Allergic rhinitis: Review of the diagnosis and management: South African Allergic Rhinitis Working Group.

BACKGROUND: Allergic rhinitis (AR) has a significant impact on the community as a whole with regard to quality of life and its relationship to allergic multi-morbidities. Appropriate diagnosis, treatment and review of the efficacy of interventions can ameliorate these effects. Yet, the importance of AR is often overlooked, and appropriate therapy is neglected. The availability of effective medications and knowledge as to management are often lacking in both public and private health systems. METHODS: This review is based on a comprehensive literature search and detailed discussions by the South African Allergic Rhinitis Working Group (SAARWG). RESULTS: The working group provided up-to-date recommendations on the epidemiology, pathology, diagnosis and management of AR, appropriate to the South African setting. CONCLUSION: Allergic rhinitis causes significant, often unappreciated, morbidity. It is a complex disease related to an inflammatory response to environmental allergens. Therapy involves education, evaluation of allergen sensitisation, pharmacological treatment, allergen immunotherapy (AIT) and evaluation of the success of interventions. Regular use of saline; the important role of intranasal corticosteroids, including those combined with topical antihistamines and reduction in the use of systemic steroids are key. Practitioners should have a thorough knowledge of associated morbidities and the need for specialist referral.Contribution: This review summarises the latest developments in the diagnosis and management of AR such that it is a resource that allows easy access for family practitioners and specialists alike.

Updated recommendations for the management of upper respiratory tract infections in South Africa.

BACKGROUND: Inappropriate use of antibiotics for non-severe upper respiratory tract infections (URTIs), most of which are viral, significantly adds to the burden of antibiotic resistance. Since the introduction of pneumococcal conjugate vaccines in 2009 in South Africa, the relative frequency of the major bacterial pathogens causing acute otitis media (AOM) and acute bacterial rhinosinusitis (ABRS) has changed. RECOMMENDATIONS: Since URTIs are mostly viral in aetiology and bacterial AOM and ABRS frequently resolve spontaneously, the guideline includes diagnostic criteria to separate viral from bacterial causes and hence, those patients not requiring antibiotics. Penicillin remains the drug of choice for tonsillopharyngitis. Amoxicillin remains the drug of choice for both AOM and ABRS. A dose of 90 mg/kg/day is recommended for children, which should be effective for pneumococci with high-level penicillin resistance and will also cover most infections with H. influenzae. Amoxicillin-clavulanate (in high-dose amoxicillin formulations available for both children and adults) should be considered initial treatment of choice in patients with recent antibiotic therapy with amoxicillin (previous 30 days) and with resistant H.influenzae infections pending the results of studies of local epidemiology (ß-lactamase production ≥15%). The macrolide/azalide class of antibiotics are not recommended routinely for URTIs and are reserved for ß-lactam allergic patients. CONCLUSION: The guideline should facilitate rational antibiotic prescribing for URTIs as a component of antibiotic stewardship. However, it requires updating when new information becomes available particularly from randomised controlled trials and surveillance studies of local etiology and antibiotic susceptibility patterns.

Bacterial aetiology of non-resolving otitis media in South African children.

