Disparities in access to ear and hearing care in Cambodia: a mixed methods study on patient experiences.

OBJECTIVE: Chronic suppurative otitis media is a major global disease disproportionately affecting low- and middle-income countries, but few studies have explored access to care for those with ear and hearing disorders. METHOD: In a tertiary hospital in Cambodia providing specialist ear services, a mixed method study was undertaken. This study had three arms: (1) quantitative analysis of patients undergoing ear surgery, (2) a questionnaire survey and (3) semi-structured in-depth interviews. RESULTS: Patients presented with advanced middle-ear disease and associated hearing loss at rates that are amongst the highest per capita levels globally. Patients reported several structural, financial and socio-cultural barriers to treatment. This study showed a significant burden of ear disease in Cambodia, which reflects a delay in receiving timely and effective treatment. CONCLUSION: This study highlights the opportunity to integrate effective ear and hearing care into primary care service provision, strengthening the package of activities delivered at government facilities.

A survey of UK and Irish surgeons' attitudes, behaviours and barriers to change for environmental sustainability.

INTRODUCTION: Surgery is a major contributor to the large environmental impact of healthcare, demanding urgent attention. To date there are no data on the attitudes and behaviours of surgeons towards climate change, or perceived barriers towards sustainable practice. METHODS: We invited surgeons and surgical trainees in the UK and Ireland to participate in an online survey (developed in accordance with the CHERRIES checklist) conducted between June and November 2020 and disseminated via the Royal College of Surgeons of England, Edinburgh and Ireland, the Association of Surgeons in Training and through local communication. RESULTS: We received 130 responses, across 14 surgical specialties. The majority of respondents (122/130; 94%) were concerned about the threat of climate change. Most respondents had instigated more sustainable practices in their personal lives (113/130; 87%) and, to a lesser extent, at work (73/130; 56%). Surgeons were willing to make changes to their clinical practice (107/130; 82%), but the main perceived barrier to improving sustainability was a lack of leadership (92/130; 70%). Surgeons welcomed greater leadership and guidance from national bodies (118/130; 91%) and more monitoring and regulation (113/130; 87%). CONCLUSIONS: The surgeons who responded to our survey are concerned about climate change and willing to engage in efforts to transition to more sustainable practice, but would welcome greater support, guidance and leadership.

A cross-sectional evaluation of the validity of a smartphone otoscopy device in screening for ear disease in Nepal.

OBJECTIVES: Hearing loss is a neglected international health problem. The greatest burden of ear disease is in low-income countries where there is also a lack of resources. In this context, screening for otological disease may be worthwhile. Cupris© has developed an otoscopy device that offers the possibility of low-cost mass screening in remote communities. We evaluated the validity of this device in diagnosing ear disease and in determining whether referral to an ENT centre is warranted. DESIGN: Cross-sectional study. SETTING: Outpatient clinic, Nepal. PARTICIPANTS: All adults and children were invited to take part over a 2-day period. The Cupris© device was used to record participants otological history and examination. Stored history and images were assessed in the United Kingdom by a Consultant-grade ENT Surgeon, who provided a diagnosis and decided whether referral to an ENT centre was warranted. After screening with the Cupris© device, participants were immediately assessed by a UK trained ENT Consultant Surgeon using a standard otoscope ("standard assessment"). A diagnosis was recorded for each participant and a decision was made as to whether referral to an ENT centre was warranted. OUTCOMES: Concordance in primary diagnosis (analysed per ear) and concordance in the decision to refer (analysed per patient). Cohen's kappa coefficient for inter-rater agreement in diagnosis. RESULTS: Fifty-six patients agreed to participate. In four patients, the quality of video recorded precluded a diagnosis or management plan. These patients were excluded from subsequent analysis, leaving 52 patients for analysis. The same diagnosis was reached for 99 of 104 ears when comparing the Cupris© device to standard assessment (95% concordance), with Cohen's kappa coefficient of 0.89. The decision as to whether a patient should be referred to an ENT centre for further assessment was the same for all 52 participants when comparing the Cupris© device to standard assessment. CONCLUSIONS: When compared to standard assessment, the Cupris© device is a valid tool for the diagnosis of ear disease and decision for onward referral. It shows considerable promise for use by trained non-medical workers, as a low-cost and portable tool to screen for ear disease in remote settings, particularly in low- and middle-income countries.

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.

