Establishing a telehealth model addressing paediatric sleep health in remote and rural Northern Territory Australia: Overcoming the distance barrier.

AIM: This study examined the outcomes of a telehealth model for sleep health assessment among Indigenous and non-Indigenous children residing in remote and regional communities at the Top End Northern Territory (NT) of Australia. METHODS: Video telehealth consultation, that included clinical history and relevant physical findings assessed virtually with an interstate paediatric sleep physician was conducted remotely. Polysomnography (PSG) and therapeutic interventions were carried out locally at Darwin, NT. The study participants were children referred between 2015 and 2020. RESULTS: Of the total 812 children referred for sleep assessment, 699 underwent a diagnostic PSG. The majority of patients were female (63%), non-Indigenous (81%) and resided in outer regional areas (88%). Indigenous children were significantly older and resided in remote or very remote locations (22% vs. 10%). Referral patterns differed according to locality and Indigenous status - (non-Indigenous via private (53%), Indigenous via public system (35%)). Receipt of referrals to initial consultation was a median of 16 days and 4 weeks from consult to PSG. Remote children had slightly longer time delay between the referral and initial consult (32 vs. 15 days). Fifty one percent were diagnosed to have OSA, 27% underwent adenotonsillectomy and 2% were prescribed with CPAP therapy. CONCLUSIONS: This study has demonstrated that a telehealth model can be an effective way in overcoming logistical barriers and in providing sleep health services to children in remote and regional Australia. Further innovative efforts are needed to improve the service model and expand the reach for vulnerable children in very remote communities.

Otitis media guidelines for Australian Aboriginal and Torres Strait Islander children: summary of recommendations.

INTRODUCTION: The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. MAIN RECOMMENDATIONS: We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINES: A GRADE approach is used. Targeted recommendations for both high and low risk children. New tympanostomy tube otorrhoea section. New Priority 5 for health services: annual and catch-up ear health checks for at-risk children. Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children. Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration. Concurrent audiology and surgical referrals are recommended where delays are likely. Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis. The use of autoinflation devices is recommended for some children with persistent otitis media with effusion. Definitions for mild (21-30 dB) and moderate (> 30 dB) hearing impairment have been updated. New "OMapp" enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.

Malignant otitis externa in Australian Aboriginal patients: A 9-year retrospective analysis from the Northern Territory.

OBJECTIVE: In the Australian Aboriginal population, type 2 diabetes occurs at a much higher prevalence, with a much younger age of onset of the disease and its complications. Despite the clear association with malignant otitis externa, no previous studies have examined malignant otitis externa in this population. This study explores the pattern of malignant otitis externa amongst Australian Aboriginal patients in the Northern Territory. DESIGN: Retrospective case series. SETTING: Otolaryngology unit in a tertiary referral hospital in Northern Territory, Australia. PARTICIPANTS: Patients admitted with malignant otitis externa between January 2007 and October 2016 were identified by reviewing case notes. Patients diagnosed with malignant otitis externa based on results from clinical, microbiological and radiological criteria were included. MAIN OUTCOME MEASURES: Complications rates, duration of hospital stay and parenteral antibiotics, age of onset and causative organisms. RESULTS: Nine patients were included. Six were Australian Aboriginal - all from regional centres. The most common causative organism was Pseudomonas aeruginosa. There was a higher-than-expected occurrence of fungal malignant otitis externa (33% of Australian Aboriginal patients), who tended to be younger at diagnosis, had longer hospital stays and had a higher disease-specific mortality. Over half of the patients did not receive follow-up gallium bone scans to monitor disease resolution, reflecting the limitations of rural health care. CONCLUSION: Malignant otitis externa in the Australian Aboriginal population is a challenging disease with high complication and mortality rates. Their rural and remote distribution is a significant barrier to specialist investigation and care. Providing effective care for this disease requires improved access to high-quality primary health care and tertiary specialist services.

Myiasis of the ear: a review with entomological aspects for the otolaryngologist.

