Ear, nose and throat

Our planned care team plan and buy services for people with ear, nose and throat and hearing problems or associated conditions.

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Audiology

If you are aged 55 and older and having problems with your hearing, your GP can refer you to an audiology provider for an assessment.

These providers are:

• Alistair Kinsey Ltd (Tavistock)
• Northern Devon Healthcare NHS Trust
• The Outside clinics (for people who need an assessment at home)
• Scrivens Ltd
• Specsavers
• University Hospitals Plymouth NHS Trust

If you are aged 54 and under, your GP will be able to refer you to a hospital ear, nose and throat or audiology department.

Aural care

This service is run by specialist nurses. They help the ear, nose and throat consultants treat conditions such as:

• cholesteatoma
• discharging ears
• mastoid cavities
• otitis externa
• perforation of ear drums
• surfers’ ear for treatment of otitis externa
• wax impaction where the commissioning policy criteria is met

Aural care briefing

We commission Royal Cornwall Hospitals NHS Trust to provide this nurse led service. The service sees people needing complex ear wax removal using microsuction. It also supports our ear, nose and throat consultants to see people with active infections and diseases that erodes bone which could progress and cause significant complications. These complications include:

• dizziness
• infection in and around the brain
• permanent irreversible hearing loss if not managed

So that we use this resource, there is an agreement in place that certain criteria (PDF, 1.5 MB) must be met for referrals to be accepted.

Some people only need to attend 1 appointment, but others may need more. A clinical assessment for when a person can be discharged is applied to all patients based on criteria set by the ear, nose and throat department. An average appointment time slot is about 15 minutes per patient, however there are around 2,000 people waiting for a follow-up appointment.

We are currently carrying out a review on whether a commissioned ear wax service should be provided in primary care for people who do not meet the secondary care criteria. The outcome of this review will be published in 2022.

Ear, nose and throat services

Services are delivered by hospital providers. Your GP can refer you for these services and you will be seen by a consultant or a member of their team.

Conditions treated include:

• fractured noses
• head and neck cancer
• neck lumps
• paediatric sleep apnoea
• persistent ear pain
• rhinitis or sinusitis
• throat problems
• unilateral tinnitus

Ear wax information for patients

Everyone has ear wax. It helps trap things like dirt and dust and protects the lining of the ear. It also protects the ear from infection. Ear wax is continuously produced and moves towards the entrance of the ear by a self-cleaning mechanism of the skin and when facial muscles are used to chew food and talk.

The colour, consistency and amount of ear wax can vary from person to person. Wax may appear to be dry and flaky, or have a crumbly consistency, honey coloured or dark brown. It may be very hard if it attaches to the underlying skin.

For most people ear wax will not cause any problems and should be left alone without any attempts to remove it. Some people, however, may experience problems with ear wax and treatment may be required.

Common problems

Age

Older people may have drier wax, and older men often develop more hairy ears.

Cleaning attempts

You should never put objects such as cotton buds and hair clips into your ears to try to clean them. This can damage your ear canal and force wax down the canal and form a hard dry plug against the eardrum.

Dusty or dirty environment

People who work in places where there is a lot of dust or dirt in the air sometimes find that this combines with the wax in the ear to form a plug.

Earplugs

The use of earplugs, often mandatory in some occupations, can have a similar effect to cotton buds.

Habit

Some people regularly have their ears irrigated because they think it is necessary and can prevent hearing loss. However, this is not the case. Ear wax is an important part of ear health and should only be removed if it has blocked the ear canal and is causing symptoms.

Hearing aid moulds

These can interfere with the natural ability to shed dead skin and wax, and cause debris to build up in the canal.

Treatment

If ear wax has built up and needs to be removed, this should be done using an ear wax softener. You can buy these from most pharmacies, and also get treatment advice.

The recommended dosage is 2 sprays per affected ear, twice a day for 3 weeks. The spray mists a coating of olive oil over the wax which softens it and enables it to come out naturally. You need to allow some time for this process to happen.

