Feasibility and acceptability of training community health workers in ear and hearing care in Malawi: a cluster randomised controlled trial.

OBJECTIVE: To assess the feasibility and acceptability of training community health workers (CHWs) in ear and hearing care, and their ability to identify patients with ear and hearing disorders. DESIGN: Cluster randomised controlled trial (RCT). SETTING: Health centres in Thyolo district, Malawi. PARTICIPANTS: Ten health centres participated, 5 intervention (29 CHWs) and 5 control (28 CHWs). INTERVENTION: Intervention CHWs received 3 days of training in primary ear and hearing care, while among control CHWs, training was delayed for 6 months. Both groups were given a pretest that assessed knowledge about ear and hearing care, only the intervention group was given the posttest on the third day of training. The intervention group was given 1 month to identify patients with ear and hearing disorders in their communities, and these people were screened for hearing disorders by ear, nose and throat clinical specialists. OUTCOME MEASURES: Primary outcome measure was improvement in knowledge of ear and hearing care among CHWs after the training. Secondary outcome measures were number of patients with ear or hearing disorders identified by CHWs and number recorded at health centres during routine activities, and the perceived feasibility and acceptability of the intervention. RESULTS: The average overall correct answers increased from 55% to 68% (95% CI 65 to 71) in the intervention group (p<0.001). A total of 1739 patients with potential ear and hearing disorders were identified by CHWs and 860 patients attended the screening camps, of whom 400 had hearing loss (73 patients determined through bilateral fail on otoacoustic emissions, 327 patients through audiometry). Where cause could be determined, the most common cause of ear and hearing disorders was chronic suppurative otitis media followed by impacted wax. The intervention was perceived as feasible and acceptable to implement. CONCLUSIONS: Training was effective in improving the knowledge of CHW in ear and hearing care in Malawi and allowing them to identify patients with ear and hearing disorders. This intervention could be scaled up to other CHWs in low-income and middle-income countries. TRIAL REGISTRATION NUMBER: Pan African Clinical Trial Registry (201705002285194); Results

Hearing as an Independent Predictor of Postural Balance in 1075 Patients Evaluated for Dizziness

Objective To evaluate the association between hearing and postural balance. Study Design Retrospective cross-sectional study. Setting Tertiary care otolaryngology clinic. Subjects and Methods Patients examined for suspected vestibular disorder were included in this study. The outcome variable was postural sway measured by static posturography during quiet standing with eyes closed. The predictor variable was pure-tone average hearing threshold on the best hearing ear at 0.5, 1, 2, and 3 kHz. Covariates were age, sex, and vestibular disease or vestibular asymmetry assessed by bithermal caloric irrigation. Results In total, 1075 patients were included. Increased hearing threshold was a strong predictor of increased postural sway (path length) after correcting for age and sex. A 10-dB increase in hearing loss on the best hearing ear predicted a mean 6.0% increase in path length (confidence interval, 2.9%-9.3%, P < .001). Of the covariates, increasing age (P < .001) and male sex (P = .009) were significant predictors of increased postural sway. The effect of increased hearing threshold was also significant after adjusting for vestibular disease. Conclusion Increased hearing threshold was an independent predictor of increased postural instability, and this effect was strongest for the best hearing ear. Unilateral vestibular disease did not seem to explain this association between hearing and postural balance. Reduced hearing is associated with impaired balance, and interventions to prevent falls should be considered for patients at risk.acceptedVersio

Long-Term Survival in 1,931 Patients With Dizziness: Disease- and Symptom-Specific Mortality

