ENT Clinic (Head and Neck Surgery)

Otolaryngology—Head and Neck Surgery Clinic (ENT)

Thank you for your consideration in referring to the ENT clinic. The below guidelines are designed to facilitate efficient and effective consultations for your patients. Please read the summary guidelines and order any necessary testing prior to referral. Additional information follows in the “Detailed Recommendations” section.

Consultations can be arranged by sending referrals to RightFax at 512-776-0476 (vs. through LeadingReach).

Brief summary of appropriate ER referrals:

• Uncontrolled nasal or oral bleeding
• Acute airway obstruction
• Suspected head, neck, or throat abscesses

Brief summary of appropriate URGENT referrals:

• Suspected Head and Neck Cancer
  • CT of the neck soft tissues with contrast should be ordered
  • CT or U/S guided FNA of lymph nodes suspected to harbor metastatic disease may be ordered, but should not delay referral to the ENT clinic
  • The head and neck cancer nurse navigator or ENT clinic coordinator should be contacted to facilitate overbooking into the ENT clinic
• Thyroid cancer
  • U/S of the thyroid should be ordered
  • U/S guided FNA of nodules should be ordered based on current American Thyroid Association criteria
  • If lateral cervical nodal disease is also seen on physical exam or ultrasound, a CT of the neck soft tissues with contrast should also be ordered
• Parathyroid adenomas
  • Laboratory findings should be consistent with primary hyperparathyroidism
  • If diagnosis is uncertain, an endocrinology consultation should be ordered
  • Thyroid ultrasound and a localizing study such as 4D CT, SPECT, or Sestamibi scan should be ordered
• Sudden sensorineural hearing loss
  • Urgent audiogram should be ordered
  • If diagnosis can be determined clinically (typically unilateral, sudden loss of hearing with a normal ear exam), consideration should be given to empirically starting oral steroids if there are no medical contraindications
  • Weber and Rinne tuning fork tests can assist in making a timely diagnosis
• Significant episodic nasal or oral bleeding
  • Evaluate and manage uncontrolled hypertension, anti-coagulant medications, and bleeding disorders which may be contributing factors
  • Episodic nasal bleeding should be managed first with hydration measures: nasal saline sprays, saline gels, use of a humidifier at night
• Patients with progressive voice or airway symptoms that do not require emergent attention
• Suspected benign head and neck masses of significant size or with significant progressive growth
  • CT of the neck soft tissues with contrast should be ordered
• Severe acute sinusitis, unresponsive to medical management
  • Patients with evidence of orbital involvement or abscess should be referred to the ER
  • CT of the sinuses with image guidance protocol should be ordered
• Nasal fracture
  • Attempts should be made to see these patients in the clinic within 2wks of the fracture
  • Septal hematoma should be ruled out. Patients with septal hematoma (rare, approximately 1%) should be referred to the ER
  • After 3 weeks, immediate reduction is unlikely to be feasible and consultation on a routine basis can be made if the patient has significant deformity or related obstruction

Brief summary of appropriate ROUTINE referrals:

