A surveillance study of bacteriologic profile in rhinosinusitis.

Objective: To review the types of bacteria found in rhinosinusitis and the prevalence of a beta-lactamase producing organism in a tertiary care hospital during the year 2004 and compared with our previous reports. Methods: Charts of patients who underwent endoscopic sinus surgery or maxillary antral puncture or endoscopic-guided culture at the Rhinology & Allergy Division, Department of Otolaryngology and the Department of Microbiology, Siriraj Hospital from January 2004 to December 2004 were reviewed. Information regarding the patient’s age, site of specimens, culture and sensitivity results were obtained. Results: There were 162 specimens and 29 bacterial species isolated. There were 50.4% positive aerobic cultures, gram-negative bacteria were more common than gram-positive bacteria (68.5% vs 31.5%). Common aerobes were Pseudomonas aeruginosa (16.2%), non-fermentative gram negative rod: NF-GNR (10.8%), Coagulase- negative Staphylococcus aureus :CNS (9.9%) and Klebsiella pneumoniae (9.9%).The most common anaerobes were Peptostreptococcus sp., Bacteroides fragilis and Fusobacterium sp. Conclusion: Contrary to our previous studies, gram negative organisms play a more important role than gram positive organisms. The causative pathogens of rhinosinusitis should be studied continuously because rapid progress in the development of new antimicrobial agents has a significant impact on their bacteriologic profile.

Chronic rhinosinusitis and recurrent nasal polyps in two children with IgG subclass deficiency and review of the literature.

Chronic rhinosinusitis (CRS) is a chronic inflammatory disorder of mucosa of the nose and the paranasal sinuses. Two major forms of CRS can be differentiated; CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). The pathophysiology and etiology of nasal polyps (NPs) are partly understood. IgG subclass deficiency was shown to be associated with an increased susceptibility to infections. However the association between NPs and IgG subclass deficiency has never been reported. OBJECTIVES: To report two cases of recalcitrant CRS and recurrent NPs with IgG subclass deficiency. CASE REPORT: Two children (6 and 8 year-old boys) were referred to the Pediatric Allergy/Immunology Clinic, Siriraj Hospital due to a prolonged history of CRS and recurrent NPs. Both of them were treated with aggressive medical (topical and systemic corticosteroids, antibiotics, leukotriene antagonist, nasal irrigation) as well as surgical therapy, without significant improvement. Immunologic investigation in both patients showed that IgG, IgA, and IgM level were normal. IgG subclasses level in patient No. 1 were IgG1 1,235 (280-1120) mg/dl (79%), IgG2 235 (30-630) mg/dl (23.5%), IgG3 27.3 (40-250) mg/dl (1.74%), and IgG4 92.4 (11-620) mg/dl (5.9%). IgG subclasses level in patient No. 2 were IgG1 1,139 (280-1120) mg/dl (82.5%), IgG2 170 (30-630) mg/dl (12.3%), IgG3 5.6 (40-250) mg/dl (0.4%), IgG4 65.7 (11-620) mg/dl (4.8%). The diagnosis of CRS and recurrent NPs with IgG3 subclass deficiency in the first patient and IgG2/IgG3 subclass deficiency in the second patient were made. Patient No. 1 was given monthly IVIG therapy for the total of 7 courses and medications were gradually tapered. Currently, the patient is doing well after the cessation of IVIG therapy for 3 months. Patient No. 2 denied the IVIG treatment and was lost to follow up. CONCLUSION: We reported two cases of recalcitrant CRS and recurrent NPs in children. Immunologic work up revealed IgG subclass deficiency. The treatment with monthly IVIG improved CRS and NPs in treated patient which brought up the possibility of association between NPs and IgG subclass deficiency. Further study on the direct role of IVIG in NPs will be needed in the future.

Tonsillectomy and adenoidectomy in pediatric patients: A current experience.

