Ear Nose and Throat Referral Guidelines tinnitus

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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., #241
Las Vegas, NV 89169

7040 Smoke Ranch Road
Las 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 &         1. Penicillin or amoxicillin for       Three or more
                            odynophagia              10 days                                episodes of
                                                                                            streptococcal
                            2. Constitutional        2. Treat all intimate contacts
                                                                                            pharyngitis in a
                            symptoms                 simultaneously
                                                                                            six-month period.
                            3. Cervical              3. Cephalosporin or macrolide
                            Lymphadenopathy          if patient is allergic to Penicillin
                                                     or if initial treatment is not
                            4. Pharyngeal petechia
                                                     successful.
                            5. Throat culture


HPN SN 2008 Section 11 Referral Guidelines
                     2008 HPN Southern Nevada Provider Summary Guide


     DIAGNOSIS              EVALUATION                MANAGEMENT OPTIONS                    REFERRAL
                                                                                           GUIDELINES
   Acute Tonsillitis       Throat pain &                                                 Documented
                            odynophagia with any                                          episodes:
                            of the following
                                                                                             4 or more in
                                                                                              previous 12
                                                                                              Months
                            Findings:
                            1. Fever
                                                      1. Penicillin or amoxicillin for       5 per year in 2
                                                      10 days                                 preceding
                            2. Tonsillar exudate                                              years
                                                      2. Cephalosporin or macrolide
                            3. Lymphadenopathy        if patient allergic to Penicillin      3 per year in
                                                      or if initial treatment not             preceding 3
                            4. Positive Strep Test
                                                      successful.                             years
                                                                                             Persistent
                                                                                              streptococcal
                                                                                              carrier state
                                                                                              with or
                                                                                              without acute
                                                                                              tonsillitis.
   Chronic Tonsillitis     Frequent or chronic       Clindamycin for 10 days             ENT referral is
                            throat pain and                                               indicated if
                            odynophagia; may                                              problem recurs
                            have any of the                                               following
                            following findings:                                           adequate response
                                                                                          to therapy
                                intermittent
                                 exudates                                                 As Above.
                                adenopathy
                                improves with
                                 antibiotic
   Mononucleosis           Throat pain &             Supportive care                     Airway
                            odynophagia with:                                             obstruction
                                                      Systematic steroids if severe
                                fatigue              dysphagia                           Needs ER referral.
                                posterior cervical
                                 adenopathy
                                CBC, mono test
   Adenoiditis             1. Purulent rhinorrhea    At least 2 weeks of therapy         1. Three or more
                                                      using B-lactamase-stable            episodes in a six-
                            2. Nasal obstruction
                                                      antibiotic:                         month period
                            3. Cough
                                                      Amoxicillin/clavulanate             2. Persisting
                            4. May be associated                                          symptoms and
                                                      Erythromycin/sulfamethoxazole
                            with otitis media                                             findings after two
                                                                                          courses of
                                                                                          antibiotics




HPN SN 2008 Section 11 Referral Guidelines
                      2008 HPN Southern Nevada Provider Summary Guide


     DIAGNOSIS              EVALUATION               MANAGEMENT OPTIONS                   REFERRAL
                                                                                         GUIDELINES
UPPER AIRWAY
OBSTRUCTION:

