Provision of hearing aids: does specialist assessment cause delay?

OBJECTIVE--To identify the main delay in the provision of hearing aids for people with impaired hearing and identify possible problems and short-comings caused by a community based hearing aid dispensing service. DESIGN--Prospective cohort analysis based on data collected from patients on the duration of hearing impairment, from the referral letters in respect of the general practitioners'' findings on otoscopy, and from the ear, nose, and throat assessment in the clinic with respect to the outcome of specialist otoscopy and management of the hearing impairment. SETTING--General ear, nose, and throat outpatient clinic. PATIENTS--100 Consecutive patients aged 19-94 referred by general practitioners for the provision of hearing aids or for assessment and treatment of impaired hearing. RESULTS--Most patients with impaired hearing did not seek medical advice for at least a year. The time from referral by the general practitioner to the provision of a hearing aid was under two months. General practitioners consistently recognised normality on otoscopy but failed to recognise abnormality in eight of 45 cases. Seven patients required further investigation to exclude serious disease and nine had conditions amenable to surgery. CONCLUSIONS--The main cause of delay in treating impaired hearing is failure by patients to seek help promptly. Specialist assessment of patients with impaired hearing is preferable and does not necessarily cause delay in providing hearing aids. The provision of hearing aids should remain a hospital based service.     

Acute red ear in children: controlled trial of non-antibiotic treatment in general practice.

OBJECTIVE--To examine the efficacy and safety of conservative management of mild otitis media ("the acute red ear") in children. DESIGN--Double blind placebo controlled trial. SETTING--17 group general practices (48 general practitioners) in Southampton, Bristol, and Portsmouth. PATIENTS--232 children aged 3-10 years with acute earache and at least one abnormal eardrum (114 allocated to receive antibiotic, 118 placebo). INTERVENTIONS--Amoxycillin 125 mg three times a day for seven days or matching placebo; 100 ml paracetamol 120 mg/5 ml. MAIN OUTCOME MEASURES--Diary records of pain and crying, use of analgesic, eardrum signs, failure of treatment, tympanometry at one and three months, recurrence rate, and ear, nose, and throat referral rate over one year. RESULTS--Treatment failure was eight times more likely in the placebo than the antibiotic group (14.4% v 1.7%, odds ratio 8.21, 95% confidence interval 1.94 to 34.7). Children in the placebo group showed a significantly higher incidence of fever on the day after entry (20% v 8%, p less than 0.05), mean analgesic consumption (0.36 ml/h v 0.21 ml/h, difference 0.14, 95% confidence interval 0.07 to 0.23; p = 0.0022), mean duration of crying (1.44 days v 0.50 days, 0.94; 0.50 to 1.38; p less than 0.001), and mean absence from school (1.96 days v 0.52 days, 1.45; 0.46 to 2.42; p = 0.0132). Differences in recorded pain were not significant. The prevalence of middle ear effusion at one or three months, as defined by tympanometry, was not significantly different, nor was there any difference in recurrence rate or in ear, nose, and throat referral rate in the follow up year. No characteristics could be identified which predicted an adverse outcome. CONCLUSIONS--Use of antibiotic improves short term outcome substantially and therefore continues to be an appropriate management policy.     

Ear wax and otitis media in children.

A study was designed to find the prevalence of ear wax in children aged 3 to 10 years and to test the belief that large amounts of wax are unlikely to be seen when otitis media is present. Roughly a quarter of the children had appreciable amounts of wax, and there was a gradual decline in prevalence with age. The amount of ear wax appeared to decrease when otitis media was present. The results did not support removing wax when assessing children''s ears in general practice.     

