NORTH OF TYNE/GATESHEAD GUIDELINES FOR
NORTH OF TYNE/GATESHEAD GUIDELINES FORMANAGEMENT OF COMMON ENT CONDITIONS INPRIMARY CAREUpdated February 20171
CONTENTSPageIntroduction3Patient information3How to use this guideline3PathwaysNasal blockage / discharge /-facial pain in adultsNasal trauma (adults)Hearing problems in childrenReferral information for requesting hearing assessment in childrenHearing problems in adultsInfectious sore throat in adultsRecurrent tonsillitis / quinsyNon-infectious sore throat in adultsAcute nose bleedsChronic recurrent nose bleedsVertigoHoarse voice in adultsFeeling of something stuck in the throatManagement of discharging earPrimary care management of snoring in mbership of the guideline development groupDate of guideline and date of reviewReferral form for requesting hearing testing in children 4 yearsCopy of NHS Screening Programmes Newborn hearing check lists2202122
INTRODUCTIONThis guidance is intended to inform initial management of common ENT conditions andhas been developed as a consensus between representatives from primary and secondarycare, with reference to national guidelines, including from NICE and SIGN.It is intended to guide clinical management, but every patient should be assessed andmanaged individually.This guideline is intended for all clinicians in the Newcastle, North Tyneside,Northumberland and Gateshead areas involved in managing patients with ENT conditions.PATIENT INFORMATIONThere are various sources of patient information. None are specifically endorsed. Somerelevant website links are included with the flow charts.How to use the guidelineThe guideline is a set of flow charts covering a variety of ENT conditions. Each of thesecan be printed and laminated for easy reference if preferred.The BNF and the Local Formularies should be referred to as appropriate.ReferralsWhen referral to ENT is recommended in the guideline, referral for patients to be seen at alocal outreach clinic may be preferred. It is anticipated that clinicians in localities wheresuch clinics are available will be aware of them, but further information can be obtainedfrom the ENT department at Freeman Hospital.3
Nasal Blockage / Discharge /- Facial Pain in AdultsPatient information at: -1Information and advice forself helpPatient information leafletsSelf medication / over thecounter medicinesChronic nasal blockage / discharge, with orwithout facial painEncompassing: chronic rhinitis (includingallergic rhinitis), sinusitis, inflammatory nasalpolyps, nasal neoplasmGP assessmentAre nasal symptoms bilateral or unilateral?Consider if could be adverse effect of currently prescribed medication(refer to BNF) and if so modify and reassessBilateral········UnilateralIf symptoms are due to ALLERGY,refer to boxInitial drug therapy with topical nasalspray /- antihistamine for 2 to 3months.Intranasal saline doucheSimple analgesiaAntibiotics for persistent symptoms ifappropriate (refer to local antibioticprescribing guidelines)Information and advice for self helpPatient information leafletsSelf medication / over the counterIf symptoms are due to ALLERGYConsider skin prick test/immunoglobulin assay(serum RAST test)Make patient aware that condition is not curable,but can be managed;· Patient information leaflet· Allergen avoidance· Importance of concordance with treatment· Nasal spray techniqueSymptoms improvedafter 6 weeks··No···YesTopical steroid drops for 4 weeks (remember tore-start initial drug therapy above after 4 weeks)Consider oral steroids (prednisolone 30mg odfor 5 days, then stop)Antibiotics only if purulent nasal discharge (referto local antibiotic prescribing guidelines) for 2weeksContinueSelf managementIf there is septal deviation, andno other symptoms considerreferral for septoplastyUrgent referral (2 week Ereferral) if symptoms could bedue to a neoplasm (veryuncommon): associated withsymptoms such as facial pain,diplopia, bleeding)Notes·Large polyps may respond totopical treatment and is first line·Consider earlier treatment with oralsteroids for polyps in patient withasthmaSymptoms improveYesNoConsidermaintenance nasalsteroid sprayContinueself managementRefer to ENT surgeon, include the following information:Patient history, symptomsTreatment tried, duration, response, any trial of steroids, any side effectsSkin prick test/immunoglobulin assay results if doneENT assessment,investigation, diagnosisand treatmentDischarge with advice for on-going management in primarycare, including management of any recurrences4
