The prevalence of latex allergy in patients with rhinitis.

Natural rubber latex hypersensitivity to the constituent proteins of natural rubber latex is now an international health problem. This study investigates the prevalence of latex allergy in patients presenting with rhinitis. Fifty-nine consecutive patients, who presented to a general Otolaryngology out-patient clinic with symptoms suggestive of rhinitis, completed a questionnaire and underwent skin prick testing. Three out of 59 (5.1 per cent) tested positive to latex. The overall positive rate (all standard aeroallergens) was 45.8 per cent. Our data supports the hypothesis that the prevalence of latex allergy in patients with rhinitis is higher than the general population and that rhinitis may be a presenting symptom.

Improving the endoscopic view of the hypopharynx with anterior neck traction during the trumpet manoeuvre.

The postcricoid subsite is difficult to visualize on flexible laryngopharyngoscopy. The view can be improved with either auto-insufflation manoeuvres or anterior neck skin traction. In this study, the view of the hypopharynx was graded whilst anterior neck skin traction was applied during the trumpet manoeuvre; the latter involves the patient blowing on his finger as if blowing up a balloon. On auto-insufflation alone, the postcricoid site was demonstrated in 22/25 (88 per cent) of cases and the upper oesophageal sphincter (UOS) in two out of 25 (eight per cent). Of the 22 cases in whom only the postcricoid site was demonstrated, subsequent neck skin traction revealed the UOS in eight. Overall, the use of auto-insufflation solely or in combination with traction resulted in UOS visualization in 40 per cent (10/25) of cases. The application of skin traction during trumpeting is easy to perform and should be used routinely.

Otitis media with effusion and size at birth.

To investigate whether recurrent or persistent otitis media with effusion (OME) was associated with particular patterns of fetal growth, we conducted a case control study of 129 children admitted for insertion of grommets and 150 controls. The risk of OME was not statistically significantly related to gestational age or individual measures of size at birth, but the ratio of head circumference to total length and the ponderal index at birth were statistically significantly lower in children with OME, both before and after adjustment for the potentially confounding effects of sex, age at current operation, and maternal gravidity. Mothers of cases were 2.2 times more likely than those of controls to have had one or more previous pregnancies that had not ended in a live birth (95% CI 1.3-3.8). We conclude that fetal growth, reflected by proportions at birth, may affect later risk of recurrent and persistent OME.

Clinical applications of photodynamic therapy.

Photodynamic therapy is a modality for the treatment of malignant disease in which a photosensitive drug is selectively absorbed or retained by malignant tissues, after intravenous injection and is then photoactivated by light of an appropriate wavelength, often produced by a laser. Over the past two decades, the combination of haematoporphyrin derivative (HPD) and then its active component dihaematoprophyrin ether (DHE), now marketed as Photofrin, plus red light at 630 nm have been used in clinical practice for the treatment of a range of tumours; some very promising results have been obtained. Several countries have approved this drug/light combination for clinical use for a number of tumours. Some second generation photosensitising agents with appropriate light sources, and with perceived advantages over Photofrin, are under investigation, and it is to be hoped that major improvements in drug/light combinations will enable photodynamic therapy to achieve its full potential in the not-too-distant future.

Treatment of hereditary haemorrhagic telangiectasia by the pulsed dye laser.

Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome, Osler's disease) is an inherited abnormality of the vasculature characterized by abnormal subepithelial vessels. Treatment has included repeated intranasal cautery, intra-arterial embolization and arterial ligation. Historically, the operation of septodermoplasty and the use of systemic/topical oestrogens have been the most effective and lasting treatments, but over time the telangiectasias recur. There is increasing interest in the use of a variety of lasers for intranasal photocoagulation. A report of nine patients suffering from hereditary haemorrhagic telangiectasia who have undergone laser treatment with the Chromos pulsed dye laser is presented. This laser produces light energy at a wavelength of 585 nm and causes localized thermal damage to the blood vessel wall. Initially, no patient saw an improvement in their symptoms, but following an average of approximately three courses of treatment, all have reported a measurable reduction in the number of epistaxes suffered. Although no treatment completely resolves the epistaxis associated with this condition, we have found the pulsed dye laser to be effective at treating telangiectasias within the anterior nasal cavity.

Long-term use of hearing aids in patients with presbyacusis.

The aim of this study was to determine how the use of a hearing aid in presbyacusis varied with the passage of time. A questionnaire survey of patients with presbyacusis who had been fitted with a monaural behind the ear NHS hearing aid for the first time was undertaken. The patients were divided into six groups ranging from 6 months to 5 years after fitting. Overall regular long-term use of the hearing aid was found in the majority of patients with presbyacusis. The main drop-out point was within the first year after fitting the hearing aid. The study furthermore revealed a relatively high demand for further help and advice with the hearing aid in all groups.

Idiopathic tracheal stenoses.

The case histories are presented of three patients with circumferential subglottic stenoses who presented, over a six-month period, to a teaching hospital's Otolaryngology department. No recognisable cause for their subglottic stenoses was found. Traumatic, iatrogenic, infectious and specific inflammatory processes were excluded. The histopathological evidence suggested a chronic inflammatory process. All patients were treated by resecting the stenosis with a carbon dioxide laser. One patient required an emergency tracheostomy for airway obstruction. A review of the published literature on this rare condition is given.

Low adrenal androgen output in patients with abnormal laryngeal epithelium.

We present 16 new patients who had abnormal vocal cord biopsies. Each had a serum sex hormone profile performed on the morning of the procedure. The striking abnormality was that 12 (75%) had low dehydroepiandrosterone sulphate (DHEAS), the main adrenal androgen, and four of these had prepubertal levels.