   Tonsillar and/or        1. Mouth breathing       1. Optional soft tissue lateral    ENT referral
    adenoid hyperplasia     2. Nasal obstruction     X-ray of nasopharynx               indicated with any
                            3. Dysphonia                                                significant
                            4. Severe Snoring with   2. Allergy evaluation when         symptoms of
                                                     indicated
                            or without apnea                                            upper airway
                            5. Daytime fatigue                                          obstruction,
                                                     3. Polysomnogram.
                            6. Dysphagia
                            7. Weight and/or                                            If Acute ER
                            height below normal                                         Referral Should
                            for age                                                     be Made
                            8. Dental arch
                            maldevelopment:
                            narrow arched palate,
                            cross bite deformity
                            9. Adenoid facies
                            10. Cor pulmonale
   Tonsillar               Spontaneous bleeding                                        ENT referral in
    Hemorrhage              from a tonsil                                               indicated
   Neoplasm                Progressive unilateral                                      ENT referral is
                            tonsil enlargement                                          indicated
   Hoarseness,             Stridor                  1. Immediate Rx;                   IMMEDIATE ER
    Associated with                                  Humidification; Parenteral         REFERRAL IS
    respiratory                                      and/or inhalant steroids           INDICATED IN
    obstruction                                                                         ALL CASES
                                                     2. Ct of neck with contrast

                                                     3. Blood cultures, if patient is
                                                     febrile

                                                     4. C1 esterase inhibitor levels
                                                     (if history of angioneurotic
                                                     edema)
   Hoarseness without      1. History of tobacco    1. Humidification                  ENT referral is
    associated              and/or alcohol use                                          indicated if
    symptoms or             2. Evaluation, when      2. Increase fluid intake           hoarseness persists
    obvious etiology        indicated, for:                                             more than two
                                                     3. Voice rest, if possible         weeks despite
                               Hypothyroidism                                          medical therapy
                               Diabetes mellitus    4. Antibiotics when
                               Gastro-esophageal    appropriate
                                reflux
                             Rheumatoid             5. Inhalant steroid sprays
                                disease
                             Lung neoplasm          6. Tapering oral steroids when
                            Esophageal or            indicated (dose pk)
                            pharyngeal neoplasm
                                                     7. Treat any medical illnesses
                                                     diagnosed on evaluation




HPN SN 2008 Section 11 Referral Guidelines
                     2008 HPN Southern Nevada Provider Summary Guide

DIAGNOSIS                   EVALUATION                 MANAGEMENT OPTIONS                   REFFERAL
                                                                                            GUIDELINES
                            When indicated,            Diagnostic studies may include:      ENT referral
DYSPHAGIA                   evaluation may              Ct neck with contrast              indicated for:
                            include:                    Chest X-ray
                            1. Foreign body             Barium swallow                     1. Foreign body
                            ingestion                   Thyroid studies                    suspected
                            2. Gastro esophageal        Lab tests for auto-immune
                                                            disorder                        2. Dysphagia in
                            Reflux
                                                       Management options may               children
                            3. Esophageal Motility
                            4. Scleroderma             include:
                                                       1. Anti-reflux therapy               3. Dysphagia
                            5. Neoplasm
                                                       2. Appropriate thyroid               assoc. with
                            6. Thyromegaly
                                                       management                           hoarseness
                                                       3. GI consultation
NECK MASS
                                                       1. Amoxicillin/Clavulanate           ENT referral is
                            1. head and neck
   Inflammatory                                                                            indicated if:
                            examination- Dental
                                                       2. Clindamycin                       Mass persists for 2
                            source?
                                                                                            weeks without
                            2. CT NECK with            3. CT Neck with Contrast             improvement
                            contrast                   should be done prior to              URGENT referral
                                                       referral. Patient must bring         if painless
                            3. CBC
                                                       films to be seen.                    progressive
                            4. Cultures if indicated   Dental/Oral Surgery eval if          enlargement
                                                       significant dental decay. (ENT       URGENT referral
                            5. TB test                 specialist is not a substitute for   if suspicion of
                            6. Inquire about           dentist/oral surgeon)                metastatic
                            possible cat scratch                                            carcinoma (PT
                                                                                            MUST BRING
                            7. HIV testing if                                               CT FILMS TO BE
                            indicated                                                       SEEN )
                            8. Toxoplasmosis titre
                            if indicated
   Non-inflammatory        Complete head and          1. Appropriate medical               ENT referral is
                            neck examination           management for multi-nodular         indicated other
                            indicated                  goiter or hyper-functioning          than for
                                                       thyroid nodule                       THYROID or
                            If lower neck, thyroid
                                                                                            PARATHYROID
                            evaluation may             2. Trial of antibiotic therapy
                                                                                            disorders
                            include:                   may be considered if an
                                                                                            PT MUST
                                                       inflammatory mass is suspected
                                Thyroid function      (see above)
                                                                                            BRING CT
                                 studies                                                    FILMS TO BE
                             Thyroid                  3. CT Neck WITH contrast
                                                                                            SEEN
                                 ultrasound
                             Thyroid uptake
                                 and scan
                             Needle aspiration
                                 biopsy
                            Open biopsy of neck
                            mass is contra
                            indicated in all cases




