Transcript Document

Key issues in ENT
for 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
Permanent congenital hearing
impairment
Why screen?
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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
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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”
Prevalence
better ear >40dBHL
Fortnum et al, BMJ 2001
Take-home message 1
Permanent 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:
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Auto-inflation
Antihistamines
Mucolytics
Decongestants
Steroids
Antibiotics
• Shown to work:
– Adenoidectomy
– Grommets
Take-home message 2
Otitis 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 3
Recurrent 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 4
Acute otitis media
• Antibiotics – never say never
– Beware under 2 years of age
• Incidence of complications is rising
Chronic otitis media
recurrent or persistent otorrhoea
Take-home message 5
recurrent 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 6
T&A
• Sore throats, nasal
congestion
– usually benign, avoid surgery
• Always enquire about sleep
apnoea
– this is serious and needs
treating