Recurrent Pharyngitis Research Articles

Genetic susceptibility to rheumatic heart disease and streptococcal pharyngitis: association with HLA‐DR alleles

Acute rheumatic fever (ARF) is a systemic inflammatory disease that develops as a consequence of an exaggerated immune response to group A beta-haemolytic streptococci, which causes pharyngitis. Major manifestations of ARF include carditis, arthritis and chorea. Several investigators have attempted to establish a relation between ARF and human leucocyte antigens (HLA). Heterogeneity in various studies has been found, although associations with certain antigens were reported. The aim of this study was to analyse whether HLA-DR alleles play a role in the resistance or susceptibility to streptococci-related disorders including rheumatic heart disease (RHD) as a sequela of ARF and recurrent streptococcal pharyngitis in Turkish patients. The study included 102 patients with RHD, 71 persons with recurrent streptococcal pharyngitis and 130 healthy controls. HLA-DR alleles were typed by using polymerase chain reaction (PCR)-sequence-specific primers. Positive association with HLA-DRB1*07 allele was found for RHD when compared with healthy controls [29.4% vs 13.1%; P < 0.01, P-corrected: P < 0.01, odds ratio (OR) 2.78, 95% confidence interval (CI) 1.43-5.26] and also for recurrent streptococcal pharyngitis (26.8% vs 13.1%; P < 0.05, P-corrected: P < 0.05, OR 2.44, 95% CI 1.17-3.56). The frequency of HLA-DRB1*11 allele was decreased in patients with RHD (23.5% vs 42.3%; P < 0.01, P-corrected: P < 0.01, OR 0.42, 95% CI 0.24-0.75). Data suggest that HLA-DRB1*07 allele may be a genetic factor in increasing the susceptibility to develop RHD and recurrent streptococcal pharyngitis. HLA-DRB1*11 allele seems to be a protective factor against RHD.

Neutropenia, With a Cyclical Pattern, In Antibody Deficiency

RATIONALE: We report 2 patients presenting with cyclic neutropenia, who were found to have antibody deficiency, with no ELA-2 mutations.RESULTS/CASES: Patient A is a 31 yo white female with a history of recurrent aphthous ulcers, skin infections, and pharyngitis, found to have a neutrophil count of 90 during her third pregnancy. Upon delivery, the infant had severe neutropenia requiring G-CSF and WBC infusions, but had a spontaneous resolution at around six months of age. Evaluation of the mother revealed a cyclical neutropenia pattern, with an 18-24 day cycle and a nadir count of 270. She had a poor antibody response to pneumococcal vaccine. G-CSF treatment successfully increased her neutrophils, but was discontinued because of severe side effects. She then developed recurrent aphthous ulcers, folliculitis, and three UTIs. She was started on IVIG (600mg/kg) with significant improvement of her symptoms, and a “re-setting” of her neutrophil nadir to about 600.Patient B is a 49 yo white female with recurrent sinusitis, sore throat, and aphthous ulcers, found to have cyclical neutropenia with a 6-week cycle and a nadir of 234. She was found to have antibody deficiency with no response to Pneumococcus, Tetanus or Diphtheria. She did well on prophylactic antibiotics.Both patients did not have ELA-2 mutations.CONCLUSIONS: Cyclic neutropenia can have several causes. These two patients suggest that neutropenia associated with anti-neutrophil antibody and/or antibody deficiency may have a cyclical pattern. Most importantly, patient A, who had anti-neutrophil antibodies, suggests that IVIG for such patients can result in significant clinical improvement. RATIONALE: We report 2 patients presenting with cyclic neutropenia, who were found to have antibody deficiency, with no ELA-2 mutations. RESULTS/CASES: Patient A is a 31 yo white female with a history of recurrent aphthous ulcers, skin infections, and pharyngitis, found to have a neutrophil count of 90 during her third pregnancy. Upon delivery, the infant had severe neutropenia requiring G-CSF and WBC infusions, but had a spontaneous resolution at around six months of age. Evaluation of the mother revealed a cyclical neutropenia pattern, with an 18-24 day cycle and a nadir count of 270. She had a poor antibody response to pneumococcal vaccine. G-CSF treatment successfully increased her neutrophils, but was discontinued because of severe side effects. She then developed recurrent aphthous ulcers, folliculitis, and three UTIs. She was started on IVIG (600mg/kg) with significant improvement of her symptoms, and a “re-setting” of her neutrophil nadir to about 600. Patient B is a 49 yo white female with recurrent sinusitis, sore throat, and aphthous ulcers, found to have cyclical neutropenia with a 6-week cycle and a nadir of 234. She was found to have antibody deficiency with no response to Pneumococcus, Tetanus or Diphtheria. She did well on prophylactic antibiotics. Both patients did not have ELA-2 mutations. CONCLUSIONS: Cyclic neutropenia can have several causes. These two patients suggest that neutropenia associated with anti-neutrophil antibody and/or antibody deficiency may have a cyclical pattern. Most importantly, patient A, who had anti-neutrophil antibodies, suggests that IVIG for such patients can result in significant clinical improvement.

