Evaluating a Questionnaire in Telephone Balance Consultations during the Coronavirus Disease 2019 Pandemic

INTRODUCTION

During the coronavirus disease 2019, pandemic clinical practice had to change, and this study trialled a diagnostic questionnaire to assess patients with dizziness over the telephone.

METHODS

All 115 patients awaiting otorhinolaryngological assessment for balance were randomised to receive a dizziness questionnaire in the post prior to their telephone consultation or not. Consultation outcomes were recorded by the clinicians conducting the consultation. Follow-up data were collected in June 2022 for final outcomes.

RESULTS

82/115 patients had consultations with complete data collection: 35 in the questionnaire group (QG) and 47 in the no questionnaire group (NQG), with a 70% response rate in the QG. Clinicians made a diagnosis in 27/35 QG consultations versus 27/47 NQG consultations. Nine out of 35 QG patients required additional investigations compared to 34/47 in the NQG (p < 0.05). Only 6/35 QG patients needed additional telephone follow-up, compared to 20/47 NQG patients (p < 0.05).

CONCLUSION

Using a diagnostic questionnaire increased clinicians' ability to come to a diagnosis in telephone consultations.

Evidence-Based Guideline for the diagnosis and management of eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, characterized by asthma, eosinophilia and granulomatous or vasculitic involvement of several organs. The diagnosis and management of EGPA are often challenging and require an integrated, multidisciplinary approach. Current practice relies on recommendations and guidelines addressing the management of ANCA-associated vasculitis and not specifically developed for EGPA. Here, we present evidence-based, cross-discipline guidelines for the diagnosis and management of EGPA that reflect the substantial advances that have been made in the past few years in understanding the pathogenesis, clinical subphenotypes and differential diagnosis of the disease, as well as the availability of new treatment options. Developed by a panel of European experts on the basis of literature reviews and, where appropriate, expert opinion, the 16 statements and five overarching principles cover the diagnosis and staging, treatment, outcome and follow-up of EGPA. These recommendations are primarily intended to be used by healthcare professionals, pharmaceutical industries and drug regulatory authorities, to guide clinical practice and decision-making in EGPA. These guidelines are not intended to limit access to medications by healthcare agencies, nor to impose a fixed order on medication use.

Acute otitis externa: Consensus definition, diagnostic criteria and core outcome set development

OBJECTIVE

Evidence for the management of acute otitis externa (AOE) is limited, with unclear diagnostic criteria and variably reported outcome measures that may not reflect key stakeholder priorities. We aimed to develop 1) a definition, 2) diagnostic criteria and 3) a core outcome set (COS) for AOE.

STUDY DESIGN

COS development according to Core Outcome Measures in Effectiveness Trials (COMET) methodology and parallel consensus selection of diagnostic criteria/definition.

SETTING

Stakeholders from the United Kingdom.

SUBJECTS AND METHODS

Comprehensive literature review identified candidate items for the COS, definition and diagnostic criteria. Nine individuals with past AOE generated further patient-centred candidate items. Candidate items were rated for importance by patient and professional (ENT doctors, general practitioners, microbiologists, nurses, audiologists) stakeholders in a three-round online Delphi exercise. Consensus items were grouped to form the COS, diagnostic criteria, and definition.

RESULTS

Candidate COS items from patients (n = 28) and literature (n = 25) were deduplicated and amalgamated to a final candidate list (n = 46). Patients emphasised quality-of-life and the impact on daily activities/work. Via the Delphi process, stakeholders agreed on 31 candidate items. The final COS covered six outcomes: pain; disease severity; impact on quality-of-life and daily activities; patient satisfaction; treatment-related outcome; and microbiology. 14 candidate diagnostic criteria were identified, 8 reaching inclusion consensus. The final definition for AOE was 'diffuse inflammation of the ear canal skin of less than 6 weeks duration'.

CONCLUSION

The development and adoption of a consensus definition, diagnostic criteria and a COS will help to standardise future research in AOE, facilitating meta-analysis. Consulting former patients throughout development highlighted deficiencies in the outcomes adopted previously, in particular concerning the impact of AOE on daily life.

Updates in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis for the ENT surgeon

ENT involvement is common in ANCA-associated vasculitis (AAV), particularly in GPA and EGPA. Early recognition and treatment is important for good outcomes, yet evidence suggests that UK ENT surgeons may not consistently recognise the early features of AAV, despite a similar incidence to vestibular schwannoma. AAV is a rapidly advancing field, with significant developments in the understanding of its pathogenesis, classification and treatment over the past decade. Relevant vasculitis mimics are also discussed with a particular focus on the increasing prevalence of vasculitis mimics driven by an increase in recreational cocaine use, as well as the emergence and reclassification of several other vasculitis mimics in the head and neck. This article reviews key recent updates in the vasculitis literature, with a particular focus on those relevant to recognition and diagnosis of AAV for the ENT surgeon. Strengths and limitations of relevant diagnostic testing are discussed, and a method of evaluation of patients with features of AAV presenting to ENT services is outlined.

