Initial report on postoperative healing after endoscopic sinus surgery with the microdebrider

Synechiae formation is a frequent occurrence after endoscopic sinus surgery and may cause symptomatic sinus outflow tract obstruction. Various means are used to reduce the incidence of synechiae formation. These include meticulous operative technique, partial middle turbinate resection, middle meatus spacers or stents, and postoperative debridement. The microdebrider is a powered rotary shaving device that precisely resects tissue, minimizing inadvertent mucosal trauma and stripping. We present 40 cases of endoscopic sinus surgery performed with the microdebrider. Patients had at least a 5-month follow-up and demonstrated rapid mucosal healing, minimal crust formation, and a low incidence of synechiae formation. These initial data suggest that the microdebrider may be advantageous in surgery for chronic sinusitis.

Th1/Th2 cytokine profiles in the nasopharyngeal lymphoid tissues of children with recurrent otitis media

The cytokine profile in adenoidal lymphoid tissue was studied in 22 patients. Lymphocytes from adenoid tissues and peripheral blood were submitted for cytokine assays using an enzyme-linked immunosorbent assay kit for interferon-gamma, interleukin (IL)-2, IL-4, IL-5, IL-6, and IL-10. Adenoidal lymphocytes appear to produce significantly less Th1 cytokines (IL-2, interferon gamma) compared to the patient's peripheral blood lymphocytes, whereas IL-4 and IL-5 (Th2 cytokines) appear to be synthesized to the same extent as, if not slightly more than, in the homologous peripheral blood lymphocytes. Because the relationship between Th1 and Th2 cytokines is extremely important in modulating the immune response, it is advisable to determine the role of the cytokine profiles of T-lymphocytes in the nasopharynx and its relationship to the development of inflammation of the eustachian tube and middle ear.

The microbial ecology and immunology of the adenoid: implications for otitis media

The nasopharyngeal tonsil, or adenoid, is a major inductive site for the synthesis of J-chain-positive B cells that may migrate to other areas of the upper respiratory tract, such as the nasal mucosa, the parotid gland, the lacrimal gland, and the middle ear during inflammation. The production of secretory IgA by both the nasopharyngeal tonsil and the nasal mucosa plays a major role in local immune protection against bacteria and viruses. The release of cytokines from Th1 and Th2 lymphocytes must be appropriate for B cells to produce IgA. The factors or mechanisms responsible for this are not, at present, known, but it appears that there is a difference in the profiles of cytokine secretion by Th1 and Th2 lymphocytes in the adenoids in both otitis-prone, as well as nonotitis-prone children. We have suggested that if this specific immune system does not protect the host from invasion by potential pathogens, there are other modalities of therapy to protect the nasopharynx from colonization with pathogenic bacteria or viruses. These include the production of specific antibodies against bacterial surface proteins that have been identified as mucin-binding proteins. Alteration of the microbial flora with commensal organisms such as viridans streptococci can be utilized. These alpha-hemolytic streptococci probably function by producing an acid environment that prevents colonization of organisms such as nontypeable H. influenzae. Finally, the induction of specific SIgA by conserved outer membrane protein antigens of potential pathogens may be another strategy in the prevention of colonization of potential bacterial pathogens in the nasopharynx.

Analysis of isolates recovered from multiple sites of the nasopharynx of children colonized by nontypeable Haemophilus influenzae

To determine whether the nasopharynx of children is colonized by a single or multiple strains of nontypeable Haemophilus influenzae, cultures were obtained from six nasopharyngeal sites in five children. For each child, all isolates yielded identical polymerase chain reaction fingerprints. The results indicate that these children were colonized in the nasopharynx with a single strain of nontypeable Haemophilus influenzae at one time.

Urinary tract infections

Urinary tract infections (UTIs) are still the precipitating cause for 7 million patient visits per year with total costs exceeding one billion dollars. Diagnostic modalities have become more "friendly" for the smaller laboratory with "dip stick" culture tests providing a rapid method of isolation of pathogens. In many cases, empiric therapy is more cost effective than culture in uncomplicated UTIs in women. The etiologic organisms implicated in UTIs have not changed dramatically over the past two decades, with E. coli still accounting for the majority of cases. Antibiotic susceptibility patterns have changed dramatically, with ampicillin losing utility die to the emergence of resistance. Quinolones, which have been exceedingly active against gram-negative enteric pathogens, are no longer universally active and more pathogenic organisms, such as pseudomonas, may be resistant. The emergence of other highly resistant organisms, such as Enterococcus faecium, must be watched for.

