Nonspecific provocation of target organs in allergic diseases: EAACI-GA(2)LEN consensus report

It is widely accepted that nonspecific tissue reactivity is a distinct pathophysiological hallmark of allergic diseases, influenced by genetic and environmental factors different from those involved in causing sensitization and allergen response of target organs. This consensus document aims at reviewing procedures currently used for nonspecific provocation of the bronchi, nose and eye and for measuring their responsiveness to nonspecific stimuli.

Foreign bodies in the upper airways: the experience of two Italian hospitals

OBJECTIVE

To study the pattern of foreign bodies in the upper airways as emerging from the hospital records in the Bologna and Siena hospitals in Italy 1997-2002.

METHODS

A retrospective review of hospital records was performed using a standardized protocol. All injuries with ICD9 (International Classification of Diseases, 9'h revision) codes ranging from 931 to 934 which occurred in children age 0-14 were considered for the database.

RESULTS

One hundred ninety seven patients were included in the database with a diagnosis of Foreign Bodies (FB) over the study period, 78 with ICD931, 105 with ICD932, 12 with ICD933 and 2 with ICD934 discharge diagnosis. Of the 197 patients, 51.90% of the patients were males and the 48.10% were female. Median age was 4 (2, 6). At the moment of the injury, the child was eating (11%), playing (83%) or studying (4%) or cleaning ears (2%). The child was supervised by an adult in doing his/her activities at the moment of injury in the 84.2% of the cases. The child reached the hospital using always private transport (100%), never by using an emergency transport (0%). Most commonly, FB were extracted in ambulatory (95.4%), more rarely using an endoscopic procedure (4.1%), and never using surgery. Hospitalization was required in the 0.5% of cases (1).

CONCLUSIONS

Our study showed the substantial epidemiological similarity of the Italian data with the experience of other center in the world. The burden of chocking was very limited in our country, as proven by the limited access to emergency and more invasive procedures. Nevertheless, some consideration can be made from the preventive point of view. Quite surprisingly, the majority of injuries occurred under the supervision of an adult in playing or recreational activities.

[Glucan solution nasal spray vs saline in the treatment of chronic rhinosinusitis: a multi-centric double blind randomised clinical trial]

OBJECTIVES

The aim of our study was to evaluate the efficacy of 30 days treatment with glucan solution nasal spray vs. saline in the treatment of signs and symptoms of chronic rhinosinusitis.

MATERIALS AND METHODS

100 patients affected by chronic rhinosinusitis were enrolled. At the beginning and at the end of the study were evaluated: nasal congestion, headache, rhinorrea, facial pain, rhinopharyngeal exudate, inferior turbinate hypertrophy; a complete instrumental analysis of nasal functions by Active Anterior Rhinomanometry, nasal Muco-Ciliary Transport time and scraping of nasal mucosa was also performed. The patients were randomized 1:1 for receiving intranasal saline or intranasal glucan solution spray. Treatment was administered as follows: 2 puffs/nostril 3 times a day for 30 days.

RESULTS

The patients in therapy with the glucan solution showed a significant improvement concerning rhinorrea facial pain, intensity of headache, inferior turbinate hypertrophy, rhinopharyngeal exudates, inspiratory/expiratory nasal resistences, Muco-ciliary transport time, normalization of nasal mucosas and rhinocytogram; saline lavage didn't show this effects. Both treatment improved rhinorrea, instead both treatment didn't affect nasal congestion.

CONCLUSIONS

According to the results of our multicentric double blind randomized study, we suggest the use of glucan solution nasal spray as an efficacious therapeutic tool in the management of nasal symptoms in patients affected by chronic rhinosinusitis.

Child mortality due to suffocation in Europe (1980-1995): a review of official data

This report outlines the current status of the official statistical data available concerning mortality rates for suffocation in children <15 years of age, stratified according to sex and country in Europe, in the years 1980-1995. The data source is the WHO Mortality Database, which comprises deaths registered in national vital registration systems, with underlying cause of death as coded by the relevant national authority. To assess the impact of the problem of suffocation, the total potential years of life lost have been calculated. In addition, for Italy, and for the years 1999-2000, data related to deaths and hospitalizations for foreign body in the pharynx and larynx are presented. In Italy, in the years 1999-2000, the ratio between the number of hospitalizations and the mortality rates is approximately one death every 10 hospitalizations (x 100,000). The European mortality rate exceeds nearly one death per 100,000 persons. No evidence of any geographical pattern or cyclic trend emerged from the analysis of this official data.

Rhinitis and asthma in athletes: an ARIA document in collaboration with GA2LEN

This consensus document is aimed at reviewing evidence that the rhinitis-asthma links have peculiar features in athletes. Beside a review of epidemological data on the high prevalence of rhinitis and asthma in athletes, the effects on intense physical exercise on the immune system and repiratory functions are discussed, with special reference to the role of allergens and pollutants. In extending the Allergic Rhinitis and its Impact on Asthma (ARIA) recommendations to athletes, the issue is addressed of adapting diagnosis and management to criteria set by the International Olympic Committee (IOC) and regulations adopted by the World Anti-Doping Agency (WADA).

Concentration of moxifloxacin in plasma and tonsillar tissue after multiple administration in adult patients

OBJECTIVES

The antibacterial spectrum of moxifloxacin includes all the major respiratory pathogens, and its pharmacokinetics demonstrate high peak concentrations in plasma as well as at respiratory sites. Nevertheless, tonsillar tissue concentrations have never been investigated. In this study we determined the moxifloxacin concentrations in plasma and tonsillar tissue after the administration of three doses of moxifloxacin 400 mg to adult patients with chronic or recurrent tonsillitis undergoing tonsillectomy.

