Louise king

Good evening. Welcome to our webinar on treatment for nose and sinus problems. My name is Louise, and I'm your host this evening. Our expert presenter is Mr Henry Sharp, a consultant ear, nose, and throat surgeon. This presentation will be followed by a Q&A session, and if you'd like to ask any questions during or after the presentation, please do so by using the Q&A icon at the bottom of your screen. This can be done with or without providing your name, but please note that if you do provide your name, the session is being recorded. If you'd like to book a consultation, we'll provide contact details at the end of this session. I'll now hand it over to Mr Henry Sharp, and you'll hear from me again shortly.

Mr Henry Sharp

Yes thank you very much for that introduction Louise and welcome everyone this evening thanks for joining us so my remit this evening is to talk to you about nose and sinus problems and how what we can do to diagnose your issues as well of course to treat them so this is a very topical subject to this time of year there's lots of coughs and colds and things like that around so I’m sure a number of you experienced those issues if not now on a regular basis so including in this session a little bit about my experience just to start us off for your interest I’ll tell you about how our ENT team works here at Benenden and then we'll move on to the sort of nitty-gritty of the nose and sinus structure a little bit about that and then really take you through your journey of how you will progress through the system should you come and see us here at Benenden with regards to how we would take your history examine you try and find out what's going on and then discuss treatments with you so that's the idea of the session this evening and I hope you find it helpful I will say at this point there is some clinical videos in here they're not very long and they're not very gruesome but for people that maybe of a sensitive disposition you may want to look away in one or two of the videos but they're certainly I promise you they won't upset you too much and I find I think they find them very helpful and interesting as to how we can treat your problems so as far as I’m concerned I trained some time ago now in London at mainly at guys and St Thomas’s and kings Hospital I did some paediatric training at great alman street Hospital and the Evina Hospital and at a very early stage I realized that I wanted to specialize in nose and sinus problems having worked with a great surgeon I then completed a special specialist rhinology fellowship in nose and sinus surgery in Germany and was appointed at east Kent Hospitals in 2003 I then joined here in Benenden Hospital as part of quadrant which is our consortium here in 2013 and I must say it's a very important and enjoyable part of my practice which I really have appreciated and I specialize in almost exclusively now in nose and sinus surgery and rhinoplasty both functional and cosmetic in other not in here but in other Hospitals so that's me as far as our team is concerned there's seven of us and we have expanded from four initially to seven as the demand has increased in reas we all work at east Kent Hospitals and we specialize in various different aspects of ENT but all of us have knowledge of nose and sinus issues but myself and my colleague Bertram Fu have particular interest in nose and sinus issues and interest in that respect so that's our team of seven who you may see one of them.

So moving on to how we would treat your pathway through the Hospital our real priority here at Benenden is diagnosis and we would want to I think one of the frustrations that we see with patients these days is it's difficult to get a diagnosis of what's going on with your nose and that may be because you're have difficulty accessing your GP or you have difficulty the GP themselves maybe not terribly knowledgeable about ENT because it is quite a niche subject so diagnosis is one of our real things that we would like to ideally on a one-stop basis provide for you here at Benenden so just you know your GP I don't need you to tell me to tell you that they are very busy and they're difficult to access and I you know I feel for them because my wife's a GP they do work hard but they are under a lot of pressure there may this was an interesting little cutting that I happen to see not that long ago that there may be some appointments that they don't need to see now okay that's fair enough and if you have d and r I would suggest that probably you don't need to see your GP however in this article they lumped together dandruff with a blocked nose now I would I find it a bit insulting because blocked noses are my main interest in my career but what I so there's 51 million appointments that could be avoided if people sought other parts of the health service but what you will see here they class d and r yes okay travel sickness yes okay but block noses I would say is not trivial certainly not you out there would clearly think the same but 5.2 million people sought an appointment with their GP for block noses so that really apart from anything else tells you an idea of the scale of the problem one in 12 of the population has a d nose and seeks advice from their doctor.

So why might you get some block nose or why might you have symptoms from your nose well let's move a little bit into the anatomy of the nose not in great detail but here is your nose basically in the middle here a schematic diagram so your nasal septum in the middle divides your two nostrils you then have paired structures in your nose so you have your cheek sinuses here or your maxillary sinuses you have your sinuses here your ethmoid sinuses between your eyes and then you have your frontal sinuses in your forehead and right at the back if we were to go to the back of your nose you'd have your sphenoid sinuses now attached to your nose or draining into your nose your tear duct which is relevant to some of your symptoms you may experience and at the back of your nose is your eustachian tube so if you have a block nose or problems in your nose you may well get added issues with regards to your eyes or your ears so that again is something that may ring a bell with you so that's just the basic nasal anatomy that we consider when we're thinking about your problems so the most important tool which we use for diagnosis is your history is the story you tell us and I worked for a very old-fashioned consultant when I was a houseman at St Thomas’s in London whose main mantra was 90% of the diagnosis can be made on the patient's history so taking it proper story from you and a history is really important to how we will decide how to move ahead and that's something that anybody can do but hopefully here we will do in some detail because we have the time to do it so what symptoms would we ask you about well the main sort of two or three symptoms are at the top there that you will you will describe to us usually discharge from the nose or mucus from the nose and that may be coming out of the front of your nose or going down the back of your throat and often people will describe postnasal drip or the back of your throat your nose may be blocked on one or both sides and this may give you other symptoms which may lead from that so snoring and often we say a sleep pattern is disturbed as a as a result of that not just yours but your sleep partner a sore throat because your nose is blocked and you tend to breathe through your mouth which gives you a dry mouth and a hoarse voice so just having a blocked nose may lead to multiple other symptoms which again may ring a bell for you deterioration in your sense of smell is very sensitive for inflammatory or problems in your nose and that may include nasal polyps which is often the end result of long-standing inflammation facial pain or headaches now that's actually surprisingly less likely to mean that you have sinus disease and it's often related to facial migraine or other types of other pain which may mimic that so that's less likely to be due to your sinuses if you have allergic problems in your nose you may get sneezing and itching and you may get some watery and itchy eyes so that tends to give you that tends to tell me that you've got more of an allergic tendency other symptoms you may describe which are less common are nose bleeds but as I’ve mentioned before you may get some problems in your eustachian tubes at the back of your nose and these may give you symptoms of blocked ears and muffled hearing so all of these symptoms I will ask you about and if you volunteer them will give me an idea more idea about what's going on so really you have blockers and you have runners in in the nasal well.

