Below are summaries of papers, articles, and guidelines that represent important updates and shifts in clinical practice. The entries focus on ENT but include broader guidance relevant to surgical trainees. For the full guidance documents, follow the links to the NICE website. NICE guidance is publicly available and free to access.
NICE NG215: Otitis Media with Effusion (Glue Ear) in Under 12s
In April 2023, NICE published updated guidance (NG215) on the management of otitis media with effusion (OME) — commonly known as glue ear — in children under 12 years of age. This replaced the previous 2008 guidance (CG60) and reflects substantial changes in the evidence base and clinical practice over the intervening 15 years.
The updated guidance recommends a watchful waiting period of 3 months before considering surgical intervention. A key change is the explicit recommendation that hearing aids should be offered as an alternative or adjunct to surgical management in children with bilateral OME and confirmed hearing loss, in particular when surgery would otherwise carry significant risk. The guidance also emphasises the importance of audiological assessment and school notification in children with significant hearing impairment from OME.
Regarding adenoidectomy, the guidance refines the previous position: adenoidectomy should be considered alongside grommet insertion where there is also a history of frequent or recurrent upper respiratory tract symptoms (such as recurrent acute otitis media or adenoidal hypertrophy). The distinction between OME with and without co-existing adenoidal problems remains clinically important. The full guidance is available at nice.org.uk/guidance/ng215.
NICE NG34: Tonsillitis and Tonsillectomy — Controversial New Guidance
NICE updated its guidance on the surgical management of tonsillitis (NG34) in August 2020, and the recommendations created significant debate within the ENT community. The guidance states that tonsillectomy should only be considered for recurrent sore throat if the patient has a documented history meeting specific criteria: at least seven episodes in the preceding year, at least five episodes per year over two years, or at least three episodes per year over three years (the "Paradise criteria"), with sore throats severe enough to interfere with normal functioning.
The guidance was contentious because it appeared to significantly restrict tonsillectomy referrals compared to existing practice, and because it did not fully align with the British Association of Otorhinolaryngology – Head and Neck Surgery (ENT UK) position or the Scottish SIGN guideline, which takes a slightly more liberal approach. The ENT UK clinical committee produced a response clarifying that surgeon and patient preference remain important factors, and that the guidance should not be applied rigidly in all circumstances.
The wider debate reflects genuine uncertainty in the evidence base: the largest trial comparing tonsillectomy to watchful waiting (the NATTINA trial, published in The Lancet in 2019) showed tonsillectomy provided modest benefit in terms of sore throat days per year, but with a significant surgical complication rate. The post-tonsillectomy haemorrhage rate in the NATTINA trial (approximately 5%) reinforced the importance of careful patient selection. The full guidance is at nice.org.uk/guidance/ng34.
NICE NG98: Hearing Loss in Adults — First Comprehensive Guidance
In November 2018, NICE published its first comprehensive guideline on hearing loss in adults (NG98). This was a landmark document because, despite hearing loss being one of the most common conditions managed by ENT departments and audiology services, there had been no previous comprehensive national guidance consolidating assessment, investigation, and management across the patient pathway.
Key recommendations include: all adults with hearing loss should be offered a hearing assessment in a timely manner; hearing aids should be offered to adults with mild-to-moderate hearing loss who will benefit from them; the guideline provides detailed criteria for referral to secondary care ENT versus direct referral to audiology for first-fit hearing aids; and cochlear implant candidacy should be assessed in adults with severe-to-profound bilateral hearing loss who are not gaining adequate benefit from hearing aids.
The guidance specifically addresses asymmetric hearing loss (where the difference between ears exceeds certain thresholds) as a red flag requiring ENT assessment and MRI of the internal auditory meati to exclude vestibular schwannoma. This is a practically important point for ENT junior doctors — any asymmetric sensorineural hearing loss must be investigated and should not be attributed to age-related hearing loss without appropriate imaging. The full guidance is at nice.org.uk/guidance/ng98.
NICE NG36: Head and Neck Cancers
NICE published its comprehensive guideline on head and neck cancers (NG36) in February 2016, with subsequent updates in 2023. The guideline covers the diagnosis, staging, management, and follow-up of cancers of the oral cavity, pharynx, larynx, salivary glands, paranasal sinuses, and neck. It is an essential reference for ENT surgical trainees.