METHODS

This was an uncontrolled, open-label, randomized, parallel group study including 35 patients assigned randomly to five groups of 7 patients each, depending on the time between the last dose of moxifloxacin and plasma and tissue sampling. Moxifloxacin was given orally once daily for 3 days; its concentrations were measured using a validated HPLC assay and fluorescence detection. Each sample was analysed twice and the mean value obtained used for the statistical analysis. Pharmacokinetic data were analysed by presenting descriptive statistics of moxifloxacin concentrations in plasma and tonsillar tissue.

RESULTS

C(max) occurred at 3 h in tonsillar tissue (mean 8.96 mg/L) and in plasma (mean 3.20 mg/L), the tissue/plasma concentration ratios (mean values) being constantly >2, ranging between 2.37 (after 2 h) and 2.93 (after 24 h), which indicates a prolonged maintenance of moxifloxacin concentration in tonsillar tissue compared with plasma. Variability among patients was present at 6 h, with the tonsillar tissue/plasma concentration ratio ranging between 0.8 and 3.4.

CONCLUSIONS

Moxifloxacin achieves a good penetration in tonsillar tissue, which compares favourably with that reported for other fluoroquinolones. The moxifloxacin concentrations we observed exceed the MICs for the usual respiratory tract pathogens.

[Rhinosinusitis: etiopathogenesis and antimicrobial therapy, an update]

The aim of the current study is to underline once again the etiopathogenetic aspects of rhinosinusitis, by a revision of most significative and updated study in otorhinolaryngologic literature to guide the right management of this disease. The focal role of ostio-meatal complex is reported; epidemiological data on old and emergent pathogens are described together with their role on acute or chronic or recurrent rhinosinusitis pathogenesis. According to recent evidence based medicine documents, diagnostic criteria and methodologies are reported to control surgical and medical long-term results. On the bases of the current etiopathogenetic concepts, medical treatment is suggested. The central role of medical management is based on the choice of antimicrobial treatment. The fundamental concepts on pharmacocinetic and pharmacodinamic are reported, togther with updated data on antimicrobial resistance.

Quality of life and psycho-social development in children with otitis media with effusion

Purpose of this study was to correlate results from a survey on otitis media and the State-Trait Anxiety Inventory test. This survey investigated prevalence of otitis media (OM) in our territory, influence on development of language and personality and social costs. State-Trait Anxiety Inventory is a suitable test to differentiate state anxiety caused by a specific event [in this case, otitis media with effusion (OME)] from a trait anxiety (anxious personality) in parents and caregivers. The otitis media study was conducted, retrospectively, in two primary public schools in Colle Val D'Elsa (Siena) on 252 children (6-11 years old). The State-Trait Anxiety Inventory test had been administered to the parents or caregivers of 20 paediatric outpatients (4-12 years, mean 6.8) at the ENT Department of Siena University. The results of the OM survey showed a correlation between OM and difficulties in speech and reading, delayed answering and limited vocabulary. All these problems improved as children grew up. On the other hand, psycho-social development appeared to be more problematic even in the 4th and 5th class, mostly due to persistent attention disturbances. In the State-Trait Anxiety Inventory test, 50% of parents or caregivers had a high state-anxiety score and so were mostly concerned with health status of the children. The State-Trait Anxiety Inventory results indicated that 50% of parents or caregivers had a high trait-anxiety score and thus had an anxious personality. These findings could be helpful in understanding the real severity of symptoms. The two proposed tests could provide complementary data to evaluate children with OME: the OM survey can be used as a screening test to detect children with non-symptomatic OME, to establish whether delayed language development may be associated with OME, to predict prognosis and children's quality of life as well as social costs of OME; the State-Trait Anxiety Inventory test can be used to reveal a state or a trait anxiety in parents and caregivers in order to better understand their point of view. Parents' and caregivers' personality has a marked influence on the impact of OME on the children's quality of life. Quality of life in children with otitis media with effusion is one of the most important parameters to be taken into consideration on account of the possible correlation with problems in development.

Psychological aspects of risk appraisal in asphyxiation accidents: a review of the factors influencing children's perception and behaviour

Psychological aspects determining children's behaviour in response to asphyxiation risk due to ingestion of foreign matter have been rarely and non-systematically examined in the literature. Aim of this report is to highlight--through a review of the most significant psychological research in the literature--which factors influence the behaviour, perception and assessments of children 0 to 14 years of age, in a risk situation. In particular, attention is focused on the direct experience of a child at risk, assuming that this experience can play a significant role in future dangerous situations. Outcomes of studies taken into consideration have highlighted the influence of age, sex, socio-economic status, parents' role, peer group, personal traits, television and personal experience. The latter refutes the initial hypotheses, showing an unexpected and clearly negative effect on future evaluation and behaviour in response to similar contexts of asphyxiation risk. The implications for research on asphyxiation due to ingestion of foreign matter are examined.

International Consensus on Nasal Polyposis 2002–2004

Seventeen well-known experts in rhinosinusology from various countries tried to achieve consensus on the etiology, conservative approach and surgical approach to nasal polyposis. A Digi-Vote electronic system was used for an immediate computer analysis of expert answers to 23 questions related to the problem of nasal polyposis.

Do tryptase, ECP and specific IgE measurement by nasal incubation increase the specific nasal provocation test sensitivity?