Nasal Trauma (Adults)Patient information at: -1Nasal traumaIs this within last 2 weeksNoYesPatient first presentsmore than 2 weeksafter nasal traumaPatient history and examinationDo all of the following apply·Patient’s nose swollen, but straight·Patient’s breathing normal·Patient is satisfied ?Is thereNasal obstructionand orNasal deformity ?NoYesNo furtherinterventionRoutinereferral to ENT····NoYesWith any of the followingNew nasal obstructionNew nasal deformityPatient concernsPractitioner concernsPatient information leafletNo further follow upIs there a septalhaematoma?NoUp to 14 days refer for to ENT forconsideration of manipulation5YesImmediate referralContact on call ENT surgeon
Hearing Problems in ChildrenLocal paediatic audiologyservice arrangementsChild resident in Northumberland,Newcastle or North Tynesideaged 4 years and or hasspecial needs: refer to FreemanHospital audiology department(referral form included in theappendix).Professional or parentalconcern about child’shearing or ears (refer toinformation sheet onnext page)OtoscopyAbnormality (eg recurrent earinfections, cholesteatoma)?YesNoRefer to ENTRefer to Local PaediatricAudiology Service*Specialist paediatric audiologyfacilities are only available atFreeman Hospital in Newcastle,Newcastle Hospitals@ManorWalks in Cramlington, or NorthTyneside Hospital andappointments will be allocated atthe most local available facility.Hearing test carriedoutHearingsatisfactoryTemporaryconductive hearinglossPermanent hearing lossHearing loss managed by localaudiology serviceLongstanding – established fromclinical historyOptions: discuss hearing aids orgrommetsShort lived.Monitor hearingReview in audiology in3 monthsIfgrommetsHearing lossstill presentRefer to ENTHearingsatisfactoryDischarge····Management tips for children with grommetsChild can swim but no deep divingNo difference in infection rates between swimmersand non-swimmersPersistent perforation occurs in 1% cases andfurther surgery may be required at a later stageGrommets should fall out in 6 to 9 months and theperforation heal concurrently6
Guidelines for Paediatric Referrals to AudiologyPlease use these guidelines for making a referral for a hearingassessment.·Parental or professional concern about an infant’s hearing, or development ofauditory or vocal behaviour, should always be taken seriously.·Genuine concern can be determined by asking the following questions.1) Is the child able to follow age appropriate instructions when spoken to, in anormal voice, from behind or out of sight. See appendix for checklist for reactionto sounds for a baby 1year old.2) Is the child’s babbling or speech and language age appropriate? Refer tochecklist on page 37 of parent child health record (PCHR) to establish if there isspeech and language delay. See appendix for checklist for making sounds.If there is concern after ascertaining the above information then consider immediatereferral to Audiology.General Information· Children are routinely offered a newborn hearing screen at 3 months old. Resultscan be found in the PCHR and on the child health information system.· School hearing screening is no longer being offered in some local areas. Thereforedo not delay and refer immediately if there is genuine concern about the hearing.· If a recent fluctuating hearing loss is reported consider monitoring the hearing for 3 months prior to referral.· If the child has repeated ear infections refer to ENT, not audiology.Other criteria used for referral to Audiology are:· Confirmed or strongly suspected bacterial meningitis, or meningococcalsepticaemia· Temporal bone fracture· Severe unconjugated hyperbilirubinaemiaAlthough the clinician in charge is responsible for referring the above, it is important to beaware when a hearing assessment is required.Referral Procedure:· Choose and book system· Complete a request form for children’s hearing assessment – see appendix· Send referral form by post or email to: Audiology Dept, Freeman Hospital,Newcastle upon Tyne, NE7 7DN or als will only be accepted from GPs, HVs, School Nurses, Speech andLanguage Therapists and Paediatricians.If you require any further information please contact:Kate Johnston, Head of Paediatric Audiology, Audiology Department, Freeman HospitalE-mail: Kate.Johnston@nuth.nhs.uk7