• Neck masses that do not meet above criteria
  • CT of the neck soft tissues with contrast should be ordered
  • Thyroid U/S alone is sufficient to evaluate masses of suspected thyroid or parathyroid origin
  • Subcutaneous masses such as sebaceous cysts do not require imaging
• Benign thyroid nodules
  • Thyroid U/S should be ordered
  • TFT’s should be ordered and patients with thyroid dysfunction should be referred to endocrinology
  • Benign nodules >3cm or causing compressive symptoms should be referred for consultation
• Milder cases of recurrent epistaxis or oral bleeding.
  • Rule out uncontrolled hypertension, medications, and bleeding disorders as contributing factors.
  • Episodic nasal bleeding should be managed first with hydration measures: nasal saline sprays, saline gels, use of a humidifier at night
• Milder cases of persistent hoarseness (>6wks)
• Recurrent tonsillitis (>3 per year for 3 or more years) or history of recurrent peritonsillar abscess
• Recurrent acute sinusitis (4 or more infections per year for multiple years)
  • CT of then sinuses when the patient is symptomatic should demonstrate sinusitis
  • If CT of the sinuses when the patient is symptomatic does not demonstrate sinusitis, then other causes of facial pain and/or other rhinosinusitis symptoms should be considered including viral URI, allergic and nonallergic rhinitis, migraine, TMJ syndrome, cluster headaches and trigeminal neuralgia
• Chronic sinusitis (>12wks of persistent sinusitis symptoms despite treatment)
  • CT of the sinuses with image guidance protocol should be ordered
  • If CT of the sinuses when the patient is symptomatic does not demonstrate sinusitis, then other causes of facial pain and/or other rhinosinusitis symptoms should be considered including viral URI, allergic and nonallergic rhinitis, migraine, TMJ syndrome, cluster headaches and trigeminal neuralgia
• Chronic nasal obstruction, nasal deformity, or septal deviation
  • Medical management including a trial of nasal steroid sprays should be attempted for patients with complaints of nasal obstruction
  • Nasal decongestant sprays should be discontinued in patients with complaints of nasal obstruction
  • CT of the sinuses is only needed if significant comorbid sinus disease is suspected or if nasal polyps are present
• Septal perforation
• Nasal fracture >3wks after trauma
• Obstructive sleep apnea
  • Sleep study should be ordered
  • Conservative management with PAP and/or oral appliance should be attempted
  • In overweight patients, weight loss should be encouraged
  • In obese patients who fail conservative weight loss measures, bariatric surgery should be considered
• Chronic otorrhea or recurrent episodes of otorrhea or chronic otitis externa
  • Audiogram is not necessary prior to referral of these patients
• Asymmetric hearing loss
  • Audiogram should be ordered
  • MRI of brain and IACs should be ordered for patients with 15dB or greater asymmetry at 3kHz or patients with asymmetry and associated neurologic symptoms
  • Patients who do not meet imaging criteria can be observed with serial audiometry
  • Patients with negative imaging can be referred for hearing aids
• Recurrent/chronic otitis media or tympanic membrane perforation
  • Audiogram should be ordered
• Vertigo
  • Audiogram should be ordered
  • Patients with history and exam findings suggestive of benign paroxysmal positional vertigo should be referred for vestibular therapy and do not need ENT consultation
  • Patients with dizziness from non-otogenic causes such as migraine, syncope, orthostatic hypotension, medication side effect, hypertension, hypotension, peripheral neuropathy, or other cardiologic, neurologic, or ophthalmologic sources do not need ENT consultation
• Cerumen impaction
• Pulsatile tinnitus

Brief summary of appropriate AUDIOLOGY ONLY referrals:

• Patients with hearing loss and/or tinnitus that do not meet any of the criteria described above for urgent or routine referral

Please do not refer to ENT clinic:

• Patients with symmetric sensorineural hearing loss seeking hearing aids. The ENT clinic does not currently have the means to provide low cost or no cost hearing aids to the MAP population. These services may be provided through the University of Texas at Austin Speech and Hearing Center, Easter Seals, or other community resources.
• Patients with sleep apnea who are successfully treated with non-surgical means and are not felt likely to need ENT surgery to assist with treatment by improving obstructive upper airway anatomy.
• Patients with TMJ syndrome or other problems related to the temporomandibular joint. These patients should see a dentist or oral surgeon
• Patients with Syncope/Presyncope should be referred to Neurology if symptoms are suspicious for seizure, or if there are high risk factors for seizures. If neither, then cardiac work up should be done and normal before referring a patient with Syncope/Presyncope to Neurology.
• Patients with Vertigo
  • First rule out non-vestibular causes such as migraines, drug-related side effects, orthostatic changes, vasovagal response.
    • Vague mild vertigo in persons with migraine is often related to the migraines. It worsens with eye movement.
    • Check orthostatic blood pressure if dizziness is postural.
    • If vertigo occurs when upright and is associated with nausea, facial pallor, dimming of vision, sweating or is provoked by unpleasant events, think of neutrally mediated syncope (vasovagal).
  • Then, perform Dix–Hallpike maneuver.
    • If positive, then likely Benign Paroxysmal Positional Vertigo (BPPV). These patients will usually respond to a home exercise program incorporating the Epley maneuver. If they do not respond to the Epley maneuver, then refer to physical therapy. If they do not respond to the recommendations from physical therapy, then refer to ENT.
    • If negative, refer to ENT.
• Patients seeking allergy immunotherapy (sublingual treatments or shots). These services are not currently offered through the ENT MAP clinic.
• Patients with acute, uncomplicated upper respiratory infections occurring less than or equal to 3 times per year.

