Ear, nose and throat

n/a

Laura Lamprell MB BS(Hons), BSc · David Wright MB BS, FRACS

PATIENTS COMMONLY have problems in the mouth, nose and throat. This new book by Geoffrey Quail, who is Clinical Associate Professor at the Department of Surgery, Monash University, Melbourne, and Director of the Dental and Maxillofacial Surgery Unit at Southern Health, Melbourne, provides clear and succinct information on the diagnosis of conditions affecting these areas. It will be helpful to anyone who needs an illustrated and ...

Michael Barakate

Objective: To review patients with severe bilateral vestibular loss associated with gentamicin treatment in hospital. Design and setting: A retrospective case series of presentations to a balance disorders clinic between 1988 and 2010. Main outcome measures: Relationship between vestibulotoxicity and gentamicin dose or dosing profile; indications for prescribing gentamicin. Results: 103 patients (age, 18–84 years; mean, 64 years) presented with imbalance, oscillopsia or both, but none had vertigo. Only three noted some hearing impairment after having gentamicin, but audiometric thresholds for all patients were consistent with their age. In all patients, the following tests gave positive results: a bilateral clinical head-impulse test, a vertical head-shaking test for vertical oscillopsia, and a foam Romberg test. In 21 patients, imbalance occurred during gentamicin treatment (ignored or dismissed by prescribers in 20) and in 66 after treatment; the remaining 16 could not recall when symptoms were first noticed, except that it was after gentamicin treatment in hospital. Total gentamicin dose range was 2–318 mg/kg (mean, 52 mg/kg), daily dose range was 1.5–5.6 mg/kg (mean, 3.5 mg/kg), and duration was 1–80 days (mean, 17 days). Six patients had only a single dose; 26 had five or fewer doses. Serum gentamicin levels, measured in 82 patients, were in the recommended range in 59. Time to diagnosis ranged from 4 days to 15 years. Nephrotoxicity developed in 43 patients. Gentamicin dosage complied with contemporary or current Australian antibiotic guidelines in under half the patients. Conclusions: Gentamicin ototoxicity is vestibular, not cochlear, producing permanent loss of balance, but not of hearing. Gentamicin can be vestibulotoxic in any dose, in any regimen, at any serum level.

Rebekah M Ahmed MB BS, FRACP · Imelda P Hannigan RN · Hamish G MacDougall PhD · Raymond C Chan MB BS, FRACP, FRCPA · G Michael Halmagyi MD, FRACP

This is the first reported Australian case of synovial sarcoma of the pharynx. A 29-year-old man had a large hypopharyngeal mass excised and received radiotherapy and chemotherapy. No recurrence was seen 12 months later. Clinical recordA 29-year-old man presented to the emergency department with stridor and a background of progressive globus sensation, loud snoring and worsening dysphagia over 2 years. He had not suffered weight loss, and past medical history was otherwise unremarkable. Flexible endoscopy examination revealed a well circumscribed, encapsulated tumour arising from the left lower lateral wall of the oropharynx and hypopharynx, and from the left arytenoid on its posterior aspect (Box 1). Computed tomography (CT) scanning revealed a 3 × 4.1 cm soft tissue mass arising from the left pharyngeal wall just inferior to the tonsillar fossa (Box 2). Endoscopic laser resection (microlaryngoscopy) was carried out with several scopes, including a bivalved speculum and a Boyle–Davis gag to gain full exposure. The capsule was broken at its deep aspect; however, macroscopic clearance was achieved with dissection down to healthy muscle. The patient made an uneventful recovery and was discharged on Day 3. Histopathological analysis revealed a well circumscribed tumour that measured 8 × 4 × 3 cm and was composed of relatively uniform spindle cells showing frequent mitotic activity. The tumour showed focal necrosis and focal calcification. The posterior surface was raw, suggesting incomplete margins. The cells stained positively for vimentin and CD99, and occasional cells stained positively for cytokeratin AE1/AE3 and epithelial membrane antigen (EMA). Fluorescent in-situ hybridisation (FISH) identified an extra copy of the 5′SS18 signal, suggesting the presence of an unbalanced translocation of the SS18 gene at the 18q11 region. Based on the histological features and FISH results, a diagnosis of monophasic synovial sarcoma was made. Repeat microlaryngoscopy was performed and biopsies of the tumour bed were taken, and histopathological analysis revealed no evidence of residual tumour. Positron emission tomography (PET) and CT staging scans revealed no evidence of regional or metastatic disease. Postoperative radiotherapy was administered to the surgical bed, delivering 60 Gy in 30 fractions over 6 weeks, with bilateral prophylactic nodal irradiation to 50 Gy. After discussion at the multidisciplinary clinic, the patient was administered four cycles of doxorubicin and ifosfamide chemotherapy. Twelve months after the initial diagnosis, there was no evidence of recurrence on endoscopy or PET scan. DiscussionSynovial sarcomas are high-grade soft tissue sarcomas that are thought to arise from pluripotential mesenchymal stem cells.1,2 They account for 10% of all soft tissue sarcomas, and less than 10% occur in the head and neck region.2,3 Since the first case of head and neck synovial sarcoma was described in 1954, there have been fewer than 200 cases reported in the world literature.4 Published cases of synovial sarcoma of the pharynx are rare,5-9 and to our knowledge, this is the first reported case in Australia. There is a male predominance, with a male-to-female ratio of 3 : 2, and although synovial sarcomas can occur at any age, they are most commonly found in patients aged between 25 and 35 years.5,9,10 The neck is the most commonly reported site for primary synovial sarcoma within the head and neck, followed by the upper aerodigestive tract.4 The most typical presentation is a painless mass;2 however, pain, odynophagia, otalgia, bleeding and, in rare cases, pulmonary metastases have also been described. Our patient presented with non-specific upper aerodigestive symptoms, which highlights the importance of a thorough clinical examination. Case reports of pharyngeal synovial sarcomas have found that most patients present within 3 months of the onset of symptoms.5-7 This is in contrast with our patient, who presented after years of loud snoring, progressive globus sensation and eventually stridor. This resulted in a very large tumour almost completely occluding the airway. There are two types of synovial sarcoma, monophasic and biphasic.11 Two-thirds are biphasic, comprising a mixture of elongated basophilic spindle cells and glandular structures made of columnar epithelial cells. Monophasic forms are composed solely of spindle cells or, very rarely, epithelial cells. Monophasic forms are easier to misdiagnose as fibrosarcomas or malignant peripheral nerve sheath tumours, and immunohistochemistry that shows positive reactions for keratin and EMA and FISH can help differentiate these from other sarcomas.1,11 Work-up should include PET and CT scanning of the head, neck and chest to determine the extent of local disease and to search for metastases. The treatment of choice is complete surgical excision with clear margins and adjuvant radiotherapy.4,12-14 For soft tissue sarcomas in general, clear margins have been associated with reduced recurrence and improved survival.12,14 The issue of margin status is particularly important for pharyngeal disease, where attaining wide margins is technically more difficult, and postoperative function for speech and swallowing are important considerations. Postoperative radiotherapy is increasingly recommended as it is associated with reduced local recurrence;4,13,14 however, a survival advantage is yet to be demonstrated. Treatment of the cervical lymph nodes in patients with nodal disease should comprise therapeutic lymph node dissection. There have been no studies on the roles of elective lymph node dissection and prophylactic regional radiotherapy in node-negative patients, and this is an area for future research. The role of neoadjuvant or adjuvant chemotherapy for synovial sarcoma is inconclusive. In a meta-analysis of 14 randomised controlled trials,15 doxorubicin-based chemotherapy was associated with improved recurrence-free survival but not overall survival. A more recent study on ifosfamide-based chemotherapy for synovial sarcomas of the extremities showed an improvement in disease-specific survival.16 As always, the benefits of chemotherapy need to be weighed against the potential significant side effects. Synovial sarcoma is an aggressive disease with a 5-year survival rate of less than 75%.17 There are conflicting conclusions regarding survival among patients with head and neck disease, with some authors reporting a better prognosis for synovial sarcomas of the head and neck compared with the extremities,18 and others reporting a worse prognosis.19 Favourable prognostic indicators include younger age (< 20 years), monophasic subtype, wide excision and, most significantly, smaller tumour size (< 5 cm).3,4 Disease recurrence is a significant problem, with up to 45% of patients with head and neck synovial sarcoma developing a local recurrence and 33% developing distant metastatic disease.4 Further, recurrences occur late, with a mean time to local recurrence of 3.6 years and a mean time to distant recurrence of 5.7 years reported for whole-body synovial sarcoma.17 This highlights the importance of long-term follow-up for these usually younger patients. All patients should initially undergo monthly review, with thorough clinical examination including nasoendoscopy of the pharynx. Where resources permit, patients should also be offered follow-up PET scanning, as this is a sensitive test for detecting recurrent disease. This case represents a rare example of a monophasic synovial sarcoma of the pharynx. Diagnosis and treatment of this disease is difficult, and recurrence is common and occurs late. Prospective studies are required to further elucidate the roles of adjuvant and neoadjuvant radiation treatment and chemotherapy. 1 Endoscopic view of the oropharynx and piriform region There is severe narrowing of the airway at the level of the epiglottis. 2 Sagittal computed tomography image The synovial sarcoma almost completely occludes the laryngeal inlet.

