and a greater number of acute otitis media during the preceding 6 months. In conclusion, pneumolysin PCR suggests pneumococcal involvement in MEE even in OMEs with no evidence of Pnc in culture, and thus offers a good diagnostic tool when a more accurate and sensitive pneumococcal diagnosis is needed.

Comparison of serum antibodies to pneumolysin with those to pneumococcal capsular polysaccharides in children with acute otitis media

BACKGROUND

Streptococcus pneumoniae is a major bacterial pathogens in acute otitis media. Pneumolysin is a species-specific protein toxin produced intracellularly by all clinically relevant pneumococcal strains, and antibodies to pneumolysin should therefore represent pneumococcal involvement in the disease, regardless of the serotype.

METHODS

Antibodies to pneumococcal pneumolysin and capsular polysaccharides were measured by enzyme immunoassay in acute and convalescent sera of 121 children with acute otitis media. A pneumococcal otitis episode was defined by a positive middle ear fluid culture and/or pneumolysin PCR.

RESULTS

Median age of the 10 children who developed a seroconversion response to pneumolysin was 1 year 8 months, and of the 21 children responding to polysaccharides it was 2 years 9 months. Eight of the 10 seroconversion responses to pneumolysin were of IgA class alone, whereas 17 of the 21 polysaccharide responses were of IgG class alone or IgG together with IgM and/or IgA. Of the 41 children with a pneumococcal otitis episode, 13 (39%) showed a seroconversion response, 3 (7%) to pneumolysin and 11 (27%) to capsular polysaccharides. The children with a pneumococcal otitis episode had lower titers of acute phase IgG to the capsular polysaccharide pool of S. pneumoniae (containing types 6B, 14, 19F and 23F), as compared with the titers in children with otitis caused by other pathogens and pneumococci only in the nasopharynx or not found at all (P = 0.04).

CONCLUSIONS

Serum antibodies to pneumolysin can be detected at an earlier age than those to the capsular polysaccharides. However, a seroconversion is rare and therefore of no diagnostic value. The presence of serum IgG to the pneumococcal capsular polysaccharides seems beneficial in the prevention of pneumococcal otitis.

Interferon production by leukocytes in children with otitis media with effusion

We have previously shown that leukocyte cultures of children suffering from recurrent respiratory tract infections produce less interferon (IFN) than those of healthy children. In the present study this tentative marker of recurrent infections was used to study the pathogenetic background of otitis media with effusion (OME). Altogether 57 consecutive children, aged 2-11 years, who came for tympanostomy and/or adenoidectomy were divided into three subgroups: 25 of them had OME and a history of recurrent acute otitis media (rAOM/OME+), 20 had OME without an infectious background (inf-/OME+), and 12 had a history of recurrent upper respiratory infections (inf +/OME-) without OME. All the children were free of acute illness at the time of sampling. Differences between the groups were seen in IFN yields when leukocyte cultures were stimulated with adeno-, rhino-, corona-, respiratory syncytial or influenza A viruses. Leukocytes from inf-/OME+ children produced more IFN than those of the other two groups. Though no sex differences in the IFN responses were seen among rAOM/OME+ and inf +/OME- children, leukocytes from inf-/OME+ girls produced significantly higher amounts of IFN than those of inf-/OME+ boys, or rAOM/OME+ and inf +/OME- children. These differences between clinically different groups of children support the view that the etiology of OME can be heterogeneous.

Antibody-secreting cells and their relation to humoral antibodies in serum and in nasopharyngeal aspirates in children with pneumococcal acute otitis media

Mucosal and systemic antibody responses to pneumococcal capsular polysaccharide were studied in 17 children with culture-verified pneumococcal acute otitis media. Serotype-specific antibody-secreting cells (ASCs) in peripheral blood and antibodies in acute and convalescent sera and nasopharyngeal aspirates were measured. A polysaccharide-specific ASC response was induced in all subjects. The response was age dependent, and the dominant antibody class was IgA. Three children > 24 months old had > 100 IgA-class ASCs/10(6) cells and serum and nasopharyngeal IgA responses; 2 had only a nasopharyngeal IgA response. None of 8 children < 24 months old showed a systemic response; however, a nasopharyngeal IgA response was detected in 1. Results suggest that whole pneumococci can induce a mucosal polysaccharide-specific antibody response independent of the systemic response. Results are also in accordance with earlier studies suggesting that the mucosal immune system matures earlier in life than does the systemic immune response.

