Prognosticating patients with necrotising otitis externa based on response to treatment.

INTRODUCTION: Necrotising otitis externa (NOE) is a severe infection of the temporal bone. The traditional severity based staging system does not fully prognosticate all patients with NOE. We hypothesise that a patient response staging system would more accurately capture the disease process and guide prognosis. METHODS: We carried out a retrospective notes review of patients diagnosed with NOE from January 2017 to December 2018 in a regional tertiary referral centre. Patient outcomes from our proposed patient response staging system were compared to a modified previously published severity based Gleeson staging system with patients requiring prolonged treatment classified as having a poor outcome. RESULTS: A total of 34 patients were treated for NOE. The majority were male (n=24) and had diabetes (n=25). Patients with the most severe Gleeson staging did not have the worst outcome. Daily delay in resolution of otorrhoea was associated with an increased need for more than six weeks of treatment. Rapid responders are patients who had resolution of otalgia, otorrhoea and C-reactive protein normalisation within 14 days, and all were cured following standard 6 weeks of treatment. CONCLUSIONS: The Gleeson staging system was valuable in assessing the extent of disease and all early Gleeson staged patients had good outcomes. However, patients with higher severity staging on the Gleeson system did not necessarily require prolonged treatment. There is a role for a joint approach in staging patients based on both modified Gleeson and treatment response, which would subsequently guide prognosis, duration of treatment and early diagnosis of potential fungal NOE.

Bacterial involvement in otitis media with effusion.

OBJECTIVE: Otitis media with effusion (OME), a common chronic childhood condition affecting hearing, is thought to be a result of bacterial infection, with biofilms recently implicated. Although bacterial DNA can be detected by polymerase chain reaction in 80% of patients, typically fewer than half of effusions are positive using standard culture techniques. We adopted an alternative approach to demonstrating bacteria in OME, using a bacterial viability stain and confocal laser scanning microscopy (CLSM): staining allows detection of live bacteria without requiring growth on culture, while CLSM allows demonstration of the three-dimensional structure typical of biofilms. METHODS: Effusion samples were collected at the time of ventilation tube insertion, analysed with CLSM and bacterial viability stain, and extended culture techniques performed with the intention of capturing all possible organisms. RESULTS: Sixty-two effusions (42 patients) were analysed: 28 (45.2%) were culture-positive, but 51 (82.3%) were CLSM-positive. Combining the two techniques demonstrated live bacteria in 57 (91.8%) samples. Using CLSM, bacteria exhibited biofilm morphology in 25 effusions and were planktonic in 26; the proportion of samples exhibiting biofilm morphology was similar in the culture-positive and culture-negative groups (50.0% and 48.3%, respectively). Biofilm samples contained an average of 1.7 different bacterial isolates and planktonic samples 2.0, with the commonest bacteria identified being coagulase-negative staphylococci. CONCLUSION: Live bacteria are present in most effusions, strongly suggesting that bacteria and biofilms are important in the aetiopathogenesis of OME.

Audit of management of periorbital cellulitis and abscess in a district general hospital and a tertiary referral centre, in line with published guidelines.

OBJECTIVE: To audit the management of periorbital cellulitis or abscess, in line with guidelines published in 2004, within a district general hospital and a tertiary referral centre. METHOD: Retrospective audit analysing 58 cases at a district general hospital and 61 cases at a tertiary referral centre, encountered since 2004. RESULTS: At the tertiary referral centre, 22 patients were diagnosed with pre-septal cellulitis and discharged, as were 20 cases at the district general hospital. At the tertiary referral centre, 95 per cent of patients were correctly seen by an ophthalmologist and 82 per cent by a senior ENT surgeon, compared with 63 and 39 per cent, respectively, at the district general hospital. In both centres, one patient did not receive a computed tomography scan where this was indicated. Despite the need for twice daily monitoring of ophthalmological criteria, both sites lacked 100 per cent compliance. At the tertiary referral centre, 76 per cent of patients were correctly treated with intravenous antibiotics, compared with 68 per cent at the district general hospital. CONCLUSION: At both sites, adherence to guidelines was suboptimal. Management may be improved through improved education and online information support.

