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Referrals to ENT Mr Robert Harris ENT Consultant.

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Presentation on theme: "Referrals to ENT Mr Robert Harris ENT Consultant."— Presentation transcript:

1 Referrals to ENT Mr Robert Harris ENT Consultant

2 Commonest referrals  Adult Hearing Loss / tinnitus  Paediatric Glue Ear  Paediatric snoring/OSA  Adult snoring/OSA  Otitis externa  Otalgia (cause unknown)  Recurrent epistaxis  Hoarseness  Rhinitis  Sinusitis  Ear Wax  Globus / cough  Throat pain  Tonsillitis  Dizziness

3 Triage options  Secondary Care  Secondary Care outside Croydon  Intermediate Care  Back to Referrer  Different Specialty  Adult Audiology  Paediatric Audiology

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8 Symptoms in acute and chronic rhinosinusitis ARS Nasal obstruction Anterior or postnasal discharge Progressive severe facial pain (affects teeth if maxillary) Reduced smell not volunteered Often pyrexia CRS Nasal obstruction Anterior or postnasal discharge (often discoloured yellow with eosinophils but green and infected uncommon) Facial pain uncommon unless acute exacerbation Hyposmia common Late onset asthma common

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10 Case study – 1 week history of itchy ear 10

11 Case study – 1 week history of itchy, painful ear, decreased hearing 11

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16 The following be adopted as formal ENT-UK guidance: When treating a patient with a discharging ear, in whom there is a perforation or patent grommet:  1.If a topical aminoglycoside is used, this should only be in the presence of obvious infection  2.Topical aminoglycosides should be used for no longer than two weeks  3.The justification for using topical aminoglycosides should be explained to the patient https://entuk.org/docs/prof/position_papers/position_paper_ear_drops‎ ENT UK evidence review and consensus document 16

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20  65 year old diabetic  3 week history of otalgia Case study 20

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22 Otitis Externa Prevention  Keep ears dry  Dry thoroughly after wet  EarCalm  Early intervention with topical steroids / antiobiotics

23  45 year old IT manager  woke yesterday with muffled right hearing Case study 23

24  Tuning fork tests  Consider high dose steroids and urgent referral for intratympanic steroids Sudden hearing loss 24

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27 Paediatric OSA

28  Nasal symptoms  Snoring  Assessment of severity  History  Video  Clinical examination  Anterior rhinoscopy  Oropharynx  Neck

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30 Silent Laryngopharyngeal Reflux  Excessive throat clearing  Persistent cough  Hoarseness  A "lump" in the throat that doesn't go away with repeated swallowing  A sensation of post nasal drip  Dry throat  Sore throat  Hallitosis  Furry tongue

31 Silent Laryngopharyngeal Reflux  Sleep on an empty stomach  Elevate head of bed  Smoking cessation  PPI double dose with evening meal for 1 month  Manage associated anxiety

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33 Thank you

34 Mr Robert Harris MSc FRCS NHS CUH T: F: k SGH T: F: AIRCALL: (SG933) Private Shirley Oaks Hospital North Downs Hospital Parkside Hospital T: F:

35 Rationale for long-term macrolides for Chronic Rhinosinusitis

36 Acute RS vs Chronic RS bacteria ARS Stretococcus pneumoniae Haemophilus influenza Moraxella catarrhalis Few anaerobes, streptococci, staphylococcus CRS –Staph Aureus –Coag neg staph –Strep pneum –anaerobes

37 Long-term antibiotics  Efficacy of long term treatment in diffuse panbronchiolitis  Asian studies CRS over last decade  Long-term low-dose macrolide  60-80% improvement in CRS refractory to surgery and steroids  Slow onset, ongoing improvement at 4/12

38 Macrolides  Increase mucociliary transport  Reduce goblet cell secretion  Accelerated apoptosis of neutrophils  Other anti-inflammatory effects  Inhibit IL expression  Reduce virulence and tissue damage caused by chronic bacterial colonisation  Increase ciliary beat

39 Long-term macrolides  Prospective RCT N=90 CRS =/- NP 3/12 erythromycinESS VAS, SNOT-22, SF36, NO, rhinometry, saccharine clearance, endoscopy No signif difference in outcome

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42 42 Medical Regimen for Chronic Rhinosinusitis  Clarithromycin 250mg bd for 6-12 weeks  Xylometazoline bd for 1 week  Nasal douche for 6-12 weeks  Topical nasal steroids for 6-12 weeks 42

43 43 Medical Regimen for nasal polyps  Maintenance dose of topical nasal steroid long-term  30mg prednisolone for 7 days as required, (but not more frequently than 3 monthly) 43

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