Sensitization to various minor house dust mite allergens is greater in patients with atopic dermatitis than in those with respiratory allergic disease.

BACKGROUND: Various allergenic proteins are produced by house dust mites (HDM). However, the allergenicity and clinical implications of these allergens are unknown. OBJECTIVE: The purpose of this study was to identify allergens in Dermatophagoides farinae and elucidate the sensitization profiles to these in Korean patients suffering from respiratory (allergic rhinitis and/or asthma) and atopic dermatitis symptoms. METHODS: IgE reactivities in sera from 160 HDM allergy patients were analysed by one- and two-dimensional gel electrophoresis and immunoblotting. IgE-reactive components were identified by liquid chromatography-coupled electrospray ionization-tandem mass spectrometry. Nine recombinant mite allergens (Der f 1, Der f 2, Der f 10, Der f 11, Der f 13, Der f 14, Der f 30, Der f 32 and Der f Alt a 10) were produced, and the IgE reactivity in sera to each was determined by ELISAs. RESULTS: Der f 1 and Der f 2 were recognized by IgE in serum samples from 88.1% and 78.1% of all patients, respectively. Patients with respiratory allergies were mainly sensitized to these major allergens, whereas patients with atopic dermatitis symptoms showed polysensitization to major and minor allergen components (including Der f 11, Der f 13, Der f 14, Der f 32 and Der f Alt a 10). CONCLUSIONS: Patients with respiratory allergic disease sensitize to major allergen components of HDM. Those with atopic dermatitis were sensitized to a broader range of minor allergen components of HDM (Der f 11, Der f 13, Der f 14, Der f 32 and Der f Alt a 10).

Ciprofloxacin-induced immune-mediated thrombocytopenia: No cross-reactivity with gemifloxacin.

WHAT IS KNOWN AND OBJECTIVE: Fluoroquinolone-induced immune-mediated thrombocytopenia is uncommon, and no reports of cross-reactivity among fluoroquinolones exist. Here, we describe a case of ciprofloxacin-induced immune thrombocytopenia with no cross-reactivity with gemifloxacin. CASE DESCRIPTION: A 77-year-old woman showed profound thrombocytopenia immediately after two ciprofloxacin injections for pneumonia. Platelet counts recovered rapidly after ciprofloxacin discontinuation. She had experienced thrombocytopenia after ciprofloxacin administration 4 years earlier, which was assumed to be ciprofloxacin-induced immune-related. Interestingly, no thrombocytopenia occurred following the subsequent exposure to another fluoroquinolone, gemifloxacin. WHAT IS NEW AND CONCLUSION: No cross-reactivity occurred between ciprofloxacin and gemifloxacin in this fluoroquinolone-induced immune thrombocytopenia case.

Ranitidine-induced anaphylaxis: clinical features, cross-reactivity, and skin testing.

BACKGROUND: Histamine H2 receptor antagonists are commonly prescribed medications and are known to be well tolerated. However, 99 cases of ranitidine-induced anaphylaxis occurred in Korea from 2007 to 2014. OBJECTIVE: The purpose of this study was to determine the incidence, clinical features, and diagnostic methods for ranitidine-induced anaphylaxis. METHODS: Ranitidine-related pharmacovigilance data from 2007 to 2014 were reviewed. Adverse drug reactions with causal relationships were selected, and clinical manifestations, outcomes, and drug-related information were assessed. For further investigation, 8 years of pharmacovigilance data were collected at a single centre. Twenty-three patients participated in in vivo and in vitro studies. Skin tests, oral provocation tests, and laboratory tests were performed, including tests using other kinds of histamine H2 receptor antagonists. RESULTS: Over 7 years, 584 patients suffered adverse reactions to ranitidine. The most common manifestation was cutaneous symptoms. Among them, 99 patients (17.0%) experienced anaphylaxis. In a single-centre study, skin prick tests were positive in 91.7% of ranitidine-induced anaphylaxis patients (11/12); the optimal concentration was 20 mg/mL. Detection of ranitidine-specific immunoglobulin E failed. Cimetidine and proton pump inhibitors showed no cross-reactivity with ranitidine based on the skin prick test, oral provocation test, or clinical determination. Surprisingly, 82.6% of patients reintroduced ranitidine and re-experienced the same adverse reactions because ranitidine was not considered the culprit drug. CONCLUSIONS AND CLINICAL RELEVANCE: Although ranitidine is known as a safe drug, it can also cause diverse adverse reactions, including anaphylaxis. This study demonstrates the need to pay attention to adverse reactions to ranitidine and consider ranitidine as a cause of anaphylaxis.

