Is the use of a bone conduction hearing device on a softband a useful tool in the pre-operative assessment of suitability for other hearing implants?

OBJECTIVE: To assess whether pre-operative assessment with a bone conduction hearing device on a softband is an accurate predictor of performance with one of two transcutaneous hearing implants.Study designCohort study comparing pre-and post-operative speech audiometry using correlation analysis. METHODS: Pre-operative pure tone audiometry and aided half optimum speech recognition thresholds were compared with post-operative aided results for each ear that had undergone implantation. Data were collected prospectively. RESULTS: Full data were available in 24 ears. In 19 out of 24 ears (79 per cent), the difference between pre- and post-operative speech scores was less than 10 dB, demonstrating a good clinical correlation. The Pearson correlation coefficient was calculated at 0.66 (95 per cent confidence interval = 0.357-0.842), indicating a strong statistical correlation. CONCLUSION: Pre-operative softband testing shows good clinical correlation and strong statistical correlation with hearing implant performance. The findings suggest there is value in using the test to predict performance and guide patients' expectations.

On the minimum requirements for otolaryngology clinics in National Health Service hospitals.

OBJECTIVE: This paper, a report by the Clinical Governance and Audit Committee of the Scottish Otolaryngological Society, presents a consensus view of the minimal requirements for ENT clinics in National Health Service hospitals. RESULTS AND CONCLUSION: The provision of adequate equipment and staff has gained increasing importance as the vast majority of ENT procedures can be safely performed in the out-patient or office setting.

Clinical efficacy of tinnitus retraining therapy and cognitive behavioural therapy in the treatment of subjective tinnitus: a systematic review.

OBJECTIVE: This study aimed to compare the outcomes of two frequently employed interventions for the management of tinnitus: tinnitus retraining therapy and cognitive behavioural therapy. METHOD: A systematic review of literature published up to and including February 2013 was performed. Only randomised control trials and studies involving only human participants were included. RESULTS: Nine high-quality studies evaluating the efficacy of tinnitus retraining therapy and cognitive behavioural therapy were identified. Of these, eight assessed cognitive behavioural therapy relative to a no-treatment control and one compared tinnitus retraining therapy to tinnitus masking therapy. Each study used a variety of standardised and validated questionnaires. Outcome measures were heterogeneous, but both therapies resulted in significant improvements in quality of life scores. Depression scores improved with cognitive behavioural therapy. CONCLUSION: Both cognitive behavioural therapy and tinnitus retraining therapy are effective for tinnitus, with neither therapy being demonstrably superior. Further research using standardised, validated questionnaires is needed so that objective comparisons can be made.

The effect of auditory stimulation on the tensor tympani in patients following stapedectomy.

CONCLUSION: We believe that a tensor tympani reflex, in response to loud sound, is present in a minority of people, although its functional significance with regard to sound transmission is questionable. The absence of startle response in our stapedectomized subjects makes us question whether the tensor component of the startle response is large enough to be identified by manometry. OBJECTIVES: This study was organized to examine reflex activity to stimulation by loud sound or by startle in the tensor tympani. Although many previous studies have been carried out, results have been contradictory, and methodological flaws have rendered the interpretations questionable. PATIENTS AND METHODS: Stapedectomized patients were invited to take part in the study. Thirteen patients underwent testing by extratympanic manometry, using a standard tympanometer. Responses were observed during repeated stimuli with loud sound at 500, 1000, 2000 and 4000 Hz to the ipsilateral and contralateral ears, and with an air jet against the closed eye. A control group was also studied for the startle test. RESULTS: Three clear ipsilateral (23%) and two clear contralateral (14%) responses to auditory stimuli were seen in the 13 patients. We found responses to startle stimuli in none of our study group and eight (42%) of control ears.

Is current UK management of oesophageal food bolus obstruction evidence based? An e-mail survey and literature review.

There is a great deal of variation in individual management of non-sharp oesophageal food bolus obstruction in the United Kingdom. An e-mail survey of consultants and specialist registrars in ENT was carried out to establish current UK practice. A review of the published literature was under-taken to establish whether current practice is evidence based. The majority of practitioners (95%) do not proceed immediately to rigid oesophagoscopy but use antispasmodic drugs (83%), most commonly hyoscine butylbromide (Buscopan) and diazepam, to try to induce spontaneous passage of the obstruction. There is currently no evidence in the published literature to support the use of these drugs. The use of Buscopan seems to have been encouraged by a misquoted reference in a prominent ENT textbook. Better evidence is needed to establish the best form of treatment for this relatively common problem.

Is unilateral tonsillar enlargement alone an indication for tonsillectomy?

