UC Davis Health System
Clinical Telehealth Program Referral Guidelines
Pediatric and Adult
Otolaryngology
Clinical Telehealth Consultations
Clinics for comprehensive otolaryngologic care including otology, head and neck oncology, facial trauma,
nasal and sinus problems, sleep apnea, and laryngology. After consult, transcribed notes with assessment
and/or recommendations are sent to primary care provider.
Procedures requiring Nasopharyngoscopy
Clinical Condition
Tests prior to Consult
Allergies
RAST
Dyspagia
Hoarseness
Neck Mass (Adult-Scope)
Nasal Obstruction
Odynohphasia
Recurrent Epistaxis
Recurrent Sinusitis
Limited sinus CT
Rhinitis
RAST
Sinus Headache
Limited sinus CT
Sleep Apnea
Sleep study
Snoring (sleep study if obstructive sleep apnea is a possible diagnosis)
Otitis Media (nasopharyngoscopy needed in adults without a history of
ear problems)
Procedures requiring Otoscopy*
Clinical Condition
Cholesteatoma
Otitis Media with Effusion (in children)
Chronic Tonsillitis
Halitosis
Hearing Loss
Perforation
Recurrent Otitis Media
Recurrent Tonsillitis
Appointment Scheduling:
Nasopharyngoscopy
New: 30 min
F/U:
20 min
Otoscopy
New: 20 min
20 min
F/U:
Level of Presenter Required:
Primary Care Provider or Nurse to perform otoscopy
or endoscopy if needed.
Video Equipment Required:
1. Videoconferencing unit
2. Video Nasopharyngoscope and/or Video
Otoscope with camera and light source
Other Equipment Required:
1. Tongue blades 4% Lidocaine
2. ¼% solution Neosynephrine
Tests prior to Consult
Audiogram
Tympanogram
The following information must be received
prior to scheduling an appointment:
1. Telehealth Referral Request Form
2. See “Necessary Clinical Information” in left
column
Audiogram
Audiogram
Tympanogram
The following information must be received one
working day prior to the scheduled
appointment:
1. Patient Questionnaire
*Please have patient’s ears cleaned up to 7 days prior to
consult
Consultants: Rodney C. Diaz, MD, FACS
Travis T. Tollefson, MD, FACS
The following must be received before the
consult begins:
1. Signed UCDHS Acknowledgement of Receipt:
Notice of Privacy Practices form (new patients
only)
2. Documented verbal consent from patient for
participation in telehealth consultation
UCDHS Clinical Telehealth Program
Toll Free: (877) 430-5332
Referral Fax: (866) 622-5944
http://healthsystem.ucdavis.edu/cht/clinic/