Role of open-ended questionnaires in patients with balance symptoms

Introduction:

A clear and detailed clinical history is essential in the assessment of patients with balance symptoms. The aim of this study was to assess the usefulness of open-ended questionnaires in the specialist balance clinic.

Methods:

Fifty-four consecutive new patients completed an open-ended questionnaire, prior to a consultation in which the clinical history was taken using a standardised proforma. The results of the two were compared.

Results:

The open-ended questionnaires provided patient-centred data, and did not provide clinicians with sufficient data for diagnosis. Patients were more likely to respond in the affirmative when asked about symptoms directly, than to report the same symptoms spontaneously on an open-ended questionnaire. When questions had a number of possible answers, patients were more likely to report them in full in an open-ended questionnaire than to provide a response during direct questioning.

Sacculo-collic response in otosclerosis and following successful stapes surgery

Introduction:

The sacculo-collic reflex is believed to be a short latency, otolith-mediated myogenic response to sound. With the application of air-conducted sound, one would expect an absent response in stapes fixation, as a fixed stapes footplate will not transmit a pressure wave to the saccule.

Methods:

Fifty patients (70 stapes surgery ears, 26 otosclerotic ears and four normal ears) and 40 controls underwent repeated sacculo-collic tests.

Results:

The results support the proposed mechanism for the sacculo-collic response. The study also suggests that, whilst stapedotomy piston prostheses are effective in the reversal of conductive hearing loss, they produce an insufficient pressure wave to elicit a myogenic response to sound.

Conclusion:

The sacculo-collic test could be a useful tool for screening otolith function and inferior vestibular nerve integrity, but further work is needed to determine the effect of stapes surgery on saccular function.

Experimental study on heat transmission to the vestibule during CO2 laser use in revision stapes surgery

We studied the transmission of heat to the vestibule during revision stapes surgery with a piston in situ, using a CO2 laser, in an in vitro model. A type K thermocouple was placed around the medial end of stainless steel and fluoroplastic wire pistons in a 'vestibule' filled with saline. The effect of laser hits on fluoroplastic wire and stainless steel stapes prostheses was investigated. The effect of introducing a vein graft to seal the stapedotomy was also examined. Greater temperature rises occurred with stainless steel than with fluoroplastic wire pistons. The addition of the vein graft reduced heat transmission. Application of the CO2 laser to fluoroplastic wire pistons, using the power settings suggested by the manufacturer, is not likely to damage the inner-ear structures. Application of 6 W laser energy to stainless steel pistons can potentially disturb the inner-ear function.

Applied comparative physiology of the avian middle ear: the effect of static pressure changes in columellar ears

We investigated the motion of the single ossicle found in the middle ears of four different species of birds. In the avian middle ear, the off centre attachment of the extracolumella to the tympanic membrane and the flexion of the joint between the extracolumella and columella results in rocking of the footplate rather than direct excursion in and out of the vestibule. We postulate that this is a protective mechanism to avoid excessive displacement of the footplate into the vestibule during changes in middle-ear pressure and that it is analogous to the ossicular ‘decoupling’ observed in the human middle ear in the same circumstances.

Rosen mobilization of the stapes: does it have a place in modern otology?

We describe two patients with stapes fixation, in both of whom Rosen mobilization seemed to be the most prudent surgical choice. In both cases, a useful hearing gain was achieved initially. In the patient with otosclerosis, the conductive hearing loss recurred and a stapedectomy was subsequently carried out. In the patient with congenital stapes fixation, the hearing gain was maintained for two years eight months. We believe that this technique still has a place in stapes surgery in rare instances.

Surgical management of retraction pockets of the pars tensa with cartilage and perichondrial grafts

Stable, self-cleansing retraction pockets of the pars tensa are common incidental findings and require no treatment. In other cases, recurrent discharge occurs and there may also be associated conductive hearing loss. In a minority of cases, cholesteatoma may develop.

