Louise King

Good evening, everyone. Welcome to our webinar on ENT treatments. My name is Louise, and I'm hosting this session. I'm joined by a presenter and consultant ENT surgeon, Mr Henry Sharp. This presentation will be followed by a short Q&A session. You can ask questions during that session or beforehand as the webinar goes on. Please note that this session is being recorded. If you'd like to book your consultation, we'll provide contact details at the end of this session and a short discount for joining the session. I'll now hand over to Mr Sharp, and you'll hear from me again shortly. Thank you.

Mr Henry Sharp

Thanks very much, Louise, for that kind introduction, and good evening, everyone. I hope you're all sitting comfortably. And the plan for this evening's talk is to run you through bits and pieces about the diagnostic pathways and the treatment pathways that we offer here at Benenden for ear and nose problems.

So without further ado, a little bit about me. I qualified in London at St Thomas's Hospital. I did most of my junior and higher surgical training in London at Guy's and St. Thomas's. Just before my consultant appointment, I did a specialist nose and sinus fellowship. with a gentleman called Professor Draf in Fulda in Germany I was appointed in January in the NHS here in East Kent, where I've been doing my NHS and private practice ever since. I joined here amongst a group of four of us in ENT at Benenden, and we've since expanded to eight. So we're clear, the work is there, and it's a very interesting and nice part of my practice, which I enjoy. So just to say a little bit about what we're going to do this evening, just to go through it in a small amount of detail, not too much, and I hope you'll find it interesting and helpful. How we diagnose your symptoms and the commonest symptoms that we see here, and that will be divided a little bit into nose. And then ear problems. The treatments that we offer here at Benenden. And then, as Louise mentioned, a question-and-answer session about anything really ENT you want to ask me about. I mean, that doesn't have to be just on the subjects that we've spoken about tonight. But I'm happy to give you my views on most other things in the ENT world.

So as we'll talk about, the ENT anatomy, the ENT part of the body is very much interconnected by tubes and passages and this, that, and the other. And this schematic is not entirely farcical. I mean, you can connect the ear, the nose, and the throat. quite easily anatomically, and that's a schematic of me perhaps sitting in the middle. But we'll talk a little bit about how all these little bits connect and the effect that can have on your symptoms and also the treatment pathways that we can offer in the light of that. as we go through.

Here at Benenden, we do cover all the little bits and pieces within an ENT within our subspeciality interests. Amongst the eight of us. There are two ear specialists. to no specialists, myself and another colleague called Bertram Fu, and then four who specialise more in the throat issue. So we have all the bases covered here at Benenden for your issues. So unfortunately, these days, you out there will know more about this than I do, but because I hear it all the time from patients, patients trying to see their GP is very difficult because GPs are overworked. Their workload is expanding all the time. My wife is a GP, so I'm well aware of the issues and the problems that they have and how that transports through to you. And unfortunately. ENT in the scheme of things doesn't take much priority. And this was an interesting little snippet I found in the newspaper about how this journalist was saying how there are lots of too many unnecessary appointments with your GP. So I wouldn't argue, in fact, that if you go and see your GP because you've got dandruff, that probably isn't necessary. And you could possibly go and see someone else about that. But if you have a blocked nose, I will say that isn't actually trivial or not something that you need to see them about because, as we all know, having a blocked nose when you've got a cold is highly unpleasant. And if you've got those symptoms all the time, it really does impact your quality of life. And the fact that if you look at the end of that little article, there are 40,000 GP visits a year for dandruff. Okay, that's pretty trivial: 20,000 for travel sickness, again, fairly trivial, but 5.2 million for blocked noses. And that's about a tenth of the population per year going to see their GP for a blocked nose. So that gives you the scale of the problem that doesn't necessarily get the attention and the treatment that it deserves. And that's what we hope to offer you here at Benenden, for you know, if your treatments and problems are not being looked after elsewhere.

Our ethos at Benenden here is really about diagnosing your problems. That's really what we want to do for you. And it's amazing; I still find, after however many years in practice, that patients have been pushed from pillar to post without actually getting a diagnosis for their nasal problems. And often have had treatments that are ineffective, or sometimes they do them a disservice, whereas actually what they need is a really thorough and comprehensive history and examination and a diagnosis made. And at the very least. That's what we can offer you here at Benenden.

We talk a little bit about the anatomy of the nose and the ears in particular. And this is a fairly simple schematic diagram, which just gives you a little bit of an idea about what's going on when we're talking about the nose and the sinuses. So it's a sort of cut through the middle of the head. like so and looking at the front of your face anatomically. So you have four sets of sinuses. You have your maxillary sinuses, which sit below your eyes. You have your ethmoid sinuses, which sit between your eyes. You have your frontal sinuses, which are in your forehead, and you have your sphenoid sinuses, which are at the back of the nose, which you can't see on this diagram. But those are the sort of sinuses. What are sinuses? Well, they're air-filled passages in your skull. And people often ask, what are the sinuses for? no one really knows. It's probably, as we climbed from four legs onto two, it made our head lighter. an evolutionary advantage to have a light head so you could keep your head upright, so you weren't eaten by a sort of sabre-toothed tiger or whatever it was. And so that's probably why we have silencers to make our skull lighter and our head lighter. But they are filled with mucus-secreting lining, exactly the same as the nose. And that's why sometimes we get into trouble. As far as the nose structure is concerned, you have a septum in the middle there dividing the right and the left nostril. And then you have a set of turbinates, three lots of turbinates, the lower, the middle, and the upper or superior turbinates. And we'll come back to that a little bit later as well because that has an implication also for treatments as well. So your turbinates in your septum are quite important to the actual breathing passage. Then also attached or connected into the nose is the tear system. So the nasolacrimal duct comes from the corner of your eye; the lacrimal sac drains into the nose, and also at the back of the nose, which you can't see on this diagram, but the eustachian tube from your middle ear drains into your nose as well. So that's of relevance as far as your ear symptoms are concerned. So with that anatomical sort of situation in mind, let's have a little look into the nose. with an endoscope.

