Oral steroids and doxycycline: two different approaches to treat nasal polyps

Journal of Allergy and Clinical Immunology (JACI) 125 (5), 1069-1076.e4 (May 2010)

 Van Zele T, Gevaert P, Holtappels G, Beule A, Wormald PJ, Mayr S, Hens G, Hellings P, Ebbens FA, Fokkens W, Van Cauwenberge P, Bachert C;

BACKGROUND: There is little scientific evidence to support the current practice of using oral glucocorticosteroids and antibiotics to treat patients with chronic rhinosinusitis and nasal polyps.
OBJECTIVE: We evaluated the effects of oral glucocorticoids and doxycycline on symptoms and objective clinical and biological parameters in patients with chronic rhinosinusitis and nasal polyps.
METHODS: In a double-blind, placebo-controlled, multicenter trial, we randomly assigned 47 participants with bilateral nasal polyps to receive either methylprednisolone in decreasing doses (32-8 mg once daily), doxycycline (200 mg on the first day, followed by 100 mg once daily), or placebo for 20 days. Participants were followed for 12 weeks. Patients were assessed for nasal peak inspiratory flow and symptoms and by nasal endoscopy. Markers of inflammation such as eosinophilic cationic protein (ECP), IL-5, myeloperoxidase, matrix metalloproteinase 9, and IgE were measured in nasal secretions. Concentrations of eosinophils, ECP, and soluble IL-5 receptor alpha were measured in peripheral blood samples.
RESULTS: Methylprednisolone and doxycycline each significantly decreased nasal polyp size compared with placebo. The effect of methylprednisolone was maximal at week 3 and lasted until week 8, whereas the effect of doxycycline was moderate but present for 12 weeks. Methylprednisolone significantly reduced levels of ECP, IL-5, and IgE in nasal secretions, whereas doxycycline significantly reduced levels of myeloperoxidase, ECP, and matrix metalloproteinase 9 in nasal secretions.
CONCLUSION: This is the first double-blind, placebo-controlled study to show a significant effect of oral methylprednisolone and doxycycline on size of nasal polyps, nasal symptoms, and mucosal and systemic markers of inflammation.

A useful procedure for observing the cervical esophagus via the hypopharynx

Auris Nasus Larynx (Apr 2010)

Nagano H, Yoshifuku K, Kurono Y;

Tags:

• diazepam
• Head and Neck Cancer

OBJECTIVE: The aim of the study was to evaluate upper gastrointestinal endoscopy with movable over tube (i.e., the movable over tube method) for observing the hypopharynx to cervical esophagus, for use in treatment, and to determine its safety.

METHODS: The study population consisted of 28 patients (23 men, 5 women; a mean age of 66.6 years old; age range of 50-80 years old). The patients consisted of nine cases of globus sensation, eight cases of hypopharyngeal cancer (post-chemoradiotherapy), three cases of hypopharyngeal cancer (untreated), two cases of hoarseness, two cases of unknown primary carcinoma, two cases of foreign body, one case of esophageal cancer, and one case of dysphagia. We used upper gastrointestinal endoscopy with movable over tube to examine the hypopharynx to the cervical esophagus in subjects.

RESULTS: With the movable over tube method, which was performed under pharyngeal surface anesthesia and an infusion of diazepam (5-10mg/kg body weight), one could observe from the hypopharynx to cervical esophagus without any blind spots. There were no complications after the examination.

CONCLUSIONS: The results suggest that the movable over tube method is an easy, useful, and safe method to observe the region from the hypopharynx to the cervical esophagus.

Early exposure to paracetamol or to antibiotics and eczema at school age: Modification by asthma and rhinoconjunctivitis

Pediatric Allergy and Immunology (Apr 2010)

Garcia-Marcos L, González-Díaz C, Garvajal-Urueña I, Pac-Sa MR, Busquets-Monge RM, Suárez-Varela MM, Batlles-Garrido J, Blanco-Quirós A, Varela AL, García-Hernández G, Aguinaga-Ontoso I

The association between early exposure to paracetamol or to antibiotics and eczema is conflicting. This study aims to know whether the early exposure to those drugs is associated with eczema at school age, and whether the strength of the association is modified by the presence of asthma or rhinoconjunctivitis.

