Video and telephone consultations in the coronavirus pandemic

One of the consequences of the coronavirus pandemic has been a dramatic rise in the use of telemedicine. This is particularly the case with ENT consultations. ENT doctors have been found to be particularly vulnerable to Covid 19 infections - in Wuhan two out of the five doctors who died were ENT doctors, in the UK one ENT consultant (out of about 700 in total) died in the early stages of the UK pandemic, and another was ventilated. This is thought to be due to the high concentration of coronavirus inhaled during the types of examinations we perform. Patients are also put at risk because an ENT surgeon may not realise he or she has a coronavirus infection. As a consequence of this our national body, ENT UK, has advised that all non-urgent in-person consultations are temporarily suspended in the UK .

As you may be wondering what can be done within a video or telephone consultation, I thought it would be helpful to write a short article about my recent experiences of it. So far, I have found it be a very useful form of consultation, with several advantages:
Time saved on travel, which is also good for the environment.
The absence of geographical restrictions. As long as you have a good internet connection, you can have an appointment with a consultant of your choosing, regardless of where you live.
Whilst ENT is a surgical specialty, it is a little known fact that, on average, over 90% of the patients we see do not require surgery. Most ENT conditions are treated with medicines or other forms of therapy, such as physiotherapy, speech therapy, hearing therapy or vestibular therapy.

Examples of common ENT conditions that can often be treated by video consultation include:
Chronic sinusitis - symptoms of this condition can include: a blocked, congested nose (like having a permanent cold); pressure or discomfort in the face; a poor sense of smell; or discharge out of the front, or down the back of the nose. In many cases, the best medical treatment is as effective as sinus surgery (and the benefits usually continue after you stop taking medication).
Nasal blockage - there are many causes of a blocked nose, ranging from problems with swelling of the lining of the nose, (sometimes caused by allergies); to structural problems, such as a deviated septum (a bend in the middle partition of the nose). Medicines are frequently effective at improving such problems.
Glue ear - in most cases, glue ear (mucous on the inside of the eardrum) can be effectively managed with observation and simple measures such as the use of an Otovent balloon.
Dizziness - the diagnosis of the cause of dizziness relies heavily on the history given by the patient. Much of the neurological examination can take place by video consultation, and tests/scans can be arranged as required. In the majority of cases, the treatment of dizziness consists of lifestyle changes, vestibular therapies and medication. Surgery is rarely required.
Nosebleeds - many nosebleeds can be managed with simple advice and antibiotic creams in the nose. These have been found to be as effective as cauterising the nose with silver nitrate (a common outpatient procedure).
Voice problems - whilst it won’t be possible to examine your voice box (larynx) via a video consultation, the history of the problem can often give helpful pointers as to possible causes; and the voice itself can be assessed. Speech therapy can be performed by video consultation, and medicines prescribed where appropriate.
Silent (Laryngopharyngeal) reflux and globus sensation (the feeling of a lump in the throat) are usually managed with a combination of advice, lifestyle adjustments and medical treatments. Surgery is rarely required.

The principal disadvantage of remote consultations is the limitations with regards to examination. However, it is often possible to get an excellent view of the face, skin problems, the mouth, and the front part of the nose with the use of mobile phone cameras. Various neurological examinations can also be performed. Scans (such as ultrasound scans, MRI or CT scans) can be arranged and provide very useful information, and these images can be subsequently reviewed with the patient during a follow-up consultation. Although in most cases, an in-person review will be required at some stage, telemedicine consultations can markedly reduce the need to travel for appointments.

Like most consultants, I did not previously undertake many video consultations. However, my recent positive experience has encouraged me to continue to expand these services after the coronavirus pandemic has ended.

Please do get in touch if you have any questions or thoughts. If you’re interested in a video or consultation, they can be booked here.

What does a tonsillectomy cost in the UK?

There are several factors that influence the total cost of having your tonsils removed (tonsillectomy) as a private patient in the UK. The cost can vary significantly depending on whether you have private medical insurance or are self-paying. Tonsillectomy is covered by most insurance policies, but may not be covered in all circumstances, so it is worth confirming this with your insurer. If you do have private medical insurance, there may be an excess to pay, and you may have limits on your cover. If you are self-paying, there are several aspects of the treatment that you need to consider:

Outpatient appointments: your surgeon will want to see you before you have a tonsillectomy on at least one occasion. This is to discuss the problems you have had with your tonsils, examine your throat and talk about treatment options. Sometimes a telescope examination of the throat (nasendoscopy) is required as part of this, which will likely be an extra cost on top of the appointment. If you do decide to proceed with tonsillectomy, your surgeon may also want to see you in the outpatient clinic.

