ENT REFERRAL
MANAGEMENT:
GUIDANCE FOR GENERAL
PRACTITIONERS
VERSION2
June2012
CONTENTS
1.0 Introduction
Page 3
2.0 ENT Consultants and Sub-specialisation
Page 3
3.0 Common Ear Conditions
3.1 Tuning Fork Tests
Page 5
Page 9
4.0 Common Nasal Conditions
Page 10
5.0 Common Throat Conditions
Page 12
6.0 Other ENT Emergencies
6.1 Facial Nerve Palsy
6.2 Stridor
Page 15
Page 15
Page 15
7.0 Emergency/ Urgent clinics
7.1 One Stop Lump & Bump Clinic
7.2 Emergency Clinic
Page 15
Page 16
2
1.0 Introduction
This referral management guidance document has been produced in collaboration with
Barts and the London ENT Consultants and representation from Tower Hamlets PCT GPs
(especially Mr Nick Eynon Lewis, Dr Rajia Khatun, Dr Shera Chok and Dr Ricardo Cabot)
as well as the BLT/PCT ENT Steering Group to give GPs an overview of ENT referral
management guidance.
A similar document was produced in April 2002 by a joint BLT/PCT ENT Group; the aim of
the document was to give GPs support in when to refer to secondary care. This remit still
applies to this version; however in addition, hyperlinks to accredited websites have been
inserted to each section to provide further clinical information which you can access as
required. This document is intended only as guidance for management of common ENT
conditions seen in primary care and when patients should be referred on to the ENT
department. This guidance document also portrays the expertise and knowledge of
clinical experts in Barts and the London NHS Hospital Trust.
For ease of reference, the names of the consultants, their sub-specialisations and
important contacts are detailed below.
For further prescribing support, please refer to the BNF website on: http://www.bnf.org/bnf/
2.0 ENT Consultants and their Sub-specialisation
CONSULTANT
Mr Santdeep Paun
Mr Mike Dilkes
Mr Mike Wareing
Mr Ghassan Alusi
Mr Khalid Ghufoor
Mr Nick Eynon-Lewis
Miss Kay Seymour
Mr Yogesh Bajaj
SUB-SPECIALISATION
Clinical Lead
Rhinology and Facial Plastic Surgery
Head & Neck tumour surgery
Otology, Neuro-otology, Voice surgery
Thyroid surgery, Head & Neck tumour surgery, Rhinology
Head & Neck tumour surgery, laser airway surgery, Paediatric ENT
Otology, Voice, Rhinoplasty,
Paediatric ENT, Otology
Paediatric ENT, General adult ENT
Paediatric patients are only seen by the stated paediatric consultants.
3
Important Contact details:
Consultant ENT Surgeons
Medical Secretary
Mr Mike Dilkes
Mike.Dilkes@bartshealth.nhs.uk
0203 594 1206
Mr Eynon-Lewis
Nicholas.EynonLewis@bartshealth.nhs.uk
0203 594 1206
Mr Mike Wareing
Mike.Wareing@bartshealth.nhs.uk
0203 594 1207
Mr Gus Alusi
Ghassan.Alusi@bartshealth.nhs.uk
0203 594 1207
Mr Khalid Ghufoor
Khalid.Ghufoor@bartshealth.nhs.uk
0203 594 1207
Mr Santdeep Paun
Santdeep.Paun@bartshealth.nhs.uk
0203 594 1193
Mrs Kay Seymour
Kay.Seymour@bartshealth.nhs.uk
0203 594 1193
ENT Associate Specialists
Medical Secretary
Mr Tapas Goswami
Tapas.Goswami@bartshealth.nhs.uk
0203 594 1198/1201
Mr Pishtiwan Mirza
Pishtiwan.Mirza@bartshealth.nhs.uk
0203 594 1193
REFERRALS
 Very urgent non cancer
call on-call ENT Registrar via switchboard, 020 7377
7000

Cancer 2 week wait
target referral for cancer,

Urgent
Choose and Book or referral letter to ENT Department

Routine
Choose and Book or referral letter to ENT Department
Key to urgency column:
* Urgent
** Cancer
*** Emergency/A&E
4
3.0 Common Ear Conditions
Urgency
Condition
1.