Clinical Stabilization of a Multiple Sclerosis Patient After Tonsillectomy

Exacerbations of multiple sclerosis (MS) are associated with viral and bacterial infections. This case report is of a patient who experienced multiple exacerbations associated with recurrent upper respiratory infections and pharyngitis. She was diagnosed with pharyngotonsillitis. After tonsillectomy, her relapse rate, brain magnetic resonance imaging scan, and neurological examination stabilized.

Aetiology of acute pharyngitis: the role of atypical bacteria.

In order to establish the role of atypical bacteria and compare characteristics of different infectious agents in acute pharyngitis, 127 patients with acute pharyngitis (66 males; median age, 5.33 years; range, 6 months to 14 years) and 130 healthy subjects of similar sex and age were studied. Serology with paired samples and PCR on nasopharyngeal aspirates and throat cultures were used to identify bacteria and viruses. Viruses were identified in 43 patients (33.8%) and five controls (3.8%; P < 0.0001), potential bacterial pathogens in 34 patients (26.8%) and 26 controls (20%; P = 0.256) and mixed viral/bacterial pathogens in 26 patients (20.5%) and none of the controls (P < 0.0001). The main aetiological agents were adenovirus, respiratory syncytial virus (RSV), Mycoplasma pneumoniae, Streptococcus pyogenes and Chlamydia pneumoniae. M. pneumoniae was the agent found most frequently as a single pathogen. A history of recurrent pharyngitis, having older siblings and a negative outcome were significantly more common among patients with acute M. pneumoniae infection than among those with infections due to other pathogens or healthy controls. This study demonstrates that: (i) adenovirus and RSV have a prominent role in acute pharyngitis; (ii) S. pyogenes is found frequently, but it is not possible to distinguish simple carriers from patients with a true infection; (iii) M. pneumoniae appears to be able to cause acute pharyngitis per se; and (iv) C. pneumoniae seems to be mainly a co-pathogen. To avoid the risk of an incorrect therapeutic approach, simple laboratory investigations that allow rapid identification of M. pneumoniae infections are urgently needed.

Group A streptococcal pharyngitis

The group A Streptococcus is the most common bacterial cause of pharyngitis. Although most cases of streptococcal pharyngitis are managed by primary care providers, the otolaryngologist is often consulted to assist in the management of patients with persistent sore throat, chronic streptococcal carriage, recurrent streptococcal pharyngitis, or complications of streptococcal infection. This article reviews recent advances in diagnosis and management of individual episodes of streptococcal pharyngitis, the clinical approach to the streptococcal carrier, and the role of tonsillectomy in the management of recurrent pharyngotonsillitis.

A systematic review of antistreptococcal interventions for guttate and chronic plaque psoriasis.

