Introduction and definition of sinusitis.
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Acute Disease↗
Biomedical subjects
G G Shapiro
Publications and source records attributed to G G Shapiro.
Bronchoprovocation committee report. American Academy of Allergy and Immunology.
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Academies and Institutes↗
Childhood asthma: update.
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Acute Disease↗
Cromolyn versus triamcinolone acetonide for youngsters with moderate asthma.
Although both cromolyn (C) and inhaled corticosteroids are anti-inflammatory therapies for childhood asthma, there are few controlled comparisons of these medications for asthma therapy in children. None were conducted in the United States, and none specifically study triamcinolone acetonide (T) versus C. This 12-week evaluation followed 31 youths, aged 8 to 18 years, with moderate asthma who were assigned to receive C or T according to a prerandomized and blinded code. Patients were instructed to take two inhalations from the study metered-dose inhaler (active T or placebo) and to inhale the contents of one study-provided ampule (C, 20 mg, or placebo) from a compressor-driven home nebulizer three times per day. Patients also used albuterol, two inhalations from a metered-dose inhaler, three times a day (before study medication) and, additionally, if needed. Patients maintained a daily diary, recording extra medication use, adverse experiences, peak flow rates morning and night, and asthma symptom scores. Laboratory assessment of pulmonary function was done at 1, 4, 8, and 12 weeks. Cosyntropin challenge and methacholine bronchoprovocation challenge were performed at the beginning and end of the study. C and T provided similar, adequate asthma control. Symptoms of wheezing, cough, and chest tightness decreased, and daily peak expiratory flow rate increased with both regimens compared to during a 2-week baseline when patients received medication only as needed. There was no significant change in methacholine sensitivity and no change in endocrine function, as measured with fasting plasma control before and after administration of cosyntropin.(ABSTRACT TRUNCATED AT 250 WORDS)
Administration, Inhalation↗
Intraoperative cardiovascular collapse secondary to latex allergy.
An apparent allergic reaction has been noted in children undergoing open urological surgery. This condition is characterized by precipitous hypotension, tachycardia and upper body flushing, and it often causes termination of the procedure. Latex allergy has been identified as the possible inciting event. Contact of latex rubber gloves with intra-abdominal structures (handling bowel) appears to be the most dramatic trigger mechanism for this reaction. We report on 10 patients with latex allergy, 6 of whom have myelomeningocele, who have undergone reconstructive surgery. Severe anaphylactic shock developed intraoperatively in 5 patients and during a barium enema performed with a latex catheter in 1 patient. These 6 patients had previous allergic reactions to latex material, which was not detected preoperatively. In the remaining 4 patients latex allergy was diagnosed preoperatively. A total of 6 patients agreed to a skin prick test to liquid latex. Three patients reacted with a wheal size greater than or equal to a histamine control at a dilution of 1:1,000 and 3 patients at 1:100. In contrast, none of the 5 normal controls reacted to any of the concentrations including full strength latex. A history of exposure to latex products (balloons, surgical gloves, catheters, condoms and so forth) with allergic reactions should heighten surgeon awareness of a potentially severe intraoperative reaction. Furthermore, a skin prick test may be used to screen high risk patients such as those with myelomeningocele. A protocol involving preoperative corticosteroid and antihistamine therapy is recommended.
Adolescent↗
Bronchoprovocation in children.
Bronchial hyperresponsiveness (BHR) is a major feature of asthma that is determined by both genetic and environmental factors. The assessment of BHR can be a valuable means of assessing asthma severity and also response to therapy. BHR can be measured with a variety of provocative agents including exercise, methacholine, histamine, hypotonic and hypertonic saline and cold air. Methacholine and histamine challenges have been well studied and standardized. They are extremely sensitive indicators of BHR, but this is not synonymous with asthma. This requires that the physician interprets the clinical significance of test results with caution.
Asthma↗
Comparison of albuterol and metaproterenol syrup in the treatment of childhood asthma.
