Discussion
On the 23rd of March 2020, the United Kingdom
announced social isolation steps to reduce the spread of coronavirus.
These steps, hitherto referred to as “lockdown”, brought about
dramatic social changes. This dramatic change in the lifestyle of the
British public may help to explain some of the trends emerging within
the patients seen in our emergency clinic.
Indication for
consultation
Otitis Externa was a frequent indication despite typically being mild
and self-limiting. The majority of these patients had undergone prior
telephone appointments with their general practitioner (GP) who had
prescribed oral antibiotics. Although inappropriate use of oral
antibiotics by GPs is a common problem in the COVID era, this may be due
to concerns around the risks of otoscopy. Without examining the ear, GPs
are likely to be reluctant to prescribe topical preparations for fear of
ototoxicity. Despite the high proportion in the clinic, this is likely
still under what you would expect. Using a 1.3% annual incidence and a
3% referral rate to ENT5, one might expect around 23
cases over a 5 week period (based on UK population of 66,435,600 and the
Royal Derby serving a population of 600,000). Accepting the
extrapolations inherent in this calculation, one possible explanation
for this is that reduced water exposure as a result of swimming pool and
beach closures has resulted in fewer cases.
Presentations with foreign bodies and nasal trauma are also potentially
explained by social restrictions. Foreign body presentations were mainly
in children, likely frustration as a result of being stuck indoors. We
anticipated that reduced car travel and opportunities for sports would
reduce nasal traumas. Sadly, lockdown measures around the world have led
to a rise in domestic violence cases 6. Additionally,
with elderly patients being advised to self-isolate, they may not have
the level of support to mobilise that they usually would predisposing
them to falls and injuries.
Peritonsillar abscess and tonsillitis represented only 6%. Social
distancing has likely impacted the spread of upper respiratory tract
infections. The 2002 UK national audit quoted 30 peritonsillar abscesses
as the average number treated per year7 which would
make 3 cases over a 5 week period appropriate. However, previously
published data from the Royal Derby Hospital demonstrates a rate of 43
over a period of 9 months8. Extrapolating this, 5-6
cases over a period of 5 weeks could be expected.
One group of patients with a surprisingly low frequency are the patients
who have had outpatient appointments cancelled or rescheduled. We
expected that large numbers of patients with postponed appointments
would present via their GPs, but so far this has not been the case. This
will likely increase as patients’ symptoms become more troublesome.
Age distribution
The high proportion of children was almost exclusively due to foreign
bodies. In the UK, those over 70 have been advised to self-isolate
completely. It is interesting to see that compliance with these measures
is reflected in the low proportion of patients in this age group
presenting to the emergency clinic. The age group 50-59 is more
difficult to explain. Individuals in this age group, though likely still
working, may well be assisting older relatives but are in an age group
where they are likely to have some co-morbidities. It is possible that
because they are less isolated than older populations, they are more
willing to present to their GPs and hence more likely to be referred.
Utility of telephone
appointments
A key recommendation from the ENTUK guidelines for COVID was to
implement telephone based consultations where
practical3,9. concerned potential concern wasthat the
need for examination to reach a diagnosis for many ENT pathologies may
limit the usefulness of telephone consultations. This dataset suggests
that for certain pathologies telephone consultations can be highly
effective. In some cases of epistaxis and nasal trauma, a telephone call
was the only appointment required. We have changed our practice such
that patients with nasal trauma are primarily managed over the
telephone. They are telephoned at 7-days post injury and are only
brought in for manipulation if they have ongoing concerns regarding
appearance or obstruction. In epistaxis, minor bleeds with no risk
factors or a clear precipitating trauma are managed over the telephone.
Telephone consultations were also effective to check treatment efficacy
in patients managed in ED. Peritonsillar abscesses and certain cases of
otitis externa were ideal cases for this. Ambulatory management of
peritonsillar abscess is well established in the literature8,10 and telephone follow-up is sufficient, provided
the abscess has been adequately drained. Similarly, in clear cut cases
of otitis externa where appropriate treatment has not yet been given
pain and discharge were used as measures of improvement over the
telephone