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Introduction: This study aims to examine the factors associated with self-reported hearing disability and early reduction in disability after first-time hearing aid (HA) fitting in Singapore. Methods: Retrospective record review of 1,068 subjects issued with HAs at a tertiary hospital from 2001 to 2013. Results: Subjects reporting ≥5 disabilities reduced from 90% to 24% after HA fitting. ‘Difficulty hearing in noise’ was the commonest disability before and after HA fitting, while ‘needs to increase volume of TV/radio’ was the disability with most improvement after fitting. In multivariable models, having worse pure tone audiometry (PTA) thresholds of the better hearing ear and being ethnically Chinese were associated with subjects reporting more hearing disabilities. A higher proportion of subjects reported a reduction rather than an absence of disability after HA fitting. In multivariable models, daily HA usage for ≥4 hours, sensorineural hearing loss (HL) and worse PTA thresholds of the better hearing ear were associated with reduction in more disabilities after HA fitting. Conclusion: Hearing disability is high among first-time HA users in Singapore. Ethnicity and PTA thresholds were associated with self-reported hearing disability. After HA fitting, higher daily HA usage, sensorineural HL, and worse PTA thresholds of the better hearing ear were associated with early reduction in disability. Patient counselling on the benefits of HL rehabilitation could focus on hearing disability rather than PTA thresholds. The management of patients’ expectations could focus on reducing rather than eliminating disability. Keywords: Epidemiology, hearing loss rehabilitation, quality of life, sensorineural hearing loss, uptake

BACKGROUND Effective contact tracing is labor intensive and time sensitive during the COVID-19 pandemic, but also essential in the absence of effective treatment and vaccines. Singapore launched the first Bluetooth-based contact tracing app—TraceTogether—in March 2020 to augment Singapore’s contact tracing capabilities. OBJECTIVE This study aims to compare the performance of the contact tracing app—TraceTogether—with that of a wearable tag-based real-time locating system (RTLS) and to validate them against the electronic medical records at the National Centre for Infectious Diseases (NCID), the national referral center for COVID-19 screening. METHODS All patients and physicians in the NCID screening center were issued RTLS tags (CADI Scientific) for contact tracing. In total, 18 physicians were deployed to the NCID screening center from May 10 to May 20, 2020. The physicians activated the TraceTogether app (version 1.6; GovTech) on their smartphones during shifts and urged their patients to use the app. We compared patient contacts identified by TraceTogether and those identified by RTLS tags within the NCID vicinity during physicians’ 10-day posting. We also validated both digital contact tracing tools by verifying the physician-patient contacts with the electronic medical records of 156 patients who attended the NCID screening center over a 24-hour time frame within the study period. RESULTS RTLS tags had a high sensitivity of 95.3% for detecting patient contacts identified either by the system or TraceTogether while TraceTogether had an overall sensitivity of 6.5% and performed significantly better on Android phones than iPhones (Android: 9.7%, iPhone: 2.7%; P CONCLUSIONS TraceTogether had a much lower sensitivity than RTLS tags for identifying patient contacts in a clinical setting. Although the tag-based RTLS performed well for contact tracing in a clinical setting, its implementation in the community would be more challenging than TraceTogether. Given the uncertainty of the adoption and capabilities of contact tracing apps, policy makers should be cautioned against overreliance on such apps for contact tracing. Nonetheless, leveraging technology to augment conventional manual contact tracing is a necessary move for returning some normalcy to life during the long haul of the COVID-19 pandemic.

To examine the time trends in demographics, hearing characteristics, hearing aid (HA) choices, usage and patient-reported disability among first-time HA users in Singapore over a decade.Cross-sectional study.An increase in number of first time HA users were seen from 2004 to 2013. Although mean age did not change significantly, the proportion of older adults (80 years) being fitted increased (From 2004 to 2013, there was a positive trend towards HA uptake in Singapore. Bilateral HA uptake increased while customisable in ear type of HA use decreased. While hearing disability showed a decreasing trend, HA usage remained suboptimal.

