How chronic ear disease affects quality of life: a qualitative research study in Nepal.

OBJECTIVE: Hearing loss is the third leading cause globally for 'years lived with disability'. The majority of those affected live in low and middle-income countries. METHOD: This study used qualitative research methods to explore the impact of chronic ear disease on quality of life in Nepal. Twenty face-to-face semi-structured interviews were conducted during a visiting ear camp at the Britain Nepal Otology Service Ear Care Centre in Nepal. Interviews were recorded, transcribed and translated with thematic content analysis performed manually by two researchers. RESULTS: Chronic ear disease has a significant impact on social interactions, emotional well-being and functionality. Barriers to surgery are cost, accessibility, reputation, gender and fear of complications. CONCLUSION: This study provided valuable new insight into patient perspectives on living with chronic ear disease in Nepal. Patients with chronic ear disease experience discrimination and stigmatisation across all levels of personal, family and social life, with their function across all domains being directly limited by symptoms.

Evaluating the inclusion of tympanometry in population-based surveys of hearing loss.

OBJECTIVE: This study aimed to determine the implications of including tympanometry in the Rapid Assessment of Hearing Loss survey protocol. A comparative study design was employed, with findings from otoscopy compared with the results of tympanometry. METHOD: A population-based survey of the prevalence and causes of hearing loss among adults aged over 35 years in The Gambia was conducted. Clinical assessments included air conduction audiometry, otoscopy and clinical history. Otoscopy outcome was recorded and for those with hearing loss, a probable cause was assigned. Following otoscopy, tympanometry was completed. Otoscopy outcome was not changed as a result of tympanometry. Clinician assigned cause was compared to the results of tympanometry. The proportion of causes potentially misclassified by excluding tympanometry was determined. RESULTS: Among people with hearing loss, including tympanometry led to a higher proportion diagnosed with middle-ear conditions. CONCLUSION: The value of adding tympanometry to population-based survey protocols is a higher estimated proportion of hearing loss being attributed to middle-ear disease rather than sensorineural causes. This can inform service needs as more people will be classified as needing medical or surgical services, and a slightly lower number will need rehabilitative services, such as hearing assistive devices. It is highly recommended that tympanometry is included in the protocol.

Disability from chronic ear disease in Nepal assessed using the World Health Organization Disability Assessment Schedule 2.0 instrument.

OBJECTIVE: Globally, South Asia has the highest proportion of disabling hearing loss. There is a paucity of data exploring the associated hearing loss and disability caused by chronic middle-ear disease in South Asia in the setting of surgical outreach. This study aimed to measure disability using the World Health Organization Disability Assessment Schedule 2.0 in patients undergoing ear surgery for chronic middle-ear disease in an ear hospital in Nepal. METHOD: The World Health Organization Disability Assessment Schedule 2.0 was translated into Nepali and administered by interview to patients before ear surgery, and results were correlated with pre-operative audiograms. RESULTS: Out of a total of 106 patients with a mean age of 23 years, the mean World Health Organization Disability Assessment Schedule 2.0 score was 17.7, and the highest domain scores were for domain 6 'participation in society' at a score of 34. There was a positive correlation of World Health Organization Disability Assessment Schedule 2 score with hearing level (r = 0.46). CONCLUSION: Patients with ear disease in Nepal have had their disability measured using the World Health Organization Disability Assessment Schedule 2.0. Our study demonstrated a correlation between impaired hearing and disability in a surgical outreach context, which was an expected but not previously reported finding.

Screening for vestibular schwannoma in the context of an ageing population.