Objective: To review experiences with tonsillectomy and/or adenoidectomy in pediatric patients. Methods: Retrospective chart study was done in pediatric patients who underwent tonsillectomy and/or adenoidectomy under supervision of the authors from August 1999 to March 2005 at the Department of Otolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University. Results: One hundred and twenty-three charts were retrieved from the total number of 129 pediatric patients who were operated during the study period. Obstructive sleep apnea syndrome (OSAS) was the most common indication for surgery (86%). Seventy percent of patients were between three to eight years old. Obesity was the most common co-morbidity (17.9%) followed by otitis media with effusion (13.8%) and allergic rhinitis (8.1%). Six patients (4.9%) had minor complications which were two cases (1.6%) of postoperative bleeding, three cases (2.4%) of loosening deciduous teeth, and one case (0.8%) of lip ulceration. Postoperative fever and inadequate oral intake prolonged hospitalization in twenty patients (16.3%). However, all patients improved and discharged within 48 hours postoperatively. All parents were satisfied with the final results of the procedures. Conclusion: Tonsillectotmy and adenoidectomy were safe, effective procedures in pediatric patients. The most common indication was OSAS. Obesity was the most common co-morbidity found in the patients with OSAS. Complications were rare, easily detected and treated.

Identification of high-risk tonsillectomy and adenoidectomy.

Objective: To identify children who were at risk to postoperative complications after tonsillectomy and/or adenoidectomy, and to propose a guideline for care giving of this group of patients. Methods: Retrospective chart study of children who underwent tonsillectomy and/or adenoidectomy and required special postoperative care was performed from August 1999 to March 2005. All children were treated under supervision of the authors at the Department of Otolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University. Results: One hundred and twenty-nine children were operated during the study period. One hundred and twenty-three charts were retrievable. Forty-seven children were included in the series. Four categories of patients, i.e., very young-age group, intensive care unit group, extended admission group, and postoperative bleeding group, were identified. Eleven children (23.4%) whose ages were less than 36 months were observed in post-anesthetic recovery unit (PACU) for 5-6 hours with oxygen saturation monitoring and oxygen supplementation. Fourteen children (29.8%) were admitted to pediatric intensive care unit (PICU) with the most common indication of morbid obesity (64.3%). Four children needed interventions, which were two intravenous dexamethasone injections and two temporary continuous positive airway pressure (CPAP) administrations in PICU. Twenty children (42.6%) had extended admission because of postoperative fever and inadequate oral intake. However, every one of them improved within 48 hours postoperatively. Two children (4.2%) had minor postoperative bleeding and one of them needed bleeding control. Conclusion: Tonsillectomy and adenoidectomy are procedures of low morbidity in healthy children. However, very young patients and those with high-risk of co-morbidities are considered to have high chance of compromised airway and inadequate oral intake. Besides our routine admission, we suggest that children under the age of 36 months need close observation for 5-6 hours in PACU. Admission in PICU is probably necessary for children who have high-risk of co-morbidities such as morbid obesity, asthma, cardiac diseases, neuromuscular disorders, craniofacial anomalies. Adequate oral intake is needed before removing intravenous fluid line and a consideration of discharge. Extended admission is unnecessary for postoperative fever, which mostly disappears within 48 hours.

Development of a health-related quality of life questionnaire for Thai patients with rhinoconjunctivitis.

The objective of this study was to develop a disease-specific questionnaire for patients with rhinoconjunctivitis. All patients were recruited at the Out-Patient Clinic at Siriraj Hospital. Related topics were gathered from several sources, and a list of 63 items was produced. In phase I, the first version of the questionnaire was completed by 363 patients. Forty-eight items were identified by clinical impact analysis during the item removal process, two more questions were then added, giving a total of 50. Two hundred and forty-three patients completed the second version questionnaire in phase II. The average time taken to complete the questionnaire was 6.38 minutes. The item removal process in phase II was achieved by a multi-step process. There were 36 items in the third version questionnaire which consisted of six dimensions and two independent items as follows: symptoms (17 items), physical functioning (3 items), role limitations (3 items), sleep (3 items), social functioning (3 items), emotions (5 items), general health (1 item), and absenteeism (1 item). The scores of each item ranged from 1 to 5; a lower score indicating a better quality of life. Data from the selected 36 items was extracted to test the validity and reliability of the final version. The floor and ceiling effects of the scores for each dimension were low. Multitrait multi-item analysis was conducted to examine construct validity. The scaling success of convergent and divergent validity was 100% and 94%, respectively. Internal consistency determined by Cronbach's alpha coefficient, was satisfactory (0.79-0.87). The study indicates that the questionnaire is suitable for use in clinical settings. While the test results are encouraging, further work needs to be done on the test-retest reliability and on responsiveness.

