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7/30/2019 Ear Nose and Throat Referral Guidelines
1/10
2008 HPN Southern Nevada Provider Summary Guide
11.3 EAR NOSE AND THROAT REFERRAL GUIDELINES
Contracted Group: Ear Nose and Throat Consultants (ENTC)
For Appointments:
Telephone Number (702) 792-6700 Fax: (702)792-7198
Locations:
10001 S. Eastern Ave., 209
Henderson, NV 89052
3131 La Canada St., #241Las Vegas, NV 89169
7040 Smoke Ranch RoadLas Vegas, NV 89128
Important Note:
Please have Patients bring their films to their appointments as indicated below. In
order for patients to be seen at the time of their appointment we will need requested
documentation.
THROAT
PLEASE send documentation for recurrent episodes
DIAGNOSIS EVALUATION MANAGEMENT OPTIONS REFERRAL
GUIDELINES
PHARYNGEAL AND
TONSILLOADENOID
PROBLEMS
Streptococcal
Pharyngitis 1. Throat pain &
odynophagia
2. Constitutional
symptoms
3. Cervical
Lymphadenopathy
4. Pharyngeal petechia
5. Throat culture
1. Penicillin or amoxicillin for
10 days
2. Treat all intimate contacts
simultaneously
3. Cephalosporin or macrolide
if patient is allergic to Penicillin
or if initial treatment is not
successful.
Three or more
episodes of
streptococcal
pharyngitis in a
six-month period.
HPN SN 2008 Section 11 Referral Guidelines
7/30/2019 Ear Nose and Throat Referral Guidelines
2/10
2008 HPN Southern Nevada Provider Summary Guide
DIAGNOSIS EVALUATION MANAGEMENT OPTIONS REFERRAL
GUIDELINES
Acute Tonsillitis Throat pain &
odynophagia with any
of the following
Findings:
1. Fever
2. Tonsillar exudate
3. Lymphadenopathy
4. Positive Strep Test
1. Penicillin or amoxicillin for
10 days
2. Cephalosporin or macrolide
if patient allergic to Penicillin
or if initial treatment not
successful.
Documented
episodes:
4 or more in
previous 12
Months
5 per year in 2
precedingyears
3 per year in
preceding 3
years
Persistent
streptococcal
carrier state
with or
without acutetonsillitis.
Chronic Tonsillitis Frequent or chronic
throat pain andodynophagia; may
have any of the
following findings:
intermittent
exudates
adenopathy
improves with
antibiotic
Clindamycin for 10 days ENT referral is
indicated ifproblem recurs
following adequate
response to
therapy
As Above.
Mononucleosis Throat pain &
odynophagia with:
fatigue
posterior cervical
adenopathy
CBC, mono test
Supportive care
Systematic steroids if severedysphagia
Airway
obstruction
Needs ER referral.
Adenoiditis 1. Purulent rhinorrhea
2. Nasal obstruction
3. Cough
4. May be associatedwith otitis media
At least 2 weeks of therapy
using B-lactamase-stable
antibiotic:
Amoxicillin/clavulanate
Erythromycin/sulfamethoxazol
e
1. Three or more
episodes in a six-
month period
2. Persisting
symptoms and
findings after two
courses of
antibiotics
HPN SN 2008 Section 11 Referral Guidelines
7/30/2019 Ear Nose and Throat Referral Guidelines
3/10
2008 HPN Southern Nevada Provider Summary Guide
DIAGNOSIS EVALUATION MANAGEMENT OPTIONS REFERRAL
GUIDELINES
UPPER AIRWAY
OBSTRUCTION:
Tonsillar and/or
adenoid hyperplasia
1. Mouth breathing
2. Nasal obstruction3. Dysphonia
4. Severe Snoring with
or without apnea
5. Daytime fatigue
6. Dysphagia
7. Weight and/orheight below normal
for age
8. Dental arch
maldevelopment:
narrow arched palate,
cross bite deformity
9. Adenoid facies10. Cor pulmonale
1. Optional soft tissue lateral
X-ray of nasopharynx
2. Allergy evaluation whenindicated
3. Polysomnogram.
ENT referral
indicated with anysignificant
symptoms of
upper airway
obstruction,
If Acute ER
Referral Should
be Made
Tonsillar
Hemorrhage
Spontaneous bleeding
from a tonsil
ENT referral in
indicated
Neoplasm Progressive unilateral
tonsil enlargement
ENT referral is
indicated
Hoarseness,
Associated with
respiratory
obstruction
Stridor 1. Immediate Rx;
Humidification; Parenteral
and/or inhalant steroids
2. Ct of neck with contrast
3. Blood cultures, if patient is
febrile
4. C1 esterase inhibitor levels
(if history of angioneuroticedema)
IMMEDIATE ER
REFERRAL IS
INDICATED IN
ALL CASES
Hoarseness without
associated
symptoms orobvious etiology
1. History of tobacco
and/or alcohol use
2. Evaluation, whenindicated, for:
Hypothyroidism
Diabetes mellitus
Gastro-esophageal
reflux
Rheumatoiddisease
Lung neoplasm
Esophageal or
pharyngeal neoplasm
1. Humidification
2. Increase fluid intake
3. Voice rest, if possible
4. Antibiotics when
appropriate
5. Inhalant steroid sprays
6. Tapering oral steroids when
indicated (dose pk)
7. Treat any medical illnesses
diagnosed on evaluation
ENT referral is
indicated if
hoarseness persistsmore than two
weeks despite
medical therapy
HPN SN 2008 Section 11 Referral Guidelines
7/30/2019 Ear Nose and Throat Referral Guidelines
4/10
2008 HPN Southern Nevada Provider Summary Guide
DIAGNOSIS EVALUATION MANAGEMENT OPTIONS REFFERAL
GUIDELINES
DYSPHAGIA
When indicated,
evaluation may
include:
1. Foreign body
ingestion
2. Gastro esophagealReflux
3. Esophageal Motility
4. Scleroderma
5. Neoplasm6. Thyromegaly
Diagnostic studies may include:
Ct neck with contrast
Chest X-ray
Barium swallow
Thyroid studies
Lab tests for auto-immune
disorder
Management options may
include:
1. Anti-reflux therapy2. Appropriate thyroid
management
3. GI consultation
ENT referral
indicated for:
1. Foreign bodysuspected
2. Dysphagia in
children
3. Dysphagiaassoc. with
hoarseness
NECK MASS
Inflammatory1. head and neck
examination- Dentalsource?
2. CT NECK withcontrast
3. CBC
4. Cultures if indicated
5. TB test
6. Inquire about
possible cat scratch
7. HIV testing if
indicated
8. Toxoplasmosis titre
if indicated
1. Amoxicillin/Clavulanate
2. Clindamycin
3. CT Neck with Contrastshould be done prior to
referral. Patient must bring
films to be seen.
Dental/Oral Surgery eval if
significant dental decay. (ENT
specialist is not a substitute for
dentist/oral surgeon)
ENT referral is
indicated if:
Mass persists for 2
weeks without
improvementURGENT referralif painless
progressiveenlargement
URGENT referral
if suspicion of
metastatic
carcinoma (PT
MUST BRING CT
FILMS TOBE
SEEN )
Non-inflammatory Complete head and
neck examination
indicated
If lower neck, thyroidevaluation may
include:
Thyroid function
studies
Thyroid
ultrasound
Thyroid uptakeand scan
Needle aspiration
biopsy
Open biopsy of neck
mass is contraindicated in all cases
1. Appropriate medical
management for multi-nodular
goiter or hyper-functioning
thyroid nodule
2. Trial of antibiotic therapy
may be considered if an
inflammatory mass is suspected
(see above)
3. CT NeckWITH contrast
ENT referral is
indicated other
than for
THYROID orPARATHYROID
disordersPT MUST
BRING CT
FILMS TOBE
SEEN
HPN SN 2008 Section 11 Referral Guidelines
7/30/2019 Ear Nose and Throat Referral Guidelines
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2008 HPN Southern Nevada Provider Summary Guide
DIAGNOSIS EVALUATION MANAGEMENT OPTIONS REFFERAL
GUIDELINES
SALIVARY GLAND
DISORDERS
Saliodentitis
