ALL Suffolk Pre-Referral Guidance
ENT (tonsillitis, grommets, rhinosinusitis and dizziness)
This form should be attached electronically to your referral letter and any investigations (see below) and submitted via C&B to the
IHT Advice Letter Listing ENT Clinic.
Patient Information
GP Information
Name: Title Forename Surname
GP Name: Sender name
Address: Patient address house Patient address road Patient
address post town Patient post code
Practice address:
Tel (Home): Patient home telephone number
Tel (Mobile): Patient mobile telephone number
Tel:
NHS No: NHS number
Referral date: Todays date
DOB: Date of birth
Gender: Gender
Referrer name: Sender name
UBRN:
Referrer signature:
Fax:
Please tick the reason for referral and that the pre-referral tasks have been completed
Reason for referral
(tick boxes)
Tonsillitis
In ordinary circumstances, referral should not
be considered unless the patient meets the
NHS Suffolk threshold procedure guidance
PCT criteria
Low priority criteria
Pre-referral work up done and results sent with this referral
(tick boxes)
(Urgent hospital admission is required for patients with sore throat who have any of the
following symptoms; stridor, progressive difficulty swallowing, increasing pain or
severe systemic symptoms)
Grommets
In ordinary circumstances, referral should not
be considered unless the patient meets the
NHS Suffolk threshold procedure guidance
PCT criteria
Low priority criteria
Complete at least 3 months of watchful waiting
The otoscopic features are atypical and accompanied by a persistent foul-smelling
discharge suggestive of cholesteatoma (Urgent referral)
The child has excessive hearing loss suggestive of additional sensorineural deafness
(Urgent referral)
Child has persistent hearing loss AND the hearing loss is having a significant impact
on child’s developmental, social or educational status
Rhinosinusitis
Diagnosis based on patients with nasal
obstruction or nasal discharge/post nasal drip
plus one of the following - facial pain/pressure
OR changing sense of smell.
Nasal steroids, oral steroids, nasal saline irrigation and antihistamines and do use
antibiotics for the purulent form. Refer after for further investigation and possible
surgery.
Dizziness or imbalance

Could be due to vestibular, cardiovascular or
neurological causes. Referrals should be
made to the appropriate departments ENT for
vestibular disorders, neurologists for
neurological disorders or to cardiologists for
cardiovascular disorders
Perform a drug review - ?dizziness a side effect of medications
Check BP & pulse – if symptoms of dizziness on standing up, take BP lying & standing
(drop of 20 mm on standing ?postural hypotension)
Syncope/pre-syncope indicates cardiovascular, refer to cardiologists
Sensation of surrounding moving indicates vestibular, refer to ENT
If vestibular problems suspected perform Dix-Hallpike positional test to look for benign
paroxysmal positional vertigo (BPPV). If positive, try the Epley’s manoeuver first.
✔ Clinical Indication/Problem:
✔ Relevant Past Medical History - include previous & current treatment/medication where relevant (attached)
✔ Current Medication (attached)
✔ Allergies (attached)
Preferred Hospital if Referral to Secondary Care is Necessary: …IPSWICH HOSPITAL………………………………..
Title Forename Surname
Date of birth
Medical History
Summary
Past Summary
Allergies
Allergies
Medication
Current repeat TemplatesCurrent Repeat IssuesCurrent Repeat Templates
Current acute issuesCurrent Acute Issues
Recent pathology results
Recent Pathology
NHS number