Complications of sinusitis

Even though they seldomly occur, the complications of sinusitis may be life-threatening. Complications can be local, orbital, and intracranial problems or combinations thereof. Orbital complications are the most frequent, and children with acute ethmoiditis are especially prone to them. To prevent permanent loss of vision, immediate and intense therapy is most important. Intracranial complications can have few symptoms, and discordance between symptoms and severity is not uncommon, which involves the importance of early radiologic diagnosis with computed tomographic or magnetic resonance imaging scans. Orbital and intracranial complications of sinusitis are medical emergencies and must be treated by specialists. Whenever possible, the underlying sinus infection should be drained at the same time. All physicians treating acute and chronic sinusitis must keep the potentially life-threatening complications of sinusitis in mind and remain suspicious because early recognition and treatment are crucial in these cases.

Local application of atropine attenuates the upper airway reaction to cold, dry air

In some individuals, inhalation of cold, dry air (CDA) provokes symptoms of rhinitis, accompanied by an increase in the levels of inflammatory mediators and markers of plasma leakage of recovered nasal lavages. Because rhinorrhea is a major component of this reaction and because nasal glands are heavily innervated by the parasympathetic system, we assessed the effect of atropine on the nasal reaction to CDA. Using a double-blind, randomized, crossover design, we administered a total dose of 0.5 mg of atropine or placebo intranasally to 18 volunteers before provocation with CDA. The reaction was monitored with symptom scores and by measuring the concentrations of histamine, N-alpha-p-tosyl-L-arginine methyl ester (TAME)-esterase activity and albumin, as well as the osmolality of lavage fluids before and after the provocation. Atropine significantly reduced rhinorrhea, the levels of histamine, and TAME-esterase activity as well as the osmolality of recovered lavage fluids, but had no effect on nasal congestion or albumin. Even with atropine, however, rhinorrhea and TAME-esterase activity were still significantly increased over the prechallenge baseline. Our results demonstrate that atropine-sensitive parasympathetic efferent pathways contribute to the CDA-induced rhinitis. We speculate that (1) the glandular and the vascular events of the upper airway reaction to dry air have different pathophysiologic mechanisms; (2) a significant component of TAME-esterase activity in lavage fluids may be of glandular origin; and (3) in addition to parasympathetic nerve activation, other mechanisms are involved in the upper airway reaction to dry air. The mechanism(s) leading to the reduction of histamine is unknown.

The nasal response to histamine challenge: effect of the pollen season and immunotherapy

To evaluate changes in the nasal response to histamine, we challenged 19 subjects with allergic rhinitis caused by ragweed (RW) before, during, and after the RW season with increasing doses of histamine diphosphate. We compared their response, as measured by symptoms and the levels of TAME-esterase activity and albumin recovered in the nasal lavage fluid, with response of two groups with allergic rhinitis undergoing immunotherapy with moderate-dose (N = 16) and high-dose (N = 11) RW (2 and 24 micrograms of antigen E [Amb a I] as maintenance dose, respectively). Four challenges with histamine were performed in each group: before, at the peak of, near the end of, and 2 weeks after the RW season. The three groups of subjects had similar skin sensitivity to antigen and levels of TAME-esterase activity and albumin recovered from nasal lavages after histamine challenge performed before seasonal exposure. Symptom diaries obtained throughout the season revealed a significant reduction only in the high-dose immunotherapy-treated group. At the peak of the season, the untreated group had more symptoms in response to the challenge compared with the challenges before and after the season (p = 0.04 for both groups). The saline challenge occurring before challenging with histamine also demonstrated a significant increase at the peak of the season compared with increases before the season (p = 0.02). This observation was also true for the levels of albumin and TAME-esterase activity. If the response after saline challenge was subtracted from each response after histamine challenge, no difference was found in the results between any of the visits.(ABSTRACT TRUNCATED AT 250 WORDS)

Ipratropium bromide (Atrovent nasal spray) reduces the nasal response to methacholine