1. Assess hydration of
patient
2. Palpate for stones infloor of mouth
3. Observe for
purulent discharge
from salivary ducts
when palpating
involved gland
4. Evaluate mass for
swelling, tenderness,
inflammation
1. Culture and sensitivity of
purulent discharge in mouth
2. Hydration
3. Occlusal view of X-ray of
floor of mouth for calculi orCT of Neckwith contrast
4. Anti-staph antibiotics:
Amoxicillin/Clavulanate or
Clindamycin 300mg, q8H
ENT referral
indicated :1. Poor antibiotic
response withinone week of
diagnosis
2. Calculi or mass
suspected on examand CT (Pt
MUST BRING
CT FILMS TO
BE SEEN)
3. Abscess
formation-
immediate referral
Salivary gland mass 1. Complete head andneck examination
2. Evaluate facial
nerve function
3. MRI scan may be
considered or Ct with
contrast
Open biopsy of
salivary mass is contra-
indicated in all cases
20% of all parotid glandmasses are malignant
50% of all submaxillary
gland masses are malignant
CT Neck with Contrast
must be done and Patient
must bring films to be
seen
ENT referral isindicated for in all
cases of suspected
salivary glandneck masses
SLEEP APNEA &
SNORING
Symptoms of
obstructive sleep apneamay include:
1. Disturbed sleep
2. Documented apnea
during sleep
3. Fatigue on waking
4. Headache onwaking
5. Daytime fatigue
Evaluation may
include:
Obesity
Hypothyroidism
Hypertension
Cardiac
disturbances
polysomnography
1. Weight control
2. Thyroid management
3. Hypertension (possibly
related to sleep apnea)
4. Cardiac disturbances
(possibly related to sleep
apnea)
5. CPAP trial as indicated
ENT referral
indicated after 1
month CPAP
home trial
1. Evaluation of
upper airway and
nasal obstruction
2. Abnormal
Polysonogram andconsidering
surgical options
3. Elective
management of
snoring in absence
of sleep apnea
(Pt. needs tobring copy of
studies)
HPN SN 2008 Section 11 Referral Guidelines
7/30/2019 Ear Nose and Throat Referral Guidelines
6/10
2008 HPN Southern Nevada Provider Summary Guide
NASAL AND SINUS PROBLEMS, ADULT
Caveats:
ENTC does not have access to SMA radiology or labs
Definitive sinus diagnosis requires CT scan: CT must be done at least 2 weeks after acute episode
(CT sinus without contrast) Please have patient bring films (not just reports) orpatient can not be seen
DIAGNOSIS EVALUATION
MANAGEMENT
OPTIONS
REFERRAL
GUIDELINES
EPISTAXIS
(NOSEBLEED);
PERSISTING OR
RECURRENT
Determine whether:
Bleeding is unilateral or
bilateral
Bleeding is anterior or
posterior
Any bleeding diathesis
or hypertension
Coagulation studies
Pressure on the nostrils
If bleeder is visible
consider cauterizationwith silver nitrate
Merocel sponge
packing-coat sponge
with antibiotic ointment
prior to insertion
Saline gel or spray for
two weeks
1. Bleeding is posterior
2. Bleeding persists
3. Bleeding recurs
Chronic
sinusitis/polyps
Symptoms: persisting
or recurrent
Nasal congestion
(unilateral or bilateral)
Post-nasal discharge
Epistaxis
Recurrent acute
sinusitis
Anterior facial pain/
headache (SINUSHEADACHE)
CT scan shows
abnormal findings.
Antibiotics, topical
steroid nasal sprays,
saline nasal wash.
(CT must be done
during non-acute
phase)
1.Recurrent three
episodes per year,
failing 3 antibiotic trials,
one at least 14 days
2. Persisting abnormal
symptoms, abnormal
findings, andabnormal
CT warrant ENT
referral (PATIENT
MUST BRING
FILMS)
Deviated Septum Symptoms:
Nasal congestion
(unilateral or bilateral)
Post-nasal discharge
Epistaxis
Recurrent sinusitis
Anterior facial pain
headache.
Physical Examination
Treat initially for any
associated allergy,chronic Sinusitis.
Confirm with CT sinus
and r/o associated sinus
pathology
ENT referral for
intranasal examinationand treatment
recommendations.
