ENT Adult Primary

and Secondary
Care Interface Guidelines
November 2023
User Information:
Purpose:

• This Guideline is intended to assist Primary and Secondary care colleagues in

decision making and does not replace clinical judgement
• We encourage users of this document to seek advice from primary or secondary
care colleagues when they are unsure, the later using established communication
channels such as Consultant Connect or advice and guidance (in some areas A&G
has been replaced by single point of referral on ERS). If there is no local clinician
available via Consultant we recommend contacting the on-call clinician via the local
hospitals switch board
• Prescribing: All prescribing should be in line with the SEL Joint Medicines
Formulary. Please refer to the BNF, Summary of Product Characteristics and local
antibiotic guidelines for any drug considered, particularly in pregnancy and
Breastfeeding
• The IMOC Guideline Allergic Rhinitis (2019) is replaced by this Guideline
Authors & Governance:
This guide has been produced utilising published guidance and in collaboration with
clinical and non-clinical staff across the Acute Provider Network (South East London’s
Secondary Care providers), South East London Integrated Care Board, South East London
Integrated Medicines Optimisations Committee (IMOC) and has undergone Primary Care
review through the LMC, Planned Care Leads, Primary Care Bulletin and Secondary Care
review through ENT Consultants at each trust and Neurology Consultant input where
relevant.
This guide was a collaborative effort from the above parties, led by Dr Alexandra
Armstrong (GP) and Mr Antonio Aymat (ENT Consultant), the SEL ICB ENT leads.
This guide has been approved by:
- South East London ICB Board
- The medicines and prescribing recommendations have been reviewed and approved
by SEL integrated Medicines Optimisation Committee (IMOC)
- Primary Care: LMC SLN, Planned Care Leads
- Secondary Care: Consultants from Lewisham & Greenwich NHS Trust, Kings
College NHS Foundation Trust (Princess Royal University Hospital) and Guys & St
Thomas' NHS Foundation trust

Glossary of terms
A&E – Accident & Emergency (/Emergency Department)
ICB – Integrated Care Board
OTC – over the counter
POM – Prescription only Medication
SEL – South East London
2ww – Two Week Wait Suspected Cancer

Version Date signed off Date of next review

1 October 2023 October 2025
Table of contents
No. Guideline
1 Ear Wax
2 Foreign Body (ear or nose)
3 Otalgia
4 Membrane Perforation
5 Ear discharge & Otitis Externa – Acute & Chronic
6 Otitis Media
7 Hearing Loss
8 Vertigo
9 Tinnitus
10 Eustachian Tube Dysfunction
11 Sinusitis
12 Nasal Congestion / Rhinorrhoea
13 Allergic Rhinitis
14 Nasal Polyps
15 Epistaxis
16 Snoring
17 Altered Smell
18 Sore throat
19 Swallowing issues & foreign bodies
20 Neck Lumps
21 Bells Palsy
22 References

Version Date signed off Date of next review

V0.1
 Ear Wax
Ear wax only needs to be removed if causing symptoms or if the tympanic membrane needs to be
visualised
Advise not to use cotton buds, to avoid recurrence continue olive oil drops twice weekly

• Otitis Media
• Acute Otitis
Externa
Evidence of additional Manage and
Yes • Dermatitis of the
pathology Review
Ear Canal
• Perforation
• Foreign body

No • Foreign body (see

dedicated guideline)
• Suspected/confirmed/
Hx of ear drum
perforation
• Recurrent or recent
otitis externa
• Previous mastoid or
Contraindication to ear surgery** Refer routinely
management in • Grommets in place to secondary
community? • Complete unilateral care via e-RS
deafness of
contralateral ear
• Otalgia / otorrhoea
• Previous
No complications of ear
irrigation –
perforation/severe If irrigation not available
pain/deafness /vertigo or failed irrigation refer to
Community Ear Wax
Removal Service for
Advise OTC drops * +/- microsuction (via e-RS).
irrigation in primary Ear wax removal for
care if available housebound people is not
commissioned by SEL ICB
however is available in
some areas – please
check with your PCN.

Self care advice: https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/

*Ear drop choice: Olive oil or Sodium Bicarbonate. Both TDS for 3-5 days. Olive oil may take up to 2
weeks to soften. Side effects: transient hearing loss, discomfort, dizziness, skin irritation. **ear surgery:
excludes cosmetic pinna surgery & grommets which have been extruded for more than 2 years AND the
individual has been discharged from secondary care
References: SEL Treatment Access Policy 2022 (1), NICE CKS Earwax (2), SEL Community Ear Wax
removal referral criteria (3)
Foreign Body of the Ear or Nose

RED FLAGS
• Foreign body in the Nose = in an airway, therefore should be seen in A&E
• If it is a battery consider if need to call 999 (button batteries swallowed / inhaled can
cause serious burns < 2 hours)(First aid for button batteries – swallow 10mls honey if
available whilst waiting for ambulance, do not delay calling 999)
• Foreign Body in Ear speak to on-call ENT via switch board/Consultant Connect for review
(do not try and manipulate without specialist equipment or training)
• Cover with oral antibiotics if evidence of cellulitis whilst waiting to be seen as per local
antibiotic guidelines
 Otalgia
Local pathology:
• Otitis Media/Otitis Externa/Foreign Body/Trauma/Wax/skin
conditions/mastoiditis/eustachian tube dysfunction
• Referred pain:
• TMJ/Salivary gland disease/Dental abscess/Sinus inflammation/Tonsillitis /peri-tonsillar
abscess/trigeminal neuralgia/ Cervical spine disease/oesophageal reflux/foreign
body/atypical migraine/ rarely Cancers: oropharyngeal/laryngeal/nasal
• Treat underlying cause, if does not resolve this is persistent otalgia and consider 2ww
Head and Neck (see below)
• If no identifiable cause advise analgesia, review after 1-2 weeks and then refer 2ww Head
and neck if non-resolved & unexplained

RED FLAGS
• Persistent unilateral otalgia in the absence of localised ear findings (2ww Head and Neck
– for laryngeal cancer: otalgia ≥ 40 years old for ≥ 3 weeks; for Ear/Nose/Sinus cancer the
Pan-London 2ww criteria does not specify time frame or age – use clinical judgement and
discuss if unsure, consider RFx such as smoking/alcohol/immunocompromise)
• Suspected Mastoiditis: Mastoid swelling/erythema/tenderness/bogginess speak to on-call
ENT (switch board/Consultant Connect) for same day assessment or via A&E if unstable
• Peri-tonsillar abscess speak to on-call ENT (switch board/Consultant Connect) for same
day assessment or via A&E if unstable
• Weight loss, persistent voice change, lymphadenopathy, neck mass, dysphagia – 2ww to
appropriate specialist – (Head and neck/Gastroenterology/Haematology/unknown
primary)

References: Pan-London urgent Suspected cancer referral forms (4)

Tympanic Membrane Perforation
• Secondary to Otitis Media, Trauma, Barotrauma, Surgical
• >90% heal within 4 weeks & Hearing loss usually recovers once healed
• If high risk for secondary infection or high risk complications from infection prescribe a
topical antibiotic e.g ciprofloxacin unit dose ear drops 0.2% ** BD until healed

• Treat any ongoing otitis

media / otitis externa
• Avoid ototoxic
preparations (e.g.
gentamicin)
• Advise on self care Review after 4 weeks
measures* to avoid and if not healed
secondary infection Refer routinely to
Perforated
• Safety net re. seeking secondary care via
tympanic Unresolved
help asap if symptoms of e-RS
membrane
infection Continue self care
• If high risk for secondary while waiting to be
infection or high risk seen
complications from
infection prescribe a
topical antibiotic e.g
ciprofloxacin 0.2% ** BD
until healed

• *Self care advice to try and stop secondary infection of the inner ear: keep it dry, particularly
no shampoo/soap to enter ear canal. Ear plugs or coat cotton wool in petroleum jelly before
bathing. Use hairdryer on low heat to dry ears after bathing:
https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/
• **ensure no allergies. Note this is off-label usage and the BNF / SPC advises caution in
perforation. If otitis externa develops consider swabbing (gently care not to come in contact
with tympanic membrane) and rationalizing treatment based on results
Ear Discharge & Otitis Externa 1 of 2
(Acute Otitis Externa)
• Discharge can be: discharging wax (normal), discharging ear drops, infection – pus/mucous/blood (otitis
externa or media +perforation), CSF Leak – clear/blood stained (trauma or surgery), Cholesteatoma
• Otitis Externa can be: Acute or Chronic. Bacterial or Fungal
• Risk Factors for Otitis Externa: Swimming, dry skin conditions, diabetes/immunosuppression, trauma (ear
buds/scratching), hearing aids/in-ear headphones
• Self care: keep ears dry (ear plugs/swim cap/ cotton wool coated in petroleum jelly), blow dry on low heat
after bathing, OTC Acetic acid after swimming:
https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/

RED FLAGS
• Suspected necrotising (malignant) otitis externa: Older than 50 or immunocompromised (including
diabetes) presenting with Otitis externa +/- severe ear pain +/- Cranial Nerve Palsy +/- offensive
discharge +/- failed treatment x2 for otitis externa +/- peri-aural cellulitis speak to on-call ENT (switch
board/Consultant Connect) for same day review
• Discharge following head trauma or cranial surgery (refer to A&E for consideration CT Head)
• Foreign Body in Ear Foreign Body in Ear/Nose A&E as an emergency: for batteries in nose, speak to
on-call ENT switch board/Consultant Connect to organise review (do not try and manipulate without
specialist equipment or training) Cover with oral antibiotics if evidence of cellulitis whilst waiting to be
seen as per local antibiotic guidelines
• Suspected Cholesteatoma: Chronic unilateral offensive discharge with hearing loss or typical tympanic
membrane - Usually originates at the top, inner edge of the tympanic membrane as a
retraction/keratinous build up +/- discharge into the canal (referral to ENT via e-RS)

See RED FLAG box

RED FLAGS Take swabs (standard wound swabs) x2
Systemically unwell? and send for MCS & Mycology
Acute Otitis Externa Yes Start oral antibiotics* in those with peri-
severe infection?
Immunocompromised aural cellulitis, severe infection or
immunocompromised
Consider admission as per any unwell
No adult / diabetic crisis