Objective: To evaluate mortality among patients referred for suspected vestibular disorder and to examine whether specific symptoms or disorders predict long-term survival among patients with dizziness or vertigo. Study Design: Retrospective cohort study. Methods: This retrospective cohort study analyzed long-term survival data. Consecutive patients examined for suspected vestibular disease at an otolaryngology clinic completed a detailed questionnaire regarding symptoms and comorbidities. Results: The study included 1,931 patients. Their mean age (standard deviation) was 50.5 (16.5) years, and 60% were women. The mean follow-up period was 20.6 years (range, 15.3–27.5 years). The standardized mortality ratio for the entire cohort compared with the Norwegian age- and sex-matched population was 1.03 (95% confidence interval [CI]: 0.94–1.12), illustrating no difference in overall survival. Patients with a cerebrovascular cause of dizziness had higher mortality in adjusted Cox regression analyses (hazard ratio [HR] 1.56, 95% CI: 1.11–2.19), whereas patients reporting periodic or short attacks of dizziness had lower mortality (HR 0.62 [0.50–0.77] and 0.76 [0.63–0.93], respectively). Reported unsteadiness between dizziness attacks was associated with higher mortality with an HR of 1.30 (95% CI: 1.08–1.57). Conclusion: This long-term study found comparable mortality rates between patients evaluated for suspected vestibular disorder and that of the general population. However, subgroup analyses showed reduced mortality in patients with periodic or short attacks of dizziness and increased mortality in patients with unsteadiness between attacks or cerebrovascular causes of dizziness. The time course of vestibular symptoms should be determined, and thorough evaluation including fall risk and comorbidities must be considered in patients with nonepisodic symptoms.publishedVersio

Long-term effects of conservative management of vestibular schwannoma on dizziness, balance, and caloric function

Objectives: To study the development of dizziness, caloric function, and postural sway during long-term observation of untreated vestibular schwannoma patients. Study Design: Retrospective review of a prospectively maintained longitudinal cohort. Setting: Tertiary referral hospital. Subjects and Methods: Patients with vestibular schwannoma undergoing wait-and-scan management were included—specifically, those who did not require treatment during a minimum radiologic follow-up of 1 year. Baseline data and follow-up included magnetic resonance imaging, posturography, bithermal caloric tests, and a dizziness questionnaire. Main outcomes were prevalence of moderate to severe dizziness, canal paresis, and postural instability at baseline and follow-up, as compared with McNemar’s test. Results: Out of 433 consecutive patients with vestibular schwannoma, 114 did not require treatment during follow-up and were included. Median radiologic follow-up was 10.2 years (interquartile range, 4.5 years). Age ranged from 31 to 78 years (mean, 59 years; SD, 10 years; 62% women). Median tumor volume at baseline was 139 mm3 (interquartile range, 314 mm3). This did not change during follow-up (P = .446). Moderate to severe dizziness was present in 27% at baseline and 19% at follow-up (P = .077). Postural unsteadiness was present in 17% at baseline and 21% at follow-up (P = .424). Canal paresis was present in 51% at baseline and 56% at follow-up (P = .664). Conclusions: There was no significant change in the prevalence of dizziness, postural sway, or canal paresis during conservative management of vestibular schwannoma, while tumor volume remained unchanged. This indicates a favorable prognosis in these patients with regard to vestibular symptoms.acceptedVersio

Vestibular Tests Related to Tumor Volume in 137 Patients With Small to Medium-Sized Vestibular Schwannoma

Objective: The video head impulse test (vHIT) and cervical and ocular vestibular evoked myogenic potentials (cVEMP and oVEMP) are new methods for measuring peripheral vestibular function. The objectives of this study were to compare these tests and the traditionally used caloric test in patients with small and medium-sized untreated vestibular schwannoma (VS) and to measure the correlation between the tests' results and tumor volume. Study Design: National cross-sectional study. Setting: Tertiary university clinic. Methods: Prevalence of abnormal cVEMP, oVEMP, caloric test, and 6-canal vHIT results on the tumor side and the nontumor side were compared and related to tumor volume with regression analyses in 137 consecutive VS patients assigned to a wait-and-scan protocol in the period 2017 to 2019. Results: The sensitivity of 6-canal vHIT, caloric test, cVEMP, and oVEMP to detect vestibulopathy in VS patients was 51%, 47%, 39%, and 25%, respectively. Normal tests were found in 21% of the patients. The results of vHIT and caloric test were related to tumor volume, but this was not found for cVEMP and oVEMP. Conclusion: The caloric test and 6-canal vHIT showed the highest sensitivity in detecting vestibulopathy in untreated VS patients. vHIT, and particularly the posterior canal, was limited with a high prevalence of abnormal results on the nontumor side. A combination of cVEMP and caloric test was favorable in terms of a relatively high sensitivity and low prevalence of abnormal results on the nontumor side. Larger tumors had a higher rate of pathology on caloric testing and vHIT.publishedVersio

