I am reminded of the privilege we enjoy in the city – we have 24 hour emergency cover through the public hospitals and as an ENT consultant, I am backed by trainee registrars – none of this is available to country GPs other than phone advice.
Google Scholar shows an analysis of 20,563 adult attendances at an ENT emergency clinic in Paris. The most frequent presentations were: pain, sudden loss of hearing, bleeding and swallowed foreign body. The most frequent nasal problem was epistaxis, the most frequent ear problem was middle and external ear infection and the most frequent throat problem was foreign body ingestion.
Just 1,225 were hospitalised – most frequently epistaxis, peritonsillar abscess, sudden hearing loss and swallowed foreign body. A little more than 100 patients required immediate transfer to the operating theatre.
Epistaxis for the country GP is most easily managed using some form of balloon tamponade such as Rapid Rhino®. Many older patients take blood thinners and this may need to be addressed. Once this has been done, the balloon can be deflated in 24-48 hours and then removed an hour or two after no further bleeding.
In cases where you are confident the bleeding arises from the anterior septum, chemical cautery can be done after pre-treating the area with local anaesthetic solution applied on a plug of cotton wool.
Sudden hearing loss
Sudden hearing loss can be inner ear failure or middle ear and eustachian tube blockage. The former has a very rapid or sudden onset and a tuning fork on the forehead (Weber test) localises to the opposite ear. The primary treatment before referral is high dose prednisolone (low level supporting evidence).
Eustachian blockage comes on over a period of hours and the tuning fork sound localises to the affected ear. Antibiotic treatment with or without prednisolone is usually appropriate before referral.
A swallowed FB in an adult is most commonly a fish bone. This may get caught in a tonsil, in the base of tongue or behind the larynx at the opening of the oesophagus.
Fish bones are often difficult to see and the only one likely to be successfully removed in the GP setting is the one impacted in a tonsil. The patient will localise the pain to the affected side. If not visible, wiping the tonsil with cotton wool may catch and identify the bone.
A peritonsillar abscess or quinsy is almost always unilateral. Many cases can be managed with antibiotics but the severely painful ones commonly ‘point’ into the soft palate above the tonsil. This spot can be incised for drainage and pain relief. A useful tool for this is an 11 scalpel blade half wrapped in tape to prevent cutting too deep.
References available on request.
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