In 2013, the Japan Society for Infection and Aerosol in Otorhinolaryngology (JSIAO) was founded. This is very beneficial for both the Japan Society for Infectious Diseases in Otolaryngology and the Japan Society for Aerosols in Medicine, because both societies will be able to collaborate with each other on research related to infections and aerosols. Based on my experience in aerosol research, I propose the following sub- jects for further analysis by JSIAO: (1) Evaluation of the effect of aerosol therapy through a double-blind, randomized, placebo-controlled study. (2) Development of antibiotics, such as quinolone and/or aminoglyco- side, for aerosol treatment of acute/chronic sinusitis. (3) Extensive study on nasal systemic drug delivery and the role of otorhinolaryngologists in this kind of treatment. (4) Application of results obtained from basic studies by both societies to clinical use. (5) Development of new topical treatments for ear, nose and throat diseases.
One of the basics of infection control is appropriate sterilization/disinfection/cleaning. We should conduct sterilization and disinfection based on the infection risk associated with the intended use as determined by Spaulding’s classification. Disinfectants are categorized into three levels according to the antimicrobial spectrum: high, intermediate, or low. We should choose a disinfectant after determining the level appropriate for the intended disinfection and considering the type of bacterium and article to be disinfected. Additionally, we should consider the concentration of the disinfectant and exposure time/temperature in order to effectively use it.
There are still no guidelines regarding disinfection of a flexible nasopharyngoscope, which is used commonly in otorhinolaryngology departments. Different medical institutions employ different disinfection methods. Ideally, we should use fully automated cleaning/disinfection equipment with a strong disinfectant. Furthermore, it is important to adequately manage medical equipment, such as a spray or drugs to be used for clinical purposes, in order to prevent the equipment from becoming a source of infection.
Toxic shock syndrome (TSS) is caused by toxic shock syndrome toxin-1 (TSST-1) produced by Staphylococcus aureus. Once it occurs, serious complications, such as shock, DIC, and multiple organ failure, could result. Early diagnosis and treatment are essential, but sometimes difficult. We report two cases of TSS after endoscopic sinus surgery (ESS). A 54-year-old female was referred to our hospital with eosinophilic sinusitis accompanied by recurrent nasal polyps. After undergoing ESS, she lapsed into a pre-shock state with cyanosis and blood pressure loss the next morning. Diarrhea and diffuse eruptions appeared after onset. Early treatment consisting of anti-bacterial administration and nasal irrigation was performed immediately. Clinical symptoms improved in a few days after onset. The other case involved a 15-year-old male who underwent ESS (modified endoscopic medial maxillectomy) for antrochoanal poly in the maxillary sinus. High-grade fever and diarrhea appeared 13 days after surgery. Delayed onset of TSS was strongly suggested, so he was admitted for internal care. Fortunately, the clinical symptoms improved 2 days after receiving similar treatment as in the first case. It is known that onset of TSS could be early or delayed. Early onset of TSS occurs within a few days after surgery. However, delayed onset of TSS occurs about 2 weeks after surgery. Therefore, we have to be mindful of severe delayed complications.
Topical steroid therapy is effective in the treatment of patients with allergic rhinitis. Inhalation therapy with a nebulizer is advantageous because the risk of adverse effects is lower than systemic drug administration. Recently, portable mesh-type nebulizers have been developed, including a new mesh-type nebulizer for nasal diseases, and a nebulizer with an intermittent function. The aim of this study was to investigate the effectiveness of this new portable device for the treatment of allergic rhinitis and discuss the appropriate therapy from the viewpoint of drug delivery.
We first examined the effectiveness of inhalation therapy with a mesh-type nebulizer in comparison with a jet-type nebulizer or topical nasal spray in allergic patients. We then examined the effectiveness of treatment with an intermittent type of nebulizer and a continuous type of nebulizer in patients with Japanese cedar allergic rhinitis randomly assigned to 2 groups. Each type of nebulizer was used for 2 weeks. The patients using the continuous type were instructed to inhale 0.5 mg /2 ml budesonide twice a day and patients using the intermittent type were instructed to inhale 0.25 mg/2 ml of budesonide twice a day. Nasal symptoms and nasal resistance were compared before and after treatment.