Now, there are a few videos in this talk. None of them are particularly gruesome, I promise you. They hopefully will be interesting for you and can show you not only the anatomy but also some of the treatments that we can offer, which are very non-invasive and very They don't cause a significant amount of bleeding or anything like that; nevertheless, if you are a little bit squeamish, you may want to look away during these videos, but I promise you they won't be too bad. So this is just a look in the nose. So this is the beginning of the operation before I do anything. We're just going to have a look in those with the endoscope. So if we look in the nostril there, that's a little sucker. There's the bottom turbinate, which I mentioned to you before. There's the middle turbinate on the side wall of the nose. And on the left of the screen is the septum. So as we look further back in the nose, the middle turbinate on the top there, the inferior turbinate, and the bottom turbinate at the bottom, there's a little spur in the septum there, which is just curving a little bit to one side. And then if we look at the back of the nose there, that's the postnasal space. And there's the eustachian opening; that little crevice on the right there is the eustachian tube opening. That in the back there is where you would have adenoids if you were a child. There's no adenoids there because it's an adult. So we come out; we have an inferior terminal and a middle terminal at the top and the septum on the left-hand side. So that's just a view inside the nose. gives you an idea of what we will be maybe operating on a bit later in the talk. So the first sort of opening gambit that I often get when I ask patients You know, why are you here? How can I help? As they say, I've got a sinus, doctor. Now, sinus can mean a lot in my experience again to patients. Sinus can mean lots of different symptoms. Some patients think that the sinuses, quite rightly, are boxes in the skull that can get blocked and can give you facial pain and a headache. So that's a perfectly reasonable symptom to have if you've got sinus issues. However, some other people may take the sinus problems, giving you a discharge from the nose. And that can be either from the front of your nose or from the back. And that will often be called postnasal drip or even Qatar by a patient. So that's another symptom you may see related to the nasal problems. If you have a structural problem with your nose or your nose is blocked, they will describe that as well. And that may well have knock-on effects on your sleep pattern if you can't breathe very well through your nose. You may well snore. And of course, that has knock-on effects on one's sleep partner and causes domestic issues. But also, if you can't breathe very well through your nose at night, you often breathe through your mouth. So you'll wake up in the morning with a very dry mouth. a sore throat and possibly a hoarse voice. So again, the knock-on effects of that can be seen in other parts of the E, the N, and the T. If your nose doesn't work very well or is blocked, you may well get a deterioration in your sense of smell, which also may be something that patients may describe. That, particularly, of course, became very high up on people's agendas during COVID. But it's gradually slipping down the agenda a little bit now. If patients have an allergy in particular, they may describe sneezing or an itchy nose. And that may be something that you can pick up again just on the basis of the history. Nosebleeds may be an issue. So all these nasal symptoms you may notice or have experienced. Then, of course, the two at the bottom are more related to those other structures that drain into the nose. So if you get problems in your nose, your eustachian tube may be blocked. And you may get problems with blocked ears and muffled hearing, a bit like if you have a cold or if you've just descended in an aeroplane. And then, of course, a watery and itchy eye. If your nasolacrimal duct, which comes into the nose as well, gets a bit blocked or problematic, you may well get a watery eye. And one of my niche interests that I have is operating with an eye surgeon with people with artery eyes called epiphora to drain their To drain their nasal lacrimal ducts was an operation I really enjoyed. So that's another side effect of a problem with the nose. So these are all symptoms that you may have or have noticed. So how do we go about looking at that? So first of all, I've taken the history, and I've listened to what you've said. And we've sort of made a bit of a plan from there. But then the next thing we'll do is that we'll look into your nose with the endoscope. And this is exactly that sort of video that I've just shown you before, except that this is with a flexible endoscope in the outpatient room.

Now, this gentleman, this is during COVID a little while ago. So we're wearing masks. That's not really necessary now. But with this flexible endoscope, this chap's sitting there quite happily. with no anaesthetic in his nose, we can use anaesthetic if people are a bit nervous, but % of the time this is using no anaesthetic. We're just having a little look in the nose. It's not painful, and it takes about four seconds. So in the left-hand picture, you'll see I'm looking in the nose, and if you look on the screen there, you'll see the septum and the sidewall of the nose. And then on the right-hand side, you'll see I've gone a little bit further down, and we're looking at the voice box there. And that's the epiglottis, that flap-like structure, and the vocal cords beyond there. So we can get a very good view just in the outpatient clinic with a patient sitting there entirely happy about the whole of the nose and the throat. So that gives us an excellent idea about what's going on. So this is done on virtually every outpatient visit that I have in my clinic. So other tests that may be necessary for you in the light of the history and the examination that I've done. I quite often organise a CT scan of your nose and sinuses, which gives us more idea about the deep-seated structure of what's going on, particularly if I'm thinking of any surgery. If the situation, I think, may be related to an allergy, we can do some blood tests. And we do what's called a total IGE, which is a sort of overall measure of your allergic status in your blood. And also then more specifically, RAST tests, which I tend to do a sort of pattern of RAST tests. house dust mite, grass pollen, dog and cat, and mold. Those are the sort of standard ones, but you can do food allergens and other things if that's appropriate. Then, of course, if there are some knock-on effects in the ears, we can do a hearing test, and we have a permanent audiologist available to us here at Benenden, but a same-day audiometry. So that's an excellent service that we do offer as part of the package here.