Mild cases e.g, minimal erythema, no significant discharge or canal narrowing: OTC acetic acid 2%
Moderate e.g. erythema, discharge: Topical Antibiotics*
Canal narrowing or significant itch/pain: Combination treatment: Topical Antibiotics + topical steroid*

Unresolved

Reassess for features of severe infection or red flags

Send Swabs x 2 (standard wound swabs) – MCS and Mycology & rationalise treatment
Consider discussion with on-call ENT if would benefit from microsuction
Consider necrotising otitis externa
Review adherence and consider changing formulation e.g. if difficulty administering drops, consider spray

*Follow local or NICE Antibiotic Guidelines

Prescribe a non-ototoxic preparation if the person has a known or suspected perforation of the tympanic membrane, including a
tympanostomy tube in situ​

References: NICE CKS Otitis Externa (5)

 Ear Discharge & Otitis Externa 2 of 2
(Chronic Otitis Externa)
• Discharge can be: discharging wax (normal), discharging ear drops, infection – pus/mucous/blood (otitis
externa or media +perforation), CSF Leak – clear/blood stained (trauma or surgery), Cholesteatoma
• Otitis Externa can be: Acute or Chronic. Bacterial or Fungal
• Risk Factors for Otitis Externa: Swimming, dry skin conditions, diabetes/immunosuppression, trauma (ear
buds/scratching), hearing aids/in-ear headphones
• Self care: keep ears dry (ear plugs/swim cap/ cotton wool coated in petroleum jelly), blow dry on low heat after
bathing, OTC Acetic acid 2% after swimming
https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/

RED FLAGS
• Suspected necrotising (malignant) otitis externa: Older than 50 or immunocompromised (including
diabetes) presenting with Otitis externa +/- severe ear pain +/- Cranial Nerve Palsy +/- offensive
discharge +/- failed treatment x2 for otitis externa +/- peri-aural cellulitis speak to on-call ENT (switch
board/Consultant Connect) for same day review
• Discharge following head trauma or cranial surgery (refer to A&E for consideration CT Head)
• Foreign Body in Ear Foreign Body in Ear/Nose A&E as an emergency: for batteries in nose, speak to
on-call ENT switch board/Consultant Connect to organise review (do not try and manipulate without
specialist equipment or training) Cover with oral antibiotics if evidence of cellulitis whilst waiting to be
seen as per local antibiotic guidelines
• Suspected Cholesteatoma: Chronic unilateral offensive discharge with hearing loss or typical tympanic
membrane - Usually originates at the top, inner edge of the tympanic membrane as a
retraction/keratinous build up +/- discharge into the canal (referral to ENT via e-RS)

Chronic Otitis Externa

RED FLAGS
Systemically unwell?
severe infection?
Immunocompromised

(STOP and manage)

No

• Consider Fungal Infection: especially if intense itch, swab and

treat: topical* antifungals – Can treat empirically whilst waiting for Consider seeking advice and guidance +/-
swab results if classic appearances: candida: off white. Aspergillus routine referral via e-RS if no red flags,
– fungal hyphae in canal – yellow/grey/black. does not require urgent treatment, not more
• Manage Risk Factors. appropriate to refer to Dermatology and if
• Consider testing for diabetes there is a failure to respond to bacterial /
• Manage skin conditions & consider routine referral to Dermatology fungal treatment in Primary care
• Consider Cholesteatoma

*such as clotrimazole 1% solution applied 2–3 times a day, to be continued for at least 14 days after infection has
resolved. Oral antifungals can be considered in confirmed cases which do not respond to topical treatment – use
clinical judgement and consider discussion with micro. ​
If Otitis Media with perforation is suspected (acute pain which is suddenly relieved followed by ear discharge) treat as
per dedicated guidelines and then review
Prescribe a non-ototoxic preparation if the person has a known or suspected perforation of the tympanic membrane,
including a tympanostomy tube in situ​

References: NICE CKS Otitis Externa (5)

 Otitis Media 1 of 2
• Acute otitis media: acute onset of unilateral pain and infective symptoms with characteristic abnormal
tympanic membrane: red / bulging / effusion +/- perforation. May be viral (approx. 2/3 of cases) or bacterial.
Consider no/delayed script of antibiotics in those who are systemically well without diabetes or otherwise
immunocompromised. Advise on natural course: 3-7 days & on regular simple analgesia
• Complications: chronic suppurative otitis media, hearing loss (no evidence that antibiotics prevent), perforation,
mastoiditis (mostly children), meningitis, intracranial abscesses, sinus thrombosis, facial nerve palsy
• Risk Factors: Smoking
• Otitis Media with Effusion: pressure, popping/clicking sensation +/- conductive hearing loss. TM dull/fluid
level/non-motile. Causes: persistent inflammation post infection, low grade ongoing infection, impaired
Eustachian tube function, allergic rhinitis
RED FLAGS
• Suspected Mastoiditis: Mastoid swelling/erythema/tenderness/bogginess speak to on-call ENT (switch
board/Consultant Connect) for same day assessment or via A&E if unstable
• Suspected complications: severe pain, severe headache, meningism, evidence of sepsis, facial nerve palsy
or abnormal neurological examination (refer to A&E for consideration of IV antibiotics and Imaging)
• Visible nasal mass (2ww Head and Neck) or if suspected nasal mass (e.g. unexplained persistent unilateral
nasal blockage / bloodstained or offensive nasal discharge) consider discussing with ENT via A&G for urgent
review / referring outside of 2ww criteria
• Discuss with ENT via A&G for urgent review / referring outside of 2ww Head and Neck criteria: recurrent or
non-resolving otitis media with symptoms between episodes/ with persistent cervical
lymphadenopathy/Unexplained persistent otitis media with effusion
• Suspected Cholesteatoma: Usually originates at the top, inner edge of the tympanic membrane as a
retraction/keratinous build up +/- discharge into the canal (Urgent [not 2ww] referral via e-RS)

Acute Otitis Media

RED FLAGS
Systemically unwell? severe
infection?
RED FLAGS: see box Immunocompromised
Immediate script oral
antibiotics* Yes No
Consider admission as per
any unwell adult / diabetic Advise simple
crisis Perforated tympanic regular analgesia
No
membrane Consider delayed
script oral antibiotics*
Yes
Unresolved
Advise self care & consider topical
antibiotics if high risk secondary
infection**, advise simple regular
analgesia +/- delayed script oral
antibiotics for acute otitis media
• Consider seeking advice and • Prescribe antibiotic or escalate
guidance +/- routine referral if antibiotics to second line
Unresolved ongoing > 6 weeks (Chronic • Re-assess for evidence of
Otitis Media) or hearing loss severe infection or Red Flags
• Consider Cholesteatoma + • Review diagnosis
Persistent perforation after 4 urgent (not 2ww) referral via
weeks: routine referral to ENT e-RS
via e-RS

• *Follow local or NICE Antibiotic Guidelines or NICE.

• **see dedicated guideline on Tympanic Membrane Perforation (slide 7)
• References: NICE Otitis media (acute): antimicrobial prescribing (6); NICE Otitis Media (acute) (7); Pan-London urgent Suspected cancer
referral forms (4); NICE CKS Head and neck cancers (8)
• Self-care https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/
 Otitis Media 2 of 2

Recurrent Acute Otitis Media

• Consider discussion with ENT for urgent review / e-RS referral outside of 2ww referral Head and
Neck if suspicious of nasopharyngeal cancer

• Consider seeking advice and guidance +/- routine referral if there is a craniofacial abnormality,
if episodes are distressing or unexplained
• Seek advice by speaking to on-call ENT (switch board/Consultant Connect) if tympanostomy tube
in situ and send MCS swab

Otitis Media with effusion

• If acutely following Viral Upper Respiratory Tract infection watchful waiting for 2-4 weeks is
appropriate
• Please note evidence base is limited for medical treatment, NICE advocate for watchful waiting or
surgery in non-resolving cases
• As ongoing symptoms are likely to be due to: Impaired eustachian tube function causing poor
aeration of the middle ear, Low-grade viral or bacterial infection or Persistent local inflammatory
reaction we believe it is reasonable to trial:
• Advise on auto-inflation 3 times a day for 1-3 months. Can buy a device over the counter or attempt
to blow up a balloon with each nostril in turn.
• Nasal decongestants (e.g. Xylometazoline 0.1%)TDS for 1 week max (warn about developing a
reliance and worsening symptoms if overuse)
• Trial of nasal steroids for 8 weeks see SEL formulary for options: e.g fluticasone or mometasone
• Consider one off course of oral antibiotics*

• Consider seeking advice and guidance +/- routine referral ongoing > 6 weeks

• *Follow local or NICE Antibiotic Guidelines or NICE guidelines for Upper Respiratory Tract infections – Otitis
Media
• References: NICE Otitis media (acute): antimicrobial prescribing (6); NICE Otitis Media (acute) (7); Pan-London
urgent Suspected cancer referral forms (4); NICE CKS Head and neck cancers (8)
 Hearing Loss
• History: Acute/gradual? Unilateral/bilateral? Associated features: tinnitus/vertigo, popping/clicking, otalgia, discharge,
history of infection, Family History
• It can be difficult to differentiate between sensorineural hearing loss and conductive hearing loss. Treat unilateral
unexplained hearing loss as sensorineural
• Conductive Hearing Loss differential diagnosis: wax, perforation, foreign body, otitis media with effusion, otosclerosis,
cholesteatoma, necrotising (malignant) otitis externa, rarely glomus tumour
• Sensorineural Hearing Loss (SNHL) differential diagnosis : presbycusis, vestibular schwannoma (acoustic neuroma),
noise induced, after cerebral infection, sudden SNHL, labyrinthitis, Meniere's, ototoxic drugs/toxins, infections: meningitis,
Ramsay Hunt syndrome, mumps

