Chronic sinusitis in children with respiratory allergy：the role of antimicrobials

n of Allergy and Immunology, Department of Pediatrics, University of California at Los Angeles, Los Angeles, Calif. Supported by a grant from Allergy Research Foundation, Inc., Roche Laboratories, and Ross Laboratories. Received for publication Oct. 12, 1981. Accepted for publication Jan. 8, 1982. Reprint requests to: Gary S. Rachelefsky, M.D., 8540 S. Sepulveda Blvd., Suite 820, Los Angeles, CA 90045.
@ 1982 The C. V. Mosby Co.
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VOLUME 69 NUMBER 4
Chronic sinusitis
383
Abbreviations used TMS: Trimethoprim-sulfamethoxazole C-P: Carbinoxamine maleate-pseudoephedrine hydrochloride
Vol. 69, No. 4, pp. 382-387
eosinophils, and immediate-type skin tests. Children were excluded from study if they (1) were judged not to have IgE-mediated disease, (2) had symptoms for less than 30 days, (3) had a documented temperature elevation in the prior 2 wk, (4) had been on antibiotics in the prior 2 wk, or (5) were receiving corticosteroids or topical nasal decongestants. Patients were selected for study if a Waters (upright) x-ray view demonstrated more than 2 mm of mucosal thickening of one or both maxillary sinuses. For each child, information was obtained concerning the presence and duration of headache, jawache, toothache, facial pain, eye or ear pain, sore throat, throat clearing, postnasal drip, nasal discharge, nasal obstruction, epistaxis, taste or smell change, change in hearing, cough, and wheezing. Physical examination included measurement of the temperature, determination for the presence of facial swelling or tenderness, or cervical lymphadenopathy. The appearance of the nasal mucosa and pharynx was noted, along with the color and consistency of upper airway secretions. Movement and appearance of the tympanic membranes were observed. The presence or absence of lower airway obstruction was determined spirometrically (Jones Pulmonar). Laboratory tests performed in addition to the sinus x-rays included peripheral blood counts and differentials and nasal smears for eosinophils, polymorphonuclear cells, and bacteria. Nasal smears were stained with Hansel's stain; the cells in 5 high-powered fields were counted and the percent eosinophils and number of polymorphonucleocytes, along with the presence of bacteria, were noted. A positive nasal smear for eosinophils required that more than 10% of the cells be eosinophils. Tympanograms were obtained on patients who had an abnormally appearing tympanic membrane, decreased movement of a tympanic membrane as
We evaluated the role of antimicrobials in the treatment of chronic maxillary sinusitis in children with respiratory allergy. Night and day cough, nasal obstruction, rhinorrhea, postnasal drip, thick green nasal secretions, and negative nasal smears for eosinophils were commonly seen. Eighty-four children were treated in a double-blind manner with either amoxicillin, erythromycin, trimethoprim-sulfamethoxazole, or an antihistamine decongestant (carbinoxamine maleate-pseudoephedrine HCl). Radiographic and clinical responses were best with amoxicillin, but trimethoprim-sulfamethoxazole was an adequate alternative. This study demonstrates that allergic children with chronic sinusitis with associated chronic respiratory symptoms are likely to respond clinically and radiologically with antimicrobial treatment. (J ALLERGY CLJPI IMMUNOL 69:382, 1982.)
MATERIALS AND METHODS
Children between 3 and 16 yr of age, originally seen in the authors' allergy practice for evaluation of chronic respiratory symptoms, were studied consecutively and prospectively . Each child had an allergy evaluation that included an in-depth history and physical examination, nasal smears for
determined by pneumatoscope, or a history of recurrent ear problems. Sinus radiographs were interpreted initially by one of the three authors and later evaluated independently by a pediatric radiologist (Michael Gyepes, M.D., Children's Hospital of Long Beach) who was not aware of prior interpretation, clinical findings, or treatment. Three of the x-rays were misinterpreted by the authors; these patients were excluded from study. The interpretations were classified as follows: (1) normal, (2) showing mucosal thickening, and (3) complete opacification or an air fluid level. Mucosal thickening (in millimeters) of the maxillary antral wall was determined by measurement of the nearest distance from the airmucosal interface to the most lateral part of the sinus wall. The patients with retention cysts or polyps on initial x-rays were excluded from study. After informed consent was obtained from the parents, patients were randomized to one of four regimens in a double-blind manner. The drugs were given by a nurse who was uninvolved in patient care. The four treatment regimens were: C-P (Rondec; one teaspoon or tablet for children older than 6 yr, `/i teaspoon or tablet for children younger than 6 yr, administered three times a day), amoxicillin (40 mgl kg/day, administered every 8 hr), erythromycin ethylsuccinate (30 to 40 mg/kg, administered four times a day), and TMS (dose dependent on weight, administered every 12 hr). Patients continued the treatment for 14 days unless their conditions worsened (i.e., increased cough, headache, fever, and/or worsening sore throat, nasal obstruction, or nasal discharge) after 5 days of treatment or unless they had side effects from their medications. If this occurred, they were crossed over to their next medication (randomized and double blinded). No other medications were allowed except bronchodilators. In our opinion, a placebo treatment was not justified, although C-P served as a control for the three antibiotic regimens. After 14 days of therapy the patients were seen by one of the authors, questioned regarding symptoms, and reexamined. The Waters radiograph and nasal smear were repeated and the following decisions were made: (1) If there was no change in x-ray and/or the patient was still symptomatic, the next treatment was given for another 14 days, followed by a repeat examination with Waters x-ray and nasal smear; if there was still no change, the third treatment regimen was given, etc. (2) If patients responded clinically and radiologically (decrease in mucosal thickening or loss of opacification or air fluid level), the treatment regimen was discontinued and participation in the study ended. (3) If patients who initially had between 2 to 6 mm thickening were clinically well with the same x-ray results, participation in the study was ended; however, if symptoms continued, the next