Guttate psoriasis is closely associated with preceding or concurrent streptococcal infection. Some authorities have claimed that chronic plaque psoriasis may also be made worse by infection. In view of this many dermatologists have recommended using antibiotics for psoriasis, particularly guttate type. Some dermatologists have also recommended tonsillectomy for psoriasis in patients with recurrent streptococcal pharyngitis. This review aims to assess the evidence for the effectiveness of antistreptococcal interventions, including antibiotics and tonsillectomy in the management of acute guttate and chronic plaque psoriasis. Studies were identified by searching the Cochrane Clinical Trials Register (Cochrane Library, Issue 3, 1999), Medline (1966-September 1999), Embase (1988-September 1999), the Salford Database of Psoriasis Trials (to November 1999) and the European Dermato-Epidemiology Network (EDEN) Psoriasis Trials Database (to November 1999) for terms (STREPTOCOCC* or ANTIBIOTIC* or TONSIL*) and PSORIASIS using the Cochrane Skin Group search strategy. Only one trial met the selection criteria. This compared the use of two oral antibiotic schedules in 20 psoriasis patients, predominantly of guttate type, who had evidence of beta-haemolytic streptococcal colonization. Either rifampicin or placebo was added to the end of a standard course of phenoxymethylpenicillin or erythromycin. No patient in either arm of the study improved during the observation period. No randomized trials of tonsillectomy for psoriasis were identified. Although both antibiotics and tonsillectomy have frequently been advocated both for patients with guttate psoriasis and for selected patients with chronic plaque psoriasis, there is to date no good evidence that either intervention is beneficial.

Peritonsillar abscess in children: a 10-year review of diagnosis and management

Objective: peritonsillar abscess is the most common deep neck infection in adults and children. However, pediatric patients with their smaller anatomy and often inability to cooperate with exam and treatment, provide a challenge. This study reviews the experience over the last 10 years at a children's hospital in the diagnosis and treatment of pediatric peritonsillar abscess. Methods: a retrospective chart review of 83 children diagnosed with a peritonsillar abscess by the Otolaryngology service over a 10-year period (March 1989–February 1999) were reviewed. Presenting signs and symptoms, physical findings, age, season of presentation, prior pharyngitis history, and prior treatment was collected from the charts. Additionally, diagnostic studies (if any), treatment performed, bacteriology, and outcome/complications were noted. Results: due to either an inability to cooperate fully for examination and treatment, or because of an earlier history of significant recurrent pharyngitis or obstructive tonsillar hypertrophy, half of the children required treatment in the operating room. Twenty-six out of 83 (31%) underwent a quinsy tonsillectomy. Length of stay was relatively short (0.9 days). There were no recurrent PTAs in our series, although four children initially treated with incision and drainage required tonsillectomy for persistent symptoms or residual abscess. Ten of those not treated with tonsillectomy (19%) required interval tonsillectomy for recurrent pharyngitis. Conclusion: limited by the ability to cooperate with treatment, children often require different treatment plans. We offer a treatment algorithm for managing children with PTAs that takes into account their age, level of cooperativeness, co-morbidities and prior history of pharyngitis, PTA or obstructive sleep disorder.

A Role for Tonsillectomy in the Treatment of Psoriasis?

Our objective was to determine whether tonsillectomy is beneficial in the treatment of recurrent childhood guttate psoriasis that is associated with recurrent streptococcal pharyngitis and tonsillitis. We retrospectively reviewed the cases of two children who were referred to our facility for treatment of repeated exacerbations of psoriasis and recurrent streptococcal pharyngotonsillitis. Both patients experienced a significant improvement in their psoriasis after undergoing adenotonsillectomy, and both were completely free of psoriatic outbreaks after 16 months of follow-up. We conclude that tonsillectomy appears to be of benefit in the treatment of children with recurrent guttate psoriasis and recurrent streptococcal pharyngotonsillitis, and we hope that further investigation will be undertaken.