Hearing Problems in AdultsAdult with hearingproblem with or withouttinnitusReassessment of hearing aid··No referral required unless existinghearing aid from another providerPatient to attend repair session orcontact audiology directlyExamine earsIdentify if unilateral orsymmetrical bilateralhearing lossUnilateral hearingloss or bilateralhearing loss aged 50 yearsBilateral hearingloss and 50 yearsRefer to ENT··NORMAL appearance of canalsand tympanic membranes, andcriteria met (see below)YesNoRefer to audiology forhearing assessment andassessment for hearing aidConsiderreferral to ENTCritieria for direct referral to audiology···Patients with symmetrical non- fluctuating hearing loss of gradual onsetReassessment of hearing aidPatient known to the service···Any ear wax has been removedNORMAL appearance of canals and tympanic membranes, andAny pre-existing ear condition has been investigated by ENT surgeon oraudiological physician8
Infectious Sore Throat in AdultsPatient information at: -1Acute pharyngitis simple tonsillitisRoutinemanagementNotesConsider use of Fever Pain Score (https://ctul.phc.ox.ac.uk/feverpain/index.php) or Centor Score aac-strep-pharyngitis)If antibiotics are indicated: Phenoxymethylpenicillin 500mg qdsfirst line if not penicillin allergic, not amoxycillin. Refer to localantibiotic prescribing guidelines9
Recurrent Tonsillitis1Patient information at: -1Patient decision aid at: oat/Acute pharyngitis simple tonsillitisNotesIf antibiotics are indicated:Phenoxymethylpenicillin 500mg qdsfirst line if not penicillin allergic, notamoxycillin. Refer to local antibioticprescribing guidelinesRoutinemanagementRecurrent tonsilitisDoes the patient meet the following criteria;·Recurrent sore throats due to acute tonsilitis with·7 or more well documented, clinically significant,adequately treated episodes in the last year, or 5 ormore episodes in each of the preceding 2 years, or 3or more episodes in each of the preceding 3 years·Minimum of 12 months of symptomsor·Two or more episodes of peritonsillar abscess (quinsy)and·Had the information leafletNoYes··Consider alternativediagnosis (see “Noninfectious sore throat”)Allow patient timeto consider surgeryand the risksReview patient (bytelephone or faceto face) after 1monthContinueconservativemanagementPatient wishesto considertonsillectomyYesConsider IFR/Value BasedCommissioning Policyhttps://ifr.necsu.nhs.uk/referrals/checklist dry run/34.If no improvement, referto ENT forpharyngoscopyNoContinueconservativemanagementIf treatment agreedRefer to ENT / ENT nursepractitioner clinicPeritonsillar abscess(quinsy) /- airwayobstructionNeck abscessStridorPatient likelyto requireemergencyadmission1Contact on call ENTsurgeonThe indications for tonsillectomy are for guidance and some patients, particularly children, who have recurrent severe infections in ashorter timescale should also be considered. GPs should also refer to the local exception treatment policy.10
Non-infectious Sore Throat in AdultsPersistent sore throat for 3weeks with no upper respiratorytract infectionHistory and examination,including oral examinationDoes the patient have any of the following:·SMOKING / ALCOHOL HISTORY·Referred otalgia·Neck lumps (unilateral or bilateral)·Hoarseness (see hoarseness pathway)·Stridor·Dysphagia·Weight loss·Oral ulcer / swelling·Unable to comprehensively examine oral cavity /oropharynxAND / OR·Clinical suspicion of malignancyYesNoUrgent referral to ENTunder 2 week rule(e referral)Symptomatic treatmentfor 6 to 8 weeksSymptoms resolveNoYesRoutine referral toENTReassure11
