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Ear, Nose, and Throat Referrals

Many ear, nose, and throat (ENT) disorders are easily diagnosed and treated by primary care physicians (PCP). Some problems, however, require a visit to an ENT specialist (otolaryngologist). If you or your child experience problems with the ear, nose, or throat which require a visit to a physician, understanding the symptoms of the disorder and the treatments available can be valuable information when deciding whether a visit to a specialist is warranted.

Ear Disorders

Earwax impaction is a common problem often caused by the use of cotton tip applicators. Symptoms include mild discomfort, decreased hearing, and a blocked sensation in the ear canal. This is easily treatable using irrigation or removal by an instrument. Softening agents also help when used prior to removal and include products such as Debrox[R] (glycerin and peroxide) or Cerumenex[R]. Earwax impaction rarely requires a referral to a specialist.

Foreign bodies in the ear surprisingly account for 1 in every 500 emergency room visits, with 50% of the cases occurring in persons over the age of twelve. Often, the foreign bodies are insects, cotton, or beads. When an insect is the problem, symptoms include intense itching and a scratching sound. While a PCP can remove a foreign body, there is a high rate (50%) of complications that occur when a nonspecialist attempts the removal. If any break in the skin occurs during the removal, antibiotic drops are required.

Ear infections are also frequently diagnosed by PCPs. Symptoms of ear infections vary depending on the location in the ear, but they include mild to severe pain, a discharge from the ear canal, different levels of hearing loss, itching, or a blocked sensation or pressure in the ear canal. Treatment also varies, but with most infections, either antibiotic drops or oral antibiotics are administered. In most cases, PCPs can easily treat ear infections and referral to an ENT is rarely needed.

Hearing loss is often a symptom of other ear disorders, but when these causes have been ruled out, referral to an otolaryngologist should be made.

Nasal Disorders

Nose bleeds are perhaps the most common complaints referred to ENT specialists. Many factors can cause nose bleeds, including cold weather, dry climates, or trauma. Most nose bleeds are mild enough that firm pressure administered for 20 minutes can stop the flow. Nasal spray decongestants such as Afrin[R] can also help alleviate the bleeding. If the bleeding persists, or becomes too frequent or heavy, an office visit is warranted. Often the physician can cauterize the bleeding site. Prevention, however, is highly important in patients who suffer from frequent nose bleeds. Any trauma to the nose should be avoided, and the inside of the nose should be kept moist at all times. Saline mists and humidifiers are extremely helpful, as well as applying petroleum jelly once or twice a day.

Seasonal allergies, which affect more than 20% of the US population, prompt many offices visits. Symptoms include clear nasal discharge, sneezing, itching, and nasal congestion. For most patients, treatment of seasonal allergies can be confined to the primary care setting and includes patient education and avoidance of allergens. Allergy testing can be helpful, and a nasal steroid spray such as Flonase[R] often alleviates discomfort. For symptoms that are moderate to severe, a non-drowsy antihistamine can be helpful. If symptoms become difficult to control or if bleeding or visual changes occur, a referral to an ENT specialist is necessary.

Throat Disorders

Mouth sores vary in size, severity, and type, but most lesions are mouth ulcers occurring in half of all Americans. They can appear as a single lesion or in multiples, with discomfort ranging from uncomfortable to mildly painful. Mouth ulcers can be caused by infection, immune disorders, menstrual cycle, trauma, or stress. These typically heal within 3 to 14 days, but a physician can prescribe a mouthwash to alleviate discomfort and promote healing. Antibiotics are sometimes prescribed for major lesions or for clusters of lesions. If lesions persist for more than 3 weeks and are raised and firm, oral cancer may be suspected. Oral cancer occurs most frequently in males, tobacco users, and patients with a history of alcohol use. There are 19,000 cases of oral cancer reported each year.

Sleep apnea is concerning because of possible effects on the nervous system, heart, and lungs. Signs and symptoms of sleep apnea include obesity, hypertension, loud snoring, gasping for air, daytime sleepiness, poor memory or difficulty concentrating, morning headaches, or restless sleep. Up to 60% of habitual snorers have sleep apnea and should be seen by a physician. Treatment options include weight loss; diet modification, including the removal of alcohol, caffeine, and tobacco; and improvement in sleeping environment. A referral to an ENT specialist is often required.

From "Common ENT Disorders." By Drs. Kevin S. Emerick and Daniel G. Deschler. Southern Medical Journal. October 2006.

The information on this page was compiled by the Editorial Office of the Southern Medical Journal, Johnson City, TN. Please feel free to photocopy this page and share it with your patients.

Bridget Garland, MA