We investigated the efficacy of local ipratropium bromide on methacholine-induced nasal secretions in a double-blind, placebo-controlled experiment. Twenty subjects with perennial rhinitis received a total intranasal dose of 21, 42, 84, and 168 micrograms of ipratropium bromide or placebo in each nostril. One hour later, filter paper disks were used to deliver increasing doses of methacholine and to collect secretions from the left septum. Concomitantly, symptoms of rhinorrhea and nasal congestion were scored. Compared with doses of placebo, all doses of ipratropium bromide significantly reduced the methacholine-induced increase in nasal secretion weights and symptoms of rhinorrhea (p less than 0.01). The highest dose was significantly more effective than the lower doses in reducing secretion weights (p = 0.01). We speculate that ipratropium bromide may prove beneficial for the treatment of rhinorrhea in perennial rhinitis. Furthermore, increasing the delivered dose to 168 micrograms may increase efficacy without augmenting side effects.

Tryptase and histamine as markers to evaluate mast cell activation during the responses to nasal challenge with allergen, cold, dry air, and hyperosmolar solutions

We have used assays for histamine and for the specific mast cell enzyme, tryptase, to examine the response of the nasal mucosa to provocation with several different stimuli and to evaluate the reliability of histamine as a marker of mast cell activation. High levels of histamine detected in baseline lavages of some subjects are not associated with any detectable tryptase, suggesting they are not mast cell derived. During pronounced immediate allergic responses, however, mast cell degranulation clearly occurs, and a striking correlation between histamine and tryptase is observed. This correlation is weaker when a more modest allergic response is induced, possibly reflecting differential diffusion of the two mediators across the epithelium. Provocation of susceptible individuals with cold, dry air leads to increased recoveries of both histamine and tryptase, confirming that mast cell degranulation occurs during this reaction. Although hyperosmolarity of the nasal mucosa may contribute to mast cell degranulation induced by cold, dry air, a brief exposure of the nasal cavity to hyperosmolar mannitol was not associated with measurable production of tryptase. The combined use of histamine and tryptase measurements can therefore provide useful evidence regarding the role of mast cell activation in the pathogenesis of inflammatory responses.

Histamine-containing cells obtained from the nose hours after antigen challenge have functional and phenotypic characteristics of basophils

The pattern of mediators and appearance of cells that stain with alcian blue during human experimental early and late phase allergic reactions suggest that basophils accumulate in nasal secretions within hours of local Ag stimulation. To further explore whether the histamine containing cells that enter the nose after Ag challenge are mast cells or basophils, we studied their functional and phenotypic characteristics. Approximately 24 h after intranasal Ag provocation of subjects with allergic rhinitis, nasal lavage was performed, and the cells were isolated for degranulation studies, analysis of surface Ag, and viability. The average histamine content per alcian blue staining cell was 0.78 +/- 0.2 pg (n = 7), similar to that reported for peripheral blood basophils. Nasal cells were challenged in vitro with anti-IgE, ragweed Amb a I, and FMLP and their responses were compared to those of peripheral blood basophils isolated simultaneously from the same donors. Nasal leukocytes released histamine maximally at 0.1 micrograms/ml of anti-IgE (35.8 +/- 7.8%, n = 7) and responded to FMLP (25.4 +/- 9.9%, n = 7). The response of the cells to ragweed Amb a I and anti-IgE was attenuated compared to peripheral blood basophils. Anti-IgE-induced histamine release was calcium and temperature dependent. Dual color immunofluorescence and flow cytometric analysis of the recovered nasal cells coexpressed CD18, a leukocyte marker not expressed by mast cells. The nasal cells consistently had high levels of spontaneous histamine release (19.5 +/- 2.0%, n = 22). The viability of all cells, assessed by erythrosin B dye exclusion, was 70 +/- 2% (n = 15). However, the viability of IgE-bearing cells was only 28.3 +/- 5.7% (n = 4). The characteristics of histamine release and the nature of the cellular surface markers provide functional proof that the histamine-containing cells accumulating after nasal Ag challenge are basophils and not mast cells.