Here is your blockers blocking the way and here is your runners for you for your American football fans so you know if we think of people as being blockers or runners that's not far off how they are and they may coincide so you may be a bit of a blocker and a bit of a runner as well so that's what we try and work out what's going on next stage we'll move on to is the examination now a simple device like this I’d imagine not many of you will see this in your GP practice but this is a nasal speculum which will allow me here to look inside the nose with a headlight to look you know see the structure and the function of your nose with very great detail and ease and then in the same breath we can take you to the endoscopy here in the same room in this particular environment to examine your nose with an endoscope so just being able to examine your nose properly is something that often you won't be able to access in your GP practice so we do that we then we'll examine your nose with a flexible nose endoscope so this gentleman here has no anaesthetic in his nose it's very painless you look inside the nose with a little tiny camera and I can have a look in the nose on the screen here and also if I go a little bit further down you can look at the throat so that's actually the voice box that I’m looking at there so you can go get a very detailed examination he's quite happy he's sitting there and I’m getting a very detailed view inside his nose and his throat so that happens at the same time in the actual clinic room while we're seeing you on the same day this was covid times when we were all wearing masks happily that doesn't have to happen anymore.

The first video just a look around the nose so this is the this is the picture that I will get inside your nose coming in from the front with my endoscope so if we're going into the left nostril here we will see I’m just a little sucker we will see this structure which is inferior tube large structure normal structure inside your nose often mistaken for a pop there's your nasal septum your middle tube above where my sucker is there and we're going to the back of the nose it's a little bit dark I’m sorry the septum there a little bit of a spur there we're coming to the back and nowhere the adenoids would be there's no adenoids in this patient an adult there is the eustachian tube opening on the right hand side there so you can see how the station tube that little crescentic structure opens into the nose so the inferior turbinate as we come out middle turbinate above and the septum on the left hand side so that is the structure of the nose that's a normal a pretty normal structure inside the nose there so that's what we will examine when we look inside your nose with the endoscope when you come to clinic at that stage we may want some further tests and these tests are all available for you here at Benenden often on the same day they will be a CT scan will be done and some blood tests will be arranged as required so the blood test we often do is just a normal full blood count and in particular we look for the white blood cell count which is a marker of infection and inflammation.

We look at the different types of white cells that may be raised or lacking the neutrophils and the ear cells so that's useful to us and we can also do some allergy tests now in days gone by we used to do skin prick tests which some of you may have had but they are a bit more difficult to administer take more time so we tend now to do blood tests so we measure a total allergy score something which is one of your immunoglobulins and then we do rest tests and these are specific tests for individual allergens so I normally do a panel of several which is dog and cat house dust mite meld and grass pollen because they're the common sort of ones that we do but we can also do food stuffs and other aero allergens that will test whether you have an allergic tendency and that's helpful to know a for treatment as to what medication to give you but also for you to know what it is you're allergic to because obviously one of the main treatments for allergy is actually avoidance so if you know what it is you're allergic to are the problem then unfortunately they may have to take a sideline but there are treatments that we can give you for that if that's the case so what may cause your nasal symptoms so let's look a little bit more into more detail so essentially there's two things that can really cause your symptoms whether you're a blocker or a runner so you may have inflammation of the nasal lining and this is termedritis or more commonly rhinosinusitis because the lining of the nose and the sinuses is one structure and is continuous with one another and that may be with or without infection so you may have rhinos sinusitis which just causes inflammation of your nose nasal lining without infection or you may have infection with it and then at the end result of that if you have long-standing inflammation inside your nose is you may have nasal polyps and that's something that we can readily diagnose by looking in your nose as we've just seen the other thing that particularly with blockers so if your nose is blocked is you may have a problem with the nasal structure so you may have in particular a twisted nasal septum or weakness of the nasal skeleton itself and that's readily discernible by examining your nose just in outpatient so that's something that we can tell you what's causing in that.