Efficacy of 5-day cefpodoxime proxetil for recurrent pharyngitis in adults. A comparative study with 10-day penicillin V or amoxycillin—clavulanate

OBJECTIVE: To compare the clinical and bacteriologic efficacy of a 5-day course of cefpodoxime proxetil (CPD) with that of a 10-day course of penicillin V (PNV) or amoxycillin---clavulanate (AMC) in recurrent pharyngitis in adults. A cost-effectiveness study (reported elsewhere) was carried out at the same time. METHODS: This multicenter, randomized, open label trial involved 580 adult patients consulting general practitioners for clinical recurrent pharyngitis (greater-than-or-equal3 episodes within the last 12 months) regardless of the bacterial etiology. Patients were treated for 5 days with CPD, 100 mg twice daily, or for 10 days with PNV, 1x106 IU three times a day, or for 10 days with AMC, 500 mg (amoxycillin) three times a day. Clinical and bacteriologic outcomes were noted at the end of treatment, and cases of clinical recurrence were recorded during a 6-month follow-up period. RESULTS: At the end of treatment, clinical response was satisfactory in 157 of 170 (92.3%) patients on CPD, 147 of 166 (88.5%) patients on PNV, and 168 of 177 (94.9%) patients on AMC. Group A beta-hemolytic streptococci (GABHS) were eradicated in 22 of 23 (95.65%) patients on CPD, 16 of 16 (100%) patients on PNV, and 19 of 20 (95%) patients on AMC. The rates of clinical success and GABHS eradication were not significantly different between the groups. Compliance (p<0.001) and tolerance (p<0.001) were significantly better in the CPD group than in the other two groups. Among the 389 patients evaluable 6 months after the end of treatment, the recurrence rate of acute pharyngitis (due to any bacterium) was significantly lower in the CPD group (p=0.01 versus PNV; p<0.01 versus AMC). A Kaplan---Meier analysis (469 patients over 6 months) of the rate of non-recurrence, with comparison by the log-rank test, also showed a significant difference in favor of CPD. CONCLUSIONS: A 5-day treatment of recurrent pharyngitis with CPD was as effective and better tolerated than a 10-day treatment with PNV or AMC. The risk of recurrence was lower with CPD.

Strategies for managing group A streptococcal pharyngitis. A survey of board-certified pediatricians.

To assess the management strategies and knowledge of board-certified pediatricians regarding group A beta-hemolytic streptococcal (GABHS) pharyngitis. Survey of 1000 US pediatricians in 1991, chosen randomly from the membership of the American Academy of Pediatrics. The survey included questions related to 2 clinical scenarios, respondent demographics, and knowledge of streptococcal pharyngitis. Pediatricians who treated patients with pharyngitis. Of the 690 surveys that were returned, 510 pediatricians treated patients with pharyngitis and were included in the data analysis. Data were analyzed using Chi 2 statistics for categorical data and the Student t test for continuous variables. Antigen detection tests (ADTs) were used by 64% of the pediatricians; 85% used throat cultures. Strategies for diagnosing streptococcal pharyngitis were throat culture alone (38%), consider positive ADTs definitive and use throat culture when ADTs are negative (42%), ADT alone (13%), ADT and throat culture for all patients with pharyngitis (5%), and no tests for GABHS performed (2%). Thirty-one percent usually or always treated with antibiotics before test results were available. Only 29% of these "early treaters" always discontinued antibiotics when tests did not confirm the presence of group A streptococci. The drug of choice for treatment was penicillin (73%); another 26% preferred a derivative of penicillin, particularly amoxicillin. Many pediatricians altered their management when a patient had recurrent streptococcal pharyngitis. Nearly half of the respondents would use a different antibiotic than they used for routine acute streptococcal pharyngitis. They most often changed to erythromycin (25%), cefadroxil (23%), or amoxicillin-clavulanate (20%). Follow-up throat culture was obtained by 51% of pediatricians after treatment of recurrent streptococcal pharyngitis. A patient with chronic carriage of GABHS and symptoms of pharyngitis would be treated with an antibiotic by 84%; most (62%) would use a penicillin. Other choices were cephalosporins (19%), erythromycin (12%), clindamycin (3%), or rifampin plus penicillin (3%). Tonsillectomy was recommended for symptomatic carriers by 31% of respondents. Carriers without symptoms were less likely to be treated with antibiotics (23%) or referred for tonsillectomy (21%). Most surveyed board-certified pediatricians managed acute GABHS pharyngitis appropriately, but 15% to 20% used diagnostic or treatment strategies that are not recommended. There was lack of a consensus about the management of recurrent GABHS pharyngitis and chronic carriage of GABHS.

