Chronic suppurative otitis media.

Chronic suppurative otitis media (CSOM) is a leading global cause of potentially preventable hearing loss in children and adults, associated with socioeconomic deprivation. There is an absence of consensus on the definition of CSOM, which complicates efforts for prevention, treatment, and monitoring. CSOM occurs when perforation of the tympanic membrane is associated with severe or persistent inflammation in the middle ear, leading to hearing loss and recurrent or persistent ear discharge (otorrhoea). Cholesteatoma, caused by the inward growth of the squamous epithelium of the tympanic membrane into the middle ear, can also occur. The optimal treatment of discharge in CSOM is topical antibiotics. In resource-limited settings where topical antibiotics might not be available, topical antiseptics are an alternative. For persistent disease, surgery to repair the tympanic membrane or remove cholesteatoma might offer long-term resolution of otorrhoea and potential improvement to hearing. Recent developments in self-fitted air-conduction and bone-conduction hearing aids offer promise as new options for rehabilitation.

Country of Origin of Medical Products and Risk of Labour Rights Abuse: A Cross-Sectional Analysis Using Four Procurement Datasets.

Background Case studies have highlighted labour rights abuse in the manufacture of several healthcare products, but little is known about the scale of the problem or the specific products involved. We aimed to quantify and compare the overall and product-specific risks of labour rights abuse in the manufacture of healthcare products supplied to high-income settings using multiple datasets on the product country of origin (COO). Methods Public procurement data from South-Eastern Norway (n=23,972 products) were compared to datasets from three other high-income settings: procurement data from Cambridge University Hospitals, trade data from UN Comtrade, and registry data from the US Food and Drug Administration (FDA). In each dataset, the product COO was matched to the International Trade Union Confederation risk rating for labour abuse and deemed high-risk when rated 4, 5, or 5+. Results In the Norway data, 55.4% of products by value had a COO declared, 49.1% of which mapped as high-risk of labour rights abuses. COO was identified for 70/100 products in the Cambridge data, with COO matching high-risk at 59.9% by value. The level of risk for specific medical product categories varied between the Norway, US FDA, and UN Comtrade datasets, but those with higher proportional risk included medical/surgical gloves and electrosurgical products. Conclusion Evidence of high-risk of labour rights abuse in the manufacture of healthcare products present in these data indicates a likely high level of risk across the sector. There is an urgent need for global legislative and political reform, with a particular focus on supply chain transparency as a key mechanism for tackling this issue.

Virtual reality technology for surgical learning: qualitative outcomes of the first virtual reality training course for emergency and essential surgery delivered by a UK-Uganda partnership.

INTRODUCTION: The extensive resources needed to train surgeons and maintain skill levels in low-income and middle-income countries (LMICs) are limited and confined to urban settings. Surgical education of remote/rural doctors is, therefore, paramount. Virtual reality (VR) has the potential to disseminate surgical knowledge and skill development at low costs. This study presents the outcomes of the first VR-enhanced surgical training course, 'Global Virtual Reality in Medicine and Surgery', developed through UK-Ugandan collaborations. METHODS: A mixed-method approach (survey and semistructured interviews) evaluated the clinical impact and barriers of VR-enhanced training. Course content focused on essential skills relevant to Uganda (general surgery, obstetrics, trauma); delivered through: (1) hands-on cadaveric training in Brighton (scholarships for LMIC doctors) filmed in 360°; (2) virtual training in Kampala (live-stream via low-cost headsets combined with smartphones) and (3) remote virtual training (live-stream via smartphone/laptop/headset). RESULTS: High numbers of scholarship applicants (n=130); registrants (Kampala n=80; remote n=1680); and attendees (Kampala n=79; remote n=556, 25 countries), demonstrates widespread appetite for VR-enhanced surgical education. Qualitative analysis identified three key themes: clinical education and skill development limitations in East Africa; the potential of VR to address some of these via 360° visualisation enabling a 'knowing as seeing' mechanism; unresolved challenges regarding accessibility and acceptability. CONCLUSION: Outcomes from our first global VR-enhanced essential surgical training course demonstrating dissemination of surgical skills resources in an LMIC context where such opportunities are scarce. The benefits identified included environmental improvements, cross-cultural knowledge sharing, scalability and connectivity. Our process of programme design demonstrates that collaboration across high-income and LMICs is vital to provide locally relevant training. Our data add to growing evidence of extended reality technologies transforming surgery, although several barriers remain. We have successfully demonstrated that VR can be used to upscale postgraduate surgical education, affirming its potential in healthcare capacity building throughout Africa, Europe and beyond.

