Damien

Right, there we are, one minute past. Right, so evening everyone, and a warm welcome to our webinar tonight on treatment for blocked ears and nose. My name's Damien, and I'll be hosting this session, and I'm delighted to be joined by our expert speaker, Mr Henry Sharp, Consultant ENT surgeon.

Now, tonight's session will begin with a presentation from Mr Sharp, followed by a live Q&A. So, if you have any questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen.

You're welcome to ask anonymously or include your name. Just a quick note, though, that the session is being recorded, so any names shared may be visible in the recording. So to help us get through as many as possible, please keep your questions as brief as possible.

If you're interested in booking a consultation, we'll share all the relevant contact details at the end of the session and I'll now hand you over to Mr Sharp. Thank you.

Mr Henry Sharp

Thanks, Damien. I'd just like to echo his welcome to you. I hope you're, sitting comfortably, and the idea this evening is to give you an overview of treatments for blocked ears and nose, and as you'll see, a lot of those, the problems that can be caused, causing that issue are, and can coincide.

Hopefully by the end of it, you'll have an idea of what we can do for that, and to offer you here at Benenden.

So, first of all, a little bit about myself. I qualified in medicine back in the Dark Ages at St Thomas' in 1990. I did my ENT junior training in Oxford and in London at Charing Cross and the Brompton Hospital, where I particularly became interested in nasal and sinus issues.

Subsequent to that, I was a registrar at Guy's St Thomas' and King's, and at the end of my training, completed a specialist rhinology fellowship in Fulda, Germany, with Professor Draft, who was one of the world's pioneers in sinus surgery and subsequent to that, was appointed in the NHS in East Kent Hospitals.

In 2004, where I worked until 2024, when I retired to concentrate full-time in private practice.

I was appointed here, to Benenden in 2013, as a group of four of us and subsequent to that, we've expanded to now to be a group of eight, and the ENT service here is always appreciated, I think, and it's a part of my private practice that I really enjoy. So that's enough about me.

So, this evening, we're going to talk a little bit about the diagnosis of the symptoms that you, I suspect, will be experiencing, because you're here this evening. We're going to talk about common nose problems, the treatment of that, and the surgery for that.

Talk about common ear problems, again, the treatment and the surgery, particularly with reference to what we offer here at Benden and then, at the end, we'll have, I'm sure, a considerable time for a Q&A session, which I'm sure you'll have lots of bits and pieces that you'd like to ask me, and I'd be happy to answer those as much as possible. So that's the plan for the evening.

So first of all, let's just have a little look at the schematic of the ear, the nose, and the throat. I mean, it's a little bit frivolous but there's me in the middle, sitting between the ear, the nose, and the throat and actually, that does have a degree of anatomical relevance, because the nose sitting in the middle is very much the gatekeeper of the ears and the throat, and they are all interconnected.

So, if you do have a problem with your nose, which is what I am particularly interested in, my subspecialty interest, you can get knock-on effects into the ear and the throat quite readily, and that often does happen, and you may well experience a number of different symptoms with your ear, your nose, and the throat. They're not all, by any means, exclusive to each other.

So we'll talk about that more as we go through this talk.

Now, I'm always on the lookout for bits and pieces in the papers and in the, now, of course, on the, on the net, about, you know, ENT and how it is perceived, and one of the things that gets my goat, being someone that's spent most of my career trying to unblock people's noses, is the fact that a block nose is regarded as a great triviality.

Well, I'm sure that's not the case for the awful number of people that do actually experience a blocked nose, and I'm sure you sitting out there will echo that but A&E Department, this is very recent from the Times, A&E departments under siege by patients with hiccups, ingrown toenails, which you may regard as frivolous, and blocked noses. So, you sort of think of your blocked nose in terms of hiccups and ingrown toenails.

Last but actually, if you look at the figures later on in the article, last winter, 83,000 cases of earache, 97,000 cases of sore throats, 6,000 cases of blocked noses, and then the ingrown toenails but you will see the degree of problem of getting an appointment and a diagnosis for your earache, your sore throat, and your blocked noses, and hence why we in ENT are particularly busy, because often people go and see their GP, or they go to A&E, they're regarded as a time waster and actually, the people that you may see there, through no fault of their own, are not actually very well trained in ear, nose, and throat, because it is rather a niche specialty.

So, you know, people undergoing training, their general medical training or nursing training, will not necessarily have had any experience of ENT, other than very minor, so you may not see someone who knows an awful lot about what your problem is, but that's what we aim to remedy for you here at Benenden.

So anyway, that's the problem with A&E overrun by blocked noses and this is a rather older article, but along the same lines, one in five GP appointments unnecessary, as patients complain of ailments such as blocked noses and now dandruff.

So we're now put in the category of dandruff, as far as your GP appointment is concerned. 51 million appointments in England could be avoided if patients sought help.

So if you look at but what's actually interesting in the later part of this article is that if you look at the number of patients that, go and see people for the various conditions, 40,000 GP visits were for dandruff.

You may think that's a little bit over the top, 20,000 for travel sickness, but 5.2 million for blocked noses and that is something that tells you, again, the degree of the problem that's out there amongst the community, and I know you're sitting there thinking, hopefully you're nodding, thinking the same thing but it's not trivial in any way, and it's also very, very prevalent.

I mean, that's one in 11 or 12 of the population will have consulted their GP about their blocked nose in a year, so it's a big problem which, you know, I try my best to remedy.

So that's the degree of the issue, and also the fact that it's not taken very seriously, sadly.

So our ENT ethos at Benenden Hospital is to get you a diagnosis. That is the really important thing that we want to do for you, is to get you a diagnosis, and to treat it as much as possible as we can here and now, either in outpatients or, if needed, through procedures that we can offer for you. So that's the thing that we really offer to do hope to do for you when you come and visit us, is give you a diagnosis, which I'm sure some of you out there will have struggled to get thus far.

So, as a little anatomical schematic here, to show really what we're dealing with, as far as the treatments that we're going to offer you, either medical or surgical, for your nasal conditions.

So, there are one or two things to notice here. The nasal septum in the middle of your nose there, which in this case is beautifully straight, but often is not, and can, if it is twisted, cause you problems with blocked nose.

The other thing you'll notice on the side wall of your nose, there is three little growths, which are normal, called your turbinates. The inferior one, the bottom one, which is the largest, the middle one, and the top one and these are just a part of the nasal lining, but they're composed of bone as well and these can be structurally quite large and block your nose, and may need treatment, either medical or surgical, to remedy that.

