Raymond W. Clarke

Passive smoking, allergic rhinitis and nasal obstruction in children

Allergic rhinitis is a common cause of nasal obstruction in childhood. This prospective study looked at the effect of passive smoking on nasal obstruction in children with and without allergic rhinitis. Eighty-one children took part. Each child was asked to score his or her degree of nasal obstruction on a visual analogue scale. Exposure to passive smoking was determined subjectively using a parental questionnaire, and objectively by measuring the urinary cotinine/creatinine ratio. Results were tabulated using Microsoft Excel and analysed with SPSS statistical software. Nasal obstruction was significantly worse in children with a positive history of allergic rhinitis (p < 0.05). There was also a trend towards a higher nasal obstruction score in children without allergic rhinitis exposed to passive smoking compared to those who were not so exposed. As would be expected, nasal obstruction is worse in children with allergic rhinitis than in those without. Passive smoking tends to increase the symptom of nasal obstruction in children without allergic rhinitis.

The effect of passive smoking on the levels of matrix metalloproteinase 9 in nasal secretions of children.

Background Matrix metalloproteinase (MMP) 9 is a gelatinase associated with tissue remodeling. It is thought to play a part in the pathogenesis of allergy. Increased levels of MMP-9 have been shown to increase in the acute allergic response in the nose, lungs, and skin. Exposure to passive tobacco smoke is associated with an increase in sneezing, nasal blockage, and a decreased sense of smell. The aim of this study was to study the effect of passive smoking on the levels of MMP-9 in nasal secretions of children. Methods A prospective descriptive study was performed. Thirty-nine children aged between 7 and 16 years were enrolled in the study. They were selected based on attendance at the Otorhinolaryngology Outpatients Clinic with a primary complaint unrelated to the nose or paranasal sinuses. Children with allergic rhinitis, sinusitis, or a recent cold were excluded. The study was performed at a tertiary pediatric referral center. Exposure to passive smoking was determined by measuring the urinary cotinine to creatinine ratio. Nasal fluid was obtained by using a Rhino-Probe curette (Arlington Scientific, Inc., Springville, UT). The concentration of MMP-9 was determined by ELISA. MMP-9 activity was determined by gelatin zymography. Data were tabulated on Microsoft Excel (Microsoft Corp., Redmond, WA) and analyzed using SPSS (SPSS Inc., Chicago, IL). Results Using a cutoff urinary cotinine/creatinine ratio of 0.025 ng/mg, 15 children were found to be exposed to passive smoking. Both the MMP-9 concentration and the activity were significantly higher in nasal secretions of children exposed to passive smoking. There was a distinct difference between the two cohorts with regard to the level of enzyme activity per weight of protein. The lowest level of enzyme activity recorded in the “exposed” cohort was over twice that of the level in the “not exposed” cohort. Conclusion MMP-9 activity and concentration is higher in nasal secretions of children exposed to passive smoking. This suggests that passive smoking might alter the inflammatory response within the nasal mucosa in a similar way to allergy.

‘Spontaneous’ auricular haematoma: a rare differential diagnosis of NAI

Sir, Haematoma auris is a collection of blood between the auricular cartilage and perichondrium. It is usually the result of trauma. We describe an immobile infant who developed a ‘spontaneous’ auricular haematoma. A 5-week-old boy presented with a haematoma on the left pinna (Fig. 1). There was no history of trauma or any memorable incident. Examination revealed a soft, fluctuant, non-tender swelling measuring 1.4 × 1.5 cm in the concha of the left auricle. There was no associated bruise behind or on the helix of the auricle. There was no bruising anywhere else. The baby had received vitamin K at birth, and there was no family history of bleeding diathesis. The baby’s full blood count and clotting screen were unremarkable. A skeletal survey, ophthalmic examination and CT scan of the brain were negative. The family was not known to social services. On aspiration under antibiotic cover, 0.5 mL of blood was obtained, and a compression bandage was applied. There were no post-operative complications. On follow-up 6 months later, the baby had no further bleeding manifestations. Auricular haematomas are usually the result of blunt trauma, and in the absence of clear history, non-accidental injury should be considered (1). However, they can also occur spontaneously or with minimal trauma in children with bleeding diathesis. Rarely, as in our baby, auricular haematomas may be caused by spontaneous rup-

Paediatric otolaryngology services in the UK: a postal questionnaire survey of ENT consultants.

Approximately half a million children in England and Wales receive in-patient or day-case surgical treatment annually. Otolaryngology is the surgical specialty that provides the greatest number of episodes of such care. As 30-50 per cent of our total volume of work is paediatric, we feel it is important to assess current attitudes to paediatric otolaryngological practice. In its year 2000 document Childrens Surgery: a First Class Service, The Royal College of Surgeons (RCS) of England sets out recommendations on how childrens surgical services should be delivered in the UK. A postal questionnaire was sent to all UK-based ENT consultant members of the British Association of Otorhinolaryngologists-Head and Neck Surgeons (BAO-HNS). The questionnaire was designed to assess the current practice of paediatric otolaryngology in the UK with an emphasis on the RCS recommendations. Wide variations were found, and they are discussed with reference to the recommendations.

Manoeuvre to aid Endoscopic division of aryepiglottic folds (Aryepiglottoplasty)

Laryngomalacia, a congenital malformation of larynx is the commonest cause of stridor in young infants. Ninety percent of cases resolve by the age of 2 years without any active intervention (1).The most consistent abnormality seen in non-resolving cases is shortening of the aryepiglottic folds (picture 1).(2) This article is protected by copyright. All rights reserved.

Nontuberculous mycobacterial adenitis: Effectiveness of chemotherapy following incomplete excision: Management of nontuberculous mycobacterial lymphadenitis

Background: Management of lymphadenopathy caused by nontuberculous mycobacteria (NTM) is primarily surgical. Where this cannot achieve sufficient clearance of infected nodes, chemotherapy is often given. Aim: This study compared results of surgery alone with surgery followed by chemotherapy in instances where there was incomplete surgical removal of diseased tissue. Methods: Chemotherapy comprised azithromycin 10 mg/kg and rifabutin 6 mg/kg both given once daily for 6 mo. Ninety‐eight children with NTM infection were seen in the period 1990–2004. Sixty‐eight cases with adenopathy where “time to healing” (discharge stopped and inflammation settled) was known were available to compare response to treatment. Results: The median (range) “time to healing” in weeks for 43 patients who had surgery alone was: incision and drainage (I&D)/curettage 6 (1–72) (n=10); excision 3 (1–28) (n=22); and from the last operation of multiple (repeat) surgery 3 (1–40) (n=11). For 25 patients who required chemotherapy in addition to surgery, the median (range) “time to healing” in weeks was I&D/curettage 10 (1–40) (n=17), excision 14 (8–20) (n=2) and multiple surgery 29 (2–88) (n=6).

Complete tracheal rings: lower airway symptoms can delay diagnosis

Bronchial asthma is a very common condition seen in children diagnosed by clinical examination. While treating these children, all the other possible causes of breathlessness including complete tracheal rings should be considered. Further investigations in the form of endoscopy may need to be carried out in doubtful cases.