So going a little bit into more detail, what can cause your nasal symptoms? I mean, what's going to cause, in the vast majority of cases, the blockage in your nose or your Qatar or issues of that, which are the commonest symptoms that I hear? Well, generally, it's one of two things. It's a problem with the nasal lining. which is termed rhinitis or rhinosinusitis, because, as I mentioned earlier, the nose and the sinuses are basically lined by the same structure and are all continuous with one another. So we tend to lump them together in rhinosinusitis. So that's the first thing that can happen. And the second thing is you may have problems with the nasal structure. And these two things can, of course, coexist. So you can have both causing your problems. And this is where the endoscopic examination of your nose can be so helpful in discerning that. So let's talk a little bit about the rhinitis or the rhinosinusitis. And the first thing that we say if it's chronic. It means that you've had symptoms for more than weeks. And chronic in medical terms does not mean it's sort of worse than any other. It just means it's the time you've had it. So symptoms lasting more than weeks turn you into chronic rhinitis rather than an acute problem, which tends to be more short-lived. And the chronic rhinosinusitis or rhinitis may be allergic or non-allergic. in simple terms. And as I mentioned earlier, the diagnosis between those two is very much related to the history. So an allergic type of scenario is often patients will have associated asthma and eczema. And the trio is often termed atopic. A patient is atopic if they have asthma, eczema, or rhinitis. The discharge from the nose is more watery. So if we think of it in terms of hay fever-type problems. You get watery discharge, you get sneezing and itching in the nose, and that may well be associated with eye symptoms as well, like itchiness and watery eyes. So if a patient describes those types of symptoms, I'm thinking to myself, this is likely to be allergic. However, other patients may describe a more mucky, thick. mucoid mucus-type discharge, not watery, and have more in the realms of facial pressure and pain And that suggests to me that it's non-allergic in origin. So that even just on the history, we can sort of get an idea about what's going on. And that's quite important as to the treatment protocols that you will use. One thing I would say, and this is the frustration for me, and I'm sure for you as well, is that actually if you diagnose these problems reasonably early. A lot of them can be treated very easily without the need for surgery.

Now, I'm a surgeon. I like to operate. However, I'm well aware that most patients do not like surgery, and they want to be treated medically. And I quite understand that. And that is the... the aim of the whole scenario. But unfortunately, by the time patients often get to see us., their disease has progressed to a point where actually medical treatment is going to be less effective. So this is why getting an early diagnosis and getting an early treatment plan, even though it may eventually require surgery at some stage, is really important. Because if you don't, there's increasing evidence that this rhinosinusitis becomes worse. And if you have long-standing rhinosinusitis, you can get things like nasal polyps, which makes surgery much more likely, and also the symptoms can worsen your aspirin chest symptoms. And there is this scenario called the allergic march, where a lot of the symptoms get worse as time goes by. So an early diagnosis is optimal. And unfortunately, as I mentioned earlier, ENT does not take priority in the scheme of things. It is our impression. And unfortunately, we often get to see people quite late in the deal and in the day, rather. frustrating all round. So if, unfortunately, you don't get treatment, or the disease progresses despite treatment, you may require functional endoscopic sinus surgery. So you'll notice the difference just on the still here of the structure inside your nose; those grey gelatinous-type structures in the nose are polyps. And these are the end result or the sort of further down the spectrum. of long-standing rhinosinusitis that has not responded or has not been treated medically. And once you get to this stage, you usually will require surgery. Now, we have, in the last 10 to 15 years, developed these machines called debriders, which we can use to very accurately and non-invasively take out these polyps. So I'll show you a little video of the debriders. It's a bit like Pac-Man; if people remember that people of a certain age remember Pac-Man. And it's quite fun just to munch these polyps. So here comes our debris. It's a spinning blade. Very precise, very accurate, and we can munch these polyps very easily with minimal blood loss. People can do this locally. I don't personally. But you can either have this done under local certain individuals. But generally, the procedure is bloodless or quite bloodless and is very accurate and precise. So this is the way we now get rid of polyps, which is very effective.

Structural problems. So we've talked a little bit about rhinosinusitis and the inflammatory problems associated with the nasal lining. But structural problems as well can exist, which may require surgery as well. So the first one that we see a lot of, probably this is the operation I do the most of. In my working week is septoplasty. And this is where the nasal septum between the two nostrils is deviated to one side or the other. So people will often come and describe how particularly one side of the nose is blocked, or actually quite often both sides of the nose are blocked because the septum bends to one side of the nose and then crosses to the other like an S bend. So you'll actually get people with blockage on both sides. And if that's the case and the septum is proved to be twisted when you look in the nose with the endoscope. Then the only answer to that really is septoplasty surgery. And I'll show you a little video on that in a moment. The other thing that may occur with rhinitis, with severe rhinitis, as we mentioned, that doesn't respond to the medical treatments, is you get very swollen inferior turbinates. So the bottom turbinates, the largest ones that I showed you on that video, can get very swollen. And there is a procedure; there are lots of procedures, actually, that have been described for reducing those turbinates in size. People have tried laser ablation and diathermy, and I've tried them all during my career, and I've come up with the best one that works, which was one called turbinoplasty. And I'll show you why that is on a little video in a minute. But that's where the inferior terminals are actually surgically reduced in size. They're a bit like a joint of beef, the turbinates. They have a bit of bone in the middle surrounded by soft tissue. So the idea with a turbinoplasty is you fill out the bone from the turbinate; you reduce the soft tissue element with the debris, the same instrument I showed you a minute ago. And that significantly reduces the size of the inferior turbinate without significantly reducing its effect on the airflow inside the nose, which is what they do. So if you just chop the turbinate out completely, it's not a good thing to do. But if you reduce it in size and actually reshape it. It creates a larger airway without causing too many side effects. So it's an excellent operation, which I thoroughly believe in.