Patch testing in allergic contact dermatitis.

A deterioration in chronic inflammatory ear disease despite topical medication, or failure of the condition to improve with such treatment, should raise the possibility of allergic contact dermatitis. Allergen testing (patch testing) is the 'gold standard' method of identifying an agent causing allergic contact dermatitis. We describe an ENT patch test series applied by our department as a screening device for this condition.

What is the impact of consultant supervision on outpatient follow-up rate?

This study investigated the impact of consultants on recycling rates of patients in the ENT outpatient clinic. A retrospective case review of 4205 consecutive patients who attended ENT outpatient clinics of an UK teaching hospital over a 3-month period was conducted. There was a significant association between grade of medical staff and recycling rate of new patients, and also for review patients. Junior doctors have lower recycling rates in consultant-led clinics compared with clinics in the absence of consultants for both new patients (consultant-led 41.0%, without consultant 60.1%; P < 0.01) and old patients (consultant-led 48.9%, without consultant 65.0%; P < 0.01). Individual consultant's practice was reflected upon the overall recycling rate of the clinic as a whole (r = 0.94, P = 0.001). In conclusion, individual consultant's practice dictated recycling rate in the ENT outpatient clinic. Junior doctors were less likely to make follow-up appointments when directly supervised by their consultants.

Is otitis media with effusion a biofilm infection?

Recent attention has focused on the possibility that otitis media with effusion (OME) may represent a chronic infective state such as those evidenced in conditions secondary to biofilms or small colony variants. This review discusses the evidence suggesting that this may indeed be the case and explains why this may prove to be important in the future management of this condition by discussing recent advances in understanding these bacterial phenotypic variants.

The middle cranial fossa approach: an anatomical study.

Hearing preservation surgery has become an option for an increasing number of patients with vestibular schwannomas due to diagnosis at an earlier stage. The middle cranial fossa approach represents one such surgical approach for resection of vestibular schwannomas with hearing preservation. We have undertaken an anatomical study of the middle cranial fossa approach to the internal auditory meatus using 20 fresh temporal bones. By simulating the surgical approach it was possible to analyze critically two of the main recognized subapproaches to the internal acoustic meatus. The results confirmed that the angle subtended by the facial nerve and "blue-lined" semicircular canal was much less than 60 degrees but equally important was the degree of individual variability. Furthermore the roof of the geniculate fossa was not infrequently dehiscent. The distance measured from the inner table of the craniotomy to the superior semicircular canal was on average 22 mm, similar to previous reports and utilized by some in their approach in this challenging surgery. From this anatomical study it appears that safe dissection of this area is facilitated by observing the more acute angle between the facial nerve and superior semicircular canal and by taking advantage of the relationship between the inner table and important landmarks.

Influence of prednisolone on the secretion of mucin from the HT29-MTX cell line.

Glucocorticoids have been used in the treatment of otitis media with effusion with promising but inconsistent results. The HT29-MTX cell line is a completely differentiated and almost exclusively mucus-secreting goblet cell line. To assess the potential of steroids in suppressing mucin secretion, we have studied the response of this cell culture to prednisolone. Confluent cell cultures were trypsinized, subcultured in six-well plates and incubated with five doses of prednisolone from 10-3 M to 10-11 M and over a varying time course from 6 to 36 h. Analysis was performed using a monoclonal mouse antibody to human gastric mucin by dot-blot ELISA. Prednisolone caused a consistent reduction in mucin production from this cell line. Increasing concentrations of prednisolone resulted in increasing suppression of MUC5AC secretion. There is a dose-dependent suppression of mucin secretion by prednisolone, with a maximum effect of 21% over control seen at the highest steroid concentration used.

