James P. Dudley

Sales of nonprescription cold remedies: a unique method of influenza surveillance.

Summary: In 1976, the National Institute of Allergy and Infectious Disease sponsored a nationwide network for influenza surveillance. In this paper, in addition to reporting the surveillance findings in Los Angeles, sales of nonprescription cold remedies in a large supermarket chain were evaluated as an indicator of influenza activity in the community. Twenty-seven isolates of influenza B occurred between February 17 and April 26, 1977. Peak influenza B activity occurred from mid-March to early April, 1977. A 5–10% increase in percent of respiratory and febrile respiratory illness seen in outpatient clinics was observed in late December and January. No variation in these statistics occurred during the peak of influenza activity. In contrast, sales of nonprescription cold remedies were apparently influenced by influenza B activity. Peak sales (345% increase) occurred 4 wk after the first influenza B isolate and 1 wk before peak influenza activity was documented by peak rates of isolation.Speculation: The data suggest that monitoring sales of nonprescription cold remedies may be a useful technique of influenza surveillance, especially in years when minimal activity occurs.

Epidermolysis Bullosa Dystrophica of the Larynx and Trachea Acute Airway Obstruction

Epidermolysis bullosa dystrophica (EBD) is a rare inherited skin disease generally presenting in newborns. It is characterized by noninflammatory bullous lesions which can involve the mucous membranes of the oral cavity and oropharynx. If death occurs, it is usually the result of septicemia or fluid and electrolyte imbalance. Although mucous membrane involvement may be extensive and despite the reported evidence of tracheal and indirect evidence of laryngeal involvement, airway obstruction has not been implicated as a possible contributor to mortality in these patients. Since the presence of EBD in the larynx of a newborn might be expected to produce upper airway obstruction, however, and because of the absence of reports of laryngeal EBD, a case is presented of EBD-induced airway obstruction accompanied by photographic evidence of laryngeal and tracheal involvement with EBD. A three-week-old boy with biopsy-proven EBD present at birth was admitted to UCLA Medical Center with increasing stridor. The patients extremities, diaper area, and numerous pressure-bearing sites on the back and elbows demonstrated erythematous denuded skin with occasional bullae up to 2 cm in size. The mucous membranes of the mouth and oropharynx showed similar denuded lesions. A tracheotomy was performed followed by a direct microlaryngoscopy and bronchoscopy revealing EBD on the supraglottic structures, vocal cords, and trachea. Otolaryngologists who are involved in the care of newborns should be aware of the possible, nearly fatal laryngeal involvement that can accompany this disease.

Atrophic rhinitis: Antibiotic treatment

Atrophic rhinitis is a term used to describe a rare nasal infection. Although it does not have a fatal outcome, cause osteomyelitis, or produce pain, it does induce bilateral nasal obstruction and a persistent foul odor of which the subject and others are painfully aware. The organism most often associated with atrophic rhinitis is Klebsiella ozenae. Antibiotic susceptibility patterns of this microorganism have made treatment with orally administered antibiotics difficult. K ozenae was cultured from the nasal cavity of three patients. Two patients were treated for two weeks with tobramycin (MIC, 4 micrograms/ml; 4 mg/kg/day). Odor decreased in one patient, but K ozenae failed to clear. In the second patient both odor and K ozenae disappeared. The third patient was treated for 1 week with tobramycin (MIC, 4 micrograms/ml; 4 mg/kg/day); odor decreased, but K ozenae could still be cultured. She was treated for an additional 2 weeks with topical gentamicin (MIC, 0.5 micrograms/ml) with disappearance of both odor and K ozenae. Intravenous aminoglycoside may be helpful in treating atrophic rhinitis, but topical aminoglycoside may provide an effective and cheaper form of treatment.

Scanning electron microscopic demonstration of goblet cell discharge and mucous layer on nasal ciliated respiratory epithelium.

Respiratory cilia is covered by a layer of mucus. The manner in which the mucus makes its way to the cilia tips and distributes itself on the tips is not known. Scanning electron microscopic examination of nasal mucosa demonstrated cone-like goblet cell discharge as well as a thin layer of mucus enmeshed in the cilia tips. Further demonstration of mucus may demonstrate the differences in these two components.

Effects of topical nasal decongestants on the cilia of a chicken embryo tracheal organ culture system.

There is little physiologic data concerning the possible toxicity of nasal decongestants on respiratory cilia. Consequently, a chicken embryo tracheal organ culture system was employed to study the effect on ciliary activity of various preparations and concentrations of the following medications: tetrahydrozoline hydrochloride (Tyzine®), xylometazoline hydrochloride (Otrivin®), Dristan,® Sinex®, NTZ® oxymetazoline hydrochloride (Afrin®), naphazoline hydrochloride (Privine®), and phenylephrine (Neosynephrine®). Only two dilutions of injectable phenylephrine 0.25% and 0.10% produced essentially no ciliotoxicity when compared to the cilia in control cultures. All the other topical nasal medications in the concentrations tested possessed some toxicity for cilia. The use of these medications should be tempered with the warning of possible cilia damage.

The effect of mucolytic agents and topical decongestants on the ciliary activity of chicken tracheal organ cultures.

Summary: The chicken tracheal organ culture system was used to study the effect on cilia function of two frequently used topical decongestants and four mucolytic agents. The agents used were: phenylephrine hydrochloride spray 0.25%, oxymetazoline 0.05%, sodium bicarbonate 7.5%, acetylcysteine 10%, pancreatic dornase 50,000 units/ml, and L-arginine 5.6%. The tracheal rings were given two kinds of exposure to the test drugs. Only pancreatic dornase was not ciliotoxic. Until further data arc available, including studies with human organ cultures, it would perhaps be wise to discourage the topical use of phenylephrine hydrochloride spray 0.25% and oxymetazoline 0.05%, and to consider pancreatic dornase as the mucolytic agent of choice.Speculation: Topical medications have been used on mucous membrane surfaces with little regard for whether the ciliary system is affected by them. Since all but one of the agents tested here showed pronounced ciliotoxic effect, we suggest that all topical drugs should undergo testing in a physiologic system such as chicken tracheal organ cultures.

