Ear Nose and Throat Referral Guidelines

7/30/2019 Ear Nose and Throat Referral Guidelines

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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


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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



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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



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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



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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)



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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.



7/10


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.



8/10


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)


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



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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



10/10



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


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Ear Nose and Throat Referral Guidelines