Immunoglobulin G Subclass Response to Major outer Membrane Proteins of Nontypable Haemophilus Influenzae in Children with Acute Otitis Media

Children with acute otitis media as the result of nontypable Haemophilus influenzae often develop serum bactericidal and/or opsonic IgG antibodies to this organism during convalescence. Outer membrane proteins appear to be the principal targets for such antibodies. In this study we characterized the IgG subclass responses to major outer membrane proteins of nontypable H. influenzae in otitis-prone children in whom this organism had colonized. Three of the major outer membrane proteins (P2, P5, and P6) were isolated from the homologous nontypable H. influenzae strain recovered from the middle ear at the time of acute infection. Sera were obtained during the acute phase and at 1 and 6 months thereafter. The outer membrane proteins, which were isolated by preparative sodium dodecylsulfate-polyacrylamide gel electrophoresis, were used as test antigens in a quantitative IgG subclass enzyme immunoassay. The results of this analysis indicate that the temporal characteristics and distribution of IgG subclass antibodies were found to differ for each of the outer membrane proteins. Moreover, substantial variation between patients was observed with respect to both temporal characteristics and subclass distribution of the IgG response to the three outer membrane proteins. Significantly, sera from two of three otitis-prone subjects contained detectable levels of IgG antibody to the conserved P6 outer membrane protein at the time of acute infection, with serum from one subject also containing detectable levels of lgG3 antibody to this same protein. Nevertheless, the organism persisted in the middle ears of these patients. The results of this study indicate that otitis-prone children manifest a highly variable IgG subclass response to both conserved (P6) and variable (P2) outer membrane proteins of nontypable H. influenzae. Further study is required to ascertain whether these IgG subclass antibodies are biologically efficacious and whether otitis-prone children possess the immunologic maturity to respond to nontypable H. influenzae outer membrane protein-based vaccines in a predictable manner.

Middle ear mucin glycoprotein: purification and interaction with nontypable Haemophilus influenzae and Moraxella catarrhalis

Nontypable Haemophilus influenzae and Moraxella catarrhalis are important pathogens in children and adults. The mechanisms of their adherence to the epithelial cell surface and colonization are not clear. For the pathogen to adhere to the epithelial cell, it must first attach to and penetrate the mucus barrier. Mucin glycoproteins of the mucus layer generally are thought to be involved in bacterial attachment. To understand the precise mechanisms of middle ear mucin-bacterial interactions, we used an overlay binding assay with a highly purified middle ear mucin and outer membrane proteins of both nontypable H. influenzae and M. catarrhalis. Outer membrane proteins P2 and P5 were identified as the major components that medicate the binding between nontypable H. influenzae and human middle ear mucin. Moreover, the 57 kDa protein, CD, of the outer membrane protein of M. catarrhalis was found to be the only protein binding human middle ear mucin. Finally, it appears that a protein-oligosaccharide interaction is responsible for binding because asialo-mucin does not bind to either of the bacteria. Knowledge of the specific bacterial-mucin interaction may provide an understanding of the bacterial-epithelial cell colonization. Conversely, comprehension of this interaction between bacteria and purified mucin may be a strategy to prevent colonization of potential pathogens that cause otitis media and sinusitis in children.

Nasal polyposis: immunohistochemistry and bioelectrical findings (a hypothesis for the development of nasal polyps)

Nasal polyps and turbinates were obtained from individuals undergoing surgery for symptomatic nasal obstruction caused by nonatopic rhinosinusitis or allergic rhinosinusitis. One part of the tissue from each patient was fixed in neutral buffered formalin and prepared for study by histochemical and immunohistochemical methods. Monoclonal antibodies were used to identify macrophages, lymphocytes, and plasma cells. In most cases (12 of 16, 75%) the remainder of the polyp and turbinate samples was treated with protease to achieve disaggregation of the epithelial cells. Those cells were cultured on permeable collagen matrix supports. Transepithelial potential difference and resistance were measured daily. At the time of maximal transepithelial potential difference, the epithelial cells were mounted in modified. Ussing chambers and exposed to a sodium-positive channel blocker (amiloride hydrochloride) and to selected chloride-negative channel agonists (isoproterenol bitartrate and adenosine triphosphate). Middle turbinates and polyps were found to have more macrophages, lymphocytes, plasma cells, HLA-DR-positive cells, and eosinophils than the inferior turbinates. Epithelial cells obtained from polyps exhibited higher transepithelial potential differences and equivalent short-circuit currents than turbinate cell cultures. The responses to amiloride, isoproterenol, and adenosine triphosphate were also greater for polyp than for turbinate cultures. A theory for the pathogenesis of nasal polyps is proposed. Local release of inflammatory mediators could cause sodium absorption and chloride permeability to be higher in polyps than in turbinate epithelia. Increased sodium absorption is consistent with the hypothesis that epithelial fluid absorption contributes to the development of nasal polyps and is a result of the increased recruitment of inflammatory cells, which are present in nasal polyps.

