[Efficacy of bioregulative drugs in the treatment of otitis media with effusion associated with rhinosinusitis and adenoiditis]

PURPOSE

Improving of otitis media with effusion (OME) with rhinosinusitis (RS) and adenoiditis treatment effectiveness.

MATERIALS AND METHODS

The study included 112 patients 12-18 y.o. with otitis media with effusion, who were divided into 2 groups depending on the treatment scheme. The Group I (the main group) patients treatment included Traumeel S and Euphorbium compositum Nasentropfen S in addition to the standard treatment, and the Group II (comparison), children were prescribed standard therapy. Patients of both groups were divided into 3 subgroups depending on the upper respiratory tract inflammation symptoms: A - patients with adenoiditis; B - with rhinosinusitis and C - combination of adenoiditis and rhinosinusitis. The comparison group (groups IIB and IIC) treatment scheme (children with rhinosinusitis) included topical corticosteroids and the main group patients didn't receive corticosteroids. All patients went through complaints and anamnesis collection, routine otorhinolaryngological and instrumental examination before and after treatment.

RESULTS

Analysis of treatment results demonstrated high efficacy of multicomponent drugs with low doses of active ingredients in the therapy of patients with OME, regardless of comorbid pathology. Significantly better results were obtained in the patients treated with bioregulatory drugs when comparing the outcomes of OME therapy in combination with adenoiditis (groups IA and IIA). Comparable efficacy results were obtained in the treatment group of patients with OME associated with RS (in groups IB and IIB as well as in groups IC and IIC), where GCS was received in the comparison group. The high efficacy and safety of bioregulatory drugs makes the use of these agents a promising treatment for patients with OME, RS and adenoiditis.

Association of Preinjury Medical Diagnoses With Pediatric Persistent Postconcussion Symptoms in Electronic Health Records

OBJECTIVE

To identify risk factors and generate hypotheses for pediatric persistent postconcussion symptoms (PPCS).

SETTING

A regional healthcare system in the Southeastern United States.

PARTICIPANTS

An electronic health record-based algorithm was developed and validated to identify PPCS cases and controls from an institutional database of more than 2.8 million patients. PPCS cases (n = 274) were patients aged 5 to 18 years with PPCS-related diagnostic codes or with PPCS key words identified by natural language processing of clinical notes. Age, sex, and year of index event-matched controls (n = 1096) were patients with mild traumatic brain injury codes only. Patients with moderate or severe traumatic brain injury were excluded. All patients used our healthcare system at least 3 times 180 days before their injury.

DESIGN

Case-control study.

MAIN MEASURES

The outcome was algorithmic classification of PPCS. Exposures were all preinjury medical diagnoses assigned at least 180 days before the injury.

RESULTS

Cases and controls both had a mean of more than 9 years of healthcare system use preinjury. Of 221 preinjury medical diagnoses, headache disorder was associated with PPCS after accounting for multiple testing (odds ratio [OR] = 2.9; 95% confidence interval [CI]: 1.6-5.0; P = 2.1e-4). Six diagnoses were associated with PPCS at a suggestive threshold for statistical significance (false discovery rate P < .10): gastritis/duodenitis (OR = 2.8; 95% CI: 1.6-5.1; P = 5.0e-4), sleep disorders (OR = 2.3; 95% CI: 1.4-3.7; P = 7.4e-4), abdominal pain (OR = 1.6; 95% CI: 1.2-2.2; P = 9.2e-4), chronic sinusitis (OR = 2.8; 95% CI: 1.5-5.2; P = 1.3e-3), congenital anomalies of the skin (OR = 2.9; 95% CI: 1.5-5.5; P = 1.9e-3), and chronic pharyngitis/nasopharyngitis (OR = 2.4; 95% CI: 1.4-4.3; P = 2.5e-3).

CONCLUSIONS

These results support the strong association of preinjury headache disorders with PPCS. An association of PPCS with prior gastritis/duodenitis, sinusitis, and pharyngitis/nasopharyngitis suggests a role for chronic inflammation in PPCS pathophysiology and risk, although results could equally be attributable to a higher likelihood of somatization among PPCS cases. Identified risk factors should be investigated further and potentially considered during the management of pediatric mild traumatic brain injury cases.

Nasopharyngeal Proteobacteria are associated with viral etiology and acute wheezing in children with severe bronchiolitis

In the nasopharyngeal microbiome of children with severe bronchiolitis, Proteobacteria, specifically Haemophilus influenzae and Moraxella catarrhalis , were associated with the viral etiology of bronchiolitis, and Moraxella species were more common among children with acute wheezing.

