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.

Infections following cochlear implantation.

Cochlear implantation has become routine in the management of children and adults with profound sensorineural hearing loss. In rare cases postoperative infections necessitate removal of the implant. We present six such cases that have been managed within our programme. Extensive infected granulation tissue was found around the implant at exploration despite prolonged intravenous treatment with appropriate antimicrobial agents. All devices were explanted and three have been reimplanted at our unit. We discuss our management of these cases, the need for explantation, consideration for reimplantation and their functional outcome following reimplantation. We also highlight how systemic inflammatory markers can be unhelpful in detecting significant infection surrounding a cochlear implant.

Retropharyngeal abscess from an unusual organism-Kingella denitrificans-in a patient on low-dose methotrexate.

Retropharyngeal abscess can be a life-threatening emergency with potential for airway compromise. We report a case of retropharyngeal abscess caused by Kingella denitrificans in a 66-year-old Caucasian man taking low-dose methotrexate for psoriatic arthritis. K denitrificans has not been previously reported as a cause of retropharyngeal abscess. K denitrificans, along with other Kingella species, is often found to be part of the normal upper respiratory tract flora. Potentially life-threatening complications of retropharyngeal abscess can occur in immunocompromised patients. Although complications of immunosuppression are thought to be rare with the use of low-dose pulse methotrexate for non-neoplastic conditions, such complications with prolonged use of low-dose pulse methotrexate may be seen.

Osteomyelitis of the ear canal caused by Staphylococcus lugdunensis.

Osteomyelitis of the temporal bone caused by Staphylococcus lugdunensis has never been reported before. This infection was diagnosed in a 51-year-old diabetic man. S. lugdunensis is an unusually virulent coagulase negative staphylococcus and has been implicated in a variety of severe infections. Considering the serious morbidity and mortality associated with osteomyelitis and in particular with S. lugdunensis, special awareness and alertness are required when otitis externa, which predisposes to osteomyelitis, is refractory to treatment.