The Global Otolaryngology-Head and Neck Surgery Workforce.

Importance: A core component of delivering care of head and neck diseases is an adequate workforce. The World Health Organization report, Multi-Country Assessment of National Capacity to Provide Hearing Care, captured primary workforce estimates from 68 member states in 2012, noting that response rates were a limitation and that updated more comprehensive data are needed. Objective: To establish comprehensive workforce metrics for global otolaryngology-head and neck surgery (OHNS) with updated data from more countries/territories. Design, Setting, and Participants: A cross-sectional electronic survey characterizing the OHNS workforce was disseminated from February 10 to June 22, 2022, to professional society leaders, medical licensing boards, public health officials, and practicing OHNS clinicians. Main Outcome: The OHNS workforce per capita, stratified by income and region. Results: Responses were collected from 121 of 195 countries/territories (62%). Survey responses specifically reported on OHNS workforce from 114 countries/territories representing 84% of the world's population. The global OHNS clinician density was 2.19 (range, 0-61.7) OHNS clinicians per 100 000 population. The OHNS clinician density varied by World Bank income group with higher-income countries associated with a higher density of clinicians. Regionally, Europe had the highest clinician density (5.70 clinicians per 100 000 population) whereas Africa (0.18 clinicians per 100 000 population) and Southeast Asia (1.12 clinicians per 100 000 population) had the lowest. The OHNS clinicians deliver most of the surgical management of ear diseases and hearing care, rhinologic and sinus diseases, laryngeal disorders, and upper aerodigestive mucosal cancer globally. Conclusion and Relevance: This cross-sectional survey study provides a comprehensive assessment of the global OHNS workforce. These results can guide focused investment in training and policy development to address disparities in the availability of OHNS clinicians.

The carbon footprint of products used in five common surgical operations: identifying contributing products and processes.

OBJECTIVES: Mitigating carbon footprint of products used in resource-intensive areas such as surgical operating rooms will be important in achieving net zero carbon healthcare. The aim of this study was to evaluate the carbon footprint of products used within five common operations, and to identify the biggest contributors (hotspots). DESIGN: A predominantly process-based carbon footprint analysis was conducted for products used in the five highest volume surgical operations performed in the National Health System in England. SETTING: The carbon footprint inventory was based on direct observation of 6-10 operations/type, conducted across three sites within one NHS Foundation Trust in England. PARTICIPANTS: Patients undergoing primary elective carpal tunnel decompression, inguinal hernia repair, knee arthroplasty, laparoscopic cholecystectomy, tonsillectomy (March 2019 - January 2020). MAIN OUTCOME MEASURES: We determined the carbon footprint of the products used in each of the five operations, alongside greatest contributors through analysis of individual products and of underpinning processes. RESULTS: The mean average carbon footprint of products used for carpal tunnel decompression was 12.0 kg CO2e (carbon dioxide equivalents); 11.7 kg CO2e for inguinal hernia repair; 85.5 kg CO2e for knee arthroplasty; 20.3 kg CO2e for laparoscopic cholecystectomy; and 7.5 kg CO2e for tonsillectomy. Across the five operations, 23% of product types were responsible for ≥80% of the operation carbon footprint. Products with greatest carbon contribution for each operation type were the single-use hand drape (carpal tunnel decompression), single-use surgical gown (inguinal hernia repair), bone cement mix (knee arthroplasty), single-use clip applier (laparoscopic cholecystectomy) and single-use table drape (tonsillectomy). Mean average contribution from production of single-use items was 54%, decontamination of reusables 20%, waste disposal of single-use items 8%, production of packaging for single-use items 6% and linen laundering 6%. CONCLUSIONS: Change in practice and policy should be targeted towards those products making greatest contribution, and should include reducing single-use items and switching to reusables, alongside optimising processes for decontamination and waste disposal, modelled to reduce carbon footprint of these operations by 23%-42%.

Whole exome sequencing study identifies candidate loss of function variants and locus heterogeneity in familial cholesteatoma.

Cholesteatoma is a rare progressive disease of the middle ear. Most cases are sporadic, but some patients report a positive family history. Identifying functionally important gene variants associated with this disease has the potential to uncover the molecular basis of cholesteatoma pathology with implications for disease prevention, surveillance, or management. We performed an observational WES study of 21 individuals treated for cholesteatoma who were recruited from ten multiply affected families. These family studies were complemented with gene-level mutational burden analysis. We also applied functional enrichment analyses to identify shared properties and pathways for candidate genes and their products. Filtered data collected from pairs and trios of participants within the ten families revealed 398 rare, loss of function (LOF) variants co-segregating with cholesteatoma in 389 genes. We identified six genes DENND2C, DNAH7, NBEAL1, NEB, PRRC2C, and SHC2, for which we found LOF variants in two or more families. The parallel gene-level analysis of mutation burden identified a significant mutation burden for the genes in the DNAH gene family, which encode products involved in ciliary structure. Functional enrichment analyses identified common pathways for the candidate genes which included GTPase regulator activity, calcium ion binding, and degradation of the extracellular matrix. The number of candidate genes identified and the locus heterogeneity that we describe within and between multiply affected families suggest that the genetic architecture for familial cholesteatoma is complex.