[The experience with the application of selective polarized chromotherapy in the clinical practice]

A series of investigations have demonstrated the anti-inflammatory, bactericidal, analgesic, and vegetocorrective effects of extraocular selective polarized chromotherapy using blue and red light and the possibility to optimize autonomous regulation with the help of this technique. The results of the study confirmed the high clinical effectiveness and safety of the method being considered for the treatment of acute respiratory diseases, chronic tonsillitis, cervical dorsopathies, and vegetative dysfunction.

[Primary acute rheumatic fever in juveniles from an organized community]

A closed population of juveniles was studied to follow-up manifestations of primary rheumatic fever. In line with other unfavourable factors, the onset of the disease within the first 6 months of the observation was due to cross streptococcal infection (foci of chronic nasopharyngeal infection were detected in 68.6% examinees, rheumatism debut after acute nasopharyngeal infection was in 91.0% patients). Persistence of streptococci was established in many blood counts in immunofluorescence reaction in 88.2% patients in acute disease, in more patients with lingering rheumatic process. Clinical manifestations include, aside from arthritis and rheumocarditis, frequent thyroid and gastrointestinal lesions. It is thought valid to raise the dose and duration of administration of penicillin in patients with primary rheumatic fever as it eradicates chronic infection foci, prevents recurrences, reduces the number of patients with a lingering course of the disease, with recurrences and valvular defects of the heart.

Chromobacterium violaceum infection in children: a case of fatal septicemia with nasopharyngeal abscess and literature review

This previously healthy 5-year-old boy initially presented with fever and purulent conjunctivitis. The course evolved rapidly into preseptal and facial cellulitis, nasopharyngeal abscess and sepsis. Chromobacterium violaceum was isolated from conjunctival exudate and blood cultures. He received intravenous cefazolin therapy for 2 days, followed by penicillin, oxacillin and netilmicin. However, no improvement was noted, and he died on the fifth days of illness.

The nasopharynx and the middle ear. Inflammatory reactions in middle ear disease

The host-parasite interactions in the nasopharynx with bacterial colonization and antigen uptake in the lymphoid tissue, the adenoid, has an impact on the maturation of local and systemic immunity. The adenoid is a part of mucosa associated lymphoid tissue and is responsible for both effector and inductor functions in the nasopharynx. Increasing evidence supports the role of serum antibody in protecting the middle ear cavity from disease. There is evidence for a minor immunologic defect in a number of children with recurrent episodes of AOM.

How to manage patients with hard-to-recognize postnasal drip?

Postnasal drip (PND), commonly regarded as a phenomenon wherein nasal fluid drips into the pharynx, is one of the main symptoms of chronic sinusitis and other nasal lesions. This definition is controversial, however, because some patients have PND with no evidence of fluid either in the oropharynx or around the choanae. Among 220 patients in whom PND was diagnosed at the University of Tokyo Hospital between January 1996 and December 1997, 19 (8.6%) had hard-to-recognize PND on routine examination. Through careful observation, responsible lesions could be identified in all patients with hard-to-recognize PND. Seven patients had latent chronic sinusitis, 5 had nasopharyngeal lesions, such as Tornwaldt's cyst and inflammation, 3 had "old man's PND", 2 had "reflux PND", and 2 had polyps around the sphenoid ostium. Five patients received no treatment. In the other patients, medical therapy, mainly long-term treatment with low doses of macrolides, now regarded as a standard regimen for intractable chronic sinusitis in Japan, was effective in alleviating symptoms regardless of the cause.

Mucosa-associated lymphoid tissue in middle ear and Eustachian tube in children

The presence of mucosal lymphoid follicles with germinal centers, so called mucosa-associated lymphoid tissue (MALT), in the Eustachian tube (ET) and middle ear (ME) was investigated in 23 human temporal bones containing the entire ET obtained from 23 children, 3 months to 10 years old at death. Greater numbers of MALTs were found in specimens from children with otitis media (OM) than from those without OM. MALT showed a wedge-shaped distribution through the ME and ET: in all 3 specimens that had MALTs in the ME, these tissues were seen throughout the ET; in all 4 specimens with MALTs in the bony portion of the ET, these tissues were present both in the tympanic and pharyngeal portions of the cartilagines ET; all 7 specimens that had MALTs in the tympanic half of the cartilagines ET had MALTs in the pharyngeal portion of the cartilagines ET as well. Furthermore, MALTs were noted in the pharyngeal portion of the ET in more than half of the specimens without OM but in none of the MEs of specimens without OM. These results support the hypothesis that persistent and recurrent inflammation in the nasopharynx spreads through the ET to play a role in the pathogenesis of chronic OM in children.

