Do patients report quality of life improvements after fitting of their unilateral bone conducting hearing implant?

OBJECTIVE: The audiological benefits of a bone conducting hearing implant are well documented; however, there is a paucity of literature comparing pre- and post-operative quality of life benefits. This study assessed the quality of life status before and after the device is implanted. METHODS: A prospective study was conducted of all adult bone conducting hearing implants inserted in a teaching hospital between 2012 and 2017. All patients completed the Glasgow Health Status Inventory, a validated quality of life questionnaire, before and three to six months after implantation. RESULTS: Sixty-two patients received a unilateral bone conducting hearing implant. All scores except the social score improved post-operatively. The paired t-test showed that the differences in the means for the Glasgow Health Status Inventory total, general and physical scores were statistically significant at the 5 per cent level (p < 0.0001). CONCLUSION: This study, one of the few to assess quality of life pre- and post-implantation, showed a vast improvement in patients' perceived quality of life from the pre- to the post-operative phase.

Cholesteatoma in children and adults: are there really any differences?

BACKGROUND: Cholesteatoma is widely considered to be more aggressive in children than adults, yet few studies have directly compared the operative findings and surgical outcomes between these two groups. This study aimed to assess differences between childhood and adult cholesteatoma. METHODS: The operative caseload of a single consultant surgeon was reviewed between January 2006 and May 2017 using the online Common Otology Audit database. Extracted data were categorised according to patient age (children, aged below 16 years, and adults, aged 16 years or over) and compared. RESULTS: This study included data from 71 operations on children and 281 operations on adults, performed for cholesteatoma. Childhood cholesteatoma demonstrated significantly more extension (into the sinus tympani, mastoid antrum and mastoid air cells) and ossicular erosion (of the malleus, incus and stapes superstructure) compared to adults. No significant differences were seen in revision rates, post-operative complications or hearing gain. CONCLUSION: Childhood cholesteatoma was more extensive and destructive compared to adults, representing a more aggressive disease in this cohort.

The genetics of cholesteatoma. A systematic review using narrative synthesis.

OBJECTIVE: A cholesteatoma is a mass of keratinising epithelium in the middle ear. It is a rare disorder that is associated with significant morbidity, and its causative risk factors are poorly understood; on a global scale, up to a million people are affected by this each year. We have conducted a systematic literature review to identify reports about the heritability of cholesteatoma or any constitutional genetic factors that may be associated with its aetiology. DATA SOURCES: A systematic search of MEDLINE (EBSCO) and two databases of curated genetic research (OMIM and Phenopedia) was conducted. STUDY SELECTION: The participants and populations of interest for this review were people treated for cholesteatoma and their family members. The studies of interest reported evidence of heritability for the trait, or any association with congenital syndromes and particular genetic variants. DATA EXTRACTION: The searches identified 449 unique studies, of which 35 were included in the final narrative synthesis. DATA SYNTHESIS: A narrative synthesis was conducted, and data were tabulated to record characteristics, including study design, genetic data and author conclusions. Most of the studies identified in the literature search, and described here, are case reports and so represent the lowest level of evidence. In a few case reports, congenital and acquired cholesteatomas have been shown to segregate within families in the pattern typical of a monogenic or oligogenic disorder with incomplete penetrance. Evidence from syndromic cases could suggest that genes controlling ear morphology may be risk factors for cholesteatoma formation. CONCLUSIONS: This is the first systematic review about the genetics of cholesteatoma, and we have identified a small body of relevant literature that provides evidence of a heritable component for its aetiology. Cholesteatoma is a complex and heterogeneous clinical phenotype, and it is often associated with chronic otitis media and with some rare congenital syndromes known to affect ear morphology and related pathologies.

Results of revision myringoplasty: are they different to those of primary myringoplasty?