Longus colli tendinitis (LCT) has been described in several case reports, and is likely underdiagnosed due to its non-specific symptoms and self-limiting nature. It usually presents as acute neck pain with retropharyngeal swelling seen on nasoendoscopy and imaging studies. This may lead to unnecessary invasive interventions if physicians are unaware of the disease course. We discuss a case of LCT in a young woman who was treated at our institution, with recommendations on how to identify and treat such cases accurately without overtreatment.

Objective To examine the epidemiological and audiological profile, pattern of hearing aid (HA) fitting and usage among HA users in Singapore. Design Retrospective cross-sectional study. Study sample Cohort of 1068 subjects issued with HAs at a tertiary hospital between 2001 and 2013. Results Mean age was 70 years with 50.8% male. Mean hearing loss (HL) was 63.1 dB and 69.5% had at least moderate-severe HL. Sensorineural HL was present in 66.4% and 69.8% had symmetrical HL. "Behind-the-Ear" HAs were cheaper than "In-Ear" HAs. Standard "Behind-The-Ear" HAs were also cheaper than "Receiver-in-Canal" HAs. Among In-Ear HAs, "In-the-Canal" and "Completely-in-Canal" were more popular than "In-the-Ear" HAs despite costing more. HA was used ≥4 days/week by 85.6% but >7 h per day by only 35.7%. Only 18% received bilateral first HA fitting. In multivariate analysis, younger age and symmetrical HL were predictors of bilateral HA uptake while better Pure-Tone-Audiometry of aided ear and >7 h of daily HA usage were predictors of successive HA fitting. Conclusions HA users in Singapore were elderly and presented with advanced HL. Bilateral HA adoption and average daily use were low compared to other developed countries. Future research on understanding the suboptimal HA usage should explore patients' motivation, hearing disability, and HA effectiveness.

BackgroundEffective contact tracing is labor intensive and time sensitive during the COVID-19 pandemic, but also essential in the absence of effective treatment and vaccines. Singapore launched the first Bluetooth-based contact tracing app—TraceTogether—in March 2020 to augment Singapore’s contact tracing capabilities.ObjectiveThis study aims to compare the performance of the contact tracing app—TraceTogether—with that of a wearable tag-based real-time locating system (RTLS) and to validate them against the electronic medical records at the National Centre for Infectious Diseases (NCID), the national referral center for COVID-19 screening.MethodsAll patients and physicians in the NCID screening center were issued RTLS tags (CADI Scientific) for contact tracing. In total, 18 physicians were deployed to the NCID screening center from May 10 to May 20, 2020. The physicians activated the TraceTogether app (version 1.6; GovTech) on their smartphones during shifts and urged their patients to use the app. We compared patient contacts identified by TraceTogether and those identified by RTLS tags within the NCID vicinity during physicians’ 10-day posting. We also validated both digital contact tracing tools by verifying the physician-patient contacts with the electronic medical records of 156 patients who attended the NCID screening center over a 24-hour time frame within the study period.ResultsRTLS tags had a high sensitivity of 95.3% for detecting patient contacts identified either by the system or TraceTogether while TraceTogether had an overall sensitivity of 6.5% and performed significantly better on Android phones than iPhones (Android: 9.7%, iPhone: 2.7%; PConclusionsTraceTogether had a much lower sensitivity than RTLS tags for identifying patient contacts in a clinical setting. Although the tag-based RTLS performed well for contact tracing in a clinical setting, its implementation in the community would be more challenging than TraceTogether. Given the uncertainty of the adoption and capabilities of contact tracing apps, policy makers should be cautioned against overreliance on such apps for contact tracing. Nonetheless, leveraging technology to augment conventional manual contact tracing is a necessary move for returning some normalcy to life during the long haul of the COVID-19 pandemic.