The other thing you'll see is that the sinuses are paired structures. You have sinuses on both sides, starting from the top, your frontal sinuses, between your eyes, your ethmoidal sinuses, and then underneath your eyes and in your cheeks, your maxillary sinuses and these are, structures that can cause you problems, obviously, which we'll go into a bit later.

The other thing is, is that your tear duct, or your lacrimal duct, is connected to your nose as well, so blockages in your nose may have knock-on effects into your tear ducts and your eyes.

So this is a sort of schematic idea of what we're dealing with when we think about your nose and your sinuses. At this point, I'll say the talk does contain some videos. These videos are not particularly gruesome, don't show any awful surgery, but if you are a little bit squeamish, then just be a little bit aware that there are some videos, and if you want to sort of switch off or look away, then maybe there will be time to do so. So this is the first one, which is purely showing you a look around the nose.

This is going to show you with an endoscope, which is something we do I don't know, I've done a clinic this afternoon, probably half a dozen times this afternoon alone, looking into people's noses with an endoscope, just see what the structure and the function of the nose is doing and the advantage of this in outpatients is that you will actually be able to look, if you want, on the screen yourself.

To see what's going on, and I can talk you through what the bits and pieces that may be causing your problems are. So this is just a look, actually, this is a patient on an operating table before I did an operation but just shows you the structure of the nose. So as we look into the nose, into the nostril, left nostril, that's this little sucker, which I use as a pointer. There's the inferior turbinate, there's the middle turbinate, which I mentioned before on the sidewall, and there's the septum in the middle.

The septum in this case is fairly straight. At the inferior turbin, I'm inching my way past there. To get to the back of the there's a little spur in the septum there, a little arrow-shaped spur that may be causing some blockage. We then get to the back of the nose, and you'll see there on the where I'm putting my sucker there, that's the eustachian tube opening. We'll come back to that a bit later and that at the back of the nose there is normal, that's where you would have adenoids if you were a child.

So then we come out of the nose, the inferior terminate there, the middle terminate higher up and the septum on the left of the screen, which in this case is relatively normal.

So that is a video of just a normal, relatively normal nose, and we'll compare that later to one or two that isn't normal.

So, the first question that I always ask, of course, when you come into my outpatient room is how I can help and most people, or a lot of people, say, I've got sinus, Doctor.

Now, sinus means different things to different people, and this can mean, I've found over the years, anyone of a number of symptoms, which people may be describing. So, if you've got sinus problems, that may mean your particular symptoms of facial pain or headache.

That's actually remarkably you would have thought that often is the main symptom, but it's not, and actually it's rather uncommon that people with sinus problems do have facial pain or headache, unless it's really bad but it'd also mean you get that you have discharge from your nose, either from the front or down the back, which people may describe as post-nasal drip.

A very common symptom is of a blocked nose, and this, of course, may have a number of knock-on symptoms associated with it, particularly problems with sleeping at night and these may be problems to you, because you can't breathe very well through your nose, but also problems for your sleep partner, because you're snoring, or even sometimes stopping breathing if you have obstructive sleep apnoea but also, if you can't breathe very well through your nose, it tends to make you mouth breathe, and that often makes you wake up with a sore throat, and lots of throat symptoms that you may not think are related to your nose, but often are. Hoarse voice as well, because you're breathing through your mouth, which you're not physiologically meant to do. You're meant to breathe through your nose, which acts as a moisturizer and a humidifier for the air that comes through. The mouth doesn't do that.

If the nose is blocked or other problems, you may get a deterioration in your sense of smell. This came in very much into the public consciousness during COVID but also can be a problem on an everyday basis through other problems.

If you have problems of allergy in particular, you may get a lot of problems with sneezing and an itchy nose, which is a point in the history that I take from you that very much points me in the direction of allergy. You may get nosebleeds for various reasons and then, of course, you may get the knock-on effects that I mentioned earlier, if you do have a blocked nose, that you may get problems in that eustachian tube at the back of your nose.

Which causes blocked ears and a muffled hearing sensation and then, of course, if you get problems in the nose that knocks on into your tear ducts, you may get watery and itchy eyes and again, that's another thing that may happen with allergy.

So all these symptoms, you may have one or a combination of these symptoms if you have problems with your nose, and these are the things that I will try and sort of eke out of you as part of my thorough nose and sinus history, which is the first thing that we will do when you come into my consulting room.

So, the next thing I will probably do for you is to look in your nose with an endoscope and this is a setup that we still have. This was obviously during COVID, when we were all wearing masks, when we were slightly worried, because people sometimes do get a, do sneeze and things, and obviously in those days, we really didn't want to get sneezed on, so we wore, well, masks and more in the way of protection.

We don't bother with that now, really and it's really a very painless procedure for you. As you can see, this chap's sitting here quite happily, having this, endoscope inside his nose.

You'll look on the left of the picture there, you'll be looking in the nose, and then you pass it a little bit further down, and on the right, you can see I'm down at the level of the voice box. It probably doesn't mean much to you, but it shows that with an endoscope, you can look very thoroughly in the nose, all the way down to the voice box, to look at the vocal cords and that is a very easily tolerated procedure that takes around 20 to 30 seconds, and gives us a very good view and if I turn that screen round, which some people ask me to do, and I'm very happy to do, then you can also look at the screen and see what's going on, which is which is people find very helpful.

So that's the first thing I will do after I'll after I'm taking a history and then there are other tests that may be necessary for you, depending on what the main symptoms and signs that you have. We can perform a CT scan of the nose and the sinuses. This is a very quick procedure, takes about 5 minutes and often, actually, here at Benenden, you can have that done the same day. We see a lot of people that come from various parts of the countryside and London, and farther afield, and it's very useful for them to get the CT scan done the same day, so that they don't have to come back again and that is often the case, and perfectly possible.

I may do some allergy tests, and these really are blood tests, which, again, you can have done the same day. We can do a measure of your IgE, which is an overall allergy score, and then we can do what's called RAST test which is a specific test for certain allergens. So I often do things like house dust mite, grass pollen, pets, and Mold.

Those are my sort of standard four tests that I will do to see the sort of standard allergens that you may be sensitive to and then, of course, if there are problems with the hearing, we can do audiometry, and we have a dedicated audiometrists who sits in the next-door room to me with a soundproofed audio booth who can do hearing tests for you very accurately the same day and sometimes it's useful that I can look in your ears beforehand to clean any wax out, so that we get an accurate measure of your hearing without being obscured by wax. So that all can be done on the same day that you come and see us.

So let's talk a little bit about, you know, the cause of nasal symptoms, and what the individual treatments may be. So, in very simple terms, what can cause your nasal symptoms?