Acute Nose BleedPatient information about epistaxis at: http://www.entuk.org/patient information leaflets 1First aid measures for acute nose bleeds·Sit patient down·Lean patient forward (ideally over sinkor table)·Pinch the lower part of the nosebetween thumb and forefinger·Pinch nose for 5 minutes. DO NOTrelease the pressure 5 minutes. Ifpersists repeat x 2.·Consider inserting nasal tampon iffamiliar with its use·Spit out any blood·Check if the patient is taking aspirin,clopidogrel, prasugrel, ticagrelor,NOAC or warfarin. If so, bleeding isless likely to stop easilyAcute nose bleedFirst aid measuresBleeding stops within 20 to30 minutes andpatient haemodynamicallywell?YesNoApply ointment / cream(eg naseptin), to thenosebleed side twicedaily for 1 weekEmergency referral tonearest A&E departmentTreatment options for persistent nosebleedsNasal cautery if bleeding site can beidentifiedNasal packing eg nasal tamponsAdmit to hospitalNose bleeds can be serious and lifethreatening.Patients who have had serious,prolonged, recurrent nose bleeds shouldbe given the information leaflet aboutprevention of nose bleeds12
Chronic Recurrent Nose BleedsPatient with chronicrecurrent nose bleedsReview history·Is the patient treated with oral anticoagulants and/or anti-platelet agents?·Any history of excess alcohol intake?·Does the patient have uncontrolledhypertension?·Are there any other signs of bleedingtendency?·Exclude “red flags” (see notes)··NotesNeoplasm is very rare.Red flags in patients withrecurrent nose bleeds,requiring urgent referral to ENT(choose and book):· Facial pain / swelling· Otalgia· Unilateral nasal obstruction· Reduced sense of smell· Visual symptoms· Dental symptomsManage any reversible causesApply ointment / cream (eg naseptincream twice daily for 1 weekNose bleeds can be seriousand life threatening.Patients who have had serious,prolonged, recurrent nosebleeds should be given theinformation leaflet aboutprevention of nose bleedsFurther nose bleeds?YesNoContinue conservativetreatmentCautery of Little’s area withsilver nitrate under LAFurther nose bleeds?YesNoRefer to ENT /ENT nursepractitioner clinic /GPwSI (if locallyavailable)Continue conservativetreatment13
VertigoPatient information at: -1DizzinessRed flags which suggest a brainstem stroke or other central causeAny central neurological symptomsor signs, particularly cerebellar signsNew type of headache (especiallyoccipital)Acute deafnessVertical nystagmus“Rotatory vertigo”as main symptomNoYesHave a high index of suspicion ofcerebellar pathology in those withsevere symptoms, including unableto stand at all unaided, and noimprovement within a few hoursAre there any red flags?Detailed historyand examination,and appropriatemanagement /referral (eg fallsand syncopeservice,cardiology)UnsteadinessRecurrent fallsLightheadnessPresyncopeLoss of confidenceOlder patient (eg 75 years)YesRefer to secondary care; useclinical judgment how urgentlythis should be, but mayrequire admissionNoConfirmatory history and examination to rule in benign positionalvertigo (Hallpike manoeuvre) or acute vestibular neuronitisNoYesPositional vertigo andtorsional nystagmusfatigues in 30seconds ( ve DixHallpike manoeuvre)Sustained vertigo andhorizontal nystagmusNot positionalNausea and vomitingcommonBenign paroxysmalpositional vertigoAcutevestibularneuronitisEpley ManoeuvreIf fails, routine referral toENT / ENT GPwSI (if locallyavailable)Consider vestibularmigraine if vertigoplus migraine isrecurrent andexamination normalTreat, refer ifdiagnosis notsecureNotesSymptoms of BPPV usuallylast a short time and arepositional eg rolling over inbed, lying downTransient unilateralhearing loss ANDtinnitus, ANDprevious episodes ofdizzinessConsider MenieresdiseaseRoutine ENTreferral / ENT GPwSI(if locally available)Significant on-goingsymptoms and notimproving (usually 6weeks unless particularclinical / patient concern)Routine referral to ENT / ENTGPwSI (if locally available)Notes·To distinguish vertigo from non-rotatory dizziness consider asking; “Did you just feel lightheaded or didyou see the world spin round as though you had just got off a playground roundabout”·Patients with ‘dizziness’ but not vertigo, need history and examination, including cardiovascular andneurological examination. Some may need referral for further investigation eg (falls and syncopeservice, cardiology, elderly care)Flow chart adapted from Barraclough K et al. BMJ 2009;339:749For more information about determining the cause of vertigo, refer to the CKS 407680)14
