ENT & AUDIOLOGY REFERRALS Robert Harris Consultant in ENT

2015-16 Cress triage summary - Adults Audiology 1439 IC 2943 SC 1996 Back to GP 116 Total 6506

Audiology triage (N=1439) Deafness 1053 Dizziness 362 Tinnitus 24

Triage 2015-6 ‘Deafness’ ‘Tinnitus’ Audiology 1053 IC 733 SC 284 Total 2070 Audiology 24 IC 379 SC 23 Total 426

What happens to patients seen with hearing impairment in intermediate care? Often 3 appointments in IC first tinnitus management? Onward referral to audiology for hearing aids Additional hearing test appointments for hearing aids Onward referral to SC from IC and audiology Multiple appointments and delays

Other EAR-related Triage 2015-6 Total IC SC Cholesteatoma 11 0 11 Ear ache 231 156 71 Glue ear 11 0 11 Perforation 109 18 91 Otitis externa 183 154 29 Wax 359 352 7 Total 904

Total ‘ear’ referrals Deafness, tinnitus, pain, discharge (excluding dizziness) = 3400 (-1053 triaged to audiology)=2347 Only 127 needed an operation, so why are all these patients traditionally seen by a surgeon?

2015-6 triage data - Nose Nasal operations=200 Anosmia 55 (ic22,sc33) ‘Breathing problem’ 260 (ic72,sc188) Snoring 267 (ic39,sc228) Epistaxis 168 (ic151,sc17) Nasal polyps 90 (ic8,sc82) Rhinitis 278 (ic141,sc137) Rhinoplasty 2 (ic0,sc2) Sinus symptoms 386 (ic143,sc243) Total 1506 (IC=576, SC=930) Polyps,Rhinitis,Rhinoplasty,sinus=756 (ic292,sc464) Nasal operations=200

Throat data Annual adult tonsillectomy= 81 Total ic sc Breathing problems 260 72 188 Cough 99 76 23 Dysphagia 47 13 34 Globus 208 192 16 Hoarseness 171 85 8 Throat pain 422 108 314 Neck lump 40 0 40 Annual adult tonsillectomy= 81

Why is ENT traditionally secondary care? 400 operations 6500 referrals (6% needed surgery) 2000 triaged to secondary care (20% needed referrals) How many were cancer? Specialist equipment necessary

Most ENT referrals could be managed in the community! Most hearing related referrals could be managed by audiology!

The Proposed Pathways!

TRIAGE! Primary care / hearing screening protocols must be strictly adhered to for a referral to be accepted

Deafness

Tinnitus Tinnitus

Ear discharge

SOS clinic 500 Croydon episodes at SGH a year

Ear ache

Dizziness

Dizziness Cress Chris Wood total volume Chris Wood 362 SC 60 IC 81 New 899 F/up 800 + emails + phone calls

Rhinitis ? Investigate with CT & RAST

Anosmia

Epistaxis

Globus

Throat pain

Neck lump

USC 602 / year move from SC to IC? exclude smoker plus over 40 neck lump

Extra IC capacity needed? Total triage into SC 1996 Deafness/tinnitus -307 (to go to audiology) =1689

Triage 2015-6 ‘Deafness’ ‘Tinnitus’ Audiology 1053 IC 733 SC 284 Total 2070 1112 new referral capacity created in IC Audiology 24 Total IC 379 1112 SC 23 Total 426

Other EAR-related Triage 2015-6 Total IC SC Cholesteatoma 11 0 11 Ear ache 231 156 71 Glue ear 11 0 11 Perforation 109 18 91 Otitis externa 183 154 29 Wax 359 352 7 Total 904 524

Therefore - No Extra IC capacity needed! Total triage into SC 1996 Deafness/tinnitus -307 (to go to audiology) =1689 -524 -1112 =53

How much extra capacity needed for audiology? ‘Deafness’ ‘Tinnitus’ Audiology 1053 IC 733 SC 284 Total 2070 IC + SC = 1017 Audiology 24 IC 379 SC 23 Total 426 IC = SC = 402

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

Rationale for long-term macrolides for Chronic Rhinosinusitis

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

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

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

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

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