Hearing outcomes after mobile ear surgery for chronic otitis media in Greenland

Success rates in restoring hearing loss in patients with chronic otitis media: A systematic review

OBJECTIVE

To assess the effectiveness of tympanoplasty in treating chronic otitis media-related hearing loss, published literature was systematically reviewed to determine the clinical success rate of tympanoplasty at restoring hearing in chronic otitis media patients at a minimum follow-up period of 12-months.

DATA SOURCES

PubMed, Embase and the Cochrane Library.

METHODS

Two independent reviewers performed literature searches. Publications reporting long-term (≥12-month) hearing outcomes and complications data on adult and pediatric patients with chronic otitis media were included and assessed for risk of bias and strength of evidence. To assess how tympanoplasty influences long-term hearing outcomes, data on pure tone audiometry (air-bone gap) and complications were extracted and synthesized.

RESULTS

Thirty-nine studies met the inclusion criteria. Data from 3162 patients indicated that 14.0% of patients encountered postoperative complications. In adult patients, mean weighted air-bone gap data show closure from 26.5 dB hearing level (HL) (preoperatively) to 16.1 dB HL (postoperatively). In studies that presented combined adult and pediatric data, the mean preoperative air-bone gap of 26.7 dB HL was closed to 15.4 dB HL. In 1370 patients with synthesizable data, 70.7% of patients had a postoperative air-bone gap ˂ 20 dB HL at long-term follow-up. Finally, subgroup analysis identified that mean improvement in ABG closure for patients with and without cholesteatoma was 10.0 dB HL and 12.4 dB HL, respectively.

CONCLUSION

In patients with chronic otitis media, tympanoplasty successfully closed the air-bone gap to within 20 dB HL in 7/10 cases and had an overall complication rate of 14.0%.

LEVEL OF EVIDENCE

2a.

Charitable platforms in global surgery: a systematic review of their effectiveness, cost-effectiveness, sustainability, and role training

Objective

This study was designed to propose a classification scheme for platforms of surgical delivery in low- and middle-income countries (LMICs) and to review the literature documenting their effectiveness, cost-effectiveness, sustainability, and role in training. Approximately 28 % of the global burden of disease is surgical. In LMICs, much of this burden is borne by a rapidly growing international charitable sector, in fragmented platforms ranging from short-term trips to specialized hospitals. Systematic reviews of these platforms, across regions and across disease conditions, have not been performed.

Methods

A systematic review of MEDLINE and EMBASE databases was performed from 1960 to 2013. Inclusion and exclusion criteria were defined a priori. Bibliographies of retrieved studies were searched by hand. Of the 8,854 publications retrieved, 104 were included.

Results

Surgery by international charitable organizations is delivered under two, specialized hospitals and temporary platforms. Among the latter, short-term surgical missions were the most common and appeared beneficial when no other option was available. Compared to other platforms, however, worse results and a lack of cost-effectiveness curtailed their role. Self-contained temporary platforms that did not rely on local infrastructure showed promise, based on very few studies. Specialized hospitals provided effective treatment and appeared sustainable; cost-effectiveness evidence was limited.

Conclusions

Because the charitable sector delivers surgery in vastly divergent ways, systematic review of these platforms has been difficult. This paper provides a framework from which to study these platforms for surgery in LMICs. Given the available evidence, self-contained temporary platforms and specialized surgical centers appear to provide more effective and cost-effective care than short-term surgical mission trips, except when no other delivery platform exists.

The risk of hearing loss in a population with a high prevalence of chronic suppurative otitis media

BACKGROUND

Chronic suppurative otitis media (CSOM) affects 65-330 million people in the developing part of the world and develops in early childhood. Knowledge of the long-term effects on hearing is scarce. Hearing loss (HL) can cause reduced ability to communicate, impair language development and academic skills.

OBJECTIVE

To estimate the prevalence of HL in a population with a high-risk of CSOM and to identify the risk of permanent hearing loss from CSOM.

METHODS

Ten and 15 years follow-up of two Greenlandic population-based children cohorts. Participants underwent otologic examination and audiometric evaluation. HL was defined using both the American Speech-Language-Hearing Association's (ASHA) and the World Health Organizations's (WHO) definition. Risk factors for HL were analyzed, using binomial logistic regression analysis.

RESULTS

A total of 438 individuals aged 11-24 years participated. Using the ASHA definition of HL the prevalence was 50% (95% CI 45.3-54.7). Using the WHO definition of HL the prevalence was 2.5% (95% CI 1.1-3.98). CSOM was the main cause of HL. Co-existing CSOM (OR 16.7, 95% CI 8.29-33.65), spontaneous healing from CSOM (OR 3.75, 95% CI 1.62-8.67), and male gender (OR 2.2, 95% CI 1.28-3.78) were associated with HL. Ninety-one percent of children with CSOM developed a permanent hearing loss >15dBHL.

CONCLUSION

CSOM was strongly associated with permanent hearing loss. CSOM was the main reason for HL in this population. The WHO definition of hearing loss is likely to underestimate the burden of hearing loss among children and adolescents in developing countries with a high prevalence of CSOM.

Factors affecting hearing improvement following successful repair of the tympanic membrane

BACKGROUND

The main aim of tympanic membrane repair is the elimination of chronic or intermittent aural discharge. Hearing improvement may or may not occur following a technically successful operation.