Well, it can be a problem with the nasal lining, swelling of the nasal lining, and congestion of the nasal lining, which you will see referred to as rhinitis or sometimes rhinosinusitis.

Because the lining of the nose and the sinuses are all as one, and continuous with another, so really, it shouldn't be rhinitis, it should be rhinosinusitis, but either will do and then a problem with the nasal structure.

So, particularly if that nasal septum that I was referring to earlier is twisted, then that's something that can cause particularly problems with blockage. So, once I've had the history from you and looked in your nose, I'll have an idea about particularly which part which of those two things will be causing your main problems but those are what generally we like to think of.

So if we're talking about swelling of the lining of your nose, or chronic rhino rhinitis or rhinosinusitis, we really are talking and chronic refers to not how severe it is. People think acute and chronic refer to how bad the problem is. It more refers to the time you've had it. So chronic rhinosinusitis, it means that you've had symptoms for more than 12 weeks and these symptoms may be related, again, to one of two things.

One gen the first one is allergy, and the first thing I'll ask you, if this is likely to be the case, is, is it seasonal? Does it come and go with a particular season or is it year-round? and there are particular aspects of the history, that I will, be able to ascertain to see whether your problems are likely to be allergic.

So, if you have associated asthma or eczema, you're so-called atopic and that really is a sign that you may well have allergic rhinitis and the symptoms that you get with that are often watery nasal discharge, like we have, you all know if you have hay fever, which is a particular allergic rhinitis to grass pollen, of course.

You may have sneezing or itching in your nose, and again, you may get symptoms with your eyes, itchy and watery eyes.

So, all that will point me in the direction of an allergy rather than non-allergy and that literally will come from the history without even looking in your nose and then the other main type is non-allergic, and the symptoms with that are more of a mucky discharge rather than a watery one, and then you do get some congestion and pressure feeling in your sinuses related to long-term mucky discharge collecting in there.

So, that's the sort of, diagnostic pathway that I will take, mainly on the history, to give the likely cause of your problem, because the treatment of that will vary, depending on which one that is.

So once we've got a diagnosis, we've taken a history, we've done a thorough examination, we then can decide how we're going to treat your rhinosinusitis and the great advantage of getting an early diagnosis is that it can be treated medically without the need for surgery in a large degree of patients and that's really what we I mean, I'm a surgeon, I like to operate, but the fact is, you know, if I cannot operate on people, that's actually what you want, and at the end of the day, that's a good thing. So, you know, if we get you early, we can give you treatment and then, you know, you can be discharged with advice and appropriate treatment moving forwards.

The problem with, and if you're not seen early, and of course this is an increasing problem with the issues that I described earlier of getting to see anyone and getting any treatment, and unfortunately it tends to be a downward spiral and if inflammation and infection in the sinuses goes on a long time, you then get the formation of polyps, which then makes the situation worse, and down and down you go down this sort of downward spiral.

The other problem is, is that if you can't breathe very well through your nose and the problem is getting worse, then it tends to worsen your asthma and your chest symptoms, which I'm sure some of you out there will have experienced as well, and you get this phenomenon called the allergic march.

Where, chest symptoms, skin symptoms, all the rest of it tend to go downhill because of the inflammatory markers that are circulating in your blood get worse. So, you know, it is a problem. People waiting a long time for treatment for this issue is a problem.

So, the next thing I'll show you is just a small video of a non-invasive procedure for polyps. So, as I mentioned just briefly there, if you do have long-term inflammation in your nose, and certainly in some patients who have long-term asthma and things, the formation of polyps is more likely, then you do form these nasal polyps, which are basically gelatinous, grape-like structures inside your nose.

which cause increasing problems with sense of smell loss, blocked nose, and sometimes, as you said, nasal congestion pain. So these are treated medically in the first instance by nasal steroids, and as I've suggested before but also, if they get to a size like these ones are, then you can treat them surgically with certain instrumentation.

So this is just a short video of treatment with a debriders, and this is those of a certain age will remember Pac-Man, which was a video game that used to be played. It always reminds me of that, but it's, it's surgery just to chomp the polyps, basically, and it's very, precise, very, and a non-invasive, and virtually bloodless, if you watch this little thing. So here comes the debriders.

All right a little spinning device, a bit like Pac-Man. Here are the polyps, these grey, gelatinous things, and what the debriders does, this is under a short general anaesthetic, is it munches these polyps, and it's, it's, you know, it really is, as you can see, very precise. That tip of that instrument is 0.3 millimetres wide, so it's very, very small. It looks huge on the screen, but it's very, very precise surgery and we're just munching away at these polyps, virtually no bleeding and the polyps disappear up the pipe, and it's all very satisfying. The patient goes home instantly better.

Now, if the situation gets to polyps like that, you're probably going to need treatment with intranasal steroid sprays into the future, but if the polyps are of that size, then no medical treatment is going to work. So that's when the surgery comes in handy, and then we can treat you with the medical treatment afterwards once we've got to that stage. So that's a very non-invasive surgery, functional endoscopic sinus surgery to remove nasal polyps.

So what about the structural problems? So we've talked a little bit about rhinitis, the inflammation of the lining of the nose, so sometimes the formation of polyps. So what structural problems can cause blockage in your nose? Well, in this situation, we refer to the anatomy diagram I showed you earlier.

A twisted nasal septum is a major, cause of a blocked nose and that's the midline structure between the nostrils, which you can be born with it bent to one side, or if you get a bang to the nose, or an injury to the nose, it can actually twist as a result of that and you must remember, it may not be obvious, but just because your nose is twisted on the inside does not mean you have a twist on the outside as well.

So people most people with a septal deviation do not have a twist on the outside as well. So don't think that just because your nose is straight on the outside.

your nose is straight on the inside because that doesn't necessarily mean that, that it is and the treatment for this is an operation called septoplasty, and this is an operation that I do probably well, it is the operation I do the most of, and I think I checked my logbook recently. I've done 2,000 recently.

So, not recently, but in my consultant career. So, it is the one I do the most of. It's a day case procedure under general anaesthetic and it's very well very, very successful in the right circumstances and we'll talk a little bit about that in a moment and then the other thing that can structural problem that can cause issues in your nose is swelling of the inferior turbinates, or hypertrophy of the inferior turbinates, a medical term.

So this often refers to, you know, patients with severe problems with the swelling of the laser lining, and we've tried medical treatments for that, and unfortunately, for some reason, or the fact that it's so bad, the turbinates have not responded to that and there is a surgery that you can do for that, for surgical reduction of the turbinates to create more room inside the nose.

So those are the main structural problems which we have treatment for here, which we can offer you.