Hoarse voice in AdultsPatient information at: -1Hoarse voiceAny of the following, particularly aged 40years and 3 weeks of symptoms:· History of smoking· Referred otalgia· Dysphagia· Stridor· Neck examination abnormal e.g enlargednodesNoYesConsider:Urgent referral toENT (2 week rulevia e referral)No, and after 4weeks ofpersistent hoarsevoiceHistory of:· Occupational voice user· Steroid inhaler use· Recent respiratory tractinfectionCheck thyroid statusYesTreatment:· Voice care – providepatient information leaflet(see above)· Optimum steroid doseand inhaler device andtechnique· HydrationNotes*Urgent referral to the voice clinic (orto a locality ENT clinic) may beconsidered sooner if there is, forexample:· Patient / clinical concern· Occupational concernsFollow up 6-8weeks or sooner ifany worseningsymptoms*Symptoms resolved?15NoYesRefer to voiceclinicNo furtherintervention
Feeling of something stuck in the throatFeeling of somethingstuck in the throatAre symptoms:· Noticed between rather than during meals?· Not aggravated by swallowing food?· Noticed at midline or suprasternal notch?· Intermittent?On physical examination does the patient have:· Normal oral cavity, head and neck examination?· No pain?· Normal voice quality?NoYes·If the patient has any of the following:· Smoking / alcohol history· Significant referred otalgia· Dysphagia· Hoarseness (see hoarseness pathway)· Stridor· Persistently unilateral symptoms· Abnormal neck examination e.g. enlargednodesand/or clinical concern··Reassure the patient, no furtherinterventionAdvise the patient to return if theydevelop any new symptomsAntacid (e.g. peptac) if oesophagealsymptoms (consider need for OGD orTNO (transnasal oeosphagoscopy)particularly if new or worseningsymptoms)If newsymptomsdevelopRefer to ENT.Use clinical judgementto determine theurgency of referral16
Management of discharging earPatient information at: -1Patient with discharging ear:green, yellow fluid eliminatingfrom the ear canalDoes the patient have acutesymptoms of otitis externa:itch, non-mucoid discharge,hearing lossNoYesCleanse the ear canal with drymopping or gentle syringing /irrigationConsider 2% acetic acid eardrops if mild symptoms (OTC)Topical antibiotic and steroiddropsGeneral advice eg do not pokeears or let shampoo and soap intoearsIs it acute otitis mediaTreat accordingto otherguidelines, suchas SIGN66Is it chronic suppurativeotitis media?i.e. persistent mucoidsmelly discharge, with orwithout deafnessNoYesConsideralternativediagnosis2 week course oftopical antibiotic /steroid drops andreviewRefer to nursepractitioner earcare clinicNoRefer to ENT with thefollowing information· Patient history· Treatments tried:duration, sideeffects, response· Results of anyinvestigationsContinueself managementNote:Aminoglycoside ear drops may in theory beototoxic in the presence of a non-intact tympanicmembrane, but in general are safe to use for upto 2 weeks in the presence of definite infection.However, aminoglycoside ear drops are notrecommended in the better or only hearing ear inpatients with pre-existing hearing loss.Consider ofloxacin eye drops as an alternative(unlicensed indication).Discharge from clinicwith specificmanagement plan17Refer to ENTcasualtyIf symptomsdo not clearSymptomsresolve?YesIf severe pain /cellulitis/facialpalsy
Primary Care Management of Snoring in AdultsPatient information:····From the Newcastle upon Tyne Hospitals NHS Foundation Trust website at http://www.newcastlehospitals.org.uk/services/ent treatment-and-medication /patient-information-leaflets-1The British Snoring and Sleep Apnoea Association website at: www.britishsnoring.co.ukInformation on Newcastle Hospitals DVD available at:http://www.britishsnoring.co.uk/shop/snoring self help dvd.phpHistory, include:Loudness of snoringExcessive / intrusive daytimesleepinessWitnessed apnoeasImpaired alertnessNocturnal choking episodesWaking unrefreshedCo-morbidityeg hypothyroidism, ischaemic heartdisease, cerebrovascular disease,diabetes, hypertensionSmoking historyAlcohol consumptionMedication historyPresentation with snoringto Primary Care ClinicianHistory andexamination,Epworth SleepinessScale (ESS)OSA notsuspectedSuspected OSA,ESS 10 , and/orwitnessedapnoeas or STOPBANG 3Consider psycho-social impactExamination, include:BMICollar sizeSTOP BANG questionnaire isavailable at:https://www.blf.org.uk/sites/default/files/BLF OSA-Top-Tips-forGPs DOWNLOAD.pdfOffer lifestyle advice /intervention and considerif patients should bereassessed following thatbefore referral tosecondary careOffer lifestyle advice, includingweight loss,smoking cessationreduce alcohol consumptionConsider providing NUTH“Self Help for Snoring” DVDRefer to sleepservice (checkTFT r providinginformation from theBritish Snoring andSleep ApnoeaAssociationContinue lifestylemeasuresConsider referral forENT / ENT nursepractitioner assessmentif symptoms severe andor intrusive18