This paper presents the results of surgery using a graft composed of cartilage and perichondrium for retraction pockets involving the posterior half of the tympanic membrane, as well as early results using a larger graft designed to manage retraction of the entire tympanic membrane. Data on 51 patients with posterior retraction pockets are presented. Forty-two (82 per cent) patients had no aural discharge one year following surgery and the tympanic membrane was not retracted in 43 (84 per cent). The larger ‘Mercedes-Benz’ graft was used in four patients and the results obtained suggested that it may prove a successful technique for extensive retraction pockets.

Noise induced hearing loss in dance music disc jockeys and an examination of sound levels in nightclubs

Noise exposure, hearing loss and associated otological symptoms have been studied in a group of 23 disc jockeys using a questionnaire and pure tone audiometry. The level of noise exposure in the venues where they work has also been studied using Ametek Mk-3 audio dosimeters. Three members of the study group showed clear evidence of noise-induced hearing losson audiometry, 70 per cent reported temporary threshold shift after sessions and 74 per cent reported tinnitus. Sound levels of up to 108 dB(A) were recorded in the nightclubs. The average level for a typical session was 96 dB(A) which is above the level at which the provision of ear protection is mandatory for employers in industry. It can be concluded that DJs are at substantial risk of developing noise-induced hearing loss and noise exposure in nightclubs frequently exceeds safe levels.

Management of stenosis and acquired atresia of the external auditory meatus

The aim of this study was to investigate the aetiology of acquired atresia and stenosis of the external auditory meatus and to present our results for surgical management. Over an 18-year period (from 1986 to 2004), data were collected prospectively from patient cohorts in Dundee and Edinburgh. Stenosis of the auditory meatus was due to chronic otitis externa in 64 per cent of cases, compared with 37 per cent of cases with acquired atresia; the latter had instead a history of chronic suppurative otitis media in 43 per cent. Surgical treatment of canal stenosis with meatoplasty alone achieved a widely patent ear canal in 80 per cent of cases, with 78 per cent of ears remaining free of discharge. Cases of acquired atresia treated with simple surgical excision of the soft tissue plug experienced a 100 per cent failure rate. The additional use of a split skin graft achieved a patent meatus in 70 per cent of cases, with hearing improvement in 79 per cent. However, the ear canal remained unstable and late recurrence was observed.

The prevalence of ear, nose and throat problems in the community: results from a national cross-sectional postal survey in Scotland

OBJECTIVE

To assess the prevalence of ear, nose and throat (ENT) symptoms experienced by individuals living in Scotland, and their use of GP or hospital services for these problems.

METHODS

A cross-sectional postal self-completed questionnaire was sent to a random sample of 12,100 households throughout Scotland. 15,788 individuals aged 14+ years living in the 7244 households who returned the questionnaire (adjusted response rate 64.2%) participated in the study.

RESULTS

Roughly a fifth of respondents reported currently having hearing difficulties, including difficulty following conversations when there is background noise and hearing problems causing worry or upset; few wore a hearing aid regularly. A fifth reported noises in head or ears (tinnitus) lasting more than five minutes. In the previous year, between 13 and 18% of respondents reported persistent nasal symptoms or hayfever, 7% sneezing or voice problems and 31% had at least one episode of severe sore throat or tonsillitis. Nearly 21% of all respondents reported ever having had dizziness in which things seemed to spin around the individual; 29% unsteadiness, light-headedness or feeling faint; 13% dizziness in which the respondent seemed to move. Important gender, age, occupation and deprivation differences existed in the occurrence of these ENT symptoms. There was considerable variation in the proportion of individuals consulting their GP or being referred to hospital for different problems.

CONCLUSIONS

ENT problems occur frequently in the community, and most are managed without consulting medical services. Whilst reasonable for many problems, there are likely to be important groups in the community with ENT problems that might benefit from modern interventions.

