1. ENT & AUDIOLOGY REFERRALS
Robert Harris
Consultant in ENT

3. 2015-16 Cress triage summary - Adults
Audiology 1439 IC SC
Back to GP 116
Total 6506

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

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

6. 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

7. Other EAR-related Triage 2015-6
Total IC SC
Cholesteatoma
Ear ache
Glue ear
Perforation
Otitis externa
Wax
Total 904

8. 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?

9. 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 (IC=576, SC=930)
Polyps,Rhinitis,Rhinoplasty,sinus=756 (ic292,sc464)
Nasal operations=200

10. Throat data Annual adult tonsillectomy= 81 Total ic sc
Breathing problems
Cough
Dysphagia
Globus
Hoarseness
Throat pain
Neck lump
Annual adult tonsillectomy= 81

11. 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

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

13. The Proposed Pathways!

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

15. Deafness

16. Tinnitus
Tinnitus

17. Ear discharge

18. SOS clinic
500 Croydon episodes at SGH a year

19. Ear ache

20. Dizziness

21. Dizziness Cress Chris Wood total volume Chris Wood 362 SC 60 IC 81
New
F/up 800
+ s
+ phone calls

22. Rhinitis
? Investigate with CT & RAST

23. Anosmia

24. Epistaxis

25. Globus

26. Throat pain

27. Neck lump

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

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

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

31. Other EAR-related Triage 2015-6
Total IC SC
Cholesteatoma
Ear ache
Glue ear
Perforation
Otitis externa
Wax
Total

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

33. 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

45. 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

47. Rationale for long-term macrolides for Chronic Rhinosinusitis

48. 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

49. 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

50. 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

51. 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

54. 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