“TERMINOLOGY” - IN PRIVATE PRACTICE
BHJ mainly caters for private practitioners - these include GPs, family physicians
and consultants. Although, we would like the journal to have highly academic
sections, we should at every stage discuss frankly our problems which we face
in general practice.
The guest editor of this issue is the young dynamic ENT specialist Dr. Nishit
Shah who should be complemented in introducing the concept of diagnostic and
therapeutic “endoscopy” in the management of sinus problems. And why not? Every
other speciality has used this invasive method to have a “naked eye” picture
of the area which one is dealing with instead of “ghost” shadows which are seen
on X-rays and scans! After reading this issue, many ENT specialists will like
to start learning to do this procedure.
Now coming to private practice - first of all ENT speciality like urology is
dying out. In future it will not be safe for your children to take up the above
type of specialities. Yes - if one super specialises - like Deafness specialist,
Sinus endoscopist, etc. there will still be a big scope in practice.
What are the reasons for fading out of ENT speciality? The main reason is terminology.
For years, for personal gains, the public and the GPs have been educated to
use the following terminology (by whom? ENT specialists?)
1. The word “sinus” is used for allergic
rhinitis. I must have seen thousands of patients who complain of “sinus” with
or without symptoms of asthma (cough or/and dyspnoea). I have seen such patients
going to ENT specialists who would often perform some surgical procedure, when
the nasal drainage or the symptoms improved for few weeks or months only to
relapse once more.
Although, like many other complaints involving other areas of the body (e.g.
a duodenal ulcer), surgery is occasionally required, these complaints should
be managed medically at the GP level. Patients suffering from Allergic Rhinitis
are fed up of hundreds of sneezes and profuse watery nasal discharge interfering
with their social life and their office work or profession and readily accept
to see an ENT specialist for “sinus” problem. Although, “Allergic Desensitization”
is still being practised by some, steroid nasal sprays bring instant relief.
In children and young patients, Disodium Cromoglycate sprays can be used. In
patients having the background of hyperacidity, Ipratropium sprays can be used
which are non-steroidal. In fact many patients do not mind nasal symptoms if
their associated asthma is looked after and breathing becomes easy - a point
which is never attended to by ENT surgeons.
I must stress that for every one patient of bacterial sinusitis, I see few “hundred”
patients having allergic rhinitis. In fact, because of the new broad spectrum
antibiotics being prescribed on a big scale by the GPs, purulent infective sinusitis
(chronic) is becoming rarer and at times I do not see a single patient in the
2. The word “tonsils” - the public has “learnt” (from whom?) that any throat
pain or discomfort is “tonsils” and patients are rushed to see an ENT specialist.
It is not surprising to know that in our country the main indication (till recently)
of tonsillectomy was “school vacations” when the patients will take all the
children to the ENT doctor to remove the tonsils, so that they do not have throat
symptoms in future. Needless to say that it never worked. Although, the symptoms
persist, the parents are happy to have the satisfaction that at least the “septic
focus” has been removed. This is another terminology started to lure the GPs
to send patients for tonsil surgery. Gone are the days of “septic focus”.
The fact is that allergic pharyngitis (or viral pharyngitis if the condition
is acute) is the most common cause of throat discomfort, sore throat or pain
in the throat. Often hot salt water gargles and avoiding cold drinks and “fridge”
water works. In severe cases steroid MDI inhalers can be used. For every one
case of chronic tonsillitis, I see few “hundred” patients of allergic pharyngitis.
Chronic tonsillitis is over diagnosed because the doctors do not take advantage
of modern investigations. Of course, the unhealthy look of tonsils, purulent
discharge on squeezing the tonsils, enlarged tonsillar glands, a raised ESR
and CRP, an elevated levels of ASO titre and a culture of streptococcus (pathogenic
type) grown from a tonsil swab and finally a temporary response to antibiotics
are helpful in making a diagnosis. I am waiting for the day when some “imaging”
procedure can help us in the diagnosis.
3. “Sinus headache” is another wrong terminology used freely by the patients
and GPs. I must stress that it is extremely rare for a patient of chronic headache
to have “chronic” sinusitis. All such patients have either migraine or tension
headache or a combination of both. With the interventional procedures carried
out by the ENT doctors, no doubt, they feel temporarily better (so called remission
in medical terminology) to relapse once more. It will not be a bold statement,
if I say that there is nothing like a chronic sinus headache. Yes, occasionally
patients with acute URTI may develop aches around the facial sinuses responding
well to antibiotics or anti-allergic treatment or even steam inhalations!
4. “Giddiness” is another complaint often attended to by ENT doctors. In my
experience, after doing the caloric test, audiogram, recruitment tests, ECG,
ENG, BERA and many other tests, the diagnosis is often “wrong” or not “confirmed”.
Or else at the end of it, “MRI” imaging is often asked for to exclude “brain”
causes. In my opinion city of Mumbai needs “giddiness” clinics. Headache clinics
have already become popular. The ENT doctor will then be a part of the giddiness
clinic. Often the caloric tests and audiograms are done by technicians and misinterpreted
by ENT specialists. The BERA studies are done by non-medical or para medical
specialists - who may interpret them wrongly - because all investigations should
be reported in the light of “clinical findings” and the likely diagnosis. In
fact none of the ENT specialists or physicians perform “Epley” manoeuvre for
diagnosis and treatment of “giddiness”. These problems will be solved by a group
practice of “Giddiness Clinics”.
Finally, I must hasten to add that we all doctors do malpractice at some stage
of life - the difference is that some do because of lack of knowledge or wrong
teaching or wrong concept. Others do to please the patient or for personal gains.
ENT specialists are no exception. The younger generation has realised this and
hence this special issue.