Objective To examine the factors associated with late presentation at first hearing aid (HA) fitting, HA choice and usage among users in Singapore. Design Retrospective cross-sectional study. Study sample 1068 subjects issued with HAs at a tertiary hospital from 2001 to 2013. Results Half of the subjects presented with more severe (>55 dB) hearing loss (HL) in their better ear. In multivariable analysis, older age, Malay ethnicity, conductive and mixed HL, and combination type of HL were associated with more severe HL at first presentation. Over 70% of subjects were older than 65 years. Worse pure tone audiometry (PTA) thresholds of the better ear, gradual onset and sensorineural HL were associated with older age presentation. For unilaterally fitted subjects, PTA thresholds were the only determinant of having the better ear aided. Better PTA thresholds, younger age and sensorineural HL were associated with choosing in ear compared to behind the ear HAs. Younger age and worse PTA of the better ear were associated with ≥4 h of daily HA usage. Conclusions Age, ethnicity and type of HL were important determinants for more severe HL at first HA fitting. Older patients and those with better hearing were less likely to use their HAs regularly.

This article is to evaluate the clinical efficacy of Anioxyde 1000 (5-minute clinic process) and automated-washer (30-minute centralized process) in FNE decon-tamination, and to examine the bio-burden of the FNE following its use.

Background:Sensorineural hearing loss is a recognised complication of cryptococcal meningitis. The mechanism of hearing loss in patients with cryptococcal meningitis is different from that in bacterial meningitis.Case report:An immune-competent man with cryptococcal meningitis presented with sudden onset, bilateral, severe to profound sensorineural hearing loss and vestibular dysfunction. He was initially evaluated for cochlear implantation. However, he had a significant recovery; he no longer required surgery and was able to cope without a hearing aid.Conclusion:Typically, cochlear implantation is performed with some urgency in patients with hearing loss post-bacterial meningitis, because of the risk of labyrinthitis ossificans. However, this process has not been described in patients with cryptococcal meningitis. Furthermore, patients with hearing loss associated with cryptococcal meningitis have shown varying degrees of reversibility. In this case report, hearing loss from cryptococcal meningitis is compared with that from bacterial meningitis, and the need for cochlear implantation in patients with cryptococcal meningitis is discussed.

Most ENT surgeons treat discharging ears with topical antibiotics but many may not routinely utilise ear microbiology specimens. One reason could be that ear microbiology reports may not reflect their usual therapeutic options. This paper explores how microbiology departments in England process ear swabs. We carried out a telephone questionnaire of 104 microbiology departments in England. Results were obtained from 95 hospitals. Various culture methods are used, with sensitivity testing for up to 51 different antibiotics. Only five are licensed for topical use. Systemic antibiotics seemed to be preferentially tested for over topical antibiotics. Anaerobes and fungus are routinely tested. Many microbiology departments do not routinely report on all sensitivities tested. Antibiotic sensitivity testing for various micro-organisms cultured from ear swabs seemed to be guided by protocols for systemic infections. Microbiologists may not fully appreciate ENT surgeons' preferential usage of topical antibiotics in treating discharging ears, albeit there are other factors in their consideration for antibiotics to test. To gain better guidance from swab results, and to reduce needless lab costs, discussion with the microbiologists may be of benefit.

OBJECTIVE: To assess patient satisfaction with the Bone-Anchored Hearing Aid (BAHA) Cordelle device and to identify any user- and device-related issues. STUDY DESIGN: Retrospective, anonymized, cross-sectional postal survey using the Entific Medical Systems questionnaire. SETTING: Tertiary referral center. PATIENTS: Fifty adult patients who had been using the BAHA Cordelle for more than 6 months. INTERVENTION: Hearing rehabilitation using BAHA Cordelle. MAIN OUTCOME MEASURES: Patients' satisfaction with the BAHA Cordelle in a variety of real-life hearing scenarios, their actual use of the device, and other issues with the device. RESULTS: Response rate was 66%. Responders were happy with their Cordelle in quiet situations and 1-to-1 conversations but less so in noisy or in group situations.However, approximately 80% of Cordelle users will use their device everyday for more than 8 h/d, and the overall satisfaction level is high. Compared with ear-level BAHA patients, Cordelle users are older and have mixed hearing loss with poorer sensorineural reserve, making hearing rehabilitation more challenging. CONCLUSION: The findings of this study support the use of the BAHA Cordelle as a viable, safe, low-morbidity hearing rehabilitation option in patients with mixed hearing loss with poor sensorineural reserve. Patients should be counseled appropriately to help manage their expectations.

