Treatment of invasive fungal sinusitis with liposomal amphotericin B: a report of four cases.

Invasive fungal sinusitis increasingly causes significant morbidity and mortality in immunocompromised patients. It is difficult to treat. Despite standard treatment by surgical debridement and intravenous amphotericin B, morbidity and mortality remain high. Conventional amphotericin B is the standard drug but its use is limited by dose-related nephrotoxicity and infusion-related acute toxicity. Liposomal amphotericin B has proven to be as effective as conventional amphotericin B with less nephrotoxicity and infusion reaction. We report four cases of invasive fungal sinusitis who were treated with liposomal amphotericin B after having severe side effects from conventional amphotericin B. There were two cases of mucormycosis and two cases of aspergillosis. All patients had diabetes millitus. One patient had systemic lupus erythematosus and another was receiving immunosuppressive drugs after kidney transplantation. All cases needed multiple operations for sinus surgery. Two cases had acute reaction to amphotericin B infusion, one had active lupus nephritis with renal insufficiency, and one was considered treatment failure from amphotericin B. The patients received liposomal amphotericin B at the total doses of 4.55-8.85 g. Two cases of mucormycosis were considered to be successfully treated. In cases of aspergillosis, one was considered improved and another one with immunocompromised status died with active disease. From our experience, surgery is the main treatment for patients with invasive fungal sinusitis and liposomal amphotericin B is an effective alternative drug for adjuvant medical treatment. However, the degree of immunosuppression of the patients, the extension of fungal sinusitis and perhaps the species of fungus are important factors determining the clinical response.

CO2 laser surgery in otorhinolaryngology-site and complications: a 10-year experience at Ramathibodi Hospital.

OBJECTIVE: To present data on ten years' experience in CO2 laser surgery and associated complications among otorhinolayngologic patients. MATERIAL AND METHOD: The study involved examining records of otorhinolaryngologic patients who underwent CO2 laser operations during a 10-year period (July 1, 1986-June 30, 1996). The sample consisted of 733 patients: 370 male and 363 female patients. CO2 laser surgery in otorhinolaryngology was first used in Ramathibodi Hospital on July 10, 1986. RESULTS: These patients were aged 2 months to 93 years with the mean age of 24.3 years (median = 16 years). Among 1,725 operations, 1,570 operations (91%) were performed under general anesthesia and 155 operations (9%) were performed under local anesthesia. In our series, the most frequent sites for laser surgery were as follows: larynx (77.22%), oral cavity and oropharynx (12.64%), skin (5.04%) and nose and paranasal sinuses (3.31%). Intraoperative complications occurred in 18 out of 1,725 (intra-operative complication rate of 1%). Laser-related complications were found in 13 out of 1,725 operations (0.75%) and non laser-related complications were found in 5 out of 1,725 operations (0.25%). There was no mortality. CONCLUSION: CO2 laser is a useful modality of treatment in otorhinolaryngologic surgery especially in the larynx. Our experience demonstrates the relative low incidence of complications (1%) and no mortality in otorhinolaryngology head and neck surgery.

Polymerase chain reaction study of Epstein-Barr virus in high risk group of nasopharyngeal carcinoma: a preliminary report.

The incidence of nasopharyngeal carcinoma (NPC) is relatively high in Thailand. Early diagnosis which leads to early treatment is crucial, in order to obtain a high salvage rate. Epstein-Barr virus (EBV) has long been known to be associated with nasopharyngeal carcinoma. Polymerase chain reaction (PCR) is a sensitive and specific technique for the detection of EBV genome in NPC. The first generation of members in the families of NPC patients is considered a high risk group. This study utilized the PCR technique as a screening test for early detection of EBV DNA in this group and also attempted to compare the result with that of IgA antibody level. The data was collected from July 1995 to 1996, this included 35 high risk volunteers, 15 males and 20 females. All subjects underwent telescopic examination and biopsies were performed to obtain specimens for PCR. Blood samples were also taken to determine serum titer of EBV IgA. All specimens studied were negative for EBV DNA and low IgA antibody titer obtained. The negative results implied that either the sample studied was inadequate to detect the low percentage of positivity of EBV in a high risk population or prolonged infection of EBV in nasopharyngeal mucosal cells is not necessary for initiation of NPC.

Combined use of fine needle aspiration cytology and polymerase chain reaction in the diagnosis of cervical tuberculous lymphadenitis.

Although fine needle aspiration cytology (FNAC) is an effective mean for the diagnosis of cervical tuberculous lymphadenitis (CTL), it still poses a certain degree of false negative and false positive. The objective of this study was to determine the efficiency of polymerase chain reaction (PCR) in combination with fine needle aspiration cytology in the diagnosis of CTL. Thirty three patients who presented with enlarged cervical lymph nodes, and were clinically suggestive of CTL were included in the study. Fine needle aspiration or surgical biopsy of lymph nodes was performed, the specimens were studied for cytology, acid fast bacilli stain, culture for mycobacteria and PCR technique. The sensitivity and specificity of FNAC was 48 per cent and 87.5 per cent respectively, while that of PCR was 84 per cent and 75 per cent respectively. When FNAC and PCR were combined, the sensitivity and specificity increased to 84 per cent and 100 per cent respectively. We concluded that FNAC in combination with the PCR technique is a fast and effective clinical diagnostic approach for CTL.

The potential alveolar hazard of carbon dioxide laser-induced smoke.

Carbon dioxide laser is a continuous wave laser, it is well known for its capacity of tremendous smoke production while contact with tissue. Smoke may cause nausea, vomiting, headache and airway irritation. Smoke particles 0.5-2 micrometers in diameter usually travel down the tracheobronchial tree and lodge in the alveoli posing a health hazard. The objectives of this study were to evaluate possible health hazards of carbon dioxide laser smoke in the operating room environment, by determining the size and density of smoke particles also determine the efficacy of surgical masks as a smoke protectant. Ten fresh specimens of papillomatous tissue obtained from the patients were lased by carbon dioxide laser in a continuous mode. The plume generated was collected by 0.45 micrometers pore size microfilter which was attached to the tip of a suction hose connecting the smoke evacuator. The effectiveness of 2 types of commonly used surgical masks were also determined by trapping the smoke after passing through each mask using the same model. Smoke particles were evaluated by scanning electron microscope. The smoke particle density of microfilter that directly trap plume averaged 6 particles/mm2, particles ranging in size from 0.5-27 micrometers, of which 70 per cent were 0.8 micrometers. For the particles trapped after passing through both cotton and paper surgical mask, the size were ranging from 1.6-37 micrometers where 65 per cent were 3.7 micrometers and the particle density average 2.7/mm2. We concluded that the smoke particles derived from carbon dioxide laser application are within the alveolar hazard zone. The conventional surgical masks may not be an effective tool against laser smoke hazard.