Histamine-containing cells obtained from the nose hours after antigen challenge have functional and phenotypic characteristics of basophils

The pattern of mediators and appearance of cells that stain with alcian blue during human experimental early and late phase allergic reactions suggest that basophils accumulate in nasal secretions within hours of local Ag stimulation. To further explore whether the histamine containing cells that enter the nose after Ag challenge are mast cells or basophils, we studied their functional and phenotypic characteristics. Approximately 24 h after intranasal Ag provocation of subjects with allergic rhinitis, nasal lavage was performed, and the cells were isolated for degranulation studies, analysis of surface Ag, and viability. The average histamine content per alcian blue staining cell was 0.78 +/- 0.2 pg (n = 7), similar to that reported for peripheral blood basophils. Nasal cells were challenged in vitro with anti-IgE, ragweed Amb a I, and FMLP and their responses were compared to those of peripheral blood basophils isolated simultaneously from the same donors. Nasal leukocytes released histamine maximally at 0.1 micrograms/ml of anti-IgE (35.8 +/- 7.8%, n = 7) and responded to FMLP (25.4 +/- 9.9%, n = 7). The response of the cells to ragweed Amb a I and anti-IgE was attenuated compared to peripheral blood basophils. Anti-IgE-induced histamine release was calcium and temperature dependent. Dual color immunofluorescence and flow cytometric analysis of the recovered nasal cells coexpressed CD18, a leukocyte marker not expressed by mast cells. The nasal cells consistently had high levels of spontaneous histamine release (19.5 +/- 2.0%, n = 22). The viability of all cells, assessed by erythrosin B dye exclusion, was 70 +/- 2% (n = 15). However, the viability of IgE-bearing cells was only 28.3 +/- 5.7% (n = 4). The characteristics of histamine release and the nature of the cellular surface markers provide functional proof that the histamine-containing cells accumulating after nasal Ag challenge are basophils and not mast cells.

Evaluation of a bedtime dose of a combination antihistamine/analgesic/decongestant product on antigen challenge the next morning

The effects of CAAD (diphenhydramine hydrochloride, 50 mg; pseudoephedrine hydrochloride, 60 mg; acetaminophen, 1 g in 10% ethanol) were evaluated in a double-blind, three-way, placebo-controlled, cross-over study on 18 volunteers with allergic rhinitis. The number of sneezes following nasal challenge with antigen was significantly reduced after a bed-time dose of CAAD (P less than .005) and a single dose of diphenhydramine (P less than .001) given 2 hours before the challenge. The levels of N-alpha-tosyl-L-arginine methyl ester (TAME) activity decreased after diphenhydramine treatment, while histamine levels following challenge were not different. The drowsiness reported after CAAD was equal to placebo, but significantly less than diphenhydramine (P less than .002 for both). The active treatments reduced the actions of histamine without suppressing its release from mast cells. The effect of CAAD persists 10 hours after administration without inducing drowsiness.

Tympanostomy tube insertion: anterosuperior vs. anteroinferior quadrant

We studied the extrusion rate of Paparella type I tympanostomy tubes in the anterosuperior quadrant compared to those placed in the anteroinferior quadrant in a prospective study. Thirty-five patients were evaluated. The duration (mean +/- SEM) in the anteroinferior quadrant was 211 +/- 18 days, whereas the duration in the anterosuperior quadrant was 211 +/- 11 days. We conclude that placement in the anterosuperior quadrant does not prolong duration of these tympanostomy tubes.