Vikram Balakrishnan MB BS, BMedSc, DipSurgAnatomy · Sam Flatman MB BS, BSc · Benjamin J Dixon MB BS, FRACS · Bernard Lyons MB BS, FRACS

The inaugural Australian Otitis Media (OMOZ) workshop, Darwin, 25–26 May 2010, was well timed. The workshop — held in the same month that the Australian Senate tabled its report, Hear us: inquiry into hearing health in Australia1 — brought together 70 of Australia’s leading otitis media (OM) researchers. The workshop reinforced that OM is a major concern in Australia, identified important research advances, and highlighted future research areas and strategies for long-term interventions. As emphasised in the Senate report, findings from conferences on hearing health should be made publicly available. The purpose of our report, therefore, is to share the main findings from the OMOZ workshop with the broader community of OM researchers, health care professionals and policy leaders. Why otitis media mattersOM, or inflammation of the middle ear, is a prevalent and costly disease. The associated fluid accumulation behind the tympanic membrane can lead to pain, tympanic membrane perforation, and hearing impairment. The prevalence of OM in Australian Indigenous children (about 80% by 12 months of age) is among the highest in the world.2 Tympanic membrane perforation rates among Indigenous children (20%) exceed the threshold of 4% that the World Health Organization considers a “massive public health problem requiring immediate action”.3 Conductive hearing loss in Indigenous Australians has been associated with language and speech development delay, poor educational and employment outcomes, and a heightened risk of criminal activity.1 In 2008, the estimated costs of treating OM in Australia ranged from $100 million to $400 million.4 Clinically important advances in otitis media researchDelegates gained insight into important advances from laboratory-based research, environmental and epidemiological studies, intervention programs and clinical trials. It was highlighted that a multidisciplinary approach is required to better understand, prevent and manage OM. Laboratory-based researchResearchers from the University of Western Australia (UWA) and Telethon Institute for Child Health Research (TICHR), Perth, WA, reported that bacteria (particularly non-typeable Haemophilus influenzae and Streptococcus pneumoniae) and respiratory viruses are more commonly found in the nasopharynx of OM-prone children than in healthy children. They also reported that bacteria persist in the middle ear of OM-prone children, both in biofilms and within cells. Such persistence may contribute to the chronic and recurrent nature of OM. Researchers from WA, Queensland and the Northern Territory highlighted the importance of investigating the interactions between bacteria and viruses in the pathogenesis of OM. Delegates acknowledged that further research is needed to determine the clinical significance of Haemophilus haemolyticus, Alloiococcus otitidis and polyoma viruses in OM. Associate Professor Peter Richmond (School of Paediatrics and Child Health, UWA) noted that children vaccinated with pneumococcal conjugate vaccine were protected from life-threatening disease, but cautioned that children who have normal antibody responses may still experience OM. He reasoned that more appropriate assays are required to adequately assess antibody function. Professor Jennelle Kyd (Deputy Vice-Chancellor [Academic and Research], Central Queensland University [CQU], Rockhampton, Qld) emphasised that evaluation of vaccine effectiveness should include measurements of mucosal immunity. Researchers from CQU and the University of Newcastle in New South Wales are using cell culture models to further our understanding of the interactions between external risk factors (eg, cigarette smoke), otopathogens and host immunity. Researchers from CQU have also developed animal models to enhance our understanding of OM pathogenesis, support OM vaccine development and optimise antigen delivery. A study of 1000 non-Indigenous families in WA led by Dr Sarra Jamieson (Division of Genetics and Health, TICHR) demonstrated that immunological genotypes were associated with OM susceptibility. Together, this led to the conclusion that further immunological studies in other populations and settings are warranted. Environmental studies, intervention programs and clinical trialsAssociate Professor Deborah Lehmann (Division of Population Sciences, TICHR) stressed that crowding at home is the strongest predictor of nasopharyngeal carriage of otopathogens in Indigenous children, whereas daycare attendance is the strongest predictor in non-Indigenous children. Delegates agreed with previous assertions that “reducing overcrowding is the key to fighting the disease”.5 Lehmann reported that exposure to environmental tobacco smoke increases the risk of OM 1.6-fold, and that reducing exposure to tobacco smoke could reduce the risk of OM by up to 27%. The link between hygiene and OM generated much discussion. Delegates agreed that further evidence is required to optimise hygiene education and practices in order to improve ear and general health. Such evidence may be forthcoming from an ongoing intervention study (promoting regular ear screening, frequent hand washing and reduced smoke exposure) of Indigenous children in WA. Debra Fernando (Sax Institute, Sydney, NSW) described the Study of Environment on Aboriginal Resilience and Child Health, which is examining ear disease, mental health, housing and environmental factors in urban Indigenous children from NSW. Preliminary findings indicate that over a third of the cohort had some middle ear abnormality detected by otoscopy. Associate Professor Chris Perry (School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Qld) updated delegates on the Deadly Ears program that involves a