Trans-cortical vessels in the mouse temporal bulla bone are a means to recruit myeloid cells in chronic otitis media and limit peripheral leukogram changes.

Chronic otitis media, inflammation of the middle ear, is a sequel to acute otitis media in ∼8% of children. Chronic otitis media with effusion is the most common cause of childhood deafness and is characterised by effusion of white blood cells into the auditory bulla cavity. Skull flat bones have trans-cortical vessels which are responsible for the majority of blood flow in and out of the bone. In experimental models of stroke and aseptic meningitis there is preferential recruitment of myeloid cells (neutrophils and monocytes) from the marrow in skull flat bones. We report trans-cortical vessels in the mouse temporal bone connect to the bulla mucosal vasculature and potentially represent a means to recruit myeloid cells directly into the inflamed bulla. The mutant mouse strains Junbo (Mecom Jbo/+ ) and Jeff (Fbxo11 Jf/+ ) develop chronic otitis spontaneously; Mecom Jbo/+ mice have highly cellular neutrophil (90%) rich bulla exudates whereas Fbxo11 Jf/+ mice have low cellularity serous effusions (5% neutrophils) indicating differing demand for neutrophil recruitment. However we found peripheral leukograms of Mecom Jbo/+ and Fbxo11 Jf/+ mice are similar to their respective wild-type littermate controls with healthy bullae and infer preferential mobilization of myeloid cells from temporal bulla bone marrow may mitigate the need for a systemic inflammatory reaction. The cytokines, chemokines and haematopoietic factors found in the inflamed bulla represent candidate signalling molecules for myeloid cell mobilization from temporal bone marrow. The density of white blood cells in the bulla cavity is positively correlated with extent of mucosal thickening in Mecom Jbo/+ , Fbxo11 Jf/+ , and Eda Ta mice and is accompanied by changes in epithelial populations and bone remodelling. In Mecom Jbo/+ mice there was a positive correlation between bulla cavity WBC numbers and total bacterial load. The degree of inflammation varies between contralateral bullae and between mutant mice of different ages suggesting inflammation may wax and wane and may be re-initiated by a new wave of bacterial infection. Clearance of white blood cells and inflammatory stimuli from the bulla cavity is impaired and this may create a pro-inflammatory feedback loop which further exacerbates otitis media and delays its resolution.

Barriers to access to ear and hearing care services in low- and middle- income countries: A scoping review.

People living in low- and middle- income countries (LMICs) meet significant challenges in accessing ear and hearing care (EHC) services. We conducted a scoping review to identify and summarise such barriers, to recognise gaps in the literature, and to identify potential solutions. Reviewers independently screened titles, abstracts and full-text articles and charted data. We undertook thematic analysis of supply and demand side dimensions of access, and summarised findings mapped against the Levesque framework. Of 3048 articles screened, 62 met inclusion criteria for review. Across the five access dimensions, supply-side constraints were more frequently described, the most common being a shortage of EHC workforce or appropriate facilities, despite high demand. We identified a thin geographical spread of literature on barriers to accessing EHC services in LMICs, reflecting low availability of such services. LMICs face a diverse range of demand and supply side challenges including workforce, equipment and resource shortages, and challenges for the majority of the population to pay for such services. There is a need for many LMICs to develop health policy and programmes in EHC, including integration into primary care, scaling up the EHC workforce through increased training and education, and improving EHC literacy through public health measures.

Density of Health Workforce Correlates to Disease Outcomes: Evidence From Global Data in Otolaryngology.