Quantitative IgE- and IgG-subclass responses during and after long-term ragweed immunotherapy

We studied the quantitative responses of short ragweed (RW)-pollen-specific serum antibodies in 22 patients with RW immunotherapy (IT) and in a different set of 31 patients, 16 of whom stopped RW IT after more than 5 years of treatment. Serum was assayed before and after season, 1 year before and 1 and 2 years after starting IT, and 1 year and 2 years after stopping IT. RW pan-IgG, RW IgG1, and RW IgG4 were measured by ELISA, and RW IgE by RAST. Absolute quantities of RW IgG1 and RW IgG4 in reference sera were estimated by least-squares multiple regression analysis of 223 sera with the equation RW pan-IgG = RW IgG1 + RW IgG4. IgG1 is dominant in the early immune response of IT and disappears relatively slowly when IT is stopped. In contrast, IgG4 appears in significant quantities only after prolonged IT and disappears rapidly when IT is stopped. The apparent average half-life of RW IgG4 (9 months) was significantly shorter than that of RW IgG1 (29 months) (p less than 0.001). Before IT, mean RW IgE rose 180% (p less than 0.01) during the RW pollination season (August to November). This seasonal rise in RW IgE was ablated after IT from 1 year up to 8 years, but returned the year after IT was stopped. After 2 years of IT, the RW IgG1 and IgG4 levels were significantly correlated with RW IgE (r = 0.94 and 0.81; p = 0.0001 and 0.005).

The effect of azelastine on the early allergic response

To study the effect of azelastine on the immediate reaction to nasal allergen challenge, we performed a double blind, placebo-controlled cross-over clinical trial. Thirteen subjects with seasonal allergic rhinitis underwent nasal challenge with antigen 4 hr after a single oral 2 mg dose of azelastine. The response was monitored by counting the number of sneezes and by measuring the levels of histamine, prostaglandin D2, immunoreactive sulphidopeptide leukotrienes, kinis and TAME-esterase activity in recovered nasal lavages. After a single dose of azelastine, there was a significant reduction in sneezing (10 vs 2, P = 0.01) and in the median levels of recovered TAME-esterase activity (63.1 vs 17.5 c.p.m. x 10(-3), P = 0.01), immunoreactive sulphidopeptide leukotrienes (7.5 vs 2.1 ng/ml, P = 0.03) and kinins (1370 vs 251 pg/ml, P = 0.03), with no significant reduction in the median levels of histamine (3.7 vs 1.2 ng/ml, P = 0.2) and prostaglandin D2 (70 vs 70 pg/ml, P = 0.2) compared to placebo (numbers represent total increase over diluent challenge). These results suggest that azelastine does not inhibit mast cell activation but affects the consequences of released histamine, namely sneezing, increased vascular permeability and the generation of kinins. The results further suggest that other cells, in addition to mast cells, might be responsible for the generation of leukotrienes during the early allergic response, and that azelastine reduces their ability to generate this mediator or that inhibition of leukotriene release from mast cells occurs at lower drug concentrations.

Antigen-provoked increase in histamine reactivity. Observations on mechanisms

To investigate the effect of antigen provocation on nonspecific reactivity to histamine, nine allergic individuals underwent multiple nasal challenges with histamine, or antigen. The response to challenge was assessed by counting the number of sneezes and measuring the levels of albumin and TAME-esterase (TAME; [3H]N-alpha-tosyl-L-arginine methyl ester) activity in recovered nasal lavages. In the case of antigen, levels of histamine were also measured. In response to histamine, the subjects sneezed and had increased levels of albumin and TAME. The responses to antigen or histamine were unchanged 24 h after histamine provocation. The responses to histamine provocations were increased with respect to symptom scores and to the levels of TAME activity and albumin in nasal lavages compared to baseline challenge, however, 24 h after antigen provocation. Increasing antigen exposure from 1 to 3 days did not further increase the responsiveness to histamine. Histamine reactivity returned to baseline 12 days after antigen exposure. The number of eosinophils, neutrophils, and alcian blue-positive cells in the lavages after antigen challenge and before the histamine challenges correlated with the changes in response to histamine. The increase in sneezing induced by antigen stimulation correlated with the increase in the same parameter after histamine provocation 24 hr after antigen challenge (r = 0.88; p less than 0.01). Surprisingly, the other parameters assessed did not show similar correlations.(ABSTRACT TRUNCATED AT 250 WORDS)