So here we are. Here is another video just to show a deviated septum in a patient and also large and congested inferior turbinates. So the idea is here to show you the preoperative situation and then the postoperative situation to see the effect that the operation has. So again, a little look through the nose, the same as we did before, inferior terminal on the right, there's a little bit of polepiece change of the turbinate there, back of the nose. So the turbinate is quite large and chunky. The septum is mainly bent actually to the opposite right side, as you'll see in a minute. And just as we put the camera in, you'll see that there's a little bit of blood there because the camera on my first pass just caught the septum, which is really twisted, and there's a sharp twist I wish we could get underneath there, but there's a sharp spur just at the back there bending to that side with a large and chunky turbinate as well. So we've got a bent septum, and we've got large turbulence. So here is the end result after the surgery. Which shows you the improvement. So we look in here to the left side, and we'll see on the right of the screen, the turbinate is now much smaller in size, and there's been significantly more airway there, such that we can get really easily in that side of the nose. On this, the other side of the nose where the septum is twisted, the spur in the septum is now gone. That spur there is gone. Much more room, and the turbine has been reduced in size in the same way. on that side as well. So that's a combination of septoplasty and inferior turbinate. So after the turbinoplasty, after that. The patient can breathe a lot, lot easier. Straight away, even at the end of the procedure, they'll wake up with a much clearer nose. And here is an example just on a CT scan, which I mentioned earlier. This is an operation, sorry, an x-ray, which we do to give us more information about the anatomy. Here you will see the preoperative situation where there's the septum down the middle and a huge, big spur here, a bony white spur in the septum, which is deviated over to this left-hand side. L is for left there, and R is for right. And here is a big polyp in the cheek sinus, in the maxillary sinus here. So you'll see the difference between this grey area here in the cheek sinus, whereas the black area on the right side is completely clear, which is air.

So this is a polyp, and then at the end of the procedure, the septum, the spur, is now gone. The septum sits nicely in the middle of the nose here. And there's an opening being made here into the sinus. The polyp has been removed. So there's now no polyp to be seen, and the septum is straight. So this is the sort of anatomical radiological sign of the surgery that's been done. So that's a little bit now about the ear. So I'm mainly, as I say, I'm a nose surgeon, but I do bits and pieces on the ear. predominantly those features and conditions that coincide with issues in the nose. But talk a little bit about problems in the ear that you may come and see us about. So the ear generally is divided into three subdivisions. The outer ear and the ear canal, which goes down to the level of the eardrum. So when we look in your ear, what we're looking at really is the ear canal where there's any blockage or any infection in there. But also at the appearance of the eardrum, which will give us some idea of what's going on in the middle ear. In the middle ear, there are three ossicles, the malleus, the incus, and the stapes, which conduct the noises through from the outer ear to the inner ear, which is where the ossicles connect to. So the hearing mechanism is in the cochlea. And you'll see up here, there's a sort of seashell-type structure, which is a cochlea, which is where all the hearing things are. This is connected to these semicircular canals at the top here, which are like gyroscopes for the balance mechanism, and then this cochlea and this apparatus here connect with this nerve that goes off to the brain, the vestibulocochlear nerve. So we think in terms of the outer ear, middle ear, and inner ear when we're talking about problems that you may experience.

So what symptoms may, you know, you describe when you come and see us? Well, the top three there are basically the top sort of chronic symptoms that people get, i.e., long-term symptoms that people get. They get an alteration in their hearing. They get tinnitus. Tinnitus is described as noises in the ears with no external source. So it can be any noise at all that doesn't have an external source. It can be whistling, it can be crackling, it can be a static noise. So we hear all sorts of people, and no one can really measure that. No one knows what it is apart from you. So you're the only person to describe that to us. People may get balance problems and vertigo; dizziness, or a feeling of being off balance, is different from vertigo. Vertigo particularly means rotational movement. So to actually say you've got vertigo, and it doesn't mean also you've got fear of heights, that's a rather lay term for it. But vertigo means a rotational movement, a bit like you've been on a merry-go-round, or you've had too much to drink. That sort of idea of the room spinning around you. Then you may get more acute, in other words, more sudden-onset and short-lived symptoms such as pain and discharge from the ears. And that generally is associated with infection in the middle or the outer ear generally. But the top three are the ones that people describe on a more long-term basis. And these are the types of dividing it again into the subdivisions of the ear. These are the sorts of things that we see in relation to those subdivisions. So problems in the outer ear may well be wax. And one of the problems that we now, or one of the things that we see more of, is people coming to see us with issues with wax impaction and wax problems in the outer ear because GPs no longer offer that. I would be careful about going to see High Street. I would say this wouldn't die, but I'd be a little bit careful about going to see high street um spec savers, etc., because some of them can be a little bit um not quite as well trained as perhaps they could be, I would say. So I would potentially recommend that you do come to see an ENT person, maybe not here, but somewhere whose expertise in cleaning the ear out is honed over many years because we do use something called microsuction, which we'll show you in a minute, which is very accurate. And pain-free. You may get infections in the outer ear, and otitis externa is very common. That means an infection in the outer ear. often can be associated with swimming, particularly if you're a keen swimmer, and may well be an issue from that perspective. And that may cause swelling. pain, discharge, and hearing loss if the canal gets very swollen. We see lots of things stuck in the ear, particularly in children. That's not such an issue here. But we certainly see hearing aid moulds. and cotton buds. And I wouldn't recommend anyone use cotton buds in their ears. Nothing smaller than your elbow is the old terminology. But yeah, we do see people sheepishly coming to have cotton buds removed from their ears. So those are the main things we see in the outer ear. How about the middle ear and the eustachian tube? Well, eustachian tube dysfunction is very common. This is a sort of feeling as though your ear is blocked and muffled. Sometimes it feels as though your head's in a bucket. And this is something that previously was very frustrating as an ENT surgeon because we couldn't really offer you very much in the way of effective treatment. However, in the last three or four years, there has been this new surgical treatment called balloon eustachian tuboplasty, which I've been very, I was a cynic to start with, but I've been very pleased at how well it seems to work. And I have a good database of patients now that I've treated. Very effectively. And I get very good feedback from patients on that operation. We'll talk about that in a second.