team of ear, nose and throat surgeons, audiologists, speech pathologists, nurses and Indigenous health workers. They provide screening, surgery, rehabilitation and educational services to remote Indigenous communities in Queensland. Associate Professor Amanda Leach (Child Health Division, Menzies School of Health Research [Menzies], Darwin, NT) described the PREV-IX_COMBO randomised controlled trial (ACTRN12610000544077; NCT01174849) that will compare the effect of two new pneumococcal conjugate vaccines (Prevenar13 [Wyeth] and Synflorix [GlaxoSmithKline]) and a combination schedule of these vaccines on immunogenicity, nasopharyngeal carriage and OM prevalence in Indigenous infants. Associate Professor Ross Andrews (Child Health Division, Menzies) noted that recruitment for the PneuMum study (NCT00714064) — assessing the effect of maternal pneumococcal vaccination on early-onset OM in Indigenous infants — is nearing completion. As highlighted by Associate Professor Peter Morris (Child Health Division, Menzies), trials such as PREV-IX_COMBO and PneuMum provide data for evidence-based guidelines that can be used to change policy and practice and, ultimately, to improve health outcomes. Research priorities and recommendationsThe OMOZ workshop enabled delegates to identify specific research priorities and recommendations, particularly those involving interagency participation, that could help reduce the burden of OM in Australia (Box). Research prioritiesFurther research into interventions to reduce ear disease in Indigenous communities is urgently required. The manner in which studies are conducted is critical if research is to be sustainable and meaningful to Indigenous communities. Involvement of Indigenous people in research will allow important questions to be addressed and promote research skills within Indigenous communities. Research into ear health in urban Indigenous children is urgently required. Further studies are required to determine whether the incidence of OM can be reduced by modifying risk factors such as hygiene practices, breastfeeding duration, cigarette smoke exposure and household crowding. Diagnostic accuracy is required to ensure appropriate treatment. Laboratory and clinical protocols should be standardised for accurate interpretation and comparison of research findings. Bacterial and viral density and diversity studies are required to help explain the vast difference in risk of OM between Indigenous and non-Indigenous children. RecommendationsResearch that strengthens the evidence for action (and the anticipated health benefits) must be clearly communicated to health care providers, policy leaders and the broader community. OM with tympanic membrane perforation for greater than 2 weeks’ duration must be considered a chronic disease. To reduce the unacceptably high levels of OM in Indigenous children, broader initiatives are required. Interagency collaboration should focus on promoting an agreed set of short-, medium- and long-term strategies. An ear health and hearing taskforce led by Indigenous Australians (supported by researchers, policymakers, clinicians and public health workers) is needed. This taskforce should inform government agencies about options for improving ear health and hearing in Indigenous Australians until the problem of OM is solved. Long-term funding is crucial to enable the conduct of long-term research and intervention studies that are required to address the large and complex problem of OM in both Indigenous and non-Indigenous children. As OM in Indigenous children is often asymptomatic, health care professionals should be encouraged to examine Indigenous children’s ears regularly. Immunisation data from the Australian Childhood Immunisation Register should be made available to facilitate evaluation of vaccine impact through data linkage. An OM research advisory board should be established to communicate research findings that have the greatest potential to influence policy and practice. Researchers should use the EarInfoNet website (http://www.healthinfonet.ecu.edu.au/other-health-conditions/ear) to share research findings with the community, promote standardisation of research methods, raise awareness of research expertise within Australia, and foster collaboration among researchers. We are listening — are you?The inaugural OMOZ workshop was timely and highly successful. It highlighted that OM is a major but unrecognised public health issue in Australia. Researchers are aware of the complexity of the condition, the gaps in knowledge about the pathogens and their interaction with the host, the difficulty of accurate diagnosis, and the challenges of prevention and appropriate treatments. However, they are optimistic that with enhanced awareness and stronger collaborative efforts with health care providers, policy leaders and the community, the burden of OM in Australia can be reduced. We all need to listen ... and take action. Keys to reducing the burden of otitis media (OM) in Australia Prevention — known risk factors for OM must be addressed. The costs and benefits of reducing the risk of severe disease should be quantified. Intervention — defined and evaluable interventions to prevent and treat OM are required. We must establish how, where and when to intervene. Treatment — children at high risk of severe OM should be identified early and treatment options should be enhanced. Investigation — ongoing laboratory research is essential to understand host–pathogen interactions and to develop and evaluate OM treatments and vaccines. Participation — involvement of Indigenous people in prioritisation, implementation and transfer of research is critical to sustainable improvements in ear health. Communication — research findings should be conveyed to the broader community, particularly health care service providers and policy leaders.

