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Revised Referral Guideline Kit
American Academy of Otolaryngology – Head and Neck Surgery, Inc
One Prince Street  Alexandria, Virginia 22314-3357
(703) 836-4444  Fax (703) 683-5100  TDD (703) 519 1585  home page http://www.entnet.org
The Case for Patient Referral Guidelines
Total Quality Management (continuous quality improvement) has shown that controlling variability decreases costs, increases
efficiency, and improves quality. Referral guidelines are one example of the efforts in clinical medicine to control variability. Referral
guidelines are being used by the Henry Ford Medical Group to improve patient access, to refine clinical practice, and to facilitate and
expedite appropriate referral from primary care physicians to the specialist.
Dr. Michael Benninger, chairman of Henry Ford’s Department of Otolaryngology, reported a prospective study organized to
assess the role of primary care evaluation, treatment, and referral guidelines for general ear, nose, and throat disorders. The
study measured patient access to otolaryngologists, patient satisfaction, appropriateness of referrals, primary care providers’
utilization, and their satisfaction.
Evaluation, treatment, and referral guidelines were developed collaboratively by otolaryngologists and general internal medicine, family
practice, and pediatric clinicians. The disorders addressed were tonsillitis/adenoiditis, acute suppurative Otitis media, chronic Otitis media
with effusion (serious Otitis media), globus syndrome, acute and recurrent sinusitis, chronic sinusitis, dizziness, hearing loss, and tinnitus.
The guidelines were developed by utilizing the prevailing ENT, pediatric, and internal medicine literature and established recommendations
from the American Academy of Pediatrics, the American College of Physicians, and the Agency for Health Care Policy and Research
(AHCPR). The Department of Family Practice reviewed the guidelines, and they were subsequently field tested in the Northeast Region of
the Henry Ford Health System.
The results of the study were quantifiable and sustainable. While 45 percent of visits were appropriate prior to the guidelines; 88
percent were appropriate after the guidelines were implemented. This referral pattern has remained constant after a decrease to 70
percent measured fie and eleven months later. The ratio of emergency referrals to routine referrals decreased from 31 to 21 percent, while
primary care providers, assessment of good access time for patients to see otolaryngologists improved from 53 to 67 percent.
All patients were reported to be satisfied with the waiting period for scheduled appointments (30 percent of patients were seen within
one month prior to the guidelines, while 59 percent were able to be scheduled within a month after implementation of the guidelines).
Thirty-one percent of the patients needed to see another physician while waiting to see otolaryngologists prior to the guidelines. This fell to
only 3 percent when the guidelines were adopted. Five patients saw physicians outside the Henry Ford Health System prior to the
guidelines. No patients saw outside physicians afterward.
Eighty-six percent of the primary care providers used the guidelines, and 72 percent of them felt the practice guidelines improved their
ability to treat patients. Not only were the guidelines used, but 85 percent of the primary care providers responding to the survey wished to
expand the guidelines to other specialty areas.
Good guidelines for evaluation, treatment, and referral are the product of physicians’ collaborative efforts reflecting documented clinical
success and physician consensus. Patient referral guidelines should lead to improved patient outcomes and increased patient
satisfaction-key criteria for defining quality care.
INSTRUCTION SHEET
Instructions for the Development of Local Primary Care Referral Guidelines to Otolaryngology
This document is created to serve as a resource for Otolaryngologists who wish to develop primary care referral guidelines in the
context of their own practices and community standards of care.
I. Identification of local/regional need for referral guidelines.
A. Evaluate need of referral guidelines for your practice and in the community.