OBJECTIVE: Myiasis is the infestation of live humans (or animals) by fly larvae. Although the diagnosis is relatively straightforward, how to best treat aural myiasis has not been well described in the literature. This comprehensive literature review, therefore, was performed to identify current management principles in aural myiasis, especially with regard to the causative fly family. In addition, we explore the possible relationship between aural myiasis and the highly lethal intracranial myiasis. DATA SOURCES: Literature review using the Medline database (PubMed), Scopus, and Google Scholar. REVIEW METHODS: Manuscripts published in the English language between January 1, 1992, and December 31, 2012, were included. RESULTS: Forty-five cases of aural myiasis were reported in 34 manuscripts. Most cases were caused by species of the Sarcophagidae family (n=26/45, 57.8%). The majority of cases (n=40/45, 88.9%) were successfully treated with simple aural toilet and topical treatments alone. No deaths were reported and no cases were seen in conjunction with intracranial myiasis. CONCLUSION: Aural myiasis is a rare but benign fly infestation of the ear, most commonly by species of the Sarcophagidae family. The overwhelming majority of cases can be successfully managed without the need for surgical intervention.

Inter-rater agreement between 13 otolaryngologists to diagnose otitis media in Aboriginal and Torres Strait Islander children using a telehealth approach.

INTRODUCTION: Telehealth programs are important to deliver otolaryngology services for Aboriginal and Torres Strait Islander children living in rural and remote areas, where distance and access to specialists is a critical factor. OBJECTIVE: To evaluate the inter-rater agreement and value of increasing levels of clinical data (otoscopy with or without audiometry and in-field nurse impressions) to diagnose otitis media using a telehealth approach. DESIGN: Blinded, inter-rater reliability study. SETTING: Ear health and hearing assessments collected from a statewide telehealth program for Indigenous children living in rural and remote areas of Queensland, Australia. PARTICIPANTS: Thirteen board-certified otolaryngologists independently reviewed 80 telehealth assessments from 65 Indigenous children (mean age 5.7 ± 3.1 years, 33.8% female). INTERVENTIONS: Raters were provided increasing tiers of clinical data to assess concordance to the reference standard diagnosis: Tier A) otoscopic images alone, Tier B) otoscopic images plus tympanometry and category of hearing loss, and Tier C) as B plus static compliance, canal volume, pure-tone audiometry, and nurse impressions (otoscopic findings and presumed diagnosis). For each tier, raters were asked to determine which of the four diagnostic categories applied: normal aerated ear, acute otitis media (AOM), otitis media with effusion (OME), and chronic otitis media (COM). MAIN OUTCOME MEASURES: Proportion of agreement to the reference standard, prevalence-and-bias adjusted κ coefficients, mean difference in accuracy estimates between each tier of clinical data. RESULTS: Accuracy between raters and the reference standard increased with increased provision of clinical data (Tier A: 65% (95%CI: 63-68%), κ = 0.53 (95%CI: 0.48-0.57); Tier B: 77% (95%CI: 74-79%), 0.68 (95%CI: 0.65-0.72); C: 85% (95%CI: 82-87%), 0.79 (95%CI: 0.76-0.82)). Classification accuracy significantly improved between Tier A to B (mean difference:12%, p < 0.001) and between Tier B to C (mean difference: 8%, p < 0.001). The largest improvement in classification accuracy was observed between Tier A and C (mean difference: 20%, p < 0.001). Inter-rater agreement similarly improved with increasing provision of clinical data. CONCLUSIONS: There is substantial agreement between otolaryngologists to diagnose ear disease using electronically stored clinical data collected from telehealth assessments. The addition of audiometry, tympanometry and nurse impressions significantly improved expert accuracy and inter-rater agreement, compared to reviewing otoscopic images alone.

An Artificial Intelligence Computer-vision Algorithm to Triage Otoscopic Images From Australian Aboriginal and Torres Strait Islander Children.