According to the results, there was no statistically significant difference between the 3 types of devices in terms of effectiveness as a topical steroid therapy. The effect of low dose steroid inhalation was similar to that of as high dose steroid therapy using an intermittent type of nebulizer. In conclusion, the new intermittent type of mesh nebulizer was effective in treating allergic rhinitis.
Cervical lymphadenopathy, caused by various infections and tumors, is commonly encountered in clinical practice. Definitive diagnosis of this condition should always follow a differential diagnosis. Here we report a case of miliary tuberculosis in a 58-year-old woman who visited our department with a chief complaint of cervical lymphadenopathy. Three months earlier, she developed progressively worsening pain in the left shoulder, followed by swelling in the left shoulder extending to the supraclavicular region. Administration of non-steroidal anti-inflammatory drugs prescribed for shoulder periarthritis did not improve her symptoms, and she continued to have a fever above 39°C. Although ultrasonography and hematology findings were initially indicative of purulent lymphadenitis, administration of antibiotics failed to improve her symptoms. The patient visited our department for a complete evaluation, which revealed lymphadenopathy in the left supraclavicular fossa with no tumor-like lesions in the laryngopharynx, indicating tuberculous lymphadenitis. During the course of clinical observation, the patient developed skin redness which expanded over time and was positive for interferon gamma specific to Mycobacterium tuberculosis in an enzyme-linked immunosorbent spot assay. Although her symptoms and clinical findings led to a diagnosis of tuberculous lymphadenitis, metastatic tumor could not be excluded because neck computed tomography (CT) showed multiple shadows in the lungs. The patient was admitted for further evaluation because of the negative results of acid-fast bacilli smears of sputum and gastric aspirates, lack of bacterial shedding, and persistent fever. Due to the absence of tumor-like lesions that could cause similar symptoms, fine-needle aspiration and polymerase chain reaction for the detection of M. tuberculosis were performed to make a definitive diagnosis of tuberculous cervical lymphadenitis. In addition, follow-up CT revealed a newly developed pulmonary nodule, despite shrinkage of the initial pulmonary nodule, leading to the diagnosis of miliary tuberculosis. The patient was transferred to the Department of Internal Medicine for the administration of anti-tuberculosis drugs, which improved her fever and general symptoms. Because miliary tuberculosis presents a wide variety of chest CT imaging features, it is sometimes difficult to differentiate the disease from other pulmonary and metastatic lesions. In addition, cervical lymphadenitis usually has no general symptoms and often develops as chronic lymphadenopathy without tenderness. However, as in the present case, it is possible for patients with the chief complaint of fever and lymph node tenderness to have tuberculous lymphadenitis, necessitating the exclusion of tuberculosis in the presence of a cervical mass.
We studied changes in antimicrobial susceptibilities of Haemophilus influenzae isolated from the nasopharynx of pediatric patients treated at Nemuro Municipal Hospital between 2008 and 2013. A rapid increase in β-lactamase producing strains of H. influenzae, such as BLPAR and BLPACR, was observed from 0.3–2.3% between 2008 and 2011 to 30.4% in 2012 and 33.5% in 2013. A rapid decrease in BLNAR strains
was also observed from 55.3–59.8% between 2008 and 2011 to 25.4% in 2012 and 11.9% in 2013. The most important difference between BLNAR and BLPAR in the management of pediatric acute otitis media (AOM) is the susceptibility to amoxicillin/clavulanate (CVA/AMPC). CVA/AMPC is more appropriate as the first-line antibacterial agent in this environment where BLPAR is the dominant drug-resistant strain of H. influenzae.
Although it is difficult to distinguish H. influenzae from non-haemolytic H. haemolyticus by standard microbiological methods, we determined that these susceptibility changes are those of true H. influenzae, not of H. haemolyticus, since a similar susceptibility pattern was also seen in the isolates obtained from the middle ear effusions of AOM.