So, just on that subject, often patients have a structural problem and a problem with the lining, or issues with the turbinates. So, a very common combination is septoplasty and inferior turbinoplasty.

So, these two videos just show the result of that. So, this first one is a picture of the patient at the beginning of the procedure, before I'd actually done the operation, and then the next video will show you the results of that, and you can see the improvement in the breeding through the or the passageway through the nose at the end of the procedure. So here's at the beginning.

You'll see on the right there, the turbinate, middle turbinate at the top. You'll see the sort of polypoid, there's the back of the nose there, eustachian orifice, but polypoid swelling there of the turbinate, inferior turbinate, quite large, septum on the left of the screen there. So we move to the other side and you'll see on this side that the septum is twisted to this side.

You'll see a big spur. In fact, I've just gently caught it with the endoscope. Big spur there, blocking the nose at the back, big swollen inferior turbinate on the left of the screen, little bit of just where I've caught it with the endoscope there, a little bit of bleeding, but that spur is very sharp, and it's blocking that right side of the nose.

So he's got this patient has got a combination of a twisted septum and large and congested inferior turbinates.

So here, we move on to the, after. So this is at the end of the procedure, after we've finished.

Just as we're about to wake the patient up. So we look in the left side of the nose here, and you'll see on the right of the screen, the turbinate is much smaller. I've done a procedure there to reduce the turbinate in size, much more room, slide into the nose there much easier on that side.

The septum looks fine from that side. You'll see that the septum has lost the spur, now the spur is gone, and the turbinate on this side has also been largely reduced. We go straight to the back of the nose without a problem, you can drive above through that nose now.

So on both sides now, there is much more space. The septum is now sitting in the midline, and that's, as I say, a very common combination of procedures that I do to improve people's breathing through the nose and here is a CT scan of that situation.

So here is preoperatively, and you'll see, if I give you an idea, so this is the top of the head over here, the brain here, these are the eyes on either side, right side and left side, so the patient is looking out of the screen, and teeth down here and these are your sinuses, a bit similar to that schematic diagram I showed at the beginning.

So here is the right cheek sinus, here is the left cheek sinus, and you'll see that this is full of grey matter. This can be a polyp, you can't tell on a scan. It can be a polyp, it can be, mucus, it can be pus.

Anyway, it's not right sinus is blocked. In fact, it was a polyp in this case. You'll also see the midline septum here goes down straight, and then there's a big, huge spur, bony spur here, before it straightens up again. So this big bony spur blocking the left side of the nose here, associated with all this polypoid stuff.

So then, this is, further down the line, a couple of months later, so you'll see that this sinus has been opened, there's now a nice opening into this sinus here. It's completely clear, and nothing in here, exactly the same as the other side and these sinuses up here have been clear as well, the ethmoid sinus and also, the septum now is sitting beautifully in the middle. That spur that was sticking out here has been removed, so septum straight.

Sinus is all cleared out, or sinus on this side all cleared out. So that's the sort of radiological, result of surgery for a deviated septum and the removal of a left nasal polyp.

So that's really all I wanted to say about the nose, and I'm sure you'll have some questions maybe you want to ask about that, but we'll move on to the bits and pieces that, about the ear. Now, of course, these subjects are very convoluted and complicated and this, that, and the other, but I really just give you a little idea, for the people out there with ear problems, what can cause issues.

in the various parts of the ear, and what we can do to help you. So the first thing, just to talk briefly about the anatomy of the ear is, essentially, it can be divided into three bits.

There's the outer ear that is composed of the pinner, which is the bit that we think of as the ear on the outside, and then, of course, the tube, the ear canal, going down to the eardrum. Now, the eardrum is like the top of a drum, and the ear canal is a blind-ending tube, which ends at the eardrum.

So, literally, the outer ear is composed of outer ear canal down to the eardrum and then there is the middle ear, which is beyond that, which is on the other side of the eardrum, and that is basically an air-filled box, and the only way out of that, which you can see on the diagram there, is through the eustachian tube, which goes into your nose.

So the only way that the air in the middle ear can equalize the pressure with atmospheric pressure, which is, of course, the pressure at the back of your nose is via the eustachian tube and when you do your, what's called a Valsalva manoeuvre, and you press on your nose, and you clear your ear, and you pop it. What you're doing is, you're actually opening the eustachian tube and equalizing the pressure in the middle ear.

Now, if your eustachian tube doesn't work very well, then unfortunately you can't equalise the pressure in that middle ear, and that can cause if it's acute, if it's like in an airplane or something like that, that causes a lot of pain, but if it's over a period of time, it can give you quite a lot of symptoms of, like, your head being in a box, and having a blocked ear, and this, that, and the other.

So eustachian tube problems which, of course, if you've got a problem in the nose at this end of the eustachian tube, here's the nose here. If you've got a problem in your nose causing backup into your eustachian tube, that can be a problem.

So, the middle ear in the eustachian tube is quite an important part of our practice here. Patients do get problems with that and then, of course, and actually, what I should say, is in the middle ear, there are also three little bones of hearing called the hammer, the anvil, and the stirrup.

Which can get you can get problems with that as well. I won't go into that beyond the scope of this talk, but that can cause problems with your hearing as well and then the inner ear is composed of the cochlea, where all the delicate circuitry of your hearing is and the semicircular canals, which are those sort of structures at the top there, looking at the top of your so here is your cochlea, which is like a seashell, and then these structures here are semicircular canals, which are concerned with balance.

This is concerned with hearing, these are concerned with balance and then there is a nerve that goes off from these structures, from the cochlea here and from the vestibular, or balanced part here, off to your brain. This is a vestibular cochlear nerve. So, this is the structures in your inner ear. So, three parts, and you can get problems with any part of those three.

So, what symptoms may you, you present to us, here at Benenden, with problems with your ears. Well, there's 3 main, sort of, chronic symptoms, long-term symptoms, that people often ask us to look into. Hearing loss, obviously, or altered hearing. Tinnitus, which is any noise that you hear in your ear with no external source.

So, basically, it can be whistling, it can be ringing, it can be pulsation, any noise that has no reason for it being there is tinnitus. Then, of course, you may have problems with your inner ear and semicircular canals, so you may get problems with balance, dizziness, or vertigo.

Now, vertigo is not, as you may think, fear of heights. It's actually a particular diagnosis of spinning dizziness, where the room spins round you. Sometimes if you've come off a circus ride, or you've had too much to drink, and you get that bed-spinning moment, that's what vertigo is like.

