ENT webinar transcript

Louise King

Good evening and thank you very much for joining our webinar on blocked noses and blocked ears. My name is Louise and I'm your host. Our expert presenter this evening is Consultant ENT Surgeon Henry Sharp who you can see on the screen.

Today's presentation will be followed by a Q&A session. You can ask questions throughout the presentation. You do this via the Q&A icon at the bottom of your screen. When you ask questions, you can do so by providing your name or anonymously - it's up to you - and just to let you know that this session is being recorded.

At the end of this session we'll put a phone number up on the screen and my colleague Paul will be at the end of the line to answer any questions about consultations. That number is also available Monday to Friday between 9am and 5pm. I think that's everything, so I will now hand over to Henry Sharp.

Mr Henry Sharp

Thank you and thank you very much Louise. I’d just like to echo her welcome to you all and thank you very much for joining us. I hope you've got a glass of something pleasant or perhaps a cup of tea or coffee.

The idea is just to talk to you a little bit about what I do most of the time, which is deal with problems particularly in the nose but the ear as well. But also, to explain to you how these can have a knock-on effect into problems in the throat as well.

So, I’ll cover the basics really of ENT for you in a talk for about 20 minutes or so and then give you the opportunity (I hope) to ask as many questions as you'd like. So as far as Benenden (Hospital) goes I'm part of a team of six ENT surgeons who work here. We were appointed to Benenden in 2013. On a personal note I was appointed in the NHS into private practice in 2004 but Benenden is a part of my practice that I really enjoy.

So, moving swiftly onwards. Just to show you really a schematic diagram which is, apart from being a pretty picture, really sort of shows the interconnection between the ear, the nose and the throat. And it's (sort of) me in the middle between the different bits. But it is a fairly accurate representation of how the ears, the nose and the throat are connected and clearly symptoms are one part of that.

Part of ENT can reflect in another and I think, hopefully, you'll realise that as we go through the talk. So unfortunately, at the moment as we all know GPs are under an awful lot of pressure and that they're absolutely snowed under. COVID-19 has not helped that, and they really are under a huge amount of stress.

I'm well aware that a lot of patients say to me how difficult it is to access their GP at the moment and that's a problem that we feel in ENT that reflects unfortunately in people's experience of treatment of their ENT conditions.

The other problem is that GPs do tend to see a lot of people, perhaps, who maybe shouldn't really be going to the GP in the first place. This was an interesting little article that I found in the Daily Telegraph a while back before COVID-19 (so clearly it must be true if it was in the Telegraph!) but one in five GP appointments are said to be unnecessary.

Now you may agree that dandruff may be unnecessary to go and see your GP about, but it’s also classed in that group of ailments - a blocked nose. Actually I wouldn't say that's actually trivial at all because - as we all know-  having a blocked nose and having a cold is actually extremely unpleasant and having that every day of your life - as a number of you out there will know -- really does impact on your quality of life.

If you look at the last few lines of that article, you know, there were several thousand with dandruff, several thousand with travel sickness, but 5.2 million patients with blocked noses. Now a twelfth of the population has a problem with a blocked nose so I think that's not trivial at all. And it's clearly indicating what an issue it is for the population at large.

So, the key here at Benenden is diagnosis. You know, a lot of the patients I see here are struggling to get a diagnosis through their GP, either because they can't access them, because they're too busy or actually they don't have the equipment to hand in a GP’s practice.

ENT is quite a niche specialty because you need microscopes, you need endoscopes and also you need ENT training, to be honest, to actually be able to diagnose people accurately and swiftly. And that's something that the GPs may struggle with sometimes. So, we really want to offer you an excellent diagnostic service here at Benenden as much as anything and potentially treatment as a result of that.

So, let's just talk a little bit, without going into too much sort of medical detail, but you may know about your sinuses. So, let's just talk a little bit about the anatomy of that.

So, the sinuses basically are paired structures; they're air-filled cavities in your skull and you have several pairs of them. There are the maxillary sinuses in your cheeks, here there are the frontal sinuses in your head and your forehead and then there are the ethmoid sinuses, which is a little sort of honeycomb structure between your eyes.

Here, as far as your nose is concerned, you have a nasal septum - a partition between the two sides - and you have three pairs of paired turbinates which are sort of projections from the side wall of your nose. And you'll see those in a minute when I show you a little video.

But there are little projections inside your nose that may have an effect on the nasal passage and block the nose, potentially. So, these are things that you'll see in a minute.

Then also you'll see the tear duct comes into the nose. The tear passage (the lacrimal system) comes into the nose and at the back (which you can't see) the Eustachian tube comes into your nose, which is the tube that drains from your middle ear into your nose and allows pressure changes in your middle ear.

So, here's let's have a little look around inside of the nose. I sort of caution here if people are a bit squeamish. This is not any bloody, horrible sort of appearance but it may be of interest for you to look what it's like inside your nose and to show you what some of that anatomy is like. So, look away if you're a bit squeamish but it's not going to be that bad, I promise you.

