Diagnostic criteria and core outcome set development for necrotising otitis externa: the COSNOE Delphi consensus study.

OBJECTIVE: Evidence for necrotising otitis externa (NOE) diagnosis and management is limited, and outcome reporting is heterogeneous. International best practice guidelines were used to develop consensus diagnostic criteria and a core outcome set (COS). METHODS: The study was pre-registered on the Core Outcome Measures in Effectiveness Trials (COMET) database. Systematic literature review identified candidate items. Patient-centred items were identified via a qualitative study. Items and their definitions were refined by multidisciplinary stakeholders in a two-round Delphi exercise and subsequent consensus meeting. RESULTS: The final COS incorporates 36 items within 12 themes: Signs and symptoms; Pain; Advanced Disease Indicators; Complications; Survival; Antibiotic regimes and side effects; Patient comorbidities; Non-antibiotic treatments; Patient compliance; Duration and cessation of treatment; Relapse and readmission; Multidisciplinary team management.Consensus diagnostic criteria include 12 items within 6 themes: Signs and symptoms (oedema, otorrhoea, granulation); Pain (otalgia, nocturnal otalgia); Investigations (microbiology [does not have to be positive], histology [malignancy excluded], positive CT and MRI); Persistent symptoms despite local and/or systemic treatment for at least two weeks; At least one risk factor for impaired immune response; Indicators of advanced disease (not obligatory but mut be reported when present at diagnosis). Stakeholders were unanimous that there is no role for secondary, graded, or optional diagnostic items. The consensus meeting identified themes for future research. CONCLUSION: The adoption of consensus-defined diagnostic criteria and COS facilitates standardised research reporting and robust data synthesis. Inclusion of patient and professional perspectives ensures best practice stakeholder engagement.

Otolaryngology contribution to the care of patients following non-fatal strangulation in the settings of alleged sexual assault.

BACKGROUND: Non-fatal strangulation as a consequence of a sexual assault attack or domestic violence represents serious bodily harm. Otolaryngologists have an important role in documenting physical findings and managing airway symptoms. This study aimed to describe our otolaryngology department's experience managing patients referred from the sexual assault referral centre who suffered non-fatal strangulation. METHOD: A retrospective analysis of patients suffering non-fatal strangulation referred to the Manchester University Hospitals NHS Foundation Trust Otolaryngology Department from Saint Mary's Sexual Assault Referral Centre in Manchester between 1 January 2017 and 31 December 2019 was carried out. RESULTS: A total of 86 patients were referred from Saint Mary's Sexual Assault Referral Centre. Of these patients, 56 were given telephone advice and the remaining 30 were seen by the on-call otolaryngology team. In addition, 20 out of 30 (66.6 per cent) patients underwent fibre-optic nasal endoscopy. Common presenting symptoms were neck pain (81.4 per cent), dyspnoea (80.2 per cent) and dizziness (72.1 per cent). Five patients had identifiable laryngeal injury on endoscopy. CONCLUSION: Meticulous documentation is recommended when managing patients who suffer non-fatal strangulation because medical records may be used as evidence in criminal investigations.

Management of a recurrent right juvenile nasopharyngeal angiofibroma using direct tumorous puncture embolisation and a subtemporal-preauricular infratemporal fossa surgical approach.

A juvenile nasopharyngeal angiofibroma (JNA) is a benign vascular tumour that arises from the pterygopalatine fossa. It is seen near exclusively in young males though female cases have been reported. Symptoms are due to their high vascularity and mass effect. Commonly reported symptoms include: nasal obstruction, epistaxis and nasal discharge. The mainstay of treatment is surgical resection either via an endonasal endoscopic approach or open surgical resection. Preoperative embolisation has been shown to decrease intraoperative bleeding. Embolisation may be undertaken via a transarterial (TA) approach or, more recently, via direct tumorous puncture (DTP). Options for recurrent or residual disease may include revision surgery, radiotherapy or close clinical surveillance. The following case presentation describes the management of a recurrent JNA in an adult male using preoperative embolisation via a combination of TA and DTP embolisation and an open surgical resection via a subtemporal-preauricular infratemporal fossa approach.

Skull base chondroblastoma presenting as a deep lobe parotid tumour.

Chondroblastomas are rare, benign cartilage-producing primary bone tumours that account for 1% of all primary bone tumours. They are usually seen in young adult males and affect long tubulous bones such as the femur or humerus. Occurrences in non-tubular flat bones such as the craniofacial skeleton do occur but are seen in older adults. With only around 100 cases reported in the English literature, 'Temporal Bone Chondroblastomas' can present a diagnostic challenge for both surgeon and histopathologist. Clinical presentation can be subtle and patients may have longstanding symptoms due to compression of surrounding structures. Imaging in the form of contrast CT and/or MRI is recommended to assess size, proximity to neurovascular structures and plan operative approach. Definitive treatment is surgical excision, with radiotherapy reserved for recurrence or unfit surgical patients. Long-term follow-up is recommended for surveillance due to high recurrence rates. We present our experience managing this rare entity.

Embryonal rhabdomyosarcoma masquerading as a left vocal cord granuloma.

Embryonal rhabdomyosarcoma (ERMS) of the larynx in adults is an extremely rare diagnosis with insidious onset and progression. Only six reports (including this one) have been documented in the literature. Clinical presentation is dependent on the site, size, subtype of ERMS and growth rate. Hoarseness is the usual first symptom, followed by stridor and dyspnoea, with dysphagia being late in onset. Accurate staging and risk stratification is necessary to avoid overtreating/undertreating patients and should be guided by local Head and Neck/Sarcoma Multidisciplinary Teams. Treatment has moved away from radical therapeutic regimens to less-invasive, organ-preserving therapies. Long-term follow-up is required due to the risk of late recurrence.

Orbital abscess as a complication of Pott's puffy tumour in an adolescent male.

Pott's puffy tumour (PPT) is a known complication of frontal sinusitis. It is defined as subperiosteal abscess formation due to osteomyelitis of the frontal bone presenting as a forehead swelling. It is a life-threatening condition that can lead to intracranial and intraorbital complications. Gadolinium-enhanced MRI and contrast CT scan are the best modalities to localise and define the collection, in addition to confirming disease extension. Once confirmed by imaging and depending on disease extension, management of PPT requires a multidisciplinary team approach and depends on the local provision of surgical care. Following surgical drainage of the abscess cavity, a prolonged course of antibiotics is required postoperatively to treat the underlying osteomyelitis.