Utiity of tests used to diagnose asthma, gastroesophageal reflux and upper airway cough syndrome in patients with chronic cough and normal chest radiography

Despite the clinical significance of cough, research efforts aimed at improving diagnostic capabilities and developing more effective therapeutic agents have been, to date, disappointing in their limited scope and outcomes. Asthma, gastro-oesophageal reflux disease [GERD] and upper airway cough syndrome [UACS] are common causes for chronic cough with a normal chest X-ray [CXR]. To describe the frequency of these three causes in a cohort of outpatients with chronic cough and normal CXR and to identify the diagnostic tests best able to identify the aetiology in the vast majority of cases using the response to specific therapy as a gold standard. Nonsmoking outpatients of both genders who complained of cough for more than 8 weeks and had normal findings on CXR were studied prospectively. All patients were subjected to spirometery [including postbronchodilator reversibility], sinuses CT scan, rhinoscopy, and 24-h esophageal pH monitoring to get "an initial diagnosis". The assumed causes were confirmed by treating them sequentially. "The final diagnosis" depended on a successful response to therapy. Hundred patients were studied: the laboratory tests established initial diagnoses of asthma, UACS, GERD, or various combinations of these in 78 patients, of those; 35 patients [44.9%] had a single cause, 39 patients [50%] had two causes, and 4 patients [5.1%] had all three causes. After treatment of those 78 patients, the final diagnoses were established as follow: 47 patients [60.3%] has a single cause, 28 patients [35.9%] had two causes and 3 patients [3.8%] had all three causes. There was a good agreement between the laboratory tests and the definite causes [agreement in 65 patients [83%] and discrepancy in 13 patients [17%], k > 0.75]. Twelve patients had their diagnoses changed for two causes to a single cause and one patients had the diagnosis changed from three causes to two causes. Asthma, UACS, GERD, or some combination of these represent 78% of the causes of chronic cough in our sample. Therefore, these conditions should be considered first during diagnostic evaluation of patients with chronic cough and normal CXR. Inspite of some discrepancy between initial and final diagnoses, the study identifies the group of diagnostic methods best able to identify the cause in the vast majority of cases of chronic cough including sinuses CT scan, rhinoscopy, pulmonary function tests, and esophageal pH monitoring

Allergic fungal sinusitis: detection of universal fungal, aspergillus and bipolaris DNA in sinus aspirate using polymerase chain reaction and evaluation of aspergillus specific IgE

Allergic fungal sinusitis [AFS] is believed to represent a hypersensitivity reaction to fungal antigens. The pathophysiology of AFS is still not clearly understood. It is believed that it is not a true fungal infection, but an allergic response to fungal organisms that have colonized the sinus mucosa and secondarily cause a hypersensitivity reaction in the host. However, some patients with AFS do not have allergy to the fungi identified in their eosinophilic mucous but may have elevated IgE levels to other fungi. The patients are usually atopic to multiple aeroallergens. Early reports noted primarily Aspergillus species in allergic mucin, but more recently, the dematiaceous fungi, which include Bipolaris, Curvularia, Alternaria and Helmenthosporium species have been identified in most AFS cases. PCR is significantly more sensitive than nasal swabs cultures in detecting the presence of fungi in nasal mucosa. In our study, 68 cases were selected and sinus aspirates were withdrawn whereas a part of the mucous was used for fungal culture and the other part was used for PCR assay for universal fungal, Aspergillus and Bipolaris DNA. Measurement of Aspergillus specific IgE in sinus aspirate and serum total IgE were done. A control group [10 cases] was included. Among the total number of AFS [68], only 42 cases gives positive fungal growth with a percentage of 61.7% while among 10 control cases, only 3 cases gives positive growth with a percentage of 30%. Regarding AFS [42 cases], Dematiaceous family was the most common as it was isolated from 30 cases [71.4%]. Bipolaris was the most common isolated species [18 cases] followed by Curvularia [11 cases] and Alternaria [1 case]. Aspergillus family was isolated from 11 cases [26.1%]. Aspergillus fumigatus was more common as it was isolated from 8 cases followed by Aspergillus niger [3 cases]. The results of PCR assay assured the detection of fungal DNA in all cases of AFS group [68 cases] and in 4 cases of control group [40%]. Aspergillus DNA was detected in 15 cases [22.05%] while Bipolaris DNA was detected in 27 cases [39.70%]. Ten patients were positive for Aspergillus fumigatus specific IgE [14.7%] out of 68 patients and the mean value was 11.32 +/- 4.12 IU/ml which was significantly higher than the mean value of this specific IgE in our control group which was 0 IU/ml. Also, only 7 patients from the above 10 patients were positive to Aspergillus fumigatus by PCR [5 only gives positive culture] and this indicates that 3 patients were negative to Aspergillus fumigatus either by culture or PCR but they showed Aspergillus fumigatus allergen specific IgE, on the other hand, 8 cases were positive to Aspergillus fumigatus by PCR and 3 cases were positive by culture failed to show any Aspergillus fumigatus specific IgE indicating that the presence of fungus is not essentially accompanied with allergic process