Antibodies to pneumolysin and pneumococcal capsular polysaccharides in middle ear fluid of children with acute otitis media

Antibodies to pneumococcal pneumolysin and capsular polysaccharides were measured by enzyme immunoassay in 169 acute phase middle ear fluid samples of 116 children with acute otitis media. Antibodies to pneumococcal pneumolysin were detected in 84% and to capsular polysaccharides in 50% of the MEF samples. The Ig class detected most often was IgA to both types of pneumococcal antigens, and it was present in MEF even with non-detectable levels of serum IgA of the same specificity. 59% of the MEF samples positive for IgA to pneumolysin were also positive for secretory component of the same specificity, and 53% of IgA to capsular polysaccharide pool (containing serotypes 6B, 14, 19F, and 23F), respectively. This suggests both leakage of specific IgA from serum to the middle ear and local production of it. In contrast, specific IgG was detected in MEF only with concomitant IgG in serum. Antibodies to pneumolysin occurred in no relation to bacterial findings in MEF. On the contrary, IgG class antibodies to capsular polysaccharides, most likely serum-derived, were detected less often in MEF samples positive for pneumococcus than for other bacteria.

Nasopharyngeal antibodies to pneumococcal pneumolysin in children with acute otitis media

Pneumolysin, an intracellular protein toxin of all clinically relevant pneumococcal serotypes, is released in vivo during the autolysis of pneumococci and is believed to pave the way for intact pneumococci to invade and cause disease. Therefore, antibodies to pneumolysin should prevent its destructive function. We measured antibodies to pneumococcal pneumolysin in acute- and convalescent-phase nasopharyngeal aspirate samples of 120 children (median age, 2.5 years) with acute otitis media by enzyme immunoassay. Nasopharyngeal immunoglobulin M (IgM) and IgG class antibodies to pneumolysin were rarely detectable, whereas IgA class antibody was detected often, occurred independently of serum IgA antibody in serum, and correlated with the presence of the secretory component in pneumococcal antibody, indicating local production of IgA antibodies. Nasopharyngeal IgA antibody to pneumolysin was detected in 93% of the children already in the acute phase of otitis. Twenty percent of the children developed at least a threefold rise in the pneumolysin-specific IgA antibody concentration by the convalescent phase of otitis, with the youngest at 6 months of age, regardless of the pneumococcal findings in the nasopharynx or middle ear fluid. We suggest that nasopharyngeal IgA antibody to pneumolysin can be produced early in life by pneumococcal colonization.

Nasopharyngeal antibodies to pneumococcal capsular polysaccharides in children with acute otitis media

Antibodies to pneumococcal capsular polysaccharides were measured by EIA in acute- and convalescent-phase nasopharyngeal aspirates from 120 children with acute otitis media. Nasopharyngeal IgM- and IgG-class antibodies were rare, whereas IgA was detected more often, occurred independently from serum IgA, and correlated with the presence of the secretory component in pneumococcal antibody, indicating local production of IgA. Thirty-four percent of the children with pneumococci in middle ear fluid developed a nasopharyngeal IgA response to the polysaccharide pool of serotypes 6B, 14, 19F, and 23F compared with 7% of the children with pneumococci only in the nasopharynx or not found at all (P = .004). The responses were observed in children of all ages, the youngest 6 months of age. This supports the hypothesis that mucosal immunity to bacterial polysaccharides matures earlier than systemic immunity.

A comparison of transcranial magnetic stimulation with electroneuronography as a predictive test in patients with Bell's palsy

The aim of this study was to examine the neuronographic findings of electrical and transcranial magnetic stimulation of the facial nerve and to compare their ability to predict clinical recovery from idiopathic facial nerve palsy (Bell's palsy). Eighty-six patients were examined clinically and neurophysiologically immediately on presentation to Tampere University Hospital. Electroneuronography (ENoG) and transcranial magnetic stimulation (TMS) were performed 1-6 times for each patient. The time interval between each examination varied from 2 to 7 days. Seventy-eight patients were followed for a median period of 13 months after the onset of palsy. Facial nerve function was graded according to the House-Brackmann grading system. Relative amplitude differences of ENoG and TMS during the acute phase were then correlated with clinical outcome. Statistical analysis of the results showed that a TMS response elicitable during the first 5 days of the palsy was correlatable with a good prognosis. ENoG results correlated with clinical outcome at a later time from onset of symptoms. TMS was well tolerated and no adverse effects were seen. These results indicate that TMS is a useful method for the early prediction of outcome in patients with Bell's palsy.