We report a case of a deep lingual abscess caused by a foreign body in the form of a fish bone. The patient was a 57-year-old female who was referred to our department because of a tongue abscess. Computed tomographic and intraoral ultrasonographic examinations demonstrated an intramuscular abscess around a fine foreign body in the tongue. Surgical incision and drainage of the abscess was performed, and a lost fish bone with granulation tissue was removed under local anesthesia. Immediately after surgery, both pain and swelling of the tongue improved. A foreign body in the form of a fish bone in the oral cavity may cause serious complications depending on the size and localization. Combined examinations for plural images are useful in the diagnosis of foreign bodies.
The efficacy of once-daily oral administration of 500 mg Levofloxacin for treatment of adult patients with severe acute pharyngotonsillitis was investigated. Thirty patients diagnosed with severe pharyngotonsillitis by a pharyngotonsillitis scoring system were enrolled in this study. Twenty-three and 7 patients were treated with internal Levofloxacin and Amoxicillin, respectively. The effectiveness of each antibacterial agent was evaluated by comparing the score before and after treatment. The score significantly decreased after treatment with each antibacterial agent. Score 0, which represents disappearance of the symptoms and no abnormal local findings, was seen in 18 (78%) patients treated with Levofloxacin; however, score 0 was seen in only one (14%) patient treated with Amoxicillin. According to these results, we concluded that once-daily oral administration of 500 mg Levofloxacin was very effective for the treatment of severe acute pharyngotonsillitis.
Cervical necrotizing fasciitis (CNF) is a progressive infection and easily leads to descending necrotizing mediastinitis (DNM), which is associated with high mortality rates. We report a case of a 68-year-old woman suffering from CNF with DNM. She showed renal and liver dysfunction and coagulopathy. She was treated with surgical debridement and drainage of the neck and mediastinum, antibiotic agents, and systemic management in the intensive care unit (ICU). Although she recoverd from DNM, severe dysphagia occurred due to postinflammatory scar formation. She was finally able to swallow after nine months of rehabilitation.
Active treatment with both surgery and medication is crucial for overcoming life-threatening CNF and DNM. However, severe inflamation and active surgical treatment may cause dysphagia. Therefore, it is important to monitor for dysphagia and start swallowing rehabilitation as soon as possilbe after recovery from the life-threatening phase of these diseases.
Deep neck abscess is an important clinical problem that sometimes results in death. Between January 2010 and December 2012, 24 patients with deep neck abscess were treated in our department. We retrospectively analyzed their clinical features and treatment. Twenty-two patients were treated with surgical drainage, and 2 patients with conservative treatment. Seven patients with infrahyoid and mediastinal abscess underwent airway management, including tracheotomy and intubation. Anaerobes were cultured in most cases of widespread abscess. None of the 39 strains were resistant to ampicillin/sulbactam (ABPC/ SBT) or carbapenem (CBP). ABPC/SBT should be used as the first-line antibiotic for the treatment of deep neck abscess.
Pediatric ozex® granules 15% (tosufloxacin) is an oral fluoroquinolone antibiotic which became an approved indication for otitis media and pneumonia in children in October 2009. For the purpose of investigating its efficacy and safety, we carried out post-marketing surveillance in 600 otitis media and pneumonia patients between March 2010 and March 2011. Clinical efficacy in otitis media subjects was 97.7% (515/527 patients) and bacteriological efficacy was 100% (35/35 patients) in Haemophilus influenzae and 93.8% (15/16 patients) in Streptococcus pneumoniae. Appropriate use in patients with otitis media was 87.3% (524/600 patients). The incidence of adverse drug reaction (ADR) was 2.29% (13/567 patients) and the most common ADRs were digestive symptoms, such as diarrhea and vomiting. The results of this survey suggest that tosufloxacin is clinically effective and safe in pediatric patients with otitis media and its appropriate use is necessary in order to prevent an increase in resistant bacteria.