Effectiveness, perceptions and environmental benefits of remote consultation for adults referred with recurrent tonsillitis.

INTRODUCTION: We evaluate remote consultation for adult patients referred with recurrent sore throat, measuring the effectiveness of the consultation, satisfaction and environmental impact. METHODS: Eligible patients were invited to telephone clinics, undertaking a satisfaction survey after consultation, focusing on perceived convenience, satisfaction, cost and travel arrangements (used to calculate potential environmental benefit). Provider opinion was also captured. RESULTS: Forty-eight of 60 patients attended, with 38 (63%) eligible for inclusion. Thirty-six of these 38 patients (95%) had a definitive outcome of tonsillectomy (27/38) or discharge (9/38). Thirty-three of the 38 patients (87%) responded to the survey and reported high satisfaction in all arms of questioning (mean Likert ranking = 4.7/5). A mean of 3.76 hours of missed work and 5.17kg carbon dioxide emission equivalents were saved per patient. Provider responses were positive towards ongoing remote consultation use. CONCLUSIONS: Telephone consultation for adult patients considered for tonsillectomy is convenient to patients in terms of cost and time, reduces environmental harm and is associated with high patient and provider satisfaction.

Outcomes of remote versus face-to-face ear, nose and throat outpatient consultation on patient pathways.

INTRODUCTION: Remote consultation has potential benefits in increasing patient pathway efficiency and has been found to reduce costs and carbon emissions. Previous studies of remote consultation in ear, nose and throat (ENT) practice have reported mixed results and used relatively small sample sizes. The aim of this article is to study the impact of remote telephone consultation on ENT clinic outcomes and pathway efficiency, compared with in-person review, within new and follow-up patient cohorts and subspeciality, where previous studies demonstrate mixed and inconclusive results. METHODS: This was a comparison of remote clinic appointment outcomes over a 2-month period from a single ENT referral centre (426) with an equivalent data set of face-to-face clinic appointments over a similar time frame (1,533). Statistical analysis included chi-squared test for clinic outcomes and two-sample t-squared test for mean hand-off between both cohorts (p < 0.05). RESULTS: For new referrals, remote consultation was associated with statistically significantly greater rates of follow-up (p < 0.00001), investigation (p = 0.00251) and hand-off (p < 0.00013) than patients seen face-to-face - particularly where presenting with head and neck symptoms. For follow-up patients, remote consultation had similar rates of investigation (p = 0.11071) or further follow-up (p = 0.08) and mean hand-off (p < 0.11764) to those seen face-to-face. CONCLUSIONS: Remote consultation in ENT could become the norm for follow-up patients, but should be used with caution in the initial consultation of new patients.

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.

Access to ear and hearing care services in Cambodia: a qualitative enquiry into experiences of key informants.

OBJECTIVE: In Cambodia, little is known about the state of ear and hearing care, or the roles providers or key stakeholders play in delivering services. METHOD: This was an exploratory study using semi-structured qualitative interviews and a questionnaire addressed to key stakeholders to explore their perceptions and experiences in providing services to people suffering from ear disease or hearing loss in Cambodia. RESULTS: Several challenges were described including a lack of hearing services to meet the demand, especially outside Phnom Penh in primary care and aural rehabilitation. Supply-side challenges include a shortage of trained professionals, facilities and resources, poor co-ordination between providers, unclear referral pathways, and long wait times. CONCLUSION: Now is an opportune time to build on the positive trend in providing integrated care for non-communicable diseases in Cambodia, through the integration of effective ear and hearing care into primary care and strengthening the package of activities delivered at government facilities.

Effectiveness of an online module: climate-change and sustainability in clinical practice.

BACKGROUND: Climate change has significant implications for health, yet healthcare provision itself contributes significant greenhouse gas emission. Medical students need to be prepared to address impacts of the changing environment and fulfil a key role in climate mitigation. Here we evaluate the effectiveness of an online module on climate-change and sustainability in clinical practice designed to achieve learning objectives adapted from previously established sustainable healthcare priority learning outcomes. METHODS: A multi-media, online module was developed, and 3rd and 4th year medical students at Brighton and Sussex Medical School were invited to enrol. Students completed pre- and post-module questionnaires consisting of Likert scale and white space answer questions. Quantitative and qualitative analysis of responses was performed. RESULTS: Forty students enrolled and 33 students completed the module (83% completion rate). There was a significant increase in reported understanding of key concepts related to climate change and sustainability in clinical practice (p < 0.001), with proportion of students indicating good or excellent understanding increasing from between 2 - 21% students to between 91 - 97% students. The majority (97%) of students completed the module within 90 min. All students reported the module was relevant to their training. Thematic analysis of white space responses found students commonly reported they wanted access to more resources related to health and healthcare sustainability, as well as further guidance on how to make practical steps towards reducing the environmental impact within a clinical setting. CONCLUSION: This is the first study to evaluate learner outcomes of an online module in the field of sustainable health and healthcare. Our results suggest that completion of the module was associated with significant improvement in self-assessed knowledge of key concepts in climate health and sustainability. We hope this approach is followed elsewhere to prepare healthcare staff for impacts of climate change and to support improving the environmental sustainability of healthcare delivery. TRIAL REGISTRATION: Study registered with Brighton and Sussex Medical School Research Governance and Ethics Committee (BSMS RGEC). Reference: ER/BSMS3576/8, Date: 4/3/2020.

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.

Models of service delivery for ear and hearing care in remote or resource-constrained environments.

BACKGROUND: There is poor availability of ear and hearing services globally, because of a lack of infrastructure, funding, equipment and appropriately trained personnel. When deciding upon delivery of ear and hearing services, an approach based upon community assessment is advocated, with subsequent asset mapping and acquisition. OBJECTIVES: Some of the challenges to delivery of care in resource-constrained or remote environments are acknowledged, with discussion of several existing models of service delivery, and their advantages and disadvantages. Public health and telehealth are also mentioned. This article may assist those trying to set up new programmes in ear and hearing health.

Implementation and results of a surgical training programme for chronic suppurative otitis media in Cambodia.

BACKGROUND: Chronic suppurative otitis media is a massive public health problem in numerous low- and middle-income countries. Unfortunately, few low- and middle-income countries can offer surgical therapy. METHODS: A six-month long programme in Cambodia focused on training local surgeons in type I tympanoplasty was instigated. Qualitative educational and quantitative surgical outcomes were evaluated in the 12 months following programme completion. A four-month long training programme in mastoidectomy and homograft ossiculoplasty was subsequently implemented, and the preliminary surgical and educational outcomes were reported. RESULTS: A total of 124 patients underwent tympanoplasty by the locally trained surgeons. Tympanic membrane closure at six weeks post-operation was 88.5 per cent. Pure tone audiometry at three months showed that 80.9 per cent of patients had improved hearing, with a mean gain of 17.1 dB. The trained surgeons reported high confidence in performing tympanoplasty. Early outcomes suggest the local surgeons can perform mastoidectomy and ossiculoplasty as safely as overseas-trained surgeons, with reported surgeon confidence reflecting these positive outcomes. CONCLUSION: The training programme has demonstrated success, as measured by surgeon confidence and operative outcomes. This approach can be emulated in other settings to help combat the global burden of chronic suppurative otitis media.

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.