Hearing and acute otitis media in 13-year-old children

Air and bone conduction thresholds of 330 unselected urban 13-year-old children with a known history of otitis were measured under ideal conditions, using standard clinical audiometry. In the subgroups of children with different numbers (0, 1-2, 3-7, > or = 8) of attacks of acute otitis media (AOM) in their history, the mean air conduction thresholds varied from 0.2 to 11.5 dB at different frequencies in different AOM subgroups. Air conduction pure tone averages (PTA, mean threshold at 0.5, 1 and 2 kHz) > 20 dB were not found in any of the ears. The mean bone conduction thresholds varied from -0.0 to 1.8 dB, depending on the subgroup and frequency (0.25 to 4.0 kHz) studied. Bone conduction PTAs > 10 dB were measured in 5 (0.8%) ears. Single bone conduction thresholds > 10 dB were found at different frequencies in 3 to 15 (0.5 to 2.3%) of the ears, and thresholds > 20 dB in only 2 ears (0.3%). The mean thresholds and number of ears with decreased hearing were distributed equally between different AOM subgroups, except that some air conduction high frequency losses were more frequent in children with > or = 8 attacks of AOM. We conclude that childhood AOM, even if it occurs frequently, seems not to have a significant harmful long-term effect on hearing.

Comparison of PCR assay with bacterial culture for detecting Streptococcus pneumoniae in middle ear fluid of children with acute otitis media

We have studied etiological diagnosis of acute otitis media (AOM) by comparing a newly developed pneumococcal PCR for Streptococcus pneumoniae to bacterial culture with 180 middle ear fluid (MEF) samples of 125 children with 125 episodes of AOM. For pneumococcal PCR assay, DNA from MEF samples was extracted by phenol-chloroform. The outer primers used amplified a 348-bp region of the pneumolysin gene, and the inner primers amplified a 208-bp region. S. pneumoniae was cultured in 33 (18%) samples, and pneumolysin PCR was positive for 51 (28%) of 180 MEF samples. Only 2 of 21 PCR-positive, S. pneumoniae culture-negative samples were positive for other otitis pathogens. By combining MEF culture and PCR results, 54 (30%) of 180 MEF samples had evidence of pneumococcal etiology. In conclusion, pneumolysin PCR is a sensitive and specific new method to study pneumococcal involvement in MEF samples of children with AOM.

The site of impulse generation in transcranial magnetic stimulation of the facial nerve

The facial nerve can be stimulated in its intracranial course through transcranial magnetic stimulation (TMS). We studied the site of impulse generation produced by TMS by comparing the latencies of the muscle evoked potentials (MEPs) elicited with TMS and intracranial electrical stimulation (IES) of the facial nerve during neurosurgical posterior fossa procedures. In a series of 25 patients, the mean latency of the TMS elicited MEPs, recorded in the orbicularis oris muscle, was 5.0 ms (SD 0.58). Also IES of the distal part of the facial nerve in the internal acoustic meatus showed a mean latency of 5.0 ms (SD 0.68). Proximal IES in the root entry zone of the facial nerve, and intermediate IES between root entry zone and meatus, produced MEPs with significantly longer latencies compared to TMS and distal IES (p < 0.05). The findings suggest that the TMS induced facial nerve activation, leading to a MEP response, takes place within the internal acoustic meatus.

Magnetic facial nerve stimulation in Bell's palsy

The transcranial magnetic stimulation (TMS) technique makes it possible to stimulate the intracranial part of the facial nerve. In a total of 51 patients with acute Bell's palsy, TMS was performed, and the responses were compared with those elicited by conventional extracranial electric stimulation (EES). Clinical recovery was evaluated at 258-539, mean 410, days from the beginning of the palsy. With both techniques the motor evoked potentials (MEPs) could always be elicited on the healthy side, the mean latency being 4.7 ms with TMS and 3.7 ms with EES. In the acute phase, TMS elicited MEPs on the paralyzed side in 47% of the patients, and EES in 98%. The patients with TMS elicitable MEPs during the first 4 days of the palsy had significantly better recovery than those without response (p less than 0.05). The difference in recovery between patients with or without elicitable TMS responses on days 5-8 and 9-14 was not significant. In EES, the amplitude difference between the two sides within the first 4 days was not significantly (p greater than 0.05) different. On days 9-14 the patients with a less than 80% difference between the two sides recovered significantly (p less than 0.05) better than those with a difference of greater than or equal to 80%, So, TMS may be of help in the early prognosis of Bell's palsy.

