Key issues in ENT for GP Registrars

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Key issues in ENTfor GP Registrars

• Haytham Kubba
• Consultant Paediatric Otolaryngologist
• Yorkhill, Glasgow

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• Permanent congenital hearing impairment
• Glue ear
• Recurrent acute otitis media
• Adenoids and tonsils
• Services on offer at Yorkhill

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Permanent congenital hearing impairment
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Why screen?

• Serious
• Asymptomatic phase
• Treatment available
• Outcome better when treated early
• Test available and acceptable

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How have we screened?

• Universal behavioural tests in infants
• Health visitor distraction test at 8 months
• Targeted objective tests for high risk neonates
• Evoked response audiometry within 6 weeks

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Who is considered high risk?

• Sensorineural deafness in 1st degree relative
• Bacterial meningitis
• SCBU graduates
• preterm lt 32 weeks
• very low birthweight lt1500g
• required ventilation
• known toxic levels of aminoglycosides
• serum bilirubin gt400mmol/l at term

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Health visitor distraction tests

• Distraction test can be effective
• Requires
• good technique
• equipment
• quiet environment
• cooperative child
• Results often poor - 50 deaf children missed by
  HV tests

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NDCS targets

• National Deaf Childrens Society 1994
• 40 deaf children identified by 6 months
• 80 by 1 year of age
• Ayrshire results (Kubba, 1996)
• 17 by 6 months
• 40 by 1 year
• UK average age at diagnosis 18 months

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How can we improve?

• Universal neonatal screening
• May use
• evoked response audiometry
• automated response cradle
• otoacoustic emissions

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Universal Neonatal Screening

• Pilot sites - Dundee, Edinburgh, Highlands
• Implemented across Scotland Oct 2005
• Local policies
• test methods
• pass criteria
• infrastructure

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UNHS in Glasgow

• Automated ABR
• 13 screeners in 3 maternity units
• Community follow up clinics
• 95 screen coverage
• 15 new cases of PCHI in 1st year
• Only ½ had risk factors
• Mean age at diagnosis 9 weeks
• Prev 20 months

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Haythams 1st law of screening

• those most at risk of the disease are also the
  ones LEAST LIKELY TO ATTEND for screening

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Prevalencebetter ear gt40dBHL

• Fortnum et al, BMJ 2001

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Take-home message 1Permanent hearing impairment

• UNHS is fantastic, but
• UNHS is not the end of the story
• Constant vigilance throughout childhood

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Otitis media with effusion
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• Bacterial biofilm disease
• Eustachian tube dysfunction is old hat

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• Discredited
• Auto-inflation
• Antihistamines
• Mucolytics
• Decongestants
• Steroids
• Antibiotics

• Shown to work
• Adenoidectomy
• Grommets

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Take-home message 2Otitis media with effusion

• If the child is bad enough to need treatment,
  they need an operation

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Recurrent acute OM

• Treat as when
• Antibiotics
• 35 RCTs 3/12 prophylaxis
• Effective, side effects
• Grommets
• Le 1991, RCT n44
• 1.2 fewer infections in 6/12
• Adenoidectomy
• Paradise 1999, Koivunen 2004
• Little or no benefit

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Take-home message 3Recurrent acute otitis media

• Our treatments are largely unsatisfactory
• Watch and wait is often the best approach

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Acute OM

• Antibiotics
• 4 systematic reviews
• no effect on pain scores
• shorten illness
• Outcomes?
• Diagnostic criteria?

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Take-home message 4Acute otitis media

• Antibiotics never say never
• Beware under 2 years of age
• Incidence of complications is rising

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Chronic otitis mediarecurrent or persistent
otorrhoea
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Take-home message 5recurrent or persistent
otorrhoea

• refer

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• Sore throats
• SIGN guidelines
• Often settle without surgery
• Nasal congestion
• Preschool ads
• Settles with time
• School allergy
• Nasal steroids

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Obstructive sleep apnoea

• Features
• Heavy snoring
• Snort arousals
• Disturbed sleep
• Enuresis
• Night terrors
• Fatigue

• Effects
• Poor concentration
• Cognitive impairment
• Fatigue
• Hyperactivity
• Hypertension
• Cor pulmonale

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Take-home message 6TA

• Sore throats, nasal congestion
• usually benign, avoid surgery
• Always enquire about sleep apnoea
• this is serious and needs treating