J. David Osguthorpe

Allergic Rhinitis: Clinical Practice Guideline

This guideline was compiled by members of a standing committee of the American Academy of Otolaryngic Allergy. The intent of this guideline is to provide practitioners, referring physicians, patients, third-party payers, and cognizant government authorities with the fundamental principles involved in the diagnosis and treatment of the patient with allergic rhinitis. Although developed solely through the American Academy of Otolaryngic Allergy, the statements and recommendations are drawn from the entire spectrum of English-speaking literature from the United States and Europe. Articles were independently reviewed by members of the Committee, many of whom sit on editorial review boards for major professional publications. A grading system was used to categorize individual articles to demonstrate the format used to arrive at conclusions. The grade is recorded at the end of each article reference. The grading scale follows: Grade A: A study involving prospective or well-selected retrospective patient populations. The conclusions drawn are well supported by the scientific work. Little controversy relating to these conclusions would be expected. Grade B: A scientific study executed without major flaws. Limitations may exist such that the conclusions drawn remain subject to controversy. Grade C: An anecdotal or case report study.

Evidence-Based Clinical Update: Rhinosinusitis 2007

Rhinosinusitis (ABRS) is one of the most common reasons that patients visit their primary care provider for consideration of treatment with medications. Because ABRS represents a significant societal burden due to diminished quality of life of patients along with the economic pressures of decreased work productivity and costs of treatment, patients demand appropriate medical care. Increasing resistance to antimicrobial agents that target the key pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis and Staphylococcus aureus) has complicated the management of bacterial rhinosinusitis. The Sinus and Allergy Health Partnership published initial Guidelines for the appropriate management of ABRS in 2000 and updated this information in 2004. However, new medications have been released, and other medications have shown superior efficacy based on new clinical studies. In addition, several medications will be introduced in the near future that demonstrate not only increased potency, but similar safety to established medications. This presentation will focus on the current and potential future developments in the management of patients with symptoms of ABRS with specific regard to evidence-based review of recent articles. Rhinosinusitis clinical trials establish a reference basis for medical management and a review of the definitions for clinical trials will allow the clinician to consider future patient enrollment. The current evidence-based treatments for rhinosinusitis on which the federally mandated payfor-performance criteria will be based will be reviewed.

Miniseminar: Resident Academic Bowl

OBJECTIVES: 1. Compare the locoregional control rates in advanced cases of SCC of head & neck (stage III & IV) in two groups receiving concomitant chemo-radiotherapy using Cisplatin and Paclitaxel. 2. Compare the acute and chronic toxicities in the two groups. METHODS: A prospective study of 94 previously untreated patients of SCC of head & neck–AICC stage 3 and 4 (T3 & T4 with N0 –N3, M0) treated with concomitant chemoradiation over a three-year period (2003-2005) in a medical college hospital. The patients were divided into two groups. Group A (44 patients) received concomitant chemotherapy (CT) with Paclitaxel 40 mgm/m2, while Group B (50 patients) received concomitant chemotherapy with Cisplatin 40 mgm/m2. In each group, six cycles of chemotherapy were given on a weekly basis. RESULTS: In Group A (Paclitaxel R.T.), complete response was seen in 72.7% and partial response in 27.3%, while in Group B (Cisplatin R.T.) complete response was seen in 52% and partial in 48%. There was a higher incidence of skin (Grade 3 in 41% & Grade 4 in 4.8%) and mucosal toxicity with Paclitaxel while the gastro-intestinal (Grade 2 in 66%) and haematological(Grade 1 & 2 in 70%) toxicity was more with Cisplatin. No significant chronic toxicity except xerostomia was observed in either group. CONCLUSIONS: The use of Paclitaxel as a radiosensitizer is associated with better locoregional control of SCC of head and neck as compared with Cisplatin. However, more severe skin and mucosal reactions were observed with Paclitaxel while Cisplatin was associated with higher incidence of GIT and haematological toxicity.