If we move on to the sort of more inflammatory side of things the chronic ritis or rhinosinusitis we chronic in a medical term does not mean the sort of how bad it is it means the length of time you've had it so we have acute which means usually less than four weeks or 7 to 10 days really with sinusitis whereas chronic means more than 12 weeks so and often by definition by definition many of you out there will be experiencing these things for more than 12 weeks so what may cause the chronic ritis or rhinosinusitis well it may be allergic or it may be non-allergic and this again is something that's often readily discernible on a history by just asking you your story so allergic patients and it may be the first thing to say is it all year round or is it there a seasonal element because in the spring if it's worse in the spring it's often tree pollen if it's worse in the summer it's often grass and if it's in the autumn it's often moulds when the when the leaves drop off the trees so there may be a seasonal element or it may be year round and the commonest cause for year round allergic ritis is house dust might so instantly by asking the patient yourself what part of the year is involved you can get more idea about what's going on so allergic ritis is often associated with asthma and eczema so if you've got those other conditions you may well have a degree of ritis as well but this tends to be more watery discharge and you tend to get the more irritative type symptoms such as sneezing and itching and you may well have associated symptoms with your eyes like runny itchy and runny eyes and conjunctivitis and then there's the more non-allergic ritis which tends to be more infective in nature chronic infection long-term infection in the nose and sinuses and that tends to be more of a mucky discharge and you tend then to get a bit more in the way of facial pressure and pain because the sinuses tend to get a little bit blocked so those are the two sort of subsets that I like to think of the allergic and the nonallergic rhinosinusitis and you may fit into one of those brackets yourself so how many we how may how may it be treated what on the left there is a something that I use a lot of my patients do which is sinus rinse nasal douche which is a kit that you can buy and I don't have any royalties or anything but it comes in a little pack which contains a squeezy bottle and sachet of powder so you put the powder in the bottle you fill it up to the line there which makes about half a pint of salt water and that's very useful for flushing out your nose and getting rid of lot of the mucus and irritants inside your nose so the key thing here is and I know I keep going on about it but it it's very important for you to realize that these things need to be diagnosed and diagnosed early because if they are the vast majority of them can be treated medically without the need for surgery and there's just a list there of things that you know may well be appropriate to a number of you once the diagnosis is made so intranasal steroid drops and sprays can be used long-term and this is often not known by your GP your GP may say you can't use nasal steroid sprays long term well if you're on one of the modern ones you can there are certain caveats to that which we can go into if you like but most internasal steroid sprays are very safe to use long-term and a lot of my patients have to use them so that's the first thing to say anti-histamine tablets are useful in the allergic sense and the allergic patients I’ve mentioned saline nasal douches and there are various other more niche treatments that can be given such as Montelukast which is an inhibitor of a certain protein that's going around your blood that causes some of the inflammatory change that's useful in some patients particularly if you've got asthma as well and if there's a chronic infection a long-term infection we sometimes do give antibiotics not for five days but for three months or so to try and eradicate the infection.

These are things that may be relevant in a small proportion of patients but certainly sinus rinse nasal douche and this other one which is called sterimar are useful for an awful lot of patients and I would thoroughly recommend you look into them if you do have these issues sterimar is more of an aerosol type preparation and those clever French doctor clever French pharmacists basically siphon off channel water sterilize it stick it in a can and then sell it back to us which is exactly what star is and but it's more it's a little bit gentler inside nose than actually squeezing the fluid through your nose but either of them are beneficial so what happens if we don't treat your nasal conditions and well I think some of you may have got to this point unfortunately because you're that's why you're here but I’m you may well have recognized that unfortunately if it becomes more and more symptomatic as time goes by and you're increasingly likely then to require surgery which although I like doing it is not ideal for you so you know you want to try and catch this early so you can treat it medically you develop worsening inflammation and potentially polyps which is the end of the line as far as inflammatory change goes as it gets worse there is also this phenomenon called the allergic march so if you do have potentially a small degree of inflammatory change inside your chest as well which often people with ritis do you know that one can lead to worsening of the other and there's good evidence that people with worsening nasal symptoms get worsening asthma and vice versa so you know there the common airway between the nose and lungs is important you've got to treat the whole thing and not just rely on one treatment of one or the other well incidentally on that subject one of the things that is one of my bug bears is that people say postnasal drip causes a causes a cough it's not the postnasal drip causing the cough it's the fact that your nose and your sinuses and your chest are exactly the same so you have it's not the trip drip causing the cough it's the fact you have a widespread inflammatory change inside your nose your sinuses and your chest so that's one of the things that you know means you need treatment from all perspectives and sometimes I will refer my patients to see a chest position for that reason you may get potential worsening of your ear symptoms because of the effect on the eustachian tube as we've mentioned and then really at the end you can get some really nasty problems with untreated infection with swelling around the eye potential blindness periorbital cellulitis or big red swollen eye and if the sinus infection spreads upwards it can cause inflammation around your lining of your brain and mantis and ultimately brain infection now that is extremely rare but it's something that we do see a few people who've had long-standing sinus issues hasn't been treated effectively or properly and they do develop these complications coming as an emergency so that is something to bear in mind what about the more structural problems well the blockers you may have a twist twisted nasal septum and if there's one operation that I probably do more of than any anything else it's septoplasty and it's important to say that you may have a twist in your nasal septum without an external twist being visible so just because your nose is straight on the outside doesn't mean it's straight on the inside and in fact vast majority of patients with bent septum do not have an external twist of their nose.