1. Evaluate own practice
2. Discuss with primary care clinicians, perceived need for primary care referral guidelines to Otolaryngology.
3. Access payer/employer requirements or needs for primary care referral guidelines.
2. Determine if guidelines will be developed by or purchased for local payers, whether they are developed by Otolaryngologists or
via other sources.
II. Establish collaborative venture with primary care colleagues.
2. Open line of communication for primary care physicians’ role in the development of Otolaryngology referral guidelines.
3. Review guidelines with primary care physicians prior to implementation.
4. Use primary care physician input in assessing the effectiveness of guidelines once implemented.
Guidelines can be developed either by the Otolaryngologist or collaboratively with the primary care clinician. Community
standards and relationships will dictate which is the best approach. Under most circumstances primary care clinician input in
some portion of the guideline development will facilitate the successful utilization of these guidelines. Certain guidelines may
also benefit from input from Audiologists or Speech-Language Pathologists.
III. Determine what is expected to be accomplished by development and implementation due to high frequency or referrals.
A. Facilitation ease and early referral to Otolaryngology
B. Decreasing the frequency or unnecessary referrals.
C. Aiding primary care physicians in determination of a need for referral.
D. Accomplishing payer/employer need/desire to change referral patterns or limit referrals.
E. Cost savings
F. Improve quality of care.
IV. Identify disorders that should be addressed in the guidelines.
A. Disorders where significant impact on referrals can occur via guideline implementation due to high frequency of referrals.
B. Identity disorders for which referrals are frequently made and often unnecessary.
C. Clarify the criteria for referrals for surgical procedures.
D. Identify disorders where early referral to Otolaryngologist is either needed, or will enhance quality of care and minimize risk of
complications.
E. Identify disorders where early referrals with significantly decrease costs.
F. Identify disorders where changes in referral mechanism will substantially improve patient satisfaction.
G. Identify disorders where referral guidelines will impact cost of treatment.
V. Establish format of guidelines.
Guidelines can be developed in a number of formats. It will depend on the need and ease of use as to which format should be
developed. Descriptive guidelines give more information but may be difficult to use in a busy clinical setting. Bullet guidelines may
often be easier to use; however, they may be somewhat superficial in content. A combination of descriptive and bullet-oriented
guidelines is an option. Guidelines that can be placed in quick easy references or on medical information systems should be
considered.
Examples of possible guidelines are included. These are only examples. They were established based on the local needs and
clinical practice styles of the authors of these guidelines. However; they do give formats which might be used as templates for local
guidelines development.
VI. Determine how success of guidelines will be measured.
If guidelines are going to be utilized and effective, some measurement of the changes in referral patterns that occur after
implementation of guidelines is needed. The assessment mechanism will depend upon the style and format of the guidelines.
Furthermore, assessment of referring primary care physician and otolaryngologists satisfaction with the guidelines is an important
component of continuous improvement. This should be expanded to payers or employers if they are driving guideline formation.
Finally and perhaps most importantly, patient satisfaction should be considered.
THROAT
DIAGNOSIS
GENERAL PROBLEMS
INCLUDE:
1. Upper airway obstruction
2. Throat Rain
3. Hoarseness
4. Dysphagia
EVALUATION
These general symptoms may
include any or all of the general
or specific problems noted.
Through history and physical
examination of the head and
neck is required for determining
the specific diagnosis, as noted
below.
MANAGEMENT OPTIONS
Specific treatments depend on the
specific problems identified, as
noted below.
