GP paediatric ENT referral guidelines - Women's and ... · Investigations ear discharge if present...
Transcript of GP paediatric ENT referral guidelines - Women's and ... · Investigations ear discharge if present...
Women’s & Children’s Hospital
Paediatric Ear Nose and Throat referral guidelines
Contents
Ears
Otitis Externa 2
Acute suppurative otitis media (ASOM) 3
Otitis media with effusion (glue ear) 4
Perforated eardrum 5
Nose/Sinus
Rhinorrhoea 6
Sinusitis 7
Epistaxis - recurrent 8
Throat
Hoarseness 9
Tonsillitis - recurrent 10
Snoring and Obstructive Sleep Apnoea 11
Other
Neck mass 12
Priority
Priority will be based upon the information provided in this referral. They will be triaged by a
Paediatric Ophthalmology Consultant according to the clinic process and booked accordingly:
Emergency: Proceed to the emergency department
Urgent: We aim to see these patients as soon as possible
Semi-urgent/ Next available appointment. Please note many routine referrals may not be
routine: seen at present due to the increasing demand on the service
To help us best triage your referral, it may be returned for further investigations if the following
process has not been adhered to.
Please note this is a guideline for referral only. If concerned about a patient please
contact the ENT Registrar via switchboard on 8161 7000.
Mandatory referral
content
Demographic
child’s name
date of birth
parent/guardian contact details
referring GP details
interpreter requirements
Clinical
reason for referral
clinical urgency
duration of symptoms
management to date
and response to treatment
relevant pathology,
imaging and audiology reports
past medical history
current medications
functional status
family history
Page | 2
Ears
Otitis externa – all ages
Initial pre-referral workup GP management Guidelines for specialist referral
Clinical history
usually due to water
contamination following
swimming
children with dermatitis of the external ear canal
Physical examination
presents with inflammation of
the ear canal and pre-auricular tenderness
if copious mucus or pus
consider perforated tympanic
membrane
hearing loss
Investigations
swab ear discharge for
microscopy/culture and sensitivity
reassure parents
education on protecting
ears from water
exposure
topical antibiotics
systemic antibiotics are
rarely required
Medical guideline
WCHN ear infections
medical guideline
Kids information
Swimmer's ear
Parent information
Otitis Externa - swimmer's ear
Emergency
ear canal is swollen shut
and antibiotic eardrops
cannot enter the ear canal
cellulitis has extended
beyond the ear canal in
which case the child will need IV antibiotics
Semi-urgent / routine
ear pain is severe and
not relieved by regular simple analgesia
send pathology results if
known, documentation
of clinical course and treatment and response
Page | 3
Otitis media – acute suppurative otitis media (ASOM)
Initial pre-referral workup GP management Guidelines for specialist
referral
Clinical history
very often preceded by a viral respiratory tract infection
Physical examination
middle ear effusion – loss of
normal tympanic membrane translucency
yellowish discolouration or bulging of tympanic membrane
PLEASE NOTE - be cautious
of accepting Acute Supprative
Otitis Media (ASOM) as the
sole diagnosis in an unwell
infant with a fever
Investigations
ear discharge if present – swab
for culture/sensitivity if indicated
reassure parents
adequate analgesia
acute symptoms usually
resolve within 24 hours in most cases
Medical guideline
SA Health Paediatric
Practice Guidelines –
Acute Otitis Media in
Children
WCHN ear infections medical guideline
Kids information
Looking after your ears
Parent information
middle ear infection
Aboriginal ear health
Emergency
mastoiditis with facial
nerve palsy, dizziness,
meningitis must be
referred immediately
to the Paediatric
Emergency
Department and/or
discussed with the ENT Registrar on call
send pathology results if known
Semi-urgent / routine
if medical treatment has
been unsuccessful and
the child remains symptomatically unwell
more than 3 episodes of
acute otitis media in
6 months or more than
4 episodes in a 12 month period
send pathology results if
known, documentation
of clinical course and treatment and response
PLEASE NOTE - a simple
perforation of the ear drum
as part of an acute otitis
media does not require a
referral unless there are
ongoing concerns after 6 weeks.
Page | 4
Otitis media with effusion (glue ear)
Initial pre-referral workup GP management Guidelines for specialist
referral
Clinical history
hearing loss, balance and
coordination problems, speech and language delay
Physical examination
middle ear effusion – loss of
normal tympanic membrane
translucency
Investigations
consider audiometry
reassure parents
(80 -90% of cases will
spontaneously resolve in
3 months)
antihistamines,
decongestants and
antibiotics have no
beneficial effect in the
management of otitis
media with effusion
(OME)
review at 3 months - for
persistent middle ear effusion or hearing loss.
