George G Browning

Measuring Patient Benefit from Otorhinolaryngological Surgery and Therapy

The Glasgow Benefit Inventory (GBI) is a measure of patient benefit developed especially for otorhinolaryngological (ORL) interventions. Patient benefit is the change in health status resulting from health care intervention. The GBI was developed to be patient-oriented, to be maximally sensitive to ORL interventions, and to provide a common metric to compare benefit across different interventions. The GBI is an 18-item, postintervention questionnaire intended to be given to patients to fill in at home or in the outpatient clinic. In the first part of the paper, five different ORL interventions were retrospectively studied: middle ear surgery to improve hearing, provision of a cochlear implant, middle ear surgery to eradicate ear activity, rhinoplasty, and tonsillectomy. A criterion that was specific to the intervention was selected for each study, so that the patient outcome could be classified as above and below criterion. In all five interventions, the GBI was found to discriminate between above- and below-criterion outcomes. The second part of the paper reports on the results and implications of a factor analysis of patient responses. The factor structure was robust across the study, and so led to the construction of subscales. These subscales yield a profile score that provides information on the different types of patient benefit resulting from ORL interventions. The GBI is sensitive to the different ORL interventions, yet is sufficiently general to enable comparison between each pair of interventions. It provides a profile score, which enables further breakdown of results. As it provides a patient-oriented common metric, it is anticipated that the GBI will assist audit, research, and health policy planning.

Benefit from binaural hearing aids in individuals with a severe hearing impairment

The relative benefits of binaural as opposed to monaural hearing aids were assessed by the use of a diotically presented, audiovisual speech-in-noise task in a group of bilateral, severely hearing-impaired individuals. Significantly greater benefit was gained from binaural amplification, irrespective of hearing level and degree of asymmetry. The benefit was considered to be due to central summation. It is concluded that binaural amplification should be attempted in all bilateral, severely hearing-impaired subjects. About 80% will accept this and be able to demonstrate benefit in an audiovisual task.

Estimation of the Benefit of Bone-Anchored Hearing Aids

Implantable bone conduction hearing aids are a valuable alternative to conventional aids for those who cannot use a conventional air conduction aid or find it difficult to use because of an aural discharge, most commonly due to chronic otitis media. Previously reported series of the use of a bone-anchored hearing aid (BAHA) come from the originators of this device, and an independent report of their benefit and use, especially in previous air conduction aid users, would be of value. Twenty-three patients were evaluated at least 6 months after implantation of a BAHA. All 7 previous bone conduction aid users were delighted with their BAHA, reporting increased comfort and hearing benefit that was backed by audiometric evidence. Of the 16 individuals who previously used an air conduction aid, 11 (69%) were delighted users of their BAHA. Unfortunately, the other 5 (31%) reverted to solely using their air conduction aid. There was no obvious predictor as to how these individuals might have been identified prior to implantation. In particular, their pure tone thresholds, especially the bone conduction thresholds, were no different from those of the 11 BAHA users. However, in free field audiometry, the users gained superior benefit from their BAHA compared to their air conduction aid, whereas the nonusers did not. In conclusion, in all series to date, previous users of a conventional bone conduction aid have been delighted users of a BAHA and have gained superior audiometric benefit. This is not necessarily the case with previous air conduction aid users. As most patients rate hearing ability to be more important than absence of an aural discharge, it is important to develop methods that might predict benefit from a BAHA prior to implantation.

Hearing in Chronic Suppurative Otitis Media

In individuals with chronic otitis media, mixed hearing impairments are common but it is unclear whether the raised bone conduction thresholds are a reflection of the pathologic process affecting the inner ear or a combination of the high prevalence of sensorineural hearing impairments in the population along with the artificial elevation of bone conduction thresholds associated with a conductive defect. a total of 395 ears with chronic otitis media but without cholesteatoma were studied. In them, once the artificial elevation (Carhart effect) of the bone conduction thresholds, which occurs whenever there is an abnormality of the sound conduction mechanism, had been taken into account, there was no difference in the bone conduction thresholds compared with those in 920 control ears. In addition, in 100 instances, the contralateral ear was normal and there was no difference in the bone conduction thresholds between the diseased and the normal ears. Raised bone conduction thresholds in chronic otitis media are considerably likely to reflect both the Carhart effect and the high prevalence of sensorineural impairments, rather than disease damage to the inner ear.

The Glasgow Benefit Inventory: a systematic review of the use and value of an otorhinolaryngological generic patient‐recorded outcome measure

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.

