Draft ENT Referral Guidance – NHS Hounslow v5 7/12/09
Version No. Approved by Approval date
ENT Referral guidance for Primary Care clinicians This is intended to be a guide only. It is not exhaustive and appropriate clinical judgement should be used for individual cases.
Review date
When referring to ENT, please provide information in accordance with the core required information fields of the referral letter [LINK TBC] with particular attention to the following sections:
• Past history: relevant family history, relevant symptoms, significant co-morbidity.
• Investigations: state whether the patient has had any relevant investigations (and attach results if available), some of which may be available at Heart of Hounslow
(Please see relevant sections in the guidelines for further details)
Please note, if you are concerned about your patient's condition and require urgent assessment it is not necessary to undertake routine tests unless this will significantly alter your referral decision.
All new referrals for the attention of a ENT surgeons, should be sent via the Referral Facilitation Service (except where investigations are indicated to facilitate a diagnosis and is available without an OP appointment)[NAME TBC] (except for 999 Emergency admissions) or unless patient is under active or recent (<=12 months) management by a specialist ENT surgeon.
Suggested Referral
Emergency admission likely to be appropriate
Suggested referral to Secondary Care
Continue to manage in Primary Care if appropriate
Note: All follow up appointments following inpatient stays in hospitals, for the same condition, should be arranged via secondary care and NOT booked by GPs
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Nasal Bleeding (Epistaxis)
Review date
External resources • Bertrand B, Eloy P, Rombaux P et al. Guidelines to the management of
epistaxis. B-ENT 2005; Suppl 1: 27-41. • The Royal Children Hospital, Melbourne LINK
What to consider in Primary Care before referring:
Risk factors:
• there is bimodal incidence distribution with age, with peaks at age 2-10 years and 50-80 years: • children commonly present with anterior bleeding that is usually successfully managed with first-
line treatment or cauterisation • the elderly are more likely to suffer from complications and to have poorer outcomes - posterior
bleeds are common and hence the elderly should be managed more aggressively than other patients and followed up closely
• a neoplastic process should be excluded in the elderly, which requires endoscopic assessment when the primary event has been controlled
• a number of local and systemic pathologies and injuries may lead to epistaxis, but the majority of cases are idiopathic
Local causes that may give rise to epistaxis include:
• trauma, including: nose picking, foreign bodies • chemicals, including: cocaine, steroids, decongestants, ammonia • inflammatory reactions associated with: infection, rhinitis, sinusitis • benign or malignant tumours • nasal septal perforations • systemic pathologies that may give rise to epistaxis include: coagulopathy, due to oral
anticoagulants (e.g. warfarin), non-steroidal anti-inflammatory drug (NSAID) or aspirin use • thrombocytopenia and platelet disorders • bleeding disorders e.g. haemophilia, Von Willebrand disease • scurvy • hepatic insufficiency and alcohol
• granulomatous disorders, including: sarcoidosis, systemic lupus erythematosus • iatrogenic causes such as nasogastric and nasotracheal intubation • intoxication by: cobalt, lead, arsenic, phosphorous, vascular disease, including Osler-Weber-
Rendu disease, atherosclerosis, hypertension • in children recurrent epistaxis is often related to allergic rhinitis
• History: o Duration, nature, any predisposing factors, H/O injury o Determine whether bleeding is unilateral or bilateral o Determine whether bleeding is anterior or posterior o Medications – NSAIDS, aspirin, Warfarin? o Determine past or known medical history like coagulopathy, platelet disorder or hypertension
is present o If suspecting blood dyscrasia
Thorough history (i.e. bruising, bleeding). Family history.
• Clinical Examination:
o Check BP, Pulse o Most nose bleeds can be visualised in the anterior section of the nasal cavity
o perform a methodical examination of the nasal cavity o Consider blowing the nose removes clots and hence allows a better examination o Consider application of a vasoconstrictor (e.g. xylometazoline or oxymetazoline), if
possible, may reduce haemorrhage and help to pinpoint the precise bleeding site o A posterior bleed is indicated by failure to visualise an anterior source and suggested by
haemorrhage from both nares or oro-pharyngeal blood o Investigations
o If significant blood loss, leukemia, or malignancy is suspected or if recurrent bleeding occurs, perform a FBC count with differential
o If a coagulopathy is suspected, perform FBC count and obtain prothrombin time (PT)/activated partial thromboplastin time (aPTT) and bleeding time.
• Primary Care Management o Immediate control may occur with:
o encourage the patient to sit forward to reduce swallowing blood and to pinch the anterior nose tightly whilst breathing through the mouth for 10-20 minutes - this simple intervention is often sufficient to stop bleeding
o if not already performed for the purposes of examination, consider applying a vasoconstrictor (e.g. xylometazoline or oxymetazoline) if available; an absorbent pad (e.g.
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cotton wool) soaked with these reagents can be inserted into the nostrils to anaesthetise and shrink nasal mucosa, and provide a short-term solution
Paediatric cases: o Reassurance and information to parents in paediatric cases(LINK) o Trial of steroid ointment to anterior septum 2x a day for 2 weeks o Observation of side o Acute bleeding usually settles with local pressure to the lower nasal septum
If bleeding continues for more than 20 minutes, consider A&E referral (but only if inadequate response to compression
Follow up: o advise all patients to avoid strenuous activities for 7-10 days o provide education for the prevention of future epistaxis, including:
o the avoidance of trauma, such as nose picking o the use of humidifiers in dry environments o the use of nasal saline spray
o instruct patients to firmly pinch their nose for 20 minutes, possibly with the use of an ice-pack over the nasal bridge, in the event of re-bleeding or future nose bleeds
o trial of steroid ointment to anterior septum 2x a day for 2 weeks o Chronic epistaxis resulting from a dry nasal mucosa can be treated by spraying saline in the nose
three times per day, lubricating the nose with ointments or creams, such as vasoline, and installing a humidifier in the bedroom
Referral Threshold
• Patients with recurrent epistaxis, especially if episodes are severe and/or cause significant interference of daily life, or if associated symptoms raise the possibility of neoplasia, eg. unilateral nasal obstruction.
• Patients treated for epistaxis caused by suspected underlying disease, intoxication or medication should be referred as appropriate for investigation and management
o In children, o Recurrent idiopathic epistaxis (2/3 episodes within one month) with no obvious anterior
cause or unresponsive to treatment o Suspected underlying conditions like bleeding disorders, chronic disorders like leukaemia,
• Bleeding is persistent (over 20 minutes) and not responding to conservative treatment
• Severe nosebleed in children than needs volume replacement
• 999 for emergency admission
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Otitis Externa
Review date
External resources • Otitis Externa, GP Notebook, LINK • Otitis Externs, CKS.NHS, LINK (patient information leaflet)
What to consider in Primary Care before referring:
• Otitis Externa: inflammation of external ear canal, due to: o infection (usually bacteria, e.g. Pseudomonas aeruginosa or Staphylococcus aureus or, rarely,
fungi or yeasts, especially after antibacterial therapy) o allergies o irritants o can occur as a complication of eczema, psoriasis or other skin conditions
• Classification: types are classified - in terms of chronicity (acute, chronic, recurrent) or in terms of location (localised (restricted to a well demarcated area of the external canal) diffuse (throughout the ear canal))
• Epidemiology: life-time prevalence 10%, typically affects females age 45-54 years and males age 65-74 years
Clinical presentation: • pain, fullness or pressure in ear • decreased hearing – which is usually mild • itching in external ear canal • tenderness in ear canal • scanty discharge - there are no mucous secreting glands in the external ear; profuse discharge
suggests middle ear disease • pain and purulent discharge- only if secondary bacterial infection occurs
The condition may be generalised (diffuse) throughout ear canal (may be acute, acute-recurrent or chronic); or localised inflammation (furuncle) within ear canal.