educate parents on
management of
environmental factors (until definitive surgery)
Medical guideline
WCHN ear infections medical guideline
Kids information
Looking after your ears
Parent information
Aboriginal ear health
middle ear infection
Semi-urgent / routine
send documentation of
clinical course, treatment and response
if hearing tests have
been performed send
with referral
Page | 5
Perforated ear drum
Initial pre-referral workup GP management Guidelines for specialist
referral
Clinical history
causes of a perforated eardrum
are usually from trauma or infection
if possible, ensure any foreign body is removed from ear canal
Physical examination
hole in the tympanic membrane
chronic or recurrent ear discharge
hearing loss
Investigations
audiogram (if possible)
reassure parents
topical antibiotic
eardrops for discharging ear (e.g. Ciprofloxacin)
advise to keep ear dry
Semi-urgent / routine
ongoing discharge for greater than three weeks
failure of dry perforation to heal after two months
all non-acute long term
perforated ear drums
should be referred
send pathology results if
known, documentation
of clinical course and treatment and response
PLEASE NOTE - a simple
perforation of the ear drum
as part of an acute otitis
media and does not
require a referral unless
there are ongoing concerns after 6 weeks.
Page | 6
Nose
Rhinorrhoea (in younger children)
Initial pre-referral workup GP management Guidelines for specialist referral
Clinical history
establish if chronic –
persistent symptoms (more
than 8 weeks, recurrent or more than episodes a year)
nasal obstruction
nasal discharge
facial pain/ frontal headaches
disturbance of smell and taste
rule out allergic rhinitis
Physical examination
swollen mucosa
secretions – if discoloured this
does not necessarily indicate an infection
in children, unilateral foul-
smelling discharge suggests a
nasal foreign body. If no
foreign body is seen, sinusitis
is suspected when purulent
rhinorrhoea persists for 10
days along with fatigue and a cough
Investigations
none required
older children – CT to confirm
condition (ideally following a
full course of medical
management)
younger children - consider
x-ray of sinuses and post nasal space
reassure parents
manage co-existing allergies
manage environmental
factors
treat any acute bacterial
infection
saline rinse/irrigation (not spray)
allergy testing if indicated
topical steroid nasal
sprays for perennial and
seasonal allergic rhinitis,
as well as perennial non-
allergic rhinitis. (Long term
use has not been shown
to cause suppression of
the hypothalamicpituitary – adrenal axis)
in seasonal rhinitis –
commence spray one
month prior to the relevant
pollen season and
continue over the
symptomatic period
antihistamines – do not
use as a first line
treatment but may be
used for seasonal rhinitis
Kids information
your nose
Emergency
unilateral discharge
suspicion of foreign
body must be referred
immediately to the
Paediatric Emergency
Department and/or
discussed with the ENT Registrar on call
Semi-urgent / routine
assessment by ENT Consultant/Registrar if:
adenoidal
hyperplasia
suspected
rhinorrhoea not
responsive to
treatment
assessment by allergist
if history suggestive of
allergy
send any x-rays if
completed
send pathology results if
known, documentation
of clinical course and
treatment and response
Page | 7
Sinusitis (in older children)
Initial pre-referral workup GP management Guidelines for specialist
referral
Clinical history
history and physical
examination may be non-contributory
signs of sinusitis include:
post nasal drip
Rhinorrhoea
facial, periorbital, and frontal pain
disturbance of smell and taste
establish if chronic – persistent
symptoms more than 8 weeks,
recurrent or more than 3 episodes a year)
Physical examination
unilateral or bilateral nasal
congestion, usually evolving
from a viral upper respiratory
tract infection
Investigations
CT scan rarely indicated
reassure parents
manage co-existing allergies
manage environmental factors
treat any acute bacterial infection
saline rinse/irrigation (not spray)
allergy testing if
indicated
topical steroid nasal
sprays for perennial and
seasonal allergic rhinitis,
as well as perennial non-
allergic rhinitis. (Long
term use has not been
shown to cause
suppression of the
hypothalamicpituitary – adrenal axis)
in seasonal rhinitis –
commence spray one
month prior to the
relevant pollen season
and continue over the symptomatic period
antihistamines – do not
use as a first line
treatment but may be
used for seasonal rhinitis.
Parent information
sinusitis
Emergency
complications of
sinusitis such as
severe pain, ocular
problems, forehead
swelling or
drowsiness must be
referred immediately
to the Paediatric
Emergency
Department and/or
discussed with the ENT Registrar on call
Semi-urgent / routine
persistent symptoms
despite 6 weeks of
appropriate treatment
where sinusitis is
persistent and seems to
exacerbate asthma symptoms
send any x-rays and/or
CT if done
send pathology results if
known, documentation
of clinical course and treatment and response
Page | 8
Epistaxis – recurrent
Initial pre-referral workup GP management Guidelines for specialist
referral
Clinical history
rule out allergic rhinitis
if suspecting blood disorder:
Patient history (i.e.