Really very unpleasant, and you know, needs further investigation and treatment, sometimes for that and then there are the more acute, in other words, short-term symptoms, more concerned usually with infection, like pain in your ears and discharge from your ears, which people may consult us as well.

So, let's go through a little bit about what individual bits, you know, what individual problems may affect the individual parts of your ear. So, problems in the outer ear, so the ear canal down to the eardrum there. Well, the most common one, of course, is wax, and this can cause discomfort in the ear, blockage in the ear, and hearing loss.

And, you know, increasingly, unfortunately, GP practices don't do, clearance of wax, and getting access to, people that do, can be more difficult. so that's something that we can readily, sort out with you here via micro suction.

Which I'll show you in a minute and wax impaction, or long-term wax problems, may lead on to the next one, which is infection in your outer ear, termed otitis externa, which is an infection in your outer ear, and that may cause swelling of the outer ear, pain, discharge, and hearing loss, often related to the swelling. So that can be really quite uncomfortable, otitis externa. Very uncomfortable, in fact, in some instances, and people really come to us in a lot of pain.

You'd be surprised how often we see people with foreign bodies in their ear, and you ask them, have you put anything inside your ear? No, no, I haven't, Doctor, no, promise you I haven't, no. Well, how come this little bit of cotton bud is in there?

Oh, yes, I remember that a little while back. Oh, yes, maybe I used a cotton bud. So we do see, some interesting things in the ears, often in well, we don't see children here, but you can find all sorts of things in children's ears but cotton buds and hearing aid moulds are a common, foreign body that we have to sometimes just gently extract.

So then are the main problems in the outer ear. Then we may see problems in the middle ear, or eustachian tube and as I've mentioned, problems with the eustachian tube and inability to equalize the pressure in your middle ear because of that is a common problem and up until recently, it was a very difficult problem to treat.

We didn't really have much in our armamentarium that we could do for you but recently, in the last 5 years or so, technology using balloons that we were previously using in the sinuses has also been used in the eustachian tube, and I'll show you a little video of that in a minute. It's a really very effective treatment for eustachian tube dysfunction, which can be very annoying for some people.

If that eustachian tube problem gets worse over a period of time, you can actually start to get mucus collection in that middle ear box, because that middle ear box is actually lined by mucus-secreting lining, and if it can't drain properly, and it can't ventilate properly, then the mucus starts to collect, and that is termed glue ear in the middle ear.

More common in children, because their eustachian tube doesn't work very well in childhood but you can definitely see it in adults, and that can really give you significant hearing loss and problems of blockage in the ear.

So that's something that we can use a slightly different treatment for, which is to insert a grommet which is a tiny little drainage tube, shaped like a tiny little cotton reel, with a hole down the middle and that allows it basically creates an artificial hole in the eardrum to allow the middle ear to ventilate and I'll show you a little video of that in a second as well and those are usually inserted either under local anaesthetic, with some anaesthetic cream put in the ear for a while.

Which is then removed, which numbs the eardrum and allows us to make a little cut in the eardrum, or sometimes a very short general anaesthetic. Certainly in children, that's the case.

So that's something we can do for you as well. As I mentioned earlier those little bones of hearing, the ossicles may get disrupted, or sometimes you can get a deep-seated, progressive infection called a cholesteatoma, which can cause erosion of those little ossicles, and that can give you hearing loss as well. Now, that's quite a serious thing, and that needs that does need diagnosis and treatment.

Not necessarily here at Benenden, that's not something we can do for you here, but certainly we can diagnose it and instigate appropriate treatment elsewhere but that really can be serious and can cause erosion into the balance system and really bad infection, and sometimes into the brain and cause brain infection.

So that does need diagnosis, and certainly if you have offensive, nasty discharge from your ear for a long period of time, then a cholesteatoma is something that needs to be excluded.

So then you can get problems in the inner ear, as I mentioned, the cochlear and the vestibulocochlear nerve and the commonest cause of that is, of course, age-related hearing loss, and to some degree, we all have that as we get older. It's a question of just a question of how bad it is.

So that's something, again, that by doing audiometry, we can test for and there is a specific type of shape of hearing loss on your audiogram that points us in that direction.

There is then a condition called Meniere's disease, which, again, is rather outside the scope of this talk, but is a condition where there is too much fluid in your cochlea, in the inner ear, which gives a characteristic triad of symptoms of hearing loss, tinnitus, and vertigo and that's something, again, that we can diagnose for you here and instigate appropriate treatment.

Lastly, an acoustic neuroma is an extremely, otherwise called a vestibular schwannoma, it's the same thing. That is an extremely rare, benign lump on your hearing and balance nerve, that nerve that I showed you running from the inner ear and the semicircular canals to your brain, which grows very slowly over a period of a number of years and often presents with a combination of one-sided hearing loss, obviously on the side that you're experiencing it, along with hearing loss on that side, and sometimes dizziness and we do get a fair amount of patients referred to us from GPs and audiologists in the community, where they notice that patients have one-sided hearing loss or one-sided tinnitus for further investigation and particularly, that means an MRI scan of that particular nerve to make sure that there's no acoustic neuroma there, because that does need following up.

Very rarely requires surgery but needs following up and appropriate investigation in the light of that.

So those are the sorts of things we see day in, day out here at Benenden, and can help you with.

So here are the outpatient procedures that we can do. Again, patient on the couch in the outpatient room here. We can look in your ear with a microscope. A very detailed look into your ear, and see what's going on, and give you, first of all, a diagnosis, which is, of course, is our main ethos.

We can then perform micro suction, if needed, which is a tiny little vacuum cleaner, which you can see on the left-hand side there in my right hand, which we can clean out any wax or debris or infection that's in your ear to give you relief, but also to allow us to accurately diagnose what's going on.

Then, once that's done, if required, we can send you up the corridor, literally 10 yards, to have a hearing test, where one of my audiological colleagues there has a soundproof booth just in front of her, where she can do a very accurate hearing test then and there.

Other than waiting, you know, for ages after an appointment to do it, we can do it for you on the day.

So that's really what we can do for you as far as your ears are concerned in outpatients.

So let's talk a little bit, before I finish, about surgical ear procedures and I mentioned this a little bit earlier, what can we do for your issues, particularly in relation to that middle ear problems.

So, first of all, balloon eustachian tuboplasty. Now, this is the procedure I was mentioning earlier, using a little balloon to pass it into the eustachian tube opening at the back of your nose. So, you're now experts on the anatomy of the nose.

So I'll show you in the base again, but with particular reference now to the eustachian tube, and what I will be doing is I will be putting in the balloon, introducer, which is a metal, little curved metal introducer, into the eustachian tube, and then introducing over the top of that, the balloon, which then I will stretch the eustachian tube up to give you relief from your symptoms.

