Training, supervision and performance of Community Health Workers in the delivery of ear and hearing care to 321 community members in rural Uganda.

OBJECTIVES: Community Health Workers are one way to address the shortage of ear and hearing care specialists in low-resource settings. However, there are few reports evaluating training and service delivery by Community Health Workers. DESIGN, SETTING AND PARTICIPANTS: We trained 13 Community Health Workers in primary ear and hearing care in Mukono District, Uganda. Community Health Workers attended a two-day training workshop and received remote supervision thereafter during service delivery in the community. An ear camp was held at the local health centre every two months, where a local ENT specialist could assess referred cases. MAIN OUTCOME MEASURES: Clinical and diagnostic skills and decision-making were assessed using an Objective Structured Clinical Examination, with scores recorded at baseline and six months. Service delivery was evaluated by analysing the following: (i) number of individuals evaluated; (ii) treatments delivered; (iii) cases referred for specialist opinion; (iv) proportion of appropriately referred cases; and (v) agreement between Community Health Worker and specialist diagnosis. RESULTS: Observed Structured Clinical Examination scores were high and stable for six months. 312 individuals were screened in the community by the Community Health Workers, with 298 classified as having an abnormality. Care was delivered in the community to 167 of these, and the remaining 131 referred to the ear camp. Diagnostic agreement was 39%, but 98% of referrals were deemed "appropriate" by the ENT specialist. 27 individuals self-presented to the ear camp without prior assessment by a Community Health Worker, and 97% of these were deemed appropriate. CONCLUSION: Trained Community Health Workers can play an important role in delivering ear and hearing services. Future work should look to explore this model in other contexts and/or compare it to other models of service delivery.

[The management of patients with congenital malformations of the external and middle ear]. / Algoritm vedeniia bol'nykh s vrozhdennymi porokami razvitiia naruzhnogo i srednego ukha.

Rehabilitation of the patients suffering from with congenital malformations of external and middle ear is a specific area of medicine requiring special knowledge and skills of the audiologists and ear surgeons. This article highlights the issues of epidemiology, classification and methods for the rehabilitation of patients presenting with this pathology that reflect our own experience and the methodology based on it for all phases of both functional and aesthetic surgical inerventions. Special attention is given to the assessment of the effectiveness of the treatment, as part of the evaluation of the quality of medical services. The results were demonstrated in 56 patients aged from 5 to 17 years. 32 of them underwent reconstructive, hearing improving surgery (meatotympanoplasty), 24 patients were managed by means of the implantation of the bone-anchored hearing systems. The assessment of the effectiveness of the treatment was conducted according to the algorithm developed by the authors, including free field pure tone audiometry and validated questionnaires for the assessment of the quality of life (the Glasgow Children's Benefit Inventory).

Assessing physical functioning in otolaryngology: feasibility of the Short Physical Performance Battery.

PURPOSE: Objective measures of physical functioning and mobility are considered to be the strongest indicators of overall health and mortality risk in older adults. These measures are not routinely used in otolaryngology research. We investigated the feasibility of using a validated physical performance battery to assess the functioning of older adults seen in a tertiary care otolaryngology clinic. MATERIALS AND METHODS: The Short Physical Performance Battery was performed on 22 individuals aged 50 years or older enrolled in the Studying Multiple Outcomes after Aural Rehabilitative Treatment (SMART) study at Johns Hopkins. RESULTS: We successfully administered the SPPB to 22 participants, and this testing resulted in minimal participant and provider burden with respect to time, training, and space requirements. The mean time to complete 5 chair stands was 13.0 ± 3.8 seconds. The mean times for the side-by-side, semi-tandem, and tandem stands were 10.0 ± 0.0, 9.5 ± 2.1, and 8.8 ± 3.2 seconds, respectively. Mean walking speed was 1.1 ± 0.3 meters per second, and composite SPPB scores ranged from 6 to 12 (mean = 10.45, S.D. = 1.6). CONCLUSIONS: Our results demonstrate the feasibility of implementing a standardized physical performance battery to assess physical functioning in a cohort of older adults seen in a tertiary otolaryngology clinic. We provide detailed instructions, references, and analytic methods for implementing the SPPB in future otolaryngology studies involving older adults.

New closed skin bone-anchored implant: preliminary results in 6 children with ear atresia.