RED FLAGS
• Suspected Cholesteatoma: Usually originates at the top, inner edge of the tympanic membrane as a
retraction/keratinous build up +/- discharge into the canal (Urgent [not 2ww] referral via e-RS)
• Suspected vestibular schwannoma (acoustic neuroma): Unexplained constant unilateral tinnitus > 6 weeks
(referral to ENT)
• Foreign Body in Nose= airway, refer to A&E, consider 999 if a battery. All other foreign bodies speak to on-
call ENT (switch board/Consultant Connect) do not try and manipulate without specialist equipment or
training) Cover with oral antibiotics if evidence of cellulitis whilst waiting to be seen

Sudden Unilateral
RED FLAG symptom If no clear cause e.g Foreign body/ acute otitis media (see dedicated
Hearing Loss
guidelines) speak to on-call ENT (switch board/Consultant Connect) for urgent review & start
(hearing loss that
treatment: Prednisolone 1mg/kg up to 60mg OD for 10 days with PPI cover. If evidence of
develops within
herpetic infection and presentation < 72 hours start Aciclovir as per NICE shingles guidance
<72 hours)

RED FLAG symptom neurological signs e.g. severe headache, cranial nerve involvement,
Unilateral Hearing
motor/sensory deficit of limb or face, convulsions, severe nausea/vomiting/instability, very sudden
Loss with
onset (refer to A&E or call 999 if acute stroke suspected – please note hearing loss is not a
neurology
common stroke symptom, use clinical judgement or call the local stroke team for guidance)

Rapidly worsening Rapidly worsening hearing loss (Seek advice from ENT via advice and guidance or speak to
hearing loss on-call ENT Consultant Connect/telephone, normally needs ENT assessment <2 weeks)

Normally pathological and requires

routine referral to ENT via e-RS
History and Unexplained
Gradual Unilateral if no Red Flag features (onset <72
examination gradual unilateral
Hearing Loss hours is a Red Flag).
Exclude Red Flags hearing loss
Safety net advice: acute
worsening or additional symptoms

Treat any Foreign

After 4 weeks refer to ENT
Clearly visible Body, Excessive
routinely via e-RS
pathology suggesting wax, Infection,
Safety net advice: acute
conductive cause perforation*, Otitis
worsening or additional symptoms
Media with effusion
*

• Can be difficult to differentiate between Conductive • After 4 weeks if unresolved:

& Sensorineural refer directly to audiology
• Gradual: wax / otitis media with effusion / (Community provider in SEL
presbycusis / noise induced / ototoxic drugs / via e-RS).
Gradual bilateral
Otosclerosis
Hearing Loss
• Acute: Red Flag, unless consistent with Otitis
• If less than 55 please also
Media with effusion*, speak to on-call ENT (switch
consider if a direct refer to
board/Consultant Connect) for urgent review
ENT routinely via e-RS
• Treat any underlying cause. Assess for Red Flags.

• *see dedicated Guideline (slide 11 Otitis Medea slide 2 of 2)

• For more detail please consider referring to the RCGP Deafness and hearing loss toolkit
https://elearning.rcgp.org.uk/mod/book/view.php?id=12532
References: NICE CKS Hearing loss in Adults (10); RCGP deafness and hearing loss toolkit (11)
 Vertigo 1 of 3
Traditionally we have considered Vertigo (vestibular/neurological) & dizziness (cardiovascular/
systemic/medications) to be separate. For some patients this is helpful, for others (especially when there is co-
morbidity/older adults) it is not– history should focus on timing and triggers. There can also be overlap between
the two. Vertigo – motion/rotatory/spinning/nystagmus. Syncope/pre-syncope –lightheaded/faint/giddy. Always
consider red flags & rule out significant cardiac pathology

For people presenting with suspected vertigo:

1. perform a neurological + HINTS exam (if meeting criteria- see table below and consider watching a video
online if unfamiliar as parts of the exam are counter intuitive)
2. ENT exam + Dix-Hallpike to assess for BPPV. If Dix-Hallpike is negative manage as for acute unilateral
vestibulopathy
3. Cardiovascular exam – pulse, murmurs, sitting/standing BP

All central causes (Abnormal neuro exam or HINTS positive) need urgent neurological assessment.
If stroke within 4 hours is suspected call 999 or if more than 4 hours with local stroke team.
If stroke is not suspected speak with on-call neurologist/ admit if necessary or refer 2ww neurology if meeting
criteria

Recurrent Vertigo:
1. BPPV Is the commonest cause, suspect if short episodes (less than 1 min) triggered by head movement in
the vertical plane (Dix Hallpike)
2. Vestibular migraine is the second commonest cause – suspect if longer episodes, spontaneous or with
recognized migraine triggers
3. Vascular causes are rare – suspect if any associated neurological features or high vascular risk
4. Other causes to consider – if triggered by exertion/recognized syncopal triggers, other cardiac symptoms
e.g. chest pain/palpitations

Chronic dizziness/imbalance: consider referral to ENT MDT Balance clinic via e-RS if neurological & cardiac
causes excluded or considered unlikely (dedicated referral form)

RED FLAGS
• Severe headache, cranial nerve involvement, motor/sensory deficit of limb or face, convulsions, severe
nausea/vomiting/instability, sudden onset (refer to A&E or call 999 if acute stroke suspected <4 hours onset)
• Suspected stroke (posterior circulation symptoms – vertigo, severe imbalance, limb weakness, slurred speech, double
vision, headache, nausea/vomiting) (999 if <4 hours or A&E/discuss with stroke on-call)
• New-onset persistent headache or prolonged, severe vertigo (suspect central cause, discuss with Neurology, refer to
A&E in an emergency)
• Head injury preceding vertigo/head or other significant injury as a result of severe vertigo/Loss of Consciousness (refer
to A&E)
• Cardiovascular risk factors or FHx Sudden cardiac death (consider cardiac causation e.g. acute ischaemia, arrhythmia,
follow appropriate guidelines, discuss with cardiology or call 999 in an emergency)
• Sudden unilateral hearing loss (occurring in under 72 hours). See dedicated guidance (new onset unilateral hearing loss
and vertigo – consider possibility of a stroke)

HINTS exam to distinguish between peripheral and central causes of acute vestibular symptoms exam when:
1. normal neurological exam (other than nystagmus)
2. current, constant vertigo over hours or days
3. nystagmus

Peripheral Vertigo Central Vertigo

Head impulse test Abnormal: corrective saccade to Normal; no corrective saccade
midline with rotation of head
Nystagmus Unidirectional: horizontal Horizontal & direction changing;
vertical; torsional
Test of Skew No skew deviation Skew deviation present

• * HINTS exam – if not familiar with this please consider watching a video online as can be counterintuitive (e.g. abnormal head impulse is
a sign of peripheral disease)
References: NICE CKS Vestibular neuronitis (12); NICE CKS Meniere’s disease (13)
 Vertigo 2 of 3

Vertigo on moving head. Self-Epley Refer to ENT MDT Balance clinic

BPPV Dix-Hallpike positive. No maneuver Unresolved via e-RS for consideration of
red flags exercises at home vestibular physiotherapy if ongoing
after 4 weeks

Consider 3 days** of regular

prochlorperazine** for vertigo or
cyclizine 50mg TDS for vomiting or
Acute Continuous for HINTS Exam*
cinnarizine 30mg TDS for If symptoms
unilateral over 24 hours indicates
vestibular symptoms ongoing after 4
vestibulopath often with peripheral cause,
Vestibular neuronitis (no hearing weeks seek
y nausea/vomiting. no red flags or
loss or tinnitus) is separate from advice and
(Labyrinthitis/ Often with viral indication of
Labyrinthitis (hearing loss). If guidance +/-
Vestibular URTI symptoms cardiovascular or
symptoms are severe please routine referral
neuronitis) preceding systemic origin
discuss with speak to on-call
ENT (switch board/Consultant
Connect)

• * HINTS exam – if not familiar with this please consider watching a video online as can be counterintuitive (e.g.
abnormal head impulse is a sign of peripheral disease)
• **Courses 3-7 days, standard release 5mg PO TDS (max 30mg daily dose). Buccal prochlorperazine can be
considered in nausea/vomiting. If cases are mild consider no drug treatment as this can prolong symptoms by
delaying physiological compensatory mechanisms. Long term courses are not recommended as they lead to
dependence and do not have an evidence base
References: NICE CKS Vestibular neuronitis (12); NICE CKS Meniere’s disease (13)
 Vertigo 3 of 3

Diagnosis made in secondary care when there

is a clear episodic history over time **. Initial
Episodic attacks Unless having an presentation may need to be assessed for
Meniere’s
vertigo/tinnitus/ SN attack stroke (if acute unilateral hearing loss and
(see box
hearing loss. examination is vertigo) Seek advice if unclear..Exclude red
below)
Fullness/pressure often normal flags.
Recurrent attacks to be considered for
intratympanic treatment

• Meniere’s is an uncommon cause of vertigo. Attacks last 20 mins – 12 hours. Attacks are often clustered. Symptoms
include: Fluctuating hearing loss, perception of aural fullness, tinnitus (not necessarily at the same time as vertigo). As the
disease progresses the tinnitus and hearing loss may become more continuous. May be unilateral or bilateral. There may be
residual unsteadiness for days after an acute vertigo attack. Diagnosis requires definitive history and suspected early cases
(e.g. less than 3 episodes) should be managed in primary care until the history is clear. ENT review is required to confirm
diagnosis- routine referral via e-RS

Most common cause of non- Examination is usually

Vestibular
positional recurrent vertigo normal +/- classic
Migraine
attacks migraine history

First Episode

Suggest A&E / Discussion with on call

Ambulatory Future episodes can be managed in Neurologist via Consultant
emergency clinic primary care with prochlorperazine** Connect/switch board according to
(AEC) where available for vertigo plus standard migraine severity and any red flags
management for acute attacks /
prophylaxis

Consider referral to referral to ENT MDT Balance clinic via e-RS if

symptoms persist between attacks or are poorly controlled on migraine
prophylaxis