Grassheads in the Tracheobronchial Tree: Two Different Outcomes

Many vegetable foreign bodies can produce serious pulmonary complications because of chemical irritation to the airway. Barley grass, a type of grasshead, does not induce such a reaction because of its resistance to organic decay. Complications which may occur are illustrated by the clinical course of two patients with aspiration of this foreign body. In the first patient the grasshead entered the trachea with the flowering unit first and the stem following. In the second patient the stem entered the trachea first. Recurrent pneumonias were noted in the first patient. Despite its presence in the right stem bronchus for three years, no further episodes of pneumonia followed its removal. In the second patient the grassheads could not be removed endoscopically. They migrated into the right lower lobe producing pneumonia and ultimately resulting in a brain abscess. The difference of entry of the same foreign body into the trachea, stem first versus flowering unit first, is an essential factor in altering the clinical outcome.

Pharyngeal and tonsil infections caused by non-group A streptococcus

Non-group A streptococci are members of the genus Streptococcus but do not share the notoriety of their cousin from group A. Most physicians, including otolaryngologists and head and neck surgeons, do not associate them with upper respiratory tract and head and neck infections. Some laboratories do not bother to report their presence on culture. At the University of California, Los Angeles they have been shown to cause (1) tonsillitis, painful tonsils lacking exudate and erythema (group C, one case; group F, one case), (2) acute nonexudative tonsillitis (group B, two cases; group C, one case; group F, one case), and (3) acute exudative tonsillitis (group C, one case). It should be remembered when there is a report of their presence that they are usually vulnerable to penicillin and its analogs. By judicious use of these drugs, morbidity can be diminished.

Demonstration of the adherence of Streptococcus pyogenes to the surface of human tonsillar tissue

One of the mechanisms by which bacteria become pathogenic on mucosal surfaces is their capacity to adhere to those surfaces. Although adherence of pathogens has been demonstrated on other mucosal surfaces, it has never been demonstrated on tonsillar tissue. A section of the surface of a pharyngeal tonsil was thoroughly washed with phosphate buffered saline and divided into fragments of Gram staining, scanning electron microscopy, and incubation with group A beta hemolytic Streptococcus pyogenes isolated from the upper respiratory tract. After 30 minutes and 24 hours of incubation the fragment was removed, washed thoroughly with phosphate buffered saline to remove any nonadherent S. pyogenes, and divided into three parts for Gram staining, scanning electron microscopy, and homogenization for tube and plate dilution. Adherence of S. pyogenes was demonstrated by Gram staining, scanning electron microscopy, and plate dilution. This first demonstration of bacterial adherence on tonsillar mucosa tract points to adhesion as a mechanism of pathogenesis in S. pyogenes infection in the tonsil.

Effect of Topical Anesthetics on Ciliary Activity of Chicken Embryo Tracheal Organ Cultures: Study Using Total Immersion and Intratracheal Injection

Because of conflicting reports concerning the effect of topical anesthetics on cilia, testing of four different agents was undertaken. The agents were hexylcaine 5% (Cyclaine), tetracaine 2% (Pontocaine), cocaine 5% and 10%, and lidocaine 4% (Xylocaine). Tracheas were removed from 19 to 20 day old chicken embryos. Ciliary activity was graded as to extent and vigor. Two methods of testing were used. In the first, dilutions of each agent were made, and tracheal rings were placed in the wells of microtiter plates and completely covered with the test drug. In the second method of testing, 0.8 ml of the test drug was injected in vivo into the exposed trachea of the embryo. In immersion testing, cilia stopping effect (CSE) in tracheal rings was noted in all drug dilutions tested within 1 to 20 minutes. When the drug was injected directly into the trachea, a complete CSE was noted the next day in the rings from the tetracine and hexylcaine injected tracheas. Three days following in vivo transtracheal injection of lidocaine and cocaine, ciliary activity in these and the control rings was similar. Although cilia did not tolerate total immersion in any of the agents tested, ciliary activity in tracheas injected with lidocaine and cocaine did not differ significantly from the control tracheal rings. Physicians who use topical anesthetics should be aware of this.Because of conflicting reports concerning the effect of topical anesthetics on cilia, testing of four different agents was undertaken. The agents were hexylcaine 5% (Cyclaine®), tetracaine 2% (Pontocaine®), cocaine 5% and 10%, and lidocaine 4% (Xylocaine®). Tracheas were removed from 19 to 20 day old chicken embryos. Ciliary activity was graded as to extent and vigor. Two methods of testing were used. In the first, dilutions of each agent were made, and tracheal rings were placed in the wells of microtiter plates and completely covered with the test drug. In the second method of testing, 0.8 ml of the test drug was injected in vivo into the exposed trachea of the embryo. In immersion testing, cilia stopping effect (CSE) in tracheal rings was noted in all drug dilutions tested within 1 to 20 minutes. When the drug was injected directly into the trachea, a complete CSE was noted the next day in the rings from the tetracine and hexylcaine injected tracheas. Three days following in vivo transtracheal injection of lidocaine and cocaine, ciliary activity in these and the control rings was similar. Although cilia did not tolerate total immersion in any of the agents tested, ciliary activity in tracheas injected with lidocaine and cocaine did not differ significantly from the control tracheal rings. Physicians who use topical anesthetics should be aware of this.