Lea-Ann S Kirkham PhD · Selma P Wiertsema PhD · Heidi C Smith-Vaughan PhD · Ruth B Thornton BSc(Hons) · Robyn L Marsh BSc(Hons) · Deborah Lehmann MB BS, MSc · Amanda J Leach BAgSc(Hons), MAgSc, PhD · Peter S Morris MB BS, FRACP, PhD · Peter C Richmond MB BS, FRACP

Clinical records Patient 1 A 59-year-old man infected with HIV presented to hospital with sudden onset of tinnitus, vertigo and hearing loss in his right ear. An audiogram showed moderate bilateral sensorineural hearing loss, which was worse on the right. A magnetic resonance imaging scan of his brain showed no abnormalities. He was diagnosed with Meniere’s disease and managed symptomatically. Symptoms worsened over the following months, and he was reviewed in the neurology and ear, nose and throat (ENT) clinics of another tertiary hospital. Both clinics agreed with the diagnosis of Meniere’s disease. Serological tests for syphilis were performed 12 months after symptom onset. The rapid plasma reagin (RPR) and Treponema pallidum particle agglutination (TPPA) test results were reactive, with the RPR test showing a titre of 1:128. Cerebrospinal fluid (CSF) examination showed a mild lymphocytic pleocytosis and a reactive TPPA test result but a negative RPR test result (Box 1). A diagnosis of otosyphilis was made and the patient was treated with intravenous benzylpenicillin 2.4 million units 4 hourly and oral probenecid 2 g daily for 2 weeks, followed by three doses of weekly benzathine penicillin 2.4 million units intramuscularly. His symptoms stabilised but did not improve. Patient 2 A 30-year-old man infected with HIV presented to an HIV clinic having had tinnitus, hearing loss and imbalance for 3 months. He was referred to ENT clinics in two tertiary hospitals, both of which diagnosed Meniere’s disease. Audiological tests showed mild right sensorineural hearing loss. Serum RPR and TPPA test results were reactive, with an RPR titre of 1:516. CSF examination showed a mildly elevated protein level, but no other abnormalities (Box 1). A diagnosis of otosyphilis was made, and the patient was treated for 2 weeks with benzylpenicillin 2.4 million units 4 hourly. His symptoms resolved completely, and an audiogram performed 6 months after treatment showed that his hearing had returned to normal. The recent increase in early syphilis infections in Australia has been accompanied by the re-emergence of disease manifestations unfamiliar to modern clinicians. Otosyphilis is a rare cause of sensorineural hearing loss and dizziness, and is important for clinicians to consider because the hearing loss is potentially reversible with early diagnosis and treatment. We report two cases of otosyphilis occurring in patients infected with HIV. In both cases, the diagnosis of otosyphilis was initially missed, despite review by several specialist medical units. Cochleovestibular dysfunction is a well described complication of congenital and acquired syphilis. In acquired syphilis, it can occur at any stage of infection. In the pre-penicillin era, hearing loss was reported in 17% of patients with early latent infection and in 80% with symptomatic neurosyphilis.1 Cochleovestibular symptoms of neurosyphilis can occur via two main mechanisms. First, the eighth cranial nerve may be affected, for example in acute syphilitic meningitis. In these situations, hearing loss is usually accompanied by other neurological deficits, and findings on cerebrospinal fluid (CSF) examination will usually be abnormal. Second, and more commonly, hearing loss and vestibular symptoms present without features of coexisting neurosyphilis. These symptoms may occur at any stage of syphilis and are thought to result from direct damage to the vestibulocochlear apparatus. During dissemination, spirochaetes invade the inner ear perilymph, leading to inflammation of the labyrinthine structures and otic capsule. CSF parameters are usually found to be normal but, histologically, fibrosis and ischaemic necrosis of labyrinthine structures are seen2 and endolymphatic hydrops is common. These pathological findings are identical to those of Meniere’s disease, explaining the similar clinical features. Symptoms may be sudden or insidious in onset, and include bilateral (but often asymmetrical) sensorineural hearing loss, tinnitus and vestibular symptoms ranging from dizziness to severe vertigo. These symptoms closely resemble those of Meniere’s disease. Audiological testing shows sensorineural hearing loss, classically affecting low or high frequencies while sparing middle frequencies, and speech discrimination is poor. Without treatment, otosyphilis will progress to profound deafness over months to years. Symptoms can fluctuate markedly over time, but the overall course is one of deterioration.3 There is no established case definition for otosyphilis, but the diagnosis should be made on the basis of a typical clinical presentation and positive serological test results for syphilis. This approach is purposely “over inclusive”, as otosyphilis is a potentially reversible cause of hearing loss. The optimal treatment for otosyphilis is not established. The published literature is limited, consisting of case reports and small case series, but indicates that intravenous therapy is required. Intramuscular penicillin penetrates the perilymph poorly, and there are numerous reports of treatment failure when patients with otosyphilis are treated with penicillin regimens for latent syphilis. In one report, spirochaetes were recovered directly from a patient’s perilymph after treatment.4 Intravenous penicillin G at a dose of 18–24 million units per day, administered as 3–4 million units every 4 hours for 14 days, is the regimen recommended by the United States Centers for Disease Control and Prevention for treatment of otosyphilis. Probenecid is sometimes added, as are subsequent courses of intramuscular or intravenous penicillin.5 There is no high-level evidence to support any of these approaches. Steroids are commonly coadministered, although there are few supporting clinical data. The rationale is that inflammation of the endolymphatic duct appears crucial to the pathogenesis of otosyphilis. A typical steroid treatment regimen is prednisolone at a dose of 0.5–1.0 mg/kg tapered over 1–2 months. Regardless of the penicillin regimen used or whether steroids are employed, treatment outcomes are uniformly poor. Studies consistently show that auditory symptoms abate for only 30% of patients, while 7%–15% have improved results in audiological or speech discrimination tests. Tinnitus and dizziness have better outcomes, with 70%–80% of patients reporting improvement. Factors associated with better outcomes include duration of symptoms less than 5 years, age less than 60 years and fluctuating hearing loss.6 Both of these patients had HIV infection. Rates of syphilis are known to be substantially higher in the HIV-positive population.7 Otosyphilis has previously been described in patients infected with HIV, but relevant published literature is sparse. Patients co-infected with HIV and syphilis appear no different to HIV-negative patients in their clinical features, severity of disease or likelihood of developing this manifestation of syphilis. In both of the cases we report, the diagnosis of otosyphilis was missed despite review by several specialist medical units. In the past few years, rates of early syphilis have risen markedly in Australia, predominantly among homosexual men.8 Relevant practitioners should be aware of this diagnosis in patients presenting with the symptoms described here, especially those at risk of syphilis, such as sexually active homosexual men, including those with HIV infection. Current guidelines recommend syphilis screening in sexually active homosexual men at least annually (up to every 3 months in those at higher risk) and at regular intervals in individuals infected with HIV.9 1 Cerebrospinal fluid and serological test results for two patients with HIV and otosyphilis Patient 1 Patient 2 Cerebrospinal fluid Appearance Clear, colourless Clear, colourless White cell count (× 106/L) 1 polymorph 8 lymphocytes 0 polymorphs 1 lymphocyte Red cell count (× 106/L) 0 0 Protein (g/L) (reference range, 0.15–0.45 g/L) 0.52 0.7 Glucose (mmol/L) (reference range, 2.5–5 mmol/L) 2.7 2.7 Microbiological culture and sensitivity Nil Nil Treponema pallidum DNA polymerase chain reaction test Not detected Not detected Serum Rapid plasma reagin (titre) Reactive (1:128) Reactive (1:516) T. pallidum particle agglutination Reactive Reactive Lessons from practice Consider the possibility of otosyphilis in any patient (especially those with HIV infection or at risk of syphilis and/or HIV infection) presenting with auditory symptoms, particularly sensorineural hearing loss with tinnitus and vestibular dysfunction. Positive serological test results for syphilis will establish the diagnosis. All sexually active men who have sex with men should be screened for syphilis at regular intervals. Otosyphilis must be treated with intravenous penicillin regardless of findings of cerebrospinal fluid testing.

