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Ear, Nose and Throat · PDF file Ear, Nose and Throat . Dr Stephen Rodrigues . Head of Department . GP education event . 2 September 2017 . Solutions . Pathways . Referral criteria

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  • Ear, Nose and Throat Dr Stephen Rodrigues

    Head of Department

    GP education event

    2 September 2017

  • Solutions Pathways

    Referral criteria

    Fast Track Clinics

  • ENT Topics

    • Tonsillitis

    • Rhinitis

    • Sinusitis

    • Hearing Loss & Tinnitus

    • Vertigo

  • Tonsillitis Indications for Surgery Recurrent Infection



    Suspected malignancy

  • Indications for consideration for tonsillectomy Paradise criteria :≥ 7 episodes in the preceding year, or≥ 5 episodes in each of the preceding 2 years, or≥ 3 episodes in each of the preceding 3 years. Extraordinary circumstances e.g., excessive time off work (> 3 weeks per year), or school (> 4 weeks per year) documented. Episodes must be well documented, clinically significant and adequately treated.

  • Rhinitis Treatment mainly medical


    Non Allergic


  • Rhinitis History – Atopy, Asthma, Triggers

    Examination – Rhinoscopy

    Investigations – Skin test / RAST

  • Rhinitis

    Allergy test

    Immunology review if

    significant abnormality

    6 week Trial Intranasal steroid

    Refer ENT if nasal obstruction


  • Sinusitis Acute vs Chronic

    Spectrum of disease - Rhinosinusitis

    Same underlying pathophysiology


  • Differential Diagnosis Migraine

    Tension Headache

    Midfacial Pain Syndrome

    TMJ Arthropathy

  • Midfacial Pain Syndrome Common

    Analagous to tension headache

    Presentation similar to CRS

    No nasal obstruction or rhinorrhoea

    No improvement with antibiotics

  • Midfacial Pain Syndrome Exclude CRS (Normal CT)

    Low dose TCA for min 6/52

  • Chronic Sinusitis Intranasal Steroids

    Saline Irrigation

    Second line treatments – antihistamines, Atrovent

    Antibiotics – 6 week course of Roxithromycin


  • Chronic Sinusitis

    CT Paranasal Sinuses

  • Facial Pain

    Nasal Symptoms eg Obstruction, Mucus,

    Postnasal drip

    6 week trial of intranasal steroids, Saline irrigation

    4 weeks of antibiotic therapy

    CT paranasal sinuses if no improvement

    Refer ENT

    No nasal obstruction

    Consider alternate diagnoses eg myofascial pain, tension headache,

    CT paranasal sinuses

    Refer ENT if significant abnormality

    Refer orofacial pain specialist if CT negative

  • Systemic symptoms Severe, persistent frontal headache Periorbital oedema or erythema Facial cellulitis Altered visual acuity or diplopia

  • Hearing Loss and Tinnitus Common Audiology When to refer and where?

  • Hearing Loss and Tinnitus DIAGNOSIS – Air and Bone Conduction Audiometry TREATMENT – SNHL – Hearing Aid -- CHL – Hearing aid / surgery ? NOTHING

  • Hearing Loss and Tinnitus ENT Review - Conductive HL - SNHL not responsive to aids - Unable to wear aid eg infection - Asymmetric SNHL with imaging abnormalities

  • Tinnitus Pulsatile vs non-pulsatile Unilateral vs bilateral Hearing status

  • Tinnitus



    Normal Examination

    Refer Audiology for

    audiogram and tinnitus


    Abnormal examination

    Refer ENT


    Audiogram MRI IAM

    MRI Normal

    Refer audiology for

    tinnitus therapy +/- hearing aid

    MRI Abnormal

    Refer ENT


    Audiogram Contrast CT Brain, Skull

    Base and Neck

    Refer ENT


  • Balance Clinic Long wait Undifferentiated referrals Many treatable

  • Problems Wrong diagnosis ie NOT vertigo - Postural hypo tension - Arrhythmia – VT!!! - Migraine Symptoms gone

  • Balance Clinic Vestibular Physio review Disc w ENT Consultant – d/c or review Review in combined Balance Clinic if required

  • Balance Clinic Does it work??

  • Key points – Health Pathways

    Shift in approach

    Improve access

    Reduce unnecessary follow up

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