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SIERRA NEVADA MEDICAL ASSOCIATES, INC. (IPA) UTILIZATION GUIDELINES PRIMARY CARE MANAGEMENT GUIDELINES OTOLARYNGOLOGY The Primary Care Physician should: 1. Treat tonsillitis and streptococcal infections including scarlet fever. a) Refer for consideration of tonsillectomy if: i) there have been three documented episodes of tonsillitis within four months or six episodes within one year despite adequate antibiotic therapy. ii) Recurrent tonsillitis complicated by peritonsillar abscess, abscessed cervical lymph node, airway obstruction, febrile seizures, or resulting in significant absence from school or work iii) tonsillar enlargement suspicious for malignancy. 2. Evaluate and treat other otopharyngeal infections such as stomatitis, herpangina or herpes simplex. 3. Treat acute otitis media with up to three different ten day courses of antibiotics if it is unresolved. Treat persistent effusions for up to three months if unresolved. Treat recurrent otitis media (three episodes within six months) with continuous low-dose prophylactic antibiotics for three to six months. Evaluate with tympanogram and/or audiograms if indicated. a) Refer for: i) acute otitis media that continues toxic for 48 hours despite treatment because of consideration of tympanocentesis. ii) persistent infection after three courses of antibiotics. iii) persistent effusion lasting greater than three months despite antibiotic treatment. iv) failure of prophylaxis. v) Persistent hearing loss or delayed speech and articulation in children under the age of three. vi) Persistent retraction of tympanic membranes. 4. Treat acute sinusitis with antibiotics, topical and systemic decongestants, and nasal lavage. 5. Treat chronic sinusitis with up to three courses of antibiotics for up to three weeks each, topical and systemic decongestants, naval lavage and topical steroids. Evaluate for nasal polyps, septal deviation, other structural abnormalities and NSAID sensitivity. a) Those who do not respond to the above may require coronal CT of sinuses and/or fiberoptic rhinolaryngoscopy. Although a Water’s view of PC MGMT - OTOLARYNGOLOGY PAGE 1 OF 2 the sinuses may be helpful, limited coronal CT of the sinuses is generally preferred over plain radiographs of the sinuses. 6. Treat allergic, eosinophilic, and vasomotor rhinitis and other forms of chronic non-infectious with antihistamines, decongestants, nasal steroids and cromolyn, nasal anticholinergics, and short bursts of systemic steroids. Avoid NSAID if sensitivity present. a) Refer to ENT or allergist if continued symptoms despite three months of treatment or if symptoms interfere with activities. 7. Remove ear wax with hydrogen peroxide, irrigation and curettement. 8. Treat nasal polyps with nasal steroids, appropriate short courses of systemic steroids, decongestants, and antihistamines. Institute environmental control if appropriate. Avoid NSAIDs. a) ENT or allergy referral appropriate if poorly responsive. 9. Diagnose and treat acute parotitis and acute salivary gland infections with antibiotics, heat and massage. a) Refer if unresponsive after ten days, shows indications of abscess formation, stone formation, or for two or more recurrences of parotitis. 10. In general, refer for: a) draining ear not responsive to treatment within ten days. b) oral lesions which are suspicious or non-healing after ten to fourteen days. c) parotid and other neck masses/cysts. d) acute or persistent hearing loss not attributable to fluid or wax. e) unexplained hearing loss f) hoarseness which persists for longer than three weeks. g) hemoptysis h) a foreign body that the PCP is unable to remove. i) unexplained facial palsy j) peritonsillar abscess requiring drainage k) vertigo with hearing loss or tinnitus l) sudden onset or asymmetrical tinnitus with abnormal audiogram m) nasal fractures with nasal obstruction, functional / cosmetic deformity within five to seven days after trauma. n) persistent hearing loss or delayed speech and articulation in children. PC MGMT - OTOLARYNGOLOGY PAGE 2 OF 2