ENT

Introduction

Welcome to the Ear, Nose & Throat CASES webpage. We hope you will find the links and videos educationally useful and relevant.

The Pie chart shown below represents the breakdown of ENT referrals received into CASES from the Pilot until 31 January 2017. Around 16% of the referrals were sent back to practices with advice on management that can be carried out in primary care. A further 7% were sent back to practices asking for more information to be included in the referral letter before sending to secondary care.

Dr Nadeem Petkar, Dr Nabeel Makmahi and Dr Scott Davison peer review ENT referrals for CASES. They are supported by Mr Jaydip Ray, Consultant ENT surgeon and Clinical Director of ENT at Sheffield Teaching Hospitals NHS Foundation trust who provides valuable mentorship, advice and guidance.

Educational materials and advice

Please contact PCS if you feel you would benefit from receiving CASES information based on individual GP or Practice referrals for reflective learning (please note this can support CPD training and appraisal). You may wish to use the below template:

Record of learning template

Videos:

In the following videos, Mr Ray discusses common ENT problems and their recommended management.

In video 1, he describes Dix Hallpike technique to diagnose Benign Paroxysmal Positional Vertigo (BPPV) followed on by Epley’s manoeuvre to treat it. Both these manoeuvres can be performed in primary care:

In video 2, Mr Ray demonstrates management of epistaxis by nasal cauterization using a silver nitrate cautery stick:

Video 3 shows the assessment of a dizzy patient:

Useful links and Top ENT tips:

1) Epistaxis management: In video 2 above, Mr Ray demonstrates nasal cauterization in a GP surgery along with the equipment needed to perform this safely (silver nitrate stick, nasal speculum, otoscope for illumination, lignocaine cotton pellet to anaesthetise the nostril prior to cautery). However, it was not possible to show actual application of the silver nitrate stick on the reel patient in the video.

However, click here to view a YouTube video that demonstrates nasal cauterization on a real patient with left septal little’s area bleeding. As can be seen in the video, and also explained by Mr Ray, it is important to firstly cauterize with the silver nitrate cautery stick around the bleeding vessel and then completely cauterize the bleeding vessel itself.

TOP TIPS WHEN PERFORMING NASAL CAUTERY:

Use cotton wool soaked in lignocaine (preferably with 1:100000 Adrenaline if available and if not contraindicated. However, one can use plain lignocaine as well) to anaesthetise the septal mucosa prior to cautery.
Only cauterize one side of the septum at the same sitting. This is to prevent septal perforation
Once the septum is cauterized, the patient has to be commenced on antibiotic cream (please ensure patient has no allergy to peanuts if prescribing naseptin cream) for two weeks along with saline spray.

2) OSA and Snoring referral form: This is available at the CCG Press Portal

3) Tonsillectomy: Sheffield CCG has published guidelines on referring patients for tonsillectomy in adults.

Please note that an Individual Funding Request (IFR) approval is needed when a patient is referred for tonsillectomy.

4) Allergy avoidance advice at Allergy UK , which is a charity that provides patient information and support network for those with allergy

5) British Society for allergy and Clinical Immunology (BASCI):The BSACI is the national, professional and academic society whose aim is to improve the management of allergies and related diseases of the immune system in the United Kingdom, through education, training and research. BSACI guidelines are designed to give guidance in the United Kingdom and are based on the best available evidence. Guidelines are summarised and adapted for Primary Care to be published by e-Guidelines and/or other allergy journals, e.g. The Primary Care respiratory journal

6) British Tinnitus Association: This has GP guidance as well as patient information leaflets on self care and living with tinnitus.

7) Watery bilateral rhinorrhoea:
Where there are no polyps or no obvious medication causes (eg ACE-I/NSAIDs) and allergy is not suspected or steroids ineffective (3 month trial), then ipratropium bromide spray 1-2 puffs prn/tds is often effective but shouldn’t be used in glaucoma patients. Sterimar spray (isotonic) is an alternative in these cases.

8) Ear exam in suspected Serous Otitis Media with Effusion (OME):

When assessing for OME, or for other causes of hearing loss, especially in patients with conductive hearing loss (ie, true Rinne’s negative: Bone Conduction is greater than Air Conduction), ask the patient to undertake a Valsalva (“make your ears pop”) when you are in position with your otoscope. If the patient cannot make their TM move then either they can’t do Valsalva (most can when taught), or their Eustachian Tube (ET) is blocked. If the TM is retracted and dull, more likely than not, there is an effusion. If the TM does move, you may see bubbles. This confirms that fluid is present and it is worth persisting with treatment, as long as there are no red flags, such as progressive ipsilateral nasal blockage or posterior chain neck lymphadenopathy. In the absence of these red flags, persistence of OME beyond 8 weeks, despite treatment with nasal steroid and regular Valsalva, should prompt ENT referral.

9) Sore throat (acute): antimicrobial prescribing

There is a new update from NICE (2018) on managing sore throats, sent to us from the Laboratory Medicine department at Sheffield Teaching Hospitals. The FeverPain score is a validated method for assessing which patients are likely to benefit from antibiotics.

Each of the FeverPAIN criteria score 1 point (maximum score of 5): Fever; Purulence; Attend rapidly (3 days or less); Severely Inflamed tonsils; No cough or coryza.

We would suggest sending a bacterial throat swab to the laboratory in the following circumstances:

recurrence of symptoms
where person wishes to take antibiotic only in the context of a positive sample
severely unwell
penicillin allergy (susceptibility to non-beta-lactams is not predictable)
healthcare workers / care home residents / outbreak setting / scarlet fever.
NB: Positive group A streptococcal results from any site will no longer be phoned to practices as the patients will be already managed appropriately and the results will continue to be reported electronically.