• * HINTS exam – if not familiar with this please consider watching a video online as can be counterintuitive (e.g.
abnormal head impulse is a sign of peripheral disease)
• **Courses 3-7 days, standard release 5mg PO TDS (max 30mg daily dose). Buccal prochlorperazine can be
considered in nausea/vomiting. If cases are mild consider no drug treatment as this can prolong symptoms by
delaying physiological compensatory mechanisms. Long term courses are not recommended as they lead to
dependence and do not have an evidence base
References: NICE CKS Vestibular neuronitis (12); NICE CKS Meniere’s disease (13)
 Tinnitus
• Is a symptom and is experienced differently. Ringing / hissing / roaring / clicking / buzzing / pulsing / humming / whistling
• Confirm history: Unilateral/bilateral. Associated features. Constant or episodic. How long does each episode last. Review
medications and relationship to onset.
• Examination: ear, cranial nerves, carotid bruits (murmur if pulsatile tinnitus)
• Impact on quality of life – sleep, concentration, mental health, suicidality
• Pulsatile tinnitus = beating with heart. If constant/frequent it requires imaging. DDx: atherosclerosis, A-V malformations.
Tumours. Pagets disease. Otosclerosis. Idiopathic intracranial hypertension

RED FLAGS
• Suicidal ideation or at risk of suicide (previous attempts, insomnia, history severe mental illness). Refer to mental health
services. 999 if immediate danger. Make a crisis plan * refer for urgent ENT review via e-RS / discuss with on-call
ENT
• Significant vestibular symptoms (see Vertigo guidelines)
• History of head trauma preceding onset of tinnitus (refer to A&E)
• Sudden onset or fluctuating hearing loss or sudden deterioration in hearing (see Hearing loss guideline)
• Unilateral pulsatile tinnitus which is continuous/persistent without obvious cause speak to on-call ENT (switch
board/Consultant Connect)
• Neurological symptoms/signs. Evaluate for intracranial pathology (discuss with neurology via Consultant Connect/on-
call via switch)
• Suspected vestibular schwannoma (acoustic neuroma): Unexplained constant unilateral tinnitus > 6 weeks (Urgent [not
2ww] referral to ENT)

Persistent for > 4 weeks

History, Examination,
Refer for hearing assessment +/-
Red flags: see box.
Tinnitus Bilateral Yes hearing aids. Community provider
Exclude wax, foreign
SEL via e-RS
body, infection
Self care advice **

No Unresolved

Pulsatile Review for red flags/ pathology. Routine referral

After 4 weeks - consider seeking If distressing or
advice and guidance pathology
suspected
Yes No

Examine for Carotid Watchful waiting with self

bruit. If present refer -care advice & safety net
for imaging of this. to return if non-resolved
within 4 weeks; treat any
co-existing ENT
pathologies as per
If absent and appropriate guidelines
persistent seek
advice and Unresolved
guidance from ENT
+/- neurology +
referral for
appropriate imaging After 4 weeks referral to
ENT via e-RS to exclude
vestibular schwannoma
(acoustic neuroma)**

• * Crisis support services: Should contact own GP in-hours. Out of hours helplines: SANEline, Samaritans, SLAM crisis line 0800 731
2864 and choose option 1. Crisis information available from SLAM in different languages: https://slam.nhs.uk/crisis/. Advise to call 999 or
go to A&E if in immediate danger. The Listening Place is a suicide prevention charity which usually requires a self-referral for face to face
support: https://listeningplace.org.uk/
• ** self care advice & support services – https://www.tinnitus.org.uk/ or https://rnid.org.uk/information-and-support/tinnitus/
• ** vestibular schwannoma (acoustic neuroma)s are rare and slow growing and are therefore not a 2ww referral
References: NICE CKS Tinnitus (14)
 Eustachian Tube Dysfunction
• Usually causes mild-moderate intermittent symptoms, can be unilateral but usually bilateral
• Can be associated with infection (current or recent), nasal inflammation (allergies or sinus issues), smokers, acid reflux,
nasal blockage – deviated septum, large polyps, (rarely) cancer, scarring post-operative or post-radiotherapy
• Symptoms: Reduced or muffled hearing / pressure / fullness / popping / crackling / intermittent discomfort/ tinnitus /
abnormal sound own voice / feeling slightly off balance/ dizzy (for dizziness this is a diagnosis of exclusion – please
exclude other pathologies such as cardiac/systemic)
• Examination may show: inflamed nasal mucosae consistent with infection/inflammation, dull non-motile tympanic
membranes (ask to gently perform Valsalva maneuver while examining)
• Typically worsened by changes in pressure or altitude e.g. flying or scuba diving

RED FLAGS
• Visible nasal mass (2ww Head and Neck) or if suspected nasal mass (e.g. unexplained persistent unilateral nasal
blockage / bloodstained or offensive nasal discharge) consider discussing with ENT via A&G for urgent review / referring
outside of 2ww criteria
• Discuss with ENT via A&G for urgent review / referring outside of 2ww Head and Neck criteria: recurrent or non-
resolving otitis media with symptoms between episodes/ with persistent cervical lymphadenopathy/Unexplained
persistent otitis media with effusion
• Suspected vestibular schwannoma (acoustic neuroma): Unexplained constant unilateral tinnitus > 6 weeks (Urgent [not
2ww] referral to ENT)
• Unilateral pulsatile tinnitus which is continuous/persistent without obvious cause speak to on-call ENT (switch
board/Consultant Connect)
• Sudden onset or fluctuating hearing loss or sudden deterioration in hearing (see Hearing loss guideline)
• Any severe symptoms are not consistent with Eustachian Tube Dysfunction, refer to appropriate guidelines

• Treat underlying cause:

History, examination • Viral URTI - watchful waiting, self-care advice *
Suspected
(including nasal • Otitis Media – refer to guideline
Eustachian Tube
passageways), exclusion • Allergic Rhinitis – refer to guideline
Dysfunction
of Red Flags • Sinusitis – refer to guideline
• Consider managing any co-existing acid reflux

Unresolved

• Reassess for Red Flags

• Consider short course of nasal or oral decongestants 1 week
only **
• Self care advice to be continued
• Consider 8 week trial of nasal steroids***

Unresolved

Seek advice and guidance via e-RS +/- routine referral

• Self care advice*:

• Yawning or opening mouth widely, swallowing whilst pinching nostrils.
• Valsalva maneuver: take a deep breath, pinch your nose and close your mouth, and gently pop your ears, for 10-15
seconds, repeat as needed. Over the counter devices can be bought to do this - Auto-inflation devices e.g. such as the
Otovent. Doing it too forcefully can perforate the tympanic membrane
• Salt water rinses once a day – twice a day
• Flying: can buy OTC earplugs which aim to equalise pressure, can use nasal decongestant sprays 30 mins before flying,
continue valsalva maneuver, chewing gum/sucking a sweet
• Diving: avoid when suffering with blocked Eustachian tubes as risk perforation of the tympanic membranes
https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/

• ** nasal decongestants (e.g. xylometazoline) should only be used continuously for one week. Longer courses risk worsening symptoms
and reliance on decongestant. Oral decongestants e.g. pseudoephedrine or phenylephedrine may not be as effective however they do
not lead to rebound nasal congestion on withdrawal.
• *** 1st line are intranasal mometasone or fluticasone
• References: Pan London Urgent Suspected Cancer Referral forms (4); NICE CKS. Head and Neck cancers – recognition and referral
(8); NICE CKS Otitis media with effusion (15)
 Sinusitis 1 of 2
• Inflammation of paranasal sinuses & lining of nose
• Presentation: nasal discharge/ post-nasal drip, nasal congestion/blockage, facial pain, changes in
sense of smell, eyes watering, toothache, fever
• Acute or Chronic or Chronic with Polyps – managed differently
• Infective, Inflammatory or Allergic
• More than 90% of cases are viral and self limiting with self care – do not routinely prescribe antibiotics
• Complications: chronic sinusitis (more than 12 weeks), rarely severe complications: orbital abscess,
intracranial abscess, sepsis :
https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/

RED FLAGS
• Visible nasal mass (2ww Head and Neck) or if suspected nasal mass (e.g. unexplained persistent
unilateral nasal blockage / bloodstained or offensive nasal discharge) consider discussing with ENT via
A&G for urgent review / referring outside of 2ww criteria
• Discuss with ENT via A&G for urgent review / referring outside of 2ww Head and Neck criteria:
recurrent or non-resolving otitis media with symptoms between episodes/ with persistent cervical
lymphadenopathy/Unexplained persistent otitis media with effusion
• Suspected orbital abscess: Proptosis of eye, double vision, ophthalmoplegia, new reduction in visual
acuity or facial mass (ocular emergency, refer to on-call ENT (switch board/Consultant Connect) or to
A&E out of hours)
• Peri-orbital oedema or cellulitis (pre-septal cellulitis can be managed in primary care if high confidence
in diagnosis, systemically well and follow up <48 hours, if unsure or for orbital cellulitis refer to A&E)
• Suspected intracranial infection: severe frontal headache, swelling over forehead, symptoms/signs
meningitis, altered consciousness, vomiting, seizure, neurological signs (A&E or 999)

Evidence of bacterial
History, Examination,
Acute infection? Symptoms > Advise self care measures** and
Red Flags? No No
Sinusitis* 10 days, unilateral normal duration < 3 weeks
Immunocompromised?
green/brown/offensive
Unwell Adult
discharge, temp >38
degrees C, marked Unresolved
deterioration after initial
cold
No improvement within 7 days
Manage appropriately, • Reassess for Red Flags / requiring
consider immediate Yes
admission / bacterial treatment
antibiotic prescribing in • Consider nasal steroids for 14 days
immunocompromised • Consider trial of OTC non-sedating
individuals ( including antihistamine
Treat with oral
diabetics) or need for • Continue self-care, safety net and
antibiotics for 5 days
admission via A&E review after 2-3wks
Follow local/
NICE antibiotic guid
elines
Consider seeking advice and guidance
via e-RS +/- referral

Routine referral for recurrent episodes

(> 3x/year) / non-resolving acute
episodes

• *Acute sinusitis normally follows a cold – is defined as an increase in symptoms after 5 days or persistent symptoms after 10 days, lasts less
than 12 weeks. Diagnose: nasal blockage or nasal discharge WITH facial pain/headache and/or reduction/loss of sense of smell
• ** self care measures – over the counter: simple painkillers, nasal saline rinses can be very effective, nasal decongestants have limited
evidence but if chooses to use advise max duration 7 days or can cause reliance and worsening
https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/
• *** Follow local or NICE antibiotic guidelines
References: NICE CKS Sinusitis (16); Pan London Urgent Suspected Cancer Referral forms (4); NICE CKS. Head and Neck cancers –
recognition and referral (8)
 Sinusitis 2 of 2