Janet M Pasricha MB BS(Hons) · Tim R Read MB BS, FAChSHM · Alan C Street MB BS, FRACP

A 90-year-old man presented to the emergency department with multiple symptoms including double vision, reduced mobility, dysphagia, recent rapid weight loss, ear discharge and deafness. He had diabetes and other chronic medical problems, including otitis media with mastoiditis. This case highlights the difficulty of investigating weight loss in older people, who may not show the usual clinical features of infection, and of distinguishing between infection and malignancy when radiological findings are inconclusive. His eventual diagnosis was osteomyelitis of the skull base with cranial nerve involvement. Clinical recordA 90-year-old, previously fit Estonian man was admitted to hospital from the emergency department (ED) with multiple symptoms including acute diplopia, difficulty with walking, several falls over 2 weeks, decreased taste sensation, dysphagia with solids over several months, a 10 kg weight loss over 5 months, and a 6-week history of otalgia, aural fullness, otorrhea, and deafness. Four months earlier, the patient had presented to the ED with acute onset of left facial nerve palsy, dysphonia and dysphagia. The facial nerve palsy had resolved spontaneously after 2 weeks without specific treatment. The patient had several significant background medical problems: late-onset diabetes mellitus of 17 years’ duration; peripheral neuropathy; chronic atrial fibrillation; hypertension; and chronic left otitis media with effusion and mastoiditis, for which he had been treated with insertion of a tympanostomy tube 5 months before admission, and a short course of a topical corticosteroid and an oral antibiotic 1 month before admission. The dysphagia was investigated before admission with a barium meal, oesophageal manometry and gastroscopy, which showed severe oesophageal dysmotility and no obstructive lesion. The patient was an ex-smoker with a 55 pack-year smoking history, regular moderate alcohol intake, and occasional salted fish but no areca (or “betel”) nut consumption (which have been linked to nasal and oral cancers, respectively). There was no family history of cancer. His regular medications included metformin, gliclazide, amiodarone, lercanidipine, frusemide and amitriptyline. The main findings on examination included failure of abduction (but no medial deviation) of the left eye consistent with abducens nerve palsy, bilateral haemoserous ear discharge, cachexia, and unsteady gait. No other localising neurological signs were found. The patient remained afebrile throughout the admission. A bedside swallowing assessment by a speech pathologist demonstrated moderate pharyngeal dysphagia. Communication with the patient was conducted through writing. The results of blood tests were unremarkable: his creatinine level was 100 μmol/L (reference range [RR], 70–110 μmol/L); leukocytes, 9.0 × 109/L (RR, 4.0–10.0 × 109/L); glycated haemoglobin, 7.1%; and C-reactive protein (CRP), 51 mg/L (RR, < 5.0 mg/L). One week later, the leukocyte count remained within the normal range and his CRP level had fallen to 35 mg/L, remaining at this level throughout the admission without any specific treatment. A computed tomography (CT) scan and magnetic resonance imaging (MRI) of the brain showed extensive skull base and prevertebral soft tissue thickening with contrast enhancement, bilateral mastoid air cell opacification, and bony destruction of the clivus and both petrous parts of the temporal bones (Box). Bone scintigraphy, performed using technetium-99m hydroxymethane diphosphonate, and a fluorodeoxyglucose positron emission tomography (FDG-PET) scan showed intense tracer uptake in the nasopharynx, base of the skull and mastoid air cells. There was no evidence on the FDG-PET scan of distant uptake. A culture of ear discharge grew a mixture of Staphylococcus aureus and Pseudomonas aeruginosa that were sensitive to flucloxacillin and ciprofloxacin, respectively. Nasopharyngeal carcinoma was strongly suspected by the treating medical team on the basis of radiological findings, significant weight loss (even though the weight loss could be partially attributed to dysphagia), and only a moderate rise in the CRP level. However, the treating ear, nose and throat (ENT) surgeon was of the strong opinion that the abnormalities were due to an infective process and that nasopharyngeal biopsy was not necessary. In view of the radically different nature of the treatments for the two conditions, the divergent opinions about the diagnosis, and the patient’s family wanting more certainty, the opinion of a second ENT surgeon was sought. Subsequent nasopharyngeal biopsy results showed only submucosal chronic inflammation. A diagnosis of skull base osteomyelitis complicating otitis media was made. The patient was started on oral ciprofloxacin 500 mg twice a day (to be continued long term), rehabilitated (practice in transfers, ambulation and self-care), and discharged after 31 days, having shown improvements in weight, mobility and other functional status. At 4-month follow-up, diplopia and abducens nerve palsy had resolved, the patient’s CRP level was 0.3 mg/L and he had gained 8 kg in weight. At 7-month follow-up, there was no ear discharge, the patient’s weight was stable, he felt well and had returned to his previous level of activity. Using hearing aids, the patient was able to converse. Cessation of ciprofloxacin would be considered at 1-year follow-up if there were signs of resolution of osteomyelitis on gallium imaging and repeat bone scan and MRI. DiscussionOsteomyelitis of the base of the skull is commonly associated with malignant otitis externa. However, this patient had chronic otitis media and mastoiditis. Involvement of lower cranial nerves (VI to X) is common in skull base osteomyelitis due to their anatomical proximity to the clivus.1,2 Accurate diagnosis of abnormalities in the base of the skull is important but difficult. Both infection and malignancy can result in severe disability and death, but a good clinical outcome can be achieved with the correct treatment.2 The difficulty of diagnosing either infection or malignancy in similar cases has been reported previously.3-5 However, this patient’s case is unique because of his advanced age, complete resolution of symptoms, attainment of his ideal body weight and full return to his previous level of functioning. The diagnosis at discharge relied on the negative biopsy result for malignancy, the history of complicated chronic otitis media with effusion, and the patient’s improvement after antibiotic treatment. Subsequent clinical improvement at follow-up gave further support to the diagnosis of infection. Although weight loss was the major sign raising suspicion of malignancy, it is not a common feature of nasopharyngeal carcinoma without distant metastases.6 As occurs in many older patients, this patient did not have the usual clinical features of infection. CT, MRI and bone scans demonstrated the extent and location of abnormalities but could not distinguish between infection and malignancy. The FDG-PET scan indicated there were no metastases. Ciprofloxacin was chosen on the basis of the ear discharge culture result and because P. aeruginosa has been implicated as the major pathogen causing skull base osteomyelitis related to ear infections — especially in people with diabetes who have otitis externa.7 S. aureus was thought likely to be a colonising organism rather than a copathogen; the clinical response to the ciprofloxacin was consistent with this. A challenging question with this patient was the optimal duration of ciprofloxacin treatment, especially when the ear discharge persisted for up to 7 months. The decision to stop treatment with the antibiotic would be a matter of judgement based on clinical features, persistently normal CRP levels and improvements on serial scans. After cessation of antibiotic treatment, the patient would require regular and prolonged follow-up to detect early relapse of infection. Magnetic resonance image showing skull base osteomyelitis and otitis media Axial T1 weighted, fat suppressed contrast enhanced scan showing extensive skull base enhancement (white region) with extension anteriorly to the retropharyngeal space (thin white arrow) and posteriorly to dura at the left cerebellopontine angle cistern (thick white arrow).