Olive oil drops are a suitable alternative. Patient experience indicates that the sprays are easier and less messy to use but drops work just as well. 3 drops should be put into the affected ear(s) twice a day for 3 weeks.

If you have any concerns about the use of ear wax softeners and dissolvers, please ask your local pharmacy or GP practice for advice and support.

What if wax softeners have not worked?

Most people’s symptoms will resolve within 3 weeks with the use of wax softeners, but if the blockage persists sodium bicarbonate drops can be used to dissolve the ear wax. 3 drops should be applied to the affected ear 3 times a day for 1 week.

Sodium bicarbonate is not recommended if you have had a previous perforation to your eardrum. If this is the case, you should continue to use the olive oil spray or drops for 1 more week.

If after using the sodium bicarbonate drops you still have issues, wax can be removed using irrigation, micro-suction or a special probe.

The NHS in Cornwall and Isles of Scilly does not contract for ear wax removal services at this time. Some GP practices perform ear wax removal services, but most do not have the staff and equipment to do so.

If there is other ear disease, you may be referred to the local hospital for specialist care. However, this is not an ear wax removal service and there is strict access criteria that must be met. Your GP will be able to advise if you meet the referral criteria.

There are a number of local private providers who offer ear wax removal to people who would like to use this service.

Download the ear wax information patient information leaflet (PDF, 396 KB)

Throat symptoms information for patients

When the ear nose and throat (ENT) department looked back at previous referrals, virtually all patients had a benign (not cancer) cause for their symptoms. On their own, the risk of these symptoms being associated with cancer is less than 2 in 100 people.

What is the function of my throat?

The upper throat is the shared entry to our windpipe (trachea) and gullet (oesophagus). This area has to be very sensitive to ensure that food and drinks are appropriately pushed towards the back of our throats to be safely swallowed away from your airway. If these sensitive surfaces detect solids or liquids in or on the entry to the windpipe, a cough happens as a reflex action to clear and protect the airway. The sensitivity of the tissues in the throat that can lead patients to have one or more of the chronic throat symptoms listed above.

Common throat conditions

The most common conditions encountered in patients with 1 or more of these symptoms are:

• globus pharyngeus
• laryngopharyngeal reflux
• pharyngeal hypersensitivity
• muscle pain of the neck or throat

Globus pharyngeus

What is globus pharyngeus?

This is the name of a condition which is primarily associated with a sensation of a lump or something in the throat. Some describe a tightness in the throat. Despite a feeling of difficulty in swallowing, patients with globus typically do not have problems swallowing food or liquids. It is usually experienced centrally and low down in the neck. It is common to have minor voice problems such as huskiness, hoarseness or tiring of the voice with globus pharyngeus.

Why does it cause a sensation of a lump or something in the throat?

It is thought to be due to muscle tension or a lack of relaxation of the small circular muscles at the top of the gullet (called the cricopharyngeus). Typically, the sensation may improve on swallowing food as the muscles are prompted to relax by the weight of food passing through into the food pipe (oesophagus).

How common is globus pharyngeus, and how long does it last?

Globus pharyngeus is very common and affects most people at some point. It may fluctuate in severity, and it may be intermittent. It may be resolved for years before recurring. It should be noted that symptoms with a long stable history are unlikely to be due to any sinister underlying cause. Serious conditions such as cancer tend to get worse over time rather that stopping and starting like globus can.

What causes globus pharyngeus??

There are a variety of reasons thought to cause this, sometimes there are multiple factors at play. Sometimes there is no obvious cause. The most common are listed below.

Reflux

Many patients with globus often have underlying acid reflux (stomach acid flowing the wrong way up into the oesophagus or gullet). This does not always cause heartburn or indigestion. The muscle at the top of the gullet, known as the cricopharyngeus, tightens in response to acid reflux, probably to prevent it coming into the throat.