Excision of large solid haemangioblastomas of the cerebellopontine angle by a skull base approach.

Solid haemangioblastomas can be difficult to treat surgically because of their hypervascularity and requirement for circumferential dissection. We report two cases of large solid cerebellopontine angle haemangioblastomas that were safely resected utilizing wide transtemporal posterolateral skull-base exposures. In both cases, good tumour exposure was achieved with trans-cochlear approaches and division of the sigmoid sinus. These were large tumours and we felt that the added complexity of the approach was justified by providing panoramic exposure to allow safe resection.

Health-related quality of life in patients with skull base tumours.

The objective of the investigation was to report on the health-related quality of life (HRQoL) of patients diagnosed with skull base tumours using the Short Form Health Survey questionnaire (SF-36). Those patients suffering with vestibular schwannoma were examined to determine the effect facial nerve function had on their quality of life. It took place at the tertiary referral centre at the Department of Clinical Neurosciences, Western General Hospital, Edinburgh. A prospective study of 70 consecutive patients was taken, who harboured the following tumours: 54 vestibular schwannomas, 13 meningiomas, two haemangioblastomas and one hypoglossal schwannoma. Patients were interviewed using the short form 36 (SF-36) questionnaire. Facial nerve function was assessed in those patients who had vestibular schwannomas. The entire cohort of live skull base patients were assessed after a median follow-up time of 38.4 months. Patients with vestibular schwannoma treated conservatively with interval MRI had a quality of life similar to t he normal population. Those who underwent surgery had a significant difference in two of the SF-36 domains. No statistically significant correlation was found at final assessment between the degree of facial nerve functioning and any of the domains of SF-36. Patients with non-vestibular tumours had an impaired HRQoL in seven of the eight domains. Patients with skull base tumours have a significant impairment of their HRQoL. A conservative policy of follow up with interval MRI for patients with small vestibular schwannomas may therefore be more appropriate to preserve their HRQoL. Facial nerve outcome has little influence on quality of life in vestibular schwannoma patients.

Prophylaxis for venous thromboembolism in head and neck surgery: the practice of otolaryngologists.

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are an important cause of morbidity and mortality in the surgical patient. The first guideline produced by the Scottish Intercollegiate Guidelines Network was for the prophylaxis of venous thromboembolism. Patients undergoing major head and neck cancer surgery commonly exhibit risk factors for venous thromboembolism. Currently, however, there are no data on its incidence in these patients. A questionnaire survey was performed to assess the current practice of consultant otolaryngologists regarding DVT prophylaxis in patients undergoing head and neck cancer surgery. Of those respondents who managed these patients, 57 per cent did not use routine DVT prophylaxis while 43 per cent did. A wide variety of techniques were employed among those practising DVT prophylaxis. A consensus is needed concerning the use of thromboembolism prophylaxis in head and neck surgery patients.

Sensorineural hearing loss in MELAS syndrome.

A case of sensorineural hearing loss (SNHL) in MELAS syndrome, a variety of mitochondrial cytopathy, is presented. Mitochondrial cytopathies have gone almost unreported in the otolaryngology literature, despite evidence from a recent review that about 60 per cent of such patients suffer from SNHL (Gold and Rapin, 1994). The same review revealed that only one of 117 case reports in the period 1984-1993 contained an audiogram (Swift and Singh, 1988), and none presented sequential audiograms. However, audiometry has since been published on 23 members of a family with a mitochondrial point mutation causing only sensorineural hearing loss with no other symptoms (Vernham et al., 1994). We present a case of mitochondrial cytopathy three years after diagnosis with two sequential audiograms.

Systematic approach to intradural tumors ventral to the brain stem.

