Radiographic imaging studies in pediatric chronic sinusitis.

BACKGROUND: The diagnosis of chronic sinusitis is dependent on the radiographic evidence of sinus disease. METHODS: We evaluated the performance of radiographs and computed tomographic (CT) scans for the examination of the paranasal sinuses of 91 patients of both sexes, ranging in age from 2 to 17 years, who had chronic upper respiratory tract symptoms for at least 3 months. The CT scan findings were categorized as no disease; minimal disease, and mild, moderate, and severe sinusitis. RESULTS: Fifty-eight patients (63%) had chronic sinusitis: CT scan abnormalities were minimal in 17%, mild in 19%, moderate in 21%, and severe in 43%. There was a statistically significant correlation between rhinorrhea (r = 0.25, p = 0.01), cough (r = 0.27, p = 0.009), and the severity of sinus abnormality as determined by CT scan. Clinical presentation in the mild, moderate, and severe sinusitis groups (p < 0.05) was significantly different from that of the no disease group, whereas the minimal disease group had subclinical presentation (p = 0.11). Clinically significant chronic sinusitis often occurred at multiple sites: 44% of patients had pansinusitis, 50% had disease involvement of at least two sinuses, and 6% had disease in a single sinus. When sinus radiographs were compared with CT scans (n = 70 cases), radiographs could not identify minimal disease. For clinically significant sinusitis, sinus radiographs detected disease in 1 of 5 (20%) frontal sinuses, 0 of 12 (0%) sphenoidal sinuses, and 17 of 31 (54%) ethmoidal sinuses. With the minimal criteria of 40% to 50% opacification or fluid level filling of the maxillary antrum, radiographs detected disease in 37 of 49 (75%) cases. The sensitivity and specificity for a Waters view to confirm clinically significant chronic sinusitis without specifying the sites and severity were acceptable at 76% and 81%, respectively. When limited sinus CT scans were compared with full CT evaluation (n = 49 cases), limited studies detected 5 of 5 (100%) frontal, 9 of 11 (82%) sphenoidal, 14 of 19 (73%) ethmoidal, and 39 of 40 (97%) cases of maxillary sinusitis. The overall agreement was 88%. CONCLUSIONS: A single Waters view is an acceptable part of the initial evaluation of pediatric chronic sinusitis; however, a limited CT scan is a better alternative.

Cockroach allergy in Kentucky: a comparison of inner city, suburban, and rural small town populations.

The cockroach has been reported as a major allergen in inner city asthmatic patients. The retrospective chart review of 799 patients tested over a 10-year period (1981-1991) derived from a private allergy practice and a university allergy clinic is reported. Patients from both groups were divided geographically by home zip codes into inner city, suburban, or rural small town populations. Criteria for positive skin tests were wheal greater than 5 mm for prick and greater than 10 mm for intradermal tests with flare. Overall, 36.9% (295/799) of all patients surveyed were positive by either prick or intradermal skin testing. Cockroach reactivity was observed in 38.6% (95/246) of the private patients tested with 36.2% (200/553) of the university patients showing positive results. The inner city populations in both groups of patients were similar with 43.7% and 40.3% of the private and university patients, respectively, testing positive, with an overall positivity of 41% for all inner city patients. Inner city and rural small town populations for both study groups demonstrated almost identical reactivity with 41% and 43% overall positivity, respectively. Of the suburban group, 37.5% of the private patients and 28.8% of the university patients had reactive skin tests results with an overall rate of positivity of 30.1%. This rate (30.1%) is significantly less than the rate for either inner city (41.0%, P < .05) or rural small town (43.6%, P < .01) populations.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic sinusitis among pediatric patients with chronic respiratory complaints.