The art of otology

Management of chronic ear infections dependent on recognition of the differences (pathological and clinical) between tympano-tubal lesions and attico-antral disease. Chronic suppurative otitis media as a reason for rejection for military service. Statistics obtained from the Ministry of Labour and National Service. Relative incidence of tympanic and attico-antral disease in a series of 500 hospital patients at the present time. Resistant chronic tympanic disease still a problem. Relation to acute suppurative otitis media. Recurrent and relapsing attacks of acute otitis media. Does early chemotherapy interfere with development of immunity?Problems presented by acute otitis media likely to be elucidated by the general practitioner rather than by the otologist. The general practitioner's opportunities for research in this clinical problem. Incidence of ear diseases in average general practice.Training of medical students in diseases of the ear, nose and throat. Methods of instruction followed in the teaching schools of Great Britain and Northern Ireland and attitude of the Examining Bodies to this subject. The contribution of otologists to the education of doctors.Some observations on facial paralysis. Importance of prognosis. Different criteria in early and late stages of paralysis. Reasons for abandoning the faradic-galvanic tests in the management of facial paralysis. Use of constant current square pulse stimulators in early days of facial paralysis. Electromyography of value in later stages.Present-day difficulties in acquiring skill for facial nerve surgery. Importance of the stylomastoid artery. Recent investigations on the blood supply of the facial nerve: gross vascular pattern and the interfascicular plexus. Further work necessary to relate these anatomical facts to the condition of Bell's palsy.     

Acute otitis media: a new treatment strategy.

The incidence of acute otitis media and its response to treatment only with nose drops and analgesics (but without antibiotics or myringotomy) were assessed over three months by 45 doctors in and around Tilburg. In addition, over 17 months 60 general practitioners assessed the effects of this limited treatment in children aged 2 to 12 years and referred all those in whom the condition took an unsatisfactory course (either a severe course--illness continuing beyond three to four days with high temperature or pain, or both--or persistent discharge after 14 days) to an ear, nose, and throat specialist. Those referred because of appreciable illness continuing beyond three or four days were entered into a further study, comparing the effects of myringotomy alone, antibiotics alone, and myringotomy and antibiotics combined. Bacteriology was assessed in all children in whom the course of the condition was unsatisfactory. More than 90% of an estimated 4860 children seen over 17 months (estimation based on incidence of severe course in the three month study) recovered within a few days. The course of the condition was severe in only 126 (2.7%) patients; haemolytic streptococci group A were identified in 30 of these 126 patients but Haemophilus influenzae in only one. One hundred of these patients with a severe course entered the trial of treatment, which showed antimicrobial treatment either alone or in combination to be more effective than myringotomy alone. Whether combined treatment was more effective than antibiotics alone remained unconfirmed. Acute otitis media in children can be treated with nose drops and analgesics alone for the first three to four days. Patients in whom this regimen is not accompanied by satisfactory recovery can be recognised within a short time and treated by the general practitioner.     

Reproductibilité interobservateur d'un tympanomètre portatif,le MicroTymp.

OBJECTIVE: To determine the interobserver reliability of tympanograms obtained with the MicroTymp, a portable tympanometer. SETTING: Family medicine teaching unit in a tertiary care hospital. PATIENTS: Thirty-three patients who presented to the ear, nose and throat clinic in August 1990 for an ear problem. INTERVENTION: Three residents in family medicine independently attempted to record with the MicroTymp one tympanogram for the 66 ears. We excluded the results for seven ears for which tympanograms could not be obtained. MAIN OUTCOME MEASURE: Using objective criteria, two family physicians and two residents in family medicine independently classified the 177 tympanograms into five categories (normal, possible effusion, possible perforation, possible tympano-ossicular dysfunction and unclassifiable). Reliability was estimated by means of the kappa (kappa) coefficient on 161 tympanograms from 59 ears for which the interpretation of the three tympanograms agreed. MAIN RESULTS: The interpretation of the three tympanograms agreed for 34 of the 59 ears (0.58) (kappa = 0.52, 95% confidence limits 0.45 and 0.59). There was no significant difference in interobserver reliability between pairs of observers or between symptomatic and asymptomatic ears. CONCLUSIONS: The interobserver reliability of the MicroTymp is moderate. The tympanograms obtained with the instrument should be interpreted in the context of the clinical findings.     