Hospital fees: these are usually the most expensive part and form the majority of the cost of tonsillectomy. There can be significant differences in the hospital costs. Many surgeons operate at different private hospitals, so it is worth enquiring about the different costs.

Investigations: whilst they are not usually required, sometimes other tests need to be performed as part of your treatment, for example, blood tests, x-rays or scans or tracings of the heart.

Surgeon’s fees for performing the procedure.

Anaesthesia: The operation is performed whilst you are asleep under a general anaesthetic. The anaesthetic is administered by an anaesthetist who will bill for her services.

Whilst it is unusual, occasionally complications can occur following tonsillectomy. If these are dealt with in a private hospital, there are usually associated fees.

Don’t forget, there are also personal the costs that vary from person to person. For example, if you are self-employed, and not earning whilst recovering or if you need to pay for childcare costs.

When enquiring about costs, make sure that you ask about all of them so you know what the total cost is likely to be. Many private hospitals offer fixed-price packages which can help remove uncertainty around the cost, which it is often worth enquiring about. Financing options to help spread the cost of the procedure are often available.

If you are a UK resident, tonsillectomy is also available as an NHS patient, if you meet certain criteria. These criteria vary from area to area, and waiting list times are variable.

The fees for a tonsillectomy performed by me (correct as of the time of writing) are as follows:

Nuffield Health, Tunbridge Wells (adult)

Hospital £2029
Anaesthetist: £235
Surgeon: £550

Total - £2,814

Nuffield Health, Tunbridge Wells (child)

Hospital £2160
Anaesthetist £235
Surgeon: £550

Total - £2,945

Spire Hospital, Tunbridge Wells (adults and children)

Hospital: £2266
Anaesthetist: £235
Surgeon: £550

Total - £3,051
 

Should I (or my child) have my tonsils and/or adenoids removed?

This is a common question that I'm asked by patients. There is much mystery and misinformation about tonsils and adenoids; what they do; and whether they should or shouldn't be removed and what having the operation is like. This naturally gives rise to concern about what the right thing to do is. You can read more about tonsillectomy here, here and here or adenoidectomy here. 

A common anxiety is that the tonsils are useful, and removing them will somehow harm the immune system or body in some way. This is an entirely understandable concern - we have tonsils and adenoids, so they must serve some kind of purpose? 

Yes, that is certainly true. Tonsils and adenoids are made of lymphoid tissue and play a role in the development of the immune system and fighting infections. However, they only really play a role in the development of the immune system in the first year or two of life.  This is certainly a relevant point, however, this benefit needs to be weighed against the harm that tonsils and adenoids sometimes cause in children under the age of two.

After the age of two, there are no adverse effects on the immune system from tonsil removal. The average person has a couple of hundred lymph glands in the head and neck region, and the lining of the mouth and throat is peppered with lymphoid tissue, so there is more than enough surplus lymphoid tissue to fight infections.
 

So when should tonsils or adenoids be removed? 

Sometimes the answer is obvious - if you're having severe tonsillitis every month or your snoring is so bad that you can't breathe properly a night, then the decision may be an easy one. However, in many cases it isn't quite so clear. As a consequence, guidelines have been written, and research performed, to help patients and doctors decide whether tonsils or adenoids should be removed or not. It's important to remember that guidelines are just that, guidelines, and not rules. There may be situations, such as with multiple antibiotic allergies or other health problems, that may make tonsillectomy or adenoidectomy appropriate, even if criteria are not perfectly met. Conversely, if a patient has a bleeding disorder that cannot be controlled or conditions that make a general anaesthetic hazardous, then further observation and medical management rather than surgery may be appropriate.  

Tonsil and adenoid problems can be grouped into obstructive or infective problems, which I will discuss as separate groups. 

Infective Problems

Recurrent Tonsillitis: In the UK, the most commonly followed guidance is that written by the Scottish Intercollegiate Guidelines Network (SIGN), which is broadly similar to the guidance in the United States. In summary, these guidelines recommend tonsillectomy may be an appropriate treatment if the sore throats due to tonsillitis are severe and occur:

• Seven times in the previous year, if you have only had tonsillitis for one year. 
• Five times a year if you have had tonsillitis for two years. 
• Three times a year if you have had tonsillitis for three or more years. 

However, this does not mean that the tonsils should be removed. An acceptable alternative may be to continue monitoring the situation, with further courses of antibiotics being used to treat infections as they occur. Most people will 'grow out' of tonsillitis at some stage, the problem is not knowing when that is going to happen. 

Peritonsillar abscess ("Quinsy"): This is an unusual condition where a collection of pus ( an "abscess") forms next to the tonsil. If it occurs on one occasion, then tonsillectomy is usually not required, unless there is a background history of recurrent tonsillitis or blockage of the airway. If you have had two or more quinsies, then it is likely that you will have further quinsies, and tonsillectomy should be considered as a treatment. 

