Referrals to ENT
Mr Robert Harris
ENT Consultant
Commonest referrals
 Adult Hearing Loss / tinnitus
 Paediatric Glue Ear
 Paediatric snoring/OSA
 Adult snoring/OSA
 Otitis externa
 Otalgia (cause unknown)
 Recurrent epistaxis
 Hoarseness
 Rhinitis
 Sinusitis
 Ear Wax
 Globus / cough
 Throat pain
 Tonsillitis
 Dizziness
Triage options
 Secondary Care
 Secondary Care outside Croydon
 Intermediate Care
 Back to Referrer
 Different Specialty
 Adult Audiology
 Paediatric Audiology
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
Case study – 1 week history of itchy ear
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Case study – 1 week history of itchy, painful ear,
decreased hearing
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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
https://entuk.org/docs/prof/position_papers/position_paper_ear_drops
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Case study


65 year old diabetic
3 week history of otalgia
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Otitis Externa Prevention
 Keep ears dry
 Dry thoroughly after wet
 EarCalm
 Early intervention with topical steroids / antiobiotics
Case study


45 year old IT manager
woke yesterday with muffled right hearing
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Sudden hearing loss


Tuning fork tests
Consider high dose steroids and urgent referral for intratympanic
steroids
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Paediatric OSA
Paediatric OSA
 Nasal symptoms
 Snoring
 Assessment of severity
 History
 Video
 Clinical examination
 Anterior rhinoscopy
 Oropharynx
 Neck
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
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
Thank you
Mr Robert Harris MSc FRCS
NHS
CUH
T: 02084013327
F: 02084013339
robert.harris@croydonhealth.nhs.u
k
SGH
T: 02087252054
F: 02087253306
robert.harris@stgeorges.nhs.uk
Private
Shirley Oaks Hospital
North Downs Hospital
Parkside Hospital
T: 02086576653
F: 02086576653
mayhew.karen@googlemail.com
Rationale for long-term macrolides
for Chronic Rhinosinusitis
ARS
Stretococcus pneumoniae
Haemophilus influenza
Moraxella catarrhalis
Few anaerobes,
streptococci,
staphylococcus
• CRS
Acute RS vs Chronic
RS
bacteria
– Staph Aureus
– Coag neg staph
– Strep pneum
– anaerobes
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
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
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
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
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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)
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