So this is the as we go into the nose, the introducer going into the nose there. There's the terminate again, middle turbinate above it, but we're not concerned with that today. We're going to put this little metal introducer with the balloon over the top of it, just gently towards the back of the nose and there is the eustachian tube opening at the back of your nose, so I gently curved that around the corner and just then put the balloon over the top of that and then, I say to my colleague, please inflate the balloon, and there's the balloon inflating.

So we leave that balloon in there for two minutes, then we take it out, and then we put it back in there for 1 minute. So that's literally all it does. We gently put it in, we inflate the balloon for 2 minutes, then 1 minute, then we remove it. So here is the balloon in place. I had it in for 3 minutes. I then say to my colleague, please deflate.

The balloon is then deflated, and we remove it. Nothing stays in there. It all comes out, there's nothing to stay in there, and you'll see if we look in there, the eustachian tube is now nicely wide open, a much more wider calibre than it was previously. So that's your eustachian tube going up into your middle ear there.

So that's balloon eustachian tuboplasty, very effective for patients with, eustachian tube dysfunction and then there's the grommet. So, this is for someone whose eustachian tubes function has gone on a little bit further, unfortunately, and they've got some mucus collection in the middle ear, some glue ear.

It's so-called glue ear because it's often the consistency of sort of Yoo-hoo glue. I don't know if you remember, sort of, that really sort of sticky, thick stuff, but the mucus that's in there is often very tenacious and thick, so we call it glue ear. So here is a view down a microscope.

Think back to the picture of me looking into the ear with the microscope. This is me looking down a speculum at the ear at the eardrum. So this is the eardrum at the distance there. Now, if you think of it in size, it's a size it's smaller than your little fingernail, so it's small, and this is massively amplified, magnified.

So we're looking down a microscope, and we will shortly be making a little cut in the eardrum with a tiny little knife called a moringa tome. So in comes the moringa tome in a second. Down the speculum, using the microscope, here comes a little tiny knife.

Two or three mm long, three mm wide, sorry and we make a little cut in the eardrum there, just a tiny little nick through. So that's the middle ear through there.

So now, you'll see, obviously it's a little bit of blood there, nothing much and then there's some mucus in there, so we now need to suction that out. So we get our little micro suction device here and we, we then suction that, that, mucus out.

So it's really, you get the, you know as that all comes out, and out comes the mucus. So instantly, that patient will now hear better. You wake up from the anaesthetic, and it's great in children, because they wake up, they don't know why the world's so loud. I think it's amazing. So anyway, there is the, there is the cut which we're then going to put in a little grommet into. So that's the cut. We're now going to insert this tiny little grommet

Which is like a little cotton reel with a hole down the middle, so we put that into there's a flange on it, so we put the flange into the hole, and then we gently, in a minute, with a little needle.

Push that through, that flange, into the middle ear, and position it correctly, and you'll see when I do that, that this little grommet has got a little hole down the middle.

So that gently flicks in, and then you have this picture down the hole. So that's a picture down now into your middle ear. So I gently position it, so it's in the right spot, so it's facing outwards.

Like so. Taking rid of that little bit of wax and there you have a picture of the grommet in place. So that now will stay in, generally, for about 6 to 9 months and over time, usually, the eardrum will push that out but once the middle ear has been ventilated by that grommet, it usually gets better on its own, so very rarely do you need another grommet in the future.

So those are pictures of procedures that we can do in order to help your ear.

So, in summary, what's our ENT ethos here? Well, basically, it's to give you a diagnosis, and I'm sure a lot of you are frustrated by the fact that you don't get a diagnosis, and often you see people that may not have a huge amount of expertise or experience in ENT, but here, you're getting treatment in whatever area you come to see us in by subspecialist experts in their field and we have, of the eight of us, we have two nose and sinus specialists, two ear specialists, and four head and neck and throat specialists.

So, you know, you're seeing experts in their field to give you a diagnosis on the day. So it's a one-stop ethos. That's what we like to do. We give you a diagnosis, we instigate the treatment plan straight away, ideally doing all the investigations that you need on the same day, so you don't have to come back. Not always, but most of the time.

You will then get a best-stroke treatment plan, you know, directed at the cause of your individual problems, but the most important thing is we know why, or you know, and we know, why you've got those problems before we do that and if, you know, if you don't get better with medical problems, then as I hope you've realized, there is a wide range of daycare surgical solutions to your problems.

Virtually never do we keep people in, in any of the procedures that we do. I can't remember the last time I kept anyone in hospital overnight. So it is really unusual for us to have to keep you in hospital.

So that obviously is very good for you and it allows early return to work and to your normal activities.

So, I hope that gives you a flavour of what we aim to do, what we can do, and I think that's all I really have to say.

So if there's anything that you would like me to answer questions on from now onwards, I'd be happy to do so.

Damien

Yeah, thank you, Mr Sharp. Yeah, so there's a lot of you tonight, so if we can ask if you can keep those questions nice and brief, and then we can get through as many as we can.

You'll also notice that we've got some pricing, and you can view those on the screen now.

Let's start with Maria. So, Maria's asking, she's had, ear suction recently, but her right ear still feels partly blocked due to an echo when she speaks, eats, or touches her head. What do you think this could be?

Mr Henry Sharp

Well, Maria, you've brought me onto a subject which I was trying to avoid, but I think I'm going to have to say, I don't know, first of all, whether your ear has been suctioned completely and efficiently.

I'm not sure who did it, and I'm not casting expressions at all but there are certain practitioners who are setting up in the community who I'm not sure are entirely trained in this technique.

So, we do see quite a lot of people who've said they've had their ear cleaned and things, and maybe paid for it on the high street, and you come and actually look in their ears, and there's still quite a lot of wax in there. So, the first thing I would say to you is to make sure that you have actually had all the wax removed but if you have, then, probably with those symptoms.

You it sounds as though you may have a little bit of conductive hearing loss, and by that, I mean that some of the conduction mechanism, either in the outer or the middle ear, isn't working properly and of course, that can be, eustachian tube dysfunction.

So I think probably what you need is to see someone such as not necessarily, but obviously we'd like to see you here, to look in your ear, but also to perform a hearing test. I think probably with those symptoms.

I don't know how long you've had them, but it would be worthwhile having a hearing test to see what exactly the level of your hearing is and what is causing those symptoms.

Damien

No, fantastic. So we've got an anonymous, question here. So this person has been prescribed nasophan for sinusitis and basically asking how long she can use that for.