PHARYNGEAL AND
TONSILLOADENOID
PROBLEMS
1.
2.
3.
4.
5.
1. Penicillin VK 25-50 mg/kg/day
for 10 days
2. Treat all intimate contacts
simultaneously
3. Cephalosporin or macrolide if
patient is allergic to Penicillin or if
initial treatment is not successful.
1. Penicillin VK 25-50 mg/kg/day
for 10 days
2. Cephalosporin or macrolide if
patient allergic to Penicillin or if
initial treatment not successful.
Streptococcal Pharyngitis
Acute Tonsillitis
Months
Chronic Tonsillitis
Mononucleosis
Acute viral pharyngitis
Adenoiditis
Throat pain & odynophagia
Constitutional symptoms
Cervical Lymphadenopathy
Pharyngeal petechia
Throat culture
Throat pain & odynophagia with
any of the following
Findings:
1. Fever
2. Tonsillar exudate
3. Lymphadenopathy
4. Positive Strep Test
Frequent or chronic throat pain
and odynophagia; may have any
of the following findings:
 intermittent exudates
 adenopathy
 improves with antibiotic
Throat pain & odynophagia with:
 fatigue
 posterior cervical
adenopathy
 CBC, mono test
Throat pain and odynophagia in
absence of above findings
Clindamycin 10-25 mg/kg/day for
10 days
1. Purulent rhinorrhea
2. Nasal obstruction
3. Cough
4. May be associated with otitis
media
REFERRAL GUIDELINES
1. If problems resolve in
less that three treatment
attempts, specialty referral is
not indicated.
2. If symptoms or finding
persist, or recur a third time,
specialty referral is
indicated.
3. If there is a question of
incomplete resolution of
obstruction, pain,
hoarseness, or dysphagia,
referral is indicated.
Three or more episodes of
streptococcal pharyngitis in
a six-month period.
Documented episodes:
 4 or more in previous 12
 5 per year in 2
preceding years
 3 per year in preceding
3 years
Persistent streptococcal
carrier state with or without
acute tonsillitis.
ENT referral is indicated if
problem recurs following
adequate response to
therapy
Supportive care
Systematic steroids if severe
dysphagia
Airway obstruction
Supportive care
Continued symptoms for
greater than two weeks
At least 2 weeks of therapy using
B-lactamase-stable antibiotic:
 Amoxicillin/clavulanate 20-40
mg/kg/day q8H
 Erythromycin/sulfamethoxazole
½ to 2 tsp q6H
1. Three or more episodes
in a six-month period
2. Persisting symptoms and
findings after two courses of
antibiotic therapy
DIAGNOSIS
UPPER AIRWAY
OBSTRUCTION:
Tonsillar and/or adenoid
hyperplasia
Tonsillar Hemorrhage
Neoplasm
HOARSENESS
Associated with upper
respiratory infection
Hoarseness, associated with
neck trauma
 Blunt
 Sharp
Hoarseness, Associated with
respiratory obstruction
Hoarseness without associated
symptoms or obvious etiology
EVALUATION
1. Mouth breathing
2. Nasal obstruction
3. Dysphonia
4. Severe Snoring with or
without apnea
5. Daytime fatigue
6. Dysphagia
7. Weight and/or height below
normal for age
8. Dental arch maldevelopment:
narrow arched palate, cross bite
deformity
9. Adenoid facies
10. Cor pulmonale
Spontaneous bleeding from a
tonsil
Progressive unilateral tonsil
enlargement
1. Throat pain
2. Dysphagia
3. Constitutional symptoms
4. Stridor/airway distress
History of neck trauma preceding
hoarseness May or May not
have:
1. Skin laceration
2. Ecchymosis
3. Tenderness
4. Subcutaneous emphysema
Stridor
1. History of tobacco and/or
alcohol use
2. Evaluation, when indicated,
for:
 Hypothyroidism
 Diabetes mellitus
 Gastro-esophageal reflux
 Rheumatoid disease
 Lung neoplasm
Esophageal or pharyngeal
neoplasm
MANAGEMENT OPTIONS
1. Optional soft tissue lateral X-ray
of nasopharynx
2. Allergy evaluation when
indicated
3. Sleep audio tape may be
helpful for possible apnea
REFERRAL GUIDELINES
ENT referral indicated with
any significant symptoms of
upper airway obstruction
ENT referral in indicated
ENT referral is indicated
1. Humidification
2. Increase hydration
3. Voice rest, if possible
4. Antibiotics when appropriate
5. Inhalant steroid sprays
6. Tapering oral steroids when
indicated
Immediate treatment with:
1. Humidification
2. Parenteral and/or inhalant
steroids
ENT referral is indicated if:
1. Stridor or airway distress
2. Associated with
significant dysphagia
3. Hoarseness persists
greater than two weeks
1. Immediate Rx; Humidification;
Parenteral and/or inhalant steroids
2. Soft tissue lateral of neck with
neck hyper-extended, only if
patient is stable
3. Blood cultures, if patient is