So here we are, going into the nose with an endoscope. Here we have the inferior turbinate which, as you can see, is quite a large structure. There's the middle turbinate - they do fill up quite a lot of the nasal cavity. Here's the nasal septum as we go towards the back of the nose. There is a mild, in this patient, little deviation of the nasal septum there, which is slightly narrowing the nose on this left side.

If we go towards the back of the nose you'll see here where the adenoids would be in a child, and there is the eustachian tube opening. So, you can see why children get glue ear if the adenoids are enlarged there, which blocks the Eustachian tube opening at the back there and they get glue ear. But it happens in adults as well.

So that's a little view inside the nose. The inferior turbinates there, which we'll come back to later as far as treatments go. So, there you have a fairly normal appearance of the nose from the inside.

Now the opening gambit. When I see patients, who come to see me, I say well what can I do to help you and they say, “I've got sinus, doctor” or they say “I've got sinusitis”.

Now that, in my experience, can mean a number of things. It can mean any of these symptoms that I've written down here, because these are the symptoms really that you may be describing when you think you've got sinus or sinusitis.

So, sinusitis to me generally means you've got facial pain or headaches. Those sinuses that I showed you earlier get blocked and so you get pressure pain in your cheeks, in your forehead because of the problems in your sinuses. So facial pain or headaches is really what I describe as sinusitis, but you may also get discharge from the nose which may come from the front or down the back which people often describe as postnasal drip or catarrh. But other people may get problems having to blow their nose all the time.

The other symptom many people may describe is a blocked nose and if you can't breathe through your nose, this may have a number of knock-on effects in your daily life such as snoring; your sleep pattern is disturbed because you can't breathe. You breathe through your mouth, so you get a sore throat and you get a hoarse voice hence the knock-on effect into other parts of the E, the N and the T which I described earlier.

Your sense of smell may deteriorate, which has come particularly into focus with COVID-19 but happens a lot in other people with problems with their nose.

You may have a sneezing or itchy nose which may specifically suggest an allergy, you may have nose bleeds and if your Eustachian tube at the back there is blocked, you may get blocked ears and muffled hearing. And if your tear duct is blocked you may get watery or itchy eye.

So, a lot of knock-on effects from problems in your nose, but any of those symptoms may be something that you're experiencing at the moment.

So, as I said earlier, diagnosis is key here. We have here at Benenden, special endoscopes and here I am demonstrating on this patient, endoscopy of the nose which is carried out in outpatients. No anaesthetic is necessary. This patient's sitting there, he's quite happy, he doesn't look particularly anxious or in pain because he isn't.

It's very easy to do. It takes about ten seconds; it gives me a very good view on the left there of the internal aspects of the nose which you saw earlier when I showed you. Then on the right picture, those observant of you will see the larynx, so we can see all the way down which is the voice box.

We can see all the way down through the nose to look at the nose, the back of the nose and down towards the larynx there. So, we get a full view of the nose and the throat with that very simple procedure, which we can do in outpatients for you.

We may organise some further tests and particularly these tests: a CT scan, a special diagnostic x-ray may be necessary, and also some allergy tests if you do have some symptoms suggested with allergy, like sneezing or itching of the nose or itching of the eyes, running of the eyes. That does suggest allergy and we can do some blood tests for you to fully diagnose that and to see exactly what it is you're allergic to.

The rust blood tests I refer to there, we can do to lots of different potential allergens and tell you exactly what it is you're allergic to. So, these are tests that we may arrange for you in your outpatient visit.

So, what can cause these nasal symptoms? Well, in general, it's one of two things or a combination of them which is not unusual.

Problems with the nasal lining - you may have heard of rhinitis or rhinosinusitis which basically means an inflammation of the nasal lining and also problems with the nasal structure. Here, I particularly mean the nasal septum may be deviated and an operation to correct the nasal septum is probably the most common operation I do.

So, chronic rhinitis or rhinosinusitis. This is what I mean when I mean inflammation or swelling of the lining of the nose. When we say it's chronic, we don't mean it's really bad (which some people think chronic means it's really bad) It actually means it's long-standing.

So chronic rhinosinusitis means you've got symptoms for more than three months generally and you can describe it or diagnose it as being allergic or non-allergic. That's really done as much as anything on the history and what you tell us your symptoms are. So allergic problems, I mean most people will be familiar with hay fever, you get a watery discharge from your nose, you get sneezing episodes, your nose itches, it's uncomfortable.

You may well get symptoms with your eyes as well and you may also have an association with asthma or eczema which is termed ‘atopy’ because allergic rhinitis is very common with those other conditions. However, other people may describe a mucky, green, horrible, yellow, nasty discharge from the nose and more problems with facial pressure and pain and that suggests to me more of a non-allergic type problem; a chronic infective problem inside your sinuses rather than allergy.

So, we can tell quite a lot about the likely causes of your problems just by asking you a thorough and decent history from you.

How can that be treated? Well I would emphasise to you that’s what about coming to Benenden is - early diagnosis. It's really important to get diagnosed early with these situations because, if you don't, then it's likely to get worse.

And it sounds obvious, but it is, and the earlier you get diagnosed the less likely you are to need surgery because most cases of rhinosinusitis - once they're diagnosed - are treatable medically without the need for surgery. With advice, various nasal drops, or sprays targeted antibiotics and treatment for your allergy, if necessary.