Reliability of patient choice between hearing aid systems

Various hearing aid provision strategies have been suggested but it is important to compare patient benefit from these, not only in the laboratory, but in everyday life. The latter can only be assessed by patient report. The false positive report rate of a difference between aids and the reproducibility of patient choice of aids was assessed in two groups of patients. The first received the same system on two occasions and were asked to report if they had any preference. The second group received two different systems on two occasions and the reproducibility of any preference was assessed. Of the 22 patients who were given the same hearing aid system on each visit, eight (36%) reported no differences, 10 (45%) a little and four (18%) a moderate or large difference between them when, in fact, there was none. Of the 34 patients who were asked to compare two acoustically different aids, 32 chose an aid on both occasions but only 22 (65%) chose the same aid, of whom 11 (32%) reported a moderate or large difference on both occasions. If reports of a little difference between aids are discounted and only moderate or large differences are accepted, it is concluded that the false positive report rate of a difference is approximately 20%. In addition, when patients are being asked to compare two NHS hearing aid systems, the rules of chance, order effect and reproducibility of patient choice have all to be controlled for, before decisions regarding patient preference can be made.

Optimum side for fitting a monaural hearing aid 1. Patients' preference

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 patients 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.

Positive pressure therapy for Meniere's syndrome/disease with a Meniett device: a systematic review of randomised controlled trials

Incidence rates of Menieres syndrome/disease vary considerably from 157 per 100 000 in the United Kingdom to 15 per 100 000 in the United States. A wide range of treatments are used for the treatment of the condition with no consensus on the most effective intervention.

The real ear effect of adjusting the tone control and venting a hearing aid system

The effect of modifying the frequency response of a hearing aid system has previously been reported only on 2 cc couplers. Although it is recognized that coupler measurements do not accurately reflect real ear measures, they are frequently quoted when describing the effect of modifying a hearing aid system. To investigate the correlation, the real ear effect was assessed in 43 ears by measuring the effect on the insertion gain of adjusting the tone control of a hearing aid and acoustically venting the mould with a 2 mm parallel vent, singly and in combination. The results were considerably different from those measured in couplers. By comparing insertion gain with 2 cc coupler gain measurements, it was found that: (1) adjusting the tone control had a lesser mean effect than predicted; (2) venting the earmould with a 2 mm parallel vent produced a mean reduction in the frequency response at 0.75 to 1 kHz of 8 dB SPL; (3) by combining a 2 mm earmould vent and adjusting the tone control, a mean reduction in the frequency response of 10 dB SPL was produced at 0.75 to 1 kHz. In addition, the range of acoustical effects was considerable, from virtually none to greater than those predicted in coupler experiments. This was presumably due to variation in the anatomy of normal canals. It is concluded that for both research and clinical purposes, the effect of modifying the frequency response of a hearing aid system should be measured by insertion gain rather than predicted from laboratory results.

A facial palsy grading system that appears to be invalid

House and Brackmann, two well known names in otology wrote an editorial in 1985 suggesting a six level grading scale for facial palsies. This was accepted that year by the American Academy of Otolaryngology – Head and Neck Surgery as their recommended grading system and has since become, without any real debate, the gold standard scale for grading facial palsies. This was perhaps acceptable practice in the 1980s but hopefully would not be the case today, where it would require to be fully validated and in particular have its reliability and reproducibility assessed. So how are the House–Brackmann grades used clinically and is it important that they be validated? The most common situation where they are used is to record recovery or otherwise of a facial palsy. The majority of these will be idiopathic and in them, as the management is medical with steroids, accurate grading is not relevant unless it is for research purposes. There will also be a small but important subset of traumatic cases where the decision to operate depends on the progression of the palsy and a valid grading system is essential. In these situations it is often not always the same individual that charts progress, so the reproducibility of a single observer and the inter-observer correlation between observers are important to know. In the study whose abstract we reproduce, 26 clinicians (13 senior and 13 junior) graded video recordings of 8 patients with a facial palsy on two occasions, three weeks apart. In each video the patient was recorded at rest and performing five different facial expressions, repeating each three times in succession. This sequence was then repeated and recorded. Such a study can be analysed in several different ways and this is done in the paper being discussed. However, in this commentary, one that is clinically understandable is chosen to report the findings. The repeatability of one observer grading the same patients twice was poor with a mean overall agreement of 63%. Only 35% (9 of 26) of the clinicians graded at least 50% of the patients the same on both occasions. The interobserver correlation was even poorer there being overall agreement between clinicians in only 49% of cases. The degree of disagreement between doctors of more than one grade was not infrequent. So in patient 4 in the first round the break down of the 26 observations was 1 grade II, 8 grade III, 9 grade IV and 10 grade V. In the second round it became 3 grade III, 15 grade IV and 8 grade V. Junior staff performed no better than the senior staff which is often the case in such studies. So would one be happy to have the House–Brackmann grading used to decide whether your own facial palsy was getting better or worse? Probably not but is there anything better? In the paper being discussed, the Sunnybrook Facial Grading system would appear to be superior but still not as good as one might like. The reason it is superior is because it takes more time to complete and breaks down the face into three areas; the eye, the mouth and the cheek. What now needs to be done is to assess whether video recordings of facial movements can be used more reliably to monitor progression. Having read this commentary, the editorial that follows (previously submitted as a paper) is interesting to read. It confirms what many have suspected, that cited articles are not necessarily ‘good’ articles. George G. Browning W H A T O T H E R J O U R N A L S T E L L U S