If the eustachian tube dysfunction gets a little bit worse over a period of time, you can get a collection of mucus in the middle ear because the middle ear lining also produces mucus, which normally drains out through that eustachian tube. But if the eustachian tube doesn't work, then it can collect and form a middle ear effusion or middle ear fluid. And that can be sometimes termed glue or is the same thing as glue ear. Now, this is more common in children, as we know, but sometimes it occurs in adults and can be longstanding and may require a grommet in the same way that it does in children. And I mentioned those three little bones of hearing in the middle ear. So those can get disrupted or broken up, and the joints can come detached. Sometimes due to what's called a cholesteatoma, which is a deep-seated progressive infection in the middle ear. Now, that's beyond the scope of this talk and also beyond the scope of the treatment we offer here at Benenden. However, if we spot one of those, it's very important that we do spot it, and you get treatment done elsewhere. That's certainly something that we would be able to tell you should you have that issue here. But that is unusual. And then lastly, problems in the inner ear, which relate more to hearing problems and tinnitus, really, and balance problems. As I explained, that's really what the inner ear does. So the most common thing we see is age-related hearing loss. And you do get particularly high-frequency hearing loss as you get older. And the only real answer for that is A, diagnosing it, which we can do for you. And secondly, potentially offering hearing aids or the guidance towards getting hearing aids. Many SDs, again, you could talk about that for an hour on that alone. It's a disease essentially where it's a bit like high blood pressure in the inner ear. There's too much fluid in the inner ear. And so it gives you a trio of symptoms of those three main symptoms I mentioned earlier: hearing loss. tinnitus and dizziness. And there are various medical and surgical treatments for that. Which again, we could identify that for you and suggest treatments in the light of. that diagnosis. We get quite a few patients sent to us from high street audiologists with asymmetric hearing loss or one-sided tinnitus. Now, if you have tinnitus, it's generally both-sided. Generally on both sides. However, it's on one side; it can sometimes be due to what's called an acoustic neuroma, or to be accurate in terminology, vestibular schwannoma. That is a benign tumour on the hearing nerve I mentioned earlier that goes between your inner ear and your brain. Which causes one-sided symptoms. So in those situations, we tend to do an MRI scan of the inner ear and the balance and hearing nerve to give us more information. An acoustic neuroma, as I say, is not anything too serious. But it certainly may require monitoring by serial CT scans and potentially surgery should it get large. But the first thing to say about it is it needs diagnosing. And that's something, again with patients with those sorts of scenarios, that we can do for you here at Benenden. So those are the sorts of things we see commonly in relation to the ears.

So what can we do in relation to your ear treatment in the outpatient clinic? Well, as I mentioned, we can clean them out. We can do microscopy of the ear. We can have a very close look into your ear. using a microscope, and then we can use this tiny little vacuum cleaner to very accurately clean your ears out. And with the expertise of ENT surgeons. We'll be able to clean your ear out fully and completely right down to the eardrum, which is something that may not be offered elsewhere. We can do audiometry or hearing tests, and that's a same-day service. We have a booth here, a soundproof booth, which gives a very accurate hearing test, and we have expert audiometrists to do that. So that's all done on the day of your appointment. What may we do in terms of surgical ear procedures? Just on the subject of that, we can actually look in your ear with an endoscope. as well now. So we can get a very close view inside your ear and at your eardrum using the same endoscope we do in the nose. So here is balloon eustachian tuboplasty. So what we do with this is we look in your nose with the endoscope. We pop a little probe into the eustachian tube opening at the back of the nose. And then pop a balloon in there and inflate the balloon. The eustachian tube is made up of a soft tissue section, which is the section that we cannulate during this operation, and then a bony section, which is further in. So we only cannulate the soft tissue part of the eustachian tube, which is the first couple of centimetres. Then we blow the balloon up and hold it in that position for two minutes. What that does is it creates, obviously, a bit of trauma to the eustachian tube. It stretches it. The eustachian tube then heals, and as it does so, it forms some scar tissue, and the scar tissue, as it matures, slightly stretches the eustachian tube open. And that's how this works. And it's interesting to look in the nose. six weeks post-operatively, which I unfortunately haven't got any post-op videos, but the eustachian tube definitely looks wider, and you look in the back of the nose, and the eustachian tube looks much wider than it did. before the operation itself.

So this is just a little video of that procedure. So we're looking in the nose. We're introducing this probe, which is going to go to the back of your nose. We're then going to just pop that gently into the eustachian tube, which, as we know now, we're all experts on the anatomy, is just at the back of your nose there. Just there. We popped a little probe in, and then we, over the top of the probe, slid in the balloon. And then the balloon sits in that soft tissue part of the eustachian tube, and then we inflate it. All right, so I hold that balloon there in that position for two minutes. Happily, you won't have to wait two minutes because we'll move on to the next bit, which is when the balloon is deflated. So here the balloon is deflated after two minutes. It's just gently withdrawn. And removed. And as you can see, the eustachian tube opening now looks nice and wide. And you can imagine how that would work better. Six weeks later, when you look in there, that looks much more mature and open than it does even there. So if you get the slightly worsening of those symptoms, you get fluid behind the eardrum. glue ear, you can then put a grommet in the eardrum. So this is just a little surgical video of a grommet. This is taking down a microscope. So the eardrum, which we're looking at the bottom there, is about slightly smaller than your little fingernail. So it's all taken down a little speculum, which we put in your ear here. So in a minute, you'll see me introducing a tiny little knife called a myringotomy, and that little knife is going to make a tiny little nick in your eardrum just at the bottom there, a radial cut just from the middle out to the outer part of your eardrum there. And that just allows the fluid to be withdrawn from the middle ear. in a moment. So here comes a little sucker, a tiny little vacuum cleaner again, and we're just going to suck out that mucus in the milieu. Sometimes it can be very impressive, and lots of mucus comes out. Other times less so. But anyway, we're removing that mucus from the middle ear gently through that hole. And that will allow that fluid to dissipate. Then, through that hole, we put our grommet in. And a grommet, here it comes, is like a tiny little cotton reel with a hole down the middle. We place that into the hole we've made. And then gently using a little needle Just gently position that so that the opening of the grommet is lying flat; try not to get my fingers in the way. The opening of the grommet faces outwards, so it allows the air in and out of the middle ear. So it ventilates the middle ear. So you'll see there, it's got a flange on it, the grommet, so that flange sits on the inside just to keep it from falling out. We gently just position that so that the hole is facing outwards so we can see. And that grommet sits in there generally for about six to nine months. And then the eardrum usually will push it out of its own accord. So that allows the air in and out of the middle ear. much more effectively.

