In the last 10 years, there has been a relentless drive by the Department and Health and commissioners to re-direct healthcare from hospital-based to community-based. Hospitals are given targets to reduce the follow up rates for outpatient attendances. Consultants are under pressure to discharge patients back to the care of their GPs.
Outcome in ear surgery is predominately based on patient feedback, post-operative hearing test and the otoscopic appearance of the ear. Technical success of ossiculoplasty is determined by the hearing gain and the air-bone gaps. That requires the measurements of the masked air and bone conduction thresholds. Otoscopic examination of a surgically reconstructed middle ear or mastoid cavity requires specialist skill and knowledge. Hence surgical outcome after ear surgery can only be reliably assessed by an ENT specialist. For cholesteatoma surgery, recurrent or residual cholesteatoma often take years to become apparent. In the past, a number of alloplastic ossicular prostheses were introduced into the market based on favourable short term results, but were later withdrawn from the market because of unacceptable long term failure rates.1 The systematic monitoring of outcome in ear surgery was traditionally carried out by relatively few otologists who were dedicated in data collection. Currently, such dedication is being eroded by the relentless drive by the commissioners to reduce the new to follow up ratio for outpatient attendance. It will be difficult to obtain long term (> 5 years) or even medium term (1-5 years) outcome in middle ear surgery in the future.
In recent years, the Department of Health has been promoting patient reported outcome measures (PROMs), both disease generic and specific ones. This is logical as the ultimate measure of the quality of a medical effort is whether it helps patients as they see it. The other benefit is that such questionnaires can be administered by GPs or by hospital administrators, and allow the hospital specialists to systematically monitor the outcome without recalling the patients to the clinic. To date, PROMs for chronic otitis media are not yet well developed. Also, PROMs will not identify covert problems within the ear, such as retraction pockets, cholesteatoma pearls, dry perforations, and ear discharge unless it drips out of the ear. One possible solution is to capture the otoscopic images by a healthcare professional in the community, and send the digital images to the specialist for assessment and record keeping.
Currently, there is a need for a guideline or at least a consensus on the length of follow up regimes regarding myringoplasty, stapedectomy and cholesteatoma surgery. Also, the otologist community need to develop a disease specific PROMs instrument for chronic otitis media that is appropriate for the NHS.