Role of IgE-mediated hypersensitivity in otitis media with effusion: pathophysiologic considerations

A pathophysiologic model of otitis media with effusion secondary to IgE-mediated hypersensitivity is described. Specific mediators of inflammation are released by mucosal mast cells in the nasal mucosa following the interaction of antigen and specific IgE antibody. These mediators increase vascular permeability, mucosal blood flow, and, most important, mucus production. Furthermore, accessory cell types are recruited by colony-stimulating factors that in turn provide an autocrine-positive feedback for the influx of further inflammatory cells. The eustachian tube is then effectively obstructed by both intrinsic venous engorgement and extrinsic mucus plugs, isolating the middle ear space from the ambient environment. The net result is the increased exchange of nitrogen into the middle ear mucosa from the middle ear cavity. This causes the development of a significant middle ear underpressure that disrupts tight junctions and allows for transudation of fluids into the middle ear space. The prolonged obstruction of the eustachian tube with mucus results in middle ear inflammation, mucosal metaplasia, and increased glandular activities, all of which are hallmarks of chronic otitis media with effusion.

Adult bacterial nasopharyngitis: a clinical entity?

OBJECTIVE

To investigate bacterial nasopharyngitis as a cause of adult upper respiratory infection.

DESIGN

Prospective case series.

SETTING

Walk-in medical clinic of a university hospital.

PATIENTS

507 patients with cold or flu symptoms, sore throat, or recent cough; 21 control subjects without symptoms of upper respiratory infection.

MEASUREMENTS AND MAIN RESULTS

After thorough history and physical examination, the patients underwent nasopharyngeal aspiration and throat culture. Nasopharyngeal specimens were cultured for both bacteria and viruses; antigens for influenza, parainfluenza, and respiratory syncytial virus were sought by enzyme-linked immunosorbent assay (ELISA); serum antibodies to viral respiratory pathogens were determined. Group A beta-hemolytic streptococci grew from the throat specimens of 39 of the 507 patients (8%) or 38 of 334 patients (11%) who had clinical diagnoses of pharyngitis. Thirty-three cases of influenza A, 20 cases of influenza B, and seven cases of parainfluenza infections were diagnosed. Bacteria were cultured from the nasopharyngeal secretions of 284 patients (56%). In contrast to pharyngeal culture, commensal mixed flora were rarely found in nasopharyngeal culture. Nasopharyngeal culture of bacteria usually considered to be respiratory pathogens was significantly associated with the presence of leukocytes. Streptococcus pneumoniae (odds ratio 6.0, 95% confidence interval 2.6-14.2), Moraxella catarrhalis (odds ratio 12.9, 95% confidence interval 3.1-79.5), and Hemophilus influenzae (odds ratio 3.0, 95% confidence interval 1.2-7.4) were all associated with the presence of leukocytes. In contrast, nasopharyngeal culture of coagulase-negative staphylococci, mixed flora, and the documentation of a viral infection were not associated with the presence of leukocytes. For none of 21 control subjects were "pathogenic" bacteria found.

CONCLUSIONS

These data suggest that potentially pathogenic bacteria may have a causal role in adult nasopharyngitis, although further data are needed to confirm this hypothesis.

Chronic idiopathic inflammation of the retropharyngeal space presenting with sequential abducens palsies

We describe a patient who presented with sequential, bilateral abducens palsies associated with a mass of the nasopharynx. Biopsy of the mass showed chronic non-specific inflammation and fibrosis. The diagnosis of idiopathic inflammatory pseudotumor was arrived at by exclusion of other known causes of inflammation of the retropharyngeal space. Magnetic resonance imaging suggested that injury to the sixth cranial nerves probably occurred as they traversed the dura and subarachnoid space overlying the clivus.

[A national survey on the criteria of prescription antibiotic therapy in nasopharyngitis in pediatric practice]

Although nasopharyngitis usually results from a viral infection, it is the leading cause of use of antimicrobials in pediatric patients. A study of the criteria used by pediatricians to prescribe antimicrobials in uncomplicated nasopharyngitis was undertaken. Each of 700 pediatricians enrolled ten consecutive patients with uncomplicated nasopharyngitis. Use of antimicrobials was left to the discretion of the physician. Antimicrobials were used in 59% of pediatric patients evaluated for nasopharyngitis. Criteria considered as the most important for deciding to use antimicrobials induced purulent secretions (87.2%), congestion of both tympanic membranes (82.8%), cough (79.2%), fever greater than 39 degrees C (77.2%), and a history of otitis media (69.8%). Data on the outcome was available for 69% of patients. Acute otitis media was the main complication, with a rate of 7.7%; this rate was lower in the treated group (5.4%) than in the untreated group (10.9%). A positive history for otitis media and the appearance of the eardrums at evaluation were the best predictors of otitis media.