So we're coming to the end. What's a summary of our ENT ethos here at Benenden? Well, I think hopefully you've sort of got the impression that we offer a prompt and accurate diagnosis of all aspects of ENT disease, and we all are subspecialist experts in our field of ENT and the different parts of the E, the N, and the T. There's very much a one-stop ethos of diagnostics and instigation of treatment plan. And that's something that suits everybody that you don't want to be coming back lots of times if you can possibly help it. a bespoke treatment plan once we've identified the cause of your problems. And the best treatment, then that's ideally what we'd like to offer you according to your individual issues. We have a wide range of surgical solutions and medical solutions as well. But if the medical solutions are not effective, we have your backs covered as far as the day surgical solutions. surgical solutions. And most of the, if not all of the solutions we offer you are encouraging early return to work and normal activities, which again is something that a lot of people will be interested in before we instigate things. So hopefully that's something that I've got across to you. If there are any questions, and I think there are some lining up there, I'd be happy to answer them. Thank you.

Louise King

Thank you. Thank you for that interesting presentation. There's so much covered in such a short period of time. So really interesting. We do have some questions, and I will go through those as best as I can. Hi, I've been diagnosed with tinnitus in my left ear. I've had no scan. What treatment do you offer tenderness, and what charges are appropriate?

Mr Henry Sharp

Well, the first thing to say, I think, is that if you do have tinnitus in one ear, you do need an MRI scan. I think, as I mentioned earlier, it's very, I mean, we see people with these unilateral symptoms, and we do scans on them. Around one in a thousand people in that scenario will have an acoustic neuroma. So it's very unlikely. But if you've got tinnitus in one ear, you do need an MRI scan. Ideally, you would have a hearing test as well. So really, the ideal situation would be to come and see one of us. have a hearing test on the day to see if you do have a significant hearing loss in that ear as well. Have your ear examined and then have an MRI scan on the back of that. And that would be my recommendation. Whether you come here or whether you go elsewhere, or the NHS isn't up to you. But I think if you spoke to your GP about it, they would almost certainly send you somewhere to have an MRI scan in that scenario with a hearing chest if possible. Okay. the charges, you can see a little bit about the charges, but that's not my remit really this evening. That's something that you could talk to the office here at Benenden about should you wish to come here.

Louise King

Yes, indeed. Thank you.

Okay, our next question They have blocked eustachian tubes lasting days, and they've been using medication. prescribed by GP for five days. They are then going to South America at the beginning of February. With stopovers, we'll have about seven aircraft take offs and descents in days. If the tubes don't clear. Is there any danger of lasting damage to their ears with all this travelling?

Mr Henry Sharp

Yeah, so the first thing to say is that the fluticasone spray that your GP has given you for five days is nothing really. I mean, you need to probably use it for at least a month before it's going to start having any effect. I would say five days is really minimal. So you could potentially persevere with that. Yeah, the up and down in the aeroplane, that's not ideal if you've got problems with your Eustachian tubes. Lots of, I mean, it's the take off and descent that is the issue, as you well know, the pressure changes, particularly in descent. And interestingly here, I think since word has got around, potentially since I last gave this talk. We've had quite a lot of people coming to see me from the airlines, quite a lot of cabin crew and things like that, who obviously have a lot of these issues as well. So, you know, you may well be a candidate if you have problems with the balloon tube velocity operation I've just described.

So, you know, come and talk to us about that. The lasting damage jury is, I mean, it can be quite painful, as you well know, if you've experienced it. Particularly on descent, if you're not able to equalise your ears. And in the worst scenario, your eardrum can actually burst as a consequence of that, and you get some trauma. So I wasn't going to say it's definitely going to cause lasting damage, but you may well get uncomfortable, very uncomfortable, when you're on your aeroplane flights, which you know it would not be good for you. The one thing you can do if you don't have time or the inclination to come here is, when you are flying, you can use nasal decongestants. So before you take off. Particularly before you land, before you start to descend, spray some Atrevine or Sudafed or one of those decongestant sprays in your nose. And that will optimise your eustachian function in that scenario. I'm not suggesting you use that regularly because it's not very good for your nose, those sprays. But certainly when you're flying and you do have that type of issue, that would optimise your chance of not getting problems.

Louise King

Thank you. Trisha says she's had treatment as a child for a blocked nose because she was told she had a small nose and generally breathed through the mouth. She then had her adenoids taken out later as a teen and had her nose cauterised. Since then, she's had nothing else done. She's now having problems sleeping through And she snores and wakes up with no dry mouth. She still tends to breathe through her mouth. I think she may have a twisted septum, but wouldn't they have noticed that when she had a child and corrected it?