If, however, it's left untreated, you may get more inflammation inside your nose and, eventually, nasal polyps which are a sign of long-standing inflammation which has been not adequately treated in your nose.

Also, actually there's good evidence that having problems in your nose makes your other asthma and chest symptoms worse and you get what's called the ‘allergic march’. In other words, your symptoms are marching along without being treated properly and many people out there who have asthma and problems with their nose will know what I mean. If one is bad the other tends to be bad as well so it is, particularly if you are asthmatic, important to get treated properly with regards to your nose - it's often forgotten with problems with your nose. Asthma is thought of as being very serious and everyone takes it very seriously, but the problems with your nose are, you know, equally serious in some ways.

So, here's again maybe a little bit more of this, less for the squeamish than before, but here is a nasal polyp inside the nose. So, this is a sign of long-standing sinusitis that's been allowed to progress to a point where these polyps are formed. So, this sort of grey, gristly, nasty structure is a nasal polyp. It's entirely benign but when it gets to this point, surgery is going to be required. You're not going to treat that medically, and I'll show you how I do treat it which is a little debriding device. It's a bit like (those of you a certain age will remember) Pacman. Well this is my version of Pacman which is a little debrider and it removes the polyps very quickly and easily with minimal blood.

This is in real time as I do it. So, it really doesn't take very long for my little Pacman device to remove these polyps and for instantly your nose to be very much better. So, you know, this is what I do. Again, probably the second most common operation I do is this one.

To remove all these polyps, one has to be a little bit careful but just to the right of the screen is your eye and just to the top of the screen is your brain so you have to be a little bit careful about where you debride but obviously within reason. With these delicate little devices and under direct vision like this it's a very safe procedure.

So that is surgery - when you get to the stage of having nasal polyps - called Functional Endoscopic Sinus Surgery.

What can go wrong? What can happen with the structure of your nose? As I mentioned earlier, well, you can have a twisted nasal septum which is a partition between your two nostrils, and this can be deviated particularly to one side or the other and it may be very obvious.

You'll tell me “The right side of my nose is blocked” or “The left side of my nose is blocked”, which side it's bent to but obviously sometimes it's not so obvious until I look in your nose with my little endoscope.

It's important to think to yourself “I haven't got a bend in my nose on the outside so I can't have a bend on the inside”, but actually that's not the case. It's actually more common for people to have a straight nose on the outside and a bent nose on the inside than to have both being bent at the same time. So just because you've got a straight nose on the outside does not mean you haven't got a bent septum.

Something worth thinking about, and the treatment for that is a relatively straightforward operation called a septoplasty, which takes about 40 minutes under a general anaesthetic as a day case that's very easily remedied once diagnosed.

The other thing that can cause a problem is hypertrophy or swelling of those inferior turbinates that I showed you earlier. Now, as you can see, they're really quite large and they do fill up quite a lot of the nasal airway; so if they get particularly swollen with severe rhinitis that I mentioned earlier that doesn't respond to medical treatments, they may need surgically reducing in size. And that's an operation that we term turbinoplasty.

So the inferior turbinate is reshaped, the bone that actually is a bit like filleting a bit of beef. The bone is filleted out and the actual lining of the turbinate is reshaped to give you far more room inside your nose. Very successful operation for improving the nasal airway. So, here's an example of a patient that's had a combination of things has had a bent partition, a bent septum and a nasal polyp.

So just to orientate you, on the left here this is a CT scan of the sinuses. So, we've taken a picture of your face. Here's the top of the head going over there, which we've cut off. This is the mouth down here, which we've cut off. Here are the eyes and here's the brain.

So, in the middle here are the sinuses. Here is the right, this is the right side, and this is the left side, so the patient is looking out of the screen at us. Here is the right maxillary sinus which I mentioned earlier, which is full of black - which is air which is what you want. Here is the left maxillary sinus, which is full of grey, which is polyp. Alright, so that's a big polyp coming out of the maxillary sinus poking into the nose.

Here, in addition to that, you will see that the nasal septum here is bent. Instead of being straight down the middle as it should be, it goes up and then it curves with this big bony sort of spike here; so, a big sort of curve over to the left side.

So, you've got a bent partition, a bent septum and a large polyp completely blocking the left side of the nose. So, we do a combination here of septoplasty and Functional Endoscopic Sinus Surgery and this is the post-operative results. On this side you'll see now the septum is nice and straight down the middle here and the polyp is gone and a nice opening from the maxillary sinus here into the nose. All the grey stuff which was here has now completely gone and these sinuses have been opened up. These are the ethmoid sinuses here, but the main thing is this big polyp in the maxillary sinus is completely gone. So that shows you the radiological results of the procedures that I mentioned earlier.

So, moving onwards. Let's just talk a little bit about the ear, which again is something that we do a lot of treatments and diagnosis for you here at Benenden. The anatomy of the ear generally and the problems you'll experience with it, can be divided into three sections.

So, the outer ear canal (your outer ear of course is actually termed a pinna), you then have the ear canal which goes down to your eardrum and that those three structures are generally termed as the outer ear.