Children aged 6-7 (n = 13908) from the International Study of Asthma and Allergies in Childhood in Spain provided data about current asthma, rhinoconjunctivitis and eczema. Parent-reported information was also obtained on paracetamol and antibiotic consumption during the first year of life. Logistic regression analysis with eczema as outcome and including exposure to paracetamol or to antibiotics, together with possible confounders, was carried out in the whole sample of children and in five different strata: no respiratory symptom and any respiratory symptom further subdivided into: asthma with rhinoconjunctivitis, asthma without rhinoconjunctivitis and rhinoconjunctivitis without asthma. In the whole sample, exposure to paracetamol was associated with eczema (aOR 1.56 [1.36-1.80]) as was antibiotic consumption (aOR 1.66 [1.43-1.92]). These associations did not substantially change after additionally adjusting for the other drug. A similar pattern was found among children without respiratory symptoms.
In children with symptoms, adjusting for the other drug modified the association with paracetamol (aOR from 1.32 [1.03-1.71] to 1.09 [0.83-1.43]) but did not change that with antibiotics (aOR from 1.80 [1.38-2.35] to 1.81 [1.37-2.39]). Early exposure to paracetamol or to antibiotics is associated with an increased prevalence of eczema at school age. Asthma and/or rhinoconjunctivitis substantially modifies this association.

Ear-acupressure for allergic rhinitis: a systematic review

Clinical Otolaryngology 35 (1), 6-12 (Feb 2010)

Zhang CS, Yang AW, Zhang AL, Fu WB, Thien FU, Lewith G, Xue CC

BACKGROUND: Allergic rhinitis affects 10-40% of the population globally with a substantial health and economic impact on the community.
OBJECTIVE OF REVIEW: To assess the effectiveness and safety of ear-acupuncture or ear-acupressure for the treatment of allergic rhinitis by reviewing randomised controlled trials and quasi-randomised controlled trials.
TYPE OF REVIEW: This review followed the methods specified in the Cochrane Handbook for Systematic Reviews of Interventions. SEARCH STRATEGY: A total of 21 electronic English and Chinese databases were searched from their respective inceptions to April 2008. Key words used in the search included the combination of ear, auricular, acupuncture, acupressure, acupoint, allergic, allergy, rhinitis, hayfever, randomised clinical trial and their synonyms. EVALUATION METHOD: The methodological quality was assessed using Jadad's scale. The effect size analysis was performed to explore the difference between interventional groups. RESULTS: Ninety-two research papers were identified and seven of them referring to five studies met the inclusion criteria. All included studies involved ear-acupressure treatment. These studies mentioned randomisation, but no details were given. None of the five studies used blinding or intention-to-treat analysis. Ear-acupressure was more effective than herbal medicine, as effective as body acupuncture or antihistamine for short-term effect, but it was more effective than anti-histamine for long-term effect.
CONCLUSIONS: The benefit of ear-acupressure for symptomatic relief of allergic rhinitis is unknown due to the poor quality of included studies

Mometasone furoate nasal spray reduces the ocular symptoms of seasonal allergic rhinitis

Journal of Allergy and Clinical Immunology (JACI) (Apr 2010)

Prenner BM, Lanier BQ, Bernstein DI, Shekar T, Teper A

BACKGROUND: Mometasone furoate nasal spray (MFNS), a potent intranasal corticosteroid with proved efficacy in relieving nasal allergic rhinitis symptoms, has demonstrated effectiveness in improving ocular symptoms associated with seasonal allergic rhinitis (SAR) in retrospective analyses.

OBJECTIVE: We sought to evaluate prospectively the efficacy of MFNS in reducing total ocular symptom scores (TOSSs) and individual ocular symptoms in subjects with SAR.

METHODS: Subjects 12 years or older (n = 429) with moderate-to-severe baseline symptoms were randomized to MFNS, 200 mug once daily, or placebo in this 15-day, double-blind, parallel-group study. Subjects evaluated morning instantaneous TOSSs and daily reflective TOSSs, total nasal symptom scores (TNSSs; both instantaneous TNSSs and reflective TNSSs, respectively), and individual ocular and nasal symptoms. Mean changes from baseline averaged over days 2 to 15 (instantaneous) and days 1 to 15 (reflective) were calculated. Quality of life was assessed by using the Rhinoconjunctivitis Quality of Life Questionnaire.

RESULTS: MFNS treatment yielded significant reductions from baseline versus placebo in instantaneous TOSSs (-0.34, P = .026, coprimary end point), instantaneous TNSSs (-0.88, P<.001, coprimary end point), reflective TOSSs (-0.44, P = .005), and reflective TNSSs (-1.06, P<.001). Significant decreases in all individual reflective ocular symptoms and instantaneous eye itching/burning and eye watering/tearing were observed for MFNS versus placebo (P<.05). Numeric improvements in instantaneous eye redness were seen but did not reach statistical significance. Improvements in Rhinoconjunctivitis Quality of Life Questionnaire total scores and individual symptom domains were achieved with MFNS treatment versus placebo (P<.001). MFNS was well tolerated.

