Management of Common ENT Cases MS ANN O CONNOR MD FRCS (ORL-HNS) BEACON HOSPITAL 21 ST APRIL 2018
Introduction GP referrals to ENT services Highest of all specialities Number of patients waiting an OPD appointment (NTPF Mar 2018) 68,069 patients (18,335 >18/12) Ms Ann O Connor MD FRCS (ORL-HNS)
Most common referrals Guidelines available Chronic rhinosinusitis • • Tonsillitis Globus pharyngeus • • Otitis media Hoarseness • Vertigo • Snoring / Sleep apnoea • Otitis externa • Ms Ann O Connor MD FRCS (ORL-HNS)
Chronic Rhinosinusitis Red Flags Diagnostic Criteria Chronic = >12 wks; incomplete resolution Unilateral blockage 2 or more symptoms, 1 of which must be ‘hard’ Unilateral discharge Hard symptoms Soft symptoms Bloodstained discharge Nasal block/congestion Loss of smell Crusting • Nasal discharge Facial pain • Eye symptoms/signs N.B. Facial pain in absence of nasal symptoms Focal facial swelling is not suggestive of rhinosinusitis Elderly • Diagnosis is confirmed by; Smokers • Endoscopic signs (oedema, pus or polyps) and/or • Woodworkers • CT findings (mucosal disease) • Evidence based guidelines available in summary form at www.ep3os.org Ms Ann O Connor MD FRCS (ORL-HNS)
Chronic Rhinosinusitis Primary Care management When to refer If no polyps evident; Any red flags Saline nasal douche/spray Intranasal No response to medical therapy • steroid spray for 3/12 ± antihistamine (if If patient willing to consider allergy) surgery → if no response add oral macrolide for • 3/12 If polyps evident; NB Mild symptoms - steroid spray for 3/12 Consider allergy tests in parallel • • with referral Moderate symptoms - steroid drops for • 3/12 Plain XR films not useful • Severe symptoms - steroid tablets for 1 • week Evidence based guidelines available in summary form at www.ep3os.org Ms Ann O Connor MD FRCS (ORL-HNS)
Globus Pharyngeus Red Flags Diagnostic Criteria Pain (throat or ear) Clinical diagnosis based on history Dysphagia Feeling of something in the Persistent hoarseness throat Lateralising symptoms Tickle/hair • Lump • Constriction • Often exacerbated by e.g. stress Usually in non-smokers May have reflux symptoms Ms Ann O Connor MD FRCS (ORL-HNS)
Globus Pharyngeus When to refer Primary Care management Any red flags Reassurance is key Persistent symptoms > 3/12 Address life issues Need for further reassurance Discourage throat clearing → ice water sips If reflux symptoms Raise end of bed • Consider b.d. proton pump inhibitor • + Gaviscon Advance 3/12 Ms Ann O Connor MD FRCS (ORL-HNS)
Hoarseness Red Flags Diagnostic Criteria Persistent hoarseness > 3 weeks Persistent hoarseness more suggestive of pathology than Pain intermittent hoarseness Dysphagia Haemoptysis Enquire about voice use/abuse Otalgia Neck lump ? Reflux symptoms Especially in Smokers • Over 40yrs • Ms Ann O Connor MD FRCS (ORL-HNS)
Hoarseness Primary Care management When to refer Red flags Lifestyle measures Stop smoking Intermittent hoarseness >12 weeks and not responding to lifestyle Review inhaler use ± rinsing measures across Consider effects from occupation e.g. teacher, singer, call centre operator Ms Ann O Connor MD FRCS (ORL-HNS)
Vertigo Diagnostic Criteria Red Flags VERTIGO = perception of room spinning ► Otalgia IMBALANCE = Light-headedness/fuzziness ► Ear Discharge History is suggestive when otological cause – ► Headache onset, duration, frequency e.g. Sec/mins = BPPV • Hours = Menieres • Days = Labyrinthitis / Neuronitis • ?Associated ear symptoms Otoscopy + tuning fork tests Dix-Hallpike test for BPPV Head Impulse Test /Nystagmus / Eye Skew Ms Ann O Connor MD FRCS (ORL-HNS)
Vertigo Primary Care management When to refer Lifestyle measures – caution Red flags driving For Epley (if unfamiliar) BPPV Meniere’s disease Epley manoeuvre 80% success rate • Meniere’s disease Reduce salt, chocolate, red wine • Bendrofluazide 2.5mg • Betahistine 8-16mg tds(prophylaxis) • Labyrinthitis/Neuronitis Self-limiting but often recurs with • decreasing frequency/intensity No long term vestibular sedatives • Ms Ann O Connor MD FRCS (ORL-HNS)
Snoring / Sleep apnoea Red Flags Diagnostic Criteria Daytime somnolence Apnoea = breath-holding episode lasting >10 seconds Witnessed apnoeas terminated by a snort/rousal Epworth Sleepiness Score assesses symptoms of daytime somnolence ESS <10 (OSA unlikely) • Children with OSA tend to be • hyperactive during the day rather than somnolent Ms Ann O Connor MD FRCS (ORL-HNS)
Snoring / Sleep apnoea Primary Care management When to refer Suspected sleep apnoea Active weight loss Snoring refractory to above Stop smoking conservative measures Avoid alcohol 4 hours before Patient willing to be considered bed for (painful) snoring surgery Review sedative prescription BMI <29/30 Treat rhinitis Suggest trial of mandibular advancement device Ms Ann O Connor MD FRCS (ORL-HNS)
Otitis externa Red Flags Diagnostic Criteria Painless discharge Pain/itch + discharge If one without the other, Pain out of keeping with unlikely to be simple OE findings Mastoid tenderness in adults is Protracted otalgia (especially more often OE than true in diabetic) mastoiditis Recurrent/persistent unilateral Malignant OE infection • Severe, deep boring pain + Cranial nerve weakness granulations in canal +/- cranial nerve palsy in diabetic patient Ms Ann O Connor MD FRCS (ORL-HNS)
Otitis externa Primary Care management When to refer Immediate Any red flags Ear swab for microbiology • Suspected cholesteotoma Dry mop conchal bowl/distal • e.g. abnormal attic, canal painless discharge Treatment is topical with • drops/spray Protracted symptoms If pinna involved, oral antibiotics • resistant to topical therapy can be added Longterm/prophylaxis Cellulitis spreading onto face Consider underlying skin condition • Close diabetic control • Infections interfering with Water precautions hearing aid use • Review shampoo • Earcalm spray (acetic acid) • Ms Ann O Connor MD FRCS (ORL-HNS)
Questions For patient specific advise and questions: • Gpbuddy • Email: ann.oconnor@beaconhospital.ie Ms Ann O Connor MD FRCS (ORL-HNS)
Thank you Ms Ann O Connor MD FRCS (ORL-HNS)
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