Magnetic facial nerve stimulation in normal subjects. Three groups of responses

Magnetic stimulation provides a method to stimulate the facial nerve transcranially. With this method, the stimulation can be directed to the intracranial part of the facial nerve, whereas conventional electric stimuli are delivered to a more peripheral part of the nerve. In 40 healthy subjects, ipsilateral responses with latencies of 4.5 +/- 0.4 ms were recorded on the nasolabial folds. The latencies were 1.1 ms longer than those elicited at the stylomastoid foramen by electric stimulation. Furthermore, a response with a mean latency of 12 ms (range 10-16 ms) appeared in 6 out of 10 healthy subjects and a polyphasic response with a mean latency of 32 ms in 9 out of 10 of these subjects. Transcranial magnetic stimulation seems to allow the examination of motor conduction through the proximal part of the facial nerve. In addition, the method may give further information concerning the facial activation mechanisms possibly by other central pathways.

Azithromycin concentrations in sinus fluid and mucosa after oral administration

The concentrations of azithromycin in sinus fluid and mucosal tissue were determined in a total of 23 patients with acute or chronic sinusitis. Five patients with acute sinusitis and four with chronic sinusitis were administered a five-day course of oral azithromycin (500 mg on day 1, 250 mg on days 2-5, all as single doses), and the remaining 14 patients, all with chronic sinusitis, received single oral doses of azithromycin (500 mg). With the five-day regimen, the mean levels of azithromycin in sinus fluid were markedly higher in patients with acute sinusitis (1.34 micrograms/ml) than in patients with chronic sinusitis (0.25 micrograms/ml) 24 h after the first dose. The levels of azithromycin in the sinus fluid increased from the first to the last dose in both patient groups; the mean levels of azithromycin 24 h after the last dose were 2.33 micrograms/ml in acute sinusitis patients and 0.38 micrograms/ml in chronic sinusitis patients. In chronic sufferers, the mean levels of azithromycin in the sinus fluid following a single oral dose were 0.25, 0.41, 0.57 and 0.22 micrograms/ml at 24, 48, 72 and 96 h, respectively, after administration. In these patients the mean sinus drug concentrations were much greater in the mucosal tissue (1.23 micrograms/g) than in the sinus fluid (0.41 micrograms/ml) 48 h after administration of the single dose. There were no treatment-related changes in laboratory function tests, and side effects were described as mild to moderate (five patients complained of nausea, abdominal pain or headache).(ABSTRACT TRUNCATED AT 250 WORDS)

Transcranial facial nerve stimulation by magnetic stimulator in normal subjects

Magnetic stimulation provides a new method to stimulate facial nerve transcranially. Stimulation can be directed to the intracranial part of the facial nerve, whereas the conventional electric stimuli are delivered extracranially to a more peripheral part of the nerve. Fourty healthy volunteers were examined to determine the normal responses for transcranial facial nerve stimulation. The center of the inducing coil ring was located so that its center was 3 cm posterior and 6 cm lateral to the vertex. Responses were recorded on the nasolabial fold. Latencies were 4.5 +/- 0.4 ms on both sides, being 1.1 ms longer than those elicited by electric stimulation of the nerve at the stylomastoid foramen. Amplitudes with magnetic stimuli were equal to those obtained with electric stimuli. The transcranial magnetic stimulation seems to be an accurate and promising method to examine the facial nerve.

A clinical research form for use in the documentation of middle ear effusion

A form for use in both the clinical and research setting for documenting the presence and course of otitis media with effusion by pneumatic otoscopy has been developed. The form is based on the data obtained in a large Finnish study on pneumatic otoscopy signs and findings at myringotomy (Karma P, Penttilä M, Sipilä M, & Kataja M, Int J Pediatr Otorhinlaryngol 1989). The rationale for development and the clinical and research applications of the form are discussed.