Objective:We postulated that epistaxis patients frequently have their nose packed in the accident and emergency department without any reasonable prior attempt at nasal assessment and nasal cautery.Design:Telephone survey of 104 accident and emergency departments.Results:A 100 per cent response rate was achieved. In all but one of the departments surveyed, first line management was carried out by accident and emergency doctors. Seventy-four per cent of accident and emergency doctors perform nasal cautery as first line management. Within accident and emergency departments, the availability and usage of head illumination, nasal speculums, topical anaesthesia and suction was grossly suboptimal. Only one-sixth of the accident and emergency doctors surveyed had received training in the management of epistaxis, whilst 81 per cent of accident and emergency departments would admit nasally packed patients under the ENT team.Conclusion:Despite the majority of accident and emergency doctors claiming to attempt nasal cautery before packing, this is unlikely to be effective if performed without the correct equipment. Better training and equipment need to be provided to accident and emergency doctors in order to optimise the management of epistaxis patients. This could potentially reduce inappropriate admissions.

We describe the unusual complication of the cochlear implant electrode eroding through the lateral bony wall of the cochlear basal turn in 2 different patients. This complication, occurring during life, has not been previously described in the literature. Radiological investigations were vital in making this diagnosis. We also discuss the likely pathophysiology behind this complication. Copyright © 2007 John Wiley & Sons, Ltd.

Introduction: We hypothesised that general practitioners and ENT specialists manage discharging ears differently. This study was designed to investigate this further.Methods and materials: Postal questionnaires were sent to all general practitioners in the Birmingham area and all UK consultants on the British Association of Otolaryngology–Head and Neck Surgery address list.Results and discussion: In the presence of an intact tympanic membrane, 99 per cent of consultants and 90 per cent of general practitioners would use topical antibiotics. In the presence of a perforated tympanic membrane, 97 per cent of consultants would continue to use topical antibiotics, compared with only 43 per cent of general practitioners. This was attributed to a fear of ototoxicity. If a topical non-ototoxic antibiotic of proven efficacy could be made available, 93 per cent of consultants and 88 per cent of general practitioners in this study would seriously consider using it as first line treatment.Conclusion: The majority of general practitioners would not use topical antibiotics in the presence of a perforated tympanic membrane. Most doctors would consider using a non-ototoxic topical antibiotic as first line treatment should one be made available.

Partial middle turbinate avulsion is a rare complication of nasotracheal intubation. Patients usually experience a brisk hemorrhage at the time of injury. Postoperatively, some patients develop a unilateral nasal obstruction, while others are asymptomatic. We present an unusual case in which a patient became symptomatic many years after the incident. We hope to raise awareness that a traumatic disruption of the turbinates secondary to nasotracheal intubation might lead to the development of an abnormal nasopharyngeal mass.

Key points • There are various effective treatment options for refractory posterior epistaxis including endoscopic diathermy or endoscopic artery ligation. • If these treatment options are not immediately available, posterior nasal packing with Foley catheter is an effective and rapid non-surgical treatment alternative. • A systematic approach is presented. The principles and mechanisms of action of the posterior nasal packing are explained. • Nevertheless, there are morbidities involved and posterior packing can be painful and uncomfortable for the patient. • Marking and modifying the catheter will help one inflate the balloon in the correct place and avoid the problem of nasal alar pressure necrosis.

A careful history should always be taken when patients present with upper limb injuries. This should be followed by a detailed examination, which must include the neurovascular status of the limb, distal to the injury. Radiographs are vital in confirming the nature of the injury and should always include the joints proximal and distal to the injured segment. The principles of management are to reduce and hold the fracture by closed or open techniques and then to rehabilitate the limb. Management decisions, however, should not depend on classification alone, and must include consideration of: • functional demand • hand dominance • bone quality • patient's age, expectation and likely compliance with treatment. The biggest problems with upper limb fractures are stiffness and chronic pain, which are often due to poor and inappropriate rehabilitation, and can result in severe disability. Fractures and dislocations of the elbow are detailed in ‘Fractures of the forearm’, page 248. This contribution should be read in conjunction with ‘The painful shoulder’, page 241.