The specific Nasal Provocation Test (sNPT) is a third level diagnostic tool. Fitted to reproduce natural exposure condition to pick the responsible allergen for nasal symptoms out, it is applied when prick test and RAST responses are doubtful. SNPT results have been evaluated measuring nasal resistance (anterior rhinomanometry) and nasal symptoms (clinical score), reaching 50% of sensitivity. This study focused on the determination of allergic response markers, triggered by nasal challenge: tryptase levels in the nose, specific IgE and ECP (Eosinophil Cationic Protein). The aim was to increase sNPT sensitivity. Twenty patients suffering from allergic rhinitis and 16 age-matched-nonallergic subjects were enrolled in the study. Tryptase, specific IgE and ECP were determined in nasal mucosa applying a new method, based on in situ incubation, before and after sNPT. The latter was performed following a standardized method. Tryptase levels increased in 13 patients (65%), were unchanged in four patients (20%), and slightly decreased in three patients (15%). The increase recorded was significant in mite allergic patients (p=0.005), but not significant (p> 0.05) in pollen allergic patients. ECP values increased in 13 patients (65%), were unchanged in two patients (10%), and highly decreased in five patients (25%). ECP increase was not significant (p> 0.05). Specific IgE levels increased in seven patients (35%), were unchanged in 11 patients (55%) and decreased in two patients (10%). The IgE increase was significant in pollen-allergic patients (p<0.05), while it was not significant in mite-allergic patients (p>0.05). Tryptase, ECP, and specific IgE were not detected in the control group. The data obtained showed a positive sNPT response in 12 patients (60%). Comparing our results with those derived from classical-parameter employment, we gathered an improvement of 10%. On the basis of the usual parameters, in fact, we recorded 50% positivity, while the use of mediators provided an additional 10% improvement in sNPT sensitivity: taking together the usual parameters and nasal allergic mediators values, we reached an sNPT over-all sensitivity of 85%.

P0 antigen detection in sudden hearing loss and Ménière's disease: a new diagnostic marker?

OBJECTIVE

To evaluate the presence of IgG autoantibodies against the P0 antigen in patients affected by sudden hearing loss and Meniere's disease (MD).

MATERIAL AND METHODS

All patients underwent a tonal audiometric evaluation, tympanometry, evaluation of the stapedial reflex threshold with decay time, determination of auditory brainstem responses and a complete vestibular assessment involving evaluation of spontaneous and positional nystagmus (Frenzel glasses), a head thrust test and a caloric test (Fitzgerald-Hallpike technique). Blood samples were drawn from all patients for the immunologic assessment of IgG antibodies against the P0 antigen (30-kDa protein) of guinea pig inner ear extracts using a Western blot assay.

RESULTS

Ten patients affected by sudden hearing loss showed specific IgG antibodies against the P0 protein. Specifically, the P0 positive band was detectable in 5/45 patients with unilateral auditory impairment and in 5/5 of those with bilateral forms of auditory impairment. Among MD patients, the P0 positive band was detectable only in those with bilateral audiovestibular impairment (n = 10). Interestingly, in none of the 35 patients affected by monolateral MD were specific IgG antibodies against the P0 protein detectable.

CONCLUSION

The positive reactions to P0 in all bilateral MD and bilateral sudden hearing loss patients found in this study strongly indicate that these pathologies are the result of an ongoing autoimmune process directed against specific antigens of the inner ear.

[Rationale of the use of COX-2 inhibitors in ENT pathologies]

Upper airways inflammations (rhinitis, rhinosinusitis, polyposis, otitis, pharyngitis, etc) the pathologies most commonly encountered in the daily clinical practice and they represent, because of the high sanitary costs, an important social problem. The Literature suggests that almost all the symptoms, which characterize upper airways inflammations, are induced by the production of prostaglandins by cyclooxigenase (COX); it is obvious the need of a therapeutic action at this level. The non steroidal anti-inflammatory drugs (NSAID) block the activity of both COX-1 and COX-2, whereas the selective inhibitors of COX-2 (the coxibs) act only on this isoform. Actually, the therapeutic effects of both NSAIDs and coxibs are due to their actions on COX-2, while the system toxicity of NSAIDs (gastrointestinal perforation or ulcer, reduction of glomerular filtration rate, prolongation of bleeding time) is ascribable to the inference of these drugs with the COX-1. In conclusion, a correct approach to ENT inflammations must implies the use of drugs efficacious against the typical symptoms of the inflammatory process (and specifically the symptom: pain), eventually joined with an appropriate antibiotic treatment; in this context, a selective inhibitor of COX-2 short course treatment offers the double advantage of managing the inflammation and avoiding damages to the gastric mucosa.

Allergic rhinitis in Italy: epidemiology and definition of most commonly used diagnostic and therapeutic modalities

Allergic rhinitis is classically defined as an IgE-mediated inflammation of nasal mucosa, characterised by nasal obstruction, rhinorrhea, sneezing and nasal itching. It is certainly a high-prevalence disease and an important social and medical problem in many industrialised Countries, affecting about 20% of the general population; moreover, it is diagnosed with increasing frequency, both in adults and children in many developing countries. In view of the high medical and social costs, a correct diagnostic approach to allergic rhinitis is a fundamental need for the otorhinolaryngologist, also considering the severe complications (asthma, rhinosinusitis, rhino-otitis, rhinosinusal polyposis) which could develop if this disease is not recognised and adequately treated in its early phases. In order to evaluate not only the present epidemiological characteristics of allergic rhinitis in Italy but also the most commonly used diagnostic and therapeutic approaches in the management of this disease, 145 Italian otorhinolaringologists were selected to take part in the investigation. Each was invited to complete a questionnaire, divided into 8 different sections, to be answered according to their daily clinical practice. The significance of the results has been compared with those of the international samples comprised in the ARIA Document and in the epidemiologic survey of the Standing Committee on Rhinology and Allergy of the International Federation of Otorhinolaryngological Societies. A critical analysis of these data leads to some interesting epidemiological and therapeutic considerations.

Double-blind, randomized, multicenter study comparing the effect of betahistine and flunarizine on the dizziness handicap in patients with recurrent vestibular vertigo

OBJECTIVE

The aim of this double-blind, randomized, multicenter study was to compare the efficacy of betahistine dihydrochloride (BH) and flunarizine (FL) using the Dizziness Handicap Inventory (DHI), a validated self-assessment questionnaire that has not previously been used in a clinical trial to evaluate antivertigo drugs.