OBJECTIVE: To report preliminary results of a new closed-skin, transcutaneous bone conduction device (BCD) in 6 children with high-grade ear atresia. SETTINGS: Tertiary care center; prospective study; we evaluated the gain with masking of the contralateral ear and the benefit of hearing rehabilitation with the transcutaneous BCD in noise: speech-in-noise tests, conducted in real life condition (with contralateral ear unmasked and fitted with a hearing device if done before implantation), with and without BCD, with determination of the speech reception threshold (SRT). Children and parent's satisfaction was assessed. RESULTS: Patients' ages ranged from 6 to 9 years. All had high-grade ear atresia with a preoperative mean pure-tone average (PTA) loss of 71.46 +/- 6.59 dB on air conduction and 14 +/- 4.98 dB on bone conduction. At M6, all children used the implant 5 to 12 hours daily (mean, 10) without pain or cutaneous complications. At M6, the mean air conduction PTA with transcutaneous BCD was 28.45 +/- 1.68 dB, the mean gain 43 +/- 6.96 dB, and the mean SRT gain 33.33 +/- 10.75 dB. Using speech-in-noise tests in real-life conditions, the mean SRT was statistically improved with the transcutaneous BCD (-8 +/- 2.83 dB, p = 0.0313). Both children and parents reported being satisfied or very satisfied. CONCLUSION: These preliminary results show satisfactory functional gain, cutaneous tolerance, and patients' satisfaction with the new transcutaneous BCD.

[Ossiculoplasty with hydroxyapatite bone cement]. / Apport du ciment d'hydroxyapatite en ossiculoplastie.

OBJECTIVE: To analyze the results obtained with hydroxyapatite bone cement (HABC). PATIENTS: A total of 73 ossiculoplasties with HABC were evaluated. Ears were divided into 4 groups: Group 1: Reinforcement of the incudo-stapedial joint with HABC; Group 2: Reconstruction of an incus long process defect with HABC; Group 3: Partial ossicular reconstruction between stapes and malleus handle with HABC; Group 4: Reconstruction of stapes with mobile or fixed footplate with moderate or extensive incus long process erosion using a titanium piston glued to the incus remnant using HABC. RESULTS: The mean follow-up was 21 months. The percentage of postoperative average air-bone gap (ABG) < or = 20 dB for groups 1, 2, 3 and 4 were 100%, 95%, 83% and 91% respectively; for ABG < or = 10 dB: 90%, 71%, 50% and 50%. No complications related to HABC and extrusion occurred. CONCLUSION: Today, the use of HABC seems to help us improve our functional results and also to avoid extrusion. In our experience, ossiculoplastie with HABC seems to provide better and more stable functional results. HABC is safe and easy to use. The use of cement with or without biocompatible ossicular prostheses allows us to repair different types of ossicular defects whilst trying to conserve an anatomical and physiological ossicular chain. Reconstruction of the incus long process or incudo-stapedial joint defect with cement is preferable rather than using partial ossicular reconstruction with HABC.

[Neurootologic and psychosomatic habituation therapy. Treatment approaches in chronic tinnitus]. / Neurootologisch-psychosomatische Habituationstherapie. Therapieansätze bei chronischem Tinnitus.

Modern tinnitus therapy, especially for chronic tinnitus accompanied by psychosomatic disturbances, is based on an understanding of the controlled network of auditory perception. The symptom of tinnitus derives from damage or defective coding in this system, mainly the inner ear. It becomes an independent disease as a result of disturbed auditory perception with pathologic evaluation and emotional association in the cortex. We present different therapeutic approaches based on these models. The therapy aims to eliminate or diminish the symptom of tinnitus through retraining, cognitive restructuring, or enhancement of efferent filter mechanisms in the auditory pathway. Psychosomatic stabilization of patients is an important preliminary condition for effective habituation; therefore, an integrative neurootologic and psychosomatic therapy is proposed that requires an interdisciplinary therapeutic team and can be mostly carried out in an outpatient setting.

A comparative study of patient satisfaction with day case and in-patient major ear surgery.

