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Background The Glasgow Benefit Inventory (GBI) is a validated, generic patient-recorded outcome measure widely used in otolaryngology to report change in quality of life post-intervention. Objectives of review To date, no systematic review has made (i) a quality assessment of reporting of Glasgow Benefit Inventory outcomes; (ii) a comparison between Glasgow Benefit Inventory outcomes for different interventions and objectives; (iii) an evaluation of subscales in describing the area of benefit; (iv) commented on its value in clinical practice and research. Type of review Systematic review. Search strategy ‘Glasgow Benefit Inventory’ and ‘GBI’ were used as keywords to search for published, unpublished and ongoing trials in PubMed, EMBASE, CINAHL and Google in addition to an ISI citation search for the original validating Glasgow Benefit Inventory paper between 1996 and January 2015. Evaluation method Papers were assessed for study type and quality graded by a predesigned scale, by two authors independently. Papers with sufficient quality Glasgow Benefit Inventory data were identified for statistical comparisons. Papers with 50% and gave sufficient Glasgow Benefit Inventory total and subscales for meta-analysis. For five of the 11 operation categories (vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery) that were most likely to have a single clear clinical objective, score data had low-to-moderate heterogeneity. The value in the Glasgow Benefit Inventory having both positive and negative scores was shown by an overall negative score for the management of vestibular schwannoma. The other six operations gave considerable heterogeneity with rhinoplasty and septoplasty giving the greatest percentages (98% and 99%) most likely because of the considerable variations in patient selection. The data from these operations should not be used for comparative purposes. Five papers also reported the number of patients that had no or negative benefit, a potentially a more clinically useful outcome to report. Glasgow Benefit Inventory subscores for tonsillectomy were significantly different from ear surgery suggesting different areas of benefit Conclusions The Glasgow Benefit Inventory has been shown to differentiate the benefit between surgical and medical otolaryngology interventions as well as ‘reassurance’. Reporting benefit as percentages with negative, no and positive benefit would enable better comparisons between different interventions with varying objectives and pathology. This could also allow easier evaluation of factors that predict benefit. Meta-analysis data are now available for comparison purposes for vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery. Fuller report of the Glasgow Benefit Inventory outcomes for non-surgical otolaryngology interventions is encouraged.

Traditionally, outcomes of medical care are based on clinical observations or laboratory measurements, but in recent years, there has been an increasing recognition that these need to be complemented by quantitative measures of the impact of the intervention on patients’ health status or health-related quality of life (‘HRQoL’). The three major measures are the Health Utilities Index mark 3 (HUI-3),1 the EQ-5D,2 and the SF-363 questionnaires. These are generic questionnaires that are applicable to the full spectrum of health: their items cover experiences of illness, such as pain, fatigue, or disability, as well as broader aspects of the patient’s physical, emotional and social well-being. The importance of these measures is demonstrated by their wide use in the current National Services Scotland (NHS). For instance, the EQ-5D is the questionnaire used to assess the generic health status in the Patient Reported Outcome Measures (PROMs) for hip replacements, knee replacements, hernias and varicose veins.4 It is also recommended by the National Institute for Health and Clinical Excellence for the measurement and valuation of HRQoL in economic evaluations of health care.5 In audiology and otolaryngology, there have been studies of HRQoL in the specific domains of hearing aids6–8, cochlear implantation9–12 and head and neck cancer13,14. But there has been no large-scale HRQoL study of the general population of patients referred to otolaryngology clinics. We reasoned that such a study would be particularly useful as its outcomes would allow overall comparisons of otolaryngology with other specialities, as the majority of otolaryngology problems are neither life-threatening nor require surgery and so do not allow comparisons by mortality rates or surgical success rates. We therefore designed a suitable project to address this gap. We measured the baseline values of HRQoL of a broad spectrum of patients referred to six otolaryngology clinics across Scotland and then the changes in HRQoL owing to their otolaryngological management. We also collected relevant clinical data. The results are reported according to patients’ initial diagnosis and how they were managed.

