The Society of Physician Assistants in Otorhinolaryngology / Head & Neck Surgery
(SPAO-HNS)

SPAO-HNS supports AAO-HNSF "TOP 5"Campaign to Improve the Nation’s Healthcare Quality and Safety

SPAO-HNS proudly supports AAO-HNSF's Campaign to Improve the Nation's Healthcare Quality and Safety. The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAOHNSF) released its list of five things physicians and patients should question as part of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely┬« campaign. To date, 25 specialty societies have developed and released lists as part of the initiative.

The AAO-HNSF‘s list of recommendations was carefully selected after a review of the current evidence that included AAO-HNSF clinical practice guidelines. Each list includes language communicating when a particular test or treatment may be appropriate based on clinical evidence and guidelines. Consumer Reports, along with a coalition of consumer partner organizations, is also a part of the Choosing Wisely effort and is working with many of the societies to help patients understand the tests and treatments that are right for them

Five Things Physicians and Patients Should Question

Don't order CT scans of head/brain for sudden hearing loss.
Computed tomography scanning is expensive, exposes the patient to radiation and offers no useful information that would improve initial management. CT scanning may be appropriate in patients with focal neurologic findings, a history of trauma or chronic ear disease 1.

Don't prescribe oral antibiotics for uncomplicated tympanostomy tube otorrhea.
Oral antibiotics have significant adverse effects and do not provide adequate coverage of the bacteria that cause most episodes; in contrast, topically administered products do provide coverage for these organisms. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections 2.

Don't prescribe oral antibiotics for uncomplicated acute external otitis.
Oral antibiotics have significant adverse effects and do not provide adequate coverage of the bacteria that cause most episodes; in contrast, topically administered products do provide coverage for these organisms. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections 3.

Don't order imaging studies for patients meeting diagnostic criteria for uncomplicated acute rhinosinusitis.
Imaging of the paranasal sinuses, including plain film radiography, computed tomography (CT) and magnetic resonance imaging (MRI) is unnecessary in patients who meet the clinical diagnostic criteria for uncomplicated acute rhinosinusitis. Acute rhinosinusitis is defined as up to four weeks of purulent nasal drainage (anterior, posterior or both) accompanied by nasal obstruction, facial pain-pressure-fullness or both. Imaging is costly and exposes patients to radiation. Imaging may be appropriate in patients with a complication of acute rhinosinusitis, patients with comorbidities that predispose them to complications and patients in whom an alternative diagnosis is suspected 4.

Don't order CT or MRI for a patient with a complaint of hoarseness before examining the larynx.
Examination of the larynx with mirror or fiberoptic scope is the primary method for evaluating patients with hoarseness. Imaging is unnecessary in most patients and is both costly and has potential for radiation exposure. After laryngoscopy, evidence supports the use of imaging to further evaluate 1) vocal fold paralysis, or 2) a mass or lesion of the larynx 5.

AAO-HNSF’s second list identifies the following recommendations:

Don’t place ear tubes in otherwise healthy children who have had a single episode of ear fluid lasting less than 3 months. Ear fluid of short duration is likely to resolve spontaneously. The child should be monitored to ensure resolution of the fluid. In children with comorbid conditions or speech delay, earlier tube placement may be appropriate.  6

Don’t order imaging studies in patients with non-pulsatile bilateral tinnitus, symmetric hearing loss and an otherwise normal history and physical examination. The utility of imaging procedures in primary tinnitus is undocumented; imaging is costly, has potential for radiation exposure and does not change management.  7

Don’t order more than one computerized tomography (CT) scan of the paranasal sinuses within 90 days to evaluate uncomplicated chronic rhinosinusitis patients when the paranasal sinus CT obtained is of adequate quality and resolution to be interpreted by the clinician and used for clinical decision-making and/or surgical planning. Computerized tomography scanning is expensive, exposes the patient to ionizing radiation and offers no additional information that would improve initial management. Multiple CT scans within 90 days may be appropriate in patients with complicated sinusitis or where an alternative diagnosis is suspected.8

Don’t routinely use perioperative antibiotics for elective tonsillectomy in children. Oral antibiotics may have significant adverse effects and do not provide demonstrable benefit after tonsillectomy. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections.  9

Don’t routinely perform sinonasal imaging in patients with symptoms limited to a primary diagnosis of allergic rhinitis alone. History, physical examination and allergy testing are the cornerstones of diagnosis of allergic rhinitis. The utility of imaging for allergic rhinitis is unproven.  10

Sources

1. Stachler RJ, Chandrasekhar SS, Archer SM, Rosenfeld RM, Schwartz SR, Barrs DM, Brown SR, Fife TD , Ford P, Ganiats TG, Hollingsworth DB, Lewandowski CA, Montano JJ, Saunders JE, Tucci DL, Valente M, Warren BE, Yaremchuk KL, Robertson PJ. Clinical practice guideline: Sudden hearing loss. Otolaryngol Head Neck Surg [Internet]. 2012 Mar [cited 2012 Oct 18];146(3 Suppl):S1-35.