Allergic Rhinitis: What’s True about What’s New

Allergy is said to be a causative factor in up to 50 percent of patients presenting to an otolaryngologist’s office. This includes “typical” allergic patients such as those with perennial or seasonal nasal congestion and sneezing, or with chronic rhinosinusitis, as well as those in whom the role of allergy is not commonly considered, such as with hoarseness, disordered sleep, and the sequelae of eustachian tube dysfunction. The most common treatments for allergic rhinitis have been avoidance or environmental modification, and pharmacotherapy. With better elucidation of the immunology underlying type 1 hypersensitivity disease, therapy is increasingly being directed at disease modulation rather than solely confined to symptom control. This not only involves traditional injection-based immunotherapy, but potentially more cost effective and less morbid approaches such as the sublingual delivery of allergens. This miniseminar will detail the currently available modalities for the treatment of allergies, and will focus on salient aspects that the physician should consider when selecting among these therapies. Pharmacotherapeutic agents likely to be available within the next few years, such as anti-chemokines and anti-interleukins, and more effective varieties of anti-IgE agents, will then be detailed. Finally, a synopsis of novel immune modulation strategies researchers are using to modify the host response to allergens via the Th2 lymphocyte pathway will be provided.

Outcomes in allergic rhinitis and rhinosinusitis—What we know

Description of Symposium: Quinolones are the newest class of antimicrobials to be used in otolaryngology. Available agents include ciprofloxacin, ofloxacin, levofloxacin, trovafloxacin, sparfloxacin, gatifloxacin, and several others. They have some unique advantages: consistent activity against pneumococci that are resistant to other classes, activity against Pseudomonas aeruginosa, and no known associated ototoxicity. This panel will discuss the pros and cons of quinolone usage in sinus and ear disease, differentiate between the various agents, and discuss problems related to quinolone resistance. The thrust of the presentation will be on areas of appropriate usage. Topical agents and special cases, such as necrotizing external otitis, will also be discussed.

Cost-effective allergy management for otolaryngologists

Given that 20% to 25% of persons in the United States have some manifestation of atopy and that those persons have a higher incidence of rhinitis, sinusitis, otitis media, and laryngitis than the general population, a substantial proportion of patients presenting to otolaryngologists could benefit from allergy management as part of a comprehensive care plan. With increasing emphasis on the limitation of expenditures for health care, identification of efficient protocols for the evaluation and treatment(s) of the patient with allergies that have caused head and neck disease(s) is a priority. The panel will present multidisciplinary views of how to cost-effectively care for these patients in the managed care setting, from pharmacotherapy to immunotherapy, and will present critical parameters in a capitated contract that covers the otolaryngic allergy aspects of patient care.

OSHA Exposure Control Plan for the Otolaryngology Office

Educational objectives: To develop an exposure control plan for an otolaryngology office or ambulatory care facility and to teach universal precautions, proper use of personal protective equipment, and safe techniques to otolaryngology office employees.

Orbital Surgery for Head and Neck

Educational objectives: To become familiar with conditions causing proptosis and nasolacrimal obstruction and with medical and surgical management of these problems.

Book Review: Symposium on Pediatric Plastic SurgerySymposium on Pediatric Plastic Surgery edited by KernahamD.A., ThomsonH.G., and BauerB.. St. Louis, 1982, The C. V. Mosby Co. Price

This text is culled from a symposium sponsored by the Plastic Surgery Educational Foundation in 1979 and many of the chapters overlap. Five of the eight sections are relevant to the otolaryngologist/head and neck surgeon. The first section addresses congenital deformities of the first two branchial arches. The evaluation and correction of hemifacial microsomia are well detailed in illustrations and text, but the chapters on branchial cysts and congenital facial paresis are quite basic. Construction of an external auditory canal is ignored in the microtia/anotia chapters, and common operations such as the Mustarde otoplasty are subordinated to the authors personal procedures. The second section outlines current trends in cleft surgery. Topics ranging from orthodontic management to lip revision are reviewed, although velopharyngeal insufficiency and the associated speech problems are Book Reviews 343