Background and objectives of review: The use of aminoglycoside drops in the presence of a perforation/grommet is still a common practice amongst the UK ENT community, in spite of theoretical risk of ototoxicity. Mindful of the need to produce clinical guidelines based on the best available evidence, it was the intention of the Clinical Audit and Practice Advisory Group of the British Association of Otolaryngologists – Head and Neck Surgeons (ENT-UK) to produce evidence-based guidelines. In the absence of good evidence, intentions were shifted towards producing consensus guidelines using validated methodology. Type of review: Literature review, review of international guidelines and consensus guidelines. Search strategy: A MEDLINE literature search (1966 to August 2006) was conducted, using the following strategies: ‘ototoxicity and drops’, ‘ototoxic and drops’, ‘vestibulotoxicity and drops’, ‘vestibulotoxic and drops’, ‘cochleotoxicity and drops’, ‘cochleotoxic and drops’. Foreign language articles were not excluded. Results of the literature review: The inclusion of foreign language articles and manually searching the reference sections of identified articles revealed further evidence not considered in previous reviews on this subject. However, the available ‘evidence’ that does exist remains to be of poor quality, consisting of data from a number of case reports and small case series. Prospective studies into the ototoxic effects of aminoglycoside ear drops either support their use but lack power to statistically confirm this, or are performed in conditions that are not representative of normal clinical conditions. Evaluation method: In the light of issues raised from the literature review, a questionnaire was produced. The questionnaire was initially completed by council members of the British Society of Otology, then revised and presented at a meeting of the British Society of Otology, where a consensus panel was formed. Conclusions: ENT-UK recommends that when treating a patient with a discharging ear, in whom there is a perforation or patent grommet: if a topical aminoglycoside is used, this should only be in the presence of obvious infection. Topical aminoglycosides should be used for no longer than 2 weeks. The justification for using topical aminoglycosides should be explained to the patient. Baseline audiometry should be performed, if possible or practical, before treatment with topical aminoglycosides.

Objectives TNO-AZL Preschool Quality of Life Questionnaire (TAPQOL) is one of the few instruments designed to assess health-related quality of life in preschool children but its applicability to otolaryngology is unknown. Study design and setting We studied a consecutive series of children aged 1 to 5 years referred to hospital with recurrent sore throats, recurrent acute otitis media, or otitis media with effusion. Results TAPQOL domain scores were not influenced by age, sex, or socio-economic class, but correlated with markers of disease severity (frequency of sore throat or pyrexia, time off school), ear-related handicap (assessed with the OM6 questionnaire), and other measures of health-related quality of life (visual analogue scale, 5-point rating scale and the Health Utilities Index mark III). Comparison with published data from healthy children suggests that these common otolaryngologic problems have a large impact on a child’s quality of life. Conclusions TAPQOL seems to be appropriate for use in this context. Marked ceiling effects in some domains, however, may limit their sensitivity.

The aim of the present study is to examine the extent to which caregiving stressors could explain change in family relationships over time – a construct termed stress proliferation – in a secondary analysis of an existing database. The sample of caregivers and care recipients (N = 132) was drawn mainly from records held by general practitioners in Glasgow. Care recipients were aged 65 years and over, and the majority had impaired hearing. Caregivers were younger non-spouse relatives of care recipients. Using hierarchical multiple regression analysis, two stressors were found to be significantly related to deterioration in family relationships over a period of six months, irrespective of change in caregiver distress: the care recipient's hearing disability (β = −0.21), and change in the caregiver's negative reactions to caregiving (β = −0.23). It was concluded that the care recipient's hearing disability and more negative reactions to caregiving were related to a deterioration in family relationships over ...