へん桃摘出術が著効を呈した潰よう性大腸炎例

Ulcerative colitis is an idiopathic, non-specific inflammatory disorder of the colon, and its etiology remains unknown. We present a case of ulcerative colitis in which clinical symptoms were remarkably improved by palatine tonsillectomy. The patient was diagnosed with severe ulcerative colitis and treated with internal medicine. When pharyngitis and aphthous stomatitis developed, his bowel symptoms worsened. A tonsillar provocation test was performed, and the result was positive. Moreover, bowel symptoms worsened after the tonsillar provocation test and the patient developed a sore throat and fever. Therefore, we suspected tonsillar focal infection and carried out palatine tonsillectomy. In the early postoperative period, bloody diarrhea recovered despite the interruption of sulfasalazopiridine and lymphocyte afferesis. In addition, recurrent pharyngitis and aphtous stomatitis were resolved entirely.

Hypersensitivity pneumonitis caused by soybean antigens

Hypersensitivity pneumonitis caused by soybean antigens

Streptococcus pyogenes pharyngitis: characterization of strains by multilocus enzyme genotype, M and T protein serotype, and pyrogenic exotoxin gene probing.

Multilocus enzyme electrophoresis, serological characterization of M and T proteins, and probing for pyrogenic exotoxin A and C genes were used to investigate the bacteriologic epidemiology of strains of Streptococcus pyogenes recovered primarily from patients with recurrent pharyngitis. A total of 164 strains recovered from individuals living in nine states of the United States was analyzed. Two-thirds of the patients in our sample were infected with the homologous strain following antibiotic therapy and presumably represented treatment failures, whereas the other one-third of the patients were infected with a heterologous strain after therapy and probably represented reinfections. Multilocus enzyme electrophoresis was as efficacious in strain discrimination as serologic typing techniques were and, in addition, successfully characterized all organisms that were serologically nontypeable. Two clones of S. pyogenes responsible for most of the episodes of toxic shock-like syndrome in the United States are geographically widespread, but they vary by locality in the frequency of their occurrence. Compared with a sample of strains cultured from patients whose pharyngeal infections were eliminated by antimicrobial therapy, these two clones were statistically overrepresented among organisms that cause recurrent pharyngitis.