The comparative efficacy and safety of clarithromycin and amoxycillin in the treatment of outpatients with acute maxillary sinusitis

The efficacy and safety of clarithromycin and amoxycillin in the treatment of acute maxillary sinusitis were compared in a single-blind, multicentre outpatient study. Fifty patients were randomly assigned to receive either clarithromycin 500 mg 12-hourly or amoxycillin 500 mg 8-hourly orally. Clinical signs and symptoms, sinus culture and blood and urine laboratory profiles were assessed prior to treatment, at four to six days during treatment, and within 48 h of the end of therapy (usually 9-11 days). Patients from whom beta-lactamase producing strains were isolated were excluded from the study. Both antibiotics achieved a clinical success rate of 91% within 48 h post-treatment; radiological resolution or improvement was observed in 91% of patients treated with clarithromycin and 89% of patients who received amoxycillin. Bacteriological cure was achieved in 88% and 91% of evaluable patients for clarithromycin and amoxycillin, respectively. Adverse events were reported for 16% of patients in the clarithromycin group compared to 26% in the amoxycillin group. Gastrointestinal disturbance was the most commonly occurring adverse event in both groups. The results of this study suggest that clarithromycin is as effective and well tolerated as amoxycillin in the treatment of acute maxillary sinusitis.

Low- and high-frequency hearing in patients with Menière's disease

We determined the pure-tone hearing thresholds of 25 patients with unilateral active Menière's disease using standard clinical audiometry, high-frequency audiometry (10-18 kHz), and low-frequency audiometry (20-80 Hz). In addition to hearing loss at the conventional frequencies, all of the affected ears showed deterioration of the thresholds at both low- and high-frequency areas as compared with the reference ears. The degree of hearing loss at these frequencies correlated to the degree of the hearing loss at the conventional frequencies, where it was greatest at 0.5-1 kHz. Our findings suggest that in Menière's disease the whole cochlear sensory area is affected, and that the damage caused by Menière's disease advances simultaneously in all parts of the cochlea.

Radical surgery for lingual cancer

The survival rates of 58 patients treated for squamous carcinoma of the tongue between 1972 and 1985 were evaluated. The overall 5-year survival rate was 41.6%; for stage I it was 61.8%; stage II 59.5%; and stage III, 27.7%. No patient survived for more than 2 years when their tumour was stage IV on presentation. A composite pull-through resection with radical neck dissection gave a 5-year survival rate of 50.7%, which was significantly (P less than 0.01) higher than the 13.8% achieved by other treatments, mainly local tumour excision combined with radiation therapy. The same trend in favour of radical surgery was also seen stage by stage. In 45% of the patients regional neck metastases (palpable in 35% and occult in 10%) were present and predicted a poor prognosis. Among T1-T2 cases the 5-year survival of 58.5% in the N0 group was significantly (P less than 0.01) higher than the 15.1% among those with nodal involvement. The location of the primary tumour did not affect the survival rates.

Hypopharyngeal reconstruction with free microvascular jejunal transfer after total laryngopharyngectomy

One-stage laryngopharyngeal free microvascular jejunal transfer after total laryngopharyngectomy was performed in 8 patients with advanced laryngopharyngeal cancer. The study showed that this was a relatively safe and time-saving method for hypopharyngeal reconstruction after radical cancer surgery. It improved the quality of life of the patients, allowing normal alimentation, though in some cases only temporarily due to the highly malignant nature of the disease.

Sensorineural hearing loss and acute otitis media in children

Sensorineural hearing of 359 otoscopically and tympanometrically normal 5-year-old children with known otitis-history was studied under ideal conditions. In the subgroups of children with a different number (0, 1-2, 3-7, greater than or equal to 8) of attacks of acute otitis media (AOM) in their history, the mean bone conduction thresholds unregularly varied from 0.1 dB to 7.4 dB, depending on the frequency and the subgroup studied. The proportion of the ears with a bone conduction threshold greater than 10 dB at 0.5, 1, 2 or kHz ranged, also unregularly, from 10.8% to 0.5%, the greatest percentages being found at 0.5 and 1 kHz in the children without a history of AOM. Thus, neither AOM nor its treatment, even if frequently occurring, seem to cause permanent sensorineural hearing loss in children.