An open-label, prospective study of an oral polyvalent bacterial lysate (Luivac) in the treatment of recurrent respiratory tract infections in Thai patients.

An open-label, non-comparative study was performed in the Department of Otolaryngology, Siriraj Hospital, Bangkok, Thailand, to assess the safety, tolerability, acceptability and efficacy of an oral polyvalent bacterial lysate (Luivac) in the treatment of recurrent respiratory tract infections (RTIs) in Thai patients. Thirty-three patients were included in this study, 18 males and 15 females, with a mean age of 34.0 +/- 14.7 years. The mean number of RTIs during the 12-month period preceding the study was 9.5 per patient. During the study each patient received one tablet of Luivac daily for 28 days followed by a treatment-free period of 28 days. This was followed with another 28 days on Luivac, after which there was a 28-day treatment-free follow-up period. This study lasted 4 months with five scheduled patient visits (V1-V5). Laboratory studies were done at baseline (V1) and after treatment (V4), which included complete blood count and serum immunoglobulins (IgA, IgE, IgG and IgM). The incidence of all adverse events was 15.2% and no case was related to the studied drug. There were no clinical relevant changes in laboratory parameters after treatment. The reduction rate of RTIs per month at the end of the study period was 63.5% when compared to the average RTIs rate per month during the 12 months preceding the study. A comparison of the first study period (V1-V3) and the second study period (V3-V5) showed a reduction in duration of RTIs (23.1%), in the clinical infection score (17.5%), in the number of antibiotics used (2.1%), in the number of symptomatic treatments (3.5%), and in the number of days absent from school or work (50.0%). Overall tolerability and acceptability were assessed as very good and good in 96.8% of the patients. This study suggests that oral polyvalent bacterial lysate (Luivac) was safe and also showed a tendency to be effective in preventing RTIs in Thai patients with or without risk factors for recurrent RTIs. Other clinical advantages were reduction in the severity and duration of infection as well as in reduction of the cost of treatment and the number of days absent from school or work.

A comparative study of the major allergenic components in house dust extracts between siriraj and commercially prepared extracts.

The quantity and concentration of major allergens in mite allergenic extracts are crucial for skin testing, which is the recommended standard method for the diagnosis of house dust mite allergic disease. The purposes of this study were 1) To compare the constituents of major mite allergens in 3 types of mite extracts, i.e., extracts from mite reared in-house (Dermatophagoides pteronyssinus and Dermatophagoides farinae), extracts from commercial mite products and commercial ready-made mite extracts. These in-house extracts were prepared either with or without the preservative, glycerine. The concentrations of the major constituents of group 1 and 2 allergens of the extracts were determined by a two-site monoclonal based ELISA. 2 ) Biological assays were also carried out to determine the relative potency of the extracts in 120 allergic patients by skin prick test. It was found that the mean concentrations of Der p1, Der f1 and group 2 mite allergens in extracts from mites reared in-house were 102, 195 and 94 ตg/ml, respectively, compared to 169, 238 and 91 ตg/ml, respectively in commercial mite extracts. The commercial with product had the lowest concentrations of mite allergens (1 ตg/ml). Comparison of mite extracts with and without glycerine preservative showed no significant difference in concentrations of major allergens. Reduction of allergens concentration from 10,000 to 1,000 PNU/ml also reduced the concentration of mite allergen proportionately. Siriraj mite extracts were stable for at least 1 year at 4 oC without any significant change in composition or concentration. In conclusion, mite reared in-house can be used as raw material for preparation of mite allergenic vaccine.

An open-label, non-comparative phase IIIb study of oral gatifloxacin in the treatment of acute, uncomplicated bacterial sinusitis in Thai patients.

