Four of the five patients reported for follow-up examination within 7 to 10 days. In two the otitis externa had completely cleared and in the others it was markedly improved. No side effects were reported. Treatment of children All patients received trimethoprim-sulfamethoxazole as a Table I-Organisms isolated from lesions of 28 patients with otitis externa Streptococcus sp. Staphylococcus aureus Pseudomonas aeruginosa Hemophilus influenzae Serratia marcescens Diplococcus pneumoniae Proteus sp. Klebsiella Mixed S. aureus and Streptococcus sp.

4 8 7 2 1 1 2 1 2

liquid preparation (Septra Pediatric Suspension). The dosage for the two patients under 2 years of age was 2.5 ml, for the II aged between 2 and 5 years, 5 ml, and for the 10 aged between 6 and 14 years, 10 ml. The amounts mentioned were given twice daily. Side effects were reported by eight patients. Five had mild nausea and anorexia, two had mild diarrhea as the sole complaint, and one 12-year-old had severe diarrhea and vomiting, checked by reducing the dosage from 10 to 5 ml. Eighteen patients were seen for follow-up examination within 7 to 10 days. Marked improvement was evident in 15; in these the Septra suspension was discontinued but the local application of a hydrocortisone-antibiotic ointment was advised for a further 5 to 7 days. In one patient the otitis externa had cleared slightly but the associated otitis media was unimproved and therefore a different antibiotic was prescribed; cultures from this patient were positive for Pseudornonas aeruginosa. The remaining two patients showed some improvement but required prolongation of treatment with tri methopri m-sul fa methoxazole for a further 5 days; both were instances of mixed staphylococcal and streptococcal infection. Thanks are expressed to Burroughs Wellcome Ltd. for supplies of Septra and to J.K. Gorrie, BSc, N4RSH for his assistance.

Comparison of penicillin and trimethoprimsulfamethoxazole in the treatment of ear, nose and throat infections CEDRIC A. QUICK, MD

Summary: A double-blind trial of penicillin and the combination trimethoprim-sulfamethoxazole was undertaken in adult patients with active infection of the ears, nose or throat. The results indicated that the drug trimethoprim-sulfamethoxazole was as effective as penicillin in achieving clinical improvement and showed a broader spectrum than penicillin in the elimination of pathogenic organisms. The difficulties in obtaining positive cultures that were reflective of the clinical condition are described. ResumA: Efficacit6 compar6e de I'ampicilline et du trim6thoprime-sulfam6thoxazole Pour Atudier l'efficacitA de l'ampicilline et du trimAthoprime-sulfamAthoxazole dans l'otite moyenne aigue. nous avons traitA 79 enfants souffrant de cette infection. Ils ont re.u au hasard un des deux mAdicaments d'aprAs Ia methode A double anonymat. mais en prenant en considhration le poids de l'enfant. On n'a pas note de difference sensible entre les resultats cliniques des deux From the department of otolaryngology, University of Minnesota medical school Reprint requests to: Dr. Cedric A. Quick, Hospital Box 406, 412 Union St. SE, Minneapolis, MN 55455, USA

m6dications. Los reactions secondaires d.favorabIes du TMP-SMX ont etA cependant remarquablement rares.

The etiologic agents responsible for infections of the ears, nose and throat are most commonly either bacterial or viral. Frequently it is assumed that both agents contribute to the disease state. In the case of tonsillitis and pharyngitis it is particularly difficult to distinguish between viral and bacterial infections as there are no differences in the clinical picture produced by these two agents. It is also a fact that there are no distinguishing features in any of the various forms of bacterial infection. Routine bacteriologic culture techniques cannot be relied upon to provide the answer because the absence of viable, growing bacteria on an agar plate in a laboratory does not mean that bacterial organisms were not growing in the patient and certainly cannot be construed to mean that the infection in the patient was probably viral. Consequently, to the primary care physician the management of certain infections of the ears, nose and throat presents a dilemma. It must be remembered that statistics for patient first-visits clearly show that the primary care physician sees more problems related to ears, nose and throat than any other disease or symptom complex, including malignant growths.' The magnitude of the problem only serves CMA JOURNAL/JUNE 14, 1975/VOL. 112

83S

compound the difficulty. It is not surprising that a primary physician may place more reliance on his clinical judgernent of the severity of the patient's condition than on the results of laboratory tests. It is essential that we realize fully the nature of this situation, and until we can provide rapid, accurate diagnostic tests we must accept the fact that antibacterial agents are going to be used on a wide scale for these infections. In this respect it is important that the practising physician should have available a variety of efficient, relatively nontoxic antibacterial agents. This paper presents the results of a double-blind study to compare the efficacy of phenoxymethyl penicillin with the combination of trimethoprim (TMP) and sulfamethoxazole (SMX) in treating infection of the ears, nose and throat. In addition, some of the difficulties in establishing reliable labora¬ tory data to confirm the clinical diagnosis will be described. to

care

Materials and methods The conditions studied included acute tonsillitis, acute pharyngitis, acute sinusitis, acute otitis media, chronic sinusitis and peritonsillar abscess. The patient population was limited to those over the age of 16 years and in otherwise good health. Any previous history of disease of the liver, kidney, heart or hematopoietic system, or known allergy to penicillin or sul¬ fonamides excluded patients from the study. The majority of patients came from the staff, students and civil service personnel of a single university campus with a population of nearly 50 000. In addition, when appropriate, some patients were included who had been referred to the otolaryngology service for a specialist's opinion. When the clinical diagnosis of one of the infections mentioned above was made, appropriate cultures were plated on sheep blood, mannitol salt, eosin methylene blue and chocolate agar. The swab was then placed in thioglycolate medium. After isolation, specific biochemical and serologic tests were performed to identify the organism. To qualify for the study each patient had to have a definite clinical infection, meet the entrance standards and have a pathogenic organism isolated on culture. The organisms that were considered pathogenic for our patient population are listed in Table I. The subject was then entered in the study and a series of investigations were performed (Table II). The patients were given either potassium phenoxymethyl penicillin, 1000 mg daily, or SMX, 800 mg, combined with TMP, 160 mg daily. Teble

I.Organisms considered to be pathogenic

Code 1+ 10 colonies or less. =

2+

=

>

10 colonies and

3+

=

>

100 colonies but

P Organism is actual quantity.