Objectives: To determine the sensitivity and specificity of the whispered voice test (WVT) in detecting hearing loss when administered by practitioners with different levels of experience.\ud \ud Design: Diagnostic accuracy study of WVT, through acoustic analysis of whispers of experienced and inexperienced practitioners (experiment 1) and behavioural validation of these recordings (experiment 2).\ud \ud Setting: Research institute with a pool of patients sourced from local clinics in the Greater Glasgow area.\ud \ud Participants: 22 people had their whispers recorded and analysed in experiment 1; 4 older experienced (OE), 4 older inexperienced (OI) and 14 younger inexperienced (YI). In experiment 2, 73 people (112 individual ears) took part in a digit recognition task using 2 OE and 2 YI whisperers from experiment 1.\ud \ud Main outcome measures: Average level (dB sound pressure level) across frequency, average level across all utterances (dB A) and within/across-digit deviation (dB A) for experiment 1. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of WVT for experiment 2.\ud \ud Results: In experiment 1, OE whisperers were 8–10 dB more intense than inexperienced whisperers across all whispered utterances. Variability was low and comparable regardless of age or experience. In experiment 2, at an optimum threshold of 40 dB HL, sensitivity and specificity were 63% (95% CI of 58% to 68%) and 93% (92% to 94%), respectively, for OE whisperers. PPV was 56% (51% to 61%), NPV was 95% (94% to 96%). For YI whisperers at an optimum threshold of 29 dB HL, sensitivity and specificity were 80% (78% to 82%) and 52% (50% to 55%), respectively. PPV was 65% (63% to 67%) and NPV was 70% (67% to 72%).\ud \ud Conclusions: WVT is an effective screening test, providing the level of the whisperer is considered when setting the test's hearing-loss criterion. Possible implications are voice measurement while training for inexperienced whisperers.

When selecting the frequency response of a hearing aid, a target is usually selected using a predictive formula from the international literature. Nowadays real ear measurements can readily be carried out to ensure that the real ear gain closely matches the prescribed target. Such measurements are usually only carried out on a subset of patients fitted in the UK, though it has been suggested that they should be carried out on all hearing aid prescriptions. Real ear insertion gains were measured on 319 first-time National Health Service (NHS) hearing aid issues. A total of 181 (57%) failed to come within 10 dB of the target gain at one or more frequencies between 0.25 and 3 kHz. Though there were audiometric differences between those who achieved satisfactory gain and those who did not, there was too much overlap between groups to make any audiometric index or combination of indices of value in predicting the likelihood of failure to achieve target gain. Sixty-eight patients with inadequate real ear gain were invited to attend for alterations to their hearing aid prescription. Twelve (18%) were fitted with a high frequency aid, while the rest were managed by alterations to their NHS aid or to the earmould and tubing. After appropriate changes, 58 (85%) achieved a satisfactory gain. The routine use of real ear insertion gains in all hearing aid fittings would result in many patients having a more accurately fitted hearing aid. As the majority of prescriptions could be adequately improved using NHS hearing aids, the effects on the hearing aid budget would be relatively small.