This was an open-label, non-comparative phase IIIb study of oral gatifloxacin in the treatment of acute, uncomplicated bacterial sinusitis in Thai patients. The study was conducted at three otolaryngologic centers in Thailand, i.e. Siriraj Hospital, Srinakarind Hospital, and Bhumipol Hospital, during the period of November 1999 through October 2000. Thirty patients with symptoms and signs of acute maxillary sinusitis, which were confirmed by abnormal radiological findings, were included. Documentation of infection was made by pre- and post-therapy culture and susceptibility testing. All patients received gatifloxacin 400 mg tablet orally once daily for 10 days. Symptoms and signs were evaluated on four occasions, i.e. before treatment started (day 0, V1), day 3-5 (V2), the third (V3) on day 11-14 (V3), and day 21-28 (V4). Primary outcome measures were the changes in the percentage of patients who had general clinical symptoms (i.e. fever, malaise, chill, sore throat, headache, cough, and halitosis), and also the clinical symptoms and signs of sinusitis (i.e. sinus pain, sinus tenderness, purulent nasal discharge, facial pressure, nasal congestion, postnasal drip, and anosmia). The clinical responses were classified as cure, improvement, relapse or failure at the end of treatment (V3) and at follow up (V4). Treatment success was defined as cure or improvement. The safety of gatifloxacin was assessed from vital signs, general physical examination, hemato-biochemical parameters, and adverse events reported. There were 13 males and 17 females, with a mean age of 34.7 + 12.2 years (range 21-70). The mean duration of symptoms was 2.4 + 8.8 weeks. At V1,23 patients (76.7%) had headache, 19 patients (63.3%) had cough, and 14 patients (46.7%) had halitosis. At V3 and V4 all these symptoms had resolved, except in 1 patients who still had cough. The percentages of patients who had symptoms and sign of sinusitis at V1 were as follows : purulent nasal discharge 90%, nasal congestion 86.7%, postnasal drip 86.7%, sinus pain 80%, facial pain 66.7%, and sinus tenderness 63.6%. After 3-5 days of treatment (V2), the percentages of patients who had symptoms and signs of sinusitis decreased significantly for every symptom and sign. The same was true at V3 and V4. The total percent improvement in radiological findings was 83.4% (41.7% resolution, 41.7% improvement). Pretreatment cultures were positive in 23 out of 30 patients (76.7%). The most common pathogens were Hemophilus influenzae (18.4%), Streptococcus pneumoniae (9.4%), other Streptococcus species (9.4%), Klebsiella pneumoniae (6.3%) and coagulase negative Staphylococcus (6.3%). The anaerobes found were Peptostreptococcus prevotii (9.4%), Fusobacterium nucleatum (9.4%), Bacteroides species (6.1%) and Prevotella species (3.1%). Bacteriological responses at V3 were 30.4% eradication, 65.2% presumed eradication, and 4.4% persistence. Clinical responses at V4 were 88.9% cured, 7.4% relapsed, and 3.7% failed. Adverse events were found in 4 patients (13.3%) which were transient and resolved spontaneously. Adverse events found were nausea, vomiting, dry mouth, constipation, agitation and tremor. This study showed the efficacy and safety of a 10-day course of oral gatifloxacin 400 mg once daily in the treatment of acute uncomplicated bacterial sinusitis. 88.9% of patients experienced a cure, and bacteriological eradication was achieved in 95.6%. The excellent profile of gatifloxacin makes it suitable for the treatment of community acquired acute bacterial sinusitis. The once daily regimen enhances patient compliance.

Clinical and histopathological classification of nasal polyps in Thais.