MATERIAL AND METHODS

Patients with recurrent vertigo of peripheral vestibular origin and who were severely handicapped by vertigo were randomized to an 8-week course of treatment with oral BH 48 mg daily or oral FL 10 mg daily. The efficacy endpoints were the total DHI score and the physical, functional and emotional subscores.

RESULTS

Fifty-two patients completed the study. After 8 weeks of treatment the mean total DHI score and the physical subscore were significantly lower in the BH group compared to the FL group (7.5 and 3.6 points, respectively). The mean total DHI score as well as the three subscores decreased significantly after 4 and 8 weeks in both treatment groups.

CONCLUSION

This study showed that at 8 weeks BH is significantly more effective than FL in terms of improving the total DHI score and the physical subscore. It was also established that the DHI is a useful and reliable method for evaluating the efficacy of antivertigo drugs.

Differences in nasopharyngeal bacterial flora in children with nonsevere recurrent acute otitis media and chronic otitis media with effusion: implications for management

BACKGROUND

The interactions between nasopharyngeal flora and the individual entities covered by the broad term otitis media have not been completely elucidated. We investigated in infants and children ages 6 months to 7 years with nonsevere recurrent acute otitis media (rAOM) or with chronic otitis media with effusion (cOME): (1) the nasopharyngeal carriage rate and bacterial density of respiratory pathogens and alpha-hemolytic streptococci in comparison with healthy children; (2) the resistance pattern of respiratory pathogens; and (3) the relationship between the type of nasopharyngeal colonization and long term outcome.

METHODS

Nasopharyngeal cultures were obtained from 85 children with rAOM,113 children with cOME and 55 controls. A semiquantitative analysis was used in the reading of cultures. A 12-week follow-up without treatment was planned.

RESULTS

The carrier rate of respiratory pathogens was significantly greater in cOME (70%) than in rAOM (45%) (P = 0.0006) or controls (31%) (P < 0.0001). Similarly colonization density was significantly greater in cOME than in rAOM. The carriage rate and the colonization density of alpha-hemolytic streptococci were significantly lower in rAOM than in cOME or controls. The incidence of resistant (R) strains was greater in rAOM (Streptococcus pneumoniae penicillin-R, 24%; macrolide-R, 64%; Haemophilus influenzae amoxicillin-R, 24%) compared with cOME (S. pneumoniae penicillin-R,18%; macrolide-R, 44%; H. influenzae amoxicillin-R, 5%) or controls (S. pneumoniae penicillin-R, 8%; macrolide-R, 23%; H. influenzae amoxicillin-R, 10%). During the follow-up period persistence of OME and occurrence of AOM were greater among carriers of respiratory pathogens at baseline.

CONCLUSIONS

There are substantial differences in nasopharyngeal flora between children with nonsevere rAOM and children with cOME. The results of nasopharyngeal cultures should be taken into account to avoid treatment with drugs that are ineffective and likely to select resistant organisms.

Newborn hearing screening by transient evoked otoacoustic emissions: analysis of response as a function of risk factors

Hearing loss can be considered as the most common birth defect. Early detection of hearing loss by screening at, or shortly after, birth and appropriate intervention are critical to speech, language and cognitive development. In the present study, the characteristics of Transient Evoked Otoacoustic Emissions have been evaluated as a function of known pre- and perinatal risk factors for hearing loss. All newborns were screened for hearing loss using a physiologic test of hearing function, the Transient Evoked Otoacoustic Emissions. A total of 532 consecutive newborn infants received binaural Transient Evoked Otoacoustic Emission testing (262 males, 270 females; mean gestational age 39.2 +/- 2.1 weeks, range 26-43; birth weight: 3,240 +/- 550 g, range 910-4,780). The population examined comprised 448 control infants and 84 high-risk for hearing loss infants (Joint Committee on Infant Hearing 1994 criteria). All Transient Evoked Otoacoustic Emission recordings were performed at comparable postconceptional ages. Audiological screening by Transient Evoked Otoacoustic Emission recording showed an overall 100% sensitivity, 99.02% specificity, with negative and positive predictive values of 100% and 62.5%, respectively. As compared to controls, high-risk infants showed: 1. increased rates of Fail-1 (Transient Evoked Otoacoustic Emissions absent at first examination, 21.4% vs 9.8%, p = 0.004), Fail-2 (Transient Evoked Otoacoustic Emissions absent on retesting: 8.64% vs 1.37%, p = 0.0014), false positives (Transient Evoked Otoacoustic Emissions absent/V wave present: 3.7% vs 0.46%, p = 0.029) and true positives (Transient Evoked Otoacoustic Emissions absent, V wave absent: 2.47% or 24.5 per 1,000 live births vs 0.22% or 2.2 per 1,000 live births, p = 0.013); 2. significantly reduced Transient Evoked Otoacoustic Emission intensity in the 0.7-1 kHz (right side) and 1-2 kHz (left side) frequency ranges. Multivariate logistic regression analysis showed a significant positive correlation between congenital hearing loss and the following risk factors: assisted ventilation lasting > 10 days (Odds ratio 14.8; 95% confidence interval, 4.5-48.8, p < 0.000001), severe birth asphyxia (Odds ratio 5.8; 95% confidence interval; 2.1-16.1; p = 0.0006) and administration of ototoxic drugs (Odds ratio 4.5; 95% confidence interval; 1.4-13.9; p = 0.009). Results of this study confirm the feasibility and accuracy of universal neonatal hearing screening based on recording Transient Evoked Otoacoustic Emissions. These data stress the importance of the risk factors for hearing loss, including prolonged assisted ventilation, ototoxic drugs, and severe birth asphyxia.

