Ear, nose and throat

Otitis media is just one example of a common and serious childhood illness with economic, social and environmental risk factors on track to escalate with the effects of climate change

Georgia M Tongs (Wiradjuri) · Isabella Ludbrook · Jennifer H Martin · Robert Eisenberg · Kelvin M Kong (Worimi)

Primary care clinicians are central to increased engagement and partnership with families in shared decision making

Valerie M Swift · Christopher G Brennan‐Jones

Shared decision making informed by the experience of parents and carers could reduce antibiotic use for managing acute otitis media

Jennifer S Reath · Sarah O'Brien · Letitia Campbell · Hasantha Gunasekera · Claudette A Tyson · Deborah A Askew · Wendy Hu · Tim Usherwood · Kelvin Kong · Peter Morris · Amanda J Leach · Robyn Walsh · Penelope A Abbott

New recommendations for primary care assessment of ear health and hearing status of young Aboriginal and Torres Strait Islander children

Samantha Harkus · Vivienne Marnane · Isabel O'Keeffe · Carmen Kung · Meagan Ward · Neil Orr · John Skinner · Kelvin Kong · Lose Fonua · Michelle Kennedy · Mary Belfrage

To the Editor: We write in response to Reid and colleagues’1 article on congenital cytomegalovirus (CMV). While many countries worldwide have established congenital CMV screening programs, Australia urgently needs to recognise the importance of targeted congenital CMV screening and tracking its outcomes. Our 2019–2020 study tested the feasibility and acceptability of a parent‐completed targeted congenital CMV saliva polymerase chain reaction (PCR) screening program in Victoria.2 Parents of infants who did not pass their newborn hearing screening at four Victorian maternity hospitals completed their infants’ saliva swabs in the hospital or at home. The program was feasible with a 76% participation rate, and all 96 swabs (100%) were completed within the required 21days from birth, despite the majority being completed at home. Furthermore, more than 90% of families found the screen easy to do, thought it was a good idea, and were glad their baby had congenital CMV screening. However, there were challenges: false positive screens due to CMV contamination in breast milk, and excessive time taken from completing the screen to return of results due to reliance on the only laboratory in the state accredited to process saliva CMV PCR. We now have the means to overcome these challenges, determine whether universal congenital CMV screening in Australia is warranted, and systematically track outcomes of targeted congenital CMV screening. For 2years from October 2021, Murdoch Children’s Research Institute’s Generation Victoria (GenV) is recruiting a whole‐of‐state infant–parent cohort, collecting over 110000 saliva swabs from newborns to test for CMV using novel CRISPR technology at the Walter and Eliza Hall Institute of Medical Research.3 Our study, funded by the National Health and Medical Research Council, will determine the population prevalence of congenital CMV, develop a rapid bedside point‐of‐care test for congenital CMV screening, and establish whether universal congenital CMV screening is cost‐effective. In addition, the Australasian Congenital CMV Registry has been recently established to track outcomes of congenital CMV.4 These initiatives will pave the way for Australia to emerge as a leader in congenital CMV screening, better recognise this undetected condition of public health importance, and provide personalised care to affected children.

Emma Webb · Cheryl A Jones · Valerie Sung

A 21-year-old man noticed a blackish discoloration of the tongue at day 6 of oral penicillin intake following the extraction of retained molars

Dennis A Nowak · Benjamin E Nowak

About two in three of participating urban Aboriginal infants had mild or moderate hearing loss at twelve months of age

Tamara Veselinović · Sharon A Weeks · Valerie M Swift · Deborah Lehmann · Christopher G Brennan‐Jones

The evolution of treatment for a distinctly Australian affliction

Alon Taylor · Hannah North · Narinder P Singh · Paul A Fagan

Australia lacks a comprehensive approach to CMV screening, and most infected infants go undiagnosed

Allison Reid · Asha C Bowen · Christopher G Brennan‐Jones · Jafri B Kuthubutheen

Workers at particular risk of tinnitus need targeted interventions that reduce its impact on their quality of life

Kate Lewkowski · Jane Heyworth · Elinor Ytterstad · Warwick Williams · Helen Goulios · Lin Fritschi

A 67-year-old man presented to his rural GP with left facial pain

Timothy R Holmes · Jenny L Hepschke · Ian Jacobson · Anthony Maloof

A 67-year-old woman was referred to our ear, nose and throat department with confirmed cerebrospinal fluid (CSF) rhinorrhoea

Sandeep G Mistry · Wallace Walker · James Earnshaw · Anders Cervin

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.