History: • nature and duration of symptoms; pain may not be prominent with chronic OE, which rather may
be associated with itch and discomfort, whether recurrent, whether unilateral or bilateral • nature of any discharge • whether there is bleeding • presence of risk factors for OE: water exposure, e.g. swimmers, divers, humid environments • over-use of cotton buds • history of eczema or psoriasis • possible contact dermatitis, e.g. from shampoo or soap, earrings, hair dye, hearing aid • diabetes mellitus • Immuno-compromised, e.g. steroids, HIV • systemic symptoms suggestive of sepsis • malignant otitis externa is more common in the elderly diabetic
On examination: • pain on gentle pulling on external ear, narrowed, oedematous meatus • meatal debris • tenderness on moving jaw • +/- tender regional lymph nodes • assess for facial nerve palsy (may complicate severe OE such as necrotising OE or herpetic OE) • temperature • signs of dermatitis around the pinna • on otoscopy:
o erythema, oedema and debris in ear canal o scanty white discharge o eardrum inflamed but intact
• if chronic, the following features may be present: o thickened abnormal skin in ear canal o reduced production of ear wax o bloody or muco-purulent discharge o narrowing of the ear canal
Investigations: • screen for Diabetes Mellitus (important predisposing factor for OE in adults) in recurrent or chronic
OE or in suspected malignant OE • ear swab for Gram stain and culture of ear canal discharge is not routinely required unless there
is evident discharge and/or condition is chronic or previous treatment has failed
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(Tuning fork tests may demonstrate mild conductive deafness)
Management
• prescribe suitable eardrops containing antibiotic and anti-inflammatory: Gentisone-HC contains gentamicin and hydrocortisone appropriate for most bacteria including anaerobes such as pseudomonas
• note that review of the evidence suggests no clinical benefit with the use of oral antibiotics plus topical anti-infective agents compared with topical anti-infective agents alone
• Educate the patient re general principles of prevention:
o not to poke the ear at all o to use olive oil for wax removal and minor irritation o not to rub ears when drying after washing/swimming
after bathing or swimming, all water in the ear canals should be drained out by tilting the head to the sides
the external ear canal should be then dried using a hair dryer on the lowest heat setting. acidifying drops (vinegar) with alcohol drops can be used as prophylactic after each swim
(2) o can be prevented by maintaining a dry ear and avoiding the many above mentioned
precipitants o insertion of cotton swabs into the ear canal and any manipulation of the canal should be
avoided
• If no response in one week then consider an alternative eardrop (if swab taken on initial visit then prescribe based on result)
• fungal infection o if persistent otitis externa then consider the possibility of a fungal infection and treat with
topical preparation containing an antifungal, such as clotrimazole 1% ear drops (Canesten®), or flumetasone pivalate 0.02%, clioquinol 1% ear drops (Locorten-Vioform®)
• Refer for aural toilet if there is no response
Referral Threshold
• Refer otitis externa to hospital if: o Aural toilet is required o Previous history of complex ear problems o Erysipelas (Erysipelas is a rapidly spreading Streptococcal infection of the skin and
Secondary care resource • Consider referral to an ENT specialist
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subcutaneous tissue characterized by cellulitis and lymphangitis) o Malignant otitis externa (Malignant otitis externa is otitis externa which has spread to cause
osteomyelitis of the skull base. It is due to Pseudomonas aeruginosa and anaerobes causing a mound of tissue in the external canal. A facial nerve palsy occurs in 50% of patients with this condition, and nerves IX to XII may also be involved. It affects immunocompromised patients, especially elderly diabetics)
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Otitis Media
Review date
External resources • Otitis Media, GP notebook, LINK • Surgical management of otitis media with effusion in children, NICE (February
2008) LINK • Diagnosis and management of childhood Otitis Media in Primary Care, SIGN LINK • Otitis Media, CKS.NHS, LINK
What to consider in Primary Care before referring:
• Otitis Media is an inflammation of the middle ear, sometimes associated with upper respiratory tract infection. It can be classified as follows: o acute suppurative :
o may be caused by viral or bacterial infections, or bacterial infection complicating a viral illness,
o it causes ear pain and tenderness o chronic suppurative
o manifests as persistent drainage from the ear associated with tympanic membrane perforation and some degree of conductive hearing loss. (Chronic ear)
o conditions are not usually painful. o serous / secretory
o refers to non-suppurative fluid accumulation in the middle ear o this condition is frequently associated with dysfunction or obstruction of the eustachian
tube, such as may result from tonsillar hyperplasia or recurrent infection o this condition is an important cause of hearing problems in children. o in adults, a unilateral serous effusion may be due to a nasopharyngeal tumour which
should be excluded.
Acute Otitis Media: It is a common condition, occurring most frequently in children, and is often bilateral. Acute otitis media has a peak incidence of between 3 years and six years. • common causes are upper respiratory tract infections which may be viral or bacterial • clinical features associated with recent, abrupt, onset of signs and symptoms of middle-ear
inflammation and middle-ear effusion increase in the likelihood of acute otitis media o ear pain o ear rubbing o cloudy eardrum o bulging eardrum o distinctly immobile eardrum
o distinct erythema of the tympanic membrane o distinct otalgia (discomfort clearly referable to the ear[s] that interferes with normal activity or
sleep) • 80% recover in around three days without antibiotics • complications are rare
Management:
A review concluded that antibiotics should not be prescribed routinely for acute otitis media in children ( MeReC Bulletin 2006;17(3):9-11) • there may be benefit for antibiotic treatment in specific sub-groups of patients. For example,
children: o under two years with bilateral infection or o with discharge from the ear or o who are systemically unwell (e.g. fever or vomiting) or o with recurrent infections
• a strategy of watchful waiting and use of delayed prescriptions may be appropriate for many
• Paracetamol and ibuprofen have been shown to reduce earache • insufficient evidence to support the use of decongestants or antihistamines.
Chronic suppurative otitis media: The factors which predispose to a chronic suppurative otitis media include: • an otitis media that was not promptly treated • inappropriate or inadequate antibiotic therapy • sepsis in the upper airway • lowered resistance to infection, e.g. immunodeficiency, malnutrition, anaemia • infection with a particularly virulent virus, e.g. measles
Two types of chronic suppurative otitis media are recognised: • safe, tubotympanic or mucosal disease:
o there is a perforation of the pars tensa, and local destruction doesn't occur • unsafe, attic-oantral or bony disease:
o there may be a cholesteatoma developing in the pars flaccida and postero-superior portion of the pars tensa. This may lead to local destruction of bone
If earache or headache is present, this suggests the possibility of an intracranial complication Painful chronic ear disease suggests complications such as: acute mastoiditis • meningitis • extra-dural abscess • brain abscess - especially temporal lobe or cerebellum
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• sub-dural abscess • labyrinthitis • lateral sinus thrombosis • facial nerve paralysis • petrositis (Infection/osteomyelitis of petrous temporal bone) Management: refer to secondary care for diagnosis and treatment
Secretory otitis media (Otitis media with effusion)
Adults: A unilateral serous effusion in an adult is due to nasopharyngeal tumour until proven otherwise.
Secretory otitis media, or `glue ear', is the most frequent cause of hearing problems in children. The accumulation of serous or viscous fluid within the middle ear may produce pain or a conductive hearing loss, or may remain symptomless.
Over 50% of effusions resolve spontaneously within 8 weeks, but bilateral hearing loss, persisting 12 months, occurs in 5% of cases.
NICE suggest that with respect to children: • concerns from parents/carers or from professionals about features suggestive of otitis media with
effusion (OME) should lead to initial assessment and referral for formal assessment if considered necessary. These features include: o hearing difficulty (for example, mishearing when not looking at you, difficulty in a group, asking
for things to be repeated) o indistinct speech or delayed language development o repeated ear infections or earache o history of recurrent upper respiratory tract infections or frequent nasal obstruction o behavioural problems, particularly lack of concentration or attention, or being withdrawn; poor
educational progress o less frequently, balance difficulties (for example, clumsiness), tinnitus and intolerance of loud
sounds All children with Down's syndrome and all children with cleft palate should be assessed regularly for OME because of the increased incidence of OME associated with these conditions
Management:
In children, 50% of cases will resolve spontaneously within 6 weeks. Medical treatments used for this condition include decongestants and antibiotics. NICE however suggest that: • Following treatments are not recommended for the management of otitis media with
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effusion : o antibiotics o topical or systemic antihistamines o topical or systemic decongestants o topical or systemic steroids - homeopathy o cranial osteopathy o acupuncture o dietary modification, including probiotics o immunostimulants o massage
• Hearing aids should be offered to children with persistent bilateral OME and hearing loss as an alternative to surgical intervention where surgery is contraindicated or not acceptable
• NICE suggest that the persistence of bilateral otitis media with effusion and hearing loss in a child should be confirmed over a period of 3 months before intervention is considered. The child's hearing should be re-tested at the end of this time.
Referral Threshold
• Recurrent acute otitis media (either three or more acute infections of the middle ear cleft in a six-month period, or at least four episodes in a year)
• Unresponsive acute otitis media
• Suspected chronic suppurative otitis media
• Adult unilateral suspected secretory otitis media (for exclusion diagnosis of nasopharyngeal tumour)
• With persistent effusion should, be referred if:
o features are atypical and accompanied by a persistent foul-smelling discharge suggestive of cholesteatoma (they are a greasy-looking mass or accumulation of debris that is seen in a retraction pocket or perforation in middle ear)
o they have excessive hearing loss suggestive of additional sensori-neural deafness (refer after audiology report)
o Children with proven persistent hearing loss detected on two occasions separated by 3 months or more (results of formal testing should be included in the referral letter)
o Children with hearing problems plus difficulties with speech, language, cognition or behaviour
o Children with hearing problems plus a second disability, such as Downs syndrome
Secondary care resource • Consider referral to an ENT specialist
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Tinnitus
Review date
External resources • Tinnitus, GP note book LINK • Tinnitus, CKS.NHS, LINK [patient information leaflet] •
What to consider in Primary Care before referring:
Tinnitus is an unwanted auditory perception of internal origin, which is usually localized, and may rarely be heard by others. It may range from ringing, hissing, buzzing, and roaring, to clicking, or rough sounds; some patients experience infrequent, soft sounds while for others it may be unbearable. • may be unilateral or bilateral
o unilateral tinitus with or without association with unilateral otologic features is more serious • it is caused by incorrect processing of auditory stimuli due to:
o structural disease of the auditory apparatus o perceptual abnormalities o psychological disease
• several classifications have been put forward o subjective tinnitus and objective tinnitus
subjective tinnitus o more common o heard only by the individual
objective tinnitus o can be auscultated over the head and neck (near the ear)
vibratory tinnitus and non-vibratory tinnitus • most cases are benign, but since there are serious and treatable causes, it should always be
assessed thoroughly • a diagnostic approach to identify an underlying aetiology of tinnitus should include:
o a detailed history onset
• in old age progressive hearing loss with tinnitus is associated with presbycusis (is the loss of hearing that gradually occurs in most individuals as they grow older.)