TinnitusPatient information at: -1Tinnitus with or without hearing lossUnilateral or bilateralUnilateralAssess if pulsatile, intermittent,or Listen for bruitAssess severityAbsentSevereMildSleep disturbanceInterfering with work / social lifeReassurance andinformation sheetPresentRefer tovascularsurgeryNo other ENTsymptomsRefer to Audiology ereferral Direct AccessTinnitus ClinicOther ENT symptomse.g. balance problems,ear infectionsFromaudiology asindicatedRefer to ENTExplanationReassuranceAdvice about homemaskingConsider MRI19Refer to AudiologyTinnitus clinic for groupsession or 1-2-1appointment
APPENDIXMembership of the guideline development groupDr J Skinner, Consultant Community Cardiologist (guideline co-ordinator), Newcastle uponTyne Hospitals NHS Foundation TrustMr S Carrie, Consultant in ENT, Newcastle upon Tyne Hospitals NHS Foundation TrustDr J Davison, Consultant in Elderly Care, FASS, Newcastle upon Tyne Hospitals NHSFoundation TrustDr D Grainger, Director of Planned Care, Newcastle Gateshead CCGKate Johnston, Head of Paediatric Audiology, Newcastle upon Tyne Hospitals NHSFoundation TrustDr S Kirk, GP, Whickham Surgery, GatesheadDr J Lawson, Associate Specialist, FASS, Newcastle upon Tyne Hospitals NHSFoundation TrustDr N Iqbal, GP, Swarland Avenue Surgery, North TynesideMr V Paleri, Consultant in ENT, Newcastle upon Tyne Hospitals NHS Foundation TrustDr M Scott, GP, Newburn Surgery, Newcastle upon TyneMr G Siou, Consultant in ENT, Newcastle upon Tyne Hospitals NHS Foundation TrustMs C Robson, Matron in ENT, Newcastle upon Tyne Hospitals NHS Foundation TrustDr J Viswanath, GP, The Grove Medical Group, Newcastle upon TyneDr B Warner, GP, Well Close Square Surgery, Berwick upon Tweed, NorthumberlandProf J Wilson, Consultant in ENT, Newcastle upon Tyne Hospitals NHS Foundation TrustMr P Yates, Consultant in ENT, Newcastle upon Tyne Hospitals NHS Foundation Trustand in consultation withDr DA Richardson, Consultant Physician / Geriatrician, Northumbria Healthcare NHSFoundation TrustDr S West, Consultant in Respiratory Medicine and Sleep Studies, Newcastle upon TyneHospitals NHS Foundation TrustDr J Hill, Consultant in ENT, Newcastle upon Tyne Hospitals NHS Foundation TrustDate and date of reviewUpdated February 2017, review February 202020
The Newcastle upon Tyne HospitalsNHS Foundation TrustREQUEST FOR HEARING TESTING FOR ALL CHILDRENOnly to be used for children resident in Newcastle, North Tyneside and NorthumberlandPLEASE COMPLETE ALL SECTIONS BELOW AND SEND TO: AUDIOLOGY DEPARTMENT, FREEMAN HOSPITAL, NE7 7DN 223 1043 FAX: 213 7039 ore-mail to: tnu-tr.childrensaudiologynorthoftyne@nhs.net (confidential information MUST be sent from another nhs.net account)WE WILL ONLY ACCEPT REFERRALS FROM SPEECH AND LANGUAGE THERAPISTS, GPS, HEALTH VISITORS AND SCHOOLNURSES. THERE MUST BE A GENUINE PARENTAL OR PROFESSIONAL CONCERN ABOUT THE CHILD’S HEARING; THIS IS NOT ASCREENING SERVICE.REFERRER INFORMATIONPATIENT INFORMATIONReferrer Name:Referrer Title: GP HV School Nurse S&L Therapist Address: Tel:Fax:NHS NO:Sex: Home: Mobile:Patient Name:D.O.B:Patient Age:Address:GP Name and Address if not referrer:School/Nursery Name and Address if notreferrer:REASON FOR REFERRALPATIENT HISTORYPrevious hearing test results (ifknown)Newborn hearing screen:School entry hearing test:Birth History:Developmental HistoryVerbal/written consent obtained from parentsInterpreter requiredYes Yes No No LanguageSignature of referrer: Date:21
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It is intended to guide clinical management, but every patient should be assessed and . Refer to ENT surgeon, include the following information: Patient history, symptoms Treatment tried, duration, response, any trial of steroids, any side effects . x Persistent perforation occurs in 1% cases
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