Documentation required for scheduling an appointment:

• Past Medical History (PMH)
• Current medication list
• Most recent progress note describing condition for which patient is being referred
• Recent pertinent labs (appropriate labs per worksheet, drawn within the past month, substantiating the disorder. Please send lab flow sheets if they exist.)
• Recent pertinent scans or imaging reports

 Detailed Recommendations

Below are a few additional details about conditions that may require referral to the ENT clinic. The intent is to provide additional nuance to the basic recommendations listed above. A comprehensive overview of these and other ENT conditions is beyond the scope of this document, so some limitations should be anticipated. Protected health information can be shared, if needed, through DocBook MD, which is a HIPAA compliant medical texting application.

Head and Neck Cancer

The term “head and neck cancer” refers to cancers that originate in the nose, sinuses, mouth, throat, larynx, or salivary glands. The most common type of head and neck cancer is squamous cell carcinoma. Typically, these cancers present with either a visible lesion at the primary site, progressive symptoms related to the primary site, or a neck mass with or without related aerodigestive tract symptoms.

Adults with neck masses should be viewed with a high level of clinical suspicion. Reactive lymphadenopathy that is associated with a clinically apparent infectious process does not generally warrant further work-up. Antibiotic therapy should be prescribed for suspected bacterial infections and a period of observation should be allowed for lymphadenopathy that appears reactive in nature. Enlarged lymph nodes and other neck masses that emerge in the absence of an infectious or inflammatory process should be evaluated with a CT of the neck with contrast and a referral to the ENT clinic should be placed. Computed tomography is preferred for initial evaluation because of the ability to provide cross sectional images of the mass and surrounding structures in three dimensions, to allow for complete visualization of locoregional lymph nodes, and the lack of dependence on a technician and a concomitant reduction in inter-test and inter-observer variability. If patients are unable to receive IV contrast, a non-contrast CT can be ordered, though this reduces the diagnostic value of the CT significantly. Patients who also have suspicious lesions of the mouth or throat, upper aerodigestive tract symptoms, B symptoms (fever in the absence of clinically apparent infection, night sweats, unexpected weight loss), and those with a significant history of tobacco and/or alcohol abuse, should be referred urgently for evaluation. Patients with masses that have been stable for years, likely have a benign process that can be managed on a routine basis. While tobacco and alcohol use are risk factors for head and neck cancer, the absence of a history of tobacco and alcohol abuse should not be viewed as an indication that the patient is unlikely to have head and neck cancer. HPV infection has emerged as an independent risk factor for head and neck squamous cell carcinoma. These patients tend to be younger, healthier, do not necessarily have a history of tobacco and alcohol abuse, and more often present without an obvious aerodigestive tract primary tumor.

Squamous cell carcinoma of the head and neck can also present with exam findings or symptoms related to the primary site. Ulcers and suspicious appearing masses of the mouth and throat that fail to heal or are progressive in size and symptoms warrant urgent ENT evaluation. Pain and friability are concerning features, but are not, in and of themselves, diagnostic of a malignant process. Other aerodigestive tract symptoms such as changes in the voice, difficulty swallowing, painful swallowing, referred ear pain, symptoms of upper airway obstruction, and hemoptysis, should also raise clinical suspicion, particularly if these symptoms are prolonged and progressive. Since the nature of malignant processes is to grow and spread, symptoms that are transient or that wax and wane are less likely to represent a cancerous process.

Patients with a history of head and neck cancer treated elsewhere can also be referred to the MAP ENT clinic for ongoing surveillance. Patients with squamous cell carcinoma should followed closely for 5 years. Other forms of malignancy may require longer periods of surveillance. Since lymphoma is not treated surgically and does not rely significantly on ENT examination and endoscopy for follow-up, these patients are usually followed primarily by their oncologists and usually do not need regular follow-up in the ENT clinic.