Important recommendations include: all patients with suspected head and neck cancer should be assessed by an MDT (multidisciplinary team) with specific membership requirements including a clinical oncologist, ENT surgeon, maxillofacial surgeon, specialist nurse, radiologist, histopathologist, and dietitian; the choice between primary surgery, primary radiotherapy, or chemoradiotherapy should be MDT-driven and take into account tumour site, stage, and patient preference; and post-treatment surveillance should follow a defined pathway with particular attention to late complications of radiotherapy (hypothyroidism, dental problems, swallowing difficulties, osteoradionecrosis).
For ENT trainees preparing for ST3 interviews, a working knowledge of the NG36 framework — particularly regarding MDT referral, treatment decision making, and the evidence base for transoral robotic surgery (TORS) versus open surgery for oropharyngeal cancers — is expected. The full guidance is at nice.org.uk/guidance/ng36.
NICE IPG580: Balloon Dilation of the Eustachian Tube
In August 2017, NICE published interventional procedures guidance on balloon dilation of the Eustachian tube for Eustachian tube dysfunction (ETD) — a technique analogous to balloon sinuplasty, in which a catheter with an inflatable balloon is advanced through the Eustachian tube under endoscopic guidance and inflated to dilate the lumen. The procedure aims to restore normal Eustachian tube function in patients with chronic ETD causing symptoms such as ear fullness, muffled hearing, pressure sensation, and chronic middle ear effusion.
NICE concluded that current evidence shows the procedure is safe in the short term, and that there is some evidence of efficacy in improving subjective ETD symptoms and audiological outcomes. However, it noted that the evidence base was still relatively limited at the time of publication, and recommended that the procedure should only be performed in specialised centres, with robust arrangements for clinical governance, data collection, and audit. Subsequent studies have continued to show generally positive results in appropriately selected patients.
This is an area of active development in rhinology and otology practice. The full guidance is at nice.org.uk/guidance/ipg580.
NICE NG51: Sepsis — Recognition, Diagnosis and Early Management
NICE published its comprehensive sepsis guideline (NG51) in July 2016. While not specific to ENT, this guideline is highly relevant to ENT surgeons managing deep space neck infections, peritonsillar abscesses that have progressed beyond the peritonsillar space, necrotising fasciitis, and acute epiglottitis. These are all conditions in which the progression to sepsis or septic shock can be rapid and life-threatening.
The guideline introduced the concept of the Sepsis Six as a management bundle and emphasised early identification using NEWS (National Early Warning Score). Key recommendations include: suspecting sepsis in any acutely unwell patient; taking blood cultures and a serum lactate before giving antibiotics in stable patients; giving broad-spectrum intravenous antibiotics within one hour of recognising sepsis; IV fluid resuscitation; and early escalation to critical care where indicated.
For ENT on-call junior doctors, recognising when a patient with a deep neck space infection or peritonsillar abscess is becoming septic — and escalating promptly — is a critical skill. The combination of tachycardia, hypotension, fever, and raised lactate should trigger immediate senior review and consideration of emergency airway management alongside sepsis treatment. The full guidance is at nice.org.uk/guidance/ng51.
The TARGET Trial — Grommets vs Watchful Waiting in Children with OME
The TARGET trial (Treatment Approaches in Children with Otitis Media with Effusion), published in the BMJ in 2012 and conducted by researchers at the University of Southampton, was the largest randomised controlled trial to compare grommet insertion versus watchful waiting in children with bilateral otitis media with effusion (glue ear) and hearing loss. 228 children aged 2–9 years with confirmed bilateral OME and hearing loss of at least 20 dB in the better ear were randomised to either immediate bilateral grommet insertion or watchful waiting for six months.
The results showed that children who received grommets had significantly better hearing in the first six months after insertion, and improved language development scores compared to the watchful waiting group. However, the benefit in hearing largely disappeared after the grommets extruded (typically at 9–12 months), with no significant difference in hearing between groups at 18 months. The trial concluded that grommets provide a short-term benefit in hearing and development but that the long-term benefit is limited.