Intradural tumors that are situated anterior to the midbrain, pons, and medulla have historically been among the most inaccessible of all intracranial lesions. The classic approaches to the posterior fossa (e.g., suboccipital, retrosigmoid) provide only limited access to the anterior midline, primarily due to interposition of the cerebellum, brain stem, and numerous cranial nerves between the tumor and the viewpoint of the surgeon. A variety of techniques have been developed in recent years that create a craniotomy by removal of a portion of the lateral skull base. These procedures enhance exposure of the ventral surface of the brain stem while markedly reducing the need for brain retraction. An underlying theme of transbasal craniotomy is judicious removal of a portion of the petrous pyramid. The most radical form of petrosectomy, the extended transcochlear approach, involves removal of the entire petrous pyramid along with the lateral aspect of the clivus. This provides an unimpeded view of the ventral surface of the pons, including the basilar artery, vertebrobasilar junction, and both abducens nerves. Whereas this technique provides splendid exposure along the midsegment of the brain stem, it carries substantial morbidity, including hearing loss and transient facial palsy, which typically recovers incompletely and with synkinesis. Over the past few years transcochlear procedures have been gradually supplanted, at the University of California Medical Center, by techniques that involve creating a simultaneous craniotomy of both the middle and posterior fossae fashioned around a more limited petrosectomy. These versatile procedures, in particular the middle fossa/retrolabyrinthine approach, provide excellent exposure of the region ventral to the midbrain and pons with less morbidity than the transcochlear approach. When tumors extend inferiorly, ventral to the lower medulla and/or upper cervical spinal cord, augmented inferior exposure is required. Approaches to ventrally situated lesions at the craniovertebral junction include the far lateral (transcondylar) approach to the foramen magnum and the transjugular approach, both of which involve removal of the inferior portion of the petrous bone. To efficiently utilize these innovative surgical options the surgeon must decide which of the potential approaches optimizes resection while minimizing morbidity. An analysis of the anatomy of the tumor, the functional integrity of cranial nerves, and the extent of resection planned provides the surgeon with the information needed to arrive at a rational choice.

Otolaryngological indicator operations: one year's experience.

One year's experience of otolaryngological indicator operations is presented. Of 59 myringoplasties, 47 (79%) were successful; trainees performed 44 (74%) of the procedures. Seventy patients undergoing septal surgery reported significant improvements in nasal obstruction (P < 0.001), catarrh and facial pain (P < 0.005). Seventeen laryngectomies were performed for stage III and IV disease. The median operative time of 3.1 h rose to 5.1 h with a concomitant neck dissection. Eleven complications ensued, and the median stay for an uncomplicated laryngectomy was 16 days and 30 days following complications. Forty-one parotidectomies, 19 submandibular gland excisions and 10 ductal procedures were performed with 5 wound complications and 5 minor temporary facial nerve weaknesses. We have established a baseline for comparison of our practice with others and concluded that septal surgery gives good symptomatic relief, trainees perform reasonable numbers of myringoplasties, and improvements remain to be made in our outpatient septal surgery data collection.

Tuberculoma of the nasopharynx.

A 67-year-old female patient with tuberculosis of the nasopharynx is reported. The diagnosis was confirmed on histological and bacteriological examination of a biopsy from her postnasal space. There was no evidence of any other active foci of tuberculosis but she had had a right nephrectomy 45 years previously for renal tuberculosis. A review of the literature on nasopharyngeal tuberculosis shows this to be a very rare disease in the absence of active pulmonary involvement.

Reinke's oedema and thyroid function.

Reinke's oedema (RO) of the vocal folds is a condition of unknown aetiology. Cigarette smoking and vocal abuse may contribute to its development. Hypothyroidism has been described as an aetiological factor but, to date, no controlled study has been published confirming this association. This prospective, controlled study compared thyroid function in 61 consecutive RO patients with an age and sex matched control group (n = 65) without laryngeal disease. Thyroid function was assessed by measuring serum thyroid stimulating hormone (TSH), free thyroxine (T4) and tri-iodothyronine (T3). Hypothyroidism was diagnosed when TSH was above normal with a T3 and T4 below the normal range. Four RO patients were hypothyroid at the time of diagnosis, compared to five of the control group. Six RO patients had past or present hypothyroidism compared to seven of the controls. One RO patient and two controls were euthyroid with marginally elevated TSH levels. Although the incidence of hypothyroidism in this group of Reinke's oedema patients is higher than expected in a normal population, it is similar to that in an age and sex matched control group, reflecting the prevalence of hypothyroidism in middle aged women. This study suggests that hypothyroidism is not an aetiological factor in the development of Reinke's oedema.