CONCLUSION: This prospective study demonstrates that MFNS significantly reduces ocular symptoms in subjects with SAR.

Is there a role for leukotriene antagonists in the prevention of recurrent nasal polyps?

Current Opinion in Allergy and Clinical Immunology 10 (3), 200-5 (Jun 2010)

Rasp G

PURPOSE OF REVIEW: The aim of this review is to provide the current available data for leukotriene receptor antagonists in the treatment of nasal polyps, the use in the postoperative therapy single or as an add-on to standard treatments.

RECENT FINDINGS: Surgical treatment of nasal polyps was refined in the last 30 years by the introduction of functional endoscopic sinus surgery and nasal endoscopy for monitoring nasal polyp patients. As the relapse is the main challenge and as nasal steroids only delay it, a more efficient treatment is needed. Leukotriene antagonists have effects on asthma and allergic rhinitis; preliminary data show some benefits in nasal polyps.

SUMMARY: In the surgery of nasal polyps, recurrence is the main problem. Steroids are the current standard therapy, but the limitations are obvious. The role of leukotrienes in the disorder of nasal polyps is well established now, and with the antagonists available, interest rose in treating nasal polyps. A total of 356 patients took part in several studies involving leukotriene antagonists in the nasal polyp population. Some studies have minor levels of evidence; the data show positive effects for patients in preoperative and postoperative studies and medical treatments. There were benefits as an add-on to steroids and data from allergic rhinitis studies also show possible synergism with antihistamines. There are hints for a positive effect on eosinophil inflammation, clinical symptom scores, nasal airflow, sneezing and postnasal drip. Although some effects are shown, more controlled studies are necessary for reliable data.

Congestion and sleep impairment in allergic rhinitis

Current Allergy and Asthma Reports 10 (2), 113-21 (Mar 2010)

 Craig TJ, Sherkat A, Safaee S;

Allergic rhinitis is a prevalent disease in developed nations, and its prevalence has been increasing throughout the world. Nasal congestion is the most common and bothersome symptoms of rhinitis.

Congestion is associated with sleep-disordered breathing and is thought to be a key cause of sleep impairment in individuals with rhinitis. The end result is a decrease in quality of life and productivity and an increase in daytime sleepiness. Treatment with intranasal corticosteroids has been shown to reduce nasal congestion.

Data on sleep-related end points from clinical trials of intranasal corticosteroids indicate that this reduction is associated with improved sleep, reduced daytime fatigue, and improved quality of life. Other therapies, such as montelukast, also have a positive influence on congestion and sleep.

This review examines nasal congestion and the associated sleep impairment of allergic rhinitis patients. It explores the adverse effects of disturbed sleep on quality of life and how these conditions can be reduced by therapies that decrease congestion.

Rhinosinusitis and Comorbidities

Current Allergy and Asthma

Ryan MW, Brooks EG; 

A variety of systemic conditions impact the incidence, severity, prognosis, and treatment approach in patients with chronic rhinosinusitis (CRS). The controversy surrounding the impact of allergic rhinitis on CRS continues, but it is reasonable to consider and treat allergic sources of inflammation in any patient with CRS.
CRS is more severe in patients with aspirin sensitivity but improves-at least temporarily-to the same degree as in non-aspirin-sensitive patients, given appropriate therapy.
Polypoid rhinosinusitis in cystic fibrosis patients is characterized by compromised mucociliary clearance and infection with staphylococcal and pseudomonal organisms. Affected individuals require frequent antibiotic treatment, saline lavage, and repeated surgeries.
Rhinosinusitis is among the most common infectious complications of humoral immunodeficiency, which is not uncommon in patients with refractory CRS. The treatment approach in immunodeficiency includes aggressive antibiotic treatment and intravenous immunoglobulin. Specific diagnosis of comorbid systemic conditions with CRS will facilitate appropriate management.

Usefulness of computed tomography Hounsfield unit density in preoperative detection of cholesteatoma in mastoid ad antrum

American Journal of Otolaryngology (Apr 2010)

Park MH, Rah YC, Kim YH, Kim JH;

PURPOSE: This study was performed to evaluate the usefulness of Hounsfield unit (HU) to better distinguish cholesteatoma from other inflammatory conditions in the mastoid ad antrum before primary mastoid surgery.

MATERIALS AND METHODS: We enrolled 82 patients who underwent tympanomastoidectomy for treatment of chronic otitis. Forty-one patients were pathologically diagnosed with cholesteatoma, whereas the others were diagnosed with inflammatory granulation. These lesions were confirmed, and HU was measured in preoperative computed tomography. The difference in HU between cholesteatoma and non-cholesteatoma tissues was analyzed, and the improvement in the diagnosis of cholesteatoma after inclusion of HU data was calculated.

