Mr Robert Harris ENT Consultant Referrals to ENT Mr Robert Harris ENT Consultant

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

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

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

Case study – 1 week history of itchy ear 10

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

12

13

14

15

ENT UK evidence review and consensus document 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 16

17

18

19

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

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

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

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

Paediatric OSA

Paediatric OSA Nasal symptoms Snoring Assessment of severity History Video Clinical examination Anterior rhinoscopy Oropharynx Neck

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

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

Thank you

Mr Robert Harris MSc FRCS NHS CUH T: 02084013327 F: 02084013339 robert.harris@croydonhealth.nhs.uk SGH T: 02087252054 F: 02087253306 robert.harris@stgeorges.nhs.uk AIRCALL: 08448 222888 (SG933) Private Shirley Oaks Hospital North Downs Hospital Parkside Hospital T: 02086576653 F: 02086576653 mayhew.karen@googlemail.com

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 last decade 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 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

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