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The aim of this secondary analysis was to examine the relationships between the ways in which caregivers coped with caregiving stressors and their experience of distress over time. Three coping subscales were derived from the Carers' Assessment of Management Index (CAMI) coping scale: "maintaining balance", "focusing on caregiving" and "avoidance". A proportional (relative) scoring technique was applied. The analysis was based on the responses of 115 pairs of caregivers and care recipients. Care recipients were aged 66-92 years, with no symptoms of dementia, and the majority had mild to moderate hearing impairment. Data were collected at baseline and 6 months later. Caregivers who increased the proportion of strategies endorsed in the "maintaining balance" subscale experienced a decrease in distress, irrespective of change in the proportion of strategies endorsed in the "avoidance" subscale. "Focusing on caregiving" was not significantly related to distress. The results highlight the potential benefits to these caregivers of maintaining a balance in their lives by taking breaks from caregiving.

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.

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.

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 …

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.

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)

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.