The Romberg sign, unilateral vestibulopathy, cerebrovascular risk factors, and long-term mortality in dizzy patients

Objectives: Describe the relationship between unsteadiness, canal paresis, cerebrovascular risk factors, and long-term mortality in patients examined for dizziness of suspected vestibular origin. Study design: Observational cohort with prospective collection of survival data. Setting: University clinic neurotological unit. Patients: Consecutive patients aged 18–75 years examined in the period 1992–2004 for dizziness of suspected vestibular origin. Outcome measures: Overall survival. Standardized mortality ratio (SMR). Factors: Unsteadiness, canal paresis, age, sex, patient-reported diabetes, hypertension, heart disease, stroke, or TIA/minor stroke. Patients were classified as steady or unsteady based on static posturography at baseline compared to normative values. Results: The study included 1,561 patients with mean age 48 years and 60 % females. Mean follow-up was 22 years. Unsteadiness was associated with higher age, heart disease, diabetes, hypertension, and cerebrovascular dizziness. There were 336 deaths over 31,335 person-years (SMR 0.96; 95 % confidence interval: 0.86–1.07). Canal paresis was not related to unsteadiness (chi square: p = 0.46) or to mortality (unadjusted Cox hazard ratio: 1.04, 95% CI: 0.80–1.34). Unsteadiness was an independent predictor of mortality (adjusted Cox hazard ratio: 1.44, 95% CI: 1.14–1.82). Conclusions: Unsteadiness measured by static posturography is associated with higher age, known cerebrovascular risk factors, and with increased long-term mortality, but not with canal paresis in patients evaluated for dizziness. The study highlights the importance of evaluating patients with conspicuous postural instability for non-vestibular causes.publishedVersio

Measuring pressure pain threshold in the cervical region of dizzy patients-The reliability of a pressure algometer

Objectives: A tool for measuring neck pain in patients with dizziness is needed to further investigate the relationship between the two symptoms. The objective of this study was to examine the reliability and validity of a hand‐held pressure algometer in measuring pressure pain threshold (PPT) in different cervical regions of dizzy patients. Methods: PPT was measured at two bilateral standardized sites of the neck by a trained physiotherapist in 50 patients with dizziness. Intraclass correlation coefficients (ICC) were calculated for intrarater and test–retest reliability. Concurrent validity was assessed by measuring the association between PPT and the American College of Rheumatology (ACR) tender points at each site and with the numeric pain rating scale (NPRS). Results: Almost perfect intrarater (ICC = 0.815–0.940) and within‐session test–retest (ICC = 0.854–0.906) reliability was found between the measures. On each site, a low PPT predicted a positive ACR tender point at each site (OR = 0.864–0.922). Last, we found a statistical inverse relationship between the PPT and the NPRS (R = −0.52 to −0.66). Conclusion: The study shows that a pressure algometer is a reliable tool for measuring PPT in the neck of dizzy patients. Further, the PPT correlates significantly with other subjective measures of pain indicating that it may be a useful tool for further research.publishedVersio

Children with hearing impairment in Malawi, a cohort study.

OBJECTIVE: To assess the outcomes of children diagnosed with hearing impairment 3 years earlier in terms of referral uptake, treatment received and satisfaction with this treatment, and social participation. METHODS: We conducted a population-based longitudinal analysis of children with a hearing impairment in two rural districts of Malawi. Key informants within the community identified the cohort in 2013 (baseline). Informants clinically screened children at baseline, and by questionnaires at baseline and follow-up in 2016. We investigated associations between sociodemographic characteristics and outcomes by multivariate logistic regression. RESULTS: We diagnosed 752 children in 2013 as having a hearing impairment and traced 307 (40.8%) children of these for follow-up in 2016. Referral uptake was low (102/184; 55.4%), more likely among older children (odds ratio, OR: 3.5; 95% confidence interval, CI: 1.2-10.2) and less likely for those with an illiterate caregiver (OR: 0.5; 95% CI: 0.2-0.9). Few of the children who attended hospital received any treatment (33/102; 32.4%) and 63.6% (21/33) of caregivers reported satisfaction with treatment. Difficulty making friends and communicating needs was reported for 10.0% (30/299) and 35.6% (107/301) of the children, respectively. Lack of school enrolment was observed for 29.5% (72/244) of children, and was more likely for older children (OR:?28.6; 95% CI: 10.3-79.6), girls (OR:?2.4; 95% CI: 1.2-4.8) and those with an illiterate caregiver (OR: 2.1; 95% CI: 1.0-4.1). CONCLUSION: More widespread and holistic services are required to improve the outcomes of children with a hearing impairment in Malawi