Objective: To better understand the impact of the otolaryngology-specific workforce on the burden of related diseases. Study Design: Retrospective analysis of existing workforce density data as compared with the incidence, mortality, and morbidity data for 4 otolaryngologic diseases. Setting: An overall 138 countries with known otolaryngology-head and neck surgery workforce and epidemiologic data. Methods: We obtained raw data on workforce estimates of ear, nose, and throat surgical specialists from the World Health Organization. Disease burdens for 4 conditions were estimated via 2 ratios, the mortality:incidence ratio (MIR) and YLD:incidence ratio (years lost to disability), as specified in the Global Burden of Disease database. These were correlated to country-specific otolaryngologist density data in univariate and multivariate analyses. Results: Increased density of the ear, nose, and throat workforce correlated with better outcomes for otolaryngologic-treated surgical diseases. A 10% increase in otolaryngology workforce density was associated with a 0.27% reduction in YLD:incidence ratio for chronic otitis media, a 0.94% reduction in MIR for lip and oral cavity cancer, a 1.46% reduction in MIR for laryngeal cancer, and a 1.34% reduction in MIR for pharyngeal cancer (all P < .001)-an effect that remained after adjustment for health systems factors for all conditions but chronic otitis media. Conclusion: The density of the surgical workforce is assumed to affect disease outcomes, but ours is the first analysis to show that increased workforce density for a specific surgical specialty correlates with improved disease outcomes. While there is a consensus to increase access to health care providers, quantifying the effect on disease outcomes is an important metric for those performing health economics modeling, particularly where resources are limited.

The EDA-deficient mouse has Zymbal's gland hypoplasia and acute otitis externa.

In mice, rats, dogs and humans, the growth and function of sebaceous glands and eyelid Meibomian glands depend on the ectodysplasin signalling pathway. Mutation of genes encoding the ligand EDA, its transmembrane receptor EDAR and the intracellular signal transducer EDARADD leads to hypohidrotic ectodermal dysplasia, characterised by impaired development of teeth and hair, as well as cutaneous glands. The rodent ear canal has a large auditory sebaceous gland, the Zymbal's gland, the function of which in the health of the ear canal has not been determined. We report that EDA-deficient mice, EDAR-deficient mice and EDARADD-deficient rats have Zymbal's gland hypoplasia. EdaTa mice have 25% prevalence of otitis externa at postnatal day 21 and treatment with agonist anti-EDAR antibodies rescues Zymbal's glands. The aetiopathogenesis of otitis externa involves infection with Gram-positive cocci, and dosing pregnant and lactating EdaTa females and pups with enrofloxacin reduces the prevalence of otitis externa. We infer that the deficit of sebum is the principal factor in predisposition to bacterial infection, and the EdaTa mouse is a potentially useful microbial challenge model for human acute otitis externa.

Minimising carbon and financial costs of steam sterilisation and packaging of reusable surgical instruments.

BACKGROUND: The aim of this study was to estimate the carbon footprint and financial cost of decontaminating (steam sterilization) and packaging reusable surgical instruments, indicating how that burden might be reduced, enabling surgeons to drive action towards net-zero-carbon surgery. METHODS: Carbon footprints were estimated using activity data and prospective machine-loading audit data at a typical UK in-hospital sterilization unit, with instruments wrapped individually in flexible pouches, or prepared as sets housed in single-use tray wraps or reusable rigid containers. Modelling was used to determine the impact of alternative machine loading, opening instruments during the operation, streamlining sets, use of alternative energy sources for decontamination, and alternative waste streams. RESULTS: The carbon footprint of decontaminating and packaging instruments was lowest when instruments were part of sets (66-77 g CO2e per instrument), with a two- to three-fold increase when instruments were wrapped individually (189 g CO2e per instrument). Where 10 or fewer instruments were required for the operation, obtaining individually wrapped items was preferable to opening another set. The carbon footprint was determined significantly by machine loading and the number of instruments per machine slot. Carbon and financial costs increased with streamlining sets. High-temperature incineration of waste increased the carbon footprint of single-use packaging by 33-55 per cent, whereas recycling reduced this by 6-10 per cent. The absolute carbon footprint was dependent on the energy source used, but this did not alter the optimal processes to minimize that footprint. CONCLUSION: Carbon and financial savings can be made by preparing instruments as part of sets, integrating individually wrapped instruments into sets rather than streamlining them, efficient machine loading, and using low-carbon energy sources alongside recycling.

Healthcare worker protection against epidemic viral respiratory disease.

Lower respiratory infections are often caused or precipitated by viruses and are a leading cause of global morbidity and mortality. Mutations in these viral genomes can produce highly infectious strains that transmit across species and have the potential to initiate epidemic, or pandemic, human viral respiratory disease. Transmission between humans primarily occurs via the airborne route and is accelerated by our increasingly interconnected and globalised society. To this date, there have been four major human viral respiratory outbreaks in the 21st century. Healthcare workers (HCWs) are at particular risk during respiratory epidemics or pandemics. This is due to crowded working environments where social distancing, or wearing respiratory personal protective equipment for prolonged periods, might prove difficult, or performing medical procedures that increase exposure to virus-laden aerosols, or bodily fluids. This review aims to summarise the evidence and approaches to occupational risk and protection of HCWs during epidemic or pandemic respiratory viral disease.