INTRODUCTION: Unilateral tonsillar enlargement is often seen in the out-patient setting. Frequently, these patients are listed for tonsillectomy for the purpose of ruling out malignant histology. This study aims to determine the necessity for tonsillectomy. METHOD: This retrospective case-note review looks at all the tonsillectomies performed for histological examination at our institution over a five year period, and analyses the histological findings in those with unilateral tonsillar enlargement (UTE) alone, and those with UTE with other clinical features (history of chronic pain, dysphagia, the presence of tonsillar or peritonsillar mucosal abnormality, those with cervical lymphadenopathy). All patients who underwent tonsillectomy for the purpose of histological examination from 1 June 1998 to 30 May 2003 were identified and their notes reviewed. Exclusion criteria included cases where there were no pre-operative out-patient notes, those patients where the specimens had been sent from other hospitals, those patients who had malignancy already diagnosed, and those cases where tonsillectomy had been performed by other surgical specialties (e.g. maxillofacial, plastics). There were 1475 tonsillectomies, of which 181 performed over this period were sent for histological analysis. After excluding those patients that did not meet our criteria, we were left with 53 patients who had UTE. The primary outcome measure was the rate of malignancy in the two groups. RESULTS: Of these, 33 had UTE alone, 20 had associated clinical features. In the former group, none of the patients were found to have malignancy. In the latter, nine (45 per cent) had a malignancy. Fisher's exact test was used to test for differences between the UTE alone group versus the UTE plus other features group (p<0.001). DISCUSSION: The prevalence of malignancy in tonsils which exhibit asymmetry with no other clinical features is very low; in our study it was zero. However, other studies have found a small percentage representing underlying malignancy. In view of this, we feel that a 'watch and wait' policy is initially more appropriate, and if symptoms or signs are progressive, tonsillectomy should then be advised.

Audit of specialist registrar training in tympanomastoid surgery for chronic otitis media.

BACKGROUND: A prospective audit of specialist registrars' (SRs') training in tympanomastoid surgery for chronic otitis media within the Anglia Regional Training Scheme is described. This audit recorded the surgical activity of the trainees and their contribution to operative procedures, and assessed the results of the procedures. This type of systematic approach to the audit of surgical training is important in light of the current shortened training programmes and increased accountability of trainers. OBJECTIVES: The study aimed to establish the levels of exposure to, supervision of and outcome of ear operations for chronic otitis media performed by ENT trainees in the East Anglia region. METHOD: A prospective, region-wide, minimum otology dataset-based proforma audit was undertaken, with compulsory SR participation. Proformas were completed at the time of operation (form one) and at a minimum interval of nine months post-operatively (form two). Data on form one included hospital, supervising consultant, name and training year of SR, contribution of SR (based on England Royal College of Surgeons guidelines interpreted by the SR), pre-operative audiology average (air conduction/bone conduction over 0.5, 1, 2 and 4 kHz), the pathology and the state of the ear at the time of surgery, and a breakdown of the procedure(s) undertaken. Form two recorded data relevant to form one as well as information regarding patient satisfaction and the operative result obtained, graded as 'gold' (no disease, dry ear and hearing average < 25 dB), 'silver' (two of these three) and 'bronze' (one of these three). All completed forms were analysed using Microsoft Access software. RESULTS: Completed copies of 409 form ones and 156 form twos were analysed. With advancing years, SRs' contributions to procedures increased without significant effect on the graded outcome, which appeared to be independent of SR year of training. Different regional hospitals were compared. Data collected also provided an otology training portfolio for SRs, forming part of their registrar in-training assessment (RITA). CONCLUSION: The East Anglia SR audit of SRs' training in tympanomastoid surgery for chronic otitis media was a powerful training tool. It demonstrated the safe progression of SR training in supervised ear surgery, with SRs' results being comparable to those for consultant-performed procedures.

Team working to improve outcome in vestibular schwannoma surgery.

The concept of the 'learning curve' in the early years of consultant appointment is no longer acceptable and yet, for most complex operations, learning is a career-long process. Sub-specialization offers part of the solution to this problem by concentrating expertise, but there remains the question of how to introduce new team members without adversely affecting patient outcome. Shortened training and an increasingly aware public, who are more questioning of the experience and outcomes of those treating them, has required the surgical profession to move away from individual consultant practice and embrace team-working. When, in 1997, a second neurosurgeon joined the skull base team at Addenbrooke's Hospital, his introduction to acoustic neuroma surgery was mentored and operative cases were carefully selected at first. In this article, we discuss our experience with consultant mentoring, and compare the results of the first 100 translabyrinthine acoustic neuroma operations performed under this system with the first cohort of a similar number of patients published from Cambridge in 1989.

Hyperbaric oxygen as an adjuvant treatment for malignant otitis externa.

BACKGROUND: Malignant, or necrotising, otitis externa is a potentially fatal infection of the external ear canal and surrounding soft tissue and bone. It may be complicated by involvement of cranial nerves, principally the facial nerves and the contents of the jugular foramen. It is an uncommon condition mainly found in the elderly or in diabetics. OBJECTIVES: To assess the effectiveness of adjunctive hyperbaric oxygen treatment for malignant otitis externa. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2003), MEDLINE (January 1966 to April 2004) and EMBASE (January 1985 to April 2004) with pre-specified terms. The date of the last search was 5th April 2004. SELECTION CRITERIA: Randomised controlled trials, involving adults, undergoing hyperbaric oxygen therapy in malignant otitis externa. DATA COLLECTION AND ANALYSIS: No identified articles described randomised controlled trials of hyperbaric oxygen therapy in the treatment of malignant otitis externa. MAIN RESULTS: Due to the lack of data no results could be presented. AUTHORS' CONCLUSIONS: No clear evidence exists to demonstrate the efficacy of hyperbaric oxygen therapy when compared to treatment with antibiotics and/or surgery. No data were found to compare rates of complication between the different treatment modalities. Further research is required.