Thyroid and Parathyroid Tumors

Masses that are felt to be of thyroid origin should be evaluated with thyroid ultrasound. American Thyroid Association (ATA) guidelines can be used to determine which nodules warrant further work-up with FNA. The Austin Radiological Association (ARA) radiologists that read films conducted through Seton and ARA facilities typically reference these guidelines in their report. Ultrasound-guided FNA can be ordered through Seton interventional radiology or can be performed in the ENT clinic. Advance notice is preferred, for scheduling purposes, if need for in-clinic FNA is anticipated. Consideration should be given to empiric removal of thyroid nodules that are larger than 3-4 cm, nodules with compressive symptoms, or nodules with substernal extension. Patients with nodules that meet these criteria also warrant referral to the ENT clinic, even if they are cytologically benign. TSH should be ordered early in the work-up of thyroid nodules, so that thyroid dysfunction can be addressed prior to any necessary surgery. Also, in patients with hyperthyroidism, the treatment algorithm changes and often includes nuclear medicine studies to attempt to identify hyper functional or “toxic” nodules. These patients should generally see endocrinology for work-up and treatment prior to ENT consultation. Patients with hypothyroidism do not require antecedent endocrinology evaluation, but attempts should be made to render the patient euthyroid prior to surgical intervention.

Thyroid cancer may present in various ways. Often, these tumors are detected incidentally during unrelated imaging studies, but patients may present with a palpable thyroid mass, palpable metastatic adenopathy, or with voice changes, swallowing problems, or dyspnea related to extrinsic compression or direct invasion of the tumor. There are 4 subtypes of thyroid cancer. Most thyroid cancer (approximately 90%) falls into the category of well-differentiated thyroid cancer, which includes papillary (80-84%) and follicular thyroid carcinoma (6-10%). These forms of thyroid cancer typically have a very favorable prognosis. Less common medullary thyroid carcinomas and, in particular, anaplastic thyroid carcinomas are much more aggressive and, as a result, have a more guarded prognosis. In almost all cases of thyroid cancer, primary treatment is surgical. An exception to this is anaplastic thyroid carcinoma, which often presents at an advanced stage and may be inoperable, even at time of initial diagnosis. Well differentiated thyroid cancer may also be treated with radioactive iodine, in cases that meet ATA criteria. Thyroid cancer patients are typically co-managed with endocrinology, but referral of patients to the ENT clinic for evaluation and treatment of suspected or known thyroid cancers need not be delayed by waiting for an endocrinology appointment.

Patients may also be referred into the ENT clinic for management of recurrent thyroid cancer originally managed elsewhere or for neck dissection when patients have developed locoregional metastases. Specialized treatment of complications related to thyroid surgery performed elsewhere, such as recurrent laryngeal nerve injury or airway injury, can also be managed through the ENT clinic, though careful avoidance of surgical pitfalls remains the preferred approach.

Parathyroid tumors are typically recognized by identification of elevated serum calcium on routine evaluation. This prompts measurement of parathyroid hormone (PTH), which is found to be elevated in cases of primary hyperparathyroidism. Primary hyperparathyroidism (hyperparathyroidism originating from a hyperfunctioning parathyroid tumor) usually involves a single gland. Treatment is typically surgical, as removal of the affected gland is curative. Localizing studies, such as 4D CT, SPECT, or Sestamibi scans, can be employed to help identify the adenomatous gland for surgical removal. Intraoperative changes in PTH are measured to confirm removal of the affected gland at time of surgery. In cases where the gland cannot be identified preoperatively or where PTH levels do not fall as expected, exploration and inspection of all four glands may be necessary.

Hearing Loss and Tinnitus

Hearing loss and tinnitus are common conditions which increase in prevalence as age advances. They often occur together as both are indicators of injury or disease of the auditory system. Patients who have a significant history of noise exposure or have a family history of early onset hearing loss may be expected to have earlier onset of these complaints. Since the ENT clinic does not currently provide complimentary hearing aid services, and, in an effort to decrease the number of unnecessary ENT referrals, routine hearing testing and counseling about the nature and management of tinnitus should be performed through other community resources, such as those detailed above. Patients who are identified to have hearing loss and tinnitus should also be counseled to use hearing protection in loud noise situations to prevent further damage to the inner ear. Management of tinnitus principally relies on habituation techniques such as providing background noise. Cognitive behavioral therapy has been shown to help quality of life measures in patients who suffer from tinnitus. There is not a specific medical or surgical therapy that has been reliably shown to be effective for tinnitus, so a visit to the ENT clinic for this condition tends not to be highly productive. Additional tests, such as laboratory or imaging studies, are also not indicated for the vast majority of patients that suffer hearing loss and tinnitus.

