Key issues in ENT for GP Registrars Haytham Kubba Consultant Paediatric Otolaryngologist Yorkhill, Glasgow

Permanent congenital hearing impairment Glue ear Recurrent acute otitis media Adenoids and tonsils Services on offer at Yorkhill

Permanent congenital hearing impairment

Why screen? Serious Asymptomatic phase Treatment available Outcome better when treated early Test available and acceptable

How have we screened? Universal behavioural tests in infants –Health visitor distraction test at 8 months Targeted objective tests for high risk neonates –Evoked response audiometry within 6 weeks

Who is considered high risk? Sensorineural deafness in 1st degree relative Bacterial meningitis SCBU graduates –preterm < 32 weeks –very low birthweight <1500g –required ventilation –known toxic levels of aminoglycosides –serum bilirubin >400mmol/l at term

Health visitor distraction tests Distraction test can be effective Requires –good technique –equipment –quiet environment –cooperative child Results often poor - 50% deaf children missed by HV tests

NDCS targets National Deaf Children’s Society 1994 –40% deaf children identified by 6 months –80% by 1 year of age Ayrshire results (Kubba, 1996) : –17% by 6 months –40% by 1 year UK average age at diagnosis 18 months

How can we improve? Universal neonatal screening May use –evoked response audiometry –automated response cradle –otoacoustic emissions

Universal Neonatal Screening Pilot sites - Dundee, Edinburgh, Highlands Implemented across Scotland Oct 2005 Local policies –test methods –pass criteria –infrastructure

UNHS in Glasgow Automated ABR 13 screeners in 3 maternity units Community follow up clinics 95% screen coverage 15 new cases of PCHI in 1 st year Only ½ had risk factors Mean age at diagnosis 9 weeks Prev 20 months

Haytham’s 1 st law of screening “those most at risk of the disease are also the ones LEAST LIKELY TO ATTEND for screening”

Prevalence better ear >40dBHL Fortnum et al, BMJ 2001

Take-home message 1 Permanent hearing impairment UNHS is fantastic, but… UNHS is not the end of the story Constant vigilance throughout childhood

Otitis media with effusion

Bacterial biofilm disease Eustachian tube dysfunction is old hat

Discredited: –Auto-inflation –Antihistamines –Mucolytics –Decongestants –Steroids –Antibiotics Shown to work: –Adenoidectomy –Grommets

Take-home message 2 Otitis media with effusion If the child is bad enough to need treatment, they need an operation

Recurrent acute OM Treat as & when Antibiotics 35 RCTs 3/12 prophylaxis Effective, side effects + Grommets Le 1991, RCT n= fewer infections in 6/12 Adenoidectomy Paradise 1999, Koivunen 2004 Little or no benefit

Take-home message 3 Recurrent acute otitis media Our treatments are largely unsatisfactory Watch and wait is often the best approach

Acute OM Antibiotics –4 systematic reviews –no effect on pain scores –shorten illness Outcomes? Diagnostic criteria?

Take-home message 4 Acute otitis media Antibiotics – never say never –Beware under 2 years of age Incidence of complications is rising

Chronic otitis media recurrent or persistent otorrhoea

Take-home message 5 recurrent or persistent otorrhoea refer

Sore throats: –SIGN guidelines –Often settle without surgery Nasal congestion –Preschool = ads –Settles with time –School = allergy –Nasal steroids

Obstructive sleep apnoea Features: Heavy snoring Snort arousals Disturbed sleep Enuresis Night terrors Fatigue Effects: Poor concentration Cognitive impairment Fatigue Hyperactivity Hypertension Cor pulmonale

Take-home message 6 T&A Sore throats, nasal congestion –usually benign, avoid surgery Always enquire about sleep apnoea –this is serious and needs treating