We examined the prevalence of chronic sinusitis among children who presented to allergy clinics with chronic (> or = 3 months) respiratory symptoms. Ninety-one patients, ranging from 2 to 17 years of age with 62% male and 72% white, completed the study. Fifty-nine percent of patients had positive skin test results, and 25.3% had chronic asthma. Paranasal sinuses were examined by coronal sinus computed tomographic scan. Sixty-three percent (58 to 91) had chronic sinusitis, 5.5% (5 of 91) had concha bullosa, 1% (1 of 91) had foreign body, and 19% (19 of 91) had deviated nasal septums. Among symptoms of sneezing, nasal congestion, postnasal drip, coughing, wheezing, rhinorrhea, and headache, no single symptom was an acceptable predictor of abnormality on computed tomographic scan examinations. Combining the symptoms of moderate to severe rhinorrhea and cough with minimum sneezing had a specificity of 95% and a sensitivity of 38% in predicting the presence of chronic sinusitis. Allergic rhinitis (p = 0.27), mild deviated nasal septum (p = 0.11), unobstructive concha bullosa (p = 0.13), and passive exposure to cigarette smoke (p = 0.53) were not risk factors associated with sinus abnormalities. Age (r = 0.30, p = 0.004) in pediatric patients with chronic respiratory symptoms was the single risk factor significantly associated with abnormalities on sinus computed tomographic scan. Seventy-three percent of children 2 to 6 years of age, 74% of children 6 to 10 years of age, and 38% of children older than 10 had chronic sinusitis.(ABSTRACT TRUNCATED AT 250 WORDS)

C1 esterase inhibitor deficiency: three presentations.

We have presented three patients representing three of the four reported forms of C1 esterase inhibitor deficiency. The C1INH deficiencies are in general distinguishable from each other and from other forms of angioedema by their complement patterns. The acquired C1INH deficiency must be part of the differential in patients without a family history of angioedema since it may precede the diagnosis of more serious medical conditions such as lymphoproliferative disorders.

Intranasal fluocortin butyl in patients with perennial rhinitis: a 12-month efficacy and safety study including nasal biopsy.

Fluocortin butyl (FCB) is a recently developed topical intranasal corticosteroid that is inhaled as a powder and has been demonstrated to be well tolerated and to improve symptoms and signs of perennial rhinitis in previous short-term studies. This multicenter, open-label study evaluated the efficacy and safety of FCB during a 12-month treatment period in patients with perennial rhinitis. Treatment was initiated with one inhalation of FCB in each nostril three times a day (total dosage, 3 mg/day). In subsequent months, one third of the patients was maintained at the dosage of 3 mg/day, one third at a lower dosage of 2 mg/day, and the remaining one third of the patients at a larger dosage of 4 to 8 mg/day. Of 109 patients enrolled in the study, 90 patients (82.6%) completed all 12 months of treatment. Symptom and sign scores decreased significantly (p less than 0.001) at the 2-month evaluation compared to scores at baseline, and the improvement was maintained throughout the 12-month study period. After 12 months, greater than 80% of the patients had substantial control of symptoms. Specimens of nasal biopsies, performed at the beginning and end of treatment, revealed a decrease in eosinophils and other cellular infiltrates, a slight tendency of an increase in mast cell counts, and a trend toward normalization of the nasal mucosa. There were few adverse effects. Mean plasma cortisol levels were normal before and after corticotropin stimulation at baseline and after 12 months of FCB therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of severe reactions to sweat bee stings.

Thirteen patients with severe reactions to sweat bee stings were evaluated. Eleven patients had had systemic reactions and two, large local reactions. Skin testing and RAST with venom of other Hymenoptera and whole body extract of sweat bees disclosed negative reactions to both skin tests and RAST of all other insects tested in eight, while three showed sensitivity to honey bee. Only one patient had a positive RAST reaction to whole body extract of sweat bee. Whole body extract of sweat bee causes some irritant reaction when skin testing controls and is not a reliable diagnostic agent even though patients were more reactive than controls. Hypersensitivity reactions to sweat bee stings are distinct and not associated with reactions to other stinging insects. Currently, no reliable antigen is commercially available for diagnosing or treating this condition. Sweat bee venom or other venom antigens might be beneficial.