ENT clinic referral is appropriate for patients with primarily conductive hearing loss, patients with sudden or significant asymmetric sensorineural hearing loss, and patients with pulsatile tinnitus. Conductive hearing loss can be identified on audiometric testing or through careful examination of the ear and use of the Weber and Rinne tuning fork tests. Since conductive hearing loss indicates injury to the auditory system before sound reaches the inner ear, many of these sources of hearing loss are medically or surgically treatable. While some patients with conductive hearing loss may ultimately be best suited for treatment with hearing aids, these patients still benefit from evaluation in the ENT clinic prior to fitting.

Sudden sensorineural hearing loss is an uncommon phenomenon that is often idiopathic and has numerous proposed etiologies. It should be suspected in patients who report sudden loss of hearing, often accompanied by onset of tinnitus, in absence of other symptoms (such as pain, discharge, or fever) and without obvious trigger (URI, allergies, trauma). Examination of the ear in these cases is otherwise normal. Audiometric and tuning fork testing can confirm the diagnosis. Timely evaluation and management is essential, as early administration of systemic steroids is the only medical treatment that has been shown to help restore hearing and decrease tinnitus, though these patients will often improve spontaneously to some degree. In cases where urgent evaluation in the ENT clinic and audiometric testing are not possible, consideration should be given to empirically prescribing steroids if this diagnosis is highly suspected, , since the benefit from steroids decreases over time. Since sudden sensorineural hearing loss can be a presenting symptom for retrocochlear pathology such as vestibular schwannoma, an MRI of the IACs with and without contrast is usually ordered for these patients.

Asymmetric sensorineural hearing loss warrants ENT evaluation primarily because this too can be associated with retrocochlear pathology. Various guidelines have been published to define the degree of sensorineural hearing loss that should be considered significantly asymmetric. An acceptable, evidence-based guideline is a 15dB or greater asymmetry at 3 kHz. Patients with this degree of asymmetry should be evaluated with MRI of the IACs with and without contrast. An exception is cases where asymmetry is strongly suspected to be the result of asymmetric noise exposure (most commonly from unprotected firearm use) or as a direct result of head or ear trauma. Consideration should be given to ordering imaging for patients that don’t meet the above guideline, if they have balance problems, disequilibrium, or other neurologic symptoms that may suggest central nervous system pathology. Patients that don’t meet imaging criteria can be followed with serial audiometry and further work-up can be considered if asymmetry progresses or if the patients develop additional symptoms.

Pulsatile tinnitus represents a subset of tinnitus that is unique because it may indicate more serious pathology including idiopathic intracranial hypertension, vascular tumors in proximity to the auditory system, arteriovenous malformations, carotid artery disease, or aneurysmal or other disease of the cerebrovascular system. Usually patients will describe hearing a “whooshing” or similar quality sound that corresponds with their pulse. This is marked distinction to most types of tinnitus, which have more of a ringing, buzzing, or roaring quality and do not change in character or intensity depending on heart rate or blood flow.