Then there is the middle ear which is an airtight little box, demonstrated on the picture here, which has three little what's called ossicles or bones in the middle ear, the hammer, the anvil and the stirrup, also called the malleus, the incus and the stapes, which are the proper names for them and they're connected together by little joints.

So, what happens is noise comes in here, it vibrates the eardrum. These three bones vibrate and then it goes into the inner ear here, which is the cochlear. The cochlear is a seashell type structure. It's also connected to these gyroscope type structures here, which control your balance, so the in-ear area’s control is concerned with hearing and balance. At the same time this nerve here goes from the cochlear and the balance system and goes off to your brain that's called the vestibular cochlear nerve, one of the cranial nerves in our head.

So that these are the structures that we must think about when we think about what may go wrong with your ears.

So, what symptoms may your ear problems give you? Well, the three main things that people describe are an alteration in their hearing, usually hearing loss, obviously their hearing is not as good as it has been, they may get tinnitus and that the diagnosis of the tinnitus means noises in the ears with no external source and that can be any noise you hear. It can be a buzzing, a ringing, a whooshing, any noise you experience is actually tinnitus.

The definition - noises in the ears with no external source - so people may hear these noises, you may get balance problems and obviously that may be due to the inner ear. Not always though because there's lots of things that can cause problems with your balance, but one of the things that can is your inner ear. As I've described, those gyroscopes which are in your inner ear can get problems and you may get dizziness.

Then the more acute type symptoms that you may describe, particularly if you have infections either in your outer ear or your middle ear are pain and discharge. So, the more chronic type long-term symptoms are hearing loss, tinnitus and balance problems and the more acute infective type issues pain and discharge. So, these are the things you may get with problems with your ears.

So, when we think about how we're going to treat these things we obviously have to think what the cause is.

So, problems in the outer ear; what may be your experience with that? Well you may get some wax and this is very common now, particularly as people can't access (unfortunately) wax clearance services in primary care. We're seeing a lot of patients now who are getting wax impacted in their ears and also getting infections in relation to that, because when you get impacted wax it often gets infected. You may get what we term infection in the outer ear or otitis externa and this is very painful, this is a really sore condition with discharge and your ear may well swell up and so therefore give you hearing loss as well.

If you're unlucky or a little careless you may get a foreign body stuck in your ear and as adults we often see people with hearing aid moulds that have snapped off, will come off, or if you're trying to remove your wax with a cotton bud, which is probably not the best thing to do, you may get your cotton buds stuck in your ear and these are things we often fish out. There are all sorts of things we also fish out in children but we won't go into that today.

Problems in the middle ear are often related to that problem with that tube I mentioned at the back of your nose, the Eustachian tube which may- for some reason - not work as well as it should. And we term this Eustachian tube dysfunction. This has been traditionally a condition that's been very difficult to treat actually but we have this new treatment now called Balloon Eustachian Tuboplasty which is a quite exciting new development and I'll show you a little video of that in a minute to actually help that along. And it really has beneficial results for people with this condition which is very irritating, giving you a feeling of muffled hearing and sometimes popping and cracking in your ears; a bit like you get when you've had a cold and before it sort of gets better.

If that gets worse - and I've mentioned in children it can happen more commonly than in adults, but it also happens in adults - you may actually get fluid behind the eardrum in that middle ear: so-called glue ear.

This is effectively just mucus in the middle ear. It can't get out because the Eustachian tube; the only way out of the estate of the middle ear is via the Eustachian tube. If that's not working, the mucus just gets stuck and so you get glue ear and again this gives you a very muffled sensation with your hearing and can be very irritating. If that's the case, you may need an insertion of a grommet. I'll show you a little video on that in a second which is a very simple and easy way to clear this up.

Occasionally, very unusually, you may get disruption of those three little bones of hearing I described earlier. That may give you hearing loss but, more seriously, you may get something called a cholesteatoma which is a very deep seated and progressive infection in your middle ear which can lead to some quite severe consequences and really bad side effects.

So, if you have a smelly, nasty discharge and it's not getting better, it's really worth seeing someone sooner rather than later to exclude a cholesteatoma which, if it's there, does need quite extensive surgery to treat.

Lastly, of course, problems in the inner ear. And this is more related to hearing loss and tinnitus. Clearly this is your main sort of sensory organ as far as hearing is concerned and if you get, for some reason, problems in there you may well get some hearing loss and tinnitus in particular - but also balance problems as well.

The issues that we see most of generally are age-related hearing loss. Unfortunately we all lose our higher frequency hearing as we get older and this is termed presbycusis and once diagnosed by a hearing test (which we can obviously do for you here at Benenden) we can offer you or we can suggest you get some hearing aids for that. We don't often actually offer hearing aids here but it's certainly something we can recommend for you elsewhere.

Meniere's disease is a disease where basically you have too much fluid in your inner ear in that cochlea that I described to you earlier. And that gives you the classic triad of symptoms. As I said earlier, the hearing loss, the tinnitus and the vertigo or the dizziness. That’s a condition that I won't go into more detail here but again would be something that we can diagnose for you here at Benenden by examining you and performing a hearing test.