The effects of unilamellar perichondrial dissection on the growth of rabbit ear cartilage

The effects of elevation of the perichondrium from a surface of growing ear cartilage were investigated in immature rabbits. Eight 21-day-old rabbits completed the study in which perichondrium was elevated from one cartilaginous surface of one ear and the nonoperated ear served as a control. By maturity, both ears had developed symmetrically and no statistically significant difference could be demonstrated in length and surface area. Although several ears demonstrated subtle shape changes, the overall growth and development of the surgically manipulated ear cartilages did not appear to be affected. These findings appear to contradict a widely held view that perichondrial dissection of developing cartilage has a high potential for subsequent growth disturbances. The corollary has been that cartilage manipulation, such as that required in the surgical repair of the cleft lip nose deformity, should be delayed until the growth of cartilage is complete. These data would support the findings of long-term clinical studies which demonstrate the efficacy of early limited perichondrial dissection in the correction of the cleft lip nose deformity.     

Rhinoplasty and endoscopic surgery for functional and inflammatory nasal/sinus disorders

The rhinoplastic surgeon when faced with nasal sinusitis has traditionally delayed aesthetic treatment of the nose, referring the patient to the ear, nose, and throat consultant until complete resolution of the inflammatory condition. Often, under such a scenario, the patient found the ear, nose, and throat procedure to be a traumatic experience that discouraged further surgery of an aesthetic nature. The advent of functional endoscopic sinus surgery has significantly modified the management of paranasal sinus disorders. This minimally invasive, sophisticated procedure can easily be combined with rhinoplasty. More recently, an endoscopic approach has been advocated for management of the septum and lower/middle turbinates. The authors call this functional endoscopic nasal surgery. Functional endoscopic nasal surgery allows a clearer view of the operative field (septum and turbinates), a more accurate correction of nasal obstruction, and better control of bleeding. Thus, endoscopic techniques permit the treatment of functional and inflammatory nasal disorders in a single stage, along with aesthetic improvement. Only the patient with severe sinusitis is unsuitable for combined therapy. The authors present their experience based on 72 consecutive cases of combined functional endoscopic sinus surgery/functional endoscopic nasal surgery with aesthetic rhinoplasty. Complications were minimal and functional failures were limited to 4 percent, whereas aesthetic outcomes remained uncompromised.     

Medical housing "lines".

General practitioners are often asked for medical certificates (housing "lines") by applicants for council housing who claim to have medical problems requiring housing priority. The results of a survey by questionnaire showed that general practitioners in Edinburgh do not know how the housing system works and that they seem to overestimate their patients'' chances of obtaining suitable council housing. General practitioners need to know how the housing system works, and communication between general practitioners and housing departments should be improved. A comparison was also made between the number of medical points awarded by a community medicine specialist and a group of general practitioners who had written housing "lines" for their patients. The general practitioners tended to award more points than the specialist. Social priority for housing should be recognised as an independent factor and a new category of top social priority added.     

Decontamination of instruments and control of cross infection in general practice.

OBJECTIVE--To assess the effectiveness of decontamination procedures in general practice. DESIGN--Anonymous postal questionnaire survey of 600 general practitioners randomly selected from the national register. SETTING--General practices throughout the United Kingdom. SUBJECTS--382 General practitioners, a response rate of 65%. RESULTS--186 General practitioners had autoclaves but 125 used hot water disinfectors or chemical disinfectants to reprocess instruments. 22% (474/2132) Of high risk instruments were inadequately decontaminated. Decontamination was performed by the practice nurse or receptionist in 306 practices. Knowledge of treatment of spillages of blood fluids was uncertain, and only 114 general practitioners used effective methods for dealing with spillages. CONCLUSIONS--A comprehensive central code of practice for control of infection is needed for primary health care staff.     

Sexual contact in the doctor-patient relationship in The Netherlands.

OBJECTIVE--To obtain data on sexual contact between doctors and their patients. DESIGN--Anonymous questionnaire with 17 items sent to all working gynaecologists (n = 595) and all ear, nose, and throat specialists (n = 380) in the Netherlands. RESULTS--Response rate was 74%; a total 64 doctors gave a reason for not completing the questionnaire. 201 (59%) male gynaecologists and 128 (56%) male ear nose, and throat specialists indicated that sexual feelings are acceptable in the doctor-patient relationship; 286 (85%) and 186 (81%), respectively, had felt sexually attracted to a patient at some time, as had 14 (27%) female gynaecologists. More than half (59%) of the doctors who indicated that sexual feelings are unacceptable in the doctor-patient relationship had experienced these feelings, and 91% of this group had a negative attitude towards these feelings. 4% of respondents in each group had had actual sexual contact with patients. Most gynaecologists were in favour of having more attention paid to sexual problems during training; having their professional society take an official viewpoint; subsequent public support of this viewpoint; and taking on an impartial counsellor for the patients as well as the doctors. CONCLUSION--Sexuality exists in the doctor-patient relationship. Gynaecologists have a higher risk of having sexual contact with their patients than do ear, nose, and throat specialists but compensate for this greater risk by a higher state of recognition and acknowledgement.     