Introduction: Hereditary angioedema (HAE) is an autosomal dominant disease caused by deficiency of the plasma protein C1 inhibitor (C1-INH). Patients classically present with recurrent localized subcutaneous or submucosal edema lasting for 2 to 5 days, severe abdominal pain, or acute airway obstruction which can be fatal. Case presentations: We highlight 2 patients with acute airway compromise secondary to HAE who were successfully treated with plasma-derived C1-INH concentrates. Conclusions: The timely administration of plasma-derived C1-INH concentrates for the acute treatment of HAE has been proven to be effective in both patients in aborting an airway complication. A high index of suspicion is required for the early diagnosis and treatment of this potentially fatal condition.

With training time for junior doctors now reduced, it is crucial to optimise training opportunities during elective clinical activities. Teaching ENT examination skills presents unique challenges as often, only the examiner can observe what's going on. We set out to explore the utilisation of microscope and nasendoscope teaching devices for ENT junior doctors. Telephonic survey of 102 English ENT units. ENT junior doctors spent an average of 7 h per week in elective ENT outpatient clinics. 92% of them felt that spending time in outpatient clinics helped improve their confidence in patients' management. 81% of ENT junior doctors stated that being able to observe others or being observed themselves would help to improve their clinical abilities. The availability and utilisation of nasendoscopy and microscopy teaching tools are currently suboptimal. Doctors working in departments that utilised the teaching tools stated that their educational needs were more likely to be met. Most ENT junior doctors found it beneficial to attend elective outpatient clinics although their learning needs were more likely to be met should ENT teaching devices be available. The availability and utilisation of ENT teaching devices are currently suboptimal and needs addressing.

Objectives:Evaluate the usefulness of the Screening Version of the Hearing Handicap Inventory for the Elderly (HHIE-S) questionnaire in screening for hearing impairment in the general population.Methods:We recruited subjects at a health awareness event organized by the ENT Department of a tertiary hospital. Members of the public were invited to fill in the HHIE-S questionnaire and to undergo a four-frequency pure tone audiogram (PTA), of which 37 subjects aged 25 to 82 years completed both.Results:Conventionally, moderate or high scores on the HHIE-S questionnaire are considered strongly suspicious of a hearing impairment. If hearing impairment is defined as four-frequency average (0.5kHz, 1kHz, 2kHz & 4 kHz) PTA > 26dB in the better hearing ear, the sensitivity of the HHIE-S questionnaire in screening for hearing impairment is 80%, but its specificity is low at 18%. The positive predictive value is 40% and the negative predictive value 57%. However, if hearing impairment is defined as four-frequency aver...

OBJECTIVE To investigate whether the fitting of bilateral Bone-anchored Hearing Aid (BAHA) would result in any additional improvement in patients' quality of life (QOL) over and above what we would experience from the fitting of a single-sided BAHA. STUDY DESIGN Retrospective, anonymized, cross-sectional postal survey using the Glasgow Benefit Inventory (GBI). SETTING Tertiary referral center. PATIENTS All 93 adult patients who had been using bilateral BAHA for more than 6 months. INTERVENTION(S) Hearing rehabilitation using bilateral BAHA. MAIN OUTCOME MEASURE(S) These include the GBI benefit scores across the following domains: "overall benefit," "general health benefit," "physical health benefit," and "social benefit." Comparison of GBI scores against other otological interventions including single-sided BAHA. RESULTS Response rate was 76%. Ninety-two percent of patients reported improvement in QOL. Positive QOL improvement scores were reported across all domains. Overall GBI benefit score was +ve 38. This is higher than the benefit scores reported by patients with single-sided BAHA, although this may not be statistically significant. CONCLUSION After fitting the second BAHA, patients may report additional improvement in their QOL (of a smaller magnitude) over and above the initial improvement in their QOL after fitting of their first BAHA. In fact, the overall benefit score for bilateral BAHA seem to be close to that for cochlear implantation.

