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