Choanal adenoids in adults: diagnosis and treatment

Choanal adenoids, a rather rarely defined phenomenon, is the presence of adenoid tissues in the choanae, without being extension of the commonly well-known nasopharyngeal adenoids. We present a series of 22 adult patients [17-38 years; 15 males, 7females], with persistent bilaeral nasal obstruction and recurrent nasal infections, and with history e of repeated unsuccessful medical and, in many cases, repeated surgical procedures, in whom choanal adenoids was diagnosed by nasal endoscopy and/or CT scanning. Absence of adenoid tissues in the nasopharynx was confirmed in all cases. Surgical removal of choanal adenoids was undertaken in all cases endoscopically. Some other surgical. procedures like straightening of a deviated septum or reduction of a hypertrophied turbinate were undertaken in some indicated cases. Most of cases experienced complete relief of obstruction and return of a patent nasal airway and improvement of associated complaints as dry mouth and persistent cough. A thorough review of this phenomenon and its clinical relevance and methods of diagnosis and management are presented. We recommend a thorough nasal endoscopy as a routine in cases of persistent nasal obstruction even in the presence of an apparent cause of obstruction

Complications of endoscopic management of choanal atresia

A prospective study in Mansoura University Hospital, Egypt in the period between 2000-2004 in 19 patients presented with nasal obstruction either unilateral in 10 cases with average age 4-18 years and male to female is 7:2, and 9 neonates presented with bilateral choanal atresia where seven females and 2two males]. Follow up period is 12-18 months. All patients of neonates stay one night at ICU. All patients operated under general anesthesia endoscopically two cases required for revision surgery and stent for 12 weeks two had adhesions that need splint, only one had collumellar injury and vestibular stenosis and one had posterior pharyngeal wall ulcer. We conclude that endoscopic treatment for choanal atresia is safe with minimal complications

Outcome of endoscopic sinus surgery for nasal polyposis

Nasal polyposis is the most common mass lesions in the nose. It has been shown that it reduces quality of life. It has characteristically frequent recurrences. The objective of this study is to evaluate the outcome of nasal polyposis with medium term follow up [mean of 42 months]. This s M y included 216 adult patients with nasal polyps treated with endoscopic sinus surgery in the period from June 1997 to June 2003. All operations were done at Otori7inoiaryngoiogy Department, Mansoura University Hospital. Patients were grouped into polyposis, polyposis with asthmas, and polyposis with aspirin intolerance. Outcome measures include symptomatic improvement, residual and recurrent diseases, CT score, endoscopic score and complications. Patients symptom score and CT scores improved significantly after surgery. Recurrence rate was 19.9% [16%, 34%, and 38%] for the three groups, respectively]. Better control of asthma with less dependency on medication was not achieved in patients with asthma as well as patients with aspirin intolerance In conclusion; endoscopic sinus surgery is effective in treating patients with nasal polyposis. Patients with asthma and aspirin intolerance have worse outcome than patients with polyps with no asthma