Acute Otitis
Media
GP Management
Refer To
Treat each attack symptomatically with
analgesia. If no improvement after 72
hours, prescribe broad spectrum
antibiotics e.g. amoxicillin for 5 days.
Start antibiotics at presentation if
systemically unwell e.g. high
temperature and vomiting (SIGN
2003).
If tympanic membrane not visible reexamine in two weeks. If perforation
seen, further review needed. If more
than 4 episodes in 6 months then refer
to ENT.
2.
Recurrent
Acute Otitis
Media
http://www.sign.ac.uk/pdf/qrg66.pdf
If problems continue e.g. more than 4
episodes in 6 months refer to ENT
(SIGN 2003, NICE pilot).
Any paeds
consultant for
children
Consultant to consider ventilation
tubes (grommets) or prophylactic
antibiotics
http://www.sign.ac.uk/pdf/qrg66.pdf
3.
Glue ear in
childhood
Persistent
hearing
problems or
language
delay.
Recurrent
earaches.
*
4.
Chronic
Supurative
Otitis Media
(with or
without
Cholesteatom
a)
Hearing loss,
abnormal or
Refer to the Community Paediatric
Audiology Service for assessment at
Steel’s Lane
Any paeds
consultant for
children
http://www.sign.ac.uk/pdf/qrg66.pdf
Refer to ENT consultant for further
assessment and diagnosis. Surgery
may be indicated for straightforward
perforation and is usually indicated for
cholesteatoma.
Traumatic perforations can be treated
by keeping the ear dry and observing
for 6 weeks, if they fail to heal, referral
is indicated.
5
Wareing
Eynon-Lewis
Seymour
Urgency
Condition
perforated
eardrum, or
offensive
discharge
**
GP Management
http://www.gpnotebook.co.uk/simplepa
ge.cfm?ID=-435814389
5.
Acute Otitis
Externa
Discharge
with
oedematous
painful ear
canal
Aural toilet then ear drops containing
antibiotics and steroids for 7 days. If
systemically unwell, evidence of
spreading infection to the pinna or if
there is no improvement with the
above measures then the patient
should be referred to the emergency
clinic.
http://www.prodigy.nhs.uk/otitis_extern
a/view_whole_guidance
6.
Chronic
Otitis
Externa
Painless
persistent
discharge or
itching with
intact ear
drum
Advise against using buds and
avoiding getting water in ears. Aural
toilet. Take swab for microscopy
culture and sensitivity and treat
accordingly.
Unilateral
Earache
without
Otological
signs
Exclude obvious causes e.g. tonsillitis,
temporomandibular joint or dental
problems. In absence of clear cause,
treat symptomatically.
7.
Wax
Impaction
Cause of
reversible
hearing loss
and otalgia.
Wareing
Eynon Lewis
Seymour
If unable to control refer routinely to
ENT
http://www.prodigy.nhs.uk/otitis_extern
a/view_whole_guidance
Dilkes
Alusi
Ghufoor
Refer for ENT assessment if symptoms
persist beyond 3 weeks, since there
may be an underlying Head and Neck
cancer, particularly if associated with
dysphagia, lump in neck or hoarseness
(Fax in a cancer referral form).
8.
Refer To
The different types of drops to soften
wax such as bicarbonate and olive oil
are probably all about equally effective.
Wax can be removed by syringing (if
the ear drum is intact) or by
microsuction if equipment and
expertise is available.
Advice to avoid using buds should also
be given.
6
Urgency
Condition
GP Management
Refer To
http://www.prodigy.nhs.uk/earwax/view
_whole_guidance
www.entnursing.com
9.
Tinnitus
Exclude obvious local causes such as
wax impaction. If healthy tympanic
membrane, review after 4 weeks. If
symptoms persist and are troublesome
refer to ENT consultant.
Wareing
Eynon Lewis
Seymour
Refer all unilateral tinnitus as rarely
this can be a presentation of acoustic
neuroma.
http://www.gpnotebook.co.uk/simplepa
ge.cfm?ID=26542053&linkID=56408&cook=yes
www.tinnitus.org.uk
10. Acute
vertigo
Requires ENT and neurological
examination by GP. Treat with
vestibular sedatives such as
prochlorperazine (po/ IM injection) or
Buccastem.