Little is known of the aetiology, serotypes or susceptibility of the pathogens causing non-resolving otitis media in children receiving care from specialists in private practice in developed or in developing countries. Increased access to antibiotics in the community amongst children receiving such private care in South Africa may be anticipated to lead to levels of resistance similar to those found in countries with similar models of private practice, such as the United States. This study was conducted to determine the aetiology of non-resolving otitis media in South African children receiving private care and to determine the antimicrobial resistance patterns and serotypes of the bacterial isolates. Middle-ear fluid was cultured from 173 children aged two months to seven years with non-resolving acute otitis media accompanied by persistent pain or fever who were referred to otorhinolaryngologists for drainage of middle-ear fluid within 14 days of the start of symptoms. While 92 per cent of the children had recently received antibiotics and 54 per cent were currently receiving them, bacteria were isolated from 47 children (27 per cent). Streptococcus pneumoniae was the most common pathogen (35), followed by Haemophilus influenzae (nine), Staphylococcus aureus (six), Moraxella catarrhalis (two), Streptococcus pyogenes (two) and Pseudomonas aeruginosa (one). Two isolates were identified in each of eight children. Antimicrobial resistance to one or more antibiotics was found in 33/35 (94 per cent) of the pneumococci isolated, with resistance to penicillin in 86 per cent, resistance to trimethoprim-sulfamethoxazole in 54 per cent and to erythromycin and clindamycin in 69 per cent and 57 per cent, respectively. The pneumococcal serotypes found were 19F (28 per cent), 14 (26 per cent), 23F (23 per cent), 6B (nine per cent), 19A (87 per cent), and four (three per cent). Children with a bacterial pathogen isolated were younger (mean age of 17 months) than children from whom no bacteria were isolated (mean age of 23 months; p = 0.03). Isolation of a pneumococcus was also significantly associated with younger age (mean = 16 months versus 22 months, p = 0.03), the presence of fever (OR = 2.15, p = 0.049), and having one or more prior episodes of otitis media within the six months before tympanocentesis (OR = 7.72, p = 0.03). Almost all pneumococci isolated from non-resolving acute otitis media in this community are antibiotic-resistant and should be considered especially in young children who have failed previous therapy and who have non-resolving pain or fever.

Chronic rhinitis in South Africa: update 2013.

The term rhinitis implies inflammation of the lining of the nose. Characteristic symptoms are a blocked nose, anterior and posterior rhinorrhea, sneezing and itching. Not all cases of chronic rhinitis have an allergic basis. Chronic non-allergic rhinitis is defined as a condition where ongoing rhinitic symptoms are present for many months (as for persistent allergic rhinitis) but there is no IgE basis. Many common conditions may present as chronic rhinitis, which will need to be investigated and managed on their own merits. Not all cases of chronic rhinitis respond to allergic rhinitis therapy: continued attempts to manage chronic rhinitis as allergic rhinitis may be hampered by pathophysiological conditions where other specific therapy may be required. Chronic rhinitis impacts on patient quality of life, and therefore therapy is important. Managing patients with chronic rhinitis requires attention to patient education in order to achieve the maximal therapeutic benefit of medication. This update is intended to provide clinicians with a sound basis for management of a common condition.

Developmental changes in cochlear orientation--implications for cochlear implantation.

OBJECTIVES: To investigate changes in cochlear orientation with age and discuss the implications of any change with respect to cochlear implantation. STUDY DESIGN: Cross-sectional study of computed tomographic scans of the temporal bones in patients with no congenital abnormalities. PATIENTS: One hundred fifty-nine patients were included in the study, making a total of 318 ears. The age range was 9 months to 85 years. INTERVENTION: Axial computed tomographic scans showing the basal turn of the cochlea were identified. The angle of the basal turn of the cochlea was measured by drawing a line through the long axis of the basal turn and measuring its angle with a line drawn through the midsagittal plane. The patients were grouped according to age, and a 1-way analysis of variance was used to identify any statistically significant change in basal turn angulation. Interobserver and intraobserver errors were calculated and presented as repeatability coefficients. The basal turn angles of 3 difficult cases of cochlear implantation were related to the findings. RESULTS: The mean basal turn angle was 54.6 degrees (range, 46.8-63.8 degrees; standard deviation, 3.5). There was a statistically significant reduction in the angulation of the basal turn with increasing age (F = 10.1; p = 0.002). The majority of the change occurs between the ages of 11 and 15 years. The interobserver reliability coefficient was 4.8. The intraobserver reliability coefficient was 2.0. The 3 difficult cases had basal turn angles that were at the upper limit of the reference range. CONCLUSION: There is a statistically significant reduction in basal turn angulation relative to the midsagittal plane with increasing age. However, care should be taken in interpreting these results in light of the inherent error in the measuring technique, although the intraobserver repeatability coefficient was only 2.0. The more obtuse angulation of the basal turn in children may have implications for cochlear implantation.