HPN SN 2008 Section 11 Referral Guidelines
7/30/2019 Ear Nose and Throat Referral Guidelines
7/10
2008 HPN Southern Nevada Provider Summary Guide
DIAGNOSIS EVALUATION MANAGEMENT
OPTIONS
REFERRAL
GUIDELINES
Allergic Rhinitis Symptoms:
Seasonal or perennial;
congestion
Watery discharge
Sneezing fits
Watery eyes
Itchy eyes/throat.
Physical Examination:
boggy swollen bluishturbinates
Allergic shiners
Allergic salute.
Antihistamines
Topical cortisone sprays
Topical cromolyn sprays
Refer to ALLERGIST
If suspicious of
Sinusitis, see above.
Acute nasal fracture 1. Immediate changes:
edema, Ecchymosis,
epistaxis.
2. Evaluate forassociated nasal
congestion, septal
fracture of septal
hematoma.
3. Nasal bone X-rays
usually positive.
1. Early treatment: cool
compresses to reduce
swelling.
2. Re-evaluate in 3-4days to determine if
nose looks normal and if
breathing is normal.
1. Immediate referral if
possible septal
hematoma (significant
airway obstruction).
2. ENT referral within
approximately 7 days if
external nasal deformity,
septal deformity, or
breathing problem.
HPN SN 2008 Section 11 Referral Guidelines
7/30/2019 Ear Nose and Throat Referral Guidelines
8/10
2008 HPN Southern Nevada Provider Summary Guide
EAR PROBLEMS, CHILDHOOD
Caveats:
The so called light reflex is not a valid indicator of ear health
Absence of the so-called light-reflex is not a valid indicator of ear disease
In a crying child, one may see uniform injection of tympanic membrane without infectionOtoscopic examination is NOT capable of evaluating middle ear negative pressure
Otoscopic examination is often NOT adequate for identifying non-infected middle ear effusionOtoscopic examination is often NOT adequate for identifying tympanic membrane retraction
Pneumo-Otoscopic examination improves reliability for identifying middle ear effusion/pressure/retractionTympanometry provides high reliability for identifying middle ear effusion/pressure (though it is not
infallible)
DIAGNOSIS EVALUATION MANAGEMENT
OPTIONS
REFERRAL
GUIDELINES
ACUTE OTITIS
MEDIA
Ear infection 1) Symptoms: ear pain,decreased hearing, ear
drainage, fever
2) Physical
Examination: Inflamed
tympanic membrane
TM, desquamated
epithelium on TM,
bulging TM, middle eareffusion
3) Audio (not required is
A & B are present)
tympanogram may showpositive or negative
pressure
4) Caveat: Tender,
swollen ear canal
usually indicated
external otitis rather
than otitis media
A) Initial Treatment:
1) Broad-spectrum
antibiotic including
coverage for S.
Pneumoniae, H.
Influenza and M.
Catarrhalis
2) For adults,
systemic and/or topical
nasal steroid sprays may
be considered.
3) If associated
allergy antihistamines
and/or topical nasal
steroid sprays may beconsidered
B) Secondary
Treatment: If primary
treatment fails, prescribe
a betalactamase-resistant
antibiotic
1) Secondary antibiotictreatment fails
2) Complications are
noted mastoiditis, facial
weakness, dizziness,
meningitis
HPN SN 2008 Section 11 Referral Guidelines
7/30/2019 Ear Nose and Throat Referral Guidelines
9/10
2008 HPN Southern Nevada Provider Summary Guide
DIAGNOSIS EVALUATION MANAGEMENT
OPTIONS
REFERRAL
GUIDELINES
CHRONIC OTITIS
MEDIA
i.e., persistent effusion
or negative middle ear
pressure, with orwithout recurrent acute
otitis media
MAY HAVE NO
SYMPTOMS:
pneumotoscopy and/ortympanogram are
crucial1) Symptoms: ear pain,
decreased hearing, ear
drainage
2) Physical
Examination: (may
include) TM discolored
thinned, or retracted;
bubbles behind TM,
Pneumo-otoscopy
reveals sluggish orretracted TM.