If severe and vomiting refer to A & E. If
mild but persists for more than 6 weeks
consider ENT or neurological referral.
http://www.entuk.org/patient_info/ear/di
zziness_html
http://www.icms.qmul.ac.uk/chs/Docs/6
3538.pdf
11. Chronic
Unsteadines
s /Dizziness
The history is usually the key to the
diagnosis. Patients require a multisystem assessment including
cardiovascular, ENT and neurological
examination as appropriate.
Consider referral to appropriate
specialist such as ENT/ Neurology/
Elderly Care etc.
7
Wareing
Eynon Lewis
Seymour
Urgency
Condition
GP Management
Refer To
http://www.gpnotebook.co.uk/simplepa
ge.cfm?ID=-1348861947
12. Hearing loss
a)
***
b)
c)
d)
Sudden
unilateral
conductive
hearing loss
caused by
ET
dysfunction
or middle
ear fluid
May follow
URTI/air
flights/diving.
Diagnose
with tuning
fork tests and
clinical
examination
Topical nasal decongestant e.g.
xylometazoline hydrochloride bd for 1
week with nasal steroid for 4 weeks or
a combination spray e.g DexaRhinaspray bd for 2 weeks. Gentle
“auto inflation” of middle ear if possible
may help.
Sudden
unilateral
sensorineural
hearing loss
with normal
tympanic
membrane
Refer to ENT doctor on call. This
needs to be seen urgently as early
treatment may improve prognosis.
Over 65
years old
with bilateral
hearing loss
Other forms
of hearing
loss
Refer to Hearing Aid service/clinic at
the Audiology department
If continued problems after 4 weeks
refer to ENT consultant.
(Remember Nasopharyngeal
carcinoma can present with unilateral
middle ear fluid)
http://www.gpnotebook.co.uk/simplepa
ge.cfm?ID=-389021685
Refer routinely to ENT Consultant for
assessment.
Wareing
Eynon-Lewis
Seymour
http://www.gpnotebook.co.uk/simplepa
ge.cfm?ID=1214971909
3.1 TUNING FORK TESTS (512 HZ TUNING FORK)
8
These can be helpful in the clinical assessment of hearing impairment but need to be
taken in the context of the history, examination and audiometry if available
Rinne's Test: Vibrate the fork gently by striking it on your elbow, then hold the fork parallel
to the side of the head so that the end of the nearest tine is held 1cm from the entrance of
the ear canal. Ask patient to compare the loudness heard when doing this compared with
the loudness heard when the fork base is placed firmly on the adjacent mastoid tip. A
positive test is when the former is loudest, a negative test is when the mastoid is loudest
(signifies possible conductive hearing loss although can be negative in a dead ear as the
sound is transmitted to the opposite cochlea i.e. false negative)
Weber's Test: Vibrate the fork as before, place it with the base firmly on the forehead. If
the patient hears the sound in only one ear this may indicate one of 2 things – either the
ear in which it is heard has a conductive loss or the ear in which it is not heard has a
sensori-neural loss.
PICTURE
9
4.0 COMMON NASAL CONDITIONS
Urgency
***
Condition
1.
Fractured
Nose
GP Management
Refer To
Following injury, check for complications
such as other facial fractures, diploplia
and septal haematoma. If there are none
review the patient in 5 days. If there is a
new deformity refer to the next day’s
emergency clinic. Nasal fractures
generally require manipulation within 2
weeks.
Emergency
clinic
http://www.entuk.org/patient_info/nose/in
juries_html.
***
2.
Nose Bleeds
a)
Childhood
recurrent
b)
Adult
1) Naseptin cream or mupirocin 2%
ointment to Little’s area twice daily
for 10 days. Advise against nose
picking.
2) Consider performing Silver Nitrate
cautery to Little’s area in GP surgery
after local anaesthetic, e.g. Xylocaine
spray, then prescribe Naseptin
antibiotic cream. Advise against
nose picking.
3) Refer to ENT consultant if not
controlled.
http://www.gpnotebook.co.uk/simplepag
e.cfm?ID=1818951686
http://www.entuk.org/patient_info/nose/tu
mours_html
1) For intermittent short-lived bleeds,
manage as above if bleeding point is
on the anterior septum.
2) For prolonged or severe epistaxis
attempt nasal packing if possible and
refer to ENT doctor or Accident &
Emergency Department depending
on severity, for further management.
http://www.gpnotebook.co.uk/simplepag
e.cfm?ID=1818951686
http://www.entuk.org/patient_info/nose/tu
mours_html
10
Bajaj
Seymour
Ghufoor
Paun
Eynon Lewis
Ausi
Bajaj
Seymour
Urgency
Condition
GP Management
3.