HPN SN 2008 Section 11 Referral Guidelines
                      2008 HPN Southern Nevada Provider Summary Guide


DIAGNOSIS                   EVALUATION                 MANAGEMENT OPTIONS               REFFERAL
                                                                                        GUIDELINES

SALIVARY GLAND                                                                          ENT referral
DISORDERS                                                                               indicated :
                            1. Assess hydration of     1. Culture and sensitivity of    1. Poor antibiotic
   Saliodentitis           patient                    purulent discharge in mouth      response within
                                                                                        one week of
                            2. Palpate for stones in   2. Hydration                     diagnosis
                            floor of mouth
                                                       3. Occlusal view of X-ray of     2. Calculi or mass
                            3. Observe for
                                                       floor of mouth for calculi or    suspected on exam
                            purulent discharge
                                                       CT of Neck with contrast         and CT (Pt
                            from salivary ducts
                                                                                        MUST BRING
                            when palpating
                                                       4. Anti-staph antibiotics:       CT FILMS TO
                            involved gland
                                                        Amoxicillin/Clavulanate or     BE SEEN)
                            4. Evaluate mass for        Clindamycin 300mg, q8H         3. Abscess
                            swelling, tenderness,                                       formation-
                            inflammation                                                immediate referral

Salivary gland mass         1. Complete head and          20% of all parotid gland     ENT referral is
                            neck examination               masses are malignant         indicated for in all
                            2. Evaluate facial            50% of all submaxillary      cases of suspected
                                                           gland masses are malignant   salivary gland
                            nerve function
                                                          CT Neck with Contrast        neck masses
                            3. MRI scan may be             must be done and Patient
                            considered or Ct with          must bring films to be
                            contrast                       seen
                            Open biopsy of
                            salivary mass is contra-
                            indicated in all cases
SLEEP APNEA &               Symptoms of
SNORING                     obstructive sleep apnea
                            may include:
                                                       1. Weight control                ENT referral
                            1. Disturbed sleep
                                                                                        indicated after 1
                            2. Documented apnea        2. Thyroid management            month CPAP
                            during sleep                                                home trial
                                                       3. Hypertension (possibly        1. Evaluation of
                            3. Fatigue on waking       related to sleep apnea)          upper airway and
                            4. Headache on                                              nasal obstruction
                                                       4. Cardiac disturbances
                            waking
                                                       (possibly related to sleep       2. Abnormal
                            5. Daytime fatigue         apnea)                           Polysonogram and
                                                                                        considering
                                                       5. CPAP trial as indicated       surgical options
                            Evaluation may
                            include:                                                    3. Elective
                                                                                        management of
                                Obesity                                                snoring in absence
                                Hypothyroidism                                         of sleep apnea
                                Hypertension                                           (Pt. needs to
                                Cardiac                                                bring copy of
                                 disturbances                                           studies)
                                polysomnography



                          NASAL AND SINUS PROBLEMS, ADULT

HPN SN 2008 Section 11 Referral Guidelines
                       2008 HPN Southern Nevada Provider Summary Guide