Audit question: Does revision myringoplasty have worse outcomes than primary surgery? METHODS: The International Otology Database has been used to record data on surgery for middle-ear disease in Norfolk, UK, over nine years. The data show the results of all myringoplasty cases and the results of revision cases. Outcome measures are perforation and hearing change. Comparison is made with benchmark centres of excellence. RESULTS: A total of 611 operations included myringoplasty; 356 (58 per cent) of cases had a recorded follow up at 3 months. Twenty-nine patients (8.1 per cent) had a post-operative perforation. Benchmark centres performed 2319 operations; 1284 (55 per cent) of these had a follow up at 3 months, and 82 patients (6.4 per cent) had a perforation at follow up. Sixty-nine of the Norfolk patients were revision cases. Six of the 69 patients (8.7 per cent) had a perforation at follow up. The average hearing gain in the revision myringoplasty patients in Norfolk was 7 dB. CONCLUSION: The results of the revision myringoplasty cases are the same as those for the primary myringoplasty cases in this series.

Perilymph fistula: the patients' experience.

OBJECTIVE: This study aimed to assess the experiences and outcomes of patients who underwent surgical repair of a perilymph fistula in Norfolk, UK. METHODS: The study involved a retrospective questionnaire-based patient survey and case note review of patients who had undergone tympanotomy and perilymph fistula repair between 1998 and 2012 in two district general hospitals. RESULTS: Fourteen patients underwent 20 procedures, of whom 7 completed the pre- and post-operative Vertigo Symptom Scale. In five patients, there was no obvious precipitating cause. Perilymph fistula was precipitated by noise in one patient, by a pressure-increasing event in six patients and by trauma in two patients. The Vertigo Symptom Scale scores showed a statistically significant improvement following surgical repair, from a median of 67 (out of 175) pre-operatively to 19 post-operatively. CONCLUSION: In selected patients with vertigo, perilymph fistula should be considered; surgical repair can significantly improve symptoms.

Hearing loss following myringoplasty - implications for informed consent.

BACKGROUND: There are many reports of operations performed to successfully close ear drum perforations. Hearing deterioration after myringoplasty is not a widely published topic. This paper presents an audit of this complication. METHODS: A six-year retrospective analysis of a series of myringoplasty operations was performed using electronic patient records. Patients with post-operative hearing loss were identified and those with hearing loss greater than 10 dB were further scrutinised. RESULTS: Out of 187 patients who underwent myringoplasty procedures, 44 (23.53 per cent) experienced a reduction in hearing thresholds. In seven cases (3.74 per cent), the hearing loss was greater than 10 dB. A case note review revealed no obvious predictive factors, although posterior perforations and the possibility of ossicular chain manipulation were considered. CONCLUSION: Hearing loss following myringoplasty is not rare, and this may alter the consent process for this procedure.

An audit of 'dead ear' after ear surgery.

INTRODUCTION: 'Dead ear' is a rare and serious complication of ear surgery. This paper presents an audit of this complication. METHOD: Over 6 years, data for all 617 middle-ear operations performed under the care of a single consultant were recorded for the International Otology Audit. All cases of dead ear were identified and assessed. RESULTS: A post-operative dead ear occurred in 6 cases (approximately 1 per cent). No cases of post-operative dead ear occurred following the 83 otosclerosis operations and the 62 children's procedures. Amongst 187 adult patients undergoing mastoid surgery for cholesteatoma, there were 5 cases of post-operative dead ear (2.7 per cent of cases). CONCLUSION: The occurrence of dead ear after cholesteatoma surgery in adults is less rare than previously thought. This has implications for the surgical consenting process. The current series suggests that, whilst dead ear is often avoidable, it is sometimes inevitable.

Initial UK experience of patient satisfaction with the Meniett® device for Ménière's disease treatment.

OBJECTIVES: To evaluate patient satisfaction and symptom improvement following treatment of Ménière's disease with the Meniett® device. METHODS: Retrospective, questionnaire-based audit and analysis of unilateral Ménière's disease patients' records, following on from a previous study from our departments on intra-tympanic gentamicin for Ménière's disease, using the Vertigo Symptom Scale and Glasgow Benefit Inventory as outcome measures. RESULTS: Of 33 consecutive patients treated with the Meniett® device for four to six weeks, 30 responded to the questionnaires (90.9 per cent). Respondents' mean Vertigo Symptom Scale score was 0.7 (range 0-2.1), and their mean Glasgow Benefit Inventory general subscale score was 24.1. Nineteen (63.3 per cent) patients felt that the device had alleviated their vertigo and tinnitus. CONCLUSIONS: This is the first UK study of the effectiveness of the Meniett® device in treating Ménière's disease. It shows that the Meniett® device is a well tolerated, useful and minimally invasive means of treating Ménière's disease after medical treatment has failed, and before more potentially cochleo- and vestibulo-toxic therapies and invasive procedures are utilised.