Mr Henry Sharp

Okay, I'll go back to I'll go back to my original bit about, you know, I've got sinus doctor, so have you I don't know what your main symptoms are, so I would say nasophan is a nasal steroid, it's one of the newer ones, so it's perfectly safe to use long-term, but it depends what your main symptom is, and hopefully you've got a flavour from the talk, is that, you know, if your main symptom is watery discharge or slight congestion, then that's fine but if it's different things than that, a particular blockage of your nose on one side, or this, that, and the other, then maybe nasophan is not the right treatment but if you're finding it helpful, and you want to carry on with it, I would say it's perfectly safe.

The only thing we say about long-term intranasal steroids you don't get steroid side effects as such, and a very small amount is taken into your bloodstream but if you have glaucoma or issues like that, then it's slightly you have to have your pressures checked for your eyes and things like that but very rarely do you get side effects with nasophan, and you can use that long-term, but make sure it's for the right symptom, is what I would say.

Damien

No, fantastic. So we've got David asked, basically, David's got tinnitus and had done for a few years, and asked, is there any correlation with having a blocked nose, or ears, or all the combination of all of those? and the best way to eliminate ear and nose issues.

Mr Henry Sharp

Okay, there's a few things there, I think, David. So first, the tinnitus.

I mean, I don't know whether you've had a hearing test, but probably it's worthwhile having a hearing it's worthwhile having someone look in your ears, first of all, because, I mean, something simple like wax, whatever, can cause tinnitus. So you need to have someone look in your ears, see if there's anything easy that they can do about that, but also, I don't know what age you are, but you may want to have a hearing test in association with that, something we can do for you, as I'm sure you've seen here at Benenden on the same day.

Regarding blocked nose, I think I've hopefully made it clear that that can be related. Tinnitus is not the main symptom with eustachian tube dysfunction, but, you know, you can

get problems of that nature with a blocked nose or ears, which can cause issues in your eustachian tube, so there may be a correlation, but really, without looking in your ear and doing a hearing test, I wouldn't be able to say that for sure.

When you say the best way to eliminate ear, nose, and nose issues, well, that's my entire career. I can't answer that in 2 seconds. So, I think the best thing I could advise you is to have someone look in your ear and do a hearing test.

Damien

Now, fantastic. So we've got Seamus, Seamus asks, is vertigo the same as labyrinthitis?

Mr Henry Sharp

Okay. Seamus, I think, but yeah, I think it's probably Seamus. So vertigo is a particular, symptom, as I think I mentioned, which is spinning dizziness.

So if you have so that's different from imbalance. I mean, people you know, the people that just feel off-balance or slightly off-balance is not the same as vertigo, which is actually the spinning sensation, as I say, you get when you have too much to drink or come off a circus ride.

Now, labyrinthitis is a particular cause of the vertigo but it's a particular cause that is related to inflammation or a viral illness sometimes in your inner ear and that often gives you a combination of hearing loss, tinnitus, and dizziness. So, they're not the same, and labyrinthitis can be a cause of vertigo, but not exclusively so.

Now, you can get another condition called vestibular neuronitis, which is a particular inflammation of that hearing imbalance nerve, which I mentioned to you before, which does cause just vertigo, because it doesn't cause so much of the inner ear type symptoms, the hearing loss, and the tinnitus.

So I hope that makes sense, but vertigo is a particular symptom, and the cause of that, is something that we can look into here at Benenden. I mean, labyrinthitis is only one cause of vertigo.

So I hope that makes sense but again, if you have vertigo, the best thing to do would be come here and see one of us to try and work out why you have it.

Damien

Fantastic. So Georgie's asked, she's basically been diagnosed with a deviated septum and eustachian tube dysfunction. The consultant couldn't get the camera up one side of my nose, and nasal sprays don't seem to work anymore. Would this suggest I need something more than just sprays?

Mr Henry Sharp

Okay, Georgie, yeah, I mean, I think that's the, the symptoms oh, the causes, I was mentioning earlier, structural and lining. In your case, it's likely to be the structural problem, isn't it? You've got a deviated septum.

The consultant could get the camera up one side of her nose. There you are. So your septum is very deviated. The nasal spray won't work because it's a structural problem, not a problem with your lining. Now, you may have a problem with your lining as well, as I mentioned earlier, but I don't think sprays are really going to help in your case, so I think you need that operation septoplasty which I think, hopefully, you sort of saw the result of that, and the nature of that on that video earlier.

So, I think you would be an excellent candidate. Now, eustachian tube dysfunction can be associated with problems in the nose and a deviated septum, so that's something we could talk about with you, should you come and see us. We can look in your nose, do a hearing test, see whether you do have eustachian tube dysfunction. We get people to fill in a questionnaire to see how much, and the higher they score on that questionnaire.

the more likely they are to have eustachian tube dysfunction. So I think you'd be a good candidate to come and see us, and we could help you, actually.

Damien

Grand, fantastic. So, yeah, we've got another anonymous asking about nasal sprays, or steroid nasal sprays over long periods of time. I think you've partly answered that, but maybe there are some that can be used a longer time, or some maybe not so much?

Mr Henry Sharp

Yeah, I think that that is absolutely I mean, I think the newer ones so, some people, I think, get prescribed well, I know they do get prescribed Beconase, which is a rather old spray, I think it's because it's cheap, because the GPs prescribe it. That's that you do take a little bit of that into the bloodstream, so it's probably not one I would recommend long-term, but the newer ones, such as Fluticasone, or Flixonase, or Mometasone, Nasonex.

Dymista, all these ones are newer ones, and they really only act inside the nose. So they are safe to use. People always do worry about steroid side effects, but in this case, it's no different to an asthmatic having to take an asthma inhaler, which is a, which is a, you know, which is a steroid for that. So, you know, I regard rhinitis as asthma of the nose, and then people tend to relax a bit more about it, because they think, well, I'm going to have to take a steroid nasal spray for it.

The only reason I would take breaks sometimes is that the sprays do sometimes cause a little bit of bleeding, paradoxically. They irritate the nose and if you do use steroids and nasal sprays a long period, and people often don't know this, you need to spray it sideways in your nose.

So, I recommend people use your right hand for your left nostril and spray it towards the corner of your eye here and then swap hands and use your left hand and your right nostril to spray it towards the corner of your eye there.

So, like a cross and that will prevent, because if you spray it towards the middle of your nose, towards the septum, it can cause irritation and bleeding. So, if you just spray the side the spray sideways, it often causes little in the way of bleeding or irritation, and that's often why people don't like it.

If you do get that, I would stop it for a little while and let that settle down but generally restart it again if you need it.

