Surgical treatment of chronic ear disease in remote or resource-constrained environments.

BACKGROUND: Surgery for chronic suppurative otitis media performed in low- and middle-income countries creates specific challenges. This paper describes the equipment and a variety of techniques that we find best suited to these conditions. These have been used over many years in remote areas of Nepal. RESULTS AND CONCLUSION: Extensive chronic suppurative otitis media is frequently encountered, with limited pre-operative investigation or treatment possible. Techniques learnt in better-resourced settings with good follow up need to be modified. The paper describes surgical methods suitable for resource-poor conditions, with rationales. These include methods of tympanoplasty for subtotal wet perforations, hearing reconstruction in wet ears and open cavities, large aural polyps, and canal wall down mastoidectomy with cavity obliteration. Various types of autologous ossiculoplasty are described in detail for use in the absence of prostheses. The following topics are discussed: decision-making for surgery on wet or best hearing ears, children, bilateral surgery, working with local anaesthesia, and obtaining adequate consent in this environment.

Knowledge, attitudes, beliefs and practices related to chronic suppurative otitis media and hearing impairment in Pokhara, Nepal.

BACKGROUND: Nepal has a high prevalence of chronic suppurative otitis media and hearing impairment. An improved understanding of patients' knowledge, attitudes, beliefs and practices is therefore important for effective healthcare planning and intervention. METHOD: Questionnaires designed to explore their current knowledge, attitudes, beliefs and practices were completed by 153 participants: 71 were affected by a known ear disease and 82 were unaffected. RESULTS: In the unaffected group, 31.7 per cent considered breast milk to be a risk factor for ear infection. Home remedies (e.g. leaf paste, oils, and urine and/or bodily fluids) had been used by 42.3 per cent of the affected group. Most participants (71.9 per cent) believed that society discriminates against those with hearing impairment. CONCLUSION: Knowledge deficits and false beliefs were found in both groups, along with a significant use of home remedies and a perception of discrimination against people with hearing impairment. These findings are relevant for healthcare providers and may aid the development of policy, interventions and public education initiatives.

Postinflammatory medial meatal fibrosis: early and late surgical outcomes.

OBJECTIVES: To evaluate the primary and long-term surgical outcomes of patients with postinflammatory medial meatal fibrosis. METHODS: A retrospective study was conducted of 14 ears (in 12 patients) with postinflammatory medial meatal fibrosis managed surgically. Outcome measures were primary (i.e. less than six months) and long-term (i.e. greater than five years) closure of the air-bone gap, and the incidence of otorrhoea and restenosis. RESULTS: At primary review, the mean air-bone gap ± standard deviation had decreased from 29.9 ± 11.6 dB to 12 ± 8.4 dB (p < 0.0006). Seven (50 per cent) ears had closure of the air-bone gap to within 10 dB. However, for the 9 ears receiving long-term review, the mean air-bone gap ± standard deviation increased to 19.3 ± 15.2 dB; there was no significant difference between this result and pre-operative values (p = 0.06). Of the 9 long-term review ears, 3 (33 per cent) showed closure of the air-bone gap to within 10 dB. Recurrent otorrhoea was the most common complication, occurring in 5 of the 9 long-term review ears (56 per cent); in addition, 3 (33 per cent) of these 9 ears developed restenosis. CONCLUSION: Over time, the success of surgery for postinflammatory medial meatal fibrosis diminishes. This was demonstrated in the present study by progressive post-operative hearing decline and a high prevalence of otorrhoea and restenosis.

Chronic suppurative otitis media in Nepal: ethnicity does not determine whether disease is associated with cholesteatoma or not.

OBJECTIVES: To determine the frequency of cholesteatoma in a population of patients with chronic suppurative otitis media, and to determine whether this frequency is affected by ethnicity. PATIENTS: The study included 6005 patients with chronic suppurative otitis media seen during the course of 30 charitable surgical 'ear camps' in Nepal. MAIN OUTCOME MEASURES: Proportion of patients with each subtype of disease, and their ethnicity. A secondary outcome measure was concordance of surname with Nepalese ethnic affiliation. RESULTS: A total of 762 patients were grouped as being of Tibeto-Mongolian origin, and 4875 as Indo-Caucasian. The rate of chronic suppurative otitis media with cholesteatoma, expressed as a proportion of the rate of all chronic suppurative otitis media subtypes, was 17.8 per cent in Tibeto-Mongolian patients and 18.6 per cent in Indo-Caucasian patients (p > 0.05). The effect of other risk factors (i.e. age, gender and geographical district) on disease distribution was also non-significant. Analysis of secondary outcome measures indicated that patients' surnames were a reliable predictor of ethnicity in this Nepalese population. CONCLUSION: There is almost complete concordance in proportions of patients with significant genetic, cultural, and even geographical heterogeneity, suggesting that, in Nepal, the aetiology of cholesteatoma owes little to these factors.

Results of primary ossiculoplasty in ears with an intact stapes superstructure and malleus handle: inflammation in the middle ear at the time of surgery does not affect hearing outcomes.

OBJECTIVE: To determine whether any factors are predictive of success or failure in primary ossiculoplasty employing autologous bone in Austin-Kartush Group A (stapes and malleus handle present) ears. STUDY DESIGN: Retrospective review of a single-surgeon case series. SETTING: Two District General Hospitals in the United Kingdom. PATIENTS: Of 135 patients undergoing primary repair, 116 had sufficient data for analysis (mean follow-up 33 months). MAIN OUTCOMES MEASURED: Postoperative air-bone gaps (pABG) in patients with differing qualities of middle-ear mucosa (active versus inactive), differing pathologies (mucosal versus squamous) and differing surgical procedures [canal-wall up (CWU) versus canal-wall down (CWD)]. SECONDARY OUTCOME MEASURE: 'Belfast Rule of Thumb' (operated ear hearing brought to 30 dB or better or to within 15 dB of contralateral ear). RESULTS: Postoperative ABGs were closed within 10 dB in 37%, 20 dB in 74% at latest follow-up. The only significant factors predicting hearing outcomes were the status of the canal wall (CWU = 14.1 dB, CWD = 24.7 dB: significant, P = 0.00) and whether surgery was primary or revision. Mean ABG was 14.7 for inactive middle ear mucosa, 17.2 for active middle ear mucosa (not significant, P = 0.25). Excluding CWD procedures from the analysis improved outcomes to 80% (within 20 dB) and 41% (within 10 dB) overall, and the mean for active and inactive ears to 14.2 and 14.0 dB respectively. Postoperatively, 82% of patients fulfilled the 'Belfast Rule of Thumb'. CONCLUSION: The most significant prognostic factor affecting hearing outcomes - status of the canal wall - is independent of staging. The factor most associated with staging - the status of the middle ear mucosa - is only weakly associated with a successful functional outcome.