Multi-center, double-blind, placebo-controlled trial of fluocortin butyl in perennial rhinitis.

Fluocortin butyl (FCB) is a newly synthesized corticosteroid with a high ratio of topical to systemic activity. FCB was studied in a multi-center, double-blind, placebo-controlled trial of therapy of perennial rhinitis. The study was conducted between January and May 1981. Patients evaluated suffered from either chronic allergic or chronic nonallergic rhinitis or both. A total of 306 patients from 16 investigative centers were evaluated by comparing FCB to placebo. Three separate dosage regimens were employed. Patients received a total daily dose of 2, 4, or 8 mg. FCB was found to be an effective therapeutic agent. It reduced symptoms of nasal congestion, rhinorrhea, postnasal drainage, and sneezing. It also markedly reduced the use of concomitant medications (chlorpheniramine maleate and/or pseudoephedrine). Relief of symptoms was noted as early as the first week of therapy, and the degree of improvement increased progressively during the study. There was little difference between the relief produced by the 4 mg and 8 mg regimens. Both of these were superior to the 2 mg regimen. The drug was well tolerated; no significant side effects were noted.

Stinging insect allergy.

One to two million Americans have a history of systemic allergic reactions to stinging insects and must live with the knowledge that future stings could be catastrophic. Recent advances have been made in diagnosis and treatment of this problem. Pure venoms have been recognized to be superior to the whole body extract as diagnostic and treatment antigens. Use of pure venoms for immunotherapy gives far better protection than whole body extract for the allergic patient and represents a major advance in the field of allergy. The imported fire ant is very different from the other common stinging insects in its venom components, the type of local reactions caused by its sting, and the fact that whole body extract from this insect seems to be as good an antigen for diagnosis and treatment as pure venom. Although important discoveries about insect allergy have been made recently, some very important questions are yet to be answered. Among these are: (1) Can suppliers of venom provide us with enough venom to treat all patients with insect allergy? (2) How long should immunotherapy be continued? and (3) Would treatment with specific antigens from venom be superior to using whole venom? We all await the answer to these and other questions with hopeful anticipation.

Immunotherapy for mountain cedar pollinosis. A double-blind controlled study.

In this study, the effect of a single preseasonal course of injection therapy on the symptoms of patients with allergic rhinitis or asthma due to pollen from the conifer, mountain cedar, was evaluated in a double-blind controlled manner. Patients treated with specific injection therapy were found to have significantly fewer symptoms than those who received placebo injections. Specific serum IgE antimountain cedar antibody decreased during the pollen season in the treated group and increased in the placebo group.

Imported fire ant hypersensitivity. Studies of human reactions to fire ant venom.

It is now apparent that venom and venom components of the Hymenoptera superfamilies of Apida (honeybee) and Vespida (wasps, yellow jackets, and hornets) are becoming increasingly important in the diagnosis and treatment of hypersensitivity reactions. Stings from fire ants (superfamily Formicidae, family Myrmicinae) have also been recognized as causes of systemic reactions in man. Fire ant venom is unique in its composition, consisting mainly of alkaloids in aqueous suspension with only trace amounts of protein. This study compares the skin reactivity of fire ant venom and synthesized alkaloid components with the whole body extract (WBE) of fire ants and other Hymenoptera. The venom as well as the WBE of fire ants was found useful for skin test diagnosis of sensitive individuals. There appear to be cross-reactive or shared antigens between fire ant venom, WBE, and WBE of other Hymenoptera. Successful passive transfer of skin reactivity to nonsensitive individuals was accomplished with sera from sensitive individuals. Loss of this passive transfer by heating sera at 56 degrees C for 4 hr is evidence in favor of IgE mediating the positive skin test to the venom.