In-vivo allergenic potency of Siriraj Mite Allergen Vaccine (SMAV) comparing with standardized vaccine in mite-sensitive patients.

Background: The prevalence of allergic diseases, particularly asthma and allergic rhinitis, has increased tremendously in Thailand and worldwide. House dust mite (HDM) is the major IgE sensitizer among allergic children and adults. We have developed local standardized mite allergen extracts, Siriraj Mite Allergen Vaccine (SMAV) from Dermatophagoides pteronyssinus (Dp) and Dermatophagoides farinae (Df) from our source materials which were highly purified (99%). Objective: To compare in-vivo allergenic potency of both SMAV Dp and Df with commercial standardized mite allergen vaccine by using skin prick testing in mite-sensitive individuals. Methods: This was a double-blind, randomized, self controlled study comparing SMAV and commercial standardized mite allergen vaccine (Dp and Df) by using skin prick testing in mite-sensitive adult volunteers, 18 – 60 years of age. Results: The study was performed in 54 adult volunteers (19 males, mean age 26.6 + 5.5 years old) who had positive skin test to commercial Dp and Df. Seventeen of them had no allergic disease. The most common allergic disease among the volunteers was allergic rhinitis (21/37). Mean wheal diameter of SMAV Dp and commercial Dp at the concentration of 10,000 and 5, 000 AU/ml were equivalent but at the concentration of 2,500 AU/ml was inequivalent. Mean wheal diameter of SMAV Dp was significantly larger than commercial Dp at concentration of 2,500 AU/ml (p < 0.05). Mean wheal diameter of SMAV Df and commercial Df at all 3 concentrations were equivalent. There was no systemic side effect in all subjects. Conclusion: The study demonstrated that in mite-sensitive adults, SPT using SMAV Dp (10,000 AU) and Df (10,000 AU) had equivalent allergenic potency to the commercial comparator without any systemic side effect.

The accuracy of limited CT in the evaluation of chronic rhinosinusitis and for endoscopic sinus surgery: a multicenter study.

Objective: To compare the accuracy of Limited CT with the Full CT as the standard evaluation for inflammatory disease of PNS and the identification of anatomical variations. Methods: From Full CT of PNS, Limited CT were retrieved. Computerized tomographic scans were performed for the preoperative planning of endoscopic sinus surgery (ESS) in 3 tertiary care university hospitals in Thailand. The two types of examinations were reviewed independently and in random order by two experienced radiologists. Using Full CT as the standard, the accuracy of Limited CT were evaluated for 1) the radiologic staging of rhinosinusitis (Lund-Mckay scoring system) and 2) the anatomic variations which are an important landmark for surgical operations in rhinosinusitis. Results: Totally 132 patients were included. Two hundred and sixty four half-faces were reviewed. Lund-McKay radiographic sinus staging system showed 97-99% specificity except for the ostiomeatal complex region. Regarding anatomic variation, Limited CT was able to yield accurate results for the frontal cell type II-IV, Haller cell, Agger nasi cell, paradoxical middle turbinate, concha bullosa and the protrusion of the optic nerve. Conclusion: Limited CT can be used as a surgical roadmap for the cases with the anterior group of sinus involvement. It may be utilized for surgical planning of chronic CRS involving the anterior group of sinuses. For the posterior group of sinuses, it may not yield enough accuracy and the standard Full CT should be requested to prevent erroneous estimation.

Nasopharyngeal hamartoma: A case report and literature review.

Hamartoma is a non-neoplastic tumoral lesion resulting from a developmental anomaly and is characterized by the existence of cells and mature tissues common to the place of origin. Although hamartoma is common in the lung, kidney, and intestines, it is rare in the nasal cavity, the paranasal sinuses and particularly in the nasopharynx. Within the nasal cavity, the most common site of occurrence is the posterior aspect of the nasal septum. We reported a case of 15-year-old Thai male who presented with chronic rhinitis and left eustachian tube dysfunction for several months. Nasal telescopy revealed one smooth pink mass which originated from the left eustachian tube opening and another mass originated from the roof of the nasopharynx near the posterior part of nasal septum. Tumor removal was performed by endoscopic approach, and left myringotomy and a pressure equalization tube placement was done. No postoperative complications were found. Pathological diagnosis is consistent with hamartoma. After a 3 -month follow-up period, the patient still had a small residual mass in the left eustachian tube without any symptoms. Endoscopic approach enables the satisfactory role in the treatment of this rare condition.

Intranasal corticosteroid.