Exacerbation of ulcerative colitis

A 17-year-old girl with a history of ulcerative colitis and a recent pilonidal cyst excision was admitted to the hospital with fever, severe abdominal pain, and frequent, bloody diarrhea. The diagnosis of idiopathic ulcerative colitis was made 4 years before admission and was based on colitis symptoms, endoscopic pancolitis, and unequivocal histological changes. The patient was started on sulfasalazine and prednisone therapy but failed to achieve a complete remission. One year before admission she was having three episodes of bloody diarrhea daily. Her medications were prednisone, 30 mg daily, and sulfasalazine, 1 g t.i.d. She complained of intolerable mood swings due to prednisone, but tapering resulted in continuous diarrhea. Her colonic mucosa was edematous, erythematous, granular, and friable from the mid-descending colon to the rectum. The patient responded well to the addition of one 4-g mesalamine enema per day, and steroid therapy was tapered off completely over the next 8 months. She experienced a brief relapse 3 months before admission manifest by abdominal cramping and two to three blood-streaked, loose stools per day. The patient attributed this relapse to a viral upper respiratory infection she had contracted several days earlier. She observed that her colitis flared “every time she had a cold.” This relapse resolved with an increase in oral sulfasalazine and mesalamine enemas. When the patient was seen 10 weeks before admission she was in clinical and sigmoidoscopic remission, with no complaints of pain, diarrhea, or bleeding on a regimen of sulfasalazine, 2 g daily, and mesalamine enemas, 2 g daily. The patient was scheduled to have a pilonidal cyst excised. The case was discussed with the surgeon, who agreed not to use antibiotics perioperatively unless treating a specific infection because of the concern about provoking antibiotic-induced diarrhea or Clostridium dijjkile colitis. Several days before surgery the patient developed recurrent fevers and pharyngitis. Her examination showed tonsilar hyertrophy, but there was no significant adenopathy or splenomegaly. Her white blood cell count was elevated to 1300 with 78% lymphocytes, most of which were atypical. Results of a mono spot test were positive, and infectious mononucleosis was presumed to be the cause of the patient’s fevers. Surgery was performed 7 weeks before admission. The patient’s ulcerative colitis remained in clinical remission throughout her febrile illness and during the immediate postoperative period. However, 2 weeks after surgery (5 weeks before admission) she developed abdominal cramping, tenesmus, and bloody stools. Her symptoms became worse despite an increase in her sulfasalazine to 4 g daily and mesalamine enemas to 4 g daily. A flexible sigmoidoscopy performed approximately 2 weeks before admission revealed mucosal edema, erythema, granularity, and friability from the rectum to the descending colon. The hematocrit was 29.5%, the white cell count was 8100, the platelets were 625,000, and the erythrocyte sedimentation rate was 58 mm/h. The differential white blood cell count showed 16% segmented neutrophils, 16% banded neutrophils, 39% lymphocytes, 9% monocytes, and 20% eosinophils. Because of the patient’s eosinophilia and worsening condition, the sulfasalazine dosage was reduced to 2 g daily. Abdominal pain, stool frequency, and bleeding all continued to increase. The patient, complaining of progressive weakness, was admitted to the hospital after a syncopal episode during a phlebotomy. Physical examination revealed a pale, thin, and mildly diaphoretic female patient. Her temperature was 37.8”C, her heart rate was 100 per minute, and her systolic blood pressure was 100 mm Hg supine but fell to 90 mm Hg in the sitting position. She had no ocular or oral lesions, and the chest examination results were normal except for tachycardia. The patient had active bowel sounds, and her abdomen was soft and nondistended with mild, diffuse tenderness. There was no rebound, guarding, or liver or spleen enlarge-

Symptoms and Signs of Chronic Fatigue Syndrome

This review summarizes the symptoms and signs seen in patients with chronic fatigue syndrome (CFS). It is based on the authors' experience with two cohorts of approximately 510 patients with chronic debilitating fatigue and on the reported experience of other investigators with similar patients. The most characteristic symptoms of CFS are the sudden onset of an infectious-type illness, the subsequent chronic and debilitating fatigue, and postexertional malaise; many patients also have recurrent fevers, pharyngitis, adenopathy, myalgias, sleep disorders, and cognitive impairment.

Optimal Dosing Interval for Penicillin Treatment of Streptococcal Pharyngitis

One-hundred-forty-two children with symptomatic pharyngitis had throat cultures positive for group A beta-hemolytic streptococci (GABHA). All were treated orally with penicillin V for ten days. Patients were randomly assigned to receive daily doses of 250 mg four times daily, 500 mg twice daily, or 1000 mg once daily. They were followed four weeks for either recurrent symptomatic pharyngitis or asymptomatic repeat positive throat culture. Patients treated two or four times daily had comparable outcomes. Children given penicillin once daily were more likely to have persistent positive culture after 48 hours treatment (5 of 48 or 10.4% vs. none of 94, p = .004) and more likely to have recurrent positive cultures after end of treatment (10 of 43 or 23% vs. 8 of 94 or 8%, p = .04). The treatment regime of penicillin V 500 mg twice daily is recommended for treatment of pharyngitis due to GABHS.