Matrix-specific effect of endothelial control of smooth muscle cell migration.

PURPOSE: Smooth muscle cell (SMC) migration is a critical element in the development of intimal hyperplasia. The effect of endothelial cells (ECs) on SMC migration and the modulation of this cell-to-cell interaction by extracellular matrix is not well understood. METHODS: To examine this relationship SMCs and ECs were cocultured on opposite sides of a semipermeable membrane and were compared with SMCs cultured alone. To assess migration SMCs were plated at confluent density into the center of the membrane with a steel fence. After the fence was removed, SMCs were treated for 2 hours with mitomycin C (20 micrograms/ml) to assess migration independent of proliferation. Cell migration was measured with morphometry. Experiments were performed on plastic and membranes coated with fibronectin or type I collagen (n > or = 8/group). Cell adhesiveness was quantitated by cell attachment and spreading assays. RESULTS: ECs stimulated SMC migration by 187% when compared with SMCs cultured alone on plastic and by 160% when cultured on fibronectin (p < 0.01). Type I collagen stimulated migration of SMCs cultured alone and prevented EC stimulated migration in cocultured SMCs (p < 0.01). Cell adhesiveness was significantly increased in cocultured SMCs compared with SMCs cultured alone regardless of whether cells were cultured on plastic (EC/SMC, 13.5 +/- 0.6 SMCs/high power field vs SMC, 8.9 +/- 0.5, p < 0.01), fibronectin (16.3 +/- 0.8 vs 12.3 +/- 0.7, p < 0.01) or type I collagen (15.5 +/- 1.0 vs 12.4 +/- 0.6, p < 0.01). ECs increased SMC cell spreading on plastic and fibronectin when compared with SMCs cultured alone. No difference in SMC cell spreading was seen in the presence or absence of ECs when cells were cultured on type I collagen. EC-SMC contact was not required; EC-conditioned media alone increased SMC migration by 75% when compared with SMCs cultured alone. Our data suggest that ECs increase SMC migration by a diffusable molecule that may also alter SMC adhesion molecule expression. Extracellular matrix composition can attenuate these effects.

Diet-modified sex hormone metabolism: is this the way forward in recurrent respiratory papillomatosis and squamous carcinoma prophylaxis?

We report two cases of recurrent laryngeal papillomatosis in women who subsequently developed squamous cell carcinoma as they approached the climacteric. The role of human papilloma virus (HPV) and oestrogen metabolism is outlined. The use of indoles from cruciferous vegetables is also discussed.

Laryngeal papillomatosis with subsequent development of papillomata in the paranasal sinuses--is it seeding by intubation?

Concern has been expressed regarding the seeding of viral DNA, in laryngeal papillomatosis, to other sites in the respiratory tract during treatment. Controversy exists regarding the concept of seeding by the laser plume. However, instrumentation and anaesthetic intubation are also strongly implicated in seeding DNA to the proximal respiratory tract. No cases of recurrent laryngeal papillomatosis and subsequent papilloma in the paranasal sinuses have been reported.

Tubeless anesthetic technique for optimal carbon dioxide laser surgery of the larynx.

PURPOSE: To evaluate the operative conditions and safety of a tubeless technique of anesthesia for carbon dioxide laser surgery of the larynx. MATERIALS AND METHODS: This prospective study evaluated 78 consecutive procedures in 72 adult patients undergoing carbon dioxide laser microlaryngeal surgery. Anesthesia was maintained by an intravenous infusion of Propofol (ICI Pharmaceuticals, Cheshire, UK) while the patient breathed spontaneously without endotracheal intubation. RESULTS: The operative conditions were optimal in 76 of the 78 procedures providing a clear uninterrupted view of the larynx with no combustible material in the surgical field. CONCLUSIONS: This series shows the technique described to be safe without risk of combustion and provides an unobstructed view to the larynx.

Orbital infection secondary to sinusitis in children: diagnosis and management.

A series of 18 children with orbital infection secondary to sinusitis is described. The presenting symptoms were headache and periorbital swelling but it was found to be impossible to determine the stage of the orbital infection on clinical grounds. CT scanning can accurately identify the presence of a sub-periosteal abscess but both axial and coronal sections may be needed to diagnose abscesses in the superomedial portion of the orbit. Cellulitis may be managed by antibiotic treatment alone, but if an abscess is present it should be drained immediately with a formal ethmoidectomy to decompress the orbit if there is any evidence of reduced visual acuity.

Necrotizing fasciitis of the face without significant trauma.

Necrotizing fasciitis is a rare but well recognized clinical entity which most often occurs on the trunk, perineum or legs following surgery or trauma. The condition is much less common in the head and neck and it is particularly uncommon in the midface/periorbital region. In almost all the cases occurring in the neck the condition follows obvious dental or oropharyngeal sepsis and in all the cases of the scalp there is a history of previous surgery or trauma. However, necrotizing fasciitis of the midface/periorbital region may lack any obvious traumatic aetiology or may follow relatively minor trauma. The diagnosis in these cases may not be suspected and treatment may be delayed with fatal consequences. Treatment by wide excision of all affected skin can lead to disastrous cosmetic consequences in facial disease and it is suggested that disease control can be achieved by raising wide based skin flaps with excision of the underlying necrotic tissue. The flaps are then returned onto normal muscle with much improved cosmetic results. This paper discusses the diagnosis and treatment of patients with necrotizing fasciitis of the face which has arisen without significant trauma.