Vertical hyoid bone displacement and fundamental frequency of phonation

Vertical displacement of the hyoid bone as well as its effects on F0 were studied using five excised human larynges. Cranial force introduced to the hyoid bone caused a widening of the vestibule of the larynx, enlargement of the laryngeal ventricles, abduction of the ventricular folds, heightening of the epiglottis and slight abduction of the vocal folds. The displacement (X +/- SD) of the anterior part (corpus) of the bone was 8.0 +/- 5.2 mm and of the posterior part, 22.2 +/- 6.1 mm with a 10 N force. The difference was statistically significant and was found to depend mainly on the tight middle hyothyroid ligament. The cranial force displacing the hyoid bone invariably showed a positive relationship with F0. The F0 changes were statistically significant but relatively small (X +/- SD): 8 +/- 8.4 Hz (about 10%) with an intact hyothyroid ligament. When the subglottal pressure was low, a change in the vibratory pattern of the vocal folds was found in several specimens. The F0 changes found in the present study are too small to explain alone the differences in the so-called intrinsic F0 of vowels. However, they are believed to contribute to this phenomenon.

Pure-tone hearing thresholds in otologically healthy 5-year-old children in Finland

We measured the pure-tone air and bone conduction hearing of 359 randomly selected otologically normal urban preschool children in Finland at the average age of 5.2 years. Children with otoscopically verified middle ear pathology or abnormal impedance audiometry were not included in this sample. The mean air conduction thresholds varied from 16.6 dB at 0.125 kHz to 6.6 dB at 2 kHz, and the mean bone conduction thresholds from 6.0 dB at 0.25 kHz to 0.7 dB at 4 kHz. The pure-tone average (of air conduction thresholds at 0.5, 1 and 2 kHz) of all the ears was 7.6 dB. The distribution of single air conduction hearing thresholds at the frequencies from 0.25 kHz to 4 kHz showed that 66%-75% were at the 5-10 dB level.

Evaluation of the hearing loss associated with cis-platinum treatment by high-frequency audiometry

The effect of cis-platinum treatment on the hearing of 23 ovarian cancer patients was evaluated using standard and high-frequency audiometry. Twenty-two percent of the patients developed a hearing loss of at least 15 db, 13% in the range 125-8000 Hz and 9% only in the high-frequency area above 8 kHz. However, due to the high-frequency hearing loss (presbyacusis) in older patients high-frequency audiometry was often unobtainable. Hearing screening using standard pure-tone audiometry is recommended for cis-platinum patients as a routine procedure.

Morbidity of very young infants with and without acute otitis media

Perinatal and other morbidity of 96 consecutive infants with acute otitis media (AOM) before the age of 3 months is compared with that of 96 birthday- and sex-matched controls without AOM. Perinatal problems were found in 57 AOM infants and in 38 controls, prematurity and asphyxia being significantly (p less than 0.05) more common in the study group than in the controls. At the time of AOM, 51 infants had concurrent illnesses ('colds' excluded) or anomalies, while only 19 controls (p less than 0.001) showed any respective morbidity during their 3 months of life. While AOM infants frequently presented with other, especially respiratory, infections, the controls hardly ever did so. Symptomatology during otitis was varying, and frequently suggestive of respiratory problems other than AOM. Subsequent otitis morbidity of AOM infants was heavy, but other disease history was similar to that of the controls. The study stresses the importance of examining the ears in young infants presenting with any illness, and especially of a respiratory nature.

Hearing and hearing loss in 5-year-old children. Pure-tone thresholds and the effect of acute otitis media

Air and bone conduction pure-tone thresholds of 420 unselected urban children were measured with standard clinical audiometry. The mean of air conduction pure-tone averages (average threshold at 0.5, 1 and 2 kHz) was 8.6 dB HL in girls and 8.3 dB HL in boys. In only 5 ears (0.6%), was this average greater than or equal to 35 dB HL. The threshold greater than or equal to 35 dB HL at 4 kHz was found in 1.4% of the ears and at 8 kHz in 4.1%. The bone conduction threshold greater than 20 dB HL at any of the frequencies from 0.5 to 4 kHz was very rare, and only once, at 4 kHz, was it greater than 35 dB HL. Earlier attacks of acute otitis media seemed to have only a marginal long-term effect on air conduction hearing, and an almost negligible effect on bone conduction hearing.