The composition and functional protein subsystems of the human nasal microbiome in granulomatosis with polyangiitis: a pilot study

BACKGROUND

Ear, nose and throat involvement in granulomatosis with polyangiitis (GPA) is frequently the initial disease manifestation. Previous investigations have observed a higher prevalence of Staphylococcus aureus in patients with GPA, and chronic nasal carriage has been linked with an increased risk of disease relapse. In this cross-sectional study, we investigated changes in the nasal microbiota including a detailed analysis of Staphylococcus spp. by shotgun metagenomics in patients with active and inactive granulomatosis with polyangiitis (GPA). Shotgun metagenomic sequence data were also used to identify protein-encoding genes within the SEED database, and the abundance of proteins then correlated with the presence of bacterial species on an annotated heatmap.

RESULTS

The presence of S. aureus in the nose as assessed by culture was more frequently detected in patients with active GPA (66.7%) compared with inactive GPA (34.1%). Beta diversity analysis of nasal microbiota by bacterial 16S rRNA profiling revealed a different composition between GPA patients and healthy controls (P = 0.039). Beta diversity analysis of shotgun metagenomic sequence data for Staphylococcus spp. revealed a different composition between active GPA patients and healthy controls and disease controls (P = 0.0007 and P = 0.0023, respectively), and between healthy controls and inactive GPA patients and household controls (P = 0.0168 and P = 0.0168, respectively). Patients with active GPA had a higher abundance of S. aureus, mirroring the culture data, while healthy controls had a higher abundance of S. epidermidis. Staphylococcus pseudintermedius, generally assumed to be a pathogen of cats and dogs, showed an abundance of 13% among the Staphylococcus spp. in our cohort. During long-term follow-up of patients with inactive GPA at baseline, a higher S. aureus abundance was not associated with an increased relapse risk. Functional analyses identified ten SEED protein subsystems that differed between the groups. Most significant associations were related to chorismate synthesis and involved in the vitamin B₁₂ pathway.

CONCLUSION

Our data revealed a distinct dysbiosis of the nasal microbiota in GPA patients compared with disease and healthy controls. Metagenomic sequencing demonstrated that this dysbiosis in active GPA patients is manifested by increased abundance of S. aureus and a depletion of S. epidermidis, further demonstrating the antagonist relationships between these species. SEED functional protein subsystem analysis identified an association between the unique bacterial nasal microbiota clusters seen mainly in GPA patients and an elevated abundance of genes associated with chorismate synthesis and vitamin B₁₂ pathways. Further studies are required to further elucidate the relationship between the biosynthesis genes and the associated bacterial species.

A Case of Cutaneous Malakoplakia in the Head and Neck Region and Review of the Literature

Malakoplakia is a rare inflammatory condition that typically occurs in the urinary tract. The cutaneous form is less prevalent, and most commonly occurs in the perianal or genital regions. Here we present a 61 year old lady with cutaneous malakoplakia of the neck, which was successfully treated with surgical excision and a prolonged course of ciprofloxacin. We follow our case report with a discussion and literature review of all seventeen previously reported cutaneous head and neck malakoplakia cases from the literature. A diagnosis of cutaneous malakoplakia should be considered in nodular, ulcerated or discharging lesions that are refractory to treatment. Histology is essential, not only to diagnose malakoplakia, but also to exclude other important differential diagnoses, such as malignancy. Combined surgical excision and prolonged antibiotic courses appear to have the highest success rate. Antibiotics should be culture specific, but quinolones appear to be the best empirical choice.

Radiologically predicting when a sternotomy may be required in the management of retrosternal goiters

OBJECTIVES

Surgery remains the most effective treatment for retrosternal goiters. These commonly present as asymptomatic lesions in elderly patients, but may also cause airway and esophageal compression and, less commonly, may also be malignant. Although the majority of these goiters are amenable to transcervical thyroidectomy, in a minority of patients sternotomy is required. The ability to predict the need for sternotomy before operation would allow for safer surgery and operative counseling, as well as improved logistical efficiency if coordination with thoracic surgeons is required. In this report, we assess the radiologic factors that might be predictive of the need for sternotomy.