Betahistine dihydrochloride in the treatment of peripheral vestibular vertigo

The present study compares the efficacy and safety of betahistine dihydrochloride to that of a placebo in recurrent vertigo resulting from Meniere's disease (MD) or in paroxysmal positional vertigo (PPV) of probable vascular origin. The design was double-blind, multicentre and parallel-group randomised. Eleven Italian centres enrolled 144 patients: 75 of the patients were treated with betahistine (41 MD/34 PPV) and 69 with placebos (40 MD/29 PPV). The betahistine dosage was 16 mg twice per day for 3 months. Compared to the placebo, betahistine had a significant effect on the frequency, intensity and duration of vertigo attacks. Associated symptoms and the quality of life also were significantly improved by betahistine. Both the physician's judgement and the patient's opinion on the efficacy and acceptability of the treatment were in agreement as to the superiority of betahistine. The effective and safe profile of betahistine in the treatment of vertigo due to peripheral vestibular disorders was confirmed.

A randomized controlled trial showing efficacy of once daily intranasal budesonide in nasal polyposis

A randomized, double-blind, placebo-controlled trial was performed to assess the efficacy of once daily budesonide in patients with nasal polyps. After a 2-week run-in period, 157 patients with symptomatic bilateral nasal polyposis were randomized to receive budesonide, 140 micrograms once or twice daily or 280 micrograms once daily (delivered doses) via Turbuhaler, or placebo for 8 weeks. Polyp size was assessed endoscopically and, in two centres, by magnetic resonance imaging (MRI). Nasal symptoms (blocked nose, runny nose, sneezing) were recorded daily, and patients provided an overall assessment of efficacy at the end of the study. Budesonide, 280 micrograms/day (280 micrograms o.d. and 140 micrograms twice daily), significantly reduced polyp size, compared with placebo, whereas budesonide, 140 micrograms once daily, had no significant effect. Nasal polyp mass score, measured by MRI, was also significantly reduced in patients receiving 280 micrograms/day. All three doses of budesonide significantly reduced symptom scores, and there were no significant differences between the groups. Overall, approximately 70% of patients receiving budesonide, 280 micrograms/day, reported substantial or total control of symptoms, compared with 45% of placebo-treated patients. It is concluded that budesonide, 280 micrograms once daily, reduces polyp size and relieves symptoms in patients with nasal polyposis.

Short course therapy with cefitbuten versus azithromycin in pediatric streptococcal pharyngitis

OBJECTIVE

To compare the safety and efficacy of a short course (5 days) of ceftibuten vs. azithromycin for 3 days for treatment of group A beta-hemolytic streptococcal (GABHS) pharyngitis in children.

METHODS

A multicenter, open label, prospective, randomized trial in which patients > or =3 to < or =16 years of age with proven GABHS pharyngitis were randomized to receive either once daily ceftibuten for 5 days or azithromycin for 3 days. Patients were evaluated for clinical outcomes and/or for adverse events at days 6 to 8, 13 to 15 and 33 to 35 posttherapy. Microbiologic assessments (pharyngeal cultures) were conducted at baseline and at each follow-up visit.

RESULTS

A total of 132 patients in the ceftibuten arm and 116 in the azithromycin arm were enrolled in the safety analysis, whereas 126 and 101, respectively, were enrolled for ceftibuten and azithromycin efficacy evaluation. Clinical success (cure or marked amelioration) at days 6 to 8 was recorded in 98 and 94% in the 2 groups, respectively. In the bacteriologic efficacy analysis at 6 to 8 days, the GABHS strain was eradicated in 76% of the patients treated with ceftibuten and in 76% of those receiving azithromycin. At 33 to 35 days, 84% of the patients in the ceftibuten arm and 71% in the azithromycin arm were GABHS-negative, and bacteriologic relapse was observed in 4 and 7% of the ceftibuten and azithromycin cases, respectively. Both treatments were well-tolerated by all patients.

CONCLUSIONS

Ceftibuten and azithromycin allow simple treatment schedules (i.e. once daily administration, short duration of treatment). The somewhat higher eradication rate recorded after ceftibuten administration is consistent with the overall superior bactericidal activity of beta-lactams compared with macrolides vs. GABHS in vitro.

Treatment of benign paroxysmal positional vertigo: no need for postmaneuver restrictions

The liberatory maneuver of Semont is an effective physical treatment for benign paroxysmal positional vertigo. It works because it causes otoconia to move out the posterior canal. The effectiveness of the maneuver is thought to be indicated by the appearance of a liberatory nystagmus. After the maneuver, patients are usually instructed to keep their heads erect for several days and not to lie on the pathologic side for about a week. Here we investigated the prognostic value of liberatory nystagmus and whether restrictions are necessary after treatment. Fifty-six patients with posterior canal benign paroxysmal positional vertigo underwent the Semont maneuver and were checked after 20 minutes, 24 hours, and 1 week. The patients were told that they could sleep or move as they pleased, without any particular precautions. We found that liberatory nystagmus had a high prognostic value and that it was not necessary for patients to avoid certain positions or movements after treatment.

Twenty years of experience with Marullo's supraglottic laryngectomy

We present a follow-up study of 142 patients on whom we performed supraglottic laryngectomy (SL) with an anterior subperichondral approach using Marullo's technique, which was described in 1975. Between January 1976 and December 1992, 142 patients (age range, 35-73 years) with squamous cell carcinoma of the supraglottic larynx were treated with SL or extended SL (ESL) and ipsilateral or bilateral neck dissections with or without postoperative radiotherapy. All cases were staged according to the 1997 UICC TNM classification. Survival was defined by the Kaplan-Meyer method and showed an overall survival of 77% and a local control rate of 78%. Regarding functional rehabilitation, the mean nasogastric tube-removal time was 16 days (range, 10-39 days) for SL and 23 days (range, 11-102 days) for ESL. Voice quality was very satisfactory after SL, while the voice was often harsh or breathy after ESL with postoperative radiotherapy. The overall oncologic and functional results obtained with Marullo's SL were very similar to those obtained with the classic Alonso's operation and demonstrated that this technique makes it possible to reach "en bloc" supraglottic sites and the hyothyroepiglottic space. We consider the operation to be safe and simple to perform, provided the sub-perichondral plane is correctly identified. This approach allows the surgeon easily to reach the correct transverse level above the anterior commissure of the vocal cords. Inferiorly, the resection cuts through the floor of the ventricle and is considered to be the safe oncologic plane for pure supraglottic lesions. This technique has also been used successfully in extended resections to treat tumors involving the base of the tongue, pyriform sinus and one arytenoid.