Tattooing and the risk of wrong-site ear surgery.

Wrong-site surgery could occur in cases of bilateral pathology or in patients with normal tympanic membranes such as those undergoing stapedectomy. This report highlights the pitfalls in current surgical checklists despite best efforts being put into their design. The practice of marking the earlobe in ear surgery may be less safe than using larger arrows on the neck to indicate the side of surgery.

Familial cholesteatoma in East Anglia, UK.

OBJECTIVE: To report a cluster of families affected by cholesteatoma in the East Anglia region of the UK. SETTING: Otology service for the population of Norfolk and North Suffolk, East Anglia, UK. METHOD: Prospective and systematic collection of family history data for patients presenting with cholesteatoma over 10 years. RESULT: Several families were identified with affected individuals over several generations. CONCLUSION: There is likely to be a genetic propensity for cholesteatoma in some individuals.

A study of olfactory testing in patients with rhinological pathology in the ENT clinic.

BACKGROUND: Despite the common occurrence of rhinological pathology presenting to the ENT clinic, routine testing of olfactory ability is rarely performed. OBJECTIVES: The aim of this study was to determine the role of routine olfactory testing. METHODS: This was a prospective study conducted in the outpatient clinic of a district general hospital. Patients presenting with rhinological complaints had their olfactory status assessed using the combined olfactory test (COT) before and after rhinological surgery. RESULTS: Eighty patients (56 men, 24 women) had tests completed over a 12-month period. Patients assessed mostly had nasal polyposis, chronic rhinosinusitis or septal deformity. 83% of patients had either a complaint of olfactory disturbance or a COT score of 6 or less, or had both; but correlation between symptoms and scores was poor. Post-operative COT scores showed significant improvement (p = 0.02) with post-septoplasty patients showing the most significant improvement as a group (p = 0.001). CONCLUSIONS: Olfactory disturbance is very common in rhinological pathology and the patient's history alone cannot be relied upon. Simple olfactory assessment, such as with the combined olfactory test, is easy to perform and cheap to use and should be a commonly used resource in the ENT clinic. Formal testing can help to document any pre-existing olfactory loss and any post-operative changes as well as detecting unreported hyposmia.

Frontal mucocele caused by an ectopic maxillary tooth.

OBJECTIVE: To present a previously unreported cause of frontal mucocele. CASE REPORT: A patient presented with a frontal mucocele and maxillary sinusitis. Computed tomography revealed an ectopic maxillary tooth as the cause of her signs and symptoms. Removal of the tooth by a Caldwell-Luc procedure facilitated resolution of the mucocele. Conventional treatment of mucoceles by endoscopic sinus surgery, and other rhinological sequelae of ectopic teeth, are considered. CONCLUSION: This is the first documented case of an ectopic tooth causing a frontal mucocele, and demonstrates how effectively the patient's symptoms resolved on removal of the tooth.

Intratympanic gentamicin treatment in Meniere's disease: patients' experiences and outcomes.