Dizziness

Dizziness is a relatively common complaint whose diagnosis and management are complicated by the vague nature of the term “dizzy”, the broad array of symptoms that are clumped together under that term, and the numerous and varied pathophysiologies that can produce sensations that patients might label “dizziness”. Like most complex medical problems, the key to effectively diagnosing and managing patients with complaints of dizziness is first conducting a thorough history and physical exam. These first steps can help narrow the differential diagnosis and determine whether further testing and specialty referral is needed. Since dizziness is common, since ENT clinic access is limited, and since the majority of patients with complaints of dizziness do not have pathology of the inner ear, most of these patients should be managed outside of the ENT clinic. It is inefficient and unnecessary for patients with a chief complaint of dizziness to be sent to the ENT clinic for triage purposes. Similarly, pan-consultation of numerous specialists that cover organ systems that can be associated with dizziness (e.g. neurology, ophthalmology, cardiology, and ENT) should be discouraged. There are numerous review articles in the family practice and internal medicine literature which offer simplified algorithms for the evaluation and management of dizzy patients and familiarization with this material will go a long way toward avoiding unnecessary testing and overuse of specialty services. Of particular importance in evaluating patients with dizziness, is trying to understand what the patient is describing when they use the term dizzy. For instance, symptoms of lightheadedness (especially with postural changes), presyncope, or syncope generally arise from the lack of efficient delivery of oxygenated blood to the brain. Patients with this type of pathophysiology will not benefit from evaluation in the ENT clinic. Conversely, since the inner ear vestibular system (utricle, saccule, and semicircular canals) has the function of perceiving linear and rotary acceleration, patients with inner ear disorders will generally suffer from a false sense of movement, or vertigo. It is worth clarifying here that vertigo is a specific term that refers to an aberrant sensation of movement and is not a unifying term for all the different sensations that may fall under the umbrella of “dizziness”. It should also be noted that vertigo is not a diagnosis, it is a symptom. Identifying the presence of vertigo is only one step in providing a diagnosis to a dizzy patient.

Of patients that do present to an ENT clinic with vertigo, the most common diagnosis is benign paroxysmal positional vertigo (BPPV). While this is a disorder of the inner ear and ENT referral is not inappropriate, it is easily diagnosed and treated and most of these patients can be managed without an ENT referral. The patient usually complains of movement provoked rotary vertigo lasting seconds to minutes that subsides when the offending movement ceases. Patients may complain of vague disequilibrium in between episodes of vertigo. Other otologic symptoms are typically absent. The Dix-Hallpike maneuver can help confirm the diagnosis and guide treatment with canalith repositioning maneuvers, such as the Epley maneuver. These maneuvers can be performed in clinic, prescribed as a home exercise program, or coordinated with a physical therapist who is skilled in vestibular therapy. Other sources of peripheral vertigo include Meniere’s disease, endolymphatic hydrops, vestibular neuritis, and labyrinthitis. It should be noted that vertigo can also arise from central pathology, so this symptom is not, in itself, diagnostic of vestibular pathology. The onset of vertigo in patients with a history of migraine headaches, particularly when associated with migraine symptoms, should arouse suspicion of migrainous vertigo (also known as migraine associated vertigo or vestibular migraine). This diagnosis does not rely on the presence of headaches concurrently with the vertigo episodes.

Nasal and Sinus Disease

Acute rhinosinusitis is a very common clinical condition and is typically managed at the primary care level. Most patients that present with symptoms of acute rhinosinusitis have a viral infection and should undergo symptomatic management alone. It is well established within the medical literature that antibiotics do not significantly improve the outcome of most patients with this condition. Many attempts have been made to identify patients with acute bacterial rhinosinusitis who would be expected to benefit from antibiotic therapy. Unfortunately, no classification based on clinical signs and symptoms has emerged that is able to consistently identify which patients with acute rhinosinusitis have a bacterial infection. As an example, purulent rhinorrhea and postnasal drainage have been shown to be inaccurate predictors of the presence of bacterial infection, despite these symptoms being commonly used to justify the prescription of antibiotics. The reliance on these and other diagnostically ambiguous signs and symptoms likely contributes to the over-prescription of antibiotics that is common for this condition. To confuse the issue further, inflammatory conditions such as allergic and non-allergic rhinitis and even atypical forms of migraine can present with many of the hallmark features of sinusitis. Only nasal endoscopy and computed tomography have been shown to accurately diagnose acute bacterial rhinosinusitis. Both are not practical to employ on a routine basis given the high incidence of this disease and low cost/benefit ratio. As a result, a clinical paradox emerges, where the diagnosis must be made on clinical features, yet these features do not allow for a reliable diagnosis. At least one study has shown that experienced practitioners are able to correctly identify bacterial sinusitis, based on history and physical exam findings alone, only approximately half of the time. On the positive side, even most bacterial sinus infections are self-limited and will resolve without antibiotic management. Perhaps as a result, several guidelines rely principally on the duration of symptoms (typically greater than 10 days without improvement), severity of symptoms, and/or the occurrence of a “double worsening” where symptoms worsen after initially appearing to improve. Amoxicillin or Augmentin are generally identified as first line treatments of choice.

