1. ENT in Primary Care proposed management guidelines
Alison Hunt
ENT Consultant
ENT Dept MKUH

2. Discussion points to be covered
Tinnitus
Sensorineural Hearing loss
Vertigo
Snoring and OSA

3. Nature of tinnitus Bilateral/unilateral Pulsatile/non pulsatile
Subjective/objective
All patients should have oto-neurological examination
If pulsatile listen for bruits
Hearing test

4. General management of tinnitus
Explanation that tinnitus is benign in most cases
Sound therapy and distraction techniques help
Hearing aid where SNHL is very useful
Manage depression/ exacerbating psychological factors
If no better consider referral for tinnitus counseling

5. Management of tinnitus
Check hearing
Explain hearing test results and nature of tinnitus
If SNHL consider hearing aid/sound therapy/Tinnitus couselling
Unilateral tinnitus or asymmetric SNHL >15 dB in 2 consecutive frequencies :MRI IAMS

6. Adult Unilateral Hearing loss
Sudden onset SNHL needs urgent PO high dose steroid, followed by E Clinic referral. Confirm with community hearing test and tympanogram.
Chronic hearing loss.
Unilateral SNHL requires MRI IAM (only refer to ENT if abnormal scan), consideration of hearing aid.
Symmetrical SNHL does not require referral unless rapid progression.

7. Vertigo in Primary care
General imbalance, "dizziness” or being “a bit wobbly” are NOT ENT RELATED SYMPTOMS. Suggest referral to falls clinic/medical review.
General imbalance in the elderly is NOT ENT related.
Suggest general medical work up in primary care /elderly care community/geriatrician review
3 key questions in the history for ENT related true vertigo (spinning sensation).
1 Does the patient experience true spinning?
2 How long does it last, seconds minutes or hours?
3 Is there associated hearing loss?

8. Vertigo lasting Seconds- almost always BPPV
During head movement which side precipitates symptoms
Normal TMs , no hearing loss
Dixhallpike testing either in primary care/GPwSpi/Physiotherapy
If positive test epley
See 4-6 week to check for resolution/repeat epley
If no improvement with 2x epley, PTA , tympanogram, Refer to ENT

9. Vertigo in Primary Care
Seconds- BPPV
ref to community GPWSpI/physio for epley
Minutes to hours- vestibular neuronitis /labyrinthitis if
single episode. Prochlorperazine prn observe
multiple separate attacks consider Meniere's treatment/recurrent vestibulopathy +/- referral.
1-2 Days neuronitis/labyrinthitis.
Usually settles with prochlorperazine observe
1 week or more and no recovery
consider CVA and medical referral first
Consider vestibular decompensation and refer.

10. Vertigo in Primary Care
All patients require hearing test. If asymmetric SNHL on testing, SNHL protocol will apply.
Patients with imbalance following episode of true vertigo will require balance physiotherapy in some form
Cawthorne-cooksey exercises
Referral to community physio

11. Vertigo in primary care
Acute/single episodes- prochlorperazine
Meniere's
low salt < 2g day
Betahistine 16mg TDS
Intermittent prochlorperazine for acute episodes

12. Vertigo in Primary Care
? Only hospital referrals via GPwSpi
?Only those failing community management to be referred

13. Snoring Simple Snoring vs OSA Do not require referral to ENT
Define in history
Epworth score for OSA
Do not require referral to ENT
Snoring-manage in community: TSH, BMI, Wt loss, tailor made mandibular advancement device via dentist (British Snoring and Sleep Apnoea Association)
OSA –ref to respiratory team to consider CPAP

14. Implementation and facilitating change
Access to hearing tests in the community promptly and interpretation of tests
Community vestibular physiotherapy
(Matt Search resigned post ? Alternative arrangements)
Tinnitus counselling in the community- could this be offered by community audiology team?
Hearing aid provision in the community- access/availability