A multicenter trial of specific local nasal immunotherapy

OBJECTIVE

To assess the efficacy and safety of specific local nasal immunotherapy (LNIT) in powder form in patients with allergic rhinitis, using subjective and objective parameters.

STUDY DESIGN

A double-blind randomized multicenter trial of 102 patients with allergic rhinitis who were treated with specific LNIT for 8 consecutive months.

METHODS

After identifying allergens with the skin prick test and sensitization threshold dose with the specific nasal provocation test, 102 patients were selected, of whom 55 were allergic to mites and 47 were allergic to Graminaceae or Parietaria pollen. The specific treatments were self-administered using an insufflator in two phases (phase 1: increasing doses; phase: 2, maintenance dose). Patients were evaluated before and after 32 weeks of treatment by subjective analysis of their self-reported symptoms and by objective analysis of nasal provocation test, nasal resistance by anterior rhinomanometry, and mucociliary clearance time.

RESULTS

Clinical efficacy of LNIT for allergy to mites and pollens was confirmed by the differences in the symptoms score between the active group and the placebo group. The nasal provocation test results confirmed that this difference was statistically significant. The rhinomanometric analysis gave positive results for the treated group mainly in LNIT for mites. No differences in mucociliary clearance time were found.

CONCLUSIONS

Specific LNIT is effective for allergic rhinitis and appears to offer considerable advantages over other hyposensitization methods. It can be done at home, patient compliance is good, and the treatment is safe.

Monitoring methods of nasal pathology

The importance of correct clinical and therapeutic monitoring of allergic rhinitis is understandable in the light of the social and economic impact of this pathology: its prevalence is over 10% of the total population all over the world. For the evaluation of the local nasal pathology we include: (1) anterior rhinoscopy, (2) active anterior rhinomanometry, (3) positioned acoustic rhinometry, (4) determination of mucociliary transport time, (5) specific nasal provocation test. Active anterior rhinomanometry allows reliable assessment of the nasal respiratory function, acoustic rhinometry shows the geometry of nasal cavity, mucociliary transport time is an indicator of the mucosa eutrophism. In our experience, the specific nasal provocation test is one of the most important tests in this field. It is more sensitive than the skin test and the radioallergosorbent test (RAST) in the asymptomatic phase and it is able to show organ allergies. In this study we review the importance of this test and the methodology we commonly use.

Nasal allergy and atmospheric pollution

Among the effects that pollution of the air causes on human health, irritation of the exposed mucosa is the earliest and the most obvious one. Pollutants damage the anatomical and functional integrity of the primary airways, in particular they cause alteration of the mucociliary system. The mucosa undergoing continuous aggression by an aerosol loaded with pollutants assumes the characteristics of a tissue with chronic inflammatory processes with dysepithelialised areas that could be an easy entrance for airborne allergens. The loss of integrity of epithelial lining, the interference with the repulsion of extraneous particles trapped in the mucus, the infiltration of the inflammatory cells and lymphocytes called into action by the phlogistic reaction multiply the occasion of meeting between environmental allergens and the immunological system of the host and basically of setting in motion the process of sensitisation. So there is a strict relationship between nasal allergy and pollution, that should not be ignored: allergy is the cause of considerable disturbances interfering with study, work and social activity and can lead to local and distal complications.

Epidemiology and treatment of otitis media with effusion in children in the first year of primary school

In this multicentre study we evaluated the prevalence and risk factors of otitis media with effusion (OME) in Italian school-children and the effectiveness of medical treatment of chronic OME with a new cephalosporin, ceftibuten. During two winter periods, 3413 children, aged 5 to 7 years, were examined for the presence of OME by means of pneumotoscopy and a portable, hand-held tympanometer. The prevalence of asymptomatic OME was 14.2%, with no difference as regards sex, age, month of examination or geographic area. Younger children had significantly more bilateral than unilateral effusion. A recent episode of acute otitis media and previous tonsillectomy or adenoidectomy were associated with an increased risk of OME in multivariate logistic regression models. The presence of OME was unrelated to such factors as birthweight, prematurity, sibling or parental history of allergy, duration of daycare attendance, family history of ear infections. After 12 weeks, 26.6% of children with OME still had middle-ear fluid: 52 were randomized to ceftibuten (9 mg/kg q.d. for 14 days) and 59 to no treatment (nasal saline drops allowed). Children treated with ceftibuten had a significantly better resolution of middle-ear effusion after 4 and 8 weeks. As mass screening programmes for OME in the year of school entry are questioned, a focus only on children with known risk factors seems advisable. Ceftibuten can be useful in reducing the duration of middle-ear effusion.

The management of horizontal-canal paroxysmal positional vertigo

Horizontal-canal paroxysmal positional vertigo (HC-PPV) is a vestibular syndrome due to canalolithiasis of the horizontal canal. The more common posterior-canal paroxysmal positional vertigo has a well defined and effective therapy, while there have been few reports on physical therapy for HC-PPV, and these have been tried in relatively few patients. We report the results of two different types of treatment of HC-PPV in 92 patients. A group of 21 untreated patients acted as a control group. One method, known as forced prolonged position (FPP), proposes liberating the affected canal by gravitation, and involves having the patient lie on the healthy side for many hours. The other method (the barbecue rotation) is a liberatory manoeuvre which proposes to expel the otoconia from the canal by rotating the patient 270 degrees around the longitudinal axis of the body in rapid steps of 90 degrees. FPP was successful in more than 70% of our patients; the barbecue rotation had slightly less successful but more immediate results. Both methods enable otoconial debris to migrate into the posterior canal. We suggest treating all patients with the two methods in succession.

