1. Mr Robert Harris ENT Consultant
Referrals to ENT
Mr Robert Harris
ENT Consultant

2. 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

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

8. 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

10. Case study – 1 week history of itchy ear10

11. Case study – 1 week history of itchy, painful ear, decreased hearing11

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16. 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 16

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

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

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

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

27. Paediatric OSA

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

30. 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

31. 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

33. Thank you

34. Mr Robert Harris MSc FRCS
NHS
CUH T: F:
SGH T: F:
AIRCALL: (SG933)
Private
Shirley Oaks Hospital
North Downs Hospital
Parkside Hospital T: F:

35. Rationale for long-term macrolides for Chronic Rhinosinusitis

36. 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

37. 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

38. 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

39. 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

42. 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

43. 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