• precipitous onset may suggest loud noise exposure or head injury character of sound
• a low-pitched rumbling sound suggests Meniere's disease
• a high-pitched sound may indicate sensorineural hearing loss • if the tinnitus is made up of "voices" then this warrants psychiatric advice/assessment
pattern • pulsatile tinnitus
o may indicate anxiety or acute inflammatory ear conditions o vascular aetiologies may cause pulsatile tinnitus
including tumours (glomus, carotid body), carotid stenosis, arteriovenous malformations, intracranial aneurysms, high cardiac output states
• continuous tinnitus is associated with hearing loss • episodic tinnitus is associated with Meniere's disease (is a disorder of the inner ear
that can affect hearing and balance. It is characterized by episodes of dizziness and tinnitus and progressive hearing loss, usually in one ear. It is caused by lymphatic channel dilation)
localisation • bilateral tinnitus is usually benign • causes of unilateral tinnitus include
o cerumen (ear wax) impaction o otitis externa o otitis media
• when tinitus is associated with unilateral sensorineural hearing loss acoustic neuroma should be suspected
intrusion • not all patients suffer intrusion from their tinnitus • if the tinnitus is intrusive then this raises patients' concern about serious
intracranial disease, reinforcing tinnitus. There may be deterioration in sleep, mood, and concentration. Intrusion dictates whether and how much treatment is needed
o otological history tinnitus may result from almost any ear problem
• particularly causes of deafness, such as audiovestibular symptoms, exposure to noise, head injury, and ear surgery
when aural fullness, hearing loss and vertigo are associated, Meniere's disease should be suspected
o other causes to consider: tinnitus may be associated with:
• fever • cardiovascular disease e.g. hypertension, cardiac failure
o also tinnitus may be associated with high cardiac output states (anaemia, thyrotoxicosis, pregnancy)
• neurological disease e.g. multiple sclerosis, neuropathy, alcoholism • physical immobility • tinnitus may be associated with mental stress and depression (therefore it is
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important to obtain a psychosocial history) • drugs may rarely cause or exacerbate tinnitus e.g. salicylates, aminoglycosides,
• Rinne's test and Weber's test differentiate conductive and sensorineural losses note that audiometry is better for defining and documenting deafness
o examine cranial nerves: particularly trigeminal and facial. Points from the history will indicate the need for further
neurological or general examinations o auscultate over the neck, periauricular area, mastoid, orbits o when tinnitus is of venous origin, it can be suppressed by pressing on the ipsilateral jugular
vein • audiometric tests
o an audiometric assessment should be done on all patients with tinnitus o diagnostic testing should include the following
audiography tests for speech discrimination tympanometry
• Further investigations o if the patient has an abnormal medical history the following tests should be obtained
thyroid function tests, hematocrit, complete blood chemistry, lipid profile • Tinnitus may present with the patient reporting perception of noises as varied as pure tones,
music, speech or random white noise. The site of perception is ascribable to the head generally, or occasionally one ear. The association with intermittent bouts of vertigo and hearing loss direct one to a diagnosis of Meniere's disease.
• Otoscopy may disclose impacted wax, a tympanic membrane perforation or middle ear disease.
Management: • history and examination • audiogram • explanation – patient information LINK • If the history and examination do not reveal a condition which should be referred, and the
audiogram is normal, then the condition should be managed in general practice. • several treatments are available to help people cope with tinnitus; these include:
o medical management sedatives or antidepressants help secondary agitation or depression but do not eliminate
tinnitus. Referral Threshold • Patients with unilateral tinnitus should be referred to an ENT specialist
o to exclude an acoustic neuroma and also if associated with deafness (must exclude cerebellar pontine angle pathology and glomus tumour)
o If its pulsatile and o persistent
• If tinnitus is associated with severe anxiety - this requires urgent assessment
Secondary care resource: • Urgent referral to ENT specialist
Referral Threshold
• Tinnitus is severe enough to interfere with daily activities • Tinnitus with membrane abnormalities with diagnostic uncertainty • Objective tinnitus - this defines a tinnitus-like noise that can be heard by the examiner or anyone
who cares to listen - this is very rare but may be caused by vascular tumours or neuromuscular disorders such as stapedius myoclonus
Secondary care resource: • Consider referral to ENT specialist
tract infections in adults and children in primary care NICE (June 2008), LINK • BMJ 1997; 9: 315(7104):350-2
What to consider in Primary Care before referring:
History: • symptom duration • absence or presence of trismus • symptoms of systemic upset e.g. fever, malaise • symptoms of dysphagia? • rash? • history of previous episodes?
Note: • If there is stridor then this is an ominous sign. • A child may complain of abdominal pain. • A cough indicates a lower likelihood of streptococcal infection
General examination • Assessment of how ill patient is e.g. pulse, temperature. • Examine trunk for rash - scarlet fever rash generally starts on the chest and spreads to involve the
neck and face; there may be sparing of the circumoral area. The rash associated with infectious mononucleosis tends to be generalized.
• Examine the neck for cervical lymphadenopathy. • Note any trismus or dribbling. • Inspect the tongue and throat. In streptococcal disease there may be a 'strawberry tongue'. In
cases of infectious mononucleosis there may be petichiae on the palate. • Examine the tonsils. There may be hallitosis. If there is stridor then do not examine the throat
because acute airways obstruction from epiglottitis may be provoked
Investigations: • Throat swabs - in general, throat swabs are of little value in the management of sore throat as up
to 20% of patients carry strep. pyogenes as a commensal; there are no criteria for distinguishing between carriage and infection
• Full blood count and monospot may be helpful if glandular fever or blood dyscrasia is suspected
(Establish the reason for the consultation as most patients with a sore throat do not see a doctor - the sore throat may be 'the last straw ')
Management principles: • establish the duration of the illness - infections usually resolve within five – ten days • consider aetiology of sore throat - most frequently look for features suggesting: • an infective cause or other risk factors • an indication for antibiotics (see Centor criteria below) Management: Reviews (MeReC Bulletin 2006;17(3):12-14) have concluded that antibiotics are unnecessary for most patients with sore throat as it is a self-limiting condition, which resolves by one week in 85% of people, whether it is due to streptococcal infection or not. The Centor criteria may be useful to predict patients (both adults and children) who are at higher risk of Group A beta-haemolytic streptococcus (GABHS) and complications, who may benefit from antibiotics • tonsillar exudate • tender anterior cervical lymph nodes • absence of cough • history of fever • presence of three or four of these clinical signs suggests that the chance of the patient having
GABHS is between 40% and 60%, so the patient may benefit from antibiotic treatment • absence of three or four of the signs suggests that there is an 80% chance that the patient doesn't
have the infection, and antibiotics are unlikely to be necessary • In patients with tonsillitis who are unwell, and have three out of four of these criteria, the risk of
quinsy is 1:60 compared with 1:400 in those who are not unwell. • If antibiotics are clinically indicated, phenoxymethylpenicillin is an appropriate first choice (adult
dose: 500mg two to four times a day for 10 days) (see end of Section for guidance) • Offer advice and reassurance, and recommend analgesics (Paracetamol is the drug of choice;
NSAIDs are not routinely recommended)for symptom relief in all patients
Paediatric patients: Most children with recurrent sore throat (five or more episodes of sore throat per year with symptoms for at least a year –SIGN) can be managed in primary care. NICE has given guidance concerning referral if recurrent episodes of acute sore throat in children aged up to 15 years.
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Referral Threshold
Paediatric group • the swelling is interfering with swallowing, causing dehydration and marked systemic upset • suspicion of a serious underlying disorder such as leukaemia
Other Groups: • abscess • suspected oropharyngeal tumour
Secondary care resource • Consider urgent referral to paediatrician/ ENT specialist.