INTRODUCTION: Major ear surgery can be safely performed on a day case basis (i.e. six hour stay). This study aimed to ascertain whether patients had the same level of satisfaction and speed of recovery following major ear surgery when it was performed as a day case compared with performance as an in-patient procedure. METHOD: A cross-sectional survey, by postal questionnaire, of patient satisfaction with day case and in-patient major ear surgery was carried out with 158 patients. Comparisons were made between the responses of the two groups. RESULTS: The response rate was 71 per cent. Patients returned to work significantly sooner following day surgery (p < 0.025) but felt their operation to be of significantly more benefit following in-patient surgery (p < 0.05). CONCLUSIONS: Patient satisfaction following day case major ear surgery is as good as that following in-patient surgery. This has supported the expansion of this service in our unit.

Magnetic nanoparticles: inner ear targeted molecule delivery and middle ear implant.

Superparamagnetic iron oxide nanoparticles (SNP) composed of magnetite (Fe(3)O(4)) were studied preliminarily as vehicles for therapeutic molecule delivery to the inner ear and as a middle ear implant capable of producing biomechanically relevant forces for auditory function. Magnetite SNP were synthesized, then encapsulated in either silica or poly (D,L,-Lactide-co-glycolide) or obtained commercially with coatings of oleic acid or dextran. Permanent magnetic fields generated forces sufficient to pull them across tissue in several round window membrane models (in vitrocell culture, in vivo rat and guinea pig, and human temporal bone) or to embed them in middle ear epithelia. Biocompatibility was investigated by light and electron microscopy, cell culture kinetics, and hair cell survival in organotypic cell culture and no measurable toxicity was found. A sinusoidal magnetic field applied to guinea pigs with SNP implanted in the middle ear resulted in displacements of the middle ear comparable to 90 dB SPL.

[Descriptive study of 21,804 ENT emergencies in a third level hospital]. / Estudio descriptivo de 21.804 urgencias ORL en un hospital de tercer nivel.

We present a descriptive study about 21.804 emergency patients (ENT Department) treated in our hospital between 1994 and 2000. We have seen about 260 patients every month being the otologic pathology (35.63%) the most frequent one, followed by the nasosinusal (26.65%). Individually, the epistaxis where the 13% of all cases attended. The nasal traumas (contusions and fractures) where about a 10% of the total and in a third place, the external otitis (6.84%). We estimate in more than a 60% of the patients with a simple pathology (not urgent) and in a 3% of the patients without ENT pathology when they came to emergency. We believe, like other consulted authors, that there is a high patients index coming to the Hospital, for other reasons, without a justifiable ENT emergency. That contributes to different levels, with other specialities, to the collapse of the emergencies services.

Tissue-integrated prostheses in the rehabilitation of auricular defects: results with percutaneous mastoid implants.

Functional and cosmetic rehabilitation of the severely atretic auricle poses a formidable challenge. Conventional autologous grafts for auricular reconstruction may produce inconsistent results, and revision of failed grafts is often unsatisfactory. Osseointegrated implant systems to retain auricular prostheses provide an alternative approach in rehabilitating patients with severe auricular defects. Fourteen patients were implanted with 30 osseointegrating implants for rehabilitating major auricular defects and were followed for 1 to 3.5 years, yielding 143 implant observations. Symptomatic skin reactions to the percutaneous implant were noted in 3.5 percent of the observations. Implant extrusion did not occur. This evaluation of tissue-integrated prosthetic systems suggests this approach to be an extremely reliable alternative for selected patients with major auricular defects. The technique of implanting the retention unit is readily adapted to atresia repair.

[A case of congenital middle ear abnormalities of Siebenmann's type]. / Przypadek wrodzonego niedorozwoju ucha srodkowego typu Siebenmanna.

There is presented a case of congenital anomalies of the middle ear. TORP (Richards) prosthesis successfully substituted for the aplastic chain of auditory ossicles and made it possible that hearing returned to the norm.

A silastic prosthesis for total replacement of the middle-ear ossicular chain, its acoustic properties and clinical application.

The authors designed and made a prosthesis for total replacement of the middle ear ossicular chain (TORP) from Silastic MDX 44-516. A great advantage of this substitute is that it can easily be modified to a prosthesis for partial replacement of the middle-ear ossicular chain (PORP). The transfer properties of the PORP type prosthesis were verified by using an electroacoustic model measurement. Very good anatomical and functional results were obtained in the clinical testing of both types of middle-ear substitutes. No undesired reactions to the implanted polymer were observed.