Amanda J Leach · Peter S Morris · Harvey LC Coates · Sandra Nelson · Stephen J O'Leary · Peter C Richmond · Hasantha Gunasekera · Samantha Harkus · Kelvin Kong · Christopher G Brennan‐Jones · Sam Brophy‐Williams · Kathy Currie · Sumon K Das · David Isaacs · Katherine Jarosz · Deborah Lehmann · Jarod Pak · Hemi Patel · Chris Perry · Jennifer S Reath · Jessica Sommer · Paul J Torzillo

Clinical record A 42‐year‐old woman presented to the Sunshine Coast University Hospital, Queensland, with a 5‐day history of odynophagia, orthopnoea and rapid onset of neck swelling over 12 hours. She had returned one week prior from a year‐long trip to Central America, Sri Lanka and Indonesia. Relevant past medical history included nephrotic syndrome due to minimal change disease, use of prednisolone 2.5 mg daily and previous treatment with rituximab. Childhood vaccinations were reported, but she had no booster travel vaccinations. On examination, she had right‐sided neck swelling, consistent with “bull neck” (Box, A), and an exudative right tonsil with a haemorrhagic component (Box, B). The patient had several healed skin lesions and a 2 cm non‐healing ulcer on her buttock. Flexible nasendoscopy showed supraglottic oedema with a patent airway. The diagnosis of diphtheria was strongly considered, with differentials including peritonsillar abscess and tonsillitis. Computed tomography scan of the neck demonstrated peritonsillar phlegmon and oedema in the parapharyngeal space, pre‐vertebral fat and subcutaneous neck tissues. She was commenced on intravenous benzylpenicillin, lincomycin and dexamethasone, was placed on contact and droplet precautions, and was admitted to the intensive care unit. Multiple tissue and swab samples were taken from the pharyngeal membrane and the buttock wound and urgently sent to the laboratory for culture into selective media. She underwent elective intubation 24 hours later due to worsening laryngeal oedema. Tissue and swabs from the pharyngeal membrane and sacral wound grew Corynebacterium diphtheriae. Diphtheria antitoxin (DAT) 100 000 IU was administered 36 hours into her admission. The isolates were confirmed to be toxigenic by polymerase chain reaction.1,2 The patient was discharged from the intensive care unit on Day 6. On Day 7, she developed anterior T wave inversions on her electrocardiogram, with an elevated troponin value (0.39 μg/L; reference range, < 0.040 μg/L). Her cardiac enzymes showed serial improvement. She developed a moderate glossopharyngeal and vagal palsy, which resolved after 3 weeks, and peripheral neuropathy, which resolved after 4 months. The cardiac and neurological sequelae were thought to be complications of pharyngeal diphtheria. The local Public Health Unit and the infection management service identified 12 staff and seven close community contacts. All contacts had nasal and throat swabs taken, were treated with oral erythromycin and were vaccinated where appropriate.3 Staff were excluded from work until returning negative throat and nasal cultures at 48–72 hours. Discussion Diphtheria is an acute pharyngeal or cutaneous infection caused by toxigenic strains of C. diphtheriae — a gram‐positive, non‐motile, non‐encapsulated bacillus.4 The infection spreads by respiratory droplets or direct contact with nasopharyngeal secretions or skin lesions. The incubation period of diphtheria is commonly 2–5 days. Data from the World Health Organization show that diphtheria is endemic to South‐East Asia, including Indonesia, Malaysia and the Philippines.5 Our case illustrates the need for a thorough travel history and administration of timely antitoxin therapy in suspected diphtheria cases to limit diphtheria‐related neurological and cardiovascular consequences. Diphtheria is rare in Australia after the widespread use of the effective vaccine following World War II, with most cases associated with sporadic importations. There have been seven cases of diphtheria reported since 2001, including one that was fatal in 2011.6 Diphtheria affects the upper respiratory tract, presenting with sore throat and cervical lymphadenopathy; a coating membrane forms in about a third of cases. Simultaneous infection of the skin and respiratory tract is uncommon. Accumulation of the C. diphtheriae organism within the membrane along with fibrin debris result in the appearance of a white pseudomembrane.4 The pathognomonic bull neck is caused by superficial oedema of neck tissues and is associated with a more severe course and higher mortality. The diphtheria toxin is produced by toxigenic strains of the bacterium and affects the cardiovascular, renal and nervous systems via haematogenous spread. The toxin is bound on cell surface receptors and acts to arrest protein synthesis.7 Toxin‐producing infections have a mortality rate between 5% and 10%.8 Diphtheritic myocarditis occurs in 10–20% of patients with pharyngeal diphtheria manifesting as ST disturbance, corrected QT interval (QTc) prolongation, or heart block.9 Cardiac abnormalities are associated with extensive respiratory tract involvement and bull neck appearance as well as neurological sequelae, which occur in 75% of patients with severe respiratory disease.4 Cranial nerve neuropathy develops first; often presenting as swallowing difficulties and resulting in aspiration. DAT and antibiotics should be administered promptly upon clinical suspicion. Early administration of DAT reduces circulating toxin load and reduces clinical sequelae.3 Our patient received DAT at 36 hours, yet significant neurological sequelae were observed up to 4 months later. Penicillin and/or erythromycin are the antimicrobials of choice; however, resistance has been described.10 Lessons from practice Diphtheria should be suspected in patients presenting with pseudomembranous tonsillitis, significant neck swelling and relevant travel history. It is important for clinicians to liaise with their local laboratory and Public Health Unit in suspicious cases so appropriate investigations and follow‐up can be established. Timely administration of diphtheria antitoxin is imperative and should not be delayed awaiting laboratory confirmation. Booster vaccinations should be considered before travel, particularly in patients who may have waning immunity. Box – “Bull neck” characteristic of diffuse cervical lymphadenopathy with tracheal deviation (A). Pseudomembrane coating right tonsil, soft palate and uvula on presentation (B)