Referral Threshold
Paediatric group • H/O sleep apnoea, daytime somnolence or failure to thrive • H/O 5 or more episodes of acute sore throat in the preceding 12 months documented by the parent
or doctor, and which have been severe enough to disrupt the child’s normal behaviour or day-to-day activity
• Associated with guttate psoriasis (a type of psoriasis that looks like small, salmon-pink drops on the skin) which is exacerbated by recurrent tonsillitis
Other groups
• recurrent tonsillitis • blood dyscrasias (diseases of the blood forming organs) associated with recurrent infections
Secondary care resource: • Consider referral to specialist
Referral Threshold
Paediatrics group • Children presenting with Stridor • suspected of having a quinsy (peri tonsillar abscess) • the swelling is causing acute upper airways obstruction
NICE GUIDANCE on ANTIBIOTIC PRESCRIPTION FOR COMMON ENT CONDITIONS:
A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions:
• acute otitis media • acute sore throat/acute pharyngitis/acute tonsillitis • common cold • acute rhinosinusitis • acute cough/acute bronchitis
Depending on clinical assessment of severity, patients in the following subgroups can also be considered for an immediate antibiotic prescribing strategy (in addition to a no antibiotic or a delayed antibiotic prescribing strategy):
• bilateral acute otitis media in children younger than 2 years • acute otitis media in children with otorrhoea • acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria are present
For all antibiotic prescribing strategies, patients should be given:
• advice about the usual natural history of the illness, including the average total length of the illness (before and after seeing the doctor): o acute otitis media: four days o acute sore throat/acute pharyngitis/acute tonsillitis: one week o common cold: one and a half weeks o acute rhinosinusitis: two and a half weeks o acute cough/acute bronchitis: three weeks
• When the no antibiotic prescribing strategy is adopted, patients should be offered: o reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example,
diarrhoea, vomiting and rash o a clinical review if the condition worsens or becomes prolonged
• When the delayed antibiotic prescribing strategy is adopted, patients should be offered: o reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example,
diarrhoea, vomiting and rash o advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if a significant worsening of
symptoms occurs o advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription. A delayed prescription with instructions can either
be given to the patient or left at an agreed location to be collected at a later date
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Hoarseness (dysphonia)
Review date
External resources
• Clinical practice guideline: Hoarseness (Dysphonia), Otolaryngology–Head and Neck Surgery (2009) 141, S1-S31 LINK
• Hoarseness, patient.co.uk, LINK • Evaluating Hoarseness, American Academy of Family Physician, LINK
What to consider in Primary Care before referring:
The voice quality that may be described as hoarseness and their differential diagnosis are as follows: • breathy
Targeted History: • In the absence of an upper respiratory tract infection, any patient with hoarseness persisting for
more than four weeks requires evaluation. • In most cases, hoarseness is a relatively benign symptom of voice overuse or the result of
laryngitis. • Hoarseness that persists for more than four weeks requires an urgent referral to an ENT
department. In any patient with chronic hoarseness(>4 weeks) and a history of tobacco use, head and neck cancer is the first diagnosis to consider, as hoarseness is often the only presenting symptom
• Duration, nature of hoarseness • associated symptoms such as pain, dysphagia, cough or shortness of breath; symptoms of
gastroesophageal reflux, such as an acid taste in the mouth in the morning; • associated sinonasal diseases (allergic rhinitis or chronic sinusitis) and use of medications that dry
the upper airway mucosa. • Tobacco and alcohol use must be determined, as these products are irritating to the oral and
laryngeal mucosa, and use of either is a risk factor for head and neck cancer. • H/O other irritant exposure, particularly in the workplace, should be obtained. • An essential part of a thorough history is elucidating the patient's voice use pattern. This process
includes an evaluation of the patient's "vocal personality type" (amount and style of voice use), recent voice use (such as screaming at a baseball game) and vocal environment (where the patient uses his or her voice--such as talking while wearing ear-muffs on an assembly line).
• H/O hearing loss in the patient or in a family member may be a contributing factor in voice abuse. • Occupational history (anyone, from teachers to professional singers, whose occupation or
livelihood depends on the normal use of the voice). • Previous surgery on the head and neck or other surgery requiring intubation. • Associated symptoms like anxiety • H/O chronic conditions: Stroke, Diabetes, Parkinson’s disease, Diseases from the Parkinson’s
Medication History • Hypertension (because of certain medications used for this condition) • Schizophrenia (because of anti-psychotics used for mental health problems) • Osteoporosis (because of certain medications used for this condition) • Asthma, chronic obstructive pulmonary disease (because of use of inhaled steroids) Medications that may cause hoarseness: (a) Coumadin, thrombolytics, phosphodiesterase-5 inhibitors, Biphosphonates (Chemical laryngitis)
Primary care management: • Anti-reflux medicines should not be prescribed for hoarseness unless there are (a) signs or
symptoms of gastro-oesophageal reflex disease (GORD), such as heartburn or regurgitation, or (b) signs of inflammation of the larynx seen during laryngoscopy.
• Advice vocal hygiene (staying well-hydrated, avoiding irritants (especially tobacco smoke), voice training, and amplification during heavy voice use).
Note: Hoarseness may be a feature of laryngeal obstruction - so can be a warning of impending airway obstruction (This may occur in Infections: acute epiglottitis, diphtheria, croup, laryngeal abscess, Inflammation/oedema: airway burns, anaphylaxis, angio-oedema, physical trauma, vocal cord immobility: laryngeal nerve palsy (depending on position of the cords) or cricoarytenoid joint disease2 Possible signs of laryngeal obstruction are: Dyspnoea, stridor, wheeze, exertional dyspnoea, anxiety or signs of hypoxia Dysphagia or drooling, Facial or oral oedema
Management for laryngeal obstruction: Do not examine the throat or attempt distressing procedures; allow patient to find the most comfortable position. Refer for emergency admission Referral Threshold
• Refer > 4 weeks for diagnosis Secondary care resource: • Refer to specialist Please state all relevant symptoms and signs particularly, occupation, smoking history, alcohol consumption, weight loss, lump in the neck (if any), duration of hoarseness, dysphagia
Referral Threshold
• Suspected laryngeal obstruction 999 for emergency admission
What to consider in Primary Care before referring:
• due to infection or inflammation (usually painful) (This is commonly seen when lymph nodes swell up at the angle of jaw, in children with tonsillitis)
• benign swellings as seen in sebaceous cysts and other cysts of the neck. • growths can form in the parotid and thyroid glands. These can be benign or malignant. • Cancers that begin in the head or neck usually spread to lymph nodes in the neck before they
spread elsewhere. For this reason, a lump in the neck that lasts more than one month, needs to be seen by a head & neck surgeon. But a lump (or lumps) in the neck can be the first sign of cancer of the mouth, throat, voice box (larynx), thyroid gland, or of certain lymphomas or blood cancers. Such lumps are generally painless and continue to enlarge steadily.
• Congenital mass (brachial cysts, thyroglossal cysts etc.)
History and Clinical Examination: • Duration, nature (painful/painless), progress/growth in size? • Any exacerbation or relieving factors • Associated features like (Earache, hoarseness, difficulty swallowing, painful swallowing, weakness
of surrounding muscles, generalised loss of weight) • H/O cough, fever, sore throat • Risk factors include smoking and alcohol. • Social History (H/O exposure to various irritants like asbestos, nickel, wood dust), family history of
goitre or thyroid cancer, exposure to Tuberculosis • Examine cervical and other lymph nodes • Location of the mass (midline, anterior triangle or posterior triangle) is suggestive of pathology
(Ref end of section) • Examination should include the mass itself, the rest of the neck, the skin of the head and neck and
the ENT system (ears, oral cavity, nasal cavity, nasopharynx, oropharynx, hypopharynx and the larynx). In cases where pathology is suspected in an area that is difficult to examine without specialised equipment, for example the nasopharynx, hypopharynx and larynx, patients should be referred to an ENT specialist
• The size, consistency, tenderness and mobility of the mass provide diagnostic clues. Acute
inflammatory masses tend to be soft, tender and mobile. Chronic inflammatory masses are often non-tender and rubbery and either mobile or matted. Congenital masses are usually soft, mobile and non-tender unless infected. Vascular masses may be pulsatile or have a bruit. Malignant masses may be hard, nontender and fixed.
Investigations: • Ultra sound scan (for clinically suspected thyroid) • Blood Tests: This includes a full blood count, Glandular fever tests, Thyroid function tests, and if
indicated Toxoplasmosis, and HIV serology • Chest X-ray
Management • Inflammatory:
o many inflammatory lymph nodes resolve with no treatment, although close observation is required.