Geriatric medicine in the era of climate change.

Climate change has been termed the greatest threat to human health of the 21st century. Older people and those living with frailty are more vulnerable to the effects of climate change including heatwaves and extreme weather events, and therefore, we have a responsibility to advocate for action on the climate emergency and take steps to reduce the environmental impact of our care provision. The NHS contributes 5.7% to the carbon footprint of the UK, and by reviewing the financial costs associated with frailty, we estimate the carbon footprint of frailty to be 1.7 MtCO2e, or 7% of the total NHS carbon footprint. Resource use also increases with age with particular interventions and medical equipment such as hearing and mobility aids being predominantly associated with the care of older people. The NHS has committed to net zero carbon emissions by 2045 and in order to achieve this we all need to act-balancing the triple bottom line of environmental, social and financial impacts alongside outcomes for patients and populations when making decisions about care. The principles of sustainable healthcare are already embedded in the geriatrician's holisitic approach to the care of older people and those living with frailty, and the imperative to reduce the carbon footprint of healthcare should add weight to the argument for extending the role of the geriatrician into other specialties. It is time to begin our journey to net-zero geriatric medicine.

Environmental impact and life cycle financial cost of hybrid (reusable/single-use) instruments versus single-use equivalents in laparoscopic cholecystectomy.

BACKGROUND: Hybrid surgical instruments contain both single-use and reusable components, potentially bringing together advantages from both approaches. The environmental and financial costs of such instruments have not previously been evaluated. METHODS: We used Life Cycle Assessment to evaluate the environmental impact of hybrid laparoscopic clip appliers, scissors, and ports used for a laparoscopic cholecystectomy, comparing these with single-use equivalents. We modelled this using SimaPro and ReCiPe midpoint and endpoint methods to determine 18 midpoint environmental impacts including the carbon footprint, and three aggregated endpoint impacts. We also conducted life cycle cost analysis of products, taking into account unit cost, decontamination, and disposal costs. RESULTS: The environmental impact of using hybrid instruments for a laparoscopic cholecystectomy was lower than single-use equivalents across 17 midpoint environmental impacts, with mean average reductions of 60%. The carbon footprint of using hybrid versions of all three instruments was around one-quarter of single-use equivalents (1756 g vs 7194 g CO2e per operation) and saved an estimated 1.13 e-5 DALYs (disability adjusted life years, 74% reduction), 2.37 e-8 species.year (loss of local species per year, 76% reduction), and US $ 0.6 in impact on resource depletion (78% reduction). Scenario modelling indicated that environmental performance of hybrid instruments was better even if there was low number of reuses of instruments, decontamination with separate packaging of certain instruments, decontamination using fossil-fuel-rich energy sources, or changing carbon intensity of instrument transportation. Total financial cost of using a combination of hybrid laparoscopic instruments was less than half that of single-use equivalents (GBP £131 vs £282). CONCLUSION: Adoption of hybrid laparoscopic instruments could play an important role in meeting carbon reduction targets for surgery and also save money.

Research Equity in Otolaryngology-Head and Neck Surgery.

Equitable research collaborations benefit the quality and relevance of global otolaryngology-head and neck surgery research. However, analyses of existing global health literature have shown disproportionate representation by foreign authors. To avert this inequity and improve global otolaryngology-head and neck surgery research, we propose a framework that emphasizes local representation and capacity building in research.

Endoscope and image-guided ventral bulla osteotomy in the dog: A cadaveric and patient study.

BACKGROUND: Surgery of the bulla in the dog can be difficult and associated with suboptimal resolution of disease and risk of complications, particularly in treatment of cholesteatoma. We explored use of image guidance and endoscopic assistance in ventral bulla osteotomy (VBO), initially with cadaveric studies and subsequently on dogs with cholesteatoma. METHODS: For surgical approach we used cone beam CT with an optical image navigation system. For endoscopic surgery we used 4 mm and 2.7 mm diameter endoscopes and a camera viewing system, with micro-instruments for dissection. RESULTS: Image guidance allowed us to accurately identify and approach the bulla in cadavers (n = 2) and patients (n = 2). The endoscope enabled us to define detailed endoscopic anatomy in cadaveric canine heads (n = 15), and in patients (n = 5) it enabled reliable and safe removal of pathological tissue. CONCLUSION: Image and endoscopic assistance could be a significant advance to the reliability and safety of VBO. Our techniques may be applicable to other indications and species.