Reflections on integrating mental health into primary health care services in remote Indigenous communities in Far North Queensland and the Northern Territory

At present, there is a perceived and functional separation of mental health services from the general delivery of primary health care services in remote Indigenous communities in most places in the country. There are a range of issues underlying this separation; many are historical but continue to influence patterns of thinking about mental and physical health. With the increasing shift of focus of care at primary level from being largely reactive to presentations of acute illnesses towards proactive and strategically guided approaches to the management of chronic diseases, coupled with similar national strategic documents guiding mental health care into a primary health care format, the opportunity to integrate the provision of mental and physical health care has never been better. Accompanying this integration should be a reflection and improvement on models of care that address needs of Indigenous people in a more culturally and contextually appropriate manner, as is clearly defined in an increasing range of Indigenous health policy documents. This paper will begin with a summary of the link between mental and physical health supported by key references. It will then briefly reflect on the current organisation of mental and physical health services in remote Indigenous settings of Far North Queensland and the Northern Territory, identifying some of the major disadvantages being experienced. The paper will close with a description of the approach and some early outcomes to address these issues by the Indigenous Stream of the AIMhi project (Australian Integrated Mental Health Initiative), which is a major National Health & Medical Research Council (NH&MRC) Strategic Partnership initiative that began implementing a framework of research activities in mid-2003.

The management of acute oesophageal obstruction from a food bolus. Can we be more conservative?

The objective was to assess the number of patients with acute oesophageal bolus obstruction that resolves spontaneously and to aid the identification of the best practice. This prospective and retrospective case series study at a teaching hospital and a district general hospital in Scotland, UK, involved 37 patients with acute oesophageal obstruction from a food bolus who were observed for 24 h from the beginning of symptoms. The bolus passed spontaneously in 54% of the patients during the observational period. A short observational period following the admission of patients with acute food bolus obstruction is reasonable as it may reduce exposure to surgical morbidity and decrease inpatient stay.

Ear, nose and throat manifestations of ectodermal dysplasia

This review of ectodermal dyplasias (ED) presents the particular syndromes that might present to the otolaryngologist for management and discusses the ear, nose and throat manifestations of the condition.

Early experience with the Mills sleeve prosthesis for reconstruction of the incus long process

This paper describes the Mills sleeve technique of ossicular reconstructionfor defects of the incus long process and reviews the results of 27 procedures. A retrospectivereview of operations was performed by eight otologists. The results are compared with those from three other reconstruction techniques (cortical bone graft, cortical bone sleeve and incus autograft).

Prostheses were supplied to surgeons who expressed an interest. Pre- and post-operative audiological data forms were analysed for each case along with a questionnaire about use of the prosthesis. The mean post-operative air bone gap (ABG) was compared with results from cortical bone sleeve, incus autograft and simple cortical bone graft reconstruction cases previously performedby the senior author.

Twenty-seven procedures were performed. Closure of the ABG to within 10dB was achieved for 44.4 per cent of Mills sleeve cases compared with 44.7 per cent for the cortical bone sleeve, 52.9 per cent for ossicular and 26.9 per cent for cortical bone grafts. The responses to a questionnaire sent to participating surgeons are discussed.

For the current follow-up period (three months to three years) the Mills sleeve prosthesis appears to be safe and easy to use with audiological results at least as good as other reconstructive techniques.

Movements of the intact and reconstructed ossicular chain during changes in static pressure

OBJECTIVE

To investigate the motion of the normal and reconstructed ossicular chain during changes in static pressure.

MATERIAL AND METHODS

Experiments were carried out using seven fresh human temporal bones Using digital photography, movements of the malleus were measured during incremental pressure changes between +500 and -500 daPa with the incus in situ and following its removal. The pattern of movement of the ossicles was recorded in the form of digital video clips. This was carried out with the ossicular chain intact and also when it had been reconstructed with an incus graft and four different types of artificial prosthesis.

RESULTS

The lateral to medial movement of the malleus during changes in static pressure is converted into a predominantly superior to inferior movement of the incus. Conventional reconstructions using a graft or prosthesis transmit the malleus movement directly to the stapes so that it is pushed in and out of the oval window. Reconstructions with prostheses which restore the mammalian three-ossicle pattern, by contrast, move in a similar manner to the normal incus.

CONCLUSION

Ears reconstructed using conventional techniques are more at risk from pressure changes than those in which a "physiological" method is used.

