Dr. Stepniak and Dr. Van Osch are open to new referrals.
Due to the high volume of referrals, and to help ensure timely and efficient patient care, please review the following information before submitting a referral. Referrals may be declined if required information is missing or if the patient’s work-up is incomplete.
Head & Neck
Tonsils and Adenoids• The diagnosis of tonsillar or adenoidal hypertrophy is based on history and clinical examination.• Lateral neck X-rays are not helpful for diagnosis.• Referrals for tonsilliths (tonsil stones) are not accepted, as tonsillectomy for this indication is not covered by OHIP. Good oral hygiene and gargling with water after meals are recommended management strategies.
Thyroid Nodules• Thyroid nodules are very common and often found incidentally. Thyroid ultrasound is the best imaging modality for assessment and must be completed for appropriate work-up.• Please refer to TI-RADS guidelines (see below) and only refer when a nodule meets criteria for biopsy.• Follow-up intervals for thyroid nodules should also follow TI-RADS recommendations.
Nose
Chronic Sinusitis / Nasal Congestion• Please ensure the patient has completed a minimum 3-month trial of an intranasal steroid spray, used consistently, before referral.• Steroid sprays are ineffective if used inconsistently or for less than approximately 8 weeks.• Sinus X-rays are not useful. CT Sinus is the preferred imaging modality and can assist with triaging referrals.
Nasal Fractures• A nasal fracture is a clinical diagnosis based on examination.• Nasal X-rays are unnecessary. CT scans are indicated only if additional facial fractures are suspected.• Refer urgently if there is a septal hematoma discovered on exam.• Please refer for reduction only if there is a clinical deformity or functional impairment related to the fracture
Ear
- Sudden Sensorineural Hearing Loss (SSNHL)
- • This is an otologic emergency. Confirm sensorineural loss with tuning forks or an urgent audiogram.
- • If confirmed, initiate high-dose oral steroids (e.g., prednisone 50 mg daily for 10 days) as soon as possible (unless any contraindications)—ideally within 2 weeks of onset.
- • Please send an urgent referral for consideration of intratympanic steroid therapy.
- Chronic Asymmetric Sensorineural Hearing Loss (SNHL)
- • Asymmetric hearing loss is defined as:
- ≥ 30 dB difference at 1 frequency, or
- ≥ 20 dB difference at 2 frequencies, or
- ≥ 10 dB difference at 3 or more frequencies.
- • Please defer referral until an MRI of the Internal Auditory Canals (IAC) has been completed to rule out a retrocochlear lesion.
- • Refer only if:
- o The MRI reveals a retrocochlear lesion, or
- o Hearing loss is profound and hearing aids are not beneficial, for discussion of cochlear implantation.
- Tinnitus and Hearing Loss
- • Tinnitus is the perception of ringing, buzzing, or other sounds without an external source and commonly occurs with hearing loss—even when the hearing loss is mild. When the inner ear does not provide normal sound input, the brain may compensate by generating these phantom sounds. While tinnitus can be bothersome, it is not dangerous and can often be managed effectively.
- • Helpful strategies include a formal hearing test, as hearing aids frequently reduce tinnitus by restoring sound input. Sound therapy (background noise or sound generators), education and reassurance, stress and sleep management, and cognitive behavioral therapy (CBT) can all lessen symptom impact. With appropriate support, most patients experience meaningful improvement in quality of life.
- • ENT referral is not required.
- Bloodwork for Tinnitus
- Routine bloodwork is not required for most patients with tinnitus. Testing should be targeted based on history, exam, and audiogram findings.
- Consider bloodwork if clinically indicated: CBC – anemia, infection
- TSH – hypo- or hyperthyroidism
- Vitamin B12 – deficiency can be associated with tinnitus and neuropathic symptoms
- Iron studies – if anemia suspected
- Fasting glucose / HbA1c – diabetes-related neuropathy
- Lipid panel – vascular risk factors (especially pulsatile tinnitus)
- Bottom line: Most tinnitus is related to hearing loss, and management should focus on audiologic evaluation and symptom control, not extensive lab testing. Bloodwork should be selective and symptom-driven.
- Pulsatile Tinnitus
- • If the patient experiences true pulsatile tinnitus (tinnitus synchronous with the heartbeat) and otoscopy is normal, please refer to the imaging algorithm for appropriate investigations prior to referral.
Ontario e-consult
Dr. Stepniak and Dr. Van Osch are available on eConsult for clinical questions