Prevalence and distribution of musculoskeletal pain in patients with dizziness—A systematic review

Background and purpose Musculoskeletal disorders are among the leading causes of disability globally, but their role in patients with dizziness and imbalance is not well understood or explored. Such knowledge may be important as musculoskeletal pain and dizziness can mutually influence each other, leading to a complex condition requiring more comprehensive approaches to promote successful recovery. We conducted a systematic review to examine the extent and characteristic of reported musculoskeletal pain in patients with dizziness. Methods A comprehensive literature search in Medline, Embase, Cochrane, Scopus, Amed, Google Scholar, SveMed+, and Web of Science was conducted in March 2021. Inclusion criteria were studies examining patients with a vestibular diagnosis, patients with cervicogenic dizziness and patients included based on having dizziness as a symptom; and reported musculoskeletal pain. Data regarding age, sex, sample size, diagnosis and musculoskeletal pain was extracted. The Crowe Critical Appraisal Tool was used for assessing methodical quality of the included studies. Results Out of 1507 screened studies, 16 studies met the inclusion criteria. The total sample consisted of 1144 individuals with dizziness. The frequency of patients reporting pain ranged between 43% and 100% in the included studies. Pain intensity were scored between 5 and 7 on a 0–10 scale. Pain in the neck and shoulder girdle was most often reported, but musculoskeletal pain in other parts of the body was also evident. Discussion In the included studies, musculoskeletal pain was highly prevalent in patients with dizziness, with pain intensity that may have a moderate to severe interference with daily functioning. Pain in the neck and shoulder is well documented, but there are few studies addressing musculoskeletal pain in additional parts of the body. More research is needed to understand the relations between dizziness and musculoskeletal pain.publishedVersio

Musculoskeletal pain patterns and association between dizziness symptoms and pain in patients with long term dizziness – a cross-sectional study

Background The impact of long-term dizziness is considerable both on the personal level and in society and may lead to self-imposed restrictions in daily activities and social relations due to fear of triggering the symptoms. Musculoskeletal complaints seem to be common in persons with dizziness, but studies addressing these complaints as a widespread occurrence, are scarce. This study aimed to examine the occurrence of widespread pain in patients with long-term dizziness and investigate the associations between pain and dizziness symptoms. Further, to explore whether diagnostic belonging is related to the occurrence of pain. Methods This cross-sectional study was conducted in an otorhinolaryngology clinic and included 150 patients with persistent dizziness. The patients were categorized into three groups: episodic vestibular syndromes, chronic vestibular syndromes, and non-vestibular group. The patients completed questionnaires on dizziness symptoms, catastrophic thinking, and musculoskeletal pain when entering the study. Descriptive statistics were used to describe the population, and associations between pain and dizziness were investigated by linear regression. Results Pain was reported by 94.5% of the patients. A significantly higher prevalence of pain was reported in all the ten pain sites examined compared to the general population. Number of pain sites and pain intensity were associated with the dizziness severity. Number of pain sites was also associated with dizziness-related handicap, but not with catastrophic thinking. There was no association between pain intensity and dizziness-related handicap or catastrophic thinking. Pain was equally distributed in the diagnostic groups. Conclusion Patients with long-term dizziness have a considerably higher prevalence of pain and number of pain sites than the general population. Pain co-exists with dizziness and is associated with dizziness severity. These findings may indicate that pain should be systematically assessed and treated in patients with persisting dizziness.publishedVersio