Holt Gr

Human Curvularia infections: Report of five cases and review of the literature

Curvularia lunata is a saprobic dematiaceous mould that resides primarily in soil (Ellis, 1966). Reports of human disease caused by this organism are rare but include: endocarditis, brain abscess, skin infections, onychomycosis, keratitis, pneumonia, disseminated disease, mycetoma, allergic bronchopulmonary disease, and one case of sinusitis. Since 1983, we have encountered five cases of paranasal sinusitis due to C. lunata. None of the patients suffered from known immunologic disorders or underlying debilitating diseases. These five cases are presented and the literature of human phaeohyphomycosis caused by Curvularia spp. is reviewed.

Post-tympanostomy otorrhea

Otorrhea is the most common complication of surgical drainage of the tympanum for the treatment of chronic secretory otitis media. Otorrhea present at the first postoperative visit may be due to the operative procedure, the underlying disease process, or both. After analyzing data from 525 operations on 1045 ears of 396 children with chronic secretory otitis media, and finding an over‐all incidence of immediate postoperative otorrhea of 3.4%, we conclude that preparation of the ear canal with povidone iodine and the postoperative prophylactic use of an antimicrobial‐corticosteroid topical preparation provides optimal control of postoperative wound infection. Sporadic increases in the incidence of postoperative otorrhea may be due to extrinsic factors such as outbreaks of upper respiratory infection.

Infectious diseases of the sphenoid sinus

Thirty‐one patients with sphenoid sinusitis were treated from 1978‐1982. Twenty patients had infections contiguous with other paranasal sinus disease. Five of these patients had fungal sinusitis. Eleven patients were seen with isolated sphenoid sinusitis; 3 were secondary to trauma and 8 were due to nontraumatic causes. Possible etiologies include upper respiratory infections, developmental abnormalities, and water forced into the nasal cavity during swimming. The immunocompromised patient is more likely to present with minimal symptoms with a fungal infection, and aggressive diagnostic and therapeutic measures should be undertaken. Because the symptoms of headache, nasal stuffiness, proptosis, ptosis and decreased visual acuity may be interpreted as an intracranial, neurological, or vascular problem, a misdiagnosis may be made. A high index of suspicion for sphenoiditis should be maintained. Therapy involves a combination of medical (antimicrobial agent) and surgical (sinus drainage and marsupialization) management.

Cartilage of the baboon contains estrogen receptors

SummaryCastrated-adrenalectomized aged female baboons were injected with 3H-estradiol-17 B (E2) and killed one hour later. Specimens from all regions of the larynx and oral cavity were taken and processed for autoradiography. A consistent and heavy uptake of 3H-E2 by the perichondrium and cartilage was found in all laryngeal sections with cartilage present and in the articular cartilage of the condyle of the mandible. These data provide evidence that cartilage contains receptors for estrogen. These data along with data already present in the literature suggest that circulating estrogen may act directly on cartilage to modulate collagen synthesis and further that the loss in circulating estrogen associated with menopause might in part explain the large sexual dimorphism associated with the incidence of osteoarthritis.

An intraosseous device for studies of bone-healing. The effect of transforming growth-factor beta.

A novel implantable device, the analytic bone implant, was used in order to establish a model for studies of bone-healing and the evaluation of factors that augment the process, such as transforming growth-factor beta (TGF-beta). This device was implanted into the tibiae of four baboons. After healing, bone was removed from the center chamber. Recombinant human TGF beta-1 was then delivered to the core of the device. After twenty-two days of healing, the device was disassembled and the newly formed bone was removed from the core of the implant for histomorphometric analysis. An analysis of the bone revealed a substantial effect of TGF-beta on osteoblastic activity and proliferation compared with that seen in control and placebo groups. However, despite increased osteoblastic activity, trabecular bone volumes at twenty-two days were equivalent among the groups. The number of osteoclasts and the erosion of the surface were also increased, although not significantly so. Substantial endochondral formation of bone was seen in the supraperiosteal tissues directly over the implants that contained TGF-beta but not over the implants in the control and placebo groups. These data demonstrate the utility of this bone-implant model for studies of bone-healing with minimally invasive methods. In addition, use of the device provided the first in vivo data on the effects of TGF-beta at an intermediate (twenty-two-day) time-point in the healing process in a non-human primate.

Acute coalescent mastoiditis.

A retrospective review of 11 cases of acute coalescent mastoiditis from 1974 to 1979 is presented. The common historical data include the recent onset of purulent otitis media, which was often incompletely treated with antibiotics, and fever, lethargy, and irritability. The eardrums were red, bulging, and usually intact. A postauricular abscess was present, and the affected ear protruded downward and outward. The mastoid radiographs invariably showed cloudiness and dissolution of the air cell septations. Initial therapy included paracentesis for culture and sensitivity, and initiation of parenteral antibiotics. Surgical therapy consisted of wide myringotomy, drainage of the postauricular abscess, and complete mastoidectomy. Hearing was normal postoperatively in all cases.A retrospective review of 11 cases of acute coalescent mastoiditis from 1974 to 1979 is presented. The common historical data include the recent onset of purulent otitis media, which was often incompletely treated with antibiotics, and fever, lethargy, and irritability. The eardrums were red, bulging, and usually intact. A postauricular abscess was present, and the affected ear protruded downward and outward. The mastoid radiographs invariably showed cloudiness and dissolution of the air cell septations. Initial therapy included paracentesis for culture and sensitivity, and initiation of parenteral antibiotics. Surgical therapy consisted of wide myringotomy, drainage of the postauricular abscess, and complete mastoidectomy. Hearing was normal postoperatively in all cases.