Middle Ear Mucin Glycoprotein: Purification and Interaction with Nontypable Haemophilus Influenzae and Moraxella Catarrhalis

Nontypable Haemophilus influenzae and Moraxella catarrhalis are important pathogens in children and adults. The mechanisms of their adherence to the epithelial cell surface and colonization are not clear. For the pathogen to adhere to the epithelial cell, it must first attach to and penetrate the mucus barrier. Mucin glycoproteins of the mucus layer generally are thought to be involved in bacterial attachment. To understand the precise mechanisms of middle ear mucin-bacterial interactions, we used an overlay binding assay with a highly purified middle ear mucin and outer membrane proteins of both nontypable H. influenzae and M. catarrhalis. Outer membrane proteins P2 and P5 were identified as the major components that mediate the binding between nontypable H. influenzae and human middle ear mucin. Moreover, the 57 kDa protein, CD, of the outer membrane protein of M. catarrhalis was found to be the only protein binding human middle ear mucin. Finally, it appears that a protein-oligosaccharide interaction is responsible for binding because asialo-mucin does not bind to either of the bacteria. Knowledge of the specific bacterial-mucin interaction may provide an understanding of the bacterial-epithelial cell colonization. Conversely, comprehension of this interaction between bacteria and purified mucin may be a strategy to prevent colonization of potential pathogens that cause otitis media and sinusitis in children.

Further observations on the role of the MHC genes and certain hearing disorders

The pathogenetic mechanism of many hearing disorders have not been fully defined. Studies of certain hearing disorders in man have suggested a role for the major histocompatibility complex (MHC)-encoded genes in disease pathogenesis. In a cohort of unrelated patients with Meniere's Disease, otosclerosis and strial presbycusis as well as other types of sensorineural hearing losses, we have identified an extended MHC haplotype common to the majority of these patients, supporting a hypothesis that a gene(s) within the MHC domain may confer susceptibility to these hearing ailments. In addition, a preliminary study of 27 individuals with various hearing maladies, a striking finding is that 44% of the patients express the following extended MHC haplotype in contrast to only 7% of the general population: DQw2-DR3-C4BSf-C4A0-G11:15-Bf:0.4-C2a-HSP70:7.5-TNF a5-B8-Cw7-A1. The expression of this haplotype by subsets of patients with hearing loss is significant in comparison to regional and international controls.

Morphologic and motility changes of nasal cilia in primary culture caused by Haemophilus influenzae

We focused on the pathogenicity of otitis media with effusion (OME) with respect to the susceptibility of the upper respiratory tract mucosa to Haemophilus influenzae. Human nasal polyps in outgrowth culture were used to study H influenzae disturbance of the ciliary beat frequency (CBF) and the morphology of cilia. The CBF of control primary culture was 11.7 +/- 2.7 Hz. The CBF slowed down significantly, to 8.5 +/- 5.7 Hz, after incubation with the filtrate of 10(8) CFU/mL of H influenzae, and to 4.1 +/- 4.1 Hz with a suspension of 10(8) CFU/mL of H influenzae (p<.05). In the morphologic study, we classified the shapes of the cilia into five types: normal cilia, immotile cilia, swollen cilia, clumped cilia, and exfoliated ciliated cells. The abnormal shapes of cilia increased after incubation with the suspension or the filtrate of H influenzae. By scanning electron microscopy, we saw that aggregated bacteria tended to associate with cilia. Thus, the findings suggest that H influenzae disturbs the ciliary clearance of nasal cells and makes them more susceptible to infections.