ENT referral is appropriate in cases of severe acute sinusitis that is unresponsive to medical management, cases of recurrent acute sinusitis, or for patients with chronic sinusitis (arbitrarily defined as 12 weeks of continuous sinusitis symptoms) with or without nasal polyps. Given the diagnostic difficulty that surrounds sinusitis, patients considered for referral to the ENT clinic for management of sinusitis should have a CT scan that demonstrates significant sinus disease. In cases of recurrent acute sinusitis, an attempt should be made to obtain the imaging study when the patient is symptomatic. When allergic rhinitis is felt to be a contributing factor to recurrent sinusitis, attempts should be made to maximally control allergies with medications and/or immunotherapy before placing an ENT consult. Limited coronal CT scans are adequate to make an accurate diagnosis of sinusitis and are cheaper and require less radiation exposure than standard sinus CT scans. More detailed CT scans may be necessary if surgical intervention is planned. In cases where CT fails to show significant sinus disease, further consideration should be given to the numerous other clinical conditions that can mimic sinusitis.

Obstructive Sleep Apnea (OSA)

OSA is most accurately diagnosed with a polysomnogram (PSG) or, in common parlance, a sleep study. Patients with a high pretest probability of having OSA based on clinical symptoms can usually be adequately screened with a home sleep test (HST). Patients with borderline or mild sleep apnea or with comorbid insomnia have a high false negative rate (approximately 30%) with this test modality, however, and consideration should be given to obtaining a formal PSG if HST results do not appear to reflect the clinical picture or if technical difficulties are encountered during the study. HST is also not useful for evaluating sleep disorders other than OSA. Patients with OSA that are overweight should be encouraged to lose weight as this is a common contributing factor to OSA. First line treatment for OSA is typically with positive airway pressure (PAP) therapy. Optimal pressure settings are generally determined by performing a titration study. This may be done during the same night as the PSG in what is referred to as a split night study, or as a full night titration study. As the technology behind autotitrating PAP devices has improved, use of AutoPAP and AutoBiPAP has increased and, in some settings, supplanted formal titration in the sleep laboratory. Oral appliance therapy may be appropriate first line therapy in patients with mild to moderate OSA. It may also provide an alternative for patients who do not tolerate PAP therapy.

Surgery can be performed either to facilitate CPAP use or with a goal of treating OSA directly. Usually, this is considered when less invasive treatments have failed. Nasal surgery (typically septoplasty and/or turbinate reduction) may be considered in cases where obstructive nasal anatomy precludes successful use of nasal CPAP. Nasal surgery alone is not highly successful in treating significant levels of OSA, but it can be considered as part of a multilevel surgical plan aimed at eliminating sites of upper airway obstruction. Sleep surgery has evolved significantly from prior decades where uvulopalatopharyngoplasty (UPPP) was performed somewhat indiscriminately with curative intent. Work by Friedman and other authors helped to clarify which patients may respond to UPPP, which patients may need additional upper airway surgery, and which patients are poor surgical candidates. This stratification occurs based on anatomic features noted on exam and endoscopy and takes into consideration body habitus, as surgical success rates have an inverse correlation to elevations in BMI. In addition, UPPP has been improved upon, with several recent studies advocating for a modification known as expansion sphincter pharyngoplasty which has been shown to improve success rates, presumably because it allows for better expansion of both the anterior-posterior and lateral dimensions of the airway. To successfully treat OSA with surgery, all levels of upper airway obstruction should be addressed. This may include nasal surgery, palatopharyngeal surgery, base of tongue surgery, and/or surgical reduction or repositioning of the epiglottis. Craniofacial surgery such as maxillary mandibular advancement may also be considered, however, this is not offered through the ENT clinic. Hypoglossal nerve stimulation is a newer intervention that shows promise in a select cohort of patients, but is costly and still considered experimental by most payors. Patients who are obese typically have poor surgical success rates. In these patients, if conservative weight loss measures fail, bariatric surgery should be considered. As a last resort, tracheostomy may be considered. This is an effective surgical treatment since the collapsible portions of the upper airway are bypassed by allowing respiration to occur through the tracheostomy tube. Due to the associated morbidity, however, this is approach is avoided, if at all possible.

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