Lastly, acoustic neuroma. This is a benign tumour on the hearing nerve, so that hearing nerve that goes from your inner ear into the brain can get a benign tumour of the Schwann cells, which are the cells which surround the nerve. And that leads to often a one-sided inner ear nerve type hearing loss, and also potentially one-sided tinnitus which is unusual. Tinnitus is usually both sides if you're going to get it so one-sided tinnitus is something to be aware of and hearing loss.

So if you get one-sided hearing loss, one-sided tinnitus and some dizziness we would certainly perform what's called an MRI scan of your inner ear and your balance and hearing nerve and your brain to check that you haven't got one of these vestibular schwannomas, and we do pick them up every now and again. I mean from the people that we see with those one-sided symptoms, about one in a thousand will have a distributed schwannoma. So, it's very unusual but we do pick them up from now and again, and we do an MRI scan to put your mind at rest in any case.

In the clinic what do we do? Well we can do microscopy of the ear. So you know, we sit you down, we have a microscope in the clinic, we can look in your ear, we can clean out any debris, we can clean out any infection we can look at your eardrum.

So here is another patient having that exact procedure - very quick and easy. The little thing I'm holding in my right hand there is a tiny little hoover device, so it's called micro suction using the microscope. We can also, as I've mentioned, perform an audiogram. So, we have a dedicated, very skilled Audiometrist here who can perform a hearing test for you while you wait. And then you have the combination of my consultation and also a hearing test here, which I can tell you the result of straight away. So, this is a sort of setup that we would do for someone with ear problems in the clinic when we see them.

This is a grommet, so for someone who has glue ear. This is a little video of a grommet. So that's your eardrum. If you put it into perspective, that's smaller than your little fingernail. So, we're looking down a microscope, down a little speculum there.

We're going to make a little cut in the eardrum with a tiny little knife called a myringotome. So, we make a little cut in an appropriate area of your eardrum there. A tiny little cut in the eardrum about one or two millimetres long. And in the middle ear there is sometimes glue ear or the mucus will flood out. In this case it hasn't, but if I put a little micro suction device, as I showed you on the last slide, into the ear I can then remove the the mucus or the glue from your middle ear.

So, there's me suctioning into your middle ear to get the mucus out and there you can see the sort of yellow mucus in the middle ear there as it comes out. So, we make the hole and we actually remove the mucus at the same time. Then we put in the grommet which is this tiny little drainage tube. It basically looks like a tiny little cotton reel with a little hole down the middle. So, we place that carefully into the hole that we've done and gently position it. There's a little flange on it that stops it coming out, so with a little needle we pop a grommet in the right position.

So, this is a procedure that sometimes we can do under local anaesthetic. So we put some cream in your ear for half an hour to an hour to numb it up, if you're quite stoical, and we can do that; otherwise we most of the time we do under a general anaesthetic. But it is possible to do that under a local anaesthetic, if possible.

So, there's the grommet in position. You can see the hole down the middle which allows the middle ear to ventilate and stops the fluid from re-accumulating inside the ear. So that is a grommet.

Balloon Eustachian Tuboplasty is the operation I mentioned earlier. This is for people with not full-blown glue ear but with Eustachian tube dysfunction. So, the Eustachian tube, for some reason, is not working properly. So, we put a little balloon into that Eustachian tube that I showed you earlier, into the opening, and blow it up and what that does is inflate it, I should say rather than blowing it up, to stretch the Eustachian tube up, to allow it to work better.

Here is a Balloon Eustachian tuboplasty going into the nose, much the same as before, this is a little introducer. This is a little gentle, blunt-ended introducer that we put towards the back of the nose under endoscopic guidance, operating off a television screen. So we put the little introducer into the Eustachian tube opening at the back there, gently put that into there and then push the balloon over the top of that into the Eustachian tube and blow it up and you'll see the air going in a minute.

So, there is the balloon in place in the Eustachian tube. We then wait for two minutes; we deflate it for a minute and then we inflate it again for another minute. So that's three minutes of inflation, then here's the balloon in situ. We deflate the balloon and we remove it so again that's pretty much in real time. It's a very quick and easy manoeuvre and you'll see there's the nicely open Eustachian tube there with a nice big hole.

Basically, the Eustachian tube drains through into your middle ear and that's successful in a good number of patients to improve their Eustachian tube dysfunction. Previously, we had very little that we could do for this condition so it's quite exciting this new balloon technology.

So just in summary, what is Benenden Hospital's ENT ethos? Well as I would like to emphasise more than anything else it's prompt and accurate diagnosis. It's so important to not let your ENT problems, you know, fester as it were for months and years on end as I see so commonly.

Unfortunately, now in these days it really is very common that people don't get swift and accurate diagnosis which, you know, is disheartening. But that's just the way it is at the moment I'm afraid.

A one-stop ethos of diagnosis and instigation of a treatment plan. We try to see you and, as I've said, we do a hearing test, sometimes we need to do a CT scan but that's- you know - often just to confirm the diagnosis. The diagnosis is usually made after your visit, once we've examined your nose and done various tests and things. So very much a one-stop ethos, a bespoke treatment plan, you know, towards your particular symptoms.

