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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
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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.
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