One hundred and forty five patients with nasal polyps (NP) who underwent a first operation at the Department of Otolaryngology, Faculty of Medicine Siriraj Hospital during the 2-year period January 1998 to December 1999, were studied to determine the incidence of clinical and histolopathologic types of NP in Thai patients. The clinical types of NP were classified into 5 groups, using Stammberger's criteria i.e. isolated polyps (IP); antrochoanal polyps (ACP); NP and chronic rhinosinusitis (NPCRS) associated with non-eosinophilic infiltration; NPCRS associated with eosinophilic infiltration or NP with asthma (NPA); and NP with specific diseases (NPSD). The histopathologic types were classified into 4 types, using Hellquist's criteria i.e. Type I, edematous, eosinophilic (allergic) polyps; Type II, chronic inflammatory (fibroinflammatory) polyps; Type III, polyps with hyperplasia of seromucinous glands; and Type IV, polyps with stromal atypia. There were 86 males (59.3%) and 59 females (40.7%), with a male : female ratio = 1.5 : 1. The mean age was 36.1 + 16.5 years, ranging from 9 to 74 years. The mean duration of symptoms was 63.6 + 75.2 months, ranging from 1-420 months. The clinical classification study showed that 17 patients (11.7%) had IP, 13 patients (8.9%) had ACP, 105 patients (72.4%) had NPCRS, 5 patients (3.5%) had NPA, and 5 patients (3.5%) had NPSD (one case of Katargener's syndrome, bronchiectasis, aspirin intolerance, immotile cilia syndrome, and AIDS respectively). The histopathologic study showed that 17 specimens (11.7%) were Type I, 118 specimens (81.4%) were Type II, 9 specimens (6.2%) were Type III, and 1 specimen (0.7%) was Type IV. In the group of patients with NPCRS (105 patients), the most common histopathologic type was type II (86 patients, 81.9%). Type I and Type III were found in 12 patients (11.4%) and 7 patients (6.7%) respectively. The incidence of eosinophilic polyps in the groups of NPCRS was only 18.1% (Type I + Type III). This finding is different from that of NP in the western countries, in which the incidence of eosinophilic polyps is 80-90%. The pathogenetic mechanism underlying this difference is still not known. Is this difference due to racial or genetic factors, or geographic differences? The answers to these question are to be studied further.

Adverse reactions to allergen injection : The siriraj experience.

A retrospective review of the medical records of adult patients, who had skin testing and allergen immunotherapy at the ENT Allergy Clinic, from January 1987 to December 1999 was performed, to ascertain the incidence of adverse reactions to allergen injection. For skin prick testing, 5,879 patients with 82,306 skin tests were recorded with no adverse systemic reaction. For intradermal testing, 5,490 patients with approximately 109,800 tests were recorded and two patients developed mild systemic reactions which were probably related to the test. The systemic reaction rate to intradermal skin testing was therefore 36.4 per 100,000 patients or 2.2 systemic reactions per 100,000 intradermal tests. The overall reaction rate to both types of allergy skin test in 11,369 patients tested for aeroallergens was 0.018% or 17.6 systemic reactions per 100,000 patients. Concerning immunotherapy 42,810 allergen injections were recorded, the rate of excessive local reactions was 4.8% (4.08% were immediate and 0.77% were delayed types), the rate of systemic allergic reactions was 0.08%. None of the reactions was fatal. In a prospective study conducted from January 2000 to December 2001, 4,764 allergen injections were performed with 27 systemic reactions occurring in 23 patients (7 men and 16 women). Twenty-two events were classified as mild to moderate (0.46%) and 5 events were acute severe reactions (0.11%). No cases of hypotension and laryngeal edema were observed and none of the reactions was fatal. The possible risk factors for developing a systemic reaction during immunotherapy in this study were :- vaccines comprising grass/weed pollen or house-dust mite, an increased dose, symptomatic asthmatics, prior systemic reactions and changing to a new vial. The incidence of adverse reaction after allergen injection and the possible causative factors associated with immunotherapy in our clinic are similar to other reports from western countries. In order to minimize the number and the severity of systemic reaction, an allergen injection should be performed by physicians and personnel who are well aware of the risks and well trained to recognize and manage the systemic reactions immediately.

An open-label study of the efficacy and safety of a herbal secretolytic preparation as a sole therapy in patients with sinusitis.