It's a great sort of raison d'etre of mine to give people’s noses really good sort of plans, not just for the immediate future, but also for the medium and long term to keep your nasal problems under control. Even if you do require surgery that'll be something that I'd be keen to give you moving forwards.

There are a wide range of day case surgical solutions as I've sort of outlined here, should your medical problems and medical treatments that I offer you not be effective. Then the underlying sort of ethos really for all my patients is early return to work and normal activities, we don't like to have people off work for long periods of time and most of my patients will say how, you know, the surgery and the treatment we've done has made their quality of life so much better, that their sleep is better, their work is better, their personal relationships are better, which is you know which is a great sort of thing to hear.

So, I hope you found that helpful, if you'd like to ask any questions I'm sure we'd be pleased to hear them.

Louise King

Thank you very much, thank you that was really fascinating, really interesting, especially the videos it was amazing seeing in action so thank you.

Mr Henry Sharp

Weren't too gruesome?

Louise King

I don't think so I think they're okay hopefully. So, we have a few questions and I'll just go through them. So, the first one is they have inflamed sinuses and their doctor prescribed them with a steroid nasal spray, but they still suffer with headaches and head pressure. What should they do?

Mr Henry Sharp

Well I'm afraid I'm going to say you should come and see me. Yes, that's a very reasonable thing for your GP to have given you early on. A nasal spray, a steroid nasal spray, is designed to reduce the inflammation inside your nose so hopefully to open the sinuses up and allow the sinuses to drain easier.

If it doesn't work then basically the next trick, the thing you need to do is to have someone look in your nose with one of those endoscopes which I showed earlier and potentially you need a CT scan of your sinuses. So, I think you would fit in very much into that category of patients that have tried medical treatment.

The one thing I would do if I saw you was possibly to give you some stronger medical treatment before anything else. So I would normally move up to something like nasal drops, which are a slightly stronger steroid preparation than the nasal spray. But I think, in general, if the nasal spray has not worked then you need to possibly go and see myself or a colleague an ENT colleague to have a look in your nose with the endoscope.

Louise King

Yeah okay thank you the next two are around earwax. What are your thoughts on ear candling?

Mr Henry Sharp

No.

Louise King

That's nice and clear.

Mr Henry Sharp

Just there is no evidence of ear candling helping. People ask me this and I just fear for ear candling because, you know, it you can set your hair on fire - you can do all sorts of things. I really wouldn't recommend ear candling.

I mean syringing is fine, and it doesn't work for some people because the water inside your ear can cause a little bit of irritation and infection. The best treatment is micro suction. And I would say that, of course, but the point is with micro suction you are looking in the ear, you are seeing exactly what you're doing and the other thing is you're removing absolutely every scrap of wax because you know I won't stop until I've got every little bit out.

Ear candling is relying on - sort of, you know - a little bit of pressure changes in the outer ear, pulling the wax out of your ear. The thing is wax varies very much in consistency so I would imagine maybe ear candling - and syringe for that matter - works for people with very dry wax which comes out fairly easily. But if people (as they often do) have tried olive oil - and this happened the other day - and it creates a sort of sloppy wax inside your ear and that's not going to come out with candling. I'm afraid it's not going to come out really by syringing either, it needs to be suctioned out with micro suction.

So, my advice - and I know I’m a traditionalist, you know and whatever - it is not to do candling to be honest. I wouldn't recommend that.

Louise King

Okay thank you, the next participant says they wear a hearing aid which causes their ear to create more wax and can cause a blocked ear. What would you advise they do?

Mr Henry Sharp

Well I'm afraid that's the same thing really. You need to have people who wear hearing aids and also unfortunately it's a bit of a self-fulfilling prophecy. If you've had your ears cleaned out before it tends to make the wax form a bit more regularly. So, in general, if you wear a hearing aid, it will stop the natural migration of wax out of your ears because wax is very clever, or the ear canal is very clever.

The skin migrates out of your ear, so if you put an ink dot - a non-absorbable ink dot - in the middle of your eardrum, six weeks later that dot will be visible on the outside of your ear because the skin migrates outwards. So as the skin migrates outwards, the wax is pushed outwards as well.

So unfortunately, if you wear a hearing aid that sort of skin function is slightly - you know - is not functioning quite as well as it should. The wax can get stuck a little bit. So, I think, to be honest, you will need to have some sort of help to get the wax out either by syringing from your GP or possibly micro suction.

I mean, for instance, there are certainly - I work in East Kent hospitals in the NHS and - there are a number of my clinic nurse specialists that do it in the NHS. There are also GP practices that do it in East Kent around here. But of course, there is the option to come here to Benenden to have that carried out by me or one of my Consultant colleagues, which will give you the peace of mind of getting absolute complete clearance of your wax.

So, I think hearing aids probably you will need to have wax clearance every now and again - possibly every year.

Louise King

Okay thank you. I have two questions relating to dizziness now, so the first participant says they experience bouts of dizziness is it still safe for them to drive?

Mr Henry Sharp

Well that's a very good question. It depends on your balance. How your balance problem presents itself.