That is correctable by an operation called septoplasty straightening of the partition you may also have large and in and swollen inferior turbinate which I showed you a little bit earlier on that that video and there is surgery that you can do to that to reduce the size of them now medically you can treat that with nasal steroids that will shrink your inferior turbos to some degree but what I would not encourage you to do is to use nasal decongestants now nasal decongestants do shrink your turbine and that's why they give you that lovely instant hit of where your nose gets better but the trouble is over time your nose becomes addicted to them and you get something called ritis medicamentosa and once that happens that's a permanent thing your nose is your nasal lining is permanently so I would advise you not to use nasal decongestant for a long period of time but to consider this operation called turbinoplasty where we remodel and reshape the inferior turbine to give you more room and that's a very useful operation for someone with large and soil and inferior turbine and I’ll show you a little video of that in a minute on that subject.

Here's one or two just little video vignettes about the operations that we do so as I mentioned you may get nasal polyps so here is a nasal pop this is another view inside your nose I will run the video in a minute but here is the difference between your normal nasal lining here is your nasal septum on the side wall of your nose and these grey glistening sort of jelly like things are nasal polyps now we can treat these with nasal steroids but often when they get to this size they need surgery so we have a little device called the debride which is a bit like pac-man for those of you of a certain age out there you'll remember a game called pac-man where you can run around the screen and munch things and here's our debride which does that so here we are we're looking in the nose with a camera an endoscope here's our debride coming in and we munch the polyps all right so you will notice that it's this is under general anaesthetic it's fairly bloodless the polyps don't bleed very much all right so you know these patients having this operation will go home the same day they will have no pack inside the nose at all just dissolvable dressing you know and so we munch these polyps is all very satisfying the patient wakes up instantly with better breathing and you know these polyps are gone I won't complete the operation but that's how it goes so this tubal device is very precise very you know very safe to use generally in the right hands and creates minimal bleeding so if you get nasal polyps is not the end of the world we can do surgery of that nature to get rid of them there is another procedure now so that's basically what I just showed you is functional endoscopic sinus surgery so we put a camera inside the nose we then use another instrument like the debride to remove tissue basically and to remodel the sinus outflow pathways so that's the sort of picture of the on the left there on the right there is an alternative procedure called balloon sinuplasty where we can actually and there's a little collection of mucus stagnant mucus in the cheek sign there on the right hand side so instead of doing a procedure to remove tissue we'll do a more sort of minim invasive procedure where we put a balloon into the opening into the sinus stretch it up and allow the sinus to drain properly so that's an alternative procedure it's particularly useful for the sinuses in the forehead the frontal sinus which is quite difficult to get at with conventional instruments so we tend to use the balloon sinuplasty particularly in the frontal sinus if that's where the problem is for the patient so that's another targeted operation that we can do in certain individuals.

I think you're getting the flavour that we very much target the operations that we do towards the individual so it's a bespoke type procedure according to your individual symptoms and your individual CT scan findings then we come on to an inferior turbinoplasty now this is again exactly the same picture as you saw before a different patient left hand nostril here is the nasal septum the first thing you see this is not entirely straight the nasal septum has a spur here which is blocking slightly the left nostril and this inferior turbinate here is large and chunky this is not a polyp some people look in their nose and think I’ve got a polyp that is not a polyp that's an inferior turbinate polyps are higher up here and as you've seen on the previous video they look slightly more gelatinous grey in in in in appearance so here I’m going to show you a video of before the operation here and I’m going to show you a picture of afterwards this is a septoplasty so an operation to straight stem this nasal partition and a turbinoplasty to reduce the size of this turbinate so it's a two-prong operation but you can see I think the improvement that it gives so here is the view before so we go into the nose there's a septum on the left inferior turbinate on the right you see the chunky bit of inferior turbinate the back there there's the back of the nose bit of chunky turbinate inferior turbinate out we come we go to the other side now this side the septum is even more twisted to this side and you can see I’ve actually just caught the septum a little bit with the with the endoscope there's a tiny little bit of blood there where I’ve just caught it's so narrow there's a big spur there like spur in the septum and again on the left of the screen a large and chunky imperior turbinate with a big spur in the septum going to this side so this patient needs septoplasty and bilateral turbinoplasty or inferior turbinate plastic so that's before I won't go through the duomo details of the operation itself suffice to say it's done under general anaesthetic all internally up your nose there's no cuts on the outside all with these delicate fine instruments that are designed for the purpose so here's the after so this is the same patient at the end of the operation and I think you'll see the difference so we'll go in the left side so the septum has been straightened the inferior turbinate has been reduced in size it's completely remodelled and you see the space in the lows now massive amounts of space drive a bus through there so that's the left side and then on the right side you'll see the septum that big spur has gone and that inter inferior terminate has been remodelled as well so then now on both sides you could literally drive a 113 through there so much room the patient will wake up with no packing inside the nose and will instantly be able to breathe easier so that's a very useful operation for the blocker type patient so this is a CT scan view of that precise or very similar to that thing this is actually a sepal deviation so as you can see this is the this is the before and this is the after same patient and not often do we do a CT scan after the operation but this one we did the septum is very bent so here's the septum in the middle it's the same sort of diagram that I showed you before on a CT scan so here are the eyes here's the brain up here and the nose and the sinus is in the middle so your nasal septum goes should go straight down but there's this big bony out cut here in the septum almost completely blocking the left side of the nose and here on this side you'll see this is a normal cheek sinus which is black full of air and here on the left there is it's completely grey so it's full of a large polyp so what I’ve done here is I’ve straightened the partition and I’ve removed all the polyps and here is the end result of it afterwards so the septum is now straight and you'll see here is the opening I’ve made into the cheek sinus on the left side but the sinus is now completely black and full of air which is exactly what you want so now both sides are the same and your septum lies in the middle so this is a septoplasty and a left functional endoscopic sinus surgery procedure so that's another bespoke operation to that particular person who had a left nasal polyp and a septoplasty other procedures that are now coming on stream which may be appropriate to you some people and I’m seeing a lot of particularly a lot of patients as they get older get a drippy nose for no apparent reason than we think because there is an overactive stimulation of the nose the nerves inside the nose there causing too much mucus to be produced so there's this new procedure called clarifix of which the instrument itself dispose instrument on is on the right of the screen there and what we do with this is we put the clarifix device into the nose it uses very cold material which is then pumped into that little probe at the end of the gun type structure there and that put inside the nose and it basically zaps the nerve inside the nose which is causing your nasal lining to produce too much mucus so that's a new procedure which we're bringing on stream which can be very useful for the particular patient that has a watery nasal discharge and no other significant abnormality and as I say that's useful for patients as they get older and do get runny nose so that's something that may be appropriate for you as well.