This study compared the acute and chronic effects of albuterol syrup (2 mg) and metaproterenol syrup (10 mg) three times a day over 28 days in 65 children, aged 6 to 9 years, with mild to moderate asthma. Wright peak flow, symptom scores, and rescue medication use were recorded twice daily during the 28 days; the acute cardiopulmonary effects of these syrups were compared over 8 hours on treatment days 1 and 28. Albuterol syrup produced a significantly greater peak magnitude of bronchodilation than metaproterenol, 29% vs 20% above baseline, respectively, on treatment day 1. Albuterol syrup had a duration of action of at least 8 hours and produced greater bronchodilation than metaproterenol syrup from 2 to 8 hours on both treatment days 1 and 28. The chronotropic effect of metaproterenol was greater than that of albuterol at 1 to 1 1/2 hours postdose on treatment days 1 and 28. There was a trend toward higher morning and evening Wright peak flow measurements during 28 days of treatment in the albuterol group. Side effects of both drugs were comparable. These findings imply therapeutic advantages of albuterol syrup over metaproterenol syrup in currently recommended doses with respect to improvement in pulmonary function, chronotropic effects, and frequency of dosing required to maintain optimum bronchodilation over a 24-hour period.
Administration, Oral↗
Clinical evaluation of triamcinolone acetonide nasal aerosol in children with perennial allergic rhinitis.
Triamcinolone acetonide aerosol (TAA), a topical corticosteroid, now available for intranasal use, has been shown to be highly effective in the treatment of both seasonal and perennial allergic rhinitis (PAR) in adults. To evaluate the efficacy and safety of TAA in children, 210 patients (ages 4 to 12 years) with PAR were randomly assigned to one of three treatment groups (placebo, TAA 82.5 micrograms/day, or TAA 165 micrograms/day). Medication was given tid over 12 weeks in a double-blind fashion. Response to medication was evaluated using symptom scoring, physician evaluation, and, in 44 patients, nasal airflow determinations by anterior rhinomanometry. The higher dose of TAA (165 micrograms/day) significantly improved rhinitis symptoms relative to placebo: the total nasal symptom score and most individual symptom scores (eg, nasal stuffiness, itch, sneezing) were significantly better, duration of rhinitis symptoms (hours per day) was significantly reduced, and nasal airflow in a subset of patients showed significant improvement. The lower dose of TAA (82.5 micrograms/day) was superior to placebo by the same parameters as the higher dose, but this improvement was not as consistently significant as the higher dose. There were no clinically significant adverse events; nasal irritation and epistaxis were rare with a similar incidence among treatment groups. In conclusion, TAA at 165 micrograms/day was effective in controlling the symptoms of PAR and in improving nasal airflow in pediatric patients; the lower dose (82.5 micrograms/day) was marginally effective. Both doses were safe and well-tolerated in the children studied.
Administration, Inhalation↗
Immunologic defects in patients with refractory sinusitis.
Sixty-one patients with chronic sinusitis who were referred for an allergy evaluation were evaluated for immunologic competence including assessment of quantitative serum immunoglobulin levels, IgG subclass levels, and response to pneumococcal and Haemophilus influenzae vaccines. In addition to chronic sinus disease, recurrent otitis media and asthma exacerbation were common problems in this group. Five patients had an elevated age-adjusted IgE level and 22 patients had positive prick tests to one or more environmental inhalants; these findings suggest an allergic component in this subgroup. Twelve additional patients had highly reactive intradermal tests to common environmental allergens, which also may be clinically significant for underlying atopy. Eleven patients had low immunoglobulin levels, 6 had low immunoglobulin levels and vaccine hyporesponsiveness, and 17 had poor vaccine response only. Thus, 34 of 61 patients with refractory sinusitis had abnormal results on immune studies, with depressed IgG3 levels and poor response to pneumococcal antigen 7 being most common. In addition to allergy, immunologic incompetence may be an important etiologic factor in patients with chronic, refractory sinusitis.
Adolescent↗
Effects of albuterol and procaterol on exercise-induced asthma.