So, if you are concerned you should check on the DVLA website because there are sort of bits and pieces [of information] on that. In general, the guidance is obviously if you're dizzy all the time then you shouldn't drive. But if you have the occasional bout of dizziness and you get no warning - so in other words you can be driving along and suddenly you get hit by this bout of dizziness - then you shouldn't drive. So, no warning for your dizziness, you shouldn't drive.

However, if you do get warning and you can sort of pull over and stop and then sort of take stock of yourself and whatever, then that's usually okay. But if you're in any doubt you want to talk to the DVLA because, of course, the other issue of course is whether your car insurance will cover you if you're known to have dizziness.

So it's something to be aware of but, in general, if you look on the DVLA website it's if you get a warning or if you don't get a warning.

Louise King

Another one relating to dizziness is what could be possible to help one-sided tinnitus plus dizziness when tilting head back?

Mr Henry Sharp

Well, as I say, if you've got one side of dizziness you probably ought to come and see someone about it because - you know - one-sided tinnitus and dizziness you know very rarely can be a sign of an acoustic neuroma or vestibular schwannoma.

So we really ought to come and see us here or access your local services to have a hearing test and potentially have an MRI scan just to, you know, just to be sure there's nothing else going on there. So general ENT in general actually for one-sided symptoms. You've got two nostrils, two ears, you know. One-sided symptoms are more worrying than both side symptoms, although I think it's probably very unlikely that you do have it to worry about but one-sided symptoms is definitely something worth consulting someone about.

Louise King

Okay thank you. Okay I have a question from Sarah. She says she has had a croaky cough and throat for the past year. She also suffers with a stuffy nose and postnasal drip she has always had problems with catarrh but has become more constant.

She also gets sinus bother and experiences forehead pain and she uses this and Dymista which helps a bit and a more recent problem is a dry mouth but it may be due to high blood medicines. Could an underactive thyroid cause the throat problem, and would it be better to get it all investigated?

Mr Henry Sharp

I think the issues with your nose, I think probably needs some stronger medication. So, the blocked nose, the catarrh, things like that Dymista is not going to be enough for that.

By the sounds of it, you probably need - at the very least - some stronger nasal steroids as I was mentioning earlier; some nasal drops for a period of six to eight weeks, something of that nature to try and clear the nose out a little bit. That nasal problem will probably be causing you a dry mouth because you can't breathe very well through your nose, so you will tend to get a dry mouth and problems of that nature. So that knock-on effect will probably be quite understandable.

So, I think, in general, what I would say to you is to come and see someone. I mean that, just as I described earlier those are the sorts of symptoms that we see all the time and - if you've been trying medicines from your GP which haven't worked - then the next stage is secondary care with us. Basically, we can examine your nose with the endoscope. We may want to do a CT scan because, if you've got a lot of infection and - you know - inflammation in your sinuses, you may need surgery.

I think if it's going on a year that may well be the case. I think that, as I say, the throat problems, the croaky voice may well be related to your nasal problems. You've got postnasal drip, which is irritating your throat, you can't breathe very well through your nose, so that's causing a dry mouth. So, it all would add up.

The one thing I would say, an underactive thyroid can give you voice problems. So if you haven't had your thyroid function tested, or you know yourself to be under active thyroid, hypothyroidism can cause voice problems so worth getting that checked as well. But it sounds as though you do need to come and see someone.

Louise King

Okay thank you just a few more questions. One participant says how does progressive submucosal fibrosis affect ears in a patient?

Mr Henry Sharp

Progressive submucosal fibrosis? I'm going to have to plead ignorance there I'm sorry, I don't know that condition. I don't know that condition I have to admit to you but I'm very happy to look it up if you want to write to me, but I can't specifically comment on that condition because I don't know of it.

Louise King

Okay another participant says they have eczema and sometimes have itchy, runny blocked ears. Over the years, various GPs have said put oil in but this just makes them more blocked. Can you suggest alternatives please?

Mr Henry Sharp

Yeah that's what I mean, unfortunately people's problems in their ears is not all - you know - the same. Wax is not the same and the skin problems are not the same. I mean we do see a lot of patients with eczema and psoriasis you get problems you know skin general skin problems who have problems in their outer ears.

One thing I would say is keep your ears scrupulously dry if you've got dry skin around the ear you mustn't get water in your ears because the natural barrier to infection is not you know if your skin is not as good as it should be in general I wouldn't advise using oil and stuff. What I would advise is you can use some steroid ear drops, because steroids much the same as you would use for your eczema as a liquid form inside your ears is good for the skin.

But again occasionally I'm afraid in your case in particular syringes not going to be any good. You may need to have your ears cleaned out microsuction is the best way because that's the most gentle way it's the way that you know get all the debris out of your ear under direct vision. So we'll see you know everyone will know exactly what we're doing so I think every now and again if you do have these conditions you will need to have your ears microsuctioned this is the access problem that I know will be a problem to you but that's what I recommend as well as keeping your ear scrupulously dry and steroid drops.

Louise King

Okay thank you. Julia said she's sadly already had nasal polyps and a deviated septum, both of which were resolved under surgery some years ago. She's also needed a grommet in the past, but now she finds postnasal drip is bad and constant throat clearing, constant blowing of the nose and low-level tinnitus in the ear. She suspects the polyps may have returned and she uses Dymista and Cetrizine daily with Flixonase droplets. When it gets very bad, should she come and see you and if so, does she need to get a GP referral to do so?