OBJECTIVE: The aim of this study was to assess the experiences and outcomes of patients receiving intratympanic gentamicin treatment for Ménière's disease in Norfolk, UK. DESIGN: This study was based on a retrospective questionnaire survey and a review of patients' medical records. SETTING: Two district hospitals. PARTICIPANTS: All 29 patients treated between 1999 and 2001, with a minimum follow up of two years post-treatment, were included in the study. Twenty-three patients completed the questionnaires (79 per cent response rate). MAIN OUTCOME MEASURES: Glasgow benefit inventory (GBI) and vertigo symptom scale (VSS) scores, plus change in hearing thresholds. RESULTS: The mean GBI total score was +36, indicating substantial improvement in patients' overall quality of life following gentamicin treatment. The VSS scores demonstrated low levels of vertigo or unsteadiness in treated patients. Three patients suffered deterioration in their hearing thresholds following a single injection of gentamicin. However, 96 per cent of responders stated that they would be willing to have such treatment again, if necessary. CONCLUSION: Intratympanic gentamicin treatment ought to be offered to Ménière's patients suffering from disabling vertigo, with the proviso that they be made aware of the possibility of hearing deterioration.

An unusual presentation of sphenoid sinusitis with septicaemia in a healthy young adult.

Streptococcus pneumonia and Haemophilus influenzae account for more than 50% of bacterial acute sinusitis. Isolated sphenoid sinusitis is a rare disease with potentially devastating complications such as cranial nerve involvement, brain abscess, and meningitis. It occurs at an incidence of about 2.7% of all sinus infections. There have been no previous reported cases of unilateral sphenoid sinusitis presenting as septicaemia in an otherwise healthy young immunocompetent adult.

Audit of specialist registrar training in tympanomastoid surgery for chronic otitis media.

BACKGROUND: A prospective audit of specialist registrars' (SRs') training in tympanomastoid surgery for chronic otitis media within the Anglia Regional Training Scheme is described. This audit recorded the surgical activity of the trainees and their contribution to operative procedures, and assessed the results of the procedures. This type of systematic approach to the audit of surgical training is important in light of the current shortened training programmes and increased accountability of trainers. OBJECTIVES: The study aimed to establish the levels of exposure to, supervision of and outcome of ear operations for chronic otitis media performed by ENT trainees in the East Anglia region. METHOD: A prospective, region-wide, minimum otology dataset-based proforma audit was undertaken, with compulsory SR participation. Proformas were completed at the time of operation (form one) and at a minimum interval of nine months post-operatively (form two). Data on form one included hospital, supervising consultant, name and training year of SR, contribution of SR (based on England Royal College of Surgeons guidelines interpreted by the SR), pre-operative audiology average (air conduction/bone conduction over 0.5, 1, 2 and 4 kHz), the pathology and the state of the ear at the time of surgery, and a breakdown of the procedure(s) undertaken. Form two recorded data relevant to form one as well as information regarding patient satisfaction and the operative result obtained, graded as 'gold' (no disease, dry ear and hearing average < 25 dB), 'silver' (two of these three) and 'bronze' (one of these three). All completed forms were analysed using Microsoft Access software. RESULTS: Completed copies of 409 form ones and 156 form twos were analysed. With advancing years, SRs' contributions to procedures increased without significant effect on the graded outcome, which appeared to be independent of SR year of training. Different regional hospitals were compared. Data collected also provided an otology training portfolio for SRs, forming part of their registrar in-training assessment (RITA). CONCLUSION: The East Anglia SR audit of SRs' training in tympanomastoid surgery for chronic otitis media was a powerful training tool. It demonstrated the safe progression of SR training in supervised ear surgery, with SRs' results being comparable to those for consultant-performed procedures.

Spitting in the ear: a falsified disease using video evidence.

We present the case of Munchausen's syndrome by proxy (MSBP) in which the mother spat and placed blood in her child's ear, and videoed the result, in order to gain the attentions of the medical profession. This is the first case report of this kind and may represent a disturbing trend in the use of digital photography and video to support factitious illnesses.

Bilateral objective tinnitus secondary to congenital middle-ear myoclonus.

Subjective tinnitus (heard only by the patient) is a common otological complaint. Objective tinnitus (heard by the examiner as well as the patient) is extremely rare. There are only a few cases of objective tinnitus, secondary to middle-ear myoclonus, described in the literature. We present the case of a child with bilateral, congenital, objective tinnitus, secondary to middle-ear myoclonus, with otherwise normal hearing thresholds (250 Hz-8 kHz), and with no evidence of intra-cerebral or systemic disorders. No similar case has been reported in the world literature.