Jenson C S Mak MB BS, FRACP, FAFRM(RACP) · Lawrence H Kim MB ChB · Lawrence T C Ong BPsych(Hons), MB BS · Triet M Bui MB BS, FRACP, MPH

To the Editor: We read the article by Gibson and colleagues on the assessment and management of cough1 with some concern, specifically regarding the authors’ classification of levels of evidence for current therapies for allergic rhinitis. We would agree that a trial of antihistamines, intranasal corticosteroids and allergen immunotherapy is unlikely to help non-specific cough in the absence of allergic rhinitis. This consensus should be distinguished from the beneficial impact of these modalities on symptoms of allergic rhinitis, for which the authors misquote their main source of information2 and suggest that evidence of benefit from these is “weak”. Although evidence of benefit from allergen avoidance to help manage allergic respiratory disease is controversial,3 a large number of double-blind placebo-controlled trials of all other modalities show Level I evidence of benefit and category A strength of recommendation specifically for treatment of allergic rhinitis, as recently reviewed2,4-6 — evidence consistent with “strong” recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.7 We do our patients and colleagues a disservice to suggest otherwise.

Raymond J Mullins · Constance H Katelaris · Janet Rimmer

To the Editor: We read with interest the Australian Cough Guidelines summary statement by the CICADA multidisciplinary group.1 However, we feel that the role of direct examination of the upper aerodigestive tract in assessing cough was underemphasised. Flexible nasal endoscopy (FNE) is a quick, relatively straightforward examination performed under topical anaesthesia as part of an ear, nose and throat (ENT) consultation. It allows direct visualisation of the nasal cavities, postnasal space, oropharynx and larynx, and can be performed on adults and older children and also some younger children.2 Nasal causes of cough, and hence the potential role of FNE, appear to have received more emphasis in previous chronic cough management strategies, including those proposed by the American College of Chest Physicians in 20063 and the European Respiratory Society task force in 2004.4 The diagnosis of chronic rhinosinusitis or upper airway cough syndrome (postnasal drip syndrome) is enhanced by direct examination. The presence of mucopus in the middle meatus of the nasal cavity is associated with a positive diagnosis of chronic rhinosinusitis.1 FNE can also provide direct evidence of the presence of gastro-oesophageal reflux affecting the larynx (laryngopharyngeal reflux), and plays a significant role in the clinical diagnosis of laryngopharyngeal reflux.5 FNE should be used in patients with alarm symptoms for serious underlying disease (as suggested by the CICADA group1), particularly those potentially related to laryngeal causes (hoarseness, haemoptysis, feeding difficulties, stridor or smoking). As part of a complete examination, FNE can help in targeting therapy for two of the three most common causes of cough in adults (gastro-oesophageal reflux and rhinosinusitis), and in excluding some of the significant causes of cough in both adults and children. It is particularly recommended in patients with a suspected nasal or laryngeal cause, in those with alarm symptoms, and in those for whom initial therapy fails.

Nicholas J Potter · Eduard I Pudel

In reply: The recently published CICADA cough guidelines1 draw attention to the important role of systematic assessment of chronic cough in children and adults, and provide an appraisal of the evidence that treating specific conditions will improve cough. Mullins and colleagues raise a key point that requires emphasis, and is relevant beyond the instance of allergic rhinitis that they cite. Chronic cough is associated with several common conditions, such as allergic rhinitis, asthma, gastro-oesophageal reflux disease and sleep apnoea. For each of these conditions, there are well established treatment guidelines that describe the effectiveness of treating that primary condition. However, in developing the CICADA guidelines we were considering the effect of the treatments on the symptom of cough, not on the primary condition. It was stated at the bottom of Box 1 (page 2661) that “The final GRADE recommendations were based on [the] votes [of committee members] and considered cough in the context of the respective conditions”. We agree that the evidence for treating symptoms of allergic rhinitis per se is strong, as published.2 But in the case of a patient presenting with cough and associated rhinitis, the CICADA group determined that the evidence that treating allergic rhinitis would resolve the cough was weak. It is often not possible to determine from successful trials of immunotherapy for rhinitis the outcome for cough. For example, trials of injectable or sublingual immunotherapy both mention cough only once, and it is not possible to determine the effect of the treatment on this symptom.3,4 We welcome the comments by Potter and Pudel giving more specific details of the role of FNE in assessing the upper airway in people with chronic cough. We agree that this is a quick and useful examination. We believe we have placed greater emphasis on upper airway disorders compared with other cough guidelines. Specifically, we have identified vocal cord dysfunction and sleep apnoea as relevant upper airway disorders that are associated with chronic cough. These conditions are not featured in previous guidelines, yet they respond well to specific therapy. We also devote comparatively more space to upper airway disorders that to lower airway disorders.