K型杂交小麦901及亲本花后茎叶组织结构特征研究

采用大田栽培的杂交小麦901及其父本恢复系R205,母本不育系K3314A和常规小麦陕229(对照)为试材,在花后15～20d内采样,用常规石蜡切片法和显微测量的方法,对旗叶、叶鞘、穗下第一节间及穗轴的维管束结构等进行了系统测定。结果表明,杂交小麦901及其亲本恢复系花后旗叶、鞘、茎节间、穗轴的维管束数目、横截面积均比对照陕229高,输导组织发达,物质运输能力强。这些特征可能是其穗大、小穗数多、颖花较多的结构基础。其同化产物滞留源端可能是其它原因所导致。而不育系的维管束数目少,横截面积小,可能与其不育特性有关。     

Otoplasty: the experience of 100 consecutive patients

Although prominent ears are the most common congenital deformity in the head and neck region, only approximately 8 percent of patients who present for treatment of this deformity will have some family history of the abnormality. More than 200 techniques have been described for correction of this deformity, indicating that there is no single widely accepted procedure that has been adopted by most surgeons. The authors of this study present their choice of a procedure that combines the most beneficial features of three previously described techniques and that provides consistently satisfactory results.The surgical technique consists of scoring of the antihelical cartilage on its anterior surface in a subcutaneous position (as described by Stenstrom), suturing to recreate the fold of the antihelix (in the fashion of Mustarde), and concha-mastoid suturing applied to the back of the ear to decrease the concha-scaphoid angle (in the manner of Furnas). The last 100 consecutive patients operated on by the senior author (J.A.F.) over a 10-year period were evaluated. Follow-up data were analyzed using the Kaplan-Meier survival method. The postoperative analysis focused on the incidence of postoperative complications and the overall results of the technique.Most operations were performed bilaterally, on women, and with the patient under local anesthesia. There were few complications, and the incidence of complications was much lower than had been noted in previously reported series. All patients were very satisfied with the improvement in the appearance of their ears.The combined technique presented is safe, easy to perform, and has few complications, and its final outcome is reproducible and long-lasting. It can be considered a standard technique to be used for treating patients of any age and with any magnitude of defect.     

Manipulation of the somatosensory cortex modulates stimulus-induced repetitive ear movements in a seizure-sensitive strain of gerbil

Some Mongolian gerbils (Meriones unguiculatus) respond to stimulation by seizures, the pattern of which changes progressively during development. We previously established a seizure-sensitive strain, MGS/Idr, in which all animals exhibit such stimulus-induced seizures. We have now noted that all adults of this strain also show repetitive backward movements of the ears at the ears at the beginning of stimulus-induced seizures, although the incidence varies with the individual. We examined whether the cerebral cortex was involved in these movements and found that electrical stimulation of an area of the somatosensory cortex elicited strong backward movement of the ear on the contralateral side, and that unilateral application of bicuculline, a GABAA receptor antagonist, induced spontaneous repetitive backward movements of the same ear. In this area, sharp waves appeared in the electrocortigram during the repetitive ear movements induced by seizure-inducing stimuli. Unilateral ablation of this area abolished stimulus-induced repetitive movements of the contralateral ear, but had no effects on those of the ipsilateral ear. These results suggest that, in certain types of seizure-susceptible subjects, it may be possible to modify stimulus-induced repetitive movements by manipulating a certain area of the somatosensory cortex which is related to these movements and that this gerbil strain may be useful in research on this subject.     

