Vincent Cumberworth BSc FRCS Consultant Ear, Nose and Throat Surgeon
Clementine Churchill Hospital Sudbury Hill Harrow Middlesex HA1 3RX
Private Secretary: Tel: 020 8872 3866 Fax: 0208872 3861

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Ent Referral Guidelines For The Throat

Recurrent Sore Throats

The majority of sore throats are viral in nature and hence will not respond to antibiotics. The average sore throat lasts between 5 to 7 days and the condition results in significant loss of time from school or work for a large number of patients. A significant percentage of children grow out of tonsillitis at about 5 or 6 years old, however the timescale for this in some individuals may be many years.

Symptoms and signs (of recurrent tonsillitis): Painful dysphagia,systemic upset, fever, inflamed/infected tonsils and cervical lymphadenitis. Children often present with fever, abdominal pain and refusal to eat.

Treatment:  There is no effective medical treatment for recurrent sore throat which shortens the duration of the illness or reduces the frequency of attacks. Simple analgesia and plenty of fluids should be advised. A throat swab is unnecessary. Symptomatic management is satisfactory for most patients provided that the episodes of sore throat are not recurring with unacceptable frequency. If antibiotic treatment is indicated penicillin V or erythromycin for ten days is usually sufficient. Antibiotics should be prescribed if a child has features of marked systemic upset, peritonsillar cellulitis, a history of rheumatic fever or if he is immunocompromised or a diabetic.

When to refer: If a patient develops a quinsy ( peritonsillar abscess –soft palate swelling, medialisation of the tonsil and trismus ) or dehydration, refer to the ENT emergency clinic. Refer children if there is an obstructed airway or a history of sleep apnoea. Unilateral tonsillar enlargement or tonsil ulceration should be referred for urgent biopsy. Primary care records should have documented the number of episodes and the associated morbidity. The consensus for routine tonsillectomy is approximately half a dozen episodes for a single year, 5 or more per year for 2 years or three or more in each of three successive years. However, each patient should be taken on his own merit.

Enlarged Neck Nodes

The majority of neck lumps are benign. Consider whether the lump is a lymph node, salivary gland or thyroid swelling. Most malignant lymph nodes in the neck arise from a primary tumour in the upper aero-digestive tract. A full and formal ENT examination is essential.

Symptoms: There may be no symptoms other than a lump. Hoaresness, referred otalgia and dysphagia are suspicious as are a hard, fixed, rapidly growing neck lump.

Treatment: Do not biopsy the lesion in the primary setting as seeding of a tumour can occur. The ENT department will  assess the patient fully and perform fine needle aspiration of the lump.

When to refer: Refer neck lumps of more than a few weeks duration for an urgent clinic appointment (head and neck cancer pathway). Document a history of smoking and alcohol abuse.

Hoarse Voice

Most hoarseness in non-smokers is as a result of laryngitis or voice abuse. Acid reflux may play a part.

When to refer: If the hoarseness lasts longer than 4 weeks or is unassociated with a preceeding URTI, refer to the ENT clinic urgently to exclude laryngeal cancer (head and neck cancer pathway). It is helpful to document within the letter if the patient has a history of smoking or alcohol abuse.

Suspected Pharyngeal Malignancy

Symptoms: Many patients present with a feeling of a lump in the throat and most have the benign condition of globus pharyngeus. There is no true dysphagia, indeed the sensation is less noticeable with meals. Some may have associated reflux disease. Symptoms of pharyngeal malignancy are subtly different:

When to refer: If the patient complains of food sticking or pain on swallowing, particularly pain referred to the ear, refer to the urgent ENT clinic. Refer if there is ulceration of the pharynx or a neck lump. Other factors raising the index of suspicion are age over 40, smoking, alcohol abuse and weight loss. It is helpful to mention these risk factors in the referral letter.

Oral Lesions

Symptoms : The patient may complain of pain, dysphagia,bleeding or halitosis. Oral cancer is closely linked to smoking and alcohol abuse.

Treatment : Exclude causes such as poor dentition, badly fitting dentures and trauma. Try a simple mouth wash and advise the patient on oral hygiene.

When to refer : Leukoplakia (white lesions), erythroplakia (red lesions) and ulceration should be referred for an urgent ENT appointment, particularly if present for more than two weeks.