OBJECTIVE: To develop an artificial intelligence image classification algorithm to triage otoscopic images from rural and remote Australian Aboriginal and Torres Strait Islander children. STUDY DESIGN: Retrospective observational study. SETTING: Tertiary referral center. PATIENTS: Rural and remote Aboriginal and Torres Strait Islander children who underwent tele-otology ear health screening in the Northern Territory, Australia between 2010 and 2018. INTERVENTIONS: Otoscopic images were labeled by otolaryngologists to classify the ground truth. Deep and transfer learning methods were used to develop an image classification algorithm. MAIN OUTCOME MEASURES: Accuracy, sensitivity, specificity, positive predictive value, negative predictive value, area under the curve (AUC) of the resultant algorithm compared with the ground truth. RESULTS: Six thousand five hundred twenty seven images were used (5927 images for training and 600 for testing). The algorithm achieved an accuracy of 99.3% for acute otitis media, 96.3% for chronic otitis media, 77.8% for otitis media with effusion (OME), and 98.2% to classify wax/obstructed canal. To differentiate between multiple diagnoses, the algorithm achieved 74.4 to 92.8% accuracy and an AUC of 0.963 to 0.997. The most common incorrect classification pattern was OME misclassified as normal tympanic membranes. CONCLUSIONS: The paucity of access to tertiary otolaryngology care for rural and remote Aboriginal and Torres Strait Islander communities may contribute to an under-identification of ear disease. Computer vision image classification algorithms can accurately classify ear disease from otoscopic images of Indigenous Australian children. In the future, a validated algorithm may integrate with existing telemedicine initiatives to support effective triage and facilitate early treatment and referral.

Are trainees being adequately taught myringoplasty? A prospective study of Eastern Deanery otolaryngology trainees' surgical experience.

Reviewing surgical training is an important function of a modern ENT unit, even more so following recent reform of postgraduate medical training in the UK. We have developed a tool to review otology training of Eastern Deanery trainees by constructing a middle ear surgery data base and use a commonly performed procedure, myringoplasty, to illustrate its function. Three hundred and ninety-three myringoplasty operations were identified between March 2002 and March 2006, of which 307 were included in this study as having had a myringoplasty alone uncomplicated by another middle ear procedure. Perforation closure was successful in 83% of these cases with 90% of patients experiencing a beneficial outcome regardless of supervision level. Trainees at all stages of training are being exposed to myringoplasty with an adequate de-escalation of supervision. Myringoplasty outcomes are independent of seniority, if appropriately supervised, implying that otology training in the Eastern Deanery is appropriate.

Outcomes of primary myringoplasty in indigenous children from the Northern Territory of Australia.

AIM: To report the surgical and audiological outcomes of myringoplasty (Type I tympanoplasty) in Indigenous Australian children living in remote and regional communities in northern Australia. METHOD: An observational cohort study, with prospective recording of the details of surgery. Audiological outcomes were collected independently, and these data were integrated in the present study. Children aged 5-18 year underwent myringoplasty in the Northern Territory during a program initiated by the Australian Government. Surgery was performed by surgeons drawn from across Australia. RESULTS: 412 primary myringoplasties were performed. The mean age at surgery was 11 years. The tympanic membrane was closed in 64.2% of cases. Fascial grafting was associated with greater surgical success than cartilage. Dryness of the ear at surgery did not affect drum closure. Post-operative aural discharge was half that reported in historical literature. Surgical success was independent of the patient's age at surgery. Post-operative audiograms were available on 216 cases. At last review, hearing had improved even when the operation was not a surgical success, with hearing aid candidacy falling from 84 to 34%. Hearing was similar irrespective of the size of the perforation at surgery or the graft used and did not change with the time between surgery and review. The best hearing was associated with drum closure and Types A or C tympanograms. A conductive hearing loss persisted after surgery that was greater when there was an immobile drum. CONCLUSIONS: Indigenous children benefited from myringoplasty, even when the operation was not a "surgical success" as deemed by drum closure. There lower incidence of post-operative discharge from persistent perforations suggests an improvement in the ear health of the population. A persistent conductive loss persists, likely a consequence of the underlying disease but possibly from the surgery.

Povidone-iodine ear wash and oral cotrimoxazole for chronic suppurative otitis media in Australian aboriginal children: study protocol for factorial design randomised controlled trial.