• Diagnosed after 12 weeks duration of

symptoms
• Ensure adequate control of
asthma/allergic rhinitis (see appropriate
guidelines) History, examination,
Chronic • Advise to stop smoking / passive smoke Red Flags? Seek advice and
Sinusitis inhalation & direct to stop smoking Consider intranasal guidance via e-RS
services corticosteroids for up
• Advise to ensure regular dental checks to 3 months****
and dental hygiene as can pre-dispose to
Routine referral if
infection
Ongoing symptoms
• Avoid scuba diving if significant
or Nasal Polyps
symptoms

• *Acute sinusitis normally follows a cold – is defined as an increase in symptoms after 5 days or persistent
symptoms after 10 days, lasts less than 12 weeks. Diagnose: nasal blockage or nasal discharge WITH facial
pain/headache and/or reduction/loss of sense of smell
• ** self care measures – over the counter: simple painkillers, nasal saline rinses can be very effective, nasal
decongestants have limited evidence but if chooses to use advise max duration 7 days or can cause reliance and
worsening
https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/
• *** Follow local or NICE antibiotic guidelines
• **** intranasal steroids: see formulary beclomethasone or fluticasone propionate/fuoate or mometasone furoate
References: NICE CKS Sinusitis (16); Pan London Urgent Suspected Cancer Referral forms (4); NICE CKS. Head
and Neck cancers – recognition and referral (8)
 Nasal Congestion/ Rhinorrhoea
• Note separate Allergic Rhinitis guideline
• Symptoms: sneezing/running nose/nasal congestion/post-nasal drip/cough/mouth breathing/snoring
• Differential diagnosis: Acute infections, allergic, post-operative adhesions, septal deformities – acquired (trauma or cocaine
use) or congenital, acute post-traumatic (e.g. septal haematoma), rarely cancer, Medication side effects (aspirin, NSAIDs,
beta-blockers, contraceptive pills, overuse of decongestants, antidepressants, urological drugs), pregnancy, Irritants (e.g.
cigarette smoke, pollution, wood burning stoves, cleaning agents, strongly scented products, weather changes)
• In chronic rhinitis order allergy testing for common allergens (Allergen specific IgE blood testing – tree pollen, grass pollen,
dust mites, pets, mould or others depending on history) and refer to allergic rhinitis pathway if suggestive of allergic cause

RED FLAGS
• Visible nasal mass (2ww Head and Neck) or if suspected nasal mass (e.g. unexplained persistent unilateral nasal
blockage / bloodstained or offensive nasal discharge) consider discussing with ENT via A&G for urgent review / referring
outside of 2ww criteria
• Suspected CSF leak: Head injury followed by clear nasal discharge (refer to A&E)
• Suspected raised Intracranial pressure: Progressive headache / vomiting / abnormal optic discs / blurred vision / behavior
change (refer to A&E)
• Unilateral symptoms e.g anosmia + nasal symptoms or facial/orbital pain. Suspect mass (nasal/paranasal/intracranial)
refer to appropriate specialism 2ww or speak to on-call ENT (switch board/Consultant Connect)
• Suspected orbital abscess: Proptosis of eye, double vision, ophthalmoplegia, new reduction in visual acuity or facial
mass (ocular emergency, refer directly to ENT via Consultant Connect/telephone or to A&E out of hours)
• Peri-orbital oedema or cellulitis (pre-septal cellulitis can be managed in primary care if high confidence in diagnosis,
systemically well and follow up <48 hours, if unsure or for orbital cellulitis refer to A&E)
• Foreign Body in Ear Foreign Body in Ear/Nose (consider 999: for batteries in nose, A&E for FB in Nose, Consultant
Connect/telephone for ear do not try and manipulate without specialist equipment or training) Cover with oral antibiotics
if evidence of cellulitis whilst waiting to be seen as per local antibiotic guidelines

History, examination,
Review medications (including
exclusion of • Cocaine use?
OTC) and any triggers +
Red Flags • Deviated septum
emphasis on trigger avoidance
If suggestive of allergic Acute No • History of nasal or
Allergy testing +/- manage as per
rhinitis perform allergy sinus
allergic rhinitis guideline
testing and refer to surgery/radiotherap
Advise self care*
appropriate guideline

No Yes

Yes
Trial of steroid nasal spray** AND Seek advice and
nasal saline rinsing for 6 weeks, if guidance via e-
effective can stop and assess, RS +/- routine
may need long term. If ineffective referral
Likely viral upper review technique of nasal spray
respiratory tract usage, self-care and trigger
infection, reassure, avoidance, try alternative steroid
may last several spray for minimum 6 weeks.
weeks, safety net
advice
If continues to be debilitating
routine referral via e-RS

• *self care: nasal rinsing with homemade salt water solution or OTC solutions e.g. Sterimar spray or NeilMed rinse. Various OTC nasal
devices such as douches may be beneficial. Trigger avoidance and rinsing nose, face, hands, hair and changing clothes as soon as
possible after exposure. Information on how to make a homemade salt water solution is available from the NHS website:
https://www.nhs.uk/conditions/sinusitis-sinus-infection/
https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/
• ** see NICE guidelines & SEL formulary. 1st line are OTC intranasal fluticasone propionate or alternatives are prescription only medicines:
fluticasone furoate or mometasone furoate. Drop dose once symptoms controlled. Information on how to use nasal sprays and flixonase
nasules is available from the NHS website

References: References: NICE CKS Sinusitis (16); Pan London Urgent Suspected Cancer Referral forms (4); NICE CKS. Head and Neck
cancers – recognition and referral (8)
Allergic Rhinitis 1 of 2
• Note separate Nasal congestion/Rhinorrhea guideline which contains advice on allergen
avoidance, nasal rinsing and nasal steroids
• Symptoms: sneezing/running nose/itchy nose, throat, mouth/nasal congestion – mouth breathing,
snoring/post-nasal drip/cough
• Common, can cause significant impact on quality of life
• Screen for eczema, food allergy, asthma - uncontrolled allergic rhinitis increases risk of asthma
exacerbations
• ARIA Classification of Allergic Rhinitis: Splits into intermittent, persistent, mild, moderate-severe &
can be helpful to guide treatment
• Establish adherence to therapy and check nasal spray technique before stepping up treatment
• Start nasal sprays 1-2 weeks before pollen season. Treat eye symptoms*
• Sedating antihistamines, Nasal decongestants and depot steroids are not recommended

RED FLAGS
• Visible nasal mass (2ww Head and Neck) or if suspected nasal mass (e.g. unexplained persistent
unilateral nasal blockage / bloodstained or offensive nasal discharge) consider discussing with ENT
via A&G for urgent review / referring outside of 2ww criteria
• Suspected raised Intracranial pressure: Progressive headache / vomiting / abnormal optic discs /
blurred vision / behavior change (refer to A&E)
• Unilateral symptoms e.g anosmia + nasal symptoms or facial/orbital pain. Suspect mass
(nasal/paranasal/intracranial) refer to appropriate specialism 2ww or speak to on-call ENT (switch
board/Consultant Connect)
• Suspected orbital abscess: Proptosis of eye, double vision, ophthalmoplegia, new reduction in visual
acuity or facial mass (ocular emergency, refer directly to ENT via on-call ENT or to A&E out of
hours)
• Peri-orbital oedema or cellulitis (pre-septal cellulitis can be managed in primary care if high
confidence in diagnosis, systemically well and follow up <48 hours, if unsure or for orbital cellulitis
refer to A&E)
• Foreign Body in Ear Foreign Body in Ear/Nose (999: for batteries in nose, A&E for FB in Nose,
on-call ENT for ear do not try and manipulate without specialist equipment or training) Cover with
oral antibiotics if evidence of cellulitis whilst waiting to be seen as per local antibiotic guidelines
 Allergic Rhinitis 2 of 2

History, examination (including Add in PRN topical

nasal), exclusion of red flags, if Trial of nasal treatment: intranasal
suggestive of allergic rhinitis Mild and rinsing and azelastine / OTC sodium
Unresolved cromoglicate eye drops
perform allergy testing, if polyps are intermittent allergen
present refer to specific guidance avoidance only OR OTC non-sedating oral
antihistamines (fexofenadine
Always advise on nasal rinsing* is now OTC but is second
and allergen avoidance** – these line after cetirizine or
must be continued at all stages of loratadine)
the pathway Review after 2-3 weeks
Assess severity
Mild/intermittent: not affecting daily
activities, sleep not affected, At every stage check compliance with
seasonal Nasal rinsing and self care, oral and intranasal preps and
Mod/
allergen avoidance spray techniques and
Severe or
Moderate-severe or persistent in addition to other Consider alternative diagnosis
persistent
Impaired daily activities, sleep measures Step 1: Regular oral antihistamine
disturbance, perennial (fexofenadine is now OTC but is
second line after cetirizine or
loratadine) OR regular intranasal
antihistamine (Azelastine) +/- OTC
sodium cromoglicate eye
drops Review after 2-3 weeks
Step 2: add a regular intranasal
corticosteroid***
Review after 2-3 weeks
At every stage check compliance with self care, oral
Step 3: continue oral antihistamine and
and intranasal preps and spray techniques.
add in combination nasal spray
Consider alternative diagnosis
azelastine/fluticasone (formulary
recommendation)
If there are severe symptoms which are uncontrolled Unresolved
Step 4: for refractory symptoms as
consider a ONE OFF short course of oral
adjuncts: In asthmatics consider
prednisolone. Adult dosing: 0.5mg/kg in the morning
adding Montelukast, nasal
for 5 - 10 days. Consider risk factors for adrenal
decongestants (short term use only),
insufficiency and PPI cover.
intranasal ipratropium bromide
Significant eye symptoms: evidence
supports intranasal antihistamines, if
not effective consider olopatadine
Refer:
(formulary recommendation) 0.1%
Structural nasal problem:
ENT via e-RS
Allergen: to specialist
allergy clinic for
consideration of
immunotherapy