OBJECTIVE: To review the literature regarding screening for vestibular schwannoma in the context of demographic changes leading to increasing numbers of elderly patients presenting with asymmetric auditory symptoms. METHODS: A systematic review of the literature was performed, with narrative synthesis and statistical analysis of data where appropriate. RESULTS: Vestibular schwannomas diagnosed in patients aged over 70 years exhibit slower growth patterns and tend to be of smaller size compared to those tumours in younger age groups. This fact, combined with reduced life expectancy, renders the probability of these tumours in the elderly requiring active treatment with surgery or stereotactic radiotherapy to be extremely low. Vestibular schwannomas in the elderly are much more likely to be managed by serial monitoring with magnetic resonance imaging. The weighted yield of magnetic resonance imaging in the diagnosis of vestibular schwannoma in all age groups is 1.18 per cent, with almost 85 scans required to diagnose 1 tumour. CONCLUSION: An evidence-based approach to the investigation of asymmetric hearing loss and tinnitus in the elderly patient can be used to formulate guidelines for the rational use of magnetic resonance imaging in this population.

Quality of life measures in otitis media.

Disabling hearing impairment is the world's most common disability. Traditionally, hearing levels measured by pure tone audiometry have been used to define and quantify hearing loss. The effects of disabling hearing loss on patients' quality of life can be profound, and audiometric data alone may not correlate with quality of life measures. Generic measures of quality of life can be used to compare different diseases, and as such are useful in resource allocation and burden of disease studies. Their disadvantage is that they are not disease-specific and can therefore under-estimate the effects of a disease on patients' quality of life. Disease-specific measures are more sensitive. In chronic otitis media, additional factors such as discharge augment the effect of hearing loss alone on quality of life. Many of the quality of life measures developed for chronic otitis media have been used to assess improvement following reconstructive surgery. Quality of life measures have also been used to assess the effect of paediatric otitis media. Quality of life measures also have utility in the developing world, where hearing impairment is a huge burden.

Diagnostic otoscopy skills of community ear assistants in Western Nepal.

INTRODUCTION: Deafness is a major problem in developing countries. Rural communities tend to be affected more than urban ones, and chronic otitis media is common. The World Health Organization has proposed primary ear care as a method of providing otological services in developing countries. This study aimed to assess the diagnostic otoscopy skills of community ear assistants in rural Western Nepal. MATERIALS AND METHODS: Community ear assistants undertook the pre-operative evaluation of 92 patients selected for middle-ear surgery in an 'ear camp' setting. The otoscopy skills of community ear assistants were also assessed by means of an otoscopy quiz. Consultant otologists and trainee otolaryngologists underwent an identical assessment. RESULTS: The community ear assistants' selection of patients for middle-ear surgery concurred with the consultant otologists' opinion in 87 of 92 patients (94.5 per cent). The level of community ear assistants' otoscopy skills was between that of junior and senior otolaryngology trainees. CONCLUSIONS: With intensive training, medically unqualified community ear assistants can develop otoscopy skills comparable to those of medically qualified otolaryngology trainees. These results support the development of primary ear care in poorer countries where access to specialist otological services is difficult or impossible.

Long-term stenting for chronic frontal sinus disease: case series and literature review.

OBJECTIVE: The frontal sinus outflow tract consists anatomically of narrow channels prone to stenosis. Following both endonasal and external approach surgery, up to 30 per cent of patients suffer post-operative re-stenosis of the frontal sinus outflow tract, with recurrent frontal sinus disease. This paper proposes the surgical placement of a long-term frontal sinus stent to maintain fronto-nasal patency, as an alternative to more aggressive surgical procedures such as frontal sinus obliteration and modified Lothrop procedures. DESIGN: We present a series of three patients with frontal sinus disease and significant co-morbidity, the latter making extensive surgery a significant health risk. We also review the relevant literature and discuss the use of long-term frontal sinus stenting. RESULTS: These three cases were successfully treated with long-term frontal sinus stenting. Stents remained in situ for a period ranging from 48 to over 60 months. CONCLUSION: Due to the relatively high failure rates for both endonasal and external frontal sinus surgery, with a high post-operative incidence of frontal sinus outflow tract re-stenosis, long-term stenting is a useful option in carefully selected patients.

Endoscopic endonasal laser versus endonasal surgical dacryocystorhinostomy for epiphora due to nasolacrimal duct obstruction: prospective, randomised, controlled trial.