Role of allergy in eustachian tube blockage and otitis media with effusion: a review

Recent studies continue to support a role for allergy in the pathogenesis of otitis media with effusion. Although a variety of mechanisms have been proposed to relate these two disease conditions causally, none has been completely validated by experimental or clinical studies. This review suggests that the observed relationship between allergy and otitis media with effusion is caused by mediators of inflammation and cytokines and colony-stimulating factors released by mucosal mast cells and other inflammatory and epithelial cells in the nose and nasopharynx. These mediators produce blockage of the eustachian tube through a number of mechanisms, which may include local injury or vascular- or neural-mediated changes in the eustachian tube opening pressure and in middle ear perfusion. It is likely that the nasal allergic response in patients predisposes to eustachian tube blockage and, if prolonged, causes changes in gas absorption in the middle ear space. This gas exchange primarily involves nitrogen absorption, which may take several days to develop. This persistent underpressure will then lead to middle ear effusion. Irrespective of the theoretical mechanism, the relationship between allergy and otitis media with effusion will remain controversial until well-controlled clinical studies are conducted documenting that in select populations antiallergy therapy is efficacious in preventing or limiting the duration of otitis media with effusion.

Role of Allergy in Eustachian Tube Blockage and Otitis Media with Effusion: A Review

Recent studies continue to support a role for allergy in the pathogenesis of otitis media with effusion. Although a variety of mechanisms have been proposed to relate these two disease conditions causally, none has been completely validated by experimental or clinical studies. This review suggests that the observed relationship between allergy and otitis media with effusion is caused by mediators of inflammation and cytokines and colony-stimulating factors released by mucosal mast cells and other inflammatory and epithelial cells in the nose and nasopharynx. These mediators produce blockage of the eustachian tube through a number of mechanisms, which may include local injury or vascular- or neural-mediated changes in the eustachian tube opening pressure and in middle ear perfusion. It is likely that the nasal allergic response in patients predisposes to eustachian tube blockage and, if prolonged, causes changes in gas absorption in the middle ear space. This gas exchange primarily involves nitrogen absorption, which may take several days to develop. This persistent underpressure will then lead to middle ear effusion. Irrespective of the theoretical mechanism, the relationship between allergy and otitis media with effusion will remain controversial until well-controlled clinical studies are conducted documenting that in select populations antiallergy therapy is efficacious in preventing or limiting the duration of otitis media with effusion.

Binding between outer membrane proteins of nontypeable Haemophilus influenzae and human nasopharyngeal mucin

Bacterial colonization of the epithelial cells precedes infection. Mucins of the epithelial cell secretions modulate bacterial colonization. This study was designed to understand the mechanism of mucin-bacterial interactions and in particular binding between nontypeable Haemophilus influenzae and nasopharyngeal mucin(s). In an overlay assay, binding appears to be mediated by outer membrane proteins P2 and P5 of bacteria and sialic acid-containing oligosaccharides of mucin.

Adenoid lymphocyte responses to outer membrane protein P6 of nontypable Haemophilus influenzae in children with and without otitis media

The cellular immune responses to nontypable Haemophilus influenzae in adenoids were determined in children by measuring lymphocyte blast transformation and antibody secretion in response to the P6 outer membrane protein. In the lymphocyte transformation assay, stimulation index of adenoid lymphocytes stimulated by P6 in otitis children (2.34 +/- 0.25) was significantly lower than that in non-otitis children (3.91 +/- 0.64, p <0.05). The number of IgM as well as IgA secreting cells after 8 days' culture with P6 were significantly smaller in otitis children (IgM: 7,534 +/- 2,843/10(6) lymphocyte; IgA: 1,573 +/- 620/10(6) lymphocyte) than those in non-otitis children (IgM: 12,994 +/- 2,533, p <0.05; IgA: 2,828 +/- 528, p <0.05). These data suggest that P6 protein is a target for the cellular immune response of the adenoid, and failure of adenoid lymphocytes to recognize it as a specific immunogen may be one of the causes of recurrent otitis media.

Role of allergy in nasal polyposis: a review

We propose a multivariate theory for the pathogenesis of nasal polyps. Turbulent flow of air in the lateral wall of the nose or viral-bacterial-host interactions produce an inflammatory change in the mucosa of the lateral wall of the nose. Ulceration and prolapse of the submucosa with reepithelialization and new gland formation may then follow. The structural cells of the nasal polyp, including epithelial cells and fibroblasts, have the ability to produce messenger RNA for granulocyte-monocyte colony-stimulating factor and other cytokines. Stimulation of such an effector capability by structural cell-derived cytokines would undoubtedly represent a major amplification pathway of the inflammatory response in nasal polyps. Allergy may be one mechanism for the development of this cascade of events. This microenvironmental structural inflammatory response in the nasal polyp, in turn, can affect the bioelectric integrity of the Na+ and Cl- channels at the luminal surface of the respiratory epithelial cell. The change in the Na+ absorption, which has been demonstrated in our studies, may result in an increased movement of water into the cell and into the interstitial fluid. The resultant edema can lead to growth and enlargement of the nasal polyp. Finally, the rapid recurrence of nasal polyps despite adequate surgery may reflect some intrinsic phenotypic characteristic of nasal epithelial cells in the lateral wall of the nose, which is likely to be under genetic control.