METHOD

This study entailed a retrospective analysis of prospectively collected data from 203 operations that resulted in an intact tympanic membrane 6 months after surgery.

RESULTS

Complete hearing data were available for 169 operations on 160 patients. Of these, 53 per cent resulted in closure of the air-bone gap to within 10 dB, and 54 per cent of cases had post-operative hearing thresholds of at least 30 dB. The mean hearing change after surgery was +8.3 dB. Multiple regression analysis indicated that hearing improvement was more likely in large compared with small perforations. Smaller hearing gains occurred in ears with erosion of the stapes arch and/or fixation of the stapes, as well as in those with active discharge at the time of surgery and in revision cases.

CONCLUSION

Greater hearing improvement can be expected following successful repair of perforations involving more than 50 per cent of the drum area. Poorer results are likely to occur in ears with additional middle-ear pathology and in revision cases.

Long-term follow-up of chronic suppurative otitis media in a high-risk children cohort

OBJECTIVE

Chronic suppurative otitis media (CSOM) is the leading cause of mild to moderate hearing impairment in children worldwide and a major public health problem in many indigenous populations. There is a lack of basic epidemiological facts and knowledge on the development of CSOM, as the disease primarily affects developing countries where research capacities often are limited. The purpose of this study was to determine the long-term outcome of CSOM in a high-risk population and to identify risk factors.

METHODS

Follow-up study (2008) on a population-based cohort of 465 children in Greenland, initially examined (1996-8) between the ages 0 and 4 years. Follow-up was attempted among 307 children living in the two major towns. Binomial logistic regression analysis was made to identify risk factors for developing CSOM and for maintaining disease in to adolescence (odds ratios). Log linear binomial regression was used to estimate risk ratios and absolute risks.

RESULTS

At follow-up 236 participated (77% of those available). The prevalence of CSOM was 32/236 (14%) at age group 0-4 years and 21/236 (9%) at age group 11-15 years. Thirteen had disease debut after the initial study. Of those with CSOM in the initial study 24/32 (75%) healed spontaneously. Risk factors for the development of CSOM at any time in childhood was the mother's history of CSOM OR 2.55 (95% CI 1.14-5.70; p=0.02), and mothers with low levels of schooling OR 1.57 (1.03-2.40; p=0.04). Once CSOM had developed boys were more likely to have persistent disease OR 5.46 (95% CI 1.47-20.37; p=0.01). The absolute risk of CSOM if the mother had both a history of CSOM and low schooling was for boys 45.4% (95% CI 26.5-77.7) and for girls 30.7% (95% CI 17.8-53.10). The cumulative risk of CSOM was 19% at follow-up.

CONCLUSIONS

Even though a large number of CSOM cases seemed to heal spontaneously, the prevalence of untreated CSOM among school-age children in Greenland remained high as new cases were found at follow-up. Increased focus on prevention and identification of children at special risk could reduce the high prevalence of CSOM.

Health care and health care delivery in Greenland

OBJECTIVES

To describe the health care system and health care delivery in Greenland.

STUDY DESIGN AND METHOD

This was a literature study that included literature and articles searched in PubMed published from 1989 to 2009 about health care in Greenland.

RESULTS

The health care system is a publicly financed governmental responsibility. Its major challenges are limited economic resources, Greenland's demographic structure, rapid epidemiological changes, increased public demand for specialized treatment, difficulty in recruiting professionals and the economic burden imposed by around-the-clock maintenance of specialized staff in sparsely populated areas. To meet these challenges, a public health program focusing on health promotion and prevention, educational initiatives to improve recruitment and a system reorientation moving towards larger health care regions is proposed to be gradually implemented from 2010. One fundamental component of this plan is tying the system together with a telemedicine system and in the future also with a joint electronic patient file system. The importance of better surveillance and monitoring of health has been recognized, while securing best clinical practice and implementing better steering instruments on resource allocation and quality are areas needing focus in the future.

CONCLUSION

Many of the challenges for the Greenlandic health care system are being addressed with promising strategies, but only the future will show whether they are successful.

Mobile, one stage, bilateral ear surgery for chronic otitis media patients in remote areas

OBJECTIVES

We evaluated the results of mobile, one stage, bilateral ear surgery conducted in Greenland, where chronic otitis media with and without suppuration is prevalent. The study aimed to increase the number of operations conducted and to reduce the cost of ear surgery in remote areas.

MATERIALS AND METHODS

The study was longitudinal and prospective, with a two-year follow up. Seventeen East Greenlandic patients with bilateral chronic suppurative otitis media or chronic otitis media were selected. Their median age was 16 years; 53 per cent were female and 47 per cent male. Hearing was assessed using median air conduction pure tone average gain, and the 'take rate' (i.e. the percentage of total ears with a closed perforation) was evaluated.

RESULTS

All patients attended for follow up. Eighty-two per cent had at least one perforation closed, and the overall take rate was 65 per cent of the 34 ears. The median air conduction pure tone average gain after two years was 18 dB and 13 dB for the right and left ears, respectively. Fourteen patients (82 per cent) obtained an air conduction pure tone average hearing level of < or =25 dB in at least one ear. In total, 71 per cent of the patients were satisfied. There were no hearing hazards.

CONCLUSIONS

The results of mobile, one stage, bilateral ear surgery conducted in Greenland for long-lasting chronic suppurative otitis media and chronic otitis media were acceptable and safe, and more ears underwent surgery at reduced cost compared with unilateral ear surgery.