Download Tonsillectomy or Grommet Insertion

Leeds CCGs Targeted Interventions Referral Form
Hospital Referral for Children or Adults for consideration for Tonsillectomy or
Grommet Insertion
Referral to:
(insert patient’s choice of hospital)
Patient Details:
Title
Surname
Forename(s)
Address
D.O.B
NHS Number
Tel (home)
Tel (mobile)
Gender
Ethnicity
Age
Is an interpreter required
Yes
No
Is transport required
Yes
No
Referrer Details:
Referring GP
Practice Address
Telephone
Fax
Practice Code
Tonsillectomy
Tonsillectomy is appropriate in any of the following conditions: (Tick box)
Recurrent sore throat in children or adults due to acute tonsillitis. Episodes or sore throat are
disabling and prevent normal functioning
AND either
Seven or more well documented, clinically significant, adequately treated sore throats
in the preceding year
OR
Five or more such episodes in each of the preceding two years
OR
Three or more such episodes in each of the preceding years
In patient with recent history of peritonsillar abscess with previous history of recurrent tonsillitis
Chronic tonsillitis for more than 6 months, associated with illness, halitosis and/or disruption to life
Obstructive sleep apnoea in children
As part of a palatal procedure for heavy snoring or sleep apnoea in adults
Where malignancy is suspected
Grommet Insertion
Grommet insertion is appropriate in the following conditions: (Tick box)
Child has persistent (>3 months) documented otitis media with effusion with a hearing level in the
better ear or 25db or worse averaged at 0.5, 1, 2 and 4 KHz
Child has speech or language problems or child has developmental problems or child has
significant behavioural problems and her persistent bilateral otitis media with effusion
Severe otalgia in otitis media requiring admission, and unresolved with conservative treatment
over 3 days
Review Date: April 2016
In immunocompromised patients with otitis media where microbiologic specimens are required
Complications or otitis media such as meningitis, facial nerve paralysis, coalescent mestoiditis, or
brain abscess
Child with recurrent acute otitis media more than 6 times in the previous 12 months
Chronic retraction of the tympanic membrane
Adults with otitis media with effusion where conservative management has failed over 6 weeks or
where malignancy is suspected
Autophone due to patulous Eustachian tube
As part of treatment for vestibular disorders either alone or with gentamicin
Clinical Notes:
Past Medical History:
Drug List:
Allergies:
GP Signature:
Date:
Supporting evidence
Tonsillectomy:
Sign Guidelines: http://www.sign.ac.uk/pdf/qrg117.pdf
AETNA Clinical policy bulletins: http://www.aetna.com/cpb/medical/data/400_499/0475.html
Grommet Insertion:
Sign Guidelines: http://www.sign.ac.uk/guidelines/fulltext/66/index.html
NICE: http://www.nice.org.uk/nicemedia/pdf/CG60NICEguideline.pdf
Review Date: April 2016