RESULTS: The HU was calculated as 42.68 +/- 24.42 in the cholesteatoma group and 86.07 +/- 26.50 in the non-cholesteatoma group. The differences between the 2 groups were statistically different (Student t test, P<.01). By applying the HU, the sensitivity (51.2%-80.5%), specificity (80.5%-87.8%), positive predictive value (72.4%-86.8%), and negative predictive value (62.3%-81.8%) to diagnose cholesteatoma improved.

CONCLUSIONS: The HU density was found to be statistically different between cholesteatoma and inflammatory granulation tissue in mastoid antrum. An improved diagnosis of cholesteatoma was achieved after adjusting for the HU.

Medical treatment of adenoid hypertrophy with "fluticasone propionate nasal drops"

International Journal of Pediatric Otorhinolaryngology (Apr 2010)

Demirhan H, Aksoy F, Ozturan O, Yildirim YS, Veyseller B

BACKGROUND: Adenoid hypertrophy treatment for children is generally planned in accordance with the degree of airway obstruction and related morbidity. If surgical treatment is indicated, the individual risk/benefit analysis of patients should be assessed in terms of anesthetic and postoperative complications. Although there are few alternative treatment options, these may be considered as a nonsurgical approach in less serious cases. Accordingly, studies about intranasal steroid applications under various protocols have been presented.

STUDY DESIGN: The prospective, randomized, placebo-controlled study.

SETTING: Tertiary referral center.

PATIENTS AND METHODS: Patients indicated for surgery were randomly divided into two groups. The study group was treated by fluticasone propionate nasal drops (NSD-nasal steroid drops) of 400mug/day for 8 weeks. The control group was treated by normal saline (NS) in the same way. All the patients were called for follow-up every 4 weeks.

RESULTS: At the end of 8 weeks, statistically significant improvement (p<0.05) was observed in the NSD treated group compared to the NS treated group in terms of nasal airway obstruction, mouth breathing, speech abnormalities, apnea and night cough. At the end of 8 weeks, the average total symptoms score of the NSD treated group dropped from 13.7 to 2.9 while the NS treated group's score changed from 14.8 to 14.6. After 8 weeks of NSD treatment the initial adenoid/choana (A/C) rate had dropped from 87 to 56% and a total decrease of 35.6% was observed. After 8 weeks of NS treatment the A/C rate dropped from 87 to 85% and a total decrease of 2.2% was observed.

CONCLUSIONS: In this study, the effect of fluticasone propionate nasal drops on adenoid hypertrophy is examined for the first time. This method provides an effective alternative to surgical treatment in children with adenoid hypertrophy. With the protocol applied in this study 76% of the patients were eliminated the surgery and removed from the surgical waiting list.

Stuttering and the basal ganglia circuits: a critical review of possible relations

Journal of communication disorders   ISSN 0021-9924   CODEN JCDIAI 

2004, vol. 37, n^o4, pp. 325-369 [45 page(s) (article)] (7 p.3/4)
ALM Per A. ^{(1 2)} ;

⁽¹⁾ Department of Clinical Neuroscience, Lund University, Lund, SUEDE
⁽²⁾ Department of Clinical Psychology, Lund University, Box 213, 22100, Lund, SUEDE

Résumé / Abstract

The possible relation between stuttering and the basal ganglia is discussed. Important clues to the pathophysiology of stuttering are given by conditions known to alleviate dysfluency, like the rhythm effect, chorus speech, and singing. Information regarding pharmacologic trials, lesion studies, brain imaging, genetics, and developmental changes of the nervous system is reviewed. The symptoms of stuttering are compared with basal ganglia motor disorders like Parkinson's disease and dystonia. It is proposed that the basal ganglia-thalamocortical motor circuits through the putamen are likely to play a key role in stuttering. The core dysfunction in stuttering is suggested to be impaired ability of the basal ganglia to produce timing cues for the initiation of the next motor segment in speech. Similarities between stuttering and dystonia are indicated, and possible relations to the dopamine system are discussed, as well as the interaction between the cerebral cortex and the basal ganglia. Behavioral and pharmacologic information suggests the existence of subtypes of stuttering. Learning outcomes: As a result of this activity, the reader will (1) become familiar with the research regarding the basal ganglia system relating to speech motor control; (2) become familiar with the research on stuttering with indications of basal ganglia involvement; and (3) be able to discuss basal ganglia mechanisms with relevance for theory of stuttering.