Procaterol and albuterol, beta agonists, were studied using a placebo-controlled, repeated exercise challenge design in order to assess their duration of effectiveness in both bronchodilation and in modifying exercise-induced asthma (EIA). Fifty-three subjects aged 12 to 50 years who had at least a 20% drop in FEV1 during a screening exercise tolerance test were entered. Subjects took two inhalations of procaterol (10 micrograms/inhalation), albuterol (90 micrograms/inhalation), or placebo. Thirty minutes later they exercised on a treadmill at a workload sufficient to induce greater than or equal to 80% aerobic O2 consumption for six minutes. Pulmonary function was measured before and serially for 30 minutes after exercise. The same exercise challenge was repeated three, six, and nine hours after drug administration. Both procaterol and albuterol bronchodilated and modified EIA at 30 minutes and three hours, mean drops in FEV1 being 8.2 and 9.7% respectively at 30 minutes and 16.8 and 16.3% at three hours. This was compared with placebo falls of 30% and 26%. At six hours the subjects' response was similar after both procaterol and albuterol, and fewer subjects had a 20% fall in FEV1 than with placebo, although protection afforded by both beta agonists was substantially less than at three hours. Both drugs were tolerated well.
Adolescent↗
Evaluation of symptom relief, nasal airflow, nasal cytology, and acceptability of two formulations of flunisolide nasal spray in patients with perennial allergic rhinitis.
A new formulation of intranasal flunisolide containing less propylene glycol was compared with the original formulation for efficacy and acceptability in more than 200 patients with symptoms of perennial allergic rhinitis. In this multicenter, randomized, double-blind, parallel group study, symptomatic patients were treated with either the new or the original formulation of 0.025% solution of intranasal flunisolide for 4 weeks to provide 200 micrograms flunisolide daily. Both formulations were highly effective in decreasing symptom scores as evident from patient diary reports before and after treatment (P less than .001). Similarly, nasal airflow was improved with each treatment as measured by anterior rhinomanometry (P less than .0002) and the number of patients with nasal eosinophilia decreased (P less than .01). Finally, fewer patients using the new formulation reported nasal burning or stinging and the acceptability rating of the new formulation was higher.
Administration, Topical↗
Clinical expression of bronchial hyperreactivity in children.
Airway hyperreactivity is a consistent finding in most children with asthma and is responsible for many clinical manifestations of asthma. BH in children has been elicited by bronchial challenge with methacholine and histamine, cold air (isocapnic hyperventilation), and exercise. Pharmacologic agents employed in therapy of childhood asthma, which may modulate both the late asthmatic reaction and bronchial hyperreactivity, include cromolyn sodium, glucocorticoids, and possibly ketotifen. Beta adrenergic agonists, though effectively blocking the early asthmatic response, had no effect on the late response and did not alter bronchial hyperreactivity. Theophylline, in both children and adults, and enprophylline (not yet studied in children) may modify both the early and late responses, but do not appear to have an effect on bronchial hyperreactivity. New drugs that may have potential value in reducing bronchial hyperreactivity include calcium channel blockers and PAF antagonists.
Airway Resistance↗
Pulmonary sequelae of meconium aspiration.
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Asthma↗
Terfenadine blockade of exercise-induced bronchospasm.
Terfenadine, in doses of 60, 120, and 180 mg, provided significant bronchodilation for up to four hours after administration. In addition, when the same doses were given four hours prior to exercise, the drug demonstrated significant blockade of exercise-induced bronchospasm at two and five minutes postexercise. These effects on exercise-induced bronchospasm followed a dose-response curve; 180 mg had the most significant effect. All dosing levels, however, produced both bronchodilation and a significant degree of blockade of exercise-induced bronchospasm. No patients were bothered by adverse effects during this single-dose study. Eight of the 11 subjects who completed the study also noted some improvement in their nasal congestion during the testing period when they were on the active drug.
Adolescent↗
Is a uniform round-the-clock theophylline blood level necessary for optimal asthma therapy in the adolescent patient?