Background Bell's palsy is an acute unilateral facial paralysis of unknown aetiology and should only be used as a diagnosis in the absence of any other pathology. As the proposed pathophysiology is swelling and entrapment of the nerve, some surgeons suggest surgical decompression of the nerve as a possible management option; this is ideally performed as soon as possible after onset. This is an update of a review first published in 2011, and last updated in 2013. This update includes evidence from one newly identified study. Objectives To assess the effects of surgery in the early management of Bell's palsy. Search methods On 20 March 2020, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and WHO ICTRP. We handsearched selected conference abstracts for the original version of the review. Selection criteria We included all randomised controlled trials (RCTs) or quasi-RCTs involving any surgical intervention for Bell's palsy. Trials compared surgical interventions to no treatment, later treatment (beyond three months), sham treatment, other surgical treatments or medical treatment. Data collection and analysis Three review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. The primary outcome was complete recovery of facial palsy at 12 months. Secondary outcomes were complete recovery at three and six months, synkinesis and contracture at 12 months, psychosocial outcomes at 12 months, and side effects and complications of treatment. Main results Two trials with 65 participants met the inclusion criteria; one was newly identified at this update. The first study randomised 25 participants into surgical or non-surgical (no treatment) groups using statistical charts. One participant declined surgery, leaving 24 evaluable participants. The second study quasi-randomised 53 participants; however, only 41 were evaluable as 12 declined the intervention they were allocated. These 41 participants were then divided into early surgery, late surgery or non-surgical (no treatment) groups using alternation. There was no mention on how alternation was decided. Neither study mentioned if there was any attempt to conceal allocation. Neither participants nor outcome assessors were blinded to the interventions in either study. There were no losses to follow-up in the first study. The second study lost three participants to follow-up, and 17 did not contribute to the assessment of secondary outcomes. Both studies were at high risk of bias. Surgeons in both studies used a retro-auricular/transmastoid approach to decompress the facial nerve. For the outcome recovery of facial palsy at 12 months, the evidence was uncertain. The first study reported no differences between the surgical and no treatment groups. The second study fully reported numerical data, but included no statistical comparisons between groups for complete recovery. There was no evidence of a difference for the early surgery versus no treatment comparison (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.05 to 11.11; P = 0.84; 33 participants; very low-certainty evidence) and for the early surgery versus late surgery comparison (RR 0.47, 95% CI 0.03 to 6.60; P = 0.58; 26 participants; very low-certainty evidence). We considered the effects of surgery on facial nerve function at 12 months very uncertain (2 RCTs, 65 participants; very low-certainty evidence). Furthermore, the second study reported adverse effects with a statistically significant decrease in lacrimal control in the surgical group within two to three months of denervation. Four participants in the second study had 35 dB to 50 dB of sensorineural hearing loss at 4000 Hz, and three had tinnitus. Because of the small numbers and trial design we also considered the adverse effects evidence very uncertain (2 RCTs, 65 participants; very low-certainty evidence). Authors' conclusions There is very low-certainty evidence from RCTs or quasi-RCTs on surgery for the early management of Bell's palsy, and this is insufficient to decide whether surgical intervention is beneficial or harmful. Further research into the role of surgical intervention is unlikely to be performed because spontaneous or medically supported recovery occurs in most cases.

Objective: To determine whether oral prednisolone or aciclovir, used separately or in combination, early in the course of Bell's palsy, improves the chances of recovery at 3 and 9 months.Design: A 2 x 2 factorial randomised double-blind trial. Patients were randomly assigned to treatment by an automated telephone service using a permuted block randomisation technique with block sizes of four or eight, and no stratification.Setting: Mainland Scotland, with referrals mainly from general practice to 17 hospital trial sites.Participants: Adults (aged 16 years or older) with unilateral facial nerve weakness of no identifiable cause presenting to primary care, the emergency department or NHS24 within 72 hours of symptom onset.Interventions: Patients were randomised to receive active preparations or placebo for 10 days: (I) prednisolone (50 mg per day, 2 x 25-mg capsules) and aciclovir (2000 mg per day, 5 x 400-mg capsules); (2) prednisolone and placebo (lactose, indistinguishable); (3) aciclovir and placebo; and (4) placebo and placebo.Outcome measures: The primary outcome was recovery of facial function assessed by the House-Brackmann scale. Secondary outcomes included health status, pain, self-perceived appearance and cost-effectiveness.Results: Final outcomes were available for 496 patients, balanced for gender; mean age 44 years; initial facial paralysis moderate to severe. One half of patients initiated treatment within 24 hours of onset of symptoms, one-third within 24-48 hours and the remainder within 48-72 hours. Of the completed patients, 357 had recovered by 3 months and 80 at 9 months, leaving 59 with a residual deficit. There were significant differences in complete recovery at 3 months between the prednisolone comparison groups (83.0% for prednisolone, 63.6% for no prednisolone, a difference of + 19.4%; 95% confidence interval (CI): + 11.7% to + 27.1%, p Conclusions: This study provided robust evidence to support the early use of oral prednisolone in Bell's palsy as an effective treatment which may be considered cost-effective. Treatment with aciclovir, either alone or with steroids, had no effect on outcome.