[An assessment of middle ear involvement in children with allergic rhinitis: a comparison with chronic hypertrophic adenoiditis]

The allergic inflammation may contribute to the development of otitis media with effusion (OME). For this reason we have examined two groups of children: the first (group A) formed by 12 children with allergic rhinitis, the second (group B) by 15 children with hypertrophic adenoids. We have found respectively: pathologic otoscopy in 75% and 93% of cases; pathologic tympanometry in 83% and in 90%; pathologic audiometry in 60% and in 83%. This values are not significant according to a statistic analysis. Instead, the degree of compromission has been significant: in fact 16% of the children belonging to group A had a retracted and atelectatic eardrum in comparison with 33% of the children belonging to group B. Also tympanometry has confirmed this aspect: in fact 33% of group A showed type C and B tympanograms in comparison with 77% of group B. Besides, audiometry has confirmed the presence of hearing loss in the subjects with tympanometry of type C and B, belonging to both groups. For this reason the allergic rhinitis, because it may cause OME, must be treated in order to limit the negative effects of allergic nasal obstruction on the functionality of the middle ear.

[Rare complications during the treatment of retropharyngeal abscess]

In the Province Integrated Hospital in Czestochowa a 2-year-old child was treated for a retropharyngeal abscess on the left side. During the treatment complication developed in the form of haemorrhage caused by damage to a large retropharyngeal artery, and cardiac arrest due to plugging of the glottis and trachea with mucus.

Choanal bleeding due to nasopharyngitis

Twenty-two patients with bleeding from the nasopharynx which due to secondary changes in acute nasopharyngitis were treated at the Fujisaki Hospital. The titers of IgG, IgM and IgA of the viral capsid antigen (VCA), IgG and IgA of the early antigen (EA), and EB nuclear antigen (EBNA) were measured. There was no correlation between season of coryza or changes in season and the onset of nasopharyngitis, except for a slightly greater occurrence during mid summer and mid winter. One of three patients with severe bleeding, underwent posterior nasal packing using a rolled 10 X 10 cm gauze sponge. The majority of cases of bleeding from the nasopharynx were most satisfactorily treated by administration of the ranitidine hydrochloride (Zantac) of a selective antagonist for the H2-receptor of histamine.

Phenothiazines and sudden infant death syndrome

A relationship between sudden infant death syndrome (SIDS), sleep apnea, and upper airway infections has been reported. The present observation stresses the possible influence of phenothiazine-containing medications and the occurrence of SIDS. The drug is commonly used for the treatment of infants with nasopharyngitis in Belgium and in some other European countries. In a prospective study, 52 SIDS victims, 36 near miss infants, and 175 control infants were compared for the coexistence of nasopharyngitis and phenothiazine treatment in the days preceding death or hospitalization. The incidence of nasopharyngitis was comparable in the three groups (approximately 31%), but phenothiazines were used significantly more frequently in SIDS victims (23%) and near miss infants (22%) than in control subjects (2%). It is postulated that phenothiazines, as CNS depressors, may contribute to the occurrence of SIDS.

[Mortality from an asthma-like syndrome in pediatrics]

The medical records of children who died from asthmatiform syndrome at Hospital de Pediatría del Centro Médico Nacional, during 1963 through 1980. were examined. There were sixteen asthmatic deaths; out of these, ten were males and six females; 88% occurred before the age of five years. Half of the deaths occurred during the first asthmatiform attack. In 69%, an upper respiratory tract infection was the precipitating factor and in 31%, bronchopneumonia was associated. There were cardiac failures in 88%. A poor medical management was the main factor in about 66%. The mortality rate was 0.5%. The significance of the clinical course is discussed and a program for treatment outlined.

The temporal bone as route of infection in recurrent meningitis

Three successive episodes of recurrent meningitis in connection with an infection of the upper respiratory tract appeared to be related to a congenital idiopathic oval window CSF leak. An inner ear dysplasia was the underlying factor and accounted for the deafness and for the absence of signs of acute labyrinthis during these infectious episodes.