Use of the longer (8.5 mm) abutment for a Bone-Anchored Hearing Aid has been helpful for a certain group of patients. The most common reason for its use is soft tissue problems with tissue overgrowth interfering with device function. The longer abutment has been used in our institution, a tertiary referral center, on a named patient basis since 2002, and more than 100 patients have received it.This paper will review this subgroup of patients and describe their demographics. Comorbidity, smoking history, graft failure, infection, and index of deprivation will be looked at as contributing factors for this group with soft tissue problems.We identified 111 patients who had longer abutments ordered for them, and a retrospective case review was performed.Eighty-one patients required soft tissue reduction surgery because of overgrowth, and all but one (80/81 [98.8%]) of these patients required no further surgery after having their 5.5-mm abutment changed to the 8.5-mm version. One patient underwent further surgery 10 months after the longer abutment was inserted but has been problem-free for 16 months since then. Length of follow-up ranged from 6 months to 5 years after converting to the longer abutment.We have found the longer abutment to be very successful for the small proportion of patients with troublesome soft tissue overgrowth. We would advocate its use when topical management and surgical intervention have failed to control the skin reaction.

In the published series of our first 100 cochlear implants only three developed major complications (Proops et al., 1999). We present a rare case of late granulations forming around a Nucleus cochlear implant, giving rise to erosion of the entire cochlea and adjacent mesotympanum. This pathology has only been reported once in the literature (Bertuleit et al., 1999).

We report an unusual case of contralateral deafness in a 31-year-old man after an uncomplicated blunt force head injury. The patient was presented with a left-sided head injury and complained of profound deafness in his right ear, dysequilibrium, and vertigo. Pure tone audiogram revealed total sensorineural deafness in the right ear. A high-definition computed tomography scan demonstrated no radiological evidence of bony injuries or a fistula. His dysequilibrium had improved 2 months later, but his vertigo and hearing loss persisted. We will discuss several possible mechanisms of injury that may result in deafness after head injury without bony fractures. The literature has been reviewed. Although deafness is not an uncommon complication of head injuries, its presentation in the contralateral ear in the absence of temporal bone fractures following head injury has not been reported before in the medical literature.

Objectives:To assess the value of lateral soft tissue neck X-rays in patients presenting with upper aero-digestive tract foreign bodies.Design:Retrospective study.Inclusion criteria:(1) Patients referred to the ENT team, via either the accident and emergency department or their general practitioner; (2) a history of a non-aspirated, upper airway, aero-digestive tract foreign body; and (3) a lateral soft tissue neck X-ray taken on admission.Results:A total of 62 patients met the inclusion criteria. Twenty-four patients (38.7 per cent) had positive findings on lateral soft tissue neck X-ray. ‘Soft’ signs, such as widened pre-vertebral shadow and loss of lordosis, were seen in all 24 patients, and foreign bodies were visualised in six patients. Overall, lateral soft tissue neck X-rays were helpful in the management of 32 patients (51.6 per cent). Rather worryingly, doctors in the accident and emergency and ENT departments missed 79.2 and 66.6 per cent of the positive findings, respectively.Conclusions:A lateral soft tissue neck X-ray is a helpful tool in the management of patients presenting with upper aero-digestive tract foreign bodies. Junior doctors need better radiology training.

Background Percutaneous dilatational tracheostomy (PDT) is increasingly popular within intensive care units for patients who need prolonged ventilatory support. Significant complications are rare. Case presentation Our patient suffered tracheal ring fracture and early tracheomalacia following this procedure. These complications are demonstrated in our accompanying video. Conclusion Contrary to common beliefs, tracheal rings are commonly fractured during the PDT procedure. The consequent granulation can lead to tracheal stenosis and tracheomalacia.

Keypoints • There is a significant risk of blood contamination during the non-surgical management of epistaxis. Contamination beyond gloves happens in 55% of cases1 and the contamination risk to eyes as high as 18%.2 • There is a lack of awareness and a majority of ENT doctors underestimate this risk. • Protective barrier equipment and eye protection in particular are suboptimally available in all clinical areas where epistaxis is dealt with. • Consequently, there is poor utilization of protective barrier equipment.

The standard treatment of a pinna haematoma involves drainage and compression to prevent recurrence and subsequent disfigurement. Compressive methods can be non-invasive or invasive, utilising a head bandage or through and through sutures, respectively, to keep compression in place. Leonard buttons are effective alternative compressive devices. They are simple to use and easily available.