Microbiology of chronic sinusitis in children

To better understand the factors involved in chronic sinusitis in childhood, we cultured the sinuses, middle meatus, and nasopharynx in 39 children requiring surgical intervention. Sixty-nine percent of these patients had other medical problems, including asthma (49%) and immunologic compromise (18%). We cultured coagulase-negative staphylococcus in 18 patients, Streptococcus viridans in 14 patients, normal flora in 10 patients, Staphylococcus aureus in nine patients, group D streptococcus in five patients, Corynebacterium in five patients, Haemophilus influenzae in three patients, Neisseria in three patients, and Streptococcus pneumoniae, group A streptococcus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella oxytoca, Propionibacterium acnes, Actinomyces, and an anaerobic gram-negative bacillus in one patient each. Cultures yielded no growth in nine patients. A strong association between cultures of the middle meatus obtained ipsilaterally and cultures of the maxillary (83%) and ethmoid sinuses (80%) occurred. A poor correlation was found between cultures of the nasopharynx and maxillary (45%) and ethmoid sinuses (49%). All seven patients who had both maxillary and ethmoid sinus cultures showed the same organisms in both sinuses. Only 41% of organisms were found on both sides when procedures were performed bilaterally. Cultures of the middle meatus appear to be sensitive and specific for organisms within sinuses. The presence of predominantly nonvirulent organisms in low titers suggests that additional factors other than bacterial overgrowth contribute to the pathogenesis of chronic sinusitis in children.

Immunotherapy decreases antigen-induced eosinophil cell migration into the nasal cavity

We investigated the effect of immunotherapy (IT) on eosinophil (EOS) migration into the nasal cavity after nasal provocation with ragweed antigen and during seasonal exposure. In the first study, three groups of subjects participated: one group with no treatment (N = 19), one group with 10 months of IT, reaching maintenance at 2 micrograms of Amb a I (antigen E) (N = 15), and one group with 22 months of IT, reaching maintenance at 24 micrograms of Amb a I (N = 10). The percent of EOSs in nasal lavages performed during December before and 24 hours after nasal challenge with ragweed extract was determined. No significant difference between groups existed before challenge. The no treatment group demonstrated a significant increase in the percent of EOSs from 26% to 69.5% (p less than 0.008), whereas the treated groups demonstrated no significant change. In the second study, 45 patients were divided into four groups based on maintenance dose in micrograms of Amb a I and duration of treatment: (1) no treatment (N = 15), (2) 1 year at 2 micrograms (N = 13), (3) 2 years at 2 micrograms (N = 11), and (4) 3 years at 24 micrograms (N = 9). Nasal mucosal brushings were done during the ragweed season. A significantly smaller percentage of EOSs in 3-year IT-treated individuals was obtained compared to the control group (18 versus 8.4; p less than 0.04). The smaller dose of IT, regardless of duration, did not reveal a reduction compared to that in the no-treatment group.(ABSTRACT TRUNCATED AT 250 WORDS)

Additional properties of cetirizine, a new H1 antagonist

Cetirizine, an H1 antihistamine, has properties in addition to H1 blockade that may be useful in the treatment of seasonal rhinitis and urticaria. For example, cetirizine has been shown to block the influx of eosinophils into the site of antigen-stimulated skin blisters. Studies with other antihistamines suggest that this is not a universal property of this type of drug. Pretreatment with cetirizine also has been found to block the augmented sensitivity to methacholine that occurs 24 hours after antigen provocation of the nasal mucosa. This reduction takes place despite the absence of an effect on eosinophil influx into this area, and suggests another action of cetirizine. Our study of allergic rhinitis patients examined the effect of cetirizine on early response to nasal challenge with antigen. Cetirizine, although it did not block the release into nasal secretions of histamine, significantly reduced sneezing and decreased levels of albumin and TAME-esterase activity, which are indicators of vascular permeability. Cetirizine also blocked the generation of leukotriene C4. In vitro studies have shown that cetirizine does not block the release of leukotriene from anti-IgE stimulated mast cells, raising the possibility that cells in the nasal mucosa in addition to mast cells generate leukotrienes.