This trial is directly relevant to the 2023 NICE NG215 guidance on OME, which reflected the TARGET findings by emphasising a watchful waiting period before considering surgery, and by endorsing hearing aids as a non-surgical alternative. The key clinical question — "which children benefit most from early surgical intervention?" — remains an active area of research, with factors such as the severity of hearing loss, impact on schooling, co-existing speech and language delay, and family preferences all informing the decision.
NICE NG149: Thyroid Disease — Assessment and Management
NICE published its guideline on thyroid disease (NG149) in November 2019. While thyroid disease is managed primarily by endocrinologists and general practitioners, it is directly relevant to ENT and head and neck surgeons, who perform the majority of thyroid operations in the UK. Understanding the indications for thyroid surgery, the evidence base for different surgical approaches, and the management of thyroid cancer is an important component of an ENT surgeon's knowledge base.
The guideline recommends that ultrasound examination should be performed in all patients with a palpable thyroid nodule or goitre; fine needle aspiration cytology (FNAC) should be performed for suspicious or indeterminate nodules; and the British Thyroid Association (BTA) U classification system (U1–U5) should be used to risk-stratify nodules on ultrasound. All malignant or indeterminate thyroid nodules should be discussed at a specialist MDT before management decisions are made.
For ENT surgical trainees, knowledge of total versus hemithyroidectomy for differentiated thyroid cancer, the role of radioiodine ablation, the indications for central and lateral neck dissection, and the management of intraoperative recurrent laryngeal nerve injury is expected. The complication rates for thyroid surgery — particularly recurrent laryngeal nerve injury and hypoparathyroidism — are important for consent discussions. The full guidance is at nice.org.uk/guidance/ng149.
NICE NG12: Suspected Cancer — Two-Week-Wait Referral Criteria
NICE NG12, first published in June 2015 and updated in 2023, provides guidance on the recognition and referral of patients with suspected cancer via the urgent two-week-wait (2WW) pathway. For ENT, this is one of the most clinically impactful guidelines, as it defines which patients in primary care should be referred urgently for specialist assessment.
The ENT-relevant 2WW criteria include: unexplained hoarseness for three weeks or more (suspected laryngeal cancer); a neck lump that is unexplained or new in a patient over 45 (suspected thyroid or head and neck cancer); unexplained oral ulceration lasting more than three weeks or an unexplained swelling in the mouth (suspected oral cancer); and persistent unilateral nasal obstruction, particularly if associated with bloodstained discharge (suspected sinonasal malignancy). The 2023 update also included criteria for salivary gland lumps.
Understanding the 2WW criteria is directly relevant to ENT junior doctors who will encounter patients referred via this pathway daily. More importantly, it is relevant for ST3 interview discussions: candidates may be asked how they would counsel a patient who has been referred via the 2WW pathway, or about the principles of early cancer detection. The full guidance is at nice.org.uk/guidance/ng12.
NICE QS25: Allergic Rhinitis — Quality Standards
NICE published its quality standards for allergic rhinitis (QS25) in May 2013, building on its earlier clinical guideline (CG134, 2008). Allergic rhinitis is one of the most common conditions seen in ENT outpatient clinics and, when poorly managed, significantly impacts quality of life, sleep, and productivity. The quality standards were designed to identify areas where NHS care in this area was inconsistent or suboptimal.
Key quality statements include: adults and children with allergic rhinitis should receive a documented history including confirmation of triggers; pharmacotherapy should be prescribed in a stepwise manner beginning with a non-sedating antihistamine or an intranasal corticosteroid depending on symptom predominance; and patients with moderate-to-severe allergic rhinitis that is uncontrolled on optimal pharmacotherapy should be considered for allergen immunotherapy (AIT), either subcutaneous (SCIT) or sublingual (SLIT) — a treatment that remains underutilised in the UK compared to much of Europe.
For ENT juniors, allergic rhinitis is often the co-morbidity that drives decisions about surgical management of the nasal airway. Understanding when to optimise medical management before considering septoplasty, turbinoplasty, or functional endoscopic sinus surgery (FESS) is an important aspect of rhinology practice. The 2008 CG134 guidance is also worth reviewing.
NICE Guidance on Cochlear Implants
On 28 January 2009, the National Institute for Health and Care Excellence issued its guidance on cochlear implants for severe to profound deafness in children and adults (Technology Appraisal 166). NICE broadly supported the use of cochlear implants in patients with profound deafness — defined as a hearing threshold of 90 dBHL or worse — but the guidance also contained notable sections on cost management and value for money, including advice to implanting centres to "shop around" for the best price from device manufacturers. This suggested that NICE was concerned about the growing economic impact of this technology as it evolved and became more widely available.