Mr Henry Sharp

Well the thing to say about that is that's not too uncommon. If you have nasal polyps, as I mentioned earlier you've often got an underlying inflammatory tendency - be it asthma or whatever - and that's the same, you know, in your nose.

Your nasal lining will not change after surgery, so the old adage used to be if you've got nasal polyps no point having surgery because they always come back. Well that's not true actually. If you do the surgery very carefully, and you remove all the polyps, then you will have a much less chance of having your polyp back.

But you will need to use - as you've said - long-term intranasal steroids by ways of sprays or drops and some GPs are reluctant to prescribe these sprays. But the newer generation ones are very safe to use long term, so you're not unusual in that you're experiencing some stuffiness in your nose after surgery.

If the symptoms are still there, despite the fact you're using intranasal steroid sprays, then probably someone ought to look up your nose to make sure your polyps aren't back. By the sounds of things there maybe, you know, there may be a little bit of inflammation inside there. You may need a little bit more tidying up surgery or you may need something slightly stronger by means of steroids by a short course of oral steroids or - as I say - some drops are slightly stronger than the spray.

So, I think in balance you probably should go and see someone and let them have a look up your nose to see what the state of play is.

As much as anything, the other thing that can be quite helpful - which I haven't mentioned before actually - for mucus and things is saltwater douching or sinus rinse. So, there is a kit that you can buy called ‘Sinus rinse’. The other one that people use is an aerosol spray called Sterimar which is saltwater, essentially, at the right concentration. And to flush out your nose every now and again with this stuff is very helpful; it keeps the mucus blanket healthy and makes your nose feel nice and clean. I'd give it to everybody after surgery, but - you know - if you've had issues inside your nose on a daily basis, flushing it out with saltwater sinus rinse made by a company called Neomed. I don't get commission on that but it's a very good device, a little squeezy bottle like a Fairy Liquid bottle and sachets of powder. It’s very easy to use and it makes the nose near feel nice and clean.

So, you might find that helpful as well from the mucus point of view.

Louise King

Just last two questions as we're running out of time. Peter said he woke up with ringing in his ears about three months ago. He's had a sterile and steroid nasal spray treatment which made it slightly better. The ringing comes and goes. He believes it's somatic caused by neck issues. He's had two MRIs booked for the near future for spine and neck and would this pick up anything to help with the tinnitus?

Mr Henry Sharp

Well, what you also probably should have is a hearing test to be honest, if you haven't had a hearing test.

So I'm not sure if you've seen one of us, or which department you've come through, but if you have tinnitus, one of the first things we do is probably just to do a hearing test to see whether you've got any hearing loss associated with it or whether your hearing's normal.

Tinnitus is very common. I mean I could talk to you for an hour on tinnitus. I don't think you'd want me to, but it's very common and there are lots and lots of different causes of it.

To be honest, most of the time we don't really find a cause. I mean you know there's a list as long as your arm and when I was a trainee ENT surgeon, you know, one of the things you learned before an exam was causes of tinnitus about five pages long.

But most of the time you know you don't find a cause and it's just treating the symptoms. I think if you're wanting advice on tinnitus there's a very good website. The British Tinnitus Association, which is www.tinnitus.org.uk and that will give you very good bits and pieces of advice on tinnitus.

But generally, if you're concerned about it and - as I said before particularly one sided - then you know you ought to come see someone. But it's worth reading about tinnitus on the British Tinnitus Association website and educating yourself, actually in the first instance I would say.

Louise King

Thank you, okay last question is, hopefully I get this word right. Avamis is that safe to use in the long term?

Mr Henry Sharp

Yes, absolutely Avamis is fluticasone which is a nasal steroid which we've been using for a long time. It's one of the newer generation of steroids which you can use long term. It's usually one puff in each nostril once a day and that's one of the ones I tend to give for my patients who've had nasal polyps surgery to try and prevent recurrence and to keep things under control so, yes, that's a safe one.

Louise King

Great okay well that's all our questions. Thank you everyone for sending in your questions and participating and it's been really interesting. If we haven't answered all your questions we will do so after this, so please do send them in still, and we will send you an answer.

There's a number on the screen which you can book a consultation on. Paul Pharo is there till 8 pm this evening if you want to call up and book, otherwise our friendly Private Patient team are there nine till five Monday to Friday.

After this webinar ends, you'll receive a short survey and we'd really appreciate it if you could fill that in. It won't take more than a couple of minutes and it just helps improve these webinars for future sessions.

Our next webinar is a very different subject. It's on weight loss surgery, it's on the 27th of January and it's with Mr Ahmed Hamouda, Consultant surgeon and Maria Duckworth. So, if you would like to look into that please do so via our website.

So, thank you very much Henry Sharp for your presentation it's been really interesting.

Mr Henry Sharp

Thanks very much and thank you for joining us.

Louise King

Yes, thank you very much for joining us. And on behalf of the hospital and the team we’d like to say thank you and we'll see you all soon and have a good evening and Christmas.

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