A common pathophysiology for sudden cot death and sleep apnoea. "The vacuum-glossoptosis syndrome"

Several congenital and acquired conditions, characterized by upper airway narrowing, may result in respiratory, cardiac, and sleep disturbances. In all these conditions the leading clinical feature is the occurrence of cyclic obstructive apnoea, mainly during sleep. The common pathogenic mechanism for the airway occlusion seems to be a backward displacement of the tongue and mandible, favoured by the muscle relaxation which occurs during sleep and by gravity in the supine position. A constant factor determining the glossoptosis is the pharyngeal vacuum occurring in these conditions as a result of inspiratory efforts in face of a narrowed upper airway. The response to this type of obstruction is age-dependent, since only in early infancy may these apnoeic spells be life-threatening. A similar pathophysiology is suggested for sudden cot death, which could be considered as a peculiar presentation of this "vacuum-glossoptosis syndrome". This hypothesis could explain why sudden cot death is often associated with nasopharyngitis and occurs always in infancy, almost invariably during sleep.

Nasopharyngitis and the sudden infant death syndrome

Infants who died of SIDS in Onondaga County (New York) were classified into a Nasopharyngitis Group (N = 59) or a No Nasopharyngitis Group (N = 57) on the basis of symptoms, within one week prior to death, referable to the upper respiratory tract. Examination of the postnatal age of death revealed that infants in the Nasopharyngitis Group tended to be older than those in the No Nasopharyngitis Group. These results are consistent with a prediction derived from the hypothesis that prolonged sleep apnea is part of a pathophysiologic process resulting in SIDS.

A new approach to the treatment of allergic nasopharyngitis

Orally inhaled and nasally exhaled beclomethasone diproprionate (b.d.) under increased nasopharyngeal pressure was found beneficial in ameliorating symptoms of allergic nasopharyngitis. The most spectacular help was obtained by patients suffering from sinus headache. This treatment also was found to avert the flaring up of rhinitis, an occasional "unmasking" effect of orally inhaled b.d.

Normal and abnormal middle ear ventilation

Studies in infants and children have suggested a functional rather than mechanical obstruction of the Eustachian tube as a predisposing factor in middle ear effusions (MEE). To simulate this condition in the laboratory, an animal model was prepared using juvenile Rhesus monkeys. The tensor veli palatini muscle was transected or expunged posterior to the hamulus of the medial pterygoid lamina. Transection of the muscle resulted in negative middle ear pressure without effusion, whereas when the muscle was expunged, the animals developed a brief episode of negative middle ear pressure followed by a persistent MEE that was sterile for bacteria. An acute bacterial MEE developed following instillation of Streptococcus pneumoniae into the nasopharynx of animals that had had a previous unilateral transection of the muscle. The condition of the middle ear was documented by impedance measurements and presence of the effusion was verified by myringotomy. Animals were periodically examined and tested for Eustachian tube ventilatory function over a period of one year. Before surgical alteration of the tensor muscle. Eustachian tube function tests demonstrated normal ventilatory function, whereas, functional Eustachian tube obstruction patterns similar to studies in children who had MEE were found during the postoperative period. Only after the development of a reliable animal model can current and future methods of management of MEE be tested under controlled laboratory conditions. These data suggest that the Rhesus monkey appears to be an excellent model for the study of normal as well as abnormal tubal function.

Nasopharyngitis and prolonged sleep Apnea

The effect of nasopharyngitis on the simultaneous occurrence of prolonged sleep apnea (greater than or equal to 20 seconds in duration) was studied in 26 infants managed at home on an apnea monitor. During the observation period, these infants had a total of 69 illnesses which appeared to represent an upper respiratory tract inflammatory process. In general, the daily frequency of prolonged apneic episodes was significantly greater during nasopharyngitis when compared to comparable time intervals immediately prior to and following the illness. In addition, there was a decrease in the frequency of apneic episodes with increasing postnatal age until the episodes finally ceased to occur during the illness-related intervals. Apneic episodes ceased to occur at an earlier age for the before- and after-illness intervals than for the time interval during which there were clinical symptoms. Thus, it would appear that infants go through an age-related phase wherein prolonged apnea occurs during nasopharyngitis but not when free of illness. The implications of these results for the management of infants having prolonged sleep apnea are discussed. In view of the hypothesis that prolonged sleep apnea is part of the physiological process resulting in the sudden infant death syndrome, these results also provide for the prediction that infants who suddenly die in association with nasopharyngitis would do so, in general, at a later age than those who succumb when free of an upper respiratory tract inflammatory process.

[Renal papillary necrosis in an infant]

Report of a case of renal papillary necrosis in an infant, following acute dehydration with cardio-vascular failure. Evolution was favourable and diagnosis was established retrospectively by I.V. urogram.