2. Goldblatt EL, Dohar J, Nozza RJ, Nielsen RW, Goldberg T, Sidman JD, Seidlin M. Topical ofloxacin versus systemic amoxicillin/clavulanate in purulent otorrhea in children with tympanostomy tubes. Int J Pediatr Otorhinolaryngol. 1998 Nov 15;46(1-2):91-101.

Rosenfeld RM, Schwartz SR, Pynnonen MA, Tunkel DE, Hussey HM, Fichera JS, Grimes AM, Hackell JM, Harrison MF, Haskell H, Haynes DS, Kim TW, Lafreniere DC, LeBlanc K, Mackey WL, Netterville JL, Pipan ME, Raol NP, Schellhase KG. Clinical Practice Guideline: Tympanostomy tubes in children. Otolaryngol Head Neck Surg. 2013; Otolaryngol Head Neck Surg. 2013;149(1 Suppl):S1-35.

3. Rosenfeld RM, Brown L, Cannon CR, Dolor RJ, Ganiats TG, Hannley M, Kokemueller P, Marcy SM, Roland PS, Shiffman RN, Stinnett SS, Witsell DL. Clinical practice guideline: Acute otitis externa. Otolaryngol Head Neck Surg [Internet]. 2006 Apr [cited 2012 Oct 18];134(4 Suppl):S4-23.

4. Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, Gelzer A, Hamilos D, Haydon RC 3rd, Hudgins PA, Jones S, Krouse HJ, Lee LH, Mahoney MC, Marple BF, Mitchell CJ, Nathan R, Shiffman RN, Smith TL, Witsell DL. Clinical practice guideline: Adult sinusitis. Otolaryngol Head Neck Surg [Internet]. 2007 Sep [cited 2012 Oct 18]:137(3 Suppl):S1-31.

5. Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES, Gillespie MB, Granieri E, Hapner ER, Kimball CE, Krouse HJ, McMurray JS, Medina S, O’Brien K, Ouellette DR, Messinger-Rapport BJ, Stachler RJ, Strode S, Thompson DM, Stemple JC, Willging JP, Cowley T, McCoy S, Bernad PG, Patel MM. Clinical practice guideline: Hoarseness (dysphonia). Otolaryngol Head Neck Surg [Internet]. 2009 Sep [cited 2012 Oct 18];141(3 Suppl 2):S1-S31.

6. Rosenfeld RM, Schwartz SR, Pynnonen MA, Tunkel DE, Hussey HM, Fichera JS, Grimes AM, Hackell JM, Harrison MF, Haskell H, Haynes DS, Kim TW, Lafreniere DC, LeBlanc K, Mackey WL, Netterville JL, Pipan ME, Raol NP, Schellhase KG. Clinical practice guideline: Tympanostomy tubes in children. Otolaryngol Head Neck Surg. 2013 Jul;149(1 Suppl):S1-35.

7. Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER Jr, Archer SM, Blakley BW, Carter JM, Granieri EC, Henry JA, Hollingsworth D, Khan FA, Mitchell S, Monfared A, Newman CW, Omole FS, Phillips CD, Robinson SK, Taw MB, Tyler RS, Waguespack R, Whamond EJ. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014 Oct;151(S2):S1-40.

8. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Kumar KA, Kramper M, Orlandi RR, Palmer JN, Patel, ZM, Peters A, Walsh S, Corrigan MD. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg. 2015 Apr;152(2 Suppl):S1-S39. 

9. Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, Darrow DH, Giordano T, Litman RS, Li KK, Mannix ME, Schwartz RH, Setzen G, Wald ER, Wall E, Sandberg G, Patel MM. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011 Jan;144(1 Suppl): S1-30.

10. Seidman MD, Gurgel RK, Lin SY, Schwartz SR, Baroody FM, Bonner JR, Dawson DE, Dykewicz MS, Hackell JM, Han JK, Ishman SL, Krouse HJ, Malekzadeh S, Mims JW, Omole FS, Reddy WD, Wallace DV, Walsh SA, Warren BE, Wilson MN, Nnacheta LC. Clinical practice guideline: allergic rhinitis. Otolaryngol Head Neck Surg. 2015 Feb;152(1 Suppl):S1-S43.




These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

Visit the AAO-HNS website. Vist Choosing Wisely website

Updated 11/16/2015

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