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.

Blinded comparison of computed tomography, ultrasound and needle methods to measure skin flap thickness for cochlear implantation.

PURPOSE: Patient suitability for cochlear implant (CI) devices compatible with magnetic resonance imaging and CI processor configuration is dependent on their retro-auricular skin flap thickness. This is typically measured intra-operatively using a needle and therefore patients are not guaranteed their implant of choice prior to surgery. We aimed to identify an accurate method to measure skin flap thickness pre-operatively to streamline CI selection and simplify the consent process. METHODS: Blinded prospective skin flap thickness measurements for patients undergoing CI surgery were recorded using pre-operative computed tomography (CT) and ultrasound (US), and intraoperative needle measurement. RESULTS: Fifty-six adult patients (36 females, 20 males; mean age 59 years) were included. The mean flap thickness was measured highest by CT (6.9 mm, 95% CI 6.5-7.3 mm), followed by US (6.3 mm, 95% CI 5.9-6.7 mm) and lastly needle (5.5 mm, 95% CI 5.1-5.9 mm) (p < 0.0001). A strong positive correlation (p < 0.001) was noted between all three modalities: CT vs needle (r = 0.869), US vs needle (r = 0.865), and CT vs US (r = 0.849). CONCLUSION: Accurate, non-invasive measurement of skin flap thickness prior to CI surgery can be achieved using CT or US. We recommend the routine use of US in the outpatient clinic to minimise unnecessary radiation exposure.

A comparison of imaging techniques to measure skin flap thickness in cochlear implant patients to enable pre-operative device selection.

OBJECTIVES: Magnetic resonance imaging (MRI)-compatible cochlear implants have weaker internal magnets than non-MRI-compatible devices. Their suitability for individual patients is limited by skin flap thickness, traditionally measured with a needle in the operating theatre. We aimed to establish the accuracy of imaging modalities to measure skin flap thickness pre-operatively, with the goal of streamlining device selection and simplifying the consent process. METHODS: Skin flap measurements were taken using ultrasound (US), computed tomography (CT) and MRI and compared for agreement with intra-operative needle measurement. RESULTS: Twenty-seven skin flaps were included. Absolute agreement between needle and imaging methods was low: needle/US: 44.4% (95% confidence interval [CI]: 27.7-62.7), needle/CT: 39.1% (95% CI: 22.2-59.2), needle/MRI: 20.8% (95% CI: 9.2-40.5). However, US and CT showed 95.7% agreement (95% CI: 76.0-99.8) with intraclass correlation of 0.996 (95% CI: 0.991-0.998) and narrow Bland-Altman limits of agreement (-0.37, 0.45 mm). BMI and skin flap thickness showed a significant positive correlation (rs = 0.664, P = 0.002) but no significant correlation was observed for age (P = 0.659). DISCUSSION: The high level of agreement between US and CT suggests that there are more accurate measurements of skin flap thickness compared with needle or MRI. Needle measurements are consistently smaller. CONCLUSION: The use of CT or US should be considered when making pre-operative device choices.

Higher Speciality Training Boot Camp in Otolaryngology: A Quantitative and Qualitative Analysis of the Northern National Formative Specialty Training 3 Induction Course.

Background Opportunities for new otolaryngology trainees to develop their skills as they embark on specialty training can be limited. Our facility hosted a national simulation-based boot camp for new otolaryngology trainees in the UK. This study aimed to assess the effectiveness of the boot camp in improving trainee confidence as they transitioned from core surgical training (CST) to higher specialty training (HST) in otolaryngology. Methodology We conducted a prospective study on the effectiveness of the boot camp on trainee induction. The boot camp included hands-on simulation, small group teaching and didactic lectures addressing technical skills in the fields of otology, laryngology, rhinology, facial plastics, and paediatrics, as well as non-technical skills involving human factors, simulated ward round, and cognitive simulation. The boot camp curriculum reflected the competencies expected by the Joint Committee of Surgical Training (JCST) at this level of training. Participants completed a pre- and post-course questionnaire addressing their self-confidence for the technical and non-technical skills they developed during the boot camp. All participants were invited to participate in an interview 12 months after the boot camp. Results A total of 27 new otolaryngology trainees (approximately half of all new otolaryngology trainees in the UK) participated in the boot camp. A significant increase in median confidence was observed for all technical and non-technical stations (p < 0.0001). The increase in confidence observed was similar for participants regardless of prior experience in otolaryngology. Five candidates were interviewed a year after the boot camp. Analysis of the transcripts generated distinct comments that were grouped into five key themes. Conclusions A simulation-based boot camp mapped to the JCST curriculum can increase the confidence of new otolaryngology Specialty Training 3 trainees during their transition from CST to HST. It can provide valuable and durable technical and non-technical skills to aid trainees in the clinic, theatre environment, and when on-call during their inaugural year of training.

Simultaneous bilateral cochlear implantation under local anaesthesia in a visually impaired adult with profound sensorineural deafness: A case report.

Objective: The National Institute of Clinical Excellence recommends that adult patients with severe to profound deafness are eligible for simultaneous bilateral cochlear implantation if they are blind or have other disabilities increasing their reliance on auditory stimuli. Cochlear implant (CI) surgery is routinely performed under general anaesthesia (GA), precluding patients who have higher risk associated with GA. Recent literature describes the safety and efficacy of performing unilateral CI surgery under local anaesthesia (LA). We report the first simultaneous bilateral CI under LA in the UK in an adult patient with profound sensorineural deafness and visual impairment.Case study: A 46-year-old gentleman, registered blind, presented with a 20-year history of bilateral progressive hearing loss. He was assessed as unfit for surgery under GA due to significant cardiac comorbidities. We performed simultaneous bilateral CI surgery under LA on the patient; he was discharged home the following day. Postoperative free field audiometry showed a significant improvement; speech discrimination using Bamford, Kowal and Bench sentences presented in quiet, increased from 0% pre-operatively to 100% four months post-operatively.Conclusion: Simultaneous bilateral CI surgery under LA is a safe and feasible procedure for eligible patients who may otherwise have been denied surgery due to their GA risk.