The aim of this study was to compare individuals referred to an Audiology Clinic (consulters) with hearing-impaired individuals in the population who have never sought advice (non-consulters) in order to identify factors which lead some individuals with hearing problems to seek management while others with apparently similar impairments do not seek advice. Two hundred and sixty nine consulters referred to the Audiology Clinic at Glasgow Royal Infirmary were compared with 289 individuals identified in the MRC National Study of Hearing who had never sought advice as an adult about hearing problems. Age, sex, socio-economic group and better-ear hearing threshold were controlled for in all analyses. Consulters were found to have more asymmetrical hearing than non-consulters. They had greater measured disability and reported more disability when their measured disability and impairment were controlled for. They were also more handicapped when impairment and disability were controlled for.

To determine whether patient self-reported handicap correlates with scores obtained from the modified Clinical Test for the Sensory Interaction on Balance as assessed by the Neurocom VSR Balance Master platform.Prospective observational.Balance clinic in tertiary referral center.Patients referred with dizziness or imbalance as their primary complaint.The modified Clinical Test for the Sensory Interaction on Balance scores as assessed by the Neurocom VSR Balance Master platform, the Dizziness Handicap Inventory, and the Health Utilities Index Marks 2 and 3.One hundred fifty-nine patients were entered into the study. The mean age of participants was 54.5 years, with a female-to-male ratio of 2.1:1. The scores for the Dizziness Handicap Inventory and Health Utilities Index are similar between sexes, and although the Dizziness Handicap Inventory score did not correlate with age, Health Utilities Index 2 and 3 scores did show a negative correlation with increasing age. There are weak, positive correlations between the Dizziness Handicap Inventory and the firm surface conditions of the modified Clinical Test for the Sensory Interaction on Balance but no useful correlation with the foam conditions. Similar weak negative correlations were found between the Health Utilities Index 2 and 3 and the modified Clinical Test for the Sensory Interaction on Balance scores.Patient-perceived handicap of imbalance appears to correlate poorly with assessment of postural stability using the modified Clinical Test for the Sensory Interaction on Balance.

There are many reports in the literature on the outcome of ear surgery. However, it is difficult to make comparisons from these reports because of a lack of uniformity in the way in which outcomes are reported. At the same time, the general public expects doctors to provide them with information regarding the benefits and risks of surgery. Many ear surgeons will not be able to provide this information because few have an up-to-date database. A group of otologists in Europe has attempted to establish a common otology database. The aim is to create a framework whereby surgeons in Europe can contribute to a common ear database using a web-based system. The proposed methodology involves two levels of data entry. Level 1 is a minimal database where the main outcomes are included. Level 2 is a comprehensive database where detailed information on pathologies, risk factors, and surgical procedures is also recorded. As both databases share the same core data, clinicians using database 1 can still compare their outcomes with those using database 2. Clinicians will be able to input and retrieve ear data onto or from the web-based database. There has already been an international consensus on the content of the common ear database. The website address is www.ear-audit.net. The international project has now been in operation for more than 6 months, and Ear UK has already given its endorsement. The founder members include 27 otologists from 12 European countries. The cumulative outcome from this group of surgeons will be used as the benchmark for the purpose of comparative audit. These benchmark sites will be subjected to regular external validation. The web-based system is interactive and gives instant feedback to individual surgeons who wish to compare their results to the benchmark. Therefore, it can be a good learning tool for trainees or less experienced surgeons. The common data entry system also provides an opportunity for clinicians to collaborate in clinical research.

Most health-related quality-of-life measures make an assessment at a single point in time. Comparing results before and after an intervention is often difficult, because the difference measured is usually small compared with the variation between individuals. A retrospectively applied measure specifically worded to assess benefit would be very useful for clinical research. Such a measure exists for adults. We aimed to develop a similar measure for children. We chose potential items after reviewing existing health-related quality-of-life measures, published literature, and parental interviews. A draft questionnaire was given to a group of parents and modified. The resulting Glasgow Children's Benefit Inventory (GCBI) comprised 24 questions on the consequences of a specified intervention on various aspects of the child's day-to-day life, without reference to any specific symptoms, and was worded to apply to children of any age. The questionnaire was mailed to the parents of all 1,777 children who had undergone tonsillectomy or ventilation tube insertion at one hospital during the period January 1998 to December 2001. There were 670 questionnaires returned. The GCBI scores correlated well with parental satisfaction with surgery and with estimates of technical success (residual sore throats, reported hearing impairment, ear infections). The questionnaire had high internal consistency. Factor analysis showed 4 dimensions in the pattern of responses relating to emotion, physical health, learning, and vitality. The GCBI is a means to retrospectively assess benefit after an intervention in children, and we have shown initial evidence of reliability and validity. Although not restricted to any branch of pediatric medicine, it is eminently suitable for use in pediatric otolaryngology.