o A single course of a broadspectrum antibiotic and reassessment in 1 - 2 weeks is a reasonable treatment choice when the symptoms and signs are suggestive of any inflammatory process (short duration, fever, pain, erythema), or a history of recent infection
o If suggestive of Infectious mononucleosis or Tuberculosis, consider referral to relevant specialist for diagnosis and treatment
• Non inflammatory: o any mass persistent beyond 4 - 6 weeks requires further investigations
• Congenital: usually solitary and require referral • Thyroid: features suspicious of malignancy are solitary nodules increasing in size, patient with
history of neck irradiation or family history of thyroid cancer, patient >65 years of age, unexplained voice change associated with goitre, associated with thyroid lymphadenopathy; these patients should be sent for urgent referral
• All other patients with suspected clinically thyroid neck lump should be referred to specialist and
then followed up in primary care Refer to Guidance on Lymphadenopathy section in Paediatric Referral Guidance Referral Threshold
• Any inflammatory mass persistent beyond 3 weeks with antibiotic treatment
• Lump associated with hoarseness and persisting for>3 weeks ; (w or w/o Chest X-ray being suggestive of UAT malignancy)
• Suspected Infectious mononucleosis or Tuberculosis
Secondary care resource • Consider referral to relevant specialist
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• Congenital
• Persistent neck mass (non inflammatory) beyond 4-6 weeks
• mass is rapidly enlarging with or without inflammation and/or fixed
• mass is in the thyroid gland
• mass is in the parotid gland
Referral Threshold
• Lump associated with features of malignancy (oral mucosa ulcer >3 weeks, oral swelling > 3weeks, red or red & white patches of oral mucosa, dysphagia > 3 weeks, unilateral nasal obstruction with purulent discharge, cranial neuropathies, orbital mass, lympadenopathy (>1 cm) persisting more than 6 weeks, hepatosplenomegaly, features of thyroid malignancy (as above))
Secondary Care Resource:
• Consider urgent referral
(ADVISE 2 WEEK RULE REFERAL WHERE MALIGNANCY SUSPECTED]
Referral Threshold
• Lump presenting with stridor
• 999 for emergency admission
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Neck lumps and anatomical location
Midline lumps
The most common midline lumps are: 1) Thyroglossal cysts are usually found at the level of the hyoid bone or thyroid cartilage. They move upward on swallowing and on protrusion of the tongue. 2) Thyroid lumps are midline swellings but also present as lateral lumps if one lobe of the thyroid is involved. They are more common in adults and in Females. 3) Dermoid cysts are found at or above the level of the hyoid bone although they can be found much lower in the neck as well. They do not move upward on swallowing or protrusion of the tongue. Lateral Neck Lumps in Children The majority of neck lumps in children are reactive lymph nodes secondary to infections in the head and neck. They usually settle between 4 and 6 weeks. Solitary neck masses are usually congenital in origin. The most common one being a branchial cyst. A branchial cyst presents as a lump at the junction of the upper one third and lower two third of the sternocleidomastoid. Cystic hygromas present as congenital swellings as well. Neoplastic lumps in children are usually due to a primary cancer (e.g. sarcoma and lymphoma). Lateral Neck lumps in Adults As in children the majority of neck lumps in adults are inflammatory as well. Almost all of them settle between 4-6 weeks. Metastatic neck nodes may be the first presenting sign of an underlying malignancy. Any persistent lump (> 6 weeks) should be considered malignant until proven otherwise and needs urgent referral for an ENT assessment. Parotid lumps are classically found below and behind the ear lobule. Thyroglossal and branchial cysts although congenital can also be found in adults. Lumps in the anterior triangle: node, thyroid lump, thyroglossal cyst and branchial cyst Lumps in the posterior triangle: node, cystic hygroma and neuroma
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Approval date
Dysphagia
Review date
External resources
• An interdisciplinary approach to the management of dysphagia, 1 September, 2002, Davies, Steve (Link)
What to consider in Primary Care before referring:
Dysphagia is difficulty in swallowing is a symptom that affects 15% of hospital inpatients, older people, people with neurological disease, cancers of the head and neck and people with severe reflux.
History: • Whether associated with pain • Affects swallowing solids, liquids and or saliva production? • Which stage of swallowing is affected - transition of a bolus at the oral, pharyngeal or
oesophageal stage of swallowing
Clinical symptoms and signs: • Oesophageal dysphagia : An oesophageal cause is suggested by:
o poorly localised symptoms o pain on swallowing o pain radiating to upper back
(30% of people with oesophageal causes identify the neck as the site of symptoms) • an oropharyngeal (neuromuscular) cause is suggested by:
o aspiration and choking with swallow o liquids more troublesome than solids o nasal regurgitation
• oropharyngeal dysphagia should always be considered in those with a history of neurological disability
• Psychosomatic associated with acid reflux (lump in throat feeling not affecting solid food or liquid intake) – Globus hystericus
Management: • Patients complaining of feeling of lump in throat but no problems with swallowing liquids or
solids: reassurance and observation. many cases are secondary to acid reflux (Globus hystericus)
• Globus hystericus : o patient reassurance (LINK)
• refer to appropriate service for further investigation and treatment: o Symptoms associated with difficulty in swallowing liquids more than solids; ‘going down the
wrong way’ or coming down nose; +/- associated with neurological signs - neurology o ENT for those with symptoms indicating airway compromise or mechanical obstruction
(solids more than liquids; tend to get stuck) o Refer for suspected oesophageal malignancy
Referral Threshold
• Symptoms associated with difficulty in swallowing liquids more than solids; ‘going down the wrong way’ or coming down nose; +/- associated with neurological signs - neurology
• ENT for those with symptoms indicating airway compromise or mechanical obstruction (solids more than liquids; tend to get stuck)
• Suspected oesophageal malignancy associated with dysphagia
Secondary care resource: • Refer to appropriate specialist clinic (ADVISE 2 WEEK RULE REFERAL WHERE MALIGNANCY SUSPECTED]
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Version No
Approval date
Hearing loss (paediatrics)
Review date
External resources
• Testing and Screening in young children for hearing loss, patient.co.uk, LINK
What to consider in Primary Care before referring:
• Symptoms of hearing loss: o The child may be:
Inattentive, not reacting when called. Talking too loudly, listening to TV at high volume. Mispronouncing words. Unsettled at school. Tired, grumpy or over-active.
• Risk factors for hearing loss in children: there are a number of special reasons why a child's hearing may need to be screened or tested. Common indications for a hearing evaluation include o speech delay, o frequent or recurrent ear infections, o a family history of hearing loss (hearing loss can be inherited), o syndromes known to be associated with hearing loss (for example, Down syndrome, the
Alport syndrome, and Crouzon syndrome), o infectious diseases that cause hearing loss (for example, meningitis, measles, and
cytomegalovirus [CMV] infection), o medical treatments that may have hearing loss as a side effect, including some antibiotics
and some chemotherapy agents, o poor school performance, and o diagnosis of a learning disability or other disorder, such as autism or pervasive
developmental disorder (PDD). o In addition, the circumstances surrounding the pregnancy and birth may be associated with
subsequent hearing loss. If there is a history that includes any of the following, a child should have a hearing assessment. low birth weight (less than 2 pounds) and/or prematurity assisted ventilation (to help with breathing for more than 10 days after birth) low Apgar scores (numbers assigned at birth that reflect the newborn's health status) severe jaundice after birth maternal illness during pregnancy (for example, German measles [rubella])
Management: • Refer for diagnosis and assessment if suspected hearing loss (Always believe the parents)
Notes 1. Screening protocols in UK
Newborns (Well baby protocol): For babies who had no requirement for special care (or <48 hours in special care). Uses the AOAE test. Babies not passing this test are given the AABR test. Neonatal intensive care/special care baby unit protocol:Uses both AOAE and AABR tests. The latter can detect auditory neuropathy, which is more common in
special care babies. Then if these tests are not 'passed', babies are referred for audiological assessment. If there are risk factors requiring surveillance, refer for continued audiological assessment.
School entry hearing test3
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Currently, this is performed in most areas of the UK. The test used is the 'pure tone sweep test'.
Referral Threshold
• Babies with hearing loss found on neonatal screening • Other children with suspected hearing loss (as above)
Secondary care resource • Referral to secondary care (Specialist multi disciplinary team referrals should be considered according to local availability)
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Owner
Version No
Approval date
Hearing loss (adults)
Review date
External resources
• Hearing loss in adults, best practice, NHS health equality, LINK
What to consider in Primary Care before referring:
Causes of hearing loss in adults • Conductive hearing loss (This is caused by anything that stops sound moving from your outer
ear to your inner ear.) o Middle ear infections (acute otitis media). o Blockage of the outer ear, usually by wax. o Otosclerosis, a condition where the ossicles of the middle ear harden and become less able to
vibrate. o Damage to the ossicles, for example by serious infection or head injury. o Perforated (pierced) eardrum, which can be caused by an untreated ear infection (chronic
suppurative otitis media), head injury or a blow to the ear, or from poking something in your ear.
• Sensorineural hearing loss (This is caused by damage to the pathway between the inner ear and the brain. It affects sound intensity and makes it more difficult for you to recognise complex sounds). o Age-related hearing loss (presbyacusis). This is a natural decline in your hearing. Many
people get this as they get older because of damage to the hair cells in the cochlea. o Damage to the hair cells by loud noises (acoustic trauma). This is more likely to happen if you
work in a noisy place. o Certain infections such as measles, mumps or meningitis. Ménière's disease, which causes
hearing loss, dizziness and tinnitus (a persistent ringing in the ears). o Certain medicines, such as some powerful antibiotics, can cause permanent hearing loss. At
high doses, aspirin is thought to cause temporary hearing loss and tinnitus. o Certain cancer treatments, such as chemotherapy and radiation therapy, can cause hearing
loss. o Acoustic neuroma. This is a benign (non-cancerous) tumour affecting the auditory nerve
causing deafness and tinnitus. o Cholesteatoma (benign skin growth) in the middle ear, causing deafness and vertigo
(sensation of movement when you're standing still). • Mixed hearing loss is a combination of conductive and sensorineural hearing loss
Note: • Presbyacusis or age-related hearing loss typically affects the high frequencies and is due to a
progressive loss of hair cells in the cochlea. The age of onset is variable, although most people will present clinically from 65 years onwards
• Non organic hearing loss : cerumen (wax), foreign body • Sudden hearing loss should be urgently referred to ENT. This is an uncommon ENT emergency.
Causes may be head injury, viral (such as mumps, measles) or microvascular acoustic neuroma, although often no cause is identified.