• *nasal rinsing advice from NHS website

• **allergen avoidance
• *** 1st line are OTC intranasal beclomethasone or fluticasone propionate or alternatives are prescription only
medicines: fluticasone furoate or mometasone furoate. For severe obstruction consider fluticaseone furoate drops.
Drop dose once symptoms controlled.
• How to use nose drops & sprays
https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/
References: NICE CKS Allergic Rhinitis (17); Pan-London Allergic Rhintitis guideline 2023 (18)
 Nasal Polyps
• Chronic inflammatory condition of the nose and paranasal sinuses
• Symptoms – nasal obstruction +/- reduction in sense of smell
• Yellow/gray in appearance , usually bilateral, unilateral polyps all need investigating. Not to be confused with
large inferior turbinates' – look on the internet for comparison photos / ask a colleague for an opinion if in doubt
• 1/3 have asthma. Other associations are cystic fibrosis, aspirin intolerance
• Considered to be a sub-type of allergic rhinitis & allergy testing and management of allergic rhinitis is
necessary
• Confidence in diagnosis is key before starting on long-term steroid sprays. High dose nasal steroids are
absorbed systemically and usually should be used short term
• If the person is also taking oral or inhaled corticosteroids they may be at further risk of adrenal insufficiency
• Surgery to remove polyps often relieves symptoms however recurrence of the polyps is common

RED FLAGS
• Unilateral polyps especially those with atypical appearances e.g. ulcerated or bleeding or in people
over 60 years old (2ww Head and Neck)
• Visible nasal mass (2ww Head and Neck) or if suspected nasal mass (e.g. unexplained persistent
unilateral nasal blockage / bloodstained or offensive nasal discharge) consider discussing with
ENT via A&G for urgent review / referring outside of 2ww criteria

Escalate
treatment to 6
week course of
RAST testing
Fluticasone
Allergen Avoidance +
propionate 400
Nasal rinsing with
Suspected or micrograms nasal Seek advice
saline
Recurrent Bilateral drops (nasules) ** and guidance
Regular non-sedating Unresolved Unresolved
Nasal Polyps with once daily- more via e-RS +/-
anti-histamine OTC
classic appearances effective if added routine referral
and
to nasal saline**
8 week trial of nasal
(continue allergen
steroid spray*
avoidance and
nasal saline
rinsing)

Good response –
likely to need regular
long term nasal
steroid – attempt to Good response –
reduce dose for reduce to nasal
maintenance** & spray* and
ongoing management continue long term
of allergic rhinitis at maintenance
dosing**

Consider 2ww if suspicious

Unilateral Nasal appearance e.g.
Refer to ENT bleeding/ulcerated or over
Polyps
60 years old. Discuss with
ENT if unsure

• *nasal steroids: Consider initial higher dose such as - fluticasone furoate 200 micrograms 1–2 times a day, to be
administered into each nostril or 100 micrograms daily for 5–6 weeks, dose to be sprayed into each nostril, then increased if
necessary to 100 micrograms twice daily, dose to be sprayed into each nostril. For both: ** consider alternative treatment if
no improvement after further 5–6 weeks, reduce to the lowest effective dose when control achieved.
• **ENT consultants find better response if this is added to a Nasal saline sinus rinse e.g. NeilMed (OTC)/see NHS website for
homemade solution then applied. Flixonase (Fluticasone propionate) nasules are being discontinued but another
manufacturer is taking over. If there is a shortage an alternative is budesonide 0.5mg which comes in a 2ml ampoule twice
daily, added to sinus rinse
• Information on how to use nasal sprays and fluticasone propionate nasules is available from the NHS website
• References: NICE CKS Chronic Sinusitis (19)
 Epistaxis & Broken Nose
• Common presentation in primary care however to remain alert as in rare cases is life threatening. 50% of
children 6-15 have regular nose bleeds
• Most can be treated at home and are not the sign of an underlying problem
• 80% are anterior from littles area which is easily damaged e.g. picking nose, blowing nose, minor injury,
colds, sinusitis, temperature changes, hay fever, nasal sprays
• 20% are posterior and are more common in the elderly or those with hypertension
• Acute epistaxis history – one or both nostrils, down back of throat, duration of bleeding, any trauma, any
anticoagulants, previous epistaxis/abnormal bleeding, in heavy bleeding signs of hypovolaemia

RED FLAGS
• Septal haematoma (in the context of trauma - refer for same day ENT assessment speak to on-call
ENT (switch board/Consultant Connect)
• Large volume of blood loss / haemodynamically unstable (refer to A&E / 999 in an emergency)
• Visible nasal mass (2ww Head and Neck) or if suspected nasal mass (e.g. unexplained persistent
unilateral nasal blockage / bloodstained or offensive nasal discharge) consider discussing with ENT via
A&G for urgent review / referring outside of 2ww criteria
• Nose bleeds under 2 years old (after examination consider bloods +/- referral to appropriate specialism
– ENT or Haematology)

History,
Advise 1st aid – pinch the soft After 15-20 mins
examination,
part of the nose and keep head Take vital signs and
Acute Red Flags?
in neutral, if available apply ice Unresolve transfer to A&E,
epistaxis unwell &
or cold compress between the particularly if on
requiring
eye brows or suck ice cubes anticoagulation
admission?

If stopped advise not to blow

nose or remove dried blood
from nose for at least 48 hours
& safety net advice if returns

• Trial of antiseptic nasal ointment * for 14

Seek advice
days to reduce crusting and nasal bacterial
and
infection
Recurrent guidance
• consider need for investigations for anaemia, Unresolved
epistaxis via e-RS +/-
clotting abnormalities
routine
• review of medications
referral
• Management of hypertension

• Broken noses where there is a deformity need to

RED FLAGS be reviewed by ENT 5-7 days post-injury as if
MUA is needed this occurs within 2-3 weeks
Broken Nose
• Refer to ENT emergency clinic by speaking
• Septal haematoma (refer for same
day ENT assessment via Consultant
with on-call ENT
Connect/telephone) • For late presentations: Septo-rhinoplasty is a
• Large volume of blood loss / restricted procedure on the NHS. There needs to
Broken
haemodynamically unstable (refer to No be both:
Nose
A&E / 999 in an emergency)
• Meeting NICE guidelines for CT 1. severe nasal deformity with complete
Head (refer to A&E) obstruction of at least one nostril
2. causing a severe functional limitation
• Suspect other facial bone fractures
(refer to A&E)
• If the individual is meeting both these criteria:
• Major trauma (refer to A&E)
routine referral via e-RS

• *Naseptin QDS for 10 days or if there is a peanut allergy the alterative is Bactroban (unliscenced use. Licenced for nasal infection with
carriage of Staphylococcus aureus)
• References: NICE CKS epistaxis (20)
 Snoring
• Simple snoring is noisy breathing during sleep without irregular breathing / apnoeas and daytime
sequelae
• In Adults simple snoring is not treated by ENT under the SEL Treatment access policy
• Assess for Sleep apnoea e.g with Epworth sleepiness scale, physical examination and assessment
of risk factors +/- refer to Sleep Disorders Clinic - there are commercially available smartphone
apps which will record /track snoring if its unclear if apnoeas are occurring
• Assess for and manage as appropriate any associated conditions: hypothyroidism, acromegaly,
nasal obstruction, septal deviation
• Advise on factors that increase chance of snoring: alcohol intake, sedative medications, smoking,
sleeping on back, increasing age, male gender

RED FLAGS
• Visible nasal mass (2ww Head and Neck) or if suspected nasal mass (e.g. unexplained persistent
unilateral nasal blockage / bloodstained or offensive nasal discharge) consider discussing with
ENT via A&G for urgent review / referring outside of 2ww criteria

History
• Any Red Flags?
• Onset, continuous or intermittent,
any reported apnoeas
• Weight changes • If consistent with simple snoring, reassure
• Systemic symptoms and direct to self care measures*
• Nasal symptoms / history of issues • If consistent with Obstructive Sleep Apnoea
• Impact on relationship/socially refer to Sleep Disorders Clinic locally
• Alcohol/smoking/sedative • Consider the need to exclude thyroid
Snoring medications history & impact these pathology / acromegaly
have on symptoms • Manage any associated Hypertension, Mental
• Epworth Sleepiness scale Health Conditions, substance misuse or
consider weight management referral
Examination • Refer to specific ENT guidelines for
• Nasal passages management of ENT conditions
• Neck masses, throat
• Neck circumference
• Blood pressure
• BMI

• *self care strategies: alcohol/smoking/sedative advice as appropriate. Tennis ball taped to back of PJs to prevent rolling onto back, ear
plugs for partner/white noise, there are various devices available over the counter e.g. nasal strips – these do not have a clear evidence
base and its unclear which if any are beneficial
https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/

References: SEL treatment access policy 2022 (1); NICE CKS Obstructive Sleep apnoea (21)
 Altered Smell (Dysosmia)
• Anosmia – total loss of sense of smell
• Hyposmia – reduced sense of smell
• Parosmia – distortions in sense of smell – usually intermittent with anosmia
• Phantosmia - olfactory hallucinations – smelling scents that are not there – usually intermittent with anosmia
• Differential: post-viral, post-traumatic including post-operative, exposure to toxins – prescribed medication*,
chemo/radiotherapy, cocaine, alcohol, smoking, neurological: MS, temporal lobe Epilepsy, Parkinson's,
Alzheimer's, Space occupying lesion, nasal blockage: rhinitis, polyps, tumours, congenital – Kalman’s
• History: duration, onset, triggers/preceding events, nasal symptoms such as discharge, recreational drugs,
alcohol, medications, neurological symptoms

RED FLAGS
• Unilateral symptoms e.g anosmia + nasal symptoms or facial/orbital pain. Suspect mass
(nasal/paranasal/intracranial) refer to appropriate specialism 2ww or speak to on-call ENT (switch
board/Consultant Connect)
• Cacosmia: foul smell in one nostril – consider foreign body or dental disease
• Phantosmia rarely can indicate a space occupying lesion e.g. temporal lobe lesion – normally few seconds of
intense smell, same smell each time – A&G neurology who may recommend referral or MRI
• Visible nasal mass (2ww Head and Neck) or if suspected nasal mass (e.g. unexplained persistent unilateral
nasal blockage / bloodstained or offensive nasal discharge) consider discussing with ENT via A&G for urgent
review / referring outside of 2ww criteria
• Severe frontal headaches, persistent nausea/vomiting, meningism, neurological symptoms (refer to A&E or
2ww Neurology as appropriate)
• Visual symptoms, ophthalmoplegia, orbital swelling/proptosis (refer to A&E to consider urgent imaging)