The role of leukotrienes in allergic rhinitis: a review

Leukotrienes are potent proinflammatory mediators. Our understanding of their role in allergic rhinitis has increased, but further, extensive investigation is required. The sulfidopeptide LTs are generated during the immediate response to antigen provocation and are probably increased during the late inflammatory phase and during seasonal exposure. The source of LTC4 in the early allergic reaction includes the mast cell, but other cell types may also contribute. LTD4 causes nasal congestion and increased blood flow, but not sneezing or significant rhinorrhea. Studies in which LT generation was pharmacologically reduced support a role for these mediators in allergic rhinitis. There is now a need to evaluate the more potent, recently developed, LT antagonists in rhinitis. These agents should help establish the relative importance of LTs to the many other inflammatory mediators that are implicated in the pathogenesis of allergic rhinitis. Such knowledge will broaden and improve our choice of therapeutic modalities for this disease.

Effects of immunotherapy on the early, late, and rechallenge nasal reaction to provocation with allergen: changes in inflammatory mediators and cells

We investigated the effects of immunotherapy (IT) on the early (ER), late (LPR), and rechallenge reactions (RCRs) to nasal challenge with antigen as well as on the cutaneous ER and LPR to intradermal skin challenge. Our expectation was that IT would have a preferential effect on the LPR, and our aim was to understand the mechanism. Twenty-one ragweed hay fever-sensitive subjects were treated with a moderate dose of antigen extract (maintenance dose of 1.94 micrograms of antigen E (Amb a I)) during a period of 8 months (total dose equivalent to 24 micrograms of antigen E), and 20 matched subjects received placebo injections in a double-blind manner. Both groups underwent identical nasal challenges and intradermal skin tests with ragweed-antigen extract both before (1985) and during (1986) IT. Symptom and medication diaries, recorded during seasonal exposure, and changes in specific serum IgE and IgG antibodies confirmed the efficacy of the administered IT dose. Between-group analysis revealed that IT significantly reduced the levels of histamine, TAME-esterase activity, and kinins, as well as symptoms of rhinorrhea and congestion generated during the ER to nasal challenge. Within-group paired analysis demonstrated ER, LPR, and RCR mediators and symptoms also to be reduced by IT. Surprisingly, the placebo-treated group demonstrated an increase in the ER. There was no decrease of the LPR without an antecedent decrease of the ER. IT did not clearly change the late cellular inflammatory response. In the case of skin challenge, IT significantly reduced the cutaneous ER. The reduction of the cutaneous LPR was more pronounced. We speculate that moderate-dose IT ameliorates seasonal symptoms of allergic rhinitis by reducing the ER, LPR, and RCR to antigen challenge but does not preferentially reduce the nasal LPR.

Steroid-induced reduction of histamine release does not alter the clinical nasal response to cold, dry air

In some persons, cold, dry air (CDA) provokes symptoms of rhinitis that are associated with increased levels of histamine and other inflammatory mediators in nasal lavages. Because the patterns of mediators released during the early reaction to antigen and CDA-induced rhinitis are similar, we believe that mast cell activation is part of the reaction to CDA. In view of our previous finding that 1-wk pretreatment with topical steroids reduced symptoms and mediator release in the early nasal response to antigen of allergic subjects, we examined the effect of beclomethasone dipropionate on the response to CDA. Using a double-blind, crossover design, 84 micrograms of beclomethasone or placebo were administered in each nostril twice a day to 13 volunteers for 7 days prior to CDA challenge. The reaction to CDA was monitored by measuring the levels of histamine, N-alpha-p-tosyl-L-arginine methyl ester (TAME)-esterase activity and albumin in nasal lavages before and after provocation. Overall symptom scores, as well as scores for rhinorrhea and congestion, were also obtained. Cold, dry air challenge resulted in elevation over baseline of all parameters after placebo pretreatment. After beclomethasone, a significant reduction in histamine levels, but not in TAME-esterase activity or albumin levels or in number of symptoms, was observed. These results indicate that 1-wk pretreatment with beclomethasone affects mast cells, reducing histamine release after CDA, as it did in antigen-induced rhinitis. They also indicate that histamine may not be essential for the development of the immediate nasal reaction to CDA.

