Tips on when to refer to chop otolaryngology | otolaryngology - ear, nose and throat

Collaborative Practice:
Tips on when to refer to CHOP Otolaryngology

Recurrent Acute Otitis Media
• Not an urgent referral, may take 4-6 weeks for a new patient visit. • Children 3 yrs & under in daycare with 2-3 AOM in 3 months, plan ahead & have parents make appointment with ENT, they can cancel the office visit if symptoms improve. It will make it easier for our staff to expedite an appointment when needed if the patient’s information is already in the system i.e. child has been given Rocephin without success. Persistent Middle Ear Fluid
• Refer for persistent middle ear fluid for >2 months especially for children under 2 yrs in daycare, delayed speech/language and other risk factors i.e.: Down syndrome. • Does the child have bilateral middle ear fluid at every office visit, even at their
Otitis Externa
• No urgent treatment is necessary unless external auricular canal edema is so severe that steroid otic drops are unable to go in. • Child typically is added to the schedule the same day for ear wick placement. • Weekends & after hours send to CHOP ED for ear wick placement. • Pain management may require narcotics.
Traumatic TM Perforation

• Refer to ENT for an appointment within 1-2 weeks. • Treatment in our office consists of suctioning the blood & remaining debris and a • Watchful waiting, we will continue to follow these patients and most traumatic perforations, even large ones, will heal spontaneously. • Maintain dry ear precautions until perforation is resolved. Collaborative Practice:
Tips on when to refer to CHOP Otolaryngology
Blocked Tympanostomy Tubes
• May be blocked with blood clot, wax or thick otorrhea • Treat with Hydrogen Peroxide 5gtts BID for 3-5 days until burning or stinging is reported. Burning/stinging indicates peroxide in middle ear & has unblocked the PET. If no response after 1 week, stop peroxide gtts. Follow up with Floxin otic gtts BID for 5 days • If PET blocked and AOM treat with peroxide gtts as above, OTC pain
Otorrhea from PET
• No referral necessary unless it is recurrent or not resolving with otic gtts. • Treat with antibiotic otic or antibiotic ophthalmic drops. • Oral antibiotics are not indicated for otorrhea from PET. • Even if child is on an oral antibiotic they must use drops for otorrhea from a tube. • No need for otic drop with a steroid unless inflammation, erythema or granuloma
Antibiotic Drops
• If Rx plan does not cover Floxin then Ocuflox ophthalmic drops or Quixin ophthalmic drops or Ciloxan ophthalmic drops
Antibiotic Drops with Steroid
• If RX plan does not cover Ciprodex then Cipro HC otic drops
Wax Impaction
• Not an urgent referral unless child wears hearing aids & is unable to wear aids • Have parents use Hydrogen Peroxide drops in the ears BID for 7 days prior to office visit to help soften wax for in office debridement • Straight Hydrogen Peroxide is cheaper than OTC Debrox which is hydrogen

Tongue Tie

Collaborative Practice:
Tips on when to refer to CHOP Otolaryngology
• Refer immediately for infants less than 6 weeks of age, some of our surgeons will perform frenectomy in the office. (Referral procedure code will need to be added to these referrals). • Infants over 6 weeks of age will need to go to the OR for frenectomy under • This is not an urgent referral for older children with speech articulation problems and frenotomy is often not paid by insurance.
Infant Stridor/ Laryngomalacia

• Mild to moderate stridor is not an urgent referral. • Urgent referral if stridor interferes with PO feedings & poor weight gain, infant will • If severe stridor with cyanosis, severe retractions and unable to feed, refer to CHOP ED; we are not equipped in the office to care for an infant with severe symptoms.
Enlarged Tonsils & Adenoids
• Enlarged T&A with no symptoms, do not refer. • Refer if child is chronic mouth breather, loud snoring, apneic pauses, daytime somnolence, restless sleeping, nocturnal enuresis, or dysphagia. • X-rays are not necessary for tonsillar assessment. If tonsils are small and evaluation of adenoids is desired, lateral neck xray may be obtained prior to visit or time of visit. • Not urgent referral, appointment may be within 4-6 weeks. • Please add lateral neck film and nasopharnygoscopy to referrals as some physicians may order these on the day of the office visit.
Recurrent Strep Pharyngitis

• Refer for #6 Strep (+TC) in 12 months • Not an urgent referral, appointment may be within 4-8weeks.
Recurrent/Chronic Viral Pharyngitis (Negative TC)
• Not an urgent referral, appointment may be within 4-8weeks.
Peritonsillar Abscess

• Febrile, drooling, trismus. Refer to CHOP ED. Child will likely be admitted for IV antibiotics, fluid & possible I&D of abscess
Nasal Fracture or Facial Trauma

Collaborative Practice:
Tips on when to refer to CHOP Otolaryngology
• No X-Rays necessary prior to referral. • Call day of injury for appointment. Will be seen within 5-7 days of trauma. Must be seen after swelling has subsided to determine if fracture with deviation present. • If closed reduction indicated, it is done within 14 days of injury! • Please see your patient in the office prior to referral to ENT, r/o septal hematoma which requires urgent same day visit or ED visit.
Thyroglossal Duct Cyst

• Not an urgent referral, appointment may be within 4-8weeks. • Pre-op thyroid US indicated to be sure there is thyroid tissue present.
• Encourage families to daily use of moisture therapy prior to ENT referral. • Neosporin ointment painted in nares with Q-tip BID and Saline nasal spray QID.
If patient continues to have nosebleeds despite exhaustive moisture therapy then ENT is warranted. • Nasal cautery is done in the OR under general anesthesia. Some of our physicians will use topical cautery in the office but most do not.
Expedited Appointment Request Process
• If you want a child seen sooner, fill out the expedited form with clinical symptoms & details why the child should be seen sooner (Note to CHOP primary care providers – please do not write “see EPIC”). • Have the family call & make an appointment (regardless of how long a wait it is • It is easier for us to move up an appointment once it is determined that an appointment needs to be expedited if there is an appointment already in the computer system. • Appointments within 15-30 days may not be offered anything sooner. • Have families consider driving to other office locations for sooner visits, • Follow-up visits may always be made closer to home.



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