BACKGROUND: Rhinostomy patency is a problem in all forms of dacryocystorhinostomy. Laser-assisted procedures are potentially fast and result in excellent haemostasis. However, they may induce more fibroblastic activity, resulting in excessive scarring and stenosis of the rhinostomy, compared with non-laser dissection. OBJECTIVES: The objective of this study was to compare subjective outcomes following dacryocystorhinostomy conducted with endoscopic endonasal laser and with endonasal surgical techniques. STUDY DESIGN: Prospective, randomised, controlled trial comparing potassium titanyl phosphate endonasal laser dissection with endonasal surgical techniques, for dacryocystorhinostomy to treat epiphora due to primary, acquired nasolacrimal duct obstruction. PARTICIPANTS: One hundred and twenty-six adult patients with chronic epiphora due to primary, acquired nasolacrimal sac or duct obstruction. INTERVENTIONS: INTERVENTIONS comprised endonasal dacryocystorhinostomy, performed using potassium titanyl phosphate laser or surgical dissection, in order to open the lacrimal sac into the nasal cavity. OUTCOME MEASURES: These were: symptom score and symptom relief of epiphora (at three and 12 months post-procedure); duration and ease of procedure; and duration of hospital stay. RESULTS: Sixty patients underwent endonasal laser dacryocystorhinostomy and 66 underwent endonasal surgical dacryocystorhinostomy. Symptomatic success was 82 per cent at three months and 68 per cent at 12 months in the laser group, and 76 per cent at three months and 74 per cent at 12 months in the surgical group. A two-point reduction in the symptom score was associated with symptomatic success at three and 12 months. Eight patients randomised to the laser group required additional instrumentation in order to remove thick bone over the lacrimal sac. CONCLUSIONS: At three months, endonasal laser dacryocystorhinostomy had better results than endonasal surgical dacryocystorhinostomy. However, at 12 months, the surgical procedure had better results than the laser procedure. There was no statistically significant difference between the two groups at three or 12 months with regard to symptomatic outcome. The ease of procedure (on a scale of zero to 10) was 4.5 for the laser procedure and 4.1 for the surgical procedure. The average times for the procedures were 25 minutes in the laser group and 20 minutes in the surgical group. No statistical difference was found when comparing: symptom score improvement for local anaesthetic vs general anaesthetic; ages over and under 70 years; laterality; or operating surgeon. Change in the symptom score was a useful indicator of symptomatic success.

Navigational systems in rhinology: should we all be using them?

The proximity of the paranasal sinuses to important anatomical structures creates the potential for serious complications following endoscopic sinus surgery. Over recent years, navigational systems have been developed and are increasingly being used by some centres. We summarise the history and principles of navigational sinus surgery, review the medical literature on the topic, and try to assess what role navigational systems should play in modern day rhinology practice.

Isolation rearing and hyperlocomotion are associated with reduced immediate early gene expression levels in the medial prefrontal cortex.

Environmental deprivation contributes in important ways to the development of a wide range of psychiatric disorders. Isolation rearing of rodents, a model for environmental deprivation in humans, consistently produces hyperlocomotion, which provides a measurable parameter to study the underlying mechanisms of early adverse psychosocial stressors. Male Sprague-Dawley rat pups were separated from dams at postnatal (PN) day 20 and reared either in groups of three or in isolation. On PN 38, locomotion was assessed in the open field. On PN 46, rats were killed and gene expression patterns examined in the medial prefrontal cortex (mPFC). Isolation-reared rats displayed increased locomotor activity and decreased resting time in the open field. Specific gene expression patterns in the mPFC were associated with both isolation rearing and hyperlocomotive behavior in the open field. Genes involved in these expression patterns included immediate early genes (IEGs) and genes that regulate cell differentiation and apoptosis. The study of these genes could provide important insights into how abnormal early psychosocial events affect brain function and behavior.

Otolaryngological requirements for recreational self-contained underwater breathing apparatus (SCUBA) diving.