febrile
4. C1 esterase inhibitor levels (if
history of angioneurotic edema)
1. Humidification
2. Increase fluid intake
3. Voice rest, if possible
4. Antibiotics when appropriate
5. Inhalant steroid sprays
6. Tapering oral steroids when
indicated (dose pk)
7. Treat any medical illnesses
diagnosed on evaluation
IMMEDIATE ENT
REFERRAL IS INDICATED
IN ALL CASES
IMMEDIATE ENT
REFERRAL IS INDICATED
IN ALL CASES
ENT referral is indicated if
hoarseness persists more
than two weeks despite
medical therapy
DIAGNOSIS
DYSPHAGIA
EVALUATION
When indicated, evaluation
may include:
1. Foreign body ingestion
2. Gastro esophageal Reflux
3. Esophageal Motility
4. Scleroderma
5. Neoplasm
6. Thyromegaly
NECK MASS
1. Complete head and neck
examination for site of
infection
2. Lateral X-rays of neck &
nasopharynx with neck hyperextended
3. CBC
4. Cultures when indicated
5. Intradermal TB test
6. Inquire about possible cat
scratch
7. HIV testing if indicated
8. Toxoplasmosis titre if
indicated
Complete head and neck
examination indicated
If lower neck, thyroid
evaluation may include:
 Thyroid function studies
 Thyroid ultrasound
 Thyroid uptake and scan
 Needle aspiration biopsy
Open biopsy of neck mass is
contra indicated in all cases
Inflammatory
Non-inflammatory
SALIVARY GLAND DISORDERS
Saliodentitis
1. Assess hydration of patient
2. Palpate for stones in floor
of mouth
3. Observe for purulent
discharge from salivary ducts
when palpating involved gland
4. Evaluate mass for
swelling, tenderness,
inflammation
MANAGEMENT OPTIONS
Diagnostic studies may include:
 Soft tissue X-ray of neck (for
foreign body)
 Chest X-ray
 Barium swallow
 Thyroid studies
 Lab tests for auto-immune
disorder
Management options may include:
1. Anti-reflux therapy
2. Appropriate thyroid
management
1. Amoxicillin/Clavulanate 20-40
mg/kg/day in 3 divided does, or
2. Clindamycin 10-25 mg/kg/day in
3 divided doses
REFERRAL GUIDELINES
ENT referral indicated for:
1. Foreign body suspected
2. Dysphagia in children
3. GE reflux despite medical
therapy
4. Dysphagia assoc. with
hoarseness
5. Dysphagia persists
despite negative medical
evaluation
6. Fine-needle aspiration of
thyroid
1. Appropriate medical
management for multi-nodular
goiter or hyper-functioning thyroid
nodule
2. Trial of antibiotic therapy may
be considered if an inflammatory
mass is suspected (see above)
Note 800/0 of all non-thyroid neck
masses are malignant
Note: 800/0 of all non-thyroid neck
masses are malignant
1. Culture and sensitivity of
purulent discharge in mouth
2. Hydration
3. Occlusal view of X-ray of floor
of mouth for calculi
4. Anti-staph antibiotics:
 Amoxicillin/Clavulanate
500mg, q8H, or
 Clindamycin 300mg, q8H
ENT referral is indicated in
all cases of suspected
salivary gland neck masses,
other than documented
multi-nodular goiter or
hyper-functioning nodule
ENT referral is indicated if:
Mass persists for 2 weeks
without improvement
URGENT referral if painless
progressive enlargement
URGENT referral is
suspicion of metastatic
carcinoma
ENT referral indicated for:
1. Poor antibiotic response
within one week of diagnosis
2. Calculi suspected on
exam or X-ray
3. Abscess formationimmediate referral
4. Recurrent saliodentitis
5. Hard mass presentpossible neoplasm
DIAGNOSIS
Salivary gland mass
SLEEP APNEA & SNORING
EVALUATION
1. Complete head and neck
examination
2. Evaluate facial nerve
function
3. MRI scan may be
considered
Open biopsy of salivary mass
is contra-indicated in all cases
Symptoms of obstructive
sleep apnea may include:
1. Disturbed sleep
2. Documented apnea during
sleep
3. Fatigue on waking
4. Headache on waking
5. Daytime fatigue
Evaluation may include:
 Obesity
 Hypothyroidism
 Hypertension
 Cardiac disturbances
 polysomnography
MANAGEMENT OPTIONS
20% of all parotid gland
masses are malignant
50% of all submaxillary gland
masses are malignant
REFERRAL GUIDELINES
ENT referral is indicated for
in all cases of suspected
salivary gland neck masses
1. Weight control
2. Thyroid management
3. Hypertension (possibly related
to sleep apnea)
4. Cardiac disturbances (possibly
related to sleep apnea)
ENT referral indicated for:
1. Evaluation of upper
airway and nasal obstruction
2. History suggestive of
obstructive sleep apnea
3. Elective management of
snoring in absence of sleep
apnea