Peter G Gibson · Anne B Chang · Andrew S Kemp

To the Editor: A 59-year-old woman presented with acute bilateral deafness, ataxia, and pyrexia. She had no significant past medical history and was taking no medications or antibiotics. Examination revealed normal tympanic membranes. Audiology and fundoscopy were not performed. Full blood examination results, electrolyte levels and renal function were normal. A plain chest x-ray was unremarkable, but a computed tomography scan showed lobar consolidation. The patient had microscopic haematuria but no pyuria, and negative urine culture. Blood cultures were repeatedly negative. She was commenced on a third-generation cephalosporin, as well as corticosteroids on suspicion of vasculitis. Her condition improved initially, but relapsed on weaning from the steroids. Further history-taking revealed that 3 weeks before the onset of her illness, the patient’s pet budgerigar had a prolonged diarrhoeal illness and subsequently died. On suspicion of Chlamydophila infection, she was commenced on doxycycline, and the fever resolved within 24 hours. Doxycycline was continued for 14 days, and the patient remained well thereafter. Her hearing returned to normal over 3 days. Autoimmune markers, and serological tests for Legionella species, Mycoplasma species and respiratory viruses were negative. However, her Chlamydophila psittaci IgG titre was > 512 and Chlamydophila pneumoniae IgG titre was > 2048, consistent with a recent infection with either C. psittaci or C. pneumoniae. Convalescent serological tests were not performed. To our knowledge, acute hearing loss has been reported only four times as an extrapulmonary feature of Chlamydophila infection. Puolakkainen and colleagues reported the case of a 49-year-old man who presented with otitis media in one ear and sudden deafness in the other after a severe influenza-like illness thought to be due to psittacosis.1 Crosse performed a retrospective study that looked at the clinical and epidemiological features of cases in which there was a fourfold rise in C. psittaci titre. One patient developed deafness, although no further detail was given.2 Brewis and McFerran reported the case of a 61-year-old pig farmer with sudden bilateral hearing loss associated with C. psittaci pneumonia. The hearing loss resolved with antibiotics and prednisolone.3 Finally, Darougar et al reported the case of a 15-year-old girl who presented with chronic relapsing sensorineural hearing loss, uveitis, keratitis and vertigo.4 In this case, chlamydial antibody titres were raised, and C. psittaci was isolated from the conjunctiva. She had no respiratory involvement. Her only animal exposure was to a cat with conjunctivitis, which tested negative for chlamydial and viral infections. Interestingly, Dünne et al have recently found an epidemiological association between sensorineural hearing loss and elevated C. pneumoniae IgA titres.5 This case represents further evidence that acute deafness may be a component of atypical pneumonias, and especially of Chlamydophila infection.

Andrew F Whyte · Richard Yu

Objective: To assess the extent to which general practitioners in Australia are engaged in identifying age-related hearing loss and facilitating its management.Design, setting and participants: Cross-sectional analysis of data collected between 1998 and 2000 from the Blue Mountains Hearing Study (BMHS), a representative population-based cohort of people aged ≥ 50 years in two postcode areas west of Sydney. Also analysed were data collected between 2003 and 2008 from random samples of Australian GPs who participated in the Bettering the Evaluation and Care of Health (BEACH) study, a national continuous cross-sectional survey of GP activity.Main outcome measures: Rate of facilitating management and identification of hearing loss in older patients; content of GP–patient encounters with hearing-impaired people; characteristics of participants seeking help from their GP.Results: Of older people in the BMHS with measured (objective) bilateral hearing loss, about a third reported seeking help frovm their GP. BEACH survey data showed that only about 3 per 1000 GP consultations with patients aged ≥ 50 years involved management of age-related hearing loss. For every 100 age-related hearing problems managed, GPs undertook 12 procedural treatments, provided 20 referrals to specialists, and made 29 referrals to allied health professionals.Conclusion: In their routine consultations with patients, GPs have opportunities to identify hearing loss and appropriately refer patients to specialists or allied health professionals. Although GPs are responding to patient presentations for hearing loss, referring around 50% of cases, there appear to be relatively few cases in which hearing loss is identified opportunistically. Levels of identification and management of hearing loss by GPs in Australia are relatively low.

Julie M Schneider BAppSc(Hons), PhD · Bamini Gopinath BTech(Hons), PhD · Catherine M McMahon PhD · Helena C Britt BA, PhD · Christopher M Harrison BPsych(Hons), MSocHlth · Tim Usherwood MD, BS · Stephen R Leeder MD, PhD · Paul Mitchell MD, PhD, FRANZCO

Objective: To compare the clinical effectiveness of single-dose azithromycin treatment with 7 days of amoxycillin treatment among Aboriginal children with acute otitis media (AOM) in rural and remote communities in the Northern Territory. Design, setting and participants: Aboriginal children aged 6 months to 6 years living in 16 rural and remote communities were screened for AOM. Those diagnosed with AOM were randomly allocated to receive either azithromycin (30 mg/kg as a single dose) or amoxycillin (50mg/kg/day in two divided doses for a minimum of 7 days). We used a double-dummy method to ensure blinding. Our study was conducted from 24 March 2003 to 20 July 2005. Main outcome measures: Failure to cure AOM by the end of therapy; nasal carriage of Streptococcus pneumoniae and non-capsular Haemophilus influenzae (NCHi). Results: We followed 306 of 320 children (96%) allocated to the treatment groups. Single-dose azithromycin did not reduce (or increase) the risk of clinical failure (50% failure rate [82/165]) compared with amoxycillin (54% failure rate [83/155]) (risk difference [RD], – 4% [95% CI, – 15% to 7%]; P = 0.504). Compared with amoxycillin, azithromycin significantly reduced the proportion of children with nasal carriage of S. pneumoniae (27% v 63%; RD, – 36% [95% CI, – 47% to – 26%]; P < 0.001) and NCHi (55% v 85%; RD, – 30% [95% CI, – 40% to – 21%]; P < 0.001). Nasal carriage of S. pneumoniae with intermediate or full resistance to penicillin was lower (but not significantly so) in the azithromycin group (10% v 16%), but this group had significantly increased carriage of azithromycin-resistant S. pneumoniae (10% v 3%; RD, 7% [95% CI, 0.1% to 12%]; P = 0.001). Carriage of β-lactamase-producing NCHi was about 5% in both groups. Conclusion: Although azithromycin reduced nasal carriage of S. pneumoniae and NCHi, clinical failure was high in both treatment groups. The possibility of weekly azithromycin treatment in children with persistent AOM should be evaluated. Trial registration: Australian Clinical Trials Registry ACTRN 12609000691246.