Some treatments affecting growth substances in developing wheat ears

Cytokinin, auxin and gibberellin-like substances were bio-assayed in extracts from developing ears of wheat plants grown in various conditions. Changes in cytokinin activity along the ears may be related to the earlier flowering in the middle of the ear. Ears on the main stems of plants from which all the tillers had been removed contained less cytokinin than the main-stem ears of normal tillered plants. When grain development was stopped by preventing fertilization of the ovules the ear contained more cytokinin than normal ears. With de-tillered plants, removing flag leaves before anthesis increased cytokinin, gibberellin and auxin in the ears; later removal of flag leaves did not affect cytokinin but decreased gibberellin in the ears. Conversely, removing ears before anthesis did not affect cytokinin or auxin in the flag leaves, but their gibberellin was less than that of flag leaves on intact plants. Treatment of wheat ears with zeatin did not affect grain weight or number per ear which supports the conclusion that the growth substances in the ear may be adequate for normal grain growth.     

The occurrence of Mycoplasma arthritidis in the throat and middle ear of rats with chronic respiratory disease.

Twenty-three rats with chronic respiratory disease were examined for the presence of Mycoplasma arthritidis in the throat and middle ear. Samples were taken at necropsy and swabbed onto an agar medium. Morphologically typical colonies were subcultured and identified serologically. All of the rats showed evidence histopathologically of chronic respiratory disease, and typical M pulmonis colonies were isolated from 21 of 23. M arthritidis was isolated from 7 (30=) of the middle ears and 3 (13%) of the throats, confirming a previous observation of the occurrence of this organism in the middle ear of rats and also indicating it can be present in the throat.     

Transplantation of Xenopus laevis ears reveals the ability to form afferent and efferent connections with the spinal cord

Previous comparative and developmental studies have suggested that the cholinergic inner ear efferent system derives from developmentally redirected facial branchial motor neurons that innervate the vertebrate ear hair cells instead of striated muscle fibers. Transplantation of Xenopus laevis ears into the path of spinal motor neuron axons could show whether spinal motor neurons could reroute to innervate the hair cells as efferent fibers. Such transplantations could also reveal whether ear development could occur in a novel location including afferent and efferent connections with the spinal cord. Ears from stage 24-26 embryos were transplanted from the head to the trunk and allowed to mature to stage 46. Of 109 transplanted ears, 73 developed with otoconia. The presence of hair cells was confirmed by specific markers and by general histology of the ear, including TEM. Injections of dyes ventral to the spinal cord revealed motor innervation of hair cells. This was confirmed by immunohistochemistry and by electron microscopy structural analysis, suggesting that some motor neurons rerouted to innervate the ear. Also, injection of dyes into the spinal cord labeled vestibular ganglion cells in transplanted ears indicating that these ganglion cells connected to the spinal cord. These nerves ran together with spinal nerves innervating the muscles, suggesting that fasciculation with existing fibers is necessary. Furthermore, ear removal had little effect on development of cranial and lateral line nerves. These results indicate that the ear can develop normally, in terms of histology, in a new location, complete with efferent and afferent innervations to and from the spinal cord.     

Incidence of poliomyelitis; the effect of tonsillectomy and other operations on the nose and throat

A statistical survey was made of all the cases of poliomyelitis occurring in all of Los Angeles County during the three years of 1949, 1950 and 1951 in an attempt to determine the effect of operations on the nose and throat on the incidence of poliomyelitis. Tonsillectomy and adenoidectomy were the only operations noted with any degree of frequency. Yet, in the total of 3,601 cases of poliomyelitis that occurred in this three-year period there were only 20 (0.55 per cent) in which the patient had had recent tonsillectomy and adenoidectomy. The incidence of this disease in patients who had had tonsillectomy and adenoidectomy was compared with the "expected" incidence as determined from the incidence in other patients, in the same age group. There was no significant difference between actual and expected incidence even during the summer months when most cases of poliomyelitis occurred. The same was true with regard to recently tonsillectomized patients in the epidemic months of July through October. In a separate survey of 675 patients with poliomyelitis, it was noted that only 30 per cent ever had had tonsillectomy or adenoidectomy. Inasmuch as it is estimated that one of every three persons in the general young population nowadays has had tonsillectomy and adenoidectomy, this figure is no more or less than could be expected.