NECK MASS. Clinical history and examination: Document detail history of mass. Imaging: US or CT of neck

Transcription

1 ENT ENT Referral Referral Guidelines Guidelines Austin Health ENT Clinic holds fortnightly multidisciplinary meetings with Plastics/ Maxillary Facial and Oncology units to discuss and plan the treatment of patients with cancerous conditions. Department of Health clinical urgency categories for specialist clinics Referrals should be categorised as urgent if the patient has a condition that has the potential to deteriorate quickly, with significant consequences for health and quality of life, if not managed promptly. Semi Referrals should be categories as Semi Urgent that has the potential to deteriorate within days. Routine: Referrals should be categorised as routine if the patient s condition is unlikely to deteriorate quickly or have significant consequences for the person s health and quality of life if specialist assessment is delayed beyond one month. Exclusions: Out of catchment area policy. Nasal foreign body to be sent directly to Emergency Department (do not attempt to remove unless experienced). Acute Nasal Fracture to be sent directly to Emergency Department. NECK MASS Inflammatory (i.e. Painful) Completed head and neck examination indicated for sight of infection Consider FNA if unsure of diagnosis Document detail history of mass Imaging: US or CT of neck FBE, Cultures where indicated. Consider TB and cat scratch disease HIV testing if indicated, Toxoplasmosis titre if indicated, Glandular fever investigations

2 Non Inflammatory (i.e. painless) Is there hoarseness, dyspnoea or dysphagia Consider FNA Complete head and neck examination Detailed history of mass Refer to ENT or Endocrinology Dept. Imaging: Consider US of neck Open biopsy is contraindicated Thyroid Mass Completion of head and neck examination Check generalised or localised thyroid enlargement Document any signs of dysphagia, dyspnoea or hoarseness Imaging: Thyroid US Urgent Thyroid Mass can be also referred to Endocrinology Dept. TFTs

3 Persistent Nasal Obstruction Treat any associated allergy or sinusitis Assess symptoms unilateral/bilateral, altering post nasal discharge, recurrent sinusitis If offensive bloody discharge If not responding to treatment Intranasal examination after decongestion- polyps, deviated septum, enlarged turbinates NASAL AND SINUS Epistaxis- persistent or recurrent Educate patient on applying pressure on nostrils Consider cautery with silver nitrate Document medications- NSAIDS, aspirin, warfarin etc. Persistent bleeding refer to emergency Dept. Intranasal pack Recurrent episodes Assess whether bleeding in unilateral or bilateral Determine whether bleeding in anterior or posterior Determine if coagulopathy/platelets disorder or if Hypertension present

4 Salivary Gland Mass Evaluation of facial nerve function with parotid lesions Consider FNA Complete head and neck examination Chronic Sinusitis/Polyposis Trial antihistamines, antibiotics intranasal sprays Intranasal examination after decongestion Document symptoms, duration and treatments tried Imaging: CT scan If abnormal symptoms persist and/or abnormal findings Acute Sinusitis Trial Antihistamines, Intranasal steroids and/or antibiotics Assess signs of Unilateral or bilateral nasal congestion including: - Purulent discharge - Dental pain - Facial, forehead o periorbital - Persisting URTI >7 days Document symptoms, duration and treatments tried If treatment not successful Routine: If treatment relieving symptoms

5 Facial Pain Assess whether associated with significant: - nasal congestion or discharge - TMJ dysfunction - Dental pathology, sinus pathology - Intranasal deformity. If evidence of acute sinusitiscommence treatment Document symptoms, duration and treatments tried Routine: May include dental referral prior to ENT referral GENERAL PROBLEMS Nasal Congestion (unilateral-bilateral) Nasal Discharge (unilateral-bilateral) Diminished sense of smell Assess whether associated with significant: - nasal congestion or discharge - TMJ dysfunction - Dental pathology, sinus pathology - Intranasal deformity Document symptoms, duration and treatments tried Routine: May include dental referral prior to ENT referral Allergic Rhinitis Vasomotor Rhinitis Commence antihistamines Intranasal sprays Consider referral to allergy specialist If pt. has seen allergist- enclose skin prick results/rast Semi

6 PHARYNGEAL,TONSILITIS & ADENOID Acute tonsillitis Treat with antibiotics Document frequency of attacks Document tonsillar exudate Between 7-10 days Semi Post 10days Chronic tonsillitis Treat with antibiotics Document frequency of attacks Document tonsillar exudate More than 7 episodes in 1 year Peritonsilar cellulitis IM penicillin for adults Quinsy Mononucleosis Viral Pharyngitis Systemic steroids if severe dysphagia Mono test CBC Refer to ED if severe or dehydrated

7 Adenoiditis hypertrophy + Upper airway obstruction Start antibiotics Severe symptoms present directly to ED. Neoplasm Tonsillar haemorrhage If persistent bleeding refer immediately to ED. Call and ask for ENT Registrar HOARSENESS Hoarseness without associated symptoms or obvious aetiology Commence where indicated: - Rest voice - Antibiotics - Inhalant steroid sprays - Humidification and all alcohol and smoking history If symptoms persisting over 4wks

8 Hoarseness associated with neck trauma/thyroid surgery Hoarseness associated with upper respiratory Tract Infection Urgent Hoarseness associated with Respiratory obstruction and Stridor EARS Refer immediately to ED. Acute Otitis Media Start broad spectrum antibiotics Start Analgesia Children: start topical decongestants Adult: start systemic decongestants

9 Otitis Media with Effusion Glue Ear Start systemic antibiotics and at least one course B- Lactamase resistant antibiotic Urgent Acute Otitis Externia Apply topical antifungal therapy Start systemic antibiotics if cellulitis around canal. Insert wick if confident to do so Fungal swab of ear canal Urgent Foreign Bodies Remove if only technically able HEARING LOSS Urgent Bilateral Symmetrical hearing loss Cerumen dissolving ear drops Valsalva manoeuvres Audiometry Semi

10 Acute Sudden Hearing Loss Audiometry Unilateral Hearing Loss Audiometry TINNITUS Chronic Bilateral Clear cerumen Check TM-if clear no treatment Non urgent

11 Unilateral or recent onset Clear cerumen Check TM If persists refer Non urgent Pulsatile Urgent to rule out tumour DIZZINESS Chronic or Episodic History of pervious ear surgery Routine: Sudden onset associated with Barotrauma

12 Orthostatic Routine: Benign Positional Vertigo & Vestibular Neuronitis? Associated with URTI Audiology TM joint examination If persistent and increased severity FACIAL PARALYSIS Facial Paralysis Corneal abrasion-lacrilube & tape eye shut nocte Steroid treatment if no associated findings Anti-viral treatment if associated with vesicles

13 DYSPHAGIA Dysphagia Imaging: Chest x-ray Barium swallow Soft tissue studies of neck Thyroid studies