Objective The primary goal of the study was to find out whether the Yung vent would remain patent long-term. The secondary goal was to find out whether mastoid ventilation could overcome permanent ventilation disorder within the middle ear. Study design The study was an open prospective investigation. Setting The study was a multicenter study involving three tertiary referral centers. Patients Twenty-three subjects older than 12 years were included. The inclusion criteria were complete atelectasis, failed tympanoplasty because of persistent eustachian tube dysfunction, and persistent otitis media with effusion in spite of repeated ventilation tube insertion. Intervention Tympanoplasty with insertion of the Yung percutaneous mastoid vent. Main outcome measures Patency of the vent, adverse effects, patient acceptance, hearing results, and appearance of the tympanic membrane were assessed every 3 months up to 18 months postoperatively. Results : At 18 months, 20 of 23 vents were still patent. Overall, there had been no unacceptable adverse effect on any patient. Eighteen of 23 ears had improved hearing. The tympanic membrane had returned from a collapsed state to near normal in 13 of 17 completely atelectatic ears. There were five patients who had no benefit from the vent because of blockage within the epitympanum or middle ear effusion. Conclusion The Yung percutaneous mastoid vent can maintain long-term patency. It is effective in the treatment of complete atelectasis as an adjunct to tympanoplasty.

EDITOR—Holland and Weiner's clinical review (albeit a traditional non-systematic, opinion based one) on the important topic of Bell's palsy is welcome,1 but we are concerned that their conclusions about treatment are simply not supported by current evidence. The most recent Cochrane reviews show that no treatment has yet been shown to be more effective than placebo.2 3 The recent studies cited have not yet been included in the systematic reviews but since they are non-randomised, statements that combination therapy …

Background The OM6 is a 6-item condition-specific handicap measure developed in the United States for children with recurrent acute otitis media and otitis media with effusion. Easy and quick to use, it has high test-retest repeatability and is sensitive to change after ventilation tube insertion. Objectives To explore aspects of the validity of OM6 in a United Kingdom population and to specifically address the instrument's ability to discriminate between children with different burdens of disease. Design The parents of 179 consecutive newly referred children with otitis media with effusion or recurrent acute otitis media completed the OM6 on their first visit to the hospital. The parents of 72 children with sore throats completed the OM6 for comparison. Scores were compared with markers of disease severity, demographic variables, and generic quality-of-life measures. Results Poorer scores were found in those with ear complaints than in those with sore throats. The OM6 scores were not associated with age, sex, socioeconomic class, or respondent (mother vs father). The OM6 scores did not correlate with frequency of otalgia, frequency of otorrhea, or time off school in the recurrent acute otitis media group. In the otitis media with effusion group, poorer scores were associated with bilateral B or C2 tympanometric findings but not with a better ear threshold of more than 20 dB. Correlation with a global 10-cm visual analog scale for quality of life and with the Health Utilities Index Mark III was good. Conclusions The OM6 scores correlate well with global quality-of-life measures and are free from many potential biases. However, OM6 does not adequately reflect disease severity, which may limit its usefulness as a discriminative measure.

Many older people develop hearing disability; however, only a small proportion who would benefit from a hearing aid own one. Communication is a shared experience which can be substantially limited by hearing difficulty, so this lack of hearing aid provision is likely to affect both individuals and those around them. This study, a randomized, controlled trial, was designed to examine the influence of hearing aid provision on dependent older people and caring family members who lived together within multigeneration households. A total of 63 intervention families and 70 control group families participated in the trial. We found that hearing disability and handicap are related to reduced wellbeing and depression in older people, and in turn these are related to increased levels of carer distress. Of the 63 older people in the intervention group fitted with hearing aids, all but one was experiencing benefit at 6 months, although no changes in depression were detected. Hearing aids significantly reduced the carer's perception of related difficulties and was a welcomed intervention.