Sinusitis
Examine nose for obvious purulent
discharge and assess maxillary
tenderness.
a)
Acute
maxillary
Many are viral and will resolve without
antibiotics. Oral analgesia may be
required.
If severe or persistent, treat with
augmentin or erythromycin.
Refer To
Refer to ENT emergency clinic if
symptoms worsen in spite of medical
treatment. Patient may require antral
drainage. Chronic problems refer to
ENT department
http://www.gpnotebook.co.uk/simplepag
e.cfm?ID=1678114826
http://www.gpnotebook.co.uk/simplepag
e.cfm?ID=2120941596&linkID=21882&c
ook=yes
b)
Chronic
Examine as above. Treat patients with
topical steroid drops such as
betamethasone for 3 weeks followed by
topical steroid sprays for a further 3
weeks. Consider asking to douch with
alkaline salty solution (OTC such as
sterimar / sinus rinse or can be made up
by patient). Add antihistamines if allergic
symptoms. If symptoms persist despite
this, refer for specialist opinion.
Paun
Alusi
Eynon Lewis
Bajaj
4.
Nasal
Obstruction
11
Urgency
**
Condition
a)
Unilateral
and always
on the same
side
GP Management
Refer To
Trial of topical steroid spray such as
mometasone or fluticasone for at least 8
weeks with antihistamine if possible
allergy e.g hay fever.
Refer to ENT consultant. Often a
deviated septum.
Paun
Alusi
Eynon Lewis
Bajaj
Refer urgently if any worrying
symptoms such as pain or bleeding
which may indicate a tumour.
(Fax in a cancer referral form)
http://www.gpnotebook.co.uk/simplepag
e.cfm?ID=241893387
b)
Bilateral or
alternating
sides
(usually
allergic or
vasomotor
rhinitis,
polyps, or
adenoid)
Trial of topical steroid spray such as
Beclomethasone for at least 8 weeks
with antihistamine if possible allergy e.g
hay fever.
If symptoms persist refer to ENT for
assessment and allergy tests as
required.
http://www.ncbi.nlm.nih.gov/entrez/query
.fcgi?cmd=Retrieve&db=pubmed&dopt=
Abstract&list_uids=15725193&query_hl=
15
http://www.gpnotebook.co.uk/simplepag
e.cfm?ID=959446990&linkID=63777&cook=yes
5.0 COMMON THROAT CONDITIONS
12
Paun
Alusi
Eynon Lewis
Bajaj
Urgency
Condition
1.
Acute
Tonsillitis
GP Management
Refer To
Treat with analgesics, hydration and
antibiotics if failure to resolve. Choice of
antibiotic is controversial but Penicillin V
will cover Streptococcus pyogenes and
is usually a good first line.
On call
as
required
Consider Infectious Mononucleosis .
Refer to ENT for possible tonsillectomy,
if a 3 year history of at least 4 attacks
per year or significant disruption to life.
http://www.cks.library.nhs.uk/sore_throa
t_acute/in_depth/management_issues
***
2.
3.
Quinsy
Usually
Unilateral
peri-tonsillar
swelling,
dysphagia
and “hot
potato voice”
Hoarseness/
loss of voice
https://entuk.org/ent_patients/throat_con
ditions/tonsil_surgery
Refer to Emergency clinic or ENT doctor
on call.
http://www.gpnotebook.co.uk/simplepag
e.cfm?ID=1778778125
If this arose following upper respiratory
infection/laryngitis consider treatment
with broad-spectrum antibiotics, voice
rest for 4 days and steam inhalations.
If hoarse voice persists beyond 3 weeks
or is not associated with URTI refer to
ENT consultant urgently.
(Fax in a cancer referral form)
Patients with long-standing hoarseness
can be referred to a voice clinic.
http://www.gpnotebook.co.uk/simplepag
e.cfm?ID=1221591081
http://www.entuk.org/patient_info/throat/
hoarseness_html
http://www.mrw.interscience.wiley.com/c
ochrane/clsysrev/articles/CD005054/fra
me.html
13
Ghufoor
EynonLewis
Urgency
Condition
4.