Arteriovenous malformation of the mandible.

2. Montgomery AH: Ossifying fibroma of the jaw. Arch Surg 36: 874-898. 1938. 3. Lichtenstein L. Jaffe HL: Fibrous dysplasia of bone: Condition affecting one. several or many bones. graver cases of which may present abnormal pigmentation of skin. premature sexual development. hyperthyroidism. and still other extra-skeletal abnormalities. Arch Path 33:777-816. 1942. 4. Reed RJ: Fibrous dysplasia of bone. A review of 25 cases. Arch PathoI75:48O-495. 1963. 5. Hammer 1£ III. Scofield HD. Coryn J: Benign fibro-osseousjaw lesions of periodontal membrane origin: An analysis of 249 cases. Cancer 22:861-878. 1968. 6. Khalil MK. Leil ML: Cemento-ossifying fibroma of the orbit. Can J OphthalmoI14:195-200. 1979. 7. Dehner LP: Tumors of the mandible and maxilla in children. I. Clinicopathologic study of 46 histologically benign lesions. Cancer 31:364-384. 1973. 8. Batsakis JO: Non-otontogenic tumors of the jaws. In Tumors of the head and neck. ed 2. Baltimore. 1979. The Williams & Wilkins Co. pp 381-419. 9. Langdon JD. Rapidis AD. Patel MF: Ossifying fibroma-one Case Reports

ENT Medications in Pregnancy

Eighty-five percent of pregnant women receive some kind of prescription medication from a physician during their pregnancy, and in the course of pregnancy the average woman takes four to five drugs. More alarming is the statistic that 65% of pregnant women take some form of medication not prescribed by a physician (i.e., over-the-counter drugs). It is therefore mandatory that the otolaryngologist caring for a pregnant patient be aware of the effects of certain drugs on the mother and fetus and conversant with drug interactions. The physiologic changes of pregnancy affect ingested drugs in a number of ways. Serum albumin is decreased, leading to less drug binding and more free circulating drugs. Alterations in liver metabolism and renal excretion as a result of changes in vascular dynamics will decrease the amount of drug metabolized. The placenta plays a definite role in the effect of maternal drugs on the fetus. Transfer of most drugs across the placenta is by pure diffusion and is highest with drugs of low molecular weight, greater during late gestation, and greater with higher drug concentration. In addition, drugs can alter placental enzymes by reducing placental blood flow and interfering with active nutrient transport. Most fetal drug levels reach 50% to 100% that of maternal serum concentration. Fetal blood levels of diazepam (Valium) and local anesthetics such as lidocaine (Xylocaine) reach higher concentrations than maternallevels, presumably because of an active transport system in the placenta. Therefore, when a local anesthetic is used, either topically or by injection, the dosage should be slightly reduced to allow for this phenomenon. The total fetal exposure to a drug is more important than the rate of transport, and chronic drug exposure is more likely to affect fetal development than an acute exposure.

Bipolaris-caused fungal sinusitis

Fungi classified in the genera Bipolaris and Exserohilum are relatively infrequent, but are escalating etiologic agents in human disease.’ Often clinical laboratory isolates reflect surface contamination or colonization rather than true clinical disease. However, both normal and immunocompromised hosts can and have become infected with these organisms, which has been reflected in several recent reports reviewing the literature and presenting an increasing number of new cases.’-“ Whether this increase in reporting reflects a true increase in incidence or merely an increased awareness in the clinician’s mind of fungal disease entities is not known. The clinical disease is characterized often by invasive fungal growth, which can present difficult management problems. It is therefore imperative to correctly identify this type of fungal infection early in its course, so as to minimize morbidity and avoid the mortality that can ensue. Species of the ubiquitous mould genus Bipolaris, particularly B. spicifera and B . hawaiiensis, have emerged as major agents of phaeohyphomycotic (disease caused by the dematiaceous or darkly pigmented fungi) sinusitis.’ In patients with chronic sinusitis, infected tissue takes on a characteristic thick, dark, “molasses” or “peanut butter” consistency, a nearly pathognomonic sign. Though often assumed to be uncomplicated chronic polypoid sinusitis, this case report exemplifies the potentially invasive and destructive nature of these fungi in sinus disease.

Head and neck manifestations of uncommon infectious diseases.

Certain uncommon systemic infections may be present with head and neck manifestations either initially or during the course of the disease. A high index of suspicion is required on the part of the otolaryngologist with the subsequent procedures leading to the appropriate diagnosis. The manifestations of infectious diseases such as erysipelas, histoplasmosis, rabies, tetanus, botulism, and cysticercosis must be understood by the head and neck specialist. For successful management, many of the infections require prompt identification and initiation of therapy. Airway maintenance, ventilatory support, and medical chemotherapy may be required.