Clear History of Viral

illness or expected side
effect to medical Reassure and direct to
procedure (surgical or self-care measures**
Dysosmia Yes
chemo/radiotherapy), Advise intranasal
normal examination steroids for 8 weeks***
cranial nerves, nose &
and no Red Flags

No Unresolved

Manage any
Suspected neurological underlying ENT Seek advice and
No Unresolved guidance via e-RS
cause? conditions as
per guidance

Yes
routine referral
If ongoing for more
Discuss with neurology than 3 months and/or
causing significant
distress / affecting
livelihood or unclear
cause

• * such as ACE inhibitors, diuretics, calcium channel blockers, statins

• **Scent training – information available from: https://www.fifthsense.org.uk/; https://abscent.org; Patient information on parosmia and
phantosmia: https://www.fifthsense.org.uk/parosmia-and-phantosmia/ ENT UK suggest that Omega 3 supplementation can be considered
(OTC) however there is no definitive evidence
• ***see formulary: intranasal fluticasone propionate/furoate or mometasone furoate or beclometasone
References: Pan-London urgent Suspected cancer referral forms (4); NICE CKS Head and neck cancers (8); BMJ Anosmia and loss of sense
of smell in the era of covid-19 (22); BJGP Anosmia: an evidence-based approach to diagnosis and management in primary care (23)
 Sore Throat
• 70% are viral and do not require or respond to antibiotics
• 82% resolve within 1 week without antibiotics and pain is only reduced by 16 hours. Complications are rare
• Use FeverPAIN score to decide if antibiotic prescription is necessary at all or if a delayed prescription can be considered
• It is common for tonsils to be large in children, they normally shrink in the teenage years/early adulthood
• Peri-tonsillar abscess (Quinsy) can be a complication of tonsillitis or occur spontaneously – requires admission – fever,
severe sore throat, usually unilateral, unable to open mouth fully (trismus), “hot potato” voice, in advanced cases can cause
drooling and airway compromise. Examination: (can be difficult due to trismus) extensive erythema, soft palate swelling,
uvula deviated away from swelling

RED FLAGS
• Evidence of sepsis or difficulty in breathing (999)
• Unable to swallow any fluids (refer to A&E)
• Immunocompromised (including diabetics) (consider immediate antibiotics, review at 48hrs or admission if appropriate)
• Evidence of peri-tonsillar abscess (refer to ENT same day assessment by discussing with on-call ENT, if systemically
unwell via A&E)
• Suspected epiglottitis – sudden onset severe sore throat, stridor, drooling, systemically unwell (Do not examine mouth,
call 999, nebulised adrenaline if available whilst waiting for ambulance)
• Non-resolving symptoms, systemically unwell, neck stiffness, neck tenderness (signs of deep space neck infection, refer
to A&E)
• Atypical prolonged symptoms: tonsillar mass, tonsillar ulceration either without classic infective symptoms or not resolved
after antibiotics (Discuss with ENT via A&G for urgent review / refer outside of 2ww Head and Neck criteria)
• ≥ 4 weeks of persistent, particularly unilateral, discomfort in the throat or throat pain (2ww Head and neck )
• ≥ 40 years old with ≥ 3 weeks of one or more: persistent unexplained hoarseness / dysphagia / odonophagia / otalgia
(2ww Head and neck )
• Unexplained neck mass consider 2ww Head and neck or imaging as appropriate

Advise all patients on self Prescribe antibiotics** only if

History, examination,
care measures* & normal indicated by FeverPAIN
Acute sore throat FeverPAIN score,
duration (10 days) and score or the person is
exclusion of red flags
safety net advice immunocompromised

Reassess for red flags

Send throat swab (standard charcoal
swab for bacteria) for MCS +/- bloods for
EBV IgM & IgG

Referrals for tonsillectomy for recurrent tonsillitis:

Please discuss tonsillectomy and if they wish to be put forward for surgery before you make a
referral and outline the risks and recovery period – Patient information available from ENT UK ***
The NHS does not routinely fund tonsillectomy for recurrent tonsillitis except under the SIGN criteria:
1. Sore throats are due to acute tonsillitis AND
2. Episodes of sore throat are disabling and prevent normal functioning AND
3. 7 or more well documented episodes of significant sore throats in the preceding year (requiring treatment)
4. OR 5 or more such episodes in each of the preceding 2 years
5. OR 3 or more such episodes in each of the preceding 3 years
Tonsillectomy may be considered beneficial at a lower threshold after specialist assessment for certain people for whom
recurrent tonsillitis poses a significant risk to their health :
• Acute and chronic renal disease resulting from acute bacterial tonsillitis
• As part of the treatment of severe guttate psoriasis
• Metabolic disorders where periods of reduced oral intake could be dangerous to health
• PFAPA (Periodic fever, Apthous stomatitis, Pharyngitis, Cervical adenitis)
• Severe immune deficiency that would make episodes of recurrent tonsillitis dangerous
Tonsillectomy is performed for other indications without these restrictions e.g. Sleep disordered breathing in children,
sleep apnoea, recurrent Quinsy, cancer. Check treatment access policy.

• *self care – OTC paracetamol for pain/fever +/- ibuprofen, adequate fluid intake, there is some evidence for medicated lozenges, no
evidence for non-medicated lozenges, mouthwashes or local anaesthetic spray on its own
https://www.selondonics.org/icb/your-health/medicines/sel-imoc/sel-imoc-self-care/
• **Refer to NICE or local antibiotic guideline
• *** https://www.entuk.org/patients/conditions/59/tonsillectomy_taking_out_your_tonsils_because_of_repeated_infections_new
• *** https://www.entuk.org/patients/conditions/63/helping_you_decide_about_tonsil_surgery_for_your_child_new
References: NICE CKS Sore throat – acute (24); SEL Treatment access policy 2022 (1); Pan-London urgent Suspected cancer referral forms
(4); NICE CKS Head and neck cancers (8)
 Swallowing issues & Foreign Bodies
• Difficulty swallowing (dysphagia) can be due to ENT, gastrointestinal, neurological causes (Motor
Neurone Disease, Myasthenia gravis, stroke) or rarely due to compression from masses (e.g. GI,
ENT, thyroid, intrathoracic) or as a complication from procedures such as surgery or radiotherapy

• Consider if following local guidance for GI causes is most appropriate or the need for
investigating for GI or intra-thoracic malignancies

• Thorough history of swallowing issue: food sticking / regurgitating / coughing after eating / pain on
swallowing / solids / liquids / both and which one came first / sudden onset or a gradual worsening /
foreign body / systemic features – weight loss, abdominal pain, night sweats, bony pain, lumps,
smoking/alcohol history. Family history cancers

• ENT causes of impaired swallow: acute infective sore throat/tonsillitis, foreign body, rarely cancers

• Globus: suitable for diagnosis and management in primary care; painless sensation of a lump in the
throat, centrally, above the level of the sternum, intermittent symptoms, normal neck, nose and oral
examination. No pain, no dysphagia, no hoarseness/ change in voice, no progressive features, no
haemoptysis, no weight loss, not unilateral. Screen for anxiety and reassure. Do not routinely offer PPI
unless there are symptoms of oesophageal reflux

RED FLAGS
• Dysphagia at any age 2ww gastroscopy –direct access endoscopy or 2ww upper GI, check
local guidance)​
• 55 with weight loss AND any of the following: upper abdominal pain, reflux, dyspepsia (2ww
gastroscopy –direct access endoscopy or 2ww upper GI, check local guidance)​
• Acute foreign body (refer to A&E – batteries / difficulty breathing / drooling / significant chest
pain / cardiovascular unstable call 999)​
• Dysphagia resulting in complications: dehydration, malnutrition, airway obstruction (999), aspiration
pneumonia (consider if needs to be admitted via A&E or if it can be managed in the community with
any urgent referrals e.g. 2ww, dietician, SALT, GSTT/KCH hospital @home team etc.)​
• Sore throat with atypical symptoms such as: Systemically unwell with neck stiffness and/or
significant neck tenderness (signs of deep space neck infection, refer to A&E)​
• Atypical prolonged symptoms: tonsillar mass, tonsillar ulceration either without classic infective
symptoms or not resolved after antibiotics (consider 2ww referral Head and Neck)​
• Unexplained discomfort in the throat for more than 4 weeks, particularly unilateral (2ww Head and
neck)​
• Unexplained neck lump (2ww Head and Neck)
• Persistent unexplained hoarse voice > 3 weeks in over 40 year olds (2ww Head and Neck)
• 40 years or older with > 3 weeks dysphagia, >3 weeks of odonophagia, > 3 weeks of otalgia (2ww
Head and Neck)
 Neck Lumps

• Neck lumps can be: Dermatological lesions, skin infections, lipoma, Thyroid, Lymphadenopathy,
Salivary gland, Carotid, developmental/congenital
• Risk factors for head and neck cancer: smoking/tobacco use, alcohol, HPV, HIV, previous
irradiation of the head and neck, FHx thyroid cancer
• After history and diagnosis consider need for imaging (e.g. USS or 2ww based on clinical judgement
e.g. lymphoma or head and neck)
• ENT Causes of neck lumps: frequently infected sebaceous cysts on ear lobe, scalp around the ear,
hairline: firm, mobile, in the skin (not subcutaneous), frequently a yellow/white punctum +/- caseous
discharge, appear cellulitic – trismus and systemic illness is NOT typical – if there is no
immunocompromise and the individual is fit and well, consider trial or oral antibiotics in the
community – follow local guidance as per skin infections – infrequently can require incision and
drainage – refer for ENT assessment by speaking to on-call ENT (switch board/Consultant
Connect)