• Adults with a hereditary hearing loss may be referred for assessment, genetic investigations and genetic counselling in conjunction with a clinical geneticist
History and Examination: • Take a relevant clinical history (onset, duration, gradual or rapid deterioration, associated
symptoms) • Examine the external ear area for lesions or tenderness including mastoid area • Examine ear drum for colour, landmarks and perforation • Check for wax, foreign body, discharge or tenderness
Investigations: • Tuning Form tests (ref end of section) • Audiometry
Primary care management: • Presbyacusis:
o it is important to reassure patients that they will almost never lose their hearing completely. One should emphasise that their hearing at lower frequencies may be very good. Management is aimed at educating both patients and their families, friends and or work colleagues about potential communications activities, (Information leaflet- (Link)
o enhancing any significant hearing loss with a hearing aid (Ref to end of section). • Wax:
o If you advise an ear drop regime, it should be tailored to individual needs eg 2-5 drops of wax softening ear drops (olive oil or the patient’s choice) twice a day for 3-7 days
o Supplemented by Patient information (Link) o Advice the patient to stop using the ear drops if he/she experiences any pain. o Follow up and refer for syringing if necessary
Referral Threshold
• Suspected foreign body Secondary care resource • Refer to ENT
• Persistent hearing loss due to wax not relieved by ear drops or impacted wax
• Referral for ear infections (refer to relevant sections in guidance)
• Unilateral sensori-neural hearing loss
Referral Threshold
• Referral for age related hearing loss (only if want a hearing aid)
Secondary care resource • Refer to audiometry and hearing aid clinic
Referral Threshold
• Sudden hearing loss
Urgent referral to ENT
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Hearing aids Where a diagnosis of presbyacusis has been made clinically, the tuning fork tests are normal and the eat canals free of any wax, direct referral for a hearing aid is possible in most hospitals. The standard NHS hearing aid is now a behind-the-ear digital gearing aid. There are also body-worn aids for those with dexterity problems or when a very strong hearing aid is required. Bone conductor hearing aids are available when an aid cannot be worn in the ear. Bone anchored hearing aids are available when a normal air conduction aid is not suitable. It is difficult to predict what level of hearing loss will benefit from a hearing aid. The central auditory discrimination of complex sounds such as speech is not usually assessed when prescribing an NHS hearing aid. As a rough guide, those with bilateral hearing thresholds worse than 30dB hearing level will probably benefit from a hearing aid. All patients who need a hearing aid will now have to have a digital aid because the manufacturers are discontinuing production of analogue hearing aids. The common problems associated with wearing hearing aids relate to the comfort of the mould. Occasionally the mould can cause an otitis externa or the individual may be sensitive to the acrylic mould material. More often, the complaint is that the aid does not give normal hearing and this is very difficult to address. Hearing aids may be cleaned with warm soapy water and left to dry in a warm place if they become dirty or blocked with wax. They should never be heated as they can melt. Most NHS community clinics will supply spare tubing and batteries. Cochlear implants are small electronic devices that may help provide a sense of sound to those aptiens who are profoundly deaf and have little or no benefit from hearing aids. In congenitally deaf children, implantation is usually advised within the first four years of life to get the maximum benefit. Older children or adults who lose their hearing (for example following meningitis) may also benefit
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Tuning fork tests:
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Owner
Version No
Approval date
Dizziness
Review date
External resources
• Hanley K, O'Dowd T, Considine N. A systematic review of vertigo in primary care. Br J Gen Pract 2001; 51: 666-71.
• Dizziness, patient.co.uk, LINK
What to consider in Primary Care before referring:
The most common complaints included under the heading dizziness comprise: • vertigo
o vertigo is defined as an illusion or hallucination of movement often with a rotatory element and is typically thought to arise from an abnormality involving the peripheral or central vestibular pathways:
o objective vertigo is the illusion that one's surroundings are moving o subjective vertigo is the feeling that with eyes closed one's body or head is moving or
turning in space • disorientation and imbalance
o disequilibrium is defined as a feeling of imbalance or unsteadiness • Syncope/ pre-syncope
o defined as light-headedness, dizziness and giddiness, representing a sensation of being about to faint:
o it is important to realise that not all dizziness is vertigo, even though patients may describe vertigo as dizziness
• non-specific light-headedness o non-specific light-headedness occurs without true vertigo, near-syncope or disequilibrium
• Dizziness may result from disturbance in a number of systems: o visual o proprioceptive o peripheral vestibular system (about 40% of cases) o cardiovascular o central nervous system (about 10% of cases) o psychological or psychiatric (about 15% of cases) o auto-immune disorders (systemic, inner ear) o may be caused by a variety of general medical conditions o conditions such as benign paroxysmal positional vertigo, vestibular neuronitis and familial
vestibulopathy selectively affect the peripheral vestibular system without any hearing loss
History: Patient should use their own words to describe
o the exact sensation o the time course of the dizziness; is it episodic (eg benign paroxysmal positional vertigo
[BPPV], migraine, Meniere's postural hypotension), or is it present much of the time (eg vestibulopathy or psychological)
o when the dizziness occurs Associated symptoms: nausea , vomiting , headache, hearing loss or tinnitus, loss of consciousness Ask the patient about any symptoms that may indicate a central nervous system (CNS) cause for their dizziness, e.g. dysarthria A general medical history will be required, which should include a review of medications that may cause dizziness or postural hypotension.
Physical examination: • pulse • blood pressure (lying and standing) • test vestibular function: • look for presence of nystagmus • Hallpike manoeuvre (see end of section)
Cardiovascular: (dizziness associated with lightheadedness) (Refer to cardiology Guidelines on Syncope) • murmurs • abnormal rhythm
Neurological examination: look for any signs that may indicate a central disorder, such as motor weakness, dysmetria, sensory changes ; also consider: cerebellar signs, focal deficits
Features to help distinguish peripheral from central vertigo:
• Nystagmus: is more likely to be vertical, and to be 'slow to fatigue' in central than in peripheral vertigo
• Hallpike's test is critical - upbeat geotropic torsional nystagmus should be seen, if other types of nystagmus are seen, consider central causes
• Nausea and vomiting: tends to be more severe in peripheral than in central vertigo • Associated neurological symptoms: rare in peripheral vestibular disorders as opposed to central
vestibular dysfunction • Compensation: peripheral vestibular failure can leave a patient feeling dizzy and unsteady for
weeks;slow or incomplete in central vestibular disturbance
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Syncope: bradycardia and vasodilation which lead to a transient loss of consciousness • rapid and complete recovery (often with fatigue) • caused by global cerebral hypoperfusion • distinguish between cardiac and neurogenic syncope:
Neurogenic syncope: generally has an excellent prognosis; also known as vasovagal syncope; occurs when prolonged upright posture results in pooling of blood in the legs
Cardiac syncope: is due to arrhythmias and often occurs without warning
Pre-syncope: sensation of impending loss of consciousness; sensation of 'nearly blacking out'
Dizziness associated with light-headedness (Psychiatric causes): light-headedness may be related to anxiety and/or depressive disorders (hyperventilation may be peri-oral (sensation of numbness around the mouth) and digital parasthesia)
Investigations: • Urinalysis for glucose: diabetes, urinary tract infection • Full blood count: anaemia; MCV high with alcohol abuse • Renal function, electrolytes, liver function tests: systemic disease, alcohol abuse, electrolyte
abnormalities • ECG and ambulatory 24-hour ECG for possible arrhythmia (if indicated)
Management: • careful history and examination • In elderly care, special consideration should be given to nutrition and hydration states • Thorough discussion with the patient and explanation of the problem and any underlying cause. • Evaluation and correction or amelioration of any associated medical problem (refer if indicated
for further assessment and treatment) Referral Threshold
• Dizziness only on ambulation (having excluded other medical causes by history or physical examination (possible diagnosis)
Secondary Care Resource:
The most common causes of dizziness whilst walking are vestibular in origin
• referral should be made to ENT specialist
• balance testing and audiometry may be recommended
• vestibular rehabilitation physiotherapy is most commonly recommended
• history of barotrauma (consider round window rupture or perilymph fistula) • associated with hearing loss and/or tinnitus (consider Meniere's disease, acoustic neuroma,
bilateral vestibular dysfunction) • chronic dizziness (labyrinthitis or inner ear dysfunction) lasting more than 4 weeks
Secondary care resource
• Refer to ENT specialist
Referral Threshold • irregular pulse (consider cardiac arrhythmia – ECG results to be included) • abnormal neurological examination (consider cerebrovascular accident, central nervous system
[CNS] medications, multiple sclerosis) • history of cervical spine or head trauma • recent history of amino glycoside antibiotics, diuretics or chemotherapy (consider bilateral
vestibular dysfunction) • Neurologocial causes (usually manifest as Ataxia- an unsteady and clumsy motion of the limbs or trunk
due to a failure of the gross coordination of muscle movements.)
