Managing common ENT problems

Tuesday, 20 November 2018. 7.30 - 8.45 pm

 

ENT and Sleep Surgeon Mr Sumit Samant discusses the diagnosis and management of common ENT problems seen in primary care. He focusess on the common issues of snoring and obstructive sleep apnoea, potential long-term sequelae of these, when to refer and what management options are available.

Topics covered include:

  • Hearing loss, tinnitus, vertigo, otitis externa/media
  • Deviated septum and rhinitis, sinusitis, epistaxis
  • Tonsillitis, quinsy and parapharyngeal abscess
  • Head-neck cancer, salivary glands, globus, hoarseness, laryngomalacia
  • OSA

Resources

Presenter

Mr Sumit Samant

Sumit is an upper airway surgeon specialising in surgery for snoring, obstructive sleep apnoea, nose and sinuses. Contact Sumit at ENT Associates.

He is a consultant at Auckland City Hospital, a member of the Royal Australasian College Otolaryngology Training Committee and a member of the International Surgical Sleep Society. Sumit got his Fellowship in Otolaryngology and Head-neck Surgery from the Royal Australasian College of Surgeons and has undergone additional advanced training as a Fellow in ENT and Head-Neck Surgery in the UK, New Zealand and the USA.


Q&A

Sumit has kindly taken the time to personally answer all of the questions that there wasn't time to cover live on the webinar. You can view Sumit's responses below:

  1. Q: Looking for an approved ENT Training programme for GP and Urgent Care Physician to provide care in the community.
    We are looking at setting up options in ADHB from short-term observer type position to six-month registrar type jobs.
  2. Q: when audiologist letter often recommends Ent referral if more than 20db difference between ears, and dhb regularly refuses referral-what to say and when to really refer?
    In a child, emphasis on the importance on binaural hearing on speech and brain development might be helpful. In an adult with stable 20 dB difference, DHB resource constraints might not allow them to offer surgery or hearing aid.
  3. Q: Would you recommend steroid spray for a 6 year old or grommet surgery if the otitis media with effusion has been there since 2 years old?
    Grommets without doubt. There would likely be speech development delay at that stage with long-term risk to the health of tympanic membranes. They may need speech therapy afterwards to catch up over subsequent months.
  4. Q: for eustachian tube dysfunction apart from steroid spray , any other management?
    Valsalva manoeuvre, blowing balloons, nasal rinsing if associated allergic rhinitis, Univent spray if there is suggestion of non-allergic rhinitis (sensitivity to smoke, perfumes, fumes, temperature changes etc.) and grommets in an adult.
  5. Q: His tonsils are grade 2 and constantly has blocked nose. He has otrivin and has blown balloons!
    Quite likely he has adenoid issues. Flixonase spray for 6-8 weeks as a trial with consideration for adenoidectomy (+/- tonsillectomy if there is snoring or sleep apnoea type picture) if no improvement.
  6. Q: How is differentiated sensorineural and conductive deafness? What tests are done?
    Audiometry is the best option here as clinical tests are not easy and often not accurate. Free audiometry is often available through private audiology services if DHB cannot help. It is best to get it done within 2 weeks of onset of hearing loss so that tapering oral steroid therapy can be started in time if it is indeed sensorineural hearing loss.
  7. Q: Regarding symptom of vertigo how common is BPPV any advances in knowing cause and what is the management
    It is reasonably common and even though it is brief and episodic, its unrelenting nature can be quite disabling. Epley and Brandt Daroff exercises every night for three weeks are both quite effective.
  8. Q: From what age we can use steroid spray for children
    Usually from 6 years onwards, after explaining to parents about it being safe at once a day dosage if there are any concerns with the “not for use below 12 years” warning on the packaging.
  9. Q: can you discuss the approach to TMJ dysfunction management
    Rest (no hard or chewy foods), simple combination analgesics (Paracetamol, Ibuprofen and sometimes even a short 3-day course of 20mg Prednisone) with warm compresses. Symptoms settle pretty quickly, usually within a week. They can come back but if repeat treatment as outlined, they tend to fade with time.
  10. Q: Hi, if you have a patient with chronic otitis externa with positive swabs that does not improve on drops, would you refer them for ENT review? If yes what timeframe would you allow before referring?
    I would have a low threshold for referring since they may need frequent ear suctioning and to rule out malignant otitis externa especially if immunocompromised.
  11. Q: What is the treatment for a patulous Eustachian tube?
    Great question! It is difficult to manage and quite debilitating. With deep, slow breathing, one can often see the tympanic membrane move with respiration. In the first instance, grommet can be inserted with the understanding that it may not help or even make it worse. Second line treatment can be injection of saline or Restylane filler into the Eustachian tube cushions through the nose. I use a 22 gauge spinal needle with insulin syringe.
  12. Q: For us GPs, what is a useful way to get patients aural toilet without sending them to ear clinic for suction? Tissue spears?
    Great idea. Even gentle cleansing with cotton wool bud, especially to mop up discharge rather than attempting through clearance. Difficult to do it yourself but parent or partner might be able to do it for the patient.
  13. Q: What is first line treatment for AOM with perforation (i.e. otorrhoea) - orals and drops? And discharging grommets - orals vs topical?
    Drops – Ciloxan or short course of Sofradex with oral antibiotics in children if no improvement in 24-48 hours. Any suggestion of mastoiditis should be referred right away.
  14. Q: How do you decide which patients with unilateral tinnitus need an MRI for acoustic neuroma?
    Unless I am quite clear that it is muscular or non-otogenic, we should have a low threshold for MRI.
  15. Q: older person with hearing loss in one ear only, any benefit of having a hearing aid in that ear?
    If the difference between ears is more than 20 dB, they will notice an improvement in binaural hearing with a hearing aid. If the gap is huge, they may not get enough improvement to notice a difference. They can have a trial at a private audiologist before buying it.
  16. Q: What are some of the other ENT specific questionnaires you would recommend practitioners use for young people (12-24yrs) in primary care
    DizzyQuest, Tinnitus Handicap Inventory, NOSE, SNOT22, Voice Handicap Index, Reflux Symptom Index, Snoring Severity Scale, Epworth Sleepiness Scale, SYTOP BANG, Sleep Hygiene Index, Sleep Disorders Questionnaire. See the resources section above for links.
  17. Q: what would make you suspect a fungal sinusitis?
    Allergic fungal sinusitis can often be found in someone with nose allergies and clinical suggestion of sinusitis. CT confirms the diagnosis. Invasive fungal sinusitis is a lot less common and thankfully so because it can be fatal! Usually seen in immunocompromised patients.
  18. Q: I’m sorry I missed the first 15 mins of the talk so I may have missed this but would you recommend routinely reviewing the ears of a child 4-6 weeks after acute om and whether there is evidence to support the use of longer course of antibiotics for chronic om with effusion?
    Review in 3-4 months would probably be better. Long course of antibiotic does not show any benefit.
  19. Q: was that epos guideline for sinusitis?
    Yes.
  20. Q: What is best treatment for children who have chronic itchy noses leading to redness and possible fungal infections at the site?
    Flixonase spray with Mometasone ointment for the skin redness before they get fungal infection. Alternative is Chlorsig ointment for the skin.
  21. Q: If a child will not use a steroid nasal spray can you use a ICS inhaler via spacer and mask and tell them to breath through the nose instead?
    Great idea!
  22. Q: Is there any connection between kids with OME and nose bleeds?
    Not to my knowledge.
  23. Q: Do you advice any ointment to apply after nasal cauterisation?
    Chlorsig, Vaseline or very occasionally Foban.
  24. Q: How long would acceptable for benign globus sensation to last?
    With anti-reflux treatment and reassurance, patients generally start noticing an improvement within a week and should settle down completely in 6-8 weeks.
  25. Q: You have said you are taking medication for laryngitis, what have you taken?!
    Paracetamol, Ibuprofen and Dexamethasone 4mg bd for three days!
  26. Q: What’s your opinion on an oesophageal pouch that requires surgery please in adults in their 60’s?
    Excellent question! Pharyngeal pouch that is symptomatic in 60s should be looked at by ENT. Barium swallow confirms the diagnosis. Treatment options include endoscopic stapling or laser or external approach with cricopharyngeal myotomy.
  27. Q: Ciprofloxacin (eye drops) for OE - only subsidised 2nd line for CSOM. Is there any other options for patients with OE with grommets/perforation who cannot afford Ciprofloxacin drops?
    Short course of Sofradex is usually fine. Risk of ototoxicity is comparable to that from untreated infection.
  28. Q: how many hours on average are we in REM a night
    About 20% of sleep time, with majority occurring in early hours of the morning.
  29. Q: What can be done for older children experiencing chronic bed wetting? Huge impacts on sleep and therefore learning.
    ENT assessment for large adenoids and/or tonsils and surgery if clinical suggestion of sleep disordered breathing. Parents can record a video or audio of their child’s breathing while asleep. Daytime nasal obstruction should be promptly treated with nasal spray while awaiting ENT review.
  30. Q: what was the sleep study mentioned please.
    Level 3 sleep study done at home often uses a machine like Resmed Apnoealink Air.
  31. Q: How does sleep hygiene help for OSA?
    With OSA disrupting the quality of sleep architecture, eliminating screen time prior to sleep and also ensuring regular and adequate sleep duration will not fix the OSA but make the problem a bit smaller to deal with. On the flip side, any treatment for OSA will not be as effective as it could be if there are associated sleep hygiene issues.
  32. Q: comment : This topic of sleep /OSA would be better as an independent presentation.
    Absolutely. That was the original plan. Including other common ENT problems was also a pressing need, hence this whirlwind tour. There is more specific material in the pipeline.
  33. Q: Is there any known problems or side effects with long term use of CPP machines ?
    Some studies show nasal obstruction due to engorgement of tissues inside the nose. Patients report discomfort from airflow, especially at high pressure flows. Some patients report tinnitus. If they can tolerate these issues, it is generally not know to have any significant side effects.