RED FLAGS
• As for swallowing/foreign bodies
• Evidence of sepsis or airway compromise (999)
• Immunocompromised (including diabetics) (for infective pathology consider immediate antibiotics,
review at 48hrs or admission via A&E if appropriate)
• An unexplained lump in the neck (2ww Head and neck)
• An unexplained persistent swelling in the parotid or submandibular gland (2ww Head and neck)
• Suspicious mass on imaging (refer to appropriate 2ww pathway e.g. lymphoma, Head and neck)

• References: Pan-London urgent Suspected cancer referral forms (4); NICE CKS Head and neck cancers (8); NICE CKS Neck Lump (25
 Facial Nerve (including Bells Palsy)
• Bells palsy is idiopathic Facial nerve palsy with acute (onset <72 hours), unilateral facial nerve palsy, usually with preceding
pain and a viral illness
• Most common between 15-45 years old
• Complications: corneal ulceration, dry mouth, abnormal facial contractions, sensitivity to loud noises, psychological
• In primary care is primarily a diagnosis of exclusion, MRIs do show changes however are not normally indicated for classic
cases
• Affects the forehead and the lower ½ of the face. Strokes do not involve the forehead (except in rare cases) and often
have accompanying limb weakness
• Ear pain on the affected side, change in taste, incomplete eye closure, eye watering, drooling, speech difficulties,
hyperacusis are normal
• There are other causes of Facial nerve palsy – these should all be seen in secondary care – anyone without classic
Bells palsy should be discussed with on-call ENT / Neurology +/- review organized

RED FLAGS
Discuss with on-call doctor (ENT or Neurology)
Refer to A&E or call 999 if acute stroke suspected

• Systemically unwell or local ear infection • Bilateral signs (suspect Lyme disease or sarcoidosis)
• abnormalities examining the head/neck e.g. • Evidence of skin cancer
mastoiditis/masses • Head or neck mass
• trauma preceding (including surgical) • Frequent relapses
• additional neurological signs • Forehead sparing (suspect stroke)
• evidence of cancer • Vesicular skin rash (suspect Ramsay Hunt)
• gradual onset or progressive symptoms (suspect cancer) • Confusion
• Previous stroke • Evidence of cholesteatoma (foul smelling otorrhoea and
• Known cancer hearing loss)
• Vestibular or hearing abnormalities (other than
hyperacusis)
• Diplopia

Suspected Typical • Reassure & advise that most Advise if there is no

bells examination, no Yes people have a full recovery Unresolved evidence of
palsy additional within 3 months improvement within
features • Offer Patient information leaflet 3 weeks to make
and no red flags • Advise on eye care* and red contact with
flags Primary Care and
No • If presents within 72hours request a referral
prescribe prednisolone** if no to ENT – routine
contraindications referral via e-RS
Consider alternative Do NOT routinely prescribe
diagnosis, refer to A&E or antivirals. If Ramsay Hunt is
discuss - speak to on-call suspected discuss - speak to on-
ENT (switch call ENT (switch board/Consultant
board/Consultant Connect) Connect)

• reactivation of varicella-zoster virus at geniculate ganglion of facial nerve

• Distinct from other forms of shingles as it causes a motor weakness of the facial nerve that mimics but is not
Bells Palsy
• Presentation: Vertigo, tinnitus, hearing loss, deep pain in the ear, vesicular rash – present in ear canal /outer
Suspected ear/inside mouth
Ramsay • Consider discussing with on-call ENT/Consultant connect if there is uncertainty or A&E if red flags
Hunt • NICE guidelines advocate treating with anti-virals only as per shingles guideline HOWEVER local ENT
Syndrome clinicians advocate for co-prescribing prednisolone as per advice for Bells Palsy/ acute hearing loss –
discuss with ENT if any doubt
• Eye care as for Bell’s Palsy
• Complications: corneal ulcers, secondary bacterial infection, post-herpetic neuralgia, chronic
tinnitus/vestibular dysfunction

• *Eye care: over the counter lubricating eye drops (such as hyaluronate 0.1% or carmellose 1% eye drops) every 2 hours or more if
needed. At night apply lubricating eye ointment (such as paraffin based eye ointment) and tape the eye closed. Dry eye symptoms
persisting, direct to local Minor Eye Condition Services (MECS) Red Flags: red eye, painful eye, feeling something in eye, blurred
vision, photophobia – advise to attend to eye casualty ?corneal ulcer
• **Adult dosing: Prednisolone 50mg once a day for 10 days OR if a reducing regimen is preferred: 60mg daily for 5 days followed by daily
reduction of 10mg for the next 5 days
References: NICE CKS Bell’s Palsy (26); NICE CKS Shingles (27)
 References
1) South East London ICB. South East London Treatment Access Policy. July 2022. Available from:
https://selondonccg.nhs.uk/wp-content/uploads/2023/04/SEL-Treatment-Access-Policy-Final-July-2022-v1.1-02.23-
1.pdf [accessed 16/5/2023]
2) NICE Clinical Knowledge Summaries. Earwax. March 2021. Available from: https://cks.nice.org.uk/topics/earwax/
[accessed 16/5/2023)
3) South East London ICB. Community Ear Wax Removal Service. July 2022. Available from:
https://selondonccg.nhs.uk/wp-content/uploads/2022/07/220701-Introduction-to-the-Community-Ear-Wax-
Removal-Service-vF.pdf [accessed 16/5/2023]
4) Transformation Partners in Health and Care. Pan London Urgent Suspected Cancer Referral forms. January 2023.
Available from: https://www.transformationpartnersinhealthandcare.nhs.uk/our-work/cancer/early-diagnosis/two-
week-wait-referral-repository/suspected-cancer-referrals/ [accessed 16/5/2023]
5) NICE Clinical Knowledge Summaries. Otitis Externa. February 2022. Available from:
https://cks.nice.org.uk/topics/otitis-externa/ [accessed 16/5/2023]
6) NICE Otitis media (acute): antimicrobial prescribing. 2022. Available from:
https://www.nice.org.uk/guidance/ng91/resources/visual-summary-pdf-4787282702 [accessed 16/5/2023]
7) NICE Clinical Knowledge Summaries. Otitis media – acute. March 2022. Available from:
https://cks.nice.org.uk/topics/otitis-media-acute/ [accessed 16/5/2023]
8) NICE Clinical Knowledge Summaries. Head and Neck cancers – recognition and referral. Available from:
https://cks.nice.org.uk/topics/head-neck-cancers-recognition-referral/ [accessed 16/5/2023]
9) NHS Southwark CCG, NHS Lambeth CCG. Southwark and Lambeth Antibiotic Guideline for Primary Care 2019. 2019.
Available from: https://selondonccg.nhs.uk/wp-content/uploads/dlm_uploads/2021/09/Antibiotic-guideline-final-
October-2019-1.pdf [accessed 16/5/2023)
10) NICE Clinical Knowledge Summaries. Hearing loss in adults. 2019. Available from:
https://cks.nice.org.uk/topics/hearing-loss-in-adults/ [accessed 16/5/2023]
11) Royal College of General Practitioners. Deafness and hearing loss toolkit. Available from:
https://elearning.rcgp.org.uk/mod/book/view.php?id=12532 [accessed 16/5/2023]
12) NICE Clinical Knowledge Summaries. Vestibular neuronitis. January 2023. Available from:
https://cks.nice.org.uk/topics/vestibular-neuronitis/ [accessed 16/5/2023]
13) NICE Clinical Knowledge Summaries. Meniere’s disease. March 2023. Available from:
https://cks.nice.org.uk/topics/menieres-disease/ [accessed 16/5/2023]
14) NICE Clinical Knowledge Summaries. Tinnitus. April 2022. Available from: https://cks.nice.org.uk/topics/tinnitus/
[accessed 16/5/2023]
15) NICE Clinical Knowledge Summaries. Otitis media with effusion. June 2021. Available from:
https://cks.nice.org.uk/topics/otitis-media-with-effusion/ [accessed 16/5/2023]
16) NICE Clinical Knowledge Summaries. Sinusitis. March 2021. Available from: https://cks.nice.org.uk/topics/sinusitis/
[accessed 16/5/2023]
17) NICE Clinical Knowledge Summaries. Allergic Rhinitis. June 2023. Available
from: https://cks.nice.org.uk/topics/allergic-rhinitis/ [accessed 10/10/2023]
17) Pan-London Allergic Rhinitis Guidelines. 2023.
18) NICE Clinical Knowledge Summaries. Chronic Sinusitis. March 2021. Available from:
https://cks.nice.org.uk/topics/sinusitis/management/chronic-sinusitis/ [accessed 16/5/2023]
19) NICE Clinical Knowledge Summaries. Epistaxis. December 2022. Available from:
https://cks.nice.org.uk/topics/epistaxis-nosebleeds/ [accessed 16/5/2023]
20) NICE Clinical Knowledge Summaries. Obstructive sleep apnoea. November 2021. Available from:
https://cks.nice.org.uk/topics/obstructive-sleep-apnoea-syndrome/ [accessed 16/5/2023]
21) BMJ. Anosmia and loss of smell in the era of covid-19. BMJ 2020;370:m2802. Available from:
https://www.bmj.com/content/370/bmj.m2808; [accessed 16/5/2023]
22) Deutsch, PG., Evans C., Wahidah Wahid, N., Amlani, AD., Khanna, A. Anosmia: an evidence-based approach to
diagnosis and management in primary care. BJGP 2021;71 (704): 135-138. Available from:
https://bjgp.org/content/71/704/135 [accessed 16/5/2023]
23) NICE Clinical Knowledge Summaries. Sore throat – acute. January 2023. Available from:
https://cks.nice.org.uk/topics/sore-throat-acute/ [accessed 16/5/2023]
24) NICE Clinical Knowledge Summaries. Neck Lump. October 2020. Available from: https://cks.nice.org.uk/topics/neck-
lump/ [accessed 16/5/2023]
25) NICE Clinical Knowledge Summaries. Bell’s Palsy. May 2019. Available from: https://cks.nice.org.uk/topics/bells-
palsy/ [accessed 16/5/2023]
26) NICE Clinical Knowledge Summaries. Shingles. January 2023. Available from: https://cks.nice.org.uk/topics/shingles/
Glossary

Abbreviation Definition
ICB Integrated Care Board
OTC over the counter
POM Prescription only Medication
SEL South East London
2ww Two Week Wait Suspected Cancer