Secondary care resource • Refer to relevant specialist
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Hallpike Manouvre The Dix-Hallpike test is performed with the patient sitting upright with the legs extended. The patient's head is then rotated by approximately 45 degrees. The clinician helps the patient to lie down backwards quickly with the head held in approximately 20 degrees of extension. This extension may either be achieved by having the clinician supporting the head as it hangs off the table or by placing a pillow under their upper back. The patient's eyes are then observed for about 45 seconds as there is a characteristic 5-10 second period of latency prior to the onset of nystagmus. If rotational nystagmus occurs then the test is considered positive for benign positional vertigo. During a positive test, the fast phase of the rotatory nystagmus is toward the affected ear, which is the ear closest to the ground. The direction of the fast phase is defined by the rotation of the top of the eye, either clockwise or counter-clockwise. Home devices are available to assist in the performance of the Dix-Hallpike Maneuver for patients with a diagnosis of BPPV.[3]
o There are several key characteristics of a positive test: o Latency of onset (usually 5-10 seconds) o Torsional (rotational) nystagmus. If no torsional nystagmus occurs but there is upbeating or downbeating nystagmus, a central nervous system (CNS) dysfunction is
indicated. o Upbeating or downbeating nystagmus. Upbeating nystagmus indicates that the vertigo is present in the posterior semicircular canal of the tested side. Downbeating
nystagmus indicates that the vertigo is in the anterior semicircular canal of the tested side. o Fatigable nystagmus. Multiple repetition of the test will result in less and less nystagmus. o Reversal: Upon sitting after a positive manoeuvre the direction of nystagmus should reverse for a brief period of time
To complete the test, the patient is brought back to the seated position, and the eyes are examined again to see if reversal occurs. The nystagmus may come in paroxysms and may be delayed by several seconds after the manoeuvre is performed. If the test is negative, it makes benign positional vertigo a less likely diagnosis and CNS involvement should be considered
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Sinusitis
Review date
External resources • Upper respiratory infection flow chart, NHS Scotland, Pg 7, LINK • Clinical Practice Guideline: Management of Sinusitis, American Academy of
Paediatrics, LINK • Sinusitis management, patient.co.uk, LINK
What to consider in Primary Care before referring:
Definition of bacterial infection: an inflammation of the sinus cavities, open air passageways within the human body, caused by bacteria such as streptococci, staphylococci, pneumococci, or Haemophilus influenzae. Prevalent symptoms include congestion in the nasal passages and pain, tenderness, and swelling in the approximate area of the affected cavity. Headaches, chills, and fever may also occur. In some cases, it may develop immediately after a viral infection in the upper respiratory tract.
Acute bacterial sinusitis: Bacterial infection of the paranasal sinuses lasting less than 30 days in which symptoms resolve completely.
Sub acute bacterial sinusitis: Bacterial infection of the paranasal sinuses lasting between 30 and 90 days in which symptoms resolve completely.
Recurrent acute bacterial sinusitis: Episodes of bacterial infection of the paranasal sinuses, each lasting less than 30 days and separated by intervals of at least 10 days during which the patient is asymptomatic.
Chronic sinusitis: Episodes of inflammation of the paranasal sinuses lasting more than 90 days. Patients have persistent residual respiratory symptoms such as cough, rhinorrhoea, or nasal obstruction.
Acute bacterial sinusitis superimposed on chronic sinusitis: Patients with residual respiratory symptoms develop new respiratory symptoms. When treated with antimicrobials, these new symptoms resolve, but the underlying residual symptoms do not
• Presence of a foreign body • Inhalation of irritants (e.g. cocaine) • Iatrogenic (e.g. nasogastric tubes, mechanical ventilation) • Dental problems (e.g. trauma, infection) • Some sporting activities (e.g. swimming, diving, high altitude climbing) • Mechanical obstruction (e.g. normal anatomical variations, nasal polyps) • Previous history of trauma (nose, cheeks) • Immunocompromise
Diagnosis:
• The diagnosis of acute bacterial sinusitis is based on clinical criteria in children who present with upper respiratory symptoms that are either persistent or severe.
• Acute bacterial sinusitis is an infection of the paranasal sinuses lasting less than 30 days that presents with either persistent or severe symptoms. Patients are asymptomatic after recovery from episodes of acute bacterial sinusitis.
• Persistent symptoms are those that last longer than 10 to 14, but less than 30, days. Such symptoms include nasal or postnasal discharge (of any quality), daytime cough (which may be worse at night), or both.
• Severe symptoms include a temperature of at least 102°F (39oC) and purulent nasal discharge present concurrently for at least 3 to 4 consecutive days in a child who seems ill. The child who seems toxic should be hospitalized.
• Uncomplicated viral upper respiratory infections generally last 5 to 7 days but may last longer. Although the respiratory symptoms may not have completely resolved by the 10th day, almost always they have peaked in severity and begun to improve. Therefore, the persistence of respiratory symptoms without any evidence that they are beginning to resolve suggests the presence of a secondary bacterial infection. Significant fever or complaints of facial pain or headache are variable. It is important for the practitioner to attempt to differentiate between sequential episodes of uncomplicated viral upper respiratory tract infections (which may seem to coalesce in the mind of the patient or parent) from the onset of acute sinusitis with persistent symptoms.
• The objective of treatment of acute bacterial sinusitis is to foster rapid recovery, prevent suppurative complications, and minimize exacerbations of asthma (reactive airways diseases).
• Children with acute bacterial sinusitis who present with severe symptoms need to be distinguished from those with uncomplicated viral infections who are moderately ill. If fever is present at all in uncomplicated viral infections of the upper respiratory tract, it tends to be present early in the illness, usually accompanied by other constitutional symptoms such as headache and myalgias. Generally, the constitutional symptoms resolve in the first 48 hours and then the respiratory symptoms become prominent. In most uncomplicated viral infections, purulent nasal discharge does not appear for several days. Accordingly, it is the concurrent presentation with high fever and purulent nasal discharge for at least 3 to 4 consecutive days
that helps to define the severe presentation of acute bacterial sinusitis. • Children with severe onset of acute bacterial sinusitis may have an intense headache that is
above or behind the eye; in general, they seem to be moderately ill • Subacute sinusitis is defined by the persistence of mild to moderate and often intermittent
respiratory symptoms (nasal discharge, daytime cough, or both) for between 30 and 90 days. The nasal discharge may be of any quality, and cough is often worse at night. Low-grade fever may be periodic but is usually not prominent. The microbiology of subacute sinusitis is the same as that observed in patients with acute bacterial sinusitis.29
• Patients with recurrent acute bacterial sinusitis are defined as having had 3 episodes of acute bacterial sinusitis in 6 months or 4 episodes in 12 months. The response to antibiotics is usually brisk and the patient is completely free of symptoms between episodes.
The most common cause of recurrent sinusitis is recurrent viral upper respiratory infection, often a consequence of attendance at day care or the presence of an older school-age sibling in the household. Other predisposing conditions include allergic and nonallergic rhinitis, cystic fibrosis, an immunodeficiency disorder (insufficient or dysfunctional immunoglobulins), ciliary dyskinesia, or an anatomic problem
Imaging studies are not necessary to confirm a diagnosis of clinical sinusitis in primary care
In adults and older children: In general practice, the most helpful examination technique is simple palpation as this is quick and easy to perform. Examination of the sinuses should be complemented by a simple assessment of the nose to assess for evidence of related pathology. Thereafter, investigations are guided by clinical suspicion and exposure or predisposition to risk factors
Management:
• Most patients can be reassured that this is generally a viral infection similar to a cold but which takes a little longer to resolve (about 2.5 weeks)
• Helpful measures to relieve symptoms include: o Paracetamol/ibuprofen for pain/fever o Intranasal decongestant (oral not recommended for sinusitis) for a maximum of a week o Nasal irrigation with warm saline solution o Warm face packs may provide localised pain relief o Adequate fluids and rest
• Antibiotics are reserved for severe or prolonged infections (>5 days) Most patients with acute bacterial sinusitis who are treated with an appropriate antimicrobial agent respond promptly (within 48-72 hours) with a diminution of respiratory symptoms (reduction of nasal discharge and cough) and an improvement in general well-being. If a patient fails to improve, either the antimicrobial is ineffective or the diagnosis of sinusitis is not correct.
• Offer review in 7 days for patients not treated with antibiotics or do not resolve after 72 hours for those treated with antibiotics.
• Consider antibiotics as first line treatment in the following cases where the patient is not suitable
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to admit but they are systemically unwell or at high risk of complications due to pre-existing co-morbidity. Such cases include patients with: o Significant heart, lung, renal, liver or neuromuscular disease; immunosuppression or cystic
fibrosis. o Acute cough who are older than 65 years of age with 2 of the following risk factors, or older
than 80 years of age with 1 of the following risk factors: o Hospitalisation in the previous year o Type 1 or type 2 diabetes o Congestive heart failure o Current use of oral corticosteroids
Antibiotic prophylaxis is not recommended Complications from acute sinusitis can be classified as: 1. periorbital (or preseptal) cellulitis or sympathetic oedema (periorbital cellulitis is not a true orbital
complication. The periorbital swelling is attributable to passive venous congestion; infection is confined to the paranasal sinuses),
2. subperiosteal abscess, 3. orbital abscess, 4. orbital cellulitis, or 5. cavernous sinus thrombosis. Referral Threshold
• Failure to respond to appropriate antibiotic treatment
• Worsening symptoms
Secondary care resource Consider referral to ENT specialist for management guidance (Follow up in primary care)
Referral Threshold
• Suspected complications from acute sinusitis o Suspicion of intracranial spread - look for severe frontal headache, frontal swelling, symptoms
or signs of meningitis or focal neurological signs o Suspicion of spread to orbit - see separate article Orbital Cellulitis o Immunocompromised patient o Unilateral signs (e.g. mass, bloodstained discharge, crusting, non-tender facial pain, facial
swelling or unilateral nasal polyps) o Maxillary paraesthesia o Bleeding
External resources • Diagnosis and Management of Rhinitis, Annals of allergy, asthma, &
immunology, 478-518 LINK
What to consider in Primary Care before referring:
• Rhinitis should be classified by aetiology as allergic or nonallergic
Important Historical Points in the Evaluation of Rhinitis • Symptoms: magnitude, duration, timing in relation to exposure (i.e., early and/or late-phase • allergic reactions), effects on daily living • Triggers/seasonality • Environment, including home, job and school or day care for children • History of other allergic symptoms (e.g., asthma, conjunctivitis, eczema) • Past medical history, including trauma • Feeding history in young children • Past treatment experience • Current treatment (if any) • Family history, including allergic diseases
Clinical examination: • An examination of the nose should be performed in patients with a history of rhinitis. This
should include examination of the nasal passageways, secretions, turbinates, septum, and determination of whether nasal polyps are present
• General observations: facial pallor, “allergic shiners”, mouth breathing, and nasal crease, • Evidence of systemic disease (e.g. nail clubbing). • Eyes: evidence for conjunctivitis, Dennie-Morgan lines (accentuated lines or folds below the
margin of the inferior eyelid). • Nose: presence or absence of external deformity, nasal mucosal swelling, nasal polyps,
deviated septum, septal perforation, discharge (noting colour and consistency), bleeding. • Ears: • Mouth: Observe for malocclusion or high arched palate associated with chronic mouth
breathing, tonsillar hypertrophy, lymphoid “streaking” in the oropharynx, pharyngeal postnasal discharge, halitosis, and pain upon mouth occlusion suggestive of temporomandibular joint syndrome.
