Epistaxis (recurrent)

ADULT

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    Adult

    EAR

    • Trauma
    • Mastoiditis/cholesteatoma, acute and complicated
    • ENT conditions with associated neurological signs
    • Ear canal oedema/unable to clear discharge
    • Vertigo, sudden onset, debilitating, constant (vestibular neuritis/stroke)
    • Barotrauma with sudden onset vertigo
    • Hearing loss with associated neurological signs
    • Facial weakness, sudden onset
    • Foreign body
    • Auricular haematoma
    • Sudden / Rapid onset unilateral or bilateral hearing loss (>30dBHL at 3 or more frequencies that developed over less than a 72-hour period) (direct phone contact with the ENT registrar on call to discuss the case and arrange review as clinically appropriate)

    NOSE

    • Acute bacterial rhinosinusitis - visual disturbance/signs, neurological signs/frontal swelling/severe unilateral or bilateral headache
    • Acute nasal fracture with septal haematoma
    • Unilateral facial swelling with or without dental sepsis
    • Severe or persistent epistaxis

    THROAT

    • Airway compromise- stridor/drooling breathing difficulty/acute or sudden voice change/severe odynophagia
    • Ludwig's angina
    • Acute tonsillitis with airway obstruction and/or unable to tolerate oral intake and/or uncontrolled fever
    • Tonsillar haemorrhage
    • Abscess or haematoma, (e.g. peritonsillar abscess/quinsy, salivary abscess) with or without associated cellulitis
    • Acute hoarseness associated with neck trauma or surgery
    • Laryngeal obstruction and/or fracture
    • Pharyngeal/laryngeal foreign body
    • Accidental dislodgement or obstruction of permanent tracheostomy
    • New onset of bleeding or shrinkage of laryngectomy stoma
    • Profound dysphagia (i.e. inability to manage secretions)
    • Supraglottitis

    Paediatric

    EAR

    • Foreign body
    • Trauma
    • New onset facial nerve palsy
    • ENT conditions with associated neurological signs e.g. facial nerve palsy, profound vertigo and/or sudden deterioration in sensorineural hearing
    • Acute and/or complicated mastoiditis
    • Otitis externa with uncontrolled pain and/or cellulitis extending beyond the ear canal and/or ear canal is swollen shut
    • Auricular haematoma
    • Any suspicions of the complications of ASOM i.e. Mastoiditis (proptosis of pinna), meningitis etc

    NOSE

    • Foreign body (button batteries)
    • Trauma with other associated injuries i.e. other facial fractures e.g. orbit
    • Periorbital cellulitis with or without swelling with or without sinusitis
    • Severe or persistent epistaxis
    • Septal haematoma

    THROAT

    • Foreign body (button batteries – inhaled or ingested). if suspicion of button battery immediate emergency review
    • Acutely enlarging neck mass with any associated airway symptoms e.g. stridor, drooling, dysphagia etc
    • Airway compromise: severe stridor/drooling/ breathing difficulty/acute, sudden voice change/ severe odynophagia
    • Trauma
    • Abscess or haematoma (e.g. peritonsillar, parapharyngeal (quinsy), salivary, neck or retropharyngeal abscess)
    • Post-tonsillectomy haemorrhage
    • Hoarseness associated with neck trauma or surgery
    • If new onset hoarse voice and any airway obstructive symptoms

    SLEEP DISORDERED BREATHING/OBSTRUCTIVE SLEEP APNOEA

    • Clinical concern regarding prolonged apnoeas, cyanosis, altered level of consciousness or significant and escalating parental concerns should prompt direct phone contact with the ENT registrar on call to discuss the case and arrange review as clinically appropriate

    • Refer to Healthpathways or local guidelines

    Medical management

    • Investigations of coagulopathy, platelet disorder and/or hypertension
    • Hypertension management
    • Pressure on the nostrils (> 5mins)
    • If bleed is visible in Little's area consider cautery with silver nitrate (after applying topical anaesthesia)
    • As a topical barrier can use pawpaw ointment/vaseline
    • Intranasal packing coated with antibiotic ointment
Minimum Referral Criteria
Category 1
(appointment within 30 calendar days)
  • Associated change in sense of smell
  • Epiphora
  • Diplopia
Category 2
(appointment within 90 calendar days)
  • Recurrent epistaxes with no obvious cause
Category 3
(appointment within 365 calendar days)
  • Recurrent epistaxis on a background of nasal trauma

Please insert the below information and minimum referral criteria into referral

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Current medication list including any NSAIDS, aspirin or warfarin and anti-hypertensive medication
  • Coagulopathy/platelet disorder screening results

3. Additional referral information Useful for processing the referral

  • No additional information

4. Request

  • Patient's Demographic Details

    • Full name (including aliases)
    • Date of birth
    • Residential and postal address
    • Telephone contact number/s – home, mobile and alternative
    • Medicare number (where eligible)
    • Name of the parent or caregiver (if appropriate)
    • Preferred language and interpreter requirements
    • Identifies as Aboriginal and/or Torres Strait Islander

    Referring Practitioner Details

    • Full name
    • Full address
    • Contact details – telephone, fax, email
    • Provider number
    • Date of referral
    • Signature

    Relevant clinical information about the condition

    • Presenting symptoms (evolution and duration)
    • Physical findings
    • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
    • Body mass index (BMI)
    • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
    • Current medications and dosages
    • Drug allergies
    • Alcohol, tobacco and other drugs use

    Reason for request

    • To establish a diagnosis
    • For treatment or intervention
    • For advice and management
    • For specialist to take over management
    • Reassurance for GP/second opinion
    • For a specified test/investigation the GP can't order, or the patient can't afford or access
    • Reassurance for the patient/family
    • For other reason (e.g. rapidly accelerating disease progression)
    • Clinical judgement indicates a referral for specialist review is necessary

    Clinical modifiers

    • Impact on employment
    • Impact on education
    • Impact on home
    • Impact on activities of daily living
    • Impact on ability to care for others
    • Impact on personal frailty or safety
    • Identifies as Aboriginal and/or Torres Strait Islander

    Other relevant information

    • Willingness to have surgery (where surgery is a likely intervention)
    • Choice to be treated as a public or private patient
    • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

    • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

    • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

Last updated: 21 December 2018

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