Bell's palsy is acute, idiopathic, unilateral paralysis of the facial nerve1 and most GPs will see a new case about once every 5 years. Although most patients recover well, up to 30% have a poor outcome, with persistent facial weakness, psychological difficulties, and facial pain. The rapid, often painful onset of facial weakness is distressing for patients, leading them to present urgently to their GP. Primary care management has included various options, such as prednisolone and/or antiviral drugs, or neither, but evidence for these or other strategies has been weak or absent. This persisting uncertainty about ideal management can be disconcerting for GPs and their patients. In 2001, the American Academy of Neurology published guidelines on the management of Bell's palsy, concluding that, while the benefit of steroids and/or aciclovir had not been established, the available evidence indicated that steroids were ‘probably effective’, and that aciclovir combined with prednisolone was ‘possibly effective’.1 Subsequently, two articles published in the British Medical Journal triggered controversy when they recommended the early use of steroids and aciclovir,2,3 although no further reliable data had been published since the American guideline. After decades of little persuasive evidence, four randomised controlled trials, involving over 1800 patients, …

It has been suggested that a proportion of individuals with a hearing impairment can be fitted with a hearing aid without being otolaryngologically assessed. Such assessments are deemed advisable: (a) to identify otological pathology that might require management and (b) because surgery can be a viable alternative in those with a conductive impairment.The aim of this study was to prospectively study individuals referred to an Otolaryngology Department in a teaching hospital to assess how technicians, at a direct referral clinic for the provision of a hearing aid, could screen to identify those meriting an otolaryngological opinion. Two hundred and forty-eight patients were evaluated by technicians using strict audiometric and tympanometric criteria. One hundred and twenty-five patients (50 per cent) failed these criteria and were referred to an otologist. The remaining 123 (50 per cent) were managed by technicians but were subsequently reviewed for the purpose of this study by an otologist and their management assessed. In only two patients (one per cent) was it thought that the initial management would have been different if seen by an otologist. Alternative criteria for deciding suitability for management by technicians were applied. The inclusion of tympanometry was essential to avoid missing middle ear pathology.

EDITOR—Bond et al said that nasal fluticasone propionate caused benign intracranial hypertension in a 13 year old boy with a history of Crohn's disease and subsequently reported this to the Committee on Safety of Medicines.1 We have numerous problems with this hypothesis. Firstly, Bond et al did not confirm the diagnosis of intracranial hypertension as the cerebrospinal fluid pressure, which should be markedly raised, was not measured on …

Conventionally, the results of middle ear surgery are reported in terms of postoperative closure of the air-bone gap or the improvement in air-conduction thresholds. While these are relevant in that they assess the technical success of the procedure and the lessening of monaural disability, they do not necessarily assess whether the patient has benefited. This is determined by many factors, not least of which is the hearing in the nonoperated ear. In this paper, we suggest that preoperative and postoperative plots of the air-conduction thresholds in both ears be used as an additional method of presenting the results. First, the proportion of patients that fall into each of three main preoperative impairment groups are identified. This is important, as the potential benefits from surgery are not the same in each group. Thereafter, the percentages of patients that achieve various postoperative hearing categories can be calculated, allowing surgeons to audit their results and make comparisons between series.

