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

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

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

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

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

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.

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?

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

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.

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

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

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

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

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