A competitive kinin receptor antagonist, [DArg0, Hyp3, DPhe7]-bradykinin, does not affect the response to nasal provocation with bradykinin

1. In two double-blind, placebo controlled studies, we tested the effects of intranasal administration of 500 micrograms of a competitive kinin receptor antagonist, [DArg0, Hyp3, DPhe7]-bradykinin (NPC 567), on the response to nasal provocation with 20 micrograms of bradykinin. Nasal lavage was performed before and after provocation, and subjects recorded symptom scores. Lavages were assayed for albumin and TAME-esterase activity (indicators of vascular permeability). 2. In our initial study, 12 subjects received NPC 567 or placebo 5 min before bradykinin. After placebo, bradykinin challenge resulted in values (mean +/- s.e. mean) for albumin, TAME-esterase activity and total symptom scores of 275 +/- 51 micrograms ml-1, 32.1 +/- 7.2 counts min-1 x 10(-3), and 1.8 +/- 0.5, respectively. After NPC 567, bradykinin challenge resulted in values of 317 +/- 99 micrograms ml-1, 31.4 +/- 6.9 counts min-1 x 10(-3), and 2.6 +/- 0.4 for these parameters. No significant difference was observed between placebo and drug treatment for any parameter. 3. To evaluate if the lack of drug effect was due to its enzymatic degradation prior to bradykinin administration, a second study was performed in which NPC 567 was coadministered with bradykinin (n = 8). After placebo-bradykinin challenge, values of 168 +/- 42 micrograms ml-1, 11.3 +/- 4.0 counts min-1 x 10(-3), and 2.8 +/- 0.6 were recorded for albumin, TAME-esterase activity, and symptom scores, respectively, while following NPC 567-bradykinin challenge, these values were 174 +/- 51 micrograms ml-1, 12.3 +/- 4.1 counts min-1 x 10(-3), and 3.1 +/- 0.7.(ABSTRACT TRUNCATED AT 250 WORDS)

Phenol as an adjuvant anesthetic for tympanostomy tube insertion

The use of inhalational anesthesia for insertion of tympanostomy tubes in children provides no postoperative pain relief. Our retrospective analysis of children following tympanostomy tube insertion previously had shown significant postoperative elevations of blood pressure and heart rate in over 70% of cases. These changes, along with behavioral findings and complaints of discomfort, are suggestive of pain. Phenol has been used in adults for local anesthesia during tympanostomy tube insertion. This study determined prospectively whether pain occurred postoperatively and whether phenol placed on the tympanic membrane just prior to myringotomy would reduce postoperative pain in children, as measured by behavioral and physiologic parameters. Results of a double-blind, randomized trial in 46 children showed that both the phenol-treated and the control groups demonstrated significant elevations in pain scores postoperatively (P = 0.0001), which then slowly diminished to baseline by 45 min to one hour. The phenol group had consistently higher pain scores than the non-phenol group (P less than 0.001). Possible reasons for these findings are discussed.

Histamine stimulation of the nasal mucosa does not induce prostaglandin or leukotriene generation or induce methacholine hyperresponsiveness

To further define the role of histamine in the nasal mucosa, we studied the possible effect of histamine provocation on the generation of prostanoids and leukotrienes, and on the induction of hyperresponsiveness to methacholine. In separate experiments, we performed nasal challenges with histamine and measured by gas chromatography negative ion mass spectrometry and by radioimmunoassay after high-performance liquid chromatography the levels of prostanoids and leukotrienes, respectively, in recovered nasal lavages 10 min after challenge. Hyperresponsiveness to methacholine was tested in both nostrils 24 h after unilateral provocation with histamine. Our data suggest that histamine induced an immediate symptomatic response, but neither led to the generation of prostaglandins or leukotrienes nor induced hyperresponsiveness to methacholine. These results differ from those achieved after antigen stimulation and emphasize the importance of mediators in addition to histamine in the allergic reaction.