Smoking

In smokers, this can be a factor which irritates the throat which causes muscle tension. Smoking also increases the effects of acid reflux.

Stress

Symptoms are often worse with stress which increases muscle tension. Anxiety about the cause of these symptoms further increases stress making the globus sensation worse. Stress increases the effects of acid reflux.

Voice strain

Overuse of the voice, or not having the most efficient technique for producing voice can affect the small muscles in the throat which increases muscle tension leading to globus sensation.

Could globus pharyngeus be due to cancer?

Out of 1,000 patients seen in the head and neck clinics at Royal Cornwall Hospital, 126 patients were diagnosed with globus pharyngeus without any other symptoms. None of these people had cancer.

What can be done to treat it?

Often it is associated with acid reflux so it is worth referring to the section below on laryngopharyngeal reflux to see if you have any symptoms. If you do, you could ask your GP about treatment for this condition.

Laryngopharyngeal reflux

Also called silent reflux as many patients do not know they have it. It could be present in the background without causing any symptoms until the throat becomes irritated, often by a throat infection.

What are laryngospasms?

These are episodes of the throat feeling like it is closed over, sometimes associated with noisy breathing. This does not happen in all patients with reflux. This can be quite scary as patients describe they feel like they will stop breathing. It typically happens when lying down as acid is more likely to come into the throat without gravity keeping it down as is the case when we are standing or sitting. The episodes pass without patients losing consciousness.

What symptoms does it cause?

• Sensation of a lump in the throat.
• Voice change.
• Catarrh or phlegm in throat causing throat clearing.
• Dry irritating cough.
• Post-nasal drip.
• Sensation of food or tablets sticking.
• Burning sensation or sore throat.
• Feeling of throat closing over, especially when lying down (laryngospasm).
• Persisting throat soreness and catarrh following throat infection or irritation.

Typically the effects of infection would be expected to resolve over the course of a couple of weeks, but due to the underlying damage to the lining of the throat, and ongoing reflux, the symptoms can persist for much longer following the resolution of the infection itself.

Why do I have it?

Most people will have acid coming up into the throat occasionally, but only some experience symptoms from it. Various reasons have been proposed for this.

Some people:

• are unfortunately more prone to the effects of acid irritation
• will have a weakness in the muscle that limits reflux at the junction of the gullet and the stomach (the gastroesophageal junction)

Sometimes this can be so significant that the stomach rides up above the diaphragm (the muscle that sits under the lungs) causing a condition known as hiatus hernia. Some patients with hiatus hernia will not respond fully to anti-reflux medication and may need to see a specialist (gastroenterology or upper GI surgery) to consider whether surgical intervention might be appropriate

If I do not have heartburn or indigestion, could I still have laryngopharyngeal reflux?

It is not uncommon to have laryngopharyngeal reflux symptoms without having symptoms of heartburn or indigestion symptoms. This is because the lining of the oesophagus is better adapted to withstand the effects of acid reflux than the lining of the throat.

How is it treated?

Typically, we would recommend Omeprazole 20 mg twice a day for 2 months and Gaviscon Advance 10mls four times a day to be taken after meals and before bedtime for 3 months. If symptoms worsen on coming off medication, you may need to take this for longer. Treatment for laryngopharyngeal reflux can be discussed with your GP.

If you continue to have symptoms of reflux despite taking medications and implementing lifestyle modifications, you may benefit from further assessment by gastroenterology and/or upper GI surgery. Again if you symptoms persist, you can discuss this with your GP.

Is there anything I can do to reduce my symptoms?

Alcohol

Avoid alcohol as it makes reflux worse by relaxing the muscles that try to keep acid down and away from your throat.

Diet and weight

Eat a healthy diet and modify your eating habits to reduce foods that cause increased acid reflux. This included foods that are fatty or fried, spicy foods, chocolate, cheese and pastry. Drinks such as coffee, citrus juices and fizzy drink make reflux worse by increasing acid production in the stomach. Drink water instead. Allow several hours after meal time before lying down. If you are overweight, acid reflux is worsened. Try to take measures to address this.