Mr Henry Sharp

I think you're pretty much an ideal sort of case study, I think, for some of the stuff I've just described, because it sounds to me as though you may well have a deviated septum and possibly some rhinitis and enlarged turbinate. So I think you would be well advised to come and either see me or one of my colleagues here and let us examine you because it may well be that we could have a solution for you that would be quite effective. You say you may have a twisted septum. Wouldn't they have noticed that when I was a child? We don't correct nasal septum generally before the age of two. So they may well have noticed that you had a twisted septum but not done anything about it at that stage. The reason for that is that if you operate on the septum before that, it can affect the growth of the septum and the nose itself. So it's not advisable to do that until people are fully physically mature. So you may well have a twisted septum. all your life, which is why you haven't been able to breathe. So it would be a pleasure to try and help that and try and fix that for you.

Louise King

Thank you. Yvonne says, is the dizziness as a result of inner ear problems worth seeing a doctor about, or does it right itself as she's been advised?

Mr Henry Sharp

Well, dizziness is a symptom that we could talk about again all evening, or at least for an hour. My take on dizziness is that, because I'm not a specialist ear doctor or otologist, I do see a lot of patients with dizziness, and most of the diagnosis can be done on the history, i.e., what you tell me and what the scenario is that you get dizzy, what it feels like. Is it rotational dizziness? Does the room spin around you, or is it just that you feel off balance? Do you get any associated hearing loss or tinnitus? So, as I say, a thorough history. And unfortunately, you know, a lot of GPs, one of the things I didn't mention was The other thing about a lot of GPs is that they try their absolute best, and I know they do, but they haven't actually done a lot of ENT. So they're not terribly You know, as a trainee. So they're not terribly au fait with the ins and outs of ENT issues. So you may get a GP who doesn't know an awful lot about dizziness who would say that to you. But it really depends on whether it's going to get better as to what the cause is. So I really think if it's not me or one of my colleagues here, you probably ought to go and see an ENT person somewhere. near you to get them to give you an idea about what's going on. It's very difficult to classify dizziness as all in one cause, really. This person says they had a septoplasty, turbinectomy, and washout performed some years ago. Since healing, their nostrils will now collapse on the side they are lying on during sleep. They use nasophan nasal spray. What is causing this, and can anything be done about it?

Mr Henry Sharp

Well, that's an interesting one. So the first thing you had was a septoplasty turbinate. So as I mentioned earlier, turbinate surgery can be done in many different ways. So I suspect if you had it some years ago, you probably would have had a degree of caution or something of that sort to your turbinates. And I know from experience that doesn't really work long term because the turbinate grows back again. So it may well be that your turbinates have come back again. Sometimes, after the septoplasty surgery, the septum can swing back a little bit to the side it was before. or there's a little bit more we can do to the septum. So that may also be an ongoing issue. The washout, I'm not sure it's, that's not particularly here nor there with regards to the breathing through the nose. That's more to wash your sinuses out. And the last thing is if your nose does actually collapse on the side of the nose. And it may be that your cartilages in the sidewall of your nose here become a bit weaker as you get older. And that can happen as well. So that really needs us to look at as well to see what the likely cause is. So a combination again of the history and examining you in some detail to see what the actual problem is before giving you a treatment plan. The nasophan nasal spray is a steroid nasal spray, much like fluticasone, and, in fact, I think it is fluticasone that our friend asked about earlier. So that's a steroid nasal spray that shrinks the lining of your nose down. that will potentially treat the rhinitis side of things, but not the structural side of things. So again, that's another thing that you really need to come and let us have a look at to make a recent diagnosis.

Thank you. This person's kind of, it's more of a statement, but I think there's a question within it. Let's see how we get on. They get blocked as often when they get cold. Sometimes taking Sudafed cures it, but sometimes not. And their hearing is then really badly affected to the point where they have to use subtitles in meetings. I would suspect that what you have is a degree of inflammation of the lining, rhinitis of your nose. And when you take the Sudafed, it shrinks the lining down; it shrinks those inferior turbinates down. And that obviously gets worse when you have a cold. So you live on a bit of a knife edge from the point of view of your eustachian tube drainage. But when you get a cold and the nasal lining swells up, that gets significantly worse.

So, you know, I would go back to the original point. I think let's have a look in your nose. And see whether it's a significant problem on an ongoing basis or whether it's purely a problem you get with the Coles. But I suspect there will be an underlying issue with the lining of your nose, which just gets pushed over the top when you get a cold. Sudafed is fine, and I, you know, for a short period of time, seven days is okay. But I wouldn't recommend it long term because it does a lot of damage to your nose. If you use it long term, you can get something called rhinitis medicamentosa, where your nasal lining is damaged. irreparably, but you also absorb it into your bloodstream. It causes your heart rate to go up, your blood pressure to go up. So it's really not very good for you. And I would only recommend it really short term. So I'm afraid that, again, I think probably that will need us to look in your nose and your ears.

Louise King

Thank you. Michael says he suffered with a blocked ear sensation and had tinnitus for many years. He's had it to vent balloons to inflate. and now wears hearing aids. Last year, he developed pulse et al., tetanus time. I'm going to say it perfectly. Should he be worried?

Mr Henry Sharp

Well, the first thing to say is that balloons are something that we would use in quite a lot of people who come to see us with eustachian tube problems. Essentially, what they are is a little nozzle that you put in your nose. which has a balloon on the end, and then you blow your nose, which opens the eustachian tube. orifice. So it's a similar sort of thing to the balloon tuboplasty. So yeah, I think that's absolutely fine to have used that. So what you didn't say is whether it helped your blocked ear sensation, but I don't know whether that's the case or not. So the other thing I get the impression of is that you wear hearing aids, and you have tinnitus. So you may well, I suspect, have some inner ear type hearing loss as well, which can, of course, coexist with some eustachian problems. So the hearing aids and the tinnitus are probably, or the hearing loss and the tinnitus are probably related. Pulsatile tinnitus is slightly different. You know, should I be worried? I mean, postural tinnitus can be related to other collections of blood vessels. around your inner ear, or sometimes a blood vessel inside your head that dips into the area of your inner ear so you can hear it. because of that. And sometimes we do investigate postural tinnitus if it's an ongoing issue by means, again, of an MRI scan. So if you're concerned about the postal tinnitus. and you have ongoing problems with your blocked ears, then we could look into both of those things if you come and see us.