Recreational self-contained underwater breathing apparatus (SCUBA) diving continues to grow in popularity. Medical requirements to be 'fit to dive' vary throughout the world, from self-certification to a full medical examination prior to training. This review discusses the relative merits of the most commonly used guidelines for recreational SCUBA diving, with reference to common diving-related otorhinolaryngological conditions. Areas of controversy, such as fitness to dive after rhinological and otological surgery, are discussed. The authors suggest that a unified approach from the various recreational SCUBA diving organizations involved would aid in clarification for divers and physicians alike. The difficulties in achieving such a unified approach, however, should not be underestimated.

Granuloma annulare presenting as multiple nodules on the pinna.

Granuloma annulare is a benign, idiopathic, inflammatory dermatosis characterized clinically by dermal papules and annular plaques. We describe the case of a 40-year-old man who presented with a long history of multiple nodules on the left pinna. Histological examination revealed the typical necrobiotic granulomas of granuloma annulare. The condition predominantly affects the extremities of children and young adults; cases involving the pinna are extremely rare. Nodular lesions are common in otolaryngological practice, and this case illustrates the need for careful clinical assessment and appropriate biopsy in diagnosing lesions of the outer ear

Sinusitis in adults.

Symptoms of sinusitis are among the most common reasons for patients presenting to primary care physicians. There is considerable controversy regarding appropriate management of both acute and chronic sinus disease. This article reviews etiologic mechanisms in these conditions and presents recent evidence to provide a logical basis on which to make decisions regarding medical and surgical therapy.

Epithelial migration in open mastoidectomy cavities.

Twenty patients who had undergone open cavity mastoidectomy for chronic middle ear disease were selected for study. Following initial microscopic aural toilet, each cavity was painted in its medial aspect with a marker solution of Bonney's Blue dye. Each patient was assessed at weekly intervals for a minimum of three months following application of dye, and a photographic record made of the cavity. Information was also sought regarding the clinical behaviour of the mastoid cavities, with particular regard to degree of otorrhoea, and accumulation of debris. Migration of epithelium inferred by visible movement of dye occurred in 17 of the 20 mastoid cavities. In all these cases migration occurred in a medial to lateral direction, towards the exterior. In two cases there was no visible migration throughout the period of observation, and inspection after six months revealed the dye to be still present in the original position. Both these cases were of dry trouble-free cavities in which accumulation of debris did not appear to be a problem. This finding calls into question the assumption that clean trouble-free cavities are maintained by a satisfactorily functioning epithelial migration. In the four cavities which suffered from intermittent otorrhoea, epithelial migration occurred at a similar rate to that in dry cavities.

Temporal bone histopathology of open mastoidectomy cavities.

Open cavity mastoidectomy remains the principle surgical treatment of middle ear cholesteatoma in the United Kingdom. A significant proportion of mastoid cavities are prone to intermittent or continuous discharge. In this study the temporal bone histopathology of four patients who had undergone open cavity mastoidectomy is presented. Cavities were predominantly lined with stratified keratinizing squamous epithelium. Residual air cells were obliterated by fibrous tissue, with no evidence of persistent respiratory epithelium. Where inflammatory changes were found, these consisted of areas of granulation tissue in association with epithelial ulceration. Residual cholesteatoma pearls (epidermoids) were not associated with significant inflammatory changes.

The histopathology of mastoidectomy cavities, with particular reference to persistent disease leading to chronic otorrhoea.

Open cavity mastoidectomy remains the principal surgical treatment of middle ear cholesteatoma in the United Kingdom. A significant proportion of mastoid cavities are prone to intermittent or continuous discharge. In this study the histopathological features of material removed from 159 mastoid cavities at revision surgery were reviewed. Findings included squamous epithelium with acute and chronic inflammation, foreign body granuloma and aural polyps. Of particular note was the very infrequent finding of discharging cavities lined with respiratory epithelium, suggesting that retained mucosa in mastoid air cells is not a common cause of persistent otorrhoea.