3) Audio: tympanogrammay show effusion (type
B) or negative pressure
(type C)
1) Up to three courses of
systemic antibiotics (10
days ea.); at least onetreatment course with
therapy resistant to beta-lactamase
2) Caveat: therapy with
decongestants,
antihistamines, andsteroids has not been
proved to be beneficial
(unless there are proven
allergies present)
1) Recurring otalgia or
hearing loss (3 episodes
in 6 months)
2) Effusion, TM
retraction, perforation,or negative pressure
persist > 3 months
3) Ear discharge
(persisting or recurrent)
4) Abnormal
tympanogram and/or
audiogram after 3
months
ACUTE EXTERNAL
OTITIS
Swimmers Ear
1) Symptoms: ear pain,
significant EAR
TENDERNESS,swollen external canal,
hearing may or may not
be diminished
2) Physical
Examination: Ear canal
always tender, usuallyswollen, may be
inflamed. Often unableto visualize TM because
of debris or canal edema
3) Caveat: Occasional
cases have a large
fungal pad indicating
fungal external otitis-often spores visible
1) Topical treatment is
optimal; systemic
antibiotics generallyinsufficient alone and
add little effectiveness
to topical treatment
except when there is
surrounding cellulites
NOTE!CORTISPORIN IS
OTOTOXIC and
should be Rxed only
under extenuating
conditions.
2) Insertion of
expandable wick with
topical antibacterialmedication; Burows
solution or water-
soluble antibiotic drops
3) If fungal externalotitis, through cleaning
of canal is required, plustopical anti-fungal
therapy
1) Canal is swollen shut
and wick cannot be
inserted
2) Cerumen impaction
compounding external
otitis
3) Unresponsive to
initial course of wick
and anti-bacterial drops
HPN SN 2008 Section 11 Referral Guidelines
7/30/2019 Ear Nose and Throat Referral Guidelines
10/10
2008 HPN Southern Nevada Provider Summary Guide
DIAGNOSIS EVALUATION MANAGEMENT
OPTIONS
REFERRAL
GUIDELINES
HEARING LOSS
BILATERAL,
SYMMETRICAL, ADULTS(FORCHILDREN, SEEABOVE)
Symptoms: diminished
hearing
1) Cerumen blockage
2) Middle ear effusion
3) Normal findings
1) Cerumen-dissolving
drops possible gentleirrigation
2) Oral decongestant
and re-evaluate in 3
weeks
3) No treatment; referral
hearing evaluation
1) Cerumen, or hearing
loss persists
2) Effusion persistsmore than 8 weeks
3) Referral for OTO-
HNS
UNILATERAL
HEARING LOSS
1) Symptoms: difficulty
hearing, or difficulty
localizing sound, orproblems hearing only
in a crowded
environment
2) Physical
Examination: may be
normal or may havecerumen or tympanic
membrane abnormality
When cerumen is
present, treat with drops
and possible irrigation.
If cerumen is not
present, referral isindicated
Referral for OTO-HNS
evaluation is indicated in
all cases of unilateralhearing loss, after
vascular etiology ruled
out, unless the problemresolves with
elimination of cerumen
Sudden Hearing Loss Loss of hearing with or
without vertigo
Sudden loss? Consider
Abx+steroids if
vascular etiology ruled
out.
Urgent referral to ENT
if not resolved with
cerumen removal
TINNITUS
1)Chronic bilateral2)Unilateral or recent
onset
3)Pulsatile
1) Normal tympanicmembranes or cerumen
2) Normal tympanicmembranes or cerumen
3) Mass behind
tympanic membrane?
1) Clean cerumen: notreatment
2) Clean cerumen; ifsymptoms persist,
referral indicated
3) Referral is indicated
for mass or if vascular
study normal and no
mass
1) No referral indicatedunless associated
hearing loss or dizzy
2) If persists more than 8
weeks, Oto-HNS
referral and hearing
evaluation indicated
DIZZINESS
1)Orthostatic
2)Vestibular neuronitis
3)Chronic or episode
1) Symptoms mild brief,
only standing up (usually
A.M.)
2) Associated with URI;may be positional or
persisting
3) Significant imbalance
and/or vertigo; may haveassociated hearing loss,
tinnitus, earpressure,
nausea
1) Evaluate cardiovascularsystem, reassurance
2) Self-limited over 3-6
weeks; may use systematicmedication and/or steroid
3) Referral is indicated ifCNS process (CVA) ruledout (neurology FIRST if noother otologic symptoms
1) If symptoms become
severe
2) Associated hearing
loss, increased severity,
persistence > 6 weeks
HPN SN 2008 Section 11 Referral Guidelines
Recommended