BACKGROUND: Chronic suppurative otitis media (CSOM) is a significant health issue affecting Aboriginal Australians. Long-term hearing loss can cause communication problems, educational disadvantage, and social isolation. Current standard treatment for CSOM in our region is twice daily dry mopping of the pus from the ear canal followed by instillation of ciprofloxacin antibiotic ear drops for up to 16 weeks, or until the discharge resolves for a period of 3 days. The treatment is long, laborious and fails to resolve ear discharge in 70% of cases in remote communities. Bacterial pathogens also persist. Povidone-iodine ear wash is the preferred method of clearing ear discharge in Western Australia. However, evidence of its effectiveness is lacking. In systematic reviews, topical antibiotics (ciprofloxacin) have been shown to be more effective than oral antibiotics or topical antiseptics. Currently, it is unclear whether there are any benefits of combining these treatments. METHODS: This protocol describes a 2 × 2 factorial randomised controlled trial of two different interventions (povidone-iodine ear wash and oral cotrimoxazole), given as adjunctive therapy to standard treatment for CSOM. 280 children, between 2 months and 17 years of age, Indigenous or non-Indigenous, living in participating Northern Territory (NT) communities are randomised to standard treatment (dry mopping and ciprofloxacin drops) plus one of two topical treatments (dilute povidone-iodine ear wash or no wash) and one of two oral medication treatments (16 weeks of cotrimoxazole or placebo). DISCUSSION: Current treatment of CSOM in our region shows that eradication of bacterial pathogens from the middle ear space and dry ears is often not achieved. This trial will evaluate the efficacy of adjunctive treatments of antiseptic ear washes and oral antibiotics. Clinical, microbiological and hearing outcomes will be reported. TRIAL REGISTRATION: This trial (ACTRN12614000234617) was registered with ANZCTR on 05 April 2014.

A novel use of photo messaging in the assessment of nasal fractures.

We evaluated a new method of assessing patients referred to the otolaryngology department with nasal injury. Patients possessing a mobile phone with built-in camera took an image of their face and sent it to the department for assessment. A decision was then made as to whether the patient needed further consultation or treatment. This method of nasal fracture assessment might avoid unnecessary referrals to the department. A prospective single blinded study was carried out. Twenty-five patients with a nasal injury took photographs of their face using a mobile phone camera. These images were reviewed and assessment made about whether a nasal fracture was present. The patient was then clinically assessed, the clinical examination being the 'gold standard' method of assessment. There was little agreement between photographic and clinical assessment. Sixty-two percent of patients who were clinically assessed to have a nasal fracture requiring manipulation were not picked up on assessment of their image. The greatest agreement with clinical assessment was the patient's own opinion as to whether there was new deviation of their nasal bone.

Disseminated melioidosis in the head and neck.

A 35-year-old man was admitted to an intensive care unit with unilateral facial swelling and septic shock after multiple presentations to the emergency department with non-specific unilateral pain over the parotid area. A CT scan of his neck showed diffuse right-sided facial soft tissue infection, mastoid effusion and temporal lobe cerebritis. The upper lobes of his lungs had cannonball lesions that were suggestive of septic lung metastases. Blood cultures and ear canal swabs were positive for Burkholderia pseudomallei The temporal lobe cerebritis eventually developed into an abscess, necessitating a cortical mastoidectomy, craniectomy and temporal lobectomy. After the surgical interventions, antibiotic therapy was continued for a further 6 months. The patient remained well and had no signs of recurrence up to 7 months after the initial presentation.

Insular carcinoma arising on a background of follicular carcinoma, thyrolipomatosis and amyloid goitre.

A 67-year-old man was referred with a history of a right-sided neck lump and dysphonia, secondary to a lesion in the thyroid gland. After undergoing a total thyroidectomy, he was found to have an exceedingly rare combination of follicular carcinoma, insular carcinoma, thyrolipomatosis and an amyloid goitre in his thyroid gland. He subsequently underwent further radioactive iodine ablation and has been in remission. He was also later incidentally diagnosed with systemic amyloidosis, which explained the amyloid deposition in his thyroid gland.

A prospective randomised controlled trial comparing Merocel and Rapid Rhino nasal tampons in the treatment of epistaxis.

A prospective study was performed to compare the efficacy and patient tolerance of Merocel and Rapid Rhino nasal tampons in the treatment of epistaxis. A total of 42 patients were studied. There was no significant difference between the two types of pack in efficacy or patient discomfort with pack in situ. Rapid Rhino produced significantly lower scores for subjective patient discomfort during insertion and removal of pack.