Monitoring methods for local nasal immunotherapy

When a patient is affected by specific vasomotor rhinopathy (allergic rhinitis), both perennial and seasonal, all the nasal functions are altered to various degrees. For this reason, in the evaluation of the efficacy of an antiallergic therapy we include: 1) anterior rhinoscopy; 2) active anterior rhinomanometry; 3) positioned acoustic rhinometry; 4) determination of mucociliary transport time; and 5) specific nasal provocation test. Active anterior rhinomanometry performed according to the directions of the International Committee on Standardization allows reliable assessment of the nasal respiratory function. Acoustic rhinometry is an objective method to assess the geometry of nasal cavities but, as a new method, needs more standardization with particular care in connecting the nose-piece to the nostril. Both these tests performed before and after local administration of nasal decongestants allow quantification of the congestion degree of the nasal mucosa. Determination of mucociliary transport time, according to the method of coloured tracer, is easy to perform and may be considered a reliable indicator of the mucosa eutrophism. In our clinical experience we have often found mucociliary transport times delayed or even blocked, especially in patients affected by perennial allergic rhinitis. According to our experience the specific nasal provocation test is one of the most important tests in this field: it is more sensitive than skin tests and RAST in the asymptomatic phase and it is able to show organ allergies. In this paper we review the importance of this test, the methodology we currently use as well as changes after local nasal immunotherapy.

Relapsing infective-phlogistic pathology of Waldeyer's ring and its relationship with secretory otitis media

In our previous studies on the physiopathology of the rhinopharyngeal-tubal unit, we found and reported an unmistakable correspondence between rhinopathy and otitis media. However, we have often asked ourselves how and why severe cases of otitis media were often present in subjects without an evident obstructive naso-tubal pathology. With research that we have already published, we have been able to reveal how alteration of the ventilatory function of the tube is not the only factor that provokes affections of the middle ear. In our opinion, the phlogistic event is the main cause of otitis. Our conviction has recently been confirmed and strengthened by new research to which we wish to refer. A total of 92% of young patients and 65% of adult patients who underwent tonsillectomy in our Institute suffered from otitis media. These results emphasize that it is the infection, with the concomitant inflammation, that alters the function of the tube. Altered functions of drainage and defense cause affections of the middle ear in conditions of non altered ventilation and thus they are not documentable with the routine instrumental tests.

[Comparative study of most recent surgical techniques for the treatment of the hypertrophy of inferior turbinates]

The choice among the several techniques carried out to treat the hypertrophy of inferior turbinates is still difficult and matter of great interest. In the present study the Authors evaluated the efficacy and sequelae of the most common operations suitable for this pathology. The surgical procedures taken into consideration were (1) electrocautery; (2) cryotheraphy; (3) lasertherapy; (4) submucosal decongestion without lateral outfracture; (5) sub-mucosal decongestion with lateral outfracture; (6) turbinectomy. The six groups of patients (total 382) have been followed up for 4 years after surgery. At this aim the rhinomanometry, acoustic rhinometry, MCTt and SIgA dosage have been checked up together with the symptomatologic score. The conclusion was that the submucosal decongestion with lateral outfracture was the most effective technique for the chronic nasal obstruction, able to respect all the nasal functions.

[Can the recurrence of nasal polyposis be prevented? A new therapeutic approach]

Nowadays nasal polyposis must be still considered an unsolved problem as the surgical procedures are unable to treat this pathology and the recurrence is very common. For this reason several Authors starting from the pathogenesis and the histological features have chosen a medical point of view at the aim of preventing the natural course of this disease. The present study experimented the effect of the furosemide locally administered in the prevention of polyps relapsing in subjects previously operated on. The Authors pointed out that the furosemide was able to decrease the nasal reactivity to the challenge with ultrasonic nebulized distilled water. Besides this drug locally administered for 3 months (once a day) maintained the nasal mucosa of the patients affected with hyperreactivity in a good functional condition without nasal obstruction. In fact no polyps were found at the objective examinations performed during the three years follow up and the values of acoustic rhinometry measurements were within the normal range. Finally the present research gave the opportunity to hypothesize the role of sodium, potassium and calcium ions transport regulated by drugs or other physiopathological events, in the physiology of the nasal mucosa.

Oral therapy with flurithromycin in ear, nose and throat infections

In this study efficacy and tolerability of flurithromycin ethylsuccinate (FE) were evaluated in ear, nose and throat infections. One hundred and three patients were treated with FE tablets 375 mg 12-hourly for a mean duration of treatment of 8.2 days and they were divided into groups according to the pathology: pharyngitis/tonsillitis (chronic 7, acute 38), rhinosinusitis (chronic 7, acute 12), otitis (chronic 6, acute 32) and sialadenitis (acute 1). Patients evaluable for clinical efficacy were 101, among them a complete recovery was registered in 88.2%, an improvement in 9.9% and a treatment failure in 1.9%. Bacteriological evaluation was possible in 95 patients, showing the eradication of the pathogen in 94.7%. Tolerability was judged to be excellent in 81.6%, good in 15.5% and discrete in 2.9%. These results demonstrate that FE is safe and effective in the treatment of infections established on acute or chronic inflammatory states.