In summary I’d just like to say how we would like to think that we treat patients at Benenden and in particular for me the nose and sinus issues so you know we want to diagnose you promptly and accurately and I think hopefully I’ve shown you how we may do that here at Benenden and the people that will see you are you know are experts in this field so they're able to do that very readily we like to think we give a one-stop treatment plan so that would be examination diagnosis investigations and instigation of a treatment plan if it's not the final treatment plan sometimes we have to wait for results to come back obviously it would certainly be on the way to getting final a treatment plan and that may include surgery but actually in the majority of people if it's caught early enough and the diagnosis is made then you know you can get away without surgery so that would be our aim as I’ve mentioned a bespoke treatment plan is very much again in this situation directed at the specific cause of your problems it's not a one size fits all by any means it's very important that people who see you and hear that happens realize the particular aspects of your of your problem and are able to direct you to the proper and relevant treatment we do have a wide range as I’ve hope I’ve shown you of surgical solutions to your individual problems should medical solutions not be effective and you know it's often say it's not like orthopaedics where you come in you see someone and you have an x-ray and then you have an operation the vast majority of patients that we see don't need operations providing we catch you early enough and of course the other thing is early return to work and that's important for a lot of people and to normal activities and most of the operations I’ve described to you today you know will need a two recoup operation period and most people will be back to normal activities within 3 weeks or so sometimes even earlier than that and the activities that they will be doing particularly exercise things like that will be a lot more effective because they'll be able to breathe through their nose a lot easier so that's it from me really I hope that's answered some of your questions and has given you an insight into what we do here at Benenden particularly with reference obviously to the nose and sinus work although we do see other aspects of as well but if you do have any questions then I’m sure I’d be happy to answer them I’ll try my best.

Louise king

Thank you. That's really interesting. We do have some questions that come through, but like you say, anyone else, please do submit yours. This is your opportunity. Brian says repeated use over 30 to 40 years of an inhaler—for example, for hay fever for about eight months of the year—does that cause any damage to the sinuses?

Mr Henry Sharp

I think, as I mentioned in there, you should use Bane’s brand. I think bees are certainly one of the older ones, which I wouldn't necessarily recommend. I mean, if you've used it, don't worry. One of the things about intranasal steroid sprays is that they can have some side effects. They do sometimes, if you do use them for a long time, cause a little bit of a thinning of the nasal lining. They can lead to a little bit of nose bleeding, but that's generally short-term. If you stop using them for a little while, you know, then you can usually start using them again. You need to be a little bit careful if you've got glaucoma—that's, you know, if you've got high blood pressure. High eye pressure, then that's something you need to obviously keep an eye on because they can raise the intraocular pressure, so you need to get that checked, but if you're going to be on it long-term, and I don't have any problem with that, if you need it, I would probably go on to one of the more modern ones. Beckon is an old one, so there's ones like motion or flexion fluticasone, which your GP will know about. Unfortunately, some of it comes down to price. You know, if you're on it long term, it comes down to whether they give you the one that comes out of it the cheapest, but the once-daily ones, are safe a little bit because you do take a little bit into the bloodstream, so it might be worth talking to your GP about getting a more up-to-date once-daily preparation. I will mention as well that there are some nasal sprays that you can use for allergic reactions, just specific ones that contain a steroid and an antihistamine, and those are other ones you might want to talk to a particular one called DAA, which we use, and that's useful for patients with allergies, so if you do have that, that's something to talk to your GP about as well.

Louise king

Excellent, thank you. Michael says he's been researching claims that fungal infections are often responsible for long-term sinus problems. Do you see this?

