Women’s & Children’s Hospital

Paediatric Ear Nose and Throat referral guidelines

Contents

Ears

Otitis Externa 2

Acute suppurative otitis media (ASOM) 3

Otitis media with effusion (glue ear) 4

Perforated eardrum 5

Nose/Sinus

Rhinorrhoea 6

Sinusitis 7

Epistaxis - recurrent 8

Throat

Hoarseness 9

Tonsillitis - recurrent 10

Snoring and Obstructive Sleep Apnoea 11

Other

Neck mass 12

Priority

Priority will be based upon the information provided in this referral. They will be triaged by a

Paediatric Ophthalmology Consultant according to the clinic process and booked accordingly:

Emergency: Proceed to the emergency department

Urgent: We aim to see these patients as soon as possible

Semi-urgent/ Next available appointment. Please note many routine referrals may not be

routine: seen at present due to the increasing demand on the service

To help us best triage your referral, it may be returned for further investigations if the following

process has not been adhered to.

Please note this is a guideline for referral only. If concerned about a patient please

contact the ENT Registrar via switchboard on 8161 7000.

Mandatory referral

content

Demographic

child’s name

date of birth

parent/guardian contact details

referring GP details

interpreter requirements

Clinical

reason for referral

clinical urgency

duration of symptoms

management to date

and response to treatment

relevant pathology,

imaging and audiology reports

past medical history

current medications

functional status

family history

Page | 2

Ears

Otitis externa – all ages

Initial pre-referral workup GP management Guidelines for specialist referral

Clinical history

usually due to water

contamination following

swimming

children with dermatitis of the external ear canal

Physical examination

presents with inflammation of

the ear canal and pre-auricular tenderness

if copious mucus or pus

consider perforated tympanic

membrane

hearing loss

Investigations

swab ear discharge for

microscopy/culture and sensitivity

reassure parents

education on protecting

ears from water

exposure

topical antibiotics

systemic antibiotics are

rarely required

Medical guideline

WCHN ear infections

medical guideline

Kids information

Swimmer's ear

Parent information

Otitis Externa - swimmer's ear

Emergency

ear canal is swollen shut

and antibiotic eardrops

cannot enter the ear canal

cellulitis has extended

beyond the ear canal in

which case the child will need IV antibiotics

Semi-urgent / routine

ear pain is severe and

not relieved by regular simple analgesia

send pathology results if

known, documentation

of clinical course and treatment and response

Page | 3

Otitis media – acute suppurative otitis media (ASOM)

Initial pre-referral workup GP management Guidelines for specialist

referral

Clinical history

very often preceded by a viral respiratory tract infection

Physical examination

middle ear effusion – loss of

normal tympanic membrane translucency

yellowish discolouration or bulging of tympanic membrane

PLEASE NOTE - be cautious

of accepting Acute Supprative

Otitis Media (ASOM) as the

sole diagnosis in an unwell

infant with a fever

Investigations

ear discharge if present – swab

for culture/sensitivity if indicated

reassure parents

adequate analgesia

acute symptoms usually

resolve within 24 hours in most cases

Medical guideline

SA Health Paediatric

Practice Guidelines –

Acute Otitis Media in

Children

WCHN ear infections medical guideline

Kids information

Looking after your ears

Parent information

middle ear infection

Aboriginal ear health

Emergency

mastoiditis with facial

nerve palsy, dizziness,

meningitis must be

referred immediately

to the Paediatric

Emergency

Department and/or

discussed with the ENT Registrar on call

send pathology results if known

Semi-urgent / routine

if medical treatment has

been unsuccessful and

the child remains symptomatically unwell

more than 3 episodes of

acute otitis media in

6 months or more than

4 episodes in a 12 month period

send pathology results if

known, documentation

of clinical course and treatment and response

PLEASE NOTE - a simple

perforation of the ear drum

as part of an acute otitis

media does not require a

referral unless there are

ongoing concerns after 6 weeks.

Page | 4

Otitis media with effusion (glue ear)

Initial pre-referral workup GP management Guidelines for specialist

referral

Clinical history

hearing loss, balance and

coordination problems, speech and language delay

Physical examination

middle ear effusion – loss of

normal tympanic membrane

translucency

Investigations

consider audiometry

reassure parents

(80 -90% of cases will

spontaneously resolve in

3 months)

antihistamines,

decongestants and

antibiotics have no

beneficial effect in the

management of otitis

media with effusion

(OME)

review at 3 months - for

persistent middle ear effusion or hearing loss.

educate parents on

management of

environmental factors (until definitive surgery)

Medical guideline

WCHN ear infections medical guideline

Kids information

Looking after your ears

Parent information

Aboriginal ear health

middle ear infection

Semi-urgent / routine

send documentation of

clinical course, treatment and response

if hearing tests have

been performed send

with referral

Page | 5

Perforated ear drum

Initial pre-referral workup GP management Guidelines for specialist

referral

Clinical history

causes of a perforated eardrum

are usually from trauma or infection

if possible, ensure any foreign body is removed from ear canal

Physical examination

hole in the tympanic membrane

chronic or recurrent ear discharge

hearing loss

Investigations

audiogram (if possible)

reassure parents

topical antibiotic

eardrops for discharging ear (e.g. Ciprofloxacin)

advise to keep ear dry

Semi-urgent / routine

ongoing discharge for greater than three weeks

failure of dry perforation to heal after two months

all non-acute long term

perforated ear drums

should be referred

send pathology results if

known, documentation

of clinical course and treatment and response

PLEASE NOTE - a simple

perforation of the ear drum

as part of an acute otitis

media and does not

require a referral unless

there are ongoing concerns after 6 weeks.

