Cholesteatoma: a disease of the poor (socially deprived)?

Cholesteatoma is a condition describing the accumulation of squamous epithelium and keratinocytes within the middle ear space. There is conflicting evidence regarding the influence of socioeconomical status on the prevalence of cholesteatoma. Hospital episode statistics (HES) data detailing the numbers of cholesteatoma surgeries performed per area were compared with the Index of Multiple Deprivation 2010 (IMD 2010) data that give a statistical measure of deprivation per local health authority in the UK. Statistical analysis of this data was performed to identify correlations between prevalence of cholesteatoma and deprivation. A trend was identified showing that health authorities associated with an overall low IMD 2010 value indicating more deprived, had higher numbers of mastoid operations. Our results have found that increasing levels of deprivation are associated with greater numbers of mastoid operations and thus greater numbers of cholesteatomas. Our work suggests that there is a need for additional input in deprived areas to accommodate the increased numbers of mastoid operations and chronic middle ear disease.

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.

Optical Clearing Agents for Optical Imaging Through Cartilage Tympanoplasties: A Preclinical Feasibility Study.

HYPOTHESIS: Optical clearing agents (OCAs) can render cartilage tympanoplasty grafts sufficiently transparent to permit visualization of middle ear structures in an operated ear using optical coherence tomography (OCT) imaging. METHODS: Pieces of human tragal cartilage were treated with glycerol, a commonly used OCA. A reference reflector was imaged with OCT through the tympanoplasty as it cleared and the optical attenuation of the graft was measured. The reversibility of clearing and the dimensional changes associated with glycerol absorption were also measured. In a separate experiment, a human cadaveric temporal bone was prepared to simulate an ossiculoplasty surgery with cartilage replacement of the tympanic membrane. A partial ossicular replacement prosthesis (PORP) inserted in the ear was imaged with OCT through a 0.4mm cartilage graft optically cleared with glycerol. MAIN OUTCOME MEASURE: The optical attenuation of 0.4mm cartilage grafts decreased at 2.3+/-1.1 dB/min following treatment with glycerol, reaching a total decrease in attenuation of 13.6+/-5.9 dB after 7 minutes. The optical and dimensional effects of glycerol absorption were reversable following saline washout. In the temporal bone preparation, treatment of a cartilage graft with glycerol resulted in a 13 dB increase in signal-to-noise ratio and a 13 dB increase in contrast for visualizing the PORP through the graft with OCT. CONCLUSIONS: Optical clearing agents offer a potential pathway towards optical coherence tomography imaging of the middle ear in post-surgical ears with cartilage grafts.

Peripheral histological clearance of cutaneous BCC and SCC excised using the wet blotting technique.

INTRODUCTION: Accurate identification of the peripheral margin of cutaneous basal cell and squamous cell carcinomas plays a crucial role in ensuring complete excision of the skin cancer. The recommended margin of excision for cutaneous malignancies varies in the current guidelines. The aim of this study was to assess the success rate of peripheral margin clearance with a 4 mm peripheral margin of excision when the clinical margin of the lesion has been identified using the wet blotting technique. METHODS: The peripheral margin of each skin cancer was marked using the wet blotting technique and a 4-mm margin of excision rule was applied to all skin cancers regardless of their type and other clinical features. Data collection was performed from patients who were operated on over a period of 34 months (2011 to 2014). Information gathered included patient demographics, clinical details of the lesion and histopathological data. RESULTS: The total number of patients identified were 456. The case notes were reviewed and eventually 276 patients were included and 180 patients were excluded. The histology report showed 95-97% clearance of the peripheral margin in all BCCs and SCCs regardless of their clinical features and their location. CONCLUSIONS: Our study has shown that a standard rule of maintaining a 4 mm margin around all head and neck skin BCCs and SCCs, measured after the visible margin of the lesion had been accurately identified by the wet-blotting technique, can successfully achieve 95-97% peripheral clearance of all lesions, irrespective of the subtype, size and location.