NASAL AND SINUS PROBLEMS, ADULT
Caveats:
1) Reliable diagnosis of nasal disorders requires examination of the nasal passages, anteriorly and posteriorly; examination of nasopharynx
may also be indicated
2) Diagnostic examination of the nasal passages requires headlight, nasal speculum, and decongestion of the mucosa; in general, this
examination is most thoroughly performed by a specialist
3) Evaluation of sinus disease cannot be adequately accomplished with physical examination alone
4) Transillumination of the sinuses is NOT capable of reliably evaluating the status of the sinuses
5) Plain sinus x-rays MAY be helpful in evaluating sinuses; however, significant sinus disease may exist when plain sinus x-rays appear
normal
6) Definitive sinus diagnosis requires CT scan and nasal endoscopy; determination of the indication for these evaluations should be made
by the specialist
Potential complications of untreated disease:
1) Chronic airway obstruction
2) Sleep apnea/snoring/cardiovascular disturbance
3) Exacerbation of lower airway problems
4) Anterior headache/atypical facial pain
5) Diminished sense of smell and taste
6) Orbital/vision problems
7) CNS involvement/meningitis/CSF rhinorrhea
8) Mucocele
9) Invested papilloma of the nose of sinuses (pre-malignant)
10) Nasal or sinus malignancy
DIAGNOSIS
EVALUATION
GENERAL PROBLEMS INCLUDE: These general symptoms may
include any and/or all of the
 Nasal congestion, unilateral or general or specific problems
noted
bilateral; persistent or
recurrent
Through history and physical
 Nasal discharge, unilateral or
bilateral persisting or recurrent examination of the head and
 Diminished sense of smell and neck is required for
determining the specific
taste
diagnosis, as noted below
SPECIFIC PROBLEMS INCLUDE:
EPISTAXIS (NOSEBLEED);
PERSISTING OR RECURRENT
Determine whether:
 Bleeding is unilateral or
bilateral
 Bleeding is anterior or
posterior
 Any bleeding diathesis or
hypertension
MANAGEMENT OPTIONS
Specific treatments depend of the
specific problems identified, as
noted below
Immediate control may occur with:
 Pressure on the nostrils
 If bleeder is visible consider
cauterization with silver nitrate
(after tropical anesthesia)
 Merocel sponge packing-coat
sponge with antibiotic
ointment prior to insertion
REFERRAL GUIDELINES
1. If the problems resolve in
less than three episodes,
specialty referral is not
indicated
2. If the above symptoms
persist, or recur a third time,
specialty referral is indicated
3. If there is a question of
incomplete resolution of
congestion, infection,
epitasis, or facial pain.
Specialty referral is
indicated.
1. Bleeding is posterior
2. Bleeding persists
3. Bleeding recurs
Referral is indicated to a
specialist in Otolaryngology,
Head and Neck Surgery
(OTO-HNS)
DIAGNOSIS
ACUTE VIRAL UPPER
RESPIRATORY TRACT
INFECTION
EVALUATION
1. Short duration, often sore
throat at onset
2. Nasal congestion
3. Clear nasal discharge
4. May be associated
systematic viral symptoms
ACUTE SINUSITIS
A) Unilateral or bilateral nasal
congestion, usually evolving
from viral URI. Signs of acute
sinusitis may include:
 Purulent discharge,
 Facial, forehead, or
periorbital pain