Page | 6

Nose

Rhinorrhoea (in younger children)

Initial pre-referral workup GP management Guidelines for specialist referral

Clinical history

establish if chronic –

persistent symptoms (more

than 8 weeks, recurrent or more than episodes a year)

nasal obstruction

nasal discharge

facial pain/ frontal headaches

disturbance of smell and taste

rule out allergic rhinitis

Physical examination

swollen mucosa

secretions – if discoloured this

does not necessarily indicate an infection

in children, unilateral foul-

smelling discharge suggests a

nasal foreign body. If no

foreign body is seen, sinusitis

is suspected when purulent

rhinorrhoea persists for 10

days along with fatigue and a cough

Investigations

none required

older children – CT to confirm

condition (ideally following a

full course of medical

management)

younger children - consider

x-ray of sinuses and post nasal space

reassure parents

manage co-existing allergies

manage environmental

factors

treat any acute bacterial

infection

saline rinse/irrigation (not spray)

allergy testing if indicated

topical steroid nasal

sprays for perennial and

seasonal allergic rhinitis,

as well as perennial non-

allergic rhinitis. (Long term

use has not been shown

to cause suppression of

the hypothalamicpituitary – adrenal axis)

in seasonal rhinitis –

commence spray one

month prior to the relevant

pollen season and

continue over the

symptomatic period

antihistamines – do not

use as a first line

treatment but may be

used for seasonal rhinitis

Kids information

your nose

Emergency

unilateral discharge

suspicion of foreign

body must be referred

immediately to the

Paediatric Emergency

Department and/or

discussed with the ENT Registrar on call

Semi-urgent / routine

assessment by ENT Consultant/Registrar if:

adenoidal

hyperplasia

suspected

rhinorrhoea not

responsive to

treatment

assessment by allergist

if history suggestive of

allergy

send any x-rays if

completed

send pathology results if

known, documentation

of clinical course and

treatment and response

Page | 7

Sinusitis (in older children)

Initial pre-referral workup GP management Guidelines for specialist

referral

Clinical history

history and physical

examination may be non-contributory

signs of sinusitis include:

post nasal drip

Rhinorrhoea

facial, periorbital, and frontal pain

disturbance of smell and taste

establish if chronic – persistent

symptoms more than 8 weeks,

recurrent or more than 3 episodes a year)

Physical examination

unilateral or bilateral nasal

congestion, usually evolving

from a viral upper respiratory

tract infection

Investigations

CT scan rarely indicated

reassure parents

manage co-existing allergies

manage environmental factors

treat any acute bacterial infection

saline rinse/irrigation (not spray)

allergy testing if

indicated

topical steroid nasal

sprays for perennial and

seasonal allergic rhinitis,

as well as perennial non-

allergic rhinitis. (Long

term use has not been

shown to cause

suppression of the

hypothalamicpituitary – adrenal axis)

in seasonal rhinitis –

commence spray one

month prior to the

relevant pollen season

and continue over the symptomatic period

antihistamines – do not

use as a first line

treatment but may be

used for seasonal rhinitis.

Parent information

sinusitis

Emergency

complications of

sinusitis such as

severe pain, ocular

problems, forehead

swelling or

drowsiness must be

referred immediately

to the Paediatric

Emergency

Department and/or

discussed with the ENT Registrar on call

Semi-urgent / routine

persistent symptoms

despite 6 weeks of

appropriate treatment

where sinusitis is

persistent and seems to

exacerbate asthma symptoms

send any x-rays and/or

CT if done

send pathology results if

known, documentation

of clinical course and treatment and response

Page | 8

Epistaxis – recurrent

Initial pre-referral workup GP management Guidelines for specialist

referral

Clinical history

rule out allergic rhinitis

if suspecting blood disorder:

Patient history (i.e.

bruising, bleeding)