Sensation of
lump in
throat
Able to
swallow
solids and
liquids
normally
GP Management
Examine pharynx for gross abnormality
and palpate neck for lumps.
If no other risk factors such as smoking,
a trial of antireflux therapy such as
lansoprazole for 2 weeks may be worth
trying prior to referral.
If history suggests the need to examine
the lower throat region refer to ENT
consultant for subsequent assessment.
Refer To
Dilkes
Ghufoor
Alusi
If neck lump or ulceration in pharynx
refer urgently to ENT consultant
(Fax in a cancer referral form)
http://www.gpnotebook.co.uk/simplepag
e.cfm?ID=315293621&linkID=56500&cook=yes
**
5
Foreign
Body Throat
Acute pain
and
Dysphagia
This usually requires referral to
emergency clinic or ENT Registrar on
call. It may be possible to remove a FB
such as a fish bone from the oropharynx
in your surgery.
If patient develops stridor then will
require ambulance to A & E
6.
True
Dysphagia
For liquids or
solids
Usually with
weight loss
Refer urgently to ENT consultant if
present for more than 3 weeks
(fax in a cancer referral form)
Dilkes
Ghufoor
http://www.gpnotebook.co.uk/simplepag
e.cfm?ID=315293621&linkID=56500&cook=yes
14
Alusi
6.0 OTHER ENT EMERGENCIES
6.1 Facial Nerve palsy *
Identify if upper or lower motor neurone (if there is sparing of the forehead, it is upper).
Upper motor lesions need urgent referral to neurology; lower motor lesions need basic
ENT assessment – exclude parotid gland neoplasm, middle ear abnormality. Look for
vesicles on the TM or in the ipsilateral throat – these signify possible Ramsay-Hunt. If the
lesion if felt to be traumatic, immediate referral to ENT is indicated, otherwise, if no
pathology is found, start regular acyclovir and systemic steroids for 2 weeks. If pathology
is found, urgent referral to ENT.
http://www.gpnotebook.co.uk/simplepage.cfm?ID=-281739261
6.2 Stridor ***
Airway obstruction can be due to ENT or chest problems. With ENT causes, there is often
voice change and dysphagia. Stridor is usually inspiratory or biphasic, with chest problems
it is often expiratory. Look for neck nodes to suggest an upper airway tumour. For ENT
stridor call the ENT registrar on-call, administer oxygen or heliox and call an ambulance to
take the patient to A&E immediately.
http://www.gpnotebook.co.uk/simplepage.cfm?ID=-885719031
7.0 EMERGENCY/ URGENT CLINICS
7.1 One-stop lump and bump clinic
This is a service in which referral can be made directly by GP’s telephoning the one-stop
head and neck line (see above for number). Any Head and Neck lump and bump from
thyroid tumour to sebaceous cyst can be referred. Referral guidance for suspected cancer
should be followed and cancer patients referred using the 2WW proforma and the fax
number on page 1 of this document.
If suspected cancer, patients will be seen within 10 working days, and have full ENT
examination, followed by ultrasound and cytology if indicated. Results of cytology will be
ready within 20 minutes. It is aimed that 75% of patients will either be discharged or placed
on the waiting list for surgery after 1 visit.
15
7.2 Emergency Clinic
A nurse-led ENT Emergency Clinic is held each morning, Monday-Friday at Barts Hospital,
from 9.30-12.00. Patients referred to the ENT Emergency Clinic need to bring with them
their referral form – filled out by their GP/referring clinician.
 During working hours: After filling out the referral form, please tell the patient to
contact Central Appointments (0207 767 3200 – open from 8.30am) to be given
a time-slot to attend the clinic.
 Out of hours: Clinicians will need to contact the on-call SHO, who will triage the
patient. If suitable for the Emergency Clinic, the referrer will then need to inform
the patient that they will be seen in the Emergency ENT Clinic, and again ask
them to ring Central Appointments to be given a slot.
Once the patient has been seen in the Emergency ENT Clinic, patients will be given a
follow up appointment if necessary. This will be done by the ENT reception staff.
When referring patients to the Emergency Clinic, some clinicians may wish to send
relevant patient information electronically. If this is the case, please send your emails to
_ENTBartsEmergencyclinic@bartsandthelondon.nhs.uk, ensuring you include the patient’s
NHS number within the email.
16