Cochlear implants have since evolved significantly in terms of both technology and candidacy criteria. The 2009 guidance was superseded by updated appraisal work, which broadened candidacy to include patients with severe (as opposed to solely profound) hearing loss in both ears, and introduced bilateral cochlear implantation as a funded option for children (and in select adult cases). Candidates are now assessed by specialist cochlear implant teams using a combination of pure tone audiometry, speech discrimination testing, hearing aid trial data, and CT/MRI imaging.
The guidance is available at nice.org.uk/guidance/ta166.
NICE Guidance on Surgical Site Infections
On 22 October 2008, NICE issued its guidance on the prevention and treatment of surgical site infections (CG74). This guidance is relevant to all surgeons, including ENT surgeons performing ear, nose, and head and neck operations. Much of the guidance confirmed existing best practice in the UK, but there were one or two points of particular note.
With regard to hair removal, NICE explicitly stated that routine shaving around the surgical site should not be performed in order to reduce infection rates, as this is not beneficial and may in fact increase the risk of infection through micro-abrasions. This is potentially at odds with the practice of some ENT and neurosurgical teams who shave hair around the ear or scalp before mastoid and middle ear procedures. The rationale offered by many surgeons for this practice is not infection prevention, but rather to prevent hair from falling into the wound during drilling and becoming tangled in the burr — a hazard particularly relevant in surgery near critical structures such as the facial nerve or sigmoid sinus. This distinction is worth understanding clearly.
The guidance is available at nice.org.uk/guidance/cg74.
NICE Guidance on Balloon Sinuplasty (Catheter Dilation of Paranasal Sinus Ostia)
On 28 September 2008, NICE issued its guidance on balloon catheter dilation of the paranasal sinus ostia for chronic sinusitis — a technique derived conceptually from angioplasty and coronary balloon dilation. The procedure involves advancing a flexible guidewire and inflatable balloon catheter into the sinus ostia under endoscopic guidance, inflating the balloon to dilate the natural opening and break down the bony walls of the ostium via micro-fracture, whilst preserving the surrounding mucosal tissue. This is in contrast to conventional FESS, which involves resecting bone and mucosa with powered instruments.
NICE noted that the evidence for sinuplasty at that time showed it to be a safe procedure, but that the evidence for its long-term efficacy was limited. They recommended it be used only by surgeons with expertise in complex sinus surgery. The principal limitations identified were: lack of evidence for efficacy in ethmoid sinus disease (where it cannot be applied as effectively), limited long-term data, and the significant cost of disposable equipment at that time (approximately £700 per case). It was considered that cost savings from reduced hospital stay and post-operative morbidity might eventually offset the equipment costs, but this was not established at the time of the guidance.
Since 2008, evidence for balloon sinuplasty has grown considerably, particularly for frontal and sphenoid sinus disease. It is now widely used in office-based settings in the United States, though its adoption in the UK has been more cautious due to cost constraints and equipoise about long-term durability compared to conventional FESS. The guidance is available at nice.org.uk/guidance/ipg273.
NICE Guidance on Otitis Media with Effusion (Original 2008 Guideline)
In February 2008, NICE stated that children with otitis media with effusion (glue ear) should have grommet insertion without adenoidectomy unless there is a clear history of frequent upper airway symptoms such as mouth breathing, snoring, or recurrent acute otitis media. This was a somewhat controversial position, given that it contradicted the not-yet-completed TARGET trial evidence, which at that stage appeared to suggest that grommet insertion combined with adenoidectomy would be the superior management plan in terms of long-term outcomes.
The reasoning was that adenoidectomy carries additional anaesthetic time and surgical risk, including post-operative haemorrhage and nasopharyngeal stenosis (rarely), and that unless there is a clear clinical indication for adenoidectomy beyond the OME alone, it should not be performed routinely at the time of grommet insertion.
This guidance was superseded by NICE NG215 in April 2023 (see above). The 2008 guidance remains historically interesting as a point of comparison. The quick reference guide from 2008 is available at the NICE website.