Family history

Physical examination

determine whether bleeding is

unilateral or bilateral

anterior or posterior

determine if coagulopathy,

platelet disorder or hypertension is present

Investigations

blood tests – (FBE, PT, APTT) if indicated by history

reassure parents

trial of antibiotic/ steroid

ointment/ to anterior

septum twice a day for

one week

observation of side

acute bleeding usually

settles with local

pressure to the lower nasal septum

avoidance of

precipitating factors such

as nose picking

Kids information

Uh- oh my nose is

bleeding

Parent information

Nose bleeds

Emergency

intractable epistaxis

despite appropriate

first-aid measures

must be referred to the

Paediatric Emergency

Department and/or

discussed with the ENT Registrar on call

Semi-urgent / routine

not responding to

conservative

management i.e. no

nose picking, strong

nose blowing,

application of topical

nasal steroid

epistaxis that is severe

or occurs frequently

send blood tests results

if known, documentation

of clinical course and

treatment and response

Page | 9

Throat

Hoarseness

Initial pre-referral workup GP management Guidelines for specialist referral

Clinical history

duration, onset and pattern of

symptoms; check the patient's

meaning of 'hoarseness'

rule out associated viral or

bacterial infection

signs of airways obstruction

history of overuse of voice

(shouting/yelling)

history of vocal cord cysts or nodules

history of gastro-oesophageal reflux

Physical examination

throat pain

dysphagia

stridor – refer to emergency

referral

signs of airway obstruction

laryngeal function - listen to the

patient's voice, and assess

cough and swallowing.

examine the neck - scars,

lymph nodes, thyroid gland.

Localised tenderness or may radiate to ear

treat any associated bacterial infection

observe for viral

infections – supportive management

voice rest

if presumed

inflammatory aetiology

consider a short course

of steroids

Emergency

hoarseness associated with:

neck trauma or

surgery

moderate or severe

stridor

must be referred to the

Paediatric Emergency

Department and/or

discussed with the ENT Registrar on call

Semi-urgent / routine

2 months of moderate to severe hoarseness

prolonged voice loss

Page | 10

Tonsillitis – recurrent

Initial pre-referral workup GP management Guidelines for specialist referral

Clinical history

most sore throats are due to

a viral infection

Physical examination

throat pain and/or pain on

swallowing plus the presence of:

fever

tonsillar exudate

cervical lymphadenopathy

Group A beta-hemolytic

streptococcal (GABHS) is

likely if the following are

present:

tender and enlarged

tonsillar cervical lymph nodes

inflammation of the

tonsils and the rest of

the pharynx

generalised

erythematous (scarlatiniform) rash

Investigations

consider throat swab

viral – supportive management

bacterial – antibiotics

Kids information

Tonsillitis - when your

throat is often sore

Parent information

Tonsillitis

Emergency

complications of

tonsillitis such as quinsy

(peritonsillar abscess)

and/or airway obstruction

must be referred to the

Paediatric Emergency

Department and/or

discussed with the ENT Registrar on call

Semi-urgent / routine

refer if:

4 - 6 infections in 1 year

4 infections/year for 2 consecutive years

3 infections/year for 3 consecutive years

it is acceptable to take into

account the impact of the

child’s frequency and

severity of infections upon

child’s attendance at

school and parents attendance at work

send blood tests results if

known, documentation of

clinical course and treatment and response

Page | 11

Snoring and Obstructive Sleep Apnoea

Initial pre-referral workup GP management Guidelines for specialist referral

Clinical history

parental observations and

description of sleep patterns

snoring

restlessness

snorting arousals or apnoeic episodes

disturbed sleep

enuresis

daytime symptoms

Somnolence

Irritability

hyperactivity

gagging on solid food in

presence of very large tonsils

enuresis

Physical examination

larger tonsils

nasal obstruction

craniofacial abnormality

nil GP management

recommended

Urgent

proven Obstructive

Sleep Apnoea

co-existing craniofacial

abnormality

snoring with obvious

obstructive features

(apnoea/choking)

associated with failure to thrive

Semi-urgent / routine

witnessed sleep apnoea

tonsils meeting in the

midline +/- trouble

swallowing from large tonsils

excessive day-time

sleepiness

chronic intermittent

snoring with no

reference to any

symptoms of Sleep

Disordered Breathing

mouth breathing all the time

PLEASE NOTE – referral

is based on symptoms not

size of tonsils and will be

triaged as per urgency by the ENT Consultant

 

 

For more information

Women’s and Children’s Hospital 72 King William Road North Adelaide SA 5006 Telephone: (08) 8161 7000 www.wch.sa.gov.au

© Department of Health, Government of South Australia. All rights reserved. Printed September 2014.

Other

Neck mass

Initial pre-referral workup GP management Guidelines for specialist referral

Clinical history

history of tenderness with

associated dysphagia,

dysphonia, draining sinus, fever, or increasing neck mass

Physical examination

observe for:

fluctuance

erythema

airway distress

Investigations

ultrasound of neck with notation of thyroid gland

thyroid function test if needed

full blood evaluation

reassure parents

treat infections

Emergency

the following

symptoms must be

referred immediately to

the Paediatric

Emergency

Department and/or

discussed with the ENT Registrar on call:

any signs of

infection, including

fever, redness, swelling or pain

any pain that is not

controlled with the

prescribed pain medicine

a mass or lump in

the centre of the

neck

Semi-urgent / routine

swelling that does not

respond to a course of antibiotics

send blood tests results

if known, documentation

of clinical course and

treatment and response