Tonsillar asymmetry: Occasionally one tonsil can be bigger than the other. In the vast majority of cases, this is due to previous infection, or slight differences in the anatomy of the tonsil bed on each side. Tumours or cancers of the tonsil are very rare. If there is any question or concern as to why one tonsil is larger than the other, it can be removed and sent for analysis. 

Recurrent (middle) ear infections ("recurrent acute otitis media"): These infections commonly cause symptoms of earache, raised temperature and sometimes discharge from the ear. Younger children and babies might pull their ears, or bang their head. The insertion of grommets can be very helpful if the infections are frequent. If the grommets fall out, and the problem continues, then removing the adenoids as well as putting in further grommets can help reduce the frequency of infections. 

Other conditions: There are a number of other situations where tonsillectomy might be appropriate, however good evidence from clinical trials is sometimes lacking. These conditions include:

• Recurrent tonsil stones ("tonsilloliths")
• Bad breath ("halitosis"), where other causes have been ruled out. 
• Chronic tonsillitis
• Chronic sinusitis in children. If medical treatments, such as topical steroid sprays in the nose, have not worked, then removing the adenoids is often helpful. 
• PFAPA ("Periodic Fever, aphthous stomatitis, pharyngitis and cervical adenitis") syndrome. This is an unusual condition, that as the name suggests, causes recurrent problems with fever, mouth ulcers, sore throats, and enlarged glands in the neck. It usually settles of its own accord, although occasionally removing the tonsils is appropriate. 

Obstructive Problems

Sometimes tonsils and adenoids can cause problems by virtue of their size. Depending on the circumstances, removal of the tonsils and adenoids can sometimes be helpful. 

Snoring with obstructive sleep apnoea (OSA): Snoring is the noise generated by obstructed airflow through the upper airways whilst asleep. Sometimes, the obstruction can be temporarily complete, that is to say for a short time breathing stops. This caused obstructive sleep apnoea, or "OSA". If this is severe, and the tonsils and adenoids are enlarged, then in most cases, removal of the adenoids and tonsils is advisable. In moderate or mild cases, it is often advisable to remove the tonsils and adenoids if the problem persists, although sometimes a further period of observation may be appropriate, as in many cases, children will grow out of this problem. 

Nasal obstruction: Sometimes in children, and much less commonly in adults, enlarged adenoids can cause a blocked nose. They can also give rise to a change in the quality of the voice, so it sounds as if you have a blocked nose when you speak (this is known as 'hyponasal speech'), and can sometimes affect the sense of smell. Removing the adenoids can be very helpful in relieving such symptoms. However, it is important that other causes of a blocked nose, such as allergic problems, a bend in the middle partition of the nose or chronic sinus infections are also identified and treated if present.

Less common obstructive problems where adenoidectomy or tonsillectomy may be helpful, although there is not good research evidence to support it include:
Swallowing problems ("dysphagia") caused by very large tonsils
Change in voice quality due to large tonsils or adenoids    

When should tonsils and adenoids not be removed? 

Sometimes removing the tonsils or adenoids can be especially risky, or likely to cause more problems than it solves. In these cases, it is often a good idea to avoid surgery. Such situations include:
A severe bleeding disorder: as with most operations, there is a (small) risk of bleeding when removing the tonsils or adenoids. If your body isn't able to clot properly, this can be a serious problem and surgery may be best avoided. 
Developmental problems of the palate or upper airway, such as cleft palate. In these conditions, the tonsils can play an important part in the swallowing mechanism. If the tonsils, and particularly the adenoids are removed, there is a higher risk of developing nasal regurgitation (food and especially drink, entering the nose when swallowing) and a type of nasal speech ('hypernasal' speech, collectively known as 'velopharyngeal incompetence'. Sometimes surgery is best avoided or modified to minimise this risk.
Neurological or muscular problems of the throat: operating in this situation also carries the risk of velopharyngeal incompetence (see above).
Active infection: If the tonsils are actively infected, the risk of bleeding at the time of, or after surgery is increased. In most cases, it is advisable for surgery to be postponed for two to three weeks after an episode of tonsillitis. 

What questions should I ask my surgeon?

As with any procedure, there are several factors that need to be considered:

• What does surgery involve, and what is the recovery like?
• What are the benefits and outcomes (ideally the surgeon's own outcomes) of doing the operation, or not doing the operation?
• What are the risks of the operation, but importantly, what are the risks of not having an operation? When talking about surgery, there is a natural tendency to focus solely on the risks of surgery, which will usually occur within a defined period of time. However, there are also risks of not doing surgery, such as problems developing with the heart and lungs with untreated obstructive sleep apnoea or infections from the tonsils spreading to other parts of the body. 
• Importantly, what are the alternatives to surgery?