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

Information is supplied only upon the condition that the viewer will make their own determination as to the suitability of the information for its purposes prior to use.  There will be no responsibility for information that is misused or misinterpreted and the information should not be used as a substitute for consultation with a health care professional.  It is not possible to answer questions regarding individual cases or to enter into individual correspondence.

ENT Referral Guidelines Nose

Information is supplied only upon the condition that the viewer will make their own determination as to the suitability of the information for its purposes prior to use.  There will be no responsibility for information that is misused or misinterpreted and the information should not be used as a substitute for consultation with a health care professional.  It is not possible to answer questions regarding individual cases or to enter into individual correspondence.

Epistaxis

Recurrent nose bleeds are common in all age groups. Young children usually bleed from Little’s area on the anterior septum, elderly patients from higher or further back in the nose.Common risk factors include nose picking, high blood pressure and aspirin / NSAID / warfarin usage.

Treatment: First aid measures; apply ice and pressure on the anterior, soft part of the nose. Sit the patient upright with the head forward to avoid swallowing blood. If a bleeding point is visible on the anterior septum, consider cautery with silver nitrate sticks. Topical vasocontrictors  may be helpful. Petroleum jelly or anti-staphylococcal ointment can be used in minor cases. For severe bleeding attempt packing with ribbon gauze or nasal tampons and refer to ENT.

When to refer: Refer to the emergency ENT clinic if there is persistent or severe bleeding, or a suspected clotting disorder.

Snoring And Obstructive Sleep Apnoea

The prevalence of snoring and obstructive sleep apnoea (OSA) is high and under-recognized. 24% of men and 14% of women are habitual snorers and 5% of men have OSA. In children, tonsil and adenoid hypertrophy is the commonest cause of OSA and adenotonsillectomy frequently completely relieves the condition. OSA causes multiple awakenings during sleep. This has a serious impact on wakefulness and intellectual capacity. There is mounting evidence that OSA can cause significant cardiovascular disease.

Treatment:  Weight loss, cessation of smoking and reduction in alcohol intake should be encouraged. Try simple solutions to avoid sleeping on the back. Treat any nasal obstruction and consider nasal dilator strips. The treatment of OSA is nasal CPAP which is a service best provided in the context of a sleep disorder clinic.

When to refer: If the above simple measures have failed and snoring is the primary complaint refer to ENT. If there is substantial obesity and OSA refer to a specialist sleep centre for initial assessment. Mouth breathing and snoring in children rarely warrant surgery, however refer children with OSA to ENT.

Nasal Obstruction

Over a fifth of the population have nasal complaints, of whom two thirds report nasal obstruction. Nasal blockage may be associated with a decrease in quality of life, loss of work productivity, sleep disorders and occasionally eustachian tube dysfunction.

Causes: Rhinitis, septal deviation, nasal polyps, adenoid hypertrophy, alar collapse, foreign bodies and rarely tumours of the sinonasal region

When to refer:

Rhinitis: Allergen avoidance, particularly of house dust mite is crucial in the treatment of chronic allergic rhinitis. In addition a 3 month trial of a topical nasal steroid spray should be used. This may be combined with a topical or systemic antihistamine. Failure to resolve warrants a routine ENT referral.

Septal deviation: If an obvious septal deviation exists then a routine ENT referral is appropriate.

Nasal polyps: A one month course of steroid nose drops may be more effective than sprays but they are more difficult to instill properly. Short courses of oral steroids may also be effective.If there is no resolution of symptoms or if there is gross polyposis then refer to a routine ENT clinic.

Foreign bodies: If a child presents with a unilateral nasal blockage or foul / bloody discharge, then a foreign body should be suspected and a referral to the emergency ENT service is appropriate.

Sinonasal malignancy: This is extremely rare but if this diagnosis is entertained then an urgent referral to the ENT clinic is appropriate. Suspicious symptoms are persistent facial swellings, loosening of teeth, proptosis, parasthesia of the cheek and unexplained nosebleeds.

Sinusitis

Symptoms:      Acute sinusitis: Acute facial pain following an URTI (maxillary/upper dentition, frontal or nasal bridge pain). The pain is usually unilateral and associated with purulent rhinorrhoea and fever.

Chronic sinusitis: is associated with less pain and a purulent rhinorrhoea or post-nasal drip. It is often accompanied by chronic rhinitis symptoms.

Treatment: In acute sinusitis, pain relief and decongestants (such as ephedrine or xylometazoline nasal drops) may be sufficient. If an antibiotic is required, amoxycillin (or erythromycin) for 5 days is usually adequate. If the patient fails to respond consider the possibility of anaerobic or beta-lactamase organisms.

Plain sinus x-rays have limited use in the routine management of rhinosinusitis.

When to refer: Refer to the emergency ENT clinic if there are any complications of acute sinusitis, especially peri-orbital cellulitis/abscess, deterioration of vision, severe systemic illness, drowsiness or vomiting (? intra-cerebral complications ).Refer if there has been a  failure to respond to medical treatment.

Refer chronic rhinosinusitis and recurrent acute sinusitis to the routine ENT clinic.

Fractured Nose

Symptoms: Traumatic injury to the nose resulting in peri-nasal swelling, black eyes and nasal tenderness.

Treatment: On initial presentation, examine the nose to exclude a septal haematoma (a cherry – red bilateral tender swelling with blockage) or a deviated nasal septum. Review the patient in the practice in one week when the swelling has subsided. X-rays are unnecessary unless there are concerns about other facial fractures.

When to refer: Patients with an uncomplicated or undisplaced fractured nose or those unconcerned with cosmesis do not require ENT follow-up. Refer a patient with a septal haematoma to the emergency ENT clinic. Patients who are unhappy with the cosmesis of the nose should be referred to the emergency ENT clinic at 7 days post injury as a manipulation is possible up to 14 days after trauma.