bruising, bleeding)
Family history
Physical examination
determine whether bleeding is
unilateral or bilateral
anterior or posterior
determine if coagulopathy,
platelet disorder or hypertension is present
Investigations
blood tests – (FBE, PT, APTT) if indicated by history
reassure parents
trial of antibiotic/ steroid
ointment/ to anterior
septum twice a day for
one week
observation of side
acute bleeding usually
settles with local
pressure to the lower nasal septum
avoidance of
precipitating factors such
as nose picking
Kids information
Uh- oh my nose is
bleeding
Parent information
Nose bleeds
Emergency
intractable epistaxis
despite appropriate
first-aid measures
must be referred to the
Paediatric Emergency
Department and/or
discussed with the ENT Registrar on call
Semi-urgent / routine
not responding to
conservative
management i.e. no
nose picking, strong
nose blowing,
application of topical
nasal steroid
epistaxis that is severe
or occurs frequently
send blood tests results
if known, documentation
of clinical course and
treatment and response
Page | 9
Throat
Hoarseness
Initial pre-referral workup GP management Guidelines for specialist referral
Clinical history
duration, onset and pattern of
symptoms; check the patient's
meaning of 'hoarseness'
rule out associated viral or
bacterial infection
signs of airways obstruction
history of overuse of voice
(shouting/yelling)
history of vocal cord cysts or nodules
history of gastro-oesophageal reflux
Physical examination
throat pain
dysphagia
stridor – refer to emergency
referral
signs of airway obstruction
laryngeal function - listen to the
patient's voice, and assess
cough and swallowing.
examine the neck - scars,
lymph nodes, thyroid gland.
Localised tenderness or may radiate to ear
treat any associated bacterial infection
observe for viral
infections – supportive management
voice rest
if presumed
inflammatory aetiology
consider a short course
of steroids
Emergency
hoarseness associated with:
neck trauma or
surgery
moderate or severe
stridor
must be referred to the
Paediatric Emergency
Department and/or
discussed with the ENT Registrar on call
Semi-urgent / routine
2 months of moderate to severe hoarseness
prolonged voice loss
Page | 10
Tonsillitis – recurrent
Initial pre-referral workup GP management Guidelines for specialist referral
Clinical history
most sore throats are due to
a viral infection
Physical examination
throat pain and/or pain on
swallowing plus the presence of:
fever
tonsillar exudate
cervical lymphadenopathy
Group A beta-hemolytic
streptococcal (GABHS) is
likely if the following are
present:
tender and enlarged
tonsillar cervical lymph nodes
inflammation of the
tonsils and the rest of
the pharynx
generalised
erythematous (scarlatiniform) rash
Investigations
consider throat swab
viral – supportive management
bacterial – antibiotics
Kids information
Tonsillitis - when your
throat is often sore
Parent information
Tonsillitis
Emergency
complications of
tonsillitis such as quinsy
(peritonsillar abscess)
and/or airway obstruction
must be referred to the
Paediatric Emergency
Department and/or
discussed with the ENT Registrar on call
Semi-urgent / routine
refer if:
4 - 6 infections in 1 year
4 infections/year for 2 consecutive years
3 infections/year for 3 consecutive years
it is acceptable to take into
account the impact of the
child’s frequency and
severity of infections upon
child’s attendance at
school and parents attendance at work
send blood tests results if
known, documentation of
clinical course and treatment and response
Page | 11
Snoring and Obstructive Sleep Apnoea
Initial pre-referral workup GP management Guidelines for specialist referral
Clinical history
parental observations and
description of sleep patterns
snoring
restlessness
snorting arousals or apnoeic episodes
disturbed sleep
enuresis
daytime symptoms
Somnolence
Irritability
hyperactivity
gagging on solid food in
presence of very large tonsils
enuresis
Physical examination
larger tonsils
nasal obstruction
craniofacial abnormality
nil GP management
recommended
Urgent
proven Obstructive
Sleep Apnoea
co-existing craniofacial
abnormality
snoring with obvious
obstructive features
(apnoea/choking)
associated with failure to thrive
Semi-urgent / routine
witnessed sleep apnoea
tonsils meeting in the
midline +/- trouble
swallowing from large tonsils
excessive day-time
sleepiness
chronic intermittent
snoring with no
reference to any
symptoms of Sleep
Disordered Breathing
mouth breathing all the time
PLEASE NOTE – referral
is based on symptoms not
size of tonsils and will be
triaged as per urgency by the ENT Consultant
For more information
Women’s and Children’s Hospital 72 King William Road North Adelaide SA 5006 Telephone: (08) 8161 7000 www.wch.sa.gov.au
© Department of Health, Government of South Australia. All rights reserved. Printed September 2014.
Other
Neck mass
Initial pre-referral workup GP management Guidelines for specialist referral
Clinical history
history of tenderness with
associated dysphagia,
dysphonia, draining sinus, fever, or increasing neck mass
Physical examination
observe for:
fluctuance
erythema
airway distress
Investigations
ultrasound of neck with notation of thyroid gland
thyroid function test if needed
full blood evaluation
reassure parents
treat infections
Emergency
the following
symptoms must be
referred immediately to
the Paediatric
Emergency
Department and/or
discussed with the ENT Registrar on call:
any signs of
infection, including
fever, redness, swelling or pain
any pain that is not
controlled with the
prescribed pain medicine
a mass or lump in
the centre of the
neck
Semi-urgent / routine
swelling that does not
respond to a course of antibiotics
send blood tests results
if known, documentation
of clinical course and
treatment and response