Increased ion transport in cultured nasal polyp epithelial cells

OBJECTIVE

To measure transepithelial bioelectric properties of cultured human nasal polyp and turbinate epithelial cells to test the hypothesis that nasal polyps have increased rates of ion transport.

DESIGN

Cohort study.

SETTING

Private referral center.

PATIENTS

Individuals undergoing surgery for symptomatic nasal obstruction due to polyps caused by cystic fibrosis, nonatopic rhinosinusitis, or allergic rhinosinusitis.

METHODS

Epithelial cells were removed from separated polyp and turbinate samples by protease disaggregation and cultured on permeable collagen matrix supports. Transepithelial potential difference and resistance were measured daily. At the time of maximal transepithelial potential difference, the cultures were mounted in modified Ussing chambers and exposed to a sodium-positive channel blocker (amiloride hydrochloride) and to selected chloride-negative channel agonists (isoproterenol bitartrate, adenosine triphosphate).

OUTCOME MEASURES

Maximal transepithelial potential difference, resistance, and equivalent short-circuit current. Bioelectric responses to amiloride, isoproterenol, and adenosine triphosphate.

RESULTS

Polyp cultures had higher transepithelial potential difference and equivalent short-circuit current than turbinate cultures. The mediator responses were greater for polyp than for turbinate cultures.

CONCLUSIONS

Polyp epithelia have increased Na+ absorption and Cl- permeability relative to turbinate epithelia. These results are consistent with the hypothesis that increased epithelial fluid absorption contributes to the development of nasal polyps.

Involvement of the eyebrow fat pad in Graves' orbitopathy

Involvement of the eyebrow fat pad in Graves' disease has never been reported. We noted that Graves' orbitopathy patients had bulkier eyebrows due to a larger eyebrow fat pad not associated with the preaponeurotic fat. A cadaver model was used to show that the eyebrow fat could be identified with magnetic resonance imaging (MRI) scans. Then, a series of Graves' orbitopathy patients were sent for orbital MRI scans, and the eyebrow fat was measured with maximum lengths and widths. The averages were compared to two groups of patients, one without orbital pathology, and one with orbital pathology causing proptosis but not due to Graves' disease. Graves' patients with early orbitopathy and incipient optic neuropathy or congestive orbits where optic neuropathy had to be ruled out had statistically significant larger eyebrow fat pads than either comparison group. This has clinical significance: The eyebrow fat may need to be debulked during operations such as blepharoplasty. Furthermore, periorbital fat may play a larger role in the disease process than previously thought.

Analysis of respiratory syncytial virus F, G, and SH proteins in cell fusion

Recombinant expression of the human respiratory syncytial virus (RSV) fusion (F) glycoprotein, receptor-binding glycoprotein (G), and small hydrophobic (SH) protein was performed to determine the role(s) of these proteins in syncytia formation. These studies used a vaccinia virus expressing the bacteriophage (T7) RNA polymerase gene and plasmid vectors containing the RSV genes under the control of a T7 promoter. Within the context of this expression system, expression of any individual RSV gene, or coexpression of F+G genes, did not elicit the formation of syncytia. However, at plasmid input levels which were 10-fold higher than those normally used, coexpression of F+G induced low but detectable levels of cell fusion. In contrast, coexpression of F, G, and SH together elicited extensive cell fusion resembling that of an authentically infected cell monolayer. In addition, coexpression of F and SH elicited significant cell fusion, although to a lesser extent than was observed when G was included. Cell fusion induced by coexpression of F+SH was found to be specific to the RSV proteins, since coexpression of SH with the analogous F proteins from human parainfluenza virus type 3, human parainfluenza virus type 2, Sendai virus, or simian virus type 5 (SV5) did not elicit cell fusion. Finally, coexpression of the SV5 SH protein with the RSV or SV5 glycoproteins also failed to induce syncytia, suggesting type-specific restrictions between the two sets of viral proteins.

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.

Are thymus-derived lymphocytes (T cells) defective in the nasopharyngeal and palatine tonsils of children?