Mr Henry Sharp

I do. That is absolutely true. I think what you're talking about you can get nasty deep-seated fungal infection but that's you'd know about that if you had that you can get certainly get fungal infection inside the sinuses and if you're getting smelly discharge and nasty stuff from your nose you need to come and see someone because that may be there's a fungal ball inside your sinuses which not as bad as it sounds it's just everyone's breathing in fungi all the time and occasionally these things just get stuck in your sinuses and useful for that is the saltwater douching which I mentioned you to flush it all out useful for that is nasal steroids so exactly the same but also ultimately if you do have a fungal ball or a collection of fungi in your in your sinuses particularly in your cheek sinuses we get them then you may need to have surgery just to ventilate that sinus and to let it all out so if you do have issues along those lines I would come and see one of us because you know we may be able to help you

Louise king

Excellent, thank you, okay. So, Brian says he's 72. He has a narrow-left nose channel, and it seems to block easily, so he depends on his nose. Sorry on my nose as he uses pillows using a cpap machine. Yes, he's used that machine for 13 years, and he's blocked most of the day as soon as he wakes up. Do you think there's anything that can be done well?

Mr Henry Sharp

You may have two things. That's another Brian. Sorry, did you say that was a different Brian Yes, right, that's a very common scenario that we see, so people with cpap have obstructive sleep near. Suppose you have cpap and use nasal pillows that go in your nose. By the sounds of it, your left nasal channel may be blocked because of your septum, which I just mentioned to you, so you may well need a septoplasty, which would significantly help your nasal breathing. We see a lot of patients on cpap for obstructive cpap near with mechanical or structural problems with their nose, so that may be correctable. the other problem that people get with so come and see the other thing that problems get people problems that people get with cpap is something called cpap ritis which is a specific type of ritis or inflammation of the lining of the nose related to the cpap now cpap for those that don't know blows air through your nose and your mouth to keep your passages open at night and that your nose doesn't like it frankly so the nasal lining reacts to that by swelling up so we may as well consider inferior turbinoplasty as we've suggested to try and give you more room in your nose to make your cat more effective and people often do get better use of their cpap once their nasal structural problems are sorted out so I would say possibly two problems one with your septum structural and the other, unfortunately, cpap ritis, but although you probably need to use your cpap, there may be ways around that with other bits of operations.

Louise king

Great, thank you. So, we have a question from Elena. Now that she's 67 years old, she continuously has a blocked nose, and when she's on the aeroplane, she feels the need to pop her ear, and she feels that her hearing is now quite muffled. Her dentist has said that she has infected her sinuses on several occasions. She wants to know what treatment would be appropriate for her, and she's also recently been diagnosed with asthma, which is something she didn't know she had.

Mr Henry Sharp

Well, I think you're a perfect example. I'm sorry, what was that lady's name? Elena, I think you're a perfect example. Elena, from what I've just been describing on the screen, you have, I suspect, rheumatoid arthritis, which is inflammation of the lining of your nose. You have a knock-on effect on your eustachian tube at the back of your nose into your ears, so you're getting muffled hearing. You're getting the ritis. I mean the simplest thing if you haven't tried it already would be to try an intranasal steroid spray from your GP but if not then if that doesn't work I mean and the other thing to say is they don't work instantly they do people often say you know I’ve tried an internal steroid spray and I’ll say to them how long have you tried it for and they'll say well two weeks I’m afraid you need to use it for four to six weeks continuously before it will start to kick in so that's an important thing to remember as well but if you haven't tried it already intranasal steroid sprays but really if you have and that hasn't succeeded then I’m afraid it means coming to see one of us and allowing you know to take your history examine you as I’ve described and see exactly what we can do I mean there are lots of bits and pieces that I hopefully I’ve shown you this evening that may help you but certainly if you haven't done already I would go and get a nasal intranasal steroid spray from your GP and give it a good because it sounds like you've got ritis

Louise king

Great, thank you. Our next question is from Cheryl, who says thank you very much for an informative session. Mr Sharp, by the way, her question is for her husband. He has suffered from blocked sinuses on and off for a few years, but there's never been a visit to the GP about it. Taking into account your comments about some GPs not being fully up to speed with sinus issues, how should he approach the conversation with his GP so that it's taken seriously?

Mr Henry Sharp

That's a difficult one. Cheryl I’m not sure I can answer that but I mean some GPs are interested and very good at ENT but it is a bit of a lottery unfortunately but the one thing I would say is and people come to me and I come walk into my consulting room and say doctor I’ve got sinus or I’ve got sinusitis and actually often that means different things to different people so does your husband have a blocked nose or is he really experiencing problems with his sinuses in other words is he getting facial pain is he getting discharge from his nose so that's why it's so important to take a decent history and that's unfortunately what you will get from someone like us and you may not get it elsewhere so you know taking a proper history from your husband examining them and seeing exactly what you know what the problem is I hope again I'm not repeating myself, but you know we can see exactly how we can help, but it's very difficult to do that without examining them, taking a history, and examining them first, so I would ask him first of all to concentrate on what the main symptom that he's worried about is: is it blocked, in which case it's probably not your sinuses? It's probably a structural element, as we've said, or a structural element, or a problem with your turbinate, or is it really sinusitis, where he's getting, you know, infections every now and again, or mucus? So if I had to say one thing, when you go and see your GP, hopefully you'll know a bit more about what the potential is for treatment, but also say exactly what your symptoms are to them so they'll know more about how to treat them initially, but I think ultimately you might have to come and see us, and he might have to come and see us. Kathy asks what causes a deviated septum. Good question. Most people are born with it, and a lot of people won't. A lot of people ask me that very question. Well, how was I born with it? How come it hasn't bothered me for the last 50 years? And I can't honestly answer that question, but all I know is that I think the answer is that the answer I give to people is that you are able to cope with it when you're a bit younger. You're able to compensate for that blocked nostril or nostrils because often, actually, the septum will go to both sides; it'll be bent to one side. I think you saw in the video went to the left at the front and it goes to the right at the back so often it'll block both sides to some degree but you're used to it that's all you've ever known and as you get older your physiology changes and you know you're less able to cope with it so I think that's probably why but most people are born with it and of course the other thing that can cause if someone smacks you on the nose or rugby or boxing or you know c cricket whatever it is or if you fall over I mean unfortunately amongst the more elderly patients fall over and hit their nose and therefore the septum fractures and blocks the nose so generally you're either born with it and you and you notice it often later in life for the reason I’ve mentioned or you have trauma those are the two main issues