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) or patient can not be seen
                                                           MANAGEMENT                      REFERRAL
     DIAGNOSIS               EVALUATION                        OPTIONS                    GUIDELINES
                             Determine whether:         Pressure on the nostrils     1. Bleeding is posterior
 EPISTAXIS                  Bleeding is unilateral or   If bleeder is visible       2. Bleeding persists
(NOSEBLEED);                bilateral                   consider cauterization
                                                                                    3. Bleeding recurs
PERSISTING OR                                           with silver nitrate
                            Bleeding is anterior or
RECURRENT                                               Merocel sponge
                            posterior
                                                        packing-coat sponge
                            Any bleeding diathesis      with antibiotic ointment
                            or hypertension             prior to insertion
                            Coagulation studies         Saline gel or spray for
                                                        two weeks
   Chronic                 Symptoms: persisting        Antibiotics, topical        1.Recurrent three
    sinusitis/polyps        or recurrent                steroid nasal sprays,       episodes per year,
                                                        saline nasal wash.          failing 3 antibiotic trials,
                            Nasal congestion
                                                                                    one at least 14 days
                            (unilateral or bilateral)   (CT must be done
                                                        during non-acute            2. Persisting abnormal
                            Post-nasal discharge
                                                        phase)                      symptoms, abnormal
                            Epistaxis                                               findings, and abnormal
                                                                                    CT warrant ENT
                             Recurrent acute
                                                                                    referral (PATIENT
                            sinusitis
                                                                                    MUST BRING
                            Anterior facial pain/                                   FILMS)
                            headache (SINUS
                            HEADACHE)
                            CT scan shows
                            abnormal findings.
   Deviated Septum          Symptoms:                  Treat initially for any     ENT referral for
                                                        associated allergy,         intranasal examination
                            Nasal congestion
                                                        chronic Sinusitis.          and treatment
                            (unilateral or bilateral)
                                                                                    recommendations.
                                                        Confirm with CT sinus
                            Post-nasal discharge
                                                        and r/o associated sinus
                             Epistaxis                  pathology
                             Recurrent sinusitis
                             Anterior facial pain
                            headache.
                            Physical Examination




HPN SN 2008 Section 11 Referral Guidelines
                     2008 HPN Southern Nevada Provider Summary Guide


     DIAGNOSIS              EVALUATION                 MANAGEMENT                    REFERRAL
                                                           OPTIONS                  GUIDELINES
   Allergic Rhinitis       Symptoms:                Antihistamines             Refer to ALLERGIST
                            Seasonal or perennial;   Topical cortisone sprays   If suspicious of
                            congestion                                          Sinusitis, see above.
                                                     Topical cromolyn sprays
                             Watery discharge
                             Sneezing fits
                             Watery eyes
                             Itchy eyes/throat.
                            Physical Examination:
                            boggy swollen bluish
                            turbinates
                            Allergic “shiners”
                            “Allergic salute.”




   Acute nasal fracture    1. Immediate changes:    1. Early treatment: cool   1. Immediate referral if
                            edema, Ecchymosis,       compresses to reduce       possible septal
                            epistaxis.               swelling.                  hematoma (significant
                                                                                airway obstruction).
                            2. Evaluate for          2. Re-evaluate in 3-4
                            associated nasal         days to determine if       2. ENT referral within
                            congestion, septal       nose looks normal and if   approximately 7 days if
                            fracture of septal       breathing is normal.       external nasal deformity,
                            hematoma.                                           septal deformity, or
                                                                                breathing problem.
                            3. Nasal bone X-rays
                            usually positive.