Rapidly metabolized intranasal corticosteroid (INS), with high topical potency and low systemic bioactivity, was introduced for perennial rhinitis in 1974 and found to be as effective as corticosteroids administered systemically. These second-generation INSs include beclomethasone dipropionate (BDP), budesonide (BUD), flunisolide (FLU), fluticasone propionate (FP), triamcinolone acetonide (TAA), mometasone furoate (MF), and fluticasone furoate (FF). Although these INSs represent improvements relative to earlier topical corticosteroids, they do vary from one to the other in potency and systemic bioactivity. For example, MF is equal in potency to FP and is considered to be the most potent INS to date and has almost undetectable systemic availability. FF, the most recently introduced INS, is a novel, enhanced-affinity glucocorticoid with potent anti-inflammatory activity administered in a unique side-actuated device. Among the therapeutic indications for INS are seasonal and perennial allergic rhinitis, nonallergic rhinitis, acute and chronic rhinosinusitis, rhinitis medicamentosa, and nasal polyposis.

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.

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.

How to overcome laryngotracheal stenosis.

OBJECTIVES: To review and evaluate the outcome of the treatment of laryngotracheal stenosis (LTS). DESIGN: Descriptive review cases. SETTING: Tertiary care university hospital. PATIENTS: Series of LTS patients who were treated by the first author (TW) from January 2000 to January 2003. MAIN OUTCOME MEASURES: Leading causes of LTS, details of the lesions, therapeutic procedures, complications of treatment, time to and success in decannulation. RESULTS: Twenty-one patients (9 females and 12 males), ranging in age from 1 to 32 years old were included in the present study. Half of the patients were under 10 years old. The most common site of the lesion was the subglotic lumen (14 cases), followed by the cervical trachea (5 cases). Patients were treated using endoscopic methods (6 cases), laryngotracheal reconstruction (LTR) (9 cases), tracheal resection (3 cases), and partial cricotracheal resection (3 cases). Decannulations were achieved in 19 patients (90.5%). Endoscopic treatment succeeded within 2-4 procedures in properly selected cases. Despite LTR, multiple sessions of endoscopic laser surgery, and arytenoidectomy, decannulation was not achieved in two of the cases, both of whom had all-level laryngeal stenosis. Time to decannulation ranged from 2 to 210 days. The major causes of delayed decannulation were the presence of a large bare area of cartilaginous grafts and restenosis with granulation tissue formation CONCLUSION: Appropriate LTS treatment, which is based on the description of the lesion, results in a high decannulation rate within a proper time. Multilevel LTS, especially in the supraglottic and glottic area, is refractory to various treatment modalities, and full function of the larynx may not be restored.

Nasal granuloma gravidarum presenting with recurrent massive epistaxis.

Nasal granuloma gravidarum is a rare condition associated with pregnancy and minor trauma. This condition presents with a nasal mass with varying degree of bleeding and obstruction. We report a patient with nasal granuloma gravidarum in the third trimester of pregnancy. Surgical excision is the definite treatment for this condition in order to stop the vicious cycle of recurrent massive bleeding. Possible etiology, clinical features and management are discussed.

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.

The relationship between deviated nasal septum and middle ear pressure.

The Nose/Ear Distress Syndrome is defined as the combination of nasal septal deformity and eustachian dysfunction in the absence of any other pathology (McNicoll and Scanlan,1979). Until now, there have been few literatures strongly mentioned about it in the scientific role, and this relationship has not been studied in Thai people. The relationship between deviated nasal septum (DNS) and middle ear pressure (MEP) was then studied with the audiometry, tympanometry, rhinomanometry, and acoustic rhinometry. A total of 80 patients with DNS was recruited and divided into 2 groups; The allergic rhinitis group (n = 40) and the control group (n = 40). Each group could be further divided into 2 subcategories: (a) DNS to Right (nasal airflow: right side< left side) (n = 44) (b) DNS to left (nasal airflow: left side< right side) (n = 36). The mean of patient's age was 33.5 years (range: 11-56 years). The mean of minimal cross-sectional area in patients with DNS and its length from anterior nostril (after decongestion) were 0.7 cm2; 1.6 cm on the left side and 0.7 cm2;1.4 cm on the right side, respectively. The mean of MEP (n = 80) was - 17.3 daPa (S.D.=13.4) on the left side and - 18.7 daPa (S.D.=14.3) on the right side. In each subcategory of both groups, there were no significant differences in MEP between both sides (p > 0.05) although there were significant differences in airflow and resistance (p < 0.05). Furthermore, the difference of nasal airflow or nasal resistance between both sides did not significantly correlate with the difference of MEP (p > 0.05). The number of patients who had auditory symptom was 9 (22.5%) in the control group and 4 (10%) in the allergic rhinitis group. There were no significant differences in incidence of auditory symptom between both groups (p > 0.05). Between the patients who had auditory symptom (n = 13) and had no auditory symptom (n = 67), the difference of nasal airflow, nasal resistance, and MEP between both sides did not differ significantly (p > 0.05). In summary, we found no relationship between DNS and MEP in this study.