Louise king

Thank you. Paul says that he's had many polytomies; is that correct? And the last one was about a year ago; he has no sense of smell; his breathing is fine; do you have any thoughts?

Mr Henry Sharp

Well Paul I would imagine you've probably got asthma and I would imagine you probably or may be allergic to aspirin as well so there is a we have a proportion of patients that unfortunately have a very significant inflammatory tendency and that is often with asthmatic patients and there is also this element which is sensitivity to aspirin so if aspirin makes your asthma or your nose worse you've got something called asthma exacerbated respiratory sorry aspirin exacerbated respiratory disease or sometimes called sampans triad and sas's triad is nasal polyps asthma and aspirin sensitivity now those patients unfortunately are difficult to treat and Paul you are I feel for you I have a number of patients in your situation we get to know each other quite well over the years because unfortunately I can't cure you surgically you have this underlying inflammatory problem which you will need surgery intermittently probably however you know however good the surgeon is for you know the rest of your life there are we I go to meetings a lot about talking about this and there are various surgical procedures that can be done not necessarily here because they are bigger operations inside your nose that may improve the chances of you or lessen the chances of you getting recurrence but unfortunately with your inflammatory tendency your nose is very u sensitive and will tend to produce polyps however there is the cavalry is on the horizon there are biologic drugs which are coming along which along the lines of steroids because you've been treated with tablet steroids and nasal steroids a lot these biologic treatments are new treatments they already used in other situations such as rubod arthritis and vasculitis type conditions in very bad inflammatory conditions and also interestingly in asthma actually but because they're very expensive they're not licensed for polyps yet so you can get them they work very well don't get me wrong we know already they work very well for polyps so it's a great frustration to us in the in the nose and sinus world that we don't have them for pops but nice has decreed that they're too expensive I think for a 10year course of these biologics is 200,000 so it's quite expensive but they do make an amazing difference I think they will come in the next few years I think as the price of the medication comes down other people start making them in your time there will be these new biologic medications so keep your eye open for those and they will be very exciting You may need some surgery every now and again, or maybe once or twice in your life, but with these biological medications, the chance of recurrence will be much smaller, so I think Paul is very much a niche patient, unfortunately for him, but there are various options for that either at the moment or in the future.

Louise king

Thank you. Our next question is from Wendy. She has a cough with a postnasal drip. Her GP just says that she has a chronic condition. This has been going on for over a year now. Her cough is getting worse with lots of sneezing. Should she be referred to an ENT consultant? She's getting fed up with feeling like this.

Mr Henry Sharp

Yeah I think so I mean I think you've probably got allergic ritis to be honest that that I mean that's that would be my first guess listening to your symptoms and of course as I mentioned the allergic march so unfortunately if your ritis is not treated and not appropriately dealt with then that can lead to this allergic march where your asthma gets worse your postnasal drip is not causing your cough what is causing your cough is the fact that you have widespread inflammation in your nose and your sinuses and your you know your windpipe and your and you and your lungs so you know you may need a two-pronged treatment maybe with some intranasal steroids and maybe dye that spray I was mentioning to you which is useful for allergic ritis maybe for you but also an inhaler steroid spray or inhaler sometimes in asthma asthmatics use may be helpful as well so I think to call it a chronic condition okay that may be correct but I think there is more treatment that definitely could be offered to you and certainly more investigations that could be offered to you and I think that's the frustration that a number of my patients feel in primary care is they don't get that next you know that next move from just saying there's nothing more we can do for you I’m afraid and usually there is to be honest with you it's just getting the right getting the right sort of history and examination in place so I do think you should go see any t surgeon I think you should come here obviously if you can but I certainly think you should say you know do I have allergic ritis if when you go and see an ENT surgeon and whether they should do those blood tests that I mentioned you know the ig and the rast tests which would be helpful in in telling them that so yeah I think you should go and see an in surgeon

Louise king

Thank you. We just have a few more questions. James says that he's had three of those polyp operations I mentioned earlier over the last eight years. He's now waiting for his fourth, based on a referral from his GP. He says there's no way to stop the recurrence of the polyps. He's asthmatic and currently on pricol, as the polyps have blocked both nostrils.