Metastatic salivary pleomorphic adenoma.

Pleomorphic adenomas of the salivary gland are usually regarded as benign tumours. We report a case in which a solitary pulmonary metastasis arose from a pleomorphic adenoma of the right parotid gland. The mechanism of metastasis is discussed.

Spiral ligament tension fibroblasts and extracellular fibres in the guinea pig.

Fibroblasts with stress fibres and their relationship to extracellular matrix fibres were described in the marginal regions of the spiral ligament in several mammalian species. Location, structure and attachment of these cells suggested that they facilitated the development of radial tension in the basilar membrane-spiral ligament complex. In this study, fibroblast structure and relationship with the extracellular matrix was examined by light and transmission electron microscopy in the guinea pig spiral ligament. Tension fibroblasts were found in marginal and subcentral regions of the spiral ligament. Their ultrastructure was described. They were related to the trabeculated extracellular matrix and were numerous in the marginal region at the spiral ligament-otic capsule interface. Their comparative anatomy and role in the development of spiral ligament-otic capsule tension was discussed.

Spiral prominence epithelium.

Recent studies have shown neuroendocrine-type cells in human spiral prominence epithelium. A light microscopic and ultrastructural study was made on the guinea pig spiral prominence epithelium to try and identify neuroendocrine cells. The study showed that such cells were not present in the guinea pig spiral prominence epithelium. The spiral prominence epithelium was characterized by uniformity of cellular staining with Toluidine blue and the ultrastructural appearance. The morphology of the spiral prominence epithelium was similar to that previously described. The absence of neuroendocrine cells in spiral prominence epithelium in the guinea pig is discussed in relation to species differences.

Co-existent inverted papilloma and squamous carcinoma of the nasal septum.

Inverted papilloma is an uncommon benign nasal tumour which usually occurs on the lateral nasal wall and is prone to recurrence and malignant change. Inverted papilloma of the nasal septum is rare. A case of inverted papilloma and coexistent squamous carcinoma of the nasal septum in an adult male is described. The biology and treatment of these lesions are discussed.

The ENT consultation: a prospective study of the doctor's and the patient's perceptions.

In this prospective study of 126 patients attending the ENT outpatient clinic the doctor's and the patient's perception of the consultation were evaluated by questionnaire; 96 patients completed the questionnaire correctly. The results were analysed by scattergram plot and Wilcoxon's matched-pair signed ranks test. There was a statistically significant difference between the doctor's and the patient's perception of the 'history' (p less than 0.01) and the 'explanation of diagnosis and treatment' (p less than 0.05) in the consultation. There was no statistically significant difference between the doctor's and the patient's perception of the 'examination' in the consultation. The results are discussed.

Right vocal cord paralysis after internal jugular vein cannulation.

Neurological complications are rare after central venous cannulation. We report a case of right vocal cord paralysis after internal jugular vein cannulation. The mechanism of neural injury is discussed.

Relationship of the primary choanae and anterior cranial base in the mouse embryo.

The anteroposterior growth of the primary choanae and anterior cranial base in, morphologically, staged CBA mouse embryos was measured. Embryo heads were cut serially in a frontal plane of section. Serial measurement of the primary choanae and anterior cranial base demonstrated that growth of the primary choanae was downwards and forwards with the primary palate and that it did not occur by upward and backward extension along the stomodeal roof. The results are discussed in relation to previous topographical descriptions of primary choanal development.

Primary nasal tuberculosis masquerading as a malignant tumour.

Primary nasal tuberculosis is rare. We report a case of primary nasal tuberculosis in an elderly lady who presented with symptoms and signs suggestive of a nasal fossa tumour. Histological examination of the lesion revealed the diagnosis. Treatment was with standard anti-tuberculous chemotherapy. The implications of primary nasal tuberculosis are discussed.