Pidotimod in the management of recurrent pharyngotonsillar infections in childhood

The efficacy and safety of a new synthetic immunostimulant pidotimod ((R)-3-[(S)-(5-oxo-2-pyrrolidinyl) carbonyl]-thiazolidine-4-carboxylic acid, PGT/1A, CAS 121808-62-6) in recurrent infections of the primary airways were assessed in a group of 416 children with a history of recurrent respiratory infections (RRI). This was a double-blind randomized trial of pidotimod vs. placebo, consisting of a treatment period of 60 days and a follow-up period of 3 months. A reduction in the duration and frequency of infectious episodes in the group of children treated with pidotimod (one 400 mg oral bottle daily) was observed which was statistically different from the placebo group. The protective effect produced by pidotimod was also confirmed by a series of recordings made over the five-month observation period, which showed a significant reduction in the number of days of fever, the severity of the signs and symptoms of acute episodes, use of antibiotics and antipyretic drugs and absence from school or nursery school. Safety was excellent.

[Furosemide long-term inhalation therapy in patients with nasal polyposis]

Study aimed principally at applying the data recently gathered with regard to Bronchial Reactivity to rhinology, with special regard to non-atopic or allergic hyperresponsiveness. In the past decade, Ultrasonic Nebulized Distilled Water (U.N.D.W.) was recognized as one of the best test in Bronchial Reactivity. In allergic and non-allergic rhinitis, the Authors tried to use U.N.D.W. to reproduce symptoms of rhinitis. Results show that U.N.D.W. could be included in the Nasal Hyperreactivity test. Secondly, but not less interesting, is the prevention of experimental rhinitis with U.N.D.W. by using Furosemide, a diuretic administered by inhalation. The prevention of Ca++ penetration into nasal cell can block any mediator-activation. Such procedure may be applied in polyposis after surgery in order to prevention recurrence, data show the complete applicability of this pharmacological treatment in children as well.

A comparison of azelastine nasal spray and cetirizine tablets in the treatment of allergic rhinitis

A total of 40 patients with perennial allergic rhinitis were treated with either azelastine nasal spray 0.14 mg/nostril twice daily (0.56 mg/day) or cetirizine tablets 10 mg once daily. Treatment was for a period of eight weeks. The rhinitis symptoms were evaluated according to a four-point scale (0 = absent, 3 = severe). The Total Rhinitis Symptom Score (TRSS) was derived from the sum of the individual symptom scores. Symptoms were assessed at baseline prior to treatment and at weeks 2, 4 and 8. Compared baseline, TRSS for both the azelastine and cetirizine groups were less at each assessment during treatment, a slight non-significant advantage was seen in the azelastine group. At the end of the study, physicians rated global efficacy as being "good" or "excellent" in 73.7% of azelastine patients and 55.5% of cetirizine patients. Both treatments were well tolerated and no serious adverse events were reported, however, two cetirizine patients withdrew from the study because of somnolence. In conclusion, azelastine has been shown to be at least as effective as cetirizine in the relief of the symptoms of perennial allergic rhinitis.

[Histomorphological changes induced by recurrent tonsillitis]

Palatine tonsils are lymphoepithelial mucosal structures whose particular role as a defense mechanism in the human immune system makes them fundamental in protecting organs of much greater importance. If follows, therefore, that dealing with recurrent tonsillar phlogosis--diagnosis as well as therapy choice, surgical or medical--is today problematic and shrouded in doubt. The authors examined tonsillar tissue specimens of 65 patients (age range 4-30 years) who had previously undergone tonsillectomy. Light microscopy and immunocytochemistry were used to study subepithelial tissue while scanning electronic microscope was employed to observe epithelial ultrastructure in order to determine which alterations were most meaningfully correlated to the history and clinical picture of the subjects. In 100% of the cases the cryptic reticular epithelium was hyperplastic while in 44% a squamous metaplasia was observed. Epithelial alteration in various forms was also revealed with scanning electronic microscope: cellular disjunction ridging of the cryptic floor, conrifying squamous epithelial cells, plasma cells and infiltrated lymphocytes. The authors suggest that it is precisely epithelial alteration which, due to inadequate antigen uptake, triggers the series of events which leads from tonsillar disorders to systemic metafocal manifestation.

Diurnal activity of the nasal mucosa. Relationship between mucociliary transport and local production of secretory immunoglobulins

Within the ambit of the cyclic activity of the nasal mucosa the purpose of this study was to verify the existence of possible correlation between the rate of mucociliary transport (MCT) during the day and the circadian changes of the SIgA concentrations already found in a previous study. In the present work, a daily fluctuation of the SIgA concentrations was confirmed and it was shown that the values decrease from the greatest limit at 4.00 a.m. to the lowest at 10.00 a.m. Circadian changes of the MCT times are also shown. Moreover, the comparison of the data pertaining to these two parameters showed opposite patterns: when the mucociliary transport velocity decreases, the secretory immunoglubulins reach the highest levels. The phase-displacement of the two examined functions thus makes it possible to compensate cyclic impairments of one activity with contemporary improvement of the other.

[Cyclic activity of the nasal mucosa: relationship between muco-ciliary transport and local production of secretory immunoglobulin]

The aim of the present work has been to study the existence, presumed on the basis of recollection, of a correlation between circadian changes in SIgA concentrations in nasal secretum and the M.C.T. rate throughout the day. In order to reconfirm previously obtained data, again in this case a fluctuation in SIgA concentration was studied, finding peak values at 4 a.m. and the lowest at 10 a.m. Circadian changes were also witnessed between M.C.T. times, thus making it possible to reveal further information regarding cyclic activity of the nasal mucosa. Comparison of these two parameters showed an inverse rate; in fact, when the SIgA concentration increases the muco-ciliary transport rate decreases and vice versa. In other words, the muco-ciliary transport time is more efficient when the production of secretory immunoglobulins by the nasal mucosa is lower, as though a temporary lack in nasal defense is made up for by simultaneous improvement of the other activity.