Mr Henry Sharp

Miserable, miserable conditions I feel for you. Yes, well, I think I've answered some of that already. I think you know what I mean. One thing I would say is you know these days you should ask your surgeon do you do this operation a lot because you know a simple polypectomy i.e. just plucking out the polyps will not really do your job well you won't get the long-term or even the medium-term resolution that you know that you seek so there is you know in in the in the in the hierarchy of operations you know there is an or a operation there is an a level operation and there is a you know degree operation and your operation now because you've had two or three for is right at the top of that so you need someone who does it regularly so I would say to you know to your surgeon politely you know do you do these operations a lot because you know obviously you need to do as much as you can by still being safe in order to get the because obviously there are quite a lot of bits and pieces which around and about your sinuses which you don't want to injure but you want to get someone that does the operation regularly to get the best result from that but as I say I think you again will be a very good candidate for the biologic treatment and that is something that you know is will come I you know it it's available now in Europe it's available in the us for nasal polyps and I have a one or two colleagues in London who are able to prescribe it one or two colleagues in London who prescribe it to private patients who are able have the financial wherewith all to pay for it and they have you know her she shows me their thank you letters and you know they are spectacular you know you've changed my life you know thank you so much she has some celebrity chefs on her books that can now smell you know so all that thing that you would you would have said in the past impossible you're never going to smell again I’m sorry. You know now that it is potentially possible, so you will still need the surgery. You'll still need a clear-out of all those polyps by a surgeon who does them, you know, on a regular basis, but also keep your eye open for the biologic treatments, particularly one called dillarmaab, which, you know, is really looking good but too expensive at the moment.

Louise king

Okay, we have an anonymous question that asks, Do you have a view on infrared phototherapy for allergic ritis?

Mr Henry Sharp

I do have a view on it, but I'm not sure if I should say it because it might be a bit rude. I don't think that works, to be honest with you. I don't think there's any evidence that it works. I have seen it, and I've sort of seen it, but no, I don't think that works, to be honest with you.

Louise king

Okay, that's nice and clear. Our next question is from David. He often gets blocked by your station tubes, which impairs his hearing quite badly. He thinks his tubes are quite narrow and bend quite sharply. Is there a solution to this?

Mr Henry Sharp

Well interestingly enough I haven't covered that this evening but if you go on to the website I think it's still there my last webinar which was about 18 months two years ago I did cover a lot of what I’ve said this evening so there may be a lot of overlap but also I covered balloon eustachian tuboplasty which is an operation where I mentioned to you about balloon sinuplasty where we can put balloons into the sinuses to open those but there is we can use the same balloons to put them into the back of your nose into that little opening I showed you at the back of your nose into your eustachian tube to stretch those up and that again is very successful in a number of patients in the right situation with the right clinical findings which you sound as there you may be then that may be the operation for you so if you want to look up about bel first of all if you want to look up watch me again I’m sorry if that would be the case, but you will see I put on that’d on that webinar a video of the balloon you station tuboplasty, which sounds very much as it may be helpful for you, and I’ve done quite a few of these patients in your situation, and the majority of them do feel to some degree, if not completely, better afterwards, so that may be something to look into.

Louise king

Thank you Neil said After having COVID last year, he's had blocked sinuses; he's had repeated swallowing sensations, which the doctor said was globous syndrome. They have referred him to the NHS, but he's facing a 42-week waiting list. Is his throat issue linked to his sinus or vice versa?

Mr Henry Sharp

I would say the throat problem is not related to the sinuses again. That's something I would need to ask you in more detail about your symptoms. So, you know, when you say you've got sinusitis, does that mean you've got a blocked nose, or does it mean you're, you know? So, I think you're getting the flavour here of how important it is to get a good history in and pin you down as to what your main symptoms are because people walk in and say I've got a sinus doctor, and I take that very much for a pinch of salt as to what's going on. So, a good history and seeing exactly what your symptoms are in relation to your throat symptoms—that's probably not related, i.e., globus is probably correct. Diagnosis is where the muscles in the top of your throat here get too tight, and so you get a feeling of a lump in your throat often or a tightness in your throat, which may be associated with some kind of change and things like that, but that's not normally associated with sinus issues, so it may be two separate things actually, but I think with regards to your nose, you know a proper history and examination again is what you need. I'm sorry it's 42 weeks; that's not an uncommon scenario. Unfortunately, I work in the NHS as well, and it is certainly very busy at the moment.

Louise king

I'm afraid that's all the time for the questions we have now, but I've just checked, and we do have the names of all the people with questions, so we can email you afterwards the answers to those, I'm afraid. Sorry, we didn't get time to do them all.

Mr Sharp, could you please move to the last slide?

Yes, thank you. So as a thank you for joining this session, we are offering 50% off the value of your consultation and a call back from your dedicated private patient adviser, Ana, via email tomorrow with, according to this session, further information and updates on news and future events. If you'd like to discuss or book a consultation, Chelsea from our private patient team can take your call until 8:00 p.m. tonight, and they are open between 8:00 a.m. and 6 p.m. Monday through Friday, using the number on the screen. Following this webinar, there will be a survey that will come through to you. We'd really be grateful if you could complete that because it just helps give feedback to Mr Sharp and also shapes our future events. Our next webinar is quite exciting, as it's on new replacements with robotic surgical assistance, and you can sign up for that via our website. That's on the 9th of January, so on behalf of Mr Sharp and our expert team at Benenden Hospital, I'd like to say thank you for joining us. We hope to hear from you very soon, so thank you and have a very happy Christmas.