• A prospective otological and audiological study was made of 130 consecutive persons with minor head injuries. A comparison was made with 87 consecutive persons with traumatic injuries but without head injuries. Five (4%) of the persons with head injuries had an unsuspected temporal bone fracture evident on otoscopy but not on routine skull roentgenography. These persons had a significant sensorineural hearing loss at 4 and 8 kHz compared with other patients with head injuries. Routine otoscopic examination is considered advisable in all persons with head injuries. No significant difference in the hearing was detected in persons with head injuries without a temporal bone fracture compared with control subjects. ( Arch Otolaryngol 1982;108:474-477)

The criteria generally used to decide in which ear to fit a monaural hearing aid are based on theory or anecdote and have not been verified by experimental observation. In this study to determine optimum side of fitting, 58 new hearing aid users were fitted with a hearing aid in one ear for 10 weeks, and then fitted in the other ear for a further 10 weeks. Subsequently, the subjects were asked their preference for side of hearing aid use and their reasons for this preference. 30 (52%) subjects reported better hearing with their aid in one ear than in the other; 24 (80%) of these preferred the ear with the poorer half-peak level elevation on a speech audiogram. The remaining 28 (48%) reported no difference in their aided hearing ability between ears, though 20 preferred one ear for practical reasons, unrelated to audiometric parameters. A patient's preference for side of fitting can be predicted from audiometric data but with only modest reliability. It is, therefore, recommended that bilateral ear moulds should be routinely provided for bilateral mild to moderate hearing impairment (speech frequency average less than 75 dB HL). If it is decided that only one ear mould should be provided, this should be made for the poorer hearing ear. The poorer hearing ear is best identified from the half-peak level elevation on a speech audiogram.

No previous study has investigated which ear should be fitted with a hearing aid. Fifty-eight patients with bilateral hearing loss of 25-75 dB HL were sequentially fitted with an ear level hearing aid for 10 weeks in each ear. Patients were then asked their preference for side of fitting, and their reasons for this preference. Thirty-five patients had symmetrical hearing: 17 (49%) preferred one ear because they could hear better with the aid in that ear, and 12 (34%) chose one side for practical reasons. Twenty-three patients had asymmetrical hearing: 8 (35%) preferred one side for practical reasons, and 13 (57%) could hear better with the aid in one ear, which was invariably the poorer hearing ear. As the preferred ear cannot be reliably predicted, bilateral ear moulds should be provided. If only one mould is provided, it should be for the poorer hearing ear.

Many consider that the compliance of the middle ear as measured from the tympanogram can be helpful in diagnosing otosclerosis. To test this assertion, the compliance in 34 individuals with surgically proven otosclerosis was compared with the compliance in 34 age and sex matched, normal controls, randomly selected from the population. Though the mean compliance was different in the two groups, there was considerable overlap in the range of values which severely limits the practical usefulness of tympanometry.If the level of compliance is taken at which a false negative diagnosis would be made in 10 per cent of otosclerotic ears, a false positive diagnosis of otosclerosis would be made in 88 per cent of normal ears. If the level of compliance is taken at which a false positive diagnosis of otosclerosis would be made in 10 per cent of normal ears, 72 per cent of ears with otosclerosis would be considered normal.It is concluded that tympanometry will not help to arrive at a diagnosis of otosclerosis.

The Bing test is based on the principle that occlusion of the external auditory meatus improves the perception of bone-conducted sounds unless there is a conductive hearing impairment. However, its sensitivity and specificity have not been reported. Tuning-fork and audiometric Bing tests were carried out on 126 patients with otological symptoms prior to any otological history or examination. Test results were compared with the pure tone air-bone gaps. The specificity and sensitivity of each test method was estimated. The tuning-fork Bing test was less sensitive than the audiometric Bing test, but had greater specificity. However, the Rinne test with the 256 Hz fork and the loudness comparison method was more sensitive than the Bing tuning-fork test, and had similar specificity. The Rinne is therefore the better test for clinical use.

The management of otitis media with effusion in adults The management of 38 patients with idiopathic adult onset otitis media with effusion was evaluated retrospectively. Data from 50 ears were reviewed. The standard treatment consisted of myringotomy and grommet insertion. The patients were followed up for an average period of 27 months. Only 2 ears maintained a significant improvement in the air-bone gap when reviewed approximately 3 months following grommet extrusion. In all of the others, the hearing impairment recurred, and continued to recur despite multiple grommet insertions in several patients. It is concluded that adult onset otitis media with effusion has a low tendency to resolve, and that conventional surgical measures have little to offer in its management.