The influence of prednisolone on the secretion of MUC5AC from TH29-MTX cell culture

INTRODUCTION: Glucocorticoids have been used in the treatment of otitis media with effusion with promising but inconsistent resluts. The HT29-MTX cell line is a completely differentiated and almost exclusively mucous secreting cell line, which therefore has the potential to act as an ideal model for the study of mucus-secreting epithelia. To assess this potential of steroids in suppressing mucin secretion we have studied the response of the cell culture to prednisolone. METHODS: Confluent cell cultures were trypsinized, subcultured in six-well plates and incubated with four doses of prednisolone from 10-5 M to 10-11 M and over varying time courses from 12 to 36 h. ELISA was performed using a monoclonal mouse antibody to human gastric mucin by dot-blot ELISA. RESULTS: Prednisolone caused a reduction in mucin production from the cell line consistently. Media control values ranged from 3495 to 3559 compared with untreated controls of 18 998-27 176 and steroid treatment values of 12 244-27 792. Increasing concentrations of prednisolone result in increasing suppression of MUC5AC (P = 0.005). There was no independent time-related effect. CONCLUSION: There does appear to be a genuine suppression of mucus production by prednisolone and this appears to be dose-dependent but not time-dependent at the times studied. The effect size was small.

Carcinoma of the hypopharynx and cervical esophagus in young adults.

Squamous cell carcinoma of the hypopharynx and cervical esophagus usually presents in the late-middle-aged and elderly. When diagnosed in young adults, the disease process is often thought to be more aggressive and have a worse long-term outcome. Four hundred ninety patients presented to the Christie Hospital and Manchester Royal Infirmary between 1981 and 1990 with squamous cell carcinoma of the hypopharynx and cervical esophagus. Of this group, 24 patients (5%) received their diagnosis before the age of 45. A comparison is made with a control group of 156 (32%) patients who presented between the ages of 60 and 69 years. Analysis of tumor and nodal staging at presentation demonstrates no statistically significant difference between the 2 age groups. There is a higher incidence of a combination of smoking and alcohol abuse in the older age group, but it is of no statistical significance. There is no difference in 5-year survival results between the 2 groups. We conclude that patients with squamous cell carcinoma of the hypopharynx and cervical esophagus who receive their diagnosis under the age of 45 show no difference in tumor stage or long-term outcome when compared with a control group encompassing the mean age of presentation.

Petrosal cholesteatoma: management considerations for minimizing morbidity.

OBJECTIVE: This study aimed to analyze the surgical treatment of patients presenting with petrosal cholesteatoma. STUDY DESIGN: The study design was a retrospective case review. SETTING: The study was conducted at a tertiary referral center. PATIENTS: Patients were referred to the University Department of Otolaryngology, Manchester Royal Infirmary, with surgically confirmed petrosal cholesteatoma. INTERVENTION: Interventions were diagnostic and therapeutic. MAIN OUTCOME MEASURES: Postoperative facial function, hearing loss, recurrent cholesteatoma, and petrous cavity morbidity in relation to preoperative signs, intraoperative findings, and surgical techniques were measured. RESULTS: Twenty-five patients were treated between 1979 and 1997. Complete preoperative facial paralysis was always associated with bony erosion around the geniculate ganglion, and facial nerve ischemia was thought to be an important factor. Resection of the ischemic nerve segment and end-to-end anastomosis over the posterior fossa dura allowed full removal of cholesteatoma matrix and reinnervation along a healthy and vascularized nerve. In five of the seven cases with recurrent disease, cholesteatoma was localized to the intrapetrous carotid or geniculate ganglion. The introduction of endoscopic techniques has allowed assessment of the full extent of disease and removal of cholesteatoma matrix missed using conventional microscopic visualization. Bipolar diathermy to areas of cholesteatoma, densely adherent to dura, is effective in destroying squamous epithelium. Patients with cavity obliteration and blind sac closure had minimal postoperative morbidity, and current magnetic resonance imaging techniques are effective in diagnosing and delineating recurrence. CONCLUSIONS: This study illustrates a gradual change in the treatment of patients with petrosal cholesteatoma. By defining the main areas of patient morbidity and using both recent technical advances and alternative surgical techniques, further improvement in patient outcome is envisaged.