Louise King

Great, thank you. Kay has dry, flaky, and very, very itchy ears. This gives her regular wax buildup. and has ear blocks and also micro suction every three to four months, and then it all starts again. She has a small ear canal and has been told her ear now smells. Actually, do you have any advice, and is it for menopause causing the dryness?

Mr Henry Sharp

So first of all, the dry, flaky, itchy ear. Yeah, I mean, I would ask you, do you have any other skin issues like eczema or… or psoriasis or anything like that? Because, of course, that can have a bearing on the skin around the ear and things like that. People do have very narrow ear canals, and that can mean, I mean, generally the ear is designed to clean itself. So if you put an ink dot in the middle of the eardrum. Six weeks later, a permanent ink dot, that ink dot has made its way out to the outer ear. So the skin migrates outwards. So the wax and skin should come out on their own, but if you do have a very narrow ear canal,. Sometimes for no apparent reason, the wax doesn't come out on its own. So you describe the fact you have to have microsuction, and then it starts again. I would just gently say to you, Who does the microsuction? because that can make a difference. If you get it done by one of us who can clean your ear out absolutely and completely, it's more likely to work long term. But you have a small ear canal. Unfortunately, sometimes that's just a necessity. And unfortunately, once you have your ear cleaned by microsuction, it is a bit of a self-fulfilling prophecy. You often have to have that ear cleaned. I would say to people generally once a year, sometimes twice a year; three times a year is unusual. But if you do have a very small ear canal, then that may well be the case. Sometimes if it really causes you a problem, and particularly I think if you start getting infections in relation to the ear canal, you can actually have your ear canal widened. And I was mentioning earlier, I have two specialist ear surgical colleagues here at Benenden, and they do what's called a meatoplasty. which is an operation to actually widen the ear canal and would make that potentially less likely to happen to get your wax building up. So if it's really an issue, come and see one of them and let them talk about it with you because it sounds as though it's causing you some heartache. I have heard that menopause can cause, you know, it does cause issues in the nose, some dryness in the nose. I doubt it's so much in the ear because it's not, you know, it's more skin than anything else. But certainly if you're getting dry skin elsewhere. Then that may have a knock-on effect.

Louise King

Thank you. I'm trying to think of quite a lot of questions; we're just trying to find something that is a bit different. How often does balloon eustachian tuboplasty need redoing? Or is it once and then that's it done?

Mr Henry Sharp

Yeah, good point. I haven't been doing that. I've been doing this for about three or four years. I think I've done about three, or probably three twice. But that is unusual. And most times it's just once. But I've had, as I say, three people come back where it's worked the first time; it's gotten better. But they wanted it done again because the symptoms have started to come back again. So it's very unusual. I've done, I think, probably nearly a hundred cases now. So it's very unusual that that happens, but it is a possibility. But the good thing about it is, apart from the financial aspect, which is not so good, the good thing is it's a relatively easy procedure to do. And it's non-invasive. So, you know, it's not an awful thing to have to undergo again. You know, some people have written to me saying it's changed my life. You know, literally, I've had these symptoms for years, and it's really changed my life. The vast majority of people will have a significant improvement in their symptoms. I've had a few, and I say it quite openly: it hasn't improved their symptoms. They say it's not gotten better, but I haven't had anyone where it's gotten worse. So the percentage of patients that get better or vastly better is very large.

Louise King

Thank you. We'll just do one more question because we are running out of time. This person has tinnitus in both ears. They've attended Benenden and have a hearing test. Both of them had a camera down the nose, but they didn't get an MRI scan. The doctor said they just need hearing aids; should they not have had an MRI scan to check?

Mr Henry Sharp

Not everyone needs an MRI scan. It's purely if your tinnitus is in one ear and/or you've got a hearing loss in one ear, which is significantly worse on one side than the other. So no, we don't do MRI scans on everybody with tinnitus. It's purely the people who have one-sided tinnitus or one-sided hearing loss. So if you've got hearing loss and tinnitus, a hearing aid is a perfectly reasonable treatment for that.

Louise King

Thank you. Sorry we didn't get around to answering all of your questions. We just had so many, and they're so detailed, and it's great. If we have your names, we'll be able to answer them after the webinar to contact you. If you need to provide your name.

If you can, move on to the last slide, please. Thank you.

So as a thank you for joining this session, you will be entitled to 50% off an ENT treatment consultation. at London Hospital. This is if you claim in the next seven days. You'll also have a call back from our dedicated private patient advisors. You'll receive an email with a recording of the webinar so you can go through any information you might have missed. That will also have treatment information, pricing, and information on our loyalty scheme. And you can also stay updated on our coming news offers and events. that's happening. If you'd like to discuss or book a consultation, our lines are open until 8 pm this evening, and our private patient team is available 8 am to 6 pm Monday to Friday. We have many more webinar events coming up. We've got two more this year, one on Mona Lisa touch for vagina dryness and varicose veins next Tuesday. And in the new year, we have events on orthopaedics, urology, and many other subjects. Just if you keep an eye on our website or sign up for our newsletters, you'll receive information on these. So thank you very much, Mr Sharp, for a very interesting presentation, and thank you all for listening, and thank you to everyone else at Benenden Hospital supporting this, and I hope you have a wonderful evening.

Mr Henry Sharp

Happy Christmas.

Louise King

Happy Christmas. Thank you. Bye-bye.