Damien

No, great tip, thank you. So Mark, has been diagnosed with, conductive hearing loss at Kings, and then recently confirmed with a hearing test at Boots.

That his hearing has been deteriorating. What procedures may help?

Mr Henry Sharp

Yeah, so conductive hearing loss implies a problem in your outer or your middle ear. So, as I mentioned, you know, the simplest cause of a conductive hearing loss is wax or a cotton bud in your ear. So, or but the more complex conductive hearing losses are the ones that occur in the middle ear.

Now, I don't know, Mark, what causes your conductive hearing loss, but it may well be an issue in one or more of those little bones of hearing. So that is something that we can certainly diagnose.

for you here, and very clever surgeons, of which my colleagues here, and my two ear surgical colleagues are those, can do operations on those three little bones of hearing to reconstruct or replace them.

There's a particular condition called otosclerosis, which is where the stapes bone, or the stirrup bone, gets stuck, and that can actually be replaced by a Teflon or plastic replacement, and that is a life-changing surgery.

However, most conductive hearing losses, the first line of treatment would be hearing aids. I mean, if you're I don't know your age again, but if you would, happy to live with hearing aids, then that would be fine but if you want a second opinion as to whether any there are any surgical operations or solutions to your conductive hearing loss, then that's something that we could do for you here but obviously, we'd need to see you examine you, and to do a hearing test. So, happy to do that, should you wish.

Damien

No, fantastic. So, I think we might be able to answer the next three here from, from both Pauls and Anthony, in what causes tinnitus, and then maybe some cures and guidance, from the ENT department.

Mr Henry Sharp

Yes, well, this is a subject which we could talk about for weeks, not just 5 minutes. I think tinnitus the main thing to think about tinnitus is to get a possible diagnosis of why it's happening.

So I think you need to, you need to go and see someone, if you haven't already, let someone look in your ears and let someone do a hearing test, and then they will give you a likely cause for your tinnitus.

Now, that will, in some ways, be of reassurance to you, and if you need an MRI scan to exclude an acoustic neuroma, then that is something that can be done but in general, it's a symptom that you have to live with, and how I go through the day-to-day living of tinnitus is basically, it's the, one of the things is a masking effect, so you've probably all noticed that, you, you're better, when it's open.

There's background noise, and less so, when you're in the quiet. So most people, struggle to get to sleep. So you have to use the masking part of things to help that, and really, having radio in the background, or music in the background during the day.

Or a noise you find outside, you know, if you're outside in the outside world, it's often better but you can do that at night, and there are various apps you can use now on your smartphone. One called OTO, O-T-O, which is very helpful, which actually has noises or things that you can use to do that. You can just have an earpiece in your ear at night to help you mask your internal noise. There's also the British Tinnitus Association website, www.tinnitus.org.uk.

Which is helpful for that, as well. So that's the first thing, is masking the internal noise masking the internal noise with an external noise, and over time, that will get your brain habituated.

The other thing is the psychological side of it. If you're stressed, anxious, ill, particularly if you're stressed about your tinnitus, which some people get very stressed, then that will not help. It will make it worse.

So you do need to realize that, and to try and relax psychologically in relation to the tinnitus and there are various works that's been done. So things like mindfulness meditation is very helpful for tinnitus, and to try and relax you, and to keep yourself on the straight and narrow. I recommend Headspace, which, again, is an app on your phone, to sort of optimize the psychological management of it.

But, you know, it's not easy. I'll take that. The main thing people really want is reassurance that it's, there's nothing serious, and that's what we can do for you, and put you on the right track as far how you can manage it.

I mean, we're not we're, you know, when we were running around in the jungle on all fours, our four bears, you know, we didn't like noises that we didn't know what was going on, and noise in the background was likely to be something that was going to eat us, you know, so it is a psychological, deep psychological thing that we don't like noise, that we don't like the cause of.

So, you know, we just have to you just have to psychologically relax about it, and then it gets better and sometimes, of course, there are cures for it, but that is that is unusual, and most of the time, it's just, pointing you in the right direction to manage your own tinnitus in the best way.

Damien

Grand, grand. Right, we've finished with one last one from Mike, who, swims regularly, and when he does, he always ends up with a streaming nose. Is it possible that he could be this could be caused by an allergy to the chlorine?

Mr Henry Sharp

I think that's probably very likely, Mike, to be honest with you. Yeah, I mean, it's, I mean, you know, obviously I could say to you, it's a bit like when I show up on allergy tests, that someone's allergic to dogs and cats and they said, well, I'm not getting rid of the dog.

So I said, okay, that's fine, you know, I'm just telling you, I don't I'm not asking you, not asking you to shoot the dog, and neither am I asking you to skip up swimming, but I think you'll have to realize that, you know, if you do it, it's liable, whether it's chlorine or something else, some of the chemicals that they use in the pool, because it seems to be very much you know, I mean, very much related to that.

I mean, you know, avoidance of any allergens, i.e. the dog or the cat, or molds or this and the other, and for you, chlorine, is one of the main treatment for allergy but there are, of course, if you don't want to do that, and you accept that that's going to be the case, then there are nasal sprays that are particularly good for allergic rhinitis. The one that I really like is Ryaltris.

Spelled R-Y-A-L-T-R-I-S, which is contains a nasal steroid, but also an antihistamine, so it means you don't have to take, take, antihistamines as well and the other one is Dymista, which is a similar thing, but tends to give people a slightly nasty taste in the mouth when they use it. So Ryaltris would be the one, and if you ask your GP to give you that, then that will optimize when you can swim but I'm afraid it might have been giving it up.

Damien

Lovely. Well, thank you, and thank you for all your questions and being part of this evening's session. If we haven't covered your question, and you've provided your name, we'll follow up with you via email.

If we can just move over to the last slide, thank you, Mr Sharp. So, as a thank you for attending tonight, we're pleased to offer you 50% off the value of your consultation, a callback from your dedicated private patient advisor, an email with a recording of the session, treatment information, as well as loyalty reward points, and updates on future events and health news.

We'd really appreciate if you could take a moment to complete the short survey at the end of the session. It helps us improve and tailor future webinars to your needs. If you'd like to speak with someone, or book your consultation, our private patient team is available up until 8pm this evening and from 8 till 6, Monday to Friday, you'll find the contact number on your screens.

We also have upcoming webinars on a range of topics, including orthopaedics, treatments for migraines, and plastic surgery. You can sign up for those on our website. So, finally, thank you again for all of us here at Benningham Hospital for joining us, and we hope to hear from you soon.

Thank you, Mr Sharp.

Mr Henry Sharp

Thank you. Happy Christmas, everyone.