ENT Referral Advice for Primary Care Providers

1. Advice for Primary Care Referrers to ENT Mr. Mark Draper

2. Nasal Blockage • Initial Rx with ≥ 4/52 topical nasal steroid • Any patient on regular decongestants needs to stop for ≥ 2/52 • Rx TNS e.g. Flixonase during this 2/52 period • (slightly reduces rebound effect) • Reassess. If still symptomatic consider GPwSI referral • If obvious DNS or severe external deformity – refer 2o care

3. Nasal Fracture • Wait 5 days for swelling to subside slightly • If deviation and wants realignment, refer to 2o care via Emergency ENT clinic • (contact on-call SHO during office hours)

4. Nasal Fracture • Wait 5 days for swelling to subside slightly • If deviation and wants realignment, refer to 2o care via Emergency ENT clinic • (contact on-call SHO during office hours)

5. Rhinorrhoea • Initial treatment with ≥ 4/52 topical nasal steroid spray +/- oral antihistamine • If coloured discharge then use saline/bicarbonate douching plus 2 weeks oral ABs (Co-Amoxiclav or Clarithromycin) • Referral suitable for GPwSI

6. Douching

7. Hyposmia/Anosmia • Initial Rx with ≥ 4/52 topical nasal steroid • Referral suitable for GPwSI

8. Rhinitis • Large variability of response to differing TNS sprays. • Trial ≥ 2 different sprays + oral AH prior to considering referral • Flixonase, Nasonex & Avamys tend to be more successful than Beconase • Consider Dymista spray as 2nd line treatment • Referral suitable for GPwSI

9. Epistaxis

10. Age >10 yrs <10 years Bleeding point seen 2/52 Naseptin Cream Yes No Success Failure 2/52 Naseptin Cream Cautery Discharge Failure Success Success Failure Discharge Crusting / Vestibulitis ? No Yes Discharge Success 2/52 Bactroban Ointment Failure Refer

11. Cautery Tips • Lignocaine/Phenylephrine spray • Cotton wool soaked into nostril • Leave for 15 minutes • Fresh AgNO3 stick for each application • May take 48-36 hrs for full effect

12. Facial Pain • If no nasal blockage or rhinorrhoea, then extremely unlikely to be sinus/nose related

13. (European Position Paper on Rhinosinusitis and Nasal Polyps 2007) • Inflammation of nose + sinuses characterised by ≥ 2 symptoms, one of which should be either nasal blockage/ obstruction/ congestion or nasal discharge (anterior/ posterior nasal drip): • ± Facial pain or pressure, • ± Hypo / anosmia; • AND EITHER signs of: • Polyps and/or; • Mucopus primarily from middle meatus and/or; • Oedema/mucosal obstruction primarily in middle meatus, • AND / OR CT changes: • Mucosal changes within OMC and / or sinuses

14. Facial Pain • If no nasal blockage or rhinorrhoea, then extremely unlikely to be sinus/nose related • Consider myofascial syndrome / tension-related disorders • Referral suitable for GPwSI

15. Hoarseness • Intermittent • Consider voice care advice +/- PPI / Reflux advice www.britishvoiceassociation.org.uk • Referral suitable for GPwSI / 2o care • Constant • Refer via 2WW pathway

16. Globus Pharyngeus • Are there red flag symptoms? • Pain, true dysphagia, weight loss, constant dysphonia • Smoker • If sensation of lump and intermittent without pain or true dysphagia, consider reflux / PPI trial • Referral suitable for GPwSI

17. ‘Catarrh’ / ‘Post nasal drip’

18. ‘Catarrh’ / ‘Post nasal drip’ • Most likely globus-type diagnosis • If no nasal symptoms, extremely unlikely to be related to nose/sinus. • Psychogenic viscious circle • Advise re Voice care / Stop Throat Clearing / Reflux advice / PPI trial • Referral suitable for GPwSI

19. Snoring • If unconnected to nasal blockage – Do not refer to ENT • ‘Simple’ snoring • Wt loss, alcohol, mandibular advancement splint www.britishsnoring.co.uk • Suspected OSA • Respiratory Department referral