A review of simulation platforms in surgery of the temporal bone.

BACKGROUND: Surgery of the temporal bone is a high-risk activity in an anatomically complex area. Simulation enables rehearsal of such surgery. The traditional simulation platform is the cadaveric temporal bone, but in recent years other simulation platforms have been created, including plastic and virtual reality platforms. OBJECTIVE OF REVIEW: To undertake a review of simulation platforms for temporal bone surgery, specifically assessing their educational value in terms of validity and in enabling transition to surgery. TYPE OF REVIEW: Systematic qualitative review. SEARCH STRATEGY: Search of the Pubmed, CINAHL, BEI and ERIC databases. EVALUATION METHOD: Assessment of reported outcomes in terms of educational value. RESULTS: A total of 49 articles were included, covering cadaveric, animal, plastic and virtual simulation platforms. Cadaveric simulation is highly rated as an educational tool, but there may be a ceiling effect on educational outcomes after drilling 8-10 temporal bones. Animal models show significant anatomical variation from man. Plastic temporal bone models offer much potential, but at present lack sufficient anatomical or haptic validity. Similarly, virtual reality platforms lack sufficient anatomical or haptic validity, but with technological improvements they are advancing rapidly. CONCLUSIONS: At present, cadaveric simulation remains the best platform for training in temporal bone surgery. Technological advances enabling improved materials or modelling mean that in the future plastic or virtual platforms may become comparable to cadaveric platforms, and also offer additional functionality including patient-specific simulation from CT data.

Oxidised cellulose powder for haemostasis following sinus surgery: a pilot randomised trial.

BACKGROUND: Haemorrhage is the most common major complication of endoscopic sinus surgery. Post-operative absorbable or non-absorbable nasal packing can cause pain and blockage. Haemostatic powders or gels may prevent this problem. However, when based on factors in the clotting cascade, they induce an inflammatory reaction and can cause post-operative synechiae. Oxidised cellulose powder produces haemostasis without inducing synechiae formation, but has not been trialled for sinus surgery. METHOD: A randomised clinical trial was performed to compare cellulose powder to non-absorbable packing following sinus surgery. Participants were 50 consecutive patients undergoing sinus surgery, 47 of whom completed the study. The main outcome measures were post-operative bleeding, pain scores and synechiae formation. RESULTS: Cellulose powder was effective at stopping bleeding, and was associated with less pain than nasal packing, with no evidence of increased synechiae formation. CONCLUSION: Cellulose powder appears to be a good haemostatic agent following sinus surgery. A larger trial would allow more accurate quantification of its effectiveness.

Nasal polyps do not contain olfactory structures.

BACKGROUND: Nasal polyposis can lead to olfactory dysfunction, either due to physical obstruction of the olfactory cleft or physiological disruption of the olfactory neuroepithelium. Where medical therapy has failed to relieve symptoms of nasal polyposis, surgical excision can be considered. However, removal of polyps medial to the middle turbinate is controversial: some believe this will relieve physical obstruction to odourants, others state that removal here risks excising olfactory neuroepithelium. METHODS: We stained 25 nasal polypectomy samples from the area medial to the middle turbinate with olfactory marker protein. RESULTS: We confirmed that our staining method worked on normal olfactory tissue. However, no positive staining of nasal polyps was demonstrated. CONCLUSION: We conclude that nasal polyps medial to the middle turbinate do not contain olfactory neurons, and surgical excision is not contraindicated.

Nurse-led adult ENT pre-operative assessment.

Pre-operative assessment in some ENT departments is now nurse-led rather than doctor-led. Appropriately trained nursing staff can perform medical aspects of pre-operative assessment to the same or a better standard than a doctor. Almost all patients are satisfied with a nurse-led pre-operative assessment, and in some cases they prefer it.

Cervico-thoracic teratoma masquerading as lymphatic malformation.

A case is presented of a nine-month-old male infant who presented acutely with an anterior neck and mediastinum mass compressing the trachea. Radiological assessment by ultrasound, magnetic resonance imaging and computed tomography suggested the nature of the mass to be a lymphatic malformation (cystic hygroma). The excised specimen was revealed as a mature teratoma. The inability to distinguish between lymphatic malformation and teratoma on multi-imaging modalities confers a risk of mismanaging these lesions with the use of sclerotherapy; surgical excision is the necessary treatment. The potential consequences are discussed.