Peter S Morris MB BS, PhD, FRACP · Gaudencio Gadil MD · Gabrielle B McCallum BNurs, MPH · Cate A Wilson EN, BPsych(Hons) · Heidi C Smith-Vaughan BAppSci, PhD · Paul Torzillo MB BS, FRACP, JFICM · Amanda J Leach BAgSc(Hons), MAgSc, PhD

Objective: To determine the relative radio-opacity on plain x-ray of bones of fish species commonly consumed in South East Queensland.Design: A cadaveric sheep model was used to mimic the soft tissues of a human neck. Bones of 10 fish species were placed in the paratracheal tissues and adjacent to the larynx. X-rays were taken and the images (including four control images with no bones) were incorporated into a Microsoft PowerPoint presentation to be interpreted by emergency specialists and registrars. Observers were blinded to which specimens contained fishbones and which did not.Main outcome measures: Sensitivity and specificity of plain x-rays for detecting impacted fishbones.Results: Significant interobserver variability was identified. Despite this, the overall specificity of plain x-rays was 90%. The sensitivity of the technique was 79% overall, but varied significantly between fish species.Conclusion: Lateral soft tissue neck x-ray is an appropriate screening tool in cases of a suspected impacted fishbone. If a fishbone is identified on x-ray, the patient should be referred for endoscopy without further imaging. X-ray may be of limited value in cases of Dory or Spanish mackerel bone ingestion. In such cases, a computed tomography scan should be the first-line investigation.

William R A Davies MB BS · Patricia J Bate PhD, MAppSci, BAppSc(Phty)

Otitis media in Australia, particularly among Indigenous children, has not received the attention that other less common but more emotive diseases attract. However, this condition, with its significant impact on hearing, language development and learning in the vulnerable early childhood years, has been commented on since early European settlement in Australia.1 The end result of recurrent acute otitis media — chronic suppurative otitis media — is uncommon in most developed countries, but Indigenous Australian children account for the highest prevalence of chronic suppurative otitis media in the world (70% in some remote communities). The World Health Organization regards a prevalence of chronic suppurative otitis media of over 4% in a defined population of children as a massive public health problem requiring urgent attention.2 John Ah Kit, Minister for Community Development from the Northern Territory, described the situation of Indigenous children as A spiral of being ill before birth, of being poorly fed in childhood, of being deaf at school. Of a life without work that would be cut short by a litany of disease and violence.3 What has happened in the 13 intervening years since the last Medical Journal of Australia supplement on otitis media was published?4 In some areas (described further in this supplement), our understanding of pathogenesis, new concepts of biofilm and intracellular infection, and the importance of nasopharyngeal carriage, we have progressed significantly. Likewise, new research — into the genetics of recurrent acute otitis media, the immunological responses of children to these infections, and the impact of antibacterial vaccines — is contributing to our knowledge about this condition. New social and medical interventions, such as the swimming pool project,5 building new housing, and the controversial Northern Territory Intervention, with new guidelines on the use of antibiotics in otitis media and its sequelae in children, have been partially successful in ameliorating the burden of otitis media in Indigenous (and non-Indigenous) children.6 Yet, in this time of financial constraint, the necessary programs to implement change in the fundamental and underlying causes of otitis media and its complications are not being provided. Chronic suppurative otitis media is a disease of poverty, and without actions to lessen overcrowding and provide appropriate housing and water supply, education of parents and adequate access to medical care, progress to improvement will be slow.7 In addition, throughout urban, rural and remote Australia, we must increase awareness about otitis media, and the ramifications of neglect of this silent epidemic, among parents, teachers, community leaders, and health workers. We must train more Aboriginal health workers specialising in ear conditions (and possibly also eye conditions and dental health), perhaps with support from ear nurse specialists (this has been very successful in the government-funded Variety Club ear buses program in New Zealand), and ensure there is an adequate workforce of audiologists, speech pathologists and teachers of the deaf to provide the necessary ancillary support services for children with impaired hearing and speech delays. The recent publication The cost burden of otitis media in Australia brings to light the pervasive nature and community costs of otitis media and its sequelae. Admission for insertion of grommets is the second major cause of surgical admission to hospital in Australia for children. Over 650 000 Australians had otitis media in 2008; 9.9% of these were Indigenous. For 2008, the estimated health system costs of otitis media range from $85.6 million to $163.2 million, and the net cost of lost wellbeing due to otitis media is estimated at between $1.05 billion and $2.6 billion.8 So where to next? Governments must advocate for otitis media prevention programs, improve living standards for socially disadvantaged families, ensure adequate medical and paramedical resources, and continue to fund basic and outcomes-based research into otitis media. As otitis media is, in part, a vaccine-preventable disease, attention to considering the newer vaccines available for invasive and otitis media infections in children for the immunisation schedule should be a priority.

Harvey L C Coates AO, MS, FRACS

Otitis media remains a major health problem in Australia, with an unacceptably great dichotomy of incidence and severity of otitis media and its complications between Indigenous and non-Indigenous Australians. Among most children with acute otitis media, infection resolves rapidly with or without antibiotics, with ongoing middle ear effusion the only sequela. Overcrowding, poor living conditions, exposure to cigarette smoke, and lack of access to medical care are all major risk factors for otitis media. Estimates of the number of cases of otitis media in 2008 vary between 992 000 and 2 430 000 Australians, with a total estimated cost of $100 – $400 million.

Kelvin Kong BSc, MB BS, FRACS · Harvey L C Coates AO, MS, FRACS