Referral patterns in vestibular schwannomas --10 years on.

Diagnostic imaging techniques, symptom awareness and education of local sources of referral in vestibular schwannomas, including general practitioners, have all improved in the last 10 years. The referral patterns in vestibular schwannomas in Cambridgeshire in the period 1981-1993 has been reported.(1) A direct comparison was made with regard to referral patterns seen in the last 10 years paying particular emphasis to source of referral, diagnosis at referral and symptoms/size at presentation. The incidence of vestibular schwannomas in the region is compared and discussed. Patients' managed by the 'watch and wait' policy were particularly scrutinized, as they were not discussed previously. Retrospective analysis of computerized database was used. We have demonstrated an increase in the proportion of referrals with known vestibular schwannoma to 90% of all referrals. No significant change in length of history prior to referral, source of referral or principal presenting symptom were found. An overall decrease in tumour size was found but an increase in the percentage with larger tumours (>4.5 cm). We attribute the significant findings to an increase in availability of magnetic resonance (MR) scanners in the country during the past 10 years. It appears that some tumours would still present with no symptoms until late and therefore will elude identification until large in spite of a low threshold for MR scanning.

Interventions for acute auricular haematoma.

BACKGROUND: Acute haematoma of the pinna is a condition where a collection of blood forms beneath the perichondrial layer of the pinna. It is usually caused by blunt trauma, and if untreated will ultimately result in a deformity commonly known as 'cauliflower ear' or 'wrestler's ear'. Various treatments are employed to relieve the haematoma but no clear consensus exists on the best way to do so in order to produce the best cosmetic result with the least permanent deformity. OBJECTIVES: To assess the effectiveness of treatment options in acute auricular haematoma. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 2, 2003), MEDLINE (1966 - 2003) and EMBASE (1966 - 2003) with pre-specified terms. The date of the last search was April 2003. SELECTION CRITERIA: Randomised controlled trials, case controlled trials and cohort studies including children and adults undergoing any intervention for acute auricular haematoma. DATA COLLECTION AND ANALYSIS: Fifty-nine references were identified from the searches. Forty-eight were retrieved and assessed for eligibility by the authors. None met the inclusion criteria. MAIN RESULTS: Due to the lack of data from trials fulfilling selection criteria no results could be presented. REVIEWERS' CONCLUSIONS: There is no clearly defined best treatment for acute auricular haematoma. There are no good quality data to determine either the optimal management strategy or even whether post-drainage intervention (such as splinting or bandaging) is necessary. Further research is required before any specific treatment may be recommended.

Cochlear implantation for progressive hearing loss.

The concept of neural plasticity and the early natural abilities of hearing children to acquire speech and language without instruction have led many authorities to advocate cochlear implantation before the age of 5 years in congenital deafness. Older children therefore become lower priority for scarce public funds because they are perceived to have passed the "window of opportunity" to learn speech, even if hearing is restored, and continue to rely on sign language. This paper shows that a subgroup of congenitally deaf children exists, who, having made good progress with conventional hearing aids, suffer a sudden or progressive hearing deterioration which arrests the speech development. Sixty children have been implanted in the Cambridge Programme, half for meningitis or other acquired losses and half for congenital prelingual deafness. Six of this latter group were congenital but progressive; their progress, deterioration, and improvement after implantation are summarised.

A small vestibular schwannoma arising from the inferior vestibular nerve.

The investigation of a complaint of unilateral right sensorineural hearing loss led to the identification of a right 3 mm vestibular schwannoma arising from the inferior division of the right vestibular nerve. On investigation the patient was found to have normal caloric function, this being mediated by the superior vestibular nerve. Both transient and distortion product otoacoustic emissions were absent in the right ear, and ABR was abnormal on this side. These findings are of interest as they indicate that this small lesion produced a hearing loss that was both cochlear and retrocochlear. The anatomical finding that the medial auditory efferents run within the inferior vestibular nerve is considered. This patient did not experience tinnitus or hyperacusis despite the site of the lesion arising from the inferior vestibular nerve.

Paediatric cochlear implantation--the balance between professional caution and urgency of treatment.

There is a constant pressure to reduce the age of cochlear implantation in profoundly deaf children and thereby improve the auditory verbal language development in implantees. We effected a change in the regimen for the assessment of new referrals, and show how this has shortened the time taken in Cambridge to complete assessment and offer implantation in appropriate cases. We achieved a reduction in the duration of assessment of 2.8 months (which was not, however, statistically significant) by simple reorganization, while, we believe, maintaining the standards of assessment.