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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