Dental pain

Persisting URI >7 days
B) History and physical
examination may be nondiagnostic
C) Sinus radiographs may be
helpful, or screening coronal
CT study is diagnostic.
CAVEAT transillumination is
not a reliable tool.
Symptoms: persisting or
recurrent
 Nasal congestion
(unilateral or bilateral)
 Post-nasal discharge
 Epistaxis

Recurrent acute sinusitis
 Anterior facial
pain/”migraine”/”cluster”
headache
Physical Examination:
requires complete intranasal
examination with
decongestion.
Sinus radiographs /screening
CT scan show abnormal
findings.
Symptoms:
 Nasal congestion
(unilateral or bilateral)
 Post-nasal discharge

Epistaxis

Recurrent sinusitis

Anterior facial pain”
”migraine”/”cluster”
headache.
Physical Examination:
requires complete intranasal
examination with
decongestion
CHRONIC SINUSITIS/POLYPS
DEVIATED SEPTUM
MANAGEMENT OPTIONS
1. Systematic decongestants, antipyretics, supportive therapy.
2. Topical decongestant sprays
may be used for a maximum of 5
days
3. If symptoms persist or if sinus
symptoms develop, see section on
“acute sinusitis”
4. Caveat: Antihistamines are not
beneficial and may thicken with
secretions, with possible adverse
effects.
A) Initial Treatment:
1) Broad spectrum antibiotic;
e.g., Amoxicillin, SMX/TMP
2) Systematic decongestants,
antipyretics, supportive therapy
3) Topical decongestant sprays
may be used for a maximum of
5 days
CAVEAT: antihistamines are not
beneficial.
B) Secondary Treatment
If primary treatment fails, prescribe
a betalactamase-resistant
antibiotic.
REFERRAL GUIDELINES
1. Secondary antibiotic
treatment fails, clinically or
radiographically
2. Complications are noted:
periorbital cellulites,
persisting headache.
3. Recurrent infections; 3
episodes of acute sinus
infection within a t here year
period (see section on
“chronic sinusitis”).
Antibiotics, topical steroid nasal
sprays for acute management.
1. ENT referral indicated in
all cases of chronic or
recurrent sinusitis.
2. Persisting abnormal
symptoms, abnormal
findings, and/or abnormal
radiographs warrant ENT
referral.
Treat initially for any associated
allergy, chronic Sinusitis.
ENT referral for intranasal
examination and treatment
recommendations.
DIAGNOSIS
SINUS HEADACHE/FACIAL
PAIN, UNILATERAL OR
BILATERAL: FREQUENT OR
SEVERE
ALLERGIC RHINITIS
SLEEP
DISTURBANCE/APNEA/SEVERE
SNORING: PARTICULARLY WITH
NOCTURNAL WAKING, DAYTIME
FATIGUE.
ACUTE NASAL FRACTURE
EVALUATION
May be an isolated symptom
or may be associated with
significant nasal congestion or
discharge, Potential relations
to intranasal deformity, sinus
pathology, dental pathology,
and TMJ dysfunction.
CAVEAT: anterior migraine or
cluster headache may also
relate o nasal/sinus
pathology.
Symptoms:
 Seasonal or perennial;
congestion

Watery discharge

Sneezing fits

Watery eyes

Itchy eyes/throat.
Physical Examination: boggy
swollen bluish turbinates
 Allergic “shiners”
 “Allergic salute.”
Range of Symptoms:
Unobstructed snoring to
severe apnea.
Suggestive clinical features
include:
 Apnea

Nocturnal waking
 Nightmares

Unrestful sleep

A.M. headache

Daytime fatigue.
Physical findings may include:
 Large
palate/uvula/tonsils
 May also include nasal
obstruction.
1. Immediate changes:
edema, Ecchymosis,
epistaxis.
2. Evaluate for associated
nasal congestion, septal
fracture of septal hematoma.
3. Nasal bone X-rays usually
positive.
MANAGEMENT OPTIONS
If evidence of acute sinusitis, treat
with appropriate antibiotics, etc., as
above.
REFERRAL GUIDELINES
Referral indicated in all
cases of chronic, persisting,
pr recurrent anterior facial
pains; referrals may include
ENT and dental evaluations.



Antihistamines
Topical cortisone sprays
Topical cromolyn sprays
1. If symptoms do not
respond to medical
treatment.
2. If symptoms are present
for four months or more per
year.
1) Conservative treatment for
snoring/mild apnea may include:
 Weight loss