Sarah Grigg · David Hogan · F Shaun Hosein · Dean Johns · Amy Jennison · Shradha Subedi

The fascinating history of the multichannel cochlear implant and its inventor, Professor Graeme Clark

Joyce PK Ho · Hannah North · Narinder P Singh

In settings with limited access to otolaryngologists, audiologists may appropriately select children for specialist review

Hasantha Gunasekera · Hilary M Miller · Leonie Burgess · Shingisai Chando · Simone L Sheriff · Julie D Tsembis · Kelvin M Kong · Harvey LC Coates · John Curotta · Kathleen Falster · Peter B McIntyre · Emily Banks · Natasha J Peter · Jonathan C Craig

We remain uncertain about which infants will benefit from surgical treatment

Jonathan Walsh · David E Tunkel

His gravelly voice became one of the successful politician’s most defining features

Evangelos Tseros · Faruque Riffat · Carsten E Palme · Hedley G Coleman · Narinder P Singh

A 15-year-old male presented with acute left forehead swelling and tenderness following a 1-month history of worsening headache secondary to extensive frontal sinusitis

Roza Nastovska · Lyn-Li Lim

29 June 1930 - 18 January 2017

Christine M Shearman

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Satvinder S Bakshi

The world is changing for older people left behind in their ancestral villages

Mahmood F Bhutta

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Basile N Landis · Urs Borner