Treatment of Cyclic Neutropenia with Granulocyte Colony-Stimulating Factor

Six patients with cyclic neutropenia were treated with recombinant human granulocyte colony-stimulating factor (G-CSF) for 3 to 15 months. All had a history of recurrent aphthous stomatitis, pharyngitis, lymphadenopathy, fever, and numerous infections during periods of neutropenia. Serial blood-cell counts, findings on bone marrow examination, and signs and symptoms were evaluated before and during the daily administration of G-CSF (3 to 10 micrograms per kilogram of body weight per day), either intravenously or subcutaneously. The kinetics of labeled autologous blood neutrophils and the migration of neutrophils to skin chambers were also measured. Recombinant human G-CSF increased the mean (+/- SEM) neutrophil counts from 717 +/- 171 per microliter to 9814 +/- 2198 per microliter (P = 0.009). In five of the six patients, the cycling of blood-cell counts continued, but the length of the period decreased from 21 to 14 days. The number of days of severe neutropenia was reduced (P = 0.002). Neutrophil turnover increased almost four-fold (P = 0.005), whereas neutrophil migration to a skin chamber was normal. G-CSF therapy reduced the frequency of oropharyngeal inflammation, fever, and infections in these patients. During the first 40 months of treatment, no typical mouth ulcers or bacterial infections occurred; recurrent gingivitis improved. We conclude that G-CSF is effective for the treatment of cyclic neutropenia in humans.

耳鼻咽喉科と漢方療法 咽喉頭異常感症を中心として

Chinese Medicine helps to normalize and stabilize autonomic nervous system imbalances and endocrine and metabolic disorders.In the field of oto-rhino-laryngology, Chinese Medicine is very effective when it is applied according to the traditional Chinese medical diagnoses for: 1) Abnormal sensation in the pharynx in patients with autonomic dysfunction. 2) Chronic inflammation. 3) Recurrent otitis media and pharyngitis. 4) Tinnitus, vertigo and dizziness with circulatory disturbances.

Prevalence and treatment of silent gastro-oesophageal reflux in children with recurrent respiratory disorders

Thirty-six infants and children presenting with recurrent respiratory disorders (RRD) as the sole clinical symptom including bronchial asthma (6), recurrent obstructive bronchitis with or without wheezing (18), chronic nocturnal cough (3), recurrent episodes of pneumonia (3), recurrent pharyngitis (3) and recurrent laryngitis (3) were investigated for associated gastro-oesophageal reflux (GER) by oesophagram, endoscopy and continuous 24 h pH monitoring of the distal oesophagus. The pH monitoring criteria were selected on the basis of a preliminary study comparing statistically measurements of 32 variables recorded in 15 patients who all had clinical, radiological and endoscopic evidence of GER and in 8 asymptomatic controls. Although patients with symptomatic GER differed significantly from the asymptomatic ones for 27 variables examined, 6 variables emerged as having the highest value for discrimination (overlap score 0-1). Among these, the Euler-Byrne index (number of reflux pH less than 4 + 4 times the number of reflux episodes of more than 5 min), the percentage of total reflux time and the number of reflux episodes 1 h post-cibal scored 0 (no overlap). GER was considered to be present when at least five of these six parameters were abnormal. The overall incidence of GER in children with RRD was 41% (15) when detected by oesophagram and 61% (22) when diagnosed by pH monitoring criteria. In the children with bronchial asthma or with recurrent laryngitis, the percentage of reflux time during sleep was about 40 times higher than in asymptomatic controls and 2 times higher than in those with symptomatic GER.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharyngeal infections. Causes, findings, and management.

Pharyngitis is one of the most common clinical problems. Its causes are multiple, two of the best known being streptococcal infection and infectious mononucleosis. Group A beta-hemolytic streptococcal infections are the focus of diagnostic and therapeutic efforts aimed at reducing the risk of both suppurative and nonsuppurative complications. Several non-group A infections are important to recognize as sources of pharyngitis. In addition, mycoplasmal and chlamydial pharyngitis may be more prevalent than is realized. The possibility of gonococcal pharyngitis should be given special attention because of the severity of complications. Recurrent pharyngitis is difficult to manage. Except for certain specific indications, tonsillectomy remains an unproven therapeutic approach.