The present study was conducted to evaluate the response of adenoidal T cells and B cells in the production of immunoglobulins. There appears to be a consistent inability of adenoidal T cells to turn on B cells to mature into immunoglobulin-secreting plasma cells. This phenomenon did not appear to be due to suppressor activity of adenoidal T cells because T cells from other sources appeared to effectively result in adenoidal B cell maturation, even in the presence of adenoidal T cells. Both tonsils and adenoids appear to have defective IL-2 production, in response to both mitogens and specific antigens. It is hypothesized that a cytokine(s) may be released in adenoids that downregulate IL-2 production and result in immune suppression in the adenoids of children with recurrent otitis media and chronic sinusitis.

The role of IgE-mediated hypersensitivity in the development of otitis media with effusion: a review

Otitis media with effusion is the most common cause of hearing loss in children today. This report examines the role of immunoglobulin E-mediated hypersensitivity in the development of otitis media with effusion. It is emphasized that immunoglobulin E-mediated hypersensitivity, or allergy, represents only one variable in a very complex disease entity. Bacterial infection, viral infection, and mucociliary clearance are important variables that must be considered and may be effected by the allergic response. On the basis of the world literature and laboratory investigations at the Children's Hospital of Buffalo, it is concluded that otitis media is associated with allergy in 35% to 40% of cases. Furthermore, the middle ear mucosa itself is rarely a target organ for allergy. Release of biologic mediators of inflammation from basophils and mast cells occurs in the nasal mucosa and nasopharyngeal mucosa. These mediators most likely produce eustachian tube edema and inflammation. Over a long period this chronic inflammatory response, along with viral or bacterial infection, produces middle ear effusion.

Impaired bacterial killing in early obstructive jaundice

Sprague-Dawley rats were challenged with intraperitoneal injection of 10(7) Streptococcus pneumoniae 10 days after common duct ligation (BDL) or sham celiotomy (SC). Quantitative bacterial cultures were performed on liver, spleen, lung, kidney, and heart blood samples obtained 4 hours after injection. All 13 (100%) BDL animals had positive heart blood cultures, but only 6 of 12 (50%) SC animals remained bacteremic (p < 0.05). Significantly more viable organisms were recovered from lung, liver, spleen, and kidney of BDL animals compared with SC controls. BDL impaired the host's ability to kill this encapsulated gram-positive organism. Viable bacteria remained in all organs studied, which was associated with continuing bacteremia.

Micro-ecology of the nasopharyngeal bacterial flora in otitis-prone and non-otitis-prone children

The quantitative bacteriology of the adenoid was studied in otitis-prone and non-otitis-prone children. alpha-hemolytic Streptococci (Viridans Streptococci) appeared to be predominant normal flora in the healthy nasopharynx. There was a decrease in alpha-hemolytic Streptococci in the otitis-prone child compared to the non-otitis-prone child. Concomitantly, there appears to be an increase in both nontypable Haemophilus influenzae (NTHI) and S. pneumoniae in the nasopharyngeal flora in the otitis-prone child. The mechanisms responsible for this alteration of the micro-ecology of bacteria of the nasopharynx may be related, in part, to factors that alter mucociliary function. These factors could be viral infection, allergy, local and systemic immunological deficiency and the indiscriminate use of antibiotics. An understanding of the relationship between the normal flora and the potential pathogens may be important in the understanding of both the pathogenesis of otitis media (OM) and possibly the treatment of this disease entity.

Immunologic response of adenoidal lymphocytes to respiratory syncytial virus

Adenoidal lymphocytes obtained from 43 subjects with serum antibodies to respiratory syncytial virus (RSV) were established in culture in vitro and analyzed for immunoglobulin (Ig) and RSV-specific antibody synthesis. Spontaneous synthesis of Ig was consistently observed in culture supernatants. The ratios of IgA to IgG and IgM to IgG in adenoidal lymphocyte culture supernatant were higher than in serum. In cell cultures stimulated with RSV or pokeweed mitogen, RSV antibody activity was detected in 25 of 43 (58.1%) for IgG, 5 of 43 (11.6%) for IgA, and 4 of 43 (9.3%) for IgM. Also, RSV-specific IgG was detected in some supernatants from unstimulated cultures. In seven cases the cultures of autologous tonsillar lymphocytes were also investigated. Autologous organs exhibited similar polyclonal Ig production and RSV-specific antibody synthesis. These observations demonstrate that both adenoids and palatine tonsils are continuously engaged in synthesis of local antibodies to viral pathogens available to the nasopharynx and respiratory mucosa.