Twenty-one patients, 12 to 18 years of age, with nocturnal asthma controlled with sustained-release theophylline administered twice daily, were enrolled in a 10-week, double-blind, two-way crossover study that compared Theo-Dur tablets administered twice daily with an equivalent daily dose of Uniphyl tablets administered once daily at bedtime. Seventeen patients completed the study. The mean morning theophylline serum level obtained with Uniphyl tablets was significantly higher than that obtained with Theo-Dur tablets (13.1 versus 9.6 micrograms/ml, p = 0.02). The mean evening serum level was significantly lower with Uniphyl tablets (6.3 versus 10.1 micrograms/ml, p = 0.003). Despite these differences in serum concentrations, morning and evening pulmonary function test values (forced expiratory volume in one second and peak expiratory flow rate) and symptom scores were nearly identical for the two preparations, as was the supplemental use of aerosol bronchodilators. Once-daily dosing with Uniphyl tablets may benefit adolescent patients with nocturnal asthma by increasing compliance and providing better asthma control. In addition, the lower daytime theophylline levels produced by this preparation may also reduce long-term adverse effects on behavior and cognition.
Adolescent↗
Otitis media.
Otitis media with effusion is a common disorder in children and occurs more frequently in adults than has been generally appreciated. Laboratory tools have permitted a more specific characterization of this disorder by objective means. These laboratory tests include specific ear tests (pneumatic otoscopy, pure tone, and impedance audiometry), nasal tests (inflammatory cytology), functional tests for obstruction (airway resistance measurements), and anatomic tests of obstruction and inflammation (radiographic of nose and paranasal sinuses). Immunologic tests define the presence of hypersensitivity (skin testing, RAST) and immunodeficiency in this disorder.
Adolescent↗
The role of nasal airway obstruction in sinus disease and facial development.
Allergic rhinitis in children is often complicated by bacterial sinusitis, which can lead to chronic illness and dysfunction. Sinus disease manifests differently in children than in adults, with cough, rhinorrhea, and middle ear disease being common and pain, headache, and fever being uncommon. Sinusitis may exacerbate asthma, and as many as 70% of children with allergy and chronic rhinitis have abnormal findings on sinus x-ray studies. Nasal cytologic specimens showing large numbers of polymorphonuclear cells with intracellular bacteria are also evidence of sinusitis. Obstruction of the nasal airways by allergic rhinitis or enlarged adenoids can lead to deviations in facial growth, specifically increased facial length. With the removal of the obstruction and a return to nasal breathing, facial length may become more normal. Sinusitis in children is treated with antibiotics, usually for 3 to 4 weeks, to eliminate the infection. Adjunctive therapy with antihistamines, decongestants, cromolyn, and corticosteroids may also be helpful. Topical steroids, such as flunisolide and beclomethasone, can be very useful in pediatric patients. These steroids decrease edema and prevent the release of allergic mediators that may be responsible for an environment favoring the bacterial infection causing sinusitis.
Airway Obstruction↗
Sinusitis in children.
Sinusitis is common in allergic children. We are now aware that the commonest presentation of this disorder in the pediatric age group is persistent cough and purulent rhinorrhea. Headache and facial tenderness, frequently noted in adults with sinusitis, are not common. Much remains to be learned about diagnostic techniques and therapy of sinusitis. Nasal cytology can be valuable for discriminating between allergic and infectious disease, but lacks both sensitivity and specificity. Although there is a high correlation between radiographs showing significant sinus membrane thickening or clouding and recovery of bacteria from antral taps, it is possible to see positive films in asymptomatic individuals. Similarly, films may be unremarkable, although the history and physical examination yield convincingly positive evidence for sinus infection. The clinician must sometimes decide on therapy when the diagnosis is not definitive. Antimicrobial therapy for sinusitis should be given for 3 to 4 weeks in many cases. Amoxicillin remains a good choice for therapy, but antibiotics capable of clearing infections by beta lactamase-producing bacteria should be considered in refractory situations. The value of antihistamines, decongestants, nasal steroids, and cromolyn sodium are unstudied at this time. If several antibiotic courses fail to alleviate the signs and symptoms of sinusitis, surgery is indicated. Antral lavage and creation of nasoantral windows is the usual approach in children. Patients with sinusitis often have concurrent middle ear disease. Patients with current sinusitis have a higher incidence of immunoglobulin disorders than found in a normal pediatric sample. It appears that patients with sinusitis are more often allergic than would be expected from 2 typical population distribution. More evaluation is needed to clarify these associations.
Amoxicillin↗