key issues in ent for gp registrars haytham kubba consultant paediatric otolaryngologist yorkhill,...

Key issues in ENTfor GP Registrars

Haytham KubbaConsultant Paediatric Otolaryngologist

Yorkhill, Glasgow

• Permanent congenital hearing impairment

• Glue ear

• Recurrent acute otitis media

• Adenoids and tonsils

• Services on offer at Yorkhill

Permanent congenital hearing impairment

Why screen?

• Serious

• Asymptomatic phase

• Treatment available

• Outcome better when treated early

• Test available and acceptable

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

Who is considered high risk?• Sensorineural deafness

in 1st degree relative

• Bacterial meningitis

• SCBU graduates– preterm < 32 weeks

– very low birthweight <1500g

– required ventilation

– known toxic levels of aminoglycosides

– serum bilirubin >400mmol/l at term

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

NDCS targets

• National Deaf Children’s 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

How can we improve?

• Universal neonatal screening

• May use – evoked response

audiometry– automated response cradle– otoacoustic emissions

Universal Neonatal Screening

• Pilot sites - Dundee, Edinburgh, Highlands

• Implemented across Scotland Oct 2005

• Local policies– test methods– pass criteria– infrastructure

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

Haytham’s 1st law of screening

“those most at risk of the disease are also the ones LEAST LIKELY TO

ATTEND for screening”

Prevalencebetter ear >40dBHL

Fortnum et al, BMJ 2001

Take-home message 1Permanent hearing impairment

• UNHS is fantastic, but…

• UNHS is not the end of the story

• Constant vigilance throughout childhood

Otitis media with effusion

• Bacterial biofilm disease

• Eustachian tube dysfunction is old hat

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

• Shown to work:– Adenoidectomy– Grommets

Take-home message 2Otitis media with effusion

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

Recurrent acute OM

• Treat as & when• Antibiotics

• 35 RCTs 3/12 prophylaxis

• Effective, side effects +

• Grommets• Le 1991, RCT n=44

• 1.2 fewer infections in 6/12

• Adenoidectomy• Paradise 1999, Koivunen 2004

• Little or no benefit

Take-home message 3Recurrent acute otitis media

• Our treatments are largely unsatisfactory

• Watch and wait is often the best approach

Acute OM

• Antibiotics– 4 systematic reviews– no effect on pain scores– shorten illness

• Outcomes?

• Diagnostic criteria?

Take-home message 4Acute otitis media

• Antibiotics – never say never– Beware under 2 years of age

• Incidence of complications is rising

Chronic otitis mediarecurrent or persistent otorrhoea

Take-home message 5recurrent or persistent otorrhoea

• refer

• Sore throats:– SIGN guidelines– Often settle without

surgery

• Nasal congestion– Preschool = ads– Settles with time

– School = allergy– Nasal steroids

Obstructive sleep apnoea

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

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

Take-home message 6T&A

• Sore throats, nasal congestion – usually benign, avoid surgery

• Always enquire about sleep apnoea– this is serious and needs

treating