Nocturnal positioning (sleep
off back).
2. May consider sleep study prior
to referral.
1. Significant symptoms for
apnea.
2. Persisting snoring or
apnea.
3. Abnormal sleep study
1. Early treatment: cool
compresses to reduce swelling.
2. Re-evaluate in 3-4 days to
determine if nose looks normal and
if breathing is normal.
1. Immediate referral if
possible septal hematoma
(significant airway
obstruction).
2. ENT referral within 7
days if external nasal
deformity, septal deformity,
or breathing problem.
Consultations should include
ENT evaluation to review
medical and surgical
alternatives.
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 OPTIONS
ACUTE OTITIS MEDIA
1) Symptoms: ear pain,
A) Initial Treatment:
“Ear infection”
decreased hearing, ear
1) Broad-spectrum antibiotic
drainage, fever
including coverage for S.
2) Physical Examination:
Pneumoniae, H. Influenza and
Inflamed tympanic membrane
M. Catarrhalis*
TM, desquamated epithelium
2) For adults, systemic
on TM, bulging TM, middle
and/or topical nasal steroid
ear effusion
sprays may be considered.
3) Audio (not required is A &
3) If associated allergy
B are present) tympanogram
antihistamines and/or topical
may show positive or negative
nasal steroid sprays may be
pressure
considered
4) Caveat: Tender, swollen
B) Secondary Treatment: If primary
ear canal usually indicated
treatment fails, prescribe a
external otitis rather than otitis betalactamase-resistant antibiotic
media
RECURRENT ACUTE OTITIS
Recurring episodes of acute
Alternatives include:
MEDIA
otitis media, which respond to 1) 4-6 months antibiotic
“Ear Infection”
medical treatment.
prophylaxis with the first line
with normal middle ears (I.e., no
Between episodes the middle therapy (Amoxicillin or sulfa)**
effusion or negative pressure,
ear and TM appear normal,
2) Antibiotic prophylaxis at onset of
normal tympanogram) between
and tympanogram (and
each upper respiratory infection***
acute episodes
audiogram) is normal
3) OTO-HNS referral to evaluate
and treat chronic adenoiditis,
evaluate for possible allergy
REFERRAL GUIDELINES
1) Secondary antibiotic
treatment fails
2) Complications are noted
mastoiditis, facial weakness,
dizziness, meningitis
3) Imminent air travel
Referral to specialist in
Otolaryngology-Head &
Neck Surgery (“OTO-HNS)
Treatment failure:
1) Infections continue
despite antibiotic prophylaxis
2) Middle ear effusion
occurs and persists (see
below)
* 1) Amoxicillin 30-4- mg/kg/day (3 doses); Patients with possible resistant infections may use:
2) Amoxicillin-clavulanate 20/40 mg/kg/day (3 doses)
3) Erythromycin/sulfa 50 mg/kg/day (erythro) (4 doses)
4) Cefuroxime 125-250 mg bid
5) Cefprozil 15-30 mg/kg/day (2 doses)
6) Cefpodoxime 10 mg/kg/day (2 doses)
7) Loracarbef 15-30 mg/kg/day (2 doses)
8) Cefaclor 20-40 mg/kg/day (3 doses)
** Amoxicillin 30-40 mg/kg/day (3 doses) or Sulfisoxazole 1-2 gm/day (2 doses)
*** Amoxicillin 30-40 mg/day (3 doses) or Sulfisoxazole 1-2 gm/day (2 doses) or Trimethoprim-Sulfamethoxazole (TMP-SMX) 1tsp/10
lbs/day (2 doses)
DIAGNOSIS
CHRONIC OTITIS MEDIA
i.e., persistent effusion or negative
middle ear pressure, with or without
recurrent acute otitis media
ACUTE EXTERNAL OTITIS
“Swimmers Ear”
OTALGIA WITHOUT
SIGNIFICANT CLINICAL
FINDINGS
HEARING LOSS
BILATERAL, SYMMETRICAL, ADULTS
(FOR CHILDREN, SEE ABOVE)
UNILATERAL
EVALUATION
MAY HAVE NO SYMPTOMS:
pneumotoscopy and/or
tympanogram are crucial
1) Symptoms: ear pain,
decreased hearing, ear
drainage
2) Physical Examination: (may
include) TM discolored
thinned, or retracted; bubbles
behind TM, Pneumo-otoscopy
reveals sluggish or retracted
TM.
3) Audio: tympanogrammay
show effusion (type B) or
negative pressure (type C)
1) Symptoms: ear pain,
significant EAR
TENDERNESS, swollen
external canal, hearing may
or may not be diminished
2) Physical Examination: Ear
canal always tender, usually
swollen, may be inflamed.
Often unable to visualize TM
because of debris or canal
edema
3) Caveat: Occasional cases
have a large fungal pad
indicating fungal external
otitis-often spores visible
1) Symptoms: ear pain
without tenderness or swelling
2) Physical Examination:
normal ear canal and
tympanic membrane