This is an open-label, non-comparative controlled study of the efficacy and safety of a herbal secretolytic preparation (Sinupretฎ) as a single therapy in patients with sinusitis. The study was conducted at the Department of Otolaryngology, Siriraj Hospital, Bangkok, during the period January - December 2000. Thirty-nine patients with symptoms and signs of sinusitis, which were confirmed by abnormal endoscopic findings and abnormal radiological findings, were included. All patients received Sinupretฎ, two sugar-coated tablets orally three times a day for 21 days. Symptoms and signs were evaluated on three occasions; the first (day 0, V1) before the treatment started, the second (V2) on day 14, and the third (V3) on day 21. There were no other additional adjunctive treatments. Primary outcome measures were the change in the percentage of patients who had three main symptoms (i.e. nasal obstruction, nasal discharge and sinus headache), abnormal endoscopic findings (i.e. mucosal swelling and nasal secretion), and abnormal radiological findings (i.e. air-fluid level, opacification, and mucoperiosteal thickening). Global assessment was rated by the patients using a visual analogue scale (VAS). The clinical response was classified as cure, improvement, failure, and relapse. Treatment success was defined as cure or improvement. Adverse events were also recorded. There were 14 males and 25 females, with a mean age of 39.7 + 14.1 years (16-75). Twenty three patients had chronic sinusitis (CS) and 16 patients had acute sinusitis (AS). The duration of symptoms in the CS group was 16.4 + 25.6 months (1-96), and in the AS group was 21.3 + 9.4 days (7-30). At V1, 34 patients (87.2%) had nasal discharge, 26 patients (66.7%) had obstruction, and 25 patients (64.1%) had sinus headache. At This is an open-label, non-comparative controlled study of the efficacy and safety of a herbal secretolytic preparation (Sinupretasาa single therapy in patients with sinusitis. The study was conducted at the Department of Otolaryngology, Siriraj Hospital, Bangkok, during the period January - December 2000. Thirty-nine patients with symptoms and signs of sinusitis, which were confirmed by abnormal endoscopic findings and abnormal radiological findings, were included. All patients received Sinupretฎ, two sugar-coated tablets orally three times a day for 21 days. Symptoms and signs were evaluated on three occasions; the first (day 0, V1) before the treatment started, the second (V2) on day 14, and the third (V3) on day 21. There were no other additional adjunctive treatments. Primary outcome measures were the change in the percentage of patients who had three main symptoms (i.e. nasal obstruction, nasal discharge and sinus headache), abnormal endoscopic findings (i.e. mucosal swelling and nasal secretion), and abnormal radiological findings (i.e. air-fluid level, opacification, and mucoperiosteal thickening). Global assessment was rated by the patients using a visual analogue scale (VAS). The clinical response was classified as cure, improvement, failure, and relapse. Treatment success was defined as cure or improvement. Adverse events were also recorded.V3, the percentage of patients who had symptoms decreased signiticantly to 64.1%, 41.0% and 38.5% for these three symptoms respectively. The same was true for the percentage of patients who had abnormal endoscopic findings. The percentage of patients showing radiological evidence of improvement was 61.5% (33.3% normal, 28.2% improvement), with no change in 38.5% of patients. Treatment success was recorded in 31 out of 39 patients (79.4% : cure 23.0%, improvement 56.4%). In four patients (10.3%) treatment failed and in four other patients (10.3%) there was a relapse in symptoms and signs. Adverse events were reported in 4 patients (10.3%), which were mild and resolved spontaneously. This study shows the efficacy and safety of a 3-week course of a herbal secretolytic preparation (Sinupretฎ) in the treatment of sinusitis, either acute or chronic. The incidence of adverse events was low and they were tolerated by the patients. The use of this herbal secretolytic preparation as a sole treatment is effective in most cases of uncomplicated sinusitis. This can decrease the risk of adverse drug reactions from antibiotic therapy and is a cheaper treatment.

Deep neck infection from cervical osteomyelitis in an intravenous drug abuser: A case report.

Prevertebral space abscess in the cervical region is a rare deep neck infection. Tuberculosis of the spine used to be the most frequent cause. We report a case of a 33-years-old male with Staphylococcal cervical osteomyelitis as a cause of prevertebral abscess. The patient was an IV drug abuser with positive HIV. The skin was the most likely source of infection in this patient. Diagnosis was made by lateral neck x-rays which showed collapse of an intervertebral disk between C4 and C5 with destructive lesions of the body of the spines, along with an abnormal widening of the prevertebral soft tissue. Management of the prevertebral abscess was discussed and the literature was literature was reviewed. Appropriate management should include establishment of the airway, stabilization of the spine, antibiotics and incision and drainage by external approach.