Progressive septal and palatal perforation secondary to intranasal cocaine abuse

Septal perforation from intranasal cocaine abuse is well recognised. We present a case of progressive septal as well as palatal perforation. Progression from septal perforation to palatal perforation occurred after cessation of intranasal cocaine abuse. This patient had a weakly positive cytoplasmic antineutrophilic cytoplasmic antibody (C-ANCA) but no histologic evidence of Wegener's Granulomatosis. The differential diagnosis for septal and palatal perforation is reviewed. This case represents the fifth reported case of palatal perforation secondary to cocaine abuse in the literature, and the second associated with positive C-ANCA.

Cost-effective pharmacotherapy for allergic rhinitis

This article provides guidelines for pharmacotherapy to maximize symptom relief from allergic rhinitis. Consideration of frequency, severity, and site of symptoms is important in directing pharmacotherapy efficacy and maximizing cost-effectiveness. The agents available include antihistamines, decongestants, steroids, mast cell stabilizers, anticholinergic agents, and mucolytics. Appropriate indications for each and combinations of various agents are discussed within the context of drug efficacy, side effects, affordability, and ease of compliance. The direct and indirect costs of allergic rhinitis are not well delineated but are explored to put the costs of therapy in perspective.

Allergic rhinitis. Options for pharmacotherapy and immunotherapy

A trial of allergy medication can be both diagnostic and therapeutic in a patient with suspected allergic rhinitis, but with so many treatment options, it is sometimes difficult to know where to start. In this second of two articles on allergic rhinitis, Dr Ferguson provides information on efficacy and costs for various allergy drugs and discusses when to consider immunotherapy. The first article, beginning on page 110, discusses signs, symptoms, and triggering allergens.

Allergic rhinitis. Recognizing signs, symptoms, and triggering allergens

Runny noses, sneezing, nasal congestion, and other nuisance symptoms are part and parcel of primary care practice. But how can you quickly discern which symptoms are related to common colds and which stem from allergic rhinitis? Careful history taking usually provides clues, but allergy testing may be needed when triggers are not clear. In this first of two articles on allergic rhinitis, Dr Ferguson explains what to look for, what questions to ask, when to test for allergies, and how to modify a patient's environment to minimize problems. The second article, beginning on page 117, discusses pharmacologic treatment and immunotherapy for allergic rhinitis.

Primary extracranial meningioma of the maxillary antrum

A case of primary extracranial meningioma of the maxillary antrum is reported. A 45-year-old male presented with symptoms of chronic sinusitis. Imaging studies showed a soft tissue mass with calcification, filling the maxillary antrum. The mass was removed surgically, and pathological studies revealed a ribroblastic meningioma. The maxillary antrum is an uncommon location of primary extracranial meningioma, and our case is the sixth to be reported in that location.

Allergic fungal sinusitis: allergic, infectious, or both?

Allergic fungal sinusitis is a benign noninvasive sinus disease related to a hypersensitivity reaction to fungal antigens. A wide variety of fungal agents has been implicated, with the vast majority belonging to the Dematiaceae family. Allergic fungal sinusitis should be suspected in any atopic patient with refractory nasal polyps. Sinus computed tomograms and magnetic resonance imaging findings can be quite distinctive, but not diagnostic. Diagnosis requires histopathologic examination, which shows characteristic allergic mucin. Hyphae can be demonstrated on special fungal stains or confirmed by a positive fungal culture. At surgery, the diagnosis should be considered if thick, tenacious allergic mucin is encountered in the atopic patient with nasal polyps. Fungal cultures should then be obtained, and the pathologist alerted to the possible diagnosis of allergic fungal sinusitis. Current recommendations for therapy include conservative but complete exenteration of all allergic mucin. This can often be accomplished endoscopically. Adjunctive short-term systemic steroids are often helpful, and nasal steroid sprays should be continued long term. The length and dose of steroid therapy is controversial. Persistence of allergic fungal sinusitis with recurrence of sinonasal symptoms is common, particularly when there has been incomplete eradication of allergic fungal mucin. Even when the patient is clinically disease free, recurrence can occur, presumably from reexposure to fungal antigens. Therefore close clinical, endoscopic, and radiographic follow-up is important.

Acute and chronic sinusitis. How to ease symptoms and locate the cause

Patients with acute sinusitis often have purulent nasal discharge, facial pain, and congestion, whereas those with chronic sinusitis have more subtle signs. Infection, hyperreactivity reactions, anatomic obstruction, and underlying disease are among the causes and must be differentiated before appropriate care can be offered. Plain films and sinus transillumination may provide clues in adults but are of little value in young children. Computed tomography is much more sensitive but should be reserved for patients in whom maximal medical therapy has failed, who have a confusing presentation, or who are being considered for endoscopic surgery. Antibiotic therapy is still effective for bacterial infections, but penicillin-resistant organisms are on the increase. If there is no clinical improvement in 3 days, an agent with a broader spectrum of activity should be considered. A combination of agents and prolonged administration may be required for chronic sinusitis, and patients with recurrent symptoms may need endoscopic surgery. Such adjunctive agents as decongestants and saline or steroid nasal sprays may promote drainage. Antihistamines have no role in the treatment of sinusitis.

Leucocyte migration: effects of in vitro exposure to anaesthetic agents: possible potentiation of effects by adrenaline

The effect on in vitro migration of leucocytes and lymphocytes of various drugs used in anaesthesia have been determined in the concentration range 10(-2) to 10(-6) M. The drugs included, thiopentone, bupivacaine, lignocaine, adrenaline, noradrenaline, hydrocortisone, morphine (with and without preservative), lorazepam, suxamethonium, pancuronium and atropine. Toxicity and effect on random mobility after incubation for 1 and 18 h were also determined. Thiopentone depressed leucocyte function at a concentration of 10(-5) M which is comparable to clinical plasma concentrations. Increasing the duration of exposure of the cells to the drugs significantly lowered the concentrations at which depression of function was observed. At concentrations used during local infiltration in clinical practice, bupivacaine and lignocaine were toxic to both leucocytes and lymphocytes. Adrenaline, whilst having no direct effect on cell function, potentiated the effect of lignocaine. Morphine showed no effect at 10(-4) M, a level 1,000 times greater than the reported toxic plasma levels. However, this level falls within the range reported for drug addicts. No effects were found for the other drugs.

Serum transferrin receptor distinguishes the anemia of chronic disease from iron deficiency anemia

Recent studies have shown that the serum transferrin receptor is a sensitive, quantitative measure of tissue iron deficiency. This study was undertaken to determine the serum transferrin receptor's ability to distinguish iron-deficiency anemia from the anemia of chronic inflammation and to identify iron deficiency in patients with liver disease. The mean transferrin receptor level in 17 normal controls was 5.36 +/- 0.82 mg/L compared with 13.91 +/- 4.63 mg/L in 17 patients with iron-deficiency anemia (p less than 0.001). The mean serum receptor level was normal in all 20 patients with acute infection, including five with acute hepatitis, and was also normal in 8 of 10 anemic patients with chronic liver disease. Receptor levels were in the normal range in all but 4 of 41 patients with anemia of chronic disease. We conclude that unlike serum ferritin levels, which are disproportionately elevated in relation to iron stores in patients with inflammation or liver disease, the serum transferrin receptor level is not affected by these disorders and is therefore a reliable laboratory index of iron deficiency anemia.