Symptoms: diminished
hearing
1) Cerumen blockage
2) Middle ear effusion
3) Normal findings
MANAGEMENT OPTIONS
1) Up to three courses of systemic
antibiotics (10 days ea.); at least
one treatment course with therapy
resistant to beta-lactamase****
2) Caveat: therapy with
decongestants, antihistamines,
and steroids has not been proved
to be beneficial (unless there are
proven allergies present)
REFERRAL GUIDELINES
1) Recurring otalgia or
hearing loss (3 episodes in 6
months)
2) Effusion, TM retraction,
perforation, or negative
pressure persist > 3 months
3) Ear discharge (persisting
or recurrent)
4) Abnormal tympanogram
and/or audiogram after 3
months
1) Topical treatment is optimal;
systemic antibiotics generally
insufficient alone and add little
effectiveness to topical treatment
except when there is surrounding
cellulites
2) Insertion of expandable wick
with tropical antibacterial
medication; Burow’s solution or
water-soluble antibiotic drops*
3) If fungal external otitis, through
cleaning of canal is required, plus
topical anti-fungal therapy
1) Canal is swollen shut and
wick cannot be inserted
2) Cerumen impaction
compounding external otitis
3) Unresponsive to initial
course of wick and antibacterial drops
4) Occurrence in diabetic
patient calls for urgent OTOHNS referral (possibility of
“necrotizing external otitis”)
Requires diagnosis and then
appropriate treatment, possible
etiologies include local ear canal
pustule (usually tender area
present); TMJ syndrome; referred
pain from dental pathology, sinus
pathology, head and neck
malignancy
1) Cerumen-dissolving drops
possible gentle irrigation
2) Oral decongestant and reevaluate in 3 weeks
3) No treatment; referral hearing
evaluation
When cerumen is present, treat
with drops and possible irrigation.
If cerumen is not present, referral
is indicated
OTO-HNS referral indicated
if pain persists and etilogy
not identified
1) Cerumen, or hearing loss
persists
2) Effusion or hearing loss
persists
3) Referral for OTO-HNS
and
Referral for OTO-HNS
evaluation is indicated in all
cases of unilateral hearing
loss, unless the problem
resolves with elimination of
cerumen
1) Symptoms: difficulty
hearing, or difficulty localizing
sound, or problems hearing
only in a crowded
environment
2) Physical Examination: may
be normal or may have
cerumen or tympanic
membrane abnormality
*Neomycin plus Polysporin otic drops or gentamicin
**** Amoxicillin-clavulanate 20-40 mg/kg/day (3 doses); Cefuroxime 125-160 mg bid; Cefprozil 15-30 mg/kg/day (2 doses); Cefpodoxime
10 mg/kg/day (2 doses); Loracarbef 15-30 mg/kg/day (2 doses); Cefaclor 20-40 mg/kg/day (3 doses); Trimethoprim-Sulfamethoxazole
(TMP-SMX) 1 tsp/10 lbs/day (2 doses)
DIAGNOSIS
TINNITUS
 Chronic bilateral
 Unilateral or recent onset
 Pulsatile
EVALUATION
1) Normal tympanic
membranes or cerumen
2) Normal tympanic
membranes or cerumen
3) Normal or mass behind
tympanic membrane
MANAGEMENT OPTIONS
1) Clean cerumen: no treatment
2) Clean cerumen; if symptoms
persist, referral indicated
3) Referral is indicated
DIZZINESS
 Orthostatic
 Vestibular neuronitis
 Chronic or episode
1) Symptoms mild brief, only
standing up (usually A.M.)
2) Associated with URI; may
be positional or persisting
3) Significant imbalance
and/or vertigo; may have
associated hearing loss,
tinnitus, ear pressure, nausea
Weakness or paralysis of
movement of all (or some) of
the face.
May be associated otalgia,
otorrhea, vesicles, parotid
mass, or Tympanic
abnormality
1) Evaluate cardiovascular system,
reassurance
2) Self-limited over 3-6 weeks; may
use systematic medication and/or
steroid
3) Referral is indicated
FACIAL PARALYSIS
Immediate referral is indicated in
all cases.
Steroid therapy (high dose) may be
initiated if there are no associated
findings
REFERRAL GUIDELINES
1) No referral indicated
unless associated hearing
loss or dizzy
2) It persists, Oto-HNS
referral and hearing
evaluation indicated
3) Oto-HNS evaluation
indicated in all cases
1) If symptoms become
severe
2) Associated hearing loss,
increased severity,
persistence > 6 weeks
3) Oto-HNS evaluation is
indicated in all cases
OTO-HNS evaluation is
indicated in all cases