HPN SN 2008 Section 11 Referral Guidelines
                     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 infection
Otoscopic examination is NOT capable of evaluating middle ear negative pressure
Otoscopic examination is often NOT adequate for identifying non-infected middle ear effusion
Otoscopic examination is often NOT adequate for identifying tympanic membrane retraction
Pneumo-Otoscopic examination improves reliability for identifying middle ear effusion/pressure/retraction
Tympanometry provides high reliability for identifying middle ear effusion/pressure (though it is not
infallible)

     DIAGNOSIS                   EVALUATION                MANAGEMENT                     REFERRAL
                                                             OPTIONS                     GUIDELINES
ACUTE OTITIS
MEDIA
“Ear infection”
                            1) Symptoms: ear pain,      A) Initial Treatment:        1) Secondary antibiotic
                            decreased hearing, ear                                   treatment fails
                                                           1) Broad-spectrum
                            drainage, fever
                                                        antibiotic including         2) Complications are
                            2) Physical                 coverage for S.              noted mastoiditis, facial
                            Examination: Inflamed       Pneumoniae, H.               weakness, dizziness,
                            tympanic membrane           Influenza and M.             meningitis
                            TM, desquamated             Catarrhalis
                            epithelium on TM,
                                                           2) For adults,
                            bulging TM, middle ear
                                                        systemic and/or topical
                            effusion
                                                        nasal steroid sprays may
                            3) Audio (not required is   be considered.
                            A & B are present)
                                                            3) If associated
                            tympanogram may show
                                                        allergy antihistamines
                            positive or negative
                                                        and/or topical nasal
                            pressure
                                                        steroid sprays may be
                            4) Caveat: Tender,          considered
                            swollen ear canal
                                                        B) Secondary
                            usually indicated
                                                        Treatment: If primary
                            external otitis rather
                                                        treatment fails, prescribe
                            than otitis media
                                                        a betalactamase-resistant
                                                        antibiotic




HPN SN 2008 Section 11 Referral Guidelines
                      2008 HPN Southern Nevada Provider Summary Guide


     DIAGNOSIS                   EVALUATION               MANAGEMENT                      REFERRAL
                                                              OPTIONS                    GUIDELINES
CHRONIC OTITIS              MAY HAVE NO                1) Up to three courses of    1) Recurring otalgia or
MEDIA                       SYMPTOMS:                  systemic antibiotics (10     hearing loss (3 episodes
                            pneumotoscopy and/or       days ea.); at least one      in 6 months)
i.e., persistent effusion
                            tympanogram are            treatment course with
or negative middle ear                                                              2) Effusion, TM
                            crucial                    therapy resistant to beta-
pressure, with or                                                                   retraction, perforation,
                                                       lactamase
without recurrent acute     1) Symptoms: ear pain,                                  or negative pressure
otitis media                decreased hearing, ear     2) Caveat: therapy with      persist > 3 months
                            drainage                   decongestants,
                                                                                    3) Ear discharge
                                                       antihistamines, and
                            2) Physical                                             (persisting or recurrent)
                                                       steroids has not been
                            Examination: (may
                                                       proved to be beneficial      4) Abnormal
                            include) TM discolored
                                                       (unless there are proven     tympanogram and/or
                            thinned, or retracted;
                                                       allergies present)           audiogram after 3
                            bubbles behind TM,
                                                                                    months
                            Pneumo-otoscopy
                            reveals sluggish or
                            retracted TM.
                            3) Audio: tympanogram
                            may show effusion (type
                            B) or negative pressure
                            (type C)
ACUTE EXTERNAL              1) Symptoms: ear pain,     1) Topical treatment is      1) Canal is swollen shut
OTITIS                      significant EAR            optimal; systemic            and wick cannot be
                            TENDERNESS,                antibiotics generally        inserted
“Swimmers Ear”
                            swollen external canal,    insufficient alone and
                                                                                    2) Cerumen impaction
                            hearing may or may not     add little effectiveness
                                                                                    compounding external
                            be diminished              to topical treatment
                                                                                    otitis
                                                       except when there is
                            2) Physical
                                                       surrounding cellulites       3) Unresponsive to
                            Examination: Ear canal
                                                                                    initial course of wick
                            always tender, usually     NOTE!
                                                                                    and anti-bacterial drops
                            swollen, may be            CORTISPORIN IS
                            inflamed. Often unable     OTOTOXIC and should
                            to visualize TM because    be Rx’ed only under
                            of debris or canal edema   extenuating conditions.
                            3) Caveat: Occasional      2) Insertion of
                            cases have a large         expandable wick with
                            fungal pad indicating      topical antibacterial
                            fungal external otitis-    medication; Burow’s
                            often spores visible       solution or water-
                                                       soluble antibiotic drops
                                                       3) If fungal external
                                                       otitis, through cleaning
                                                       of canal is required, plus
                                                       topical anti-fungal
                                                       therapy