• Neck: Lymph adenopathy, thyroid enlargement. • Chest: Signs of asthma. • Skin: Eczema, skin dryness, dermographism. • Other relevant organ systems.
Primary care management: • Oral antihistamines are effective in reducing symptoms of itching, sneezing, and rhinorrhoea,
and are first line therapy for treatment of allergic rhinitis. However, oral antihistamines have little objective effect on nasal congestion. Antihistamines reduce symptoms of allergic conjunctivitis , which are often associated with allergic rhinitis
• The first line treatment for nasal decongesting in moderate symptoms of allergic rhinitis is daily application of a topical nasal steroid such as fluticasone, mometasone, budesonide or beclometasone. Patient information should include the need for daily use and potential side-effects of crusting or bleeding which are usually caused by poor technique. In addition, these agents should be used with caution in patients with certain conditions, e.g. arrhythmias, angina pectoris, some patients with hypertension and hyperthyroidism.
• For acute cases consider five days of a nasal decongestants; a short course of oral prednisolone (20mg daily for five days) may relieve acute symptoms, although there is limited evidence to support such an intervention. Depot triamcinolone is no longer recommended in the UK due to concerns regarding adverse events associated with its use. Avoid prolonged use of decongestants due to risk of rhinitis medicamentosa
• Education of the patient in the regard to the management of rhinitis is essential. Such education maximises compliance and the possibility of optimising treatment outcomes
• Management for Concomitant Asthma, Sinusitis, and Otitis Media Referral Threshold
• Clarification and identification of allergic or other triggers for the patient’s rhinitis condition. • When management of rhinitis is unsatisfactory due to inadequate efficacy or adverse reactions
from treatment. • When allergen immunotherapy may be a consideration. • When there is impairment of patient’s performance because of rhinitis symptom manifestations or
medication side effects, e.g., patients involved in the transportation industry, athletes, students, etc.
• When the patient’s quality of life is significantly affected (e.g., patient comfort and well-being, sleep disturbance, small, taste).
• When complications of rhinitis develop, e.g., severe sinusitis, otitis media, orofacial deformities. • In the presence of co-morbid conditions such as recurrent or chronic sinusitis, asthma or lower
airway disease, otitis media, nasal polyps. • When patients require systemic corticosteroids to control their symptoms.
Secondary care resource • Consider referral to specialist
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Owner
Version No
Approval date
Rhinitis (Paediatrics)
Review date
External resources • Diagnosis and Management of Rhinitis, Annals of allergy, asthma, &
immunology, 478-518, LINK
In children, Rhinitis shares most of the pathophysiologic, clinical, diagnostic, and therapeutic characteristics observed in adults. Types of rhinitis: • Allergic rhinitis Food sensitization in infancy manifests as food allergy, atopic dermatitis,
urticaria/angioedema, and anaphylaxis which typically develops in infancy and early childhood. Sneezing, nasal congestion, rhinorrhoea, and ocular symptoms occur in about 30% of children during a food allergic reaction. These upper respiratory symptoms rarely occur in the absence of gastrointestinal, dermatologic, or systemic manifestations. Although upper respiratory symptoms in infancy and early childhood are frequently attributed to foods, many studies have consistently failed to demonstrate foods as a trigger for chronic rhinitis.
• Perennial allergic rhinitis: commonly associated with sinusitis • Viral-induced rhinitis, which may occur in the neonatal period, becomes more common later
in infancy with increasing exposure of the infant to other children, averaging about 6 episodes per year in children between 2 to 6 years of age
• Bacterial rhinitis: secondary to viral rhinitis prolongs infection and symptoms from several days to weeks. Staph aureus infection secondary to other primary disorders (including secondary to allergic rhinitis) manifests as impetigo of the anterior nares with characteristic crusting and irritation. Secondary bacterial rhinitis occurs with or without sinusitis in children with antibody, complement, and leukocyte deficiency disorders, hyper-IgE syndrome, structural defects (cleft palate, osteopetrosis) and cystic fibrosis, and may also occur in normal children. Primary bacterial rhinitis, though uncommon, may occur in the newborn due to congenital syphilis with characteristic rhinorrhoea followed by ulceration. Localized bacterial rhinitis may also occur in during b-haemolytic Streptococcal infections, particularly scarlet fever (50% prevalence), diphtheria, yaws, gonorrhoea, tuberculosis, typhus, and scleroma.
• Rhinitis with purulent rhinorrhoea especially if unilateral, persistent, bloody or fetid may indicate an intranasal foreign body
• Chemical/infectious rhinitis: Nasal symptoms, particularly congestion and rhinorrhoea, are common in infants and children with pharyngonasal reflux resulting from prematurity,
neuromuscular disease, or cleft palate. Those affected experience frequent choking, apnoeic spells, recurrent pneumonia (due to concomitant gastro-oesophageal reflux and/or tracheal aspiration), and aspiration of formula.
History • Onset of symptoms (infancy vs. childhood, post viral upper respiratory infection, trauma, or
acquisition of a new pet or home) • frequency (daily, seasonal, episodic, or unremitting), duration (weeks, months, or years),
severity (annoying, disabling, interfering with sleep, or leading to emotional disturbance) • symptoms (sneezing, anterior or posterior rhinorrhoea, obstruction, or anosmia), • discharge: character (watery, mucoid, or purulent) and colour (clear, yellow, green) • precipitating factors (allergens, irritants, climatic conditions) • associated factors (atopic disorders, drugs, infections) • previous response to medication/treatment (efficacy and side effects) On examination • The child with allergic rhinitis often manifests characteristic facial features and mannerisms
including the “allergic salute,” the allergic crease, Dennie-Morgan’s lines (accentuated lines or folds below the margin of the inferior eyelid), and infraorbital dark circles or “allergic shiners.”
• Examination of the nose (position of the septum, secretions and presence of any abnormal growths), ears (for infection, middle ear dysfunction), eyes (visualizing the palpebral infraorbital area for Dennie-Morgan’s lines, the conjunctiva for infection, and the lids for blepharitis), naso-pharynx (tonsils or adenoid hypertrophy) and the chest (for asthma or bronchitis)
• Malocclusions (dental examination) due to chronic mouth breathing may also be present Investigations • Allergy testing if indicated for patients with history and symptoms of allergic rhinitis Management Understanding the child’s discomfort and parent’s anxiety represents the cornerstone of therapy. The clinician must function as an advocate for the infant and child who may be unable to express the extent of their rhinitis problem. • Allergen avoidance as described in an earlier section represents the primary treatment of
allergic rhinitis and is especially relevant in early infancy and childhood in which allergen sensitization first occurs. Early effective allergen avoidance measures may function during secondary prevention to down-regulate IgE production and turn off allergic sensitization, if instituted early enough in life.
• Regurgitant rhinitis in infants should be treated with thickened and upright feedings, avoiding lying with a bottle, discontinuing formula feeding by 1 year, and prone resting at 30° following feeding.
• Nasal saline washes may be tolerated by the older child and adolescent. For the younger child
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and infant, commercial saline sprays followed by bulb syringe suctioning of the nares may be helpful in reducing the tenacity of secretions often seen in bacterial rhinitis.
• Specific intervention for infectious rhinitis of childhood include appropriate antibiotics in
childhood dosages for proven bacterial rhinitis/sinusitis Referral Threshold
• Clarification and identification of allergic or other triggers for the patient’s rhinitis condition. • When management of rhinitis is unsatisfactory due to inadequate efficacy or adverse reactions
from treatment. • When allergen immunotherapy may be a consideration. • When the patient’s quality of life is significantly affected (e.g., patient comfort and well-being, sleep
disturbance, small, taste). • When complications of rhinitis develop, e.g., severe sinusitis, otitis media, orofacial deformities. • In the presence of co-morbid conditions such as recurrent or chronic sinusitis, asthma or lower
airway disease, otitis media, nasal polyps.
Secondary care resource • Consider referral to specialist
.
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Heart of Hounslow – Polyclinic Services offered
• Out of hours consultation
• Ultrasound
• X-Ray
• Phlebotomy
• Anti Coagulation service
• Pharmacy- dispensing
(This is not an exhaustive list of services in Heart of Hounslow)