Dacryocystorhinostomy in nasolacrimal duct obstruction secondary to sarcoidosis.

Over the past 3 years we have treated 4 patients with nasolacrimal duct obstruction secondary to sarcoidosis. These patients have had mixed outcomes following endonasal laser-assisted dacryocystorhinostomy (DCR). A literature search from 1966 to the present yielded a further 11 cases of patients thought to have sarcoid who underwent DCR. The outcome of these 15 patients indicate that while all were initially successful, the subsequent failure rate is high. These patients are older than the majority of patients with sarcoidosis and there is a female preponderance. Systemic steroids reversed obstruction in one patient. We recommend nasal examination in all patients with nasal symptoms in whom DCR is proposed to help identify sarcoidosis or other intranasal disease and/or to allow treatment of specific diseases prior to surgery.

The nasal manifestations of sarcoidosis: a review and report of eight cases.

We report eight patients presenting to the Department of Otorhinolaryngology between 1990 and 1998 in whom a diagnosis of sarcoidosis was made. The most common presenting symptom was that of nasal obstruction and crusting and the most common site of involvement was the septum and inferior turbinate. These patients differ from the majority of patients who present with the other manifestations of sarcoidosis in that they are older. Where mucosal changes are present within the nose, biopsy gives a high diagnostic yield. The aim of treatment is to gain symptomatic control with the lowest dose of steroids. The majority of patient's nasal symptoms were managed with local measures and topical steroids. Nasal disease tends to follow a prolonged but benign course. Few had other organ involvement. While nasal sarcoidosis remains a rare cause of nasal obstruction, biopsy of abnormal nasal mucosa along with further investigations as dictated by history, examination and histological findings is important if delay in diagnosis is to be avoided.

Hearing preservation despite labyrinthectomy for resection of giant cholesteatoma with middle fossa extension.

A case is described of an extensive acquired cholesteatoma of the middle ear cleft which had invaded the middle cranial fossa and produced a mass effect on the temporal lobe. It had also extended into the labyrinth without causing elevation in the bone conduction threshold. Furthermore, even after total bony labyrinthectomy, there was very little elevation in these thresholds. The literature relating to hearing preservation after labyrinthectomy is reviewed.

Role of arteriography in the selection of patients for carotid endarterectomy.

BACKGROUND: Duplex ultrasonography is used increasingly to select patients for carotid endarterectomy. This study aims to clarify whether arteriography is still required. METHODS: A total of 272 patients in whom duplex imaging indicated significant disease of the internal carotid artery underwent arteriography and the results were compared. Regarding the arteriogram as the 'gold standard', three aspects were considered: the accuracy of duplex ultrasonography in detecting significant stenosis, the ability of duplex imaging to identify patients who should have arteriography and whether the arteriogram provided important additional information that might influence a decision to operate. RESULTS: Three patients (1 per cent) suffered a permanent neurological deficit as a result of arteriography. Of the 272 patients with significant stenosis identified by duplex ultrasonography, 241 (89 per cent) were confirmed as significant on arteriography. Duplex imaging was not able to predict accurately which arteriograms would provide useful additional information (sensitivity 59 per cent, specificity 65 per cent), whereas 89 arteriograms (33 per cent) contained information that might have influenced subsequent management. CONCLUSION: Duplex imaging is unable to detail the anatomy or determine the extent of carotid disease and may therefore lead to an inappropriate decision to perform carotid endarterectomy. Duplex imaging alone is not adequate before carotid endarterectomy.

Peritonsillar haematoma.

We present one patient who was admitted with a peritonsillar haematoma as a complication of acute tonsillitis and concomitant warfarin therapy for prosthetic aortic valves. While tonsillar haemorrhage as a result of acute tonsillitis has been well described, no cases of isolated haematoma formation have been documented, nor has it been recognized previously as a complication of long-term anticoagulant therapy. We discuss establishing the diagnosis, the likely aetiology and implications of this complication.