Sleeping

Consider raising the head of your bed about 6 inches with concrete blocks or something similar under the legs or base at the head end of the bed. This makes use of gravity to keep the acid down in your stomach. Do not use lots of pillows under your head as this only makes things worse, increasing abdominal pressure thereby encouraging reflux.

Smoking

If you smoke, try stopping this as it irritates the throat and makes you more likely to have reflux. Healthy Cornwall can provide smoking cessation services.

Healthy Cornwall can provide support for smoking cessation, diet and weight and alcohol.

Pharyngeal hypersensitivity: Chronic throat clearing or coughing

What is throat clearing?

Throat clearing is an abrasive action where the voice box is typically pushed and rubbed against the back wall of the throat to relieve irritation. A cough is an explosive closing and opening at the level of the vocal cords to clear the airway.

Why do some people feel the need to throat clear?

Minor throat clearing can be normal in managing secretions in the back of your throat for instance with an infection. However, the sensitive tissues in this area are not designed to be abused in this way over a long period of time. Excessive throat clearing itself becomes the cause of swelling and irritation leading to a vicious circle of irritation, sensitivity and abrasive clearing of the throat.

Why do some people feel the need to cough?

In normal circumstances coughing can be a protective reflex to clear our upper airways or in response to chest secretions. However, coughing (often dry and non-productive) can become a habit if the tissues are overly sensitive.

What are the causes of this?

All irritation to the throat (also known as the pharynx) makes the throat more sensitive. Irritation to the throat may be chemical, most commonly due to acid reflux, which is also known as laryngopharyngeal reflux (see above).

It may be due to exposure to chemicals or dusts in the workplace for example. Irritation may also be mechanical, due to chronic throat clearing and coughing, which bashes the tissues of the throat against themselves causing irritation. Irritation may also be due to infection, and/or inflammation. Often several reasons may co-exist.

Why is throat clearing and coughing bad for my throat?

The action of throat clearing and coughing is quite aggressive and can traumatise the lining of the throat making it swollen and irritated. The irritation causes the lining of the throat to swell, which makes you want to throat clear and cough more. It is important to understand that the symptoms are made worse, not better, by continuing to throat clear and/or cough.

What can I do to stop it?

Avoid throat clearing and coughing wherever possible. Try to replace this behaviour with taking a drink of water from a bottle that you carry with you, then swallowing. This will achieve clearance of throat secretions without causing mechanical trauma which would perpetuate damage to the throat and make you want to clear your throat and cough more. This is difficult to implement but is essential, otherwise it will not get better.

Muscle pain of the neck or throat

Think of the neck as having 2 parts. The back part of the neck contains the spine and all the surrounding muscles. The front part of the neck, contains the throat (the tubes that goes from the back of your nose and mouth down to your windpipe and gullet).

Why might I have pain or tenderness in the front of my neck?

This may be due to strain of the small muscles surrounding the throat. Often there is no obvious cause. Some patients report a preceding history of coughing or throat clearing behaviours which injure these muscles. Typically, patients will have tenderness pressing on the side of the voice box (thyroid cartilage) where small muscles insert, with the pain worsening when swallowing because the muscles pull on the throat as you swallow.

Why might I have pain or tenderness in the back part of my neck?

This is typically due to problems with the spine, discs, surrounding muscles or nerves and unrelated to the throat and surrounding structures. Trying to move the neck or pressing on the spine and surrounding structure can make symptoms worse. You should speak to your GP if you feel this applies to you.

What can I do to stop it?

It is usually a self-limiting condition for which simple painkillers, especially non-steroidal anti-inflammatories (such as ibuprofen) may help. If there is a history of repetitive coughing or throat clearing, avoidance of such behaviours where possible will allow the muscle injury to heal.