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In Cambodia, little is known about the state of ear and hearing care, or the roles providers or key stakeholders play in delivering services.
This was an exploratory study using semi-structured qualitative interviews and a questionnaire addressed to key stakeholders to explore their perceptions and experiences in providing services to people suffering from ear disease or hearing loss in Cambodia.
Several challenges were described including a lack of hearing services to meet the demand, especially outside Phnom Penh in primary care and aural rehabilitation. Supply-side challenges include a shortage of trained professionals, facilities and resources, poor co-ordination between providers, unclear referral pathways, and long wait times.
Now is an opportune time to build on the positive trend in providing integrated care for non-communicable diseases in Cambodia, through the integration of effective ear and hearing care into primary care and strengthening the package of activities delivered at government facilities.
Chronic suppurative otitis media is a major global disease disproportionately affecting low- and middle-income countries, but few studies have explored access to care for those with ear and hearing disorders.
In a tertiary hospital in Cambodia providing specialist ear services, a mixed method study was undertaken. This study had three arms: (1) quantitative analysis of patients undergoing ear surgery, (2) a questionnaire survey and (3) semi-structured in-depth interviews.
Patients presented with advanced middle-ear disease and associated hearing loss at rates that are amongst the highest per capita levels globally. Patients reported several structural, financial and socio-cultural barriers to treatment. This study showed a significant burden of ear disease in Cambodia, which reflects a delay in receiving timely and effective treatment.
This study highlights the opportunity to integrate effective ear and hearing care into primary care service provision, strengthening the package of activities delivered at government facilities.
Surgery for chronic suppurative otitis media performed in low- and middle-income countries creates specific challenges. This paper describes the equipment and a variety of techniques that we find best suited to these conditions. These have been used over many years in remote areas of Nepal.
Results and conclusion
Extensive chronic suppurative otitis media is frequently encountered, with limited pre-operative investigation or treatment possible. Techniques learnt in better-resourced settings with good follow up need to be modified. The paper describes surgical methods suitable for resource-poor conditions, with rationales. These include methods of tympanoplasty for subtotal wet perforations, hearing reconstruction in wet ears and open cavities, large aural polyps, and canal wall down mastoidectomy with cavity obliteration. Various types of autologous ossiculoplasty are described in detail for use in the absence of prostheses. The following topics are discussed: decision-making for surgery on wet or best hearing ears, children, bilateral surgery, working with local anaesthesia, and obtaining adequate consent in this environment.
There is poor availability of ear and hearing services globally, because of a lack of infrastructure, funding, equipment and appropriately trained personnel. When deciding upon delivery of ear and hearing services, an approach based upon community assessment is advocated, with subsequent asset mapping and acquisition.
Some of the challenges to delivery of care in resource-constrained or remote environments are acknowledged, with discussion of several existing models of service delivery, and their advantages and disadvantages. Public health and telehealth are also mentioned. This article may assist those trying to set up new programmes in ear and hearing health.
Chronic suppurative otitis media is a massive public health problem in numerous low- and middle-income countries. Unfortunately, few low- and middle-income countries can offer surgical therapy.
A six-month long programme in Cambodia focused on training local surgeons in type I tympanoplasty was instigated. Qualitative educational and quantitative surgical outcomes were evaluated in the 12 months following programme completion. A four-month long training programme in mastoidectomy and homograft ossiculoplasty was subsequently implemented, and the preliminary surgical and educational outcomes were reported.
A total of 124 patients underwent tympanoplasty by the locally trained surgeons. Tympanic membrane closure at six weeks post-operation was 88.5 per cent. Pure tone audiometry at three months showed that 80.9 per cent of patients had improved hearing, with a mean gain of 17.1 dB. The trained surgeons reported high confidence in performing tympanoplasty. Early outcomes suggest the local surgeons can perform mastoidectomy and ossiculoplasty as safely as overseas-trained surgeons, with reported surgeon confidence reflecting these positive outcomes.
The training programme has demonstrated success, as measured by surgeon confidence and operative outcomes. This approach can be emulated in other settings to help combat the global burden of chronic suppurative otitis media.
Improving understanding of the pathogen-specific seasonality of enteric infections is critical to informing policy on the timing of preventive measures and to forecast trends in the burden of diarrhoeal disease. Data obtained from active surveillance of cohorts can capture the underlying infection status as transmission occurs in the community. The purpose of this study was to characterise rotavirus seasonality in eight different locations while adjusting for age, calendar time and within-subject clustering of episodes by applying an adapted Serfling model approach to data from a multi-site cohort study. In the Bangladesh and Peru sites, within-subject clustering was high, with more than half of infants who experienced one rotavirus infection going on to experience a second and more than 20% experiencing a third. In the five sites that are in countries that had not introduced the rotavirus vaccine, the model predicted a primary peak in prevalence during the dry season and, in three of these, a secondary peak during the rainy season. The patterns predicted by this approach are broadly congruent with several emerging hypotheses about rotavirus transmission and are consistent for both symptomatic and asymptomatic rotavirus episodes. These findings have practical implications for programme design, but caution should be exercised in deriving inferences about the underlying pathways driving these trends, particularly when extending the approach to other pathogens.
Haemorrhage is the most common major complication of endoscopic sinus surgery. Post-operative absorbable or non-absorbable nasal packing can cause pain and blockage. Haemostatic powders or gels may prevent this problem. However, when based on factors in the clotting cascade, they induce an inflammatory reaction and can cause post-operative synechiae. Oxidised cellulose powder produces haemostasis without inducing synechiae formation, but has not been trialled for sinus surgery.
A randomised clinical trial was performed to compare cellulose powder to non-absorbable packing following sinus surgery. Participants were 50 consecutive patients undergoing sinus surgery, 47 of whom completed the study. The main outcome measures were post-operative bleeding, pain scores and synechiae formation.
Cellulose powder was effective at stopping bleeding, and was associated with less pain than nasal packing, with no evidence of increased synechiae formation.
Cellulose powder appears to be a good haemostatic agent following sinus surgery. A larger trial would allow more accurate quantification of its effectiveness.
Hereditary sensorineural hearing loss is the most frequently occurring birth defect. It has profound effects for the individual and is a substantial burden on society. Insight into disease mechanisms can help to broaden therapeutic options and considerably lower lifetime social costs. In the past few decades, the identification of genes that can cause this type of hearing loss has developed rapidly.
This paper provides a concise overview of the currently known genes involved in non-syndromic hereditary hearing loss and their function in the inner ear.
A case is presented of a nine-month-old male infant who presented acutely with an anterior neck and mediastinum mass compressing the trachea. Radiological assessment by ultrasound, magnetic resonance imaging and computed tomography suggested the nature of the mass to be a lymphatic malformation (cystic hygroma). The excised specimen was revealed as a mature teratoma. The inability to distinguish between lymphatic malformation and teratoma on multi-imaging modalities confers a risk of mismanaging these lesions with the use of sclerotherapy; surgical excision is the necessary treatment. The potential consequences are discussed.
Alendronate is a bisphosphonate used in treating osteoporosis. Its recognized side-effects include oesophageal irritation and ulceration. The authors describe a case of laryngitis induced by transient contact of this medication with the laryngeal mucosa. Successful management of this case is also detailed.
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