Anaesthetic management of coronary artery bypass grafting in a patient with central core disease and susceptibility to malignant hyperthermia on statin therapy

Central core disease and malignant hyperthermia (MH) are both associated with mutations in the RYR1 gene. We report the anaesthetic management of one such patient presenting for coronary artery bypass grafting. Her medication included aspirin 75 mg, atorvastatin 20 mg, isosorbide mononitrate 60 mg, atenolol 25 mg and glyceryl trinitrite sublingual spray as required. The use of aprotinin, statins and moderate hypothermia in patients with central core disease and known susceptibility to MH has not been documented.

Suicide prevention in first episode psychosis: the development of a randomised controlled trial of cognitive therapy for acutely suicidal patients with early psychosis

BACKGROUND

Young people with early psychosis are at particularly high risk of suicide. However, there is evidence that early intervention can reduce this risk. Despite these advances, first episode psychosis patients attending these new services still remain at risk. To address this concern, a program called LifeSPAN was established within the Early Psychosis Prevention and Intervention Centre (EPPIC). The program developed and evaluated a number of suicide prevention strategies within EPPIC and included a cognitively oriented therapy (LifeSPAN therapy) for acutely suicidal patients with psychosis. We describe the development of these interventions in this paper.

METHOD

Clinical audit and surveys provided an indication of the prevalence of suicidality among first episode psychosis patients attending EPPIC. Second, staff focus groups and surveys identified gaps in service provision for suicidal young people attending the service. Third, a suicide risk monitoring system was introduced to identify those at highest risk. Finally, patients so identified were referred to and offered LifeSPAN therapy whose effectiveness was evaluated in a randomised controlled trial.

RESULTS

Fifty-six suicidal patients with first episode psychosis were randomly assigned to standard clinical care or standard care plus LifeSPAN therapy. Forty-two patients completed the intervention. Clinical ratings and measures of suicidality and risk were assessed before, immediately after the intervention, and 6 months later. Benefits were noted in the treatment group on indirect measures of suicidality, e.g., hopelessness. The treatment group showed a greater average improvement (though not significant) on a measure of suicide ideation.

CONCLUSIONS

Early intervention in psychosis for young people reduces the risk of suicide. Augmenting early intervention with a suicide preventative therapy may further reduce this risk.

Delayed facial palsy following laser stapedectomy: in vitro study of facial nerve temperature

Delayed facial palsy following conventional stapes surgery is a rare event, but this complication appears to be more common when a laser is used. We have investigated the temperature in the facial canal during stapes surgery using a KTP laser or a microdrill in preserved human temporal bones. Thermocouples were placed in the facial canal and under the foot plate. The results show maximum rises in temperature of between 1.4 degrees C and 15.2 degrees C in the facial canal during laser surgery (mean 6.1 degrees C, SD 4.5 degrees C), but only between 0.45 degrees C and 2 degrees C during procedures in which a microdrill was used (mean 0.9 degrees C, SD 0.9 degrees C) (P = < 0.009). In addition, the facial nerve undergoes repeated heating and cooling cycles during the laser surgery. We conclude that heating of the facial nerve during laser surgery causes oedema, which in turn leads to compression of the nerve within its bony canal.

Transmission of heat to the vestibule during revision stapes surgery using a KTP laser: an in vitro study

The transmission of heat to the vestibule during revision stapes surgery with a piston in situ has been studied using a KTP laser in an in vitro model. A type K thermocouple was placed around the medial of each piston tested in a 'vestibule' filled with saline. The effect of laser hits on fluoroplastic, fluoroplastic-wire and stainless steel stapes prostheses was investigated. The effect of adding blood to the operative field, of introducing a vein graft to seal the stapedotomy and of vaporizing soft tissue in the oval window were also examined. Greater temperature rises occurred with stainless steel than with the other piston types and smaller rises occurred when there was a vein graft in situ. The maximum temperature rise recorded was 2.6 degrees C. We conclude that the use of the KTP laser to clear soft tissue from the oval window is safe when operated at the power levels recommended by the manufacturer.