HPN SN 2008 Section 11 Referral Guidelines
                      2008 HPN Southern Nevada Provider Summary Guide


     DIAGNOSIS                   EVALUATION                MANAGEMENT                       REFERRAL
                                                             OPTIONS                       GUIDELINES
HEARING LOSS


BILATERAL,                  Symptoms: diminished        1) Cerumen-dissolving         1) Cerumen, or hearing
SYMMETRICAL, ADULTS         hearing                     drops possible gentle         loss persists
(FOR CHILDREN, SEE                                      irrigation
                            1) Cerumen blockage                                       2) Effusion persists
ABOVE)
                                                        2) Oral decongestant          more than 8 weeks
                            2) Middle ear effusion
                                                        and re-evaluate in 3
                                                                                      3) Referral for OTO-
                            3) Normal findings          weeks
                                                                                      HNS
                                                        3) No treatment; referral
                                                        hearing evaluation
UNILATERAL                  1) Symptoms: difficulty     When cerumen is               Referral for OTO-HNS
HEARING LOSS                hearing, or difficulty      present, treat with drops     evaluation is indicated
                            localizing sound, or        and possible irrigation.      in all cases of unilateral
                            problems hearing only                                     hearing loss, after
                                                        If cerumen is not
                            in a crowded                                              vascular etiology ruled
                                                        present, referral is
                            environment                                               out, unless the problem
                                                        indicated
                                                                                      resolves with
                            2) Physical
                                                                                      elimination of cerumen
                            Examination: may be
                            normal or may have
                            cerumen or tympanic
                            membrane abnormality
 Sudden Hearing Loss         Loss of hearing with or    Sudden loss? Consider         Urgent referral to ENT
                                 without vertigo            Abx+steroids if            if not resolved with
                                                        vascular etiology ruled         cerumen removal
                                                                 out.
TINNITUS
1)Chronic bilateral         1) Normal tympanic          1) Clean cerumen: no          1) No referral indicated
                            membranes or cerumen        treatment                     unless associated
2)Unilateral or recent
                                                                                      hearing loss or dizzy
onset                       2) Normal tympanic          2) Clean cerumen; if
                            membranes or cerumen        symptoms persist,             2) If persists more than
3)Pulsatile
                                                        referral indicated            8 weeks, Oto-HNS
                            3) Mass behind
                                                                                      referral and hearing
                            tympanic membrane?          3) Referral is indicated
                                                                                      evaluation indicated
                                                        for mass or if vascular
                                                        study normal and no
                                                        mass
DIZZINESS
1)Orthostatic               1) Symptoms mild brief,     1) Evaluate cardiovascular    1) If symptoms become
                            only standing up (usually   system, reassurance           severe
2)Vestibular neuronitis     A.M.)
                                                        2) Self-limited over 3-6      2) Associated hearing
3)Chronic or episode        2) Associated with URI;     weeks; may use systematic
                            may be positional or
                                                                                      loss, increased severity,
                                                        medication and/or steroid
                            persisting                                                persistence > 6 weeks
                                                        3) Referral is indicated if
                            3) Significant imbalance    CNS process (CVA) ruled
                            and/or vertigo; may have    out (neurology FIRST if no
                            associated hearing loss,    other otologic symptoms
                            tinnitus, ear pressure,
                            nausea




HPN SN 2008 Section 11 Referral Guidelines

				
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Description: Ear Nose and Throat Referral Guidelines tinnitus