METHODS

We performed a retrospective review of 97 retrosternal goiters for which thyroidectomy was performed within the otolaryngology department at Addenbrooke's Hospital, Cambridge, between 2001 and 2011. There were a total of 80 cervical excisions and 17 cases in which sternotomy was required. A detailed computed tomographic analysis of these 17 cases was undertaken to assess the predictive factors for the requirement of sternotomy. The factors assessed included posterior mediastinal extension, presence of an ectopic nodule, extension below the carina, extension below the aortic arch, a "conical shape" of the goiter, and tracheal compression. These were compared to the same factors in the control group of 80 patients, and Fisher's exact test was used to determine statistical significance.

RESULTS

The significant predictive factors for sternotomy, were posterior mediastinal extension, extension below the carina, and a "conical" goiter in which the thoracic inlet becomes a ring of constriction (all p < 0.05).

CONCLUSIONS

Our results suggest that it is possible to predict on the basis of computed tomographic imaging the need for sternotomy in retrosternal goiters.

A disease activity score for ENT involvement in granulomatosis with polyangiitis (Wegener's)

OBJECTIVES/HYPOTHESIS

Accurate assessment of disease activity in patients with otorhinolaryngological manifestations of granulomatosis with polyangiitis (Wegener's) (ENT/GPA) is necessary for treatment decisions and clinical trials. We have designed a disease activity score (ENT/GPA DAS) for this purpose.

STUDY DESIGN

A prospective cross-sectional study.

METHODS

GPA patients seen in a tertiary center were systematically assessed for disease activity and/or infection in the ear, nose, and throat region using European Vasculitis Study Group guidelines. An ENT disease activity score was developed and validated, and compared to the ENT domain of the Birmingham Vasculitis Activity Score (ENT/BVAS).

RESULTS

One hundred forty-four patients were studied, of whom 87% (125/144) had ENT involvement. ENT items of disease activity were correlated with expert clinical assessment. Discriminant correlation tests were performed to control for infection. Six items were retained to form the ENT/GPA DAS: reported bloody rhinorrhoea, granulation, ulcers and/or friable mucosa in the upper airway on endoscopic evaluation, objective stridor, sudden sensorineural hearing loss, and inflamed tympanic membrane/middle ear without infection. Nasal crusting was excluded. Individual items of ENT/GPA DAS had higher sensitivities and comparable specificities in predicting disease activity than ENT/BVAS items. Overall ENT/GPA DAS demonstrated higher sensitivity and lower specificity for disease activity in ENT/GPA when compared to overall ENT/BVAS.

CONCLUSIONS

A tool to assess ENT disease activity in GPA has been developed. It is potentially superior to existing tools but requires further testing for intra- and interobserver reliability.

Hearing improvement in a growing vestibular schwannoma

Vestibular schwannomas are benign, slow-growing tumors that originate from Schwann cells lining the vestibular nerves, most commonly the superior vestibular nerve. They arise at the neurilemmal/neuroglial junction which is situated within the internal auditory canal. They have an incidence of 1 per 100,000 per year and a prevalence of around 700 per million. A case of a patient undergoing a period of observation for a vestibular schwannoma whose hearing improved despite growth of the tumor is described. This raises interesting questions regarding the pathophysiology of hearing loss in patients with vestibular schwannomas. Possible hypotheses are discussed.

Long-term damage to the ENT system in Wegener's granulomatosis

The objectives of the study are to describe long-term ENT damage and assess risk factors in patients with newly diagnosed and treated Wegener's granulomatosis (WG) using the vasculitis damage index (VDI). Data from four randomised controlled trials carried out by the European Vasculitis Study Group was used. Patients newly diagnosed with WG with complete data at 5 years were included. Patients enrolled into the trials without 5-year data were excluded. Total and ENT VDI scores were recorded at 12 months and after at least 5 years. Logistic regression models were constructed to assess risk factors using total ENT and overall VDI score over the follow-up period, the proportion of patients with increased VDI score and the presence or absence of damage as the main outcomes. One hundred and thirty-eight patients were included. Ninety patients (65%) had long-term damage and 81% of these (73/90) developed some damage in the first 12 months. Positive ENT activity score (BVAS) at baseline and relapses were associated with higher ENT VDI scores long-term (OR = 6.90, 95% CI 2.01-23.75; OR = 2.65, 95% CI 1.20-5.82). Increasing BVAS score showed a trend towards lower VDI scores (OR = 0.93, 95% CI 0.88-0.99). Only ENT relapses and number of relapses were associated with an increase in VDI over time (OR = 8.38, 95% CI 3.10-22.68; OR = 1.79, 95% CI 1.24-2.58). In conclusion, most of the ENT damage in these patients was accrued within 12 months of diagnosis. We have shown an association between later ENT damage and the presence of ENT disease at baseline; lower initial BVAS and higher rate of disease relapse.